Prophylactic hemodialysis following coronary angiography and one-year outcomes in non-dialysis patients with chronic kidney disease: A propensity-matched study.

BACKGROUND/PURPOSE: Prophylactic hemodialysis after coronary angiography in patients with chronic kidney disease (CKD) prevents contrast nephropathy; however, the one-year outcomes are unclear. This study aimed to investigate the one-year outcomes of prophylactic hemodialysis against standard treatment in patients with CKD who underwent coronary angiography. METHODS: A cohort study of 359 patients with CKD, coronary artery disease (CAD), and serum creatinine levels of 176.8-530.4 µmol/L, who were referred for elective coronary angiography was conducted. Propensity score matching identified 118 patient pairs for outcome comparisons. The hemodialysis group underwent prophylactic hemodialysis after coronary angiography, whereas the control group received standard treatment. The study's primary outcome was free from dialysis was considered the primary outcome, whereas the secondary outcome was overall survival. Unadjusted estimates of the probability of free from dialysis and overall survival were computed using Kaplan-Meier survival curves and log-rank tests. Cox proportional-hazards regression models were used in determining the risk factors associated with ESRD and mortality. RESULTS: During a mean 9.3 months follow-up duration, the hemodialysis group had significantly better free from dialysis (85.6% vs. 64.4%; P = 0.002) and overall survival (85.4% vs. 78.5%; P = 0.008) rates than the control group. Cox proportional-hazards regression analyses of the propensity score-matched patients showed that the hemodialysis group had reduced risks for ESRD and mortality (hazard ratios, 0.32 and 0.48, respectively). CONCLUSION: Prophylactic Hemodialysis following coronary angiography was associated with reduced ESRD and mortality risks in CKD patients with CAD, who did not routinely undergo dialysis.

Cutting Balloon Combined with Drug-Coated Balloon Angioplasty for the Treatment of In-Stent Restenosis.

Drug-coated balloon (DCB) has emerged as an alternative therapeutic choice for in-stent restenosis (ISR) lesions. Cutting balloon angioplasty (CBA) is also a strategy utilized to treat tight stenotic lesions or ISR lesions. Few studies have focused on whether CBA plus DCB could achieve a better result in lowering the incidence of recurrent ISR. This study aimed to evaluate the efficacy of CBA plus DCB for ISR lesions.Between August 2011 and December 2017, 681 patients (937 lesions) were diagnosed with ISR and treated with DCBs in our hospital. The CBA plus DCB group comprised 90 patients who underwent PCI with further CBA plus DCB, and the DCB alone group comprised 591 patients who underwent percutaneous coronary intervention (PCI) with DCB alone.Baseline characteristics, the types of previous stents, lesion type, prevalence of ostial lesion and left main lesion, and pre-PCI and post-PCI stenotic percentage showed no significant difference between the two groups. Only post-PCI reference luminal diameter and size of DCB were larger in the CBA plus DCB group. During the one-year follow-up period, late loss and clinical outcomes did not differ between the two groups before and after propensity score matching. The incidence of subtotal/total occlusion with delay flow was lower in the CBA plus DCB group after propensity score matching (4.1% versus 10.9%; P = 0.030).In these patients with ISR lesions, the clinical outcomes and the incidence of repeat target lesion revascularization were similar after treatment with CBA plus DCB versus DCB alone. Further study is warranted, including prospective, randomized comparisons.

Intra-Coronary Administration of Tacrolimus Improves Myocardial Perfusion and Left Ventricular Function in Patients with ST-Segment Elevation Myocardial Infarction (COAT-STEMI) Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: Ischemia-reperfusion injury following acute ST-segment elevation myocardial infarction (STEMI) is strongly related to inflammation. However, whether intracoronary (IC) tacrolimus, an immunosuppressant, can improve myocardial perfusion is uncertain. METHODS: A multicenter double-blind randomized controlled trial was conducted in Taiwan from 2014 to 2017. Among 316 STEMI patients with Killip class ≤ 3 undergoing primary percutaneous coronary intervention (PCI), 151 were assigned to the study group treated with IC tacrolimus 2.5 mg to the culprit vessel before first balloon inflation, and the remaining 165 were assigned to the placebo group receiving IC saline only. The primary endpoint was percentage of post-PCI TIMI-3 flow. The primary composite endpoints included achievement of TIMI-3 flow, TIMI- myocardial perfusion (TMP) grade, or 90-min ST-segment resolution (STR). The secondary endpoints were left ventricular ejection fraction (LVEF) and 1-month/1-year major adverse cardio-cerebral vascular events (MACCEs) (defined as death, myocardial infarction, stroke, target-vessel revascularization or re-hospitalization for heart failure). RESULTS: Although post-PCI TIMI-3 epicardial flow and MACCE rate at 1 month and 1 year did not differ between the two groups, TMP grade (2.54 vs. 2.23, p < 0.001) and 90-min STR (67% vs. 61%, p < 0.001) were significantly higher in the tacrolimus-treated group than in the placebo group. The STEMI patients treated with tacrolimus also had significantly higher 3D LVEF and less grade 2 or 3 LV diastolic dysfunction at 9 months compared to those without. CONCLUSIONS: IC tacrolimus for STEMI improved coronary microcirculation and 9-month LV systolic and diastolic functions. However, the benefit of tacrolimus on clinical outcomes remains inconclusive due to insufficient patient enrollment.

