Artificial intelligence in detecting left atrial appendage thrombus by transthoracic echocardiography and clinical features: the Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry.

AIMS: Transoesophageal echocardiography (TOE) is often performed before catheter ablation or cardioversion to rule out the presence of left atrial appendage thrombus (LAT) in patients on chronic oral anticoagulation (OAC), despite associated discomfort. A machine learning model [LAT-artificial intelligence (AI)] was developed to predict the presence of LAT based on clinical and transthoracic echocardiography (TTE) features. METHODS AND RESULTS: Data from a 13-site prospective registry of patients who underwent TOE before cardioversion or catheter ablation were used. LAT-AI was trained to predict LAT using data from 12 sites (n = 2827) and tested externally in patients on chronic OAC from two sites (n = 1284). Areas under the receiver operating characteristic curve (AUC) of LAT-AI were compared with that of left ventricular ejection fraction (LVEF) and CHA2DS2-VASc score. A decision threshold allowing for a 99% negative predictive value was defined in the development cohort. A protocol where TOE in patients on chronic OAC is performed depending on the LAT-AI score was validated in the external cohort. In the external testing cohort, LAT was found in 5.5% of patients. LAT-AI achieved an AUC of 0.85 [95% confidence interval (CI): 0.82-0.89], outperforming LVEF (0.81, 95% CI 0.76-0.86, P < .0001) and CHA2DS2-VASc score (0.69, 95% CI: 0.63-0.7, P < .0001) in the entire external cohort. Based on the proposed protocol, 40% of patients on chronic OAC from the external cohort would safely avoid TOE. CONCLUSION: LAT-AI allows accurate prediction of LAT. A LAT-AI-based protocol could be used to guide the decision to perform TOE despite chronic OAC.

Noninvasive Atherosclerotic Phenotyping: The Next Frontier into Understanding the Pathobiology of Coronary Artery Disease.

PURPOSE OF REVIEW: Despite recent advances, coronary artery disease remains one of the leading causes of mortality worldwide. Noninvasive imaging allows atherosclerotic phenotyping by measurement of plaque burden, morphology, activity and inflammation, which has the potential to refine patient risk stratification and guide personalized therapy. This review describes the current and emerging roles of advanced noninvasive cardiovascular imaging methods for the assessment of coronary artery disease. RECENT FINDINGS: Cardiac computed tomography enables comprehensive, noninvasive imaging of the coronary vasculature, and is used to assess luminal stenoses, coronary calcifications, and distinct adverse plaque characteristics, helping to identify patients prone to future events. Novel software tools, implementing artificial intelligence solutions, can automatically quantify and characterize atherosclerotic plaque from standard computed tomography datasets. These quantitative imaging biomarkers have been shown to improve patient risk stratification beyond clinical risk scores and current clinical interpretation of cardiac computed tomography. In addition, noninvasive molecular imaging in higher risk patients can be used to assess plaque activity and plaque thrombosis. Noninvasive imaging allows unique insight into the burden, morphology and activity of atherosclerotic coronary plaques. Such phenotyping of atherosclerosis can potentially improve individual patient risk prediction, and in the near future has the potential for clinical implementation.

Infarct-related artery and long-term mortality following recurrent ST-segment elevation myocardial infarction. Insights from a Polish nationwide registry.

