Percutaneous Coronary Intervention to a Hypoplastic Reimplanted Left Main Coronary in an Adolescent.

Critical ostial stenosis following reimplantation of an anomalous left main coronary artery is extremely rare. Currently, there is no consensus on management following diagnosis. This report demonstrates the feasibility of percutaneous coronary intervention in an adolescent with such a condition and emphasizes the importance of periprocedural multimodality imaging.

Wavelet and time-based cerebral autoregulation analysis using diffuse correlation spectroscopy on adults undergoing extracorporeal membrane oxygenation therapy.

INTRODUCTION: Adult patients who have suffered acute cardiac or pulmonary failure are increasingly being treated using extracorporeal membrane oxygenation (ECMO), a cardiopulmonary bypass technique. While ECMO has improved the long-term outcomes of these patients, neurological injuries can occur from underlying illness or ECMO itself. Cerebral autoregulation (CA) allows the brain to maintain steady perfusion during changes in systemic blood pressure. Dysfunctional CA is a marker of acute brain injury and can worsen neurologic damage. Monitoring CA using invasive modalities can be risky in ECMO patients due to the necessity of anticoagulation therapy. Diffuse correlation spectroscopy (DCS) measures cerebral blood flow continuously, noninvasively, at the bedside, and can monitor CA. In this study, we compare DCS-based markers of CA in veno-arterial ECMO patients with and without acute brain injury. METHODS: Adults undergoing ECMO were prospectively enrolled at a single tertiary hospital and underwent DCS and arterial blood pressure monitoring during ECMO. Neurologic injuries were identified using brain computerized tomography (CT) scans obtained in all patients. CA was calculated over a twenty-minute window via wavelet coherence analysis (WCA) over 0.05 Hz to 0.1 Hz and a Pearson correlation (DCSx) between cerebral blood flow measured by DCS and mean arterial pressure. RESULTS: Eleven ECMO patients who received CT neuroimaging were recruited. 5 (45%) patients were found to have neurologic injury. CA indices WCOH, the area under the curve of the WCA, were significantly higher for patients with neurological injuries compared to those without neurological injuries (right hemisphere p = 0.041, left hemisphere p = 0.041). %DCSx, percentage of time DCSx was above a threshold 0.4, were not significantly higher (right hemisphere p = 0.268, left hemisphere p = 0.073). CONCLUSION: DCS can be used to detect differences in CA for ECMO patients with neurological injuries compared to uninjured patients using WCA.

The impact of mineralocorticoid and glucocorticoid receptor interaction on corticosteroid transcriptional outcomes.

The mineralocorticoid and glucocorticoid receptors (MR and GR, respectively) are members of the steroid receptor subfamily of nuclear receptors. Their main function is to act as ligand-activated transcription factors, transducing the effects of corticosteroid hormones (aldosterone and glucocorticoids) by modulating gene expression. Corticosteroid signaling is essential for homeostasis and adaptation to different forms of stress. GR responds to glucocorticoids by regulating genes involved in development, metabolism, immunomodulation and brain function. MR is best known for mediating the effects of aldosterone, a key hormone controlling electrolyte and water homeostasis. In addition to aldosterone, MR binds glucocorticoids (cortisol and corticosterone) with equally high affinity. This ligand promiscuity has important repercussions to understand MR function, as well as glucocorticoid signaling. MR and GR share significant sequence and structural similarities, regulate overlapping sets of genes and are able to interact forming heteromeric complexes. However, the precise role of these heteromers in regulating corticosteroid-regulated transcriptional outcomes remains an open question. In this review, we examine the evidence supporting MR-GR heteromerization, the molecular determinants of complex formation and their possible role in differential regulation of transcription in different cellular contexts and ligand availability.

Association between kidney function, frailty and receipt of invasive management after acute coronary syndrome.

