Cardiovascular outcomes of complex bifurcation lesions following double kissing crush or nano-crush techniques: The multicenter EVOLUTE-CRUSH V study.

BACKGROUND: Double kissing crush (DKC) and nano-crush (NC) techniques are frequently used, but the comparison for both techniques is still lacking. The goal of this multicenter study was to retrospectively assess the midterm clinical results of DKC and NC stenting in patients with complex bifurcation lesions (CBLs). METHODS: A total of 324 consecutive patients [male: 245 (75.6%), mean age: 60.73 ± 10.21 years] who underwent bifurcation percutaneous coronary intervention between January 2019 and May 2023 were included. The primary endpoint defined as the major cardiovascular events (MACE) included cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (TLR). Inverse probability weighting (IPW) was performed to reduce treatment selection bias. This is the first report comparing the clinical outcomes of DKC and NC stenting in patients with CBL. RESULTS: The initial revascularization strategy was DKC in 216 (66.7%) cases and NC in 108 (33.3%) patients. SYNTAX scores [25.5 ± 6.73 vs. 23.32 ± 6.22, p = 0.005] were notably higher in the NC group than the DKC group. The procedure time (76.98 ± 25.1 vs. 57.5 ± 22.99 min, p = 0.001) was notably higher in the DKC group. The incidence of MACE (18.5 vs. 9.7%, p = 0.025), clinically driven TLR (14.8 vs. 6%, p = 0.009), and TVMI (10.2 vs. 4.2%, p = 0.048) were notably higher in the NC group than in the DKC group. The midterm MACE rate in the overall population notably differed between the NC group and the DKC group (adjusted HR (IPW): 2.712, [95% CI: 1.407-5.228], p = 0.003). CONCLUSION: In patients with CBLs, applying the DKC technique for bifurcation treatment had better ischemia-driven outcomes than the NC technique.

Long-term cardiovascular outcomes after mini-crush or T and minimal protrusion techniques in complex bifurcation lesions: the EVOLUTE-CRUSH III study.

BACKGROUND: Mini-crush (MC) and T-stenting and small protrusion (TAP) techniques are frequently used, but the long-term comparison of both techniques in patients with complex bifurcation lesions (CBLs) is still a debatable issue. This study sought to retrospectively evaluate the long-term outcomes of MC and TAP techniques in patients with CBLs. METHODS: A total of 271 patients [male: 202 (78.9%), mean age: 58.90 ±â€…10.11 years] patients in whom complex bifurcation intervention was performed between 2014 and 2023 were involved. The primary endpoint was major cardiovascular events (MACE) as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization. The Cox proportional hazard models were adjusted by the inverse probability weighting approach to reduce treatment selection bias. RESULTS: The initial management strategy was MC in 146 patients and TAP in 125 cases. MACE occurred in 52 patients (19.2%) during a mean follow-up period of 32.43 ±â€…16 months. The incidence of MACE (13 vs. 26.4%, P = 0.005) and major cardiovascular and cerebral events (15.1 vs. 28.8%, P = 0.006) were significantly lower in the MC group than in the TAP group. Additionally, the incidence of definite or probable stent thrombosis was numerically lower in the MC group compared with the TAP group but did not differ significantly (2.7 vs. 8%, P = 0.059). The long-term MACE was notably higher in the TAP group than the MC group [adjusted hazard ratio (inverse probability weighted): 1.936 (95% confidence interval: 1.053-3.561), P = 0.033]. CONCLUSION: In this study involving patients with CBLs, percutaneous coronary intervention with the MC technique had better long-term outcomes than the TAP technique.

Comparison of long-term outcomes of double kissing crush versus T and minimal protrusion techniques in complex bifurcation lesions: The EVOLUTE-CRUSH II registry.

