Bayesian analysis of the Substrate Ablation vs. Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia trial.

BACKGROUND AND AIMS: Bayesian analyses can provide additional insights into the results of clinical trials, aiding in the decision-making process. We analysed the Substrate Ablation vs. Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia (SURVIVE-VT) trial using Bayesian survival models. METHODS AND RESULTS: The SURVIVE-VT trial randomized patients with ischaemic cardiomyopathy and monomorphic ventricular tachycardia (VT) to catheter ablation or antiarrhythmic drugs (AAD) as a first-line strategy. The primary outcome was a composite of cardiovascular death, appropriate implantable cardioverter-defibrillator shocks, unplanned heart failure hospitalizations, or severe treatment-related complications. We used informative, skeptical, and non-informative priors with different probabilities of large effects to compute the posterior distributions using Markov Chain Monte Carlo methods. We calculated the probabilities of hazard ratios (HR) being <1, <0.9, and <0.75, as well as 2-year survival estimates. Of the 144 randomized patients, 71 underwent catheter ablation and 73 received AAD. Regardless of the prior, catheter ablation had a >98% probability of reducing the primary outcome (HR < 1) and a >96% probability of achieving a reduction of >10% (HR < 0.9). The probability of a >25% (HR < 0.75) reduction of treatment-related complications was >90%. Catheter ablation had a high probability (>93%) of reducing incessant/slow undetected VT/electric storm, unplanned hospitalizations for ventricular arrhythmias, and overall cardiovascular admissions > 25%, with absolute differences of 15.2%, 21.2%, and 20.2%, respectively. CONCLUSION: In patients with ischaemic cardiomyopathy and VT, catheter ablation as a first-line therapy resulted in a high probability of reducing several clinical outcomes compared to AAD. Our study highlights the value of Bayesian analysis in clinical trials and its potential for guiding treatment decisions. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03734562.

Effects of Cardiac Stem Cell on Postinfarction Arrhythmogenic Substrate.

Clinical data suggest that cardiosphere-derived cells (CDCs) could modify post-infarction scar and ventricular remodeling and reduce the incidence of ventricular tachycardia (VT). This paper assesses the effect of CDCs on VT substrate in a pig model of postinfarction monomorphic VT. We studied the effect of CDCs on the electrophysiological properties and histological structure of dense scar and heterogeneous tissue (HT). Optical mapping and histological evaluation were performed 16 weeks after the induction of a myocardial infarction by transient occlusion of the left anterior descending (LAD) artery in 21 pigs. Four weeks after LAD occlusion, pigs were randomized to receive intracoronary plus trans-myocardial CDCs (IC+TM group, n: 10) or to a control group. Optical mapping (OM) showed an action potential duration (APD) gradient between HT and normal tissue in both groups. CDCs increased conduction velocity (53 ± 5 vs. 45 ± 6 cm/s, p < 0.01), prolonged APD (280 ± 30 ms vs. 220 ± 40 ms, p < 0.01) and decreased APD dispersion in the HT. During OM, a VT was induced in one and seven of the IC+TM and control hearts (p = 0.03), respectively; five of these VTs had their critical isthmus located in intra-scar HT found adjacent to the coronary arteries. Histological evaluation of HT revealed less fibrosis (p < 0.01), lower density of myofibroblasts (p = 0.001), and higher density of connexin-43 in the IC+TM group. Scar and left ventricular volumes did not show differences between groups. Allogeneic CDCs early after myocardial infarction can modify the structure and electrophysiology of post-infarction scar. These findings pave the way for novel therapeutic properties of CDCs.

Morphology of far-field electrograms and antitachycardia pacing effectiveness among fast ventricular tachycardias occurring in ICD patients: a multicenter study.

