A Visualized Nomogram for Predicting Prognosis in Elderly Patients after Percutaneous Coronary Intervention.

Background: Revascularized patients still experience adverse cardiovascular events. This is particularly true for elderly patients over the age of 65, as they often have more co-morbid vascular conditions. It is important to develop a tool to assist clinicians in comprehensively assessing these patients' prognosis. The objective of this study is to create a comprehensive visual nomogram model combining clinical and physiological assessments to predict outcomes in elderly patients undergoing percutaneous coronary intervention (PCI). Methods: This study is a retrospective investigation of patients who underwent PCI between January 2016 and December 2017. A total of 691 patients with 1461 vessels were randomly divided into a training (n = 483) and a validation set (n = 208). A multivariate Cox regression model was employed using the training set to select variables for constructing a nomogram. The performance of the nomogram was assessed through the receiver operating characteristic curve (ROC) and calibration curves to evaluate its discrimination and predictive accuracy. To further assess the clinical usefulness, Kaplan-Meier curve analysis and landmark analysis were conducted. Results: Independent risk factors, including diabetes mellitus (DM), post-PCI quantitative flow ratio (QFR), previous myocardial infarction (MI), and previous PCI, were contained in the nomogram. The nomogram exhibited a good area under the curve (AUC) ranging from 0.742 to 0.789 in the training set, 0.783 to 0.837 in the validation set, and 0.764 to 0.786 in the entire population. Calibration curves demonstrated a well-fitted curve in all three sets. The Kaplan-Meier curves showed clear separation and the patients with higher scores in the nomogram model exhibited a higher incidence of target vessel revascularization (TVR) (7.99% vs. 1.24% for 2-year, p < 0.001 and 13.54% vs. 2.23% for 5-years, p < 0.001, respectively). Conclusions: This study has developed the visually intuitive nomogram to predict the 2-year and 5-year TVR rates for elderly patients who underwent PCI. This tool provides more accurate and comprehensive healthcare guidance for patients and their physicians.

Postdilatation after stent deployment during primary percutaneous coronary intervention: a systematic review and meta-analysis.

BACKGROUND: The utilization of postdilatation in primary percutaneous coronary intervention (PCI) is feared to induce suboptimal coronary blood flow and compromise the outcome of the patients. This meta-analysis sought to verify whether postdilatation during primary PCI is associated with worse angiographic or long-term clinical outcomes. METHODS: Systematic literature searches were conducted on PubMed, The Cochrane Library, ClinicalTrials.gov, EBSCO, and Europe PMC on 10 March 2024. Eligible studies reporting the outcomes of postdilatation among ST-segment elevation myocardial infarction patients were included. The primary outcome was no-reflow condition during primary PCI based on angiographic finding. The secondary clinical outcome was major adverse cardiovascular events (MACEs) comprising all-cause death, myocardial infarction, target vessel revascularization (TVR), and stent thrombosis. RESULTS: Ten studies were finally included in this meta-analysis encompassing 3280 patients, which was predominantly male (76.6%). Postdilatation was performed in 40.7% cases. Postdilatation was associated with increased risk of no-reflow during primary PCI [Odd Ratio (OR) = 1.33, 95% Confidence Interval (CI): 1.12-1.58; P = .001)]. Conversely, postdilatation had a tendency to reduce MACE (OR = 0.70, 95% CI: 0.51-0.97; P = .03) specifically in terms of TVR (OR = 0.41, 95% CI: 0.22-0.74; P = .003). No significant differences between both groups in relation to mortality (OR = 0.58, 95% CI: 0.32-1.05; P = .07) and myocardial infarction (OR = 1.5, 95% CI: 0.78-2.89; P = .22). CONCLUSIONS: Postdilatation after stent deployment during primary PCI appears to be associated with an increased risk of no-reflow phenomenon after the procedure. Nevertheless, postdilatation strategy has demonstrated a significant reduction in MACE over the course of long-term follow-up. Specifically, postdilatation significantly decreased the occurrence of TVR. Key messages: What is already known on this topic?  Optimizing stent deployment by performing postdilatation during percutaneous coronary intervention (PCI) is essential for long-term clinical outcomes. However, its application during primary PCI is controversial due to the fact that it may provoke distal embolization and worsen coronary blood flow. What this study adds?  In this systematic review and meta-analysis of 10 studies, we confirm that postdilatation during primary PCI is associated with worse coronary blood flow immediately following the procedure. On the contrary, this intervention proves advantageous in improving long-term clinical outcomes, particularly in reducing target vessel revascularization. How this study might affect research, practice, or policy?  Given the mixed impact of postdilatation during primary PCI, this strategy should only be applied selectively. Future research should focus on identifying patients who may benefit from such strategy.