The Comparison of Clinical Outcomes After Drug-Eluting Balloon and Drug-Eluting Stent Use for Left Main Bifurcation In-Stent Restenosis.

Increasing evidence is available for the use of percutaneous coronary intervention (PCI) in selected patients with unprotected left main (LM) bifurcation coronary lesions. However, little data have been reported on recurrent in-stent restenosis (ISR) for LM bifurcation lesions. The aim of this study was to evaluate the efficacy of a drug-eluting balloon (DEB) for LM bifurcation ISR compared with that of a drug-eluting stent (DES).Between December 2011 and December 2015, 104 patients who underwent PCI for unprotected LM bifurcation ISR were enrolled. We separated the patients into 2 groups: (1) those underwent PCI with further DEB and (2) those underwent PCI with further DES. Clinical outcomes were analyzed.Patients' average age was 67.14 ± 7.65 years, and the percentage of male patients was 76.0%. A total of 75 patients were enrolled in the DEB group, and another 29 patients were enrolled in the DES group. Similar target lesion revascularization (TLR) rate and recurrent myocardial infarction (MI) rate were noted for both groups. A significantly higher cardiovascular mortality rate was found in the DES group (10.7% versus 0%, P = 0.020), and a higher all-cause mortality rate was noted in the DES group (21.4% versus 6.8%, P = 0.067).It is feasible to use DEB for LM bifurcation ISR. When comparing DEB with DES, similar TLR rates were found, but lower recurrent MI and lower cardiovascular death were noted for DEB treatment.

In-Hospital Implementation of Evidence-Based Medications is Associated with Improved Survival in Diabetic Patients with Acute Coronary Syndrome - Data from TSOC ACS-DM Registry.

BACKGROUND: Patients with acute coronary syndrome (ACS) and diabetes mellitus (DM) receive less aggressive treatment and have worse outcomes in Taiwan. We sought to explore whether the current practices of prescribing guideline-directed medical therapy (GDMT) for ACS and clinical outcomes have improved over time. METHODS: A total of 1534 consecutive diabetic patients with ACS were enrolled between 2013 and 2015 from 27 hospitals in the nationwide registry initiated by the Taiwan Society of Cardiology (the TSOC ACS-DM Registry). Baseline and clinical demographics, treatment, and clinical outcomes were compared to those of 1000 ACS patients with DM recruited in the Taiwan ACS-full spectrum (ACS-FS) Registry, which was performed between 2008 and 2010. RESULTS: Compared to the DM patients in the Taiwan ACS-FS Registry, even though reperfusion therapy was carried out in significantly fewer patients, the primary percutaneous coronary intervention (PCI) rate for ST-segment elevation myocardial infarction (STEMI) and the prescription rates of GDMT for ACS including P2Y12 inhibitors, renin-angiotensin blockers, beta-blockers, and statins were significantly higher in those in the TSOC ACS-DM Registry. Moreover, significant reductions in 1-year mortality, recurrent nonfatal MI and stroke were observed compared to those of the DM patients in the Taiwan ACS-FS Registry. Multivariate analysis identified reperfusion therapy in combination with GDMT as a strong predictor of better 1-year outcomes [hazard ratio (95% confidence interval) = 0.54 (0.33-0.89)]. CONCLUSIONS: Marked improvements in performing primary PCI for STEMI and prescribing GDMT for ACS were observed over time in Taiwan. This was associated with improved 1-year event-free survival in the diabetic patients with ACS.

