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1. Long-term Follow-up Optical Coherence Tomography Assessment of Primary Percutaneous Coronary Intervention for Unprotected Left Main

Author

Zlatko Mehmedbegovic, Vladan Vukcevic, Sinisa Stojkovic, Branko Beleslin, Dejan Orlic, Miloje Tomasevic, Miodrag Dikic, Milorad Tesic, Dejan Milasinovic, Srdjan Aleksandric, Vladimir Dedovic, Milorad Zivkovic, Stefan Juricic, Dario Jelic, Djordje Mladenovic, and Goran Stankovic

Subjects
oct, unprotected left main, primary pci, long-term follow-up, strut endothelization, stent malapposition, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background: Elective unprotected left main (ULM) percutaneous coronary intervention (PCI) has long-term mortality rates comparable to surgical revascularization, thanks to advances in drug-eluting stent (DES) design, improved PCI techniques, and frequent use of intravascular imaging. However, urgent PCI of ULM culprit lesions remains associated with high in-hospital mortality and unfavourable long-term outcomes, including DES restenosis and stent thrombosis (ST). This analysis aimed to examine the long-term outcomes and healing of DES implanted in ULM during primary PCI using high-resolution optical coherence tomography (OCT) imaging. Methods: A total of 15 consecutive patients undergoing long-term OCT follow-up of ULM primary PCI from a high-volume center were included in this analysis. During the index primary PCI all subjects underwent angio-guided DES implantation, and follow-up was uneventful in all but one subject who had a non-target PCI lesion. The primary endpoint was the percentage of covered, uncovered, and malappossed stent struts at long-term follow-up. Secondary endpoints included quantitative and qualitative OCT measurements. For the left main bifurcation, a separate analysis was performed for three different segments: left main (LM), polygon of confluence (POC) and distal main branch (dMB), in all cases. Results: The average follow-up interval until OCT was 1580 ± 1260 days. Despite aorto-ostial stent protrusions in 40% of patients, optimal image quality was achieved in 93.3% of cases. There were higher rates of malapposed (11.4 ± 16.6 vs. 13.1 ± 8.3 vs. 0.3 ± 0.5%; p < 0.001) and lower rates of covered struts (81.7 ± 16.8 vs. 83.7 ± 9.2 vs. 92.4 ± 6.8%; p = 0.041) observed for the LM and POC segment compared to the dMB. Significantly malapposed stent struts (>400 μm) were less likely to be covered at follow-up, than struts with a measured strut to vessel wall distance of

Published
2024
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3. Patient-specific computational simulation of coronary artery bifurcation stenting

Author

Shijia Zhao, Wei Wu, Saurabhi Samant, Behram Khan, Ghassan S. Kassab, Yusuke Watanabe, Yoshinobu Murasato, Mohammadali Sharzehee, Janaki Makadia, Daniel Zolty, Anastasios Panagopoulos, Francesco Burzotta, Francesco Migliavacca, Thomas W. Johnson, Thierry Lefevre, Jens Flensted Lassen, Emmanouil S. Brilakis, Deepak L. Bhatt, George Dangas, Claudio Chiastra, Goran Stankovic, Yves Louvard, and Yiannis S. Chatzizisis

Subjects
Medicine, Science
Abstract

Abstract Patient-specific and lesion-specific computational simulation of bifurcation stenting is an attractive approach to achieve individualized pre-procedural planning that could improve outcomes. The objectives of this work were to describe and validate a novel platform for fully computational patient-specific coronary bifurcation stenting. Our computational stent simulation platform was trained using n = 4 patient-specific bench bifurcation models (n = 17 simulations), and n = 5 clinical bifurcation cases (training group, n = 23 simulations). The platform was blindly tested in n = 5 clinical bifurcation cases (testing group, n = 29 simulations). A variety of stent platforms and stent techniques with 1- or 2-stents was used. Post-stenting imaging with micro-computed tomography (μCT) for bench group and optical coherence tomography (OCT) for clinical groups were used as reference for the training and testing of computational coronary bifurcation stenting. There was a very high agreement for mean lumen diameter (MLD) between stent simulations and post-stenting μCT in bench cases yielding an overall bias of 0.03 (− 0.28 to 0.34) mm. Similarly, there was a high agreement for MLD between stent simulation and OCT in clinical training group [bias 0.08 (− 0.24 to 0.41) mm], and clinical testing group [bias 0.08 (− 0.29 to 0.46) mm]. Quantitatively and qualitatively stent size and shape in computational stenting was in high agreement with clinical cases, yielding an overall bias of

Published
2021
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4. The Use of Cutting Balloons in Published Cases of Acute Coronary Syndrome Caused by Spontaneous Coronary Artery Dissection

Author

Svetlana Apostolovic, Bojan Maricic, Nenad Bozinovic, Tomislav Kostic, Zoran Perisic, Aleksandra Djokovic, Mihajlo Bojanovic, Milovan Petrovic, and Goran Stankovic

Subjects
spontaneous coronary artery dissection, cutting balloon, acute coronary syndrome, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Spontaneous coronary artery dissection (SCAD) is a non-traumatic, non-atherosclerotic layering of the coronary artery wall due to the presence of a subintimal hematoma or an intimal tear with the creation of a false lumen that compresses the true lumen and restricts or obstructs the flow. Patients with SCAD and preserved coronary flow are treated conservatively according to the general recommendations. However, percutaneous coronary intervention should be considered in patients with artery occlusion and/or refractory ischemia. Stenting is associated with increased risks comprising stenting in the false lumen, in-stent thrombosis, and/or stent malappositon as well as antegrade or retrograde propagation of the intramural hematoma. Intracoronary imaging is of great value both for the diagnosis and treatment of SCAD. There is rising scrutiny on the use of cutting balloons in acute coronary syndrome caused by SCAD. The idea of using cutting balloons is to fenestrate the intima and drain the intramural hematoma. Our review presents an analysis of 17 published cases of cutting balloon (CB) use in SCAD. What is encouraging is that of the 12 published cases, in 11 Thrombolysis in Myocardial Infarction (TIMI) 3 flow was established with this technique, and TIMI 2 flow in one, without subsequent stent implantation. Four patients received a stent after the CB use, while one patient underwent CB angioplasty after hematoma propagation caused by stent implantation. In all cases, patients were asymptomatic at follow-up, with TIMI 3 flow.

Published
2023
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5. Three dimensional reconstruction of coronary artery stents from optical coherence tomography: experimental validation and clinical feasibility

Author

Wei Wu, Behram Khan, Mohammadali Sharzehee, Shijia Zhao, Saurabhi Samant, Yusuke Watanabe, Yoshinobu Murasato, Timothy Mickley, Andrew Bicek, Richard Bliss, Thomas Valenzuela, Paul A. Iaizzo, Janaki Makadia, Anastasios Panagopoulos, Francesco Burzotta, Habib Samady, Emmanouil S. Brilakis, George D. Dangas, Yves Louvard, Goran Stankovic, Gabriele Dubini, Francesco Migliavacca, Ghassan S. Kassab, Elazer R. Edelman, Claudio Chiastra, and Yiannis S. Chatzizisis

Subjects
Medicine, Science
Abstract

Abstract The structural morphology of coronary stents (e.g. stent expansion, lumen scaffolding, strut apposition, tissue protrusion, side branch jailing, strut fracture), and the local hemodynamic environment after stent deployment are key determinants of procedural success and subsequent clinical outcomes. High-resolution intracoronary imaging has the potential to enable the geometrically accurate three-dimensional (3D) reconstruction of coronary stents. The aim of this work was to present a novel algorithm for 3D stent reconstruction of coronary artery stents based on optical coherence tomography (OCT) and angiography, and test experimentally its accuracy, reproducibility, clinical feasibility, and ability to perform computational fluid dynamics (CFD) studies. Our method has the following steps: 3D lumen reconstruction based on OCT and angiography, stent strut segmentation in OCT images, packaging, rotation and straightening of the segmented struts, planar unrolling of the segmented struts, planar stent wireframe reconstruction, rolling back of the planar stent wireframe to the 3D reconstructed lumen, and final stent volume reconstruction. We tested the accuracy and reproducibility of our method in stented patient-specific silicone models using micro-computed tomography (μCT) and stereoscopy as references. The clinical feasibility and CFD studies were performed in clinically stented coronary bifurcations. The experimental and clinical studies showed that our algorithm (1) can reproduce the complex spatial stent configuration with high precision and reproducibility, (2) is feasible in 3D reconstructing stents deployed in bifurcations, and (3) enables CFD studies to assess the local hemodynamic environment within the stent. Notably, the high accuracy of our algorithm was consistent across different stent designs and diameters. Our method coupled with patient-specific CFD studies can lay the ground for optimization of stenting procedures, patient-specific computational stenting simulations, and research and development of new stent scaffolds and stenting techniques.

Published
2021
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6. Association of MMP1 and MMP3 haplotypes with myocardial infarction and echocardiographic parameters of the left ventricle

Author

Tamara Djuric, Jovana Kuveljic, Ana Djordjevic, Milica Dekleva, Goran Stankovic, Aleksandra Stankovic, and Maja Zivkovic

Subjects
haplotypes, LV remodeling, MMP1, MMP3, myocardial infarction, Genetics, QH426-470
Abstract

Abstract Background Myocardial infarction (MI) leads to ischemia and afterward to left ventricular (LV) remodeling. Matrix metalloproteinase−1 (MMP1) and −3 (MMP3) belong to the family of endopeptidases and together they can dissolve most of the components of the extracellular matrix. MMP1 and MMP3 variants have been investigated solely in association with ischemic heart disease and LV dysfunction, but not in haplotype. The aims of this study were to investigate the association of haplotypes inferred from MMP1 rs1799750 (−1607 1G/2G; NC_000011.9:g.102670497del) and MMP3 rs35068180 (−1612 5A/6A; NC_000011.9:g.102715952dup) with MI and their effect on the change in echocardiographic parameters of LV structure and function in patients within 6 months after MI. Methods The study included 325 patients with the first MI and 283 healthy controls. Gene variants were detected by PCR‐RFLP method. Parameters of LV structure and function were assessed by conventional 2D echocardiography, 3–5 days and 6 months after the first MI, on a subgroup of 160 patients. Haplotype analysis was performed with Thesias software. Results Haplotypes 2G‐5A and 1G‐6A were significantly and independently associated with MI compared with the reference haplotype 2G‐6A (adjusted, p = 0.009 and p = 0.026, respectively). After Bonferroni correction for multiple testing, MMP1 and MMP3 haplotypes lost their association with the change in LV long diameter and stroke volume within 6 months after MI. Conclusion MMP1 and MMP3 haplotypes are strongly associated with MI. Further studies are needed to validate this result and to examine their association with echocardiographic parameters of LV structure and function after MI.

Published
2022
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7. Prompt and consistent improvement of coronary flow velocity reserve following successful recanalization of the coronary chronic total occlusion in patients with viable myocardium

Author

Milan Dobric, Branko Beleslin, Milorad Tesic, Ana Djordjevic Dikic, Sinisa Stojkovic, Vojislav Giga, Miloje Tomasevic, Ivana Jovanovic, Olga Petrovic, Jelena Rakocevic, Nikola Boskovic, Dragana Sobic Saranovic, Goran Stankovic, Vladan Vukcevic, Dejan Orlic, Dragan Simic, Milan A. Nedeljkovic, Srdjan Aleksandric, Stefan Juricic, and Miodrag Ostojic

Subjects
Coronary chronic total occlusion, CTO, Recanalization, Coronary flow velocity reserve, CFVR, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Abstract Background Coronary chronic total occlusion (CTO) is characterized by the presence of collateral blood vessels which can provide additional blood supply to CTO-artery dependent myocardium. Successful CTO recanalization is followed by significant decrease in collateral donor artery blood flow and collateral derecruitment, but data on coronary hemodynamic changes in relation to myocardial function are limited. We assessed changes in coronary flow velocity reserve (CFVR) by echocardiography in collateral donor and recanalized artery following successful opening of coronary CTO. Methods Our study enrolled 31 patients (60 ± 9 years; 22 male) with CTO and viable myocardium by SPECT scheduled for percutaneous coronary intervention (PCI). Non-invasive CFVR was measured in collateral donor artery before PCI, 24 h and 6 months post-PCI, and 24 h and 6 months in recanalized artery following successful PCI of CTO. Results Collateral donor artery showed significant increase in CFVR 24 h after CTO recanalization compared to pre-PCI values (2.30 ± 0.49 vs. 2.71 ± 0.45, p = 0.005), which remained unchanged after 6-months (2.68 ± 0.24). Baseline blood flow velocity of the collateral donor artery significantly decreased 24 h post-PCI compared to pre-PCI (0.28 ± 0.06 vs. 0.24 ± 0.04 m/s), and remained similar after 6 months, with no significant difference in maximum hyperemic blood flow velocity pre-PCI, 24 h and 6 months post-PCI. CFVR of the recanalized coronary artery 24 h post-PCI was 2.55 ± 0.35, and remained similar 6 months later (2.62 ± 0.26, p = NS). Conclusions In patients with viable myocardium, prompt and significant CFVR increase in both recanalized and collateral donor artery, was observed within 24 h after successful recanalization of CTO artery, which maintained constant during the 6 months. Trial registration ClinicalTrials.gov (Number NCT04060615 ).

Published
2020
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8. Heart Rate Recovery as a Predictor of Long-Term Adverse Events after Negative Exercise Testing in Patients with Chest Pain and Pre-Test Probability of Coronary Artery Disease from 15% to 65%

Author

Vojislav Giga, Nikola Boskovic, Ana Djordjevic-Dikic, Branko Beleslin, Ivana Nedeljkovic, Goran Stankovic, Milorad Tesic, Ivana Jovanovic, Ivana Paunovic, and Srdjan Aleksandric

Subjects
chest pain, negative exercise testing, prognosis, predictors, heart rate recovery, Medicine (General), R5-920
Abstract

Background: The prognosis of patients with chest pain after a negative exercise test is good, but some adverse events occur in this low-risk group. The aim of our study was to identify predictors of long-term adverse events after a negative exercise test in patients with chest pain and a lower intermediate (15–65%) pre-test probability of coronary artery disease (CAD) and to assess the prognostic value of exercise electrocardiography and exercise stress echocardiography in this group of patients. Methods: We identified from our stress test laboratory database 862 patients with chest pain without previously known CAD and with a pre-test probability of CAD ranging from 15 to 65% (mean 41 ± 14%) who underwent exercise testing. Patients were followed for the occurrence of death, non-fatal myocardial infarction (MI) and clinically guided revascularization. Results: During the median follow-up of 94 months, 87 patients (10.1%) had an adverse event (AE). A total of 30 patients died (3.5%), 23 patients suffered non-fatal MI (2.7%) and 34 patients (3.9%) had clinically guided revascularization (20 patients percutaneous and 14 patients surgical revascularizations). Male gender, age, the presence of diabetes and a slow heart rate recovery (HRR) in the first minute after exercise were independently related to the occurrence of AEs. Adverse events occurred in 10.3% of patients who were tested by exercise stress echocardiography and in 10.0% of those who underwent stress electrocardiography (p = 0.888). Conclusion: The risk of AEs after negative exercise testing in patients with a pre-test probability of CAD of 15–65% is low. Male patients with a history of diabetes and slow HRR in the first minute after exercise have an increased risk of an adverse outcome.