Natural History and Clinical Outcomes After ST-Segment Elevation Myocardial Infarction Without Stent Insertion.

After restoration of coronary perfusion in patients presenting with ST-segment elevation myocardial infarction (STEMI), discrete severe stenotic coronary lesions are not always apparent. There remains ambiguity whether drug-eluting stent (DES) insertion or initial medical management is best practice. We sought to assess short-term clinical outcomes in patients presenting with STEMI without initial stent insertion. Patients who underwent percutaneous coronary intervention for STEMI between 2014 and 2020 were prospectively enrolled and assessed for inclusion. Patients presenting with in-stent restenosis or stent thrombosis, or who did not survive to hospital discharge were excluded. Of 13,871 patients presenting, 456 (3.3%) were treated without initial stenting. These patients were older than those treated with DES (66.1 ± 13.6 vs 62.3 ± 12.4 years, p <0.001), had higher rates of diabetes (23.5% vs 16.0%, p <0.001) and previous revascularization with either percutaneous coronary intervention (14.0% vs 7.3%, p <0.001) or coronary artery bypass graft (3.5% vs 1.8%, p = 0.008). Thirty-day mortality was elevated in patients treated without stenting compared to those receiving DES (4.2% vs 0.9%, p <0.001), as were rates of myocardial infarction (1.3% vs 0.5%, p = 0.026) and major adverse cardiac events (10.5% vs 2.4%, p <0.001). After propensity matching, a trend toward increased mortality remained (4.2% vs 2.0%, p = 0.055). In conclusion, a no-stenting initial strategy, compared with DES insertion, is associated with increased 30-day mortality in those presenting with STEMI without severe stenosis. These data suggest when appropriate, current-generation DES insertion should be undertaken.

Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis.

BACKGROUND: As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD. METHODS: A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries. RESULTS: A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes. CONCLUSIONS: ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.

Impact of Complete or Incomplete Revascularization for Left Main Coronary Disease: The Extended PRECOMBAT Study.

Background: Whether complete revascularization (CR) or incomplete revascularization (IR) may affect long-term outcomes after PCI) and coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease is unclear. Objectives: The authors sought to assess the impact of CR or IR on 10-year outcomes after PCI or CABG for LMCA disease. Methods: In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) 10-year extended study, the authors evaluated the effect of PCI and CABG on long-term outcomes according to completeness of revascularization. The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCE) (composite of mortality from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization). Results: Among 600 randomized patients (PCI, n = 300 and CABG, n = 300), 416 patients (69.3%) had CR and 184 (30.7%) had IR; 68.3% of PCI patients and 70.3% of CABG patients underwent CR, respectively. The 10-year MACCE rates were not significantly different between PCI and CABG among patients with CR (27.8% vs 25.1%, respectively; adjusted HR: 1.19; 95% CI: 0.81-1.73) and among those with IR (31.6% vs 21.3%, respectively; adjusted HR: 1.64; 95% CI: 0.92-2.92) (P for interaction = 0.35). There was also no significant interaction between the status of CR and the relative effect of PCI and CABG on all-cause mortality, serious composite of death, myocardial infarction, or stroke, and repeat revascularization. Conclusions: In this 10-year follow-up of PRECOMBAT, the authors found no significant difference between PCI and CABG in the rates of MACCE and all-cause mortality according to CR or IR status. (Ten-Year Outcomes of PRE-COMBAT Trial [PRECOMBAT], NCT03871127; PREmier of Randomized COMparison of Bypass Surgery Versus AngioplasTy Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT], NCT00422968).

Impact of Insulin-Treated Compared to Non-Insulin-Treated Diabetes Mellitus on Outcome of Percutaneous Coronary Intervention with Drug-Coated Balloons versus Drug-Eluting Stents in De Novo Coronary Artery Disease: The Randomized BASKET-SMALL 2 Trial.

