Percutaneous coronary intervention before transcatheter aortic valve implantation: A propensity score matched analysis.

BACKGROUND: The role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) who subsequently undergo transcatheter aortic valve replacement (TAVR) remains uncertain. Therefore, we conducted this study to assess the association of PCI before TAVR with mortality and cardiovascular outcomes. METHODS: We used the TriNetX database (Jan 2012 - Aug 2022) and grouped patients into PCI (3 months or less) before TAVR and no PCI. We performed propensity score matched (PSM) analyses for outcomes at 30 days and 1 year. RESULTS: Of 17,120 patients undergoing TAVR, 2322 (14 %) had PCI, and 14,798 (86 %) did not have PCI before TAVR. In the PSM cohort (2026 patients in each group), PCI was not associated with lower all-cause mortality at 30 days (HR: 1.25, 95 % CI: 0.82-1.90) or 1 year (HR: 1.02, 95 % CI: 0.83-1.24). Frequency of repeat PCI after TAVR was low in both no PCI vs. PCI (2.4 % vs. 1.2 %) at 1 year; PCI was associated with a lower rate of repeat PCI (HR: 0.49, 95 % CI: 0.30-0.80). Sensitivity analysis revealed an E-value of 3.5 for repeat PCI (E-value for lower CI for HR: 1.81). PCI was not linked to reductions in MI, heart failure exacerbation, all-cause hospitalization, major bleeding, or permanent pacemaker/implantable cardioverter defibrillator. CONCLUSION: This analysis showed that PCI prior to TAVR was not associated with improvement in all-cause mortality. However, PCI was associated with a reduced rate of repeat PCI at 1 year.

Intravascular imaging guided versus coronary angiography guided percutaneous coronary intervention: systematic review and meta-analysis.

OBJECTIVE: To assess the absolute treatment effects of intravascular imaging guided versus angiography guided percutaneous coronary intervention in patients with coronary artery disease, considering their baseline risk. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed/Medline, Embase, and Cochrane Library databases up to 31 August 2023. STUDY SELECTION: Randomized controlled trials comparing intravascular imaging (intravascular ultrasonography or optical coherence tomography) guided versus coronary angiography guided percutaneous coronary intervention in adults with coronary artery disease. MAIN OUTCOME MEASURES: Random effect meta-analysis and GRADE (grading of recommendations, assessment, development, and evaluation) were used to assess certainty of evidence. Data included rate ratios and absolute risks per 1000 people for cardiac death, myocardial infarction, stent thrombosis, target vessel revascularization, and target lesion revascularization. Absolute risk differences were estimated using SYNTAX risk categories for baseline risks at five years, assuming constant rate ratios across different cardiovascular risk thresholds. RESULTS: In 20 randomized controlled trials (n=11 698), intravascular imaging guided percutaneous coronary intervention was associated with a reduced risk of cardiac death (rate ratio 0.53, 95% confidence interval 0.39 to 0.72), myocardial infarction (0.81, 0.68 to 0.97), stent thrombosis (0.44, 0.27 to 0.72), target vessel revascularization (0.74, 0.61 to 0.89), and target lesion revascularization (0.71, 0.59 to 0.86) but not all cause death (0.81, 0.64 to 1.02). Using SYNTAX risk categories, high certainty evidence showed that from low risk to high risk, intravascular imaging was likely associated with 23 to 64 fewer cardiac deaths, 15 to 19 fewer myocardial infarctions, 9 to 13 fewer stent thrombosis events, 28 to 38 fewer target vessel revascularization events, and 35 to 48 fewer target lesion revascularization events per 1000 people. CONCLUSIONS: Compared with coronary angiography guided percutaneous coronary intervention, intravascular imaging guided percutaneous coronary intervention was associated with significantly reduced cardiac death and cardiovascular outcomes in patients with coronary artery disease. The estimated absolute effects of intravascular imaging guided percutaneous coronary intervention showed a proportional relation with baseline risk, driven by the severity and complexity of coronary artery disease. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023433568.

Outcomes With Intravascular Ultrasound and Optical Coherence Tomography Guidance in Percutaneous Coronary Intervention.