Published
2023
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10. Functional Assessment of Myocardial Bridging With Conventional and Diastolic Fractional Flow Reserve: Vasodilator Versus Inotropic Provocation

Author

Srdjan B. Aleksandric, Ana D. Djordjevic‐Dikic, Milan R. Dobric, Vojislav L. Giga, Ivan A. Soldatovic, Vladan Vukcevic, Miloje V. Tomasevic, Sinisa M. Stojkovic, Dejan N. Orlic, Jovica D. Saponjski, Milorad B. Tesic, Marko D. Banovic, Marija T. Petrovic, Stefan A. Juricic, Milan A. Nedeljkovic, Goran Stankovic, Miodrag C. Ostojic, and Branko D. Beleslin

Subjects
adenosine, dobutamine, fractional flow reserve, myocardial bridging, myocardial ischemia, stress‐echocardiography, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background Functional assessment of myocardial bridging (MB) remains clinically challenging because of the dynamic nature of the extravascular coronary compression with a certain degree of intraluminal coronary reduction. The aim of our study was to assess performance and diagnostic value of diastolic‐fractional flow reserve (d‐FFR) during dobutamine provocation versus conventional‐FFR during adenosine provocation with exercise‐induced myocardial ischemia as reference. Methods and Results This prospective study includes 60 symptomatic patients (45 men, mean age 57±9 years) with MB on the left anterior descending artery and systolic compression ≥50% diameter stenosis. Patients were evaluated by exercise stress‐echocardiography test, and both conventional‐FFR and d‐FFR in the distal segment of left anterior descending artery during intravenous infusion of adenosine (140 μg/kg per minute) and dobutamine (10–50 μg/kg per minute), separately. Exercise–stress‐echocardiography test was positive for myocardial ischemia in 19/60 patients (32%). Conventional‐FFR during adenosine and peak dobutamine had similar values (0.84±0.04 versus 0.84±0.06, P=0.852), but d‐FFR during peak dobutamine was significantly lower than d‐FFR during adenosine (0.76±0.08 versus 0.79±0.08, P=0.018). Diastolic‐FFR during peak dobutamine was significantly lower in the exercise‐stress‐echocardiography test –positive group compared with the exercise‐ stress‐echocardiography test –negative group (0.70±0.07 versus 0.79±0.06, P

Published
2021
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11. The 17th expert consensus document of the European Bifurcation Club – techniques to preserve access to the side branch during stepwise provisional stenting

Author

Manuel Pan, Jens Flensted Lassen, Francesco Burzotta, Soledad Ojeda, Remo Albiero, Thierry Lefèvre, David Hildick-Smith, Thomas W. Johnson, Alaide Chieffo, Adrian P Banning, Miroslaw Ferenc, Olivier Darremont, Yiannis S. Chatzizisis, Yves Louvard, and Goran Stankovic

Subjects
Cardiology and Cardiovascular Medicine
Published
2023
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13. Sex Differences in Modifiable Risk Factors and Severity of Coronary Artery Disease

Author

Olivia Manfrini, Jinsung Yoon, Mihaela van der Schaar, Sasko Kedev, Marija Vavlukis, Goran Stankovic, Marialuisa Scarpone, Davor Miličić, Zorana Vasiljevic, Lina Badimon, Edina Cenko, and Raffaele Bugiardini

Subjects
conventional risk factors, diabetes mellitus, obstructive coronary artery disease, sex differences, smoking, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Background It is still unknown whether traditional risk factors may have a sex‐specific impact on coronary artery disease (CAD) burden. Methods and Results We identified 14 793 patients who underwent coronary angiography for acute coronary syndromes in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries; Clini​calTr​ials.gov, NCT01218776) registry from 2010 to 2019. The main outcome measure was the association between traditional risk factors and severity of CAD and its relationship with 30‐day mortality. Relative risk (RR) ratios and 95% CIs were calculated from the ratio of the absolute risks of women versus men using inverse probability of weighting. Estimates were compared by test of interaction on the log scale. Severity of CAD was categorized as obstructive (≥50% stenosis) versus nonobstructive CAD. The RR ratio for obstructive CAD in women versus men among people without diabetes mellitus was 0.49 (95% CI, 0.41–0.60) and among those with diabetes mellitus was 0.89 (95% CI, 0.62–1.29), with an interaction by diabetes mellitus status of P =0.002. Exposure to smoking shifted the RR ratios from 0.50 (95% CI, 0.41–0.61) in nonsmokers to 0.75 (95% CI, 0.54–1.03) in current smokers, with an interaction by smoking status of P=0.018. There were no significant sex‐related interactions with hypercholesterolemia and hypertension. Women with obstructive CAD had higher 30‐day mortality rates than men (RR, 1.75; 95% CI, 1.48–2.07). No sex differences in mortality were observed in patients with nonobstructive CAD. Conclusions Obstructive CAD in women signifies a higher risk for mortality compared with men. Current smoking and diabetes mellitus disproportionally increase the risk of obstructive CAD in women. Achieving the goal of improving cardiovascular health in women still requires intensive efforts toward further implementation of lifestyle and treatment interventions. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT01218776.

Published
2020
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14. Impact of technique on bifurcation stent outcomes in the European Bifurcation Club Left Main Coronary Trial

Author

Sandeep Arunothayaraj, Jens Flensted Lassen, Gerald J. Clesham, Mark S. Spence, René Koning, Adrian P. Banning, Mitchell Lindsay, Evald H. Christiansen, Mohaned Egred, James Cockburn, Darren Mylotte, Philippe Brunel, Miroslaw Ferenc, Thomas Hovasse, Adrian Wlodarczak, Manuel Pan, Marc Silvestri, Andrejs Erglis, Evgeny Kretov, Alaide Chieffo, Thierry Lefèvre, Francesco Burzotta, Olivier Darremont, Goran Stankovic, Marie‐Claude Morice, Yves Louvard, and David Hildick‐Smith

Subjects
left main, Drug-Eluting Stents, General Medicine, Coronary Angiography, coronary occlusion, Angioplasty, Balloon, Coronary/adverse effects, Treatment Outcome, myocardial infarction, bifurcation, Myocardial Infarction/etiology, drug-eluting stent, Humans, Stents, Radiology, Nuclear Medicine and imaging, Cardiology and Cardiovascular Medicine, Aged, Coronary Artery Disease/diagnostic imaging
Abstract

BACKGROUND: Techniques for provisional and dual-stent left main bifurcation stenting require optimization.AIM: To identify technical variables influencing procedural outcomes and periprocedural myocardial infarction following left main bifurcation intervention.METHODS: Procedural and outcome data were analyzed in 438 patients from the per-protocol cohort of the European Bifurcation Club Left Main Trial (EBC MAIN). These patients were randomized to the provisional strategy or a compatible dual-stent extension (T, T-and-protrude, or culotte).RESULTS: Mean age was 71 years and 37.4% presented with an acute coronary syndrome. Transient reduction of side vessel thrombolysis in myocardial infarction flow occurred after initial stent placement in 5% of procedures but was not associated with periprocedural myocardial infarction. Failure to rewire a jailed vessel during any strategy was more common when jailed wires were not used (9.5% vs. 2.5%, odds ratio [OR]: 6.4, p = 0.002). In the provisional cohort, the use of the proximal optimization technique was associated with less subsequent side vessel intervention (23.3% vs. 41.9%, OR: 0.4, p = 0.048). Side vessel stenting was predominantly required for dissection, which occurred more often following side vessel preparation (15.3% vs. 4.4%, OR: 3.1, p = 0.040). Exclusive use of noncompliant balloons for kissing balloon inflation was associated with reduced need for side vessel intervention in provisional cases (20.5% vs. 38.5%, OR: 0.4, p = 0.013), and a reduced risk of periprocedural myocardial infarction across all strategies (2.9% vs. 7.7%, OR: 0.2, p = 0.020).CONCLUSION: When performing provisional or compatible dual-stent left main bifurcation intervention, jailed wire use is associated with successful jailed vessel rewiring. Side vessel preparation in provisional patients is linked to increased side vessel dissection requiring stenting. Use of the proximal optimization technique may reduce the need for additional side vessel intervention, and noncompliant balloon use for kissing balloon inflation is associated with a reduction in both side vessel stenting and periprocedural myocardial infarction.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02497014.

Published
2023
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15. Survival After Invasive or Conservative Management of Stable Coronary Disease

Author

Judith S. Hochman, Rebecca Anthopolos, Harmony R. Reynolds, Sripal Bangalore, Yifan Xu, Sean M. O’Brien, Stavroula Mavromichalis, Michelle Chang, Aira Contreras, Yves Rosenberg, Ruth Kirby, Balram Bhargava, Roxy Senior, Ann Banfield, Shaun G. Goodman, Renato D. Lopes, Radosław Pracoń, José López-Sendón, Aldo Pietro Maggioni, Jonathan D. Newman, Jeffrey S. Berger, Mandeep S. Sidhu, Harvey D. White, Andrea B. Troxel, Robert A. Harrington, William E. Boden, Gregg W. Stone, Daniel B. Mark, John A. Spertus, David J. Maron, Shari Esquenazi-Karonika, Margaret Gilsenan, Ewelina Gwiszcz, Patenne Mathews, Samaa Mohamed, Anna Naumova, Arline Roberts, Kerrie VanLoo, Ying Lu, Zhen Huang, Samuel Broderick, Luis Guzmán, Joseph Selvanayagam, Gabriel Steg, Jean-Michel Juliard, Rolf Doerr, Matyas Keltai, Boban Thomas, Tali Sharir, Eugenia Nikolsky, Aldo P. Maggioni, Shun Kohsaka, Jorge Escobedo, Olga Bockeria, Claes Held, Leslee J. Shaw, Lawrence Phillips, Daniel Berman, Raymond Y. Kwong, Michael H. Picard, Bernard R. Chaitman, Ziad Ali, James Min, G.B. John Mancini, Jonathon Leipsic, Graham Hillis, Suku Thambar, Majo Joseph, John Beltrame, Irene Lang, Herwig Schuchlenz, Kurt Huber, Kaatje Goetschalckx, Whady Hueb, Paulo Ricardo Caramori, Alexandre de Quadros, Paola Smanio, Claudio Mesquita, João Vitola, José Marin-Neto, Expedito Ribeiro da Silva, Rogério Tumelero, Marianna Andrade, Alvaro Rabelo Alves, Frederico Dall’Orto, Carisi Polanczyk, Estevão Figueiredo, Andrew Howarth, Gilbert Gosselin, Asim Cheema, Kevin Bainey, Denis Phaneuf, Ariel Diaz, Pallav Garg, Shamir Mehta, Graham Wong, Andy Lam, James Cha, Paul Galiwango, Amar Uxa, Benjamin (Ben) Chow, Adnan Hameed, Jacob Udell, Magdy Hamid, Marie Hauguel-Moreau, Alain Furber, Pascal Goube, Philippe-Gabriel Steg, Gilles Barone-Rochette, Christophe Thuaire, Michel Slama, Georg Nickenig, Raffi Bekeredjian, P. Christian Schulze, Bela Merkely, Geza Fontos, András Vértes, Albert Varga, Ajit Kumar, Rajesh G. Nair, Purvez Grant, Cholenahally Manjunath, Nagaraja Moorthy, Santhosh Satheesh, Ranjit Kumar Nath, Gurpreet Wander, Johann Christopher, Sudhanshu Dwivedi, Abraham Oomman, Atul Mathur, Milind Gadkari, Sudhir Naik, Eapen Punnoose, Ranjan Kachru, Upendra Kaul, Arthur Kerner, Giuseppe Tarantini, Gian Piero Perna, Emanuela Racca, Andrea Mortara, Lorenzo Monti, Carlo Briguori, Gianpiero Leone, Roberto Amati, Mauro Salvatori, Antonio Di Chiara, Paolo Calabro, Marcello Galvani, Stefano Provasoli, Keiichi Fukuda, Shintaro Nakano, Aleksandras Laucevicius, Sasko Kedev, Ahmad Khairuddin, Robert Riezebos, Jorik Timmer, Spencer Heald, Ralph Stewart, Walter Mogrovejo Ramos, Marcin Demkow, Tomasz Mazurek, Jarozlaw Drozdz, Hanna Szwed, Adam Witkowski, Nuno Ferreira, Fausto Pinto, Ruben Ramos, Bogdan Popescu, Calin Pop, Leo Bockeria, Elena Demchenko, Alexander Romanov, Leonid Bershtein, Ahmed Jizeeri, Goran Stankovic, Svetlana Apostolovic, Nada Cemerlic Adjic, Marija Zdravkovic, Branko Beleslin, Milica Dekleva, Goran Davidovic, Terrance Chua, David Foo, Kian Keong Poh, Mpiko Ntsekhe, Alessandro Sionis, Francisco Marin, Vicente Miró, Montserrat Gracida Blancas, José González-Juanatey, Francisco Fernández-Avilés, Jesús Peteiro, Jose Enrique Castillo Luena, Johannes Aspberg, Mariagrazia Rossi, Srun Kuanprasert, Sukit Yamwong, Nicola Johnston, Patrick Donnelly, Andrew Moriarty, Ahmed Elghamaz, Sothinathan Gurunathan, Nikolaos Karogiannis, Benoy N. Shah, Richard H.J. Trimlett, Michael B. Rubens, Edward D. Nicol, Tarun K. Mittal, Reinette Hampson, Reto Gamma, Mark De Belder, Thuraia Nageh, Steven Lindsay, Kreton Mavromatis, Todd Miller, Subhash Banerjee, Harmony Reynolds, Khaled Nour, and Peter Stone

Subjects
Physiology (medical), Cardiology and Cardiovascular Medicine
Abstract

Background: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, with no major difference in most outcomes during a median of 3.2 years. Extended follow-up for mortality is ongoing. Methods: ISCHEMIA participants were randomized to an initial invasive strategy added to guideline-directed medical therapy or a conservative strategy. Patients with moderate or severe ischemia, ejection fraction ≥35%, and no recent acute coronary syndromes were included. Those with an unacceptable level of angina were excluded. Extended follow-up for vital status is being conducted by sites or through central death index search. Data obtained through December 2021 are included in this interim report. We analyzed all-cause, cardiovascular, and noncardiovascular mortality by randomized strategy, using nonparametric cumulative incidence estimators, Cox regression models, and Bayesian methods. Undetermined deaths were classified as cardiovascular as prespecified in the trial protocol. Results: Baseline characteristics for 5179 original ISCHEMIA trial participants included median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% with diabetes, and median ejection fraction 0.60. A total of 557 deaths accrued during a median follow-up of 5.7 years, with 268 of these added in the extended follow-up phase. This included a total of 343 cardiovascular deaths, 192 noncardiovascular deaths, and 22 unclassified deaths. All-cause mortality was not different between randomized treatment groups (7-year rate, 12.7% in invasive strategy, 13.4% in conservative strategy; adjusted hazard ratio, 1.00 [95% CI, 0.85–1.18]). There was a lower 7-year rate cardiovascular mortality (6.4% versus 8.6%; adjusted hazard ratio, 0.78 [95% CI, 0.63–0.96]) with an initial invasive strategy but a higher 7-year rate of noncardiovascular mortality (5.6% versus 4.4%; adjusted hazard ratio, 1.44 [95% CI, 1.08–1.91]) compared with the conservative strategy. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. Conclusions: There was no difference in all-cause mortality with an initial invasive strategy compared with an initial conservative strategy, but there was lower risk of cardiovascular mortality and higher risk of noncardiovascular mortality with an initial invasive strategy during a median follow-up of 5.7 years. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04894877.

Published
2023
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16. Evaluación y tratamiento percutáneo de las bifurcaciones coronarias

Author

Carlos E. Uribe, Mauricio Zúñiga, and Goran Stankovic

Subjects
Enfermedad de la arteria coronaria, Intervención coronaria percutánea, Stents liberadores de fármacos, Bifurcaciones, Consenso, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Las bifurcaciones coronarias por motivos de estrés y turbulencia del flujo sanguíneo, son particularmente susceptibles a desarrollar lesión arterioesclerótica, la cual está presente hasta en el 30% de los pacientes con enfermedad de múltiples vasos y representan el 10 al 15% de todas las intervenciones. No obstante, el manejo percutáneo continúa siendo un reto tanto en términos de eventos cardiacos a largo plazo como de éxito técnico del procedimiento. Este documento representa una revisión actualizada de la anatomía, fisiología, clasificación y recomendaciones de las estrategias intervencionistas para su tratamiento, basadas en la evidencia clínica, con el fin de unificar conceptos.

Published
2017
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17. Complete Revascularization vs Culprit Lesion-Only Percutaneous Coronary Intervention for Angina-Related Quality of Life in Patients With ST-Segment Elevation Myocardial Infarction: Results From the COMPLETE Randomized Clinical Trial

Author

Shamir R, Mehta, Jia, Wang, David A, Wood, John A, Spertus, David J, Cohen, Roxana, Mehran, Robert F, Storey, Philippe Gabriel, Steg, Natalia, Pinilla-Echeverri, Tej, Sheth, Kevin R, Bainey, Sripal, Bangalore, Warren J, Cantor, David P, Faxon, Laurent J, Feldman, Sanjit S, Jolly, Vijay, Kunadian, Shahar, Lavi, Jose, Lopez-Sendon, Mina, Madan, Raul, Moreno, Sunil V, Rao, Josep, Rodés-Cabau, Goran, Stankovic, Shrikant I, Bangdiwala, John A, Cairns, and Dhananjai, Menzies

Subjects
Male, Percutaneous Coronary Intervention, Treatment Outcome, Quality of Life, Humans, ST Elevation Myocardial Infarction, Female, Coronary Artery Disease, Middle Aged, Cardiology and Cardiovascular Medicine, Angina Pectoris
Abstract

ImportanceIn patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion–only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown.ObjectiveTo determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD.Design, Setting, and ParticipantsThis secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021.InterventionsFollowing PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization.Main Outcomes and MeasuresSeattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end.ResultsOf 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion–only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P P P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion–only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02).Conclusions and RelevanceIn patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion–only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.