BACKGROUND: We evaluated the outcome of PCI of de novo stenosis with drug-coated balloons (DCB) versus drug-eluting stents (DES) in patients with insulin-treated diabetes mellitus (ITDM) versus non-insulin-treated diabetes mellitus (NITDM). METHODS: Patients were randomized in the BASKET-SMALL 2 trial to DCB or DES and followed over 3 years for MACE (cardiac death, non-fatal myocardial infarction [MI], and target vessel revascularization [TVR]). Outcome in the diabetic subgroup (n = 252) was analyzed with respect to ITDM or NITDM. RESULTS: In NITDM patients (n = 157), rates of MACE (16.7% vs. 21.9%, hazard ratio [HR] 0.68, 95% confidence interval [CI] 0.29-1.58, p = 0.37), death, non-fatal MI, and TVR (8.4% vs. 14.5%, HR 0.30, 95% CI 0.09-1.03, p = 0.057) were similar between DCB and DES. In ITDM patients (n = 95), rates of MACE (DCB 23.4% vs. DES 22.7%, HR 1.12, 95% CI 0.46-2.74, p = 0.81), death, non-fatal MI, and TVR (10.1% vs. 15.7%, HR 0.64, 95% CI 0.18-2.27, p = 0.49) were similar between DCB and DES. TVR was significantly lower with DCB versus DES in all diabetic patients (HR 0.41, 95% CI 0.18-0.95, p = 0.038). CONCLUSIONS: DCB compared to DES for treatment of de novo coronary lesions in diabetic patients was associated with similar rates of MACE and numerically lower need for TVR both for ITDM and NITDM patients.

Analysis of Risk Factors for Major Adverse Cardiovascular Events in Patients with Coronary Stent Restenosis after Revascularization.

Background: To investigate the risk factors for myocardial infarction, recurrent in-stent restenosis (ISR) and target vessel revascularization (TVR) in patients with coronary ISR within 4 years after revascularization. Methods: A total of 1884 patients who were hospitalized at Fuwai Hospital for ISR and successfully treated with coronary intervention between January 2017 and December 2018 were included to determine whether there were myocardial infarction, recurrent ISR, TVR and other major adverse cardiovascular events (MACEs) within 4 years after intervention. The patients were divided into the MACE group (215 patients) and the non-MACE group (1669 patients). The clinical data of patients in the two groups were compared, and the risk factors for postoperative MACEs in the ISR patients were obtained by multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve was used to determine the optimal prediction threshold for postoperative MACEs in ISR patients. The difference in survival curves between the two groups was compared using Kaplan‒Meier survival analysis. Results: The albumin (43.42 ± 4.77 vs. 44.17 ± 4.46, p = 0.021), direct bilirubin (2.5 (2, 3.5) vs. 2.8 (2.07, 3.73), p = 0.036) and free triiodothyronine (FT3) (2.85 ± 0.43 vs. 2.92 ± 0.42, p = 0.019) levels in the MACE group were significantly lower than those in the non-MACE group, and there was a significant negative correlation between albumin and FT3 and MACEs. The results of univariate and multivariate logistic regression analyses revealed that FT3 was an independent predictor of postoperative MACEs in ISR patients (Odds Ratio (OR) = 0.626, 95% CI: 0.429-0.913, p = 0.015). The ROC curve analysis determined that an FT3 value of 2.785 pmol/L was the optimal prediction threshold. According to the threshold, ISR patients were divided into the FT3 < 2.785 group and the FT3 ≥ 2.785 group. The Kaplan‒Meier analysis revealed that the postoperative recurrence rate of MACEs of the FT3 < 2.785 group was substantially greater than that of the FT3 ≥ 2.785 group (Hazard Ratio (HR) = 0.76, 95% CI: 0.58-0.994, p = 0.044). Conclusions: FT3 can be used as an independent predictor of postoperative myocardial infarction, recurrent ISR and TVR in ISR patients. When FT3 is < 2.785 pmol/L, the incidence of postoperative myocardial infarction, recurrent ISR and TVR in ISR patients increases significantly.

Trans-Stent FFR Gradient as a Modifiable Integrant in Predicting Long-Term Target Vessel Failure.