Feasibility and Safety of Transulnar Catheterization in Ipsilateral Radial Artery Occlusion.

To investigate the postprocedural cardiovascular events and vascular outcomes, including hand ischemia and neurological compromise, after transulnar (TU) catheterization in ipsilateral radial artery occlusion.Previous randomized trials have shown that the transulnar (TU) approach for coronary angiogram and intervention has safety and outcomes similar to those of the transradial (TR) approach. However, the safety of the TU procedure when ipsilateral radial artery occlusion occurs is unknown.We retrospectively reviewed 87 TU cases with ipsilateral radial artery occlusion confirmed by a forearm angiogram. Eighty percent of these patients had a history of ipsilateral radial artery cannulation or surgery. We avoided the use of over-sized sheaths or applied a sheathless approach during surgery.No ulnar artery occlusion was observed by subsequent Doppler ultrasound or pulse oximetry. No patient developed hand ischemia or serious complications requiring surgery or blood transfusion during the follow-up period of 32.2 ± 24.0 months. Review of the preprocedural forearm angiograms showed that 95.7% of the patients possessed significant collaterals supplying flow from the interosseous artery to the occluded radial artery remnant. Thus, the blood circulation to the palmar arch and digital vessels was maintained even when the ulnar artery was temporarily occluded by an in-dwelling ulnar arterial sheath.TU catheterization was safe in patients with coexisting ipsilateral radial artery occlusions and feasible for use in complex intervention procedures. Cautious manipulation of ulnar artery cannulation and hemostasis helped decrease the risk of hand ischemia.

Thirty-Day and One-Year Clinical Outcomes of Bioresorbable Vascular Scaffold Implantation: A Single-Center Experience.

BACKGROUND: Available data on the use of the Bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, CA) in real-world patients is limited, particularly in Asian populations. The aim of this study was to assess clinical outcomes of patients treated with a BVS in real-world practice in Taiwan. METHODS: This study focused on 156 patients with coronary artery disease and a total of 249 lesions who received BVS implantation from October 2012 to October 2015. The study's primary endpoint was major adverse cardiac event (MACE), such as a myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), definite or possible scaffold thrombosis, cardiovascular death, and all-cause mortality during the thirty-day follow-up period. The secondary endpoint was MACE during the one-year follow-up period. Additionally, the composite clinical secondary endpoint was target lesion failure (TLF), which was called device-oriented composite endpoint. RESULTS: The average age of the patients was 60.34 ± 10.15 years, and 81.4% were male. The average of Syntax score was 12.42 ± 8.77 points. 44.2 % lesions were type B2 or C. At 31 days, one patient experienced a MACE (1/156) the composite of two TLF (2/249) with ST elevation MI, which was related to scaffold thrombosis. At one-year, 5.1 % (8/156) of the patients experienced a MACE and 3.6% (9/249) of the lesions experienced a TLF. There was no cardiovascular or all-cause mortality in the 30-day follow-up. The one-year cardiovascular and all-cause mortality rates were each 1.3%, respectively. Diabetes, ostial lesion, bifurcation lesion, and non-standard dual anti-platelet therapy (DAPT) were the strong associations of one-year TLF. CONCLUSIONS: Even with difficult and complex lesions of patients in this study, acceptable outcomes were achieved with low definite or possible scaffold thrombosis rates after BVS implantation. And despite anatomical issues, it is important to complete standard DAPT.

Comparison of Clinical Results Following the Use of Drug-Eluting Balloons for a Bare-Metal Stent and Drug-Eluting Stent Instent Restenosis.

