Search

Background: Coronary artery disease (CAD) is a leading cause of death in the elderly population. Data regarding percutaneous coronary interventions (PCIs) in nonagenarians are scarce, and differences in long term outcomes between generations remain unclear. We aimed to study the pattern and temporal trends of nonagenarians treated with PCI., Materials and Methods: A total of 14,695 patients underwent PCI between 2009-2020. We identified 2,034 (13.8%) octogenarians (age 80-89), and 222 (1.5%) nonagenarians (age 90-99). Endpoints included mortality and major adverse cardiac events (MACE) at 1 year., Materials and Methods: A total of 14,695 patients underwent PCI between 2009-2020. We identified 2,034 (13.8%) octogenarians (age 80-89), and 222 (1.5%) nonagenarians (age 90-99). Endpoints included mortality and major adverse cardiac events (MACE) at 1 year., Results: The number of nonagenarians undergoing PCI has increased substantially during the study time period, from 89 patients in the earlier time period (2009-2014) to 133 patients in the later time period (2015-2020). At 1-year, nonagenarians had significantly higher rates of both death (24.3% vs. 14.9%, p<0.01), and MACE (30.6% vs. 22.0%, p<0.01), as compared to octogenarians. The cumulative survival rate was higher among octogenarians both in the early and late time period (p<0.01 and p=0.039, respectively). A significant reduction in nonagenarian MACE rates were observed during the study time period, resulting in a non-significant difference in MACE rates in the later time period between both groups., Conclusion: The number of nonagenarians who undergo PCI is on the rise. While their clinical outcomes are inferior as compared to younger age groups, improvement was noted in the late time period., Competing Interests: Declaration of competing interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Patients treated with percutaneous coronary intervention are often considered to be at a high bleeding risk (HBR). Drug-eluting stents have been shown to be superior to bare-metal stents in patients with HBR, even when patients were given abbreviated periods of dual antiplatelet therapy (DAPT). Short DAPT has not been evaluated with the EluNIR ridaforolimus-eluting stent. The aim of this study was to evaluate the safety and efficacy of a shortened period of DAPT following implantation of the ridaforolimus-eluting stent in patients with HBR., Methods and Results: This was a prospective, multicenter, binational, single-arm, open-label trial. Patients were defined as HBR according to the LEADERS-FREE (Prospective Randomized Comparison of the BioFreedom Biolimus A9 Drug-Coated Stent versus the Gazelle Bare-Metal Stent in Patients at High Bleeding Risk) trial criteria. After percutaneous coronary intervention, DAPT was given for 1 month to patients presenting with stable angina. In patients presenting with an acute coronary syndrome, DAPT was given for 1 to 3 months, at the investigator's discretion. The primary end point was a composite of cardiac death, myocardial infarction, or stent thrombosis up to 1 year (Academic Research Consortium definite and probable). Three hundred fifteen patients undergoing percutaneous coronary intervention were enrolled, and 56.4% presented with acute coronary syndrome; 33.7% were receiving oral anticoagulation. At 1 year, the primary end point occurred in 15 patients (4.9%), meeting the prespecified performance goal of 14.1% ( P <0.0001). Stent thrombosis (Academic Research Consortium definite and probable) occurred in 2 patients (0.6%). Bleeding Academic Research Consortium type 3 and 5 bleeding occurred in 6 patients (1.9%)., Conclusions: We observed favorable results in patients with HBR who underwent percutaneous coronary intervention with a ridaforolimus-eluting stent and received shortened DAPT, including a low rate of ischemic events and low rate of stent thrombosis., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03877848.

Introduction: The ridaforolimus-eluting stent (RES) system uses a novel cobalt alloy-based coronary stent with a durable elastomeric polymer eluting ridaforolimus., Aim of Study: To assess the safety and efficacy of small diameter (2.25 mm) RES (EluNIR) in small coronary artery disease., Methods: A prospective, multicenter, single-arm, open-label clinical trial. Clinical follow-up was performed at 30 days, 6 months, and 1 year after the procedure. Target lesions were located in native coronary arteries or bypass graft conduits, with visually estimated diameter of ≥2.25 mm to ≤2.5 mm. The primary endpoint was combined device success, defined as final in-stent residual diameter stenosis <30%, without 30-day major adverse cardiovascular events (MACE)., Results: A total of 81 patients were enrolled in the study. Twenty-three patients (28%) had acute coronary syndrome (ACS) at presentation and 37 (46%) had prior myocardial infarction (MI). Most of the target lesions were located in the circumflex coronary artery (44%) and were classified as B2/C grade according to the American Heart Association/American College of Cardiology classification. The final mean minimal lumen diameter, mean reference vessel diameter, and mean residual percent diameter stenosis were 2.0 ± 0.2 mm, 2.3 ± 0.1 mm, and 14 + 6.6%, respectively. The primary endpoint of device success without 30-day MACE was achieved in 98.8% of the patients. Target lesion failure (TLF) at 6 months was 1.2%. Thirty-day and 1-year MACE rates were 1.2% and 2.5%, respectively., Conclusion: The EluNIR 2.25 mm stent shows excellent results in small coronary artery disease and adds another tool in the treatment of this complex lesion type., (© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

While mortality of acute coronary syndrome (ACS) is known to have steadily decline over the last decades, data are lacking regarding the complex sub-population of patients with both coronary artery disease and cancer. A large single-center percutaneous coronary intervention (PCI) registry was used to retrieve patients who had a known diagnosis of malignancy during PCI. Patients were divided into two groups according to the period in which PCI was performed (period 1: 2006-2011, period 2: 2012-2017). Cox regression hazard models were implemented to compare primary endpoint, defined as the composite outcomes of major adverse cardiac events (MACE) (which include cardiovascular death, myocardial infarction or target vessel revascularization) and secondary endpoint of all-cause mortality, between the two time periods. A total of 3286 patients were included, 1819 (55%) had undergone PCI in period 1, and 1467 (45%) in period 2. Both short- and long-term MACE and overall mortality were significantly lower in patients who underwent PCI at the latter period (2.3% vs. 4.3%, p < 0.001 and 1.1% vs. 3.2%, p < 0.001 after 30 days and 24% vs. 30%, p < 0.001 and 12% vs. 22%, p < 0.001 after 2 years, respectively). However, in a multivariate analysis, going through PCI in the latter period was still associated with lower rates of overall mortality (HR 0.708, 95% confidence interval [CI] 0.53-0.93, p = 0.014) but there was no significant difference in MACE (HR 0.83, 95% CI 0.75-1.42, p = 0.16). Patients with cancer undergoing PCI during our most contemporary period had an improved overall survival, but no significant differences were observed in the composite cardiovascular endpoints, compared to an earlier PCI period. The management of coronary patients with cancer disease remains challenging., (© 2021. Springer Japan KK, part of Springer Nature.)