BACKGROUND: Reduced estimated glomerular filtration rate (eGFR) is associated with lower use of invasive management and increased mortality after acute coronary syndrome (ACS). The reasons for this are unclear. METHODS: A retrospective clinical cohort study was performed using data from the English National Institute for Health Research Health Informatics Collaborative (2010-2017). Multivariable logistic regression was used to investigate whether eGFR<90 mL/min/1.73 m2 was associated with conservative ACS management and test whether (a) differences in care could be related to frailty and (b) associations between eGFR and mortality could be related to variation in revascularisation rates. RESULTS: Among 10 205 people with ACS, an eGFR of <60 mL/min/1.73m2 was found in 25%. Strong inverse linear associations were found between worsening eGFR category and receipt of invasive management, on a relative and absolute scale. People with an eGFR <30 mL compared with ≥90 mL/min/1.73 m2 were half as likely to receive coronary angiography (OR 0.50, 95% CI 0.40 to 0.64) after non-ST-elevation (NSTE)-ACS and one-third as likely after STEMI (OR 0.30, 95% CI 0.19 to 0.46), resulting in 15 and 17 per 100 fewer procedures, respectively. Following multivariable adjustment, the ORs for receipt of angiography following NSTE-ACS were 1.05 (95% CI 0.88 to 1.27), 0.98 (95% CI 0.77 to 1.26), 0.76 (95% CI 0.57 to 1.01) and 0.58 (95% CI 0.44 to 0.77) in eGFR categories 60-89, 45-59, 30-44 and <30, respectively. After STEMI, the respective ORs were 1.20 (95% CI 0.84 to 1.71), 0.77 (95% CI 0.47 to 1.24), 0.33 (95% CI 0.20 to 0.56) and 0.28 (95% CI 0.16 to 0.48) (p<0.001 for linear trends). ORs were unchanged following adjustment for frailty. A positive association between the worse eGFR category and 30-day mortality was found (test for trend p<0.001), which was unaffected by adjustment for frailty. CONCLUSIONS: In people with ACS, lower eGFR was associated with reduced receipt of invasive coronary management and increased mortality. Adjustment for frailty failed to change these observations. Further research is required to explain these disparities and determine whether treatment variation reflects optimal care for people with low eGFR. TRIAL REGISTRATION NUMBER: NCT03507309.

Impact of lesion morphology on stent elongation during bifurcation PCI: an in vivo OCT study.

BACKGROUND: Recent observations in silico and in vivo reported that, during proximal optimisation technique, drug-eluting stents (DES) elongate, challenging conventional wisdom. The interaction between plaque morphology and radial expansion is well established, but little is known about the impact of plaque morphology on elongation. AIMS: We aimed to assess the longitudinal mechanical behaviour of contemporary DES in vivo and evaluate the relationship between post-percutaneous coronary intervention (PCI) stent elongation and lesion morphology, as assessed with optical coherence tomography (OCT). METHODS: Patients treated with OCT-guided PCI to left main or left anterior descending artery bifurcations, between July 2017 and March 2022, from the King's Optical coherence Database Analysis Compendium were included. Patients were excluded if there were overlapping stents, if they had undergone prior PCI, or if there was inadequate image quality. Lesions were characterised as fibrocalcific, fibrous or lipid-rich by pre-PCI OCT. Following stent post-dilatation, stent expansion and final stent length were assessed. The primary outcome was the percentage change in stent length from baseline. RESULTS: Of 501 eligible consecutive patients from this period, 116 were included. The median age was 66 years (interquartile range [IQR] 57-76), 31% were female, and 53.4% were treated for an acute coronary syndrome. A total of 50.0% of lesions were classified as fibrocalcific, 6.9% were fibrous, and 43.1% were lipid-rich. The change in relative stent length was 4.4% (IQR 1.0-8.9), with an increase of 3.1% (IQR 0.5-6.3) in fibrocalcific lesions, 3.3% (IQR 0.5-5.9) in fibrous lesions, and 6.4% (IQR 3.1-11.1) in lipid-rich plaque (p=0.006). In multivariate regression modelling, lipid-rich plaque was an independent predictor of stent elongation (odds ratio 3.689, 95% confidence interval: 1.604-8.484). CONCLUSIONS: Contemporary DES elongate following implantation and post-dilatation, and this is significantly mediated by plaque morphology. This is an important consideration when planning a strategy for DES implantation.