INTRODUCTION: Fast ventricular tachycardias (FVT) are less likely to be terminated by antitachycardia pacing (ATP). No information is available regarding the ability of far-field electrogram (Ff-EG) morphology (Ff-EGm) in predicting the result of the subsequent ATP. Our objective is to determine the relationship between Ff-EGm and ATP efficacy. METHODS AND RESULTS: In this multicenter study we analyzed 289 FVT (cycle length [CL]: 250-320 milliseconds) occurring consecutively in 52 ICD patients with Medtronic devices (LVEF: 37 ± 6; pacing site: right ventricular apex). FVT programming was standardized, including a single ATP burst as initial therapy. The configuration of Ff-EG was HVA versus HVB. FVTs were classified in QFVT or non-QFVT according to the presence or absence of a negative initial deflection in the Ff-EG. The mean CL was 291 ± 24 milliseconds. We observed 4 Ff-EGm: QS (n = 14, 5%), QR (n = 158, 55%), R (n = 93, 32%), and RS (n = 24, 8%). The ATP effectiveness was 80% (86% in QS, 85% in QR, 74% in R, 62% in RS). The frequency of successful ATP was higher in QFVT: 86 versus 71% (P = 0.002). By logistic regression analysis, a QFVT pattern (OR = 2.3; P = 0.015) remained as an independent predictor of effective ATP. ATP was safer in QFVTs, the frequencies of shock (14% vs 29%; P = 0.002), acceleration (5.1 vs 12.3%; P = 0.02), and syncope (4.6 vs 12.3%; P = 0.01) being lower. CONCLUSIONS: Since ATP is less effective in non-QFVTs, they are less well tolerated. Therefore, the substrate of non-QFVTs may need a specific treatment.

Spontaneous Variation of Ventriculo-Atrial Interval after Tachycardia Induction: Determinants and Usefulness in the Diagnosis of Supraventricular Tachycardias with Long Ventriculoatrial Interval.

Background: Determining the mechanism of supraventricular tachycardias with prolongedP ventriculoatrial (VA) intervals is sometimes a challenge. Our objective is to analyse the determinants, time course and diagnostic accuracy (atypical atrioventricular nodal reentrant tachycardias [AVNRT] versus orthodromic reentrant tachycardias through an accessory pathway [ORT]) of spontaneous VA intervals variation in patients with narrow QRS tachycardias and prolonged VA. Methods: A total of 156 induced tachycardias were studied (44 with atypical AVNRT and 112 with ORT). Two sets of 10 measurements were performed for each patient­after tachycardia induction and one minute later. VA and VV intervals were determined. Results: The difference between the longest and the shortest VA interval (Dif-VA) correlates significantly with the diagnosis of atypical AVNRT (C coefficient = 0.95 and 0.85 after induction and at one minute, respectively; p < 0.001). A Dif-VA ≥ 15 ms presents a sensitivity and specificity for atypical AVNRT of 50% and 99%, respectively after induction, and of 27% and 100% one minute later. We found a robust and significant correlation between the fluctuations of VV and VA intervals in atypical AVNRTs (Coefficient Rho: 0.56 and 0.76, after induction and at one minute, respectively; p < 0.001 for both) but not in ORTs. Conclusions: The analysis of VA interval variability after induction and one minute later correctly discriminates atypical AVNRT from ORT in almost all cases.

Very long-term efficacy and safety of paclitaxel-eluting balloon after a bare-metal stent for the treatment of ST-elevation myocardial infarction: 8-year results of a randomized clinical trial (PEBSI study).

Background: Drug-eluting stents (DES) are considered the therapy of choice in ST-segment elevation myocardial infarction (STEMI); however, a low persistent rate of revascularizations and stent thrombosis exist over the time. We have previously shown that a paclitaxel (PTX)-drug-coated balloon (DCB) after a bare-metal stent (BMS) implantation (DCB-combined strategy) yields superior angiographic and clinical results compared to BMS in the short term. However, the long-term safety and efficacy of this approach remain uncertain. Methods: An 8-year clinical follow-up was conducted on patients enrolled in the randomized PEBSI-1 trial (NCT01839890). The original trial included patients who suffered a STEMI, patients were randomly assigned to receive a DCB-combined strategy or BMS only and the primary endpoint was in-stent late luminal loss (LLL) at 9-month follow-up. After the completion of this study, death, myocardial re-infarction, ischemia-driven repeated revascularizations included target lesion revascularization (TLR) and target vessel revascularization (TVR), and stent thrombosis, were assessed by yearly contact by a clinical visit, telephone or by electronic records. These outcomes were adhered to ARC-2 criteria. Results: The rate of incomplete follow-up was very low, with only 3 out of 111 patients (2.7%) in the DCB-combined strategy group and 1 out of 112 patients (0.9%) in the BMS group. At 8 years there were a lower rate of TVR [3.7% vs. 14.3%; hazard ratio (HR): 0.243; 95% confidence interval (CI): 0.081-0.727; P=0.006], and a trend towards lower TLR (2.8% vs. 8.9%; HR: 0.300; 95% CI: 0.083-1.090; P=0.052) in the DCB-combined strategy group. No statistical difference between the DCB-combined strategy and BMS groups were found for all causes of death, deaths from cardiovascular disease, reinfarctions or stent thrombosis. Notably in the DCB-combined strategy group, no episode of stent thrombosis occurred after the first year. Similarly, there were no cardiovascular deaths, TVR and TLR in the DCB-combined strategy group after 5 years. In contrast, during the period from year 5 to 8, the BMS group experienced an additional cardiovascular death, as well as one case of TVR, one case of TLR, and one case of stent thrombosis. Conclusions: In STEMI patients, the DCB-combined strategy maintains its safety and clinical efficacy over time. Our rates of TVR, TLR, and very late stent thrombosis (VLST) at very long-term are the lowest ever found in a STEMI trial. Further studies are warranted to assess the potential superiority of this novel strategy as compared with new-generation DES to prevent very late events in these patients. Trial Registration: ClinicalTrials.gov; identifier: NCT01839890.

Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia.

BACKGROUND: In patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD), catheter ablation and antiarrhythmic drugs (AADs) reduce ICD shocks, but the most effective approach remains uncertain. OBJECTIVES: This trial compares the efficacy and safety of catheter ablation vs AAD as first-line therapy in ICD patients with symptomatic ventricular tachycardias (VTs). METHODS: The SURVIVE-VT (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia) is a prospective, multicenter, randomized trial including patients with ischemic cardiomyopathy and appropriated ICD shock. Patients were 1:1 randomized to complete endocardial substrate-based catheter ablation or antiarrhythmic therapy (amiodarone + beta-blockers, amiodarone alone, or sotalol ± beta-blockers). The primary outcome was a composite of cardiovascular death, appropriate ICD shock, unplanned hospitalization for worsening heart failure, or severe treatment-related complications. RESULTS: In this trial, 144 patients (median age, 70 years; 96% male) were randomized to catheter ablation (71 patients) or AAD (73 patients). After 24 months, the primary outcome occurred in 28.2% of patients in the ablation group and 46.6% of those in the AAD group (hazard ratio [HR]: 0.52; 95% CI: 0.30-0.90; P = 0.021). This difference was driven by a significant reduction in severe treatment-related complications (9.9% vs 28.8%, HR: 0.30; 95% CI: 0.13-0.71; P = 0.006). Eight patients were hospitalized for heart failure in the ablation group and 13 in the AAD group (HR: 0.56; 95% CI: 0.23-1.35; P = 0.198). There was no difference in cardiac mortality (HR: 0.93; 95% CI: 0.19-4.61; P = 0.929). CONCLUSIONS: In ICD patients with ischemic cardiomyopathy and symptomatic VT, catheter ablation reduced the composite endpoint of cardiovascular death, appropriate ICD shock, hospitalization due to heart failure, or severe treatment-related complications compared to AAD. (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia [SURVIVE-VT]: NCT03734562).

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

BACKGROUND: Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate. AIMS: We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how post-implantation deployment techniques influence clinical outcomes. METHODS: Data from the e-ULTIMASTER registry were used to perform an analysis of 4,395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at one year (follow-up rate 96.2%). RESULTS: The global one-year TLF rate was low (5.1%). The proximal optimisation technique (POT) was used in 33.9% of cases and was associated with a reduction in the adjusted TLF rate (4.0% [95% confidence interval: 3.0-5.1%] vs 6.0% [5.1-6.9%], p<0.01) due to a reduction of all components of this composite endpoint, except for cardiac death. Stent thrombosis was also positively impacted (0.4% [0.04-0.7%] vs 1.3% [0.8-1.7%], p<0.01). POT benefit was uniform across subgroups. Conversely, the use of the kissing balloon technique (36.5%) did not influence the adjusted TLF rate. CONCLUSIONS: Despite a low one-year failure rate in this large bifurcation stenting cohort, POT was associated with a further reduction in the event rate and a uniform benefit across subgroups, suggesting systematic use of this deployment technique regardless of the bifurcation anatomy and stenting technique.

Timing of Ablation and Prognosis of Patients With Electrical Storm and Scar-Related Left Ventricular Dysfunction.

