Association Between Radial Versus Femoral Access for Percutaneous Coronary Intervention and Long-Term Mortality.

Background Percutaneous coronary intervention with radial arterial access has been associated with fewer occurrences of major bleeding. However, published data on the long-term mortality and major adverse cardiac events after percutaneous coronary intervention with radial or femoral arterial access are inconclusive. Method and Results This was a territory-wide retrospective cohort study including 26 022 patients who underwent first-ever percutaneous coronary intervention between January 1, 2010 and December 31, 2017 in Hong Kong. Among the 14 614 patients matched by propensity score (7307 patients in each group), 558 (7.6%) and 787 (10.8%) patients died during the observation period in the radial group and femoral group, respectively, resulting in annualized all-cause mortality rates of 2.69% and 3.87%, respectively. The radial group had a lower risk of all-cause mortality compared with the femoral group up to 3 years after percutaneous coronary intervention (hazard ratio [HR], 0.70; 95% CI, 0.63-0.78; P<0.001). Radial access was associated with a lower risk of major adverse cardiac events (HR, 0.78; 95% CI, 0.73-0.83, P<0.001), myocardial infarction after hospital discharge (HR, 0.78; 95% CI, 0.70-0.87, P<0.001), and unplanned revascularization (HR, 0.76; 95% CI, 0.68-0.85, P<0.001). The risks of stroke were similar across the 2 groups (HR, 0.96; 95% CI, 0.82-1.13, P=0.655). Conclusions Radial access was associated with a significant reduction in all-cause mortality at 3 years compared with femoral access. Radial access was associated with reduced risks of myocardial infarction and unplanned revascularization, but not stroke. The benefits were sustained beyond the early postoperative period.

Comparison Between Bare-Metal Stents, First-Generation Drug-Eluting Stents, and Bioresorbable Vascular Scaffolds.

BACKGROUND: The long-term clinical outcomes after bioresorbable vascular scaffold (BVS) implantation have been extensively compared with second-generation drug-eluting stent (DES) implantation, but not with bare-metal stent (BMS) or first-generation DES options. OBJECTIVE: To compare the major adverse cardiovascular event (MACE) rates after implantation of BVS, first-generation DES, and BMS. METHODS: This was a single-center observational study based on a registry of percutaneous coronary intervention (PCI). The primary endpoint was MACE at 3 years, defined as a composite endpoint of death, non-fatal myocardial infarction, and target-vessel revascularization. RESULTS: A total of 170 consecutive patients who underwent PCI with implantation of everolimus-eluting BVS (Absorb; Abbott Cardiovascular) between 2014 and 2017 were compared with a control group of 622 patients implanted with BMS and 604 patients implanted with first-generation DES from 2001 to 2005. In adjusted analysis, DES had a lower risk of MACE at 3 years compared with BMS (adjusted odds ratio [OR], 0.58; 95% confidence interval [CI], 0.41-0.81; P<.01), while BVS had a similar risk of MACE compared with BMS (adjusted OR, 0.91; 95% CI, 0.55-1.52; P=.72). When compared with DES, BVS had a similar risk of MACE (adjusted OR, 1.45; 95% CI, 0.83-2.53; P=.19). CONCLUSIONS: In patients with BVS implantation, the risk of the composite outcome of MACE at 3 years was not significantly different when compared with patients with BMS or first-generation DES implantation.

Factors associated with long-term major adverse cardiac events of coronary bioresorbable vascular scaffold.

The long-term clinical outcomes after implantation of bioresorbable vascular scaffolds (BVS) in a real-world cohort were not well described. To identify factors associated with major adverse cardiovascular events (MACE) on long-term follow-up after implantation of BVS in patients undergoing elective percutaneous coronary intervention (PCI). This was an observational study based on a hospital registry of percutaneous coronary intervention. Participants were consecutive patients who underwent PCI and implanted with at least one everolimus-eluting BVS (Absorb®) in a single center between 2014 and 2017. Among the 170 cases analyzed (mean age 60.4 ± 10.7), a total of 203 Absorb BVS were implanted. MACE developed in 33 (19.4%) patients over a median follow-up period of 61 months, including 9 (5.3%) deaths, 13 (7.6%) non-fatal myocardial infarction and 19 (11.2%) ischemia driven target vessel revascularization. Definite or probable stent thrombosis developed in 4 (2.4%) patients. In crude analysis, history of smoking and initial presentation of non-ST elevation-acute coronary syndrome (NSTE-ACS) were predictors of long-term MACE. In adjusted analysis, presentation with NSTE-ACS was an independent predictor of long-term MACE [adjusted odds ratio (OR) 4.52; 95% confidence interval (95% CI) 1.50 to 13.6, P = 0.007]. Among patients receiving implantation of ABSORB BVS, presentation with NSTE-ACS was an independent predictor of MACE after a median follow-up period of 61 months. Future research is needed to confirm these findings and to determine the long-term safety of BVS in patients with NSTE-ACS.