BACKGROUND: Double kissing (DK)-crush and T-stenting and small protrusion (TAP) techniques are gaining popularity, but the comparison for both techniques is still lacking. This study sought to retrospectively evaluate the long-term outcomes of DK-crush and TAP techniques in patients with complex bifurcation lesions. METHODS: A total of 255 (male: 205 [80.3%], mean age: 59.56 ± 10.13 years) patients who underwent coronary bifurcation intervention at a single-center between January 2014 and May 2021 were included. Angiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization (TLR). The regression models were adjusted applying by the inverse probability weighted (IPW) approach to reduce treatment selection bias. RESULTS: The initial management strategy was DK-crush in 152 (59.6%) patients and TAP in 103 (40.4%) cases. The SYNTAX scores (24.58 ± 7.4 vs. 24.26 ± 6.39, p = 0.846) were similar in both groups. The number of balloon (6.32 ± 1.82 vs. 3.92 ± 1.19, p < 0.001) usage was significantly higher in the DK-crush group than in the TAP group. The rates of TLF (11.8 vs. 22.3%, p = 0.025) and clinically driven TLR (6.6 vs. 15.5%, p = 0.020) were significantly lower in the DK-crush group compared to the TAP group. The long-term TLF was significantly higher in the TAP group compared to the DK-crush group (unadjusted HR: 1.974, [95% CI: 1.044-3.732], p = 0.035 and adjusted HR [IPW]: 2.498 [95% CI: 1.232-5.061], p = 0.011). CONCLUSION: The present study showed that the DK-crush technique of bifurcation treatment was associated with lower long-term TLF and TLR rates compared to the TAP technique.

Long-Term Evaluation of Revascularization Strategies for Medina 0.1.0 Left Main Bifurcation Lesions: The LM-CROSSOVER Registry.

The present study aimed to compare long-term outcomes of patients with Medina 0.1.0 left main (LM) bifurcation lesions treated by crossover stenting (COS) versus accurate ostial stenting (AOS). A total of 229 consecutive eligible patients with Medina 0.1.0 LM bifurcation lesions were enrolled and were stratified according to the stenting techniques. The primary end-point was major cardiovascular and cerebral events (MACCE), defined as the combination of all-cause death, target vessel related-myocardial infarction (MI), clinically driven target lesion revascularization (TLR), stroke, or stent thrombosis. COS and AOS were applied to 78 (34%) and 151 (66%) patients, respectively. During a mean of 40.6 ± 21.1 months of follow-up, the rate of MACCE (27.8 vs 12.8%; P=.007) was higher in patients treated with AOS than those treated with the COS technique, mainly driven by more frequent all-cause death (13.9 vs 3.8%, P = .013) and TLR (6.4 vs 15.9%; P = .029). In multivariable Cox regression analysis, AOS strategy was one of the independent predictors of MACCE (odds ratio: 2.166; 95% confidence interval, 1.080-4.340; P = .029). The current study suggests that COS was associated with a better long-term MACCE rate and lower all-cause mortality rate than AOS in patients with Medina 0.1.0 LM bifurcation disease.

Antihypertensive Efficacy Of Nebivolol And Low Dose Spironolactone In Patients With Resistant Hypertension.

OBJECTIVE: Resistant hypertension is associated with increased mortality and morbidity. The optimal medical therapy is not fully elucidated in resistant hypertension. There are relatively few studies in the literature on the treatment of resistant hypertension. In this study, we compared the effectiveness of nebivolol 5 mg, a third generation beta-blocker, with spironolactone 25 mg in patients with resistant hypertension. METHODS: A total of 81 patients with resistant hypertension were included in the study. The spironolactone group was composed of 38 patients while the nebivolol group was composed of 43 patients. Resistant hypertension was defined as having office blood pressure ≥ 140/90 mmHg while the patients were under 3 or more antihypertensive agents treatment which included diuretic agents. Office and ambulatory blood pressure at basal and after 8 weeks of treatment were recorded. RESULTS: Office systolic blood pressure and diastolic blood pressure in 24-hour ambulatory blood  pressure monitoring were significantly lower when compared to basal values in both nebivolol and spironolactone groups. The decrease in 24-hour mean systolic and diastolic blood pressure in nebivolol group was 14.9 ± 19.8 mmHg and 9.3 ± 12.7 mmHg compared to 19.5 ± 16.4 mmHg and 13.7 ± 10.8 mmHg in the spironolactone group, respectively. The decrease in 24-hour mean systolic and diastolic blood pressure was not significantly different between the nebivolol and spironolactone groups (P = 0.338 and P = 0.153). CONCLUSION: Nebivolol is an effective treatment option for resistant hypertension and the antihypertensive effect of nebivolol is similar to low-dose spironolactone.

