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Background: Coronary disease complexity is commonly used to guide revascularization strategy in patients with multivessel disease (MVD)., Objectives: The aim of this study was to assess the interactive effects of coronary complexity on percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) outcomes and identify the optimal threshold at which PCI can be considered a reasonable option., Methods: A total of 1,444 of 1,500 patients with MVD from the FAME (Fractional Flow Reserve versus Angiography for Multi-vessel Evaluation) 3 randomized trial were included in the analysis (710 CABG vs 734 PCI). SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were transformed into restricted cubic splines, and logistic regression models were fitted, with multiplicative interaction terms for revascularization strategy. Optimal thresholds at which PCI is a reasonable alternative to CABG were determined on the basis of Cox regression model performance., Results: The mean SYNTAX score (SS) was 25.9 ± 7.1. SS was associated with 1-year major adverse cardiac and cerebrovascular events among PCI patients and 3-year death, myocardial infarction, and stroke among CABG patients. Significant interactions were present between revascularization strategy and SS for 1- and 3-year composite endpoints (P for interaction <0.05 for all). In Cox regression models, outcomes were comparable between CABG and PCI for the 3-year primary endpoint for SS ≤24 (P = 0.332), with 44% of patients below this threshold and 32% below the conventional SS threshold of ≤22., Conclusions: In patients with MVD without left main disease, PCI and CABG outcomes remain comparable up to SS values in the mid- rather than low 20s, which allows the identification of a greater proportion of patients in whom PCI may be a reasonable alternative to CABG., Competing Interests: Funding Support and Author Disclosures This work was supported by grants from Medtronic and Abbott Vascular. Dr Dawson is supported by the Australian National Health and Medical Research Council and the Australian National Heart Foundation postgraduate scholarships. Dr Kobayashi serves as a consultant for Abbott Vascular. Dr Fearon has received institutional research support from Abbott Vascular, and Medtronic; and has stock options with HeartFlow. Dr De Bruyne has consulting relationships with Boston Scientific, Abbott Vascular, CathWorks, Siemens, and Coroventis Research; has received research grants from Abbott Vascular, Coroventis Research, CathWorks, and Boston Scientific; and holds minor equities in Philips-Volcano, Siemens, GE Healthcare, Edwards Lifesciences, HeartFlow, Sanofi, and Celyad. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Approximately 30% to 50% of patients who are referred for diagnostic coronary angiography are found to have no obstructive coronary artery disease (CAD). Ischemia and nonobstructive coronary arteries (INOCA) is increasingly recognized and encompasses coronary microvascular dysfunction, vasospastic angina, symptomatic myocardial bridging, and other vasomotor disorders. However, the prevalence of these disorders and whether underlying atherosclerotic plaque burden and morphology affect the long-term outcomes of each physiologic phenotype is unknown., Methods: The DISCOVER INOCA registry is ongoing at 8 centers in the United States and plans to enroll 500 patients with ischemic heart disease referred for angiography undergoing coronary function testing (CFT). All participants will complete patient-reported outcome measures and undergo protocol-guided angiography, acetylcholine provocation, coronary thermodilution, and intravascular imaging. Follow-up assessments occur at 30 days, 6 months, 1 year, and annually for 5 years. The primary short-term end point is the prevalence of INOCA phenotypes based on physiology and the degree of atherosclerosis based on intravascular ultrasound or optical coherence tomography (intravascular imaging). The primary long-term end point is the incidence of major adverse cardiovascular events, defined as a composite of cardiovascular death, myocardial infarction, hospitalization for cardiovascular causes, or coronary revascularization at a follow-up of 5 years. At the time of this publication, 100 participants have been enrolled., Conclusions: DISCOVER INOCA is the first prospective study of INOCA patients to integrate anatomic and physiologic measures of disease and correlate them with long-term outcomes. DISCOVER INOCA will report on the prevalence of INOCA phenotypes, the safety of comprehensive invasive CFT, and the impact of testing on diagnoses and medical therapy. Symptoms and cardiovascular adverse events at long-term follow-up will be determined in patients with no obstructive CAD undergoing angiography., (© 2024 The Author(s).)

Background/purpose: It is unclear whether coronary physiology or coronary angiography (CA)-guided strategy is the more preferable approach for deferring percutaneous coronary intervention (PCI). We sought to evaluate the clinical efficacy of various PCI strategies through a network meta-analysis of randomized controlled trials (RCTs)., Methods/materials: We searched multiple databases for RCTs investigating the impact of the following strategies for the purpose of determining whether or not to defer PCI: fractional flow reserve, instantaneous wave-free ratio, quantitative flow ratio (QFR), and CA. We conducted a network meta-analysis for trial-defined major adverse cardiovascular events (MACE), all-cause death, cardiovascular death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis. We performed a subgroup analysis for those with acute coronary syndrome (ACS)., Results: Our search identified 12 eligible RCTs including a total of 13,177 patients. QFR-guided PCI was associated with reduced MACE, MI, and TLR compared with CA-guided PCI (relative risk (RR) 0.68; 95 % confidence interval (CI] [0.49 to 0.94], RR 0.58; 95 % CI [0.36 to 0.96], and RR 0.58; 95 % CI [0.38 to 0.91], respectively). There were no significant differences in any pairs for all-cause death, cardiovascular death, or stent thrombosis. QFR was ranked the best in most outcomes. In the subgroup analysis of the ACS cohort, there were no significant differences in MACE between any comparisons., Conclusions: QFR was associated with reduced MACE, MI, and TLR compared with CA, and ranked the best in most outcomes. However, this was not applied in the ACS cohort., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Nonhyperemic pressure ratios (NHPRs) have been proposed as alternatives to fractional flow reserve (FFR) without induction of hyperemia. More recently, imaging based-FFR estimation, especially coronary angiography-derived FFR (Angio-FFR) measurement, is proposed to estimate wire-based FFR. However, little is known about the diagnostic performance of these indices against conventional FFR., Aims: We aimed to assess and compare the diagnostic performance of both NHPRs and coronary Angio-FFR against wire-based conventional FFR., Methods: PubMed and Embase databases were systematically searched for peer-reviewed original articles up to 08/2022. The primary outcomes were the pooled sensitivity and specificity as well as the area under the curve (AUC) of the summary receiver-operating characteristic curve of those indices., Results: A total of 6693 records were identified after a literature search, including 37 reports for NHPRs and 34 for Angio-FFR. Overall, NHPRs have a lower diagnostic performance in estimating wire-based FFR with an AUC of 0.85 (0.81, 0.88) when compared with Angio-FFR of 0.95 (0.93, 0.97). When all four modalities of NHPRs (iFR, Pd/Pa, DPR, RFR) were compared, those had overlapping AUCs without major differences among each other. Similarly, when the two most commonly used Angio-FFR (QFR, FFR angio ) were compared, those had overlapping AUCs without major differences among each other., Conclusion: Angio-FFR may offer a better estimation of wire-based FFR than NHPRs. Our results support a wider use of Angio-FFR in the cardiac catheterization laboratory to streamline our workflow for coronary physiologic assessment., Classifications: FFR,, stable ischemic disease and non-ST elevation acute coronary syndrome., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The purpose of this study was to characterize Acute Coronary Syndrome (ACS)-associated inflammation by investigating correlates of the neutrophil-to-lymphocyte ratio (NLR), a surrogate marker of inflammation, and its relation to 1-year mortality in a cohort of patients undergoing percutaneous coronary intervention (PCI) for ACS at a single institution., Methods: We performed a single-institution, retrospective, observational study of all-comer ACS patients who underwent PCI and were discharged home before the COVID-19 pandemic between September 23, 2011 and July 31, 2017 for who outcomes data were available., Results: NLR high group tended to be older, white patients, less likely to smoke, more likely to have a history of heart failure and cardiac arrest, higher creatinine values, lower LVEF, and higher CK-MB (a surrogate for infarct size). Linear regression model demonstrated a strong correlation between increasing NLR and white race (B = 1.103, p = 0.001, hemoglobin (B = -0.30, p < 0.001), peak CK-MB (B = 0.004, p = 0.02), LVEF (B = -0.048, p < 0.001), and serum creatinine (B = 0.47, p = 0.03). There were a total of 87 deaths at one year. NLR > 3.4 was associated with worse one-year survival post-PCI (91.4 % vs. 95.4 %, log-rank p < 0.004), which was confirmed on multivariate analysis., Conclusion: Our data confirm the independent prognostic significance of inflammation to mortality after ACS and may provide some insight into the putative benefits of inflammation modulation., Competing Interests: Declaration of competing interest Yuhei Kobayashi serves as a consultant to Abbott Vascular. Manish Parikh serves on the advisory boards of Abbott Vascular, Boston Scientific, and Medtronic., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest Yuhei Kobayashi serves as a consultant to Abbott Vascular. Manish Parikh serves on the advisory boards of Abbott Vascular, Boston Scientific, and Medtronic.

