Validation of a new non-hyperemic physiological index: the constant-resistance ratio (cRR).

OBJECTIVES: The instantaneous wave-free ratio (iwFR) has limited availability. A new resting index called the constant-resistance ratio (cRR), which dynamically identifies cardiac intervals with constant and minimum resistance, has been developed; however, its diagnostic performance is unknown. The aim of this study was to validate the cRR by retrospectively calculating the cRR values from raw pressure waveforms of 2 publicly available datasets and compare them with those of the iwFR. METHODS: Waveform data from the CONTRAST and VERIFY 2 studies were used. The primary endpoint was Bland-Altman bias between cRR and iwFR. Secondary endpoints included diagnostic agreement, correlation, receiver operating characteristic (ROC) analysis, and success rates of cRR and iwFR. RESULTS: Among the 1036 waveforms, 871 were successful in determining paired cRR and iwFR values, while cRR was 6% more successful than iwFR (P less than .0001). The mean bias between cRR and iwFR was 0.003, with 95% limits of agreement [-0.021,0.028]. These 2 indices were highly correlated (r = 0.991; P less than .0001). Using an iwFR of 0.89 or less as the reference standard, the optimal cRR cutoff was 0.89, with an area under the ROC curve of 0.991 (P less than .001) and a diagnostic accuracy of 96.9% (95% CI [96%, 98%]). CONCLUSIONS: The cRR, a new resting index for identifying dynamic cardiac intervals with constant and minimum resistance, demonstrated high numerical agreement, diagnostic consistency, and a higher success rate than the iwFR based on the 2 publicly available datasets.

Soluble interleukin-2 receptor predicts acute kidney injury and in-hospital mortality in patients with acute myocardial infarction.

BACKGROUND: Acute kidney injury (AKI) is the most common and critical complication in patients with acute myocardial infarction (AMI). This study aims to evaluate the significance of elevated soluble interleukin 2 receptor (sIL-2R) levels in predicting AKI and mortality. METHODS: A total of 446 patients with AMI were enrolled between January 2020 and July 2022, including 58 patients with AKI and 388 without AKI. The sIL-2R levels were measured using a commercially available chemiluminescence enzyme immunoassay. Logistic regression analysis was used to examine the risk factors for AKI. Discrimination was assessed based on the area under the receiver operating characteristic curve. The model was internally validated using 10-fold cross-validation. RESULTS: During hospitalization, 13% of patients developed AKI following AMI, with higher sIL-2R levels (0.61 ± 0.27 U/L vs. 0.42 ± 0.19 U/L, p = 0.003) and in-hospital all-cause mortality (12.1% vs. 2.6%, P < 0.001). The sIL-2R levels emerged as an independent risk factor for both AKI (OR = 5.08, 95% CI (1.04-24.84, p < 0.045) and in-hospital all-cause mortality (OR = 73.57,95% CI 10.24-528.41, p < 0.001) in AMI patients. The sIL-2R levels were found to be useful biomarkers in prediction of AKI and in-hospital all-cause mortality in patients with AMI (AUC: 0.771 and 0.894, respectively). The respective cutoff values for sIL-2R levels in predicting AKI and in-hospital all-cause mortality were determined to be 0.423 U/L and 0.615 U/L. CONCLUSIONS: The level of sIL-2R was an independent risk factor and predictor for both AKI and in-hospital all-cause mortality in patients with AMI. These findings highlight the potential of sIL-2R as a valuable tool for identifying high-risk patients regarding AKI and in-hospital mortality.

The Association Between Angiographically Derived Radial Wall Strain and the Risk of Acute Myocardial Infarction.

