Predictors, treatment, and long-term outcomes of coronary perforation during retrograde percutaneous coronary intervention via epicardial collaterals for recanalization of chronic coronary total occlusion.

OBJECTIVE: To investigate predictors, treatment, and long-term outcomes associated with coronary perforation (CP) in patients who underwent retrograde percutaneous coronary intervention (PCI) through epicardial collaterals for chronic total occlusion (CTO). BACKGROUND: Data regarding CP during retrograde PCI through epicardial collaterals for CTO are scarce. METHODS: We included 155 patients who underwent retrograde CTO PCI through epicardial collaterals at Guangdong Cardiovascular Institute from August 2011 to December 2017. The median follow-up was 2.5 years. Major adverse cardiac events (MACEs) were analyzed using the Kaplan-Meier method, and independent predictors of long-term MACE were determined using a multivariable Cox model. RESULTS: CP occurred in 24 (15.5%) patients, with the frequency of Ellis classes 1 or 2 and 3 being 41.7% and 58.3%, respectively. Seven (4.5%) patients had tamponade, which was effectively managed using coil embolization and pericardiocentesis. Renal dysfunction (odds ratio [OR]: 5.27; 95% confidence interval [CI]: 1.47-18.88; P = 0.011), right coronary artery (RCA) CTO (OR: 4.34; 95% CI: 1.29-14.63; P = 0.018), and Epi-CTO score ≥ 2 (OR: 3.27; 95% CI: 1.12-9.58; P = 0.030) were independent predictors of CP. At the 7-year follow-up, 17 patients had MACE. Multivariable analysis revealed that CP was not associated with worse long-term clinical outcomes (hazard ratio: 1.55; 95% CI: 0.45-5.32, P = 0.484). CONCLUSIONS: Retrograde CTO PCI through epicardial collaterals is at increased risk of CP, which is associated with renal dysfunction, RCA CTO, and Epi-CTO score ≥ 2. Prompt and proper management of CP is important. CP is not significantly associated with adverse clinical outcomes.

Case report of familial sudden cardiac death caused by a DSG2 p.F531C mutation as genetic background when carrying with heterozygous KCNE5 p.D92E/E93X mutation.

BACKGROUND: Sudden cardiac death (SCD) induced by malignant ventricular tachycardia (MVT) among young adults with right ventricular cardiomyopathy/dysplasia (ARVC/D) is a devastating event. Parts of ARVC/D patients have a mutation in genes encoding components of cardiac desmosomes, such as desmoglein-2 (DSG2), plakophilin-2 and desmoplakin. CASE PRESENTATION: Here we report a potentially pathogenic mutation in the DSG2 gene, which was identified in a family with ARVC/D using Whole Exome Sequencing (WES) and Sanger Sequencing. In all, Patient III:1 with ARVC/D carried the compound heterozygous mutations of DSG2 p.F531C and KCNE5 p.D92E/E93X, which were both inherited from her mother (II:2), who died of SCD. Carriers of DSG2p.F531C showed various phenotypes, such as ARVC/D, SCD, MVT and dilated cardiomyopathy. For III:1, there were significant low-voltage regions in the inferior-apical, inferior-lateral wall of the right ventricular epicardium and outflow tracts of the right ventricle. Under the guidance of a three-dimensional mapping system, MVT was successfully ablated with an epicardial-endocardial approach targeting for late, double or fragmental potentials after implantable cardioverter-defibrillator (ICD) electrical storms. No VT recurrence was observed during the one year of follow-up. CONCLUSIONS: When coexisting with heterozygous KCNE5 p.D92E/E93X, heterozygous DSG2 p.F531C as a genetic background was found to predispose to ARVC/D, SCD and MVT, which were successfully ablated using an epicardial-endocardial approach.

Epicardial collateral channel for retrograded recanalization of chronic total occlusion percutaneous coronary intervention: Predictors of failure and procedural outcome.

OBJECTIVES: This study set out to identify significant lesion features of chronic total occlusion (CTO) that predict successful retrograde recanalization via epicardial collateral channels (CCs). BACKGROUND: Epicardial CCs remain essential in retrograde percutaneous coronary intervention (PCI) of CTO. However, the unpredictability of success and occurrence of complications limit the application of epicardial CCs for retrograde PCI technique for CTO. METHODS: 103 retro-recanalization cases were analyzed using epicardial CCs with successful recanalization as an end point. Clinical and angiography data were collected. RESULTS: The total success rate was 76.3%. Independent predictors associated with technical success included CCs tortuosity, side branch at CCs tortuosity, inadequate CCs Size and inadequate CCs exit location. Assigning a score of one for each variable, four levels of difficulty were obtained and formed the EPI-CTO score (Epicardial CTO). This score had significant predictive value for the likelihood of successful recanalization (AUC: 0.94, 95%CI: 0.89-0.98). Coronary and CCs perforation occurred in 6 and 10 cases respectively. Four cases including two coronary and two CCs perforations had tamponade that needed pericardiocentesis. CONCLUSIONS: Using epicardial CCs for retrograde approach of CTO PCI is effective. Complication rate was acceptable. We found four independent predictors relative to procedure success.

