Impact of Bifurcation Involvement and Location in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights from the EuroCTO Registry.

Bifurcation involvement close to or within the occluded segment poses increasing difficulties for chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). However, this variable is not considered in the angiography-based CTO scoring systems nor has been extensively investigated in large multicenter series. Accordingly, we analyzed a CTO-PCI registry involving 92 European centers to explore the incidence, angiographic and procedural characteristics, and outcomes specific to CTO-PCIs with bifurcation involvement. A total of 3948 procedures performed between January and November 2023 were examined (33% with bifurcation involvement). Among bifurcation lesions, 38% and 37% were located within 5mm of the proximal and distal cap, respectively, 16% within the CTO body, and in 9% of cases proximal and distal bifurcations coexisted. When compared with lesions without bifurcation involvement, CTO bifurcation lesions had higher complexity (J-CTO 2.33±1.21 vs 2.11±1.27, p<0.001) and were associated with higher use of additional devices (dual-lumen microcatheter in 27.6% vs 8.4%, p<0.001, and intravascular ultrasound in 32.2% vs 21.7%, p<0.001). Radiation dose (1544[836-2819] vs 1298.5[699.1-2386.6]mGy, p<0.001) and contrast volume (230[160-300] vs 190[130-250]ml, p<0.001) were also higher. Technical success was similar (91.5% with bifurcation involvement vs 90.4% without bifurcation involvement, p=0.271). However, the bifurcation lesions within the CTO segment (intralesion) were associated with lower technical success than the other bifurcation location subgroups (83.7% vs 93.3% proximal, 93.4% distal, and 89.0% proximal & distal, p<0.001). On multivariable analysis, the presence of an intralesion bifurcation was independently associated with technical failure (OR 2.19, 95%CI 1.52-3.16, p=0.001). In conclusion, bifurcations are present in approximately one third of CTOs undergoing PCI. PCI of CTOs with bifurcation can be achieved with high success rates except for bifurcations within the occluded segment, that were associated with higher technical failure.

Association between excess catecholamine synthesis and polymorphic premature ventricular contraction.

BACKGROUND: The reasons for the etiology of premature ventricular contractions (PVCs) are not specifically known. Many patients are resistant to medical treatment, and a factor that would predict response to medical treatment cannot be identified. This study aims to investigate if a high catecholamine level results in polymorphic PVC. METHODS: This study was obtained by prospective data registry analysis. A total of 100 patients, 50 from the PVC group, and 50 from the control group have been evaluated. The participants who were included in the patient group had a polymorphic PVC of 5% or more in their 24-h Holter evaluations. Metanephrine showing the level of adrenaline and normetanephrine, showing the level of noradrenaline levels have been measured from these urine samples. RESULT: There was no difference between the two groups in terms of biochemical and essential characteristics. Normetanephrine level has been significantly higher in the PVC group compared to the control group (323.9 ± 208.9 µg to 129.25 ± 67.88 µg; p < 0.001). Similarly, metanephrine level has also been higher in the PVC group (124.75 ± 82.43 µg to 52.615 ± 36,54 µg; p < 0.001). A positive and moderate correlation has been identified between the number and ratio of PVC and the metanephrine and normetanephrine levels. CONCLUSION: In this study, we found that the catecholamine levels were higher in the polymorphic PVC group than in the healthy volunteers. Also, an increase in the number and rate of PVC has been observed as the catecholamine levels increased. CLINICAL TRIAL REGISTRATION: Urine Levels of Metanephrine and Normetanephrine in Patients With Frequent PVC; ClinicalTrials.gov number NCT03447002.

Are Thiols Useful Biomarkers for Coronary Collateral Circulation in Patients with Stable Coronary Artery Disease?

Our aim was to investigate the relationship between thiol, which is the main component of the antioxidant system, and coronary collateral circulation (CCC). Our patients consisted of people with stable coronary artery disease (sCAD) and total occlusion in at least one vessel (n = 249). We divided the patients into two groups, good and poor, according to their CCC degree. We determined that DM, total thiol, and disulfide are independent predictors of poor CCC in multivariate logistic regression analysis (OR: 1.012, 95% CI: 1.008-1.017, p < 0.001; OR: 1.022, 95% CI: 1.000-1.044, p = 0.044; OR: 2.671, 95% CI: 1.238-5.761, p = 0.012, respectively). The ROC analysis showed a cut-off value of 328.7 for native thiol regarding the prediction of poor CCC, with 67.4% specificity and 78% sensitivity. For disulfide, it revealed a cut-off value of 15.1 regarding the prediction of poor CCC, with 57.9% specificity and 69.5% sensitivity. In this study, we detected that the patients with sCAD who developed poor CCC had lower levels of native thiol, total thiol, and disulfide compared to those with good CCC. The most interesting finding of our study is that CCC formation is an effective predictor of the antioxidant cascade rather than the inflammation cascade in sCAD patients.