Fractional flow reserve (FFR) has become the gold standard for invasively assessing the functional significance of coronary artery disease (CAD) to guide revascularization. The amount of evidence supporting the role of FFR in the cardiac catheterization laboratory is large and still growing. However, FFR uptake in the daily practice is limited by a variety of factors such as invasive instrumentation of the coronary artery that requires extra time and need for vasodilator medications for hyperemia. In this review, we describe the details of wire-based alternatives to FFR, providing insights as to their development, clinical evidence, and limitations., Competing Interests: Disclosure M.A. Parikh serves on the advisory boards of Abbott Vascular, Boston Scientific, and Medtronic. Y. Kobayashi serves as a consultant for Abbott Vascular. Others have no conflict of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The impact of donor transmitted atherosclerosis as assessed by intravascular ultrasound on development and progression of cardiac allograft vasculopathy (CAV) after heart transplantation (HT) remains poorly defined in contemporary practice. In this exploratory analysis, we sought to assess the prognostic role of early qualitative assessment of donor artery morphology using optical coherence tomography (OCT) as a more sensitive imaging modality., Methods: HT recipients were prospectively enrolled for baseline OCT imaging of the left anterior descending coronary artery. OCT findings were classified as normal, homogeneous intimal thickening, and advanced plaque characteristics. The endpoint was a composite of cardiac death, myocardial infarction, or new angiographically detectable CAV stratified by the International Society of Heart and Lung Transplantation criteria up to 4 years of follow-up., Results: A total of 35 patients underwent baseline OCT of whom 51.4% had normal OCT, 14.3% had homogenous plaque, and 34.3% had advanced characteristics. There were no significant differences in baseline demographics between patients with and without normal morphology. During a mean follow-up of 3.3 ± 0.4 years, the endpoint occurred in 11 patients including 1 death, 7 CAV 1 , 3 CAV 2 , and 1 CAV 3 . Kaplan-Meier analysis revealed a significantly higher event rate in patients with advanced characteristics (log-rank p = 0.010). In multivariate analysis, OCT-based plaque morphology was an independent predictor of clinical events (adjusted hazard ratio 4.57, 95% confidence interval 1.50-13.92, p = 0.008) while maximal intimal thickness ≥0.5 mm was not., Conclusions: Early qualitative OCT assessment of donor coronary artery morphology appears to be a reliable marker for predicting future cardiovascular events in HT recipients. Our findings warrant more careful study in a larger cohort., Competing Interests: Disclosure statement Y.K. and U.P.J. have served as a consultant to Abbott Vascular Inc. No other authors have a financial conflict of interest related to this research., (Copyright © 2023 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest YK serves as a consultant to Abbott Vascular. SL is an employee of Abbott Vascular. Rest of the authors have nothing to disclose.

Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed., Competing Interests: Funding Support and Author Disclosures Dr Samuels has served as a consultant and on a Speakers Bureau for Abbott Vascular and Philips. Dr Shah has received research support from Abbott Vascular and the Food and Drug Administration of the U.S. Department of Health and Human Services. Dr Widmer has served on advisory boards for Abbott Vascular, Philips, and Medtronic; and has received research support from Cardiol Therapeutics. Dr Kobayashi has served as a consultant for Abbott Vascular. Dr Miner has received investigator-initiated research support from Abbott Vascular. Dr Jeremias has served as a consultant for Philips, Abbott Vascular, ACIST, Neovasc, and CathWorks. Dr Blair has received research support from Abbott Vascular and Philips; and is on a Speakers Bureau for Abbott Vascular. Dr Kearney has served as a consultant for Abbott Vascular, Abiomed, Boston Scientific, CSI, Medtronic, Teleflex, and Philips. Dr Wei has served on an advisory board for Abbott Vascular. Dr Park has received honoraria from Abbott Vascular and CSI. Dr Kesarwani has served as a consultant for Abbott Vascular. Dr Lerman has served on an advisory board for Philips/Volcano. Dr Prasad has served on an advisory board and/or as a consultant for Abbott Vascular, Boston Scientific, Cardiol Therapeutics, Conavi, Chiesi, and Neovasc. Dr Quesada has received partial support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) (award K23HL151867). Dr Reynolds has received research support from Abbott Vascular, Philips, and Siemens. Dr Smilowitz has served on an advisory board for Abbott Vascular; and has received partial support from the National Heart, Lung, and Blood Institute of the NIH (award K23HL150315). Dr Sutton has received honoraria for speaking or consulting from Abbott, Philips, Zoll, and Shockwave. Dr Sweeny has received honoraria from Abbott Vascular. Dr Henry has received research support and honoraria from Neovasc. Dr Moses has served as a consultant for Covanos; and has held equity in Orchestra BioMed and Covanos. Dr Fearon has received institutional research support from Abbott Vascular, Medtronic, and the NIH (5R33HL139929-05); has served as a consultant for CathWorks and Siemens; and has held stock options with HeartFlow. Dr Tremmel has received honoraria from and served on advisory boards for Abbott Vascular; has received honoraria and research funding from Boston Scientific; and has received honoraria from Shockwave. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Centers specializing in coronary function testing are critical to ensure a systematic approach to the diagnosis and treatment of angina with nonobstructive coronary arteries (ANOCA). Management leveraging lifestyle, pharmacology, and device-based therapeutic options for ANOCA can improve angina burden and quality of life in affected patients. Multidisciplinary care teams that can tailor and titrate therapies based on individual patient needs are critical to the success of comprehensive programs. As coronary function testing for ANOCA is more widely adopted, collaborative research initiatives will be fundamental to improve ANOCA care. These efforts will require standardized symptom assessments and data collection, which will propel future large-scale clinical trials., Competing Interests: Funding Support and Author Disclosures Dr Smilowitz has served on an advisory board for Abbott Vascular and is supported, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K23HL150315. Dr Prasad has served on an advisory board and/or as a consultant for Abbott Vascular, Boston Scientific, Cardinol, CONAVI, Chiesi, and Neovasc. Dr Widmer has served on advisory boards for Abbott Vascular, Philips, and Medtronic; and has received research support from Cardiol Therapeutics. Dr Quesada is supported, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K23HL151867. Dr Sutton has received honoraria for speaking or consulting from Abbott, Philips, Zoll, and Shockwave. Dr Lerman has served on an advisory board for Philips/Volcano. Dr Reynolds has received research support from Abbott Vascular, Philips, and Siemens. Dr Kesarwani has a consulting agreement with Abbott Vascular. Dr Sweeny has received honoraria from Abbott Vascular. Dr Park has received honoraria from Abbott Vascular and CSI. Dr Blair has received research support from Abbott Vascular and Philips; and is on a Speakers Bureau for Abbott Vascular. Dr Jeremias has consulting agreements with Philips, Abbott Vascular, ACIST, Neovasc, and CathWorks. Dr Kearney has consulting agreements with Abbott Vascular, Abiomed, Boston Scientific, CSI, Medtronic, Teleflex, and Philips. Dr Kobayashi has a consulting agreement with Abbott Vascular. Dr Miner has received investigator-initiated research support from Abbott Vascular. Dr Samuels has served as a consultant and has served on a Speaker’s Bureau for Abbott Vascular and Philips. Dr Shah has received research support from Abbott Vascular and the FDA of the U.S. Department of Health and Human Services (HHS). Dr Wei has served on an advisory board for Abbott Vascular. Dr Fearon has received institutional research support from Abbott Vascular, Medtronic, and the NIH (5R33HL139929-05); has a consulting agreement with CathWorks and Siemens; and has stock options with HeartFlow. Dr Henry has received research support and honoraria from Neovasc. Dr Moses has served as a consultant for Covanos; and has equity in Orchestra BioMed and Covanos. Dr Tremmel has received honoraria from and served on advisory boards for Abbott Vascular; has received honoraria and research funding from Boston Scientific; and has received honoraria from Shockwave. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Background: Previous studies comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary disease not involving the left main have shown significantly lower rates of death, myocardial infarction (MI), or stroke after CABG. These studies did not routinely use current-generation drug-eluting stents or fractional flow reserve (FFR) to guide PCI., Methods: FAME 3 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) is an investigator-initiated, multicenter, international, randomized trial involving patients with 3-vessel coronary artery disease (not involving the left main coronary artery) in 48 centers worldwide. Patients were randomly assigned to receive FFR-guided PCI using zotarolimus drug-eluting stents or CABG. The prespecified key secondary end point of the trial reported here is the 3-year incidence of the composite of death, MI, or stroke., Results: A total of 1500 patients were randomized to FFR-guided PCI or CABG. Follow-up was achieved in >96% of patients in both groups. There was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI compared with CABG (12.0% versus 9.2%; hazard ratio [HR], 1.3 [95% CI, 0.98-1.83]; P =0.07). The rates of death (4.1% versus 3.9%; HR, 1.0 [95% CI, 0.6-1.7]; P =0.88) and stroke (1.6% versus 2.0%; HR, 0.8 [95% CI, 0.4-1.7]; P =0.56) were not different. MI occurred more frequently after PCI (7.0% versus 4.2%; HR, 1.7 [95% CI, 1.1-2.7]; P =0.02)., Conclusions: At 3-year follow-up, there was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI with current-generation drug-eluting stents compared with CABG. There was a higher incidence of MI after PCI compared with CABG, with no difference in death or stroke. These results provide contemporary data to allow improved shared decision-making between physicians and patients with 3-vessel coronary artery disease., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT02100722., Competing Interests: Disclosures Dr Pijls receives research funding from Abbott, has consulting relationships with Abbott and Opsens, and has stock or stock options with ASML, General Electric, HeartFlow, Hexacath, and Philips. Dr Mansour has consulting relationships with Abbott Vascular, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Novartis, Pfizer, and Servier Affaires, and received a research grant from Opsens Inc and Abbott Vascular. Dr Kala has a consulting relationship with Boston Scientific, Medtronic, and Servier Affaires, and receives honoraria from AstraZeneca and Bayer. Dr Angeras receives research funding from Abbott Vascular and AstraZeneca and has a consulting relationship with Abbott Vascular and Boston Scientific. Dr Miner has a consulting relationship with Abbott, Amgen, Astra Zeneca, Bayer, Boehringer, Novartis, Opsens, Pfizer, and Servier Affaires Medicales. Dr Engstrøm has a consulting relationship with Abbott Vascular, Bayer, and Novo Nordisk. Dr Christiansen has a consulting relationship with Abbott Vascular and has received research grants from Abbott Vascular. Dr Tonino has received research grants from Biosensors and Opsens. Dr Reardon has a consulting relationship with Boston Scientific and W.L. Gore & Associates. Dr Otsuki has received research grants from the Uehara Memorial Foundation, Abbott, Medtronic, Boston Scientific, and Terumo. Dr Kobayashi has a consulting relationship with Abbott Vascular. Dr Hlatky has a consulting relationship with Blue Cross and Blue Shield and research support from HeartFlow. Dr Mahaffey has received research grants or contracts from the American Heart Association, Apple, Inc, Bayer, California Institute Regenerative Medicine, Eidos, Ferring, Gilead, Google (Verily), Idorsia, Johnson & Johnson, Luitpold, PAC-12, Precordior, and Sanifit; has provided consulting or other services for Amgen, Applied Therapeutics, AstraZeneca, Bayer, CSL Behring, Elsevier, FibroGen, Inova, Johnson & Johnson, Lexicon, MyoKardia, Novartis, Novo Nordisk, Otsuka, PhaseBio, Portola, Quidel, Sanofi, and Theravance; and has equity in Precordior. Dr Yeung has a consulting relationship with Medtronic. Dr De Bruyne has an institutional consulting relationship with Boston Scientific, Abbott Vascular, CathWorks, Siemens, GE Healthcare, and Coroventis Research; receives institutional research grants from Abbott Vascular, Coroventis Research, CathWorks, and Boston Scientific; and holds minor equities in Philips, Siemens, GE Healthcare, CathWorks, Edwards Life Sciences, HeartFlow, Opsens, Celyad, Xenter, Medyria, Bayer, and Sanofi. Dr Fearon receives research funding from Abbott, Medtronic, and Boston Scientific and has a consulting relationship with Siemens and CathWorks and stock options with HeartFlow. The other authors report no conflicts of interest.

