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Left main stem percutaneous coronary intervention (LMS-PCI) is a complex high-risk procedure which can be performed as an alternative to coronary artery bypass graft (CABG) procedure in surgical turn-down patients or where there is equipoise in percutaneous versus surgical strategies. Current guidelines suggest that PCI is an appropriate alternative to CABG in patients with unprotected LMS disease and low SYNTAX score. However, "real world" data on outcomes of LMS-PCI remain limited. This study aims to quantify and determine predictors of mortality following LMS-PCI.Using local coronary angioplasty registries from two UK centers, all LMS-PCI cases were identified from 2016 to 2020. Descriptive statistics and multivariate logistic regressions were used to examine the association between baseline and procedural characteristics with 30-day and 12-month mortality.We identified 484 cases of LMS-PCI between 2016 and 2020. There was a year-on-year increase in the number of LMS-PCI, the highest being in 2020. Covariates associated with higher 30-day mortality were age (OR 1.07, 95% CI: 1.02-1.12) and shock preprocedure (OR 23.88, 95% CI: 7.90-72.20). Covariates associated with higher 12-month mortality were age (OR 1.04, 95% CI: 1.01-1.08), acute coronary syndrome (ACS) (OR 2.50, 95% CI: 1.08-5.80), renal disease (OR 5.24, 95% CI: 1.47-18.68), and shock preprocedure (OR 7.93, 95% CI: 3.30-19.05). Overall, 30-day and 12-month mortality in this contemporary data set were 9.5% and 16.7%, respectively, with significantly lower rates in elective cases (p 0.01).Older age and cardiogenic shock preprocedure were associated with increased 30-day mortality after LMS-PCI. Twelve-month mortality was associated with older age, ACS presentation, preexisting renal disease, and cardiogenic shock preprocedure.

Objectives The aim of this study is to assess the feasibility, efficacy and safety of the “RotaTripsy” approach in severe calcified coronary artery lesions. Background Coronary lesions with a high calcium content represent a challenging scenario in interventional cardiology , requiring a proper lesion preparation. In this light, very little is known about the possibility to combine the benefits of rotational atherectomy and intravascular lithotripsy . Methods We retrospectively enrolled 34 patients from a real-word, multicenter, cohort of patients affected by severe calcified coronary artery lesions, which required the “RotaTripsy” to obtain a proper lesion preparation. In all the cases, rotational atherectomy and then intravascular lithotripsy were performed as a bail-out strategy following sub-optimal non-compliant balloon expansion. In 53% of the cases, the procedure was guided by intracoronary imaging findings. Results Procedural success was reported in all the cases, without any in-hospital major complication. Few major adverse clinical events were reported at mid-term follow-up. Conclusions “RotaTripsy” can represent a valid therapeutic option for undilatable heavily calcified coronary artery lesions. Our findings demonstrate the feasibility, safety and efficacy of this approach.

BackgroundAcute coronary syndrome (ACS) is caused by arterial thrombosis and is associated with sustained activation of coagulation. Clotting requires interactions of coagulation factors with aminophospholipids (aPL): phosphatidylserine (PS) and phosphatidylethanolamine (PE) on membrane surfaces. The aPL composition of circulating membranes in coronary disease has not been characterized. Furthermore, the contribution of external-facing aPL to elevated thrombotic risk in ACS is unknown.Methods and resultsThrombin generation was measured on platelet, leukocyte and extracellular vesicles (EV) from patients with ACS (n = 24), stable coronary artery disease (CAD, n = 18), risk factor positive (RF, n = 23) and healthy controls (HC, n = 24). The aPL composition on the surface of EV, platelets and leukocytes was determined using lipidomics. Leukocytes, platelets and EV externalized PE- and PS-containing fatty acids ranging from C16:0-20:4. These included both diacyl and plasmalogen forms, with significant increases stimulated by agonist activation. Thrombin generation on the surface of EV and leukocytes was higher in ACS than HC. Also, thrombin generation was higher for EV from CAD and RF, than HC. EV counts were higher in CAD and ACS compared with HC. Thrombin generation correlated positively with plasma EV counts and membrane surface area.ConclusionThe aPL membrane of EV and leukocytes may contribute to the activation of coagulation in CAD and ACS. Targeting EV formation/clearance and the aPL surface of EV and leukocyte membranes represents a novel anti-thrombotic target in CAD and ACS.Condensed abstractAcute coronary syndrome (ACS) is associated with sustained activation of coagulation, requiring procoagulant aminophospholipids (aPL). However, the aPL composition of circulating membranes and their contribution to thrombotic risk in ACS is undetermined. Lipidomics demonstrated that leukocytes, platelets and extracellular vesicles (EV) externalized aPL-containing fatty acids ranging from C16:0-20:4. Thrombin generation on the surface of EV and leukocytes was higher in ACS patients than healthy controls (HC). EV counts were higher in ACS compared with HC and correlated positively with thrombin generation. In summary, aPL in the outer membranes of EV and leukocytes may contribute to elevated thrombotic risk in ACS.HighlightsWhat is new?The aPL profile of platelets, leukocytes and EV in patients with ACS, CAD, RF and HC is defined for the first-time using lipidomics.Thrombin generation on the surface of unstimulated leukocytes, is elevated in patients with ACS compared with HC.Thrombin generation on the surface of EV is elevated in patients with ACS, CAD and RF compared with HC.EV counts in patients with ACS/CAD/RF were elevated compared with HC and correlate positively with thrombin generation.Clinical PerspectiveWhat are the clinical implications?The membranes of EV and leukocytes may contribute to the activation of coagulation in ACS.The aPL in EV and leukocyte membranes represent a novel target for reducing thrombotic risk in ACS.Targeting EV formation/clearance could reduce thrombotic risk in CAD and ACS.