Value of increased CRP/albumin ratio in predicting embolic events in patients with infective endocarditis.

Background: The CRP/albumin ratio (CAR), a new inflammatory marker, is associated with adverse outcomes in various cardiovascular diseases. We evaluated the effectiveness of CAR in predicting embolic events in patients diagnosed with infective endocarditis (IE). Methods: A total of 145 patients with IE were included in the study and categorized into two groups according to the presence of embolic events. We retrospectively analyzed the patients' clinical, laboratory and echocardiographic data. Results: CRP (94.2 vs 63.3; p < 0.001) and CAR (25.8 vs 15.1; p < 0.001) values were significantly higher in patients who experienced embolic events. Multivariate analysis showed that a high CAR value (odds ratio: 1.030; 95% CI: 1.000-1.060; p = 0.041) was an independent predictor of embolic events in patients with IE. Conclusion: The CAR is a cheap and easily accessible marker that can predict the development of embolic events in patients diagnosed with IE.

Contemporary In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the MENATA (Middle East, North Africa, Turkey, and Asia) Chapter of the PROGRESS-CTO Registry.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been rapidly evolving in different parts of the world. We examined the clinical and angiographic characteristics and procedural outcomes of 1,079 consecutive CTO PCIs performed in 1,063 patients at 10 centers in the Middle East, North Africa, Turkey, and Asia regions between 2018 and 2022. The mean age was 61 ± 10 years and 82% of the patients were men. The prevalence of diabetes (49%) and previous PCI (50%) was high. The most common target vessel was the right coronary artery (51%), followed by the left anterior descending artery (33%) and the circumflex artery (15%). The mean Japanese CTO score was 2.1 ± 1.2 and mean PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) score was 1.2 ± 1.0. The technical and procedural success rates were high (91% and 90%, respectively) with a low incidence (1.6%) of in-hospital major adverse cardiac events. The incidence of perforation was 4.6% (n = 50): guidewire exit was the most common mechanism of perforation (48%) and 14 patients required pericardiocentesis (28%). Antegrade wire escalation was the most common crossing strategy used (91%), followed by retrograde approach (24%) and antegrade dissection and re-entry (12%). Median contrast volume, air kerma radiation dose, and fluoroscopy time were 300 (200 to 400) ml, 3.7 (2.0 to 6.3) Gy, and 40 (25 to 65) minutes, respectively. In conclusion, high success and acceptable complication rates are currently achieved at experienced centers in the Middle East, North Africa, Turkey, and Asia regions using a combination of crossing strategies.

Predictive Values of Systemic Immune-Inflammation Index in New-Onset Atrial Fibrillation Following Coronary Artery Bypass Grafting

ABSTRACT Introduction: We investigated the relationship between the newly-defined systemic immune-inflammation index and the new-onset atrial fibrillation in patients undergoing coronary artery bypass grafting. Method: This study included 392 patients who underwent coronary artery bypass grafting. We divided the participants into two groups as those with and without new-onset atrial fibrillation. Prior to coronary artery bypass grafting, we evaluated blood samples, including systemic immune-inflammation index, and other laboratory parameters of the patients. We formulized the systemic immune-inflammation index score as platelet × neutrophil/lymphocyte counts. Results: The findings revealed that new-onset atrial fibrillation occurred in 80 (20.4%) of 392 patients during follow-ups. Such patients had higher systemic immune-inflammation index, neutrophil/lymphocyte ratio, and C-reactive protein levels than those who did not develop new-onset atrial fibrillation (P<0.001, P<0.001, P=0.010, respectively). In receiver operating characteristic curve analysis, systemic immune-inflammation index levels > 712.8 predicted new-onset atrial fibrillation with a sensitivity of 85% and a specificity of 61.2% (area under the curve: 0.781, 95% confidence interval: 0.727-0.835; P<0.001). Conclusion: Overall, systemic immune-inflammation index, a novel inflammatory marker, may be used as a decisive marker to predict the development of atrial fibrillation following coronary artery bypass grafting.

Increased Serum Systemic Immune-Inflammation Index is Independently Associated With Severity of Carotid Artery Stenosis.

