Improvement of angiographic and clinical outcomes of percutaneous coronary intervention for chronic total occlusion after implementation of a dedicated team: a single-centre experience.

INTRODUCTION: In a Dutch heart centre, a dedicated chronic total occlusion (CTO) team was implemented in June 2017. The aim of this study was to the evaluate treatment success and clinical outcomes before and after this implementation. METHODS: A total of 662 patients who underwent percutaneous coronary intervention (PCI) for a CTO between January 2013 and June 2020 were included and divided into pre- and post-CTO team groups. The primary endpoint was the angiographic success rate of CTO-PCI. Secondary endpoints included angiographic success stratified by complexity using the J­CTO score and the following clinical outcomes: in-hospital complications and myocardial infarction, target vessel revascularisation, all-cause mortality, quality of life (QoL) and major adverse cardiac events (MACE) at 30-day and 1­year follow-up. RESULTS: Compared with the pre-CTO team group, the success rate in the post-CTO team group was higher after the first attempt (81.4% vs 62.7%; p < 0.001) and final attempt (86.7% vs 73.8%; p = 0.001). This was mainly driven by higher success rates for difficult and very difficult CTO lesions according to the J­CTO score. The MACE rate at 1 year was lower in the post-CTO team group than in the pre-CTO team group (6.4% vs 16.0%; p < 0.01), while it was comparable at 30-day follow-up (0.1% vs 1.7%; p = 0.74). Angina symptoms were significantly reduced at 30-day and 1­year follow-up, and QoL scores were higher after 1 year. CONCLUSION: This study demonstrated higher success rates of CTO-PCI and improved clinical outcomes and QoL at 1­year follow-up after implementation of a dedicated CTO team using the hybrid algorithm.

2020 ESC Guidelines on acute coronary syndrome without ST-segment elevation : Recommendations and critical appraisal from the Dutch ACS and Interventional Cardiology working groups.

Recently, the European Society of Cardiology (ESC) has updated its guidelines for the management of patients with acute coronary syndrome (ACS) without ST-segment elevation. The current consensus document of the Dutch ACS working group and the Working Group of Interventional Cardiology of the Netherlands Society of Cardiology aims to put the 2020 ESC Guidelines into the Dutch perspective and to provide practical recommendations for Dutch cardiologists, focusing on antiplatelet therapy, risk assessment and criteria for invasive strategy.

Development and first results of a dedicated chronic total occlusion programme.

OBJECTIVE: To describe the development and first results of a dedicated chronic total occlusion (CTO) programme in a tertiary medical centre. BACKGROUND: Because of the complexity and the increased risk of complications during percutaneous coronary intervention (PCI) for CTO, it is essential that less experienced and evolving CTO centres perform regular quality analyses. METHODS: We therefore performed analyses to describe the results during the first 3 years of a dedicated CTO programme at a high-volume PCI centre. In addition, we discuss the strategies employed to develop such a programme. RESULTS: A total of 179 consecutive patients undergoing 187 CTO procedures were included in the study. The complexity of the CTO lesions increased from a mean J­CTO (Japanese Multicentre CTO Registry) score of 1.3 in 2015 to 2.1 in 2017. In the majority of cases, the antegrade wire escalation technique was performed. Final technical success rate was 78.5% in 175 patients with a single CTO and 80.2% of all 187 CTO procedures. No peri-procedural or in-hospital deaths occurred. One peri-procedural myocardial infarction occurred. Cardiac tamponade occurred in 2 cases, both managed by pericardiocentesis. No urgent cardiac surgery was necessary. Survival and revascularisation rates at 30 days and 1 year were excellent. CONCLUSION: Following initiation of a dedicated CTO programme, using up-to-date techniques and strategies, procedural and clinical outcome were comparable with current standards in established centres.

Coronary physiology before and after chronic total occlusion treatment: what does it tell us?

