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Background Coronary chronic total occlusion (CTO) recanalization represents the most technically challenging percutaneous coronary interventions (PCI). The complexity harbours a significant increased risk risk for complications with CTO PCI as compared to non-CTO PCI. However there are evidenced biomarker cut-off levels that help to identify those patients at risk for an unfavorable clinical outcome. Objective This study aimed to assess the prognostic impact of postprocedural troponin T increase and mortality in patients undergoing CTO-PCI in order to define the threshold, where procedural related myocardial injury drives mortality. Methods We enrolled a total of 3712 consecutive patients undergoing PCI for at least one CTO lesion and performed comprehensive troponin Tmeasurements 6, 8, and 24 hours after the procedure. All-cause mortality was defined as the primary study endpoint. Results Using spline curve analysis, we observed that a more than 18-fold increase of troponin above the upper reference limit (URL) is significantly associated with mortality. In the Cox regression analysis we observed a crude hazard ratio (HR) of 2.32 (95% CI 1.83–2.93, P Conclusion This large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in CTO patients. We could define a threshold for procedure related myocardial injury in CTO patients that differ non- CTO patients and may help guide the postprocedural clinical care in this high risk patient population. Figure 1 Funding Acknowledgement Type of funding source: None

After transcatheter aortic valve implantation, early leaflet thickening, presumably reflecting thrombus, has recently been described on computed tomography angiography (CTA) in ~10% of the patients. We sought to investigate the impact of the antithrombotic regimen on the course of leaflet thickening.The study comprised 51 patients with leaflet thickening. Based on the time period, patients without an established indication for anticoagulation were put on phenprocoumon plus clopidogrel for at least 3 months or on dual antiplatelet therapy with aspirin and clopidogrel. Follow-up CTAs were evaluated for leaflet restriction, assessed by four-point-grading score, and maximal thickness.The anticoagulation and the dual antiplatelet therapy group comprised 29 and 22 patients, respectively. After a median of 86 days, we obtained follow-up CTAs in 22 patients on anticoagulation and in 16 patients on dual antiplatelet therapy. Leaflet thickening progressed in 11 on dual antiplatelet therapy, but always regressed onanticoagulation. The course of leaflet restriction and maximal thickness was significantly different between the two groups (P 0.001): in the dual antiplatelet therapy group, maximal thickness increased by a mean of 1.37 ± 1.67 mm (P = 0.005) and leaflet restriction score by a median 1[quartiles 0;2] (P = 0.013), whereas in the anticoagulation group, maximal thickness regressed by 2.57 ± 1.52 mm (P 0.001) and leaflet restriction score decreased by 1[-4;0] (P = 0.001). After a median of 91 days after discontinuation of anticoagulation, CTA performed in ten patients revealed a significant recurrent increase in leaflet restriction score and maximal thickness (P = 0.023, P = 0.007). In the entire cohort, changes in leaflet restriction correlated significantly with changes in transvalvular pressure gradients (r = 0.511, P 0.001).The course of leaflet restriction was fundamentally different depending on the presence or absence of anticoagulation, with consistent regression under phenprocoumon, but mostly progression under antiplatelet therapy alone. Changes in leaflet restriction were associated with changes in transvalvular pressure gradients.