Published
2023

18. Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club

Author

Remo Albiero, Francesco Burzotta, Jens Lassen Lassen, Thierry Lefèvre, Adrian Banning Banning, Yiannis Chatzizisis Chatzizisis, Thomas Johnson Johnson, Miroslaw Ferenc, Manuel Pan, Olivier Daremont, David Hildick-Smith, Alaide Chieffo, Yves Louvard, and Goran Stankovic

Subjects
Consensus, Time Factors, implant, Coronary Artery Disease, heart disease, Coronary Angiography, Treatment Outcome, Settore MED/11 - MALATTIE DELL'APPARATO CARDIOVASCOLARE, Humans, Stents, stent, Angioplasty, Balloon, Coronary, Cardiology and Cardiovascular Medicine, coronary bifurcation, consensus document
Abstract

Stepwise layered provisional stenting (PS) is the most commonly used strategy to treat coronary bifurcation lesions (CBL). The term 'stepwise layered' emphasises the versatility of this approach that allows the adjustment of the procedure plan according to the CBL complexity, starting with stent implantation in one branch and implantation of a second stent in the other branch only when required. A series of refinements have been implemented over the years to facilitate the achievement of predictable procedural results using this approach. However, despite its simplicity and versatility, operators using this technique require full knowledge of the pitfalls of each procedural step. Part I of this 16

Published
2022
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19. Percutaneous coronary intervention of bifurcation lesions

Author

David, Hildick-Smith, Sandeep, Arunothayaraj, Goran, Stankovic, and Shao-Liang, Chen

Subjects
Percutaneous Coronary Intervention, Treatment Outcome, Humans, Stents, Coronary Artery Disease, Atherosclerosis, Coronary Angiography, Cardiology and Cardiovascular Medicine
Abstract

Bifurcation coronary artery disease is common as the development of atherosclerosis is facilitated by altered endothelial shear stress. Multiple anatomical and physiological factors need to be considered when treating bifurcation lesions. To achieve optimal results, various stenting techniques have been developed, each with benefits and limitations. In this state-of-the-art review we describe technically important characteristics of bifurcation lesions and summarise the evidence supporting contemporary bifurcation techniques.

Published
2022
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20. Physiological Approach for Coronary Artery Bifurcation Disease

Author

Hak Seung Lee, Ung Kim, Seokhun Yang, Yoshinobu Murasato, Yves Louvard, Young Bin Song, Takashi Kubo, Thomas W. Johnson, Soon Jun Hong, Hiroyuki Omori, Manuel Pan, Joon-Hyung Doh, Yoshihisa Kinoshita, Adrian P. Banning, Chang-Wook Nam, Junya Shite, Thierry Lefèvre, Hyeon-Cheol Gwon, Yutaka Hikichi, Yiannis S. Chatzizisis, Jens Flensted Lassen, Goran Stankovic, and Bon-Kwon Koo

Subjects
Cardiology and Cardiovascular Medicine
Published
2022
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22. Stent underexpansion is associated with high wall shear stress: a biomechanical analysis of the shear stent study

Author

Sonali Kumar, David Molony, Sameer Khawaja, Kaylyn Crawford, Elizabeth W. Thompson, Olivia Hung, Imran Shah, Jessica Navas-Simbana, Arlen Ho, Arnav Kumar, Yi-An Ko, Hossein Hosseini, Adrien Lefieux, Joo Myung Lee, Joo-Yong Hahn, Shao-Liang Chen, Hiromasa Otake, Takashi Akasaka, Eun-Seok Shin, Bon-Kwon Koo, Goran Stankovic, Dejan Milasinovic, Chang-Wook Nam, Ki-Bum Won, Javier Escaned, Andrejs Erglis, Yoshinobu Murasato, Alessandro Veneziani, and Habib Samady

Published
2023
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23. The retrograde technique for recanalization of chronically occluded coronary arteries: Case series report

Author

Goran Stankovic, Zlatko Mehmedbegovic, Stefan Juricic, Dejan Orlic, Srdjan Aleksandric, Branko Beleslin, Sinisa Stojkovic, Milorad Tesic, and Milan Dobric

Subjects
Coronary arteries, medicine.medical_specialty, medicine.anatomical_structure, business.industry, Internal medicine, medicine, Cardiology, Pharmacology (medical), business
Abstract

Introduction. Chronic total occlusion (CTO) of the coronary artery still represents one of the most challenging lesion subsets in the field of interventional cardiology. Considering the complexity and increased risk posed by the retrograde approach, it is most often performed after a failed antegrade approach. Case report. We present a series of cases describing the retrograde approach as a special technique for treating CTO of the coronary artery. All cases had some special characteristics that are part of a dedicated portfolio in every catheterization lab today. In our series of cases, all three percutaneous coronary interventions (PCI) with a different strategies of the retrograde approach and supported with rotational atherectomy or intravascular ultrasound finished with successful recanalization of CTO. Conclusion. In cases where there is the presence of ?interventional? collaterals, as well as when the antegrade approach is very difficult, the retrograde approach can increase the success rate of procedures. The retrograde approach requires a long learning curve as well as very skilled and experienced operators who are able to per-form the procedure independently.

Published
2022
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24. Initial Invasive or Conservative Strategy for Stable Coronary Disease

