The impact of the bifurcation angle for the Nano-Crush two-stent coronary bifurcation technique on long-term outcomes in a real-world clinical population.

AIM: This study aims to assess the direct impact of bifurcation angle (BA) on immediate procedural outcomes and patient prognosis post-Nano-Crush stenting for coronary bifurcation lesions. METHODS: A retrospective analysis was conducted for all consecutive patients treated with the Nano-Crush technique across two high-volume interventional centers from January 2020 to October 2022. PRIMARY ENDPOINT: comparison of target lesion failure rate in two cohorts based on bifurcation angle (<70° vs. ≥70°), with secondary endpoints including side branch ostium coverage, rate of successful final kissing balloon inflation (FKBI), need for conversion to another technique, and procedure length. RESULTS: Baseline demographics included 71 patients in the BA<70° group and 49 in the BA≥70° group, with well-balanced characteristics. Angiographic characteristics revealed similar trends, including anatomic and morphological lesion characteristics (referencing Syntax score, Medina classification, and presence of calcifications). Both groups predominantly had complex coronary disease, with a baseline mean Syntax score of 24.18 ± 8.19 in the BA<70° group and 23.91 ± 7.29 in the BA≥70° group, respectively. A dedicated debulking device for lesion preparation was used in 25.35 % of patients in the first group and in 28.57 % of patients in the second group. The primary endpoint occurred in 5.63 % of patients in the BA<70° group and in 4.08 % of patients in the BA≥70° group (P = 0.7014) after ≥ 2 years of clinical follow-up. Angiographic success was achieved in 100 % of both groups, with procedural time averaging 74.99 ± 25.55 min in the BA≥70° and 76.94 ± 27.81 min in the BA<70° (P = 0.6922). The rate of successful final kissing balloon inflation was 98.59 % in the BA<70° group and 95.91 % in the BA≥70° group (P = 0.3566). The mean contrast volume was 189.54 ± 73.74 ml in BA<70° and 168.9 ± 62.77 ml in BA≥70° (P = 0.1126). Clinical follow-ups at 30 days and 2 years revealed similar outcomes and complications for each group, as summarized in Table 3. CONCLUSIONS: Our results demonstrate that the bifurcation angle does not significantly impact long-term clinical outcomes or procedural parameters, such as side branch ostium coverage, conversion to a modified DK Crush technique, FKBI success rate, and procedure length. These findings suggest that the Nano-Crush technique can be a viable option for bifurcation lesions, irrespective of the bifurcation angle, achieving optimal side branch ostium coverage while preventing excessive protrusion into the main vessel.

Atrial fibrillation, diabetes and anticoagulation with direct oral anticoagulants: time to reconsider duration of the disease to evaluate the bleeding risk?

Atrial fibrillation and diabetes: time to reconsider duration of the disease to evaluate the bleeding risk? Impact of diabetes status in patients suffering of non-valvular atrial fibrillation requiring anticoagulation have been analysed previously and risk/benefit balance of NOACs have been confirmed in these patients. The implication of that pathology in the evaluation of the thrombotic risk is discussed but more importantly bleeding risk in this growing population is analysed, perhaps neglected until now.

Sudden Cardiac Death Revealed by an Anomalous Origin of the Right Coronary Artery From the Left Sinus of Valsalva.

Aberrant origin of the coronary artery from the opposite sinus of Valsalva is a rare congenital coronary anomaly associated with increased risk of myocardial ischemia and sudden death in young patients. We report a case of resuscitated sudden cardiac death in a patient with an anomalous origin of the right coronary artery, arising from the left sinus of Valsalva and coursing between the ascending aorta and the pulmonary artery. Successfully coronary arterial bypass grafting using the left radial artery was performed. Despite the risk of fatal issue, surgical management of patient with this coronary anomaly still remains controversial.

Outcomes of Patients With Asymptomatic Aortic Stenosis Followed Up in Heart Valve Clinics.