Background: Practice guidelines emphasize the role of the SYNTAX score (SS; Synergy Between PCI With TAXUS and Cardiac Surgery) in choosing between percutaneous coronary intervention and coronary artery bypass graft surgery in cases of complex coronary artery disease. There is paucity of data on the implementation of these recommendations in daily practice, and on the consequences of guideline discordant revascularization., Methods: This was a retrospective analysis of a prospective national survey of consecutive real world patients undergoing coronary revascularization for complex coronary artery disease according to decisions of local heart team at each center. SS was calculated at a dedicated CoreLab, and patients were classified as heart team/guidelines agreement/discordant., Results: Nine hundred seventy-nine patients (571 percutaneous coronary intervention and 408 coronary artery bypass graft) were included. Mean age was 65 years and the mean SS was 22. Heart team/guidelines discordance occurred in 170 (17.3%) patients. Independent predictors of heart team/guidelines discordance were age, admission to a center with no cardiac surgery service, SS, and previous percutaneous coronary intervention/myocardial infarction. A multivariate model based on these characteristics had a C statistic of 0.83. Thirty-day outcomes were similar in the agreement/discordance groups, however, heart team/guidelines discordance was associated with a significant increase in 3 year mortality (17.6% versus 8.4%; hazard ratio, 2.05; P =0.002) after multivariate adjustment., Conclusions: Heart team/guidelines discordance is not infrequent in real world patients with complex coronary artery disease undergoing revascularization. This is more likely to occur in elderly patients, those with more complex coronary disease (as determined by the SS), and those treated at centers with no cardiac surgery service. These patients have a higher risk for mid-term mortality.

Aims: The dual antiplatelet therapy (DAPT) score is meant to aid clinicians choose the DAPT duration but attempts to examine the external validity of the DAPT score and its decision tool have reported mostly disappointing results. Our aim was to perform a meta-analysis of all available data on the external validity of the DAPT score., Methods and Results: We conducted a meta-analysis of studies that examined the external validity of the DAPT score/its decision tool. Seven studies (77 274 patients) were included. Follow-up ranged from 6 to 24 (median 18) months. Overall, high (≥2) DAPT score was associated with increased risk for myocardial infarction (MI)/stent thrombosis (ST) [odds ratio (OR) 1.54, 95% confidence interval (CI) 1.41-1.69; P < 0.01], and lower risk for bleeding (OR 0.84, 95% CI 0.73-0.97; P = 0.01). In the high DAPT score stratum, extended (12-24 months), as compared to standard (6-12 months) DAPT duration was associated with a reduction in the risk for MI/ST (OR 0.67, 95% CI 0.48-0.94; P = 0.02), and no difference in the risk for bleeding (OR 1.04, 95% CI 0.65-1.66; P = 0.88), while in the low DAPT score stratum, extended DAPT duration was associated with no difference in the risk for MI/ST (OR 1.04, 95% CI 0.76-1.43; P = 0.80), and an increased risk for bleeding (OR 1.58, 95% CI 1.15-2.15; P < 0.01)., Conclusions: This first meta-analysis of studies examining the external validation of the DAPT score and its decision tool, our results suggest that the DAPT score is useful both for stratifying post-percutaneous coronary intervention patients into risk strata for future ischaemic and bleeding events as well aiding in choosing the optimal DAPT duration for the individual patient., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Percutaneous coronary intervention (PCI) of unprotected left-main coronary artery (uLMCA) is increasingly performed. Although it is recommended to calculate the SYNTAX score, if uLMCA PCI is considered, data of outcomes by the SYNTAX score are scarce, particularly among patients with high score (SYNTAX ≥ 33)., Objective: To evaluate long-term outcomes of uLMCA PCI according to SYNTAX score in real-world practice., Methods: Patients following PCI of uLMCA throughout 2006-2018, in a tertiary hospital, were included and classified into three groups according to the SYNTAX I score. The primary outcome was three-year major adverse cardiac event (MACE) comprising all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), or coronary artery bypass surgery (CABG)., Results: Overall 632 patients were analyzed, mean age 72.8 ± 11.5, males: 69%, classified as following: SYNTAX <22 (n = 225); SYNTAX 22-32 (n = 250) and SYNTAX ≥33 (n = 157). Patients with greater SYNTAX score had higher prevalence of diabetes mellitus, renal failure, peripheral arterial disease and stroke. Additionally, they had lower ejection fraction, greater EuroScore, and number of vessels involved. Procedural success rates were very high (>95%) and did not depend on the SYNTAX score. The rates of MACE and its components were significantly higher in patients with higher SYNTAX score. Multivariate analysis showed that SYNTAX score is an independent predictor of three-year MACE following uLMCA PCI [HRSYNTAX22-32 = 3 (95% confidence interval [CI]: 1.2-11.5), HRSYNTAX≥33 = 3.4 (95% CI: 1.8-13.3]., Conclusions: Despite the high success rates of uLMCA PCI in real-world patients with high SYNTAX score, the latter was significantly associated with worse three-year outcomes.

