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Percutaneous coronary intervention (PCI) of bifurcation lesions can be challenging. We compared the angiographic characteristics, techniques, and outcomes of bifurcation vs. non-bifurcation PCIs performed at our institution. Between 2014 and 2019 1,099 of 10,278 PCIs (11%) and 1,236 of 15,623 lesions (8%) involved a bifurcation. Bifurcation lesions were longer (22 mm vs 16 mm; p<0.001), and more likely to have complex angiographic characteristics, such as severe calcification and tortuosity compared to non-bifurcation lesions (Panel A). Bifurcation PCI had lower technical success (94% vs 97%; p<0.001), and higher incidence of periprocedural complications, such as coronary dissection (3% vs 1%; p <0.001) and cardiac tamponade (1.0% vs 0.1%; p=0.009) (Panel B). [Display omitted]

Introduction:Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with increased risk of periprocedural complications. Estimating the risk of complications facilitates risk-benefit assessment and procedural planning.Methods:We analyzed the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO, NCT02061436) and created a risk score for in-hospital all-cause mortality. Logistic regression prediction modeling was used to identify independently associated variables and the model was internally validated with bootstrapping.Results:Of the 10,480 CTO PCI cases performed between 2012-2022 at 40 US and non-US centers, in-hospital mortality occurred in 47 (0.45%). The final prediction model identified 4 independent predictors of mortality: Age ≥65 years, Odds Ratio [OR]: 2.83 (95% confidence interval [CI], 1.30-6.16), 1-point; Left ventricular ejection fraction ≤45%, OR: 2.13 (95% CI, 1.14-3.98), 1-point; Moderate-severe calcification, OR: 2.45 (95% CI, 1.18-5.08), 1-point; and Antegrade dissection re-entry, OR: 2.81 (95% CI, 1.06-7.43), 1-point; or Retrograde strategy, OR: 3.51 (95% CI, 1.67-7.37), 1-point; with a bootstrap corrected c-statistics of 0.71 (95% confidence interval: 0.63-0.81). The calculated risk percentages for mortality based on the PROGRESS-CTO mortality score ranged from 0.05-2.42% for mortality, and 63% of patients in the PROGRESS-CTO cohort had PROGRESS-CTO mortality score of 1 or 2, corresponding to a mortality risk of 0.1-0.5% (Figure 1).Conclusions:The PROGRESS-CTO in-hospital mortality risk score can facilitate risk-benefit assessment and procedural planning in patients undergoing CTO PCI.

Introduction:Bifurcation percutaneous coronary intervention (PCI) techniques are rapidly evolving and can be challenging to perform.Methods:We examined the angiographic, procedural characteristics, and outcomes of 472 bifurcation PCIs in Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION, NCT05100992).Results:A total of 472 bifurcation PCIs were included. Mean age was 67±12 years, 74% were men with a high prevalence of comorbidities: hypertension (81%), diabetes mellitus (36%), dyslipidemia (90%). Overall technical success was 95%. The incidence of in-hospital major adverse cardiovascular events (MACE) was 5.1%. The most common stenting strategy was provisional (71%), double-kissing (DK) crush (12%), mini-crush wish 2 stents (3%), culotte (3%), T-and protrusion (4%), and T-stenting (1.5%). Patients treated with the DK-crush had more severe stenosis of the left main (35%±38 vs. 19%±30, p<0.001), proximal left anterior descending (68%±29, vs. 52%±35, p=0.001), and side branch lesion (82%±15, 51%±36, p<0.001). Medina classification was more often 1,1,1 (79% vs. 39%, p<0.001), with higher use of intravascular ultrasound/optical coherence tomography (57% vs. 31%, p<0.001) compared to non-DK crush. The DK-crush required use of more contrast and took longer to perform (Table).Conclusions:Despite high patient comorbidity, bifurcation PCI can be performed with high technical success and low in-hospital MACE rates. DK-crush technique was more commonly preferred in bifurcation lesions with more severe/proximal vessel involvement.

