Risk Assessment of Side Branch Compromise After Coronary Bifurcation Stenting　- A Substudy of the 3D-OCT Bifurcation Registry.

BACKGROUND: Side branch (SB) occlusion during bifurcation stenting is a serious complication. This study aimed to predict SB compromise (SBC) using optical coherence tomography (OCT).Methods and Results: Among the 168 patients who enrolled in the 3D-OCT Bifurcation Registry, 111 bifurcation lesions were analyzed to develop an OCT risk score for predicting SBC. SBC was defined as worsening of angiographic SB ostial stenosis (≥90%) immediately after stenting. On the basis of OCT before stenting, geometric parameters (SB diameter [SBd], length from proximal branching point to carina tip [BP-CT length], and distance of the polygon of confluence [dPOC]) and 3-dimensional bifurcation types (parallel or perpendicular) were evaluated. SBC occurred in 36 (32%) lesions. The parallel-type bifurcation was significantly more frequent in lesions with SBC. The receiver operating characteristic curve indicated SBd ≤1.77 mm (area under the curve [AUC]=0.73, sensitivity 64%, specificity 75%), BP-CT length ≤1.8 mm (AUC=0.83, sensitivity 86%, specificity 68%), and dPOC ≤3.96 mm (AUC=0.68, sensitivity 63%, specificity 69%) as the best cut-off values for predicting SBC. To create the OCT risk score, we assigned 1 point to each of these factors. As the score increased, the frequency of SBC increased significantly (Score 0, 0%; Score 1, 8.7%; Score 2, 28%; Score 3, 58%; Score 4, 85%; P<0.0001). CONCLUSIONS: Prediction of SBC using OCT is feasible with high probability.

The impact of geriatric nutritional risk index on one-year outcomes in hospitalized elderly patients with heart failure.

Background: Strategies that accurately predict outcomes in elderly heart failure (HF) patients have not been sufficiently established. In previous reports, nutritional status, ability to perform activities of daily living (ADL), and lower limb muscle strength are known prognostic factors associated with cardiac rehabilitation (CR). In the present study, we investigated which CR factors can accurately predict one-year outcomes in elderly patients with HF among the above factors. Methods: Hospitalized patients with HF over 65 years of age from January 2016 to January 2022 were retrospectively enrolled in the Yamaguchi Prefectural Grand Medical (YPGM) Center. They were consequently recruited to this single-center retrospective cohort study. Nutritional status, ADL, and lower limb muscle strength were assessed by geriatric nutritional risk index (GNRI), Barthel index (BI), and short physical performance battery (SPPB) at discharge, respectively. One year after discharge, the primary and secondary outcomes were evaluated by all-cause death or HF readmission and major adverse cardiac and cerebrovascular events (MACCE), respectively. Results: Overall, 1,078 HF patients were admitted to YPGM Center. Of those, 839 (median age 84.0, 52% female) met the study criteria. During the follow-up of 228.0 days, 72 patients reached all-cause death (8%), 215 experienced HF readmission (23%), and 267 reached MACCE (30%: 25 HF death, six cardiac death, and 13 strokes). A multivariate Cox proportional hazard regression analysis revealed that the GNRI predicted the primary outcome (Hazard ratio [HR]: 0.957; 95% confidence interval [CI]: 0.934-0.980; p < 0.001) and the secondary outcome (HR: 0.963; 95%CI: 0.940-0.986; p = 0.002). Furthermore, a multiple logistic regression model using the GNRI most accurately predicted the primary and secondary outcomes compared to those with the SPPB or BI models. Conclusion: A nutrition status model using GNRI provided a better predictive value than ADL ability or lower limb muscle strength. It should be recognized that HF patients with a low GNRI at discharge may have a poor prognosis at one year.

Serial changes of the side-branch ostial area after single crossover stenting with kissing-balloon inflation.