Importance: The natural history and the management of patients with asymptomatic aortic stenosis (AS) have not been fully examined in the current era. Objective: To determine the clinical outcomes of patients with asymptomatic AS using data from the Heart Valve Clinic International Database. Design, Setting, and Participants: This registry was assembled by merging data from prospectively gathered institutional databases from 10 heart valve clinics in Europe, Canada, and the United States. Asymptomatic patients with an aortic valve area of 1.5 cm2 or less and preserved left ventricular ejection fraction (LVEF) greater than 50% at entry were considered for the present analysis. Data were collected from January 2001 to December 2014, and data were analyzed from January 2017 to July 2018. Main Outcomes and Measures: Natural history, need for aortic valve replacement (AVR), and survival of asymptomatic patients with moderate or severe AS at entry followed up in a heart valve clinic. Indications for AVR were based on current guideline recommendations. Results: Of the 1375 patients included in this analysis, 834 (60.7%) were male, and the mean (SD) age was 71 (13) years. A total of 861 patients (62.6%) had severe AS (aortic valve area less than 1.0 cm2). The mean (SD) overall survival during medical management (mean [SD] follow up, 27 [24] months) was 93% (1%), 86% (2%), and 75% (4%) at 2, 4, and 8 years, respectively. A total of 104 patients (7.6%) died under observation, including 57 patients (54.8%) from cardiovascular causes. The crude rate of sudden death was 0.65% over the duration of the study. A total of 542 patients (39.4%) underwent AVR, including 388 patients (71.6%) with severe AS at study entry and 154 (28.4%) with moderate AS at entry who progressed to severe AS. Those with severe AS at entry who underwent AVR did so at a mean (SD) of 14.4 (16.6) months and a median of 8.7 months. The mean (SD) 2-year and 4-year AVR-free survival rates for asymptomatic patients with severe AS at baseline were 54% (2%) and 32% (3%), respectively. In those undergoing AVR, the 30-day postprocedural mortality was 0.9%. In patients with severe AS at entry, peak aortic jet velocity (greater than 5 m/s) and LVEF (less than 60%) were associated with all-cause and cardiovascular mortality without AVR; these factors were also associated with postprocedural mortality in those patients with severe AS at baseline who underwent AVR (surgical AVR in 310 patients; transcatheter AVR in 78 patients). Conclusions and Relevance: In patients with asymptomatic AS followed up in heart valve centers, the risk of sudden death is low, and rates of overall survival are similar to those reported from previous series. Patients with severe AS at baseline and peak aortic jet velocity of 5.0 m/s or greater or LVEF less than 60% have increased risks of all-cause and cardiovascular mortality even after AVR. The potential benefit of early intervention should be considered in these high-risk patients.

Pretreatment with P2Y12 inhibitors and outcome in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention.

AIMS: Preload with clopidogrel, ticagrelor, or prasugrel in the setting of ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) is frequently applied. Limited data are available regarding the outcome impact of pretreatment with these drugs in the real world. METHODS AND RESULTS: The outcome of 760 STEMI patients treated by primary PCI receiving clopidogrel, prasugrel, or ticagrelor (n = 269, 327, 164, respectively) was evaluated. Patients in the clopidogrel group were older, whereas those in the ticagrelor group had less hypertension but were more active smokers. Angiographic characteristics were comparable among the three groups. At 1 month, more events were observed in the clopidogrel group (11.1%) than in the ticagrelor and prasugrel groups (7.1 vs. 5.1%, P = 0.025), whereas the number of events in the ticagrelor and prasugrel groups did not differ. At 1 year, similar differences existed, mainly driven by a higher rate of death (19.5%, P = 0.008) or stent thrombosis (2 vs. 1.3% for ticagrelor, P = 0.132; vs. 0.3% for prasugrel, P = 0.07) in the clopidogrel group. In-hospital and 1-year bleeding rates were similar between groups. CONCLUSION: In real-world practice, pretreatment with prasugrel or ticagrelor in ongoing STEMI treated by primary PCI seems to be a well tolerated alternative strategy compared with clopidogrel but provides superior benefit in terms of outcomes.

Coronary chronic total occlusion intervention: utility or futility.

INTRODUCTION: Despite an incidence of about 18-52% of the patients undergoing coronary angiography, chronic total occlusions (CTO) are rarely revascularised by percutaneous angioplasty (PCI). Nevertheless, current evidence suggests that successful CTO angioplasty improves symptoms, quality of life and long-term survival. During the last decade, the improvement of specific tools and techniques for these complex procedures, and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO angioplasty. Areas covered: This review focuses on the clinical benefits of CTO revascularization and on appropriate patient selection. Expert commentary: Current evidence suggests that successful CTO-PCI improves symptoms, quality of life and long-term survival. During the last years, the improvement of specific techniques for these complex procedures and the increasing experience of operators, have led to the achievement of success and complication rates almost equivalent to non-CTO lesion angioplasty.

[Why to treat a total chronic coronary occlusion?] / Pourquoi traiter une occlusion coronaire totale chronique ?

Despite an incidence of about 15% of the patients undergoing coronary angiography, total chronic occlusions (CTO) are rarely revascularized by percutaneous angioplasty (PCI). Nevertheless, current evidence suggest that successful CTO-PCI improve symptoms, quality of live and long-term survival. During the last years, improvement of specific techniques for these complexes procedures and increasing experience of operators allow actually to obtain success and complications rates almost equivalent to non-CTO lesions angioplasty. This review focus on the clinical benefits of CTO revascularization and on appropriate patient selection.