BACKGROUND: Drug-eluting balloons (DEBs) have emerged as a potential alternative to current treatments of instent restenosis (ISR). The study aims to investigate the clinical outcomes of a DEB angioplasty to treat bare-metal stent (BMS) ISR and drug-eluting stent (DES) ISR at 1-year clinical follow-up period. METHODS: Between November 2011 and December 2014, 312 patients were diagnosed with coronary artery ISR at our hospital. A total of 426 coronary ISR lesions were treated with DEBs. The clinical outcomes, including target lesion revascularization (TLR), myocardial infarction, stroke, cardiovascular mortality, and all-cause mortality were compared between the BMS-ISR group and DES-ISR group. Propensity score matched analysis was used to minimize bias. RESULTS: The average age of the patients was 64.99 ± 10.35 years, and 76.9% of the patients were male. After multivariate Cox regression analyses about 1-year recurrent restenosis in DES-ISR group, only end stage renal disease (ESRD) (P = 0.047) and previous DEB failure (P < 0.001) were identified with significant difference. After propensity score matched analysis, the bias of baseline characteristics showed no significant difference. The DES-ISR group experienced more myocardial infarctions (2.8% vs 8.3%, P = 0.075), more TLR (8.1% vs 15.4%, P = 0.051), especially at nonostial lesion (5.7% vs 14.9%, P = 0.030) than the BMS-ISR group. Higher incidence of major cardiac cerebral adverse events happened in the DES-ISR group. (11.7% vs 22.1 %, P = 0.038) CONCLUSION: During the 1-year follow-up period, DEBs angioplasty for BMS-ISR had better clinical outcomes and less TLR than DES-ISR. ESRD and previous DEB failure were associated to TLR in DES-ISR group.

Timing of Staged Percutaneous Coronary Intervention for a Non-Culprit Lesion in Patients With Anterior Wall ST Segment Elevation Myocardial Infarction With Multiple Vessel Disease.

The optimal timing of a staged percutaneous coronary intervention (PCI) for non-culprit lesions in patients with STsegment elevation myocardial infarction (STEMI) patients with multi-vessel disease (MVD) remains controversial. We focused on patients with anterior wall STEMI with MVD and determined the clinical effects for timing of staged PCI.From November 2005 to December 2014, 258 patients were diagnosed with anterior wall STEMI with MVD in our hospital. Among them, 37 patients received staged PCI within 3 weeks, 50 patients received staged PCI during 3 weeks to one year, and 167 patients received only primary PCI for culprit lesions. Clinical outcomes such as admission for angina or heart failure, target vessel revascularization, myocardial infarction, stroke, cardiovascular mortality, and allcause mortality were compared among the 3 groups.Acute kidney injury (AKI) after PCI occurred in 18.9% of the 3-week group, 0% of the one-year group, and 7.6% of the control group (P = 0.005). Of the one-year and 3-year clinical outcomes, the one-year group had better results, such as fewer major adverse cardiac cerebral events (P = 0.028, P = 0.023), and lower recurrent MI (P = 0.065; P = 0.018), cardiovascular mortality (P = 0.043; P = 0.020), and all-cause mortality (P = 0.047; P = 0.005).In patients with anterior wall STEMI with MVD, staged PCI for a non-culprit lesion over 3 weeks to one year had a better clinical outcome. Staged PCI for a non-culprit lesion within 3 weeks may be related to the occurrence of AKI, may lead to worse clinical outcomes, and did not decrease the occurrence of angina or post-MI heart failure.

Intracoronary Transfusion of Circulation-Derived CD34+ Cells Improves Left Ventricular Function in Patients With End-Stage Diffuse Coronary Artery Disease Unsuitable for Coronary Intervention.

OBJECTIVE: This study tested the hypothesis that intra-coronary transfusion of circulation-derived autologous CD34+ cells can improve ischemia-related left ventricular dysfunction in patients with severe diffuse coronary artery disease refractory to medication and unsuitable for coronary intervention. DESIGN: A prospective, randomized, double-blinded phase I clinical trial. SETTING: Tertiary care center. PATIENTS: Thirty-eight patients with severe diffuse coronary artery disease were randomized into group 1 and group 2 receiving CD34+ cell infusion with dosages of 1.0 x 107 and 3.0 x 107 cells/vessel, respectively, after subcutaneous G-CSF injection (5 µg/kg twice a day for 4 d). INTERVENTIONS: Cardiac catheterization and intra-coronary administration of CD34+ cells. MEASUREMENTS AND MAIN RESULTS: This clinical trial was to test effectiveness and safety of these two different dosages of CD34+ cells in the setting of severe diffuse coronary artery disease. Blood samples were collected for endothelial progenitor cell culture before and after granulocyte colony-stimulating factor injection for matrigel-assay and comparison of levels of soluble angiogenesis factors (vascular endothelial growth factor, epithelial growth factor, hepatocyte growth factor, angiopoietin-1, and transforming growth factor-ß). Procedural safety was 100% with all patients uneventfully discharged. The numbers of endothelial progenitor cells in blood samples from coronary sinus after transfusion were higher than those in circulation, and the circulatory level was higher after granulocyte colony-stimulating factor treatment (all p < 0.001). Cardiac MRI and three-dimensional echocardiography at 6 month and angiographic follow-up at 9 month showed improvement in left ventricular ejection fraction (p < 0.001) and consistent increase in neovascularization (p < 0.001), respectively, in both groups. Despite good correlation in angiogenesis between 9-month angiography and matrigel-assay (p < 0.001), no significant correlation was noted in of soluble angiogenesis factor levels. Angina and heart failure were improved in both groups at 12-month follow-up (all p < 0.001). The survival rate at 18.5-month follow-up was 94.7% (n = 36). CONCLUSIONS: CD34+ cell therapy was safe and efficacious in improving heart function for patients with severe diffuse coronary artery disease unsuitable for coronary intervention and with poor response to pharmacotherapy.