Usefulness and Safety of a Novel Modification of the Retrograde Approach for the Long Tortuous Chronic Total Occlusion of Coronary Arteries.

The aim of this study was to evaluate the feasibility and efficacy of the Guidezilla guide extension catheter in a reverse controlled antegrade and retrograde subintimal tracking (CART) technique for chronic total occlusion (CTO) recanalization.We retrospectively collected 80 CTO cases using reverse CART technology from January 2015 to October 2015 and 20 CTO cases using Guidezilla reverse-CART technology from October 2015 to March 2016. Guidezilla was applied in cases when it was difficult to advance a retro-guidewire through an occlusion segment into the antegrade guide catheter.The Guidezilla group had more cases with an occlusion longer > 20 mm (100.0% versus 72.5%, P = 0.005) and "bending > 45°" (90.0% versus 63.7%, P = 0.029) than the non-Guidezilla group, while the non-Guidezilla group had more retry lesions (25.0% versus 63.8%, P = 0.002). The septal collateral channel was the preferred choice for retro-recanalization in both groups (90.0% in Guidezilla group and 68.8% in non-Guidezilla group). All cases in the Guidezilla group achieved technical success with a TIMI 3 flow in the distal true lumen (100.0% versus 75.0% in non-Guidezilla group, P = 0.010). Cardiac tamponade and perforation in the epicardial artery was observed in 1 case each in the Guidezilla group. In the non-Guidezilla group, 19 complications occurred during the PCI procedure. No target vessel revascularization or in-hospital death occurred in either group.CTO lesions using the Guidezilla guide extension catheter to facilitate entry to an antegrade catheter in reverse CART technology is convenient and safe with a high success rate.

Clinical Prediction Score for Successful Retrograde Procedure in Chronic Total Occlusion Percutaneous Coronary Intervention.

OBJECTIVE: To develop and validate a prediction score for a successful retrograde procedure in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: A total of 228 CTO lesions in 223 patients who underwent PCI by retrograde approach were analyzed. All subjects were randomly grouped to a derivation set and a validation set at a ratio of 2:1. A successful retrograde procedure was set as the end point. Each of the identified predictors for the end point by logistic regression was assigned 1 point and summed. RESULTS: Independent predictors of a successful retrograde procedure were Werner's score [odds ratio (OR) 4.841, 95% confidence interval (CI) 1.952-12.005, p = 0.001], diameter of distal CTO segment (OR 5.263, 95% CI 2.067-13.398, p < 0.001) and tortuous collateral (type b; OR 0.119, 95% CI 0.032-0.444, p = 0.002). The predictive model developed in the derivation set stratified the difficulty of achieving a successful retrograde procedure into 4 grades - very difficult (10.5%), difficult (23.7%), intermediate (50.7%) and easy (15.1%) - and was demonstrated significantly in the validation set: very difficult (15.8%), difficult (18.4%), intermediate (47.4%) and easy (18.4%). The area under the receiver-operating characteristic curve was 0.832 ± 0.042 for the derivation set and 0.912 ± 0.041 for the validation set with an almost equal performance. CONCLUSIONS: According to the experience of our center, this model performed excellently in predicting the difficulty in achieving a successful retrograde procedure.

Systematic analysis of myocardial immune progression in septic cardiomyopathy: Immune-related mechanisms in septic cardiomyopathy.