Although radiofrequency catheter ablation (RFCA) is indicated in electrical storm (ES) refractory to antiarrhythmic drugs, its most appropriate timing has not been determined. Our objective is to analyse the impact of the timing of RFCA on 30-day mortality in patients with ES and previous scar-related systolic dysfunction. In this multi-centre study, we analysed 104 patients (age: 72 ± 10, left ventricular ejection fraction: 30 ± 6%) attended consecutively due to an ES caused by monomorphic ventricular tachycardia. Sixty-four subjects were treated with RFCA (mean time from admission = 83 ± 67 hours) and 40 were not. Upon admission 25 (24%) individuals had severe heart failure. Mortality rate at 30 days was 24 (23%) patients. RFCA was associated with a reduction of 30-day mortality (hazard ratio = 0.2; p = 0.008). After showing a positive correlation between the time of the RFCA (hours) and survival at 30 days (C-statistic = 0.77; p <0.001), we found that only subjects ablated >48 hours after admission had lower mortality at 30 days than those treated conservatively: 38% (no RFCA) versus 30% (RFCA ≤48 hours) versus 7% (RFCA >48 hours) (adjusted hazard ratio for RFCA >48 hours vs others = 0.2; p = 0.007). Among the patients ablated, those who were non-inducible had lower 30-day mortality: 8% versus 29% (p = 0.03). Extracorporeal membrane oxygenation was associated with a higher rate of non-inducibility in RFCA >48 hours (100% vs 76%; p = 0.03), but not in RFCA ≤48 hours (60% vs 60%; p = 1). In conclusion, among high-risk patients with ES, RFCA performed >48 hours after admission is associated with a reduction in 30-day mortality. In such subjects, the probability of successful RFCA increases when performed under extracorporeal membrane oxygenation support.

Beta-blocker therapy is associated with a lower incidence of syncope due to fast ventricular tachycardias among implantable cardioverter-defibrillator patients with left ventricular dysfunction: results from a multicenter study.

INTRODUCTION: Among implantable cardioverter-defibrillator (ICD) patients, a substantial proportion of syncopes are due to fast ventricular tachycardias (FVTs). In the experimental models of ventricular tachycardias, the arterial vasoconstriction plays an important role in recovering the arterial pressure. Since beta-blockers increase vascular resistance, we hypothesized that beta-blockers could reduce the occurrence of syncope due to FVTs. Our objective was to determine the relationship between the beta-blocker therapy and the incidence of syncope in FVT (cycle length [CL] 250-320 ms) occurring in ICD patients. Slow VTs were excluded because of the lack of symptoms and VF episodes because of the small number. METHODS AND RESULTS: In this multicenter study, 226 patients (LVEF 31 ± 10%) with single-chamber ICDs were followed. FVT programming was standardized, including antitachycardia pacing (ATP) as initial therapy. Symptoms were correlated with ICD-stored episode data of FVTs. The beta-blocker therapy was determined at each FVT presentation. We analyzed 289 FVTs (CL 291 ± 21 ms; 77% under beta-blockers; median of the duration:8 s) occurring consecutively in 52 ICD patients. The frequency of FVT-related syncope was 22 (7.6%). Beta-blockers were associated with a lower heart rate preceding FVT (85 ± 22 vs. 94 ± 23 bpm; p = 0.009), a higher ATP effectiveness (86 vs. 57%; p < 0.001), a lower duration of episodes (8 [2] vs. 10 [14] s; p < 0.001), and a lower incidence of FVT-related syncope (4.5 vs. 18%; p < 0.001). By logistic regression, a FVT > 8 s (OR = 21; p = 0.003) and the beta-blocker therapy (OR = 0.3; p = 0.012) were found as independent predictors of syncope. CONCLUSION: Among ICD patients with left ventricular dysfunction, beta-blockers are associated with a lower incidence of FVT-related syncope.

Percutaneous closure of a giant coronary artery fistula after surgical pericardiectomy. Review of the literature.

Coronary artery fistulae (CAF) are uncommon heart defects defined as a communication between a coronary artery and a cardiac chamber or vascular structure. They are frequently asymptomatic; nevertheless, they can produce angina, dyspnea or cardiac failure. CAF are believed to be congenital; however, isolated cases of CAF have been described as rare complications of cardiac surgery. We report the percutaneous closure of a giant CAF in an adult patient with angina and previous pericardiectomy.

