Accuracy and Reproducibility of Coronary Angiography-Derived Fractional Flow Reserve in the Assessment of Coronary Lesion Severity.

Purpose: Coronary angiography-derived fractional flow reserve (caFFR) is a novel computational flow dynamics (CFD)-derived assessment of coronary vessel flow with good diagnostic performance. Herein, we performed a retrospective study to evaluate the reproducibility of caFFR findings between observers and investigate the diagnostic performance of caFFR for coronary stenosis defined as FFR ≤0.80, especially in the grey zone (0.75≤caFFR ≤0.80). Patients and Methods: A total of 150 patients (167 coronary vessels) underwent caFFR (with FlashAngio used for calculation of flow variables) and subsequent invasive fractional flow reserve (FFR) measurements. Outcomes, including reproducibility, were compared for vessels in and outside the grey zone. Results: The correlation of caFFR findings was good between the two laboratories (r = 0.723, p<0.001). The AUC of ROC were both high for caFFR-CoreLab1 and caFFR-CoreLab2 (0.975 and 0.883). The diagnostic accuracy, sensitivity, specificity, and negative and positive predictive values were not significantly different between the two laboratories (p>0.05). caFFR had a strong correlation with measures to FFR (r=0.911, p<0.001). There was no systematic difference between caFFR and FFR on Bland-Altman analysis in and outside the grey zone. There was no difference in diagnostic accuracy between the grey and non-grey zones in the prediction of FFR ≤0.80 (p=0.09). Conclusion: The inter-observer reproducibility for caFFR was high, and the diagnostic accuracy of caFFR was good compared to that of FFR.

Procedural Results and Long-Term Outcomes of Percutaneous Coronary Intervention for in-Stent Restenosis Chronic Total Occlusion Compared with de novo Chronic Total Occlusion.

BACKGROUND: In-stent restenosis (ISR) chronic total occlusion (CTO) represents a challenging subgroup for revascularization of CTO by percutaneous coronary intervention (PCI). There are limited data on the treatment and outcomes of PCI for ISR CTO. OBJECTIVE: We aimed to evaluate the procedural results and 2-year outcomes of PCI for ISR CTO compared with de novo CTO. METHODS: Patients undergoing attempted CTO PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 2-year major adverse cardiac events (MACE) in patients undergoing ISR CTO and those undergoing de novo CTO PCI. RESULTS: A total of 426 patients undergoing 484 consecutive CTO PCI (ISR CTO PCI, n=84; de novo CTO, n=400) were enrolled during the study period. Patients undergoing de novo CTO PCI had a significantly greater syntax score than those undergoing ISR CTO PCI [23.0 (17.5, 30.5) vs 21.5 (14.5, 27.0), p=0.039]. Technical (73.8% vs 79.0%, p=0.296) and procedural (73.8% vs 78.0, p=0.405) success rates, as well as the incidence of major procedural complications (1.2% vs 2.3%, p=0.842), were comparable between the two groups. After a median follow-up of 20 months, patients who underwent ISR CTO PCI had a significantly higher incidence of MACE (33.3% vs 10.3%, p<0.001), mainly attributed to the higher TVR rates (24.7% vs 7.6%, p<0.001). ISR CTO was the only independent predictor of MACE (hazard ratio, 4.124; 95% confidence interval, 1.951-8.717; p<0.001) during follow-up in patients who underwent CTO PCI. CONCLUSION: ISR CTO PCI shows comparable technical and procedural success, as well as major procedural complications compared with de novo CTO PCI. However, patients who underwent ISR CTO PCI had a significantly worse prognosis than those who underwent de novo CTO PCI, in terms of MACE, driven by TVR. ISR CTO was the only independent predictor of MACE during the follow-up.

The therapeutic effects of excimer laser coronary atherectomy therapy for in-stent restenosis chronic total occlusions.