To explore the long-term clinical outcomes following intravascular lithotripsy (IVL) in calcified coronary lesions from a real-world population.IVL is a relatively new but promising modality for treating coronary calcified lesions, but there is a dearth of long-term outcome data from real-world patients.This was a multicenter, observational study in which we enrolled all patients treated with IVL from November 2018 to February 2021 from eight centers in Europe and the United Kingdom. Procedural success, complications, and clinical outcomes (cardiac death, target vessel myocardial infarction [TVMI], target lesion revascularization [TLR], and MACE [major adverse cardiac events, the composite of cardiac death, TVMI, and TLR]) were assessed.In total, 273 patients with a mean age of 72 ± 9.1 years were treated with IVL. Major comorbidities included diabetes mellitus (n = 110, 40%) and chronic kidney disease (n = 45, 16%). Acute coronary syndrome accounted for 48% (n = 132) of patients, while 52% (n = 141) had stable angina. De novo lesions and in-stent restenosis accounted for 79% and 21% of cases, respectively. Intravascular imaging was used in 33% (n = 90) of patients. An upfront IVL strategy was adopted in 34% (n = 92), while the rest were bailout procedures. Adjuvant rotational atherectomy ("RotaTripsy") was required in 11% (n = 31) of cases. The procedural success was 99%. During a median follow-up of 687 days (interquartile range: 549-787), cardiac death occurred in 5% (n = 14), TVMI in 3% (n = 8), TLR in 6% (n = 16), and MACE rate was 11% (n = 30).This is the largest multicenter registry with a long-term follow-up showing the remarkably high procedural success of IVL use in calcified coronary lesions with low rates of hard endpoints and MACE.

Enzymatically oxygenated phospholipids (eoxPL) formed by lipoxygenases (LOX) and cyclooxygenase (COX) in platelets and leukocytes are pro-coagulant in multiple model systems. However, their generation in arterial thrombotic disease, and how their levels are modulated by common therapies is unknown. Here, eoxPL were first characterized in isolated platelets and leukocytes from an arterial vascular disease cohort, a healthy cohort administered low dose aspirin, and from retrieved human arterial thrombi. In both cohorts, aspirin reduced platelet COX-1-derived eoxPL, while elevating diacyl 12-LOX-derived eoxPL in males, through enhanced Lands’ cycle esterification. Conversely, P2Y12 inhibition reduced 12-LOX-derived eoxPL in leukocytes. Complex aspirin-dependent gender and seasonal effects on platelet eoxPL were seen in healthy subjects. Limb or coronary (STEMI) thrombi showed a platelet eoxPL signature while carotid thrombi had a white cell profile. Mice genetically lacking leukocyte 12/15-LOX, which are deficient in eoxPL, generated smaller carotid thrombi in vivo. In summary, pro-coagulant eoxPL generation is altered in human arterial vascular disease by commonly used cardiovascular therapies. These changes to the phospholipid composition of blood cells in humans at risk of thrombotic events may be clinically significant where the pro-coagulant membrane plays a central but poorly understood role in driving elevated thrombotic risk.Key PointseoxPL generation is altered in health and arterial vascular disease by aspirin or P2Y12 inhibitors, and shows gender and seasonal variation.Aspirin regulates eoxPL by inhibiting cyclooxygenase and modulating Lands’ cycle.The eoxPL profile of human arterial thrombi identifies platelet and leukocyte involvement.Mice deficient in LOX-derived eoxPL form smaller arterial thrombiin vivo.

Background: In the TALENT study, the sirolimus-eluting ultrathin strut Supraflex stent was non-inferior to the XIENCE stent for a device-oriented composite endpoint (DoCE: defined as cardiac death, target vessel myocardial infarction [TV-MI], or clinically indicated target lesion revascularisation [CI-TLR]) at 12 months. Aims: This study investigated the 3-year outcomes of the TALENT trial and long-term impact of ultrathin drug-eluting stents (DES), compared to the XIENCE everolimus-eluting thin stent. Methods: The TALENT trial is a prospective, multicentre, randomised all-comers trial comparing the Supraflex sirolimus-eluting stent with the XIENCE everolimus-eluting stent, with planned follow-up for 3 years. Results: The TALENT trial enrolled 1,435 patients (Supraflex n=720, XIENCE n=715) with 3-year follow-up data available in 97.8% in the Supraflex group, and in 98.9% in the XIENCE group. At 3 years, DoCE occurred in 57 patients (8.1%) in the Supraflex group, and in 66 patients (9.4%) in the XIENCE group (p=0.406). There were no significant between-group differences in rates of cardiac death, TV-MI or CI-TLR. The rates of definite or probable stent thrombosis were low and similar between groups (1.1% vs 1.4%; p=0.640). In a meta-analysis of long-term follow-up (3-5 years), ultrathin strut DES tended to reduce DoCE (relative risk 0.89 [0.79-1.01]; p=0.068), compared to thicker strut DES. The risks for cardiac death and definite or probable stent thrombosis were similar between ultrathin strut DES and thicker strut DES. Conclusions: At 3-year follow-up, the use of the Supraflex stent was at least as safe and efficacious as the XIENCE stent in an all-comers population. ClinicalTrials.gov