BACKGROUND: Recurrent ST-segment elevation myocardial infarction (rSTEMI) can be attributed to the same (target-vessel, TV-rSTEMI) or different culprit vessel (non-target, nonTV-rSTEMI) compared with the first infarction. We hypothesized that long-term mortality after rSTEMI depends on the infarct-related artery (the same or different compared with the first STEMI). METHODS: Using the Polish Registry of Acute Coronary Syndromes (PL-ACS) we retrospectively identified survivors of first STEMI treated with PCI who experienced rSTEMI. We divided rSTEMI into TV-rSTEMI and nonTV-rSTEMI. We compared clinical, angiographic, and procedural characteristics and utilized propensity score matching to adjust for baseline differences. Primary outcome was 1-, 3- and 5-year all-cause mortality. RESULTS: Between 2003 and 2019 a total of 3,411 patients (mean age 63.7 years, 76% male) had rSTEMI, of whom 1,916 (56%) had TV-rSTEMI and 1,495 (44%) had nonTV-rSTEMI. Median time since first infarction was 716 days (100, 1,807). Patients with nonTV-rSTEMI had higher body mass index (27.2 vs 26.7 kg/m2, P = .041), more arterial hypertension (77.4 vs 73.7%, P = .015) and atrial fibrillation (4.8 vs 3.3%, P = .02), and lower left ventricular ejection fraction (43 [35, 50] vs 45 [38, 50]%, P <.001) compared with TV-rSTEMI. On coronary angiography nonTV-rSTEMI more frequently presented with Thrombolysis In Myocardial Infarction >1 flow (25.8 vs 15.7%, P < .001), multivessel disease (51.9 vs 40.8%, P =.002), culprit lesion located in circumflex artery (22.6 vs 5.6%, P < .001), and more frequently underwent stenting (88.8 vs 76.1%, P < .001) compared with TV-rSTEMI. There was no difference in unadjusted 1-, 3- and 5-year mortality between nonTV-rSTEMI and TV-rSTEMI. After propensity score analysis, 807 well-matched pairs of patients were selected. Adjusted 1-, 3- and 5-year mortality remained similar between nonTV-rSTEMI and TV-rSTEMI (14.7 vs 14.4%, P = .88; 23.6 vs 23.1%, P = .81; 30.0 vs 32.0%, P = .50 respectively). CONCLUSIONS: Our study shows overall low frequency of rSTEMI. Patients with nonTV-rSTEMI have different clinical and angiographic characteristics compared with TV-rSTEMI. No long-term mortality difference was observed between both groups.

Left coronary artery calcification patterns after coronary bypass graft surgery: An in-vivo optical coherence tomography study.

OBJECTIVES: We sought to evaluate the severity and patterns of calcifications in the left main coronary artery (LMCA) and proximal segments of left anterior descending coronary artery (LAD) and left circumflex artery (LCX) using optical coherence tomography (OCT) in patients with and without prior coronary artery bypass grafting (CABG). BACKGROUND: CABG may accelerate upstream calcium development. METHODS: OCT images (n = 76) of the LMCA bifurcation from either the LAD or LCX in 76 patients with at least one patent left coronary graft, on average 7.0 ± 5.6 years post-CABG, were compared with 148 OCT images in propensity-score-matched non-CABG controls. RESULTS: Minimum lumen areas in the LMCA, LAD, and LCX in post-CABG patients were smaller than non-CABG controls. Maximum calcium arc and thickness as well as calcium length were greater in the LMCA and LCX, but not in the LAD in post-CABG patients versus non-CABG controls. Calcium located at the carina of a bifurcation, calcified nodules (CN), thin intimal calcium, and lobulated calcium were more prevalent in post-CABG patients. After adjusting for multiple covariates, prior CABG was an independent predictor of calcification at the carina of a bifurcation (odds ratio [OR] 5.77 [95% confidence interval, CI: 1.5-21.6]), thin intimal calcium (4.7 [1.5-14.4]), and the presence of a CN (15.60 [3.2-76.2]). CONCLUSIONS: Prior CABG is associated with greater amount of calcium in the LMCA and the proximal LCX, as well as higher prevalence of atypical calcium patterns, including CN, thin or lobulated calcium, and calcifications located at the carina of a bifurcation, compared with non-CABG controls.

Impact of the Balloon Inflation Time and Pattern on the Coronary Stent Expansion.

