Jailed high-pressure balloon technique is superior to jailed wire technique in protecting side branch of coronary bifurcation lesions.

Objectives. This study investigated the influence of higher pressure protection with a small diameter balloon of side branch (SB) on bifurcation lesions. Background. Of the different coronary stent implantation techniques, the modified jailed balloon technique has become a viable option for bifurcation lesions. However, there was no detailed study on the relationship between the balloon inflation pressure of the main vessel (MV) and SB. Methods. In this study, we collected information of patients who underwent percutaneous coronary intervention (PCI) for bifurcated lesions between March 2019 and December 2022. They were divided into two groups according to the operation way: active jailed balloon technique (A-JBT) group and jailed wire technique (JWT) group. Results. A total of 216 patients were enrolled. The A-JBT group had a larger SB stenosis diameter (1.53 ± 0.69 vs. 0.95 ± 0.52, p < .001), the lower degree of stenosis (44.34 ± 18.30 vs. 63.69 ± 17.34, p < .001) compared to the JWT group. However, the JWT group had a higher incidence of SB occlusion (18.0% vs. 1.9%, p < .001) compared to the A-JBT group. Nevertheless, the success rate for both groups was 100%. Conclusions. This novel high inflation pressure and small diameter balloon approach we propose has significant advantages. There is a lower rate of SB occlusion and SB dissection, which is more cost-effective and provides better clinical outcomes for the patient. This method should be considered in the future for treating bifurcation lesions.

Side branch predilatation during percutaneous coronary bifurcation intervention: Long-term mortality analysis.

BACKGROUND: Side branch predilatation (SBPD) during coronary bifurcation interventions is a technique that is not recommended by the latest guidelines. However, the data about the clinical outcomes after SBPD are surprisingly few. AIMS: The current study aimed to explore the association between SBPD and mortality in long-term follow-up. METHODS: All patients with coronary bifurcation stenoses revascularized with percutaneous coronary intervention were included in a prospective registry. Patients with stable angina and a bifurcation lesion with ≥50% diameter stenosis were included in the current analysis. Patients were assigned to two groups - those with SBPD(+) and those without SBPD(-). Propensity score matching was performed to equalize the risk factors and severity of coronary artery disease between the groups. A Kaplan-Meier analysis with a log-rank test for between-group differences was also performed. RESULTS: From January 2013 to June 2021, 813 patients were included in the final study population. The mean age was 67 (10) years. After propensity score matching, 648 patients remained for analysis - 324 in each group. At a median follow-up of 57 months patients in the SBPD(+) group had a higher all-cause mortality (n = 107 (33%) vs. n = 98 [30.2%]; P = 0.045) and cardiovascular mortality (n = 82 [25.3%] vs. n = 70 [21.6%]; P = 0.03) when compared with SBPD(-) patients. SBPD was independently associated with all-cause and cardiovascular mortality. CONCLUSION: SBPD treatment of coronary bifurcation stenoses is associated with worse patient survival in the follow-up of up to 8 years. SBPD treatment gives better angiographic results, but this did not translate into better clinical outcomes.

Quantitative Coronary Angiography vs Intravascular Ultrasonography to Guide Drug-Eluting Stent Implantation: A Randomized Clinical Trial.