BACKGROUND: The radial wall strain (RWS) is a novel angiography-based method to assess the biomechanical property of the coronary artery and whether it can predict future acute myocardial infarction (AMI) events remains to be elucidated. OBJECTIVES: This study aimed to investigate the association between angiography-derived RWS and future AMI events in mild to intermediate lesions. METHODS: We performed a matched case-control analysis nested in a retrospective cohort of patients who had received prior angiography (the index procedure) at least 1 month before and were hospitalized again for repeat angiography. Patients with at least 1 de novo mild to intermediate lesion identified at the index procedure and eligible for RWS analysis were enrolled. The study identified cases with target lesion-related AMI diagnosed at the repeat angiography, matching each case to 3 control subjects without AMI. RESULTS: Altogether 44 patients with lesion-related AMI and 132 matched controls were enrolled. The median diameter stenosis of the overall interrogated lesions was 34.0%. The baseline maximum RWS (RWSmax), which was defined as the highest RWS in the stenotic segment, was significantly higher in lesions responsible for AMI than those that remained quiescent (median 13% vs 10%; P < 0.001). RWSmax was predictive of lesion-related AMI, with an area under the curve of 0.83 (95% CI: 0.76-0.90; P < 0.001) and an optimal cutoff >12%. RWSmax >12% was found to be independently associated with subsequent AMI events with a risk ratio of 7.25 (95% CI: 3.94-13.37; P < 0.001). CONCLUSIONS: Among angiographically mild to intermediate lesions, a high-strain pattern identified by angiography-derived RWS was associated with an increased risk of AMI events.

Dynamic perfusion SPECT for functional evaluation in symptomatic patients with myocardial bridging.

BACKGROUND: The aim of this study was to investigate the feasibility and diagnostic value of myocardial flow reserve (MFR) assessed by rest/stress myocardial perfusion imaging with dynamic single-photon emission computed tomography (SPECT) in the functional evaluation of myocardial bridge (MB). METHODS: From May 2017 to July 2021, patients with angiographically confirmed isolated MB on the left anterior descending artery (LAD) who underwent dynamic SPECT myocardial perfusion imaging were retrospectively included. The assessment of semiquantitative indices of myocardial perfusion (summed stress scores, SSS) and quantitative parameters (MFR) was performed. RESULTS: A total of 49 patients were enrolled. The mean age of the subjects was 61.0 ± 9.0 years. All of the patients were symptomatic, and 16 cases (32.7%) presented with typical angina. SPECT-derived MFR showed a borderline significantly negative correlation with SSS (r = 0.261, P = .070). There was a trend of higher prevalence of impaired myocardial perfusion defined as MFR < 2 than as SSS ≥ 4 (42.9% vs 26.5%; P = .090). CONCLUSION: Our data support that SPECT MFR may be a useful parameter for the functional assessment of MB. In patients with MB, the use of dynamic SPECT could be a potential method for hemodynamic assessment.

Device-based antegrade dissection re-entry versus parallel wire techniques for the percutaneous revascularization of coronary chronic total occlusions.

BACKGROUND: Device-based antegrade dissection re-entry (ADR) and parallel wire technique (PWT) are two important techniques in the antegrade approach in percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). The study is aimed to compare the procedural and mid-term outcomes between device-based ADR using the CrossBoss/Stingray system and PWT in CTO PCI. METHODS: Data was retrospectively collected from consecutive patients who underwent CTO PCI using device-based ADR or PWT. CTO due to in-stent restenosis were excluded. RESULTS: A total of 273 patients were included in the study (n = 55 in device-based ADR group, n = 218 in PWT group). Baseline characteristics were similar across groups except for higher prevalence of prior PCI and lower level of lipid profile in the ADR group. Moreover, although patients in the ADR group showed higher contrast volume (441.6 ± 162.4 mL vs. 361.5 ± 142.1 mL, p < 0.001), more intravascular ultrasound guidance (50.9% vs. 22.9%, p < 0.001), more guidewires used (4.6 ± 1.4 vs. 3.4 ± 1.2, p < 0.001) and higher troponin T level after PCI (0.167 vs. 0.087, p = 0.004), the technical success, procedural success and in-hospital complications were similar between the two groups. During a median follow-up of 1 year, the ADR group showed no difference in major adverse cardiac events (MACE, including all cause death, nonfatal myocardial infarction, and ischemia driven target vessel revascularization) (7.3% vs. 14.7%, p = 0.150) as compared with the PWT group. CONCLUSIONS: In the documented center, the use of device-based ADR for CTO PCI showed no difference in in-hospital complications and mid-term MACE as compared with PWT, despite higher procedure complexity in ADR group.

A TEMPOL and rapamycin loaded nanofiber-covered stent favors endothelialization and mitigates neointimal hyperplasia and local inflammation.

