Cardiovascular Autonomic Modulation in Chronic Coronary Syndrome Following Percutaneous Coronary Intervention.

Introduction The risk of sudden death in patients with chronic coronary syndrome (CCS) is increased by unbalanced cardiovascular autonomic function. Since myocardial ischemia appears to be the cause of this condition of autonomic dysregulation, treating this condition should improve and correct the autonomic functions. Improving myocardial perfusion by PCI might have beneficial effects on the recovery of autonomic balance in ischemia-triggered autonomic dysregulation. Objective In the present study, autonomic modulation in patients with CCS was evaluated before and after percutaneous coronary intervention (PCI) using cardiovascular reflex tests. Methods A total of 30 CCS patients were recruited from the cardiology outpatient department. The patients were tested with cardiovascular reflex tests (lying to standing, 30:15 ratio, Valsalva ratio, isometric handgrip test, and deep breathing test) before and after PCI. The licensed statistical software SPSS version 21.0 was used to compile and analyse the data. Results Out of 30 patients, parasympathetic reactivity tests conducted post-PCI were significantly higher as compared to pre-PCI patients: (1) lying to standing - 30:15 ratio (1.17± 0.102 versus 1.03± 0.064, p=0.000); (2) Valsalva ratio (1.42±0.276 versus 1.02±0.133, p=0.000), (3) delta heart rate in deep breathing test (17.23± 3.004 bpm versus 7.85± 4.076 bpm, p=0.000), and (4) expiration to inspiration (E:I) ratio (1.25± 0.050 versus 1.11± 0.064, p=0.000. Among sympathetic reactivity tests, lying to standing test for fall in systolic blood pressure was significantly higher in the pre-PCI state than post-PCI (-20.73± 10.29 versus -2.33± 7.67, p=0.000). The rise in DBP of the isometric handgrip test was significantly higher in post-PCI compared to pre-PCI patients (36.73±8.39 mm Hg versus 16.63±8.47 mm Hg, p=0.000). Conclusion Resting autonomic tone as determined by cardiovascular reflex testing reveals an increase in both parasympathetic and sympathetic reactivity following PCI in CCS, according to the findings of this preliminary study. As a result, we propose that noninvasive procedures like cardiovascular reflex tests be used to stratify the likelihood of illness development in the future.

ST-segment elevation myocardial infarction without culprit lesion-a case report picturing the challenging interplay of epicardial atherosclerosis and coronary artery spasm.

Background: Approximately 5-15% of patients with acute coronary syndrome have myocardial infarction with unobstructed coronary arteries (MINOCA). Guidelines recommend invasive assessments to identify underlying causes for MINOCA such as coronary artery spasm (CAS), spontaneous coronary dissection, or microvascular disease as well as non-invasive assessments in search of myocarditis, takotsubo syndrome, or cardiomyopathies. Case summary: A 54-year-old male patient presented with ST-segment elevation myocardial infarction (STEMI). Upon arrival, ST-segment elevation and symptoms had ceased. Emergency coronary angiography showed diffuse epicardial atherosclerosis with stenoses in the distal left anterior descending coronary artery (LAD) and second diagonal branch (D2); however, no epicardial occlusion was seen. Left ventriculography showed no clear wall motion abnormalities. Based on these findings, intracoronary acetylcholine (ACh) testing in search of CAS was performed. At 200 µg ACh intracoronary ST-segment elevation and chest pain recurred. Angiography showed occlusive epicardial spasm in the LAD and D2. Based on studies where the tendency of epicardial CAS was linked with the presence of epicardial atherosclerosis, the decision was made to perform PCI in the LAD and D2. ACh re-challenge after intracoronary nitroglycerine revealed only very mild symptoms, no demonstrable epicardial CAS, and no ST-segment elevation anymore. Cardiac enzymes reached their peak on day one [creatine kinase max 262 U/L (norm < 190 U/L), maximum of high-sensitivity troponin T 269 pg/mL (n < 14 pg/mL)]. Discussion: There is a broad spectrum of patients with STEMI without culprit lesion regarding the extent of epicardial disease. In cases with an unclear culprit lesion, other causes for the acute presentation such as CAS should be investigated in an ad hoc fashion. The interplay of epicardial atherosclerosis and CAS should receive more attention in future trials.

A network meta-analysis: evaluating the efficacy and safety of concurrent proton pump inhibitors and clopidogrel therapy in post-PCI patients.