BACKGROUND: Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) is associated with long-term outcomes. Data relating FFR-based trans-stent gradient (TSG) after PCI to long-term outcomes are sparse. OBJECTIVES: The aim of this study was to test whether TSG is associated with adverse events at follow-up after PCI. METHODS: Data were gathered from a prospective registry evaluating 501 vessels in 416 patients with median follow-up period of 596 days. Primary endpoints were: 1) target vessel failure (TVF), including target vessel revascularization, and target vessel myocardial infarction after discharge; and 2) major adverse cardiac events (MACE) including TVF, target vessel revascularization, nontarget vessel MI, cardiac death. RESULTS: After PCI, median post-PCI FFR was 0.86 and median TSG was 0.04. TSG >0.04 was associated with increased rates of TVF (8.7% vs 2.9%; P = 0.014) and MACE (17.8% vs 9.2%; P = 0.02). Post-PCI FFR < 0.86 was associated with increased rates of TVF (6.1% vs 2.2%; P = 0.03) and MACE (16.5% vs 10%; P = 0.036). The vessel subgroup with high TSG and low FFR had significantly higher rates of TVF (10.2%; P = 0.02) and MACE (20.1%; P = 0.049) than vessels with: 1) high TSG and high FFR (TVF, 2.9%; MACE, 9.7%); 2) low TSG and low FFR (TVF, 3.8%; MACE, 11.3%); and 3) low TSG high FFR (TVF, 2.2%; MACE, 7.5%). In multivariate analysis, TSG was independently predictive of TVF. CONCLUSIONS: Higher TSG was an independent predictor of adverse events, particularly TVF, and identified a subgroup of patients at higher risk for poor outcomes. The combination of high TSG and low FFR showed significantly worse outcomes compared with an "ideal result" (high FFR and low TSG). These data support a recommendation to use TSG during FFR evaluation to determine the functional success of PCI.

Modifiers of the Risk of Diabetes for Long-Term Outcomes After Coronary Revascularization: CREDO-Kyoto PCI/CABG Registry.

Background: Diabetes is a well-known risk factor for adverse outcomes after coronary revascularization. Objectives: This study sought to determine high-risk subgroups in whom the excess risks of diabetes relative to nondiabetes are particularly prominent and thus may benefit from more aggressive interventions. Methods: The study population consisted of 39,427 patients (diabetes: n = 15,561; nondiabetes: n = 23,866) who underwent first percutaneous coronary intervention (n = 33,144) or coronary artery bypass graft (n = 6,283) in the pooled CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Graft) registry. The primary outcome measure was major adverse cardiovascular and cerebral endpoints (MACCE), which was defined as a composite of all-cause death, myocardial infarction, and stroke. Results: With median follow-up of 5.6 years, diabetes was associated with significantly higher adjusted risks for MACCE. The excess adjusted risks of diabetes relative to nondiabetes for MACCE increased with younger age (≤64 years: adjusted HR: 1.30; 95% CI: 1.19-1.41; P < 0.001; 64-73 years: adjusted HR: 1.24; 95% CI: 1.16-1.33; P < 0.001; >73 years: adjusted HR: 1.17; 95% CI: 1.10-1.23; P < 0.001; P interaction < 0.001), mainly driven by greater excess adjusted mortality risk of diabetes relative to nondiabetes in younger tertile. No significant interaction was observed between adjusted risk of diabetes relative to nondiabetes for MACCE and other subgroups such as sex, mode of revascularization, and clinical presentation of acute myocardial infarction. Conclusions: The excess risk of diabetes relative to nondiabetes for MACCE was profound in the younger population. This observation suggests more aggressive interventions for secondary prevention in patients with diabetes might be particularly relevant in younger patients.

Comparison of Contemporary Drug-Eluting Stents in Patients Undergoing Complex High-Risk Indicated Procedures.