Importance: Although intravascular ultrasonography (IVUS) guidance promotes favorable outcomes after percutaneous coronary intervention (PCI), many catheterization laboratories worldwide lack access. Objective: To investigate whether systematic implementation of quantitative coronary angiography (QCA) to assist angiography-guided PCI could be an alternative strategy to IVUS guidance during stent implantation. Design, Setting, and Participants: This randomized, open-label, noninferiority clinical trial enrolled adults (aged ≥18 years) with chronic or acute coronary syndrome and angiographically confirmed native coronary artery stenosis requiring PCI. Patients were enrolled in 6 cardiac centers in Korea from February 23, 2017, to August 23, 2021, and follow-up occurred through August 25, 2022. All principal analyses were performed according to the intention-to-treat principle. Interventions: After successful guidewire crossing of the first target lesion, patients were randomized in a 1:1 ratio to receive either QCA- or IVUS-guided PCI. Main Outcomes and Measures: The primary outcome was target lesion failure at 12 months, defined as a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization. The trial was designed assuming an event rate of 8%, with the upper limit of the 1-sided 97.5% CI of the absolute difference in 12-month target lesion failure (QCA-guided PCI minus IVUS-guided PCI) to be less than 3.5 percentage points for noninferiority. Results: The trial included 1528 patients who underwent PCI with QCA guidance (763; mean [SD] age, 64.1 [9.9] years; 574 males [75.2%]) or IVUS guidance (765; mean [SD] age, 64.6 [9.5] years; 622 males [81.3%]). The post-PCI mean (SD) minimum lumen diameter was similar between the QCA- and IVUS-guided PCI groups (2.57 [0.55] vs 2.60 [0.58] mm, P = .26). Target lesion failure at 12 months occurred in 29 of 763 patients (3.81%) in the QCA-guided PCI group and 29 of 765 patients (3.80%) in the IVUS-guided PCI group (absolute risk difference, 0.01 percentage points [95% CI, -1.91 to 1.93 percentage points]; hazard ratio, 1.00 [95% CI, 0.60-1.68]; P = .99). There was no difference in the rates of stent edge dissection (1.2% vs 0.7%, P = .25), coronary perforation (0.2% vs 0.4%, P = .41), or stent thrombosis (0.53% vs 0.66%, P = .74) between the QCA- and IVUS-guided PCI groups. The risk of the primary end point was consistent regardless of subgroup, with no significant interaction. Conclusions and Relevance: Findings of this randomized clinical trial indicate that QCA and IVUS guidance during PCI showed similar rates of target lesion failure at 12 months. However, due to the lower-than-expected rates of target lesion failure in this trial, the findings should be interpreted with caution. Trial Registration: ClinicalTrials.gov Identifier: NCT02978456.

An interventional sheep model of severe aortic valve stenosis hemodynamics for the evaluation of alterations in coronary physiology and microvascular function.

We aimed to develop a large animal model of subcoronary aortic stenosis (AS) to study intracoronary and microcirculatory hemodynamics. A total of three surgical techniques inducing AS were evaluated in 12 sheep. Suturing the leaflets together around a dilator (n = 2) did not result in severe AS. Suturing of a pericardial patch with a variable opening just below the aortic valve (n = 5) created an AS which was poorly tolerated if the aortic valve area (AVA) was too small (0.38-1.02 cm2), but was feasible with an AVA of 1.2 cm2. However, standardization of aortic regurgitation (AR) with this technique is difficult. Therefore, we opted for implantation of an undersized AV-bioprosthesis with narrowing sutures on the leaflets (n = 5). Overall, five sheep survived the immediate postoperative period of which three had severe AS (one patch and two bioprostheses). The surviving sheep with severe AS developed left ventricular hypertrophy and signs of increased filling-pressures. Intracoronary assessment of physiological indices in these AS sheep pointed toward the development of functional microvascular dysfunction, with a significant increase in coronary resting flow and hyperemic coronary resistance, resulting in a significantly higher index of microvascular resistance (IMR) and lower myocardial resistance reserve (MRR). Microscopic analysis showed myocardial hypertrophy and signs of fibrosis without evidence of capillary rarefaction. In a large animal model of AS, microvascular changes are characterized by increased resting coronary flow and hyperemic coronary resistance resulting in increased IMR and decreased MRR. These physiological changes can influence the interpretation of regularly used coronary indices.NEW & NOTEWORTHY In an animal model of aortic valve stenosis (AS), coronary physiological changes are characterized by increased resting coronary flow and hyperemic coronary resistance. These changes can impact coronary indices frequently used to assess concomitant coronary artery disease (CAD). At this point, the best way to assess and treat CAD in AS remains unclear. Our data suggest that fractional flow reserve may underestimate CAD, and nonhyperemic pressure ratios may overestimate CAD severity before aortic valve replacement.