Stroke is a significant contributor to morbidity and mortality. The present study investigated how the systemic immune inflammation index (SII) could be used to predict the likelihood of developing carotid artery stenosis (CAS), which can be seen using carotid artery angiography (CAAG). This study comprised 418 individuals who underwent CAAG for CAS. SII was calculated by multiplying the platelet count by the neutrophil/lymphocyte ratio (NLR). The patients were divided into two groups: non-critical and critical CAS (stenosis below %70 and above ≥70%, respectively). Compared with the non-critical CAS, the critical CAS group had greater high sensitivity C-reactive protein levels (4.5 [3.1-5.7] vs 3.9 [2-5] [mg/L], P < .001), NLR (4.1 [2.9-7.5] vs 2.9 [1.8-3.7], P < .001), platelet/lymphocyte ratio (233 [110-297] vs 119 [96-197], P < .001), and SII (860 [608-2455] vs 604 [458-740], P < .001). Receiver Operating Characteristic Curve analysis demonstrated the best cutoff value of 672.3 for SII to predict the critical CAS with 71.2% sensitivity and 60.1% specificity. According to our study, an increase in SII is an independent predictor of the severity of CAS in patients undergoing CAAG.

Predictive Values of Systemic Immune-Inflammation Index in New-Onset Atrial Fibrillation Following Coronary Artery Bypass Grafting.

INTRODUCTION: We investigated the relationship between the newly-defined systemic immune-inflammation index and the new-onset atrial fibrillation in patients undergoing coronary artery bypass grafting. METHOD: This study included 392 patients who underwent coronary artery bypass grafting. We divided the participants into two groups as those with and without new-onset atrial fibrillation. Prior to coronary artery bypass grafting, we evaluated blood samples, including systemic immune-inflammation index, and other laboratory parameters of the patients. We formulized the systemic immune-inflammation index score as platelet × neutrophil/lymphocyte counts. RESULTS: The findings revealed that new-onset atrial fibrillation occurred in 80 (20.4%) of 392 patients during follow-ups. Such patients had higher systemic immune-inflammation index, neutrophil/lymphocyte ratio, and C-reactive protein levels than those who did not develop new-onset atrial fibrillation (P<0.001, P<0.001, P=0.010, respectively). In receiver operating characteristic curve analysis, systemic immune-inflammation index levels > 712.8 predicted new-onset atrial fibrillation with a sensitivity of 85% and a specificity of 61.2% (area under the curve: 0.781, 95% confidence interval: 0.727-0.835; P<0.001). CONCLUSION: Overall, systemic immune-inflammation index, a novel inflammatory marker, may be used as a decisive marker to predict the development of atrial fibrillation following coronary artery bypass grafting.

Association of spontaneous echo contrast with Systemic Immune Inflammation Index in patients with mitral stenosis.

OBJECTIVE: Spontaneous echo contrast (SEC) is the appearance of swirling, smoke-like echoes in the left atrium (LA) and is accepted as an independent predictor of thromboembolic risk. There is an established relationship between the inflammatory state and the prothrombotic state. Therefore, we investigated the relationship between the Systemic Immune Inflammation Index (SII), a new inflammation parameter introduced recently, and SEC in patients with mitral stenosis (MS). MATERIAL AND METHODS: A total of 262 patients who underwent percutaneous mitral valvuloplasty (PMBV) for MS were included in this study. The patients were divided into two groups: patients with MS complicated by SEC and patients with MS without SEC, based on whether SEC occurred in the LA. RESULTS: There were 79 patients (mean age 47.1 ± 6.6, 30.3% male gender) in the SEC (+) group, while there were 183 patients (mean age 46.4 ± 8.6, 29.5% male gender) in the SEC (-) group. In multivariate analysis, high levels of SII were an independent risk factor for SEC in patients with MS (OR: 1.001, 95% confidence interval (CI): 1.000-1.001, p<0.001) together with high levels of C-reactive protein (OR: 1.145, 95% CI: 1.027-1.277, p=0.014). The receiver operating characteristics (ROC) curve analysis showed that at a cutoff value of 547.6 for SII to predict SEC with 74.6% sensitivity and 77.6% specificity (area under ROC curve=0.736 (95% CI: 0.668-0.805), p<0.001). CONCLUSION: Our study showed that the SII levels were independently associated with SEC in patients with MS.

