Strategy to optimize PeriproCeduraL AnticOagulation in structural transseptal interventions: Design and rationale of the STOP CLOT trial.

BACKGROUND: Both transcatheter edge-to-edge repair (TEER) of mitral regurgitation or left atrial appendage closure (LAAC) require periprocedural anticoagulation with unfractionated heparin (UFH) that is administered either before or immediately after transseptal puncture (TSP). The optimal timing of UFH administration (before or after TSP) is unknown. The Strategy To Optimize PeriproCeduraL AnticOagulation in Structural Transseptal Interventions trial (STOP CLOT Trial) was designed to determine if early anticoagulation is effective in reducing ischemic complications without increasing the risk of periprocedural bleeding. METHODS: The STOP CLOT trial is a multicenter, prospective, double-blind, placebo-controlled, randomized trial. A total of 410 patients scheduled for TEER or LAAC will be randomized 1:1 either early UFH administration (iv. bolus of 100 units/kg UFH or placebo, given after obtaining femoral vein access and at least 5 minutes prior to the start of the TSP) or late UFH administration (iv. bolus of 100 units/kg UFH or placebo given immediately after TSP). Prespecified preliminary statistical analysis will be performed after complete follow-up of the first 196 randomized subjects. To ensure blinding, a study nurse responsible for randomization and UFH/placebo preparation is not involved in the care of the patients enrolled into the study. The primary study endpoint is a composite of (1) major adverse cardiac and cerebrovascular events (death, stroke, TIA, myocardial infarction, or peripheral embolization) within 30 days post-procedure, (2) intraprocedural fresh thrombus formation in the right or left atrium as assessed with periprocedural transesophageal echocardiography, or (3) occurrence of new ischemic lesions (diameter ≥4 mm) on brain magnetic resonance imaging performed 2 to 5 days after the procedure. The safety endpoint is the occurrence of moderate or severe bleeding complications during the index hospitalization. CONCLUSIONS: Protocols of periprocedural anticoagulation administration during structural interventions have never been tested in a randomized clinical trial. The Stop Clot trial may help reach consensus on the optimal timing of initiation of periprocedural anticoagulation. CLINICAL TRIALS REGISTRATION NUMBER: The study protocol is registered at ClinicalTrials.gov, identifier NCT05305612.

Intra-Right Ventricle Course of the Coronary Arteries on Computed Tomography Angiography.

BACKGROUND: The clinical relevance and anatomic characteristics of intracavitary coronary arteries coursing within the right ventricle (RV) are largely unknown. OBJECTIVES: The aim of our study was to assess the clinical and computed tomographic characteristics of patients diagnosed with intracavitary coronary arteries coursing within RV (intra-RV coronaries). METHODS: Electronic records from a single high-volume cardiac center were retrospectively screened for the presence of intra-RV coronaries among consecutive patients who underwent coronary computed tomography angiography (coronary CTA) from 2008 to 2019. RESULTS: Overall, 31,748 coronary CTA reports were evaluated, and 17 subjects with intra-RV coronaries were identified. None of these patients was referred for subsequent invasive coronary angiography. One patient underwent coronary artery bypass grafting, 1 patient had a history of percutaneous coronary intervention, and 1 patient had a concomitant coronary anomaly: left circumflex coronary artery originating from the right coronary artery. All of the involved coronaries (n = 17) were the left anterior descending coronary arteries (LADs). Typical segmental coronary course within RV was along the border between free RV wall and interventricular septum (beneath interventricular groove), often within trabeculae carneae of the RV. Only the midsegment and distal segment of the LAD traversed within the RV. The mean ± SD distance from the aorta to the coronary entrance into the RV was 74.5 ± 17.1 mm, whereas the mean ± SD intra-RV coronary length was 25.1 ± 14.0 mm. CONCLUSIONS: Intra-RV course of the coronaries in an adult CTA population is an infrequent anatomical variant involving LAD. It may require additional attention during interventional and surgical interventions.

Long-term follow-up and safety assessment of angiogenic gene therapy trial VIF-CAD: Transcatheter intramyocardial administration of a bicistronic plasmid expressing VEGF-A165/bFGF cDNA for the treatment of refractory coronary artery disease.

