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[Display omitted] [ABSTRACT FROM AUTHOR]

[Display omitted] [ABSTRACT FROM AUTHOR]

Diabetes mellitus is associated with more complex coronary artery diseases. Coronary artery bypass grafting (CABG) is a preferred revascularization strategy over percutaneous coronary intervention (PCI) in diabetics with multivessel coronary artery disease (MVD). This study sought to examine the different prognostic effects of revascularization strategies according to the diabetes status from the randomized BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trial. Patients (n = 880) with MVD were randomly assigned to undergo PCI with an everolimus-eluting stent vs CABG stratified by diabetics (n = 363) and nondiabetics (n = 517). The primary endpoint was the composite of death, myocardial infarction, or target vessel revascularization during a median follow-up of 11.8 years (IQR: 10.6-12.5 years). In diabetics, the primary endpoint rate was significantly higher in the PCI group than in the CABG group (43% and 32%; HR: 1.53; 95% CI: 1.12-2.08; P = 0.008). However, in nondiabetics, no significant difference was found between the groups (PCI group, 29%; CABG group, 29%; HR: 0.97; 95% CI: 0.67-1.39; P = 0.86; P interaction = 0.009). Irrespective of the presence of diabetes, no significant between-group differences were found in the rate of a safety composite of death, myocardial infarction, or stroke and mortality rate. However, the rate of any repeat revascularization was significantly higher in the PCI group than in the CABG group. In diabetics with MVD, CABG was associated with better clinical outcomes than PCI. However, the mortality rate was similar between PCI and CABG irrespective of diabetes status during an extended follow-up. (Ten-Year Outcomes of Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST Extended], NCT05125367 ; Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST], NCT00997828) [Display omitted] [ABSTRACT FROM AUTHOR]

[Display omitted] [ABSTRACT FROM AUTHOR]

[Display omitted] [ABSTRACT FROM AUTHOR]

This study assessed the efficacy of the tip detection method during intravascular ultrasound (IVUS)–based 3-dimensional (3D) wiring with a new chronic total occlusion (CTO)–specific IVUS system (AnteOwl IVUS [AO-IVUS]) for CTO percutaneous coronary intervention (PCI). The study developed angiography-based 3D wiring for CTO-PCI. Previously, the authors produced a short-tip CTO-specific IVUS system (Navifocus WR IVUS [Navi-IVUS]), which has been upgraded into the AO-IVUS system by adding a pullback transducer system for IVUS-based 3D wiring. A CTO lesion 20 mm in length composed of 2.5% agar was experimentally inserted into the coronary artery of a beating heart model. The target (a microcatheter with a 0.6-mm lumen) was placed in the distal part of the CTO lesion. IVUS-guided wiring was performed to insert the guidewire into the target using the Navi-IVUS and then using the AO-IVUS 8 times each. In wiring with AO-IVUS, the IVUS-based 3D wiring using the tip detection method was performed. The crossing time and the number of punctures to the target were calculated. The crossing time was significantly shortened and the number of punctures was significantly reduced in AO-IVUS–based wiring compared with Navi-IVUS–based wiring (median crossing time 80.5 s [interquartile range: 44.0 to 112.3 s] vs. 333.0 s [interquartile range: 88.8 to 790.0 s]; p = 0.036; median 1.0 puncture [interquartile range: 1.0 to 2.0 punctures] vs. 24.0 punctures [interquartile range: 5.8 to 52.5 punctures]; p = 0.001). The tip detection method enables the authors to easily perform the IVUS-based 3D wiring, and the new CTO IVUS system will facilitate this method in clinical practice. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to compare clinical outcomes in relation to the duration of triple antithrombotic therapy (TAT) among patients with indications for oral anticoagulation undergoing percutaneous coronary intervention (PCI). Background TAT is recommended for patients undergoing PCI with a firm indication for oral anticoagulation. Duration of TAT may influence outcomes, but the optimal period of TAT remains uncertain. Methods Between 2009 and 2013, 8,772 consecutive patients undergoing PCI for stable coronary artery disease or acute coronary syndrome were prospectively included in the Bern PCI Registry ( NCT02241291 ). Of 568 patients with indications for oral anticoagulation, 245 (43%) were discharged on a regimen of 1-month TAT and 323 (57%) on a regimen >1-month TAT (mean 5.1 ± 3.3 months, median 3 months). The primary endpoint was a composite of cardiac death, myocardial infarction, stroke, definite stent thrombosis, or TIMI (Thrombolysis in Myocardial Infarction) major bleeding within 1 year. Results Patients on 1-month compared with >1-month TAT were more commonly women, with stable coronary artery disease, had higher HAS-BLED scores, and less frequently received drug-eluting stents. In multivariate analyses, the primary endpoint did not differ between groups (adjusted hazard ratio: 1.07; 95% confidence interval: 0.56 to 2.06; p = 0.84). Results were consistent in stratified analyses in relation to clinical presentation with acute coronary syndrome (38%) and PCI with drug-eluting stents (79%) (p for interaction = 0.18 and 0.95, respectively). There were no differences in the secondary bleeding endpoint, Bleeding Academic Research Consortium ≥3 bleeding (adjusted hazard ratio: 0.62; 95% confidence interval: 0.21 to 1.80; p = 0.37) and the secondary composite ischemic endpoint (cardiac death, myocardial infarction, stroke, or definite stent thrombosis) (adjusted hazard ratio: 1.12; 95% confidence interval: 0.55 to 2.29; p = 0.76). Conclusions One-month TAT, used preferentially in patients with higher estimated bleeding risk in this observational study, was associated with similar net clinical outcomes compared with longer TAT durations throughout 1 year following PCI. [ABSTRACT FROM AUTHOR]