OBJECTIVES: To evaluate the safety and efficacy of excimer laser coronary atherectomy (ELCA) in patients with in-stent restenosis chronic total occlusions (ISR CTOs). BACKGROUND: ISR CTOs are a challenge in percutaneous coronary intervention (PCI). Although they can be treated by ELCA, limited data are available on the effects of ELCA treatment in these patients. METHODS: Fifty-nine consecutive patients underwent PCI for ISR CTOs at Beijing Hospital between December 2017 and September 2020. According to whether or not ELCA was performed, they were divided into two groups. Quantitative coronary angiography (QCA) analyses were performed routinely, including measurement of the minimal lumen diameter and calculation of the percentage diameter stenosis. The procedural success rate, the frequency of peri-procedural complications, and the incidence rates of major adverse cardiac events (MACEs) over nine months were assessed. The primary endpoint in the study was the percentage diameter stenosis. RESULTS: Procedure success was achieved in most patients in both groups (75.9%). Patients in the ELCA group exhibited a lower percentage diameter stenosis (24.5 ± 9.09 vs. 35.1 ± 18.6, p = 0.048) and a larger minimal lumen diameter (2.36 ± 0.29 mm vs. 1.78 ± 0.64 mm, p < 0.001) than those in the control group and the 9-month incidence rates of MACEs did not differ (9.5% vs 15.8%, p = 0.699). CONCLUSIONS: This study demonstrated that ELCA may be a safe and effective technique in the treatment of ISR CTOs, and the use of ELCA can achieve good immediate angiographic results, as measured by QCA, without increasing peri-procedural complications or the incidence rates of 9-month MACEs.

Agreement of Angiography-Derived and Wire-Based Fractional Flow Reserves in Percutaneous Coronary Intervention.

Background: Coronary angiography-derived fractional flow reserve (caFFR) measurements have shown good correlations and agreement with invasive wire-based fractional flow reserve (FFR) measurements. However, few studies have examined the diagnostic performance of caFFR measurements before and after percutaneous coronary intervention (PCI). This study sought to compare the diagnostic performance of caFFR measurements against wire-based FFR measurements in patients before and after PCI. Methods: Patients who underwent FFR-guided PCI were eligible for the acquisition of caFFR measurements. Offline caFFR measurements were performed by blinded hospital operators in a core laboratory. The primary endpoint was the vessel-oriented composite endpoint (VOCE), defined as a composite of vessel-related cardiovascular death, vessel-related myocardial infarction, and target vessel revascularization. Results: A total of 105 pre-PCI caFFR measurements and 65 post-PCI caFFR measurements were compared against available wire-based FFR measurements. A strong linear correlation was found between wire-based FFR and caFFR measurements (r = 0.77; p < 0.001) before PCI, and caFFR measurements also showed a high correlation (r = 0.82; p < 0.001) with wire-based FFR measurements after PCI. A total of 6 VOCEs were observed in 61 patients during follow-up. Post-PCI FFR values (≤0.82) in the target vessel was the strongest predictor of VOCE [hazard ratio (HR): 5.59; 95% confidence interval (CI): 1.12-27.96; p = 0.036). Similarly, patients with low post-PCI caFFR values (≤0.83) showed an 8-fold higher risk of VOCE than those with high post-PCI caFFR values (>0.83; HR: 8.83; 95% CI: 1.46-53.44; p = 0.017). Conclusion: The study showed that the caFFR measurements were well-correlated and in agreement with invasive wire-based FFR measurements before and after PCI. Similar to wire-based FFR measurements, post-PCI caFFR measurements can be used to identify patients with a higher risk for adverse events associated with PCI.

Severely Impaired Renal Function in Unilateral Atherosclerotic Renal Artery Stenosis Indicated by Renal Slow Perfusion.