Background: The functional SYNTAX score (FSS), which incorporates functional information as assessed by fractional flow reserve (FFR), is a better predictor of outcome after percutaneous coronary intervention (PCI) in patients with less complex coronary artery disease (CAD)., Objectives: This study sought to test the prognostic value of the FSS in patients with complex CAD eligible for coronary artery bypass grafting (CABG)., Methods: The FAME 3 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3) trial compared FFR-guided PCI with CABG in patients with angiographic 3-vessel CAD. In this prespecified substudy, the angiographic core laboratory calculated the SYNTAX score (SS) and then the FSS by eliminating lesions that were not significant based on FFR. Outcomes in the PCI patients based on the FSS and the SS were compared to each other and to the patients treated with CABG., Results: The FSS reclassified more than one-quarter of patients from an SS >22 to an FSS ≤22. In the 50% of PCI patients who had an FSS ≤22, the primary endpoint occurred at a similar rate to patients treated with CABG (P = 0.77). The primary endpoint in patients without functionally significant 3-vessel CAD was similar to the CABG group (P = 0.97). The rate of myocardial infarction and revascularization among all deferred lesions was 0.5% and 3.2%, respectively., Conclusions: By measuring the FSS, one can identify 50% of patients who have a similar outcome at 1 year with PCI compared with CABG. Lesions deferred from PCI based on FFR have a low event rate., Competing Interests: Funding Support and Author Disclosures Dr Kobayashi serves as a consultant for Abbott Vascular. Dr Oldroyd serves as a chief medical officer for Biosensors International. Dr Reardon serves as a consultant for Medtronic, Boston Scientific, Abbott, and Gore Medical. De Bruyne has stock or stock options with Edwards LifeSciences, General Electric, HeartFlow, Philips, and Siemens. Dr Pijls has received research funding from Abbott; has consulting relationships with Abbott and Opsens; and has stock or stock options with ASML, General Electric, HeartFlow, Hexacath, and Philips. Dr Fearon has received institutional research support from Abbott Vascular, Boston Scientific, and Medtronic; has a consulting relationship with CathWorks and Siemens; and has stock options with HeartFlow. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures Mr Liu is an employee of Abbott Vascular. Dr Kobayashi serves as a consultant to Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Competing Interests: Funding Support and Author Disclosures Dr Parikh serves on the advisory boards of Abbott Vascular, Boston Scientific, and Medtronic. Dr Kobayashi serves as a consultant to Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Competing Interests: Funding Support and Author Disclosures Dr Parikh serves on the advisory boards of Abbott Vascular, Boston Scientific, and Medtronic. Dr Kobayashi serves as a consultant to Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Fractional flow reserve (FFR) has become the gold standard for invasively assessing the functional significance of coronary artery disease (CAD) to guide revascularization. The amount of evidence supporting the role of FFR in the cardiac catheterization laboratory is large and still growing. However, FFR uptake in the daily practice is limited by a variety of factors such as invasive instrumentation of the coronary artery that requires extra time and need for vasodilator medications for hyperemia. In this review, we describe the details of wire-based alternatives to FFR, providing insights as to their development, clinical evidence, and limitations., Competing Interests: Disclosure M.A. Parikh serves on the advisory boards of Abbott Vascular, Boston Scientific, and Medtronic. Y. Kobayashi serves as a consultant for Abbott Vascular. Others have no conflict of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Transcatheter edge-to-edge repair (TEER) with MitraClip (Abbott, Santa Clara, California) is a frequently chosen method for mitral valve repair for patients at high surgical risk. We investigated the impact of frailty on outcomes of patients who underwent TEER. We reviewed the National Inpatient Sample to identify patients that underwent TEER with MitraClip. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. The primary end point was in-hospital mortality. The secondary end points included blood transfusion, respiratory failure, sepsis, length of stay, and total hospitalization cost. Univariate and multivariate logistic regression analyses were performed to determine any association between frailty and primary or secondary outcomes. From January 2016 to December 2017, 10,055 patients underwent TEER in the United States, and 10.6% of them met the criteria for frailty. The frail group showed increased in-hospital mortality (7.04% vs 1.61%, p &lt;0.001) and respiratory failure (3.75% vs 0.95%, p &lt;0.001). Similarly, the frail group had longer lengths of stay (6 vs 2 days, p &lt;0.001) and higher hospitalization costs ($224.8k vs $180.9k, p &lt;0.001). After multivariable logistic regression analysis, frailty was associated with increased in-hospital mortality (odds ratio [OR] 3.70, 95% confidence interval [CI] 1.91 to 7.18, p &lt;0.001), transfusion (OR 1.85, 95% CI 1.07 to 3.19, p = 0.029), respiratory failure (OR 3.56, 95% CI 1.48 to 8.52, p = 0.005), and sepsis (OR 4.17, 95% CI 1.84 to 9.46, p = 0.001). In conclusion, frailty was present in about 10% of patients who underwent TEER from 2016 to 2017. The presence of frailty was associated with worse in-hospital outcomes and greater resource use., (Copyright © 2022. Published by Elsevier Inc.)

Background: Little is known about the overall diagnostic performance of computational fractional flow reserve (FFR) derived from angiography (Angio-FFR), intravascular ultrasound (IVUS-FFR), and optical coherence tomography (OCT-FFR) to detect hemodynamically significant coronary artery disease. The present study aimed to evaluate the diagnostic performance of those novel physiologic indices using conventional FFR as the gold standard., Methods: PubMed and Embase were searched in September 2021 for a systematic review and meta-analysis of studies assessing the diagnostic performance of invasive imaging-derived FFR. The primary outcomes were the summary sensitivity, specificity, correlation coefficients of each index., Results: A total of 6572 records were initially identified and 49 studies were included in the final analysis (7010 lesions from 36 studies for Angio-FFR, 305 lesions from 5 studies for IVUS-FFR, and 667 lesions from 8 studies for OCT-FFR). Invasive imaging-derived FFR had a high diagnostic performance to detect functionally significant coronary lesions using conventional FFR as the gold standard [Angio-FFR, sensitivity 0.87 (95% CI 0.84-0.89), specificity 0.93 (95% CI 0.910.95); IVUS-FFR, sensitivity 0.90 (95% CI 0.84-0.94), specificity 0.95 (95% CI 0.90-0.98); OCT-FFR, sensitivity 0.85 (95% CI 0.78-0.91), specificity 0.93 (95% CI 0.89-0.95)]. The summary correlation coefficients of Angio-, IVUS-, and OCT-FFRs with wire-based FFR were 0.83 (95% CI 0.80-0.85), 0.85 (95% CI 0.79-0.91), and 0.80 (95% CI 0.74-0.86), respectively., Conclusions: This meta-analysis demonstrated that computational FFR derived from invasive coronary imaging has clinically acceptable diagnostic performances irrespective of modalities, supporting their applicability to clinical practice., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Heterogeneity in diagnostic criteria and provocation protocols has posed challenges in understanding the safety of coronary provocation testing with intracoronary acetylcholine (ACh) for the contemporary diagnosis of epicardial and microvascular spasm., Objectives: We examined the safety of testing and subgroup differences in procedural risks based on ethnicity, diagnostic criteria, and provocation protocols., Methods: PubMed and Embase were searched in November 2021 to identify original articles reporting procedural complications associated with intracoronary ACh administration. The primary outcome was the pooled estimate of the incidence of major complications including death, myocardial infarction, ventricular tachycardia/fibrillation, and shock., Results: A total of 16 studies with 12,585 patients were included in the meta-analysis. The overall pooled estimate of the incidence of major complications was 0.5% (95% CI: 0.0%-1.3%) without any reports of death. Exploratory subgroup analyses revealed that the pooled incidence of major complications was significantly higher in the studies that followed the contemporary diagnosis criteria for epicardial spasm defined as ≥90% diameter reduction (1.0%; 95% CI: 0.3%-2.0%) but significantly lower in Western populations (0.0%; 95% CI: 0.0%-0.45%). The rate of positive epicardial spasm and the incidence of major complications were similar between provocation protocols using the maximum ACh doses of 100 μg and 200 μg., Conclusions: Intracoronary ACh administration for the contemporary diagnosis of epicardial and microvascular spasm is a safe procedure. Moreover, excellent safety records are observed in Western populations primarily presenting with myocardial ischemia and/or infarction with nonobstructive coronary arteries. This study will help standardize ACh testing to improve clinical diagnosis and ensure procedural safety., Competing Interests: Funding Support and Author Disclosures Dr Samuels has a consulting agreement with Abbott Vascular; and serves as a consultant and on the Speakers Bureau for Abbott Vascular and Philips. Dr Parikh has a consulting agreement with Abbott Vascular; and serves on the advisory boards of Abbott Vascular, Boston Scientific, and Medtronic. Dr Wei has a consulting agreement with and serves on the advisory board of Abbott Vascular. Drs Moses, Fearon, Henry, Tremmel, and Kobayashi have consulting agreements with Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