A randomised trial of paclitaxel-eluting balloon after bare metal stent implantation vs. bare metal stent in ST-elevation myocardial infarction (the PEBSI study).

AIMS: Our aim was to assess the safety and efficacy of paclitaxel-eluting balloon (PTX-B) treatment after bare metal stent (BMS) implantation in patients undergoing primary angioplasty. METHODS AND RESULTS: After BMS implantation, patients were randomised (1:1) to treatment with a PTX-B or no PTX-B treatment (BMS group). The primary endpoint was in-stent late luminal loss (LLL) at nine-month follow-up. OCT was carried out on the first 20% of consecutive patients included in the study. Two hundred and twenty-three patients were randomised (BMS: 112, PTX-B: 111). At nine months, median LLL was 0.80 mm (interquartile range [IQR] 0.36-1.26) in the BMS group vs. 0.31 mm (IQR 0.00-0.58) in the PTX-B group, p<0.0001. Binary restenosis was significantly lower in the PTX-B group: 29.8% vs. 2.2%, p<0.0001, 95% confidence interval (CI): 3.2-54.2. Nine-month OCT showed good strut coverage in both groups but greater in the BMS group (100±0.0% vs. 99.52±1.11%, p=0.03) with very low rates of malapposed struts per lesion. One-year MACE was significantly lower in the PTX-B group (12.5% vs. 3.6%, p=0.016). CONCLUSIONS: PTX-B after successful BMS implantation resulted in less LLL and better clinical outcomes as compared with a BMS-only strategy. This was associated with good stent strut coverage and very low rates of malapposed struts.

[Right versus left radial artery approach for coronary angiography. Differences observed and the learning curve]. / Vía radial derecha o izquierda en la coronariografía. Importancia en la curva de aprendizaje.

There are anatomical differences between right and left radial artery approaches for coronary catheterization that could influence application of the technique. We present the results of a randomized study that compared the effectiveness of the two approaches and identified factors associated with failure of the procedure. The study involved 351 consecutive patients: a left radial approach was used in 180, and a right radial approach, in 171. The procedure could not be completed using the initial approach selected in 15 patients (11 right radial vs. 4 left radial; P=.007). Use of a right radial approach, lack of catheterization experience, patient age >70 years, and the absence of hypertension were found to be independently associated with prolonged fluoroscopy duration and failure using the initial approach. Use of the right radial approach in patients aged over 70 years was associated with a 6-fold increase in the risk of an adverse event. Consequently, use of the right radial approach should be avoided in patients aged over 70 years when trainee practitioners are on the learning curve.

Acute Coronary Syndromes, Gastrointestinal Protection, and Recommendations Regarding Concomitant Administration of Proton-Pump Inhibitors (Omeprazol/Esomeprazole) and Clopidogrel.

The Food and Drug Administration and the European Medicines Agency sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. The purpose is to know the gastroprotective approach in patients with acute coronary syndrome (ACS) and the level of follow-up of the alert. In 17 hospitals with catheterization laboratory in Spain, 1 per region, we studied 25 consecutive patients per hospital whose diagnosis of discharge since October 1, 2013, had been any type of ACS. We analyzed their baseline clinical profile, the gatroprotective agents at admission and discharge and the antiplatelet therapy at discharge. The number of patients included was 425: age 67.2 ± 12.5 years, women 29.8%, diabetes 36.5%. The patients presented unstable angina in 21.6%, non-ST-elevation myocardial infarction in 35.3% and ST-elevation myocardial infarction in 43.1%. Conservative approach was chosen in 17.9%, bare-metal stents 32.2%, ≥ 1 drug-eluting stent 48.5%, and surgery 1.4%. Aspirin was indicated in 1.9%, aspirin + clopidogrel 73.6%, aspirin + prasugrel 17.6%, and aspririn + ticagrelor 6.8%. Gastroprotective agents were present in 40.2% patients at admission and this percentage increased to 93.7% at discharge. Of the 313 (73.6%) on clopidogrel in 96 (30.6%) was combined with omeprazole and 3 (0.95%) with esomeprazole, whereas the most commonly used was pantoprazole with 190 patients (44.7%). In conclusion, almost the totality of the patients with an ACS receive gastroprotective agents at the moment of discharge, most of them with proton-pump inhibitors. In one every 3 cases of the patients who are on clopidogrel, the recommendation of the Food and Drug Administration and the European Medicines Agency is not followed.