Background: Limited data are available on the relative performances of diverse contemporary drug-eluting stents (DES) in patients undergoing complex high-risk indicated procedures (CHIP). Objectives: The purpose of this study was to evaluate the comparative effectiveness of contemporary second-generation DES for CHIP patients in "real-world" settings. Methods: Of 28,843 patients enrolled in the IRIS-DES registry, a total of 6,645 patients with CHIP characteristics who received 5 different types of contemporary DES were finally included: 3,752 with cobalt-chromium everolimus-eluting stents (CoCr-EES), 1,258 with Resolute zotarolimus-eluting stents (Re-ZES), 864 with platinum-chromium EES (PtCr-EES), 437 with ultrathin strut biodegradable-polymer sirolimus-eluting stents (UT-SES), and 334 with bioresorbable polymer SES (BP-SES). The primary outcome was target-vessel failure (a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization) at 12 months. Results: At 12 months, the rate of target-vessel failure was highest in the CoCr-EES (7.1%) group; intermediate in the Re-ZES (5.0%), PtCr-EES (4.6%), and BP-SES (4.2%) groups; and lowest in the UT-SES (3.8%) group (overall long-rank P = 0.001). In multiple-treatment propensity-score analysis, the adjusted hazard ratios (HRs) for target-vessel failure were significantly lower in the Re-ZES (HR: 0.71; 95% confidence interval [CI]: 0.52-0.97), the UT-SES (HR: 0.52; 95% CI: 0.29-0.95), and BP-SES (HR: 0.33; 95% CI: 0.16-0.70) groups than in the CoCr-EES group (referent). Conclusions: In this contemporary PCI registry, we observed the differential risks of target-vessel failure according to various types of contemporary DES in patients with CHIP characteristics. However, owing to inherent selection bias, the results should be considered hypothesis-generating, highlighting the need for further randomized trials. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice [IRIS-DES]; NCT01186133).

Comparison of Different Types of Drug-Eluting Stents for De Novo Long Coronary Artery Lesions.

Background: Outcomes of percutaneous coronary intervention for diffuse long lesions remain relatively unfavorable. Prior clinical trials investigated the relative efficacy and safety of different types of drug-eluting stents (DES) in long lesions. Objectives: This study sought to compare the relative performance of different types of DES for de novo long (≥25 mm) coronary artery lesions. Methods: Using a pooled analysis of individual data of 1,450 patients from 3 randomized clinical trials, we compared angiographic and clinical outcomes of 5 different types of DES: 224 patients with cobalt-chromium everolimus-eluting stents (EES), 255 with platinum-chromium EES, 250 with Resolute zotarolimus-eluting stents, 245 with biodegradable polymer biolimus-eluting stents, and 476 with first-generation sirolimus-eluting stents (SES). The primary endpoint was in-segment late lumen loss at 9 months. Results: The primary endpoint was not significantly different between 4 second-generation DES and 1 first-generation SES (0.17 ± 0.41 mm in cobalt-chromium EES; 0.11 ± 0.37 in platinum-chromium EES: 0.14 ± 0.38 in Resolute zotarolimus-eluting stents; 0.14 ± 0.38 in biodegradable polymer biolimus-eluting stents; or 0.10 ± 0.37 in SES, respectively, overall P = 0.38). Also, there were no significant between-group differences with respect to death, myocardial infarction, target-vessel revascularization, or stent thrombosis at 12 months. In the multiple treatment propensity-score analysis, the risk of angiographic and clinical outcomes was also similar among several types of DES. Conclusions: In this patient-level pooled analysis, several second-generation DES showed similar angiographic and clinical outcomes in patients with de novo long coronary lesions. (Percutaneous Treatment of LONG Native Coronary Lesions With Drug-Eluting Stent-III [LONG-DES-III]; NCT01078038; Percutaneous Treatment of LONG Native Coronary Lesions With Drug-Eluting Stent-IV [LONG-DES-IV]; NCT01186094; and Everolimus-eluting [PROMUS-ELEMENT] vs. Biolimus A9-Eluting [NOBORI] Stents for Long-Coronary Lesions [LONG-DES-V]; NCT01186120).

Prognostic Value of Sex After Revascularization for Left Main Coronary Disease: Extended PRECOMBAT Study.

