122Mechanism and impact of lesion morphology on the late lumen loss of drug-eluting resorbable magnesium scaffolds: a serial optical coherence tomography study

Introduction

Resorbable Magnesium Scaffolds have demonstrated favourable clinical results with acceptable late lumen loss (LLL). However, the pathomechanisms influencing LLL of resorbable sirolimus-eluting metallic scaffold (Magmaris) have not been analyzed.

Purpose

Using serial optical coherence tomography (OCT), we investigated potential factors, i.e. the contribution of recoil versus neointimal hyperplasia (NIH).

Methods

Patients who were enrolled into BIOSOLVE-II, and underwent serial angiography and OCT (baseline and follow-up: 6-month and/or 1-year) were analyzed. Patients were divided into 2 groups based on angiographic in-scaffold LLL <0.5mm or ≥0.5mm. Endpoints were late absolute recoil and NIH area as assessed by OCT.

Results

A total of 70 patients (LLL <0.5mm: n=41, LLL ≥0.5mm: n=29) were serially analyzed. Patient and lesion characteristics were comparable and there was no significant difference in mean and minimal scaffold area between groups at baseline. Late absolute recoil was significantly smaller among patients with LLL <0.5mm (0.53±0.68 mm2) compared with those with LLL ≥0.5mm (1.48±1.20 mm2, P<0.001) (Figure). A small difference in NIH area at follow-up was observed (LLL <0.5mm: 1.47±0.33 mm2 vs. LLL ≥0.5mm: 1.68±0.34 mm2, P=0.013). In a matched-frame analysis (baseline and follow-up), late absolute recoil varied according to the underlying plaque type (lipid: 0.63±1.23 mm2, calcified: 0.81±1.44 mm2, and fibrous: 1.20±1.52 mm2, P<0.001), while there was no difference with regards to NIH area (P=0.132).

Conclusion

The main driver of late lumen loss of sirolimus-eluting absorbable metal scaffold was late scaffold recoil, while the contribution of NIH was modest. The degree of late scaffold recoil depended on the underlying plaque type and was highest among fibrotic lesions. Future studies will address the impact of procedural factors such as adequate lesion preparation and post-dilatation.

Acknowledgement/Funding

Biotronik

P2714Time-dependent myocardial necrosis in patients suffering from ST-elevation myocardial infarction without angiographic collateral flow visualized by cardiac magnetic resonance imaging

Background

Acute complete occlusion of a coronary artery results in progressive ischemia, moving from the endocardium to the epicardium (“wavefront”). Dependent on time-to-reperfusion and collateral flow, myocardial infarction (MI) will manifest, with transmural MI portending poor prognosis. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging can detect MI with high diagnostic accuracy. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in patients with STEMI <12 hours of symptom onset.

Purpose

We sought to visualize time-dependent necrosis in a ST-segment elevation myocardial infarction (STEMI) population by LGE-CMR.

Methods

STEMI patients with: single-vessel disease, complete occlusion with Thrombolysis in Myocardial Infarction (TIMI) score 0, absence of collateral flow (Rentrop score 0) and symptom onset <12 hours were consecutively enrolled. By LGE-CMR, area at risk (AAR) and infarct size (IS), myocardial salvage index (MSI), transmurality index, and transmurality grade (0–50%, 51–75%, 76–100%) were determined.

Results

164 patients (54±11 years, 80% male) were included. Receiver-operating-characteristic (ROC)-curve (area under the curve [AUC] = 0.81) indicating transmural necrosis revealed the best diagnostic cut-off for a symptom-to-balloon time of 121 minutes, i.e. patients with >121 minutes demonstrated increased IS, transmurality index, transmurality grade (all p-values <0.01), and decreased MSI (p<0.001) vs. patients with symptom-to-balloon times ≤121 minutes.

Conclusions

In myocardial infarction with no residual antegrade, and no collateral flow, immediate reperfusion is vital. A symptom-to-balloon time of >121 minutes causes a high grade of transmural necrosis. In the present, pure STEMI population, time to reperfusion to salvage myocardium was less than suggested by current guidelines.

464Optimal timing of invasive coronary angiography following NSTEMI

Introduction

Current guidelines recommend angiography within 24 hours of hospitalisation for patients with non-ST elevation myocardial infarction (NSTEMI). The recent VERDICT study found that angiography within 12 hours of hospitalisation was associated with improved cardiovascular outcomes among high-risk patients. We aimed to obtain a real-world perspective of the impact of angiography timing on one-year outcomes of patients admitted with NSTEMI.

Methods

Data was obtained from the SPUM-ACS registry, a cohort of consecutive patients hospitalised with acute coronary syndromes in four university hospitals in Switzerland between 2009 and 2017. Patients without a door-to-catheter (DTC) time and those with life-threatening features were excluded. Cox proportional hazards models evaluated the impact of DTC time on the primary endpoint, defined as one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, stroke), and on one-year all-cause mortality.