Background and purpose Supraflex is a sirolimus-eluting stent with a biodegradable polymeric coating and 60um ultra-thin struts. In the TALENT study, we found the Supraflex stent was non-inferior to the Xience stent for a device-oriented composite endpoint (DOCE, defined as cardiac death, target-vessel myocardial infarction, or clinically indicated target lesion revascularisation) at 12 months in an all-comer population. Additionally, per-protocol analysis showed a significantly lower clinically indicated target lesion revascularisation (CI-TLR) in the Supraflex group than in the Xience group. We now present the 2-year follow-up results. Methods The TALENT study was a prospective, randomised, single-blind, multicentre study across 23 centres in Europe. Eligible participants underwent percutaneous coronary intervention in an all-comers fashion in vessels of 2.25–4.5 mm. Patients were randomized (1:1) to implantation of either Supraflex or Xience (NCT02870140). Results Between October 21, 2016 and July 3, 2017, 720 patients with 1046 lesions were randomly assigned to Supraflex, and 715 patients with 1030 lesions to Xience. At 24 months, DOCE had occurred in 49 patients (6.9%) in the Supraflex group and in 56 patients (7.9%) in the Xience group (absolute difference −1.0% [95% CI: −3.7 to 1.7], Plog-rank=0.491). Per-protocol analysis at 24 months showed CI-TLR occurred in 21 and 30 patients in the Supraflex and Xience, respectively (3.3% versus 4.5%, absolute difference −1.2%, [95% CI: −3.3 to 0.9], Plog-rank=0.267). Conclusion In an all-comer population, at 2-year follow-up, the use of Supraflex stent was at least as safe and efficacious as Xience stent. However, the significantly lower rate of CI-TLR shown in patients treated with Supraflex at 1-year was no longer retained in the 2-year results. Whether theoretical advantage of ultra-thin strut drug eluting stents Supraflex can translate into clinical benefit or not will be further elucidated through a total of 3 years of follow-up. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): SMT

Dominant negative mutations in the transcription-factor STAT3 underlie the rare primary immunodeficiency Job's syndrome. Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) has shown promise in correction of the underlying immunological defect, with one report suggesting HSCT can prevent development of wider connective tissue complications. Here, we report the case of a 26 year old male who developed an acute ST-elevation myocardial infarction due to coronary artery ectasia and thrombosis, occurring despite pediatric allogeneic HSCT for STAT3-HIES and a predicted 10-year conventional cardiovascular risk of 0.1%. Vasculopathy associated with STAT3-HIES may persist or arise following HSCT and can precipitate life-threatening complications. This has implications for counseling and vascular surveillance, and highlights the need for further studies to determine the risk, pathogenesis, and optimal management of the vasculopathy associated with STAT3-HIES.

Coronary artery aneurysm is a rare disorder, which occurs in 0.3%–4.9% of patients undergoing coronary angiography. Atherosclerosis accounts for >90% of coronary artery aneurysms in adults, whereas Kawasaki disease is responsible for most cases in children. Recently, with the advent of implantation of drug-eluting stents, there are increasing reports suggesting stents causing coronary aneurysms, months or years after the procedure. The pathophysiology of coronary artery aneurysm is not completely understood but is thought to be similar to that for aneurysms of larger vessels, with the destruction of arterial media, thinning of the arterial wall, increased wall stress, and progressive dilatation of the coronary artery segment. Coronary angiography remains the gold standard tool, providing information about the size, shape, and location and is also useful for planning the strategy of surgical resection. The natural history and prognosis remain unclear. Despite the important anatomical abnormality of the coronary artery, the treatment options of coronary artery aneuryms are still poorly defined and present a therapeutic challenge. We describe four cases, which were managed differently followed by a review of the current literature and propose some treatment strategies.

