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.

Impact of On-Site Surgical Backup on Periprocedural Outcomes of Primary Percutaneous Interventions in Patients Presenting With ST-Segment Elevation Myocardial Infarction (From the ORPKI Polish National Registry)

Conflicting data exist regarding the associations between on-site surgical backup and outcomes after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Thus, we sought to assess the impact of such a backup on periprocedural outcomes of primary PCI using data from the Polish National Registry of PCI. From 2014 to 2016 data on 66,707 patients presenting with STEMI undergoing primary PCI from 154 centers were collected. Patients were divided into 2 groups based on the presence of on-site surgical backup. Of 66,707 patients, 15,040 (22.6%) patients were treated in 28 centers with on-site surgical backup. On-site surgical backup was associated with a higher center PCI annual volume (662.4 ± 301.8 vs 1098.7 ± 483.5; p <0.001), but a lower operator PCI annual volume (226.7 ± 126.0 vs 207.8 ± 96.6; p <0.001). The periprocedural mortality (1.60% vs 1.09%; p <0.001) was lower in patients from centers with on-site cardiac surgery and both on-site surgical backup (odds ratio [95% confidence interval], 0.618 [0.517; 0.738]; p <0.001) and the mean number of PCIs by operator per year (odds ratio per 10 [95% confidence interval], 0.990 [0.984; 0.996]; p = 0.001] were independent predictors of periprocedural death. In conclusion, results of our study suggest that periprocedural mortality in patients undergoing primary PCI for STEMI is lower in centers than without on-site cardiac surgical backup. Whether this effect on mortality is attributable to such backup itself and/or whether surgical backup is a marker of overall better medical care and adherence to professional guidelines, this needs clarification in further studies.

A novel approach to quantification of aortic valve calcifications in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Precise calcium evaluation in the aortic complex may be complicated. We aimed to assess the usefulness of a novel semi-automatic algorithm for multi slice computed tomography-derived (MSCT) quantitative estimation of aortic valve calcifications (AVC) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Ten patients with severe AS who underwent TAVI with Edwards Sapien S3 26 mm prosthesis and had a pre-procedural MSCT scan were included. Data on baseline characteristics, procedural and long-term outcomes were collected prospectively. Pre-procedural MSCT data were used for AVC evaluation with 3D modeling (calcium volume, thickness, area, density, and distribution) in a dedicated program.

RESULTS

Mean calcium thickness was 4.6 (3.6-5.8) mm. Median calcium are 333.6 (274.7-386.7) mm2. We found a significant correlation between larger maximal calcium layer thickness and PVL occurrence after TAVI (P=0.039). The radial representation of the calcium distribution allowed to divide aortic valve into 3 zones and to compare each zone to parallel zone on TTE images. In zones with PVL ≥2 mean AVC was higher than in zones with PVL <2 (7354.6±4020.4 pixels vs. 4325.1±1790.6 pixels; P=0.018). Based on ROC analysis, the optimal cut-off value of AVC to predict PVL ≥2 was >6506 pixels with 57.1% sensitivity and 90.5% specificity (AUC 0.762 [95% CI: 0.564 to 0.901], P=0.029).

CONCLUSIONS

Multiplane AVC quantitative evaluation provided details on total calcium amount, pattern and distribution in aortic valve. Established AVC parameters allowed better visualization of an operating area and prediction of PVL after TAVI.

Impact of chronic obstructive pulmonary disease and frailty on long-term outcomes and quality of life after transcatheter aortic valve implantation

BACKGROUND

Association between chronic obstructive pulmonary disease (COPD) and long-term mortality as well as the quality of life (QoL) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) is still unclear.

AIM

We sought to evaluate the impact of COPD on mortality and QoL of patients with AS undergoing TAVI.

METHODS

A total of 148 consecutive patients who underwent TAVI were enrolled and stratified by history of COPD.

RESULTS

Of 148 patients enrolled, 19 (12.8%) patients had a history of COPD. Patients with COPD were high-risk patients with higher prevalence of incomplete revascularization and frailty features. At follow-up of 15.8 months, all-cause mortality in patients with COPD was over four times higher than in patients without COPD [17.8% vs. 52.6%; p = 0.002-age/gender-adjusted OR (95% CI) 4.73 (1.69-13.24)]. On the other hand, in Cox regression model, the only independent predictors of all-cause death at long-term follow-up were: incomplete coronary revascularization [HR (95% CI) 5.45 (2.38-12.52); p = 0.001], estimated glomerular filtration rate [per 1 ml/min/1.73 m² increase: 0.96 (0.94-0.98); p = 0.001], and previous stroke/transient ischemic attack [2.86 (1.17-7.00); p = 0.021]. Also, the difference in mortality between patients with and without COPD was not significant after adjustment for the most of frailty indices. Importantly, groups were comparable in terms of QoL at baseline and 12 months.