OBJECTIVES: To assess the expansion pattern of coronary stents by using different balloon inflation times and pressures. BACKGROUND: The selection of coronary stent size and its proper deployment is crucial in coronary artery interventions, having an impact on the success of the procedure and further therapy. METHODS: Ten pairs of different stents were deployed under nominal pressure using sequential (5, 5, 10, and 10 seconds of repeated inflations, thus 30 seconds of summarized time) and continuous (30 seconds) deployment pattern. After each given time-point, intraluminal stent measurements were performed by optical coherence tomography (OCT) and intravascular ultrasound (IVUS). RESULTS: Both in-stent diameters and cross-section areas (CSA) of paired stents measured by OCT at all sequential time-points were significantly smaller compared to given manufacturers charts' values (90% to 94% for diameters and 81% to 88% for CSA, p<0.05). Significant increase of in-stent diameter and CSA was observed across the step-by-step deployment pattern. In-stent lumen measurements were significantly larger when sequential deployment pattern was applied compared to continuous deployment. Additional measurements were also done for overlapping segments of stents, showing smaller in-stent measurements of the latter compared to nonoverlapping segments. Validation of OCT and IVUS measurements using a phantom metallic tube showed perfect reproducibility with OCT and overestimation with IVUS (8% for diameters and 16% for CSA). CONCLUSIONS: Stent diameter after deployment is time-dependent and not only pressure-dependent. Different stent expansion behavior, depending on the applied deployment pattern (sequential and nonsequential), was observed.

Analysis of complications in transfemoral transcatheter aortic valve implantation: a single-center study.

INTRODUCTION: Transfemoral access is a prevailing approach for transcatheter aortic valve implantation (TAVI) in contemporary practice, with a shift from surgical arteriotomy to a percutaneous arterial approach. OBJECTIVES: This study assessed long- and short­term mortality, along with Valve Academic Research Consortium-2-defined complications in percutaneous transfemoral approach (PTA) TAVI. Furthermore, it explored the impact of a learning curve on procedural outcomes. PATIENTS AND METHODS: The study included 600 patients undergoing PTA TAVI at the National Institute of Cardiology, Warsaw, Poland, from January 2009 to September 2020. Retrospective data comparison involved 2 groups: early experience (first 200 patients) and late experience (next 400 patients). RESULTS: The primary end point (composite of life­threatening bleeding, major vascular complication, or death at 30 days) occurred less often in the late experience group (28% vs 17.5%; P = 0.003). The late experience group also showed fewer cases of vascular complications (19% vs 10.7%; P = 0.005) and major bleeding (17.5% vs 8.5%; P = 0.001). Propensity matching yielded similar trends, including reduced frequency of pacemaker implantation (22.8% vs 10.9%; P = 0.03) and shorter median (interquartile range) hospitalization (11 [8-18] vs 7 [6-12] days; P <0.001) in the late experience group. CONCLUSIONS: The late experience group rated with PTA TAVI exhibited significantly reduced periprocedural complications, indicating a positive impact of accumulated expertise.

Advances in the Assessment of Coronary Artery Disease Activity with PET/CT and CTA.

Non-invasive testing plays a pivotal role in the diagnosis, assessment of progression, response to therapy, and risk stratification of coronary artery disease. Although anatomical plaque imaging by computed tomography angiography (CTA) and ischemia detection with myocardial perfusion imaging studies are current standards of care, there is a growing body of evidence that imaging of the processes which drive atherosclerotic plaque progression and rupture has the potential to further enhance risk stratification. In particular, non-invasive imaging of coronary plaque inflammation and active calcification has shown promise in this regard. Positron emission tomography (PET) with newly-adopted radiotracers provides unique insights into atheroma activity acting as a powerful independent predictor of myocardial infarctions. Similarly, by providing a quantitative measure of coronary inflammation, the pericoronary adipose tissue density (PCAT) derived from standard coronary CTA enhances cardiac risk prediction and allows re-stratification over and above current state-of-the-art assessments. In this review, we shall discuss the recent advances in the non-invasive methods of assessment of disease activity by PET and CTA, highlighting how these methods could improve risk stratification and ultimately benefit patients with coronary artery disease.

Computed Tomography Angiography-Derived Scores for Prediction of Chronic Total Occlusion Percutaneous Coronary Intervention Using the Hybrid Algorithm.