An increased level of reactive oxygen species (ROS) plays a major role in endothelial dysfunction and vascular smooth muscle cell (VSMC) proliferation during in-stent thrombosis and restenosis after coronary artery stenting. Herein, we report an electrospun core-shell nanofiber coloaded with 4-hydroxy-2,2,6,6-tetramethylpiperidine 1-oxyl (TEMPOL) and rapamycin (RAPA) that correspondingly serves as an ROS scavenger and VSMC inhibitor. This system has the potential to improve the biocompatibility of current drug-eluting stent (DES) coatings with the long-term and continuous release of TEMPOL and rapamycin. Moreover, the RAPA/TEMPOL-loaded membrane selectively inhibited the proliferation of VSMCs while sparing endothelial cells (ECs). This membrane demonstrated superior ROS-scavenging, anti-inflammatory and antithrombogenic effects in ECs. In addition, the membrane could maintain the contractile phenotype and mitigate platelet-derived growth factor BB (PDGF-BB)-induced proliferation of VSMCs. In vivo results further revealed that the RAPA/TEMPOL-loaded covered stents promoted rapid restoration of vascular endothelium compared with DES and persistently impeded inflammation and neointimal hyperplasia in porcine models.

Functional comparison of different jailed balloon techniques in treating non-left main coronary bifurcation lesions.

BACKGROUND: There is a paucity of data comparing functional difference between active jailed balloon technique (A-JBT) and conventional jailed balloon technique (C-JBT) in treating non-left main coronary bifurcation lesions (CBLs). METHODS: In this retrospective cohort study, we consecutively enrolled 232 patients with non-left main CBLs who underwent percutaneous coronary intervention (PCI) using JBTs between January 2018 and March 2019. Among them, 191 patients entered the final analysis with 12-months angiographic follow-up. We stratified patients into A-JBT group (130 patients) and C-JBT group (61 patients). The functional analysis by Murray law-based quantitative flow ratio (µQFR) and Seattleanginaquestionnaire (SAQ) were performed to compare the two techniques. RESULTS: Compared with C-JBT group, A-JBT group observed a lower abrupt (0.8% vs. 11.1%, p = 0.002) and final SB occlusion (0 vs. 7.9%, p = 0.005). Meanwhile, A-JBT group had a significantly higher µQFR of side branch (SB) both post-PCI and 12-months follow-up (median [interquartile range (IQR)]: 0.91 (0.86-0.96) vs. 0.82 (0.69-0.92), p < 0.001; median [IQR]: 0.95 (0.89-0.98) vs. 0.85 (0.74-0.93), p < 0.001) than C-JBT group. Besides, A-JBT group gained a µQFR improvement at follow-up period compared with post-PCI data (median [IQR]: 0.95 [0.89-0.98] vs. 0.91[0.86-0.96] of SB, p < 0.001) and a higher SAQ scores at 12-months follow-up compared with C-JBT group (p < 0.001). CONCLUSIONS: Compared with C-JBT, A-JBT provided excellent SB protection during MV stenting and improved the SB functional blood flow as well as the angina relief even after 12 months.

The Identification and Validation of Hub Genes Associated with Acute Myocardial Infarction Using Weighted Gene Co-Expression Network Analysis.

Acute myocardial infarction (AMI), one of the most severe and fatal cardiovascular diseases, remains the main cause of mortality and morbidity worldwide. The objective of this study is to investigate the potential biomarkers for AMI based on bioinformatics analysis. A total of 2102 differentially expressed genes (DEGs) were screened out from the data obtained from the gene expression omnibus (GEO) database. Weighted gene co-expression network analysis (WGCNA) explored the co-expression network of DEGs and determined the key module. The brown module was selected as the key one correlated with AMI. Gene Ontology and the Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses demonstrated that genes in the brown module were mainly enriched in 'ribosomal subunit' and 'Ribosome'. Gene Set Enrichment Analysis revealed that 'TNFA_SIGNALING_VIA_NFKB' was remarkably enriched in AMI. Based on the protein-protein interaction network, ribosomal protein L9 (RPL9) and ribosomal protein L26 (RPL26) were identified as the hub genes. Additionally, the polymerase chain reaction (PCR) results indicated that the expression levels of RPL9 and RPL26 were both downregulated in AMI patients compared with controls, in accordance with the bioinformatics analysis. In summary, the identified DEGs, modules, pathways, and hub genes provide clues and shed light on the potential molecular mechanisms of AMI.

