Relationship between sexual differences and cardiovascular risk factors in the prevalence of asymptomatic coronary disease.

BACKGROUND: This study investigated the sexual differences of coronary artery disease (CAD) prevalence and its association with cardiovascular risk factors in the asymptomatic population. METHODS: In total 6434 asymptomatic participants without known CAD (1740 women and 4694 men) underwent coronary computed tomography angiography (CCTA). The prevalence of significant CAD (diameter stenosis ≥50%) and other CCTA findings were compared by sex, and its influence on CAD was investigated in groups stratified by the number of cardiovascular risk factors, including age (>55 years), hypertension, diabetes, dyslipidemia, and current smoking. RESULTS: The prevalence of current smokers, hypertension, and diabetes were higher in men than women. The mean coronary artery calcium score was 13.1 ± 58.4 for women and 51.1 ± 158.2 for men; the coronary atherosclerosis burden indices were significantly higher in men than women. Significant CAD was identified in 65 women (3.7%) and 429 men (9.1%), showing a significant association (adjusted odds ratio [OR] 2.38, P < 0.001). The relatively higher risk for significant CAD in men was observed in patients with fewer risk factors, and the risk difference was not significant in patients with many risk factors (adjusted ORs: 7.69, 3.37, 1.71, 1.31, and 0.88 in patients with 0, 1, 2, 3, and 4-5 risk factors, respectively). The association between sex and risk factor groups was significant (P < 0.001). CONCLUSIONS: In the asymptomatic population, a significantly higher CAD prevalence was noted in men than women. However, women with a high number of cardiovascular risk factors showed a CAD prevalence similar to that of men.

Prognostic Impact of Left Atrial Strain After Mitral Valve Repair Surgery in Patients With Severe Mitral Regurgitation.

BACKGROUND AND OBJECTIVES: The prognostic value of left atrial (LA) function in terms of long-term clinical outcomes after mitral regurgitation (MR) surgery remains unclear. Therefore, we investigated the impact of preoperative LA global longitudinal strain (LAGLS) on the long-term postoperative clinical outcomes in chronic severe MR patients who underwent mitral valve (MV) repair surgery. METHODS: From January 2012 to December 2017, we analyzed 338 patients (mean age, 51.9±12.5 years; 218 males [64.5%]) treated with MV repair surgery for severe MR. The primary outcome was cardiovascular events, defined as the composite of all-cause death, newly developed atrial fibrillation (AF), and re-hospitalization for cardiovascular causes. RESULTS: During a median follow-up of 45 months (interquartile range, 26-65), 30 (8.9%) cardiovascular events, 5 (1.5%) all-cause death, 8 (2.4%) newly developed AF, and 26 (7.7%) re-hospitalizations occurred. On multivariable analysis, baseline LAGLS was an independent predictor of cardiovascular events (adjusted hazard ratio [HR], 0.91; 95% confidential interval [CI], 0.85-0.97; p=0.004) and re-hospitalization (adjusted HR, 0.93; 95% CI, 0.86-1.00; p=0.037). According to the optimal cutoff value of LAGLS, patients with low LAGLS (<23.6%) had a significantly higher risk of cardiovascular events (adjusted HR, 2.70; 95% CI, 1.04-7.00; p=0.041) than those with high LAGLS (≥23.6%). In a subgroup analysis, patients with high LAGLS had better clinical outcomes regardless of whether the patient had a LA volume index <60 mL/m². CONCLUSIONS: In patients with chronic severe MR who received successful MV repair surgery, preoperative LAGLS is an independent predictor of long-term postoperative outcomes.

Radial Plus Ipsilateral Femoral Approach is Feasible in Percutaneous Interventions for Iliac Artery Chronic Total Occlusion.

BACKGROUND: Compared with conventional bilateral femoral (BF) approach, radial plus ipsilateral femoral (RF) approach may be feasible in the percutaneous intervention for iliac artery chronic total occlusion (CTO). METHODS: We included patients who underwent iliac CTO intervention between August 2009 and July 2018 in a tertiary referral center in Korea. RESULTS: A total of 83 patients were enrolled in this study. Of them, 51 and 32 patients were categorized into RF and BF initial access groups, respectively. The overall success rates were 98.0% and 96.7% in RF and BF group, respectively, and the techniques were also similar including use of bilateral wiring, stent type and profile, and post balloon but longer procedure time in the BF group. Additional contralateral femoral access was needed in 6 patients for the treatment of contralateral lesions, distal embolization, and due to tortuous right subclavian artery. Periprocedural complications including vascular injury, iliac perforation, and distal embolization occurred similarly in both groups with numerically lower rate of periprocedural bleeding in the RF group (9.8%) than in the BF group (21.9%). Clinical follow-up at 6 months showed there were no difference in the rates of death, cardiovascular death, target-limb reintervention, and unplanned target limb amputation in both groups. CONCLUSIONS: RF approach for iliac CTO intervention was related to similar technical success rate with acceptable periprocedural safety outcomes compared with conventional BF approach.