Whereas coronary computed tomography angiography (CCTA) exceeds invasive angiography for predicting the procedural outcome of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), CCTA-derived scores have never been validated in the hybrid CTO PCI population. In this single-center, retrospective, observational study, we included 108 consecutive patients with 110 CTO lesions and preprocedural CCTA who underwent hybrid CTO PCI to assess the diagnostic accuracy of CCTA-derived scoring systems. Successful guidewire crossing within 30 min was set as the primary endpoint. The secondary endpoints were final procedural success and the need for using any non-antegrade wiring (AW) strategy within the hybrid algorithm. Time-efficient guidewire crossing and final procedural success were achieved in 53.6% and 89.1% of lesions, respectively, while in 36.4% of the procedures, any non-AW strategy was applied. The median J-CTO score was 1 (interquartile range (IQR): 0, 2), while the CT-RECTOR, KCCT, J-CTOCCTA, and RECHARGECCTA scores were 2 (IQR: 1, 3), 3 (IQR: 2, 5), 1 (IQR: 0, 3), and 2 (IQR: 1, 3), respectively. All scores were significantly higher in the lesions with failed versus successful time-efficient guidewire crossing. Although all of the CCTA-derived scores had numerically higher predictive values than the angiographic J-CTO score, no significant differences were noted between the scores in any of the analyzed study endpoints. High sensitivity of the CT-RECTOR and RECHARGECCTA scores (both 89.8%) for predicting successful guidewire crossing within 30 min, and high sensitivity (90.8%) of the KCCT score for predicting final procedural success, were noted. CCTA-derived scoring systems are accurate, noninvasive tools for the prediction of the procedural outcome of hybrid CTO PCI, and may aid in identifying the need for use of the hybrid algorithm.

Pericoronary adipose tissue density is increased in patients with recent spontaneous coronary dissection.

OBJECTIVE: Inflammatory activity is one of the potential mechanisms of spontaneous coronary artery dissection (SCAD). Recently, the pericoronary adipose tissue attenuation (PCAT) derived from CT angiography (CTA) has been established as a method for measuring vascular inflammation. We aimed to characterise the pancoronary and vessel-specific PCAT in patients with and without recent SCAD. METHODS: The study comprised patients with SCAD referred to a tertiary centre between 2017 and 2022 who underwent CTA and were compared with individuals with no prior SCAD. PCAT was analysed on end-diastolic CTA reconstructions along proximal 40 mm of all major coronary vessels as well as the SCAD-related vessel. We analysed 48 patients with recent SCAD (median 6.1 (IQR 3.5-14.9) months since SCAD, 95.8% female) and 48 patients in the group without SCAD. RESULTS: Pancoronary PCAT was higher in patients with SCAD compared with those without SCAD (-80.6±7.9 vs -85.3 HU±6.1, p=0.002). Vessel-specific PCAT in patients with SCAD compared with patients without SCAD was higher for both the RCA (-80.9±9.5 vs -87.1±6.9 HU, p=0.001) and the LCA (-80.3±7.8 vs -83.4±7.2 HU, p=0.04). In patients with SCAD, PCAT of the SCAD-related vessel was not significantly different from averaged PCAT of unaffected vessels (-81.2±9.2 vs -80.6±7.6, p=0.74). There was no association between PCAT and the interval from SCAD to CTA. CONCLUSIONS: Patients with recent SCAD have higher PCAT compared with patients without SCAD, suggesting an increased perivascular inflammatory activity. This association is not restricted to the dissected vessel.

Computed tomographic characteristics of congenital coronary artery fistulas in an adult population.

BACKGROUND: Coronary artery fistulas (CAFs) are usually congenital coronary artery anomalies of termination. AIMS: This study aimed to assess the prevalence, anatomic characteristics, and clinical significance of CAFs detected by computed tomography (CT) in an adult population. METHODS: We performed 45 817 CT examinations in 39 066 subjects between 2008 and 2020. The electronic database was manually checked using specific keywords to identify patients with CAFs. The CT characteristics of CAFs were evaluated. CAF was defined as clinically significant if it was the most plausible cause of myocardial infarction, infective endocarditis, heart failure, death during follow-up, hospitalization, or if it required either percutaneous or surgical intervention. RESULTS: Of 39 066 patients, 56 CAFs were detected in 42 subjects (20 men, 47.6%) with a prevalence of 0.11%. Most CAFs originated from the right coronary artery (RCA) (48.2%) and drained into the pulmonary artery (PA) (58.9%). CAFs terminating in the PA were more frequently multiple (P <0.001) and tortuous (P <0.001) as compared to CAFs without PA drainage. Clinically significant CAFs, identified in 7 of 42 patients, were more common in younger (P = 0.03) and male (P = 0.04) subjects and had larger lumen area and diameter at the site of origin (P = 0.03, P = 0.03, respectively). CONCLUSIONS: In the unselected adult population undergoing coronary CT angiography, the RCA and the PA are the most common sites of origin and termination of CAFs, respectively. CAFs draining into the PA are more often multiple and tortuous. Clinically meaningful CAFs are larger and most frequently detected in younger and male patients.