Minimizing door-to-balloon time is not the most critical factor in improving clinical outcome of ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

OBJECTIVES: We tested the hypothesis that, as compared with conventional door-to-balloon, shortened door-to-balloon time would further improve 30-day outcome in ST-elevation myocardial infarction patients undergoing primary stenting. DESIGN: Retrospective cohort study SETTING: Academic tertiary care hospital with approximately 2600 beds PATIENTS: Between January 2008 and December 2009, 266 ST-elevation myocardial infarction patients underwent primary stenting with conventional Door-to-baloon were consecutively enrolled as group 1, while 293 ST-elevation myocardial infarction patients underwent primary stenting with shortened door-to-balloon between January 2010 and December 2011 were consecutively enrolled as group 2. INTERVENTION: Shorten door-to-balloon time. MEASUREMENTS AND MAIN RESULTS: The results showed that time from chest pain onset to door did not differ between two groups (p > 0.1), whereas door-to-balloon time was significantly reduced in group 2 compared with that in group 1 (p < 0.0001). The prevalences of successful reperfusion, acute and subacute stent thrombosis, 30-day death or combined endpoint (defined as congestive heart failure ≥ New York Heart Association functional class 3 or 30-d death), and left ventricular function did not differ between two groups (all p > 0.05), whereas the peak creatine phosphokinase level was significantly reduced in group 2 (< 0.05). Further analysis showed that shortening the chest pain-to-reperfusion time to less than 240 minutes was the most important factor in improving left ventricular function (p < 0.001) and 30-day combined endpoint. Multivariate analysis showed that congestive heart failure greater than or equal to New York Heart Association functional class 3, poor left ventricular function, and age (all p < 0.001) along with unsuccessful reperfusion (p = 0.25) were independently predictive of 30-day mortality. CONCLUSION: Shortening the duration between chest pain onset and reperfusion to less than 4.0 hours was critical in reducing myocardial necrosis and improving heart function and 30-day mortality.

The predictors of successful percutaneous coronary intervention in ostial left anterior descending artery chronic total occlusion.

BACKGROUND: Percutaneous coronary intervention (PCI) to chronic total occlusion (CTO) has become one of the treatment strategies in recent era. The ostium of the left anterior descending artery (LAD) is one of the most difficult positions for CTO revascularization. Until now, limited data has been made available for the prediction of successful ostial LAD CTO PCI. OBJECTIVE: The aim of the study was to compare the differences between ostial LAD and all other CTOs and to identify the predictors of successful ostial LAD CTO PCI. METHODS: This retrospective analysis included consecutive patients referred for CTO PCI between January 2001 and September 2013. Ostial LAD CTO was defined as CTO at the position whose distance between lesion and left main bifurcation was less than 1 mm. Baseline demographics, lesion characteristics, interventional procedure details, and devices were compared between the ostial LAD group and the all other CTOs group. The predictors of successful ostial LAD CTO PCI were also evaluated. RESULTS: 621 patients who underwent CTO PCI were enrolled retrospectively to this study. A total of 70 patients of ostial LAD CTO were compared with 551 patients of all other CTOs group in this study. Ostial LAD CTO was found to have more bridging and better collaterals than all other CTOs. Procedure time, fluoroscopic time, contrast volumes, the use of contralateral injection, and the use of the retrograde approach were significantly greater in the ostial LAD CTO group. The ostial LAD CTO group also had significantly higher J-CTO scores (2.7 ± 0.8 vs. 2.2 ± 1.1, P = 0.011) and higher Syntax Scores (28.3 ± 6.5 vs. 20.9 ± 9.7, P < 0.001). A slightly lower final success rate, but statistically non-significant, was observed in the ostial LAD CTO group (80.0% vs. 81.9%, P = 0.706). Univariate and multivariate logistic regression revealed that without antegrade failure and with retrograde success were predictors of the success of ostial LAD CTO PCI. Syntax Score was also capable of predicting the ostial LAD CTO PCI outcome. J-CTO score was not found to be associated with final success for ostial LAD CTO patients. CONCLUSIONS: Ostial LAD CTO resulted in higher lesion complexity in J-CTO scores and Syntax Scores. Ostial LAD CTO PCI had a slightly lower final success rate than that of all other CTOs PCI with longer procedure duration, fluoroscopic time and larger contrast volume. Without antegrade failure, with retrograde success, and lower Syntax Score were found to predict the success of ostial LAD CTO PCI.