INTRODUCTION Prolonged dual anti-platelet therapy (DAPT) is undesirable in certain patients. The biolimus-A9 drug-coated stent (BA9-DCS) has a rapid drug-elution profile allowing shortened DAPT. METHODS The demographics, procedural data, and clinical outcomes for 505 patients presenting with an ACS to three UK centres and treated with a BA9-DCS stent (PCI-DCS) were collected, and compared to a consecutive ACS cohort of unselected patients treated in the same period with drug-eluting stents (PCI-DES). RESULTS PCI-DCS patients were older, more often female with hypertension, chronic kidney disease, severe LV dysfunction, and peripheral vascular disease more frequent than the PCI-DES cohort. PCI-DCS patients had a much higher Mehran bleed risk score (21.5 ± 7.7 vs. 15.9 ± 7.7, P

Objectives The aim of this study was to examine the clinical and procedural outcomes of patients undergoing percutaneous coronary intervention (PCI) within 1 year of coronary artery bypass graft surgery (CABG). Background CABG is the preferred revascularization strategy for patients with complex coronary artery disease due to a lower rate of repeat revascularization. Despite advances in surgical technique and medical therapy, >5% of patients require repeat revascularization within 1 year of CABG. Methods and Results Patients who underwent PCI within 1 year of CABG were identified from a prospective registry with data on over 20,000 PCI procedures (April 2000–June 2011). 203 post-CABG patients underwent 228 PCI procedures on 390 lesions during this period. 45% of patients had elective PCI while 55% had PCI on an urgent basis. 81% of PCI was performed in native coronary arteries, usually following graft failure in a previously grafted vessel (60%) or in an ungrafted native vessel (21%). Conclusions Patients who required PCI within 1 year of CABG were more likely to present on an urgent basis and have PCI performed in grafted native coronary vessels. However, nearly third of the patients had PCI to an ungrafted native vessel or to a lesion in the native vessel where the graft was still patent. Further studies are needed to determine whether the use of hybrid revascularization strategies (combination CABG and planned PCI) in appropriate patients could reduce the need for urgent PCI within the first year after CABG. © 2016 Wiley Periodicals, Inc.

Although randomized trial data suggest that complete revascularization improves outcomes after percutaneous coronary intervention (PCI), the impact of differing revascularization strategies in octogenarians is not well defined. We performed a retrospective analysis, which was conducted of 9,628 consecutive patients who underwent PCI at a large UK center. Octogenarians were more likely to have significant co-morbidity, a higher Mehran bleed risk score (24.5 ± 6.8 vs 13.3 ± 7.4, p

The success of Deep Learning techniques in last decade is phenomenal in approaching many pressing questions of intelligence, in the domain of computer vision, language models and automated agent. This quest is not only restricted to academic investigations rather finds its way commercially as different applications and touched many aspects of society as a whole. Given this way of approaching the question of intelligence in general and its application in particular makes deep learning a powerful tool for many scientific endeavor. This paper tries to highlight background of Deep learning focusing on Convolutional Neural Network and discusses its usefulness in application to Chest Radiography.

Background: Supraflex is a sirolimus-eluting stent with a biodegradable polymer coating and ultra-thin struts. We aimed to compare Supraflex with the standard of care, Xience, an everolimus-eluting stent with a durable polymer coating, regarding clinical outcomes with a randomised trial in an all-comer population. Methods: We did a prospective, randomised, single-blind, multicentre study (TALENT) across 23 centres in Europe (the Netherlands, Poland, the UK, Spain, Bulgaria, Hungary, and Italy). Eligible participants were aged 18 years or older, had one or more coronary artery stenosis of 50% or greater in a native coronary artery, saphenous venous graft, or arterial bypass conduit, and had a reference vessel diameter of 2·25–4·50 mm. Patients underwent percutaneous coronary intervention in an all-comer manner. We randomly assigned patients (1:1) to implantation of either a sirolimus-eluting stent with a biodegradable polymer coating and ultra-thin struts (Supraflex) or an everolimus-eluting stent with a durable polymer coating (Xience). Randomisation was done by local investigators by use of a web-based software with random blocks according to centre. The primary endpoint was a non-inferiority comparison of a device-oriented composite endpoint—cardiac death, target-vessel myocardial infarction, or clinically indicated target lesion revascularisation—between groups at 12 months after the procedure, assessed in an intention-to-treat population. On assumption of 1-year composite endpoint prevalence of 8·3%, a margin of 4·0% was defined for non-inferiority of the Supraflex group compared with the Xience group. This trial is registered with ClinicalTrials.gov, number NCT02870140. Findings: Between Oct 21, 2016, and July 3, 2017, 1435 patients with 1046 lesions were randomly assigned to Supraflex, of whom 720 received the index procedure, and 715 patients with 1030 lesions were assigned to Xience, all receiving the index procedure. At 12 months, the primary endpoint had occurred in 35 patients (4·9 %) in the Supraflex group and in 37 patients (5·3%) in the Xience group (absolute difference −0·3% [one-sided 95% upper confidence bound 1·6%], p non-inferiority

Background Prolonging infusions may abrogate the acute stent thrombosis (ST) associated with bivalirudin use during primary PCI but at an increased cost. We hypothesized that continuing the bivalirudin infusion commenced during the procedure at the PCI recommended dose until infusion end would prevent excess early ST. Methods Baseline demographics, procedural data and outcomes were gathered prospectively on 1395 consecutive patients undergoing primary PCI. The choice of bivalirudin versus heparin was at the cardiologist's discretion. Local protocol recommended continuation of the procedural bivalirudin at the PCI dose until infusion end. Results Patients' mean age was 62.8 ± 13.1years with 11.4% presenting with shock. The majority of patients underwent PCI using bivalirudin with fewer using heparin (87.7 vs. 12.3%, P