Prognostic value of computed tomography derived measurements of pulmonary artery diameter for long-term outcomes after transcatheter aortic valve replacement.

BACKGROUND: An increase in pulmonary artery diameter (PAD) on multi-detector computed tomography (MDCT) may indicate pulmonary hypertension. We assessed the prognostic value of MDCT-derived measurements of PAD on outcomes after successful transcatheter aortic valve replacement (TAVR). METHODS: Consecutive patients treated with TAVR from February 2013 to October 2017, with a 68.8% rate of new generation valves, underwent pre-interventional MDCT with measurements of PAD (in the widest short-axis within 3 cm of the bifurcation) and ascending aortic diameter (AoD; at the level of the PAD). The PAD/AoD ratio was calculated. Patients with high-density lipoprotein cholesterol levels ≤46 mg/dl and C-reactive protein levels ≥0.20 mg/dl at baseline were identified as the frail group. One-year mortality was established for all subjects. RESULTS: Among studied 266 patients (median age, 82.0 years; 63.5% women) those who died at 1 year (n = 34; 12.8%) had larger PAD and PAD/AoD (28.9 [5.0] vs. 26.5 [4.6] mm and 0.81 [0.13] vs. 0.76 [0.13] mm vs. the rest of the studied subjects; P = 0.005 and P = 0.02, respectively) but similar AoD. The cutoff value for the PAD to predict 1-year mortality was 29.3 mm (sensitivity, 50%; specificity, 77%; area under the curve, 0.65). Patients with PAD >29.3 mm (n = 72; 27%) had higher 1-year mortality (23.6% vs. 8.8%, log-rank P = 0.001). Baseline characteristics associated with PAD29.3 mm were a bigger body mass index, more frequent diabetes mellitus, more prior stroke/transient ischemic attacks and atrial fibrillation, and lower baseline maximal aortic valve gradient with higher pulmonary artery systolic pressure (PASP). PAD >29.3 mm and frailty, but not baseline PASP, remained predictive of 1-year mortality in the multivariable model (hazard ratio [HR], 2.221; 95%CI, 1.038-4.753; P = 0.04 and HR, 2.801; 95% CI, 1.328-5.910; P = 0.007, respectively). CONCLUSION: PAD >29.3 mm on baseline MDCT is associated with higher 1-year mortality after TAVR, independently of echocardiographic measures of PH and frailty.

Association between the acquisition of antibodies against Lyme disease and the risk of atrial arrhythmias.

INTRODUCTION: The impact of antibodies against Borrelia burgdorferi (BB) on the occurrence of cardiac arrhythmias in patients without typical symptoms of Lyme disease (LD) is largely unknown. OBJECTIVES: We aimed to assess the risk of atrial fibrillation (AF) and other atrial arrhythmias (AAs) in patients who tested positive for anti-LD antibodies. PATIENTS AND METHODS: We included consecutive patients referred for the diagnosis and treatment of AAs who had no history of erythema migrans or other symptoms of LD. The presence of anti-BB antibodies (immunoglobulin [Ig] M and IgG) was assessed in each patient, and the diagnostic workup of cardiac arrhythmias was performed. RESULTS: Of the 527 patients enrolled in the study, 292 (55%) were diagnosed with AAs, and we detected BB antibodies in 131 individuals (24.8%). The patients with a serological history of Borrelia infection were older (mean [SD], 55.6 [15.7] vs 50.3 [18.6] years; P = 0.01), had a higher probability of developing AF or other supraventricular arrhythmias (SAs) (66.4% vs 51.8%; P = 0.03), and had elevated levels of N­terminal pro-B ­type natriuretic peptide (NT­proBNP) (58% vs 47.5%; P = 0.04). We also found an as-sociation between the occurrence of AF and other SAs in patients with anti-BB antibodies and elevated NT­proBNP values, and the risk of AAs in these patients increased almost 3­fold (P = 0.01). CONCLUSION: Our data indicated an association between the exposure to Borrelia infection and the risk for AF and other AAs in the patients with elevated levels of NT­proBNP, suggesting the need for a more efficacious diagnostic approach to patients with SAs, especially in LD­endemic regions.