Intracoronary imaging has become an important tool in the treatment of complex lesions with percutaneous coronary intervention (PCI). This retrospective cohort study identified 1,118,475 patients with PCI from the Nationwide Readmissions Database from 2017 to 2019. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) were identified with appropriate International Classification of Diseases, Tenth Revision codes. The primary outcome was major adverse cardiac events. The secondary outcomes include net adverse clinical events (NACEs), all-cause mortality, myocardial infarction (MI) readmission, admission for stroke, and emergency revascularization. The multivariate Cox proportional hazard regression was used to adjust for demographic and co-morbid confounders. Of 1,118,475 PCIs, 86,140 (7.7%) used IVUS guidance and 5,617 (0.5%) used OCT guidance. The median follow-up time was 184 days. The primary outcome of major adverse cardiac events was significantly lower for the IVUS (6.5% vs 7.6%; hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.86 to 0.91, p <0.001) and OCT (4.4% vs 7.6%; HR 0.69, 95% CI 0.61 to 0.79, p <0.001) groups. IVUS was associated with significantly lower rates of NACEs (8.4% vs 9.4%; HR 0.92, 95% CI 0.89 to 0.94, p <0.001), all-cause mortality (3.5% vs 4.3%; HR 0.85, 95% CI 0.82 to 0.88, p <0.001), readmission for MI (2.7% vs 3.0%; HR 0.95, 95% CI 0.91 to 0.99, p = 0.012), and admission for stroke (0.5% vs 0.6%; HR 0.86, 95% CI 0.78 to 0.95, p = 0.002). OCT was associated with significantly lower rates of NACEs (6.6% vs 9.4%; HR 0.81, 95% CI 0.73 to 0.89, p <0.001) and all-cause mortality (1.8% vs 4.3%; HR 0.51, 95% CI 0.42 to 0.63, p <0.001). Emergency revascularization was not significantly different with IVUS guidance. Readmission for MI, stroke, and emergency revascularization were not significantly different with OCT guidance. A subgroup analysis of patients with ST-elevation MI and non-ST-elevation MI showed similar results. In conclusion, the use of IVUS and OCT guidance with PCI were associated with significantly lower rates of morbidity and mortality in real-world practice.

Assessment of Repeat Revascularization in Percutaneous Coronary Intervention Randomized Controlled Trials as a Surrogate for Mortality: A Meta-Regression Analysis.

The association of repeat revascularization after percutaneous coronary intervention (PCI) with mortality is uncertain. To assess the association of repeat revascularization after PCI with mortality in patients with coronary artery disease (CAD). We identified randomized controlled trials comparing PCI with coronary artery bypass graft (CABG) or optimal medical therapy (OMT) using electronic databases through January 1, 2022. We performed a random-effects meta-regression between repeat revascularization rates after PCI (absolute risk difference [%] between PCI and CABG or OMT) with the relative risks (RR) of mortality. We assessed surrogacy of repeat revascularization for mortality using the coefficient of determination (R2), with threshold of 0.80. In 33 trials (21,735 patients), at median follow-up of 4 (2-7) years, repeat revascularization was higher after PCI than CABG [RR: 2.45 (95% confidence interval, 1.99-3.03)], but lower vs OMT [RR: 0.64 (0.46-0.88)]. Overall, meta-regression showed that repeat revascularization rates after PCI had no significant association with all-cause mortality [RR: 1.01 (0.99-1.02); R2=0.10) or cardiovascular mortality [RR: 1.01 (CI: 0.99-1.03); R2=0.09]. In PCI vs CABG (R2=0.0) or PCI vs OMT trials (R2=0.28), repeat revascularization did not meet the threshold for surrogacy for all-cause or cardiovascular mortality (R2=0.0). We observed concordant results for subgroup analyses (enrollment time, follow-up, sample size, risk of bias, stent types, and coronary artery disease), and multivariable analysis adjusted for demographics, comorbidities, risk of bias, MI, and follow-up duration. In summary, this meta-regression did not establish repeat revascularization after PCI as a surrogate for all-cause or cardiovascular mortality.

Impact of adherence to the hybrid algorithm for initial crossing strategy selection in chronic total occlusion percutaneous coronary intervention.

INTRODUCTION AND OBJECTIVES: The hybrid algorithm was designed to assist with initial and subsequent crossing strategy selection in chronic total occlusion (CTO) percutaneous coronary interventions (PCIs). However, the success of the initially selected strategy has received limited study. METHODS: We examined the impact of adherence to the hybrid algorithm recommendation for initial CTO crossing technique selection in 4178 CTO PCIs from a large multicenter registry. RESULTS: The initial crossing strategy was concordant with the hybrid algorithm recommendation in 1833 interventions (44%). Patients in the concordant group had a similar age to those in the discordant group but a lower mean J-CTO score (2.0 ± 1.4 vs 2.8 ± 1.1; P < .01). The concordant group showed higher technical success with the first crossing strategy (68% vs 48%; P < .01) and higher overall technical success (88% vs 83%; P < .01) with no difference in the incidence of in-hospital major adverse events (1.8% vs 2.3%; P = .26). In multivariable analysis, after adjustment for age, prior myocardial infarction, prior PCI, prior coronary artery bypass grafting, J-CTO score, and scheduled CTO PCI, nonadherence to the hybrid algorithm was independently associated with lower technical success of the initial crossing strategy (odds ratio, 0.55; 95% confidence interval, 0.48-0.64; P < .01). CONCLUSIONS: Adherence to the hybrid algorithm for initial crossing strategy selection is associated with higher CTO PCI success but similar in-hospital major adverse cardiac events.

Incidence and influence of posterior capsule striae on the development of posterior capsule opacification after 1-piece hydrophobic acrylic intraocular lens implantation.