Investigation of the predictive value of a novel algorithm based on coronary CT angiography regarding fractional flow reserve and revascularization in patients with stable coronary artery disease.

Fractional flow reserve (FFR) has been established as a gold standard for functional coronary ischemia. At present, the FFR can be calculated from coronary computed tomography angiography (CCTA) images (CT-FFR). Previous studies have suggested that CT-FFR outperforms CCTA and invasive coronary angiography (ICA) in determining hemodynamic significance of stenoses. Recently, a novel automatical algorithm of CT-FFR called RuiXin-FFR has been developed. The present study is designed to investigate the predictive value of this algorithm and its value in therapeutic decision making. The present study retrospectively included 166 patients with stable coronary artery disease (CAD) who underwent CCTA screening and diagnostic ICA examination at Peking University People's Hospital, in 73 of whom wire-derived FFR was also measured. CT-FFR analyses were performed with a dedicated software. All patients were followed up for at least 1 year. We validated the accuracy of RuiXin-FFR with invasive FFR as the standard of reference, and investigated the role of RuiXin-FFR in predicting treatment strategy and long-term prognosis. The mean age of the patients was 63.3 years with 63.9% male. The CT-FFR showed a moderate correlation with wire-derived FFR (r = 0.542, p < 0.0001) and diagnostic accuracy of 87.6% to predict myocardial ischemia (AUC: 0.839, 95% CI 0.728-0.950), which was significantly higher than CCTA and ICA. In the multivariate logistic regression analysis, CT-FFR ≤ 0.80 was an independent predictor of undergoing coronary revascularization (OR: 45.54, 95% CI 12.03-172.38, p < 0.0001), whereas CT-FFR > 0.80 was an independent predictor of non-obstructive CAD (OR: 14.67, 95% CI 5.42-39.72, p < 0.0001). Reserving ICA and revascularization for vessels with positive CT-FFR could have reduced the rate of ICA by 29.6%, lowered the rate of ICA in vessels without stenosis > 50% by 11.7%, and increased the rate of revascularization in patients receiving ICA by 21.2%. The average follow-up was 23.7 months, and major adverse cardiovascular events (MACE) occurred in 11 patients. The rate of MACE was significantly lower in patients with CT-FFR > 0.80. The new algorithm of CT-FFR can be used to predict the invasive FFR. The RuiXin-FFR can also provide useful information for the screening of patients in whom further ICA is indeed needed and prognosis evaluation.

Intravascular Ultrasound-Guided Stent Implantation in the Left Main Coronary Artery Extrinsic Compression by Pulmonary Artery Aneurysm Due to Eisenmenger Syndrome.

Pulmonary arterial hypertension (PAH) is a profoundly destructive condition marked by the gradual narrowing and restructuring of small pulmonary arteries, leading to a rise in pulmonary vascular resistance (PVR), causing right-sided heart failure and, ultimately, mortality. During more advanced stages of this disease, patients may present with rare manifestations of pulmonary artery aneurysm (PAA) which are exertional chest pain, and hoarseness. The left main coronary artery compression (LMCA-Co) has been an increasingly recognized and possibly life-threatening entity in patients with severe PAH. The lack of well-established decision-making strategies for the management of both PAA and LMCA-Co has been remained as an unsolved issue in this setting. In this report, we present a case of percutaneous intervention of LMCA-Co with the guidance of intracoronary imaging in a patient with patent ductus arteriosus-Eisenmenger syndrome. Percutaneous intervention with intravascular guidance appears to be a safe and effective option for relieving symptoms and achieving positive clinical outcomes in patients with LMCA-Co.

Treatment of syphilitic aortitis with coronary artery bypass grafting and "open" stent placement.

Cardiovascular syphilis manifests many years after primary infection. Here, we report the successful treatment of a patient who developed syphilitic aortitis with bilateral coronary ostial stenosis and aortic insufficiency. The patient underwent right coronary artery bypass grafting, left main coronary ostial "open" stent placement, and mechanical aortic valve placement during open-heart surgery.