Radial artery occlusion occurs after transradial cardiac catheterization or percutaneous coronary intervention. Although use of a sheath larger than the artery is a risk factor for radial artery occlusion, radial artery size is not routinely measured. We aimed to identify bedside predictors of radial artery diameter.Using ultrasound, we prospectively measured radial, ulnar, and brachial artery diameters of 130 patients who presented for elective percutaneous coronary intervention or diagnostic angiography. Using prespecified candidate variables we used multivariable linear regression to identify predictors of radial artery diameter.Mean internal diameters of the right radial, ulnar, and brachial arteries were 2.44 ± 0.60, 2.14 ± 0.53, and 4.50 ± 0.88 mm, respectively. Results for the left arm were similar. The right radial artery was larger in men than in women (2.59 vs 1.91 mm; P0.001) and smaller in patients of South Asian descent (2.00 vs 2.52 mm; P0.001). Radial artery diameter correlated with wrist circumference (r(2) = 0.26; P0.001) and shoe size (r(2) = 0.25; P0.001) and weakly correlated with height (r(2) = 0.14; P0.001), weight (r(2) = 0.18; P0.001), body mass index (r(2) = 0.07; P = 0.002), and body surface area (r(2) = 0.22; P0.001). The independent predictors of a larger radial artery were wrist circumference (r(2) = 0.26; P0.001), male sex (r(2) = 0.06; P0.001), and non-South Asian ancestry (r(2) = 0.05; P = 0.006; final model r(2) = 0.37; P0.001). A risk score using these variables predicted radial artery diameter (c-statistic, 0.71).Wrist circumference, male sex, and non-South Asian ancestry are independent predictors of increased radial artery diameter. A risk score using these variables can identify patients with small radial arteries.

In this paper an analytical expression of surface potential, threshold voltage and drain current for Single halo Dual Material Double Gate, Double Halo Dual Material Double Gate and Double Halo Triple Material Double Gate MOSFETs are formulated by applying Gauss' law to a rectangular box in the channel region, covering the total depth of depletion region. The characteristic parameters are formulated for sub threshold regime. The uniqueness of this model lies in the fact that high-k dielectrics are used instead of Silicon dioxide. It is seen that the Triple Material Double Gate structure suppresses the short channel effects most effectively when compared to the other two. The doping profile concentrations of the two halos were considered linear with peak doping concentration at the two ends. The model results obtained by varying different parameters are compared with results obtained from the two-dimensional device simulator DESSIS. It is found that the model results tally quite effectively with those from DESSIS. So the proposed models are suitable for reducing the short channel effects and can be effectively used for devices operating in the sub-threshold region.

Background Abnormal levels of soluble CD40 ligand (sCD40L) have been reported in patients with hypertension, coronary artery disease, diabetes mellitus, heart failure, and stroke, all of which are conditions that are associated with nonvalvular atrial fibrillation (AF). We hypothesized the following: (1) CD40 ligand (CD40L)-related indexes ( ie , platelet surface expressed CD40L, the soluble fragment of CD40L [sCD40L], and the total amount of CD40L per platelet [pCD40L]) are elevated in patients with AF compared to control subjects; (2) these indexes correlate with soluble P-selectin (sP-selectin), which is an established platelet marker; and (3) these indexes differentiate "high-risk" from "low-risk" subjects. Methods We performed a case-control study of 121 AF patients, 71 "disease control subjects," and 56 "healthy control subjects." Peripheral venous levels of platelet surface-expressed CD40L were analyzed by flow cytometry, while levels of sCD40L, pCD40L, and sP-selectin were measured by enzyme-linked immunosorbent assay. Results AF patients had significantly higher sCD40L levels compared to healthy control subjects (p = 0.042), with no difference in platelet surface CD40L and pCD40L levels. A positive correlation was noted between levels of sCD40L and pCD40L, and not with sP-selectin. CD40L-related indexes failed to distinguish between high-risk and low-risk AF patients. AF patients receiving optimal antithrombotic therapy had significantly lower pCD40L levels (p Conclusion CD40L-related indexes are not useful in the risk stratification of AF patients, and abnormal sCD40L levels can be reduced by intense multifactorial risk management. While there is a significant, albeit modest, excess of platelet activation in AF patients (as measured by sCD40L levels) compared to healthy control subjects, this is not in excess of that seen in patients with underlying cardiovascular diseases.