Fate of Grafts Bypassing Nonischemic Versus Ischemic Inducing Coronary Stenosis.

There is a lack of evidence regarding the efficacy of ischemia-guided coronary artery bypass grafting. We compared the incidence of graft failure between grafts bypassing ischemia-inducing and nonischemia-inducing stenoses. Between 1997 and 2011, 2,304 patients for whom baseline coronary angiography and myocardial perfusion imaging were available were identified from a single-center coronary artery bypass grafting registry. According to baseline myocardial perfusion imaging, each graft was assigned to either graft bypassing ischemia-inducing or nonischemia-inducing stenoses (ischemia-related grafts, n = 4,904; ischemia-unrelated grafts, n = 2,709). Graft failure was defined as total occlusion on coronary computed tomography angiography, performed at the discretion of the treating physician. The incidence of graft failure was compared on a per-graft basis. At 5 years, the incidence of graft failure was significantly higher in the ischemia-unrelated grafts (4.2% vs 2.9% in ischemia-related grafts; p = 0.003). Ischemia-related graft was an independent determinant of graft patency (adjusted hazard ratio 0.61; 95% confidence interval 0.44 to 0.84; p = 0.002). Increased risk of graft failure associated with ischemia-unrelated graft was observed only in the internal thoracic artery (3.3% vs 2.0%, p = 0.021) and arterial grafts (6.5% vs 4.3%, p = 0.020), but not in the venous grafts (2.7% vs 2.7%; p = 0.99). In terms of major adverse cardiac and cerebrovascular events, 5-year incidences were comparable between the patients with and without ischemia-unrelated grafts (219, 19.3% vs 160, 18.0%; p = 0.61). In conclusion, ischemia-unrelated grafts became dysfunctional more frequently than ischemia-related grafts, and were not preventive of adverse events.

Coronary CT angiography characteristics of OCT-defined thin-cap fibroatheroma: a section-to-section comparison study.

OBJECTIVES: To evaluate whether plaque characteristics as assessed by coronary computed tomography angiography (CCTA) were associated with the presence of a thin-cap fibroatheroma (TCFA)-a precursor of plaque rupture-defined by optical coherence tomography (OCT) in a section-to-section-level comparison. METHODS: From 28 symptomatic patients, 31 coronary lesions were evaluated on 727 cross-sections co-registered by both CCTA and OCT. CCTA plaque characteristics included low attenuation plaque (LAP, <30 HU), napkin ring sign (NRS), positive remodelling (PR, remodelling index ≥1.10), and spotty calcification and plaque area and plaque burden. By OCT, presence of TCFA, lumen area and arc of lipid were determined. RESULTS: OCT revealed a TCFA in 69 (9.4%) sections from 19 (61.2 %) lesions. In per-section analysis, OCT-TCFA showed higher frequency of CCTA-detected LAP (58.0% vs. 18.5%), NRS (31.9% vs. 8.8%) and PR (68.1% vs. 48.0%) and greater plaque burden (70.6% vs. 61.9%) as compared to sections without OCT-TCFA (all p < 0.05). In multivariable analysis, LAP (odds ratio [OR] 4.05, p < 0.001) and NRS (OR 2.47, p = 0.005) were associated with OCT-TCFA. CCTA-measured lumen area correlated well with OCT-measured lumen area (R = 0.859, limits of agreement -0.5 ± 3.7 mm2). CONCLUSIONS: LAP and NRS in CCTA were associated with the presence of OCT-defined TCFA in a section-to-section comparison. KEY POINTS: • CT-defined LAP and NRS were associated with OCT-defined TCFA • OCT-TCFA showed higher frequency of LAP, NRS, PR and greater plaque burden • Non-calcified plaque area was correlated with OCT-measured lipid arc.