New Whole-Heart motion correction algorithm enables diagnostic CT of aortic valve and coronary arteries in systolic phase for transcatheter aortic valve implantation candidates.

OBJECTIVES: To investigate the ability of new generation snapshot freeze (NGSSF) algorithm in improving diagnostic image quality of both aortic valve and coronary arteries for transcatheter aortic valve implantation (TAVI) candidates in TAVI planning CT. METHODS: Sixty-four TAVI candidates underwent TAVI planning CT were enrolled. Scans from coronary CT angiography were reconstructed at 20%, 30%, 40%, and 75% R-R cardiac phases with NGSSF and standard (STD) algorithm. In each phase, following parameters were compared: aortic valve measurements and their reproducibility; image quality of aortic valve and coronary arteries. The diagnostic accuracies of TAVI planning CT for coronary artery stenosis in 30% R-R phase with NGSSF and STD algorithms were calculated in 47out of 64 patients with invasive coronary angiography as reference standard. RESULTS: For subjective image quality evaluation, the excellent rate for aortic valve improved from 25.0% to 93.8% and the interpretable rate for coronary arteries increased from 20.3% to 95.3% in the 30% phase images with NGSSF compared with images with STD. For the detection of > 50% coronary artery stenosis, the 30% phase images with NGSSF provided a sensitivity of 90%, specificity of 81.48%, negative predictive value of 91.7%, and positive predictive value of 78.3% on a per-patient basis; While images with STD, had a corresponding results of 95.0%, 33.33%, 90.0%, and 51.4%, respectively. CONCLUSIONS: NGSSF significantly improves image quality for both aortic valve and coronary arteries compared with STD for TAVI patients of all heart rates. NGSSF enables the accurate measurement for aortic valve and satisfactory diagnostic performance for coronary arteries stenosis in the same systolic phase for TAVI planning.

Determination of Left Main Coronary Artery Stenosis Through Noninvasive Testing to Guide Revascularization in Ischemic Heart Disease.

Anatomically severe left main coronary artery (LMCA) stenosis (>50%) remains one of the few groups to benefit from early revascularization in stable ischemic heart disease (SIHD). Identification of these patients through widely available noninvasive testing would decrease the need for additional upfront anatomic testing, lowering the overall cost of healthcare. Patients with SIHD who underwent either percutaneous or surgical revascularization over a 7-year period at our institution were retrospectively analyzed and categorized as having LMCA stenosis versus non-LM stenosis. All preceding noninvasive testing, including resting electrocardiogram, echocardiogram, and functional testing was evaluated and compared between groups using chi-square and t test. In total, 806 patients were evaluated. Of those, 121 were identified as having significant LMCA stenosis with 685 patients in the non-LM cohort. Between LMCA versus non-LM cohorts, there were similar rates of electrocardiogram abnormalities (68.9% vs 70.8%, p >0.05), abnormal echocardiograms (72.7% vs 69.7%, p >0.05), abnormal functional testing (83.3% vs 77.4%, p >0.05), and high-risk imaging findings (5.6% vs 4.8%, p >0.05). More importantly, of those with a complete workup, there were similar rates of normal results between the LMCA (3 of 18, 16.7%) and non-LM stenosis (9 of 189, 4.8%) groups. A comprehensive noninvasive profile of patients with IHD failed to identify or exclude patients with anatomically severe LMCA stenosis, necessitating anatomic assessment.

Intravascular Ultrasound-Based Fractional Flow Reserve for Predicting Prognosis after Percutaneous Coronary Intervention.