Group Comparisons of the Sexual Interests and Behaviors of Assigned Males and Their Association with Genital Ablation Fantasies.

We describe here the sexual histories and characteristics of 338 individuals with interests in castration (orchiectomy) and, more broadly, genital ablation (i.e., orchiectomy, penectomy, and/or nullification), recruited from the Eunuch Archive. We compared four groups: those who only fantasize about castration (Fantasy, n = 66), those who wish to be castrated in the future (Aspiring, n = 166), and those who have been castrated (Eunuchs) both with (n = 42) or without (n = 64) androgen replacement therapy (ART). In our sample, 35.6-53.8% had sexual fantasies of castrating someone, 83.3-90.8% had fantasies of being castrated, 20.6-33.3% had fantasies of removing someone's penis, and 45.3-61.9% had fantasies of having a penectomy. The four groups had similar arousal by high-risk sex behaviors, anal sex play, attraction to people under 18, common sex behaviors, and fetishistic behaviors. Fantasy of being castrated by someone was associated with elevated high-risk sexual behaviors and attraction to individuals aged 18 to 49 after controlling for age, groups, and sexual attraction. In addition, after adjusting for age, groups, and sexual attraction, fantasy of castrating someone was associated with more attraction to individuals under the age of 18 and being aroused by interaction with a stranger, whereas fantasy of cutting off someone's penis was associated with less tendency for common sexual behaviors and digital sex communication. Fantasy of being penectomized was associated with high risk and fetishistic sexual behaviors. These results support screening for high-risk behaviors in individuals who endorse an interest in genital ablation, with treatments focused on harm reduction.

Gene and cell-based therapies for retinal and optic nerve disease.

Leading causes of blindness worldwide include neurodegenerative diseases of the retina, which cause irreversible loss of retinal pigment epithelium (RPE) and photoreceptors, and optic neuropathies, which result in retinal ganglion cell (RGC) death. Because photoreceptor and RGCs do not spontaneously regenerate in mammals, including humans, vision loss from these conditions is, at present, permanent. Recent advances in gene and cell-based therapies have provided new hope to patients affected by these conditions. This chapter reviews the current state and future of these approaches to treating ocular neurodegenerative disease. Gene therapies for retinal degeneration and optic neuropathies primarily focus on correcting known pathogenic mutations that cause inherited conditions to halt progression. There are multiple retinal and optic neuropathy gene therapies in clinical trials, and one retinal gene therapy is approved in the United States, Canada, Europe, and Australia. Cell-based therapies are mutation agnostic and have the potential to repopulate neurons regardless of the underlying etiology of degeneration. While photoreceptor cell replacement is nearing a human clinical trial, RPE transplantation is currently in phase I/II clinical trials. RGC replacement faces numerous logistical challenges, but preclinical research has laid the foundation for functional repair of optic neuropathies to be feasible.

The relationship between intraocular pressure and glaucoma: An evolving concept.

Intraocular pressure (IOP) is the most important modifiable risk factor for glaucoma and fluctuates considerably within patients over short and long time periods. Our field's understanding of IOP has evolved considerably in recent years, driven by tonometric technologies with increasing accuracy, reproducibility, and temporal resolution that have refined our knowledge regarding the relationship between IOP and glaucoma risk and pathogenesis. The goal of this article is to review the published literature pertinent to the following points: 1) the factors that determine IOP in physiologic and pathologic states; 2) technologies for measuring IOP; 3) scientific and clinical rationale for measuring diverse IOP metrics in patients with glaucoma; 4) the impact and shortcomings of current standard-of-care IOP monitoring approaches; 5) recommendations for approaches to IOP monitoring that could improve patient outcomes; and 6) research questions that must be answered to improve our understanding of how IOP contributes to disease progression. Retrospective and prospective data, including that from landmark clinical trials, document greater IOP fluctuations in glaucomatous than healthy eyes, tendencies for maximal daily IOP to occur outside of office hours, and, in addition to mean and maximal IOP, an association between IOP fluctuation and glaucoma progression that is independent of mean in-office IOP. Ambulatory IOP monitoring, measuring IOP outside of office hours and at different times of day and night, provides clinicians with discrete data that could improve patient outcomes. Eye care clinicians treating glaucoma based on isolated in-office IOP measurements may make treatment decisions without fully capturing the entire IOP profile of an individual. Data linking home blood pressure monitors and home glucose sensors to dramatically improved outcomes for patients with systemic hypertension and diabetes and will be reviewed as they pertain to the question of whether ambulatory tonometry is positioned to do the same for glaucoma management. Prospective randomized controlled studies are warranted to determine whether remote tonometry-based glaucoma management might reduce vision loss and improve patient outcomes.

