Early results of the ongoing Polish Registry of Valve Thrombosis after Transcatheter Aortic Valve Implantation (ZAK‑POLTAVI)

BACKGROUND

Conflicting data exist regarding the risk factors for transcatheter heart valve thrombosis (THVT). In addition, no optimal pharmacological strategy to treat THVT has been established so far Aims: The aim of this study was to assess the incidence, risk factors, diagnostic workup, and treatment of THVT in Poland.

METHODS

Data were collected retrospectively in themulticenter registry of patients with THVT (ZAK‑POLTAVI) between November 2008 and November 2018. Transcatheter heart valve thrombosis was defined as an increased mean transvalvular gradient accompanied by a decreased effective orifice area or severe aortic regurgitation, reversible after treatment. Baseline characteristics and procedural data were compared between patients with THVT and those without THVT (matched by age, sex, and diabetic status).

RESULTS

In a group of 2307 patients undergoing transcatheter aortic valve implantation (TAVI), 26 patients with THVT were identified (incidence, 1.14%). In half of the patients, THVT was diagnosed within 6 months after TAVI. As compared with the control group, patients with THVT more frequently had chronic obstructive pulmonary disease (P = 0.035), a smaller aortic valve area (P = 0.007), a higher mean postprocedural transvalvular gradient (P = 0.037), and a lower platelet count (P = 0.029) at the time of the diagnosis. A total of 24 patients (84.6%) received anticoagulation therapy for THVT, and complete resolution of THVT was noted in 12 individuals (46.1%). We observed thromboembolic complications in 2 patients (7.7%).

CONCLUSIONS

Transcatheter heart valve thrombosis is a rare complication of TAVI. However, a higher risk of THVT may be expected in patients with chronic obstructive pulmonary disease, a smaller aortic valve area, a higher mean postprocedural transvalvular gradient, and a lower platelet count. Anticoagulation alone or combined with antiplatelet therapy seems to be the optimal pharmacological treatment in this population.

Calcium Pattern Assessment in Patients with Severe Aortic Stenosis Via the Chou's 5-Steps Rule

BACKGROUND

Progression of aortic valve calcifications (AVC) leads to aortic valve stenosis (AS). Importantly, the AVC degree has a great impact on AS progression, treatment selection and outcomes. Methods of AVC assessment do not provide accurate quantitative evaluation and analysis of calcium distribution and deposition in a repetitive manner.

OBJECTIVE

We aim to prepare a reliable tool for detailed AVC pattern analysis with quantitative parameters.

METHODS

We analyzed computed tomography (CT) scans of fifty patients with severe AS using a dedicated software based on MATLAB version R2017a (MathWorks, Natick, MA, USA) and ImageJ version 1.51 (NIH, USA) with the BoneJ plugin version 1.4.2 with a self-developed algorithm.

RESULTS

We listed unique parameters describing AVC and prepared 3D AVC models with color pointed calcium layer thickness in the stenotic aortic valve. These parameters were derived from CT-images in a semi-automated and repeatable manner. They were divided into morphometric, topological and textural parameters and may yield crucial information about the anatomy of the stenotic aortic valve.

CONCLUSION

In our study, we were able to obtain and define quantitative parameters for calcium assessment of the degenerated aortic valves. Whether the defined parameters are able to predict potential long-term outcomes after treatment, requires further investigation.

Neutrophil-to-lymphocyte ratio predicts long-term all-cause mortality in patients with chronic kidney disease stage 5

INTRODUCTION

A high neutrophil-to-lymphocyte ratio (NLR) has been reported to be a strong biomarker of inflammation.

AIM

We sought to evaluate the impact of NLR on long-term all-cause and cardio-vascular (CV) mortality in hemodialysis (HD) patients.

MATERIAL AND METHODS

total of 84 chronic kidney disease (CKD) stage 5 patients with 54 of them on HD, with a median age of 61.5 (51.3-74.8) years were enrolled. e association between NLR and clinical biomarkers was investigated. Multivariable Cox regression analysis was used to find significant predictors of all-cause and CV mortality at follow-up.