Outcome of patients with profound cardiogenic shock after cardiopulmonary resuscitation and prompt extracorporeal membrane oxygenation support. A single-center observational study.

BACKGROUND: The in-hospital outcome of patients with profound cardiogenic shock (CS) undergoing extracorporeal membrane oxygenation (ECMO) and prognostic predictors were analyzed. METHODS AND RESULTS: Between 2003 and 2010, 134 patients with profound CS undergoing 10-15 min of cardiopulmonary cerebral resuscitation (CPCR) and ECMO were prospectively recruited, including 27.6% (37) with ST-elevation myocardial infarction (STEMI), 11.9% (16) with non-STEMI, 22.4% (30) with post-surgery pump failure, 10.5% (14) with refractory congestive heart failure, 19.4% (26) with fulminant acute myocarditis, 2.2% (3) with pediatric congenital diaphragmatic hernia, and 6.0% (8) with percutaneous coronary intervention-related complications. The mean systolic pressure was 49.8 mmHg and 91.8% of patients required ventilatory support prior to ECMO. The Post-ECMO Mean Acute Physiology and Chronic Health Evaluation (APACHE) II score and peak creatine kinase level were 26.2 and 5,311 IU/L, respectively. In-hospital mortality was 57.5%. Sixty-eight patients (50.7%) were successfully weaned from ECMO and 57 (42.5%) were discharged alive. Univariate analysis identified the APACHE II score as the strongest predictor of in-hospital mortality (P<0.0001) with respiratory failure, smoking, and male gender also related (all P<0.03). Multivariate analysis identified an APACHE II score ≥22 and successful ECMO weaning as the only independent predictor for in-hospital mortality and a determinant of survival, respectively (P=0.0003). CONCLUSIONS: Profound CS was associated with high mortality. Both successful weaning from ECMO and an APACHE II score might serve as outcome predictors for risk stratification.

Application of penetration device (Tornus) for percutaneous coronary intervention in balloon uncrossable chronic total occlusion-procedure outcomes, complications, and predictors of device success.

OBJECTIVE: To evaluate procedure outcomes, complications, and the predictors of device success while using the Tornus in CTO revascularization. BACKGROUND: The success of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) may be limited by the presence of severe calcified CTO lesions, especially in the smallest balloon uncrossable arteries. A penetrating device (Tornus) could improve the success rate. METHODS: Device and angiographic success rates as well as procedural complications were assessed in 56 patients, who were consecutively and retrospectively enrolled into this study. Device success was defined as successful passage of the Tornus catheter through a CTO lesion. Procedure success was defined by a final TIMI 3 flow and <30% residual stenosis. RESULTS: The device success rate was 71.4% in 40 patients and failure rate was 28.6% in 16 patients. The final procedure success was significantly higher in the Tornus success group compared with the Tornus failure group (87.5% vs. 37.5%, P < 0.001). One patient in the Tornus success group (1.8%) had wire perforation resulting in cardiac tamponade and cardiac death. Another patient (1.8%) in the Tornus success group had acute in-stent thrombosis and non-Q MI in 24 hr and was resuscitated by emergent PCI. The only independent predictor of device success was a calcium score < 2 (odds ratio (OR): 3.86 (95% CI: 1.14-13.1, P = 0.03). CONCLUSION: The Tornus catheter can be used in severe calcified CTO PCI when the calcium score <2 and not be used in patients with a calcium score ≥2.

Six-year clinical follow-up after treatment of diffuse in-stent restenosis with cutting balloon angioplasty followed by intracoronary brachytherapy with liquid rhenium-188-filled balloon via transradial approach.