To increase the adsorption capability of Hg 2+ from aqueous media, we prepared sodium-type fine zeolite grains with various particle sizes (denoted as ZE1, ZE2 and ZE3). The particle sizes of ZE1, ZE2 and ZE3 were 16.363 ± 0.365, 1.454 ± 0.357 and 0.607 ± 0.377 μm, respectively. Moreover, the CEC, specific surface area and pore volume were in the order ZE1 (42 mmol/g and 23.5 m 2 /g) < ZE2 (72 mmol/g and 67.1 m 2 /g) < ZE3 (135 mmol/g and 176.6 m 2 /g). Subsequently, the Hg 2+ adsorption capability was investigated. The performance of tested agents on Hg 2+ adsorbed was in the order ZE1 (5.0 mg/g) < ZE2 (9.4 mg/g) < ZE3 (20.2 mg/g). It was concluded that fine crystalline zeolite was important in enhancing the adsorption capability of Hg 2+ . In addition, the mechanism of adsorption of Hg 2+ on the ZE samples was evaluated. Our results suggested that Hg 2+ was exchanged with sodium ions in the interlayers of ZE samples with correlation coefficients of 0.966-0.979. Our findings revealed that these ZE samples constitute potential agents for the adsorption of Hg 2+ from aqueous media.

Background: The Index of Microcirculatory Resistance (IMR), measured with a pressure-thermistor tipped coronary guidewire has been established as a gold standard for coronary microvascular assessment. Angiography-based IMR (angio-IMR) is a novel method to derive IMR without intracoronary instrumentation or the need for adenosine., Methods: PubMed and Embase databases were systemically searched in November 2021 for studies that measured angio-IMR. The primary outcomes were pooled sensitivity and specificity as well as the area under the curve (AUC) of the summary receiver operating characteristic curve using IMR as a reference standard., Results: A total of 129 records were initially identified and 8 studies were included in the final analysis. Overall, 1653 lesions were included in this study, of which 733 were in patients presenting with ST-segment elevation myocardial infarction. Angio-IMR yielded high diagnostic performance predicting wire-based IMR with pooled sensitivity = 0.81 (95% confidence interval: 0.76, 0.85), specificity = 0.80 (0.72, 0.86), and AUC = 0.86 (0.82, 0.88), which was similar irrespective of patient presentation. When the clinical outcome was compared between high versus low angio-IMR in patients presenting with myocardial infarction, high angio-IMR predicted an increased risk of major adverse cardiac events (MACE)., Conclusion: Our study found that coronary angio-IMR has relatively high diagnostic performance as well as prognostic values predicting MACE, supporting its use in clinical practice., (© 2022 Wiley Periodicals LLC.)

Background: Patients with three-vessel coronary artery disease have been found to have better outcomes with coronary-artery bypass grafting (CABG) than with percutaneous coronary intervention (PCI), but studies in which PCI is guided by measurement of fractional flow reserve (FFR) have been lacking., Methods: In this multicenter, international, noninferiority trial, patients with three-vessel coronary artery disease were randomly assigned to undergo CABG or FFR-guided PCI with current-generation zotarolimus-eluting stents. The primary end point was the occurrence within 1 year of a major adverse cardiac or cerebrovascular event, defined as death from any cause, myocardial infarction, stroke, or repeat revascularization. Noninferiority of FFR-guided PCI to CABG was prespecified as an upper boundary of less than 1.65 for the 95% confidence interval of the hazard ratio. Secondary end points included a composite of death, myocardial infarction, or stroke; safety was also assessed., Results: A total of 1500 patients underwent randomization at 48 centers. Patients assigned to undergo PCI received a mean (±SD) of 3.7±1.9 stents, and those assigned to undergo CABG received 3.4±1.0 distal anastomoses. The 1-year incidence of the composite primary end point was 10.6% among patients randomly assigned to undergo FFR-guided PCI and 6.9% among those assigned to undergo CABG (hazard ratio, 1.5; 95% confidence interval [CI], 1.1 to 2.2), findings that were not consistent with noninferiority of FFR-guided PCI (P = 0.35 for noninferiority). The incidence of death, myocardial infarction, or stroke was 7.3% in the FFR-guided PCI group and 5.2% in the CABG group (hazard ratio, 1.4; 95% CI, 0.9 to 2.1). The incidences of major bleeding, arrhythmia, and acute kidney injury were higher in the CABG group than in the FFR-guided PCI group., Conclusions: In patients with three-vessel coronary artery disease, FFR-guided PCI was not found to be noninferior to CABG with respect to the incidence of a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. (Funded by Medtronic and Abbott Vascular; FAME 3 ClinicalTrials.gov number, NCT02100722.)., (Copyright © 2021 Massachusetts Medical Society.)

Coal fly ash (FA) was treated by hydrothermal activation with sodium hydroxide solution at different concentrations to optimize the conversion method. Zeolite of the sodium type is prepared from coal FA by 1, 1.5, and 3 mol/L sodium hydroxide solutions (ZE1, ZE1.5, and ZE3). These adsorbents' morphology, crystal structure, scanning electron microscopy, Fourier transform (FT)-IR spectra, cation exchange capacity (CEC), specific surface area and pore volumes, and pH pzc were determined. An adsorption experiment was performed to evaluate the effects of contact time, pH, temperature, and coexistence. From the results, the values of CEC and specific surface area of prepared samples was in the order ZE3 < ZE1.5 < ZE1. The similar trends were observed in lead ions adsorption. In addition, our obtained data elucidate that the ion exchange with sodium ions in the interlayer ZE1 is one of the adsorption mechanisms of Pb 2+ from water layer. Finally, lead ions adsorbed on ZE1 could be desorbed using a hydrochloric acid solution, showing that ZE1 could be reused as a water purification agent.