Endothelial Progenitor Cells and NADPH Oxidase Enzyme Activity in the Development of an Aortic Aneurysm

Abstract Introduction: Endothelial progenitor cells (EPCs) and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase enzyme activity may affect the vessel wall and have a role in development of aortic aneurysms. EPCs originate from hematopoietic stem cells and can be enumerated from peripheral blood samples by flow cytometry. In this study, we aimed to evaluate the relation of EPC number and NADPH oxidase enzyme activity in the development of thoracic aortic aneurysm (TAA). Methods: Patients with TAA (n=30) and healthy individuals without TAA (control, n=10) were included in our study. Characterization and enumeration of EPC from peripheral blood samples were performed by flow cytometry with panels including markers of EPCs (CD34/CD133/CD309/CD146/CD144). Additionally, NADPH oxidase enzyme activity (capacity) was also measured by the dihydrorhodamine 123 (DHR 123) test. Results: The enumeration of EPC with CD34+/CD146+ marker showed that the number of mean EPC/106 cells was increased in the patient group (41.5/106 cells), but not in the control group (20.50/105 cells) (P<0.01). Additionally, patients with TAA presented significantly lower NADPH oxidase activity by DHR assay than healthy controls (mean stimulation index: 60.40± 7.86 and 75.10±5.21, respectively) (P<0.01). Conclusion: Our results showed that the number of EPCs is significantly higher in aortic aneurysm patients and may have a role in disease progression. The crosstalk between NADPH oxidase enzyme capacity and EPC number may be useful as a parameter to explain the clinical progression of TAA.

Femoral or Radial Approach in Treatment of Coronary Chronic Total Occlusion: A Randomized Clinical Trial.

OBJECTIVES: The aim of this study was to compare transradial access (TRA) with transfemoral access (TFA) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: TRA reduces the risk for vascular access complications but may make complex PCI, such as CTO PCI, more challenging. METHODS: FORT CTO (Femoral or Radial Approach in the Treatment of Coronary Chronic Total Occlusion) (NCT03265769) was a prospective, noninferiority, randomized controlled study of TRA vs TFA for CTO PCI. The primary study endpoint was procedural success, defined as technical success without any in-hospital major adverse cardiovascular events. The secondary study endpoint was major access-site complications. RESULTS: Between 2017 and 2021, 610 of 800 patients referred for CTO PCI at 4 centers were randomized to TRA (n = 305) or TFA (n = 305). Mean J-CTO (Multicenter CTO Registry in Japan) (2.1 ± 0.1 vs 2.2 ± 0.1; P = 0.279), PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) (1.3 ± 0.9 vs 1.1 ± 1.0; P = 0.058) and PROGRESS CTO complication (2.4 ± 1.8 vs 2.3 ± 1.8; P = 0.561) scores and use of the retrograde approach (11% vs 14%; P = 0.342) were similar in the TRA and TFA groups. TRA was noninferior to TFA for procedural success (84% vs 86%; P = 0.563) but had fewer access-site complications (2.0% vs 5.6%; P = 0.019). There was no difference between TFA and TRA in procedural duration, contrast volume, or radiation dose. CONCLUSIONS: TRA was noninferior to TFA for CTO PCI but had fewer access-site complications.

A Novel Predictor of Contrast-Induced Nephropathy in Patients With Carotid Artery Disease; the Systemic Immune Inflammation Index.

Contrast-induced nephropathy (CIN) is associated with increased mortality and morbidity. The present study investigated the role of systemic immune inflammation index (SII) in predicting the risk of developing CIN after carotid artery angiography (CAAG). This study included 262 patients who underwent CAAG for symptomatic carotid artery stenosis (CAS). Simultaneous carotid stenting was applied to 232 of these patients. CIN was defined as an increase in serum creatinine level ≥.5 mg/dL or ≥25% above baseline within 72 hours after the procedure. The SII score was calculated as platelet × neutrophil/lymphocyte counts. Patients who developed CIN, had higher glucose (P = .009), total cholesterol (P < .001), low density lipoprotein cholesterol (<.001), and high sensitivity C-reactive protein (P = .001) levels, as well as greater neutrophil counts (P < .001), platelet counts (P < .001), neutrophil-lymphocyte ratio (P < .001), and SII score (P < .001) than those who did not develop CIN. The Receiver Operating Characteristic analysis showed that at a cutoff of 519.9, the SII exhibited 80% sensitivity and 64% specificity for detecting CIN. SII levels on admission were independently associated with CIN development after CAAG in patients with CAS.

Endothelial Progenitor Cells and NADPH Oxidase Enzyme Activity in the Development of an Aortic Aneurysm.

