Myocardial revascularization failure among patients requiring cardiac catheterization and secondary revascularization in contemporary clinical practice: Results of the REVASEC multicenter registry.

BACKGROUND: Myocardial revascularization failure (MRF) and Secondary revascularization (SR) are contemporary interventional cardiology challenges. AIM: To investigate the characteristics, management, and prognosis of patients with myocardial revascularization failure (MRF) and need for secondary revascularization (SR) in contemporary practice. METHODS: The REVASEC study is a prospective registry (NCT03349385), which recruited patients with prior revascularization referred for coronary angiography at 19 centers. The primary endpoint is a patient-oriented composite (POCE) at 1 year, including death, myocardial infarction, or repeat revascularization. RESULTS: A total of 869 patients previously revascularized by percutaneous intervention (83%) or surgery (17%) were recruited. MRF was found in 83.7% (41.1% stent/graft failure, 32.1% progression of coronary disease, and 10.5% residual disease). SR was performed in 70.1%, preferably by percutaneous intervention (95%). The POCE rate at 1 year was 14% in the overall cohort, with 6.4% all-cause death. In the multivariate analysis, lower POCE rates were found in the groups without MRF (9.4%) and with disease progression (11%) compared with graft/stent failure (17%) and residual disease (18%), hazard ratio 0.67 (95% confidence interval: 0.45-0.99), p = 0.043. At 1 year, the SR group had less chronic persistent angina (19% vs. 34%, p < 0.001), but a higher rate of repeat revascularization (9% vs. 2.9%, p < 0.001). CONCLUSION: MRF was found in 84% of patients with prior revascularization referred for coronary angiography. Stent/graft failure and residual coronary disease were associated with a worse prognosis. SR provided better symptom control at the expense of a higher rate of new revascularization.

Spontaneous coronary artery dissection and ST-segment elevation myocardial infarction: Does clinical presentation matter?

BACKGROUND: Some patients with spontaneous coronary artery dissection (SCAD) present as ST-segment-elevation myocardial infarction (STEMI). This study evaluates the characteristics, management and outcomes of SCAD patients presenting as STEMI compared to non-ST-segment elevation myocardial infarction (NSTEMI). METHODS: We analysed data from consecutive patients included in the prospective Spanish Registry on SCAD. All coronary angiograms were centrally reviewed. All adverse events were adjudicated by an independent Clinical Events Committee. RESULTS: Between June 2015 to December 2020, 389 patients were included. Forty-two percent presented with STEMI and 56% with NSTEMI. STEMI patients showed a worse distal flow (TIMI flow 0-1 38% vs 19%, p < 0.001) and more severe (% diameter stenosis 85 ± 18 vs 75 ± 21, p < 0.001) and longer (42 ± 23 mm vs 35 ± 24 mm, p = 0.006) lesions. Patients with STEMI were more frequently treated with percutaneous coronary intervention (PCI) (31% vs 16%, p < 0.001) and developed more frequently left ventricular systolic dysfunction (21% vs 8%, p < 0.001). No differences were found in combined major adverse events during admission (7% vs 5%, p = 0.463), but in-hospital reinfarctions (5% vs 1.4%, p = 0.039) and cardiogenic shock (2.6% vs 0%, p = 0.019) were more frequently seen in the STEMI group. At late follow-up (median 29 months) no differences were found in the incidence of major adverse cardiac and cerebrovascular events (13% vs 13%, p-value = 0.882) between groups. CONCLUSIONS: Patients with SCAD and STEMI had a worse angiographic profile and were more frequently referred to PCI compared to NSTEMI patients. Despite these disparities, both short and long-term prognosis were similar in STEMI and NSTEMI SCAD patients.

Bioactive or Drug-Eluting Stents in 75 Years or Older Patients: The BIODES-75 Registry.