Despite the current evidence supporting clinical benefits of fractional flow reserve (FFR), its uptake in the cardiac catheterization laboratory has been slow due to procedural cost and increased time with the need for maximum hyperemia. Recently, novel physiological indices derived from coronary angiography and intracoronary imaging have emerged to overcome issues with a wire-based FFR. Angiography-based FFR can be measured without vessel instrumentation and has shown excellent diagnostic performance using wire-based FFR as the reference standard. Thus, angiography-based FFR may facilitate coronary functional assessment before and after percutaneous coronary intervention (PCI). Angiography-based index of microcirculatory resistance (IMR) is another new computational index for assessing the coronary microcirculation. Although angiography-derived IMR remains in an early phase of development and requires further validation, its less-invasive nature may help broaden the adoption of microvascular functional assessment in various conditions such as myocardial infarction and cardiac allograft vasculopathy. Lastly, computational FFR based on intravascular ultrasound and optical coherence tomography allows detailed lesion assessment from both morphological and functional standpoints. Given a growing interest in physiology-guided PCI optimization strategies, intravascular imaging-based FFR may become the main assessment tool to confirm successful PCI., Competing Interests: Declaration of Competing Interest A.L. has served on Advisory Boards for Medtronic, Boston Scientific, Philips, Canon, CorFlow, and Abbott. Y.K. has served as a consultant to Abbott Vascular Inc. and CONAVI Medical Inc. T.T., K.T., and H.O. have no financial conflict of interest to disclose., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The aim of this study was to evaluate the role of the distance between the aortic valve in projected position to the coronary ostium to determine risk of coronary artery obstruction after transcatheter aortic valve replacement (TAVR)., Methods: An Expected Leaflet-to-ostium Distance (ELOD) was obtained on pre-TAVR planning computed tomography by subtracting leaflet thickness and the distances from the center to the annular rim at annulus level and from the center to the coronary ostium at mid-ostial level. Variables were compared between patients with and without coronary obstruction and the level of association between variables was assessed using log odds ratio (OR)., Results: A total of 177 patients with 353 coronary arteries was analyzed. Mean annulus diameters (22.8 ± 2.8 mm and 23.4 ± 1.0 mm, p > 0.05) and mean sinus of Valsalva (SOV) diameters (31.2 ± 3.6 mm and 31.9 ± 3.6 mm, p > 0.05) were similar between patients with lower and higher coronary heights, respectively. There were three coronary obstruction cases. ELOD ≤ 2 mm in combination with leaflet length longer than mid-ostial height allowed for discrimination of cases with and without coronary obstruction. There was a significant association between coronary obstruction event and ELOD ≤ 2 mm (log OR = 6.180, p < 0.001)., Conclusions: Our study showed that a combination of ELOD < 2 mm and a longer leaflet length than mid-ostial height may be associated with increased risk for coronary obstruction during TAVR., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s).)

With aging society, one of the more challenging obstacles in percutaneous coronary interventions are calcified coronary lesions. Calcified lesions may impede stent delivery, limit balloon and stent expansion, cause uneven drug distribution, and hinder wire advancement. Even in the setting of acceptable procedural success, vessel calcification is independently associated with increased target lesion revascularization rates at follow-up and lower survival rates. In order to effectively manage such lesions, dedicated technologies have been developed. Atherectomy aims at excising tissue and debulking plaques, as well as compressing and reshaping the atheroma, generally referred to as lesion preparation that enables further balloon and/or stent expansion in contemporary clinical practice. In the current review, we will discuss the available methods for atherectomy, including rotational, orbital, and excimer laser coronary atherectomy, as well as intravascular lithotripsy. In addition, we will review the role of imaging in calcified lesions., (Copyright © 2021. Published by Elsevier Inc.)

Background: A large, prospective, multicentre trial recently showed that fractional flow reserve (FFR) derived from coronary angiography (FFRangio) has an accuracy of 92% compared with conventional guidewire-based FFR (FFRwire); however, little is known about whether specific patient/lesion characteristics affect the diagnostic performance., Aims: The primary goal of the present study was to investigate whether specific patient or lesion characteristics such as high body mass index (BMI), presentation with an acute coronary syndrome, or lesion location affect the diagnostic performance of FFRangio in patients enrolled in the FAST-FFR study., Methods: FFRangio was measured in a blinded fashion in 301 patients (319 vessels) who were undergoing FFRwire assessment. Using an FFRwire ≤0.80 as a reference, the diagnostic performance of FFRangio was compared in pre-specified subgroups., Results: The mean FFRwire and FFRangio were 0.81±0.13 and 0.80±0.12. Overall, FFRangio had a sensitivity of 93.5% and specificity of 91.2% for predicting FFRwire. Patient characteristics including age, sex, clinical presentation, body mass index, and diabetes did not affect sensitivity or specificity (p>0.05 for all). Similarly, lesion characteristics including calcification and tortuosity did not affect sensitivity or specificity (p>0.05 for all), nor did lesion location (proximal, middle, versus distal). Sensitivity was equally high across all target vessels, while specificity was highest in the LAD and lower (~85%) in the RCA and LCx (p<0.05)., Conclusions: FFRangio derived from coronary angiography has a high diagnostic performance regardless of patient and most lesion characteristics. The interaction of vessel on the specificity will need to be confirmed in larger cohorts.

In this study, complex nickel-aluminum hydroxides were prepared at different molar ratios (NA12, NA11, NA21, NA31, and NA41), and their adsorption capability on arsenic ions (As(III)) from aqueous media was assessed. The physicochemical properties such as morphology, X-ray diffraction pattern, specific surface area, numbers of hydroxyl groups, and surface pH were investigated. In addition, the effect of contact time, temperature, and pH on the adsorption capability on As(III) was also evaluated. NA41 exerted the highest adsorption capability on As(III) comparable to other prepared adsorbents. However, the specific surface area and numbers of hydroxyl groups did not significantly affect the adsorption capability on As(III). The equilibrium adsorption of As(III) using NA41 was achieved within 24 h, and the obtained results corresponded to a pseudo-second-order model with correlation coefficient value of 0.980. Additionally, the adsorption isotherms were well described by both the Langmuir and Freundlich equations. The optimal pH condition for removal of As(III) using NA41 was found to be approximately 6-8. Finally, the adsorption mechanism of As(III) was assessed by analyzing the binding energy and elemental distribution, which indicated that the electrostatic interaction and ion exchange influenced the adsorption of As(III) under experimental conditions. These results demonstrated the potential candidate of NA41 as an effective adsorbent on As(III) removal from aqueous media.