Author

Maron D. J., Hochman J. S., Reynolds H. R., Bangalore S., O'Brien S. M., Boden W. E., Chaitman B. R., Senior R., Lopez-Sendon J., Alexander K. P., Lopes R. D., Shaw L. J., Berger J. S., Newman J. D., Sidhu M. S., Goodman S. G., Ruzyllo W., Gosselin G., Maggioni A. P., White H. D., Bhargava B., Min J. K., John Mancini G. B., Berman D. S., Picard M. H., Kwong R. Y., Ali Z. A., Mark D. B., Spertus J. A., Krishnan M. N., Elghamaz A., Moorthy N., Hueb W. A., Demkow M., Mavromatis K., Bockeria O., Peteiro J., Miller T. D., Szwed H., Doerr R., Keltai M., Selvanayagam J. B., Gabriel Steg P., Held C., Kohsaka S., Mavromichalis S., Kirby R., Jeffries N. O., Harrell F. E., Rockhold F. W., Broderick S., Bruce Ferguson T., Williams D. O., Harrington R. A., Stone G. W., Rosenberg Y, ISCHEMIA Research Group: Joseph Ricci, A Tello Montoliu, A I Robero Aniorte, Abbey Mulder, Abhay A Laddu, Abhinav Goyal, Abhishek Dubey, Abhishek Goyal, Abigail Knighton, Abraham Oomman, Adam J Jaskowiak, Adam Kolodziej, Adam Witkowski, Adnan Hameed, Adriana Anesini, Afshan Hussain, Agne Juceviciene, Agne Urboniene, Agnes Jakal, Agnieszka Szramowska, Ahmad Khairuddin, Ahmed Abdel-Latif, Ahmed Adel, Ahmed Aljzeeri, Ahmed Kamal, Ahmed Talaat, Aimee Mann, Aira Contreras, Ajit Kumar, V K Kumar, Akemi Furukawa, Akshay Bagai, Akvile Smigelskaite, Alain Furber, Alain Rheault, Alaine Melanie Loehr, Alan Rosen, Albert Varga, Albertina Qelaj, Alberto Barioli, Aldo Russo, Alec Moorman, Alejandro Gisbert, Aleksandra Fratczak, Aleksandras Laucevicius, Alena Kuleshova, Alessandro Sionis, Alexander A Sirker, Alexander M Chernyavskiy, Alexandra Craft, Alexandra Vazquez, Alexandre Ciappina Hueb, Alexandre S Colafranseschi, Alexandre Schaan de Quadros, Alexandre Tognon, Ali Alghamdi, Alice Manica Muller, Aline Nogueira Rabaça, Aline Peixoto Deiro, Alison Hallam, Allegra Stone, Allison Schley, Almudena Castro, Alvaro Rabelo Ales, Amanda Germann, Amanda O'Malley, Amar Uxa, Amarachi Ojajuni, Amarino C Oliveira Jr, Amber B Hull, Ambuj Roy, Amer Zarka, Amir Janmohamed, Ammani Brown, Ammy Malinay, Amparo Martinez Monzonis, Amy J Richards, Amy Iskandrian, Amy Ollinger, Ana D Djordjevic-Dikic, Ana Fernández Martínez, Ana Gomes Almeida, Ana Paula Batista, Ana Rita Francisco, Ana S Mladenovic, Ana Santana, Anam Siddiqui, Anastasia M Kuzmina-Krutetskaya, Andras Vertes, Andre S Sousa, Andre Gabriel, André Schmidt, Andrea M Lundeen, Andrea Bartykowszki, Andrea Lorimer, Andrea Mortara, Andrea Pascual, Andreia Coelho, Andreia Rocha, Andrés García-Rincón, Andrew G Howarth, Andrew J Moriarty, Andrew Docherty, Andrew Starovoytov, Andrew Zurick, Andrzej Łabyk, Andrzej Swiatkowski, Andy Lam, Anelise Kawakami, Angela Hoye, Angela Kim, Angelique Smit, Angelo Nobre, Anil V Shah, Anja Ljubez, Anjali Anand, Ankush Sachdeva, Ann Greenberg, Ann Luyten, Ann Ostrander, Anna Di Donato, Anna Cichocka-Radwan, Anna Fojt, Anna Plachcinska, Anna Proietti, Anna Teresinska, Anne Marie Webb, Anne Cartwright, Anne Heath, Anne Mackin, Anong Amaritakomol, Anong Chaiyasri, Anoop Chauhan, Anoop Mathew, Anthony Gemignani, Anto Luigi Andres, Antonia Vega, Antonietta Hansen, Antonino Ginel Iglesias, Antonio Carlos Carvalho, Antonio Di Chiara, Antonio Serra Peñaranda, Antonio Carvalho, Antonio Colombo, Antonio Fiarresga, Anupama Rao, Aquiles Valdespino-Estrada, Araceli Boan, Areef Ishani, Ariel Diaz, Arijit Ghosh, Arintaya Prommintikul, Arline Roberts, Arnold H Seto, Arnold P Good, Arshed Quyyumi, Arthur J Labovitz, Arthur Kerner, Arturo S Campos-Santaolalla, Arunima Misra, Ashok Mukherjee, Ashok Seth, Ashraf Seedhom, Asim N Cheema, Asker Ahmed, Atul Mathur, Atul Verma, Audrey W Leong, Axel Åkerblom, Axelle Fuentes, Aynun Naher, Badhma Valaiyapathi, Baljeet Kaur, Bandula Guruge, Barbara Brzezińska, Barbara Nardi, Bartosz Czarniak, Bebek Singh, Begoña Igual, Bela Merkely, Belen Cid Alvarez, Benjamin J Spooner, Benjamin J W Chow, Benjamin Cheong, Benoy N Shah, Bernard de Bruyne, Bernardas Valecka, Bernhard Jäger, Beth A Archer, Beth Abramson, Beth Jorgenson, Bethany Harvey, Betsy O'Neal, Bev Atkinson, Bev Bozek, Bevin Lang, Bijulal Sasidharan, Bin Yang, Bin Zhang, Binoy Mannekkattukudy Kurian, Bjoern Goebel, Bob Hu, Bogdan A Popescu, Bogdan Crnokrak, Bolin Zhu, Bonnie J Kirby, Brandi D Zimbelman, Brandy Starks, Branko D Beleslin, Brenda Hart, Brian P Shapiro, Brian McCandless, Brianna Wisniewski, Brigham R Smith, Brooks Mirrer, Bruce McManus, Bruce Rutkin, Bruna Edilena Paulino, Bruna Maria Ascoli, Bryn Smith, Byron J Allen, C Michael Gibson, C Noel Bairey Merz, Calin Pop, Cameron Hague, Camila Thais de Ormundo, Candace Gopaul, Candice P Edillo, Carísi A Polanczyk, Carita Krannila, Carla Vicente, Carl-Éric Gagné, Carlo Briguori, Carlos Peña Gil, Carlos Alvarez, Carly Ohmart, Carmen C Beladan, Carmen Ginghina, Carol M Kartje, Caroline Alsweiler, Caroline Brown, Caroline Callison, Caroline Pinheiro, Caroline Rodgers, Caroline Spindler, Carolyn Corbett, Carrie Drum, Casey Riedberger, Catherine Bone, Catherine Fleming, Catherine Gordon, Catherine Jahrsdorfer, Catherine Lemay, Catherine Weick, Cathrine Patten, Cecilia Goletto, Cezary Kepka, Chandini Suvarna, Chang Xu, Chantale Mercure, Charle A Viljoen, Charlene Wiyarand, Charles Jia-Yin Hou, Charles Y Lui, Charles Cannan, Charles Cornet, Charlotte Pirro, Chataroon Rimsukcharoenchai, Chen Wang, Cheng-Ting Tsai, Chen-Yen Chien, Cheryl A Allardyce, Chester M Hedgepeth, Chetan Patel, Chiara Attanasio, Chih-Hsuan Yen, Chi-Ming Chow, Ching Min Er, Ching-Ching Ong, Cholenahally Nanjappa Manjunath, Chris Beck, Chris Buller, Christel Vassaliere, Christian Hamm, Christiano Caldeira, Christie Ballantyne, Christina Björklund, Christine R Hinton, Christine Bergeron, Christine Masson, Christine Roraff, Christine Shelley, Christophe Laure, Christophe Thuaire, Christopher Kinsey, Christopher McFarren, Christopher Spizzieri, Christopher Travill, Chun-Chieh Liu, Chung-Lieh Hung, Chunguang Li, Chun-Ho Yun, Chunli Xia, Ciarra Heard, Cidney Schultz, Clare Venn-Edmonds, Claudia P Hochberg, Claudia Wegmayr, Claudia Cortés, Claudia Escobar, Cláudia Freixo, Claudio T Mesquita, Clemens T Kadalie, Colin Berry, Constance Philander, Corine Thobois, Costantino Costantini, Courtney Page, Craig Atkinson, Craig Barr, Craig Paterson, Cristina Bare, Cynthia Baumann, Cynthia Burman, Dalisa Espinosa, Damien Collison, Dan Deleanu, Dan Elian, Dan Gao, Dana Oliver, Daniel P Vezina, Daniel O'Rourke, Daniele Komar, Danielle Schade, Darrel P Francis, Dastan Malaev, David A Bull, David E Winchester, David P Faxon, David Booth, David Cohen, David DeMets, David Foo, David Schlichting, David Taggart, David Waters, David Wohns, Davis Vo, Dawid Teodorczyk, Dawn Shelstad, Dawn Turnbull, Dayuan Li, Dean Kereiakes, Deborah O'Neill, Deborah Yip, Debra K Johnson, Debra Dees, Deepak L Bhatt, Deepika Gopal, Deepti Kumar, Deirdre Mattina, Deirdre Murphy, Delano R Small, Delsa K Rose, Dengke Jiang, Denis Carl Phaneuf, Denise Braganza, Denise Fine, Derek Cyr, Desiree Tobin, Diana Cukali, Diana Parra, Diane Camara, Diane Minshall Liu, Diego Adrián Vences, Diego Franca de Cunha, Dimitrios Stournaras, Dipti Patel, Dongze Li, Donna Exley, Dorit Grahl, Dragana Stanojevic, Duarte Cacela, Dwayne S G Conway, E Pinar Bermudez, Eapen Punnoose, Edgar L Tay, Edgar Karanjah, Edoardo Verna, Eduardo Hernandez-Rangel, Edward D Nicol, Edward O McFalls, Edward T Martin, Edyta Kaczmarska, Ekaterina I Lubinskaya, Elena A Demchenko, Elena Refoyo Salicio, Eli Feen, Elihú Durán-Cortés, Elisabeth M Janzen, Elise L Hannemann, Elise van Dongen, Elissa Restelli Piloto, Eliza Kaplan, Elizabeta Srbinovska Kostovska, Elizabeth Capasso-Gulve, Elizabeth Congdon, Elizabeth Ferguson, Elizaveta V Zbyshevskaya, Ellen Magedanz, Ellie Fridell, Ellis W Lader, Elvin Kedhi, Emanuela Racca, Emilie Tachot, Emily DeRosa, Encarnación Alonso-Álvarez, Eric Nicollet, Eric Peterson, Erick Alexánderson Rosas, Erick Donato Morales, Erin Orvis, Ermina Moga, Estelle Montpetit, Estevao Figueiredo, Eugene Passamani, Eugenia Nikolsky, Eunice Yeoh, Evgeniy I Kretov, Ewa Szczerba, Ewelina Wojtala, Expedito Eustáquio Ribeiro Silva, F Marin Ortuño, Fabio R Farias, Fabio Fimiani, Fabrizio Rolfo, Fa-Chang Yu, Fadi Hage, Fadi Matar, Fahim Haider Jafary, Fang Feng, Fang Liu, Fatima Ranjbaran, Fatima Rodriguez, Fausto J Pinto, Fauzia Rashid, Federica Ramani, Fei Wang, Fernanda Igansi, Filipa Silva, Filippo Ottani, Fiona Haines, Firas Al Solaiman, Flávia Egydio, Flavio Lyra, Florian Egger, Fran Farquharson, Frances Laube, Francesc Carreras Costa, Francesca de Micco, Francesca Bianchini, Francesca Pezzetta, Francesca Pietrucci, Francesco Orso, Francesco Pisano, Francis Burt, Francisca Patuleia Figueiras, Francisco Fernandez-Aviles, Francois Pierre Mongeon, Frans Van de Werf, Franziska Guenther, Fraser N Witherow, Fred Mohr, Frederico Dall'Orto, Fumiyuki Otsuka, G De La Morena, G Karthikeyan, Gabor Dekany, Gabor Kerecsen, Gabriel Galeote, Gabriel Grossmann, Gabriel Vorobiof, Gabriela Sanchez de Souza, Gabriela Guzman, Gabriela Zeballos, Gabriele Gabrielli, Gabriele Jakl-Kotauschek, Gail A Shammas, Gail Brandt, Gang Chen, Gary E Lane, Gary J Luckasen, Gautam Sharma, Gelmina Mikolaitiene, Gennie Yee, Georg Nickenig, George E Revtyak, George J Juang, Gerald Fletcher, Gerald Leonard, Gerard Patrick Devlin, Gerard Esposito, Gergely Ágoston, Gervasio Lamas, Geza Fontos, Ghada Mikhail, Gia Cobb, Gian Piero Perna, Gianpiero Leone, Giles Roditi, Gilles Barone-Rochette, Girish Mishra, Giuseppe Tarantini, Glenda Wong, Glenn S Hamroff, Glenn Rayos, Gong Cheng, Gonzalo Barge-Caballero, Goran Davidović, Goran Stankovic, Gordana Stevanovic, Grace Jingyan Wang, Grace M Young, Graceanne Wayser, Graciela Scaro, Graham S Hillis, Graham Wong, Grazyna Anna Szulczyk, Gregor Simonis, Gregory Kumkumian, Gretchen Ann Peichel, Grzegorz Gajos, Gudrun Steinmaurer, Guilherme G Rucatti, Guilherme Portugal, Guilhermina Cantinho Lopes, Guillem Pons Lladó, Gunnar Frostfelt, Gurpreet S Wander, Gurpreet Gulati, Gustavo Pucci, Hafidz Abd Hadi, Haibo Zhang, Haitao Wang, Halina Marciniak, Han Chen, Hanan Kerr, Hani Najm, Hanna Douglas, Hannah Phillips, Hao Dai, Haojian Dong, Haqeel Jamil, Harikrishnan Sivadasanpillai, Harry Suryapranata, Hassan Reda, Hayley Pomeroy, Heather Barrentine, Heather Golden, Heather Hurlburt, Heidi Wilson, Helen C Tucker, Helene Abergel, Hemalata Siddaram, Hermine Osseni, Herwig Schuchlenz, Hesong Zeng, Hicham Skali, Hilda Solomon, Hollie Horton, Holly Hetrick, Holly Little, Holly Park, Hongjie Chi, Hossam Mahrous, Howard A Levite, Hristo Pejkov, Huajun Li, Hugo Bloise-Adames, Hugo Marques, Hui Zhong, Hui-Min Zhang, Humayrah Hashim, Hung-I Yeh, Hussien El Fishawy, Ian Webb, Iftikhar Kullo, Igor O Grazhdankin, Ihab Hamzeh, Ikraam Hassan, Ikuko Ueda, Ileana L Pina, Ilona Tamasauskiene, Ilse Bouwhuis, Imran Arif, Ina Wenzelburger, Inês Zimbarra Cabrita, Ines Rodrigues, Inga H Robbins, Inga Soveri, Ingela Schnittger, Iqbal Karimullah, Ira M Dauber, Iram Rehman, Irena Peovska Mitevska, Irene Marthe Lang, Irina Subbotina, Irma Kalibataite-Rutkauskiene, Irni Yusnida, Isabel Estela Carvajal, Isabella C Palazzo, Isabelle Hogan, Isabelle Roy, Ishba Syed, Ishita Tejani, Ivan A Naryshkin, Ivana Jankovic, Iwona Niedzwiecka, J David Knight, Jacek Kusmierek, Jackie M White, Jackie Chow, Jacob Udell, Jacqueline E Tamis-Holland, Jacqueline Fannon, Jacquelyn A Quin, Jacquelyn Do, Jaekyeong Heo, Jakub Maksym, James E Davies, James H O'Keefe Jr, James J Jang, James Cha, James Harrison, James Hirsch, James Stafford, James Tatoulis, Jamie Rankin, Jan Henzel, Jan Orga, Jana Tancredi, Janaina Oliveira, Jane Burton, Jane Eckstein, Jane Marucci, Janet P Knight, Janet Blount, Janet Halliday, Janetta Kourzenkova, Janitha Raj, Jan-Malte Sinning, Jaqueline Pozzibon, Jaroslaw Drozdz, Jaroslaw Karwowski, Jason D Glover, Jason Loh Kwok, Jason T Call, Jason Linefsky, Jassira Gomes, Jati Anumpa, Javier J Garcia, Javier Courtis, Jay Meisner, K Jayakumar, Jayne Scales, Jean E Denaro, Jean Michel Juliard, Jean Ho, Jeanette K Stansborough, Jean-Michel Juliard, Jeanne Russo, Jeannette J M Schoep, Jeet Thambyrajah, Jeff Leimberger, Jeffery A Breall, Jeffrey A Kohn, Jeffrey C Milliken, Jeffrey Anderson, Jeffrey Blume, Jeffrey Kanters, Jeffrey Lorin, Jeffrey Moses, Jelena J Stepanovic, Jelena Celutkiene, Jelena Djokic, Jelena Stojkovic, Jenne M Jose, Jenne Manchery, Jennifer A Mull, Jennifer H Czerniak, Jennifer L Stanford, Jennifer Gillis, Jennifer Horst, Jennifer Isaacs, Jennifer Langdon, Jennifer Thomson, Jennifer Tomfohr, Jennifer White, Jen-Yuan Kuo, Jeremy Rautureau, Jerome Fleg, Jessica Berg, Jessica Rodriguez, Jessica Waldron, Jhina Patro, Jia Li, Jiajia Mao, Jiamin Liu, Jian'an Wang, Jianhua Li, Jianxin Zhang, Jie Qi, Jihyun Lyo, Jill Marcus, Jim Blankenship, Jing Zhang, Jingjing Liu, Jing-Yao Fan, Jiun-Yi Li, Jiwan Pradhan, Jiyan Chen, J M Rivera Caravaca, Jo Evans, Joan Garcia Picart, Joan Hecht, Joanna Jaroch, Joanna Zalewska, Joanne Kelly, Joanne Taaffe, João Reynaldo Abbud, João V Vitola, Joaquín V Peñafiel, Jocelyne Benatar, Jody Bindeman, Joe Sabik, Joel Klitch, Johann Christopher, Johannes Aspberg, John D Friedman, John F Beltrame, John F Heitner, John Joseph Graham, John R Davies, John Doan, John Kotter, John Kurian, John Mukai, John Pownall, Jolanta Sobolewska, Jon Kobashigawa, Jonathan L Goldberg, Jonathan W Bazeley, Jonathan Byrne, Jonathan Himmelfarb, Jonathan Leipsic, Jonean Thorsen, Jorge F Trejo Gutierrez, Jorge Escobedo, Jorik Timmer, José A Ortega-Ramírez, José Antonio Marin-Neto, Jose D Salas, Jose Enrique Castillo, Jose Francisco Saraiva, José J Cuenca-Castillo, Jose L Diez, José Luis Narro Villanueva, José Luiz da Vieira, José M Flores-Palacios, Jose Ramon Gonzalez, Jose Seijas Amigo, Jose Fragata, Josep Maria Padró, Josheph F X McGarvey Jr, Joseph Hannan, Joseph Sacco, Joseph Sweeny, Joseph Wiesel, Josephine D Abraham, Joshua P Loh, Joy Burkhardt, Joyce R White, Joyce Riestenberg-Smith, Judit Sebo, Judith L Meadows, Judith Wright, Judy Mae Foltz, Judy Hung, Judy Otis, Juergen Stumpf, Jui-Peng Tsai, Julia S Dionne, Julia de Aveiro Morata, Julie Bunke, Julie Morrow, Julio César Figal, Jun Fujita, Jun Jiang, Junhua Li, Junqing Yang, Juntima Euathrongchit, Jyotsna Garg, K Manjula Rani, K Preethi, Kaatje Goetschalckx, Kai Eggers, Kamalakar Surineni, Kanae Hirase, T R Kapilamoorthy, Karen Calfas, Karen Gratrix, Karen Hallett, Karen Hultberg, Karen Nugent, Karen Petrosyan, Karen Swan, Karolina Kryczka, Karolina Wojtczak-Soska, Karolina Wojtera, Karsten Lenk, Karthik Ramasamy, Katarzyna Łuczak, Katarzyna Malinowska, Kate Pointon, Kate Robb, Katherine Martin, Kathleen Claes, Kathryn Carruthers, Kathy E Siegel, Katia Drouin, Katie Fowler-Lehman, Kavita Rawat, Kay Rowe, Keiichi Fukuda, Keith A A Fox, Ken Mahaffey, Kendra Unterbrink, Kenneth Giedd, Kerrie Van Loo, Kerry Lee, Kerstin Bonin, Kevin R Bainey, Kevin T Harley, Kevin Anstrom, Kevin Chan, Kevin Croce, Kevin Landolfo, Kevin Marzo, Keyur Patel, Khaled Abdul-Nour, Khaled Alfakih, Khaled Dajani, Khaled Ziada, Khaula Baloch, Khrystyna Kushniriuk, Kian-Keong Poh, Kim F Ireland, Kim Holland, Kimberly Ann Byrne, Kimberly E Halverson, Kimberly Elmore, Kimberly Miller-Cox, Kiran Reddy, Kirsten J Quiles, Kirsty Abercrombie, Klaus Matschke, Konrad Szymczyk, Koo Hui Chan, Kotiboinna Preethi, Kozhaya Sokhon, Krissada Meemuk, Kristian Thygesen, Kristin M Salmi, Kristin Newby, Kristina Wippler, Kristine Arges, Kristine Teoh, Krystal Etherington, Krystyna Łoboz-Grudzień, Krzysztof W Reczuch, Krzysztof Bury, Krzysztof Drzymalski, Krzysztof Kukuła, Kuo-Tzu Sung, Kurt Huber, Ladda Douangvila, Lance Sullenberger, Larissa Miranda Trama, Laszlone Matics, Laura Drew, Laura Flint, Laura Keinaite, Laura Sarti, Laurel Kolakaluri, Lawrence M Phillips, Lawrence Friedman, Lawrence Phillips, Lazar Velicki, Leah Howell, Leandro C Maranan, Leanne Cox, Ledjalem Daba, Lei Zhang, Lekshmi Dharmarajan, Leo Bockeria, Leonardo Pizzol Caetano, Leonardo Bridi, Leonid L Bershtein, Leszek Sokalski, Li Hai Yan, Li Li, Lia Nijmeijer, Lidia Sousa, Lihong Xu, Lihua Zhang, Lili Zhang, Lilia Schiavi, Lilian Mazza Barbosa, Lillian L Khor, Lina Felix-Stern, Linda L Hall, Linda M Hollenweger, Linda Arcand, Linda Davidson-Ray, Linda Schwarz, Lindsey N Sikora, Lingping Chi, Lino Patricio, Liping Zhang, Lisa Chaytor, Lisa Hatch, Lisa McCloy, Lisa Wong, Liselotte Persson, Lixin Jiang, Liz Low, Ljiljana Pupic, Loïc Bière, Lorenzo Monti, Lori Christensen, Lori Pritchard, Loriane Black, Lori-Ann Desimone, Lori-Ann Larmand, Lorraine McGregor, Louise Morby, Louise Thomson, Luc Harvey, Luciana de Pádua Baptista, Lucilla Garcia, Ludivine Eliahou, Ludmila Helmer, Luis F Smidt, Luis Bernanrdes, Luis Guzman, Luiz A Carvalho, Luyang Xiong, Lynette L Teo, Lynn M Neeson, Lynne Winstanley, M Barbara Srichai-Parsia, M Quintana Giner, M Sowjanya Reddy, M Valdés Chávarri, M Grazia Rossi, Maarten Simoons, Maayan Konigstein, Maciej Lesiak, Maciej Olsowka, Mafalda Selas, Magalie Corfias, Magdalena Madero Rovalo, Magdalena Łanocha, Magdalena Miller, Magdalena Misztal-Teodorczyk, Magdalena Rantinella, Magdy Abdelhamid, Magnolia Jimenez, Mahboob Alam, Mahevamma Mylarappa, Mahfouz El Shahawy, Mahmoud Mohamed, Mahmud Al-Bustami, Majo X Joseph, Malgorzata Frach, Małgorzta Celińska-Spodar, Malte Helm, Manas Chacko, Mandy Murphy, Manitha Vinod, Manjula Rani, Manu Dhawan, Manuela Mombelli, Marcel Weber, Marcello Galvani, Marcelo Jamus Rodrigues, Marcia F Dubin, Marcia F Werner Bayer, Marcin Szkopiak, Marco Antonio Monsalve, Marco Bizzaro Santos, Marco Magnoni, Marco Marini, Marco Sicuro, Marco Zenati, Marcos Valério Coimbra Resende, Marek Roik, Margalit Bentzvi, Margaret Gilsenan, Margaret Iraola, Margot C 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Jr, Matthew Budoff, Matthew Jezior, Matthew Luckie, Matthias Friedrich, Mauren P Haeffner, Maximilian Tscharre, Max-Paul Winter, Mayana Almeida, Mayil S Krishnam, Mayuri Patel, Meenakshi Mishra, Megan Manocchia, Meghana Kakade, Melanie J Munro, Melissa D Chaplin, Melissa LeFevre, Mervyn Andiapen, Michael A Gibson, Michael B Rubens, Michael C Turner, Michael D Shapiro, Michael W Lee, Michael Berlowitz, Michael Davidson, Michael Mack, Michael McDaniel, Michael Mumma, Michal Wlodarczyk, Michel G Khouri, Michel S Slama, Michele Rawlins, Michelle M Bonner, Michelle M Seib, Michelle Chang, Michelle Crowder, Michelle Dixon, Michelle Mayon, Michelle McEvoy, Michelle Yee, Miguel M Fernandes, Miguel Nobre Menezes, Miguel Souto Bayarri, Miguel Barrero, Mikhail T Torosoff, Milan R Dobric, Milan Dobric, Milica Nikola Dekleva, Milind Avdhoot Gadkari, Millie Gomez, Min Tun Kyaw, Miriam Brooks, Miroslav Stevo Martinovic, Mitchel B Lustre, Mohammad Tariq Vakani, Mohammad El-Hajjar, Mohammed Al-Amoodi, Mohammed Hussain, Mohammed Saleem, Moisés Blanco-Calvo, Moisés Jiménez-Santos, Mona Bhatia, Monica Rosca, Monika Laukyte, Montserrat Gracida Blanca, Montserrat Vila Perales, Mouaz H Al-Mallah, Moysés de Oliveira Filho, Mpiko Ntsekhe, Muhamed Saric, Mulei Chen, Myriam Brousseau, Myrthes Emy Takiuti, Nada Cemerlic-Adjic, Nadia Asif, Nadia Gakou, Nafisa Hussain, Nana O Katamadze, Nancy L Clapp, Nancy Aedy, Nandita Nataraj, Nanette K Wenger, Naomi Uchida, Nasrul Ismail, Natalia S Oliveira, Natalia de Carvalho Maffei, Natalie Spitzer, Natasha C Putnam, Naved Aslam, Neamat Mowafy, Neeraj Pandit, Neeraj Parakh, Nevena Garcevic, Ngaire Meadows, Nhi N Tran, Nicholas Danchin, Nicki Lakeman, Nicola Johnston, Nicolas W Shammas, Nicole Saint Vrestil, Nicole Deming, Nier Zhong, Niket Patel, Nikola N Boskovic, Nikolaos Karogiannis, Nikos Werner, Nina Johnston, Ning Zhang, Ning Zhou, Niree Hindoyan, Nirmal Kumar, Nitika Chadha, Nitish Naik, Nodira Aripova, Noloyiso Mtana, Nona A Eskelson, Noor Syamira 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Paula García-González, Paulo Cury Rezende, Paulo Ricardo Caramori, Pavel S Kozlov, Pedro Canas Silva, Pedro Gabriel Melo Barros E Silva, Pedro Píccaro de Oliveira, Pedro Carvalho, Pedro Modas, Pedro Rio, Peeyush Jain, Peiyu He, Peter A McCullough, Peter H Stone, Peter M Pollak, Peter Douglass, Peter Henriksen, Peter OKane, Peter Ong, Philip Jones, Philip Rogal, Philippe Généreux, Philippe Menasche, Philippe Rheault, Phoebe Goold, Pierre Gervais, Pierre Michaud, Pilar Calvillo, Ping Chai, Piotr Jakubowski, Piotr Pruszczyk, Piotr Slomka, Piyamitr Sritara, Poay-Huan Loh, Poonam Sonawane, Pouneh Samadi, Pragnesh P Parikh, Prakash Deedwania, Pranav M Patel, Praneeth Polamuri, Pratiksha Sharma, Precilia Vasquez, Preeti Kamath, Prince Thomas, Priyadarshani Arambam, Puja K Mehta, Purvez Grant, Pushpa Naik, Qi Zhong, Qian Zhao, Qiang Zhou, Qianqian Yuan, Qin Yu, Qingxian Li, Qiulan Xie, Qiutang Zeng, R J Vindhya, R James Gerlach, Rachel King, Rada Vučić, Radmila Lyubarova, Radoslaw Pracon, 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Stephanie M Lane, Stephanie Ferket, Stephanie Kelly, Stephanie Wasmiller, Stephen H McKellar, Stephen P Hoole, Stephen Fremes, Stephen Preston, Steve Leung, Steven A Fein, Steven J Lindsay, Steven P Sedlis, Steven Giovannone, Steven Michael, Steven Weitz, Stijn van Vugt, Subhash Banerjee, Sudhir Naik, Suellen Hosino, Sukie Desire, Sukit Yamwong, Suku T Thambar, Sulagna Mookherjee, Suman Singh, Sundeep Mishra, Sunil Kumar Verma, Supap Kulthawong, Supatchara Khwakhong, Surendra Naik, Suresh Babu, Surin Woragidpoonpol, Suryaprakash Narayanappa, Susan Derbyshire, Susan Gent, Susan Mathus, Susan Milbrandt, Susan Moore, Susan Regan, Susan Stinson, Susan Webber, Susana Silva, Susanna Stevens, Susanne Gruensfelder, Suthara Aramcharoen, Suvarna Kolhe, Suzana Tavares, Suzanne Arnold, Suzanne Welsh, Svetlana Apostolovic, Swapna Kunhunny, Ta-Chuan Hung, Taissa Zappernick, Tali Sharir, Talita Silva, Tamara Colaiácovo Soares, Tapan Umesh Pillay, Tarun K Mittal, Tatiana Trifonova, Tauane Bello Duarte, Tauqir Huk, Téodora Dutoiu, Terrance Chua, Terry Weyand, Thabitha Charles, Theodoros Kofidis, Theresa McCreary, Thierry Lefevre, Thippeekaa Arumairajah, Thitipong Tepsuwan, Thomas J Mulhearn, Thomas M Meyer, Thomas P Rocco, Thomas R Downes, Thomas Crain, Thomas Haldis, Thomas Mathew, Thomas Redick, Thounaojam Indira Devi, Thuraia Nageh, Tia Cauthren, Tiago Silva, Tiffany Little, Tijana Andric, Tina Harding, Titus Lau, Tiziana Formisano, Tiziano Moccetti, Tomasz Ciurus, Tomasz Mazurek, Tomasz Tarchalski, Toshiyuki Nagai, Tri Tran, Tricia Youn, Trish Tucker, Trudie Milner, Tuhina Bose, Tushar Kotecha, Udo Sechtem, Uma S Valeti, Umberto Cucchini, Umesh Badami, Upendra Kaul, V K Bahl, V S Narain, Valentina Casali, Valeria Godoy, Valerie Robesyn, Vamshi P Priya, Vandana Yadav, Vera McKinney, Veronica De Lenges, Veronica Tinnirello, Vicente Miro, Victor Navarro, Victoria Gumerova, Victoria Hernandez, Vidya Seeratan, Vijay Kumar, Vikentiy Y Kozulin, Viktoria Bulkley, Vilmar Veiga Jr, Vincent Setang, C P Vineeth, Virginai Pubull Nuñez, Virginia Fernández-Figares, Vitor Gomes, Viviana Gabriel, Viviane Dos Santos, Viviane Almeida, Vlad A Iliescu, Vladan Mudrenovic, Vladimir Dzavik, Vojislav L Giga, Walter Enrique Mogrovejo, Wan Xian Chan, Wanda C Marfori, Wanda Parker, Warangkana Mekara, Wassim Nona, Wayne Old, Wayne Pennachi, Weerachai Nawarawong, Wei Chen, Wei Su, Weibing Xing, Wei-Ren Lan, Wenda Crawford, Wendy L Stewart, Wendy Drewes, Wenhua Lin, William B Abernethy, William D Salerno, William F Fearon, William Vergoni, William Weintraub, Winnie C Sia, Wlodzimierz J Musial, Xacobe Flores-Ríos, Xavier Garcia-Moll Marimon, Xi Su, Xiang Ma, Xiangqiong Gu, Xiao Wang, Xiaomei Li, Xiaowei Yao, Xin Fu, Xin Su, Xin Zeng, Xinchun Yang, Xiuhong Li, Xuehua Fang, Xutong Wang, Yaming Geng, Yan Yan, Yanek Pépin-Dubois, Yanfu Wang, Yang Wang, Yanmeng Tian, Yaping Huang, Yechen Han, Yesenia Zambrano, Yi-Hsuan Yang, Ying Tung Sia, Yining Yang, Yitong Ma, Yolayfi Peralta, Yongjian Wu, Yu Kunwu, Yu Zhao, Yudong Peng, Yueh-Hung Lin, Yulan Zhao, Yumei Dong, Yunhai Zhao, Yutthaphan Wannasopha, Yvonne Taul, Zakir Sahul, Zalina Kudzoeva, Zbigniew Kalarus, Zeljko Z Markovic, Zhen Huang, Zheng Ji, Zhenyu Liu, Zhou Yue, Zhulin Zhang, Zhuxi Li, Zile Singh Meharwal, Ziliang Bai, Zixiang Yu, Zohra Huda, Zoltan Davidovits