Macular Degeneration Drug Prescribing Patterns After Step Therapy Introduction in Medicare Advantage.

Importance: In Medicare Advantage (MA), step therapy for physician-administered drugs is an approach to lowering drug spending. The impact of step therapy in MA on prescribing behavior and the magnitude of any changes has not been analyzed. Objective: To evaluate the impact of step therapy on macular degeneration drug prescribing patterns for 3 large MA insurers. Design, Setting, and Participants: This was a retrospective encounter-based analysis using 20% nationally representative MA outpatient and carrier encounter records for 2017 to 2019. Participants were MA beneficiaries who were 65 years or older and had received a macular degeneration drug administration. Macular degeneration drug administrations for beneficiaries of MA Aetna, Humana, and UnitedHealthcare (UHC) insurers were assessed. Humana implemented macular degeneration step therapy in 2019, setting bevacizumab as the plan-preferred drug, and aflibercept and ranibizumab as the plan-nonpreferred drugs. Aetna and UHC, which did not implement macular degeneration step therapy, served as the control group. Data analyses were performed from May 2024 to December 2024. Exposures: A macular degeneration drug administration subject to a step therapy policy. Main Outcome and Measures: A binary indicator of whether the drug administered was bevacizumab. Linear probability models and a difference-in-differences framework were used to quantify changes in prescribing patterns before and after the introduction of step therapy for MA insurers that did and did not implement step therapy. To empirically measure the impact of step therapy, the first administration of a treatment episode was assessed, followed by switching patterns. Results: A total of 18 331 MA beneficiaries, 21 683 treatment episodes, and 171 985 drug administrations were included across the control and treatment groups. The difference-in-differences regressions found a 7.8% (95% CI, 4.9%-10.7%; P < .001) greater probability of being prescribed bevacizumab for the first administration due to step therapy. The predicted probabilities of preferred-drug administration in the treatment group increased from 0.61 to 0.70 between the periods before and after step therapy implementation for the first administration. Step therapy was not significantly associated with an increased rate of medication switching (hazard ratio, 0.86; 95% CI, 0.71-1.06; P = .15). Conclusions and Relevance: The findings of this retrospective encounter-based analysis indicate that step therapy is associated with a greater probability of prescribing the plan-preferred drug for the first administration. The analysis failed to find a statistically significant greater rate of medication switching within a treatment episode. Step therapy changed macular degeneration prescribing patterns, but step therapy alone did not transition all administrations to the plan-preferred drug.

Fabrication of electrospun ion exchanger adsorbents with morphologies designed for the separation of proteins and plasmid DNA.

Electrospun cellulose adsorbents are an emergent class of materials applied to a variety of bioprocess separations as an analogue to conventional packed bed chromatography. Electrospun adsorbents have proven to be effective as rapid cycling media, enabling high throughput separation of proteins and viral vectors without compromising selectivity and recovery. However, there is a current lack of knowledge in relation to the manipulation and control of electrospun adsorbent structure with function and performance to cater to the separation needs of emerging, diverse biological products. In this study, a series of electrospun cellulose adsorbents were fabricated by adjusting their manufacturing conditions. A range of fiber diameters (400 to 600 nm) was created by changing the electrospinning polymer solution. Additionally, a range of porosities (0.4 to 0.7 v/v) was achieved by varying the laminating pressures on the electrospun sheets. The adsorbents were functionalized with different degrees of quaternary amine ligand density to create 18 prototype anion exchangers. Their morphology was characterized by BET nitrogen adsorption surface area, X-ray computed tomography, capillary flow porometry and scanning electron microscopy measurements. The physical characteristics of the adsorbents were used in an adapted semi-empirical model and compared to measured permeability data. Permeabilities of prototypes ranged from 10-2 to 10-4 mDarcy. The measured data showed good adherence to modelled data with possible improvements in acquiring wet adsorbent characteristics instead of dried material. Finally, the electrospun adsorbents were characterized for their binding capacity of model proteins of different sizes (diameters of 3.5 nm and 8.9 nm) and plasmid DNA. Static binding capacities ranged from 5 mg/ml to 25 mg/ml for the proteins and plasmid DNA and showed <20 % deviation from monolayer coverage based on BET surface area. Therefore, it was concluded that the electrospun adsorbents most likely adsorb monolayers of proteins and plasmid DNA on the surface with minimal steric hindrance.