BACKGROUND: TiNO-coated BAS have demonstrated competitive outcomes compared to drug-eluting stents (DES). These devices allow short antiplatelet regimens and may be a good option for the growing elderly population undergoing percutaneous coronary intervention (PCI). METHODS: Multicenter observational trial in routine clinical practice. A propensity-score matched analysis compared a prospective cohort of patients ≥ 75 years undergoing PCI with BAS, with a contemporary and retrospective cohort treated with last-generation DES. The co-primary endpoints of the study were the Target-Lesion-Failure (Cardiac death, non-fatal myocardial infarction, or target lesion revascularization) and Major Adverse Cardiovascular Events (total death, non-fatal myocardial infarction, stroke, or new revascularization) at 1 year. RESULTS: Whole population included 1000 patients, and 326 patients in each group were matched for analysis. No differences in primary endpoints were found: TLF 10.4% vs. 11% (HR 0.96 (Confidence Interval 95%, 0.36-1.7; p = 0.87)) and MACE 16.3% vs. 17.2% (HR 0.98 (Confidence Interval 95%; 0.3-1.5, p = 0.93)). Patients treated with BAS received shorter antiplatelets regimens (dual antiplatelet therapy at 1 year, 25.7% vs. 70.6%, p = 0.0001), and they presented lower incidence of bleeding (3.7% vs. 11.7%, HR 0.3 (IC 95% 0.16-0.6, p = 0.001)). CONCLUSION: In this real-life registry of patients ≥ 75 years, BAS were similar to the latest-generation DES in terms of efficacy and reduced the duration of the antithrombotic therapy, lowering bleeding events.

Design and Rationale for a Real-World Prospective, Multicenter Registry of Myocardial Revascularization Failure and Secondary Revascularization: The REVASEC Study.

AIM: To investigate key aspects of the problem of myocardial revascularization failure (MRF) and repeat or secondary myocardial revascularization (SR) in contemporary practice. METHODS: The registry of secondary revascularization (REVASEC) is an investigator-initiated, multicenter, prospective registry enhanced with data monitoring and independent event adjudication (ClinicalTrials.govNCT03349385). It includes patients with prior revascularization referred to coronary angiography for suspected MRF with broad inclusion criteria. The main objectives are to describe the characteristics of patients with prior revascularization referred for repeat angiography, to describe and the rate and mechanisms of MRF (stent or graft failure, coronary artery disease progression or residual coronary artery disease); to evaluate the management including medical treatment and SR of these patients; and to assess the prognosis according to the outlined causative mechanisms. The registry has one year follow up for the primary endpoint (Patient-oriented composite endpoint including all-cause death, any myocardial infarction or any new unplanned revascularization according to subsets of MRF), but extended follow-up will be carried out up to 5 years. CONCLUSION: The REVASEC Registry will provide updated data on the characteristics, patterns of treatment, and 1-year outcomes of patients with MRF and SR in contemporary clinical practice.

Percutaneous Intervention in Diffuse Coronary Disease: Overlapping Versus Single Very Long Stent Technique. Results From the OVERLONG Registry.

BACKGROUND: Both stent length and stent overlap are associated with worse outcomes in the percutaneous treatment of diffuse coronary artery disease (dCAD). However, evidence comparing these issues is scarce. We aimed to compare the results between the use of single very long stent (VLS) and ≥2 overlapping stents (OS) in the treatment of dCAD. METHODS: Seven hundred twenty-four consecutive lesions were included: 275 treated with a single VLS (≥40 mm) and 449 with ≥2 OS. Procedural characteristics were assessed, and survival analysis was performed to compare the incidence of major adverse cardiovascular events (MACE; composite of cardiovascular death, nonfatal myocardial infarction, target lesion revascularization [TLR], or stent thrombosis) during a median follow-up of 31 months. RESULTS: Procedures with VLS required less contrast volume (268 ± 122 vs 302 ± 113 cm3; P < .01), fluoroscopy time (16 ± 8 vs 21 ± 16 minutes; P < .01), and procedure duration (37 ± 18 vs 47 ± 27 minutes; P < .01) than the OS procedures. The VLS group showed lower incidence of MACE (4.4% vs 10.7%; P < .01), driven mainly by lower TLR rate (1.1% vs 4.7%; P < .01). The use of OS was an independent predictor of MACE. CONCLUSIONS: In this study, the use of VLS for the treatment of dCAD was associated with better outcomes compared to OS.