Functional significance of intermediate coronary stenosis in patients with single-vessel coronary artery disease: A comparison of dynamic SPECT coronary flow reserve with intracoronary pressure-derived fractional flow reserve (FFR).

BACKGROUND: The aim of this study was to investigate the correlation of coronary flow reserve (CFR) assessed by rest/stress myocardial perfusion imaging with dynamic single-photon emission computed tomography (SPECT) with intracoronary pressure-derived fractional flow reserve (FFR) in patients with single-vessel coronary artery disease (CAD). METHODS: Patients with suspected or known stable CAD who were referred for invasive coronary angiography were prospectively enrolled. Both invasive FFR and SPECT were performed in subjects with single-vessel intermediate coronary stenosis. A cutoff value of < 0.8 was used to define abnormal FFR. RESULTS: A total of 34 patients were enrolled. The mean age of the subjects was 62.1 ± 6.7 years, and 79.4% were male. SPECT-derived CFR showed a significantly moderate correlation with FFR (r = 0.505, P = .003). The diagnostic performance for the identification of abnormal FFR in terms of sensitivity, specificity, and accuracy was 88.9%, 83.3%, and 87.9%, respectively, for CFR, with an optimized cutoff value of 1.73. CONCLUSION: In patients with single-vessel CAD, SPECT CFR was useful for the detection of functionally significant stenosis. Our data support the use of this technique as an optional method for hemodynamic assessment, especially when FFR results are in normal range.

Outcomes of contemporary versus conventional reverse controlled and antegrade and retrograde subintimal tracking in chronic total occlusion revascularization.

BACKGROUND: Chronic total occlusion (CTO) lesions remain technically challenging for percutaneous coronary intervention (PCI). The introduction of a retrograde approach has allowed marked improvement in the success rate of CTO recanalization. Reverse controlled anterograde and retrograde sub-intimal tracking (reverse CART) is the predominant retrograde wire crossing technique and can be broadly classified into three categories: (1) conventional (2) contemporary and (3) extended. The present study aimed to compare the safety and efficacy of conventional and contemporary reverse CART techniques. METHODS: From March 2015 to May 2020, 303 patients achieving successful retrograde guidewire crossing with conventional or contemporary reverse CART during CTO PCI were included in the study. The patient characteristics, procedural outcomes and in-hospital and 1-year clinical events were compared between the conventional and contemporary groups. RESULTS: The distributions of the baseline and angiographic characteristics were similar in both study arms, except the CTO lesions of the conventional group were more complex, as reflected by borderline significantly higher mean J-CTO scores (3.4 ± 0.7 vs. 3.3 ± 0.8; p = 0.059). Recanalization using contemporary reverse CART was associated with a short procedure time (189.8 ± 44.4 vs. 181.7 ± 37.3 min; p = 0.044) and decreased procedural complications, particularly target vessel perforation (3.6% vs. 0.6%; p = 0.063) and major side-branch occlusion (36.7% vs. 28.0%; p = 0.051). Technical and procedural success and the in-hospital and 1-year outcomes were not significantly different between the groups. CONCLUSIONS: Contemporary reverse CART is associated with favorably high efficiency and low-complication rates and carries a comparable success rate and 1-year clinical outcomes as conventional reverse CART.

Clinical Outcomes of Self-Made Polyurethane-Covered Stent Implantation for the Treatment of Coronary Artery Perforations.

OBJECTIVES: The present study aimed to investigate the short- and long-term clinical outcomes of self-made polyurethane-covered stents (PU-CS) in patients for the management of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI). BACKGROUND: Coronary artery perforation is reckoned as a serious complication in PCI and associated with considerable morbidity and mortality. Covered stents have been used for treating the life-threatening CAP during PCI. But in some catheterization laboratories, no commercial CS is immediately available when there is an urgent need for CS to rescue the coronary rupture site. METHODS: We retrospectively identified 24 patients who underwent 31 self-made PU-CS implantations due to CAP in Zhongshan Hospital, Fudan University, from June 2015 to January 2020. RESULTS: The total procedural success rate of CS to seal the perforation was 79.2%. Nine patients (37.5%) developed cardiac tamponade, of which 8 patients (33.3%) underwent pericardiocentesis and 4 patients (16.7%) underwent cardiac surgeries. Except for 4 cardiac death cases (16.7%), none of myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) was reported during hospital stay. Data from 22 patients (91.7%) were available at 610.4 ± 420.9 days of follow-up. Major adverse cardiac events (MACE) occurred in 6 patients (27.3%), including 5 cases of cardiac death and one TLR case. CONCLUSIONS: Self-made PU-CS demonstrates high rates of successful delivery and sealing of severe CAP during PCI. Although the in-hospital mortality remains high after PU-CS implantation, the long-term follow-up shows favorable clinical outcomes, indicating the feasibility of PU-CS in treating CAP.