RESULTS

the median NLR (interquartile range) was 3.0 (2.1-4.1). Patients with NLR ≥3.9 (the highest tertile) had higher five-year all-cause mortality then remaining patients (53.6% vs. 30.4%; p = 0.039). On the contrary, only a trend towards increased CV mortality was observed (25.0% vs. 42.9%; p = 0.10). NLR ≥3.9 was a significant predictor of all-cause mortality at five years [hazard ratio (95%CI): 2.23 (1.10-4.50); p = 0.025] in Cox regression model adjusted for age, gender, and diabetes status. Similarly, while using NLR as continuous variable a significant association between NLR and all-cause mortality was confirmed even a er adjustment for covariates [hazard ratio per 1 unit increase (95%CI): 1.26 (1.06-1.51); p = 0.009] with the area under the receiver operating characteristic (ROC) curve of 0.64. Correlations between NLR and WBC, concentration of fibrinogen, albumin were observed.

CONCLUSIONS

Asymptomatic inflammation measured by NLR showed an association with long-term all-cause mortality in stage 5 CKD patients, even while white blood cell count was in the normal range.

Direct Rapid Left Ventricular Wire Pacing during Balloon Aortic Valvuloplasty

Background: Rapid ventricular pacing is mandatory for optimal balloon positioning during aortic valvuloplasty (BAV) in patients with severe aortic stenosis. We aimed to assess the safety and efficacy of direct left ventricular (LV) guidewire pacing in comparison with regular pacing induced by temporary pacemaker (PM) placement in the right ventricle. Methods: Direct rapid LV pacing was provided with a 0.035″ guidewire. Baseline clinical characteristics, echocardiographic and procedural data, as well as complication rates, were compared between the two groups. Results: A total of 202 patients undergoing BAV were enrolled (49.5% with direct LV guidewire pacing). The pacing success rate was 100%. In the direct LV guidewire pacing group, we found a lower radiation dose, shorter fluoroscopy and overall procedural time (0.16 vs. 0.28 Gy, p = 0.02; 5.4 vs. 10.3 min, p = 0.01; 17 vs. 25 min, p = 0.01; respectively). In addition, the complication rate was lower in that group (cardiac tamponades, vascular access site complications, blood transfusions rate, and in-hospital mortality: 0% vs. 3.9%; 4.0% vs. 15.7%; 2.0% vs. 12.7%; 2.0% vs. 9.8%, p = 0.01 for all, respectively). Conclusions: Direct rapid LV guidewire pacing is a simple, safe and effective option for BAV with a reduced complication rate compared to a temporary PM placed in the right ventricle.

Knowledge and prevalence of risk factors for coronary artery disease in patients after the first and repeated percutaneous coronary intervention

BACKGROUND

Percutaneous coronary intervention (PCI) is an effective method for the treatment ofcoronary artery disease (CAD) that allows for a short hospital stay and fast recovery. It has been shown that PCI is a predictor of nonattendance at cardiac rehabilitation and correlates with poor adherence to lifestyle changes.

AIMS

The study was conducted to evaluate the influence of education offered during PCI‑related hospitalization on knowledge, awareness, and prevalence of self‑reported risk factors for CAD.

METHODS

We collected data using a self‑designed 56‑item questionnaire. Questions assessed the knowledge of CAD risk factors and the level of their control. The maximal knowledge score was 31 points and the maximal control score, 15 points.

RESULTS

The study group consisted of 200 consecutive patients undergoing PCI. Patients with a history of PCI performed at least 8 weeks prior to their current hospitalization were included in the prior‑PCI group (64%), whereas the pre‑PCI group comprised patients with no history of revascularization (36%). The median (interquartile range [IQR]) knowledge score was 19 (12.5-23) points in the pre‑PCI and 21 (12.5-24) points in the prior‑PCI group (P = 0.35). The median (IQR) risk control score was 5 (4.5-7) points in the pre‑PCI and 6 (4-8) points in the prior‑PCI group (P = 0.4). There was no correlation between the level of knowledge and the actual prevalence of CAD risk factors. We found that 50% of the prior‑PCI patients did not attend any rehabilitation, which correlated with poor control of CAD risk factors (P = 0.001).

CONCLUSIONS

Currently used models of postprocedural education do not have an adequate effect on patient knowledge and do not bring recommended lifestyle changes.