Cardiovascular Outcomes After Mini-Crush or Double Kissing Crush Stenting Techniques for Complex Bifurcation Lesions: The EVOLUTE-CRUSH Registry.

Comparison of clinical outcomes of double kissing crush (DKC) and mini-crush (MC) techniques in patients with complex coronary bifurcation lesions is lacking. This study sought to determine the clinical results of DKC and MC stenting techniques in mid-term follow-up. This retrospective study included a total of 269 consecutive patients with complex bifurcation lesions who underwent percutaneous coronary intervention; 132 (49%) of them were treated with MC technique, whereas 137 (51%) treated with DKC technique. The primary end point was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. This is the first study to compare the cardiovascular outcomes of DKC and MC stenting techniques in patients with complex bifurcation lesions. The SYNTAX scores were similar in both groups (23 [20 to 30] vs 23 [19 to 28], p = 0.631)]. The number of balloons (6.31 ± 1.80 vs 4.42 ± 0.87, p <0.001) and guidewires (3.55 ± 0.83 vs 2.86 ± 0.74, p <0.001) used, fluoroscopy time (21.55 ± 7.05 vs 16.66 ± 4.19 minutes, p <0.001), and procedure time (80.42 ± 27.95 vs 69.61 ± 18.97 minutes, p <0.001) were significantly higher in the DKC group. The rate of composite TLF was similar in complex bifurcation patients treated with MC than those treated with the DKC technique (14% vs 12%, p = 0.453). Moreover, both groups had similar rates in terms of cardiac death or all-cause death, target vessel-related myocardial infarction, clinically driven target lesion revascularization, and stent thrombosis. In conclusion, the present study showed that both techniques of bifurcation treatment met high angiographic success with low complication and similar TLF rates.

A Novel Coronary Bifurcation Stenting Technique: Double Kissing Nano-Culotte Stenting.

Percutaneous coronary intervention (PCI) of coronary bifurcation lesion (CBL) is challenging due to its complex anatomy resulting in difficulty in deciding on treatment procedure. Although there are advanced techniques and well-experienced operators, the optimal stenting strategy is still debated. The contemporary PCI techniques of CBL aim to achieve minimal stent protrusion to the main vessel and to minimize stent layers at the neocarina as well as the side branch (SB) ostium and proximal main vessel (PMV). In addition, it is necessary to avoid incomplete stent coverage at the SB ostium and stent malapposition. Traditional 2-stent strategies have been improved using minimal stent protrusion to the main vessel (MV) and double kissing (DK) balloon dilatation to reach optimal results. Although the DK crush has been the prominent treatment modality,1 there are studies showing that the DK culotte stenting may have better results especially in terms of stent malapposition and metal layers at the neocarina.2 In our case report, we demonstrate a novel minimal protruded DK nanoculotte stenting technique for the treatment of true CBL.

Clinical implication of totally occluded infarct-related coronary artery in non-ST-segment elevation myocardial infarction: the TOTAL-NSTEMI study.

BACKGROUND: A subset ofpatients found to have total occlusion of the culprit artery (TOCA), present with non-ST-segment elevation myocardial infarction (NSTEMI) and elevated biomarkers. The aim of this study is to assess the effect of the TOCA in patients presenting with NSTEMI. METHODS: This multicenter observational study was retrospectively conducted between 2015 and 2019. Thrombolysis in myocardial infarction (TIMI) flow grades 0-1 was defined as the TOCA. The primary end point included a combination of all-cause death, myocardial infarction, target vessel revascularization, stent thrombosis, and stroke. RESULTS: Of 3272 patients, TIMI 0-1 flow in the culprit artery was present in 488 (14.9%) patients. TOCA was more likely to be of thrombotic origin (54.1% vs. 10.3%; P < 0.001) and visible collaterals (22.5% vs. 4.4%; P < 0.001). The rates of 30-day (14.3% vs. 7.2%; P < 0.001) and 2-year (25% vs. 19.1%; P = 0.003) primary end points were significantly higher in TOCA patients. Fatal arrhythmias were remarkably higher at 30-day (8.6% vs. 4%; P < 0.001) and 2-year (9% vs. 5.2%; P = 0.001) follow-ups. Mechanical complications were also higher in patients with TOCA at 30 days (0.8% vs. 0.2%; P = 0.013). Moreover, TOCA (OR, 1.379; P = 0.001) was one of the independent predictors of MACCE in NSTEMI patients. CONCLUSION: The current data suggest that patients with TOCA in the context of NSTEMI are at higher risk of MACCE, fatal arrhythmias, and mechanical complications.