Distribution of the intraosseous branch of the posterior superior alveolar artery relative to the posterior maxillary teeth.

Purpose: Preoperative identification of the intraosseous posterior superior alveolar artery (PSAA) is critical when planning sinus surgery. This study was conducted to determine the distance between the cementoenamel junction and the PSAA, as well as to identify factors influencing the detection of the PSAA on cone-beam computed tomography (CBCT). Materials and Methods: In total, 254 CBCT scans of maxillary sinuses, acquired with 2 different scanners, were examined to identify the PSAA. The distance from the cementoenamel junction (CEJ) to the PSAA was recorded at each maxillary posterior tooth position. Binomial logistic regression and multiple linear regression were employed to evaluate the effects of scanner type, CBCT parameters, sex, and age on PSAA detection and CEJ-PSAA distance, respectively. P-values less than 0.05 were considered to indicate statistical significance. Results: The mean CEJ-PSAA distances at the second molar, first molar, second premolar, and first premolar positions were 17.0±4.0 mm, 21.8±4.1 mm, 19.5±4.7 mm, and 19.9±4.9 mm for scanner 1, respectively, and 17.3±3.5 mm, 16.9±4.3 mm, 18.5±4.1 mm, and 18.4±4.3 mm for scanner 2. No independent variable significantly influenced PSAA detection. However, tooth position (b=-0.67, P<0.05) and scanner type (b=-1.3, P<0.05) were significant predictors of CEJ-PSAA distance. Conclusion: CBCT-based estimates of CEJ-PSAA distance were comparable to those obtained in previous studies involving cadavers, CT, and CBCT. The type of CBCT scanner may slightly influence this measurement. No independent variable significantly impacted PSAA detection.

Sued, Subpoenaed or Sworn in: Use of a Flipped-Classroom Style Medicolegal Workshop for Emergency Medicine Residents.

Background: It is an unfortunate truth that Emergency Medicine (EM) physicians will, at some point, have contact with the medicolegal system. However, most EM residency training programs lack education on the legal system in their curriculum, leaving EM physicians unprepared for litigation. To fill this gap, we designed a high-yield and succinct medical legal workshop highlighting legal issues commonly encountered by EM physicians. We aimed to determine the effectiveness of this curriculum by measuring pre and post knowledge questions. Methods: A two-hour session included a case-based discussion of common misconceptions held by physicians about the legal system, proper steps when interacting with the legal system and review of legal documents. This session was developed with the involvement of our hospital legal counsel and discussed real encounters. The effectiveness of the session was determined using pre- and post-session surveys assessing participant knowledge and comfort approaching the scenarios. Results: A total of 34 EM residents had the opportunity to complete this workshop as a part of their conference curriculum. A total of 26 participants completed the pre-survey and 19 participants completed the post-survey. No participants had previous training in the legal aspects of medicine, including handling a subpoena, serving as a witness, or giving a deposition. The pre-survey demonstrated that there was significant uncertainty surrounding the processes, definitions, and the legal system interaction. Many participants stated they would not know what to do if they received a subpoena (85.71%), were called as a witness in a trial (96.43%) or receive correspondence from a lawyer (96.43%). The post survey revealed an increased knowledge base and confidence following the session. 100% of residents reported knowing what to do after receiving a subpoena, being called as a witness and understanding the process involved in giving a deposition. All residents reported that the session was beneficial and provided crucial information. Conclusion: EM residents have limited baseline understanding of how to approach common legal scenarios. Educational materials available for this curriculum topic are limited. Based on the rapid knowledge increase observed in our residents, we believe our workshop could be adapted for use at other residency programs.