Subjects
Male, Cardiac Catheterization, Computed Tomography Angiography, medicine.medical_treatment, Myocardial Ischemia, Coronary Disease, Coronary Artery Disease, Kaplan-Meier Estimate, 030204 cardiovascular system & hematology, Coronary Angiography, ISCHEMIA Research Group, law.invention, Angina, Coronary artery disease, 0302 clinical medicine, Randomized controlled trial, law, Cardiovascular Disease, Myocardial Revascularization, 030212 general & internal medicine, Coronary Artery Bypass, 11 Medical and Health Sciences, Cardiac catheterization, General Medicine, Middle Aged, humanities, Cardiovascular Diseases, Cardiology, Female, Human, medicine.medical_specialty, Ischemia, Article, 03 medical and health sciences, Geriatric cardiology, Percutaneous Coronary Intervention, General & Internal Medicine, Internal medicine, medicine, Humans, Angina, Unstable, Aged, business.industry, Coronary Artery Bypa, Percutaneous coronary intervention, Bayes Theorem, medicine.disease, Heart failure, Quality of Life, business
Abstract

BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).

Published
2020
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26. Clinical outcomes of the proximal optimisation technique (POT) in bifurcation stenting

Author

Mamas A. Mamas, Ariel Roguin, Farzin Beygui, Muhammad Rashid, Goran Stankovic, Thomas Hovasse, Manuel Pan, John McDonald, Joan Antoni Gómez-Hospital, J Crowley, Javier Fernández Portales, Bernard Chevalier, Adel Aminian, and Adam Witkowski

Subjects
Target lesion, medicine.medical_specialty, business.industry, medicine.medical_treatment, Percutaneous coronary intervention, Confidence interval, Primary outcome, Daily practice, Internal medicine, Propensity score matching, Cohort, Cardiology, Medicine, Cardiology and Cardiovascular Medicine, business, Bifurcation
Abstract

BACKGROUND Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate. AIMS We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how the post-implantation deployment techniques influence the clinical outcomes. METHODS Data from the e-ULTIMASTER registry were used to perform an analysis of 4395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at 1-year (follow-up rate 96.2%). RESULTS Global one-year TLF rate was low: 5.1%. Proximal optimization technique was used in 33.9 % of cases and was associated with a reduction in adjusted TLF rate [4.0 (95% confidence interval:3.0-5.1)% versus 6.0(5.1-6.9)%, p

Published
2021
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27. Abbreviated Antiplatelet Therapy in Patients at High Bleeding Risk With or Without Oral Anticoagulant Therapy After Coronary Stenting: An Open-Label, Randomized, Controlled Trial

Author

Ran Kornowski, Mirvat Alasnag, Carl Schultz, Dik Heg, David Hildick-Smith, Peter Jüni, Bernard Chevalier, Andrés Iñiguez, Yoshinobu Onuma, Felix Mahfoud, Master Dapt investigators, Marco Roffi, Marie-Claude Morice, Goran Stankovic, Antonio Colombo, Enrico Frigoli, Alfredo E. Rodriguez, Aris Moschovitis, Maciej Lesiak, Stephan Windecker, Pim A.L. Tonino, Paul Jau Lueng Ong, Pieter C. Smits, Marco Valgimigli, Pascal Vranckx, Jozef Bartunek, Yukio Ozaki, Jan G.P. Tijssen, Peep Laanmets, Juni, Peter/0000-0002-5985-0670, Schultz, Carl/0000-0002-0847-4361, Stankovic, Goran/0000-0002-9414-0885, Cardiology, and ACS - Heart failure & arrhythmias

Subjects
Male, medicine.medical_specialty, medicine.medical_treatment, MEDLINE, Administration, Oral, 610 Medicine & health, Hemorrhage, 030204 cardiovascular system & hematology, antiplatelet therapy, law.invention, 03 medical and health sciences, Percutaneous Coronary Intervention, 0302 clinical medicine, Randomized controlled trial, Risk Factors, law, Original Research Articles, Physiology (medical), medicine, Humans, In patient, 030212 general & internal medicine, intervention, Oral anticoagulation, Aged, business.industry, Anticoagulants, Coronary stenting, Percutaneous coronary intervention, dual antiplatelet therapy, 3. Good health, Surgery, ComputingMethodologies_DOCUMENTANDTEXTPROCESSING, Oral anticoagulant, Female, Stents, Open label, Cardiology and Cardiovascular Medicine, business, percutaneous coronary, Platelet Aggregation Inhibitors
Abstract

Supplemental Digital Content is available in the text., Background: The optimal duration of antiplatelet therapy (APT) in patients at high bleeding risk with or without oral anticoagulation (OAC) after coronary stenting remains unclear. Methods: In the investigator-initiated, randomize, open-label MASTER DAPT trial (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Standard DAPT Regimen), 4579 patients at high bleeding risk were randomized after 1-month dual APT to abbreviated or nonabbreviated APT strategies. Randomization was stratified by concomitant OAC indication. In this subgroup analysis, we report outcomes of populations with or without an OAC indication. In the population with an OAC indication, patients changed immediately to single APT for 5 months (abbreviated regimen) or continued ≥2 months of dual APT and single APT thereafter (nonabbreviated regimen). Patients without an OAC indication changed to single APT for 11 months (abbreviated regimen) or continued ≥5 months of dual APT and single APT thereafter (nonabbreviated regimen). Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes (composite of all-cause death, myocardial infarction, stroke, and Bleeding Academic Research Consortium 3 or 5 bleeding events); major adverse cardiac and cerebral events (all-cause death, myocardial infarction, and stroke); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding. Results: Net adverse clinical outcomes or major adverse cardiac and cerebral events did not differ with abbreviated versus nonabbreviated APT regimens in patients with OAC indication (n=1666; hazard ratio [HR], 0.83 [95% CI, 0.60–1.15]; and HR, 0.88 [95% CI, 0.60–1.30], respectively) or without OAC indication (n=2913; HR, 1.01 [95% CI, 0.77–1.33]; or HR, 1.06 [95% CI, 0.79–1.44]; Pinteraction=0.35 and 0.45, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding did not significantly differ in patients with OAC indication (HR, 0.83 [95% CI, 0.62–1.12]) but was lower with abbreviated APT in patients without OAC indication (HR, 0.55 [95% CI, 0.41–0.74]; Pinteraction=0.057). The difference in bleeding in patients without OAC indication was driven mainly by a reduction in Bleeding Academic Research Consortium 2 bleedings (HR, 0.48 [95% CI, 0.33–0.69]; Pinteraction=0.021). Conclusions: Rates of net adverse clinical outcomes and major adverse cardiac and cerebral events did not differ with abbreviated APT in patients with high bleeding risk with or without an OAC indication and resulted in lower bleeding rates in patients without an OAC indication. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03023020.

Published
2021
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28. Acute Coronary Syndrome: The Risk to Young Women

Author

Beatrice Ricci, Edina Cenko, Zorana Vasiljevic, Goran Stankovic, Sasko Kedev, Oliver Kalpak, Marija Vavlukis, Marija Zdravkovic, Sasa Hinic, Davor Milicic, Olivia Manfrini, Lina Badimon, and Raffaele Bugiardini

Subjects
acute coronary syndrome, women, young, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

BackgroundAlthough acute coronary syndrome (ACS) mainly occurs in patients >50 years, younger patients can be affected as well. We used an age cutoff of 45 years to investigate clinical characteristics and outcomes of “young” patients with ACS. Methods and ResultsBetween October 2010 and April 2016, 14 931 patients with ACS were enrolled in the ISACS‐TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry. Of these patients, 1182 (8%) were aged ≤45 years (mean age, 40.3 years; 15.8% were women). The primary end point was 30‐day all‐cause mortality. Percentage diameter stenosis of ≤50% was defined as insignificant coronary disease. ST‐segment–elevation myocardial infarction was the most common clinical manifestation of ACS in the young cases (68% versus 59.6%). Young patients had a higher incidence of insignificant coronary artery disease (11.4% versus 10.1%) and lesser extent of significant disease (single vessel, 62.7% versus 46.6%). The incidence of 30‐day death was 1.3% versus 6.9% for the young and older patients, respectively. After correction for baseline and clinical differences, age ≤45 years was a predictor of survival in men (odds ratio, 0.24; 95% confidence interval, 0.10–0.58), but not in women (odds ratio, 1.35; 95% confidence interval, 0.50–3.62). This pattern of reversed risk among sexes held true after multivariable correction for in‐hospital medications and reperfusion therapy. Moreover, younger women had worse outcomes than men of a similar age (odds ratio, 6.03; 95% confidence interval, 2.07–17.53). ConclusionACS at a young age is characterized by less severe coronary disease and high prevalence of ST‐segment–elevation myocardial infarction. Women have higher mortality than men. Young age is an independent predictor of lower 30‐day mortality in men, but not in women. Clinical Trial RegistrationURL: http://clinicaltrials.gov/. Unique identifier: NCT01218776.