Spontaneous coronary artery dissection in old patients: clinical features, angiographic findings, management and outcome.

AIMS: Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown. METHODS AND RESULTS: The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.028). They also had more often severe coronary tortuosity (36% vs. 11%, P = 0.036) and showed more frequently coronary ectasia (24% vs. 9%, P < 0.01). Older patients were more often managed conservatively (89% vs. 75%, P = 0.025), with no significant differences in major adverse cardiac events during index admission (7% vs. 8%, P = 0.858). There were no differences between groups in terms of in-hospital stay, new acute myocardial infarction, unplanned coronary angiography or heart failure. CONCLUSION: Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).

Comparison of One-Year Outcomes Between the ihtDEStiny BD Stent and the Durable-Polymer Everolimus- and Zotarolimus-Eluting Stents: A Propensity-Score-Matched Analysis.

OBJECTIVES: We sought to evaluate clinical outcomes in patients treated with the drug-eluting stent ihtDEStiny BD. BACKGROUND: The ihtDEStiny BD stent is a metallic sirolimus eluting stent with a biodegradable polymer with both drug and polymer coating the abluminal surface of the stent and balloon. METHODS: In this study, the clinical outcomes of a multicenter prospective registry of patients treated with this stent (DEStiny group) were analyzed and compared with those of a control group of patients treated with durable polymer everolimus or zotarolimus eluting stents (CONTROL group) paired by propensity score matching. Primary outcome was the target vessel failure (TVF) at 12 months defined as a composite of cardiac death, target vessel myocardial infarction (TV-MI) and target vessel revascularization (TVR). RESULTS: A total of 350 patients were included in the DESTtiny group. The control group consisted initially of 1368 patients, but after matching (1:1) 350 patients were selected as CONTROL group. The baseline clinical, angiographic and procedural characteristics were quite comparable in both groups. At 12 months follow up the TVF was 6.6% in DEStiny group and 6.3% in CONTROL group (p = 0.8). No differences were observed for any of the individual components of the primary endpoint: cardiac death 1.1% vs. 1.4%, TV-MI 3.4% vs. 3.7% and TVR 2.6% vs. 2.3% respectively. CONCLUSIONS: The use of ihtDEStiny stent in real practice is associated with a clinical performance at 12 months follow up that appears to be non-inferior to the most widely used and largely evidence supported durable polymer drug eluting stents. A longer follow up is warranted.

Long-Term Follow-Up of Percutaneous Coronary Intervention With Paclitaxel-Eluting Balloon Catheter.

Drug-eluting balloons currently constitute a therapeutic tool used in percutaneous coronary interventions (PCI). Long-term results remain unknown. We evaluated the prognosis of PCI using a second generation paclitaxel-eluting balloon (PEB) in real-world patients. We included all PCI with PEB in de novo or in-stent restenosis coronary lesions performed in our unit from March 2009 to March 2019. We assessed the composite of major adverse cardiovascular events (MACE) rate after a median follow-up of 42 months. Consecutive patients (n = 320) with 386 lesions were included; 46.9% presented with stable angina and 53.1% acute coronary syndromes; 52.6% of the lesions were in-stent restenosis and 47.3% de novo lesions with a mean diameter of 2.4 ± 0.5 mm. A bare metal stent was implanted in 6.7% and a drug-eluting stent in 8.5% of patients. The MACE rate was 8%: 10 (2.6%) cardiovascular deaths, 13 (3.4%) myocardial infarctions, and 16 (4.1%) target lesion revascularization. The all-cause death rate was 5.2%. No cases of thrombosis were recorded. In conclusion, PEB was a safe and effective tool to treat in-stent restenosis and de novo coronary lesions, especially small vessel disease, during long-term follow-up.

