Obesity paradox in patients with chronic total occlusion of coronary artery.

BACKGROUND: Obesity is associated with metabolic syndrome which increases further risk of coronary artery disease and adverse cardiovascular events. Impact of body mass index (BMI) on long-term outcome in patients with coronary chronic total occlusion (CTO) is less clear. METHOD AND RESULTS: From January 2005 to November 2020, a total of 1301 patients with coronary angiographic confirmed CTO were enrolled in our study. Patients were divided into two groups: low BMI group: 18-24.99 kg/m2 and high BMI group ≥25 kg/m2 . Clinical outcomes were 3-year all-cause mortality, 3-year cardiovascular mortality and 3-year non-fatal myocardial infarct. During the 3-year follow-up period, all-cause mortality was significantly higher in patients with low BMI group compared to those in high BMI groups (14% vs. 6%, p = .0001). Kaplan-Meier analysis showed patients with high BMI groups had significant better survival compared with those in low BMI group (p = .0001). In multivariate analysis, higher BMI was independently associated with decreased risk of 3-year all-cause mortality (Hazard ratio [HR]: 0.534; 95% confidence interval [CI]: 0.349-0.819, p = .004) after controlling for age, renal function, prior history of stroke, coronary artery bypass graft, co-morbidities with peripheral arterial disease, heart failure and revascularization status for CTO. In propensity-matched multivariate analysis, high BMI remained a significant predictor of 3-year all-cause mortality (HR, 0.525; 95% CI, 0.346-0.795, p = .002). CONCLUSION: Higher BMI was associated with better long-term outcome in patients with coronary CTO.

Long term clinical impact of successful recanalization of chronic total occlusion in patients with and without type 2 diabetes mellitus.

BACKGROUND: Diabetes mellitus is one of the risk factors for coronary artery disease and frequently associated with multivessels disease and poor clinical outcomes. Long term outcome of successful revascularization of chronic total occlusions (CTO) in diabetes patients remains controversial. METHODS AND RESULTS: From January 2005 to December 2015, 739 patients who underwent revascularization for CTO in Taipei Veterans General Hospital were included in this study, of which 313 (42%) patients were diabetes patients. Overall successful rate of revascularization was 619 (84%) patients whereas that in diabetics and non-diabetics were 265 (84%) and 354 (83%) respectively. Median follow up was 1095 days (median: 5 years, interquartile range: 1-10 years). During 3 years follow-up period, 59 (10%) in successful group and 18 (15%) patients in failure group died. Although successful revascularization of CTO was non-significantly associated with better outcome in total cohort (hazard ratio (HR): 0.593, 95% confidence interval (CI) 0.349-0.008, P: 0.054), it might be associated with lower risk of all-cause mortality (HR: 0.307, 95% CI 0.156-0.604, P: 0.001) and CV mortality (HR: 0.266, 95% CI 0.095-0.748, P: 0.012) in diabetics (P: 0.512). In contrast, successful CTO revascularization didn't improve outcomes in non-diabetics (all P > 0.05). In multivariate cox regression analysis, successful CTO revascularization remained an independent predictor for 3-years survival in diabetic subgroup (HR: 0.289, 95% CI 0.125-0.667, P: 0.004). The multivariate analysis result was similar after propensity score matching (all-cause mortality, HR: 0.348, 95% CI 0.142-0.851, P: 0.021). CONCLUSIONS: Successful CTO revascularization in diabetes may be related to better long term survival benefit but not in non-diabetic population.

Short-term and long-term clinical outcomes of rotational atherectomy in resistant chronic total occlusion.

