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BACKGROUND: The "Minimalistic Hybrid Approach" (MHA) has been proposed to reduce the invasiveness of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). AIMS: This study aims to assess whether MHA may also reduce the utilization of PCI resources (devices, radiations, and contrast) by comparing it with other conventional algorithms. METHODS: We aimed to assess the impact of MHA on device, radiation, and contrast usage during CTO-PCI analyzing data from the Belgian Working Group on CTO (BWG-CTO) registry. Patients were divided, depending on the algorithm used, into two groups: Conventional versus Minimalistic. Primary objectives were procedure performance measures such as device usage (microcatheters and guidewires), radiological parameters, and contrast use. At 1-year follow-up, patients were evaluated for target vessel failure (TVF), defined as a composite of cardiac death, new myocardial infarction, and target vessel revascularization. RESULTS: Overall, we analyzed 821 CTO-PCIs (Conventional n = 650, Minimalistic n = 171). The Minimalistic group demonstrated higher complexity of CTO lesions. After adjusting for propensity score, the Minimalistic group had a significantly lower number of microcatheters used (1.49 ± 0.85 vs. 1.24 ± 0.64, p = 0.026), while the number of guidewires was comparable (4.80 ± 3.29 vs. 4.35 ± 2.94, p = 0.30). Both groups had similar rates of success and procedural complications, as well as comparable procedural and fluoroscopic times and contrast volume used. At the 1-year follow-up, both groups showed comparable rates of TVF (hazard ratio: 0.57; 95% confidence interval: 0.24-1.34, p = 0.195). CONCLUSION: The MHA may slightly reduce the number of dedicated devices used during CTO-PCI, without adversely affecting the procedural success or long-term outcome.
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Oclusão Coronária , Intervenção Coronária Percutânea , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Resultado do Tratamento , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/terapia , Oclusão Coronária/etiologia , Fatores de Risco , Doença Crônica , Algoritmos , Sistema de Registros , Angiografia CoronáriaRESUMO
BACKGROUND: Early aspirin withdrawal, also known as P2Y12-inhibitor monotherapy, following percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) can reduce bleeding without a trade-off in efficacy. Still the average daily bleeding risk is highest during the first months and it remains unclear if aspirin can be omitted immediately following PCI. METHODS: The LEGACY study is an open-label, multicenter randomized controlled trial evaluating the safety and efficacy of immediate P2Y12-inhibitor monotherapy versus dual antiplatelet therapy (DAPT) for 12 months in 3,090 patients. Patients are randomized immediately following successful PCI for NSTE-ACS to 75-100 mg aspirin once daily versus no aspirin. The primary hypothesis is that immediately omitting aspirin is superior to DAPT with respect to major or minor bleeding defined as Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, while maintaining noninferiority for the composite of all-cause mortality, myocardial infarction and stroke compared to DAPT. CONCLUSIONS: The LEGACY study is the first randomized study that is specifically designed to evaluate the impact of immediately omitting aspirin, and thus treating patients with P2Y12-inhibitor monotherapy, as compared to DAPT for 12 months on bleeding and ischemic events within 12 months following PCI for NSTE-ACS.