BACKGROUND: Long-term follow-up studies revealed a significant decline in the benefits of intracoronary radiation for in-stent restenosis. METHODS AND RESULTS: A total of 25 study and 25 contemporaneous control patients with diffuse in-stent restenosis who underwent cutting balloon angioplasty (CBA) transradially, followed by subsequent intracoronary irradiation with a liquid ß-emitter Rhenium-188 (¹88Re)-filled balloon were enrolled in the study. The mean clinical follow-up durations were 64.9 ± 13.0 and 66.3 ± 13.8 months for the irradiated and control patients, respectively. Six-month angiographic restenosis was observed in 16% (4 of 25) of the patients in the irradiated group and 48% (12 of 25) of the patients in the control groups (P = 0.03). The 6-month major adverse cardiac events (MACE) rate was 12% and 44%, respectively (P = 0.025). The 3-year follow-up angiography was performed in 16 of 21 (76%) irradiated patients and in 4 of 13 (31%) control patients who had no significant restenosis at the 6-month angiographic follow-up. Restenosis occurred in 1 of 16 (7%) irradiated patients and 2 of 4 (50%) control patients. Late target lesion revascularization was performed in 1 irradiated and 2 control patients. The MACE rate within 6 years was significantly reduced in the irradiated group (20% vs. 56%, P = 0.019). CONCLUSIONS: Brachytherapy using ¹88Re-filled balloon following CBA for diffuse in-stent restenotic native coronary arteries is effective in reducing target lesion restenosis and improving long-term outcomes.

Comparison of drug-eluting stent with bare metal stent for distal de novo unprotected left main coronary artery stenosis. A propensity score-matched cohort study.

BACKGROUND: Percutaneous coronary intervention (PCI) with stent implantation is now considered a safe and feasible treatment for stenosis of the unprotected left main coronary artery (ULMCA). Because few studies have focused on de novo distal ULMCA lesions, a propensity score-matched cohort study was conducted to compare bare metal stents (BMS) with drug-eluting stents (DES) for long-term outcomes following PCI. METHODS AND RESULTS: This study reviewed the outcomes of patients undergoing PCI with DES (n=127) or BMS (n=51) for distal de novo ULMCA stenosis. The baseline demographic, angiographic and procedural characteristics differed between the 2 groups, indicating potential selection bias. The propensity score-matched cohort showed that the DES group had significantly less target lesion revascularization (TLR) and major adverse cardiovascular events (MACE) following PCI than the BMS group. Furthermore, heart failure (HF) of New York heart Association functional class III/IV was associated with an increased risk of TLR and MACE, whereas implantation of DES in patients with significant HF led to more favorable outcomes. CONCLUSIONS: Lower rates of TLR and MACE occurred in patients following PCI with DES implantation than with BMS implantation for distal ULMCA stenosis. Implantation of DES in patients with significant HF may improve the unfavorable outcome. When PCI is chosen to manage distal ULMCA stenosis, DES is the preferred stent type.

The safety and feasibility of bilateral radial approach in chronic total occlusion percutaneous coronary intervention.

Few studies have reported results for transradial (TR) percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. The purpose of this study was to evaluate the feasibility and safety of bilateral radial PCI for CTO lesions.Eighty-five consecutive patients with CTO lesions received PCI via a bilateral TR approach. A high radial artery puncture (10-15 cm above styloid process) accommodating a 7 Fr catheter (85 cm long) was used for a retrograde approach, and a 6 Fr catheter was used in the other radial artery for an antegrade approach. Retrograde wiring was conducted primarily or after failure of antegrade wiring. Mean duration of CTO was 42.8 ± 54.9 months. Vessels with occlusions attempted were the left anterior descending artery (40.0%; 34/85), right coronary artery (58.8%; 50/85), and left circumflex artery (1/85). PCI re-attempts were made in 41.2% of the cases. The overall success rate was 87.1%. Retrograde wiring was successful in 61/85 cases (71.8%), via septal collaterals followed by epicardial collaterals and saphenous vein graft. There were no major complications (30 day in-hospital death, Q wave myocardial infarction, or emergency bypass surgery), or serious access site complications.For experienced TR-PCI operators who are already doing complex TR coronary interventions, the bilateral radial approach for CTO lesions appears feasible and safe.

Value and level of plasma homocysteine in patients with angina pectoris undergoing coronary angiographic study.

