Determinants and Prognostic Significance of Periprocedural Myocardial Injury in Patients With Successful Percutaneous Chronic Total Occlusion Interventions

Ticagrelor vs Clopidogrel in Clopidogrel-Naive Patients With Chronic Coronary Syndrome

BACKGROUND

Whether ticagrelor may reduce periprocedural myocardial necrosis after elective percutaneous coronary intervention (PCI) in patients with and without chronic clopidogrel therapy is unclear.

OBJECTIVES

This study sought to compare ticagrelor vs clopidogrel in patients with and without chronic clopidogrel therapy before undergoing elective PCI.

METHODS

In this prespecified analysis of the ALPHEUS (Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting) trial, patients were defined as clopidogrel(+) and clopidogrel(-) according to the presence and absence of clopidogrel treatment for ≥7 days before PCI, respectively. The primary endpoint was the composite of PCI-related myocardial infarction and major injury as defined by the third and fourth universal definition 48 hours after PCI.

RESULTS

A total of 1,882 patients were included, 805 (42.7%) of whom were clopidogrel(+). These patients were older, had more comorbidities, and had more frequent features of complex PCI. The primary endpoint was less frequently present in clopidogrel(-) compared to clopidogrel(+) patients (32.8% vs 40.0%; OR: 0.73; 95% CI: 0.60-0.88), but no significant differences were reported for the risk of death, myocardial infarction, stroke, or transient ischemic attack at 48 hours or 30 days. Ticagrelor did not reduce periprocedural myocardial necrosis or the risk of adverse outcomes, and there was no significant interaction regarding the presence of chronic clopidogrel treatment.

CONCLUSIONS

Clopidogrel-naive patients presented less periprocedural complications compared to clopidogrel(+) patients, a difference related to a lower risk profile and less complex PCI. The absence of clopidogrel at baseline did not affect the absence of a difference between ticagrelor and clopidogrel in terms of PCI-related complications supporting the use of clopidogrel as the standard of care in elective PCI in patients with or without chronic clopidogrel treatment.

Association of serum laboratory parameters with periprocedural myocardial infarction after a primary percutaneous coronary intervention

BACKGROUND

Periprocedural myocardial infarction (PMI) is one of the mortality-related complications of percutaneous coronary intervention (PCI) and significantly affects short- and long-term adverse outcomes and immediate cardiovascular events. Our present study aimed to evaluate the association of preprocedural serum laboratory parameters and PMI in patients who received primary PCI and attempted to provide detailed data on the predictors of PCI-related PMI.

METHODS

A total of 1184 consecutive coronary artery disease (CAD) patients who received primary and elective PCI between July 2015 and June 2017 were included and divided into control group and PMI group. The data of serum laboratory parameters were collected from the electronic database of Meizhou People's Hospital.

RESULTS

The results indicated that preprocedural fasting blood glucose were higher in PMI group compared with the control group (p < .001). Patients with prior hyperlipidemia were more likely to have experienced PCI-related PMI (p = .018) and the preprocedural level of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, apolipoprotein B (Apo B), and LDL-C/high density lipoprotein cholesterol (HDL-C) were significantly enhanced in PMI group (p < .001). Multivariate regression analysis revealed that preprocedural fasting blood glucose > 6.11 mmol/L (p < .001, OR = 1.949, 95% CI: 1.444-2.630) and LDL-C levels ≥130 mg/dL (p = .005, OR = 1.941, 95% CI: 1.217-3.098) independently predicted PCI-related PMI.

CONCLUSION

Our results indicated preprocedural fasting blood glucose >6.11 mmol/L and LDL-C levels ≥130 mg/dL may be useful predictors for PCI-related PMI. The study may provide a detailed data on the predictors of PCI-related PMI.

Postdischarge prognostic significance of periprocedural myocardial injury after percutaneous intervention of chronic total occlusion

BACKGROUND

The postdischarge prognostic implication of periprocedural myocardial injury in patients undergoing percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) remains scarcely studied.