Results

Of 2,672 NSTEMI patients, 1,832 met the inclusion criteria. Among them, 1,464 patients underwent angiography within 12 hours of admission (12h group) while 368 patients underwent angiography between 12 and 24 hours (12–24h group). After 2:1 propensity score matching, 736 patients from the 12h group and 368 patients from the 12–24h group were deemed equivalent in terms of main baseline clinical characteristics. Multiple logistic regression identified admission out-of-hours (night or weekend) as the most significant factor associated with delayed angiography. Cox models found no significant association between early angiography and one-year MACE (12h group: n=57 (7.7%) vs. 12–24h group: n=27 (7.3%), HR: 1.050, 95% CI 0.637- 1.733, p=0.847), or one-year all-cause mortality (12h group: n=25 (3.4%) vs. 12–24h group: n=17 (4.6%), HR: 1.514, 95% CI 0.774- 2.962, p=0.225) (Figure 1A). After stratification based on GRACE score (>140 vs. ≤140), there was no significant difference in one-year MACE or one-year all-cause mortality in the 12h group compared with the 12–24h group (p for interaction=0.601 and 0.463, respectively) (Figure 1A + 1B).

Figure 1

Conclusion

In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of hospitalisation was not associated with improved one-year outcomes when compared with angiography between 12 and 24 hours, even among patients with an elevated GRACE score.

5194Impact of established cardiovascular disease on outcomes in the Global Leaders trial

Objectives

To investigate the impact of ticagrelor monotherapy following one-month dual antiplatelet therapy (DAPT) on clinical outcomes after percutaneous coronary intervention (PCI) in patients with established cardiovascular disease (CVD) who were enrolled in the Global Leaders Trial.

Background

The impact of prolonged monotherapy with P2Y12 inhibitors after PCI in patients with CVD is undetermined.

Methods

GLOBAL LEADERS was a randomized, superiority, all-comers trial comparing one-month DAPT with ticagrelor and aspirin followed by 23-month ticagrelor monotherapy (experimental treatment) with standard 12-month DAPT followed by 12-month aspirin monotherapy (reference treatment) in patients treated with a biolimus A9-eluting stent. The cohort was stratified according to those with- and without established CVD, defined as a history of ≥1 prior myocardial infarction (MI), PCI, coronary artery bypass operation, stroke or peripheral vascular disease. The degree of CVD was defined according to the number of vascular territories effected (1, 2, ≥3). The primary endpoint was a composite of all-cause death or new Q-wave MI at 2-years. Secondary endpoints were the patient orientated composite endpoint (POCE) of death, stroke, MI and any revascularization; definite stent thrombosis and net adverse cardiovascular events a composite of POCE and BARC 3 or 5 bleeding.

Results

Amongst the 15,761 patients included in this cohort were 6693 patients (42.5%) with- and 9068 patients without established CVD. Patients with CVD were older, and had significantly higher rates of diabetes, hypertension, and hypercholesterolaemia (P<0.01). The incidence of the primary endpoint was significantly higher in patients with established CVD (5.1% vs. 3.3%, P<0.001) as were all secondary endpoints and their individual components. There was a trend for a reduction in the primary endpoint in patients with established CVD receiving the experimental treatment (4.6% vs. 5.6%, HR0.82 [0.66–1.02], p=0.07), which was not seen in those without prior CVD (3.2% vs. 3.3%, HR 0.95 [0.76–1.19, p=0.66; p(interaction)=0.37).

Compared with patients without CVD the incidence of the primary and second endpoints and all their individual components, other than BARC 3/5 bleeding, rose significantly with an increasing degree of CVD.

In an unadjusted model, compared with patients without CVD, the hazard ratio for the primary endpoint rose from 1.5 (1.21–1.81) to 3.0 (2.32–4.00) in patients with one and three territories of CVD, respectively. Similar rises were seen in models adjusted by age (1.3 [1.01–1.60] to 2.56 [1.94–3.38]) and age, left ventricular ejection fraction, clinical presentation and anti-platelet strategy (1.4 [1.10–1.68] to 2.26 [1.69–3.02]).

Conclusions

PCI outcomes are poorer in patients with increasing degrees of CVD compared to those without. Prolonged monotherapy with ticagrelor does not mitigate this risk suggesting a greater need to focus on modifiable risk factors

P2812Ischemic efficacy and bleeding safety of ticagrelor monotherapy in patients with multivessel percutaneous coronary intervention: insights from the Global Leaders trial

Background/Introduction

The optimal duration of DAPT after coronary stent implantation remains a matter of debate and a novel antiplatelet regimen without an increased risk of bleeding while maintaining an anti-ischemic efficacy is of paramount importance in patients at higher risk of ischemia.