Studies performed in the last two decades demonstrate that after successful percutaneous coronary intervention (PCI) of a chronically occluded coronary artery, the physiology of the chronic total occlusion (CTO) vessel and dependent microvasculature does not normalise immediately but improves significantly over time. Generally, there is an increase in fractional flow reserve (FFR) in the CTO artery, a decrease in collateral blood supply and an increase in FFR in the donor artery accompanied by an increase in blood flow and decrease in microvascular resistance in the myocardium supplied by the CTO vessel. Analogous to these physiological changes, positive remodelling of the distal CTO artery also occurs over time, and intravascular imaging can be helpful for analysing distal vessel parameters. Follow-up coronary angiography with physiological measurements after several weeks to months can be helpful and informative in a subset of patients in order to decide upon the necessity for treatment of residual coronary artery stenosis in the vessel distal to the CTO or in the contralateral donor artery, as well as in deciding whether stent optimisation is indicated. We suggest that such physiological guidance of CTO procedures avoids unnecessary overtreatment during the initial procedure, guides interventions at follow-up, and improves our understanding of what PCI in CTO means.

Thrombus Aspiration during Percutaneous coronary intervention in Acute non-ST-elevation myocardial infarction Study (TAPAS II)-Study design.

Background and Objective. The Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) has shown that thrombus aspiration improves myocardial perfusion and clinical outcome compared with conventional primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction. Impaired myocardial perfusion due to spontaneous or angioplasty-induced embolisation of atherothrombotic material also occurs in patients with non-ST-elevation myocardial infarction (NSTEMI). The aim of this study is to determine whether thrombus aspiration before stent implantation will result in improved myocardial perfusion in patients with NSTEMI compared with conventional PCI.Study design. The study is a single-centre, prospective, randomised trial with blinded evaluation of endpoints. The planned inclusion is 540 patients with acute NSTEMI who are candidates for urgent PCI. Patients are randomised to treatment with manual thrombus aspiration or to conventional PCI. The primary endpoint is the incidence of myocardial blush grade 3 after PCI. Secondary endpoints are coronary angiographic, histopathological, enzymatic, electrocardiographic and clinical outcomes including major adverse events at 30 days and one year.Implications. If thrombus aspiration leads to significant improvement of myocardial perfusion in patients with acute NSTEMI it may become part of the standard interventional approach. (Neth Heart J 2009;17:409-13.).

Incidence, predictors, and outcome of reinfarction and stent thrombosis within one year after primary percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Reinfarction and stent thrombosis are major complications after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). OBJECTIVE: We sought to investigate the incidence, predictors, and outcome of reinfarction and stent thrombosis in a contemporary cohort of STEMI patients. METHODS: Reinfarction and stent thrombosis within 1 year after primary PCI for STEMI were analyzed in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS). RESULTS: Reinfarction was observed in 3.4% (34/995) of patients within 1 year after primary PCI. Angiographic evidence of stent thrombosis was observed in 15/34 (44.1%). During the index primary PCI, intra-aortic balloon counterpulsation was used in 10/32 (31.3%) patients with and 47/900 (5.2%) without reinfarction (P < 0.001). After the index primary PCI, thrombus was visible in 6/34 (17.7%) with reinfarction when compared with that in 25/952 (2.6%) without reinfarction (P < 0.001), and complete ST-segment resolution in 8/33 (24.2%) compared with that in 462/892 (51.8%, P = 0.002). Mortality at 1 year after the index PCI was higher after reinfarction: 6/34 (17.7%) compared with 53/961 (5.5%, P = 0.003). Patients with stent thrombosis showed myocardial blush grade 0-1 in 11/15 (73.3%) cases, distal embolization in 8/15 (53.3%), and a mortality at 1 year of 4/15 (26.7%). CONCLUSIONS: In contemporary practice with primary PCI and triple antiplatelet therapy for STEMI, the incidence of reinfarction is low. Outcome characteristics after the index PCI were important determinants of reinfarction. However, reinfarction was associated with poor prognosis, and in particular patients with stent thrombosis had poor outcome.