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There is limited data on predicting successful chronic total occlusion crossing using primary antegrade wiring (AW). The aim of this study was to develop and validate a machine learning (ML) prognostic model for successful chronic total occlusion crossing using primary AW. We used data from 12,136 primary AW cases performed between 2012 and 2023 at 48 centers in the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) to develop 5 ML models. Hyperparameter tuning was performed for the model with the best performance, and the SHAP (SHapley Additive exPlanations) explainer was implemented to estimate feature importance. Primary AW was successful in 6,965 cases (57.4%). Extreme gradient boosting was the best performing ML model with an average area under the receiver-operating characteristic curve of 0.775 (± 0.010). After hyperparameter tuning, the average area under the receiver-operating characteristic curve of the extreme gradient boosting model was 0.782 in the training set and 0.780 in the testing set. Among the factors examined, occlusion length had the most significant impact on predicting successful primary AW crossing followed by blunt/no stump, presence of interventional collaterals, vessel diameter, and proximal cap ambiguity. In contrast, aorto-ostial lesion location had the least impact on the outcome. A web-based application for predicting successful primary AW wiring crossing is available online (PROGRESS-CTO website) (https://www.progresscto.org/predict-aw-success). We developed an ML model with 14 features and high predictive capacity for successful primary AW in chronic total occlusion percutaneous coronary intervention. [Display omitted] [ABSTRACT FROM AUTHOR]

The contemporary frequency and outcomes of antegrade dissection and re-entry (ADR) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. The aim of this study was to determine the frequency and outcomes of ADR use in a large multicenter CTO PCI registry. The characteristics and outcomes of ADR were examined among 12,568 patients who underwent 12,841 CTO PCIs at 46 U.S. and non-U.S. centers between 2012 and 2023. ADR was used in 2,385 of the procedures (18.6%). ADR use declined from 37.9% in 2012 to 14.5% in 2022 (P < 0.001). Patients in whom ADR was used had a high prevalence of comorbidities. Compared with cases that did not use ADR, ADR cases had more complex angiographic characteristics, higher mean J-CTO (Multicenter CTO Registry in Japan) score (2.94 ± 1.11 vs 2.23 ± 1.26; P < 0.001), lower technical success (77.0% vs 89.3%; P < 0.001), and higher in-hospital major adverse cardiac events (3.7% vs 1.6%; P < 0.001). The use of the CrossBoss declined from 71% in 2012 to 1.4% in 2022 and was associated with higher technical success (87%) compared with wire-based techniques (73%). The Stingray device displayed higher technical success (86%) compared with subintimal tracking and re-entry (STAR) (74%) and limited antegrade subintimal tracking (78%); however, its use has been decreasing, with STAR becoming the most used re-entry technique in 2022 (44% STAR vs 38% Stingray). The use of ADR has been decreasing. ADR was used in more complex lesions and was associated with lower technical success and higher major adverse cardiac events compared with non-ADR cases. There has been a decrease in Stingray use and an increase in the use of STAR for re-entry. [Display omitted] [ABSTRACT FROM AUTHOR]

Retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with lower success and higher complication rates when compared with the antegrade approach. This study sought to assess contemporary techniques and outcomes of retrograde CTO PCI. We examined the baseline characteristics, procedural techniques and outcomes of 4,058 retrograde CTO PCIs performed at 44 centers between 2012 and 2023. Major adverse cardiac events (MACE) included any of the following in-hospital events: death, myocardial infarction, repeat target vessel revascularization, pericardiocentesis, cardiac surgery, and stroke. The average J-CTO (Multicenter CTO Registry in Japan) score was 3.1 ± 1.1. Retrograde crossing was successful in 60.5% and lesion crossing in 81.6% of cases. The collaterals pathways successfully used were septals in 62.0%, saphenous vein grafts in 17.4%, and epicardials in 19.1%. The technical and procedural success rates were 78.7% and 76.6%, respectively. When retrograde crossing failed, technical success was achieved in 50.3% of cases using the antegrade approach. In-hospital MACE was 3.5%. The clinical coronary perforation rate was 5.8%. The incidence of in-hospital MACE with retrograde true lumen crossing, just marker antegrade crossing, conventional reverse controlled antegrade and retrograde tracking (CART), contemporary reverse CART, extended reverse CART, guide-extension reverse CART, and CART was 2.1%, 0.8%, 5.5%, 3.0%, 2.1%, 3.2%, and 4.1%, respectively; P = 0.01). Retrograde CTO PCI is utilized in highly complex cases and yields moderate success rates with 5.8% perforation and 3.5% periprocedural MACE rates. Among retrograde crossing strategies, retrograde true lumen puncture was the safest. There is need for improvement of the efficacy and safety of retrograde CTO PCI. [Display omitted] [ABSTRACT FROM AUTHOR]