[Utility of the serum biochemical markers CPK, CPK MB mass, myoglobin, and cardiac troponin T in a chest pain unit. Which marker determinations should be requested and when?]. / Utilidad clínica de los distintos marcadores biológicos CPK, CPK MB masa, mioglobina y troponina T en una unidad de dolor torácico. Cuándo, cuáles y cómo pedirlos?

BACKGROUND: The prognostic value of biochemical markers in relation to time since onset of chest pain was evaluated in an emergency room with a chest pain unit. METHODS: In a single-center, prospective study we included 321 consecutive patients admitted to the emergency room with suspected unstable angina IIIB and an evolution of less than 12 hours. Blood samples were collected for CPK, CPK MB mass, myoglobin, and cardiac troponin T assays 6, 12, and 18 h after the onset of pain. ROC curve analysis was carried out to compare biochemical markers in terms of cutoff values and time since onset of pain. We determined the relation between prognosis and biochemical markers before and after adjustment for baseline characteristics. RESULTS: CPK mass and myoglobin showed the maximum sensitivity and specificity for new ischemic recurrences 6 hours after the onset of chest pain with laboratory cutoff values. We had to wait 12 h after the onset of pain for troponin T to be useful using the laboratory cutoff value (0.1 ng/ml). A single determination 6 hours after onset of chest pain of cardiac troponin T above 0.04 ng/ml was the most sensitive and specific marker for new ischemic recurrences. CONCLUSIONS: A single blood determination of cardiac troponin T 6 hours after the onset of chest pain complete the prognostic stratification in combination with clinical and ECG variables. The best cutoff point of cardiac troponin T, based on univariate and multivariate analysis, was 0.04 ng/ml 6 h after the onset of chest pain.

[Risk stratification using combined ECG, clinical, and biochemical assessment in patients with chest pain without ST-segment elevation. How long should we wait? ]. / Estratificación de riesgo en pacientes con dolor torácico sin ascenso persistente del segmento ST basado en variables clínicas, ECG y bioquímicas. ¿Cuánto tiempo debemos esperar?

INTRODUCTION: We use clinical, ECG, and biochemical data to stratify risk in patients with chest pain without ST segment elevation. However, the prognostic performance of these studies in relation to time from onset of symptoms is unknown. PATIENTS AND METHOD: In a single-center, prospective study, 321 consecutive patients who had been admitted in the emergency room with a suspected acute coronary syndrome without ST segment elevation were included in the study. Blood samples were collected for CK, CK-MB mass, myoglobin, and cardiac troponin T analysis 6, 12 and 18 hours after the onset of pain and other clinical and ECG data were recorded. Univariate and multivariate analysis was used to identify independent prognostic predictors 6 and 12 hours after the onset of chest pain. RESULTS: Five variables were independent predictors of the recurrence of ischemia. The model correctly classified 82% of the patients. Age, history of coronary artery disease, prolonged chest pain at rest in the preceding 15 days, pain, ST-segment changes with pain, and cardiac troponin T in excess of 0.1 ng/m 12 hours after the onset of chest pain were identified by logistic regression. A similar model was analyzed at 6 hours, after changing the cutoff point for cardiac troponin T. Cardiac troponin T was considered positive with values of 0.04 ng/ml 6 hours after the onset of chest pain. CONCLUSIONS: More than 80% of the patients admitted to the emergency room with chest pain without ST segment elevation can be correctly classified for new ischemic recurrences using clinical, ECG, and biochemical parameters 6 hours after the onset of pain.

Noninvasive identification of epicardial ventricular tachycardia substrate by magnetic resonance-based signal intensity mapping.