Introduction:Use of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been increasing.Methods:We examined the clinical characteristics and procedural outcomes of patients who underwent CTO PCI with radial versus femoral access in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436).Results:Of 10,954 patients who underwent CTO PCI at 55 centers in 7 countries between 2012 and 2022, 2,578 (24%) had a radial-only approach. Patients who underwent radial-only access were younger (63 ± 10 vs. 65 ± 10, years, p<0.001), more likely to be men (84% vs. 81%, p=0.001), and had a significantly lower prevalence of comorbidities compared with the femoral group, including diabetes mellitus (39% vs. 45%, p<0.001) and coronary artery bypass graft surgery (57% vs. 64%, p<0.001). In addition, radial-only cases had lower angiographic complexity with lower J-CTO (2.0 ± 1.3 vs. 2.5 ± 1.2, p<0.001) and PROGRESS-CTO (1.2 ± 1.0 vs. 1.3 ± 1.0, p<0.001) scores. After adjusting for potential confounders, radial-only access was associated with a lower risk of access site complications (odds ratio [OR]: 0.45, 95% confidence interval [CI], 0.22-0.91), similar technical success (OR: 0.87, 95% CI, 0.74-1.04) and major adverse cardiovascular events (MACE) (OR: 0.65, 95% CI, 0.40-1.07), compared with the femoral access group (Figure 1).Conclusions:Radial-only access was used in 24% of CTO PCIs and was associated with lower access site complications, and similar technical success and MACE compared with the femoral access group.

History:A 78-year-old man presented with anterior ST-segment elevation. Coronary angiography demonstrated an occluded left anterior descending coronary artery (LAD Figure 1A) with stenosis of the left circumflex (Cx) coronary artery.Procedure:The LAD was crossed with a workhorse wire (Figure 1B). Predilation restored the flow in the LAD and two diagonal branches (Figure 1C). After assessing the lesion with intravascular imaging (Figure 1D), two drug-eluting stents (DES) were deployed with provisional technique (Figure 1E). The diagonal was rewired and dilated with a 2.0 mm balloon (Figure 1F). A 3.5x20 mm DES was deployed covering the proximal LAD lesion (Figure 1G). The Cx ostium appeared pinched, but the diastolic pressure ratio was 0.95, hence no PCI was performed. Given the large MI size, we administered super saturated oxygen (SSO2). A 5F FR5 catheter was inserted into the LM ostium and SSO2 was administered for 1 hour. An excellent final angiographic result was achieved with TIMI 3 flow and well-expanded stents (Figure 1H). Peak creatinine kinase was 5840 U/l. Magnetic resonance imaging on the next day showed small thrombi, prominent microvascular obstruction in the mid LAD territory, and transmural infarction (Figure 1I). Left ventricular ejection fraction of 39% with normal left ventricular volume. The patient was discharged 3 days later on dual antiplatelet therapy and warfarin and referred to cardiac rehabilitation.Conclusion:“Time is muscle”, hence immediate revascularization is essential. Large anterior STEMIs may benefit from SSO2.

Background:Predicting technical failure in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can assist with decision making and planning of the procedure.Methods:We analyzed 6,946 CTO PCIs performed between 2016 and June 2022 at 36 international centers in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) and created a score for risk of technical failure. Logistic regression prediction modeling was used to identify independently associated variables with technical failure and model were internally validated with bootstrapping.Results:Mean patient age was 64.0±10 years, 82% were men and technical success was 86%. The following variables were independently associated with technical failure and were included in the final model: age (odds ratio [OR]: 1.08, 95% Confidence Intervals [CI]: [1.00-1.15], p=0.039; age≥ 65 years; 1 point), CTO length (OR: 1.13, 95% CI [1.10, 1.17]; length≥ 20 mm; 1 point), moderate/severe calcification (OR: 1.35, 95% CI [1.17, 1.56]; 1 point), proximal cap ambiguity (OR: 2.25, 95% CI [1.95, 2.59]; 2 points), lack of interventional collaterals (OR: 1.60, 95% CI [1.39, 1.84]; 1 point), and lack of good distal landing zone (OR: 1.51, 95% CI [1.31, 1.75]; 1 point). The resulting score showed acceptable performance on receiver-operating characteristic (ROC) curve, AUC: 0.68 (95% CI [0.67-0.71]). Internal validation with bootstrapping of 1000 samples demonstrated a good agreement with the model, observed AUC: 0.68, (95% bias corrected CI [0.67, 0.70]). PROGRESS-CTO technical failure score and corresponding risk percentage and the percentage of patients in the respective risk group within the PROGRESS-CTO registry are represented in Figure 1.Conclusion:The updated PROGRESS CTO score may be useful for assessing the likelihood of technical failure success in CTO PCI.