CONCLUSION

COPD may pose an important factor affecting long-term outcomes of patients with severe AS undergoing TAVI. However, its effects might be partially related to coexisting comorbidities and frailty.

Psoriasis is an independent predictor of increased risk of allergic reaction during percutaneous coronary interventions. Big data analysis from the Polish National PCI Registry (ORPKI)

BACKGROUND

The presence of psoriasis is currently considered by the European Society of Cardiology cardiovascular prevention guidelines of 2016 as one possible cardiovascular risk factor. Patients with psoriasis and concomitant coronary artery disease treated by means of percutaneous coronary interven-tion (PCI) are a fairly large subgroup of patients that have been usually omitted in mainstream research. The aim herein, was to identify the incidence of psoriasis, baseline characteristics and periprocedural outcome with a special focus on procedural complications in patients undergoing percutaneous coronary procedures.

METHODS

All consecutive patients who had either coronary angiography or coronary angiography with immediate PCI in Poland in 2014 and 2015 were included. Patients were assigned to two groups based on previous diagnosis: with psoriasis and without psoriasis. Clinical outcome was defined as any periprocedural death.

RESULTS

There were 405,078 patients included in this analysis. Psoriasis (moderate or severe) was di-agnosed in 1507 (0.4%) of them. Psoriasis was an independent predictor of allergic reaction occurrence (odds ratio [OR] 6.02; 95% confidence interval [CI] 1.44-25.22; p = 0.014). After propensity score adjustment, psoriasis remained a significant predictor of allergic reaction (OR 5, 95% CI 1.2-20.7; p = 0.0245). There were no differences in rates of periprocedural deaths in patients with or without psoriasis (death: 0.95% vs. 0.62%, p > 0.05).

CONCLUSIONS

Severe or moderate psoriasis is an independent risk factor for the occurrence of allergic reaction during percutaneous coronary procedures. There were no differences in periprocedural mortal-ity and complications in patients with versus those without psoriasis.

Contemporary use of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction referred to primary percutaneous coronary interventions in Poland: Data from ORPKI national registry

According to guidelines, it is recommended to give P2Y₁₂ inhibitors (preferably ticagrelor or prasugrel) at the time of first medical contact in patients with STEMI. However, in real life antiplatelet treatment strategies are different among countries. We analyzed data on antiplatelet treatment in STEMI patients included into Polish ORPKI national registry. A total of 23,139 STEMI patients from 153 invasive cardiology centers were reported in ORPKI registry between September 2015 and August 2016. Finally 19,437 patients from 122 centers (immediate PCI in 94%) were included into the analysis (lack of ticagrelor or prasugrel usage reported in 31 centers). The dominant P2Y₁₂ inhibitor was clopidogrel (69%) with a high rate of precathlab administration (51.3%). Ticagrelor was administered in 10.1% of patients (2.3% during precathlab phase) and prasugrel in 1.1% (0.4% precathlab). The periprocedural switch from clopidogrel to newer generation oral P2Y₁₂ inhibitors was rare (to ticagrelor: 2%; to prasugrel: 0.15%). Analysis of data from top 10 centers with the highest rate of newer generation P2Y₁₂ inhibitors usage (1295 patients) revealed ticagrelor administration in 43.1% (prasugrel in 3%). During precathlab phase higher proportion of ticagrelor instead of clopidogrel (ticagrelor 17.9%, clopidogrel 29.8%) and higher rate of periprocedural switch from clopidogrel to ticagrelor (11.9%) was found comparing to all centers data (p < 0.001 for all). The strategy of precathlab administration of P2Y₁₂ inhibitors applies to about half of STEMI patients in Poland. Generally, ticagrelor or prasugrel use is low, and not equally distributed among centers. In centers with high usage, ticagrelor is main newer generation P2Y₁₂ inhibitor for precathlab and periprocedural administration.