United Network for Organ Sharing (UNOS) allocation criteria changed in 2018. Information about the outcomes of elderly patients in this era is scarce. To assess the impact of the new allocation policy on mortality following heart transplantation among elderly patients. Secondary outcomes included the effect of age ≥70 on post-transplant events, including stroke, dialysis, pacemaker, and rejection requiring treatment. The UNOS Registry was queried to identify patients who solely underwent heart transplantation in the US between 2000 and 2021. Patients were divided into groups according to their age (younger than 70 and under 70 years old or older). The effects of age ≥70 on the follow-up events after transplantation are summarized in Table 1. Patients over 70 were more likely to require dialysis during follow-up, but less likely to experience rejection requiring treatment, compared with patients <70. Age ≥70 in the new allocation system, was a significant predictor of 1-year mortality (adjusted HR: 1.41; 95% CI: 1.05-1.91; p=0.024), but its effect on 5-year mortality was not significant after adjusting for potential confounders (adjusted HR: 1.27; 95% CI: 0.97-1.66; p=0.077). Undergoing transplantation under the new allocation policy vs. the old allocation policy was not a significant predictor of mortality in patients over 70 (Table 2). Age ≥70 is a significant predictor of 1-year mortality following heart transplantation, in the new allocation system. [ABSTRACT FROM AUTHOR]

The 2018 United Network for Organ Sharing (UNOS) allocation system changes resulted in greater recognition of mechanical circulatory support (MCS), leading to more heart transplantation (HTx) in patients with MCS. Purpose: To investigate the effect of the new UNOS allocation system on the need for permanent pacemaker and associated complications following HTx. The UNOS Registry was queried to identify patients that received HTx in the US between 2000 and 2021. The primary objectives were to identify risk factors for the need of pacemaker implantation following HTx. 49,529 HTx patients were identified, 1,421 (2.9%) requiring a pacemaker post-HTx. Patients who required a pacemaker were older (53.9±11.5 vs 52.6±12.8 years, p<0.001), more frequently white (73% vs 67%; p<0.001) and less frequently black (18% vs 20%; p<0.001). In the pacemaker group, UNOS status 1A (46% vs 41%; p<0.001) and 1B (31% vs 27%; p<0.001) were more prevalent and donor age was higher (34.4±12.4 vs 31.8±11.5 years; p<0.001). 1-year survival was not different between groups (HR: 1.08; 95% CI: 0.85, 1.37; p=0.515). An era effect was observed (Per year: OR: 0.97; 95% CI: 0.96, 0.98; p=0.003), while ECMO pre-transplant was associated with lower risk for pacemaker (OR: 0.41; 95% CI: 0.19, 0.86; p<0.001). While associated with various patient and transplant characteristics, pacemaker implantation does not seem to impact one-year survival after HTx. The need for pacemaker implantation was lower in the more recent era and in patients who required ECMO pre-transplant, a finding explained by recent advances in perioperative care. [ABSTRACT FROM AUTHOR]

Heart transplant remains the mainstay of treatment for end stage heart failure not controllable with maximum pharmacotherapy or surgical interventions. One of the main considerations regarding heart transplant is the risk for graft rejection and the need for immunosuppression therapy to mitigate that risk. To assess the impact of the need for immunosuppression for rejection treatment within one year for heart transplantation on mortality. Secondary objectives include risk factors for the need for anti-rejection treatment. The United Network for Organ Sharing (UNOS) Registry was queried to identify patients who solely underwent heart transplant in the US between 2000 and 2021. Patients were divided into two groups according to the need for antirejection treatment within one year from heart transplantation. Patient demographics are summarized in Figure 1. Patients who required treatment for rejection within one year after transplant were younger (49±14 vs 52±14 years, p<0.001) and had higher CPRA value (14±26 vs 11±23, p<0.001) than patients who did not require treatment. Moreover, the majority of the patients who did not require antirejection treatment underwent heart transplantation during the new allocation era, while less than half of the patients who required treatment underwent transplant after the new allocation policy implementation (65% vs 49%, p<0.001). The latter group had higher risk for 10-year mortality (HR: 1.34; 95% CI: 1.29, 1.39, p<0.001; Figure 2), although no difference was noted at the 1-year timepoint. Although medical treatment of acute rejection was associated with similar 1-year mortality with patients who did not require antirejection therapy, 10-year mortality was higher in this patient population. Further studies and newer follow up data are required to investigate the role of antirejection therapy in the heart transplant population. [ABSTRACT FROM AUTHOR]