Background: The immune infiltration and molecular mechanisms underlying septic cardiomyopathy (SC) have not been completely elucidated. This study aimed to identify key genes related to SC and elucidate the potential molecular mechanisms. Methods: The weighted correlation network analysis (WGCNA), linear models for microarray analysis (LIMMA), protein-protein interaction (PPI) network, CIBERSORT, Kyoto Encyclopedia of Genes and Genomes pathway (KEGG), and gene set enrichment analysis (GSEA) were applied to assess the key pathway and hub genes involved in SC. Results: We identified 10 hub genes, namely, LRG1, LCN2, PTX3, E LANE, TCN1, CLEC4D, FPR2, MCEMP1, CEACAM8, and CD177. Furthermore, we used GSEA for all genes and online tools to explore the function of the hub genes. Finally, we took the intersection between differential expression genes (DEGs) and hub genes to identify LCN2 and PTX3 as key genes. We found that immune-related pathways played vital roles in SC. LCN2 and PTX3 were key genes in SC progression, which mainly showed an anti-inflammatory effect. The significant immune cells in cardiomyocytes of SC were neutrophils and M2 macrophages. Conclusion: These cells may have the potential to be prognostic and therapeutic targets in the clinical management of SC. Excessive anti-inflammatory function and neutrophil infiltration are probably the primary causes of SC.

Safety and Feasibility of Rotational Atherectomy for Retrograde Recanalization of Chronically Occluded Coronary Arteries.

Objective: To evaluate the safety and feasibility of rotational atherectomy (RA) in retrograde chronic total occlusion percutaneous coronary intervention (CTO-PCI) by analyzing immediate and long-term outcomes. Background: Recent evidence supports the safety and feasibility of RA in CTO-PCI. However, few studies have focused on the use of RA in a retrograde approach to percutaneous revascularization of chronic total occlusion (CTO) lesions and information on long-term outcomes is lacking. Methods: A total of 329 patients who underwent retrograde CTO-PCI, out of 1496 consecutive CTO-PCI patients from April 2017 to July 2020, were retrospectively recruited from the 2nd Cardiology Department of the Guangdong Provincial People's Hospital. 16 patients underwent RA (RA group) whilst 313 did not (non-RA group). Results: Technical (87.5% vs. 87.5) and procedural (85.9% vs. 87.5) success rates were similar between both groups. There was no difference concerning major procedural complications between groups (12.5% vs. 19.2%; p > 0.75). No in-hospital MACCEs was recorded in the RA group while there were eight MACCEs in the non-RA group (p > 0.99). In the RA group, 2 cases recorded perforation (1 target vessel perforation case and 1 branch vessel perforation), and 55 cases of vessel perforations/dissections were recorded in non-RA group including 18 target vessel perforations, 2 branch vessel perforations, 35 collateral vessel perforations (one patient died from cardiac tamponade). No difference was found in terms of the perforation rate between the two groups (p > 0.99). Over a mean follow-up period of 26.47 ± 14.46 months, use of RA in retrograde CTO-PCI did not result in an increased mortality rate [hazard ratio (HR) 1.58, 95% confidence interval (CI), 0.31-8.21, p = 0.65], major adverse cardiac and cerebral events (HR 0.99, 95% CI 0.35-2.79, p = 0.99) or overall rehospitalization rate (HR 1.27, 95% CI 0.44-3.67, p = 0.67). Adjusted Kaplan-Meier curves according to Cox regression model suggested several predictors influencing the all-cause mortality, cardiovascular mortality, MACCEs, stroke rate, non-fatal myocardial infarction, target vessel recanalization rate and rehospitalization rate in the comparison. Conclusions: Our study demonstrates that the in-hospital outcomes and long-term follow up events were the same between RA and non-RA retrograde CTO-PCI patients. RA offered an option for skillful operators in difficult cases when the lesion was severely calcified in retrograde CTO-PCI.

Clinical and genetic spectrum in Chinese families with Fabry disease: a single-centre case series.

AIMS: Fabry disease (FD) is an X-linked genetic disease caused by mutations in the GLA gene that leads to deficient activity of lysosomal enzymes, accumulation of globotriaosylceramide in multi-organ systems, and variant clinical manifestations. We aimed to detail the clinical and genetic spectrum of FD in Chinese families. METHODS AND RESULTS: Five male probands with unexplained left ventricular hypertrophy and their family members were investigated. Genetic screening was available in 11 subjects of the 5 families, 10 of whom proved to be carriers of either GLA gene mutation, including 3 previous reported missense mutations (c.128G > A, c.811G > A, c.950T > C), 1 novel missense mutation (c.37G > C), and 1 novel deletion mutation (c.1241delT). A total of 17 patients were definitely or possibly diagnosed of FD, given their clinical manifestations and hereditary nature of FD. Echocardiography demonstrated normal cardiac structure and function in six female patients. Electrocardiographic pre-excitation occurred in 80% (4/5) of men and 16.7% (1/6) of women. Six patients (6/14, 42.9%) had chronic kidney disease with decreased renal function and all were male (6/7, 85.7%). Six patients presented with acroparesthesia, hypohidrosis, or both. Three female patients and two male patients experienced sudden death, and one male patient with the mutation (c.128G > A) died of progressive heart failure, between 41 and 66 years of age. CONCLUSIONS: We reported five unrelated families of FD with different GLA mutations. Clinical manifestations were highly heterogeneous between male and female patients even within the same family. Female patients showed relatively low risks of structural heart disease and renal insufficiency. However, the long-term outcomes might be adverse in both sexes. Our study underlines the importance of molecular screening of the GLA gene for early identification and clinical decision making in patients with FD.