Background: Female subjects have poorer outcomes in left main coronary artery (LMCA) disease compared with male subjects. However, limited information is available on the long-term prognostic impact of sex and sex-treatment interactions in patients with LMCA disease undergoing coronary revascularization. Objectives: The goal of this study was to investigate the long-term effects of sex and related differential outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in LMCA disease. Methods: The extended PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) trial evaluated the >10-year clinical outcomes in patients with LMCA disease randomized to undergo PCI with drug-eluting stents (n = 300) or CABG (n = 300). The primary outcome was major adverse cardiac or cerebrovascular events (MACCE) (composite of death, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) at 10 years. Results: Of the 600 patients, 459 (76.5%) were male. The 10-year rates of MACCE were similar between male and female subjects in the overall cohort (27.3% vs 27.0%; adjusted hazard ratio [aHR]: 1.06; 95% confidence interval [CI]: 0.70-1.59), the PCI arm (30.6% vs 27.1%; aHR: 1.19; 95% CI: 0.69-2.05), and the CABG arm (24.0% vs 26.9%; aHR: 0.93; 95% CI: 0.53-1.62). The 10-year risks for MACCE did not significantly differ between PCI and CABG in both male (aHR: 1.37; 95% CI: 0.95-1.97) and female (aHR: 1.07; 95% CI: 0.56-2.07) subjects. There was no significant sex-treatment interaction regarding the adjusted risk of MACCE at 10 years (P for interaction = 0.52). Conclusions: In this 10-year follow-up of the PRECOMBAT trial, there was no sex-related impact on the long-term risk of MACCE after PCI and CABG for LMCA disease. (Ten-Year Outcomes of PRECOMBAT Trial; NCT03871127).

Risk Burden of Coronary Perforation in Chronic Total Occlusion Recanalization: Latin American CTO Registry Analysis.

Background Coronary perforation is a life-threatening complication of acute percutaneous coronary intervention (PCI) for chronic total occlusions (CTO), but data on midterm outcomes are limited. Methods and Results Data from LATAM (Latin American)-CTO Registry (57 centers; 9 countries) were analyzed. We assessed the risk of 30-day, 1-year major adverse cardiac events of coronary perforation using time-to-event and weighted composite end point analysis having CTO PCI without perforation as comparators. Additionally, we studied the independent predictors of perforation in these patients. Of 2054 patients who underwent CTO PCI between 2015 and 2018, the median Multicenter CTO Registry in Japan and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention-Chronic total occlusions scores were 2.0 (1.0-3.0) and 1.0 (0.0-2.0), respectively. The perforation rate was 3.7%, of which 55% were Ellis class 1. After 1-year coronary perforation had higher major adverse cardiac events rates (24.9% versus 13.3%; P<0.01). Using weighted composite end point, perforation was associated with increased bleeding and ischemic events at 6 months (P=0.04) and 1 year (P<0.01). We found as independent predictors associated with coronary perforation during CTO PCI: maximum activated clotting time (P<0.01), Multicenter CTO Registry in Japan score ≥2 (P=0.05), antegrade knuckle wire (P=0.04), and right coronary artery CTO PCI (P=0.05). Conclusions Coronary perforation was infrequent and associated with anatomical and procedural complexity, resulting in higher risk of hemorrhagic and ischemic events. Landmark and weighted analysis showed a sustained burden of major events between 6 months and 1 year follow-up.

Percutaneous Coronary Intervention With and Without Intravascular Ultrasound for Patients With Complex Lesions: Utilization, Mortality, and Target Vessel Revascularization.

BACKGROUND: Intravascular ultrasound (IVUS) has several benefits during percutaneous coronary interventions (PCIs), including more accurate vessel sizing, improved stent expansion, and better strut apposition. Prior clinical trials have demonstrated a reduction in cardiac events when IVUS is used. However, there is limited information about the utilization of IVUS and the outcomes of IVUS-guided versus angiography-guided PCI in patients with complex lesions in a contemporary population-based setting. METHODS: New York's PCI registry was used to identify 44 305 patients with complex lesions (lesions that complicate stenting or that require multiple stents) undergoing PCI with and without IVUS guidance and discharged between December 1, 2013 and November 30, 2018. Trends and inter-hospital variation in IVUS use were examined. Risk-adjusted mortality and target vessel revascularization were compared. RESULTS: A total of 6174 (13.9%) PCI patients underwent IVUS-guided PCI. The median follow-up period was 2.5 years. The percent of patients with complex lesions who underwent IVUS-guided PCI rose from 13.4% in 2014 to 16.5% in 2018 (P<0.0001 for trend), with the main increases occurring in the last 2 years of the period. Only 31 of 66 hospitals in the study used IVUS for >5% of their study patients. IVUS-guided PCI patients experienced significantly lower mortality (adjusted hazard ratio=0.89 [0.79-0.98] after adjustment using a Cox proportional hazards model, and HR=0.88 [0.78-0.99] for propensity-matched patients). We also found that IVUS-guided PCI patients had a lower rate of target vessel revascularization (adjusted hazard ratio=0.88 [0.80-0.97]) after adjusting using Cox proportional hazards with competing risk of mortality and after propensity matching (0.88 [0.79-0.99]). CONCLUSIONS: Utilization of IVUS for complex lesions has increased but contemporary rates remain low, and there are large inter-hospital variations. The use of IVUS for complex lesions was associated with lower risk of medium-term mortality and target vessel revascularization.