Aims We sought to evaluate the frequency of early hypo-attenuated leaflet thickening (HALT) of the SAPIEN 3 transcatheter aortic valve (S3). Methods and results Of 249 patients who had undergone S3 implantation, we studied 156 consecutive patients (85 women, median age 82.2 ± 5.5 years) by electrocardiogram (ECG)-triggered dual-source computed tomography angiography (CTA) after a median of 5 days post-transcatheter aortic valve implantation. The prosthesis was assessed for HALT. Apart from heparin, peri-interventional antithrombotic therapy consisted of single- (aspirin 29%) or dual- (aspirin plus clopidogrel 71%) antiplatelet therapy. Hypo-attenuated leaflet thickening was found in 16 patients [10.3% (95% confidence interval (CI) 5.5–15.0%)] of the patients. None of the baseline and procedural variables were significantly associated with HALT, nor did we find a significant association with the antithrombotic regimen, either peri-interventionally or at the time of CTA. Hypo-attenuated leaflet thickening was found in 6 of 45 patients with peri-interventional single-antiplatelet therapy and in 10 of 111 patients with dual-antiplatelet therapy at the time of intervention [13.3% (95% CI 3.4–23.3%) vs. 9% (95% CI 3.7–14.3%), P = 0.42]. Hypo-attenuated leaflet thickening was not associated with clinical symptoms, but a small, albeit significant difference in mean pressure gradient at the time of CTA (11.6 ± 3.4 vs. 14.9 ± 5.3 mmHg, P = 0.026). Full anticoagulation led to almost complete resolution of HALT in 13 patients with follow-up CTA. Conclusion Irrespective of the antiplatelet regimen, early HALT occurred in 10% of our patients undergoing transcatheter aortic S3 implantation. Early HALT is clinically inapparent and reversible by full anticoagulation.

OBJECTIVES The goal of this study was to evaluate the safety and performance of the Multi-Link Frontier coronary bifurcation stent system (Guidant Corp., Santa Clara, California), a novel dedicated device designed for permanent side branch (SB) access, stent delivery by simultaneous kissing balloon inflation, and optimal main branch (MB) and SB ostium scaffolding. BACKGROUND The treatment of coronary bifurcation lesions remains challenging, and various approaches using stents have been proposed. METHODS The primary end point was the 180-day incidence of major adverse cardiac events (MACE) per intent-to-treat analysis. Secondary end points included device success, 30-day MACE, angiographic restenosis, and target lesion revascularization (TLR) rates at 180 days. RESULTS After a learning phase of two cases per center, 105 patients were prospectively included in 11 centers. The left anterior descending coronary artery/diagonal bifurcation was the target in 80% of cases. The Frontier stent was successfully implanted in 96 patients (91%), and procedural success was obtained in 93%. Two patients suffered in-hospital myocardial infarction (MI) secondary to SB occlusion, and one patient underwent elective coronary artery bypass grafting. At 30 days and 6 months, the MACE rates were 2.9% and 17.1% (no death, no subacute stent thrombosis, Q-wave MI 1.0% and 1.9%, non-Q-wave MI 1.0% and 1.9%, TLR 1.0% and 13.3%). The MB in-stent restenosis was 25.3%, in-segment 29.9%. The SB restenosis was 29.1%. The overall restenosis rate for any branch was 44.8%. CONCLUSIONS The results of this Frontier registry demonstrate the safety and performance of this dedicated stent system for the treatment of bifurcation lesions. The device can be successfully implanted in more than 90% of all cases, with a high procedural success rate and low 30-day and 6-month MACE rates.

Background: High-sensitivity troponin T (hsTnT) can improve risk prediction in stable patients. However, it is unknown if this is due to the detection of underlying cardiac diseases that are not diagnosed so far or if this prognostic value is independent of overt cardiac disease. The aim of the present analysis was to evaluate the use of hsTnT for risk prediction in subjects with or without cardiac disease. Methods: Stable patients with full cardiac assessment including ECG, echocardiography and elective coronary angiography were enrolled (n=2046). HsTnT and risk scores for adjustment (Framingham Risk Score and the SCORE) were determined before diagnostic procedures. Patients were followed for up to seven years. Primary endpoint was all-cause mortality or non-fatal myocardial infarction. All endpoints were adjudicated by independent physicians. Results: Out of the 2046 subjects enrolled, 1406 (69%) had significant heart disease defined diagnosis of obstructive coronary heart disease during index angiography and/or reduced left ventricular ejection fraction. The use of hsTnT in addition to clinical risk scores significantly improved the reclassification of the primary endpoint (Framingham: NRI=0.631, P