INTRODUCTION: Endothelial progenitor cells (EPCs) and nicotinamide adenine dinucleotide phosphate (NADPH) oxidase enzyme activity may affect the vessel wall and have a role in development of aortic aneurysms. EPCs originate from hematopoietic stem cells and can be enumerated from peripheral blood samples by flow cytometry. In this study, we aimed to evaluate the relation of EPC number and NADPH oxidase enzyme activity in the development of thoracic aortic aneurysm (TAA). METHODS: Patients with TAA (n=30) and healthy individuals without TAA (control, n=10) were included in our study. Characterization and enumeration of EPC from peripheral blood samples were performed by flow cytometry with panels including markers of EPCs (CD34/CD133/CD309/CD146/CD144). Additionally, NADPH oxidase enzyme activity (capacity) was also measured by the dihydrorhodamine 123 (DHR 123) test. RESULTS: The enumeration of EPC with CD34+/CD146+ marker showed that the number of mean EPC/106 cells was increased in the patient group (41.5/106 cells), but not in the control group (20.50/105 cells) (P<0.01). Additionally, patients with TAA presented significantly lower NADPH oxidase activity by DHR assay than healthy controls (mean stimulation index: 60.40± 7.86 and 75.10±5.21, respectively) (P<0.01). CONCLUSION: Our results showed that the number of EPCs is significantly higher in aortic aneurysm patients and may have a role in disease progression. The crosstalk between NADPH oxidase enzyme capacity and EPC number may be useful as a parameter to explain the clinical progression of TAA.

Identification of subclinical myocardial dysfunction by Speckle Tracking Imaging in patients with myocardial infarction with non-occlusive coronary arteries (MINOCA).

PURPOSE: The objective of this study was to investigate subclinical left ventricular dysfunction in patients diagnosed with myocardial infarction with non-occlusive coronary arteries (MINOCA). METHODS: Thirty-five patients with MINOCA (average age 54.26 ± 12.24 years) and thirty-five patients with ischemia with non-obstructed coronary artery disease (INOCA) (average age 55.20 ± 8.36 years) were enrolled in the study. All clinical conditions that could affect left ventricular functions were considered exclusion criteria. Echocardiographic studies were conducted in the patient and control groups in the left lateral decubitus position using a medical ultrasound device (EPIQ 7, Philips Medical System, USA). The left ventricle was examined longitudinally with apical images of chamber 4-3-2 using the available software (QLAB 6.0). RESULTS: There were no differences in age, blood pressure level, baseline echocardiogram measurements, and tissue Doppler parameters between the two groups. In two-dimensional speckle tracking echocardiography (2D-STE) measurements, left ventricular longitudinal strain and strain rate in systole, early and late diastole from apical 4-3-2 chamber and global measurements of each parameter were significantly decreased in the MINOCA group compared to the INOCA group (p < 0.05). A significant negative correlation was observed between the global longitudinal strain rate and the troponin I in the MINOCA patients group (r=-0.43 p = 0.009). CONCLUSIONS: Our study showed that while standard echocardiographic parameters for patients diagnosed with MINOCA were normal, their left ventricular systolic and diastolic functions were reduced by the 2D-STE method.

Systemic immune inflammation index: a novel predictor for coronary collateral circulation.

AIM: Recently, a new inflammatory and prognostic marker has emerged called as Systemic Immune Inflammation Index (SII). In the current study, we searched the relation between SII and Coronary Collateral Circulation (CCC) formation in stable Coronary Artery Disease (CAD). MATERIALS & METHODS: 449 patients with stable CAD who underwent coronary angiography and documented coronary stenosis of 95% or more in at least one major coronary vessel were included in the study. The study patients were divided into two groups according to the Rentrop score as well CCC (Rentrop 2-3) and bad CCC (Rentrop 0-1). Blood samples for SII and other laboratory parameters were gathered from all the patients on admission. The SII score was formulized as platelet × neutrophil/lymphocyte counts. RESULTS: Patients, who had developed bad CCC had a higher C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), platelets/lymphocyte ratio (PLR) and SII levels compared to those who had developed well CCC (p < 0.001, for all). Multivariate logistic regression analysis showed that high levels of SII was an independent predictor of bad CCC (OR: 1.005, 95% confidence interval (CI): 1.003-1.006, p < 0.001) together with dyslipidemia, high levels of CRP and NLR. In Receiver Operator Characteristic curve (ROC) analysis, the optimal cutoff value of SII to predict poor CCC was found to be 729.8, with 78.4% sensitivity and 74.6% specificity (area under ROC curve = 0.833 (95% CI: 0.777-0.889, p < 0.001). CONCLUSION: We have demonstrated that SII, a novel cardiovascular risk marker, might be used as one of the independent predictors of CCC development.