The Medina classification is the most widespread method to describe bifurcation lesions. However, little is known regarding its prognostic impact. Therefore, the aim of this study is to assess the prognostic significance of the Medina classification following percutaneous coronary intervention (PCI). From a prospective registry of 738 consecutive patients undergoing PCI for bifurcation lesions, 505 were treated with second-generation drug-eluting stents (DES). Of these, 407 (80.6%) presented with "true bifurcation" (TB) lesions (Medina class 1.0.1, 1.1.1, 0.1.1) and 98 (19.4%) in all other categories ("non-true bifurcation" = NTB). We compared rates of death and major adverse cardiac events (MACE: cardiac death, myocardial infarction, or target vessel revascularization) at 12 months and 3 years. Patients with TB had lower rates of previous bypass surgery (7.4% vs. 11.2%, p = 0.043). TB lesions were more likely to be calcified (33.9% vs. 28.6%, p = 0.003) and ulcerated (8.8% vs. 4.1%, p < 0.01). At 12 months, mortality was numerically higher for TB PCI (4.1% vs. 2.1%, p = 0.052) and MACE rates were higher (19.2% vs. 10.2%, p < 0.001). At 3 years, both all-cause death (10.1% vs. 5.1%, p = 0.002) and rates of MACE (37.2% vs. 17.6%, p < 0.001) were higher for TB PCI. After performing regression analysis, TB remained an independent predictor for poor outcomes (OR-2.28 at 12 months, CI 1.45-9.50, p = 0.007, OR-3.75 at 3 years, CI 1.52-6.77, p = 0.001 for MACE). In conclusion, TB lesions, according to the Medina classification, portend worse prognosis for patients undergoing bifurcation PCI. This may guide prognostication and decision-making in treatment.

Objective: The transradial approach (TRA) has increasingly been adopted for the use of percutaneous coronary interventions (PCI), with reported clinical benefits. Little is known regarding the change in outcomes over time., Patients and Methods: From our large single-center PCI registry, we have analyzed 15 429 patients in two periods - 2008-2012 (period 1) and 2013-2017 (period 2). We examined the proportions of use of TRA, the influence on in-hospital outcomes, and adjusted long-term effects., Results: The rate of TRA rose from 15.9% in period 1 to 69.1% in period 2, including in specific situations such as acute coronary syndrome, chronic total occlusion, bifurcation, calcified lesions, and unprotected left main PCI. In-hospital rates of bleeding were lower for TRA versus transfemoral artery (1.8 vs. 5.1%, overall, P < 0.001), as were rates of additional bleeding events in the following 12 months (1.3 vs. 2.4%, P < 0.001). Following multivariate analysis, use of TRA was associated with a lower 30-day and 4-year rate of the composite outcomes of death, myocardial infarction, target vessel revascularization, or coronary artery bypass surgery [at 4 years, hazard ratio (HR) = 0.86; 95% confidence interval (CI): 0.77-0.96; P = 0.007, during period 1 and HR = 0.62; 95% CI 0.55-0.7; P < 0.0001 during period 2]. Interaction analysis showed a stronger effect at the latter period (HR = 0.69, 95% CI: 0.59-0.81, P < 0.001)., Conclusion: Over a decade of follow-up, TRA has gained acceptance for different PCI scenarios, including complex patients - a course which is associated with consistent short and long-term clinical benefits.

Background: Current guidelines for choosing between revascularization modalities may not be appropriate for young patients., Objectives: To compare outcomes and guide treatment options for patients < 40 years of age, who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) between 2008 and 2018., Methods: Outcomes were compared for 183 consecutive patients aged < 40 years who underwent PCI or CABG between 2008 and 2018, Outcomes were compared as time to first event and as cumulative events for non-fatal outcomes., Results: Mean patient age was 36.3 years and 96% were male. Risk factors were similar for both groups. Drug eluting stents were implemented in 71% of PCI patients and total arterial revascularization in 74% of CABG patients. During a median follow-up of 6.5 years, 16 patients (8.6%) died. First cardiovascular events occurred in 35 (38.8%) of the PCI group vs. 29 (31.1%) of the CABG group (log rank P = 0.022), repeat events occurred in 96 vs. 51 (P < 0.01), respectively. After multivariate adjustment, CABG was associated with a significantly reduced risk for first adverse event (hazard ratio [HR] 0.305, P < 0.01) caused by a reduction in repeat revascularization. CABG was also associated with a reduction in overall repeat events (HR 0.293, P < 0.01). There was no difference in overall mortality between CABG and PCI., Conclusions: Young patients with coronary disease treated by CABG showed a reduction in the risk for non-fatal cardiac events. Mortality was similar with CABG and PCI.

Background: The last decade, regarded as the DES era in PCI, has witnessed significant advances in the management of coronary disease. We aimed to assess temporal trends in the practice and outcome of percutaneous coronary intervention (PCI) during the drug eluting stent (DES) era., Methods: We analyzed 18,641 consecutive PCI's performed between January 2004 and December 2016, distinguished by procedural date (Q 1 : 2004-2006, n = 4,865; Q 2 : 2007-2009, n = 4,977; Q 3 : 2010-2012, n = 4,230; Q 4 : 2013-2016, n = 4,569)., Results: At presentation, mean patients age was 65 (±11) years and 22.8% were females. Over time, there was a rise in the relative number of octogenarians (Q 1 : 10.7% vs Q 4 : 15.5%, P < 0.001) and an increase in the burden of most comorbidities (e.g., left ventricular dysfunction ≥ moderate and chronic kidney disease, P < 0.001 for both). Despite a 2-fold increase in the rate of complex interventions, and a 3-fold increase in the rate of unprotected left-main angioplasty (P < 0.001 for both), the radial approach was increasingly adopted (Q 1 : 2% to Q 4 : 63.5%, P < 0.001). DES implantation increased from 43% to 83% at the expense of bare metal stent (BMS) application, and accompanied by drug coated balloon sprout to 1.8%, P < 0.001. Kaplan-Meier survival curves revealed a time-based enhanced outcome, with a decreased rate of death, MI, target vessel revascularization and CABG over the years., Conclusions: In the last decade, PCI has evolved to offer better outcome to more elderly, sicker patient population, with more complex coronary disease interventions. The shift to second generation DES and to enhanced PCI techniques may explain part of this progress., (© 2017 Wiley Periodicals, Inc.)