Biomarcadores inflamatorios y extensión de aterosclerosis coronaria en pacientes con síndrome coronario agudo: Estudio observacional prospectivo en un hospital general universitario / Circulating markers of inflammation and severity of coronary atherosclerosis in acute coronary syndrome: Prospective observational study in a general university hospital

Resumen Objetivo: Encontrar una relación entre los niveles de proteína C reactiva (PCR) y fibrinógeno, y la extensión de la aterosclerosis en el síndrome coronario agudo. Métodos: Estudio observacional prospectivo, en el que se incluyeron 873 pacientes con síndrome coronario atendidos en un hospital entre 2016 y 2018. Se analizaron niveles de PCR y fibrinógeno, marcadores metabólicos y extensión de la aterosclerosis coronaria. Resultados: No se halló correlación positiva entre los niveles de PCR y fibrinógeno y los marcadores metabólicos, así como tampoco con enfermedad de uno, dos y tres vasos (p 0,829; p 0,810). Conclusiones: Los niveles sanguíneos de PCR y fibrinógeno se relacionan con la tasa de eventos cardiovasculares, pero no se ha podido demostrar que exista relación entre estos y la severidad de la aterosclerosis coronaria.

Abstract Objective: To determine whether there is a relationship between C - reactive protein and fibrinogen levels and the extent of atherosclerosis in acute coronary syndrome. Methods: A prospective observational study was conducted that include 873 patients with coronary syndrome treated in a hospital between the years 2016 and 2018. An analysis was made that included C - reactive protein and fibrinogen levels, metabolic markers, extent of coronary atherosclerosis. Results: No positive correlation was found between the C - reactive protein and fibrinogen levels and the metabolic markers, nor with one, two, or three vessel disease (P=.829; P=.810). Conclusions: Although blood C-Reactive Protein and fibrinogen levels are associated with the rate of cardiovascular events, this study was unable to demonstrate whether there is a relationship between these and the severity of the coronary atherosclerosis.

Clinical Prognosis Associated With the Use of Overlapping Stents With Homogenous Versus Heterogeneous Pharmacological Characteristics for the Treatment of Diffuse Coronary Artery Disease.

BACKGROUND: The clinical impact of percutaneous coronary intervention (PCI) and implantation of overlapping stents (OS) using platforms with the same versus different pharmacological characteristics is unknown. Our objective was to compare the outcomes of PCI with OS according to their pharmacological characteristics. METHODS: In this observational single-center registry, we included all PCI performed from April 2014 to December 2018 in which overlapping drug-eluting stents were implanted. Two groups were created according to whether the stents release the same drug [homogeneous: (HO)] or different [heterogeneous: (HE)]. The primary endpoint was the need for target lesion revascularization (TLR). Clinical assessment was performed after the procedure, bianually and at the end of follow-up (June 2019). RESULTS: 381 lesions with OS (HO: 209; HE: 172) were included (75.1% male, 66.7 ±â€¯11.6 years). Clinical presentation was stable coronary artery disease in 49.9%. Syntax score was 23.7 ±â€¯13.3. The number of OS implanted was 2.2 ±â€¯0.5 and the total stent length was 59.5 ±â€¯20.1 mm (HE: 61.5 ±â€¯21.6 vs. HO: 57.8 ±â€¯18.8 mm; p < 0.01). After a median follow-up of 21 months, the HE group showed a lower TLR rate than the HO group (HE:2.3% vs HO:7.2%; p = 0.03). The rates of cardiac death (p = 0.44), myocardial infarction (p = 0.36) and stent thrombosis (p = 0.85) were similar between groups. In the multivariate analysis, the OS with homogeneous-drug devices was an independent predictor of a higher rate of TLR. CONCLUSIONS: PCI using OS with homogeneous pharmacological characteristics was associated with a higher rate of TLR in comparison with the implantation of OS with heterogeneous pharmacological characteristics.

An Unusual Entity: Woven Coronary Artery Anomaly.

The recognition of woven coronary artery anomaly is difficult because of its rare nature. Optical coherence tomography imaging is challenging due to the tortuosity of the channels; however, it is crucial not only for the differential diagnosis but also to guide the treatment approach.

Angiography and Optical Coherence Tomography Assessment of the Drug-Coated Balloon ESSENTIAL for the Treatment of In-Stent Restenosis.