Purpose

The aim of the present sub-study of the Global Leaders trial is to evaluate the efficacy and safety of the experimental antiplatelet strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) vs. the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in patients with multivessel percutaneous coronary intervention (PCI).

Methods

The Global Leaders trial enrolled 15,991 patients treated by default with a biolimus A-9 eluting stent. The present sub-study of the trial sought to evaluate the impact of the long-term ticagrelor monotherapy on the primary endpoint (composite of all-cause death and new Q-wave myocardial infarction [MI] centrally adjudicated with the Minnesota code) at two years. In addition, the patient-oriented composite endpoint (POCE) (composite of all-cause death, any stroke, any MI, and any revascularization) and the net adverse clinical events (NACE) (composite of POCE and Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were also evaluated at two years.

Results

A total of 15,845 patients was included in this analysis, of whom 3,576 patients received multivessel PCI. At two years, the experimental strategy significantly reduced a risk of the primary endpoint (the composite of all-cause death and new Q-wave myocardial infarction [MI]) (3.05% vs. 4.85%, HR: 0.62, 95% CI: 0.44–0.88, p=0.006, Pinteraction=0.031) in patients with multivessel PCI. Similarly, the experimental treatment had a significant risk reduction in the patient-oriented composite endpoint (POCE), defined as the composite of all-cause death, any stroke, any MI, and any revascularization (13.37% vs. 16.74%, HR: 0.78, 95% CI: 0.66–0.93, p=0.005, Pinteraction=0.020) and the net adverse clinical events (NACE), defined as the composite of POCE and Bleeding Academic Research Consortium [BARC] defined bleeding type 3 or 5 (14.65% vs. 18.38%, HR: 0.78, 95% CI: 0.66–0.92, p=0.003, Pinteraction=0.014) at two years. There was no significant difference in BARC type 3 or 5 bleeding (2.44% vs. 2.65%, HR: 0.92, 95% CI: 0.61–1.39, p=0.685, Pinteraction=0.754) at two years between the two regimens.

KM in patients with multivessel PCI

Conclusion

The present study has demonstrated the experimental antiplatelet strategy, when compared with the reference regimen, could potentially have a favourable balance between ischemic efficacy and bleeding safety in patients who underwent multivessel PCI.

Acknowledgement/Funding

The Global Leaders trial was supported by unrestricted grants from AstraZeneca, Biosensors, and The Medicines Company. ECRI (European Cardiovascular R

Contemporary Presentation and Management of Valvular Heart Disease: The EURObservational Research Programme Valvular Heart Disease II Survey

BACKGROUND

Valvular heart disease (VHD) is an important cause of mortality and morbidity and has been subject to important changes in management. The VHD II survey was designed by the EURObservational Research Programme of the European Society of Cardiology to analyze actual management of VHD and to compare practice with guidelines.

METHODS

Patients with severe native VHD or previous valvular intervention were enrolled prospectively across 28 countries over a 3-month period in 2017. Indications for intervention were considered concordant if the intervention was performed or scheduled in symptomatic patients, corresponding to Class I recommendations specified in the 2012 European Society of Cardiology and in the 2014 American Heart Association/American College of Cardiology VHD guidelines.

RESULTS

A total of 7247 patients (4483 hospitalized, 2764 outpatients) were included in 222 centers. Median age was 71 years (interquartile range, 62-80 years); 1917 patients (26.5%) were ≥80 years; and 3416 were female (47.1%). Severe native VHD was present in 5219 patients (72.0%): aortic stenosis in 2152 (41.2% of native VHD), aortic regurgitation in 279 (5.3%), mitral stenosis in 234 (4.5%), mitral regurgitation in 1114 (21.3%; primary in 746 and secondary in 368), multiple left-sided VHD in 1297 (24.9%), and right-sided VHD in 143 (2.7%). Two thousand twenty-eight patients (28.0%) had undergone previous valvular intervention. Intervention was performed in 37.0% and scheduled in 26.8% of patients with native VHD. The decision for intervention was concordant with Class I recommendations in symptomatic patients with severe single left-sided native VHD in 79.4% (95% CI, 77.1-81.6) for aortic stenosis, 77.6% (95% CI, 69.9-84.0) for aortic regurgitation, 68.5% (95% CI, 60.8-75.4) for mitral stenosis, and 71.0% (95% CI, 66.4-75.3) for primary mitral regurgitation. Valvular interventions were performed in 2150 patients during the survey; of them, 47.8% of patients with single left-sided native VHD were in New York Heart Association class III or IV. Transcatheter procedures were performed in 38.7% of patients with aortic stenosis and 16.7% of those with mitral regurgitation.

CONCLUSIONS

Despite good concordance between Class I recommendations and practice in patients with aortic VHD, the suboptimal number in mitral VHD and late referral for valvular interventions suggest the need to improve further guideline implementation.