Long-term outcomes following drug-eluting balloons vs. thin-strut drug-eluting stents for treatment of recurrent restenosis in drug-eluting stents.

BACKGROUND: There is limited data on the optimal revascularization strategy in patients with recurrent in-stent restenosis (R-ISR). AIMS: To compare the long-term outcomes of patients treated with either a thin-strut drug-eluting stent (thin-DES) or a drug-eluting balloon (DEB) for R-ISR in a drug-eluting stent (DES). METHODS: A multicenter DEB-DRAGON registry was used to retrospectively identify patients with R-ISR who received either a thin-DES or a DEB. Propensity score matching was applied to adjust for baseline differences. The primary outcome was target lesion revascularization (TLR). RESULTS: Out of 311 patients (mean age, 67 years; 63% male) with R-ISR, 86 (27.7%) were treated with a thin-DES and 225 (72.3%) with a DEB. Median follow-up was 2.6 years. TLR occurred in 18 (20.9%) patients who received thin-DES and 61 (27.1%) patients treated with DEB (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.33-0.98; log-rank P = 0.04). The difference remained significant in a propensity score-matched cohort of 57 patients treated with thin-DES and 57 patients treated with a DEB (17.5 vs. 33.3%, respectively; HR, 0.38; 95% CI, 0.17-0.86; P = 0.01). The risks of device-oriented adverse cardiac events and all-cause mortality were similar after thin-DES or DEB in both unadjusted and propensity score-matched cohorts. In a multivariable Cox proportional hazard model, the treatment with a thin-DES was an independent predictor of a TLR-free survival (HR, 0.33; 95% CI 0.13-0.84; P = 0.02). CONCLUSIONS: In patients with R-ISR implantation of a thin-DES is associated with a lower risk of repeated revascularization compared with angioplasty with a DEB.

Intravascular Lithotripsy for the Treatment of Stent Underexpansion: The Multicenter IVL-DRAGON Registry.

Background: Whereas the efficacy and safety of intravascular lithotripsy (IVL) have been confirmed in de novo calcified coronary lesions, little is known about its utility in treating stent underexpansion. This study aimed to investigate the impact of IVL in treating stent underexpansion. Methods and Results: Consecutive patients with stent underexpansion treated with IVL entered the multicenter IVL-Dragon Registry. The procedural success (primary efficacy endpoint) was defined as a relative stent expansion >80%. Thirty days device-oriented composite endpoint (DOCE) (defined as a composite of cardiac death, target lesion revascularization, or target vessel myocardial infarction) was the secondary endpoint. A total of 62 patients were enrolled. The primary efficacy endpoint was achieved in 72.6% of patients. Both stent underexpansion 58.5% (47.5−69.7) vs. 11.4% (5.8−20.7), p < 0.001, and the stenotic area 82.6% (72.4−90.8) vs. 21.5% (11.1−37.2), p < 0.001, measured by quantitative coronary angiography improved significantly after IVL. Intravascular imaging confirmed increased stent expansion following IVL from 37.5% (16.0−66.0) to 86.0% (69.2−90.7), p < 0.001, by optical coherence tomography and from 57.0% (31.5−77.2) to 89.0% (85.0−92.0), p = 0.002, by intravascular ultrasound. Secondary endpoint occurred in one (1.6%) patient caused by cardiac death. There was no target lesion revascularization or target vessel myocardial infarction during the 30-day follow-up. Conclusions: In this real-life, largest-to-date analysis of IVL use to manage underexpanded stent, IVL proved to be an effective and safe method for facilitating stent expansion and increasing luminal gain.

Long-term outcomes following drug-eluting balloon or thin-strut drug-eluting stents for treatment of in-stent restenosis stratified by duration of dual antiplatelet therapy (DEB-Dragon Registry).