OBJECTIVES: This study sought to assess the efficacy of the drug-coated balloon (DCB) ESSENTIAL for the treatment of in-stent restenosis (ISR). BACKGROUND: DCBs have proven a valid therapeutic option for the management of ISR in several clinical trials, yet no class effect can be claimed. Accordingly, every new DCB model has to be individually evaluated through clinical studies. METHODS: This is a prospective, multicenter study including consecutive patients undergoing percutaneous coronary intervention for ISR with the ESSENTIAL DCB. A 6-month quantitative coronary angiography (QCA)/optical coherence tomography (OCT) follow-up was scheduled. The primary endpoint was OCT-derived in-segment maximal area stenosis. Secondary endpoints included QCA-derived in-segment late lumen loss (LLL) and target lesion failure (TLF) rates at 6, 12, and 24 months. TLF was defined as the composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization. RESULTS: A total of 31 patients were successfully treated with DCB, with 67% of ISR corresponding to drug-eluting stents (DES). At 6 months, 26 patients underwent the scheduled angiographic follow-up. The mean value for in-segment maximal area stenosis was 51.4 ±â€¯13% and the median value was 53% (IQR 46.4-59.5). In the DES-ISR subgroup, these parameters were 52.6 ±â€¯10% and 55.2% (IQR 49.3-58.5), respectively. In-segment LLL was 0.25 ±â€¯0.43 mm with only 2 (7.7%) patients showing binary restenosis (>50%). The incidence of TLF was 10% at 6 months, 13.3% at 12 months, and 13.3% at 24 months. CONCLUSIONS: In this study, the ESSENTIAL DCB showed sustained efficacy in the prevention of recurrent restenosis after treatment of ISR. SUMMARY: We sought to assess the efficacy of the drug-coated balloon ESSENTIAL for the treatment of in-stent restenosis through a prospective, multicenter study including QCA and OCT assessment at 6-month follow-up. The primary endpoint was in-segment maximal area stenosis. Among the 31 patients successfully treated with the ESSENTIAL DCB, an angiographic follow-up was conducted in 26. Mean in-segment maximal area stenosis was 51.4 ±â€¯13% and the median value was 53% (IQR 46.4-59.5). In the DES-ISR subgroup, corresponding values were 52.6 ±â€¯10% and 55.2% (IQR 49.3-58.5), respectively. The observed in-segment LLL was 0.25 ±â€¯0.43 mm and binary restenosis rate was 7.7%. TLF was 10% at 6 months and 13.3% at 12 and 24 months.

Magmaris Resorbable Magnesium Scaffold Implantation Assisted by Optical Coherence Tomography to Treat an Acute Coronary Dissection After a Blunt Chest Trauma.

The treatment of coronary lesions caused by blunt chest trauma is controversial. To our knowledge, this is the first report of a coronary dissection related to blunt chest trauma evaluated with OCT and treated with a magnesium resorbable scaffold.

Efficacy and Safety of Loading Doses With P2Y12-Receptor Antagonists in Patients Without Dual Antiplatelet Therapy Undergoing Elective Coronary Intervention.

BACKGROUND: European Guidelines on Myocardial Revascularization recommend clopidogrel loading dose added to acetylsalicylic acid in elective percutaneous coronary interventions (PCIs). However, there is few evidence supporting this recommendation and other P2Y12 inhibitors have not been tested in these patients. PURPOSE: To evaluate the effectiveness and safety of different loading doses of clopidogrel and ticagrelor in patients without double antiplatelet therapy and stable coronary artery disease (SCAD) undergoing elective PCI. METHODS: Retrospective study of 147 consecutive patients with SCAD undergoing elective PCI. Loading P2Y12 inhibitor doses evaluated were: clopidogrel 600 mg, clopidogrel 300 mg, clopidogrel 150 mg, and ticagrelor 180 mg. We analyzed the occurrence of major adverse cardiovascular events and periprocedural myocardial infarction. RESULTS: One hundred twenty-five patients were treated with clopidogrel (16 with clopidogrel 150 mg, 7 with clopidogrel 300 mg, and 93 with clopidogrel 600 mg) and 21 with ticagrelor 180 mg at the catheterization laboratory. The ticagrelor group had a significantly lower postprocedural peak of troponin-I (0.7 ± 3.4 vs. 0.3 ± 0.7 ng/mL; P = 0.02). There were no differences between groups in terms of major bleeding and hemoglobin drop after PCI (0.6 ± 0.8 vs. 4 ± 0.6; P = 0.8). The median of follow-up was 17 months (interquartile range 9-32.7). At the end of follow-up, major adverse cardiovascular event rate was not different between groups. CONCLUSIONS: In patients without dual antiplatelet therapy undergoing elective PCI, the use of ticagrelor showed lower postprocedural myocardial injury without more bleeding complications.