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Síndrome Coronariana Aguda , Intervenção Coronária Percutânea , Humanos , Aspirina , Inibidores da Agregação Plaquetária/efeitos adversos , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/cirurgia , Intervenção Coronária Percutânea/métodos , Quimioterapia Combinada , Hemorragia/induzido quimicamente , Resultado do TratamentoRESUMO
Background: The presence of a chronic total occlusion (CTO) and severe left ventricular (LV) systolic dysfunction are known negative prognostic factors in patients with coronary artery disease. Several studies have examined the effect of CTO revascularization on mortality, symptoms, occurrence of myocardial infarction (MI), and cardiac function in patients with normal or reduced LV function. However, the effect of CTO revascularization on heart failure-related events in patients with LV dysfunction, such as heart failure hospitalization (HFH), the occurrence of atrial fibrillation (AF), and a worsening renal function (WRF), has not yet been evaluated. To assess the success rate and safety of CTO percutaneous coronary interventions (PCIs) in coronary patients with LV ejection fractions of ≤ 40% and evaluate the impact of successful CTO revascularization on HFH, occurrence of AF, and WRF. Methods: Prospectively, data were collected from CTO PCIs performed at three referral centers and analyzed. From a total of 1435 CTO PCIs, 132 (9.2%) patients with a left ventricular ejection fraction (LVEF) of ≤ 40% were included in this analysis. The median follow-up duration was 23.18 months (interquartile range (IQR): 11.02-46.66 months). Results: A successful CTO PCI was achieved in 109 of these patients, while the procedure was unsuccessful in 23 patients (82.5% procedural success rate). Overall, the intervention had an acceptable number of peri-procedural (or in-hospital) complications (9.1%). During the follow-up period, the rates of all-cause death, cardiovascular death, and non-fatal MI were not significantly different between the two groups. The rates of HFH were significantly lower in the successful PCI group, while WRF and AF did not differ between successful and unsuccessful PCI groups. Successful PCI and higher estimated glomerular filtration rate (eGFR) were independent predictors of a lower risk of HFH, while prior stroke and diabetes were independent predictors of a higher risk of HFH. Conclusions: In patients with reduced LV systolic function (ejection fraction, EF ≤ 40%), CTO PCI is a safe and effective procedure and successful CTO PCI is independently associated with a lower risk of HFH during follow-up. Further expansion of this cohort is necessary to confirm these results.
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Left circumflex coronary artery (LCx) injury related to mitral valve surgery is a rare complication. The best treatment option is not defined, and percutaneous coronary intervention (PCI) may represent an effective treatment to avoid prolonged myocardial ischemia. To evaluate feasibility and efficacy of PCI treatment, all records of LCx injury related to mitral valve surgery and treated with PCI were included after a systematic PubMed searching. Moreover, we retrospectively analyzed our single-center PCI database and patients fulfilling the inclusion criteria were included. Patients undergoing transcatheter mitral valve intervention, non-mitral valve surgery, conservatively or surgically treated after LCx injury were excluded. Data about patient characteristics, procedural details, PCI success, and in-hospital mortality were collected. Fifty-six patients were included, 58.9% were male (n = 33) and the median age was 60.5 years (IQR = 21.75). The majority had left dominant or codominant coronary system (62.2%, n = 28 and 15.6%, n = 7, respectively). Clinical manifestations ranged from hemodynamic stability (21.1%, n = 8) to hemodynamic instability (42.1%, n = 16) and cardiac arrest (18.4%, n = 7). On ECG, 23.5% of patients (n = 12) presented ST-segment depression, 58.8% (n = 30) ST-segment elevation, 7.8% (n = 4) atrioventricular block, and 29.4% (n = 15) ventricular arrhythmias. Left ventricle dysfunction was present in 52.3% (n = 22) of patients and wall motion abnormalities in 71.4% (n = 30). PCI success rate was 82.1% (n = 46) and in-hospital mortality 4.5% (n = 2). LCx injury related to mitral surgery is a rare complication characterized by an increased risk of mortality. PCI seems a feasible treatment option, still burdened by suboptimal results, probably related to the technical challenges posed by the surgical failure.
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Vasos Coronários , Intervenção Coronária Percutânea , Humanos , Masculino , Pessoa de Meia-Idade , Feminino , Intervenção Coronária Percutânea/efeitos adversos , Resultado do Tratamento , Estudos Retrospectivos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgiaRESUMO
INTRODUCTION: The minimalistic hybrid approach (MHA) is an algorithm to perform chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The current study aims to evaluate the distribution of patients among the five different treatment strategies, the different techniques used in each strategy, the overall procedural success, and the safety of the MHA algorithm. METHODS: Data from a consecutive series of patients with a CTO who underwent elective PCI between February 2019 and July 2021 were prospectively collected and retrospectively analyzed. RESULTS: One hundred and forty-three CTOPCI in 135 patients were approached according to the MHA algorithm: 134 CTO (93.7%) were successfully recanalized and 9 procedures failed. About half of the procedures (48.3%) were approached using strategy A: antegrade "blind wiring" with contralateral retrograde options, making this the most popular strategy. A total of 89 procedures (62.2%) were completed with a single guiding catheter; in 86 (96.6%) a forearm approach was used. The remaining 54 cases were performed with dual access; in the majority of these patients (90.7%), a bilateral forearm approach was used. The only reason to use the femoral access was inadequate forearm access. One hundred and fifty-four out of 197 (78.2%) access sites were 6 French sheaths. CONCLUSION: MHA is a stepwise approach focused on the forearm approach to reduce the number of access sites and catheter size used in CTOPCI while maintaining proficiency and safety. Operators should be warned that this approach should be adopted only by experienced CTO operators who master all the strategies of the classic hybrid algorithm and the forearm approach.