BACKGROUND: Endo-epicardial substrate ablation reduces ventricular tachycardia (VT) recurrences; however, not all patients in whom the epicardium is explored have a VT substrate. Contrast-enhanced magnetic resonance imaging (ceMRI) is used to characterize VT substrate after myocardial infarction. OBJECTIVE: The purpose of this study was to determine if epicardial VT substrate can be identified noninvasively by ceMRI-based endo-epicardial signal intensity (SI) mapping. METHODS: Myocardial infarction was induced in 31 pigs. Four or 16 weeks later, ceMRI was obtained, and the averaged subendocardial and subepicardial SIs were projected onto 3-dimensional endocardial and epicardial shells in which dense scar, heterogeneous tissue (HT), and normal tissue were differentiated. An HT channel was defined as a corridor of HT surrounded by dense scar and connected to normal tissue. A "patchy" scar pattern was defined as the presence of at least 3 dense scar islets surrounded by HT forming ≥2 HT channels. Electrophysiologic study was performed after ceMRI. RESULTS: Thirty-three different sustained monomorphic VTs (291 ± 49 ms) were induced in 25 pigs. Mid-diastolic electrograms were recorded in the endocardium (endocardial VT) in 17 and in the epicardium (epicardial VT) in 13. Epicardial SI mapping showed that scar area was similar in animals with and without epicardial VT (24 ± 6 cm2 vs. 25 ± 12 cm2), but HT covered a higher surface of the epicardial scar in animals with VT (76 ± 6% vs. 61 ± 10%, P = .03). A patchy scar pattern was observed in all animals with epicardial VT but only in 3 animals without VT (P < .001). CONCLUSION: CeMRI-based SI mapping allows identification of the epicardial VT substrate.

A prospective randomised study of the paclitaxel-coated balloon catheter in bifurcated coronary lesions (BABILON trial): 24-month clinical and angiographic results.

AIMS: Paclitaxel drug-eluting balloons (pDEB) could be an attractive option to minimise side branch (SB) restenosis in bifurcated coronary lesions. We compared angiographic and clinical outcomes with pDEB plus bare metal stent (BMS) versus drug-eluting stents (DES) in de novo bifurcated lesions. METHODS AND RESULTS: This multicentre randomised trial included 108 patients. Sequential main branch (MB)/SB dilatation with pDEB, with provisional T-stenting with BMS in the MB was performed in the pDEB group, and with everolimus DES in the DES group. The primary endpoint was late lumen loss (LLL) at nine months. The secondary endpoint was the incidence of major adverse cardiac events (MACE: death, myocardial infarction, or target lesion revascularisation). In-segment MB LLL was 0.31±0.48 mm in the pDEB group, and 0.16±0.38 mm in the DES group (p=0.15); mean difference was 0.15 mm (upper limit one-sided 95% CI: 0.27 mm; p=0.001; non-inferiority test). LLL in SB was -0.04±0.76 mm in the pDEB group and -0.03±0.51 mm in the DES group (p=0.983). MACE and TLR were higher in the pDEB group (17.3% vs. 7.1%; p=0.105, and 15.4% vs. 3.6%; p=0.045), due to higher MB restenosis (13.5% vs. 1.8%; p=0.027). CONCLUSIONS: pDEB bifurcation pretreatment with BMS implantation in MB showed greater LLL (ns) and increased incidence of MACE compared to everolimus DES. Both strategies showed similar results in the SB.

Right versus left radial artery access for coronary procedures: an international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients.

BACKGROUND: Radial artery access is a mainstay in the diagnosis and treatment of coronary artery disease. However, there is uncertainty on the comparison of right versus left radial access for coronary procedures. We thus undertook a systematic review and meta-analysis comparing right versus left radial access for coronary diagnostic and interventional procedures. METHODS: Pertinent studies were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus, together with international conference proceedings. Randomized trials comparing right versus left radial (or ulnar) access for coronary diagnostic or interventional procedures were included. Risk ratios (RR) and weighted mean differences (WMD) were computed to generate point estimates (95% confidence intervals). RESULTS: A total of 5 trials (3210 patients) were included. No overall significant differences were found comparing right versus left radial access in terms of procedural time (WMD=0.99 [-0.53; 2.51]min, p=0.20), contrast use (WMD=1.71 [-1.32; 4.74]mL, p=0.27), fluoroscopy time (WMD=-35.79 [-3.54; 75.12]s, p=0.07) or any major complication (RR=2.00 [0.75; 5.31], p=0.49). However, right radial access was fraught with a significantly higher risk of failure leading to cross-over to femoral access (RR=1.65 [1.18; 2.30], p=0.003) in comparison to left radial access. CONCLUSIONS: Right and left radial accesses appear largely similar in their overall procedural and clinical performance during transradial diagnostic or interventional procedures. Nonetheless, left radial access can be recommended especially during the learning curve phase to reduce femoral cross-overs.