PURPOSE: We aimed to investigate the serial change of the side-branch ostial area (SBOA) depended on the wire-position before Kissing-balloon inflation (KBI) in the single-stent strategy for bifurcation lesions separately in the left main coronary artery (LMCA) and in non-LMCA. METHODS: Patients who underwent a single-stent KBI for a bifurcation lesion and had OCT images at the timing of the rewiring, at the post-procedure, and at the 9-month follow-up were extracted from the 3D-OCT Bifurcation Registry, which is a multicenter-prospective registry of patients with a percutaneous coronary intervention for a bifurcation lesion under OCT guidance. The SBOA was measured by dedicated software, and the rewiring position at the side-branch ostium after crossover stenting was assessed by three-dimensional-optical coherence tomography (3D-OCT). The optimal rewiring was defined as link-free-type and distal rewiring. The relationship between the optimal rewiring and the serial change of the SBOA was investigated separately in LMCA and non-LMCA cases. RESULTS: We examined 75 bifurcation lesions (LMCA, n = 35; non-LMCA, n = 40). The serial changes of the SBOA with the optimal rewiring were not significantly different regardless of LMCA and non-LMCA (LMCA:3.96 to 3.73 mm2, p = 0.38; non-LMCA:2.16 to 2.21 mm2, p = 0.98), whereas the serial changes of the SBOA with the sub-optimal rewiring were significantly reduced (LMCA:6.75 to 5.54 mm2, p = 0.013; non-LMCA:2.28 mm2 to 2.09 mm2, p = 0.024). There was no significant difference in clinical events between the optimal and sub-optimal rewiring group regardless of the LMCA and non-LMCA. CONCLUSION: The side-branch ostial area dilated with the optimal rewiring position in a bifurcation lesion treated with single crossover stenting and kissing-balloon inflation was preserved regardless of whether the bifurcation was in the LMCA or a non-LMCA.

Vascular healing after kissing balloon inflation: Nine-month 3D optical coherence tomography analysis in corelab.

Background: The jailing strut configuration with link-free and distal guidewire recrossing (LFD) at the side branch orifice (SBO) reduces incomplete stent apposition (ISA) after kissing balloon technique (KBT) in crossover stenting of coronary bifurcation lesions (CBLs). However, data regarding vascular healing after KBT are lacking. We investigated vascular healing 9 months after crossover stenting followed by KBT with optical coherence tomography (OCT) guidance in a prospective multicenter registry. Methods: Fifty-nine patients with CBLs (LFD, 35 patients; non-LFD, 24 patients) were studied. The jailing configuration of the SB and the wire-recrossing position, incidence of ISA and uncovered struts, and neointima unevenness score (NUS) in the main vessel (MV) after 9 months were determined by off-line 3D-OCT in the core laboratory. Results: The ISA rate was significantly higher at the SB ostium and distal MV after KBT in the non-LFD group, compared to the LFD group. After 9 months, incidence of ISA (18.3 ± 18.2 vs. 6.0 ± 8.7%, p < 0.01) and uncovered struts (8.7 ± 9.9 vs. 4.7 ± 7.3 %, p = 0.08) were higher at the SB ostium with higher SB restenosis in the non-LFD group. In distal MV, NUS was significantly higher (3.1 ± 1.1 vs. 2.5 ± 0.6, p < 0.05). In true-CBLs, an increase in uncovered struts and ISA rate was prominent in the proximal MV and opposite SB. No differences were observed in the 9-month clinical outcomes. Conclusion: Visualization of the wire recrossing point and the SB-jailing strut pattern by OCT plays an important role to optimize the KBT in CBL stenting, resulting in favorable mid-term vascular healing.

Corrigendum: Malnutrition and Frailty Are Critical Determinants of 6-Month Outcome in Hospitalized Elderly Patients With Heart Failure Harboring Surgically Untreated Functional Mitral Regurgitation.

[This corrects the article DOI: 10.3389/fcvm.2021.764528.].

Malnutrition and Frailty Are Critical Determinants of 6-Month Outcome in Hospitalized Elderly Patients With Heart Failure Harboring Surgically Untreated Functional Mitral Regurgitation.