Published
2017
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29. Variants Tagging LGALS-3 Haplotype Block in Association with First Myocardial Infarction and Plasma Galectin-3 Six Months after the Acute Event

Author

Ana Djordjevic, Maja Zivkovic, Maja Boskovic, Milica Dekleva, Goran Stankovic, Aleksandra Stankovic, and Tamara Djuric

Subjects
haplotype, myocardial infarction, left ventricle, plasma galectin-3, Genetics, LGALS-3 tag variants, Genetics (clinical)
Abstract

Galectin-3 is encoded by LGALS-3, located in a unique haplotype block in Caucasians. According to the Tagger server, rs4040064, rs11628437, and rs7159490 cover 82% (r2 > 0.8) of the genetic variance of this HapBlock. Our aims were to examine the association of their haplotypes with first myocardial infarction (MI), changes in left ventricular echocardiographic parameters over time, and impact on plasma galectin-3 and LGALS-3 mRNA in peripheral blood mononuclear cells, both 6 months post-MI. The study group consisted of 546 MI patients and 323 controls. Gene expression was assessed in 92 patients and plasma galectin-3 in 189 patients. Rs4040064, rs11628437, rs7159490, and LGALS-3 mRNA expression were detected using TaqMan® technology. Plasma galectin-3 concentrations were determined by the ELISA method. We found that the TGC haplotype could have a protective effect against MI (adjusted OR 0.19 [0.05–0.72], p = 0.015) and that the GAC haplotype had significantly higher galectin-3 concentrations (48.3 [37.3–59.4] ng/mL vs. 18.9 [14.5–23.4] ng/mL, p < 0.0001), both in males and compared to the referent haplotype GGC. Higher plasma Gal-3 was also associated with higher NYHA class and systolic dysfunction. Our results suggest that variants tagging LGALS-3 HapBlock could reflect plasma Gal-3 levels 6 months post-MI and may have a potential protective effect against MI in men. Further replication, validation, and functional studies are needed.

Published
2022
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30. Melanin and Neuromelanin Fluorescence Studies Focusing on Parkinson’s Disease and Its Inherent Risk for Melanoma

Author

Dieter Leupold, Lukasz Szyc, Goran Stankovic, Sabrina Strobel, Hans-Ullrich Völker, Ulrike Fleck, Thomas Müller, Matthias Scholz, Peter Riederer, and Camelia-Maria Monoranu

Subjects
Parkinson’s disease, melanin, neuromelanin, dermatofluoroscopy, Cytology, QH573-671
Abstract

Parkinson’s disease is associated with an increased risk of melanoma (and vice versa). Several hypotheses underline this link, such as pathways affecting both melanin and neuromelanin. For the first time, the fluorescence of melanin and neuromelanin is selectively accessible using a new method of nonlinear spectroscopy, based on a stepwise two-photon excitation. Cutaneous pigmentation and postmortem neuromelanin of Parkinson patients were characterized by fluorescence spectra and compared with controls. Spectral differences could not be documented, implying that there is neither a Parkinson fingerprint in cutaneous melanin spectra nor a melanin-associated fingerprint indicating an increased melanoma risk. Our measurements suggest that Parkinson’s disease occurs without a configuration change of neuromelanin. However, Parkinson patients displayed the same dermatofluorescence spectroscopic fingerprint of a local malignant transformation as controls. This is the first comparative retrospective fluorescence analysis of cutaneous melanin and postmortem neuromelanin based on nonlinear spectroscopy in patients with Parkinson’s disease and controls, and this method is a very suitable diagnostic tool for melanoma screening and early detection in Parkinson patients. Our results suggest a non-pigmentary pathway as the main link between Parkinson’s disease and melanoma, and they do not rule out the melanocortin-1-receptor gene as an additional bridge between both diseases.

Published
2019
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31. Prognostic impact of non-culprit chronic total occlusion over time in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

Author

Djordje Mladenovic, Vladimir Zobenica, Dario D Jelic, Jelena Marinkovic, Vladan Vukcevic, Zlatko Mehmedbegovic, A Pavlovic, Marija Radomirovic, Vladimir Dedovic, Dejan Milasinovic, Goran Stankovic, Sinisa Stojkovic, Milika Asanin, Milan Dobric, and Stefan Zaharijev

Subjects
medicine.medical_specialty, medicine.medical_treatment, 030204 cardiovascular system & hematology, Critical Care and Intensive Care Medicine, Culprit, Ventricular Function, Left, 03 medical and health sciences, Percutaneous Coronary Intervention, 0302 clinical medicine, Internal medicine, medicine, Humans, 030212 general & internal medicine, Myocardial infarction, Ejection fraction, Proportional hazards model, business.industry, Hazard ratio, Percutaneous coronary intervention, Stroke Volume, General Medicine, Prognosis, medicine.disease, 3. Good health, Treatment Outcome, Coronary Occlusion, Heart failure, Chronic Disease, Conventional PCI, Cardiology, ST Elevation Myocardial Infarction, Cardiology and Cardiovascular Medicine, business
Abstract

Aims Previous studies indicated that a chronic total occlusion (CTO) in a non-infarct-related artery is linked to higher mortality mainly in the acute setting in patients with ST-elevation myocardial infarction (STEMI). Our aim was to assess the temporal distribution of mortality risk associated with non-culprit CTO over years after STEMI. Methods and results The study included 8679 STEMI patients treated with primary percutaneous coronary intervention (PCI). Kaplan–Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with log-rank test, with landmarks set at 30 days and 1 year. Adjusted Cox regression models were constructed to assess the impact of non-culprit CTO on mortality over different time intervals. Tests for interaction were pre-specified between non-culprit CTO and acute heart failure and left ventricular ejection fraction. The primary outcome variable was all-cause mortality, and the median follow-up was 5 years. Non-culprit CTO was present in 11.6% of patients (n = 1010). Presence of a CTO was associated with increased early [30-day adjusted hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.54–2.36; P Conclusions Non-culprit CTO is independently associated with mortality over 5 years after primary PCI for STEMI, with a constant annual two-fold increase in the risk of death beyond the first year of follow-up.

Published
2021
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32. The European bifurcation club Left Main Coronary Stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN)

Author

Thomas Schmitz, Evgeny Kretov, David Hildick-Smith, Francesco Burzotta, Adrian Wlodarczak, Adrian P. Banning, James Cockburn, Mohaned Egred, Goran Stankovic, Philippe Brunel, Jens Flensted Lassen, Marc Silvestri, Yves Louvard, Miroslaw Ferenc, Olivier Darremont, Andreis Erglis, Manuel Pan, Thierry Lefèvre, Alaide Chieffo, Thomas Hovasse, and Marie-Claude Morice

Subjects
Male, medicine.medical_specialty, Time Factors, medicine.medical_treatment, Coronary Artery Disease, 030204 cardiovascular system & hematology, Coronary artery, Coronary Angiography, Revascularization, 03 medical and health sciences, Percutaneous Coronary Intervention, 0302 clinical medicine, Left coronary artery, medicine.artery, Coronary stent, Humans, Medicine, 030212 general & internal medicine, Myocardial infarction, Left main stem, business.industry, Surrogate endpoint, Hazard ratio, Stent, Angina, medicine.disease, Surgery, Stenosis, Treatment Outcome, Settore MED/11 - MALATTIE DELL'APPARATO CARDIOVASCOLARE, Bifurcation, Stents, Cardiology and Cardiovascular Medicine, business
Abstract

Background Patients with non-left-main coronary bifurcation lesions are usually best treated with a stepwise provisional approach. However, patients with true left main stem bifurcation lesions have been shown in one dedicated randomized study to benefit from systematic dual stent implantation. Methods and results Four hundred and sixty-seven patients with true left main stem bifurcation lesions requiring intervention were recruited to the EBC MAIN study in 11 European countries. Patients were aged 71 ± 10 years; 77% were male. Patients were randomly allocated to a stepwise layered provisional strategy (n = 230) or a systematic dual stent approach (n = 237). The primary endpoint (a composite of death, myocardial infarction, and target lesion revascularization at 12 months) occurred in 14.7% of the stepwise provisional group vs. 17.7% of the systematic dual stent group (hazard ratio 0.8, 95% confidence interval 0.5–1.3; P = 0.34). Secondary endpoints were death (3.0% vs. 4.2%, P = 0.48), myocardial infarction (10.0% vs. 10.1%, P = 0.91), target lesion revascularization (6.1% vs. 9.3%, P = 0.16), and stent thrombosis (1.7% vs. 1.3%, P = 0.90), respectively. Procedure time, X-ray dose and consumables favoured the stepwise provisional approach. Symptomatic improvement was excellent and equal in each group. Conclusions Among patients with true bifurcation left main stem stenosis requiring intervention, fewer major adverse cardiac events occurred with a stepwise layered provisional approach than with planned dual stenting, although the difference was not statistically significant. The stepwise provisional strategy should remain the default for distal left main stem bifurcation intervention. Study registration http://clinicaltrials.gov NCT02497014.

Published
2021
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33. Percutaneous coronary intervention for bifurcation coronary lesions: the 15th consensus document from the European Bifurcation Club

Author

Yves Louvard, Yiannis S. Chatzizisis, David Hildick-Smith, Goran Stankovic, Marco Zimarino, Olivier Darremont, Thomas W Johnson, Sudhir Rathore, Manuel Pan, Adrian P. Banning, Francesco Burzotta, Alaide Chieffo, Remo Albiero, Thierry Lefèvre, Jens Flensted Lassen, and Miroslaw Ferenc

Subjects
medicine.medical_specialty, Percutaneous, business.industry, medicine.medical_treatment, Psychological intervention, MEDLINE, Percutaneous coronary intervention, 030204 cardiovascular system & hematology, 3. Good health, 03 medical and health sciences, 0302 clinical medicine, Drug-eluting stent, Conventional PCI, medicine, Clinical significance, 030212 general & internal medicine, Club, Cardiology and Cardiovascular Medicine, business, Intensive care medicine
Abstract

The 15th European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019. It facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that a provisional approach with optional side branch treatment utilising T, T and small protrusion (TAP) or culotte continues to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially those involving the LM, adoption of dedicated two-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using two-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardise clinical outcome. The development of novel technical tools and drug regimens deserves attention. In particular, intracoronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored antiplatelet therapy have been identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components has resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimising the clinical outcomes for every patient undergoing PCI on a CBL.

Published
2021
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34. European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions

Author

Goran Stankovic, Francesco Burzotta, Manuel Pan, Thierry Lefèvre, Hyeon Cheol Gwon, Bon Kwon Koo, Alaide Chieffo, Yves Louvard, Adrian P. Banning, Yoshinobu Murasato, Jens Flensted Lassen, Patrick W. Serruys, David Hildick-Smith, Olivier Daremont, Vladimír Džavík, Yiannis S. Chatzizisis, Shao-Liang Chen, and Yutaka Hikichi

Subjects
medicine.medical_specialty, Clinical Decision-Making, Coronary Artery Disease, 030204 cardiovascular system & hematology, Article, 03 medical and health sciences, 0302 clinical medicine, White paper, bifurcation lesions, Humans, Medicine, Stent implantation, Radiology, Nuclear Medicine and imaging, Medical physics, 030212 general & internal medicine, Angioplasty, Balloon, Coronary, stenting technique, Bifurcation, Task force, business.industry, PCI, Subject (documents), personalized medicine, General Medicine, DES, 3. Good health, Clinical Practice, Treatment Outcome, Settore MED/11 - MALATTIE DELL'APPARATO CARDIOVASCOLARE, Conventional PCI, Stents, Club, Cardiology and Cardiovascular Medicine, business
Abstract

Background: Defining the optimal conduction of percutaneous-coronary-intervention (PCI) to treat bifurcation lesions has been the subject of many clinical studies showing that the applied stenting technique may influence clinical outcome. Accordingly, bifurcation stenting classifications and technical sequences should be standardized to allow proper reporting and comparison. Methods: The European Bifurcation Club (EBC) is a multidisciplinary group dedicated to optimize the treatment of bifurcations and previously created a classification of bifurcation stenting techniques that is based on the first stent implantation site. Since some techniques have been abandoned, others have been refined and dedicated devices became available, EBC promoted an international task force aimed at updating the classification of bifurcation stenting techniques as well as at highlighting the best practices for most popular techniques. Original descriptive images obtained by drawings, bench tests and micro-computed-tomographic reconstructions have been created in order to serve as tutorials in both procedure reporting and clinical practice. Results: An updated Main-Across-Distal-Side (MADS)-2, classification of bifurcation stenting techniques has been realized and is reported in the present article allowing standardized procedure reporting in both clinical practice and scientific studies. The EBC-promoted task force deeply discussed, agreed on and described (using original drawings and bench tests) the optimal steps for the following major bifurcation stenting techniques: (a) 1-stent techniques (“provisional” and “inverted provisional”) and (b) 2-stent techniques (“T/TAP,” “culotte,” and “DK-crush”). Conclusions: The present EBC-promoted paper is intended to facilitate technique selection, reporting and performance for PCI on bifurcated lesions during daily clinical practice.

Published
2020
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35. Clinical Outcomes Following Coronary Bifurcation PCI Techniques

Author

Jozef Bartunek, Danilo Franco, Goran Stankovic, Giuseppe Di Gioia, Emanuele Barbato, Sakura Nagumo, Takuya Mizukami, Johan Bennett, Iginio Colaiori, Emanuele Gallinoro, Bernard De Bruyne, Yves Louvard, Marc Vanderheyden, Patrick W. Serruys, Jeroen Sonck, Carlos Collet, Shao-Liang Chen, Miroslaw Ferenc, Jens Flensted Lassen, Eric Wyffels, Dobrin Vassilev, and M Kodeboina

Subjects
medicine.medical_specialty, medicine.medical_treatment, 030204 cardiovascular system & hematology, Revascularization, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, Interquartile range, Internal medicine, medicine, cardiovascular diseases, 030212 general & internal medicine, Myocardial infarction, business.industry, Percutaneous coronary intervention, Odds ratio, medicine.disease, 3. Good health, surgical procedures, operative, Conventional PCI, Cardiology, Cardiology and Cardiovascular Medicine, business, Mace
Abstract

Objectives The aim of this study was to compare clinical outcomes of different bifurcation percutaneous coronary intervention (PCI) techniques. Background Despite several randomized trials, the optimal PCI technique for bifurcation lesions remains a matter of debate. Provisional stenting has been recommended as the default technique for most bifurcation lesions. Emerging data support double-kissing crush (DK-crush) as a 2-stent technique. Methods PubMed and Scopus were searched for randomized controlled trials comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE). Secondary outcomes of interest were cardiac death, myocardial infarction, target vessel or lesion revascularization, and stent thrombosis. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. Results Twenty-one randomized controlled trials including 5,711 patients treated using 5 bifurcation PCI techniques were included. Investigated techniques were provisional stenting, T stenting/T and protrusion, crush, culotte, and DK-crush. Median follow-up duration was 12 months (interquartile range: 9 to 36 months). When all techniques were considered, patients treated using the DK-crush technique had less occurrence of MACE (OR: 0.39; 95% credible interval: 0.26 to 0.55) compared with those treated using provisional stenting, driven by a reduction in target lesion revascularization (OR: 0.36; 95% credible interval: 0.22 to 0.57). No differences were found in cardiac death, myocardial infarction, or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed among provisional stenting, culotte, T stenting/T and protrusion, and crush. In non–left main bifurcations, DK-crush reduced MACE (OR: 0.42; 95% credible interval: 0.24 to 0.66). Conclusions In this network meta-analysis, DK-crush was associated with fewer MACE, driven by lower rates of repeat revascularization, whereas no significant differences among techniques were observed for cardiac death, myocardial infarction, and stent thrombosis. A clinical benefit of 2-stent techniques was observed over provisional stenting in bifurcation with side branch lesion length ≥10 mm.