Early echocardiographic evaluation of right ventricular load adaptability after sequential combination treatment in pulmonary arterial hypertension.

BACKGROUND: Using the tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP) ratio as an index of right ventricular load adaptability, we aimed to evaluate early changes in right heart contractile function of patients with group 1 pulmonary artery hypertension (PAH) after sequential combination PAH-specific therapy. METHODS: A total of 49 patients with group 1 PAH and 31 control participants were included in the study. The baseline clinical and echocardiographic data of the control and PAH group were compared. Subsequently, clinical and echocardiographic data of PAH patients before treatment and at 6 months after PAH-specific treatment were analyzed. RESULTS: A significant increase in the TAPSE/PASP ratio was found in patients at 6 months of PAH-specific treatment (0.25 ± 0.14; 0.33 ± 0.16, p < 0.001). Right atrial pressure (8 mm Hg [5-10]; 5 mm Hg [3-8], p < 0.001) and PASP (80.8 ± 30.6 mm Hg; 65.9 ± 25.7 mm Hg, p < 0.001) were significantly lower after sequential combination PAH-specific therapy. Negative correlations were found between the TAPSE/PASP ratio and N­terminal pro-B-type natriuretic peptide (r = -0.524, p < 0.001), tricuspid regurgitation velocity (r = -0.749, p < 0.001), right atrial area (r = -0.298, p = 0.037), and right atrial pressure (r = -0.463, p = 0.001). CONCLUSION: In patients with group 1 PAH, echocardiographic evaluation at the early stage of treatment (6 months) shows a significant improvement in the TAPSE/PASP ratio indicating right ventricular load adaptation. Comprehensive studies are needed on the routine use of the TAPSE/PASP ratio in the risk assessment of PAH patients.

A Novel Closed-Loop Balloon-Stent Embolization for the Treatment of Coronary Artery Perforation.

Coronary artery perforation is a serious and potentially life-threatening complication of percutaneous coronary intervention. Although there are a few treatment options available, such as coil or fat tissue embolization and stent-graft implantation, the closed-loop balloon-stent technique can be especially effective for thin vessel ruptures. In this case report, we demonstrate the successful application of the closed-loop balloon-stent embolization for a perforation of the distal left anterior descending artery, a procedure which, to our knowledge, has not been previously documented in the literature.

Current Evidence and Future Perspective for Coronary Bifurcation Stenting.

Coronary bifurcation lesions account for 15%-20% of all percutaneous coronary interven tions and are associated with greater procedural complexity and consequently at higher risk for cardiac adverse events. Early clinical trials in the interventional approach to bifurcation lesions supported provisional stenting. However, the most recent randomized studies have indicated potentially superior results using a double-kissing crush technique, particularly for unprotected distal left main bifurcation lesions. Moreover, many operators recently favor double-kissing mini-culotte, nanocrush, and double-kissing nanocrush stenting techniques for bifurcation lesions. In this review, we describe the traditional and novel bifurcation stenting techniques and the current evidence for each and review general principles for bifurcation percutaneous coronary intervention.

Multi-Center Experience of Coronary Artery Perforation During Percutaneous Coronary Intervention: Clinical and Angiographic Characteristics, Management, and Outcomes Between 2010 and 2020.