Introduction: The objective of this research was to evaluate the risk of major adverse cardiovascular events (MACEs) associated with the use of various proton pump inhibitors (PPIs) in combination with clopidogrel in patients who underwent percutaneous coronary intervention (PCI). Methods: To accomplish this, we analyzed data from randomized controlled trials and retrospective cohort studies sourced from key electronic databases. These studies specifically examined the effects of different PPIs, such as lansoprazole, esomeprazole, omeprazole, rabeprazole, and pantoprazole, when used in conjunction with clopidogrel on MACEs. The primary focus was on the differential impact of these PPIs, while the secondary focus was on the comparison of gastrointestinal (GI) bleeding events in groups receiving different PPIs with clopidogrel vs. a placebo group. This study's protocol was officially registered with INPLASY (INPLASY2024-2-0009). Results: We conducted a network meta-analysis involving 16 studies with a total of 145,999 patients. Our findings indicated that rabeprazole when combined with clopidogrel, had the lowest increase in MACE risk (effect size, 1.05, 95% CI: 0.66-1.66), while lansoprazole was associated with the highest risk increase (effect size, 1.48, 95% CI: 1.22-1.80). Esomeprazole (effect size, 1.28, 95% CI: 1.09-1.51), omeprazole (effect size, 1.23, 95% CI: 1.07-1.43), and pantoprazole (effect size, 1.38, 95% CI: 1.18-1.60) also significantly increased MACE risk. For the secondary outcome, esomeprazole (effect size, 0.30, 95% CI: 0.09-0.94), omeprazole (effect size, 0.34, 95% CI: 0.14-0.81), and pantoprazole (effect size, 0.33, 95% CI: 0.13-0.84) demonstrated an increased potential for GI bleeding prevention. Conclusions: In conclusion, the combination of lansoprazole and clopidogrel was found to significantly elevate the risk of MACEs without offering GI protection in post-PCI patients. This study is the first network meta-analysis to identify the most effective regimen for the concurrent use of clopidogrel with individual PPIs. Systematic Review Registration: https://inplasy.com/inplasy-2024-2-0009/, identifier (INPLASY2024-2-0009).

[How to solve difficult side branch access: case report and literature review]. / Je n'arrive pas à passer mon guide dans la branche fille ; cas clinique et revue de la littérature.

We present the case of a 53-year-old patient with history of hypertension and dyslipidemia, admitted for effort-induced angina. Coronary angiography revealed two-vessel disease with severe stenosis of the LAD- Diagonal bifurcation (MEDINA 1-1-1). This lesion was considered complex regarding the severe stenosis of the bifurcation core, the angulation <45°, and the severity and length of the diagonal lesion. The procedure was planned according to a TAP technique. The flow in the diagonal was however lost after stenting the main vessel causing an ST elevation with chest pain. It was subsequently recovered using the rescue jailed balloon technique before re-crossing the stent struts of the LAD using a Gaia First® (Asahi) guidewire. The aim of this case report is to illustrate some pitfalls that can be encountered in bifurcation percutaneous interventions and to present technical solutions to solve difficult side branch access issues through a literature review.

Consequences and management of guidewire fracture-entrapment in the left circumflex artery: a case report.

Background: Entrapment and fracture of the coronary guidewire are rare but major complications of percutaneous coronary intervention (PCI). The incidence of these complications is reported to be <1%. Case summary: A 52-year-old male patient with diabetes and dyslipidaemia presented with posterior wall myocardial infarction. An angiogram revealed occlusion in the left circumflex (LCX) artery. Attempts to pass a guidewire through the lesion led to its entrapment and eventual fracture. Several techniques and manoeuvres failed to retrieve the fractured guidewire, which remained lodged in the LCX. An endovascular snare catheter also proved unsuccessful. The fragment was eventually removed using the triple-wire technique, although this caused coronary perforation and dissection. The perforation was identified and stented. A subsequent stent addressed a dissection in the left main/left ascending artery area, likely caused by the coronary snare. These interventions were crucial in stabilizing the patient's condition, leading to recovery with a left ventricular ejection fraction of 50% and a viable LCX artery. The patient exhibited an uneventful progression at the 1-year follow-up. Discussion: Coronary guidewire fracture during PCI is a rare event often associated with coronary calcifications. Percutaneous removal remains the mainstay treatment for fragment removal; however, it carries risks. The triple-wire technique, a newer method that entangles and extracts the fractured guidewire without specialized equipment, was effective in removing the fragmented guidewire. If asymptomatic, leaving the wire in situ is documented as a favourable approach. This case highlights that the triple-wire technique can effectively be used for the extraction of fractured guidewire fragments from the coronary vessels.

Complete percutaneous coronary revascularization: An elegant solution to left ventricular dysfunction caused by severe coronary artery disease.