Prevalence and Predictors of Coronary Artery Perforation During Percutaneous Coronary Interventions (from the ORPKI National Registry in Poland)

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). With a growing number of PCIs in complex lesions, the problem of CAP becomes even more important nowadays. Data on CAP rates in Poland are lacking. Presented study is an analysis of 344,517 consecutive patients treated with PCI between 2014 and 2017. Data were gathered from the Polish National PCI Registry (ORPKI). During 4 years of data collection CAP was observed in 595 (0.17%) cases. Patients diagnosed with CAP were older (69 years Q1:63; Q3:78 vs 66 years Q1:60; Q3:75; p <0.001), more often female (44% vs 32%; p <0.001), with arterial hypertension (77% vs 71%; p = 0.002), and chronic kidney disease (8.9% vs 5.4%; p <0.001). In the CAP group, a higher rate of PCIs within chronic total occlusions (8.7% vs 2.3%; p <0.001) and saphenous vein graft lesions (2.7% vs 1.3%; p = 0.002), as well as rotational atherectomy procedures (2.2% vs 0.4%; p <0.001) was observed. Patients with CAP had higher rate of no-reflow phenomenon (5.5% vs 0.5%; p <0.001) and greater periprocedural mortality (4.2% vs 0.5%; p <0.001). In conclusion, our study confirms that CAP is more common during complex PCI procedures in high-risk patients. CAP occurrence is associated with worse immediate outcomes including increased periprocedural mortality.

P4597Impact of operator experience with radial approach for clinical outcome on percutaneous coronary intervention in acute coronary syndrome performed with femoral artery access site

Introduction

Radial approach (RA) for percutaneous coronary intervention (PCI) is associated with reduced mortality and access site complications. The routine use of the RA in patients should be strongly considered, keeping in mind the learning curve associated with the technique. However, promotion of RA may interfere with the equally important goal of maintaining proficiency in the femoral approach (FA), which is essential in a variety of procedures as well as when RA fails. There is possible risk of higher rate of complications in PCI with FA performed by operators mainly using radial artery as access site.

Purpose

The aim of this study was to evaluate impact of experience and proficiency with RA for clinical outcomes on PCI via FA in “real-world” patients with acute coronary syndrome (ACS).

Methods

A total of 539 invasive cardiologists performing PCI in 151 invasive cardiology centers on the Polish territory between 2014 and 2017 were included in study analysis. Proficiency threshold has been set at >400 procedures during four consecutive years per individual operator. They were categorized to quartiles according to total volume of radial artery utilization during all PCIs. Procedures performed on patients with Killip-Kimball class IV on admission to catheterisation laboratory were excluded from analysis.

Results

The most of the operators performed >75% of all procedures via radial artery (326 (60.5%)), 112 (20.8%) used RA in 50–75% of cases, 67 (12.4%) in 25–50% of all PCIs and only 34 (6.3%) invasive cardiologist were using RA in less than 25% of all procedures. Mortality during PCI via FA was higher in group of invasive cardiologist with >75% of all procedures performed with radial access (>75% vs. 50–75% vs. 25–50% vs. <25%: 1.63% (±2.52%) vs. 0.93% (±1.05%) vs. 0.68% (±0.73%) vs. 0.31% (±0.40%); p=0.01). A trend towards higher rate of bleeding at the puncture site during PCI procedures with femoral artery were reported in groups of operators with higher expertise in RA (>75% vs. 50–75% vs. 25–50% vs. <25%: 0.43% (±1.09%) vs. 0.14% (±0.36%) vs. 0.21% (±0.45%) vs. 0.14% (±0.37%); p=0.09).

Conclusions

Higher experience in radial access might be linked to worse outcome in PCI via FA in ACS settings. Femoral artery is important vascular approach and should not be abandoned while learning procedures with radial artery utilization.

Acknowledgement/Funding

None

P5536Comparison of safety and effectiveness between right and left radial artery approach in percutaneous coronary intervention for acute coronary syndrome. Propensity score analysis of data from the ORPKI

Introduction

The use of the radial approach (RA) for percutaneous coronary intervention (PCI) has gradually increased. Several studies demonstrated that radial artery is associated with significant reduction in major adverse cardiac events for both coronary angiography and PCI in acute coronary syndrome (ACS). However, it is still unclear if the side of RA has influence on clinical outcomes in an all-comer population in ACS settings.