BACKGROUND: Coronary artery perforations are one of the most feared, rare, and catastrophic complication of percutaneous coronary intervention. Despite the remarkable increase in coronary angiography and percutaneous coronary intervention, there is no large database that collects coronary artery perforation for the Turkish population. Our study aimed to report our experience over a 10-year period for clinical and angiographic characteristics, management strategies, and outcomes of coronary artery perforation during the percutaneous coronary intervention at different cardiology departments in Turkey. METHODS: The study data came from a retrospective analysis of 48 360 percutaneous coronary intervention procedures between January 2010 and June 2020. A total of 110 cases who had coronary artery perforation during the percutaneous coronary intervention were found by angiographic review. Analysis has been performed for the basic clinical, angiographic, procedural characteristics, the management of coronary artery perforation, and outcome of all patients. RESULTS: The coronary artery perforation rate was 0.22%. Out of 110 patients with coronary artery perforation, 66 patients showed indications for percutaneous coronary intervention with acute coronary syndrome and 44 patients with stable angina pectoris. The most common lesion type and perforated artery were type C (34.5%) and left anterior descending (41.8%), respectively. The most observed coronary artery perforation according to Ellis classification was type III (37.2%). Almost 52.7% of patients have a covered stent implanted in the perforated artery. The all-cause mortality rate of coronary artery perforation patients in the hospital was 18.1%. CONCLUSION: The observed rate of coronary artery perforation in our study is consistent with the studies in this literature. However, the mortality rates related to coronary artery perforation are higher than in other studies in this literature. Especially, the in-hospital mortality rate was higher in type II and type III groups due to perforation and its complications. Nevertheless, percutaneous coronary intervention should be done in selected patients despite catastrophic complications.

Relationship Between Fragmented QRS Complex and Long-Term Cardiovascular Outcome in Patients with Essential Hypertension.

BACKGROUND: In patients with essential hypertension, fragmented QRS has been asso- ciated with many remodeling components that might lead to adverse cardiovascular effects. This study aimed to evaluate the relationship between fragmented QRS and adverse events and its potential long-term prognostic value. METHODS: The patients with essential hypertension were divided into two groups accord- ing to the presence of fragmented QRS: fragmented QRS (+) and fragmented QRS (-). During long-term follow-up, the relationship of fragmented QRS to coronary artery dis- ease, congestive heart failure, stroke, cardiovascular death, all-cause death, and majoradverse cardiovascular and cerebrovascular events was evaluated. RESULTS: The study group included 542 patients with essential hypertension. Fragmented QRS on ECG was observed in 224 (41.3%) patients. Considering the incidence rates at the end of 5.6 ± 1.3 years' follow-up, the total incidence rate of major adverse cardiovascular and cerebrovascular events (P < .001), coronary artery disease (P < .001), and congestive heart failure (P < .001) were higher in patients with fragmented QRS. No significant dif- ference was observed between the two groups in terms of stroke (P = .734), cardiovas- cular death (P=1), and all-cause death (P=.574). As a result of multiple cox regression analysis, fragmented QRS (P = .005) was identified as an independent predictor for major adverse cardiovascular and cerebrovascular events development. CONCLUSION: In patients with hypertension, the presence of fragmented QRS was found as an independent predictor for major adverse cardiovascular and cerebrovascular events development.

Long-Term Prognostic Value of Mean Platelet Volume in Patients with Hypertension.

BACKGROUND: Although it has been shown that high mean platelet volume (MPV) is associated with target organ damage in hypertensive patients, the relationship between MPV and the development of long-term major adverse cardiovascular events (MACE) has not been thoroughly investigated. In this study, we investigated the relationship between MPV and long-term MACE in hypertensive patients. METHODS: From September 2011 to July 2017, 1507 patients with hypertension were included in this study. Ambulatory blood pressure monitoring was performed in all patients. Patients with chronic renal failure, cardiovascular disease, chronic systemic disease and white coat hypertension were excluded from the study. MACE were defined as myocardial infarction, stroke and cardiovascular mortality. Patients were followed-up until january 2020. RESULTS: The mean follow-up duration was 87 (83.3 ± 24.4) months, and 876 patients completed the study. MACE developed in 79 patients, while 797 patients were event-free. In univariate Cox regression analysis, age, diabetes mellitus (DM), MPV, creatinine, 24-hour systolic blood pressure, and non-dipper hypertension were found to be associated with the development of MACE. In multivariate Cox regression analysis, creatinine and 24-hour systolic blood pressure lost significance, and age, DM, non-dipper hypertension and MPV were found to be independent predictors for MACE development (p < 0.001, p < 0.001, p = 0.044, and p = 0.049, respectively). CONCLUSIONS: MPV, age, DM, and non-dipper hypertension were independent predictors of long-term MACE in hypertensive patients.