Introduction: Data regarding the duration of dual antiplatelet therapy (DAPT) in patients with drug-eluting stent restenosis (DES-ISR) treated with percutaneous coronary intervention (PCI) and drug-eluting balloons (DEB) or DES are not unambiguous. Aim: To evaluate the relationship between long-term outcomes and the length of DAPT in patients treated with PCI due to DES-ISR with DEB or DES. Material and methods: Overall, a total of 1,367 consecutive patients with DES-ISR, who underwent PCI with DEB or DES between 2008 and 2019 entered the study. The mean length of the follow-up was 1,298.7 ±794 days. We assessed study endpoints according to the duration of DAPT (≤ 3 vs. > 3 and ≤ 6 vs. > 6 months) before and after propensity score matching (PSM): stroke, target lesion revascularisation (TLR), target vessel revascularisation (TVR), myocardial infarction (MI), death and device oriented composite endpoints (DOCE). Kaplan-Meier estimates were created to differentiate long-term outcomes. Results: Pairwise contrast analysis considering type of PCI (DES vs. DEB) and duration of DAPT (≤ 6 vs. > 6 months) before PSM revealed superiority of DES + DAPT > 6 months vs. DEB + DAPT > 6 months for DOCE (p < 0.001), TVR (p = 0.02) and TLR (p = 0.01). Also, DES + DAPT ≤ 6 months was found to be superior compared to DEB + DAPT ≤ 6 months for DOCE (p < 0.001), TVR (p = 0.02) and TLR (p = 0.01). Kaplan-Meier estimate analysis confirmed that DAPT > 6 months is related to a higher stroke rate (p = 0.01) when compared to ≤ 6 months. Conclusions: Treatment with DAPT in patients with DES-ISR is related to better long-term outcomes in the case of PCI with DES than DEB. DAPT > 6 months is related to the greater rate of strokes, independently of the type of treatment (DES and DEB) than DAPT ≤ 6 months.

Prevention of Iodinated Contrast Media-Induced Hyperthyroidism in Patients with Euthyroid Goiter.

INTRODUCTION: Iodinated contrast media (ICM)-induced hyperthyroidism is an underestimated, potentially severe condition; however, its prevention has not been sufficiently investigated. The aim of this study was to evaluate the influence of ICM on thyroid status, the advantages of prophylactic therapy for iodine-induced hyperthyroidism (IIH) in patients with euthyroid goiter and cardiovascular comorbidities, and the association between the incidence of IIH and thyroid volume. METHODS: Thirty-six euthyroid patients undergoing procedures involving ICM administration were divided into 2 groups: the first group (n = 13) received prophylactic treatment with thiamazole or thiamazole combined with sodium perchlorate during ICM exposure; the second group (n = 23) did not receive prophylaxis. Thyroid-stimulating hormone levels were evaluated before and after ICM, and thyroid hormone levels were assessed after ICM at different points in time. The morphology of the thyroid was evaluated by ultrasonography. RESULTS: Twenty-one patients (58%) developed hyperthyroidism after ICM. Hyperthyroidism was observed more frequently in the group without prophylactic treatment than in the group with prophylaxis (65 vs. 15%, respectively; p = 0.006). No cases of overt hyperthyroidism were observed in the group receiving thiamazole with sodium perchlorate. IIH persisted for a median time of 52.5 days. Larger thyroid volume was associated with a significantly higher occurrence of ICM-induced hyperthyroidism (p = 0.04). CONCLUSIONS: Patients with euthyroid goiter receiving ICM are at risk of developing hyperthyroidism. The occurrence of hyperthyroidism after ICM in euthyroid patients with goiter is higher in those with larger thyroid volume. The frequency of ICM-induced hyperthyroidism in euthyroid patients with goiter is lower in those receiving prophylactic therapy with thiamazole in monotherapy or in combination with sodium perchlorate than in those not receiving prophylactic treatment.

Mechanisms, Prevention and Treatment of Saphenous Vein Graft Disease.