Purpose

We sought to evaluate safety, feasibility, and clinical outcomes of right radial approach (RRA) compared to left radial approach (LRA) during PCI in “real-world” patients with ACS.

Methods

A total of 234,087 consecutive patients with ACS treated with PCI and stent implantation via radial approach between 2014 and 2017 in 151 invasive cardiology centers on the Polish territory. Data was based on the ORPKI Polish National Registry. Patients treated with RRA and LRA were compared using a propensity score analysis to avoid possible selection bias. The analysis was done in an “as-treated” manner.

Results

Procedure was conducted using RRA and LRA in 180,378 (77.1%) and 53,709 (22.9%) patients, respectively. After propensity score matching higher total amount of contrast (174.28 (±75.56) vs. 166.95 (±70.57) [ml]; P=0.001) and radiation doses were reported in PCI with left radial artery utilization (1210.21 (±1003.53) vs. 1054.07 (±1024.17) [mGy]; p=0.001). No differences were observed between RRA and LRA in rate of periprocedural adverse events such as myocardial infarction (0.08% vs. 0.08%; p=0.9) stroke (0.02% vs. 0.01%; p=0.1), no-reflow phenomenon (0.64%vs. 0.56%; p=0.1) and death (0.25% vs. 0.24%; p=0.7). A trend towards a lower rate of access-site-related bleeding during PCI was observed in RRA group (0.08% vs. 0.05%; p=0.066). Coronary artery perforation (0.21% vs. 0.16%; p=0.05) and cardiac arrest (0.56% vs 0.42%; p=0.01) were reported more often during PCI conducted with LRA.

Conclusions

Both radial approaches seems to be equally effective in the setting of PCI in ACS. However, utilization of left radial artery was associated with trend toward increased risk of access-site bleeding and higher rate of periprocedural complications as compared to RRA. Higher amount of contrast and radiation doses used in LRA procedures might be equivalent of generally lower experience with this access site.

Acknowledgement/Funding

None

Impact of Pre-procedural Cerebrovascular Events on Clinical Outcomes After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an increasingly common treatment of symptomatic severe aortic valve stenosis (AS). Thus, it is reasonable to carefully investigate the impact of individual clinical factors on outcomes after TAVI.

OBJECTIVES

We aimed to investigate the impact of the previous cerebro-vascular events (CVEs) on outcomes of patients with severe AS undergoing TAVI.

METHODS

A total of 148 consecutive patients scheduled for TAVI were included and stratified as with and without a history of CVEs (stroke or transient ischemic attack). Frailty features were also assessed. The primary endpoint was a 12-month all-cause mortality.

RESULTS

Seventeen (11.5%) patients had a history of CVEs (the CVE group). At 30 days and 12 months, all-cause mortality was higher in the CVE group [30-day: 5 (29.4%) vs. 7 (5.3%); p=0.005; 12-month: 9 (52.9%) vs. 13 (9.9%); p=0.001]. Similarly, at the longest available follow-up, mortality was higher in the CVE group [10 (58.8%) vs. 23 (17.6%); p=0.001]. Similar rates of other complications after TAVI were noted, apart from inhospital acute kidney injury (AKI) grade 3 [3 (17.6%) vs. 5 (3.8%); p=0.049] and blood transfusions [9 (52.9%) vs. 35 (26.7%); p=0.026]. Results of 5MWT and Katz index assessment indicated a greater level of frailty in the CVE group. There were no differences in subsequent events including CVEs, bleeding, myocardial infarction, and new-onset of atrial fibrillation (AF) at 12 months between the groups.

CONCLUSION

We showed that a history of CVEs in patients with severe AS undergoing TAVI is associated with a higher long-term mortality.