PURPOSE: Renal artery stenosis leads to ischemic renal insufficiency, but methods for assessing renal perfusion are limited. This study aimed to evaluate the association between renal slow perfusion and impaired renal function in atherosclerotic renal artery stenosis (ARAS). PATIENTS AND METHODS: A total of 79 consecutive patients with uncontrolled hypertension who underwent renal angiography and renal dynamic scintigraphy for suspected ARAS were enrolled in the retrospective descriptive study. Based on the status of renal artery stenosis and renal perfusion, participants were divided into three groups: the control group (n=26), the unilateral ARAS with renal normal perfusion group (RNP, n=30), and the unilateral ARAS with renal slow perfusion group (RSP, n=23). RSP was defined as renal blush grade (RBG) ≤1, while RBG>1 belonged to RNP. Split renal function (SRF) was achieved from 99mTc-DTPA renal scintigraphy. The value of the difference in split renal function (DSRF) is contralateral SRF minus impaired SRF of paired kidneys in ARAS. We compared the SRF and DSRF between different groups to identify the association between renal slow perfusion and renal impairment in ARAS. RESULTS: We analyzed SRF for paired kidneys and found the following: (1) The SRF of the paired kidney was similar in the RNP group (24.3 ± 10.2 mL/min vs 27.5 ± 8.4 mL/min; P = 0.19); however, the impaired SRF was obviously decreased compared with the contralateral SRF in the RSP group (13.5 ± 8.6 mL/min vs 36.7 ± 16.9 mL/min; P < 0.001); and (2) The difference in SRF in the RSP group was significantly higher than that in the control and RNP groups (19.8 ± 11.9 mL/min vs 4.8 ± 8.1 mL/min; 19.8 ± 11.9 mL/min vs 4.6±3.7 mL/min; P < 0.05). CONCLUSION: As an angiographic phenomenon, renal slow perfusion might be an indicator of severely impaired renal function.

Outcomes of coronary rotational atherectomy in patients with reduced left ventricular ejection fraction.

OBJECTIVE: We evaluated the safety and efficacy of rotational atherectomy (RA) in patients with a reduced left ventricular ejection fraction (LVEF). METHODS: In total, 140 consecutive patients with severe coronary artery calcification (CAC) who underwent RA were retrospectively enrolled. Patients were grouped based on LVEF: ≤35% (n = 10), 36% to 50% (n = 11), and >50% (n = 119). We assessed procedural success and periprocedural complication rates as well as the incidences of in-hospital and 2-year major adverse cardiac events (MACEs), defined as hospitalization for myocardial infarction and worsening heart failure, target vessel revascularization, and cardiac death. RESULTS: Procedural success was achieved in nearly all patients in each group. Most periprocedural complications were minor, and major complications were uncommon. The 2-year MACE rate was significantly higher in the LVEF ≤35% than LVEF >50% group (40.0% vs. 6.7%, respectively). Multivariable regression analysis revealed that the LVEF was the only independent predictor of 2-year MACEs in patients who underwent RA. CONCLUSIONS: Patients with a reduced LVEF who underwent RA had procedural success rates similar to those of patients with preserved left ventricular systolic function. The LVEF might be an independent predictor of 2-year MACEs in patients with severe CAC after percutaneous coronary intervention following RA.

Effect of Chronic Total Occlusion Percutaneous Coronary Intervention on Clinical Outcomes in Elderly Patients.

BACKGROUND: There are little published data reporting the effect of coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on the prognosis of elderly patients with identified CTOs. We sought to evaluate the clinical effect of CTO PCI on the prognosis of elderly patients with CTOs. METHODS: A total of 445 consecutive patients diagnosed with a CTO by angiography from January 2011 to December 2013 were enrolled. We compared long-term clinical outcomes between the elderly group (≥75 years; n = 120, 27.0%), and the nonelderly group (<75 years; n = 325, 73.0%) as well as between patients with unopened CTOs and patients with CTOs who were recanalized by PCI either during the index hospitalization or at a staged procedure within 30 days after discharge from the index hospitalization. The primary endpoint was defined as the composite of hospitalization from angina, reinfarction, heart failure or repeat revascularization and cardiac death at the 3-year follow-up. RESULTS: More elderly CTO patients had left main (LM) disease (25.0 versus 15.1%, P = 0.015), 3-vessel disease (96.4% versus 73.8%, P < 0.001) and a Japan-CTO score ≥2 (36.7% versus 23.7%, P = 0.006) than nonelderly CTO patients. Furthermore, elderly patients had a higher syntax score than nonelderly patients (27.0 [25.0, 30.0] versus 26.0 [23.0, 30.0], P = 0.006). PCI was attempted for 33 out of 135 CTO lesions (24.4%) in the elderly group, and 127 out of 378 lesions (33.6%) in the nonelderly group (P = 0.049); however, there were no statistically significant differences in the CTO PCI success rates between the 2 groups (69.7% versus 82.7%, P = 0.097). The 3-year cardiac mortality rate was 15.0% and 4.6% (P < 0.011) for the elderly and nonelderly groups, respectively. Elderly patients with CTOs who were recanalized by PCI and those with unopened CTOs exhibited comparable 3-year cardiac mortality rates (15.0% versus 16.0%, P = 1.000). There was no significant difference in primary endpoint incidence (25.0% versus 33.0%, P = 0.486). Multivariate analysis revealed that after corrections for baseline and procedural differences, right coronary artery CTO (odds ratio = 4.600, 95% CI: 1.320-16.031; P = 0.017) and LM disease combined with 3-vessel disease (odds ratio = 4.296, 95% CI: 1.166-15.831; P = 0.028) were independent predictors of 3-year cardiac mortality among elderly patients with CTOs. CONCLUSIONS: Elderly patients with CTOs presented with seriously diseased coronary arteries and poor prognoses. CTO PCI did not seem to significantly improve long-term clinical outcomes among elderly patients with CTOs. Right coronary artery CTO and LM disease combined with 3-vessel disease might be independent predictors of 3-year cardiac mortality in elderly CTO patients.