Minimally invasive surgery or stenting for left anterior descending artery disease - meta-analysis.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years' experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.

Target Vessel Versus Complete Revascularization in Non-ST Elevation Myocardial Infarction Without Cardiogenic Shock.

Introduction The role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR. Methods It was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes. Results The mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively. Conclusion CR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.

Outcomes of Patients Undergoing PCI of Ostial Coronary Lesions: A Single-Center Study.

INTRODUCTION: Ostial coronary lesions are a subset of proximal coronary lesions, which are relatively more difficult to treat and were associated with worse clinical outcomes in the early percutaneous coronary intervention (PCI) era. Data regarding the outcomes of ostial lesions' PCI in the contemporary era are lacking. METHODS: We conducted a single-center, all-comer, prospective registry study, enrolling patients undergoing PCI with the use of contemporary drug-eluting stents (DES) between July 2016 and February 2018. Included in the present analysis were only patients treated for proximal lesions. Clinical outcomes were compared between patients undergoing PCI of ostial versus proximal nonostial lesions. The primary endpoint was target vessel revascularization (TVR). Secondary endpoints included target lesion revascularization (TLR) and major cardiovascular adverse events (MACE) at 12 months. RESULTS: A total of 334 (84.7% male, 67.3 ± 10.7 years) patients were included, of which 91 patients were treated for ostial lesions and 243 were treated for proximal nonostial lesions. Baseline and procedural characteristics were similar between the two groups. At 12 months, TVR and TLR were numerically higher among patients undergoing PCI of ostial versus nonostial lesions without reaching statistical significance (5.5% vs. 3.3%; p = 0.35 and 4.4% vs. 2.5%; p = 0.47, respectively). The rate of MACE was similar between the two groups. CONCLUSION: In patients undergoing PCI with the use of contemporary DES, clinical outcomes were similar among patients treated for ostial compared to proximal nonostial lesions. Larger studies are required to further evaluate the performance of contemporary DES in this subset of lesions.

Clinical and angiographic success and safety comparison of coronary intravascular lithotripsy: An updated meta-analysis.

BACKGROUND: Intravascular lithotripsy (IVL) can be used to assist stent deployment in severe coronary artery calcifications (CAC). METHODS: Studies employing IVL for CAC lesions were included. The primary outcomes included clinical and angiographic success. The secondary outcomes, including lumen gain, maximum calcium thickness, and calcium angle at the final angiography site, minimal lumen area site, and minimal stent area site, were analyzed by the random-effects model to calculate the pooled standardized mean difference. Tertiary outcomes included safety event ratios. RESULTS: Seven studies (760 patients) were included. The primary outcomes: pooled clinical and angiographic success event ratio parentage of IVL was 94.4% and 94.8%, respectively. On a random effect model for standard inverse variance for secondary outcomes showed: minimal lumen diameter increase with IVL was 4.68 mm (p-value < 0.0001, 95% CI 1.69-5.32); diameter decrease in the stenotic area after IVL session was -5.23 mm (95 CI -22.6-12.8). At the minimal lumen area (MLA) and final minimal stent area (MSA) sites, mean lumen area gain was 1.42 mm2 (95% CI 1.06-1.63; p < 0.00001) and 1.34 mm2 (95% CI 0.71-1.43; p < 0.00001), respectively. IVL reduced calcium thickness at the MLA site (SMD -0.22; 95% CI -0.40-0.04; P = 0.02); calcium angle was not affected at the MLA site. The tertiary outcomes: most common complication was major adverse cardiovascular events (n = 48/669), and least common complication was abrupt closure of the vessel (n = 1/669). CONCLUSIONS: Evidence suggests that IVL safely and effectively facilitates stent deployment with high angiographic and clinical success rates in treating severely calcified coronary lesions.