Ultrasound-Guided Core Needle Biopsy for Head and Neck Mass Lesions in Patients Undergoing Antiplatelet or Anticoagulation Therapy: A Preliminary Report.

OBJECTIVES: We compared the complications and diagnostic adequacy of ultrasound (US)-guided core needle biopsy (CNB) for head and neck mass lesions between patients who did and did not receive antiplatelet/anticoagulation therapy. METHODS: This study was designed as a prospective case study including 146 consecutive patients who underwent US-guided CNB for head and neck mass lesions. Of these, 32 patients were undergoing antiplatelet/anticoagulation therapy involving aspirin, clopidogrel, cilostazol, and warfarin. RESULTS: None of the patients had clinical bleeding/hematoma in either group. Subclinical bleeding/hematoma recognized only by a US examination was not significantly different between the groups (P = .229). No other complications were noticed. The rate of unsatisfactory sampling was also not different between the groups (P > .999). Furthermore, when patients receiving aspirin (n = 18) were reclassified into the no-antiplatelet/anticoagulation therapy group, there was still no significant difference in the incidences of complications compared with the patients receiving clopidogrel, cilostazol, or warfarin (n = 14). CONCLUSIONS: Our study suggests that US-guided CNB is safe and provides good diagnostic results without necessitating the discontinuation of antiplatelet/anticoagulation therapy in patients with head and neck mass lesions. However, as this was a preliminary study, the cohort was relatively small. Larger studies are needed to confirm our findings.

Video-Assisted Thoracoscopic Left Cardiac Sympathetic Denervation in Patients with Hereditary Ventricular Arrhythmias.

BACKGROUND: Left cardiac sympathetic denervation (LCSD) has been underutilized in patients with hereditary ventricular arrhythmia syndromes such as congenital long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). The purpose of this study was to investigate the safety and efficacy of video-assisted thoracoscopic (VATS) LCSD in such patients. METHODS: Fifteen patients (four men, 24.6 ± 10.5 years old) who underwent VATS-LCSD between November 2010 and January 2015 for hereditary ventricular arrhythmia syndromes at Kyungpook National University Hospital were enrolled in this study. The safety and efficacy of VATS-LCSD were evaluated by periprocedural epinephrine tests and assessing the development of complications and cardiac events during follow-up. RESULTS: Fourteen patients with LQTS and one patient with CPVT underwent VATS-LCSD. Six and one patients developed ventricular tachyarrhythmia during preprocedural and postprocedural epinephrine test, respectively (P = 0.063). No serious complications such as Horner syndrome, pneumothorax, or bleeding developed after LCSD. Mean hospital stay after VATS-LCSD was 3.7 ± 1.5 days. During a mean follow-up of 927 ± 350 days, one LQTS patient and one CPVT patient, neither of whom manifested tachyarrhythmia during post-LCSD epinephrine test, developed torsades de pointes and syncope, respectively. The annual event rates of six patients who were symptomatic during the period preceding LCSD decreased from 0.97 to 0.19 events/year (P = 0.045). CONCLUSIONS: VATS-LCSD was a safe, and effective procedure for patients with hereditary ventricular tachycardia syndrome, with no serious adverse events and with short hospital stay.

Risk of New Native-Vessel Occlusion After Coronary Artery Bypass Grafting.

Coronary computed tomography angiography is widely used to evaluate the graft patency, but information on the progression of native-vessel disease remains limited. We sought to evaluate the impact of bypass grafting on native-vessel progression after coronary artery bypass grafting. We evaluated new native-vessel occlusion defined as occlusion length ≥15 mm as a surrogate marker of native-vessel progression. We evaluated 911 patients with 2,271 nonoccluded vessels who underwent coronary artery bypass grafting and received follow-up coronary computed tomography angiography. Over a mean follow-up period of 4.7 years, the new occlusion rates were 9.2% for left anterior descending artery (LAD), and 13.9% for non-LAD, respectively. For non-LAD, new occlusion rate of vessels with bypass grafts was higher compared to those without bypass graft regardless of baseline native-vessel stenosis (intermediate stenosis: 8.6% vs 1.7%, p <0.001; severe stenosis: 20.5% vs 9.9%, p = 0.003). Furthermore, new occlusion rate of vessels with venous graft was the highest, followed by vessels with arterial graft and vessels without bypass graft, regardless of baseline stenosis (intermediate stenosis: 11.1% vs 5.2% vs 1.7%, p <0.001; severe stenosis: 23.7% vs 15.9% vs 9.9%, p <0.001). By multivariate analysis, bypass grafting was associated with new native-vessel occlusion for non-LAD (odds ratio 3.04, 95% confidence interval 1.79 to 5.14; p <0.001). Bypass graft was associated with new native-vessel disease progression regardless of baseline stenosis. In conclusion, the decision to bypass or leave a native vessel with intermediate stenosis should cautiously be considered.