Background: Patients presenting with acute coronary syndrome (ACS) from left main (LM) disease are at a high risk for mortality despite recent advancement in devices and techniques during percutaneous coronary interventions (PCI). We aimed to evaluate patient characteristics, clinical presentations, and key clinical characteristics associated with adverse in-hospital outcomes among ACS patients undergoing LM-PCI., Methods: We retrospectively identified 280 LM-ACS patients (3.7 %) from 7608 ACS patients in the prospective multicenter Japan Cardiovascular Database-Keio Inter-Hospital Cardiovascular Studies registry from March 2009 to May 2016 and divided them into those with/without PCI/coronary artery bypass grafting. We compared baseline demographics, coronary lesion characteristics, PCI details, and short-term outcomes, including in-hospital mortality and periprocedural complications, between the two groups., Results: Among LM-ACS patients, 38.6 % presented with ST elevation myocardial infarction, 29.6 % with cardiogenic shock (CS), and 15.4 % with cardiac arrest. The observed in-hospital mortality rate was 18.9 % with presence of CS [odds ratio (OR): 10.16, 95 % confidence interval (CI): 4.51-22.91, p<0.001] and absence of prior revascularization (de novo patients; OR: 4.31, 95 % CI: 1.43-12.94, p=0.009) was independently associated with higher incidence of in-hospital mortality. Notably, the observed mortality rate was substantially higher among de novo patients than the predicted mortality rate with a contemporary risk model (observed: 25.1 %; predicted: 11.6 %)., Conclusions: Prior revascularization act as a protective factor among LM-ACS patients in the contemporary era of PCI. Further studies to detect those at higher risk for LM coronary lesion progression are needed to fully implement these findings into clinical practice., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: The safety and efficacy of angiotensin converting enzyme inhibition (ACEI) after heart transplantation (HT) is unknown. This study examined long-term clinical outcomes after ACEI in HT recipients., Methods: The ACEI after HT study was a prospective, randomized trial that tested the efficacy of ACEI with ramipril after HT. In this study, long-term clinical outcomes were assessed in 91 patients randomized to either ramipril or placebo (median, 5.8 years). The primary endpoint was a composite of death, retransplantation, hospitalization for rejection or heart failure, and coronary revascularization., Results: The primary endpoint occurred in 10 of 45 patients (22.2%) in the ramipril group and in 14 of 46 patients (30.4%) in the placebo group (Hazard ratio (HR), 0.68; 95% CI, 0.29-1.51; P = .34). When the analysis was restricted to comparing patients who remained on a renin-angiotensin system inhibitor beyond 1 year with those who did not, there was a trend to improved outcomes (HR, 0.54; 95% CI, 0.22-1.28, P = .16). There was no significant difference in creatinine, blood urea nitrogen, and potassium at 3 years after randomization. The cumulative incidence of the primary endpoint was significantly higher in patients in whom the index of microcirculatory resistance increased from baseline to 1 year compared with those in whom it did not (39.1 vs 17.4%, HR: 3.36; 95% CI, 1.07-12.7; P = .037)., Conclusion: The use of ramipril after HT safely lowers blood pressure and is associated with favorable long-term clinical outcomes. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT01078363., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Intracoronary acetylcholine (Ach) provocation testing is the gold standard for assessing coronary endothelial function. However, dosing regimens of Ach are quite varied in the literature, and there are limited data evaluating the optimal dose. We evaluated the dose-response relationship between Ach and minimal lumen diameter (MLD) by sex and studied whether incremental intracoronary Ach doses given during endothelial function testing improve its diagnostic utility., Methods: We evaluated 65 men and 212 women with angina and no obstructive coronary artery disease who underwent endothelial function testing using the highest tolerable dose of intracoronary Ach, up to 200 μg. Epicardial endothelial dysfunction was defined as a decrease in MLD >20% after intracoronary Ach by quantitative coronary angiography. We used a linear mixed effects model to evaluate the dose-response relationship. Deming regression analysis was done to compare the %MLD constriction after incremental doses of intracoronary Ach., Results: The mean age was 53.5 years. Endothelial dysfunction was present in 186 (68.1%). Among men with endothelial dysfunction, there was a significant decrease in MLD/10 µg of Ach at doses above 50 μg and 100 µg, while this decrease in MLD was not observed in women ( P <0.001). The %MLD constriction at 20 μg versus 50 μg and 50 μg versus 100 μg were not equivalent while the %MLD constriction at 100 μg versus 200 μg were equivalent., Conclusions: Women and men appear to have different responses to Ach during endothelial function testing. In addition to having a greater response to intracoronary Ach at all doses, men also demonstrate an Ach-MLD dose-response relationship with doses up to 200 μg, while women have minimal change in MLD with doses above 50 µg. An incremental dosing regimen during endothelial function testing appears to improve the diagnostic utility of the test and should be adjusted based on the sex of the patient.

Background: Impaired epicardial coronary vasomotion is a potential mechanism of angina and a predictor of adverse cardiovascular outcomes in patients without angiographic evidence of obstructive coronary artery disease (CAD). We sought to evaluate the association of asymmetric dimethylarginine (ADMA)-a marker of nitric oxide-mediated vascular dysfunction-with epicardial coronary vasomotor dysfunction in this select population., Methods: Invasive testing for epicardial vasomotor dysfunction was performed using intracoronary acetylcholine in the left anterior descending coronary artery. Impaired vasomotor response was defined as a luminal constriction of >20% on quantitative coronary angiography. Plasma ADMA levels were measured using high performance liquid chromatography. A robust multivariate linear mixed-effect model approach and Akaike information criterion were used to determine predictors of vasomotor dysfunction., Results: In 191 patients with angina in the absence of obstructive CAD, abnormal epicardial vasomotion was observed in 137 (71.7%) patients. Median ADMA rose as the extent of impairment progressed: none (0.48 [0.44-0.59] μM), any (0.51 [0.46-0.60] μM, p = 0.12), focal (0.54 [0.49,0.61] μM, p = 0.17), and diffuse (0.55 [0.49,0.63] μM, p = 0.02). In unadjusted analysis, ADMA was highly predictive of vasomotor dysfunction (χ 2 =15.1, p = 0.002). Notably, ADMA remained a significant predictor even after adjusting for other factors in the best fit model (χ 2 =10.0, p = 0.02)., Conclusions: ADMA is an independent predictor of epicardial coronary vasomotor dysfunction in patients with angina in the absence of obstructive CAD. These data support a very early mechanistic role of ADMA in the continuum of atherosclerotic heart disease., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The water quality in a river (water environment) is very important for human health and aquatic organisms. In 2015, the highly regarded Water Resources Management Strategy of Thailand was announced by The Ministry of Industry in Thailand. In this study, the water quality of the Ping river in Northern Thailand, including Chiang Mai and Lamphun provinces, was focused on and measured for three different seasons (summer, rainy, and winter seasons). Anions (F - , Cl - , NO 2 - , NO 3 - , and SO 4 2- ) and cations (Na + , Mg 2+ , Si 4+ , S 6+ , K + , and Ca 2+ ) were qualified by an ion chromatograph and an inductively coupled plasma optical emission spectrometry, respectively. The concentration of anions and cations (except for Mg 2+ and Ca 2+ ) in the Ping river at upstream (countryside) locations were lower than that at downstream (closer main city) locations, which indicated that the fertilizers, industrial or household wastewaters had been flowing into the Ping river at downstream locations. Additionally, the concentration of anions and cations in the rainy season was higher than other seasons. The present results provide the water quality of the Ping river which was not yet reported officially by the Thailand government.