Objectives: To assess the diagnostic performance of angiography-derived fractional flow reserve (FFRangio) measurements in patients with stable coronary artery disease when used online in the catheterization laboratory during routine coronary angiography., Background: FFR, an index of the hemodynamic severity of coronary stenosis, is derived from invasive measurements using a pressure-monitoring guidewire and hyperemic stimulus. While FFR is the gold standard, it remains under-utilized. FFRangio may have several advantages owing to the reduced operator time, no wire-related or procedural complications, and no need for administration of vasodilators., Methods: FFRangio is a novel technology that uses a patient's hemodynamic data and routine angiograms to generate FFR values at each point along the coronary tree. We present the online application of the system where FFRangio was successfully used in the catheterization laboratory during routine coronary angiography and compared to invasive FFR. Fifty-three patients (79% men) and 60 coronary lesions were analyzed., Results: Values derived using FFRangio ranged from 0.58-0.96 and correlated closely (Pearson's correlation coefficient, r=0.91; P<.001) with the invasive FFR measurements (range, 0.52-0.97). The 95% limits of agreement between invasive and non-invasive FFR ranged from -0.065 to 0.07 using Bland-Altman analysis. For an FFR cut-off value of 0.80, the sensitivity, specificity, and diagnostic accuracy of FFRangio were 86%, 100%, and 95%, respectively., Conclusions: This is the first report of using the online application of the FFRangio system. In this single-center experience, FFRangio values showed high correlation rates to invasive FFR.

Background: Fractional flow reserve (FFR), an index of the hemodynamic severity of coronary stenoses, is derived from invasive measurements and requires a pressure-monitoring guidewire and hyperemic stimulus. Angiography-derived FFR measurements (FFR angio ) may have several advantages. The aim of this study is to assess the diagnostic performance and interobserver reproducibility of FFR angio in patients with stable coronary artery disease., Methods and Results: FFR angio is a computational method based on rapid flow analysis for the assessment of FFR. FFR angio uses the patient's hemodynamic data and routine angiograms to generate a complete 3-dimensional coronary tree with color-coded FFR values at any epicardial location. Hyperemic flow ratio is derived from an automatic resistance-based lumped model of the entire coronary tree. A total of 203 lesions were analyzed in 184 patients from 4 centers. Values derived using FFR angio ranged from 0.5 to 0.97 (median 0.85) and correlated closely (Spearman ρ=0.90; P <0.001) with the invasive FFR measurements, which ranged from 0.5 to 1 (median 0.84). In Bland-Altman analyses, the 95% limits of agreement between these methods ranged from -0.096 to 0.112. Using an FFR cutoff value of 0.80, the sensitivity, specificity, and diagnostic accuracy of FFR angio were 88%, 95%, and 93%, respectively. The intraclass coefficient between 2 blinded operators was 0.962 with a 95% confidence interval from 0.950 to 0.971, P <0.001., Conclusions: There is a high concordance between FFR angio and invasive FFR. The color-coded display of FFR values during coronary angiography facilitates the integration of physiology and anatomy for decision making on revascularization in patients with stable coronary artery disease., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03005028., (© 2017 American Heart Association, Inc.)

Objectives: The study sought to examine the effect of coronary artery disease (CAD) on mortality in patients undergoing transcatheter aortic valve replacement (TAVR)., Background: CAD is common in the TAVR population. However, there are conflicting data on the prognostic significance of CAD and its treatment in this population., Methods: The authors analyzed 1,270 consecutive patients with severe aortic stenosis (AS) undergoing TAVR at 3 Israeli centers. They investigated the association of CAD severity (no CAD, nonsevere CAD [i.e., SYNTAX score (SS) <22], severe CAD [SS >22]) and revascularization completeness ("reasonable" incomplete revascularization [ICR] [i.e., residual SS <8]; ICR [residual SS >8]) with all-cause mortality following TAVR using a Cox proportional hazards ratio model adjusted for multiple prognostic variables., Results: Of the 1,270 patients, 817 (64%) had no CAD, 331 (26%) had nonsevere CAD, and 122 (10%) had severe CAD. Over a median follow-up of 1.9 years, 311 (24.5%) patients died. Mortality was higher in the severe CAD and the ICR groups, but not in the nonsevere CAD or "reasonable" ICR groups, versus no CAD. After multivariate adjustment, both severe CAD (hazard ratio: 2.091; p = 0.017) and ICR (hazard ratio: 1.720; p = 0.031) were associated with increased mortality., Conclusions: Only severe CAD was associated with increased mortality post-TAVR. More complete revascularization pre-TAVR may attenuate the association of severe CAD and mortality., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Cancer patients are mostly excluded from percutaneous coronary intervention (PCI) clinical trials and oncologic history is lacking from most PCI registries. Thus, little is known about the clinical outcomes following PCI among cancer survivors. Our aim was to examine the prevalence and long-term outcome of cancer survivors among a large PCI patient cohort., Methods: We retrospectively integrated and analyzed cardiovascular and oncologic data of 12 785 consecutive patients who underwent PCI between April 2004 and October 2014. Cancer survivors were compared with pair-matched cancer-naive patients., Results: Cancer survivors constituted 7.8% (1005) of the patients. The mean cancer diagnosis-to-PCI interval was 3.6±3.4 years and the mean post-PCI follow-up was 6.4±5.9 years. Postmatching baseline characteristics were similar between the groups. Cancer survivors were referred to the catheterization laboratory because of acute coronary syndrome and were treated with bare-metal stents more often than cancer-naive patients. Cancer survivors to cancer-naive patients' hazard ratio and 95% confidence interval were 1.46 (1.24-1.72), P value less than 0.001 for all-cause mortality and 1.41 (1.23-1.63), P value less than 0.001 for the composite of death, nonfatal myocardial infarction, target vessel revascularization, and coronary bypass surgery. Cardiac death was the leading cause of mortality in our hospital during follow-up in both groups, although more cancer survivors died of malignancy (25 vs. 5%, P<0.001)., Conclusion: Cancer survivors constitute a high proportion of the PCI population (one in every 13 patients) and have an ∼40% increased risk for cardiovascular morbidity and death. Cardiac disease was a leading cause of in-hospital mortality among these patients.