Protocol, rationale and design of DAbigatran for Stroke PreVention In Atrial Fibrillation in MoDerate or Severe Mitral Stenosis (DAVID-MS): a randomised, open-label study.

INTRODUCTION: Current international guidelines recommend non-vitamin K oral anticoagulants (NOACs) for stroke prevention among patients with non-valvular atrial fibrillation (AF) at significant ischaemic stroke risk given the superior safety and comparable efficacy of NOACs over warfarin. Nonetheless, the safety and effectiveness of NOACs have not been evaluated in patients with AF with underlying moderate or severe mitral stenosis (MS), hence the recommended stroke prevention strategy remains warfarin therapy. METHOD AND ANALYSIS: MS remains disproportionately prevalent in Asian countries compared with the developed countries. This prospective, randomised, open-label trial with blinded endpoint adjudication aims to evaluate the safety and efficacy of dabigatran for stroke prevention in AF patients with moderate or severe MS. Patients with AF aged ≥18 years with moderate or severe MS not planned for valvular intervention in the coming 12 months will be randomised in a 1:1 ratio to receive dabigatran 110 mg or 150 mg two times per day or warfarin with international normalised ratio 2-3 in an open-label design. Patients with estimated creatinine clearance <30 mL/min, or with a concomitant indication for antiplatelet therapy will be excluded. The primary outcome is a composite of stroke and systemic embolism. Secondary outcomes are ischaemic stroke, systemic embolism, haemorrhagic stroke, intracranial haemorrhage, major bleeding and death. The estimated required sample size is approximately 686 participants. ETHICS AND DISSEMINATION: The study protocol has been approved by the Institutional Review Board of the University of Hong Kong and Hong Kong West Cluster, Hospital Authority, Hong Kong for Fung Yiu King Hospital, Grantham Hospital, Queen Mary Hospital and Tung Wah Hospital in Hong Kong. Results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04045093); pre-results.

Thrombus removal prior to recanalization in vein graft occlusion intervention.

A saphenous vein graft chronic total occlusion intervention is uncommonly performed, partly due to the high risk of distal embolization. We described a strategy in which after successful wiring of a saphenous vein graft chronic total occlusion, balloon dilatation was performed to create a blind sac within the lesion, followed by aspiration thrombectomy to remove all the dislodged debris. Thereafter, balloon dilatation and stenting were safely performed in the distal occluded segment, to achieve complete recanalization.

Angiographic study of the clinical liaison of drug-eluting stent and paclitaxel-eluting balloon in unifocal side branch ostium stenosis (ASCLEPIUS).

A reliable stenting strategy for treating isolated side branch (SB) ostium stenosis is not well established. The purpose of this study was to examine the 6-month angiographic outcome of a novel technique, called the shoulder technique, on this lesion subtype. Symptomatic patients with isolated SB ostium stenosis, defined as ≥75% diameter stenosis at SB ostium and <50% diameter stenosis in main vessel (MV), were treated with paclitaxel-eluting balloon in MV and drug-eluting stent in SB using the shoulder technique. Angiographic restudy was performed at 5-9 months and clinical follow-up was scheduled regularly every 3 months. There were 46 patients of age 66 ± 12 years with male predominance (76%) recruited. Diagonal ostium (67%) was the most frequent target lesion site. The size and length of paclitaxel-eluting balloon and drug-eluting stent used in MV and SB were 3.01 ± 0.25 and 20 ± 4 mm, and 2.39 ± 0.25 and 17 ± 6 mm, respectively. Angiographic restudy was performed on 43 (93.5%) patients at 6.5 ± 1.6 months. The late loss in MV and SB were 0.04 ± 0.19 and 0.19 ± 0.32 mm, respectively. Angiographic restensosis was seen in 2 (4.7%) patients at SB, whereas no stenosis was induced in MV. Improvement of symptom was reported in 36 (78%) patients. At 1-year follow-up, no death, myocardial infarction, and stent thrombosis was observed; target vessel revascularization was performed on 3 (6.5%) patients. Treatment of isolated SB ostium stenosis using the shoulder technique is associated with a favorable short-term angiographic outcome.