Characteristics of patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA) in Poland: data from the ORPKI national registry

Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is an important clinical problem especially in the era of extensive utilization of coronary angiography in MI patients. Its pathophysiology is poorly understood which makes diagnostics and treatment of MINOCA challenging in everyday clinical practice. The aim of the study was to assess characteristics of MINOCA patients in Poland based on data from the Polish National ORPKI Registry. In 2016, 49,893 patients with non-ST-segment elevation (NSTEMI) or ST-segment elevation (STEMI) myocardial infarction entered the ORPKI registry. MINOCA was defined as a non-obstructive coronary artery disease (CAD) and a lack of previous coronary revascularization. MINOCA was identified in 3924 (7.8%) patients and clinical presentation was more often NSTEMI than STEMI (MINOCA: 78 vs. 22%; obstructive CAD 51.1 vs. 48.9%; p < 0.0001). MINOCA patients were younger and more often females with significantly lower rates of diabetes, smoking, arterial hypertension, kidney disease, previous MI and previous stroke comparing to patients with obstructive CAD. Myocardial bridge was visualized in angiography more often in the MINOCA group (2.2 vs. 0.4%; p < 0.0001). Additional coronary assessment inducing fractional flow reserve, intravascular ultrasound, optical coherence tomography was marginally (< 1%) used in both groups. Periprocedural mortality was lower in MINOCA group (0.13% vs. 0.95%; p < 0.0001). MINOCA patients represent a significant proportion of MI patients in Poland. Due to multiple potential causes, MINOCA should be considered rather as a working diagnosis after coronary angiography and further efforts should be taken to define the cause of MI in each individual patient.

Adenosine intracoronary bolus dose escalation versus intravenous infusion to induce maximum coronary hyperemia for fractional flow reserve assessment

BACKGROUND

Achievement of maximal hyperemia is mandatory for an accurate calculation of fractional flow reserve (FFR) and it is obtained with adenosine given either as an intravenous infusion or as an intracoronary bolus.

AIMS

The purpose of this study was to compare the infusion of adenosine with intracoronary adenosine bolus dose escalation in the optimal assessment of peak FFR.

METHODS

We enrolled consecutive patients with borderline coronary lesions that were assessed by FFR with the use of adenosine intracoronary boluses (100, 200, 400 and 600 µg) and intravenous infusion of 140 µg/kg/min and 280 µg/kg/min. FFR values were assessed and compared.

RESULTS

Fifty patients with 125 borderline coronary artery stenoses were enrolled. Physiological severity assessed with: intravenous adenosine infusion at 140 µg/kg/min was mean 0.82 ± 0.09; infusion at 280 µg/kg/min - 0.81 ± 0.09; intracoronary bolus of 100 µg, 200 µg, 400 µg and 600 µg - 0.83 ± 0.09; 0.83 ± 0.09, 0.83 ± 0.09; and 0.83 ± 0.09, respectively. There was a strong linear correlation between FFR values obtained from 140 µg/kg/min infusion and adenosine intracoronary 100, 200, 400 and 600 µg bolus injection (r = 0.989, r = 0.99, r = 0.993, r = 0.994, respectively, p < 0.001 for all).

CONCLUSIONS

FFR values achieved with intracoronary boluses of adenosine are very similar, but not identical to those obtained using intravenous adenosine administration. The values of FFR may vary between escalating doses of intracoronary boluses and intravenous infusion.

New-generation drug eluting stent vs. bare metal stent in saphenous vein graft - 1 year outcomes by a propensity score ascertainment (SVG Baltic Registry)

BACKGROUND

Data regarding the efficacy of the percutaneous coronary intervention (PCI) with new-designed drug-eluting stent (new-DES) vs. bare metal stent (BMS) of saphenous vein grafts (SVG) stenosis is scarce. The primary objective was to compare one-year clinical outcomes of PCI in stenosis of SVG using new-DES vs. BMS in a real-world population.

METHODS AND RESULTS

We carried out a multi-center registry comparing new-DES with BMS in all consecutive patients undergoing PCI of SVG. The primary composite endpoint was major adverse cardiac and cerebrovascular events (MACCE) at 1 year. This observation included 792 consecutive patients (mean age 69 ± 8.9y), treated with either new-DES (n = 379, 47.9%) or BMS (n = 413, 52.1%). Among patients treated with new-DES compared with BMS, there was a lower risk of MACCE (21.4% vs. 28.3%, HR = 0.69, 95% CI 0.50-0.95, p = 0.025) as well as myocardial infarction (MI) (6.3% vs. 12.1%; HR 0.49, 95% CI 0.30-0.82, p = 0.005) at 1 year. After propensity score adjustment, the similar, significant reduction in MACCE and MI was observed in favor of new-DES (HR 0.66, 95% CI 0.46-0.96, p = 0.030; and HR 0.53, 95% CI 0.31-0.92, p = 0.020, respectively).