AIMS

The aim of this study is to assess the prognostic value of periprocedural myocardial injury, defined by increased high-sensitive troponin T (hs-TnT) levels according to updated guidelines, after CTO PCI.

METHODS

Between September 2011 and April 2020, 726 patients undergoing CTO PCI at 2 Belgian referral centres were prospectively included and divided into 4 groups based on postprocedural hs-TnT levels (unelevated; ≥5 times the upper limit of normal (ULN); ≥35 times the ULN; ≥70 times the ULN). Postprocedural hs-TnT levels were subsequently related to patient and procedural characteristics, 1-year major adverse cardiac and cerebrovascular events (MACCE; excluding in-hospital MACCE) as well as 1-year mortality.

RESULTS

At 1 year follow-up (FU), elevated hs-TnT≥5 times and ≥35 times the ULN were associated with higher MACCE rates (p=0.001; p=0.007, respectively). In addition, they also resulted in a higher 1-year mortality rate (p=0.009;p=0.021, respectively). Patients with increased hs-TnT≥5 times the ULN (35% of patients) more frequently had signs of more advanced atherosclerotic disease (previous CABG p<0.001; stroke p≤0.001 and peripheral vascular disease p<0.001) and had higher procedural complexity (Japanese CTO Score p=<0.001, stent length>48 mm p<0.001, procedure time p<0.001). Antegrade wire escalation did not result in lower event rate of postdischarge MACCE compared with the other CTO crossing techniques combined (p=0.158).

CONCLUSION

Periprocedural myocardial injury was associated with a significantly higher rate of MACCE and all-cause mortality after 12 months of FU.

Predictors and prognosis of PCI-related myocardial injury in chronic total occlusion

Background

Periprocedural myocardial injury (PMI) is associated with major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI). However, the incidence predictors and prognosis of PMI in chronic total occlusion (CTO) undergoing PCI remains unclear.

Method

To evaluate the predictors and prognostic impact of PMI following PCI in patients with CTO. We consecutively enrolled 132 individuals and 8 of whom with procedural failure were excluded in this study. Thus, a total of 124 CTO patients successfully received PCI were included in this study. And patients were divided into the PMI group (n = 42) and the non-PMI group (n = 82) according to their c-TnI levels measured after procedure. The baseline and angiographic characteristics of the two groups were compared. The predictors of PMI and the correlation between PMI and MACE were investigated.

Results

Overall, PMI occurred in 42 patients (33.9%). Comparing with control group, PMI group had more diabetes (54.8% vs. 31.7%,P = 0.013) and dyslipidemia (54.8% vs. 13.4%, P＜0.001). Also, there were significant differences between the two groups in left ventricular ejection fraction(43.2 ± 7.2 vs 47.2 ± 8.0, P = 0.027), prior myocardial infarction(54.8%vs43.1%, P = 0.020), prior PCI(57.1% vs 22.0%, P＜0.001) and prior CABG(14.3% vs 2.4%, P = 0.011). Also, patients with PMI had more calcified lesions (52.4% vs 24.4%, P = 0.002) and were more likely to have multivessel disease (71.4% vs 35.4%, P＜0.001). In addition, patients in the PMI group had higher J-CTO scores (3.3 ± 1.0 vs 1.9 ± 0.5, P＜0.001) and were more likely to have wire-crossing difficulties (64.3% vs 37.8%, P = 0.005), require more use of retrograde approach (38.1% vs 7.3%, P＜0.001) and have more procedural complications (19.0% vs 2.4%, P = 0.003). In the multivariate analysis, multivessel artery disease (odd ratio [OR], 4.347;95% confidence interval [CI], 1.601– 11.809;P  = 0.004), retrograde approach (OR, 4.036; 95%CI, 1.162– 14.020;P  = 0.028) and the presence of procedural complications (OR, 16.480;95%CI, 2.515-107.987;P = 0.003) were predictors of PMI.