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Oclusão Coronária , Intervenção Coronária Percutânea , Algoritmos , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/terapia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
Objectives: To compare two different forms of mechanical circulatory support (MCS) in patients with complex high-risk indicated PCI (CHIP): the Impella CP system and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Background: To prevent hemodynamic instability in CHIP, various MCS systems are available. However, comparable data on different forms of MCS are not at hand. Methods: In this multicenter observational study, we retrospectively evaluated all CHIP procedures with the support of an Impella CP or VA-ECMO, who were declined surgery by the heart team. Major adverse cardiac events (MACE), mortality at discharge, and 30-day mortality were evaluated. Results: A total of 41 patients were included, of which 27 patients were supported with Impella CP and 14 patients with VA-ECMO. Baseline characteristics were well-balanced in both groups. No significant difference in periprocedural hemodynamic instability was observed between both groups (3.7% vs. 14.3%; p = 0.22). The composite outcome of MACE showed no significant difference (30.7% vs. 21.4%; p = 0.59). Bleeding complications were higher in the Impella CP group, but showed no significant difference (22.2% vs. 7.1%; p = 0.22) and occurred more at the non-Impella access site. In-hospital mortality was 7.4% in the Impella CP group versus 14.3% in the VA-ECMO group and showed no significant difference (p = 0.48). 30-Day mortality showed no significant difference (7.4% vs. 21.4%; p = 0.09). Conclusions: In patients with CHIP, there were no significant differences in hemodynamic instability and overall MACE between VA-ECMO or Impella CP device as mechanical circulatory support. Based on this study, the choice of either VA-ECMO or Impella CP does not alter the outcome.
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Oxigenação por Membrana Extracorpórea , Intervenção Coronária Percutânea , Doenças Vasculares , Humanos , Estudos Retrospectivos , Mortalidade Hospitalar , MãosRESUMO
Coronary sinus Reducer (CSR) implantation is currently recommended to relieve angina in patients with refractory symptoms despite optimal medical therapy and maximally achievable revascularization. The impact of diabetes mellitus on outcome after CSR implantation is at present unknown. We aimed to explore the impact of CSR in refractory angina patients with diabetes mellitus. Data from consecutive patients undergoing CSR implantation at four different centres between 2014 and 2018 were included. Patients were divided according to the presence or absence of diabetes mellitus. Primary objective of this analysis was to evaluate the clinical response to CSR implantation defined as an improvement of ≥ 1 classes of the Canadian Cardiovascular Society (CCS) Classification. A total of 219 patients were included, 116 (53%) of whom had diabetes mellitus. The median age of the population was 69 years and 167 patients (76%) were male. There were no significant differences between groups of patients with and without diabetes mellitus with respect to CCS class at baseline (p value = 0.32) and at follow-up (p = 0.75). Over a median follow-up of 393 [224-1004] days, 84 (72%) of the patients with diabetes mellitus met the primary outcome, similarly to those without diabetes mellitus (p = 0.28). Fifty-three patients (24%) did not have an improvement in CCS class and no one experienced worsening of angina. CSR implantation was equally effective in improving angina symptoms among patients with refractory angina and diabetes mellitus compared to patients without diabetes mellitus.