Introduction:Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).Methods:We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022.Results:The incidence of coronary perforation was 4.9% (n=503). Patients who experienced coronary perforation were older and were more likely to have had prior coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher J-CTO and PROGRESS-CTO scores. Technical (66% vs. 87%; p<0.01) and procedural (55% vs. 87%; p<0.01) success rates were lower among perforation cases. The most common site of perforation was the CTO target vessel (66%), the retrograde approach was responsible for the perforation in 47% of the cases and guidewire exit was the most common mechanism of perforation. The proportion of Ellis Class 1, 2, 3 and 3 -“cavity spilling” coronary perforations was 20%, 41%, 28% and 11%, respectively. In 52% of perforations, one or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%) and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events (MACE) was higher in perforation cases (18.1% vs. 1.3%; p<0.01).Conclusions:Coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital MACE.

History:A 69-year-old man presented with severe medically refractory stable angina and was referred for revascularization of a right coronary artery (RCA) chronic total occlusion (CTO Figure 1.A). The patient had undergone coronary artery bypass surgery 16 years prior as well as numerous percutaneous coronary intervention. Echocardiography demonstrated normal left ventricular systolic function.Procedure:Antegrade wiring was attempted first with a Fielder XT guidewire (GW) and a Turnpike Spiral microcatheter (MC Figure 1.B). Due to the ambiguous proximal cap and long occlusion length, retrograde crossing was attempted next. After attempting to cross multiple collaterals a Sion Black crossed a proximal septal collateral (Figure 1.C), but several MCs could not follow the GW, despite ballooning the collateral with a 1.5 mm balloon and GuideLiner support. We switched to antegrade dissection and re-entry with a knuckled Gladius Mongo that reached the distal RCA (Figure 1.D). With the Stingray balloon and ‘double blind stick and swap’ technique we crossed into the distal true lumen, but the GW position was lost after removal of the balloon. We crossed with the retrograde GW to the antegrade guide catheter (Figure 1.E), but ‘tip in’ technique as well as passing the retrograde MC was not successful. Using a new Stingray balloon and the retrograde GW as true lumen marker (Figure 1.F) we crossed into the distal true lumen. After drug-eluting stent implantation (Figure 1.G) the distal bifurcation was recanalized with kissing balloon dilation (Figure 1.H) and implantation of another stent with a nice final result (Figure 1.I).Conclusion:Persistence is key in CTO PCI in patients with severe medically refractory stable angina and limited revascularization options. Crossing the collaterals with MC can be challenging: possible solutions are smaller MC, predilation in septal collateral, ‘tip in’ or switching to another crossing strategy such as ADR with retrograde facilitation.

Introduction:Using sex-specific cutoffs, high left ventricular ejection fraction (LVEF) is associated with increased mortality in women but not in men with chronic coronary syndromes.Purpose:To explore the association between LVEF and mortality after an acute coronary syndrome in women and men.Methods:Using population-derived sex-specific LVEF cutoffs, we compared characteristics and outcomes of 1,953 ST-segment Elevation Myocardial Infarction (STEMI) patients (1,399 men and 554 women) presenting at Minneapolis Heart Institute between 2003 and 2020. Patients who had a follow-up LVEF measurement available within 2 months of the index hospitalization were included in the analysis. Sex specific cutoffs for post STEMI LVEF were a) for men, >70% (high), 47-70% (normal), <47% (low); b) for women, >72% (high), 50-72% (normal), <50% (low). Standard cutoffs were: >65% (high), 55-65% (normal), <55% (low).Results:When comparing high vs normal vs low LVEF, 1-year mortality was 0% vs 0.8% vs 4.4% in men (Plog-rank<0.001) and 13.3% vs 2.2% vs 3.4% in women (Plog-rank=0.03) (Figure). Five-year mortality was 0% vs 5.1% vs 12% in men (Plog-rank<.001) and 13.3% vs 11.4% vs 19.9% in women (Plog-rank=0.18). The findings were not replicated when standard LVEF cutoffs were used (1-year mortality in women was 6.1% vs 2.5% vs 2.5%, Plog-rank=0.33). After adjustment for baseline variables and comorbidities (age, diabetes, dyslipidemia, hypertension, history of MI, door-to-balloon time less than 90 minutes, and the presence of congestive heart failure), high LVEF was associated with 1-year mortality when compared with normal LVEF in women (HR, 10.83; 95% CI, 1.94-60.57, P=0.007). Landmark analysis showed that among women alive beyond 1 year, 5-year mortality was 0% vs 9.4% vs 16.1%, Plog-rank=0.31.Conclusion:High LVEF after STEMI using sex-specific cutoffs is associated with lower 1-year survival in women but not in men.