Reduced periprocedural mortality and bleeding rates of radial approach in ST-segment elevation myocardial infarction. Propensity score analysis of data from the ORPKI Polish National Registry

AIMS

We sought to evaluate bleeding complications and periprocedural outcomes of the radial approach (RA) as compared to the femoral approach (FA) during percutaneous coronary intervention (PCI) in "real-world" patients with ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

The study group consisted of 22,812 consecutive patients with STEMI treated with PCI and stent implantation between January 2014 and June 2015 in 151 tertiary invasive cardiology centres in Poland (the ORPKI Polish National Registry). Patients treated using the RA and FA were compared using a propensity score analysis to avoid possible selection bias. The analysis was carried out in an "as-treated" manner. The FA was used in 9,334 (40.9%) and the RA in 13,478 (59.1%) patients. After propensity score matching, a higher total amount of contrast (191.8±8.0 vs. 174.8±68.8 ml; p=0.001) and lower radiation doses (1,279.5±1,346.3 vs. 1,182.6±887 mGy; p=0.02) were reported in FA. More access-site-related bleeding complications after both angiography (0.17% vs. 0.02%; p=0.004) and PCI (0.23% vs. 0.09%; p=0.049) were reported in the FA group. Periprocedural death (1.94% vs. 0.93%; p=0.001) was more common after PCI performed with the FA.

CONCLUSIONS

The radial approach was associated with a lower incidence of periprocedural death in STEMI patients as well as a significant reduction of bleeding complications at the access site.

Efficacy and Safety of the HeartMate Percutaneous Heart Pump During High-Risk Percutaneous Coronary Intervention (from the SHIELD I Trial)

This study aimed to evaluate the use of the HeartMate percutaneous heart pump, a catheter-based axial flow pump designed to provide partial left ventricular support, in patients who underwent high-risk percutaneous coronary intervention (PCI). Patients who are hemodynamically unstable, or at risk of being hemodynamically unstable, while undergoing PCI may require mechanical circulatory support. Fifty high-risk patients were enrolled in a prospective, nonrandomized, multicenter, open-label trial. Primary end points were freedom from hemodynamic compromise during PCI and a composite measure of major adverse events. Patients were followed for 30 days. No patient met the primary performance end point. Six safety end points in 5 patients occurred, including 1 access site complication requiring intervention, 1 cerebrovascular accident, 2 major bleeding complications, and 2 cases of new or worsening aortic insufficiency. No cardiac deaths, myocardial infarctions, or surgical interventions occurred. In conclusion, initial results of the HeartMate percutaneous heart pump for mechanical circulatory support during high-risk PCI are encouraging. Hemodynamic stability was achieved in all patients with a low incidence of adverse events.

Predictors of periprocedural complications in patients undergoing percutaneous coronary interventions within coronary artery bypass grafts

BACKGROUND

During the first decade following the coronary bypass grafting, at least ten percent of the patients require percutaneous coronary interventions (PCI) due to graft failure. Saphenous vein grafts (SVG) are innately at a higher risk of periprocedural complications. The present study aimed to investigate predictors of periprocedural complications of PCI within coronary artery bypass grafts.

METHODS

This study analyzed data gathered in the Polish National Registry (ORPKI) between January 2015 and December 2016. Of the 221,195 patients undergoing PCI, data on 2,616 patients after PCI of SVG and 442 patients after internal mammary artery (IMA) were extracted. The dissimilarities in periprocedural complications between the SVG, IMA and non-IMA/SVG groups and their predictors were investigated.

RESULTS

Patients in the SVG group were older (p < 0.001), with a higher burden of concomitant disease and differing clinical presentation. The rate of de-novo lesions was lower, while restenosis was higher at baseline in the SVG (p < 0.001). The rate of no-reflows (p < 0.001), perforations (p = 0.01) and all periprocedural complications (p < 0.01) was higher in the SVG group, while deaths were lower (p < 0.001). Among the predictors of no-reflows, it was found that acute coronary syndromes (ACS), thrombectomy and past cerebral stroke, while the complications included arterial hypertension, Thrombolysis in Myocardial Infarction (TIMI) flow before PCI and thrombectomy.

CONCLUSIONS

Percutaneous coronary interventions of SVG is associated with increased risk of specific periprocedural complications. The ACS, slower TIMI flow before PCI and thrombectomy significantly increase the periprocedural complication rate in patients undergoing PCI of SVG.