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Seio Coronário , Diabetes Mellitus , Idoso , Angina Pectoris/diagnóstico , Angina Pectoris/etiologia , Angina Pectoris/cirurgia , Canadá , Seio Coronário/diagnóstico por imagem , Seio Coronário/cirurgia , Diabetes Mellitus/epidemiologia , Humanos , Masculino , Resultado do TratamentoRESUMO
OBJECTIVES: Aim of this study is to prospectively assess the feasibility of the "Minimalistic Hybrid Approach" (MHA) algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: We recently described the MHA, with focus on the classic hybrid strategies (antegrade wire escalation [AWE] or retrograde wire escalation [RWE], antegrade dissection-re-entry [ADR] or retrograde dissection-re-entry [RDR]), and also on access site (favoring "wrist" approach: radial, ulnar, and distal radial), introducer French size (favoring 6 French catheters) and nonroutine initial use of dual injection. METHODS: The MHA was prospectively attempted in 56 consecutive CTO PCI in 54 patients. Technical success was defined as the achievement of TIMI 3 antegrade flow with residual stenosis <30%, procedural success was defined as technical success without in-hospital major adverse cardiovascular events. RESULTS: Mean Japanese-CTO (J-CTO) score was 2.04 ± 0.95(J-CTO score ≥ 3 in 30.4%). The lesion-based technical and procedural success were 94.6%(53/56:three failures, two in the same patient) and 91.1%(51/56:three failures, one tamponade requiring pericardiocentesis and one periprocedural infarction), the patient-based successes were: technical 98.1%(53/54) and procedural 94.4%(51/54). In 34 procedures (60.7%), the approach was single catheter (always trans-wrist besides one femoral). Out of the 22(39.3%) lesions approached with dual catheters, one was bi-femoral, the rest was bi-wrist. In 29 cases (51.8%) AWE represented the successful technique, ADR in 5(8.9%) and retrograde in 19(33.9%); 3(5.4%) were failures. CONCLUSIONS: The current study shows that the MHA algorithm is feasible in almost every CTO lesion and it can lead to extremely successful results once applied by operators well acquainted with the wrist approach and with established experience using the full spectrum of the hybrid algorithm techniques.
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Oclusão Coronária , Intervenção Coronária Percutânea , Algoritmos , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/cirurgia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Sistema de Registros , Fatores de Risco , Resultado do TratamentoRESUMO
AIM: Chronic total occlusions (CTO) in patients with history of coronary artery bypass graft (CABG) show more advanced and complex atherosclerotic pathology. Aim of our study is to compare outcomes in patients undergoing CTO percutaneous coronary intervention (PCI) with previous CABG versus those without in the REgistry of Crossboss and Hybrid procedures in FrAnce the NetheRlands, BelGium and UnitEd Kingdom (RECHARGE). METHODS & RESULTS: The RECHARGE cohort (1,252 patients) was divided in two groups according to the presence of previous CABG (217) or not. We also focused, in the post-CABG group, on a comparison between CTO in previously grafted vessels versus non-grafted vessels. The CTO complexity scores were higher and the success rate (71.9% vs. 88.7%, p < .001) was lower in the CABG group, this difference was driven by higher failure rates in high-complexity-score CTO. The rate of in-hospital complications was similar. In the post-CABG group, the procedural success of CTO located in previously grafted vessels versus those in vessels not previously grafted, was comparably suboptimal (73.1% vs. 68%, p = .47). CONCLUSION: Patients undergoing CTO PCI with prior CABG have a higher prevalence of comorbidities and more complex lesion characteristics. In the post-CABG population the success rate was significantly lower, particularly in high CTO complexity scores, though complication rates were comparable. In the post-CABG population, the CTO success rate was independent of the presence of a previous graft on the CTO vessel.
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Oclusão Coronária , Intervenção Coronária Percutânea , Bélgica/epidemiologia , Doença Crônica , Angiografia Coronária , Ponte de Artéria Coronária/efeitos adversos , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/cirurgia , Humanos , Países Baixos , Intervenção Coronária Percutânea/efeitos adversos , Sistema de Registros , Fatores de Risco , Resultado do Tratamento , Reino Unido/epidemiologiaRESUMO
OBJECTIVES: The study aimed to demonstrate through instant wave-free ratio (iFR) measurements that myocardium distal to a chronic total occlusion (CTO) is ischemic, that ischemia is reversible by PCI, and that iFR assessment after PCI can be used to optimize PCI results. BACKGROUND: The greatest benefit of revascularization is found in patients with low fractional flow reserve. In patients with CTOs, iFR measurement may be more appropriate to evaluate ischemia as it does not require maximal microvascular vasodilation, which may be hampered by microvascular dysfunction. METHODS: The iFR was measured in 81 CTO patients, both pre- and post-PCI in 63 patients, and only post-PCI in the following 18 patients. A pressure wire pullback was performed post-PCI if iFR ≤0.89. RESULTS: The first 63 patients all had significant ischemia distal to the CTO with a median iFR of 0.33 [0.22; 0.44], improving significantly post-PCI to a median iFR of 0.93 [0.89;0.96] (p < .001). In the complete cohort, the median iFR post-PCI was 0.93 [0.86;0.96] but still ≤0.89 in 23 patients (30%). 12 of these patients had further PCI optimization because of a residual focal pressure gradient on pullback, after which only two had a final iFR ≤0.89. CONCLUSIONS: In CTO patients with an indication for PCI, iFR consistently demonstrated profound myocardial ischemia. Successful PCI immediately relieved ischemia in 70% of patients. In the remaining 30% of cases, a manual iFR pullback proved helpful in guiding further optimization of the PCI result.