OBJECTIVES: To evaluate the short- and long-term clinical outcomes of RA in CTO coronary intervention. BACKGROUND: The application of rotational atherectomy (RA) may improve the success rate of percutaneous recanalization of chronic total occlusion (CTO) with heavy calcification. METHODS: From January 2011 to September 2014, we enrolled 285 patients with CTO who underwent successful percutaneous coronary intervention (PCI). Resistant CTO lesions were defined as those with heavy calcifications as well as those that no devices are able to pass after guide wire crossing. RESULTS: All patients with resistant CTO lesions (n = 26) were successfully treated by RA without major complications, except 1 patient complicated with coronary perforation and treated by surgery successfully (success rate: RA group vs non-RA group: 96.2%, vs 89.5%, P = 0.038). Compared to the non-RA group, the patients in the RA group were older (P = 0.028), had higher J-CTO scores (P = 0.001), and needed longer stents (P = 0.001). All patients were followed up for a mean period of 3.4 ± 2.3 years, and the 1-year and long-term clinical outcomes of the RA group were excellent and comparable with those not receiving RA in multivariate analysis adjusted for multiple variables. CONCLUSION: The treatment of RA is safe and feasible for resistant CTO lesions with heavy calcification. The short- and long-term clinical outcomes of the treatment of RA were excellent and comparable with those not needing RA for CTO PCI.

Intravascular ultrasound guided wiring re-entry technique for complex chronic total occlusions.

BACKGROUND: The successful recanalization rate of chronic total occlusion (CTO) lesions without retrograde collaterals available is always low. Intravascular ultrasound (IVUS) may be useful to guide the subintimal guidewire to re-enter the true lumen. We evaluated the clinical feasibility and efficacy of the IVUS-guided wiring re-entry technique for these complex CTO lesions. METHODS: Twenty consecutive patients (19 male, mean age: 65.3 ± 12.8 years) with both failed antegrade and retrograde approaches were enrolled. The IVUS catheter was introduced into the subintimal space to identify the entry point into the subintimal space, and guide another stiff wire to re-enter the true lumen with the adjacent side-branch or first wire as markers, or using IVUS-guided parallel wire technique. RESULTS: The entry point into the subintimal space was identified by IVUS in all cases, and the IVUS-guided wiring re-entry technique succeeded in 17 cases (85%). No procedure-related complication was noted except one case of delayed cardiac tamponade due to the wire perforation. During the mean follow-up period of 1.9 ± 1.3 years, there was no adverse cardiac event, except one patient died of the complication of cardiac transplantation. CONCLUSION: The IVUS-guided wiringre-entry technique might be feasible and safe for the recanalization of complex CTO lesions.

The impact of successful revascularization of coronary chronic total occlusions on long-term clinical outcomes in patients with non-ST-segment elevation myocardial infarction.

OBJECTIVES: The purpose of this study was to assess the long-term clinical impact of revascularization of coronary concomitant coronary chronic total occlusion (CTO) in patients with Non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: CTO is associated with poorer prognosis in patients with NSTEMI. The evidence of revascularization of CTO in patients with NSTEMI is still conflicting. METHODS: Consecutive patients with NSTEMI and CTO who underwent percutaneous coronary intervention (PCI) within 72 h of admission from 2006 to 2015 were retrospectively recruited and analyzed. A total of 967 patients underwent PCI for NSTEMI. Among them, 106 (11%) patients had concomitant CTO and were recruited for analysis. CTO lesions were revascularized successfully in 67 (63.2%) patients (successful CTO PCI group), while the CTO in the remaining 39 patients were either not attempted or failed (No/failed CTO PCI group). RESULTS: The 30-day cardiac death and major adverse cardiac events (MACE) were significantly lower in the successful CTO PCI group (both cardiac death and MACE were 3% vs 30%, P < 0.001, respectively). A landmark analysis set at 30th day for 30-day survivals was performed. After a mean of 2.5-year follow-up, the long-term cardiac death was still significantly lower (16.9% vs 42.3%, P < 0.001), whereas the MACE showed a trend toward lower incidence (26.2% vs 40.7%, P = 0.051) in the successful CTO PCI group. In multivariate Cox regression analysis, successful revascularization of CTO is an independent protective predictor for long-term cardiac death (HR 0.310, 95% CI, 0.109-0.881, P = 0.028) in all population and in propensity-score matched cohort (P = 0.007). CONCLUSIONS: Successful revascularization of CTO was associated with reduced risk of long-term cardiac death in patients with NSTEMI and concomitant CTO.