Procedural and In-hospital Outcomes of Rotational Atherectomy in Retrograde Coronary Chronic Total Occlusion Intervention.

Coronary chronic total occlusions (CTOs) are characterized by a high incidence of severe plaque calcifications, which are associated with a high use of the retrograde approach and a low success rate of percutaneous coronary intervention (PCI). However, the feasibility of rotational atherectomy (RA) in retrograde CTO-PCI remains unknown. The aim of the present study is to examine the safety and efficacy of RA in retrograde CTO-PCI. Consecutive patients (n = 129) who underwent RA during CTO-PCI were categorized into anterograde and retrograde groups according to the CTO crossing approach. The distributions of the baseline characteristics were similar in the 2 groups, but the lesion type was more complex (P = .001), and the starting burr size was smaller (P = .003) in the retrograde group than in the anterograde group. There was a trend of a higher incidence of procedural complications in the retrograde group than in the anterograde group (P = .054). Technical and procedural success and in-hospital outcomes were not significantly different between the 2 groups. In conclusion, RA was feasible in retrograde CTO PCI, but some specific precautions are required before and during the procedure. In addition, further investigation of the long-term outcomes of RA in retrograde CTO PCI is necessary.

Effects of salvianolate on myocardial perfusion after primary percutaneous catheter intervention in patients with ST-segment elevation myocardial infarction: a multicenter, randomized, double-blind, placebo-controlled study.

BACKGROUND: Despite prompt revascularization following acute myocardial infarction, poor myocardial perfusion commonly occurs due to impaired microvascular circulation and is an independent predictor of adverse outcomes. The current trial sought to examine the effects of salvianolate on myocardial perfusion in patients with ST-segment-elevation myocardial infarction (STEMI) who were undergoing primary percutaneous coronary intervention (PCI). METHODS: This randomized, double-blind, placebo-controlled, multicenter study evaluated the effects of intravenous salvianolate on the achievement of complete epicardial and myocardial reperfusion after PCI, defined as thrombolysis in myocardial infarction flow grade 3 and thrombolysis in myocardial infarction myocardial perfusion grade 3. We also measured plasma total creatine kinase-mass band fraction (CK-MB)-estimated infarct size and echocardiography-derived left ventricular ejection fraction and recorded the 30-day clinical and safety outcomes. A total of 536 patients presenting with acute STEMI were randomized to receive either an i.v. infusion of salvianolate (n=265) or placebo (n=271). RESULTS: Salvianolate administration exerted beneficial effects on coronary microcirculation. There was a trend of reduced myocardial infarct size in the salvianolate group compared to the placebo group (P=0.070), although no significant difference in left ventricular ejection fraction was found between the two groups. CONCLUSIONS: Salvianolate administration is associated with improved myocardial perfusion in patients with STEMI undergoing PCI. A larger study is required to assess the impact of this therapy on clinical cardiac outcomes.

Hypoxia-challenged MSC-derived exosomes deliver miR-210 to attenuate post-infarction cardiac apoptosis.

BACKGROUND: Myocardial infarction (MI) is a major cause of death worldwide. Although percutaneous coronary intervention and coronary artery bypass grafting can prolong life, cardiac damage persists. In particular, cardiomyocytes have no regenerative capacity. Mesenchymal stem cells (MSCs) are attractive candidates for the treatment of MI. The manner by which MSCs exert a beneficial effect upon injured cells is a source of continued study. METHODS: After the isolation and identification of exosomes from MSCs, the expression of miR-210 was determined by microarray chip. Subsequently, gain- and loss-function approaches were conducted to detect the role of exosomes and exosomal-miR-210 in cell proliferation and apoptosis of cardiomyocytes, as well as the MI in vivo. Dual-Luciferase Report Gene System was used to demonstrate the target gene of miR-210. RESULTS: We tested the hypothesis that MSC-derived exosomes transfer specific miRNA to protect cardiomyocytes from apoptotic cell death. Interestingly, direct cardiac injection of MSC exosomes reduced infarct size and improved heart function after coronary ligation. In vitro, the MSC exosomes enhanced cardiomyocyte survival to hypoxia. Confirmation of exosome uptake in myocytes was confirmed. Dual-luciferase reporter assay implicated miR-210 as a mediator of the therapeutic effect and AIFM3 as a downstream target. Treatment with miR-210 overexpressing MSC exosomes improved myocyte protection to both in vitro and in vivo stress. Furthermore, the endogenous and exogenous miR-210 had the same therapeutic effects. CONCLUSION: These results demonstrated that the beneficial effects offered by MSC-exosomes transplantation after MI are at least partially because of excreted exosome containing mainly miR-210.