Saphenous vein grafts are imperfect yet indispensable conduits commonly used for coronary artery bypass grafting. Their degeneration ultimately leading to occlusion results from the pathological response of the vein to altered blood rheology and several types of vascular injury. Surgical techniques minimizing vessel damage, and prolonged antiplatelet and lipid-lowering treatment are established methods of mitigating the degeneration process hence preventing graft occlusions. Percutaneous interventions in degenerated vein grafts carry high risk of embolization, periprocedural myocardial infarction and restenosis. Thus, native vessel should be the preferred treatment target in case of graft failure whenever technically feasible.

Visually Estimated RESOLVE Score Based on Coronary Computed Tomography to Predict Side Branch Occlusion in Percutaneous Bifurcation Intervention.

PURPOSE: The quantitative RESOLVE (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion) score derived from coronary computed tomography angiography (coronary CTA) was developed as a noninvasive and accurate prediction tool for side branch (SB) occlusion in coronary bifurcation intervention. We aimed to determine the ability of a visually estimated CTA-derived RESOLVE score (V-RESOLVE score) to predict SB occlusion in coronary bifurcation intervention. MATERIALS AND METHODS: The present study included 363 patients with 400 bifurcation lesions. CTA-derived V-RESOLVE score was derived and compared with the quantitative CTA-derived RESOLVE score. The scoring systems were divided into quartiles, and classified as the high-risk and non-high-risk groups. SB occlusion was defined as any decrease in thrombolysis in myocardial infarction flow grade after main vessel stenting. RESULTS: In total, 28 SB occlusions (7%) occurred. The concordance between visual and quantitative CTA analysis showed poor to excellent agreement (weighted κ range: 0.099 to 0.867). The area under the receiver operating curve for the prediction of SB occlusion was significantly higher for the CTA-derived V-RESOLVE score than for quantitative CTA-derived RESOLVE score (0.792 vs. 0.709, P=0.049). The total net reclassification index was 42.7% (P=0.006), and CTA-derived V-RESOLVE score showed similar capability to discriminate between high-risk group (18.6% vs. 13.8%, P=0.384) and non-high-risk group (3.8% vs. 4.9%, P=0.510) as compared with quantitative CTA-derived RESOLVE score. CONCLUSIONS: Visually estimated CTA-derived V-RESOLVE score is an accurate and easy-to-use prediction tool for the stratification of SB occlusion in coronary bifurcation intervention.

Noncalcified plaque burden quantified from coronary computed tomography angiography improves prediction of side branch occlusion after main vessel stenting in bifurcation lesions: results from the CT-PRECISION registry.

OBJECTIVES: To assess the incremental value of quantitative plaque features measured from computed tomography angiography (CTA) for predicting side branch (SB) occlusion in coronary bifurcation intervention. METHODS: We included 340 patients with 377 bifurcation lesions in the post hoc analysis of the CT-PRECISION registry. Each bifurcation was divided into three segments: the proximal main vessel (MV), the distal MV, and the SB. Segments with evidence of coronary plaque were analyzed using semi-automated software allowing for quantitative analysis of coronary plaque morphology and stenosis. Coronary plaque measurements included calcified and noncalcified plaque volumes, and corresponding burdens (respective plaque volumes × 100%/vessel volume), remodeling index, and stenosis. RESULTS: SB occlusion occurred in 28 of 377 bifurcation lesions (7.5%). The presence of visually identified plaque in the SB segment, but not in the proximal and distal MV segments, was the only qualitative parameter that predicted SB occlusion with an area under the curve (AUC) of 0.792. Among quantitative plaque parameters calculated for the SB segment, the addition of noncalcified plaque burden (AUC 0.840, p = 0.003) and low-density plaque burden (AUC 0.836, p = 0.012) yielded significant improvements in predicting SB occlusion. Using receiver operating characteristic curve analysis, optimal cut-offs for noncalcified plaque burden and low-density plaque burden were > 33.6% (86% sensitivity and 78% specificity) and > 0.9% (89% sensitivity and 73% specificity), respectively. CONCLUSIONS: CTA-derived noncalcified plaque burden, when added to the visually identified SB plaque, significantly improves the prediction of SB occlusion in coronary bifurcation intervention. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03709836 registered on October 17, 2018.

Long-Term Outcomes Following Drug-Eluting Balloons Versus Thin-Strut Drug-Eluting Stents for Treatment of In-Stent Restenosis (DEB-Dragon-Registry).

[Figure: see text].