Dislodged stent after stent reverse controlled antegrade and retrograde subintimal tracking (CART) - Is stent reverse CART a necessary tool or an unnecessary evil?

We report a case of stent reverse controlled antegrade and retrograde subintimal tracking (CART) in left anterior descending artery (LAD) chronic total occlusion. Reverse CART is the method used to make a connection between the retrograde wire and the antegrade true lumen by using a balloon to dilate the antegrade space and pushing the retrograde wire into this space. We successfully crossed the septal channel from right coronary to the LAD, and proceeded to reverse CART, which was unsuccessful. After demonstrating that both the retrograde and antegrade wires were in the same subintimal space by intravascular ultrasound (IVUS), we placed the distal stent edge at the connection point of the wires and deployed the stent. We could easily wire the stent lumen with the retrograde conquest 9 g wire. Afterwards we tried to push the retrograde corsair microcatheter through the CTO and into the antegrade guiding, but unfortunately, the retrograde corsair could not pass into the antegrade guiding and was stuck just outside the antegrade guiding ostium. At this point IVUS showed that the stent had been dislodged from the LAD and pushed into the aorta just outside the left main by the retrograde corsair because the retrograde wire passed into the stent lumen through a distal side strut opening and not through the true distal end of the stent. Due to unstable hemodynamics we had to remove the retrograde system and this led to stent embolism. The case illustrates stent dislodgement after stent reverse CART and stresses the importance of using IVUS to check fully the retrograde wire path before pushing the corsair. We discuss the role of stent reverse CART in the contemporary reverse CART era and conclude that it should be relegated to the very last resort after trying transit balloon technique. We conclude that stent reverse CART is mostly an unnecessary evil. .

Effects of Ethnicity on the Prevalence of Obstructive Sleep Apnoea in Patients with Acute Coronary Syndrome: A Pooled Analysis of the ISAACC Trial and Sleep and Stent Study.

BACKGROUND: Obstructive sleep apnoea (OSA) is an emerging risk factor for acute coronary syndrome (ACS). We sought to determine the effects of ethnicity on the prevalence of OSA in patients presenting with ACS who participated in an overnight sleep study. METHODS: A pooled analysis using patient-level data from the ISAACC Trial and Sleep and Stent Study was performed. Using the same portable diagnostic device, OSA was defined as an apnoea-hypopnoea index of ≥15 events per hour. RESULTS: A total of 1961 patients were analysed, including Spanish (53.6%, n=1050), Chinese (25.5%, n=500), Indian (12.0%, n=235), Malay (6.1%, n=119), Brazilian (1.7%, n=34) and Burmese (1.2%, n=23) populations. Significant differences in body mass index (BMI) were found among the various ethnic groups, averaging from 25.3kg/m2 for Indians and 25.4kg/m2 for Chinese to 28.6kg/m2 for Spaniards. The prevalence of OSA was highest in the Spanish (63.1%), followed by the Chinese (50.2%), Malay (47.9%), Burmese (43.5%), Brazilian (41.2%), and Indian (36.1%) patients. The estimated odds ratio of BMI on OSA was highest in the Chinese population (1.17; 95% confidence interval: 1.10-1.24), but was not significant in the Spanish, Burmese or Brazilian populations. The area under the curve (AUC) for the Asian patients (ranging from 0.6365 to 0.6692) was higher than that for the Spanish patients (0.5161). CONCLUSION: There was significant ethnic variation in the prevalence of OSA in patients with ACS. The magnitude of the effect of BMI on OSA was greater in the Chinese population than in the Spanish patients.

Percutaneous Coronary Intervention for Bifurcation: How Can We Outperform the Provisional Strategy?

In the era of drug-eluting stents, the provisional stenting strategy has been established as the default strategy in percutaneous coronary intervention for bifurcation lesions. However, emerging evidence shows that, in selected situations, the complex strategy of stenting both vessels regardless could reduce side-branch restenosis without penalty. In particular, the double kissing crush technique has been proven to outperform the provisional strategy and other complex strategies in randomized trials. In this review, we present the evidence comparing the 2 strategies and individual stenting techniques and discuss the roles of other optimization techniques such as final kissing balloon inflation, proximal optimization technique, intravascular ultrasonography, and optical coherence tomography. Finally, we suggest a practical approach for choosing the optimal strategy for intervention with coronary bifurcation lesions.