Background: Hospitalized patients with acute decompensated heart failure (ADHF) frequently exhibit aggravating mitral regurgitation (MR). Those patients do not always undergo surgical mitral valve repair, but particularly in the elderly, they are often treated by conservative medical therapy. This study was aimed to investigate factors affecting 6-month outcomes in hospitalized patients with heart failure (HF) harboring surgically untreated MR. Methods: We screened the presence of MR in hospitalized patients with HF between September 2017 and May 2020 in the Yamaguchi Prefectural Grand Medical (YPGM) center. At the time of discharge of these patients, individuals with surgically unoperated MR, including primary and secondary origin, were consequently recruited to this single-center prospective cohort study. The patients with severe MR who undergo surgical mitral valve treatment were not included in this study. The primary endpoint was all-cause readmission or all-cause death and the secondary endpoint was HF-related endpoint at 6 months after discharge. The Cox proportional hazard regression analyses were employed to assess the predictors for the composite endpoint. Results: Overall, 489 patients with ADHF were admitted to the YPGM center. Of those, 146 patients (30% of total patients with HF) (median age 83.5 years, 69 men) were identified as harboring grade II MR or greater. Consequently, all the recruited patients were diagnosed as functional MR. During a median follow-up of 186.0 days, a total of 55 patients (38%) reached the primary or secondary endpoints (HF death and readmission in 31 patients, other in 24 patients). As a result of multivariate analysis, geriatric nutritional risk index [hazard ratio (HR) = 0.932; 95% CI = 0.887-0.979, p = 0.005], age (HR = 1.058; 95% CI = 1.006-1.112, p = 0.027), and left ventricular ejection fraction (HR = 0.971; 95% CI = 0.945-0.997, p = 0.030) were independent predictors of all-cause death or all-cause admission. Body mass index (HR = 0.793; 95% CI = 0.614-0.890, p = 0.001) and ischemic heart disease etiology (HR = 2.732; 95% CI = 1.056-7.067, p = 0.038) were also independent predictors of the HF-related endpoints. Conclusion: Malnutrition and underweight were substantial predictors of adverse outcomes in elderly patients with HF harboring surgically untreated moderate-to-severe functional MR.

Epicardial flow in the right ventricular wall on echocardiography: A sign of chronic total occlusion of left anterior descending artery.

Transthoracic coronary Doppler echocardiography (TCDE) can be useful for the detection of chronic total occlusion (CTO) of the proximal left anterior descending coronary artery (LAD) noninvasively, by detecting retrograde flow through the distal LAD or its septal branch. This intriguing case report details the detection of abnormal blood flow in the right ventricular free wall by TCDE. This detection of abnormal flow may be useful to predict CTO of the LAD, even in the absence of retrograde flow in the LAD and its septal branch.

Efficacy of the proximal optimization technique on crossover stenting in coronary bifurcation lesions in the 3D-OCT bifurcation registry.

AIM: We sought to investigate the efficacy of the proximal optimization technique (POT) on crossover stenting followed by side branch (SB) dilation under optical coherence tomography guidance in a multicenter registry study. METHODS AND RESULTS: A total of 135 bifurcation lesions in 134 patients were divided into POT (n = 52) and non-POT groups (n = 83). The POT was performed before SB dilatation (pre-POT; n = 26), finally (final-POT; n = 12), at both timing (re-POT; n = 13), and uncertain (n = 1). There were no significant intergroup differences in the success rate of guide wire re-crossing (GWR) into the optimal cell (72% vs. 65%), incidence of the link-free type in the configuration of the SB jailed struts (51% vs. 49%), or incomplete strut apposition at the bifurcation (13 ± 11% vs. 10 ± 9%). However, insufficient stent expansion close to the carina in the proximal main vessel (MV) due to inappropriate POT was likely to induce greater incomplete strut apposition (ISA) around the bifurcation. Only re-POT provided more symmetric proximal MV expansion, while pre- and final-POT did not. CONCLUSION: The POT did not provide the expected beneficial effects, such as reduction of ISA or more optimal GWR, under the OCT guidance. Wide stent expansion in the proximal MV induced by the POT increased the likelihood of achieving optimal GWR, whereas symmetric stent expansion was provided by re-POT.

Relationship between coronary diastolic pressure indexes during the wave-free period and a novel pressure-derived index: Diastolic pressure ratio at the optimal point.

OBJECTIVES: We aimed to determine the diastolic pressure ratio at the optimal point (DROP) using a simple measurement algorithm and to compare DROP with distal coronary-to-aortic pressure ratios during the wave-free period (PRWFP ) and at the mid-diastolic point (PRMD ). METHODS: Distal coronary and aortic pressures were measured from color pressure images of 440 beats in 48 patients with coronary stenoses. The DROP measurement point was 67% for one beat between the two rising points on the aortic pressure curve according to the distribution of the wave-free period and the mid-diastolic point. RESULTS: DROP correlated closely with PRWFP (r = 0.993, P < 0.0001) and PRMD (r = 0.997, P < 0.0001). The diagnostic efficiency was excellent (area under the receiver-operating characteristic curve, 0.997) for both PRWFP ≤ 0.89 (specificity, 0.99; sensitivity, 0.96) and PRMD ≤ 0.89 (specificity, 0.95; sensitivity, 1.00). CONCLUSIONS: A simple pressure-derived physiological marker of coronary stenosis, DROP, might represent other diastolic pressure indexes with a numerical equivalency to the instantaneous wave-free ratio. DROP can be measured automatically assuming that the rising points on the aortic pressure curve are detectable. However, further large-scale clinical investigations are needed to determine whether DROP could contribute to the further generalization of physiology-guided percutaneous coronary intervention.