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion in prior coronary artery bypass grafting patients.

OBJECTIVE: To compare the clinical characteristics and outcomes in patients with stable angina who have undergone chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in native arteries with or without prior coronary artery bypass grafting (CABG) surgery in a national cohort. BACKGROUND: There are limited data on outcomes of patients presenting with stable angina undergoing CTO PCI with previous CABG. METHODS: We identified 20,081 patients with stable angina who underwent CTO PCI between 2007-2014 in the British Cardiovascular Intervention Society database. Clinical, demographical, procedural and outcome data were analyzed in two groups; group 1-CTO PCI in native arteries without prior CABG (n = 16,848), group 2-CTO PCI in native arteries with prior CABG (n = 3,233). RESULTS: Patients in group 2 were older, had more comorbidities and higher prevalence of severe left ventricular systolic dysfunction. Following multivariable analysis, no significant difference in mortality was observed during index hospital admission (OR:1.33, CI 0.64-2.78, p = .44), at 30-days (OR: 1.28, CI 0.79-2.06, p = .31) and 1 year (OR:1.02, CI 0.87-1.29, p = .87). Odds of in-hospital major adverse cardiovascular events (MACE) (OR:1.01, CI 0.69-1.49, p = .95) and procedural complications (OR:1.02, CI 0.88-1.18, p = .81) were similar between two groups but procedural success rate was lower in group 2 (OR: 0.34, CI 0.31-0.39, p < .001). The adjusted risk of target vessel revascularization (TVR) remained similar between the two groups at 30-days (OR:0.68, CI 0.40-1.16, P-0.16) and at 1 year (OR:1.01, CI 0.83-1.22, P-0.95). CONCLUSION: Patients with prior CABG presenting with stable angina and treated with CTO PCI in native arteries had more co-morbid illnesses but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality, MACE or TVR.

Network Meta-analysis of Trials Comparing Intravascular Ultrasound, Optical Coherence Tomography, and Angiography-Guided Technique for Drug-Eluting Stent Implantation.

Background: The current advances in coronary imaging with the introduction of intravascular ultrasound (IVUS), and more recently, optical coherence tomography (OCT) have overcome the limitations of coronary angiography. Objective: This study aimed to conduct a comprehensive network meta-analysis of randomized clinical trials to report clinical outcomes among patients undergoing drug-eluting stent (DES) implantation either by IVUS- or OCT-guided technique or angiography alone. Methods: PubMed/MEDLINE and EMBASE databases were searched systematically for all relevant published randomized clinical trials from the inception of the respective database to October 15th, 2021. The outcomes of interest assessed in this meta-analysis were major adverse cardiac events, myocardial infarction, target vessel revascularization, all-cause mortality, and cardiovascular mortality. All the endpoints were expressed as odds ratio (OR) with 95% CI. The network diagrams were computed using the OR as an effective measure. All statistical analyses were carried out in R statistical software version 4.0.3. Results: A total of 14 randomized clinical trials were included in our meta-analysis. In patient undergoing DES implantation, angiography alone was associated with higher odds of major adverse cardiac events (OR, 1.62; 95% CI, 1.17-2.24), target vessel revascularization (OR, 1.60; 95% CI, 1.21-2.13) and cardiovascular mortality (OR, 1.97; 95% CI, 1.25-3.11). However, OCT demonstrated similar odds of major adverse cardiac events, cardiovascular mortality, and target vessel revascularization compared with IVUS. The odds of myocardial infarction and all-cause mortality were similar among all the 3 groups. Conclusions: Although angiography alone was associated with worse outcomes than IVUS in a patient undergoing DES implantation, no difference in outcome was noted between patients undergoing DES implantation with OCT compared with IVUS. Advanced intracoronary imaging use should be encouraged to prevent excess mortality and morbidity.