Published
2020
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36. Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations

Author

Mattia Lunardi, Yves Louvard, Thierry Lefèvre, Goran Stankovic, Francesco Burzotta, Ghassan S. Kassab, Jens F. Lassen, Olivier Darremont, Scot Garg, Bon-Kwon Koo, Niels R. Holm, Thomas W. Johnson, Manuel Pan, Yiannis S. Chatzizisis, Adrian Banning, Alaide Chieffo, Dariusz Dudek, David Hildick-Smith, Jérome Garot, Timothy D. Henry, George Dangas, Gregg W. Stone, Mitchell W. Krucoff, Donald Cutlip, Roxana Mehran, William Wijns, Faisal Sharif, Patrick W. Serruys, and Yoshinobu Onuma

Subjects
Heart Valve Prosthesis Implantation, clinical trials, Cardiac Catheterization, Asia, Academic Research Consortium, endpoints, Heart, Coronary Artery Disease, Coronary Angiography, United States, Europe, Treatment Outcome, bifurcation, Settore MED/11 - MALATTIE DELL'APPARATO CARDIOVASCOLARE, Humans, Academic research consortium, Cardiology and Cardiovascular Medicine
Abstract

The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

Published
2022
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38. Impact of dual antiplatelet therapy duration on clinical outcome after coronary bifurcation stenting: results from the Euro Bifurcation Club registry

Author

Plinio, Cirillo, Luigi, DI Serafino, Habib, Gamra, Marco, Zimarino, Emanuele, Barbato, Carlo, Briguori, Ignatio J, Amat-Santos, Alaide, Chieffo, Andrejs, Erglis, Robert J, Gil, Sasko A, Kedev, Ivo, Petrov, Francesco, Radico, Tullio, Niglio, Sunao, Nakamura, Ricardo A, Costa, Vojko, Kanic, Matteo, Perfetti, Mariano, Pellicano, Kristina, Maric, Tullio, Tesorio, Vladan, Vukcevic, Giovanni, Esposito, Goran, Stankovic, Cirillo, Plinio, DI Serafino, Luigi, Gamra, Habib, Zimarino, Marco, Barbato, Emanuele, Briguori, Carlo, Amat-Santos, Ignatio J, Chieffo, Alaide, Erglis, Andrej, Gil, Robert J, Kedev, Sasko A, Petrov, Ivo, Radico, Francesco, Niglio, Tullio, Nakamura, Sunao, Costa, Ricardo A, Kanic, Vojko, Perfetti, Matteo, Pellicano, Mariano, Maric, Kristina, Tesorio, Tullio, Vukcevic, Vladan, Esposito, Giovanni, and Stankovic, Goran

Subjects
General Medicine
Abstract

Background: Optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) of a bifurcation stenosis is still debated. We evaluated the impact of DAPT duration on clinical outcomes in all-comers patients undergoing bifurcation PCI included in the European Bifurcation Club (EBC) registry. Methods: We enrolled 2284 consecutive patients who completed at least 18 months follow-up. The cumulative occurrence of major adverse cardiac and cardiovascular events (MACCE), defined as a composite of overall-death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and stroke were evaluated. Bleedings classified as Bleeding Academic Research Consortium (BARC) ≥3 were evaluated too. Results: Patients were divided into 3 groups: short DAPT (12-months, N.=1273). At 24 months follow-up MACCE-free survival was significantly lower in short DAPT patients (Log-Rank: 45.23, P for trend

Published
2022

40. Intervenção coronariana percutânea (ICP) para pacientes estáveis: há algum benefício além do alívio dos sintomas? Intervención coronaria percutánea (icp) para pacientes estables: ¿hay algún beneficio además de los síntomas? Percutaneous coronary intervention for stable patients: is there any benefit beyond symptom relief?

Author

Goran Stankovic

Subjects
Angioplastia transluminal percutánea coronaria, revascularización miocárdica, terapia con fármacos, supervivencia, estudios prospectivos, Angioplastia transluminal percutânea coronária, revascularização miocárdica, terapia por drogas, sobrevivência, estudos prospectivos, Angioplasty, transluminal, percutaneous coronary, myocardial revascularization, drug therapy, survival, prospective studies, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

As indicações para intervenção coronária percutânea (ICP) continuam a evoluir devido ao contínuo desenvolvimento da tecnologia, critérios de seleção mais amplos para pacientes e lesões e novas evidências advindas de testes clínicos. Uma controvérsia considerável foi gerada pelos resultados principais do estudo COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation), o qual não demonstrou diferenças no resultado em longo prazo para pacientes estáveis com doença coronariana, randomizados para uma estratégia inicial de ICP mais tratamento médico otimizado versus tratamento médico otimizado isolado. Em pacientes com angina estável crônica, o tratamento médico permanece sendo a pedra fundamental e deveria ser otimizado em todos os pacientes, enquanto os maiores objetivos alcançáveis da ICP são ter efeito sobre os sintomas, através de sua diminuição ou prevenção, reduzir a necessidade de procedimentos subsequentes e aliviar a isquemia. Em pacientes com doença arterial coronariana (DAC) estável, entretanto, nenhuma redução na incidência de morte ou infarto do miocárdio foi observada e essas limitações da ICP nesse cenário clínico precisam ser enfatizadas. A mensagem do estudo COURAGE pode ser refinada com base nos recentes sub-estudos nuclear e angiográfico, de forma que os pacientes com isquemia residual significante, submetidos a tratamento médico otimizado, deveriam ser considerados para tratamento com ICP, já que estão associados com maior probabilidade de morte e infarto do miocárdio. Entretanto, esses achados precisam ser confirmados por avaliação prospectiva antes de sua mais ampla aceitação pela comunidade intervencionista.Las indicaciones para intervención coronaria percutánea (ICP) siguen evolucionando debido al desarrollo continuo de la tecnología, a criterios de selección más amplios para pacientes y lesiones y a nuevas evidencias advenidas de ensayos clínicos. Los resultados principales del estudio COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) generaron una controversia considerable, la que no reveló diferencias en el resultado a largo plazo para pacientes estables con enfermedad coronaria, randomizados para una estrategia inicial de ICP más tratamiento médico optimizado versus tratamiento médico optimizado aislado. En pacientes con angina estable crónica, el tratamiento médico sigue siendo la piedra fundamental y se debería optimizarlo en todos los pacientes; mientras que los mayores objetivos alcanzables de la ICP son producir efecto sobre los síntomas, a través de su disminución o prevención, reducir la necesidad de procedimientos subsecuentes y aliviar la isquemia. En pacientes con enfermedad arterial coronaria (EAC) estable, sin embargo, ninguna reducción en la incidencia de muerte o infarto de miocardio se observó, y han de enfatizarse esas limitaciones de la ICP en ese escenario clínico. El mensaje del estudio COURAGE se puede refinar con base en los recientes subestudios nuclear y angiográfico, de forma que los pacientes con isquemia residual significante, sometidos a tratamiento médico optimizado, se deberían tener en cuenta para tratamiento con ICP, ya que están asociados a una mayor probabilidad de muerte e infarto de miocardio. Sin embargo, esos hallazgos necesitan ser confirmados por evaluación prospectiva antes de su más amplia aceptación por la comunidad intervencionista.The indications for percutaneous coronary intervention (PCI) continue to evolve because of the steady improvement in technology, broadened patient and lesion selection criteria, and new evidence from clinical trials. Considerable controversy was generated by the main results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, in which no difference in long-term outcome was reported for stable patients with coronary disease randomized to an initial strategy of PCI plus optimal medical therapy versus optimal medical therapy alone. In patients with chronic stable angina, medical therapy remains the cornerstone and should be optimized for all patients, while the major achievable goals of PCI are to affect symptoms, either by decreasing or preventing them, reducing the need for subsequent procedures and relieving ischemia. In patients with stable coronary artery disease, however, no reduction in death or myocardial infarction has been observed, and these limitations of PCI in this clinical setting need to be emphasized. The message from the COURAGE trial may be refined based on recently presented nuclear and angiographic sub-studies, such that patients with substantial residual ischemia on optimal medical therapy should be considered for crossover PCI, as it is associated with greater likelihood of death and myocardial infarction. However, those findings need to be confirmed by prospective evaluation before being widely accepted by the interventional community.

Published
2009
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41. Impact of Medication Nonadherence in a Clinical Trial of Dual Antiplatelet Therapy

Author

Marco Valgimigli, Enrico Frigoli, Pascal Vranckx, Yukio Ozaki, Marie-Claude Morice, Bernard Chevalier, Yoshinobu Onuma, Stephan Windecker, Laurent Delorme, Petr Kala, Sasko Kedev, Rajpal K. Abhaichand, Vasil Velchev, Willem Dewilde, Jakub Podolec, Gregor Leibundgut, Dragan Topic, Carl Schultz, Goran Stankovic, Astin Lee, Thomas Johnson, Pim A.L. Tonino, Aneta Klotzka, Maciej Lesiak, Renato D. Lopes, Pieter C. Smits, and Dik Heg

Subjects
Cardiology and Cardiovascular Medicine, 610 Medizin und Gesundheit
Abstract

BACKGROUND Nonadherence to antiplatelet therapy after percutaneous coronary intervention (PCI) is common, even in clinical trials. OBJECTIVES The purpose of this study was to investigate the impact of nonadherence to study protocol regimens in the MASTER DAPT (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen) trial. METHODS At 1-month after PCI, 4,579 high bleeding risk patients were randomized to single antiplatelet therapy (SAPT) for 11 months (or 5 months in patients on oral anticoagulation [OAC]) or dual antiplatelet therapy (DAPT) for ≥2 months followed by SAPT. Coprimary outcomes included net adverse clinical events (NACE), major adverse cardiac and cerebral events (MACE), and major or clinically relevant nonmajor bleeding (MCB) at 335 days. Inverse probability-of-censoring weights were used to correct for nonadherence Academic Research Consortium type 2 or 3. RESULTS In total, 464 (20.2%) patients in the abbreviated-treatment and 214 (9.4%) in the standard-treatment groups incurred nonadherence Academic Research Consortium type 2 or 3. At inverse probability-of-censoring weights analyses, NACE (HR: 1.01; 95% CI: 0.88-1.27) or MACE (HR: 1.07; 95% CI: 0.83-1.40) did not differ, and MCB was lower with abbreviated compared with standard treatment (HR: 0.51; 95% CI: 0.60-0.73) consistently across OAC subgroups; among OAC patients, SAPT discontinuation 6 months after PCI was associated with similar MACE and lower MCB (HR: 0.47; 95% CI: 0.22-0.99) compared with SAPT continuation. CONCLUSIONS In the MASTER DAPT adherent population, 1-month compared with ≥3-month DAPT was associated with similar NACE or MACE and lower MCB. Among OAC patients, SAPT discontinuation after 6 months was associated with similar MACE and lower MCB than SAPT continuation (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen [MASTER DAPT]; NCT03023020).

Published
2022
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42. Variability in antioxidants in yellow, white, and red coloured maize grain in response to different fertilizers

Author

Vesna Dragicevic, Milena Simic, Miodrag Tolimir, Nenad Djuric, Milena Senk, Goran Stankovic, and Milan Brankov

Subjects
Fertilizing, Grain color, Genetics, Plant Science, Grain yield, Antioxidant capacity
Abstract

Maize (Zea mays L.) grain is an important source of nutrients in human diet. The differences in content and relations between certain components of maize grain impact grain colour and its nutritional quality. The objective of the Study was to examine effects of different fertilization systems: mineral fertilizer (urea), organic fertilizer, and bio-fertilizer on white, yellow, and red coloured maize hybrids, regarding grain yield and variations in content of antioxidants: phytate, phenolic compounds, glutathione, carotenoids (yellow pigment), and reduction capacity of DPPH radical. Two-fold higher average grain yield and double fold lower concentration of phenols and carotenoids were present in 2018, in comparison to drier 2017. The lowest phytate content and the highest values of phenols and DPPH reduction capacity were present in red maize kernel, as a hybrid with the highest yield, while in yellow maize kernel, the highest values of yellow pigment and glutathione occurred. The bio-fertilizer expressed the positive impact on reduction of phytate concentration and increase of phenols concentration in maize grain, while urea increased concentration of yellow pigment and glutathione. Correlation analysis showed that reduction in phytate and carotenoids was significant and positive related with grain yield increase, while phenols showed positive correlation with reduction capacity of DPPH radical. Thus, it was shown that changes in fertilization methods could affect antioxidants status in maize grain, particularly in red coloured maize, which besides high yield potential, possess remarkable higher antioxidant capacity in regard to yellow and white coloured maize.

Published
2022

43. Development of High Tryptophan Maize Near Isogenic Lines Adapted to Temperate Regions through Marker Assisted Selection - Impediments and Benefits.

Author

Marija Kostadinovic, Dragana Ignjatovic-Micic, Jelena Vancetovic, Danijela Ristic, Sofija Bozinovic, Goran Stankovic, and Snezana Mladenovic Drinic

Subjects
Medicine, Science
Abstract

Breeding program aimed at converting standard maize inbred lines to their quality protein maize (QPM) counterparts for growing in temperate climate is being conducted at Maize Research Institute (MRI). The objective of the research presented herein was to develop QPM versions of two commercial ZP inbreds through marker assisted selection (MAS) with opaque2 specific molecular markers, while maintaining their good agronomic performances and combining abilities. Donor line was a tropical QPM line CML 144. After two backcross and three selfing generations, six near isogenic lines (NILs) with 93% recovery of the recurrent parent genome were created from one cross. Average increments of 30% in tryptophan content and 36% in quality index were obtained, as well as kernels with less than 25% opaque endosperm. Grain yield was increased by 11-31% and combining abilities of the improved lines were on a par with the original line. Correlations between biochemical and agronomic parameters revealed that selection for plant height, ear length and kernel row number together with tryptophan content could be recommended for development of QPM with this material. However, several impediments emerged during selection. Major drawbacks in NIL development were small number of opaque2 recessive homozygotes (4.5% and 7.6% in BC2F2 of two crosses) and poor seed set throughout selection, which led to the loss of one cross. Moreover, in the other cross many plants in different generations had to be omitted from further selection due to the insufficient number of kernels. This phenomenon could be explained by incompatibility between pollen and style, possibly due to the exotic donor germplasm. Overall, it could be expected that the use of NILs, which are adapted to temperate climate and have high percentage of domestic germplasm, would outbalance the noted impediments and increase MAS efficiency in different breeding programs.

Published
2016
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44. IMPACT OF GEOGRAPHICAL VARIATION BETWEEN EUROPE AND ASIA ON CLINICAL OUTCOMES IN PATIENTS WITH HIGH BLEEDING RISK (HBR) AND BIODEGRADABLE-POLYMER SIROLIMUSELUTING CORONARY STENT: A SUBSTUDY OF MASTER DAPT

Author

Yukio Ozaki, Yoshinobu Onuma, Pieter Smits, Enrico Frigoli, Jan G. Tijssen, Peter Juni, pascal vranckx, Marie C. Morice, Bernard Chevalier, Stephan Windecker, Pim A. Tonino, Marco Roffi, Maciej Lesiak, Felix Mahfoud, Jozef Bartunek, David Hildick-Smith, Antonio Colombo, Goran Stankovic, Andres Iniguez, Carl J. Schultz, Ran Kornowski, Paul JL Ong, Dik Heg, and Marco Valgimigli

Subjects
Cardiology and Cardiovascular Medicine
Published
2023
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45. Coronary Flow Velocity Reserve Using Dobutamine Test for Noninvasive Functional Assessment of Myocardial Bridging

Author

Srdjan B. Aleksandric, Ana D. Djordjevic-Dikic, Vojislav L. Giga, Milorad B. Tesic, Ivan A. Soldatovic, Marko D. Banovic, Milan R. Dobric, Vladan Vukcevic, Miloje V. Tomasevic, Dejan N. Orlic, Nikola Boskovic, Ivana Jovanovic, Milan A. Nedeljkovic, Goran Stankovic, Miodrag C. Ostojic, and Branko D. Beleslin

Subjects
myocardial ischemia, myocardial bridging, dobutamine, Medicine, coronary flow velocity reserve, General Medicine, stress-echocardiography, transthoracic Doppler echocardiography, Article
Abstract

Background: It has been shown that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during dobutamine (DOB) provocation provides a more accurate functional evaluation of myocardial bridging (MB) compared to adenosine. However; the cut-off value of CFVR during DOB for identification of MB associated with myocardial ischemia has not been fully clarified. Purpose: This prospective study aimed to determine the cut-off value of TTDE-CFVR during DOB in patients with isolated-MB, as compared with stress-induced wall motion abnormalities (VMA) during exercise stress-echocardiography (SE) as reference. Methods: Eighty-one symptomatic patients (55 males [68%], mean age 56 ± 10 years; range: 27–74 years) with the existence of isolated-MB on the left anterior descending artery (LAD) and systolic MB-compression ≥50% diameter stenosis (DS) were eligible to participate in the study. Each patient underwent treadmill exercise-SE, invasive coronary angiography, and TTDE-CFVR measurements in the distal segment of LAD during DOB infusion (DOB: 10–40 μg/kg/min). Using quantitative coronary angiography, both minimal luminal diameter (MLD) and percent DS at MB-site at end-systole and end-diastole were determined. Results: Stress-induced myocardial ischemia with the occurrence of WMA was found in 23 patients (28%). CFVR during peak DOB was significantly lower in the SE-positive group compared with the SE-negative group (1.94 ± 0.16 vs. 2.78 ± 0.53; p < 0.001). ROC analyses identified the optimal CFVR cut-off value ≤ 2.1 obtained during high-dose dobutamine (>20 µg/kg/min) for the identification of MB associated with stress-induced WMA, with a sensitivity, specificity, positive and negative predictive value of 96%, 95%, 88%, and 98%, respectively (AUC 0.986; 95% CI: 0.967–1.000; p < 0.001). Multivariate logistic regression analysis revealed that MLD and percent DS, both at end-diastole, were the only independent predictors of ischemic CFVR values ≤2.1 (OR: 0.023; 95% CI: 0.001–0.534; p = 0.019; OR: 1.147; 95% CI: 1.042–1.263; p = 0.005; respectively). Conclusions: Noninvasive CFVR during dobutamine provocation appears to be an additional and important noninvasive tool to determine the functional severity of isolated-MB. A transthoracic CFVR cut-off ≤2.1 measured at a high-dobutamine dose may be adequate for detecting myocardial ischemia in patients with isolated-MB.