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Estenose Coronária , Reserva Fracionada de Fluxo Miocárdico , Intervenção Coronária Percutânea , Cateterismo Cardíaco , Angiografia Coronária , Humanos , Isquemia , Intervenção Coronária Percutânea/efeitos adversos , Valor Preditivo dos Testes , Resultado do TratamentoRESUMO
OBJECTIVES: We hypothesized that some coronary sinus (CS) anatomies allow a more straightforward CS Reducer (CSR) implantation. BACKGROUND: Recent decades have seen a rise in patients with chronic angina. When complete revascularization and maximal medical therapy fail to reduce symptoms, CSR has become a new therapeutic option. METHODS: We identified a classical C-shape-a near horizontal course of the proximal portion of a circular CS-in a retrospective analysis of 47 CSR implantations and compared the procedural time, fluoroscopic time, contrast use, presence of valves or bifurcations and procedural complications with the non-C-shape CS anatomy. RESULTS: We found a significant difference in procedural (20.0 [19.0-24.7] min vs. 24.5 [20.7-51.0] min; p = .028 and fluoroscopic time (9.5 [7.5-14.5] min vs. 11.0 [7.9-30.0] min; p = .016). There was no significant difference in contrast use. The presence of bifurcations or valves along the CS course did not influence the procedural timings. CONCLUSION: This study is the first systematic evaluation of CS anatomy and its procedural implications. We identified a favorable C-shape anatomy which allows for a more straightforward implantation. Operators should be aware of the different implications of CS anatomy, their influence on guiding catheter stability and overall procedure complexity.
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Seio Coronário , Angina Pectoris , Seio Coronário/diagnóstico por imagem , Humanos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: We aimed to evaluate the efficacy and safety of antegrade fenestration and reentry (AFR) for chronic total occlusion (CTO) recanalization in a multicenter registry. BACKGROUND: Adoption of antegrade dissection/reentry (ADR) for CTO recanalization has been limited, and novel ADR techniques are needed. METHODS: AFR involves the balloon-induced creation of multiple fenestrations between the false and true lumen. A targeted true lumen reentry is subsequently achieved with a low tip-load polymer-jacketed guidewire. Following the initial description and dissemination of AFR, patients undergoing AFR-based CTO recanalization at nine centers were included in the present registry. Study endpoints were AFR success, procedural success, and target-lesion failure (TLF) on follow-up. RESULTS: We included 41 patients. Mean J-CTO score was 2.5 ± 1.4. In 80.5% of cases, AFR was performed after failed antegrade wire escalation. Another ADR technique was used before AFR in one-third of cases. AFR achieved distal true lumen reentry in n = 27/41 (65.9%) cases. In n = 14/41 (34.1%) cases with AFR failure, use of alternative techniques led to successful CTO recanalization in eight additional patients. The overall technical and procedural success rates were 85.4% and 82.9%, respectively. No AFR-related complications were observed. One-year TLF rate was 8.3% overall, with no differences between successful and failed AFR. CONCLUSIONS: We report on AFR feasibility in a multicenter registry of patients undergoing CTO recanalization. We observed a moderate success rate, coupled with the absence of complications. Moreover, even a failed AFR attempt did not preclude the use of alternative techniques to achieve recanalization. Further studies should confirm and extend our findings.