There have been a number of angiogenic gene therapy trials, yielding mixed results as to efficacy, but demonstrating uniform short-term treatment safety. Data regarding long-term safety of angiogenic gene therapy are limited. Double-blind VIF-CAD trial (NCT00620217) assessed myocardial perfusion and clinical data in 52 refractory coronary artery disease (CAD) patients randomized into treatment (VIF; n = 33) and Placebo (n = 19) arms. VIF group received electromechanical system NOGA-guided intramyocardial injections of VEGF-A165/bFGF plasmid (VIF) into ischemic regions, while the Placebo group-placebo plasmid injections. Full 1-year follow-up data have been published. This study presents the results of over 10-year (median 133 months, range 95-149) safety follow-up of VIF-CAD patients. Overall, 12 (36.4%) patients died in VIF and 8 (42.1%) in Placebo group (P = .68). Cardiovascular mortality was 12/33 (36.4%) in the VIF group and 6/19 (31.6%) in Placebo group (P = .73). Two Placebo patients died due to malignancies, but no VIF patients (P = .17). The Kaplan-Meier curves of combined endpoint: cardiovascular mortality, myocardial infarction and stroke were similar for both patient groups (P = .71). Odds ratio of Placebo group increasing (reaching a worse) their CCS class versus VIF was non-significant (OR 1.28, 95% CI = 0.66-2.45; P = .47). However, CCS class improved in time irrespectively of treatment-OR of reaching a less favorable CCS class per each year of follow-up was 0.74 (95% CI 0.685-0.792; P < .0001, pooled data). There were no differences in readmission rates. Intramyocardial VEGF-A165/bFGF plasmid administration appears safe, with no evidence of an increase in the incidence of death, malignancy, myocardial infarction or stroke during 10-year follow-up in this limited patient population.

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.

Patterns of Coronary Calcification and Their Impact on the Diagnostic Accuracy of Computed Tomography Coronary Angiography.

OBJECTIVE: Despite coronary calcifications being a major factor affecting the diagnostic accuracy of coronary computed tomography angiography (CTA), there is a lack of established criteria for categorizing calcifications. We aimed to evaluate patterns of coronary calcification based on quantitative radiodensity and size parameters to provide coronary calcium categories and assess their impact on the accuracy of coronary CTA. METHODS AND RESULTS: We analyzed length, maximum thickness, volume, mean density, and maximum density of coronary calcium and divided each of these parameters into tertiles. Subsequently, we summarized the tertiles for each individual calcification and divided them into 3 equal groups of: mild, moderate, and severe calcification. The accuracy of coronary CTA was defined as the difference between the measurements obtained on coronary CTA versus the reference of intravascular ultrasound (IVUS). We evaluated 252 coronary calcifications within 97 arteries of 60 patients. There was an expected increase in size and density values for mild versus moderate versus severe calcifications, but there was no difference in IVUS measured minimum lumen area among the 3 groups. Of note, coronary CTA significantly underestimated IVUS minimum lumen area measurement by 1.2 ± 1.6 mm (14.6 ± 23.1%, P < 0.001) for severe calcifications and by 0.5 ± 2.0 mm (3.7 ± 32.1%, P = 0.021) for moderate calcifications. Within mild calcifications, the difference was not significant. CONCLUSION: Based on their dimensional and radiodensity characteristics, our analysis revealed patterns of individual coronary artery calcifications that affected the accuracy of coronary CTA measurements; coronary CTA inaccuracy was associated with the presence of moderate or severe calcifications, but not mild calcifications.

Ischaemia modified albumin in patients with acute coronary syndrome and negative cardiac troponin I.

BACKGROUND: Approximately 40-60% of patients with acute coronary syndrome (ACS) have normal cardiac troponin I (cTnI) concentrations on admission. Ischaemia modified albumin (IMA) has been suggested as a new biomarker of myocardial ischaemia. METHODS: A total of 43 patients presenting with symptoms suggestive of ACS but with normal (< 0.1 µg/L) cTnI concentrations and 45 healthy subjects were studied. The patients from the study group were divided into two groups: STEMI (n = 28) and NSTEMI (n = 15). All these patients were undergoing percutaneous coronary intervention (PCI) with stenting. The concentrations of cTnI, myoglobin and IMA were determined on admission and 4 h after PCI. RESULTS: Mean (SD) IMA concentrations were higher in patients with ACS (114.39 ± 25.18 U/ml) as compared to the control group (96.24 ± 6.28 U/ml, p < 0.005). IMA concentrations ≥ 104.0 U/ml demonstrated 72.1% sensitivity and 75.6% specificity for the diagnosis of ACS. The area under the receiver operator characteristic curve was 0.766 (95% CI 0.664-0.868) for ACS patients (NSTEMI + STEMI). In both groups increased median (IQR) cTnI concentration after PCI was observed (STEMI patients to 65.4 (10.9-106.9) µg/L and NSTEMI to 17.6 (0.77-84.0) µg/L). In contrast, no increase in IMA concentration was observed. CONCLUSIONS: IMA may be a useful biomarker for the identification of ACS patients presenting with typical acute chest pain and/or abnormal electrocardiograms but negative cTnI.

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.

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.

Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery.

Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.

Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery.

Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.

Efficacy and safety of coronary computed tomography angiography in patients with a high clinical likelihood of obstructive coronary artery disease.