Comparison of Clinical Outcomes Between Very Long Stents and Overlapping Stents for the Treatment of Diffuse Coronary Disease in Real Clinical Practice.

BACKGROUND: The stent length as well as the stent overlap for the percutaneous treatment of diffuse coronary disease have been considered predictors of adverse events. However, there are no comparative data on the use of very long stents or overlapping stents in this scenario. OBJECTIVE: To compare the clinical results of very long stents (≥40 mm) or overlapping stents in real clinical practice. METHODS: We included 643 lesions in 628 consecutive patients treated with a single very long stent (≥40 mm) (251 lesions) or ≥2 overlapped stents (392 lesions). We analyzed the procedural characteristics and the presentation of the combined endpoint [cardiovascular death, non-fatal myocardial infarction, need for target lesion revascularization or stent thrombosis] after a follow-up of 20 months. RESULTS: Total stent length was 54 ±â€¯18 mm and minimum diameter was 2.9 ±â€¯1.2 mm. At the end of follow-up, the rate of adverse events was 8.3% (cardiac death: 4.9%, myocardial infarction: 1.7%, target lesion revascularization: 3.1%, stent thrombosis: 0.7%). There were no significant differences between both groups in the presentation of the combined endpoint. Procedures with overlapping stents had more contrast volume (309 ±â€¯115 vs 273 ±â€¯127 ml; p = 0.002), longer duration (47 ±â€¯22 vs 39 ±â€¯18 min; p < 0.0001), higher fluoroscopy time (20 ±â€¯13 vs 16 ±â€¯9 min; p < 0.0001) and higher number of stents to treat the index lesion (2.2 ±â€¯0.5 vs 1; p < 0.0001). CONCLUSIONS: New designs of very long stents allow not only treating increasingly complex lesions, but also simplifying the procedure and decreasing the number of stents with very favorable results similar to those obtained with stent overlap.

Systematic isolated post-dilatation of the side branch as part of the provisional stent technique in the percutaneous treatment of coronary bifurcations. CR12 Registry.

AIMS: To analyse systematic isolated post-dilatation of the side branch as a part of provisional stent technique. METHODS: 1960 angioplasties performed in two centres were prospectively registered, of which 382 were coronary bifurcations with a side branch>2mm. In centre A, isolated post-dilatation of the side branch was performed regardless its impairment after main vessel stenting. In centre B, side branch post-dilatation was performed only if it was severely affected after stent implantation. RESULTS: There was no difference between the two centres in the rate of side branch affection after stent implantation (A: 44.6 vs B: 49.3%, p=0.48) nor in the procedural success rate (A: 98.6% vs B: 96.7%, p=0.45). After one-year follow-up, a reduction of cardiovascular events was observed in centre A (A: 4.4% vs B: 10.4%, p=0.043) with a trend towards lower cardiac mortality (A: 2.2% vs B: 6.5%, p=0.093) and stent thrombosis (A: 0% vs B: 2.6%, p=0.077). There were no differences in the rate of myocardial infarction related to the treated artery (A: 1.4% vs B: 3.9%, p=0.29), or target lesion revascularization (A: 1.4% vs. B: 3.2%, p=0.45). CONCLUSIONS: Systematic isolated post-dilatation of the side branch in the provisional stent technique was associated with a high angiographic success rate, and a low rate of cardiovascular events during follow-up. Although the study design does not allow definitive conclusions, this strategy could be considered a valid option in some cases or even as part of the provisional stent technique.