Phenogrouping heart failure with preserved or mildly reduced ejection fraction using electronic health record data.

BACKGROUND: Heart failure (HF) with preserved or mildly reduced ejection fraction includes a heterogenous group of patients. Reclassification into distinct phenogroups to enable targeted interventions is a priority. This study aimed to identify distinct phenogroups, and compare phenogroup characteristics and outcomes, from electronic health record data. METHODS: 2,187 patients admitted to five UK hospitals with a diagnosis of HF and a left ventricular ejection fraction ≥ 40% were identified from the NIHR Health Informatics Collaborative database. Partition-based, model-based, and density-based machine learning clustering techniques were applied. Cox Proportional Hazards and Fine-Gray competing risks models were used to compare outcomes (all-cause mortality and hospitalisation for HF) across phenogroups. RESULTS: Three phenogroups were identified: (1) Younger, predominantly female patients with high prevalence of cardiometabolic and coronary disease; (2) More frail patients, with higher rates of lung disease and atrial fibrillation; (3) Patients characterised by systemic inflammation and high rates of diabetes and renal dysfunction. Survival profiles were distinct, with an increasing risk of all-cause mortality from phenogroups 1 to 3 (p < 0.001). Phenogroup membership significantly improved survival prediction compared to conventional factors. Phenogroups were not predictive of hospitalisation for HF. CONCLUSIONS: Applying unsupervised machine learning to routinely collected electronic health record data identified phenogroups with distinct clinical characteristics and unique survival profiles.

Update on Therapies in Older Adults.

Memory loss and dementia are among older adults' greatest health fears. This article provides insight into new developments to help delay the onset of dementia, to treat dementia in its earliest stages, and to manage behavioral problems that occur in persons with dementia. Urinary incontinence (UI) is another common problem in older adults that has a major impact on quality of life. This article evaluates newer medications for reducing urinary urge/UI and provides perspective in their role for managing UI.

Variation in perceptions of genital ablation between aspiring eunuchs and individuals with paraphilic sexual fantasies.

Background: Although uncommon, some individuals assigned male at birth (AMAB) seek voluntary genital ablative procedures, and others fantasize about it. Aim: To learn more about the views of genital ablation and injuries in those who aspire to be castrated as compared with those who only fantasize about it. Methods: A survey was run on the Eunuch Archive internet community. Content analysis was conducted on the responses of 342 AMAB individuals with castration fantasy but no desire for actual surgery (fantasizers) vs 294 AMAB individuals who expressed a desire for genital ablation (aspiring). Outcomes: Study outcomes were responses to open-ended questions about genital ablations and injury. Results: Aspiring individuals were more likely to perceive a "physical appearance benefit" from orchiectomy, but fewer could recall how they first learned about the procedure. Some reasons that aspiring persons gave for desiring an orchiectomy included "achieving preferred self" and "health reasons." Fantasizers, in contrast, worried about the potential side effects of orchiectomy, and more believed there to be no benefit to it. Clinical Implications: Psychiatrists and other clinicians need to understand their patients' views on genital ablation to properly diagnose and provide the best personalized care. Strengths and Limitations: Strengths include a large sample of respondents. Limitations include the accuracy of the anonymous survey data. Conclusions: This study demonstrates divergent interests on genital ablation among AMAB individuals who have not had an any genital ablation yet have intense interest in the topic.

Ocular Dirofilariasis: A Clinicopathologic Case Series and Literature Review.