In this study, we evaluated the efficiency of fly ash (FA) recycling technology, produced from a coal-fired power plant, with the capability to adsorb cesium ion[Cs(I)] and strontium ion [Sr(II)] from aqueous phase. Zeolite was produced from FA by hydrothermal treatment in an alkaline solution. Zeolite 12, 24, and 48 have a Garronite structure. Moreover, the specific surface area of Zeolite was greater than that of FA. Zeolite 12 demonstrated the adsorption capability of Cs(I) and Sr(II) from aqueous phase. Adsorption isotherms data fitted both the Langmuir equation (correlation coefficient: >0.895) and the Freundlich equation (correlation coefficient: >0.881). In addition, the kinetic data fitted the pseudo-second-order model when compared to the pseudo-first-order model. Cs(I) and Sr(II) were selectively adsorbed by Zeolite 12 in complex solution system. Our findings indicate that Zeolite can be produced from FA by hydrothermal treatment in an alkaline solution and shows the capability to adsorb Cs(I) and Sr(II) from aqueous phase. Therefore, Zeolite can be useful adsorbent for purification in water environments.

Aims: The proximal optimization technique (POT) in coronary bifurcation stenting improves apposition and side-branch obstruction. The POT balloon should be positioned with the distal radio-opaque marker at the carina cut plane. However, the real impact of positioning remains unknown., Methods and Results: Synergy™ stents (Boston Scientific, USA) were implanted on left-main fractal bench models. Initial POT was performed in 3 positions according to distal shoulder position (loss of balloon parallelism) relative to the carina cut plane (n = 5/group): i) "proximal", 1 mm before carina; ii) "medium", just at carina; iii) "distal", 1 mm after carina. Results were quantified on 2D- and 3D-OCT. Compared to implantation, initial POT improved malapposition in all positions ("proximal": 61.5 ± 1.4% vs. 5.1 ± 2.7%; "medium": 60.2 ± 2.4% vs. 1.3 ± 0.6%; "distal": 60.5 ± 2.9% vs. 1.1 ± 1.8%, p < 0.05). However, residual malapposition was greater in "proximal" position (p < 0.05). "Proximal", unlike "medium" or "distal" POT, also failed to improve side-branch obstruction. Conversely, "distal" POT significantly overstretched the main-branch ostium, with stent/artery ratio 1.22 ± 0.04 vs. 1.11 ± 0.07 for "medium" POT (p < 0.05)., Conclusion: Shoulder positioning is essential to optimize the mechanical benefit of POT without main-branch overstretch (too distal position). Experimentally, the best position is just at the carina cut plane ("medium")., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The prognostic impact of coronary microvascular dysfunction after percutaneous coronary intervention (PCI) remains unclear in patients with stable coronary artery disease. This study sought to investigate the prognostic value of microvascular function measured immediately after PCI in patients with stable coronary artery disease., Methods: We enrolled 572 patients with stable coronary artery disease who underwent PCI and elective measurement of the index of microcirculatory resistance (IMR) immediately after PCI from 8 centers in 4 countries. Impaired microvascular function was defined as IMR≥25 (high IMR). Major adverse cardiac events, including death, myocardial infarction (MI) and target vessel revascularization, were evaluated., Results: During a median follow-up duration of 4.0 years, the cumulative major adverse cardiac events rate was significantly higher in the high IMR group (n=66/148) compared with the low IMR group (n=128/424; hazard ratio [HR], 1.56; 95% CI, 1.16-2.105; P =0.001), primarily due to a higher rate of periprocedural MI (HR, 1.59; 95% CI, 1.11-2.28; P =0.004) but also due to higher rates of mortality (HR, 1.59; 95% CI, 0.76-3.35; P =0.22), spontaneous MI (HR, 2.10; 95% CI, 0.67-6.63; P =0.20) and target vessel revascularization (HR, 1.40; 95% CI, 0.77-2.54; P =0.27). Cumulative risk for death, spontaneous MI, and target vessel revascularization was higher in the high IMR group (HR, 1.55; 95% CI, 0.99-2.43; P =0.056), as was death and spontaneous MI alone (HR, 1.79; 95% CI, 0.96-3.36; P =0.065). On multivariable analysis, high IMR post-PCI was an independent predictor of major adverse cardiac events., Conclusions: IMR measured immediately after PCI predicts adverse events in patients with stable coronary artery disease.

Objective: While >20% of patients presenting to the cardiac catheterization laboratory with angina have no obstructive coronary artery disease (CAD), a majority (77%) have an occult coronary abnormality (endothelial dysfunction, microvascular dysfunction (MVD), and/or a myocardial bridge (MB)). There are little data regarding the ability of noninvasive stress testing to identify these occult abnormalities in patients with angina in the absence of obstructive CAD., Methods: We retrospectively evaluated 155 patients (76.7% women) with angina and no obstructive CAD who underwent stress echocardiography and/or electrocardiography before angiography. We evaluated Duke treadmill score, heart rate recovery (HRR), metabolic equivalents, and blood pressure response. During angiography, patients underwent invasive testing for endothelial dysfunction (decrease in epicardial coronary artery diameter >20% after intracoronary acetylcholine), MVD (index of microcirculatory resistance ≥25), and intravascular ultrasound for the presence of an MB., Results: Stress echocardiography and electrocardiography were positive in 58 (43.6%) and 57 (36.7%) patients, respectively. Endothelial dysfunction was present in 96 (64%), MVD in 32 (20.6%), and an MB in 83 (53.9%). On multivariable logistic regression, stress echo was not associated with any abnormality, while stress ECG was associated with endothelial dysfunction. An abnormal HRR was associated with endothelial dysfunction and MVD, but not an MB., Conclusion: Conventional stress testing is insufficient for identifying occult coronary abnormalities that are frequently present in patients with angina in the absence of obstructive CAD. A normal stress test does not rule out a non-obstructive coronary etiology of angina, nor does it negate the need for comprehensive invasive testing., (Copyright © 2018 Elsevier B.V. All rights reserved.)

We hypothesized that the combination of a high neutrophil to lymphocyte ratio (NLR) and mean platelet volume (MPV) would be a stronger predictor of future cardiovascular events after percutaneous coronary intervention (PCI). Both NLR and MPV were measured in 364 consecutive patients undergoing PCI. The primary end point was the incidence of major adverse cardiovascular events (MACEs), including cardiac death, nonfatal myocardial infarction, and stent thrombosis. The median values of NLR and MPV were 2.8 and 8.2 fL, respectively. There were 26 MACEs during a median follow-up duration of 29.3 months. Kaplan-Meier analysis revealed that the higher NLR group had a significantly higher MACE rate than the lower NLR group and that the higher MPV group had a significantly higher MACE rate than the lower MPV group (log-rank: P = .0064 and P = .0004, respectively). The cumulative MACE-free survival can be further stratified by the combination of NLR and MPV. This value was especially useful in patients with acute coronary syndrome (ACS). By multivariate Cox proportional hazards model, the combination of high NLR and high MPV was independently associated with MACE ( P = .026). The combination of a high NLR and high MPV is an independent predictor of MACE after PCI, especially in patients with ACS.