Successful Recanalization of Native Coronary Chronic Total Occlusion Is Not Associated With Improved Long-Term Survival.

OBJECTIVES: The purpose of this study was to evaluate long-term clinical outcomes after drug-eluting stent-supported percutaneous coronary intervention (PCI) for native coronary total occlusion (CTO). BACKGROUND: The benefit of successful recanalization of CTO on prognosis remains uncertain. METHODS: Between March 2003 and May 2014, 1,173 consecutive patients with CTO of native coronary vessels requiring PCI were enrolled. Drug-eluting stent implantation was performed in all successful procedures (1,004 patients, 85.6%). RESULTS: During a median follow-up of 4.6 years, the adjusted risks of all-cause mortality (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 0.53 to 2.04; p = 0.92) and the composite of death or myocardial infarction (HR: 1.05; 95% CI: 0.56 to 1.94; p = 0.89) were found to be comparable between patients with successful and failed CTO-PCI, whereas the adjusted risk of target vessel revascularization (HR: 0.15; 95% CI: 0.10 to 0.25; p < 0.001) and coronary artery bypass grafting (HR: 0.02; 95% CI: 0.006 to 0.06, p < 0.001) was significantly higher in patients with failed CTO-PCI. Among patients (n = 879) in whom complete revascularization for non-CTO vessels was performed, the risk of death or the composite of death or myocardial infarction were not found to differ between patients who underwent successful recanalization of the remaining CTO and patients who did not. This finding was consistent regardless of whether the patient had a multivessel disease including CTO or only had a single CTO disease. CONCLUSIONS: Successful CTO-PCI compared with failed PCI was not associated with a lesser risk for mortality. However, successful CTO-PCI was associated with significantly less subsequent coronary artery bypass grafting.

Trends in Outcomes of Revascularization for Left Main Coronary Disease or Three-Vessel Disease With the Routine Incorporation of Fractional Flow Reserve in Real Practice.

Impact of fractional flow reserve guidance on revascularization strategies and outcomes for severe coronary artery disease was unclear. We evaluate changes in treatment strategy and clinical outcomes and to compare the effectiveness between percutaneous coronary intervention (PCI) with second-generation drug-eluting stents and coronary artery bypass graft surgery (CABG) in severe coronary artery disease patients before and after routine use of FFR. From January 2008 to December 2011, we enrolled 2,612 patients with significant left main coronary artery disease or 3-vessel disease. We obtained data of patients before (from January 2008 to December 2009) and after (January 2010 to December 2011) the routine use of FFR. We used propensity score matching to compare the rate of primary outcomes (death, myocardial infarction, stroke, or repeat revascularization [Major adverse cardiovascular and cerebral event; MACCE]) at 1 year. Introduction of routine FFR use reduced the proportion of patients receiving CABG from 54% to 43% (p <0.001). The risk of MACCE before routine FFR use was significantly higher in the PCI group than the CABG group (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.09 to 3.03, p = 0.021), whereas that after routine FFR use was not significantly different between the groups (HR 1.22, 95% CI 0.59 to 2.52, p = 0.59). The risk of MACCE in patients receiving revascularization lowered after routine FFR use compared with that before (HR 0.57, 95% CI 0.38 to 0.85, p = 0.005). In conclusion, routine incorporation of FFR resulted in improved PCI outcomes, comparable with concurrent CABG in patients with severe coronary artery disease who received revascularization.

Procedural Predictors of Angiographic Restenosis After Bifurcation Coronary Stenting (from the Choice of Optimal Strategy for Bifurcation Lesions With Normal Side Branch and Optimal Stenting Strategy for True Bifurcation Lesions Studies).