Bien que présentes chez environ 15% des patients admis pour une coronarographie diagnostique, les occlusions coronaires totales chroniques (CTO) sont très rarement revascularisées par angioplastie percutanée. Pourtant, de nombreux éléments suggèrent que la revascularisation percutanée d'une CTO est associée à une amélioration des symptômes angineux, de la qualité de vie et de la survie à long terme. Ces dernières années, l'amélioration des techniques dédiées à ces procédures complexes et l'expérience croissante des opérateurs ont permis d'obtenir des taux de succès et de complications qui approchent ceux des lésions coronaires non-CTO. Cet article fait le point sur les principaux bénéfices de traiter une CTO et sur la sélection appropriée des patients.

Ratio of high-sensitivity troponin to creatine kinase-MB in takotsubo syndrome.

BACKGROUND: Takotsubo syndrome (TT) and myocardial infarction (MI) share numerous similarities in clinical presentation, ECG modifications and biomarker elevation. We sought to determine whether the ratio of high-sensitivity cardiac troponin T (hs-TnT) to the myocardial fraction of creatine kinase (CKMB) could be a potent discriminator between TT and MI patients. METHODS: We separately present analysis of data from retrospective files and prospectively recruited patients presenting with TT (35 retrospective and 42 prospective), NSTEMI (48 retrospective and 75 prospective) and STEMI (20 retrospective and 39 prospective). We compared ratios of hs-TnT to CKMB on admission to the hospital between TT, NSTEMI and STEMI patients. Receiver operating characteristic (ROC) curves were analysed to determine optimal cut-off values. RESULTS: On admission, hs-TnT/CKMB ratio was significantly higher in TT patients than in NSTEMI and STEMI patients in both the retrospective phase (median and interquartile range, TT 0.024 [0.018-0.047] vs NSTEMI 0.009 [0.006-0.022], p<0.0001; TT vs STEMI 0.011 [0.006-0.016], p=0.0002) and the prospective cohort (median and interquartile range, TT 0.032 [0.018-0.040] vs NSTEMI 0.009 [0.006-0.015], p<0.0001; TT vs STEMI 0.009 [0.005-0.017], p<0.0001). A cut-off hs-TnT/CKMB ratio of 0.015 distinguished TT from MI with a sensitivity of 85.7% and a specificity of 67.6% (AUC 0.796; 95%CI: 0.71-0.89) in the retrospective phase. In the prospective phase, a ratio of 0.017 distinguished TT from MI with a sensitivity of 83.3% and a specificity of 78.1% (AUC 0.88; 95%CI: 0.83-0.94). CONCLUSION: hs-TnT/CKMB ratio is a novel, readily available parameter that could be used alongside clinical risk scores, other biomarkers and ECG findings to discriminate between TT and MI.

Duration of dual anti-platelet therapy - State of the art after the DAPT and PEGASUS-TIMI 54 trials.

Dual anti-platelet therapy is prescribed in the setting of coronary heart disease for the prevention of stent thrombosis and acute thrombotic events. The optimal duration of dual anti-platelet therapy is still under debate as numerous trials have shown non-inferiority of a strategy of early cessation of one of the agents as compared to the standard practice whereas two larger trials have demonstrated benefit of prolonging dual anti-platelet therapy.

Belgium: coronary and structural heart interventions from 2010 to 2015.

In a ranking of the gross domestic product per capita in 2015, Belgium ranked 19th in the world according to the International Monetary Fun1d and the World Bank. It has a Human Development Index of 0.890, in which it is preceded by only 20 other countries in the world. This is, at least in part, due to a well-developed social security system on which all citizens can rely. Over the last 5-10 years, however, this system has come under increasing pressure. This has resulted in insufficient, incomplete and late reimbursement of all technologies that were introduced over the last ten years in the cathlab: intracoronary imaging techniques are not reimbursed at all, and FFR only to a vastly insufficient degree. For several structural heart interventions, a system of limited and incomplete reimbursement has recently been set up, with a requirement to organise these procedures within the frames of hospital networks. Numbers of PCIs have risen by 15% over the last four years, coinciding with an increase in the number of cathlabs by 50%, aiming at better access to primary PCI for STEMI patients. This has also resulted in a decrease in the average procedure volume per centre. Two thirds of PCIs are performed via the radial access. DES penetration has increased to 74%, approaching 100% in some centres, while the uptake of BRS has been very limited so far.

Evaluation of vascular healing of polymer-free sirolimus-eluting stents in native coronary artery stenosis: a serial follow-up at three and six months with optical coherence tomography imaging.