Published
2021

46. Drug‐Eluting or Bare‐Metal Stents for Left Anterior Descending or Left Main Coronary Artery Revascularization

Author

Pedro A. Lemos, Patrick W. Serruys, Olivier Varenne, Alfredo E. Rodriguez, Kaare H. Bønaa, Jörg Reifart, Adam de Belder, Alex Abizaid, Christoph Kaiser, Marco Valgimigli, Lorenz Räber, William Wijns, Peter Jüni, Expedito E. Ribeiro, José M. de la Torre Hernández, Tom Wilsgaard, Stephan Windecker, Philip Urban, Goran Stankovic, Manel Sabaté, Arnoud W J van 't Hof, Robert A. Byrne, Wouter Remkes, Raffaele Piccolo, Orestis Efthimiou, Giovanni Esposito, RS: Carim - H01 Clinical atrial fibrillation, Cardiologie, MUMC+: MA Med Staf Spec Cardiologie (9), Piccolo, R., Bonaa, K. H., Efthimiou, O., Varenne, O., Urban, P., Kaiser, C., Raber, L., de Belder, A., Remkes, W., Van'T Hof, A. W. J., Stankovic, G., Lemos, P. A., Wilsgaard, T., Reifart, J., Rodriguez, A. E., Ribeiro, E. E., Serruys, P. W. J. C., Abizaid, A., Sabate, M., Byrne, R. A., de la Torre Hernandez, J. M., Wijns, W., Esposito, G., Juni, P., Windecker, S., and Valgimigli, M.

Subjects
medicine.medical_treatment, Myocardial Infarction, Coronary Artery Disease, 030204 cardiovascular system & hematology, DISEASE, left anterior descending artery, 0302 clinical medicine, Risk Factors, drug‐eluting stent, Stent, Bare metal, 030212 general & internal medicine, Original Research, media_common, OUTCOMES, Metal, Drug-Eluting Stents, Interventional Cardiology, 3. Good health, Death, Treatment Outcome, medicine.anatomical_structure, Metals, Drug-eluting stent, bare-metal stents, cardiovascular system, Cardiology, Stents, Cardiology and Cardiovascular Medicine, Human, Artery, Drug, medicine.medical_specialty, media_common.quotation_subject, 610 Medicine & health, Prosthesis Design, Revascularization, 03 medical and health sciences, 360 Social problems & social services, Internal medicine, drug-eluting stent, medicine, Humans, cardiovascular diseases, Left main disease, LESIONS, business.industry, Risk Factor, percutaneous coronary intervention, Bare-metal stent, Percutaneous coronary intervention, left main disease, bare‐metal stents, IMPLANTATION, BIODEGRADABLE-POLYMER, business, BLIND
Abstract

Background New‐generation drug‐eluting stents (DES) reduce target‐vessel revascularization compared with bare‐metal stents (BMS), and recent data suggest that DES have the potential to decrease the risk of myocardial infarction and cardiovascular mortality. We evaluated the treatment effect of DES versus BMS according to the target artery (left anterior descending [LAD] and/or left main [LM] versus other territories [no‐LAD/LM]). Methods and Results The Coronary Stent Trialist (CST) Collaboration gathered individual patient data of randomized trials of DES versus BMS for the treatment of coronary artery disease. The primary outcome was the composite of cardiac death or myocardial infarction. Hazard ratios (HRs) with 95% CIs were derived from a 1‐stage individual patient data meta‐analysis. We included 26 024 patients across 19 trials: 13 650 (52.4%) in the LAD/LM and 12 373 (47.6%) in the no‐LAD/LM group. At 6‐year follow‐up, there was strong evidence that the treatment effect of DES versus BMS depended on the target vessel ( P ‐interaction=0.024). Compared with BMS, DES reduced the risk of cardiac death or myocardial infarction to a greater extent in the LAD/LM (HR, 0.76; 95% CI, 0.68–0.85) than in the no‐LAD/LM territories (HR, 0.93; 95% CI, 0.83–1.05). This benefit was driven by a lower risk of cardiac death (HR, 0.83; 95% CI, 0.70–0.98) and myocardial infarction (HR, 0.74; 95% CI, 0.65–0.85) in patients with LAD/LM disease randomized to DES. An interaction ( P =0.004) was also found for all‐cause mortality with patients with LAD/LM disease deriving benefit from DES (HR, 0.86; 95% CI, 0.76–0.97). Conclusions As compared with BMS, new‐generation DES were associated with sustained reduction in the composite of cardiac death or myocardial infarction if used for the treatment of LAD or left main coronary stenoses. Registration URL: https://www.crd.york.ac.uk/PROSPERO ; Unique identifier: CRD42017060520.

Published
2021
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47. Prognostic Value of Transthoracic Doppler Echocardiography Coronary Flow Velocity Reserve in Patients With Asymmetric Hypertrophic Cardiomyopathy

Author

Miodrag Ostojic, Jelena Marinkovic, Vojislav Giga, Milorad Tesic, I Jovanovic, Ana Djordjevic Dikic, Stefan Juricic, Nikola Boskovic, Srdjan Aleksandric, Vladan Vukcevic, Dejan Orlic, Olga Petrovic, Goran Stankovic, Arsen D. Ristić, Branko Beleslin, Miloje Tomasevic, Sinisa Stojkovic, Milan Dobric, and Danijela Trifunovic

Subjects
Adult, Male, medicine.medical_specialty, Cardiomyopathy, microvascular dysfunction, 030204 cardiovascular system & hematology, Doppler echocardiography, adverse cardiac outcome, Imaging, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, medicine, Humans, In patient, cardiovascular diseases, 030212 general & internal medicine, Original Research, Coronary flow, medicine.diagnostic_test, business.industry, Hypertrophic cardiomyopathy, Hypertrophy, Cardiomyopathy, Hypertrophic, Middle Aged, hypertrophic cardiomyopathy, Prognosis, medicine.disease, Echocardiography, Doppler, 3. Good health, Echocardiography, Subject category: Imaging, cardiovascular system, Cardiology, coronary flow velocity reserve, Female, Cardiology and Cardiovascular Medicine, business, Value (mathematics), Blood Flow Velocity
Abstract

Background Microvascular dysfunction might be a major determinant of clinical deterioration and outcome in patients with hypertrophic cardiomyopathy (HCM). However, long‐term prognostic value of transthoracic Doppler echocardiography (TDE) coronary flow velocity reserve (CFVR) on clinical outcome is uncertain in HCM patients. Therefore, the aim of our study was to assess long‐term prognostic value of CFVR on clinical outcome in HCM population. Methods and Results We prospectively included 150 HCM patients (82 women; mean age 48±15 years). Patients’ clinical characteristics, echocardiographic and CFVR findings (both for left anterior descending [LAD] and posterior descending artery [PD]), were assessed in all patients. The primary outcome was a composite of: HCM related death, heart failure requiring hospitalization, sustained ventricular tachycardia and ischemic stroke. Patients were stratified into 2 subgroups depending on CFVR LAD value: Group 1 (CFVR LAD>2, [n=87]) and Group 2 (CFVR LAD≤2, [n=63]). During a median follow‐up of 88 months, 41/150 (27.3%) patients had adverse cardiac events. In Group 1, there were 8/87 (9.2%), whereas in Group 2 there were 33/63 (52.4%, P P P Conclusions In patients with HCM, impaired CFVR LAD (≤2) is a strong, independent predictor of adverse cardiac outcome. When the aim of testing is HCM risk stratification and CFVR LAD data are available, the evaluation of CFVR PD is redundant.

Published
2021
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48. TOTAL risk score for predicting safe very early discharge in patients with ST-elevation myocardial infarction (STEMI)

Author

Amit X. Garg, Sasko Kedev, Goran Stankovic, Sanjit S. Jolly, Purnima Rao-Melacini, Dzavik, John A. Cairns, Craig Ainsworth, Warren J. Cantor, Shahar Lavi, R Quinn, R M Gomez, and Emilie P. Belley-Côté

Subjects
medicine.medical_specialty, Total risk, business.industry, St elevation myocardial infarction, Internal medicine, Cardiology, Medicine, In patient, Cardiology and Cardiovascular Medicine, business, Early discharge
Abstract

Background/Introduction Previously validated risk scores for identifying low-risk patients after ST-segment elevation myocardial infarction (STEMI) have led to acceptance of the safety and feasibility of discharge after 48–72 hours of hospitalization, reducing hospital length of stay and costs. With ongoing improvements in outcomes, it may be possible to select patients who are safe to discharge very early (24–48 hours) but this has never been evaluated. Purpose We sought to develop and validate a novel risk score for identifying low-risk patients suitable for very early discharge (≤48 hours of hospitalization) post-STEMI. Methods We derived a novel risk score using data from patients enrolled in the Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in Patients with STEMI (TOTAL). The TOTAL database was randomly divided into a derivation cohort with 2/3 of the composite events and non-events and remaining 1/3 as the internal validation cohort. Using the derivation cohort, we identified risk factors for cardiovascular death (CV) or non-fatal cardiac arrest by performing a univariate and multivariable stepwise regression analysis of baseline clinical and angiographic characteristics. Each co-variate was assigned an integer score based on regression coefficients and the novel TOTAL risk score was developed by adding points from each risk factor profile. We externally validated the TOTAL score using data from the Radial versus Femoral Access for Coronary Intervention (RIVAL) trial. Results The TOTAL derivation cohort included 6331 participants with 287 events (CV death/cardiac arrest). Twelve independent risk-factors associated with risk of CV death and non-fatal cardiac arrest at 1 year were selected and weighted for the TOTAL risk score (Table 1). In the TOTAL validation cohort (n=3166), patients with a TOTAL score of 0–4 points (n=779 (24.6%)) were categorized as very low risk with only a 0.1% risk of CV death/cardiac arrest observed within 24 hours of hospitalization, and no further events observed between 24 hours and 30 days post-STEMI. In the RIVAL validation dataset (n=1451), patients with a TOTAL score of 0–4 points (n=737 (50.7%)) had a 0.3% risk of CV death/cardiac arrest within 24 hours, with no further events observed between 24 hours and 72 hours of hospitalization. Conclusion The TOTAL risk score identified a very low risk subset of patients for whom early discharge, 24–48 hours post-STEMI, is likely safe. These findings have the potential to change practice and support early discharge after STEMI. Funding Acknowledgement Type of funding sources: None.

Published
2021
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49. Cut-off value of coronary flow velocity reserve obtained by transthoracic Doppler echocardiography during intravenous infusion of dobutamine for diagnosis of functional significant myocardial bridging

Author

Goran Stankovic, Giga, Dejan Orlic, S Juricic, Nikola Boskovic, Srdjan Aleksandric, Vukcevic, Milan Nedeljkovic, M Tesic, Milan Dobric, Marko Banovic, Sinisa Stojkovic, Miloje Tomasevic, Ana Djordjevic-Dikic, and Biljana Beleslin

Subjects
medicine.medical_specialty, Myocardial bridging, medicine.diagnostic_test, business.industry, Cut off value, Ischemia, Diastole, Doppler echocardiography, medicine.disease, Internal medicine, Stress Echocardiography, Cardiology, medicine, Dobutamine, Systole, Cardiology and Cardiovascular Medicine, business, medicine.drug
Abstract

Background Recent studies showed that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during inotropic stimulation with dobutamine (DOB), in comparison to vasodilation with adenosine, provides more reliable functional evaluation of myocardial bridging (MB). However, the adequate cut-off value of CFVR during DOB for diagnosing functional significant MB has not been fully established. Purpose The purpose of the study was to evaluate the adequate cut-off value of TTDE- CFVR during DOB for diagnosis of functional significant MB. Methods This prospective study included 79 patients (54 males, mean age 55±10 years) with angiographic evidence of isolated MB on the left anterior descending artery (LAD) and systolic compression ≥50% diameter stenosis. Exercise stress-echocardiography test (ExSE) and TTDE-CFVR in the distal segment of LAD during DOB infusion (DOB: 10–40μg/kg/min) were performed in all patients. Percent diameter stenosis (DS) of MB at end-systole and end-diastole were analyzed using quantitative coronary angiography. Results Exercise-SE was positive for myocardial ischemia in 22/79 (28%). CFVR during peak DOB was significantly lower in SE-positive group in comparison to SE-negative group (1.94±0.16 vs. 2.78±0.53, p Conclusion A cut-off value Funding Acknowledgement Type of funding sources: None.

Published
2021
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50. Relative impact of acute heart failure and acute kidney injury on short- and long-term prognosis of patients with STEMI treated with primary PCI

Author

Milasinovic, D., Mladenovic, D. J., Jelic, D., Zobenica, V., Zaharijev, S., Vratonjic, J., Isailovic, N., Radomirovic, M., Pavlovic, A., Vukcevic, V., Asanin, M., and Goran Stankovic

Subjects
Cardiology and Cardiovascular Medicine
Abstract

Background Although both acute heart failure (AHF) and acute kidney injury (AKI) have been separately recognized as contributors to an increased mortality risk in patients with ST-segment elevation myocardial infarction (STEMI), their relative importance has not been extensively studied. Purpose Our aim was to investigate the relative impact of AHF and AKI on 30-day and 5-year mortality following primary PCI for STEMI. Methods 8 054 patients referred to primary PCI during the years 2009–2019, and with the available repeated creatinine measurements, were analyzed. AKI was defined as ≥25% relative or ≥0.5 mg/dl absolute rise in creatinine from baseline, within 72 hours of intervention. Acute heart failure was defined as Killip class ≥2 on admission to hospital. Cox regression model was used to assess the effect of the interaction of AHF and AKI on mortality. Median follow-up was 5 years. Results The incidence of AKI was 9.9% (n=805) and of AHF 12.3% (n=1050). Concurrence of AHF and AKI was noted in 1.7% of the included patients (n=315). The combined presence of AHF and AKI significantly increased mortality both at 30 days (30.7%) and at 5 years (73.3%), as compared with AKI alone (8.2% at 30 days and 32.3% at 5 years) and AHF alone (13.0% and 53.0%). When adjusted for other significant predictors, such as age, prior stroke, hyperlipidemia, atrial fibrillation, ejection fraction, final TIMI flow in the culprit artery, the use of intra-aortic balloon pump and multivessel disease, both AKI and AHF were independently associated with mortality. The adjusted relative impact of AKI on mortality was stronger than that of AHF at 30 days (adjusted HR 3.5 and 2.2, respectively), whereas it was comparable at 5 years (adjusted HR 1.3 and 1.4, respectively). Furthermore, the combined presence of AHF on admission and the post-primary PCI development of AKI was associated with the highest magnitude of risk at both 30 days (HR 5.0, CI95% 3.0–8.3, p Conclusion Acute kidney injury following primary PCI for STEMI was associated with a higher adjusted risk of short-term mortality when compared with acute heart failure, whereas their relative impact was comparable in the long-term. Funding Acknowledgement Type of funding sources: None.

Published
2021
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