United Network for Organ Sharing (UNOS) allocation criteria changed in 2018 in order to accommodate the increased prevalence of patients on ventricular assist device as a bridge to heart transplant and prioritize sicker people in anticipation of a heart graft. To assess the impact of the new allocation policy on length of stay following heart transplantation. Secondary outcomes include other risk factors for prolonged hospitalization and its effect on mortality and postoperative complications. The UNOS Registry was queried to identify patients who solely underwent heart transplant in the US between 2000 and 2021. Patients were divided into groups according to their respective length of stay quartile. Patient demographics are summarized in Figure 1. Patients in the 4th quartile of length of stay were more likely to be Status 1A (44% vs 37%, p<0.001), be on a left ventricular assist device (12% vs 9%, p<0.001), extracorporeal membrane oxygenator (5% vs 1%, p<0.001) and have an intra-aortic balloon pump (13% vs 8%, p<0.001) compared to the 1st quartile. Length of stay was longer in the new allocation era (24±25 vs 20±29 days, p<0.001). Prolonged length of stay was also associated with increased 10-year mortality (HR: 1.64; 95% CI: 1.58, 1.70, p<0.001, Figure 2). The longer hospital stay and the associated increased risk for mortality that is being observed in the era after the allocation criteria change reflect the rationale of this shift which was to prioritize heart transplant for sicker patients. Further studies are needed to track the progress of surgical and perioperative management of these studies over time. [ABSTRACT FROM AUTHOR]

Background: Death is a rare but devastating complication of chronic total occlusion (CTO) percutaneous coronary intervention. Methods: We examined the clinical characteristics and procedural outcomes of patients who died periprocedurally in the Prospective Global Registry for the Study of CTO Interventions (PROGRESS-CTO). Results: Of the 12 928 patients who underwent CTO percutaneous coronary intervention between 2012 and 2022, 52 (0.4%) died during the index hospitalization. Patients who died were more likely to have a history of heart failure (43% versus 28%; P =0.023). The J-CTO ([Multicenter CTO Registry of Japan]; 2.8±1.1 versus 2.4±1.3; P =0.019), PROGRESS-CTO mortality (2.6±0.9 versus 1.6±1.1; P <0.001), and PROGRESS-CTO pericardiocentesis (2.9±1.1 versus 1.9±1.3; P <0.001) scores were higher in patients who died. In these patients, the use of left ventricular assist devices was also higher (41% versus 3.5%; P <0.001), and retrograde crossing was more often the first crossing strategy (33% versus 13%; P <0.001). The cause of death was cardiac in 43 patients (83%) and noncardiac in 9 patients (17%). Complications leading to cardiac death were: tamponade in 30 patients (58%), acute myocardial infarction in 9 (17.3%), and cardiac arrest/shock in 4 (7.7%). Noncardiac causes of death were: stroke in 3 (5.8%), renal failure in 2 (3.8%), respiratory distress in 2 (3.8%), and hemorrhagic shock in 2 (3.8%). Conclusions: Approximately 0.4% of patients who underwent CTO percutaneous coronary intervention died during the index hospitalization. The main cause of death was tamponade in 58%. PROGRESS-CTO complication scores might help in risk stratification and procedural planning in patients undergoing CTO percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02061436. [ABSTRACT FROM AUTHOR]

Early diagnosis is crucial for the improvement of outcomes of patients with cardiac amyloidosis (CA). Emerging non-late gadolinium enhancement (LGE) based cardiac magnetic resonance (CMR) parameters may facilitate early identification of CA. We sought to investigate the diagnostic and prognostic value of T1, T2 mapping and extracellular volume (ECV) in CA. This single-center prospective analysis included 88 patients with CA, 33 patients with aortic stenosis (AS) and left ventricular hypertrophy (LVH), and 15 healthy controls who completed 3T cardiac MRI at the time of their diagnosis and were assessed with T1, T2 (modified Look-Locker inversion recovery), and ECV mapping of the heart and spleen. Echocardiographic, and biochemical parameters and clinical characteristics and outcomes were collected and analyzed. Of the patients with CA, 71 had light-chain (AL) and 17 had transthyretin (ATTR) amyloidosis. Native T1, native T2 and ECV were significantly higher in patients with CA compared to both patients with LVH-AS (P <0.001) and healthy controls (P <0.001). Good diagnostic accuracy was also demonstrated by measuring the area under the curve (AUC) of the receiver operating characteristic (ROC) curves for native T1 in the region of interest (ROI) (AUC=0.90), native T2 ROI (AUC=0.88), and ECV (AUC=0.90). Furthermore, native T1 ROI, native T2 ROI and ECV, correlated with both NT-proBNP levels and Mayo stage of patients (with AL). Spleen ECV was significantly increased in patients with AL versus ATTR amyloidosis (38.5 vs 30.5; P =0.004) and demonstrated good diagnostic accuracy in differentiating between the two types (AUC=0.79). Native T2 ROI was prognostic of mortality in AL CAwith a HR of 1.97 per 5 ms increase (P =0.001) and remained prognostic after adjustment for age, and Mayo stage. Non-LGE based CMR techniques correlated with established markers of disease and demonstrated good diagnostic accuracy, while native T2 ROI was also prognostic of mortality, thus reinforcing their use in the diagnosis and prognosis of CA. [ABSTRACT FROM AUTHOR]