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Oclusão Coronária , Intervenção Coronária Percutânea , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/cirurgia , Humanos , Sistema de Registros , Resultado do TratamentoRESUMO
OBJECTIVES: We aimed to evaluate the effect of transcatheter aortic valve implantation (TAVI) approaches on mortality and identify effect modifiers and predictors for mortality. BACKGROUND: Alternative access routes to transfemoral (TF) TAVI include the surgical intra-thoracic direct-aortic (DA) and transapical (TA) approach. TA TAVI has been associated with a higher mortality rate. We hypothesized that this is related to effect modifiers, in particular the left ventricular ejection fraction (LVEF). METHODS: This multicentre study derived its data from prospective registries. To adjust for confounders, we used propensity-score based, stabilized inverse probability weighted Cox regression models. RESULTS: In total, 5,910 patients underwent TAVI via TF (N = 4,072), DA (N = 524), and TA (N = 1,314) access. Compared to TF, 30-day mortality was increased among DA (HR 1.87, 95%CI 1.26-2.78, p = .002) and TA (HR 3.34, 95%CI 2.28-4.89, p < .001) cases. Compared to TF, 5-year mortality was increased among TA cases (HR 1.50, 95%CI 1.24-1.83, p < .001). None of the variables showed a significant interaction between the approaches and mortality. An impaired LVEF (≤35%) increased mortality in all approaches. CONCLUSIONS: The surgical intra-thoracic TA and DA TAVI are both associated with a higher 30-day mortality than TF TAVI. TA TAVI is associated with a higher 5-year mortality than TF TAVI. The DA approach may therefore have some advantages over the TA approach when TF access is not feasible.
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Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Humanos , Estudos Prospectivos , Volume Sistólico , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
PURPOSE OF REVIEW: The prevalence of angina despite optimal medical therapy is high among patients with coronary chronic total occlusions. Despite advancements in techniques and operator's experience, percutaneous revascularization of coronary chronic total occlusions is still associated with a not negligible risk of failures and complications. The Coronary Sinus Reducer, a new device developed to improve angina, has shown promising results in terms of efficacy and safety in patients with refractory symptoms. The aim of this review is to summarize the evidence so far available and to guide clinicians in the selection of patients with chronic total occlusions that could benefit more from Coronary Sinus Reducer implantation. RECENT FINDINGS: A recently published study suggests a clear value of this device in patients with chronic total occlusions. This is likely to be related to the presence of a well-developed collateral circulation. A careful evaluation of risks and benefits of both myocardial revascularization and Coronary Sinus Reducer implantation should be done in all the cases in order to better define the optimal strategy for the patient. The Coronary Sinus Reducer implantation has a rationale in patients with chronic total occlusion as an alternative or additional therapy to myocardial revascularization.
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Oclusão Coronária , Seio Coronário , Intervenção Coronária Percutânea , Angina Pectoris , Oclusão Coronária/cirurgia , Seio Coronário/cirurgia , Humanos , Resultado do TratamentoRESUMO
OBJECTIVES: To evaluate the incidence of vascular complication and major bleeding in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with a fully trans-wrist access (TWA) approach versus a conventional approach based on trans-femoral access (TFA). BACKGROUND: TFA is the preferred vascular access in CTO PCI, but it has been associated with a non-negligible risk of complications. METHODS: This retrospective registry included all patients undergoing CTO PCI at five institutions between July 2011 and October 2018. Patients were divided into two groups: Conventional (patients treated with at least one TFA) and Fully TWA (subjects exclusively treated with one or two TWA). The primary safety endpoint was a composite of vascular complications and major bleeding. The primary efficacy endpoint was procedural success. RESULTS: We included 1,900 patients (Conventional n = 1,496 and Fully TWA n = 404). Conventional patients showed higher occlusion complexity (J-CTO score 2.1 ± 1.2 vs. 1.5 ± 1.1, p < .001). Procedural success showed no significant difference between both groups (85.7 vs. 83.0%, p = .17). The primary safety endpoint occurred more frequently in the Conventional group (10.3 vs. 4.5%, p < .001), driven by vascular complications (9.4 vs. 3.7%, p < .001). On multivariate analysis, not using a Fully TWA approach was an independent predictor of the study endpoint, after adjusting for age, sex, diabetes, body mass index, chronic kidney disease, prior coronary artery bypass graft, and J-CTO score. CONCLUSIONS: Embracing a Fully TWA approach for CTO PCI might be associated with lower incidence of a composite endpoint of vascular complications and major bleeding, compared with a Conventional approach.