The aim of this study was to examine the clinical and procedural outcomes of patients undergoing percutaneous coronary intervention (PCI) within 1 year of coronary artery bypass graft surgery (CABG).CABG is the preferred revascularization strategy for patients with complex coronary artery disease due to a lower rate of repeat revascularization. Despite advances in surgical technique and medical therapy,5% of patients require repeat revascularization within 1 year of CABG.Patients who underwent PCI within 1 year of CABG were identified from a prospective registry with data on over 20,000 PCI procedures (April 2000-June 2011). 203 post-CABG patients underwent 228 PCI procedures on 390 lesions during this period. 45% of patients had elective PCI while 55% had PCI on an urgent basis. 81% of PCI was performed in native coronary arteries, usually following graft failure in a previously grafted vessel (60%) or in an ungrafted native vessel (21%).Patients who required PCI within 1 year of CABG were more likely to present on an urgent basis and have PCI performed in grafted native coronary vessels. However, nearly third of the patients had PCI to an ungrafted native vessel or to a lesion in the native vessel where the graft was still patent. Further studies are needed to determine whether the use of hybrid revascularization strategies (combination CABG and planned PCI) in appropriate patients could reduce the need for urgent PCI within the first year after CABG. © 2017 Wiley Periodicals, Inc.

Prolonging infusions may abrogate the acute stent thrombosis (ST) associated with bivalirudin use during primary PCI but at an increased cost. We hypothesized that continuing the bivalirudin infusion commenced during the procedure at the PCI recommended dose until infusion end would prevent excess early ST.Baseline demographics, procedural data and outcomes were gathered prospectively on 1395 consecutive patients undergoing primary PCI. The choice of bivalirudin versus heparin was at the cardiologist's discretion. Local protocol recommended continuation of the procedural bivalirudin at the PCI dose until infusion end.Patients' mean age was 62.8 ± 13.1years with 11.4% presenting with shock. The majority of patients underwent PCI using bivalirudin with fewer using heparin (87.7 vs. 12.3%, P 0.0001). Glycoprotein inhibitor bailout rates were 6.1% with bivalirudin and 36.3% with heparin (P 0.0001). Calculated on an individual patient basis the median intra-procedure duration of the bivalirudin infusion was 30(IQR 21-43) minutes and post-procedure 49(32-66) minutes. The acute (24-hours) ST rates were 4/1224 with bivalirudin ± GPI (0.3%) and 0/171 with heparin ± GPI (0%, P = 0.41). The sub-acute (24-hours to 30-days) ST rates were 3/1224 for bivalirudin ± GPI (0.3%) and 2/171 with heparin ± GPI (1.2%, P = 0.11). In total the early (30-days) ST rates were 7/1224 for bivalirudin ± GPI (0.6%) and 2/171 with heparin ± GPI (1.2%, P = 0.31). Acute ST was significantly more likely to occur in clopidogrel-loaded patients than prasugrel/ticagrelor patients (2.7 vs. 0.5%, P = 0.003).Continuing the bivalirudin infusion commenced during the procedure at the PCI recommended dose until infusion end combined with potent P2 Y12 inhibitors ameliorates excess early stent thrombosis.

Introduction Prolonged dual anti-platelet therapy (DAPT) may cause excess bleeding in certain patients. The biolimus-A9 drug-coated stent (BA9-DCS) has a rapid drug-elution profile allowing shortened DAPT. Data were gathered on the early experience implanting this stent in drug-eluting stent eligible patients deemed to be at high risk of bleeding. Background and Methods The demographics, procedural data and clinical outcomes were gathered prospectively for 249 patients treated with a BA9-DCS stent at 2 UK centres, and compared to a cohort of patients treated in the same period with drug-eluting stents (PCI-DES). Results Operator-defined BA9-DCS indications included warfarin therapy, age, and anaemia. Patients receiving a BA9-DCS were older (71.6±11.8 vs. 64.8±11.6yrs, p

Background The precise pathophysiologic processes underlying the prothrombotic or hypercoagulable state in patients with atrial fibrillation (AF) remain uncertain. We hypothesized a relationship among abnormal platelet activation, angiogenic factors, and coagulation, thereby contributing to increased thrombogenecity. Methods Plasma levels of soluble CD40 ligand (sCD40L [an index of platelet activation]) and tissue factor (TF [an index of coagulation]), as well as the angiogenic factors, vascular endothelial growth factor (VEGF), angiopoietin (Ang)-1, and Ang-2, were measured by enzyme-linked immunosorbent assay in 59 patients with chronic AF. Data were compared to 40 age-matched and sex-matched healthy control subjects who were in sinus rhythm. Results AF patients had significantly higher levels of sCD40L (p = 0.038), VEGF (p = 0.023), and Ang-2 (p Conclusions Plasma levels of sCD40L are elevated in patients with AF, and are related to levels of VEGF, Ang-2, and TF. This interaction among platelets, angiogenic markers, and TF may play a role in the generation of the prothrombotic state associated with AF.

Objectives The aim of this work was to comprehensively study the role of platelets in atrial fibrillation (AF), in relation to the underlying cardiovascular diseases and type of AF, and to analyze the effect of antithrombotic treatment on different aspects of platelet activation. Background Platelet activation is present in nonvalvular AF, but there is debate whether this is due to AF itself and/or to underlying cardiovascular diseases. Methods A total of 121 AF patients were compared with 65 “healthy control subjects” and 78 “disease control subjects” in sinus rhythm. Platelet activation was assessed using 4 different aspects of platelet pathophysiology: 1) platelet surface expression of CD62P (P-selectin) and CD63 (a lysosomal glycoprotein) (by flow cytometry); 2) mean platelet volume (MPV) (by flow cytometry); 3) plasma levels of soluble P-selectin (sP-selectin, enzyme-linked immunoadsorbent assay); and 4) total amount of P-selectin per platelet (pP-selectin) (“platelet lysis” assay). Results Both AF patients and “disease control subjects” had higher levels of CD62P (p Conclusions There is a degree of excess of platelet activation in AF compared with “healthy control subjects,” but no significant difference between AF patients and “disease control subjects” in sinus rhythm. Platelet activation may differ according to the subtype of AF, but this is not in excess of the underlying comorbidities that lead to AF. Platelet activation in AF may be due to underlying cardiovascular diseases, rather than due to AF per se.