Successful treatment of complex coronary chronic total occlusions improves midterm outcomes.

BACKGROUND: Data regarding outcomes of percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) is still limited. Our aim was to evaluate clinical outcomes in patients after successful CTO PCI when compared to patients with failed PCI. METHODS: The cohort study enrolled 145 eligible patients with attempted PCI of CTO. Detailed baseline clinical and procedural data, and in-hospital complications were analyzed. The primary end point was occurrence of major adverse cardiac events (MACE). RESULTS: Median follow-up was 11.49±2.01 months. Successful revascularization was associated with a significantly lower 1-year MACE compared to failed revascularization [hazard ratio (HR): 0.026; 95% confidence interval (CI): 0.004-0.176; P=0.0002]. A J-CTO score of ≥3 was associated with a significantly higher 1-year MACE compared with a J-CTO score of <3 in patients undergoing PCI (HR: 4.819; 95% CI: 1.463-15.870; P=0.0097). Moreover, in patients with a J-CTO score ≥3, success of CTO PCI was associated with significantly lower risk of 1-year MACE than failure of CTO revascularization (HR: 0.114; 95% CI: 0.023-0.569; P=0.0081). Multivariate analysis identified the J-CTO score (HR: 2.10; 95% CI: 1.09-4.04; P=0.026) as a positive predictor, and the success of CTO PCI (HR: 0.17; 95% CI: 0.05-0.59; P=0.005) as a negative significant independent predictor of MACEs. CONCLUSIONS: Among patients with CTOs, high J-CTO score was independently associated with worse clinical outcomes. Furthermore, successful PCI was associated with a lower risk of midterm MACE compared with failed revascularization of CTOs.

[Clinical analysis of coronary artery disease in elderly patients with sleep disordered breathing].

OBJECTIVE: To understand the prevalence of sleep disordered breathing (SDB) in elderly patients with coronary artery disease (CAD) and explore the relations between SDB and CAD. METHODS: Sixty-two elderly patients with and 18 without CAD identified by coronary angiography underwent examinations by polysomnography (PSG). Left ventricular ejection fraction (LVEF) was measured by 99Tc equilibrium radionuclide angiography. RESULTS: In the 62 elderly patients with CAD, 53.2% had SDB, a rate significantly higher that (22.2%) in the 18 non-CAD patients. The CAD patients with SDB had higher respiratory disturbance index (RDI) and body mass index (BMI) and lower arterial saturation of oxygen (SaO2) during sleep, with longer duration of low SPO2 (less that 90%). The incidence of hypertension was higher in CAD patients with SDB than in those without SDB. No significant correlation was found between the severity of coronary artery disease and RDI (r=-0.16, P>0.05). CONCLUSION: The elderly patients with CAD have higher incidence of SDB, and appropriate interventions should be administered in those with severe SDB.

[Relationship between chronic congestive heart failure and sleep-disordered breathing in elderly patients].

OBJECTIVE: To determine the prevalence of sleep disordered breathing (SDB) in elderly patients with chronic congestive heart failure (CHF) and explore the relations between SDB and left ventricular function. METHODS: By means of polysomnography, 56 elderly patients with CHF were divided into non-SDB, mild SDB, moderate SDB, and severe SDB groups, and the left ventricular ejection fraction (LVEF) was measure by (99)Tc equilibrium radionuclide angiography. RESULTS: In the 56 elderly patients with CHF, 38 (67.9%) had SDB, including 12 (21.4%) mild SDB, 14 (25.0%) moderate SDB, and 12 (21.4%) severe SDB patients. Thirty (53.6%) of the 56 patients with CHF had obstructive sleep apnea (OSA), 4 (7.1%) had central sleep apnea and 22 (39.2%) had mixed sleep apnea. The moderate and severe SDB groups had lower minimum arterial oxyhemoglobin saturation during sleep than the non-SDB groups, and the apnea-hyponea index was closely related to LVEF (r=-0.74, P<0.01). CONCLUSION: The prevalence of SDB, predominantly OSA, is high in elderly patients with CHF. Moderate and severe SDB might affect the left ventricular function in these patients, who require polysomnography monitoring.