Objectives The aim of the present study was to investigate the relationship between the integration process and luminal enlargement with the support of light intensity (LI) analysis on optical coherence tomography (OCT), echogenicity analysis on intravascular ultrasound, and histology up to 4 years in a porcine model. Background In pre-clinical and clinical studies, late luminal enlargement has been demonstrated at long-term follow-up after everolimus-eluting poly- l -lactic acid coronary scaffold implantation. However, the time relationship and the mechanistic association with the integration process are still unclear. Methods Seventy-three nonatherosclerotic swine that received 112 Absorb scaffolds were evaluated in vivo by OCT, intravascular ultrasound, and post-mortem histomorphometry at 3, 6, 12, 18, 24, 30, 36, 42, and 48 months. Results The normalized LI, which is the signal densitometry on OCT of a polymeric strut core normalized by the vicinal neointima, was able to differentiate the degree of connective tissue infiltration inside the strut cores. Luminal enlargement was a biphasic process at 6 to 18 months and at 30 to 42 months. The latter phase occurred with vessel wall thinning and coincided with the advance integration process demonstrated by the steep change in normalized LI (0.26 [interquartile range (IQR): 0.20 to 0.32] at 30 months versus 0.68 [IQR: 0.58 to 0.83] at 42 months, p < 0.001). Conclusions In this pre-clinical model, late luminal enlargement relates to strut integration into the arterial wall. Quantitative LI analysis on OCT could be used as a surrogate method for monitoring the integration process of poly- l -lactic acid scaffolds, which could provide insight and understanding on the imaging-related characteristics of the bioresorption process of polylactide scaffolds in human. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to assess adenosine infusion via a cannula in the back of the hand compared with central venous access to achieve peak hyperemia during fractional flow reserve (FFR). Background Adenosine is often used to induce maximal hyperemia when measuring FFR. The gold standard is continuous infusion via a large central vein; however, the increasing use of the transradial route for angiography makes it desirable to have an alternative route for adenosine. Peripheral venous access is frequently obtained in the hand, but concern exists as to whether adenosine delivery from this site can achieve adequate vasodilation for accurate FFR measurement. Our aim was to address this. Methods Subjects were selected from patients presenting for coronary angiography/intervention who required a pressure-wire study. Subjects received intravenous adenosine infusion sequentially via 2 routes: first, via a 20-gauge hand cannula, and then, after a washout period, via a 5- or 6-F femoral venous sheath. Adenosine was administered at 140 μg/kg/min from each site. Data interpretation was blinded. Minimal FFR achieved with intravenous adenosine from each infusion site was recorded as was the time to peak hyperemia. Results Paired (hand and femoral adenosine) recordings taken from 84 vessels in 61 patients were suitable for blinded analysis. The mean FFR measured using adenosine administered via hand and femoral routes was 0.85 with an SD of 0.08 (intraclass correlation = 0.986). Time to peak hyperemia was longer on average with hand-administered adenosine compared with femoral adenosine administration (63 s vs. 43 s; mean difference, 22 s with a 95% confidence interval: 18 s to 27 s; p < 0.0001). Formal comparison of FFR stability using Mann-Whitney analysis (2 tailed) gives p = 0.43, indicating no significant evidence of a difference in stability between the 2 routes. Conclusions Hand vein adenosine infusion produced FFR values very similar to those obtained using central femoral vein adenosine administration, with no systematic bias toward higher or lower reading from 1 site. This has important practical implications for radial access cases involving pressure-wire studies. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to investigate a novel method to calculate the index of microcirculatory resistance (IMR) in the presence of significant epicardial stenosis without the need for balloon dilation to measure the coronary wedge pressure (Pw). Background: The IMR provides a quantitative measure of coronary microvasculature status. However, in the presence of significant epicardial stenosis, IMR calculation requires incorporation of the coronary fractional flow reserve (FFRcor), which requires balloon dilation within the coronary artery for Pw measurement. Methods: A method to calculate IMR by estimating FFRcor from myocardial FFR (FFRmyo), which does not require Pw measurement, was developed from a derivation cohort of 50 patients from a single institution. This method to calculate IMR was then validated in a cohort of 72 patients from 2 other different institutions. Physiology measurements were obtained with a pressure-temperature sensor wire before coronary intervention in both cohorts. Results: From the derivation cohort, a strong linear relationship was found between FFRcor and FFRmyo (FFRcor = 1.34 × FFRmyo − 0.32, r2 = 0.87, p < 0.001) by regression analysis. With this equation to estimate FFRcor in the validation cohort, there was no significant difference between IMR calculated from estimated FFRcor and measured FFRcor (21.2 ± 12.9 U vs. 20.4 ± 13.6 U, p = 0.161). There was good correlation (r = 0.93, p < 0.001) and agreement by Bland-Altman analysis between calculated and measured IMR. Conclusions: The FFRcor, and, by extension, microcirculatory resistance can be derived without the need for Pw. This method enables assessment of coronary microcirculatory status before or without balloon inflation, in the presence of epicardial stenosis. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to evaluate the incidence, predictors, management, and clinical outcomes in patients with grade III coronary perforation during percutaneous coronary intervention. Background: Grade III coronary perforation is a rare but recognized complication associated with high morbidity and mortality. Methods: From 24,465 patients undergoing percutaneous coronary intervention from May 1993 to December 2009, 56 patients had grade III coronary perforation. Results: Most lesions were complex: 44.6% type B2, 51.8% type C, and 28.6% chronic total occlusions, and within a small vessel (≤2.5 mm) in 32.1%. Glycoprotein IIb/IIIa inhibitors were administered in 17.9% of patients. The device causing perforation was intracoronary balloon in 50%: 53.6% compliant, 46.4% noncompliant; intracoronary guidewire in 17.9%; rotablation in 3.6%; and directional atherectomy in 3.6%. Following perforation, immediate treatment and success rates, respectively, were prolonged balloon inflation 58.9%, 54.5%; covered stent implantation 46.4%, 84.6%; coronary artery bypass graft surgery (CABG) and surgical repair 16.0%, 44.4%; and coil embolization 1.8%, 100%. Multiple methods were required in 39.3%. During the procedure (n = 56), 19.6% required cardiopulmonary resuscitation and 3.6% died. In-hospital (n = 54), 3.7% required CABG, 14.8% died. The combined procedural and in-hospital myocardial infarction rate was 42.9%, and major adverse cardiac event rate was 55.4%. At clinical follow-up (n = 46) (median: 38.1 months, range 7.6 to 122.8), 4.3% had a myocardial infarction, 4.3% required CABG, and 15.2% died. The target lesion revascularization rate was 13%, with target vessel revascularization in 19.6%, and major adverse cardiac events in 41.3%. Conclusions: Grade III coronary perforation is associated with complex lesions and high acute and long-term major adverse cardiac event rates. [ABSTRACT FROM AUTHOR]