Effects of aggressive predilatation, sizing, and postdilatation strategy for coronary bioresorbable vascular scaffolds implantation.

BACKGROUND: The results of the recent Amsterdam Investigator-Initiated Absorb Strategy All-Comers trial showed that the predilatation, sizing, and postdilatation (PSP) technique did not lower the long-term rates of scaffold thrombosis and adverse events. We evaluated the impact of aggressive PSP bioresorbable vascular scaffold (BRS) implantation on the short- and long-term clinical outcomes. METHODS: From June 2014 to December 2016, 150 patients with BRS implantation were enrolled and received successful percutaneous coronary intervention (PCI), of whom 104 received aggressive PSP technique (high-pressure predilatation and lesion preparation in addition to the traditional PSP technique). Short- and long-term outcomes were compared. RESULTS: All patients underwent successful PCI and BRS implantation with final Thrombolysis in Myocardial Infarction grade 3 flow. The baseline and procedure characteristics were similar in both groups. Debulking techniques were used in 13 (8.7%) patients. Intracoronary imaging modalities were used in 73 (48.7%) patients. After BRS implantation, no adverse events were observed within 30 days in both groups. During the mean follow-up period of 2.98 ± 0.77 years, 12 (8.0%) patients experienced major adverse cardiovascular events (MACEs), including one cardiovascular death (0.6%), three nonfatal myocardial infarction (2.0 %), and 11 target-vessel revascularization (7.3 %). Multivariate Cox regression analysis showed that aggressive PSP remained an independent protective factor for MACEs. Moreover, the use of intracoronary imaging and rotablation atherectomy was associated with better clinical outcomes. CONCLUSION: Lesion preparation by aggressive PSP in BRS implantation was associated with better long-term clinical outcomes.

The clinical impact of serum 1,5-anhydro-D-glucitol levels on coronary artery calcification and adverse outcomes assessed by coronary optical coherence tomography in diabetic patients.

Background: Serum 1,5-anhydro-D-glucitol (1,5-AG) is a novel biomarker for short-term glycemic status and postprandial hyperglycemia. The association between serum 1,5-AG levels and coronary artery calcification (CAC) through a quantitative assessment using optical coherence tomography (OCT) is unclear. We aimed to evaluate this association using OCT in patients with diabetes mellitus (DM). Methods: From June 2016 to December 2019, we prospectively enrolled 256 patients who underwent OCT-guided percutaneous coronary intervention (PCI). Half of the patients had diabetes. Patients were followed up for a mean period of 1.8 ± 0.8 years (median: 2.2 years). The relative calcium index and relative lipid core index measured by quantitative OCT analysis were used to evaluate the intra-plaque calcium and lipid levels of culprit plaques. We also analyzed the correlation between serum 1,5-AG levels and long-term major adverse cardiovascular events. Results: Serum 1,5-AG levels were significantly lower in diabetic patients than in non-diabetic patients (DM vs. non-DM: 55.6 ± 27.9 µg/mL vs. 63.7 ± 26.1 µg/mL, p = 0.016), and lower in fibrocalcified lesions than in fibrotic or fibrolipidic lesions (fibrocalcified vs. fibrotic or fibrolipidic: 42.8 ± 19.1 vs. 72.9 ± 25.2 or 66.4 ± 27.5 µg/mL, p < 0.001, respectively). In addition, we found a significant inverse correlation between serum 1,5-AG levels and relative calcium index (r = -0.729, p < 0.001). In multivariate Cox regression analysis, low serum 1,5-AG level was identified as an independent predictor for major adverse cardiovascular events in diabetic patients (p = 0.043), but not in non-diabetic patients (p = 0.748) after adjusting for age and sex. Conclusion: This study revealed that low serum 1,5-AG levels were associated with an increased risk of CAC as assessed by OCT, especially in diabetic patients. Low serum 1,5-AG levels may predict future major adverse cardiovascular events in diabetic patients undergoing OCT-guided PCI.