Introduction:Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is an evolving field.Methods:We examined the clinical and angiographic characteristics and procedural outcomes of 8,666 CTO PCIs performed at 36 centers between 2012 and 2021.Results:Mean age was 64±10 years and 82% of the patients were men. The prevalence of prior PCI (62%) and diabetes mellitus (43%) was high. Median ejection fraction was 54% (42%, 60%). Radial access was used in 50%. The most common target vessel was the right coronary artery (52%), followed by the left anterior descending artery (26%). The target CTOs were highly complex with mean J-CTO score of 2.4 ±1.3 and PROGRESS score of (1.3 ±1). Technical and procedural success rates were high (86% and 85% respectively) with a relatively low percentage of in-hospital major adverse cardiac events (Figure 1). The final successful crossing strategy was antegrade wire escalation in 62%, retrograde in 22%, and antegrade dissection re-entry in 16%. Median contrast volume, air kerma radiation dose and procedure time were 220 (155, 300) ml, 2.2 (1.2, 3.8) Gray and 116 (75, 172) minutes, respectively.Conclusions:High success and acceptable complication rates can currently be achieved in CTO PCI among high-volume, experienced centers.

Introduction:The use of mechanical circulatory support (MCS) in complex percutaneous coronary intervention (PCI) is the subject of ongoing investigation, but the role of MCS in chronic total occlusion (CTO) PCI is not well studied.Methods:We analyzed the patient and angiographic characteristics and procedural outcomes of 7,171 CTO PCIs performed between 2012 and June 2021 at 35 international centers.Results:Mean patient age was 64.5±10 years, mean left ventricular ejection fraction was 50 ± 13 % and 82% were men. MCS was used in 4.5% of the overall cases, MCS use was elective in 78.7% and urgent in 21.3%. The most common type of MCS was Impella CP (55.5%) followed by intra-aortic balloon pump (14.8%), Tandem Heart (10.0%) and Impella 2.5 (8.7%). Diabetes mellitus (51.0% vs. 42.4%, p=0.003), prior congestive heart failure (60.6% vs. 27.9%, p<0.001) and prior myocardial infarction (52.3% vs. 45.3%, p=0.020) were more common in MCS patients. Left ventricular ejection fraction was lower in the patients with MCS use compared to patients without (Mean±standard deviation, 51.0 ± 12 vs. 34.0 ± 15 %, p<0.001). Cases in which MCS was used were more complex with higher J-CTO score compared with cases without MCS (2.94 ± 1.19 vs. 2.39 ± 1.27, p<0.001). Cases performed with MCS had lower technical (81.6% vs. 86.7%, p=0.011) and procedural (71.3% vs. 85.6%, p<0.001) success rates with higher rates of periprocedural major cardiac adverse events compared to no MCS use (12.6% vs. 1.68%, p<0.001).Conclusions:In a contemporary, multicenter registry MCS was used in 4.5% of CTO PCI. Cases where MCS was used were associated with lower technical and procedural success with higher periprocedural major complication rates. Further investigation is required to see if elective use of MCS can improve outcomes in patients with increased comorbidities and higher lesion complexity.