With increased complexity in both medical comorbidities and coronary anatomy, the proportion of surgically turndown patients and high-risk PCI will continue to rise. Impella-assisted complex PCI can be performed with high technical success and can improve quality of life, angina score, and potentially left ventricular ejection fraction.

Left Main Snorkel Stent Thrombosis in Association With Takayasu Arteritis.

Takayasu arteritis (TA) is a rare form of large vessel arteritis that predominantly affects the aorta and its major branches. This inflammation leads to thickening, fibrosis, and stenosis of the arterial walls, which may lead to thrombus formation. The resulting symptoms are typically due to ischemia of the end organs. Coronary artery involvement is uncommon and primarily affects the ostia of the arteries. Ostial involvement of the coronary arteries can have a dramatic course, including fatal outcomes. We present the case of a 16-year-old female with TA involving the ostium of the left main coronary artery, causing severe stenosis. A successful percutaneous coronary intervention was performed on the left main artery with snorkel stent placement, which was complicated by cardiac arrest seven months later due to complete thrombosis of the proximal opening of the protruding stent.

Time From Distress Call to Percutaneous Coronary Intervention and Outcomes in Myocardial Infarction.

Background: Early percutaneous coronary intervention (PCI) is recommended for ST-segment elevation myocardial infarction (STEMI) treatment. Delays in time-to-PCI, kept within guideline recommendations, have seldom been investigated. Objectives: The purpose of this study was to investigate the consequences of delay, due to system factors or hospital distance, for the time between last patient distress call and PCI. Methods: Registry-based cohort study including times of first call to medical services, admission and PCI for patients admitted with STEMI in Copenhagen, Denmark (2014-2018). The main combined outcome included death, recurrent myocardial infarction, or heart failure estimated at 30 days and 1 year from event. Outcomes according to time from call to PCI (system delay) and door-to-balloon time were standardized to the STEMI population using multivariate logistic regression. Results: In total, 1,822 STEMI patients (73.5% male, median age 63.3 years [Q1-Q3: 54.6-72.9 years]) called the emergency services ≤72 hours before PCI (1,735, ≤12 hours). The combined endpoint of 1-year cumulative incidence was 13.9% (166/1,196) for patients treated within 120 minutes of the call and 21.2% (89/420) for patients treated later. Standardized 30-day outcomes were 7.33% (95% CI: 5.41%-9.63%) for patients treated <60 minutes, and 11.1% (95% CI: 8.39%-14.2%) for patients treated >120 minutes. Conclusions: The risk of recurrent myocardial infarction, death, and heart failure following PCI treatment of STEMI increases rapidly when delay exceeds 1 hour. This indicates a particular advantage of minimizing time from first contact to PCI.

Altitude and prognosis after PCI: A propensity score-matched analysis.

Background: The impact of altitude on the prognosis of patients with coronary artery disease (CAD) after percutaneous coronary intervention (PCI) deserves further discussion and research. Methods: We conducted a post hoc analysis of a prospective observational study involving 5453 patients post-PCI, divided into medium-altitude and low-altitude groups. To control for confounding factors, propensity score matching was employed to pair patients with similar baseline characteristics between the two groups. The impact of altitude factors on patients' prognosis post-PCI was examined through endpoint events over a 2-year follow-up period. Results: During the 2-year follow-up, patients at medium altitude exhibited a lower risk of MACE (including cardiovascular mortality, myocardial infarction, revascularization, and stroke) compared to those at low altitude (1196 versus 1196 patients [medium-altitude versus low-altitude, respectively]; hazard ratio [HR], 0.781 [95 % CI, 0.629-0.969]; P = 0.025) during 2-year follow-up. Even after excluding stroke, a significant difference in heart-related adverse events (HRAE) persisted between the two groups (HR, 0.794; 95 % CI, 0.636-0.991; P = 0.042). The incidences of individual MACE components were not significantly different between the two groups. Conclusions: Patients post-PCI residing at medium altitude exhibited a lower risk of 2-year MACE compared to those at low altitude. Further research is necessary to provide more robust evidence.

Octopus follow-up: 20 year prognosis in patients randomized to on-pump CABG, off-pump CABG or PCI.