Short and long-term outcomes of coronary perforation managed by coil embolization: A single-center experience.

BACKGROUND: Coronary perforation is a serious complication in percutaneous coronary intervention (PCI). In this article, we reported the short and long-term outcomes of patients with coronary perforation managed by coil embolization in our center. METHODS: We retrospectively analyzed 66 patients who had coronary perforation treated by coil embolization during PCI performed in our center from Oct 2012 to June 2018. RESULTS: Of sixty-six cases of coronary perforation, twenty-six cases were distal coronary perforation, while 40 cases were collateral perforation. The average coil number used in distal coronary and collateral perforation lesion is 1.8 ±â€¯0.9 and 1.8 ±â€¯1.0, respectively. The maximum number of coils implanted in each patient is 4 in both groups. Two emergency cardiac surgery to seal the perforation was performed after coil embolization in distal coronary perforation and pericardiocentesis. In collateral perforation, one case of CABG was performed due to myocardial ischemia caused by CTO lesion. During a follow-up of 707 ±â€¯476 days, one patient in collateral perforation group had CABG one month later, while no death or myocardial infarction (MI) was detected. Fifty-four (81.2%) cases of perforations occurred while treating chronic total occlusion, and 74.0% of these perforations were located in collateral vessels, mostly epicardial vessels. Thirty-nine CTO cases (72.2%) were revascularized successfully with the aid of coil embolization. CONCLUSION: Coil embolization is feasible and effective in treating distal coronary perforation and collateral perforation during PCI procedure. In CTO lesions, coil embolization facilitates the success of revascularization by PCI.

Evaluation of Preprocedural Laboratory Parameters as Predictors of Drug-Eluting Stent Restenosis in Coronary Chronic Total Occlusion Lesions.

This retrospective, single-center study assessed the prognostic value of several emerging inflammatory markers as predictors of in-stent restenosis (ISR) after drug-eluting stent implantation for coronary chronic total occlusion (CTO) lesions. Consecutive patients (n = 416) who underwent successful percutaneous coronary intervention (PCI) for documented CTO lesions and with follow-up angiography were enrolled. Preprocedural high-sensitivity C-reactive protein (hsCRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and red cell distribution width (RDW) were analyzed. At mean follow-up of 14.4 ± 3.3 months, ISR occurred in 72 patients. Compared with the non-ISR group, preprocedural hsCRP level, PLR, NLR, and RDW were significantly higher in the ISR group. The ISR group also had significantly greater proportions of patients with diabetes and smoking history, lower estimated glomerular filtration rate, higher low-density lipoprotein cholesterol (LDL-C) level and neutrophil count, longer stent length, and higher rate of severe dissection. In multivariate analysis, NLR (odds ratio [OR]: 3.110; 95% confidence interval [CI], 2.102-4.063; P < .001) and PLR (OR: 1.029; 95% CI, 1.016-1.143; P < .001) were independent predictors of ISR, along with LDL-C level and stent length. In conclusion, higher preprocedural NLR and PLR levels were independent risk factors for the development of ISR in patients who underwent PCI for CTO lesions.

Exploration of Bivalirudin Use during Percutaneous Coronary Intervention for High Bleeding Risk Patients with Chronic Total Occlusion.