Coronary artery calcium (CAC) is associated with poor angiographic results and higher rates of complications after percutaneous coronary intervention (PCI). Limited data are available regarding the impact of angiographically evident CAC on long-term outcomes after primary PCI in patients presenting with ST-segment elevation myocardial infarction (STEMI). In this single-center, registry-based retrospective cohort analysis, we analyzed 2,143 consecutive patients presenting with STEMI who underwent primary PCI within 12 hours of symptom onset. Patients were divided based on degree of CAC (determined by visual inspection of angiograms) as follows: (1) moderate-to-severe CAC (n = 306; 14.3%) and (2) minimal-to-none CAC (n = 1,837; 85.7%). The primary end point was all-cause mortality at 1-year after PCI. Patients with moderate-to-severe CAC were older, women, and had higher rates of hypertension, chronic kidney disease, and peripheral vascular disease. Moderate-to-severe CAC was associated with higher rates of anterior myocardial infarction, advanced Killip class, and poor final angiographic results. At 1-year follow-up, rates of all-cause mortality were higher in the moderate-to-severe CAC cohort than those in the minimal-to-none CAC cohort (8.5% vs 4.7%; p = 0.008). However, after accounting for major clinical and angiographic characteristics, moderate-to-severe CAC on presenting STEMI angiogram was no longer predictive of 1-year all-cause mortality. In conclusion, advanced CAC burden occurs in ∼15% of patients undergoing primary PCI for STEMI and reflects a marker of adverse prognosis late into follow-up after PCI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Bioresorbable vascular scaffold (BVS) is a promising technology that potentially offers several advantages over contemporary coronary drug-eluting stents (DES). Crucial to BVS implantation is the correct choice of scaffold size (diameter and length) in order to avoid "geographic miss" in length, provide the maximal support to the vessel wall, and avoid leaving "free-floating" foreign material in the coronary vasculature., Objectives: To assess the optimal method for measuring coronary stenosis prior to BVS implantation., Methods: We compared the performance of two quantitative coronary angiography assessment (QCA) techniques: two dimensional real-time QCA (2D-QCA) and offline 3D QCA (3D-QCA) for the evaluation of coronary lesions in patients enrolled in a multicenter randomized controlled trial of BVS vs. metallic stents, by calculating the weighted kappa value for agreement regarding optimal BVS size with the reference method - CoreLab offline 2D-QCA measurements..In addition, we collected 2 year clinical outcomes (death/myocardial infarction/repeat revascularization/scaffold thrombosis) in BVS-implanted patients., Results: In 17 patients with available CoreLab data, the weighted kappa for agreement for 3D-QCA was significantly better than for 2D-QCA (0.90, 95%CI 0.72-1.00 vs. 0.439, 95%CI 0.16-0.77). The rate of clinical events at 2 years was low (9.5%)., Conclusions: Initial experience in a small group of carefully selected patients at our institution, suggests that the use of BVS for coronary revascularization is associated with a low rate of adverse events in suitable patients. 3D-QCA may be superior to 2D-QCA analysis in terms of reproducibility, and results in more patients receiving optimal size BVS.

The application of the CHA2DS2-VASC score as a novel risk stratification tool for predicting outcome in clinical applications other than atrial fibrillation and stroke prevention has been previously examined. However, its usefulness in a population of patients with coronary artery disease after percutaneous coronary intervention (PCI) has not been explored. We investigated 12,785 consecutive patients who underwent PCI in a tertiary medical center from April 2004 to August 2014 (mean follow-up 6.5 years) and computed the CHA2DS2-VASC score on their index PCI. We assessed the relation between the CHA2DS2-VASC score and clinical outcomes (for example, all-cause mortality and mortality or myocardial infarction) at 1 and 5 years. The mean CHA2DS2-VASC score was 3.7 ± 1.7, 59.1% of patients obtained a score of 3 to 5. Both the primary and secondary outcomes at 1 and 5 years were significantly more frequent as the CHA2DS2-VASC score increased. Overall, the mortality rate after PCI was 10 times higher for patients with a CHA2DS2-VASC score of 5 compared with a score of 1 at both 1-and 5-year follow-up. The CHA2DS2-VASC score predicted all-cause mortality and death or nonfatal myocardial infarction in a significant (p <0.001, C-index 0.73 and 0.72) and linear fashion. In conclusion, the CHA2DS2-VASC score can be used as a simple and effective tool to predict long-term clinical outcomes in patients undergoing PCI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To estimate the prevalence, identify predictors, and assess the prognostic implications of left ventricular ejection fraction (LVEF) changes after an elective percutaneous coronary intervention (PCI)., Methods: We included all consecutive patients who underwent elective PCI in our institution and were evaluated with echocardiography before and within 1 year of the procedure. Patients were grouped in terms of baseline LVEF. Hazard ratios (HRs) for all-cause mortality and acute myocardial infarction were calculated for baseline LVEF groups and in terms of LVEF normalization or decline., Results: A total of 974 patients were included. Patients with moderately impaired (HR 1.41, P=0.01) and poor LVEF (HR 2.44, P<0.001) had significantly worse survival in comparison with patients with good LVEF. Decline from preserved to impaired LVEF following PCI was associated with an increased 1-year risk (HR 3.48, P<0.001) and 5-year risk (HR 2.79, P<0.001) for the composite outcome of all-cause mortality and acute myocardial infarction. LVEF recovery from impaired to preserved was associated with a decreased 5-year risk for the composite outcome (HR 0.5, P<0.001)., Conclusion: Changes in LVEF after elective PCI occur often. Both higher baseline LVEF and post-PCI LVEF normalization are associated with improved outcomes.