Impaired repolarization parameters may predict fatal ventricular arrhythmias in patients with hypertrophic cardiomyopathy (from the CILICIA Registry).

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is significantly associated with high risk of fatal ventricular arrhythmias (VAs). Increased frontal QRST angle (fQRSTa), Tpe interval, and Tp-e/QTc ratio are described as ventricular repolarization parameters which are related to arrhythmias. In this study, we aimed to investigate the predictive value of these repolarization parameters for fatal VAs in patients with HCM. METHODS: A total of 127 HCM patients (mean age: 47.9 ±â€¯12.6 years; male:79) were enrolled in this retrospective study. All patients underwent transthoracic echocardiography. Moreover, the last electrocardiograms within 3 months prior to the fatal VA documentation were assessed. The primary outcome was the occurrence of fatal VAs including sustained ventricular tachycardia and ventricular fibrillation which were documented from implantable cardioverter defibrillator records. RESULTS: There were documented fatal VAs in 37 (29.1%) patients during a mean follow-up time of 70.1 ±â€¯22.6 months. The prevalence of fatal VAs was significantly higher in patients with fQRSTa ≥140 degrees (67.4 vs. 7.4%; p < 0.001) and in patients with Tp-e/QTc ratio ≥ 0.19 (61.5 vs. 6.7%; p < 0.001) as compared to others. High Tp-e/QTc ratio (hazard ratio: 1.564; 95% confidence interval: 1.086-4.796; p = 0.032) and high fQRSTa (hazard ratio: 1.864; 95% confidence interval: 1.106-8.745; p = 0.002) were found to be independent predictors of fatal VAs in HCM patients. CONCLUSIONS: Wider fQRSTa, prolonged Tp-e interval, and increased Tp-e/QTc ratio may be associated with fatal VAs in HCM patients. In addition to traditional risk factors, these simple ECG parameters may provide valuable information during evaluation of sudden cardiac death risk in HCM patients.

Relationship between myocardial energy expenditure and postoperative ejection fraction in patients with severe mitral regurgitation.

OBJECTIVE: This prospective study aimed to investigate the myocardial energy metabolism in severe mitral regurgitation (MR) and explore its effect on postoperative differentiation of ejection fraction (EF). METHODS: A total of 85 patients with severe MR were prospectively enrolled from October 2018 to June 2019. During the study period, a total of 50 patients underwent mitral valve surgery and 49 patients were finally enrolled due to 1 missing data. Left ventricular function, circumferential end-systolic stress (cESS), and myocardial energy expenditure (MEE) were measured by transthoracic echocardiography preoperatively and 3 months after surgery. Patients were divided into 2 groups according to absolute difference of postoperative differentiation of EF. RESULTS: Nine patients underwent mitral valve repair and 40 underwent prosthetic valve replacement. Patients with reduced EF had higher MEE demonstrated with cESS and MEE. Negative correlation between preoperative EF and N-terminal pro-brain natriuretic peptide (NT-proBNP), cESS, MEEs, and MEEm and positive correlation between preoperative EF and effective regurgitant orifice area were found. Complications occurred in 12 patients during hospitalization. Basal NT-proBNP, left atrium (LA), and cESS were significantly higher in postoperatively decreased EF group. Taking into consideration the covariates of multiple logistic regression analysis, LA and cESS were found to be independent predictors of EF reduction postoperatively. CONCLUSION: Higher LA and cESS are independent predictors of postoperative EF reduction. Preoperative high end-systolic stress could predict postoperative EF reduction and hence could be helpful for determining the timing of mitral valve surgery. Although MEE was higher in postoperatively decreased EF group, it did not reach statistical significance.