Background: Rotablation is mostly used to enable stent implantation in severely calcified coronary lesions. There is a lack of long term data regarding the outcome after rotablation in severe calcified lesions with either failed balloon crossing or in case of failed balloon expansion. Methods: To assess the 1-year outcome of rotabloation in this setting, we analyzed 210 consecutive patients undergoing rotablation required for preparation of stent implantation in severely calcified coronary lesions. Complete 1-year follow-up data was available for all patients. Results: Patients were on average 71 years old. The reasons for rotablation were in 42% inability to cross the lesion with the balloon and in 58% inability to expand the balloon in severe calcified lesion. Sixteen % of patients needed rotablation during PCI for acute coronary syndrom (ACS). The procedural success was 99,5%. Drug eluting stents (DES) were implanted in 88%. The majority of patients received initial rotablation with 1,5 mm burr. Elevated troponin a day post rotablation was measured in 38% of patients and elevated creatine kinase (CK) in 12%. Target vessel revascularisation (TVR) after 1 year post index PCI was performed in 13,2% of patients. The combined endpoint of death and myocardial infarction (MI) as marker for safety was reached by 14,4%. Death during 1-year follow-up occurred in 10,4%. Conclusions: Rotablation as a part of lesion preparation for stent implantation in otherwise untreatable severe calcified coronary lesions is associated with high procedural success rate. One-year event rates, however, indicate that patients in need for bail-out rotablation represent a high risk subset.

Background: For patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) current guidelines recommend antithrombotic therapy with new P2Y12 receptor antagonists (prasugrel and ticagrelor) as well as bivalirudin. Currently, there is limited long term experience with the combination of these 2 therapeutic options. Methods: Between May 2010 and November 2011, we identified 359 consecutive patients with ACS undergoing PCI, who were preloaded with either prasugrel or ticagrelor and received bivalirudin during PCI. Patients were preloaded as soon as possible before coronary angiography and PCI. The loading dose for prasugrel was 60 mg and for ticagrelor 180 mg. Immediately before PCI patients were treated with bivalirudin loading dose and with infusion during the PCI. Post PCI dual antiplatelet therapy was continued for 12 months independent of type of implanted stent. The 1 year incidences of death from any cause, the composite of death and myocardial infarction (MI) and of target vessel revascularisation (TVR) were analyzed. Results: One year follow-up was complete in all patients. Patients were 65 + 12 years old (patients with ticagrelor were in average 11 years older), 22% of patients were diabetic. STEMI patients were more frequent (70.8%) than NSTEMI patients (29.2%). With prasugrel were treated 87.0% of STEMI patients and with ticagrelor 71.4% of NSTEMI patients. Bail-out GP IIbIIIa –inhibitors were needed in 8.3%. The 1 year incidence of TVR was 16.1% in the prasugrel group and 13.9% in the ticagrelor group, those of death and MI 7.3% and 10.6% and those of death 6.5% and 8.6%, respectively. There was no case of subacute stent thrombosis. TIMI major bleeding occurred in 0.8% and only 1.1% of the patients needed blood transfusion. There were no significant differences between ticagrelor and prasugrel in any of the event rates. Conclusions: In patients with ACS undergoing PCI the combination of new generation P2Y12-selective inhibitors (prasugrel or ticagrelor) and bivalirudin is associated with low rates of severe bleeding complications and similar clinical outcome during 1 year follow-up between in the prasugrel and ticagrelor treatment group.

Purpose: Despite advancements in recanalization technique there is limited data on prognosis after percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTOs) in the era of drug-eluting stents (DES). Methods: We evaluated long-term mortality in 1642 consecutive patients who underwent elective PCI of a CTO in our center between 01/2005 and 12/2011. Median follow-up was 3.0 years (interquartile range 1.1–3.8 years). Procedural success was defined as 1.3mg/dl, 11% a prior coronary bypass operation, 24% a previous myocardial infarction and 17% a left ventricular ejection fraction