BACKGROUND: The CAT-CAD trial showed that coronary computed tomography angiography (CTA) in patients with a high prevalence of coronary artery disease (CAD) and indications for invasive coronary angiography (ICA) reduces the number of patients undergoing ICA by two-thirds and nearly eradicates non-actionable ICAs. However, the long-term benefits of this non-invasive strategy remain unknown. AIMS: To evaluate the long-term efficacy and safety of a non-invasive strategy employing coronary CTA vs. ICA as the first-line imaging test in stable patients with a high clinical likelihood of obstruc-tive CAD. METHODS: The long-term outcomes were evaluated for 36 months following randomization and included the efficacy outcome (analyzed as the composite of major adverse cardiovascular events (MACE): all-cause death, acute coronary syndrome, unplanned coronary revascularization, urgent hospitalization for a cardiovascular reason, a stroke) and the safety outcome (analyzed as a cumulative incidence of serious adverse events). RESULTS: One hundred and twenty participants at a mean age of 60.6 (7.9) years (female, 35.0%) were randomized with an allocation ratio of 1:1 to coronary CTA and direct ICA as the first-line anatomical test for suspected obstructive CAD. There were no significant differences between both diagnostic strategies neither in terms of the long-term efficacy (MACE occurrence: 15.5% in coronary CTA group vs. 16.7% in ICA group; log-rank P = 0.89) nor the long-term safety (cumulative number of serious adverse events: 36 vs. 38; P = 0.79, respectively). CONCLUSIONS: Long-term follow-up of the randomized CAT-CAD trial confirms that the strategy employing coronary CTA is an effective and safe, non-invasive, outpatient-based alternative to ICA for patients with a high clinical likelihood of obstructive CAD.

Clinical use of intracoronary imaging modalities in Poland. Expert opinion of the Association of Cardiovascular Interventions of the Polish Cardiac Society.

The article presents the most common, current indications for the use of intravascular invasive imag-ing diagnostic techniques, i.e. intravascular ultrasound and optical coherence tomography in Polish invasive cardiology centers. The application of the above-mentioned techniques in the diagnosis of stenosis of the left main coronary artery, optimization of stent implantation procedures, treatment of calcified lesions, and other clinically important issues are discussed.

Aspiration coronary thrombectomy for acute myocardial infarction increases myocardial salvage: single center randomized study.

OBJECTIVES: The aim of the study was to assess if aspiration thrombectomy in high risk patients with STEMI and angiographic evidence of thrombus may improve myocardial salvage. BACKGROUND: It is unclear if thrombus aspiration before percutaneous intervention (PCI) improves myocardial salvage. METHODS: The trial was a prospective randomized study. The inclusion criteria were: first STEMI within 12 hr from symptoms onset, culprit lesion in left anterior descending or right coronary artery, culprit artery TIMI flow ≤ 2 and angiographic evidence of thrombus. The primary endpoint was myocardial salvage index (MSI) as assessed by (99m) Tc-sestamibi SPECT imaging. RESULTS: We randomized 137 patients (98 male, mean age 64.1 ± 12.5 years) either to aspiration thrombectomy followed by standard PCI with stent implantation (n = 67) or to standard primary PCI (n = 70). Index perfusion defect was similar in both study groups: 34.2% ± 13.1% in thrombectomy group versus 37.1% ± 12.0% in primary PCI group (P = 0.2). MSI was larger in aspiration thrombectomy group than in control patients [25.4% (IQR 13.5-44) vs. 18.5% (IQR 7.7-30.3) respectively, P = 0.02]. The final infarct size was smaller in patients treated with aspiration thrombectomy (23.1% ± 13.3% vs. 28.9% ± 10.2% in the control group, P = 0.002). CONCLUSIONS: Aspiration thrombectomy improves myocardial salvage in high risk STEMI patients with angiographic evidence of thrombus.

Altered plasma fibrin clot properties are associated with in-stent thrombosis.

OBJECTIVE: We sought to investigate whether patients with in-stent thrombosis (IST) display altered plasma fibrin clot properties. METHODS AND RESULTS: We studied 47 definite IST patients, including 15 with acute, 26 subacute and 6 late IST, and 48 controls matched for demographics, cardiovascular risk factors, concomitant treatment and angiographic/stent parameters. Plasma clot permeability (K(s)), which indicates a pore size, turbidity (lag phase, indicating the rate of fibrin clot formation, DeltaAbs(max), maximum absorbance of a fibrin gel, reflecting the fiber thickness), lysis time (t(50%)) and maximum rate of D-dimer release from clots (D-D(rate)) were determined 2 to 73 (median 14.7) months after IST. Patients with IST had 21% lower K(s), 14% higher DeltaAbs(max), 11% lower D-D(rate), 30% longer t(50%) (all P<0.0001) and 5% shorter lag phase compared to controls (P=0.042). There were no correlations between clot variables and the time of IST or that from IST to blood sampling. Multiple regression analysis showed that K(s) (odds ratio=0.36 per 0.1 microm(2), P<0.001), D-D(rate) (odds ratio=0.16 per 0.01 mg/L/min, P<0.001) and stent length (odds ratio=1.1 per 1 mm, P=0.043) were independent predictors of IST (R(2)=0.58, P<0.001). CONCLUSIONS: IST patients tend to form dense fibrin clots resistant to lysis, and altered plasma fibrin clot features might contribute to the occurrence of IST.