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Cateterismo Periférico , Oclusão Coronária/terapia , Artéria Femoral , Intervenção Coronária Percutânea , Punho/irrigação sanguínea , Idoso , Cateterismo Periférico/efeitos adversos , Doença Crônica , Oclusão Coronária/diagnóstico por imagem , Europa (Continente) , Feminino , Hemorragia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Punções , Sistema de Registros , Estudos Retrospectivos , Stents , Resultado do Tratamento , Doenças Vasculares/etiologiaRESUMO
BACKGROUND: Percutaneous recanalization of coronary chronic total occlusions (CTOs) traditionally relies on the use of dual-access and large bore catheters, with trans-femoral approach adoption in most cases. OBJECTIVES: Aim of this manuscript is to describe the outcomes of an alternative hybrid algorithm, called "Minimalistic Hybrid Algorithm," which has the purpose to minimize the use of double access, large bore catheters, and femoral approach in order to minimize the risk of vascular complications and patient's discomfort, without compromising efficacy. METHODS: In this single-center registry, a "minimalistic" approach was attempted in consecutive patients undergoing CTO PCI between March 2016 and October 2017. Data regarding the applicability of this algorithm and the related procedural success rates were collected, together with common demographic and angiographic characteristics. RESULTS: Of the 100 CTO PCI performed in the study period, 91(91%) were successfully approached according to the novel algorithm. Mean J-CTO score of all minimalistic procedures was 1.9 ± 1.2, with 31(34%) patients presenting with J-CTO score ≥3. In 52 procedures, the approach consisted of single-catheter access, 49(94.2%) of which were trans-radial. Out of the 39 patients approached with dual-catheters, 26(69.2%) were biradial, and 8(21%) radial-femoral. Procedural success in patients approached with the minimalistic algorithm was 89%, in line with the results of large-multicenter experiences nowadays available. CONCLUSIONS: Our results show that an alternative algorithm limiting the routine use of large bore catheters and trans-femoral approach is feasible in the clinical practice and yields good procedural outcomes.
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Algoritmos , Cateterismo Periférico , Protocolos Clínicos , Oclusão Coronária/terapia , Artéria Femoral , Intervenção Coronária Percutânea , Artéria Radial , Idoso , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Doença Crônica , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/fisiopatologia , Árvores de Decisões , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Dispositivos de Acesso VascularRESUMO
The number of patients suffering from refractory angina is constantly increasing. Moreover, these patients are considered at higher risk for new hospitalizations and increased incidence of adverse cardiac events. The coronary sinus reducer was recently introduced as a new therapeutic option in patients with refractory angina and no possibilities for coronary revascularization. However, a consistent percentage of patients, ranging from 15 to 30%, reports no clinical benefits after coronary sinus reducer implantation. The reasons for this lack of effectiveness are at present unknown. We suggest here a possible explanation to this phenomenon.
Assuntos
Angina Pectoris/terapia , Angioplastia Coronária com Balão/instrumentação , Doença da Artéria Coronariana/terapia , Seio Coronário/patologia , Neointima , Reepitelização , Stents , Idoso , Angina Pectoris/diagnóstico por imagem , Angina Pectoris/patologia , Angina Pectoris/fisiopatologia , Angioplastia Coronária com Balão/efeitos adversos , Proliferação de Células , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/patologia , Doença da Artéria Coronariana/fisiopatologia , Circulação Coronária , Seio Coronário/diagnóstico por imagem , Seio Coronário/fisiopatologia , Hemodinâmica , Humanos , Masculino , Desenho de Prótese , Falha de TratamentoRESUMO
OBJECTIVES: Available data indicate mixed outcomes after using retrograde techniques for chronic total occlusion(CTO) recanalization, with generally higher need for repeat revascularization. Aim of this study is to analyze the angiographic and clinical outcome of patients treated with retrograde techniques in the PRISON-IV trial. METHODS AND RESULTS: This is a post-hoc sub-analysis from the randomized PRISON-IV trial. Briefly, 330 patients with a successfully recanalized CTO lesion were randomized 1:1 to receive either hybrid-SES or EES. The hybrid-SES failed to reach the non-inferiority primary endpoint of in-segment late lumen loss at 9-month angiography follow-up. In the present analysis, we divided the population according to the first technical approach, namely antegrade (n = 285) or retrograde approach (n = 45). Demographic characteristics were similar between the two groups, while angiographic features disclosed higher CTO lesion complexity in the group treated with retrograde techniques (J-CTO score: 1.8 ± 1.1 vs 2.6 ± 1.1, respectively, P < 0.001), with longer occlusions (17.6 ± 10 mm vs 28.8 ± 18.7 mm, P < 0.001) and longer stented segment (48.9 ± 24.4 mm vs 73.1 ± 33.2 mm, P < 0.001). Quantitative coronary analysis disclosed similar results at follow-up angiography, with a non-significantly higher in-stent late-lumen loss in the retrograde group (0.08 ± 0.52 mm vs 0.18 ± 0.56 mm, P = 0.32). Clinical follow-up at 12-months showed similar outcome, with a non-significantly higher target-lesions revascularization rate in the retrograde group (6% vs 11.1% respectively, P = 0.2). Significant improvements in angina functional class were observed in both groups. CONCLUSIONS: The present analysis supports the benefits of retrograde techniques in CTO revascularization, with non-significant differences in angiographic and clinical outcomes at late follow-up.