Aims: To evaluate the effect of coronary artery disease (CAD) severity and completeness of revascularization on clinical outcomes following transcatheter aortic valve replacement (TAVR) using the SYNTAX score (SS), clinical SYNTAX score (cSS), and residual SYNTAX score (rSS)., Methods and Results: We studied 287 consecutive patients undergoing TAVR at our institution. Patients were classified as having CAD or no CAD and coronary patients were stratified according to SS and cSS. The completeness of revascularization was stratified using the rSS. We compared the 2-year outcomes according to SS/cSS/rSS. Forty-nine patients (17.1%) had CAD and sustained a higher rate of the primary endpoint at 2 years (28.3 vs. 16.1%, P=0.026). Stratified by CAD severity, the difference was driven by the high-severity groups (75.0 vs. 16.1%, P=0.002 for SS>22 and 41.2 vs. 16.1%, P=0.001 for cSS>63). Low-severity CAD patients did not have worse outcomes versus no CAD. When evaluating the effect of revascularization, patients with a rSS less than 8 did not have worse outcomes versus patients who did not have CAD., Conclusion: In patients undergoing TAVR, it is the severity of CAD (as assessed by the SS/cSS) that is associated with worse prognosis and not the mere presence of CAD. More complete revascularization attenuates the effect of CAD on clinical outcomes.

Aims: In about 50-80% of ST-segment elevation myocardial infarction (STEMI) patients there is significant atherosclerotic disease in other coronary arteries in addition to the culprit vessel. There is substantial controversy as to the optimal revascularization approach in these patients. We sought to compare the outcomes of STEMI patients with multi-vessel disease (MVD) treated with culprit-only primary percutaneous coronary intervention (PPCI) without significant ischemia on subsequent non-invasive testing, to those of STEMI patients with single-vessel disease (SVD)., Methods and Results: Between 2001-2010, 1,540 consecutive patients treated with primary PCI for STEMI were prospectively observed and entered into a comprehensive clinical database. The primary end point was a composite of major adverse cardiac events (MACE), consisting of mortality, re-infarction and revascularization within 1 and 3 years following PPCI (excluding events occurring during the first 30 days). Patients with cardiogenic shock were excluded. The study included 720 patients with SVD and 185 patients with MVD who underwent culprit-only PPCI and had no residual ischemia on subsequent non-invasive stress testing. Patients with MVD were older, more likely to have hypertension or previous MI and less likely to be smokers and present with anterior MI than patients with SVD. One and 3-year MACE rates were similar between the groups. On cox proportional-hazards regression MVD without residual ischemia was not independently associated with MACE and its components., Conclusions: STEMI patients with MVD treated with culprit only-PCI without significant residual ischemia on non-invasive stress testing appear to have similar prognosis to STEMI patients with SVD.

Objective: To broaden the data supporting the use of the residual SYNTAX score (rSS) to define "reasonable" incomplete coronary revascularization (ICR) in order to improve the allocation of patients with severe coronary artery disease (CAD) to surgical/percutaneous revascularization and long-term clinical outcomes., Introduction: ICR is associated with a worse prognosis in patients with severe CAD, yet no consensus exists regarding its definition., Methods: We studied 148 consecutive patients with triple vessel/left main (3VD/LM) CVD treated by percutaneous coronary interventions (PCI). Clinical outcomes at 3 years were collected; the SS and rSS were calculated. We used various definitions of "reasonable" ICR:no post-PCI total occlusion, single vs. mutivessel residual post-PCI disease, and the rSS at a cutoff value determined according to ROC curve fitted for 3 years major adverse cardiovascular and cerebrovascular adverse events (MACCE) in order to determine which definition has the strongest correlation with long-term outcomes., Results: rSS ≤ 8 was associated with significant reductions in 3 year MACCE (19.4 vs. 51.1%, HR = 3.62, P = 0.014) Death/MI/CVA (13.7 vs. 28.8%, HR = 6.01, P = 0.030) and repeat revascularization (8.6 vs. 28.9%, HR = 3.44, P = 0.033) using a Cox proportional hazard ratio model adjusted to baseline characteristics, whereas single vessel residual disease and absence of total occlusion were not., Conclusions: "Reasonable" ICR as determined by rSS carries better long-term prognosis in terms of clinical outcomes vs. more extensive residual coronary disease in patients with 3VD/LM coronary artery disease treated by PCI. The rSS may improve the allocation of coronary patients to the optimal mode of revascularization., (© 2014 Wiley Periodicals, Inc.)

Aims: Second-generation drug eluting stent (DES) implantation gradually replaced the first-generation DES in clinical practice. Whether the new DESs in use differ from one another, in terms of clinical outcomes, is still not known. We explored potential differences among DESs., Methods and Results: We followed 9584 consecutive patients undergoing percutaneous coronary intervention at our institution (2004-2012; mean follow-up, 2.8 years). Patients treated with bare-metal stent (BMS; n = 5599; 58.4%) were compared to 3985 DES counterparts (41.5%). The sirolimus-eluting stent (SES) served as the prototype for comparison to other DES types, using propensity matching. The primary outcome was a composite endpoint of total mortality, myocardial infarction, and clinically driven target vessel revascularization or coronary artery bypass graft. At 3 years, the composite endpoint was significantly lower in the DES vs. BMS group (17.9% vs. 25.3%; P<.001). Comparisons between SES and each of the five other stent types yielded no significant differences for the primary composite endpoint: SES vs. paclitaxel-eluting stent (n = 350 pairs; 18.1% vs. 17.7%; P=.70); vs. zotarolimus-eluting stent (n = 474 pairs; 21.8% vs. 23.2%; P=.35); vs. Resolute zotarolimus-eluting stent (n = 434 pairs; 16.9% vs. 11.7%; P=.70); vs. everolimus-eluting stent (n = 824 pairs; 14.2% vs. 14.1%; P=.60); and vs. biolimus-eluting stent (n = 117 pairs 13.7% vs. 13.4%; P=.60)., Conclusions: Cardiac prognosis did not differ between sirolimus and other DES types. The use of DES was associated with better clinical outcomes compared to BMS.