Obstructive Sleep Apnea and Cardiovascular Events After Percutaneous Coronary Intervention.

BACKGROUND: There is a paucity of data from large cohort studies examining the prognostic significance of obstructive sleep apnea (OSA) in patients with coronary artery disease. We hypothesized that OSA predicts subsequent major adverse cardiac and cerebrovascular events (MACCEs) in patients undergoing percutaneous coronary intervention. METHODS AND RESULTS: The Sleep and Stent Study was a prospective, multicenter registry of patients successfully treated with percutaneous coronary intervention in 5 countries. Between December 2011 and April 2014, 1748 eligible patients were prospectively enrolled. The 1311 patients who completed a sleep study within 7 days of percutaneous coronary intervention formed the cohort for this analysis. Drug-eluting stents were used in 80.1% and bioresorbable vascular scaffolds in 6.3% of the patients, and OSA, defined as an apnea-hypopnea index of ≥15 events per hour, was found in 45.3%. MACCEs, a composite of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned revascularization, occurred in 141 patients during the median follow-up of 1.9 years (interquartile range, 0.8 years). The crude incidence of an MACCEs was higher in the OSA than the non-OSA group (3-year estimate, 18.9% versus 14.0%; p=0.001). Multivariate Cox regression analysis indicated that OSA was a predictor of MACCEs, with an adjusted hazard ratio of 1.57 (95% confidence interval, 1.10-2.24; P=0.013), independently of age, sex, ethnicity, body mass index, diabetes mellitus, and hypertension. CONCLUSIONS: OSA is independently associated with subsequent MACCEs in patients undergoing percutaneous coronary intervention. Evaluation of therapeutic approaches to mitigate OSA-associated risk is warranted. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01306526.

Relation of Tricuspid Regurgitation to Liver Stiffness Measured by Transient Elastography in Patients With Left-Sided Cardiac Valve Disease.

The aim of the study was to evaluate the relation between tricuspid regurgitation (TR) severity and liver stiffness (LS) in patients with TR. A total of 131 patients with various degrees of TR secondary to left-sided heart valve disease were enrolled. Severity of TR was quantitatively assessed by proximal isovelocity surface area-derived effective regurgitant orifice (ERO). Patients were divided into 2 groups: 48 with mild-moderate TR (ERO <0.4 cm(2)) and 83 with severe TR (ERO ≥0.4 cm(2)). Transient elastography was used to measure the level of LS, an established marker of liver fibrosis, with the threshold of significant LS set at ≥12.5 kPa. Patients with severe TR had a higher LS and prevalence of significant LS than those with mild-moderate TR. Furthermore, LS and significant LS independently correlated with TR-ERO, right atrial pressure and inferior vena cava (IVC) diameter. The presence of a large TR-ERO (≥0.4 cm(2)) and IVC diameter (>2.15 cm(2)) provided a high specificity of 78% for significant LS. In conclusion, the present study demonstrates that TR-ERO, right atrial pressure, and IVC diameter are important parameters associated with LS in patients with TR.

Angiographic result of T-stenting with small protrusion using drug-eluting stents in the management of ischemic side branch: the ARTEMIS study.

The aim of this study was to examine the mid-term angiographic result of T-stenting with small protrusion (TAP) as the bailout strategy for treating coronary bifurcation lesions. From 2009 to 2012, symptomatic patients who had severe coronary bifurcation stenoses were treated with one-stent strategy using drug-eluting stents, with kissing balloon inflation performed whenever side branch (SB) impingement occurred. TAP was performed if residual diameter stenosis of SB was ≥75%, presence of ≥type B dissection or flow impairment was observed in the SB. Seventy-one patients (83% male, mean age of 61 ± 12 years) were recruited into the study. MEDINA classification 1,1,1 lesions were observed in over 60% of patients. The mean stent size and length in the main vessel (MV) and SB were 2.86 ± 0.43 and 30 ± 12, and 2.45 ± 0.26 and 16 ± 6 mm, respectively. Restudy angiography was performed on 64 (90 %) patients at 9.2 ± 3.9 months. Angiographic restenosis was observed in 8 (12.5%) patients with late lumen loss in the MV and SB being 0.22 ± 0.19 and 0.34 ± 0.37 mm, respectively. The use of TAP as the bailout technique for treating coronary bifurcation lesions is associated with good angiographic outcomes, in terms of late lumen loss and restenosis, at 9 months.