Bilateral coronary artery fistulas with a giant coronary aneurysm complicated by aneurysm rupture: A case report.

RATIONALE: Coronary artery aneurysms and fistulas are not rare conditions in clinical practice, but bilateral fistulas with a giant coronary aneurysm in just one person are quite rare. PATIENT CONCERNS: We report a case of a 66-year-old woman with these 2 coronary abnormalities accompanied with a huge mediastinum mass. INTERVENTIONS: The giant aneurysm was ligated and the mass was resected which was proved to be an organized hematoma finally. OUTCOMES: The patient was discharged soon with no complications. LESSONS: The best treatment of giant coronary aneurysm is not clear because of its rarity, surgical resection may be the right procedure for the potential serious complications like this case.

Impact of Chronic Total Occlusion in a Noninfarct-related Artery on Clinical Outcomes in Patients With Acute ST-elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

In the setting of primary percutaneous coronary intervention (PCI), encountering with chronic total occlusion (CTO) in a noninfarct-related artery (IRA) is not a rare situation. Limited information on the impact of CTO on clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI has raised more concerns. The aim of the present study was to evaluate the effect of concurrent CTO in a non-IRA on the clinical outcomes in patients with STEMI undergoing primary PCI.In the present prospective study, 555 consecutive patients with STEMI who underwent early primary PCI from January 2010 to December 2013 were included. The patients were divided into 2 groups: no CTO and CTO. Data on 12 months follow-up was obtained from 449 patients. The primary endpoint was the composite of hospitalization from angina, reinfarction, heart failure, or re-revascularization, and cardiac death at 12 months follow-up.Of the 555 patients, 75 (13.5%) had CTO in a non-IRA. Compared with patients in no CTO group, more patients in CTO group had hypertension (62.7% vs 46.5%, P = 0.009), diabetes (49.3% vs 35.0%, P = 0.024), and 3-vessel disease (52.0% vs 32.3%, P = 0.001). Patients with CTO had a lower left ventricular ejection fraction (LVEF) (40.1% ±â€Š16.8% vs 54.3% ±â€Š12.1%, P = 0.038), more presented with cardiogenic shock on admission (13.3% vs 4.8%, P = 0.008), compared with patients without CTO. Complete revascularization (CR) was less achieved in CTO group than in no CTO group (33.3% vs 49.1%, P = 0.013). The 12-month cardiac mortality rate was 14.5% versus 6.2% (P = 0.039), the incidence of 12-month primary endpoint was 38.7% versus 21.2% (P = 0.003) for CTO and no CTO group, respectively. Multivariate analysis revealed that after correction for baseline differences, CTO in a non-IRA (hazard ratio 4.183, 95% confidence interval 1.940-6.019, P = 0.001), cardiogenic shock on admission (hazard ratio 3.286, 95% confidence interval 1.097-9.845, P = 0.034), and 3-vessel disease (hazard ratio 2.678, 95% confidence interval 1.221-5.874, P = 0.014) remained an independent predictor of 1-year cardiac mortality in patients with STEMI undergoing primary PCI.CTO in a non-IRA in patients with STEMI undergoing primary PCI is associated with a poor prognosis. The presence of CTO in a non-IRA, cardiogenic shock on admission and 3-vessel disease might be an independent risk factor for greater 1-year cardiac mortality in patients with acute STEMI undergoing primary PCI.