AccuFFRivus is an alternative to fractional flow reserve (FFR) based on intravascular ultrasound (IVUS) images for functional assessment of coronary stenosis. However, its prognostic impact in patients undergoing percutaneous coronary intervention (PCI) is still unclear. This retrospective study aimed to investigate the capability of AccuFFRivus in predicting prognosis. AccuFFRivus was calculated based on postoperative angiographic and IVUS images. Vessel-oriented clinical events (VOCE) at 2 years were recorded and analyzed. A total of 131 participants with 131 vessels were included in the study. VOCE occurred in 15 patients during 2-year follow-up. AccuFFRivus after PCI (post-AccuFFRivus) was significantly higher in the non-VOCE group than in the VOCE group (0.95 ± 0.03 vs. 0.91 ± 0.02, p < 0.001). Multivariate Cox regression showed that AccuFFRivus ≤ 0.94 was a strong independent predictor of VOCE during 2-year follow-up (hazard ratio 23.76, 95% confidence interval: 3.04-185.81, p < 0.001). The left panel displays the Receiver operating characteristics (ROC) curves of postoperative parameters (post-AccuFFRivus and post-MLA) versus vessel-oriented clinical events (VOCE) occurrence within 2-year follow-up. The right panel demonstrates Kaplan-Meier curves of VOCE stratified by the optimal cut-off of post-AccuFFRivus.

The impact of left circumflex coronary artery ostium stenosis on outcomes for patients after percutaneous coronary intervention for unprotected left main disease.

BACKGROUND: The impact of left circumflex coronary artery (LCX) ostium atherosclerosis in left main coronary artery (LM) bifurcation disease is not well-known. AIM: The study aimed to assess whether the involvement of LCX ostium carries prognostic implications in patients undergoing unprotected LM percutaneous coronary intervention (PCI). METHODS: Consecutive 564 patients with unprotected LM (ULMCA) disease who underwent LM PCI between January 2015 and February 2021, with at least 1 year of available follow-up were included in the study. The first group was composed of 145 patients with ULMCA disease with LCX ostium stenosis, and the second group consisted of 419 patients with ULMCA disease without LCX ostium stenosis. RESULTS: Patients in the group with ULMCA disease with LCX ostium stenosis were significantly older and had more comorbidities. The two-stent technique was used more often in the group with LCX ostium stenosis (62.8% vs. 14.6%; P <0.001). During 7-year follow-up, all-cause mortality did not differ significantly between groups with and without LCX ostium stenosis (P = 0.50). The use of one-stent or two-stent technique also did not impact mortality in patients with LCX ostial lesions (P = 0.75). Long-term mortality subanalysis for three groups of patients: (1) patients with LM plus LCX ostium stenosis; (2) LM plus left anterior descending artery (LAD) ostium stenosis; (3) LM plus LCX ostium plus LAD ostium stenosis also did not differ significantly (P = 0.63). CONCLUSIONS: LCX ostium involvement in LM disease PCI is not associated with adverse long-term outcomes, which is highly beneficial for the Heart Team's decision-making process.

The 17th expert consensus document of the European Bifurcation Club - techniques to preserve access to the side branch during stepwise provisional stenting.

Provisional stenting has become the default technique for the treatment of most coronary bifurcation lesions. However, the side branch (SB) can become compromised after main vessel (MV) stenting and restoring SB patency can be difficult in challenging anatomies. Angiographic and intracoronary imaging criteria can predict the risk of side branch closure and may encourage use of side branch protection strategies. These protective approaches provide strategies to avoid SB closure or overcome compromise following MV stenting, minimising periprocedural injury. In this article, we analyse the strategies of SB preservation discussed and developed during the most recent European Bifurcation Club (EBC) meetings.

Survival after PCI or CABG for left main stem coronary stenosis. A single institution registry from the NOBLE study period.