AIMS: Our aim was to assess vascular response after polymer-free sirolimus-eluting stent (SES) implantation by using an optical coherence tomography (OCT)-derived vascular healing score (HS), quantifying the deficiency of healing. METHODS AND RESULTS: In a prospective, multicentre, single-arm, open-label study, OCT examinations were performed at three months in 45 patients (47 lesions). Per protocol, 24 lesions which had not reached adequate vascular healing according to study criteria were scheduled for OCT examination at six months. The HS was calculated at two time points. Serial OCT imaging demonstrated that the proportion of covered stent struts increased from a median of 87.1% at three months to 98.6% at six months (p<0.001). The neointimal thickness increased from a median of 82.8 µm to 112.2 µm (p<0.001), whereas the median percentages of malapposed struts were 0.2% and 0.0% at the two respective time points. Neointimal volume obstruction increased from 6.3% to 12.8%, and the HS decreased from a median of 28.1 at three months to 2.4 at six months. CONCLUSIONS: In patients who had inadequate vascular healing three months after polymer-free SES implantation, serial OCT showed almost complete vascular healing at six months.

Active and total myeloperoxidase in coronary artery disease and relation to clinical instability.

OBJECTIVES: The aim of this study was to evaluate the correlation between serum total and active myeloperoxidase (MPO) levels and the presence of coronary artery disease in consecutive patients evaluated by coronary angiography and to correlate the levels of the enzyme with instability. METHODS AND RESULTS: Prospective analysis of serum samples of patients before coronary angiography. Total and active MPO concentrations were assessed by the sandwich Elisa and SIEFED® methods. Stable and unstable patients were separated into two groups. Differences between groups were analysed using the Student t test, chi square test or Fisher exact test, as appropriate. The relationship between total and active MPO was assessed using linear and curvilinear regression. Two hundred and twenty patients were included (age 66±11 years, 67% male) in the study. Among these, 62% presented significant coronary artery disease. Twenty-four patients (11%) presented unstable coronary syndrome. Mean active and total MPO levels in the population were 50.1±63.5 and 147.6±223.3 ng.mL(-1), respectively. In stable patients, mean active MPO was 47.1±47.9 ng.mL(-1) and in unstable patients 75.1±135.2 ng.mL(­1) (P=0.04). Mean total MPO was 146.3±224.7 ng.mL(-1) in the stable patients and 158.2±215.8 ng.mL(-1) in the unstable patients (P=0.8). Unstable patients had a significantly higher level of active MPO than stable patients but there was no significant difference between unstable and stable patients regarding total MPO. CONCLUSION: A correlation was observed between active MPO and clinical instability but not with total MPO. These results suggest that this marker could be a powerful indicator of instability and could have a prognostic impact.

Platelet reactivity and cardiovascular events after percutaneous coronary intervention in patients with stable coronary artery disease: the Stent Thrombosis In Belgium (STIB) trial.

AIMS: The Stent Thrombosis In Belgium (STIB) trial aimed to determine whether assessing platelet reactivity (PR) in patients with stable coronary artery disease undergoing elective percutaneous coronary intervention (PCI) could predict the risk of ischaemic complications and adverse clinical events up to 30 days post PCI. METHODS AND RESULTS: PR before intervention was determined in 891 patients undergoing PCI for stable angina pectoris. Twelve to 24 hours before PCI, all patients received a 600 mg clopidogrel dose followed by 75 mg daily, and 500 mg of aspirin followed by 80-100 mg daily. Residual PR was assessed by VerifyNow point-of-care aspirin and P2Y12 assay before PCI. "Non-responders" to antiplatelet therapy were defined as aspirin reaction unit (ARU) >550 and as P2Y12 reaction unit (PRU) >230. The endpoint of the study was the composite of periprocedural myonecrosis, stent thrombosis, non-fatal myocardial infarction (MI), stroke and death at 30 days in patients with or without high PR. The endpoint was observed in 180 patients: four deaths, one stroke, 11 Q-wave MI, three non-Q-wave MI and 161 periprocedural myonecroses. At multivariate analysis, the endpoint was predicted by total stent length (OR: 1.020), GFR <60 ml/min (OR: 1.87), history of PCI (OR: 0.58), white blood cell count (OR: 1.95) and diabetes (OR: 1.83). No significant association was found between residual PR and the primary endpoint or any of its components. CONCLUSIONS: PR measured before PCI in stable patients undergoing elective PCI who are preloaded with 500 mg of aspirin and 600 mg of clopidogrel is not predictive of periprocedural myocardial injury or adverse ischaemic complications up to 30 days.