BACKGROUND: The very long-term outcomes of off-pump versus on-pump Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) are largely unclear. We linked 20-years outcomes of two randomized trials to evaluate re-intervention and mortality outcomes for on-pump CABG, off-pump CABG and PCI. METHODS: A data linkage project was performed using data as registered within the Netherlands Heart Registration (NHR), Statistics Netherlands (CBS) and the Octopus trials. Between 1998 and 2000, these trials randomized patients with coronary artery disease to on-pump versus off-pump CABG (OctoPump trial), or to PCI versus off-pump CABG (OctoStent trial). With data linkage, the original 5 years follow-up time for clinical events was extended to 20 years, including mortality and coronary reinterventions. RESULTS: After 20 years, in the OctoPump trial all-cause mortality was 50.0% after on-pump, and 46.5% after off-pump CABG. There was no difference in the combined outcome of mortality and re-interventions (HR 0.82, 95% CI 0.59-1.12). In the OctoStent trial, all-cause mortality was 56.7% after PCI and 52.5% after off-pump CABG. There was no difference in the combined outcome of mortality and re-interventions (HR 0.76, 95% CI 0.57-1.04). Off-pump CABG patients underwent less re-interventions than PCI patients (HR 0.52, 95% CI 0.33-0.80). CONCLUSION: This study revealed no differences in 20-year survival between patients randomized to on-pump versus off-pump CABG, or to PCI versus off-pump-CABG. However, off-pump CABG patients underwent less re-interventions than PCI patients.

miR-223-5p serves as a diagnostic biomarker for acute coronary syndrome and its predictive value for the clinical outcome after PCI.

BACKGROUND: Acute coronary syndrome (ACS) is a serious cardiovascular disease that severely affects the quality of life and longevity of patients. MicroRNAs (miRNAs) play a key role in the progression of ACS with significant clinical value. The aim of this study was to examine the clinical value of miR-223-5p in ACS and on the occurrence of major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI). METHODS: The plasma expression of miR-223-5p was detected by RT-qPCR. The correlation of miR-223-5p and cTnI or Gensini score was shown by the Pearson method. Risk factors for the development of ACS were analyzed by multivariate logistic regression. The efficacy of miR-223-5p in identifying patients with ACS was shown by ROC curve. The predictive value of miR-223-5p for MACE development in ACS patients within 6 months after PCI was assessed by Kaplan-Meier curve and multivariate Cox regression. RESULTS: miR-223-5p levels were markedly elevated in ACS patients. miR-223-5p was found to be positively related to cTnI or Gensini score. miR-223-5p was a risk factor for ACS and significantly identified patients with ACS. MACE was more likely to occur after PCI in patients with high miR-223-5p levels, and miR-223-5p was an independent prognostic indicator of MACE. CONCLUSIONS: miR-223-5p had diagnostic value for ACS and predicted MACE after PCI.

One-year outcome of robotical vs. manual percutaneous coronary intervention.

BACKGROUND: Robotic-assisted percutaneous coronary intervention (R-PCI) is a promising technology for optimizing the treatment of patients with coronary heart disease. For a better understanding of the potential of R-PCI in clinical routine compared to conventional manual PCI (M-PCI) both initial treatment success of the index procedure and long-term outcome have to be analysed. METHODS: Prospective evaluation from the FRiK (DRKS00023868) registry of all R-PCI cases with the CorPath GRX Cardiology by Siemens Healthineers and Corindus in the Freiburg University Heart Center between 04/2022 and 03/2023. Index procedure success and safety, radiation dose of patients and personnel, and 1-year outcome will be reported. Findings will be compared to a prospective control group of M-PCI patients treated by the same team of interventionalists during the same observation period. RESULTS: Seventy patients received R-PCI and were included in the registry. PCI success rate was 100%, with 19% requiring manual assistance. No complications (MACE-major adverse cardiovascular events) occurred. Compared with 70 matched-pair M-PCI patients, there was a higher median procedural time (103 min vs. 67 min, p < 0.001) and fluoroscopy time (18 min vs. 15 min, p = 0.002), and more contrast volume was used (180 ml vs. 160 ml, p = 0.041) in R-PCI vs. M-PCI patients. However, there was no significant difference of the dose-area product (4062 vs. 3242 cGycm2, p = 0.361). One year after the intervention, there was no difference in mortality, rehospitalisation, unscheduled PCI or target vessel failure. Health-related quality of life evaluation 6 and 12 months after the index procedure (NYHA, CCS, SAQ7 and EQ-5D-5L) was similar in both groups. CONCLUSION: R-PCI is feasible and safe. Compared to M-PCI, index procedure success rate is high, safety profile is favourable, and manual assistance was required in only few cases. At 1-year follow-up results for R-PCI vs. M-PCI considering mortality, rehospitalisation, morbidity and target vessel failure were equal.

Interobserver Variability of Coronary Stenosis Characterized by Coronary Angiography: A Single-Center (Toronto General Hospital) Retrospective Chart Review by Staff Cardiologists.