Association between asymmetric dimethylarginine and in-stent restenosis tissue characteristics assessed by optical coherence tomography.

BACKGROUND: Impaired bioavailability of endothelium-derived nitric oxide (NO) and endothelial dysfunction may play a pivotal role in the pathogenesis of in-stent restenosis (ISR) after coronary stenting. We aimed to investigate the relation between asymmetric dimethylarginine (ADMA), an endogenous NO synthase inhibitor, and the ISR lesions tissue characteristics assessed by optical coherence tomography (OCT). METHODS AND RESULTS: Forty-five patients with symptomatic ISR lesions (17 bare metal stents, 28 drug-eluting stents, medium implantation duration: 58.0 months) were evaluated by OCT for in-stent tissue characteristics and calcification. We defined neoatherosclerosis as the presence of lipid or calcified neointima in ISR lesions, and 12 (26.7%), 33 (73.3%) ISR lesions were classified as with homogenous neointima and neoatherosclerosis respectively. The patients with neoatherosclerosis have significantly higher plasma ADMA levels compared to those of patients with homogenous neointima (1.12 ±â€¯0.21 µmol/l versus 0.83 ±â€¯0.08 µmol/l, p < 0.001). Furthermore, the plasma ADMA level of ISR lesions with intra-stent calcification (n = 24, 53.3%) was also significantly higher than those of ISR lesions without (n = 21, 46.7%; p < 0.001). There was a highly significant association between plasma ADMA level and intra-stent relative calcium index (mean calcium arc × calcium length)/(360 × analyzed length) (p < 0.001, r = 0.702). In multivariate analyses adjusted for age, sex, diabetes, eGFR, plasma ADMA level remained the only significant predictor for the presence of neoatherosclerosis (p = 0.008) and intra-stent calcification (p < 0.001). In contrast, plasma ADMA level correlated with intra-stent relative lipid core index (mean lipid core arc × lipid core length)/(360 × analyzed length) only in subgroup without intra-stent calcification (p = 0.004, r = 0.596, multivariate-adjusted p = 0.022). CONCLUSIONS: Increased plasma ADMA levels were associated with the development of in-stent neoatherosclerosis and calcification.

Sleep apnea and risk of aortic dissection: A nonrandomized, pair-matched cohort study.

BACKGROUND: Sleep apnea (SA) was associated with increased prevalence of aortic dissection (AD) in studies that were criticized for either their small sample size or lack of prospective observation. Using a considerably larger nationwide, population-based database and a long-term prospective cohort design, our study strived to explore the relationship between SA and the subsequent development of AD. METHODS: From 2000 to 2007, we gathered a study cohort consisting of 15,848 newly diagnosed cases of SA from Taiwan's National Health Insurance Research Database. For the control group, another 39,826 individuals without SA were matched for age, sex, and comorbidity. The two cohorts were followed-up to observe the occurrence of AD. RESULTS: During an average 3.59 ± 2.41 years of follow-up, we observed 33 cases of new AD occurrence [non-SA (22, 0.1%) vs. SA (11, 0.1%), p=0.669], and the incidence of AD was similar for both groups. After adjusting for age, sex, and comorbidity, only age [hazard ratio (HR) 1.03; 95% confidence interval (CI), 1.01-1.06; p=0.006], male gender (HR 2.49; 95% CI, 1.07-5.79; p=0.034), and hypertension (HR 6.28; 95% CI, 2.36-16.67; p<0.001) were independently associated with AD diagnosis. CONCLUSION: SA was not associated with an increased risk of AD using a large nationwide cohort database. Nonetheless, larger prospective studies or meta-analyses are recommended to confirm our findings.