Background: Platelet microparticles (PMPs), are procoagulant membrane vesicles that are derived from activated platelets, the levels of which are elevated in patients with hypertension, coronary artery disease (CAD), diabetes, and stroke, all of which are conditions that lead to (and are associated with) atrial fibrillation (AF). We hypothesized the following: (1) PMP levels are elevated in patients with AF compared to levels in both healthy control subjects ( ie , patients without cardiovascular diseases who are in sinus rhythm) and disease control subjects ( ie , patients with hypertension, CAD, diabetes or stroke, but who are in sinus rhythm); (2) PMP levels correlate with levels of soluble P-selectin (sP-selectin) [a marker of platelet activation]; and (3) PMP levels are related to the underlying factors in patients with AF that contribute to the overall risk of stroke secondary to AF. Methods: We performed a case-control study of 70 AF patients, 46 disease control subjects and 33 healthy control subjects. Peripheral venous levels of PMP and sP-selectin were analyzed by flow cytometry and enzyme-linked immunosorbent assay, respectively. Results: Both AF patients and disease control subjects had significantly higher levels of PMPs (p Conclusion: There is evidence of platelet activation ( ie , high PMP and sP-selectin levels) in AF patients, but this is likely to be due to underlying cardiovascular diseases rather than the arrhythmia per se .

Background Increased platelet activation has been reported in nonvalvular atrial fibrillation (AF) but it remains unclear whether or not this is due to the underlying cardiovascular diseases, clinical subtype of AF and the influence of anti-thrombotic therapy. Methods Platelet adhesion in AF patients was assessed using a ‘platelet adhesion assay', and compared to both ‘healthy controls' and ‘disease controls' (patients with hypertension, coronary artery disease, diabetes or stroke but in sinus rhythm). Results AF patients on no anti-thrombotic treatment ( N =20) had increased platelet adhesion compared to ‘healthy controls' ( N =57) ( p =0.044). Initiating treatment with both aspirin and warfarin resulted in significant reduction in platelet adhesion in AF patients ( p =0.014 and 0.019 respectively). AF patients on optimal anti-thrombotic therapy ( N =98) had no significant difference in platelet adhesion compared to ‘healthy controls' and ‘disease controls' ( p =0.312). Platelet adhesion failed to distinguish between ‘high-risk' (i.e. CHADS score≥2) and ‘low-risk' (i.e. CHADS score p =0.352). Amongst the clinical parameters that contribute to increased stroke risk in AF, platelet adhesion was only correlated with age ( r =0.215, p =0.034), and not with other stroke risk factors. There was no significant difference in platelet adhesion between paroxysmal and permanent AF ( p =0.618). Conclusion There is a significant, albeit weak, excess of platelet adhesion in AF patients on no anti-thrombotic therapy compared to ‘healthy controls'. In optimally treated AF patients, platelet adhesion is not different to both ‘healthy' and ‘disease controls'. It is possible that abnormal platelet adhesion does not significantly contribute to the increased risk of stroke and thromboembolism that persists despite anti-thrombotic treatment in AF or in identifying ‘high-risk' AF patients.

Patients treated with warfarin who undergo percutaneous coronary intervention (PCI) present a difficult therapeutic problem. Their baseline demographics, procedural characteristics, and 12-month outcomes are poorly defined. We conducted a retrospective analysis of all patients who underwent PCI at a major UK Cardiac Center from 2012 to 2013. Of the 2,675 patients who underwent PCI, 155 were on long-term warfarin treatment (5.8%). Patients on warfarin were older and more likely to have significant co-morbidity than those not on warfarin. The modified Mehran bleed score was higher in patients treated with warfarin versus those not treated (19.0 ± 5.8 vs 15.4 ± 8.0, p = 0.004). Baseline SYNTAX scores were higher in the patients treated with warfarin (18.5 ± 9.1 vs 12.4 ± 3.8, p = 0.0006) as were residual SYNTAX scores (8.3 ± 1.1 vs 3.8 ± 5.9, p = 0.001). Bare metal stents were more frequently used in warfarin-treated patients than those not treated (44.8% vs 26.3%, p0.0001). Antiplatelet monotherapy was prescribed after PCI in 14.4% of patients treated with warfarin and 0.7% of non-warfarin (p0.0001), whereas average dual anti-platelet therapy duration was also significantly shorter (4.3 vs 10.7 months, p0.0001). At 1-year follow-up, target-vessel revascularization (6.5% vs 3.3%, p0.05), stent thrombosis (5.0% vs 2.6%, p = 0.14), death (10.1% vs 4.6%, p0.01), and target-vessel revascularization/stent thrombosis/death (21.6% vs 10.5%, p = 0.004) were all more common in the warfarin cohort. In conclusion, patients treated with warfarin who need PCI are a complex cohort, more likely to receive incomplete revascularization, less intense, and shorter durations of antiplatelet therapy, and have adverse 1-year outcomes. More trials of both current DES and newer DES technologies in warfarin-treated patients are needed.