The safety and efficacy of bivalirudin during percutaneous coronary intervention (PCI) in high bleeding risk patients with chronic total occlusion lesions (CTO) has not been studied till date. The use of bivalirudin may increase the thrombotic events during CTO-PCI.Between May 2013 and April 2014, a total of 117 high bleeding risk patients with CTOs underwent PCI. Bivalirudin was used in 89 cases with different strategies, including standard usage, combination of heparin, and additional bolus of bivalirudin on the basis of standard usage. The clinical characteristics, procedural details and antithrombotic strategies were assessed, and the bleeding and ischemic events were evaluated. The first 7 of 9 patients with standard application of bivalirudin exhibited acute thrombogenesis in the procedure. Heparin was then added in decreasing amounts in the next 8 patients wherein no thrombosis occurred; however, 2 patients had bleeding complications. The subsequent 72 patients were randomly assigned to the heparin bolus or additional bivalirudin bolus groups before the percutaneous transluminal coronary angioplasty (PTCA) was performed. The baseline clinical characteristics and procedure information were identical in both the groups. There were no ischemic and bleeding events in both the groups during the 6-month follow-up.Monotherapy with bivalirudin in CTO-PCI should be treated with caution, as the potential risk of thrombogenesis may be due to the long procedure time, the frequent change of equipment and temporary blood flow convection. Combination of heparin or an additional bolus of bivalirudin before PTCA was observed to be likely to decrease the incidence of thrombogenesis.

Bivalirudin in percutaneous coronary intervention for chronic total occlusion: A single-center pilot study.

BACKGROUND: Bivalirudin has been reported to be an alternative to unfractionated heparin (UFH) for anticoagulation during percutaneous coronary intervention (PCI) and associated with less bleeding risk. However, the feasibility of bivalirudin during PCI of chronic total occlusion lesions (CTO) remains unknown. OBJECTIVE: To evaluate the efficacy and safety of bivalirudin versus UFH in CTO PCI. METHODS: In this prospective and randomized controlled trial in single center, CTO patients with high bleeding risk were randomized to treatment with bivalirudin (bolus 0.75 mg/kg followed by infusion of 1.75, extra bolus 0.3 mg/kg before stenting) or UFH (100 IU/kg). The primary efficacy end point was the incidence of major adverse cardiac events (MACEs, composite of all-cause mortality, cardiac death, stent thrombosis, periprocedural myocardial infarction, or additional unplanned target lesion revascularization, or any other post-PCI ischemic event) in-hospital, and at 1-year follow-up. The primary safety end point was the occurrence of any bleeding or entry-site complications after PCI. RESULTS: A total of 84 high bleeding risk patients undergoing PCI for CTO lesions were enrolled. The baseline characteristics were similar in both treatment arms. In hospital MACEs rates were 21.4% in the bivalirudin group and 14.3% in the UFH group (P = 0.393). During 1-year's follow-up, end points did not significantly differ between the groups either. Occurrence of the major bleeding events were 4.8% in the bivalirudin group and 9.5% in the UFH group (P = 0.676). No entry-site complication was observed. CONCLUSION: In CTO patients at high risk for bleeding undergoing PCI, our data indicates that bivalirudin appears to be at least comparable in efficacy and safety to UFH. A larger clinical trial should be designed to further elucidate its efficacy and safety.

The safety and feasibility of guidezilla catheter in complex coronary interventions and an observational study.

The monorail Guidezilla guide extension catheter was designed to provide additional backup and facilitate device delivery in percutaneous coronary intervention (PCI) for complex coronary anatomy such as chronic total occlusion (CTO), extreme vessel tortuosity, diseased bypass grafts, and anomalous coronary arteries, among others.The present retrospective, single-center study included 188 consecutive patients who underwent PCI using the Guidezilla catheter from March 2015 to August 2016. Study outcomes were rates of target lesion crossing success, procedural success, and complications.The Guidezilla catheter was used most commonly in PCI of CTOs (45%) and heavy proximal calcification (37%), followed by tortuosity (10%), previously deployed proximal stents (4%), and coronary artery anomaly (4%). The right coronary artery (48%) was most commonly intervened followed by the left ascending (35%) and left circumflex (17%) arteries. Rates of target lesion crossing success and procedural success were both 99%, with one device-related periprocedural complication, namely proximal vessel dissection secondary to deep insertion which was successfully treated with stent implantation. Ninety percent of PCI were performed and completed successfully by radial access.In a single center with experienced operators, the use of the Guidezilla guide extension catheter in PCI of complex coronary anatomy performed mostly via radial artery access appeared safe and efficacious, and greatly facilitated device delivery.