Aims: The SYNTAX score (SS) has been shown to identify subgroups of patients with left main or triple-vessel coronary artery disease (LM/3VCAD) that can be treated with a percutaneous coronary intervention (PCI) with equal clinical outcomes as coronary artery bypass surgery (CABG).We sought to assess the adequacy of referral to PCI/CABG of patients with LM/3VCAD at our institution., Patients and Methods: We retrospectively matched all patients with LM/3VCAD referred to CABG (n=145) to patients referred to PCI in our institution during 2009-2010. We calculated the SS and clinical SS (cSS) according to the European Society of Cardiology guidelines and compared the agreement rates between the revascularization modality and the SS as well as clinical outcomes at the 3-year follow-up., Results: The overall agreement rates between the revascularization procedure and the SS was 67%, for example the rate was higher in patients referred to PCI compared with CABG (78 vs. 49%) and patients with 3VCAD compared with patients with LMCAD (68 vs. 51%). Patients without agreement between the revascularization modality and the SS had higher rates of combined adverse cardiac events (42.6 vs. 27% P=0.008). Similar results were observed when using the cSS at different cutoff levels., Conclusion: At our institution, there was considerable disagreement between a clinical judgment-based coronary revascularization and the SS/cSS-based allocation process as to the preferred revascularization modality for patients with complex CAD. Our results suggest that integrating the SS/cSS into the decision-making process for assigning patients to revascularization would yield better clinical outcomes.

Functional mitral regurgitation (MR) is common in patients with ischemic cardiomyopathy. We present a case of an 83-year-old patient with ischemic heart disease and ischemic cardiomyopathy, who was repeatedly admitted for pulmonary edema and underwent a percutaneous trans-septal MitraClip procedure. During coronary angiography, a severe left main stenosis was demonstrated. Treatment included both percutaneous coronary intervention and the implantation of two MitraClip devices, with very good results. We believe that this case illustrates the need for comprehensive assessment of ischemia in patients with functional MR., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Aims: To conduct a risk-adjusted gender-based analysis of clinical outcomes following drug-eluting stent (DES) versus bare metal stent (BMS) implantation in patients with coronary artery disease., Methods and Results: We compared risk-adjusted total mortality rate, myocardial infarction, and event-free survival (defined as freedom from death, myocardial infarction and/or repeat revascularisation) in a consecutive cohort of 7,662 patients undergoing percutaneous coronary intervention at our institution, including 1,835 (25.4%) women. Follow-up was six months to 6.2 years (mean: 3.5 years; median: 3.6 years). The women were older than men and more likely to suffer from diabetes, hypertension or congestive heart failure. Smokers were more often men, and men were more likely to have had prior coronary bypass surgery compared to women. A DES was used in 39.9% of males and 39.5% of females. Both genders derived a significant long-term clinical benefit from DES compared to BMS; advantages were observed for mortality (men: HR=0.78, 95% CI: 0.64-0.96, p=0.016; women: HR=0.62, 95% CI: 0.45-0.85, p=0.003) and major adverse cardiac events (men: HR=0.73, 95% CI: 0.63-0.84, p<0.001; women: HR=0.76, 95% CI: 0.52-0.84, p=0.001). Among BMS-treated patients, women had worse cumulative clinical outcomes than men. DES eliminated the gender differences in cardiac prognosis., Conclusions: Our analysis indicated a profound prognostic advantage for DES versus BMS among both genders, though female patients appeared to derive the greatest benefit.

Objectives: We aim to explore the clinical outcome of drug-eluting stents (DES) versus bare-metal stents (BMS) implantation in diabetics versus nondiabetic patients., Background: Diabetic patients sustain worse long-term clinical outcomes after percutaneous coronary interventions (PCI) when compared with nondiabetics. The use of DES decreases the rate of repeat revascularization in this population but data concerning long-term clinical benefits, such as myocardial infarction (MI) or mortality is scant., Methods: We analyzed data from a comprehensive registry of 6,583 consecutive patients undergoing PCI at our center. A propensity score was used for analysis of outcomes and for matching (DES vs. BMS). Outcome parameters were total mortality, MI, repeat target vessel revascularization (TVR) rates, and risk-adjusted event-free survival. Within this cohort, we identified 2,571 nondiabetic patients and these were compared with 1,826 diabetic coronary patients., Results: Mean and median follow up time was 3 and 3.25 years, respectively. Overall, diabetics had higher rates of major-adverse cardiovascular events (MACE) at 4 years compared with nondiabetics (23.03 vs. 31.96 P > 0.001). DES use was associated with lower rates of TVR in both groups [diabetics hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.42-0.76, P < 0.001, nondiabetics HR = 0.73, 95% CI: 0.55-0.97, P = 0.03] while sustained decreased rates of both mortality and MI were evident solely among diabetics (HR = 0.71, 95% CI: 0.56-0.89, P = 0.004 in diabetic vs. HR = 0.88, 95% CI: 0.69-1.13, P = 0.3)., Conclusions: In a "real-world," unselected population and extended clinical use, DES in diabetics was associated with sustained decreased rates of MI, death, TVR, and MACE while this benefit was attenuated in the nondiabetic population., (Copyright © 2011 Wiley-Liss, Inc.)

Aims: Given the anecdotal reports and case series suggesting that drug-eluting coronary stents [DES] may be still vulnerable to coronary thrombosis after six months, we sought to assess this risk in patients undergoing non-cardiac surgery six months after stenting., Methods and Results: Linking the Rabin Medical Centre interventional cardiology database with its non-cardiac surgical database, we identified 78 patients who underwent DES placement and subsequently [after six months] had noncardiac surgery [15-vascular, 37- abdominal and genitourinary and 26-others, excluding ophthalmic surgery]. Outcome measures included 30-day rate of postoperative myocardial infarction (MI), DES-related thrombosis, and cardiac mortality. Major adverse cardiac events [death and non-fatal MI] occurred in 6 (7.7%) patients including 2 cardiac deaths (2.6%), 4 (5.1%) non-fatal myocardial infarctions (MIs). Two patients (2.6%) sustained stent thrombosis [one patient had 'definite' and one 'probable' stent thrombosis]. All MIs [including stent thrombosis] occurred in the vascular and abdominal surgery group. Two of the MIs events occurred while the patients were on dual antiplatelet agents., In Conclusions: Perioperative cardiac events during non cardiac surgery after six months of DES deployment still occur. These cardiac complications [not entirely prevented by continued dual antiplatelet agents] remain a matter of diagnostic and therapeutic challenge and concern., (Copyright 2009 Wiley-Liss, Inc.)