PURPOSE: To determine the incidence of intraoperative posterior capsule striae after implantation of a 1-piece hydrophobic acrylic intraocular lens (IOL), study the clinical impact on the patients' vision, and assess whether the presence of posterior capsule striae increases the risk for posterior capsule opacification (PCO). SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Case-control study. METHODS: Part 1 of this study evaluated consecutive adult eyes having cataract surgery performed using standardized techniques with in-the-bag 1-piece hydrophobic acrylic IOL implantation. Posterior capsule striae details were noted at the end of surgery. Part 2 was a case-control study comprising all patients with intraoperative striae and an age- and biometry-matched control group without striae, which was selected on a 1:1 ratio. RESULTS: Intraoperative posterior capsule striae were observed in 68 (13.6%) of 500 eyes. A single stria was seen in 43 eyes [63.2%], and multiple striae were seen in 25 eyes [36.7%]). There was no significant difference in logMAR corrected distance visual acuity at baseline (P=.881) or at 3 years (P=.191) between cases and controls. At 3 years, there was no statistically significant between-group difference in the median Evaluation of Posterior Capsule Opacification score or area values in the capsulorhexis margin (P=.36 and P=.39, respectively) or in the central 3.0 mm optic area (P=.40 and P=.42, respectively). CONCLUSION: The incidence of posterior capsule striae was 13.6%. Intraoperative striae did not influence visual acuity or the development of PCO at the 3-year follow-up.

Posterior capsule opacification in eyes with steroid-induced cataracts: Comparison of early results.

PURPOSE: To evaluate posterior capsule opacification (PCO) development after cataract surgery in eyes with or without a history of steroid use. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Comparative case series. METHODS: This study comprised consecutive patients with a history of steroid intake (oral, inhaled, injectable, or topical) for at least 4 months who developed posterior subcapsular cataract (PSC) (study group) and patients without a history of steroid intake with uncomplicated PSC (control group). Standardized surgery was performed in both groups. Digital retroillumination photographic documentation was performed 1 month and 1 year postoperatively. The digital images were analyzed for PCO using Evaluation of Posterior Capsule Opacification (EPCO) software; the entire intraocular lens (IOL) optic and the central 3.0 mm optic area were evaluated. The EPCO score and EPCO area were determined. RESULTS: One year postoperatively, the mean EPCO score was statistically significantly higher in the study group (n = 30) than in the control group (n = 60) (0.33 ± 0.37 [SD] versus 0.15 ± 0.26), as was the mean EPCO area (0.323 ± 0.36 versus 0.15 ± 0.26) (both P<.04). Within the central 3.0 mm optic area, the mean EPCO scores (0.149 ± 0.309 versus 0.003 ± 0.016 P<.04) and mean EPCO area values (0.149 ± 0.309 versus 0.003 ± 0.016) were statistically significantly higher in the study group (P<.04). CONCLUSION: Steroid-induced PSC was associated with a higher risk for PCO after cataract surgery at the 1-year follow-up. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Management of congenital bilateral subluxated cataract with Cionni ring.

Use of Cionni ring helped in the successful intraocular lens (IOL) implantation in a 30-year-old patient with bilateral congenital subluxated cataracts. The IOL was stable, well-centered without any iridodonesis or pseudophakodonesis.

Corneal endothelial safety of intracameral preservative-free 1% xylocaine.

PURPOSE: To evaluate the effect of intracameral preservative-free 1% xylocaine on the corneal endothelium as an adjuvant to topical anaesthesia during phacoemulsification and Acrysof foldable IOL implantation. MATERIAL & METHODS: This is a prospective, controlled, randomised, double-masked study. 106 patients with soft to moderately dense (Grade 1-3) senile cataract and corneal endothelial cell density of >1500/mm2 were randomised to the xylocaine group (n=53) and control group(n=53). Central endothelial specular microscopy and ultrasound corneal pachymetry were performed preoperatively. On the first postoperative day the eyes were evaluated for corneal oedema and Descemet's folds. Ultrasound corneal pachymetry was performed at 1, 3 and 12 months. Specular microscopy was performed at 3 and 12 months. Cell loss was expressed as a percentage of preoperative cell density. Six patients could not complete one year follow-up. Chi-square and paired t test (2 tail) statistical tests were applied for analysis. RESULTS: Four (7.54%) patients in the xylocaine group and 5 (9.43%) in the control group had a few Descemet's folds associated with mild central stromal oedema. Corneal thickness increased from 549.3micro +/- 37.2micro to 555.5micro +/- 36.5micro in the xylocaine group and from 553.1micro +/- 36.2micro to 559.3micro +/- 40.5micro in the control group at the one-month postoperative visit. Thickness returned to the preoperative level in xylocaine group 549.6micro +/- 34.5micro and control group 554.7micro +/- 41.1micro at three months. (P=0.484) The percentage of cell loss was 4.47 +/- 2.53% in the xylocaine group and 4.49 +/- 3.09% in the control group at one year. (P=0.97) CONCLUSION: Intracameral preservative-free 1% xylocaine does not appear to affect corneal endothelium adversely during phacoemulsification.