CONCLUSION

In patients undergoing PCI of SVG, the use of new-DES is associated with a reduced 1-year rate of MACCE and MI compared to BMS.

The obesity paradox in patients undergoing transcatheter aortic valve implantation: is there any effect of body mass index on survival?

BACKGROUND

Conflicting results have been presented regarding the influence of body mass index (BMI) on outcomes among patients undergoing transcatheter aortic valve implantation (TAVI).

AIMS

To investigate the impact of BMI on clinical outcomes after TAVI.

METHODS

A total of 148 consecutive patients were categorised using baseline BMI according to the World Health Organization criteria. Baseline patient characteristics, frailty, and procedural and clinical outcomes including 30-day and 12-month all-cause mortality were compared between the BMI categories. Patients were followed up for a median of 460.0 (182.0-1042.0) days.

RESULTS

Obesity was diagnosed in 37 (25.2%) patients, 73 (49.7%) patients were overweight, and 37 (25.2%) had normal weight. Prevalence of lower frailty as assessed by five-metre walk test was confirmed in obese patients as compared to other groups. A trend towards a lower rate of in-hospital bleeding complications (18 [48.6%] vs. 21 [28.8%] vs. 9 [24.3%] in normal-weight, overweight, and obese patients, respectively; p = 0.06) and less frequent blood transfusions (18 [48.6%] vs. 17 [23.3%) vs. 8 [21.6%]; p = 0.016) was observed in overweight and obese groups. The rate of grade 3 acute kidney injury was lowest in the overweight group (4 [10.8%] vs. 1 [1.4%] vs. 3 [8.1%]; p = 0.05). There was no difference between the groups in terms of 30-day all-cause mortality (p = 0.15). However, 12-month all-cause mortality was lowest in obese pa-tients (12 [32.4%] vs. 10 [13.7%] vs. 2 [5.4%]; p = 0.004). Increase in BMI was independently associated with lower all-cause mortality (hazard ratio [95% confidence interval] per 1 kg/m2 increase: 0.91 [0.845-0.98]; p = 0.018).

CONCLUSIONS

Increased BMI was independently associated with survival benefit after TAVI.

Chronic obstructive pulmonary disease and periprocedural complications in patients undergoing percutaneous coronary interventions

Background

The relationship between chronic obstructive pulmonary disease (COPD) and periprocedural complications of percutaneous coronary interventions (PCIs) is influenced by several factors. We aimed to investigate the association between COPD, its complication type and rate in patients undergoing PCI.

Methods

Data were prospectively collected using the Polish Cardiovascular Intervention Society national registry (ORPKI) on all PCIs performed in Poland between January 2015 and December 2016. COPD was present in 5,594 of the 221,187 patients undergoing PCI. We assessed the frequency and predictors of periprocedural complications in PCI.

Results

Patients with COPD were elder individuals (70.3 ± 9.9 vs. 67 ± 10.8 years; p < 0.05). We noted 145 (2.6%) periprocedural complications in the COPD group and 4,121 (1.9%) in the non-COPD group (p < 0.001). The higher incidence of periprocedural complications in the COPD patients was mainly attributed to cardiac arrest (p = 0.001), myocardial infarctions (p = 0.002) and no-reflows (p < 0.001). COPD was not an independent predictor of all periprocedural complications. On the other hand, COPD was found to be an independent predictor of increased no-reflow risk (odds ratio [OR] 1.447, 95% CI 1.085–1.929; p = 0.01), and at the same time, of decreased risk of periprocedural allergic reactions (OR 0.117, 95% CI 0.016–0.837; p = 0.03).

Conclusions

In conclusion, periprocedural complications of PCIs are more frequent in patients with COPD. COPD is an independent positive predictor of no-reflow and a negative predictor of periprocedural allergic reactions.