Most subordinate techniques accompanying bifurcation stenting have not been supported by relevant clinical trials. The aim of this study was to investigate the impact of technical specifications involved in bifurcation stenting on angiographic outcomes. We analyzed patients enrolled in a cohort consisting of the patients in 2 randomized studies: one comparing routine final kissing inflation (FKI) versus leave-alone strategy after the 1-stent technique for bifurcations without side branch (SB) stenosis (<50%) and the other comparing crush versus the 1-stent technique for lesions with SB stenosis (≥50%). The effects of subordinate techniques and devices on 8-month angiographic restenosis were studied using multivariate models. Of 514 patients whose 8-month angiograms were available, 58 (11.3%) were found to have restenosis involving, in total, 35 main branches (MBs) and 27 SBs. Using multivariate models, we identified FKI as the only independent predictor of MB restenosis in the technically modifiable variables. The effect of FKI was significantly different across subgroups defined by bifurcation lesion type and stenting technique (test for homogeneity, p = 0.003): FKI was unrelated to MB restenosis in the 1-stent for diseased SB (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.10 to 1.72; p = 0.22) and the 2-stent groups (OR 0.14, 95% CI 0.01 to 1.36; p = 0.09) but predictive of MB restenosis in the 1-stent for normal SB group (OR 4.90, 95% CI 1.58 to 15.16; p = 0.006).

Randomized Trial of Stents Versus Bypass Surgery for Left Main Coronary Artery Disease: 5-Year Outcomes of the PRECOMBAT Study.

BACKGROUND: In a previous randomized trial, we found that percutaneous coronary intervention (PCI) was not inferior to coronary artery bypass grafting (CABG) for the treatment of unprotected left main coronary artery stenosis at 1 year. OBJECTIVES: This study sought to determine the 5-year outcomes of PCI compared with CABG for the treatment of unprotected left main coronary artery stenosis. METHODS: We randomly assigned 600 patients with unprotected left main coronary artery stenosis to undergo PCI with a sirolimus-eluting stent (n = 300) or CABG (n = 300). The primary endpoint was a major adverse cardiac or cerebrovascular event (MACCE: a composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) and compared on an intention-to-treat basis. RESULTS: At 5 years, MACCE occurred in 52 patients in the PCI group and 42 patients in the CABG group (cumulative event rates of 17.5% and 14.3%, respectively; hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 0.84 to 1.90; p = 0.26). The 2 groups did not differ significantly in terms of death from any cause, myocardial infarction, or stroke as well as their composite (8.4% and 9.6%; HR, 0.89; 95% CI, 0.52 to 1.52; p = 0.66). Ischemia-driven target vessel revascularization occurred more frequently in the PCI group than in the CABG group (11.4% and 5.5%, respectively; HR: 2.11; 95% CI: 1.16 to 3.84; p = 0.012). CONCLUSIONS: During 5 years of follow-up, our study did not show significant difference regarding the rate of MACCE between patients who underwent PCI with a sirolimus-eluting stent and those who underwent CABG. However, considering the limited power of our study, our results should be interpreted with caution. (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968).

Readmission rate after coronary artery bypass grafting versus percutaneous coronary intervention for unprotected left main coronary artery narrowing.

Many studies have reported comparable risk of hard end points between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) stenosis. However, there are limited data regarding the morbidity associated with ULMCA revascularization. This study sought to compare the cause and risk of readmissions after PCI and CABG for ULMCA stenosis. We evaluated the unadjusted and adjusted risk of readmissions in 1,352 patients (783 PCI treated and 569 CABG treated) who were consecutively enrolled in a multicenter registry of patients with ULMCA stenosis, named the Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease trial. Overall, 206 PCI-treated patients (26.3%) experienced at least 1 readmission after the index procedure during 48.7 ± 16.0 months of follow-up compared with 84 CABG-treated patients (14.8%, p <0.001). The most frequent causes of readmission were repeat revascularization after PCI (41%) and noncardiac readmissions after CABG (48%). Through repeated events analysis, PCI was associated with more frequent readmissions than CABG (hazard ratio 2.037, 95% confidence interval 1.542 to 2.692, p <0.001), being an independent predictor of readmission (hazard ratio 1.820, 95% confidence interval 1.420 to 2.331, p <0.001). Except for the acute period, defined as the first 3 months, when there was no significant difference in readmission rate, a higher readmission rate after PCI was consistently observed over the remainder of the follow-up period. In conclusion, PCI was shown to be associated with a higher risk of readmission than CABG in treating ULMCA disease. This higher risk was attributable to more frequent revascularization in the PCI group.