Aims: To conduct a clinical registry of consecutive "real world" patients treated using the PRO-Kinetic stent at Rabin Medical Centre between January 2006 and March 2008., Methods and Results: Our study included 515 consecutive patients treated for 540 lesions. We had a 100% follow-up rate at six months. The patients' characteristics are noted as having a 43% rate of diabetics and a 17% renal insufficiency. Indications for angioplasty included patients with either stable or unstable clinical scenarios and 60% of the lesions were of class B2/C. The mean RVD was 2.81 mm and lesions length was 12.6 mm prior to PCI and with angiographic success in 99.8% of treated lesions. The six month clinical outcome data were as follow: MACE rate of 8.7% with 3.5% total mortality, 1.9% cardiac mortality, 1.4% of any MI and TVR rate of 6.4% per treated patient and 6.7% per treated lesion and 0.4% rate of stent thrombosis., Conclusions: Based on our findings, 1) The PRO-Kinetic clinical data shows excellent results on a large group of coronary patients, treated consecutively. 2) The data should emphasise the remaining role of 'state of the art' non DES platforms (i.e. such as PRO-Kinetic) for patients with a wide variety of characteristics and/or clinical syndromes.

We describe a patient with an unusual case of very late dual Cypher stent thrombosis that caused massive acute myocardial infarction and cardiogenic shock, which were treated using emergent resuscitation and angioplasty.

Aims: There are limited data regarding clinical outcomes of drug-eluting stents (DES) in saphenous vein grafts (SVGs) compared to bare metal stents (BMS). Here we compared outcomes of DES in de novo SVG lesions versus BMS in contemporary percutaneous coronary intervention (PCI)., Methods and Results: We compared in-hospital, 6-month, 1-year and two years outcomes in 68 patients (72 grafts) who underwent PCI of SVG lesions using DES and a control BMS group composed of 43 patients (46 grafts) who underwent angioplasty in de novo SVG lesions. Major adverse cardiac events (MACE) included death, myocardial infarction (MI), target lesion revascularisation (TLR), and target vessel revascularisation (TVR). The rates of TLR and TVR at the 1-year evaluation were lower in the DES group than the BMS group (TLR per patient, 7.4% vs. 21%, P=0.04; TVR per patient, 10.3% vs. 23.3%, P=0.1). MACE-free survival was 88.2% in the DES group and 69.8% in the BMS group (P=0.02). At two years clinical follow-up: death 2.9% vs. 4.7% (P=0.6); MI: 8.8% vs. 7% (P=0.6). The rates of TLR and TVR were significantly lower in the DES group compared to the BMS group (TLR per patient, 14.7% vs. 32.6%, P=0.03; TVR per patient, 10.3% vs. 27.9%, P=0.02). The rate of MACE-free survival was 79.4% in the DES group and 58.1% in the BMS group (P=0.02). Between one to two years after PCI, no cases of angiographic stent thrombosis were recorded in either group., Conclusions: DES implantation in SVG lesions was safe and had favourable outcomes after two years without excess cardiac mortality.

Background: There are few data about percutaneous coronary interventions (PCI) in nonagenarians (patients aged > or =90 years). This study aimed to assess acute and intermediate term clinical outcomes among nonagenarian patients undergoing PCI., Methods: The study included 65 consecutive patients, age > or =90 years undergoing PCI between January 2001 and August 2006. Fourteen patients were admitted with acute ST elevation acute myocardial infarction (STEAMI), one had cardiogenic shock, 39 patients sustained non-STEAMI, and 12 patients were with severe stable angina pectoris. Procedural data, in-hospital, and six-month clinical outcomes were obtained and adjudicated for all patients., Results: Coronary angiography documented multivessel disease in 86% of patients with relatively complex lesions (type B or C) in 94% treated using stent deployment in 92% of patients. In 7% of cases IABP was needed. Immediate procedural success was achieved in 92% patients. Cumulative mortality at hospital discharge and by 30-days was 14% and increased to 18% at 6-months follow-up. Total major adverse cardiac events (MACE: death, AMI, TVR, stroke) was 17% at hospital discharge and increased to 21% by 6-months. Stroke was documented in one patient (1.5%) at hospital discharge. Cumulative mortality at 6 month was 0% in patients with stable angina and 23% in emergent PCI scenario (AMI or NSTEAMI or ACS). Univariate analysis revealed that emergent PCI, systolic blood pressure, left ventricular ejection fraction, diabetes mellitus, renal failure, TIMI flow at baseline, and procedural success, are all correlative with 6-months mortality., Conclusion: We conclude that clinically stable nonagenarian patients with coronary artery disease undergoing PCI have excellent PCI related prognosis while clinically unstable patients have a worse outcome. Thus, careful attention to background medical history and clinical presentation should dictate the prognosis and/or management among nonagenarian patients., (Copyright 2007 Wiley-Liss, Inc.)

Objective: We examined our experience using the sirolimus eluting stents (Cypher) as an alternative to surgical revascularization in carefully selected cohort of patients undergoing multi-vessel percutaneous coronary intervention., Methods: Fifty consecutive patients with multi-vessel disease who were good candidates for both surgical and percutaneous revascularization were included in the current analysis. All patients underwent a careful clinical evaluation prior to the intervention, and they were followed for procedural and clinical outcomes for nine months., Results: Mean age was 64+/-11 years (40 males, 30% diabetics) and 10 patients (20%) had three-vessel disease. Angina class was 2.7+/-0.6 at baseline. Overall, 116 lesions were treated using 122 stents (mean 2.4 stents per patient). Total mean stent length was 43+/-12 mm (range: 21-90 mm). Overall, one patient died during follow-up (2%), no patient had stroke or Q wave MI and one patient experienced non-Q myocardial infarction. There was no documented stent thrombosis and two patients (4%) underwent target-vessel revascularization. The hierarchical cumulative major adverse cardiac event rate was 8% and the cardiac event-free survival rate was thus 92%., Conclusion: Multi-vessel stenting using Cypher stents is a viable treatment strategy in selected group of patients with multi-vessel coronary artery disease. It is associated with excellent intermediate-term clinical outcomes and thus it could serve as the primary revascularization strategy of choice in appropriate candidates.