Objective. To analyze 10 years mortality in an all-comers registry of patients with left main coronary artery stenoses treated with either PCI or CABG. Design. Patients with left main coronary stenoses treated with either PCI or CABG in the period of the NOBLE trial (2010-2015) were all included in an institutional database and registry (University Hospital North Norway). Fifty-six of totally 429 patients were included in the randomized, multicenter and international NOBLE trail; 426 eligible patients from the trial and registry were analyzed for mortality on 20 October 2020. The longest observation time on this date was 3611 days (9.9 years); 205 patients were treated with PCI and 221 with CABG. The patients treated with PCI were 74 ± 10 years vs 68 ± 10 years (CABG). Also, on average the PCI patients had more comorbidities (lower ejection fraction, more peripheral artery disease, more often acute presentation). Results. Survival at the last observation date was 80% for CABG patients vs 48% for PCI. A Cox proportional hazards analysis found PCI to be the strongest independent predictor for mortality (HR = 2.5, 95% CI 1.7-3.7). Also, COPD, chronic kidney disease, age, peripheral vascular disease, cerebrovascular incidents and acute presentation were factor predicting increased 10 years mortality. Conclusion. These data indicate that life expectancy in the overall patient population is shorter for patient treated for left main disease with PCI than with CABG.

Nomogram for evaluating coronary revascularisation necessity based on multi-parameter coronary CT angiography.

AIM: To build a nomogram model to improve the evaluation of revascularisation necessity using multi-parameter coronary computed tomography (CT) angiography (CCTA). MATERIALS AND METHODS: In this retrospective study, 335 patients who underwent CCTA and required revascularisation within 1 month were selected and allocated to the revascularisation group; 208 patients who did not undergo revascularisation were allocated to the non-revascularisation group. CCTA parameters, including CCTA stenosis, plaque qualitative-quantitative characteristics, and fractional flow reserve derived from CT angiography (CT-FFR), for both groups were analysed and compared. Independent risk factors for evaluating revascularisation were obtained using univariate and multivariable regression analysis, after which multi-parameter models were built. Finally, a nomogram was created with these independent risk factors using the R programming language. RESULTS: Plaque analysis was performed successfully for 543 patients with 1,072 target plaques. The performance of the multi-parameter model (AUC 0.894, p<0.001) was significantly higher than that of models based on stenosis (AUC 0.804, p<0.001), plaque qualitative/quantitative characteristics (AUC 0.754/0.789, p<0.001), or CT-FFR (AUC 0.848, p<0.001) alone, to evaluate the necessity of revascularisation. The independent risk factors were CCTA stenosis (OR 1.004, p=0.04), positive remodelling (OR 2.474, p<0.001), total plaque volume (OR 1.001, p<0.001), non-calcified plaque volume proportion (OR 1.019, p<0.001), and CT-FFR (OR 0.001, p<0.001). Subsequently, a nomogram based on these factors was created. CONCLUSION: The multi-parameter CCTA model improved performance in evaluating revascularisation necessity. The nomogram based on these factors is shows promise in clinical settings.

Accuracy of the angiography-based quantitative flow ratio in intermediate left main coronary artery lesions and comparison with visual estimation.

BACKGROUND: Revascularization of left main coronary artery (LMCA) stenosis is mostly based on angiography. Indices based on angiography might increase accuracy of the decision, although they have been scarcely used in LMCA. The objective of this study is to study the diagnostic agreement of QFR (quantitative flow ratio) with wire-based fractional flow reserve (FFR) in LMCA lesions and to compare with visual severity assessment. METHODS: In a series of patients with invasive FFR assessment of intermediate LMCA stenoses we retrospectively compared the measured value of QFR with that of FFR and the estimate of significance from angiography. RESULTS: 107 QFR studies were included. The QFR intra-observer and inter-observer agreement was 87% and 82% respectively. The mean QFR-FFR difference was 0.047 ± 0.05 with a concordance of 90.7%, sensitivity 88.1%, specificity 92.3%, positive predictive value 88.1% and negative predictive value 92.3%. All these values were superior to those observed with the visual estimation which showed an intra- and inter-observer agreement of 73% and 72% respectively, besides 78% with the FFR value. The low diagnostic performance of the visual estimation and the acceptable performance of the QFR index measurement were observed in all subgroups analysed. CONCLUSIONS: QFR allows an acceptable estimate of the FFR obtained with intracoronary pressure guidewire in intermediate LMCA lesions, and clearly superior to the assessment based on angiography alone. The decision to revascularize patients with moderate LMCA lesions should not be based solely on the degree of angiographic stenosis.