Introduction: The reliability of interpretation of coronary angiography as a diagnostic tool was investigated. Furthermore, the impact of interobserver variability of coronary lesions on clinical decision-making was assessed. One of our motivations to do this research was the research gaps and our aim to have up-to-date information regarding interobserver variability among different cardiologists. Methods: Our objective was to quantify interobserver variability among cardiologists who have seen angiograms independently. Disagreement among cardiologists in the visual assessment of invasive coronary angiography of coronary artery stenosis is not uncommon in previous studies. Three cardiologists with extensive experience in coronary angiography, including the primary cardiologist of each patient, read the angiograms of 200 patients from Toronto General Hospital independently. Results: Our research showed the mean agreement among all participating observers was 77.4%; therefore, the interobserver variability of coronary angiography interpretation was 22.6%. Discussion: Coronary angiography is still the gold-standard technique for guidance regarding coronary lesions. Sometimes, coronary angiography results in underestimation or overestimation of a lesion's functional severity. Interobserver variability should also be considered when interpreting the severity of coronary stenoses via invasive coronary angiography. This research shows that interobserver variability regarding coronary angiograms is still present (22.6%).

Plain language summary: The gold-standard method for diagnosing coronary stenosis, invasive coronary angiography has some challenges too. One of these challenges has been the difference among various cardiologists regarding determination of severity of each coronary stenosis. In this study, we focused on differences in interobserver variability in coronary angiography interpretation. Three cardiologists who were experienced in coronary angiography read each patient's coronary angiogram separately. Overall, 200 patients with a history of angiography at Toronto General Hospital were selected randomly. The research showed that overall agreement among all participating cardiologists with regard to the reading of coronary angiograms was 77.4%. In other words, interobserver variability of 22.6% was seen among the readers.

Technological Advances Are Associated With Better Clinical Outcomes of Percutaneous Coronary Intervention in Patients With Unprotected Left Main Disease.

BACKGROUND: Few large-scale studies have evaluated the effectiveness of percutaneous coronary intervention (PCI) technological advances in the treatment of patients with unprotected left main coronary artery disease (LM-CAD). We aim to identify independent factors that affect the prognosis of PCI in patients with unprotected LM-CAD and to assess the impact of PCI technological advances on long-term clinical outcomes. METHODS AND RESULTS: A total of 4512 consecutive patients who underwent unprotected LM-CAD PCI at Fuwai Hospital from 2004 to 2016 were enrolled. Multivariable Cox proportional hazards model was used to identify which techniques can independently affect the incidence of major adverse cardiac events (MACEs; a composite of cardiac death, myocardial infarction, or target vessel revascularization). The incidence of 3-year MACEs was 9.0% (406/4512). Four new PCI techniques were identified as the independent protective factors of MACEs, including second-generation drug-eluting stents (hazard ratio [HR], 0.61 [95% CI, 0.37-0.99]), postdilatation (HR, 0.75 [95% CI, 0.59-0.94]), final kissing balloon inflation (HR, 0.78 [95% CI, 0.62-0.99]), and using intravascular ultrasound (HR, 0.78 [95% CI, 0.63-0.97]). The relative hazard of 3-year MACEs was reduced by ≈50% with use of all 4 techniques compared with no technique use (HR, 0.53 [95% CI, 0.32-0.87]). CONCLUSIONS: PCI technological advances including postdilatation, second-generation drug-eluting stent, final kissing balloon inflation, and intravascular ultrasound guidance were associated with improved clinical outcomes in patients who underwent unprotected LM-CAD PCI.

Potential roles of IL-38, among other inflammation-related biomarkers, in predicting post-percutaneous coronary intervention cardiovascular events.

Percutaneous coronary intervention (PCI), as a relatively rapid and effective minimally invasive treatment for coronary heart disease (CHD), can effectively relieve coronary artery stenosis and restore myocardial perfusion. However, the occurrence of major adverse cardiovascular events (MACE) is a significant challenge for post PCI care. To better understand risk/benefit indicators and provide post PCI MACE prediction, 408 patients with CHD who had undergone PCI treatment from 2018 to 2021 in Tianjin Chest hospital were retrospectively studied for their clinical characteristics in relation with the MACE occurrence during a 12-month follow-up. In the study, 194 patients had MACE and 214 patients remained MACE-free. Using uni- and multivariate regression analyses, we have shown that smoking history, elevated serum C-reactive protein levels (hs-CRP), and high haemoglobin levels A1c (HbA1c) are all independent risk factors for MACE after PCI. Furthermore, we have discovered that the serum level of IL-38, one of the latest members identified in the IL-1 cytokine family, is another predictive factor and is reversely related to the occurrence of MACE. The serum level of IL-38 alone is capable of predicting non-MACE occurrence in subcategorized patients with abnormal levels of hs-CRP and/or HbA1c.