Microvascular obstruction (MVO) commonly occurs following percutaneous coronary interventions (PCI), may lead to myocardial injury, and is an independent predictor of adverse outcome. Severe MVO may manifest angiographically as reduced flow in the patent upstream epicardial arteries, a situation that is termed “no-reflow.” Microvascular obstruction can be broadly categorized according to the duration of myocardial ischemia preceding PCI. In “interventional MVO” (e.g., elective PCI), obstruction typically involves myocardium that was not exposed to acute ischemia before PCI. Conversely “reperfusion MVO” (e.g., primary PCI for acute myocardial infarction) occurs within a myocardial territory that was ischemic before the coronary intervention. Interventional and reperfusion MVO have distinct pathophysiological mechanisms and may require individualized therapeutic approaches. Interventional MVO is triggered predominantly by downstream embolization of atherosclerotic material from the epicardial vessel wall into the distal microvasculature. Reperfusion MVO results from both distal embolization and ischemia-reperfusion injury within the subtended ischemic tissue. Management of MVO and no-reflow may be targeted at different levels: the epicardial artery, microvasculature, and tissue. The aim of the present report is to advocate a systematic approach to prevention and treatment of MVO in different clinical settings. Randomized clinical trials have studied strategies for prevention of MVO and no-reflow; however, the efficacy of measures for reversing MVO once no-reflow has been demonstrated angiographically is unclear. New approaches for prevention and treatment of MVO will require a better understanding of intracellular cardioprotective pathways such as the blockade of the mitochondrial permeability transition pore. [Copyright &y& Elsevier]