Data on two- and three-dimensional optical coherence tomography guidance for the treatment for the bifurcation lesion.

This article comprised the data related to the research article entitled "Feasibility and usefulness of three-dimensional optical coherence tomography guidance for optimal side branch treatment in coronary bifurcation stenting" (Nagoshi et al., In press) [1]. In this article we reports details about two patterns of guide wire (GW) recrossing position after crossover stenting in bifurcation lesion classified with three-dimensional optical coherence tomography (3D-OCT) (Okamura et al., 2014) [2] and follow-up data about the treatment with percutaneous coronary intervention(PCI) for bifurcation lesion in terms of the two- (2D) or 3D-OCT guidance. Subgroup analysis about differences in the parameters between the proximal and the distal GW recrossing patterns are analyzed here.

Feasibility and usefulness of three-dimensional optical coherence tomography guidance for optimal side branch treatment in coronary bifurcation stenting.

BACKGROUND: For the treatment of coronary bifurcation lesions, optimal guidewire (GW) recrossing after main vessel stenting is important for good stent apposition at the side branch (SB) orifice in kissing balloon inflation (KBI). METHODS: We analyzed 150 bifurcation lesions treated with single stenting following KBI in the three-dimensional optical coherence tomography (3D-OCT) bifurcation registry study (2015-16) and a single center experience (2012-16). OCT examination was performed after GW recrossing to the SB and after KBI. Patients were divided into two-dimensional (2D, n=78) and 3D groups (n=72) according to 2D- or 3D-OCT guidance. GW recrossing position, jailing configuration of the stent over the SB (divided into Link-connecting type: stent link connecting to the carina and Link-free type: no stent link at the carina) and stent apposition were compared between the groups. RESULTS: Distal GW recrossing was achieved in 75.6% and 91.7% in the 2D and 3D groups, respectively (P=0.004). Compared with the 2D group, the incidence of incomplete stent apposition (ISA) toward the SB in the 3D group tended to be lower in the whole cohort (14.5±13.6% vs 10.0±9.0%, P=0.077), and was significantly lower in left main trunk bifurcations (18.7±12.8% vs 10.3±8.9%, P=0.014). Independent contributors to ISA were the Link-connecting type (ß 0.089, P<0.001), distal GW recrossing (ß -0.078, P=0.001), and age (ß -0.0020, P=0.012). CONCLUSION: Optimal GW recrossing under 3D-OCT guidance is feasible and improves stent apposition, which may lead to a better clinical outcome in the treatment of bifurcation lesions.

The impact of proximal cell rewiring compared with distal cell rewiring with single-stent deployment and subsequent kissing balloon inflation in the inadequate jailing of a Kaname stent on the side branch ostium.

BACKGROUND: The aim of the study was to identify differences between proximal and distal cell rewir-ing with subsequent kissing balloon inflation (KBI) in the presence of a link connected to a carina on the jailed side branch ostium (SBO). METHODS: Kaname stents were deployed in bifurcation models (n = 12) with subsequent KBI and were confirmed by optical coherence tomography. The jailing configuration and cell rewiring were completely controlled and classified as follows: FC-Dist, free carina (no links connected to a carina) and distal cell re-wiring; CC-Prox, connected to a carina (the presence of a link connected to a central carina) and proximal cell rewiring; CC-Dist, connected to a carina and distal cell rewiring; and FarDist, far-distal cell rewiring. RESULTS: The number of frames with malapposed struts (MS) in the SBO was significantly smaller in the CC-Prox group than in the CC-Dist group (26.7 ± 1.5 and 39.7 ± 0.6, respectively, p < 0.05). The number of frames with MS continuously present from the distal end to the proximal side of the SBO was significantly smaller in the CC-Prox group than in the CC-Dist group (17.0 ± 2.0 and 36.7 ± ± 5.8, respectively, p < 0.05). The ratio of the maximal opened stent cell area to the SBO area was significantly larger in the CC-Prox group than in the CC-Dist group (64.2 ± 1.2% and 38.8 ± 5.6%, respectively, p < 0.05). CONCLUSIONS: This study showed that in cases with a link connected to a carina, fewer malapposed struts may be present in proximal cell rewiring with subsequent KBI than in distal cell rewiring.