Current perspectives on the role of bioresorbable scaffolds in the management of coronary artery disease

New-generation drug-eluting stents are recommended as the default option in all clinical conditions and lesion subsets in patients undergoing percutaneous coronary intervention (PCI). On the other hand, despite achieving very good results in the rate of restenosis, permanent delivery of a metallic platform is affected by several drawbacks, such as caging of the vessel, side branch jailing, impairment of vasomotion, and the impossibility of lumen enlargement. Also, the presence of residual foreign material may increase the risk of late and very late stent thrombosis and support the need for long-term dual antiplatelet therapy after PCI. These pending limitations of metallic stents can be addressed by the implantation of bioresorbable scaf-folds (BRSs). At present, there are numerous devices available for preclinical or clinical evaluation. This review discusses the evidence for BRS in the management of patients with coronary artery disease.

Predictors of syncope in patients with severe aortic stenosis: The role of orthostatic unload test

BACKGROUND

There is a paucity of data regarding response of cerebral blood flow to the postural unloading maneuver and its impact on the risk of syncope in patients with aortic stenosis (AS). The aim of the present study was to assess effects of orthostatic stress test on changes in carotid and vertebral artery blood flow and its association with syncope in patients with severe AS.

METHODS

108 patients were enrolled (72 with and 36 patients without syncope) with severe isolated severe AS. Peak systolic blood-flow velocity (PSV) and end-diastolic velocity in the carotid arteries and vertebral arteries were measured by duplex ultrasound in the supine position and at 1-2 min after the assumption of the standing position.

RESULTS

The orthostatic stress test induced a significant decrease in carotid and vertebral arterial flow velocities in all examined arteries (p < 0.001). The median (interquartile range) of mean change in PSV for carotid arteries was higher for patients with syncope (syncope [-] vs. syncope [+]: -0.6 cm/s [-1.8, 1.0] vs. -7.3 cm/s [-9.5, -2.0]; p < 0.001) and similarly for vertebral arteries (-0.5 cm/s [-2.0, 0.5] vs. -4.8 cm/s [-6.5, -1.3]; p < 0.001, respectively). Age, aortic valve area, and mean change in PSV for carotid arteries were independently associated with syncope.

CONCLUSIONS

In patients with AS, a decrease in carotid and vertebral arterial flow velocities in the standing position was observed and was associated with syncope. The present findings may support the value of an orthostatic test in identifying patients with severe AS and a high risk of syncope.

Diabetes and periprocedural outcomes in patients treated with rotablation during percutaneous coronary interventions

BACKGROUND

This study is to assess differences in periprocedural outcomes among diabetic and non-diabetic patients treated with percutaneous coronary intervention (PCI) and rotational atherectomy (RA).

METHODS

Under assessment were 221,187 patients from the Polish Cardiovascular Intervention Society national registry (ORPKI) including all PCIs performed in Poland in 2015 and 2016. Data was extracted of 975 patients treated with RA - 336 (34.5%) diabetics and 639 (65.5%) non-diabetics. Periprocedural complications were defined as overall rate or particular complications such as deaths, no-reflows, perforations, dissections, cerebral strokes or bleedings.. Multivariate analysis was performed to assess predictors of periprocedural complications.

RESULTS

The mean age was similar in diabetics and non-diabetics (70.9 ± 9.0 vs. 72.1 ± 9.9; p = 0.06). Diabetics were more often females (p < 0.01), with arterial hypertension (p < 0.01), kidney failure (p < 0.01) and prior myocardial infarction (p = 0.01). No significant differences were observed in overall or individual periprocedural complications and angiographic success was expressed as thrombolysis in myocardial infarction grade 3 flow after PCI. At baseline, de-novo lesions accounted for 96.5% in diabetics and 99% in non-diabetics (p < 0.01), while overall rate of restenosis was 3.5% and 1%, respectively (p < 0.01). Diabetes was an independent predictor of periprocedural complications in the overall group of patients treated with PCI (OR 1.11, 95% CI 1.04-1.194; p < 0.001).

CONCLUSIONS

The negative impact of diabetes on the incidence of periprocedural complications and angiographic effectiveness in the group of patients treated with RA is mitigated in the comparison to the non-RA group.