Objectives: The study aimed to determine the mechanism and predictors of procedural failure in patients undergoing percutaneous coronary intervention (PCI) from the transradial approach (TR). Background: Transradial approach PCI reduces vascular complications compared with a transfemoral approach (TF). However, the mechanism and predictors of TR-PCI failure have not been well-characterized. Methods: The study population consisted of patients undergoing TR-PCI by low-to-intermediate volume operators with traditional TF guide catheters. Baseline characteristics, procedure details, and clinical outcomes were prospectively collected. Univariate and multivariate analyses were performed to determine independent predictors of TR-PCI failure. Results: A total of 2,100 patients underwent TR-PCI and represented 38% of PCI volume. Mean age was 64 ± 12 years, and 17% were female. Vascular complications occurred in 22 (1%), and TR-PCI failure was observed in 98 (4.7%) patients. The mechanism of TR-PCI failure included inability to advance guide catheter to ascending aorta in 50 (51%), inadequate guide catheter support in 35 (36%), and unsuccessful radial artery puncture in 13 (13%) patients. The PCI was successful in 94 (96%) patients with TR-PCI failure by switching to TF. On multivariate analysis, age >75 years (odds ratio [OR]: 3.86; 95% confidence interval [CI]: 2.33 to 6.40, p = 0.0006), prior coronary artery bypass graft surgery (OR: 7.47; 95% CI: 3.45 to 16.19, p = 0.0002), and height (OR: 0.97; 95% CI: 0.95 to 0.99, p = 0.02) were independent predictors of TR-PCI failure. Conclusions: Transradial approach PCI can be performed by low-to-intermediate volume operators with standard equipment with a low failure rate. Age >75 years, prior coronary artery bypass graft surgery, and short stature are independent predictors of TR-PCI failure. Appropriate patient selection and careful risk assessment are needed to maximize benefits offered by TR-PCI. [Copyright &y& Elsevier]

Objectives: With an intracoronary electrocardiogram (IcECG) recording with insulated polymer-coated guidewire without balloon catheter, we sought to examine the association between ST-segment elevation in the IcECG after elective stenting and myocardial injury. Background: An IcECG is a sensitive method to detect local myocardial ischemia. Occasionally, persistent ST-segment elevation in the IcECG was recorded after successful coronary intervention. Conventionally IcECG was recorded with a guidewire and over-the-wire system. Methods: Patients who underwent elective stenting were enrolled (n = 339). The IcECG both at baseline and after procedure were obtained with a guidewire with an insulating coated shaft suitable for IcECG recording. The presence of chest pain after percutaneous coronary intervention was recorded. Cardiac biomarkers were examined 18 h after the procedure. Results: The ST-segment elevation in the IcECG after procedure was recorded in 65 patients, and no change was recorded in 274 patients. Troponin-T, creatine phosphokinase, and creatine kinase MB isoform after the procedure were significantly higher in patients with post-procedural ST-segment elevation in the IcECG than patients without ST-segment elevation. Multivariate analysis demonstrated that ST-segment elevation in the IcECG is an independent predictor of post-procedural myocardial injury. The incidence of ST-segment elevation in the IcECG was significantly higher in patients with post-procedural chest pain than patients without chest pain (p < 0.001). Conclusions: We demonstrated a facile method to record IcECG with a guidewire with a polymer-coated shaft. The IcECG is a useful method for predicting post-procedural myocardial injuries. [Copyright &y& Elsevier]