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, with an incidence that increases twofold every decade after 55 years of age. Despite recent advances in our understanding of the mechanisms of AF, effective treatment remains difficult in many patients. Pharmacotherapy remains the mainstay of treatment and includes ventricular rate control as well as restoration and maintenance of sinus rhythm. In the light of studies demonstrating safety concerns with class IC agents, class III agents such as sotalol and amiodarone have become the preferred and most commonly used drugs. Unfortunately, a plethora of side effects often limits the long-term use of amiodarone. Thus, there have been many recent developments in antiarrhythmic drug therapy for AF that have gained more interest, particularly with the recent debate over rate versus rhythm control. It is hoped that the availability of the newer agents will at least provide a greater choice of therapies and improve our management of this common arrhythmia.

Despite recent advances in our understanding of the mechanism of atrial fibrillation (AF), effective treatment remains difficult in many patients. Pharmacotherapy remains the mainstay of treatment and includes control of ventricular rate as well as restoration and maintenance of sinus rhythm. The currently available antiarrhythmic drugs are particularly effective in converting paroxysmal AF to sinus rhythm and in enhancing the positive effect of electrical cardioversion, but are limited in their efficacy in maintaining sinus rhythm. Moreover, there are limited options in the setting of co-existing ischaemic heart disease, left ventricular dysfunction and structural heart diseases. New drugs added to our clinical armamentarium have been, or are being, developed to combine better efficacy and lack of pro-arrhythmic effects. These developments have gained more interest particularly with the recent debate over rate control versus rhythm control for AF. Although some of these agents are promising, their uptake in clinical practice will not only depend on their efficacy as antiarrhythmic agents but also on their safety in acutely terminating AF and in long-term maintenance of sinus rhythm or rate control in the community.

Atrial fibrillation (AF) is the commonest sustained cardiac rhythm disturbance in clinical practice [1]. Its presence increases mortality by two-fold [2], mostly by increasing the risk of stroke and thromboembolism. The reasons for stroke occurring in AF are multiple and complex, but many strokes related to AF represent embolism of thrombus formed within the left atrium (LA), predominantly within the left atrial appendage (LAA). The elucidation of the pathophysiological mechanisms leading to stroke and thromboembolism in AF have therefore gained much interest. Over 150 years ago, Virchow proposed a triad of abnormalities that predisposes to thrombus formation flow abnormalities, abnormalities of the vessel wall and abnormal blood constituents. The pathophysiology of thromboembolism is AF is multi-factorial but increasing evidence points to the fulfillment of Virchow's triad in this arrhythmia, leading to a prothrombotic or hypercoagulable state in AF. Flow Abnormalities

A 46-year-old man presented with non–ST-segment elevation myocardial infarction (NSTEMI). Electrocardiography showed new T-wave inversion in the inferior leads. Coronary angiography demonstrated a severe lesion in the proximal right coronary artery (RCA) ([Figures 1A and 1B][1]). Immediately

Although randomised trial data suggest that complete revascularisation improves outcomes after PCI the impact of differing revascularisation strategies in octogenarians is not well defined. We performed a retrospective analysis of 9,628 consecutive patients who underwent PCI at a large UK centre.

Introduction Patients treated with warfarin who undergo percutaneous coronary intervention (PCI) present a difficult therapeutic problem. Their baseline demographics, procedural characteristics and 12-month outcomes are poorly defined. Methods We conducted a retrospective analysis of all patients who underwent PCI at a major UK cardiac centre between 2012 and 2013. Of the 2675 patients who underwent PCI, 155 were on long-term warfarin (5.8%). Patients on warfarin were older and more likely to have significant comorbidity than patients not on warfarin. Results The Mehran bleed scores (19.0 ± 5.8 vs. 15.4 ± 8.0, p = 0.004) and baseline SYNTAX scores (18.5 ± 9.1 vs. 12.4 ± 3.8, p = 0.0006) were higher in patients treated with warfarin vs. those not treated. Bare metal stents were more frequently utilised in warfarin patients than non-warfarin patients (44.8 vs. 26.3%, p Conclusion In conclusion patients treated with warfarin who undergo PCI are a complex cohort and are more likely to receive incomplete revascularisation, less intense and shorter durations of anti-platelet therapy and have adverse 1-year outcomes.

Primary PCI is the standard of care for those presenting with STEMI. Trans-radial (TR) vascular access to perform PCI is superior to trans-femoral (TF) access, mainly due to reduced bleeding, leading to overall mortality benefit; patient satisfaction remains very high. Limited skills, concerns with