Epicardial adipose tissue radiodensity is independently related to coronary atherosclerosis. A multidetector computed tomography study.

BACKGROUND: Preliminary research indicates that epicardial adipose tissue (EAT) may display both anti- and proatherosclerotic properties. Because the varying radiodensities of selected human tissues assessed by multidetector computed tomography (MDCT) has been shown to reflect differences in biological characteristics, the present study investigated the hypothesis that the proatherosclerotic properties of EAT may be linked to its radiodensity. METHODS AND RESULTS: The study included 164 consecutive patients (82 females, mean age 58.8±11.1 years) with suspected coronary artery disease (CAD) undergoing MDCT coronary angiography. Coronary atherosclerosis was defined as: (1) CAD (ie, presence of at least 1 coronary stenosis ≥50%) and (2) coronary artery calcium (CAC) determined by Agatston score. EAT radiodensity was assessed by MDCT and averaged 81.00±4.64 HU (Hounsfield unit (HU) scale). Mean CAC score was 96.0±220.0. Patients with CAD (n=36) showed higher EAT radiodensity than patients without CAD (78.99±4.12 vs. -81.57±4.64 HU, P<0.01). In the multivariable model, only EAT radiodensity and age were independently associated with CAD (odds ratio (OR) 1.15, 95%confidence interval (CI) 1.04-1.28; OR 1.08, 95%CI 1.04-1.12; respectively). EAT radiodensity also correlated with CAC score (r=0.23, P<0.01). EAT radiodensity (P<0.001), age (P<0.001), sex (P=0.03), and past smoking (P<0.01) were independent correlates of CAC in the multivariable linear regression model. CONCLUSIONS: Increased EAT radiodensity is independently associated with coronary atherosclerosis, which may reflect the unfavorable, proatherosclerotic metabolic properties of more radiodense epicardial fat.

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.

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.

Percutaneous tricuspid edge-to-edge repair - patient selection, imaging considerations, and the procedural technique. Expert opinion of the Working Group on Echocardiography and Association of CardioVascular Interventions of the Polish Cardiac Society.

Tricuspid regurgitation (TR) is a common acquired valvular heart disease (VHD). TR has progressive character and is associated with impaired long-term survival in both symptomatic and asymptomatic subjects. Despite this knowledge, the overall number of tricuspid valve surgeries is very low worldwide and many patients with clear indications for intervention are left untreated. The development of less invasive transcatheter techniques may offer new treatment options in this growing population of patients. Out of various percutaneous methods proposed, tricuspid edge-to-edge repair has recently gained considerable attention. The article summarizes available data regarding this new treatment method.

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.

Comparison of myocardial tissue reperfusion of inferior wall and a right ventricle among patients after primary angioplasty for an inferior myocardial infarction with right ventricular infarction.

BACKGROUND: Impaired myocardial tissue reperfusion affects prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and can be identified by ST-segment analysis. To date, evaluation of the myocardial tissue reperfusion of the right ventricle (RV) among the patients treated with PCI for inferior STEMI with right ventricular infarction (RVI) has not been made yet. METHODS: Patients with inferior STEMI were screened for RVI. Tissue reperfusion was evaluated by maximal residual ST-segment deviation post PCI, independently for the RV and for inferior wall. Myocardial injury was assessed by the peak creatine kinase-mb (CK-MB) value. RESULTS: Among 456 patients with inferior STEMI, concomitant RVI occurred in 153 (33.5%) subjects (59.86±10.35 years old, 71.9% females). Tissue reperfusion of LV was present in 75 (49%), whereas 55 (35.9%) had both successful LV and RV reperfusion. Among 97 (63.4%) with successful tissue reperfusion of RV, 55 (56.7%) had associated successful tissue reperfusion of inferior wall. Adequate LV reperfusion was accompanied by RV in over 73.3% of patients (P=0.006). Mean peak CK-MB was lower in the group with adequate versus impaired RV tissue-perfusion (197±143 vs. 305±199 U/L, P=0.021 respectively). CONCLUSIONS: Impaired reperfusion of RV is observed in more than one third of inferior STEMIs with RVI and is not strictly associated with impaired reperfusion of inferior wall and clinical or angiographic variables, therefore ST-segment analysis for RV is mandatory.