Assuntos
Angiografia Coronária , Oclusão Coronária/terapia , Intervenção Coronária Percutânea/métodos , Idoso , Doença Crônica , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Fatores de Risco , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Surgery for infective endocarditis imposes great challenges in post-operative circulatory and pulmonary support but the role of veno-arterial extra-corporal membrane oxygenation in this respect is unclear. METHODS: All patients undergoing veno-arterial extra-corporal membrane oxygenation after infective endocarditis surgery were analysed for age, gender, medical history, microorganisms, clinical outcome, complications and surgical procedure. RESULTS: Between 2012 and 2016, 13 patients received veno-arterial extra-corporal membrane oxygenation following infective endocarditis surgery. The median age was 62 years (33-73) and 8/13 were male. Previous cardiac surgery was present in nine patients. Surgery for infective endocarditis consisted of a Bentall procedure in 10 patients, 2 of which received concomitant mitral valve surgery and 2 received concomitant coronary artery bypass graft. Valvular surgery alone was performed in three patients. Mortality on veno-arterial extra-corporal membrane oxygenation was 62% (8/13). Mortality during intensive care unit stay was 77% (10/13). Survival to discharge was 23% (3/13). One patient reached the 1 year survival point. Two patients who survived to discharge have not yet reached the 1 year survival point. Patient-related complications occurred in 54% (7/13) of patients and consisted of haemorrhage at the cannula site in four patients, leg ischaemia in one patient, haemorrhage at another site in one patient and infection of the cannula in one patient. Extra-corporal membrane oxygenation hardware-related complications occurred in one case consisting of clot formation in the oxygenator. CONCLUSION: Veno-arterial extra-corporal membrane oxygenation in post-cardiotomy patients who were operated on for infective endocarditis is feasible, but outcome is poor.
Assuntos
Endocardite/complicações , Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Cardíaca/terapia , Adulto , Idoso , Endocardite/cirurgia , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Coronary chronic total occlusions (CTO) usually coexist with diffusely diseased coronary segments proximal and/or distal to the CTO segment. During percutaneous treatment of CTO, multiple overlapping stents are often needed to treat these long lesions. OBJECTIVES: Aim of this study is to report the first use of long, tapered coronary sirolimus-eluting stents (SES) in this setting. METHODS AND RESULTS: This is a retrospective analysis of 100 consecutive patients undergoing CTO recanalization following the hybrid algorithm. Procedural success rate was 89% (11 failures). Among the successful cases, "conventional" drug-eluting stents(DES) were used in 40(44.9%) patients, while in 49(55%) patients long-tapered SES were attempted with a success rate of 98% (1 cross-over to regular stents). Total stent length in the long-tapered DES group was higher compared to the "conventional" stenting group (76 ± 28 mm vs 46 ± 22 mm, P < .001), with a similar total number of stent (1.6 ± 0.8 vs 1.9 ± 0.8). At quantitative coronary analysis, proximal and distal segment involvement was more extended in patients undergoing long-tapered stenting, with longer overall lesion length. No differences in periprocedural complications and clinical outcomes at a mean follow-up of 303 ± 179 days were observed. CONCLUSIONS: The use of long tapered coronary DES is technically feasible and safe for the percutaneous treatment of CTOs, especially for patients presenting with long lesions.