This study tested whether the plasma level of total homocysteine (tHcy) was predictive of obstructive coronary artery disease (CAD) and clinical outcome in patients undergoing coronary angiographic (CAG) study. From September 2002 to October 2004, 1,305 consecutive patients with angina pectoris undergoing CAG study were consecutively enrolled. Blood samples were prospectively collected to assess the plasma level of tHcy from each patient before catheterization. Of these 1305 patients, 676 (51.8%) had multivessel disease (group 1), 367 (28.1%) had single-vessel disease (group 2), and 262 (20.1%) had normal coronary artery or insignificant coronary artery disease (group 3). The plasma level of tHcy was notably higher in group 1 than in groups 2 and 3 (11.6 ± 4.4 versus 10.9 ± 4.0 versus 10.4 ± 3.8, P < 0.001). Univariate binary logistic regression analysis demonstrated that the plasma tHcy level was strongly associated with multiple-vessel disease (MVD) (defined as ≥ 2 vessel disease) (P < 0.001). Multivariate binary logistic regression analysis showed that tHcy level, fasting blood sugar, diabetes mellitus, and age were significantly and independently predictive of MVD (all P < 0.03). Univariate Cox regression analysis demonstrated that tHcy level was predictive of long-term mortality (P = 0.042). However, the tHcy level was not an independent predictor of long-term mortality on multivariate Cox regression analysis (P > 0.05). The results of our study support the hypothesis that tHcy level is an independent predictor of MVD in patients with chest pain undergoing CAG study. Conversely, our study did not support the tHcy level as an independent predictor of long-term mortality in this clinical setting.

Feasibility and Safety of Chronic Total Occlusion Percutaneous Coronary Intervention via Distal Transradial Access.

Aims: The current study aims to verify the feasibility and safety of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI) via the distal transradial access (dTRA). Methods: Between April 2017 and December 2019, 298 patients who underwent CTO PCI via dTRA were enrolled in this study. The baseline demographic and procedural characteristics were listed and compared between groups. The incidences of access-site vascular complications and procedural complications and mortality were recorded. Results: The mean J-CTO (Japanese chronic total occlusion) score was 2.6 ± 0.9 points. The mean access time was 4.6 ± 2.9 min, and the mean procedure time was 115.9 ± 55.6 min. Left radial snuffbox access was performed successfully in 286 patients (96.5%), and right radial snuffbox access was performed successfully in 133 patients (97.7%). Bilateral radial snuffbox access was performed in 107 patients (35.9%). 400 dTRA (95.5%) received glidesheath for CTO intervention. Two patients (0.7%) developed severe access-site vascular complications. None of the patients experienced severe radial artery spasm and only 2 patients (0.5%) developed radial artery occlusion during the follow-up period. The overall procedural success rate was 93.5%. The procedural success rate was 96.5% in patients with antegrade approach and 87.7% in patients with retrograde approach. Conclusions: It is both safe and feasible to use dTRA plus Glidesheath for complex CTO intervention. The incidences of procedure-related complications and severe access-site vascular complications, and distal radial artery occlusion were low.

Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock.

OBJECTIVES: This study tested the hypothesis that early extracorporeal membrane oxygenator offered additional benefits in improving 30-day outcomes in patients with acute ST-segment elevation myocardial infarction complicated with profound cardiogenic shock undergoing primary percutaneous coronary intervention. METHODS: Between May 1993 and July 2002, 920 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 12.5% (115) with cardiogenic shock were enrolled in this study (group 1). Between August 2002 and December 2009, 1650 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 13.3% (219) complicated with cardiogenic shock were enrolled (group 2). RESULTS: The incidence of profound shock (defined as systolic blood pressure remaining < or =75 mm Hg after intra-aortic balloon pump and inotropic agent supports) was similar in both groups (21.7% vs. 21.0%, p > .5). Extracorporeal membrane oxygenator support, which was available only for patients in group 2, was performed in the catheterization room. The results demonstrated that final thrombolysis in myocardial infarction grade 3 flow in infarct-related artery was similar between the two groups (p = .678). However, total 30-day mortality and the mortality of patients with profound shock were lower in group 2 than in group 1 (all p < .04). Additionally, the hospital survival time was remarkably longer in patients in group 2 than in patients in group 1 (p = .0005). Furthermore, multivariate analysis demonstrated that unsuccessful reperfusion, presence of advanced congestive heart failure, profound shock, and age were independent predictors of 30-day mortality (all p < .02). CONCLUSION: Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day outcomes in patients with ST-segment elevation myocardial infarction with complicated with profound cardiogenic shock.