Purpose: Ocular dirofilariasis is an uncommon zoonotic infection that is usually associated with a carnivore host. In this case series and literature review, we investigate the clinical presentation, management, and histopathology of ocular dirofilariasis. Methods: The database at the Florida Lions Ocular Pathology Laboratory was searched for surgical specimens at the Bascom Palmer Eye Institute under approval of the Institutional Review Board. Patients with a histopathologic diagnosis of dirofilariasis between the years 1962 and 2022 from the Florida Lions Ocular Pathology Laboratory database were included (n = 3). A systematic PubMed search was conducted by two independent authors to identify published cases of ophthalmic dirofilariasis worldwide. Keywords were used to identify articles, and exclusion criteria were applied. Results: Three patients, two males and one female, were identified from the Florida Lions Ocular Pathology Laboratory database with a diagnosis of ocular dirofilariasis. The mean age was 46.7 years (with a range 33-57 years). There were two eyelid lesions (Cases 1 and 3) and one involving the subconjunctival space (Case 2). All three organisms were excised and presumptively identified as Dirofilaria tenuis. All 3 patients were managed with curative surgical removal and recovered completely. Our review of the literature identified 540 published reports and 142 published reports with 186 cases that met the exclusion criteria. Conclusion: We present a case series and literature review of ocular dirofilariasis. Knowledge of the incidence, risk factors, prevention, and diagnosis of this unique parasitic infection will help in proper management and prevent further ocular complications.

Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club.

The 2023 European Bifurcation Club (EBC) meeting took place in Warsaw in October, and the latest evidence for the use of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to optimise percutaneous coronary interventions (PCI) on coronary bifurcation lesions (CBLs) was a major focus. The topic generated deep discussions and general appraisal on the potential benefits of IVUS and OCT in PCI procedures. Nevertheless, despite an increasing recognition of IVUS and OCT capabilities and their recognised central role for guidance in complex CBL and left main PCI, it is expected that angiography will continue to be the primary guidance modality for CBL PCI, principally due to educational and economic barriers. Mindful of the restricted access/adoption of intracoronary imaging for CBL PCI, the EBC board decided to review and describe a series of tips and tricks which can help to optimise angiography-guided PCI for CBLs. The identified key points for achieving an optimal angiography-guided PCI include a thorough analysis of pre-PCI images (computed tomography angiography, multiple angiographic views, quantitative coronary angiography vessel estimation), a systematic application of the technical steps suggested for a given selected technique, an intraprocedural or post-PCI use of stent enhancement and a low threshold for bailout use of intravascular imaging.

Unintended Deformation of Stents During Bifurcation PCI: An OCTOBER Trial Substudy.

BACKGROUND: Unintended deformation of implanted coronary stents can lead to loss of coronary access, stent thrombosis and coronary events during follow-up. The incidence, mechanisms and clinical outcomes of unintended stent deformations (USD) during complex bifurcation stenting are not well characterized. OBJECTIVES: In a prespecified analysis of the OCTOBER (European Trial on Optical Coherence Tomography Optimized Bifurcation Event Reduction) trial, we aimed to: 1) determine the incidence and characterize mechanisms of USD identified by optical coherence tomography (OCT); and 2) evaluate physician's detection and correction of accidental abluminal rewiring and USD. METHODS: OCT scans were analyzed for accidental abluminal rewiring and USD. When USD was identified, the plausible mechanism was determined by analysis of all procedural OCT scans and the corresponding angiograms. RESULTS: USD was identified by the core lab in 9.3% (55/589) of OCT-guided cases. Accidental abluminal rewiring was the cause in 44% (24/55), and guide catheter collision was the cause in 40% (22/55) of cases. USD was found in 18.5% of all cases with left main bifurcation percutaneous coronary intervention. The total incidence of abluminal rewiring was 33 in 32 OCT-guided cases (5.4%) and was corrected by physicians in 18 of 33 appearances (54.5%). The 2-year major adverse cardiac event rate for patients with untreated USD (n = 30) was 23.3%, whereas patients with confirmed or possibly corrected USD (n = 25) had no events during follow-up. CONCLUSIONS: USD was associated with adverse procedural complications and cardiac events during follow-up when not identified and corrected. The predominant mechanisms were undetected abluminal rewiring and guide catheter collision. Left main bifurcation percutaneous coronary intervention was a particular risk with USD detected in 18.5% of cases.