Conclusion

The incidence of PMI in CTO patients after PCI was 33.9%. Multivessel artery disease, retrograde approach, and the presence of procedural complications were predictors of PMI after CTO-PCI. Patients who develop PMI tend to have a poorer clinical prognosis and more MACE than those who do not develop PMI.

Impact of Periprocedural Myocardial Injury and Infarction Definitions on Long-Term Mortality After Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND

The prognostic implications of biomarker elevation following percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions remain controversial. This study assessed the association of periprocedural myocardial injury and clinically relevant definition of periprocedural myocardial infarction with subsequent outcomes after CTO-PCI.

METHODS

We enrolled consecutive patients between January 2010 and December 2013 who underwent CTO-PCI at a large-volume center with serial CK-MB (creatine kinase-myocardial band) or cTnI (cardiac troponin I) measurements. The primary outcome was 5-year cardiovascular death.

RESULTS

A total of 2616 patients (2691 CTOs) with postprocedural CK-MB or cTnI undergoing PCI recanalization were included, per-lesion technical success rate was 74.4%. Postprocedural CK-MB and cTnI elevation occurred in 5.6% and 65.5% patients, respectively. For 2485 patients with serial CK-MB measurements, only postprocedural peak CK-MB ≥5× upper reference limit was associated with increased 5-year cardiovascular death (adjusted hazard ratio, 9.88 [95% CI, 3.06-31.9]). In contrast, for 1233 patients with serial cTnI measurements, no such association was present in any threshold. The Society for Cardiovascular Angiography and Interventions definition of periprocedural myocardial infarction was associated with 5-year cardiovascular death (adjusted hazard ratio, 8.45 [95% CI, 3.58-20.0]), whereas the ARC-2 (Academic Research Consortium-2) and fourth UDMI (Universal Definition of Myocardial Infarction) were not.

CONCLUSIONS

In a large cohort of CTO-PCI, moderate to high levels of peak postprocedural CK-MB were prognostically significant, whereas such association was not observed in postprocedural cTnI. The Society for Cardiovascular Angiography and Intervention criteria (but not ARC-2 and fourth UDMI) were identified as clinically relevant periprocedural myocardial infarction definition following CTO-PCI. Graphic Abstract: A graphic abstract is available for this article.

Clinical outcomes of post-stent intravascular ultrasound examination for chronic total occlusion intervention with drug-eluting stents

BACKGROUND

Few studies have evaluated intravascular ultrasound (IVUS) use in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

AIMS

In CTO-PCI, we aimed to (1) evaluate the clinical benefits of performing post-stent IVUS in preventing adverse clinical events, and (2) identify IVUS parameters and cut-off values for prediction of target lesion revascularisation (TLR)/reocclusion.

METHODS

A total of 1,077 patients with 1,077 CTO lesions treated with drug-eluting stents (DES) were included. Clinical outcomes during a median follow-up of 6.3 years were compared between subjects with and those without post-stent IVUS using the inverse probability weighting method.

RESULTS

Of 1,077 patients, post-stent IVUS was performed in 838 (77.8%) cases while in the remaining 239 (22.2%) cases it was not. In the weighted population, the risk of TLR/reocclusion was significantly lower in subjects with post-stent IVUS (9.6% vs 18.9%, hazard ratio [HR] 0.54, 95% confidence interval [CI]: 0.34-0.86, p=0.01), compared with those without post-stent IVUS. Cox regression analysis showed that minimal stent area (MSA) measured by IVUS was the only parameter independently associated with TLR/reocclusion (HR 0.78, 95% CI: 0.64-0.95; p=0.01) and the optimal MSA cut-off value was 4.9 mm2 for prediction of TLR/reocclusion (area under the curve=0.632, p=0.001).

CONCLUSIONS

In CTO-PCI with DES, post-stent IVUS evaluation was associated with a lower risk of TLR/reocclusion. The final MSA was independently associated with TLR/reocclusion with a cut-off value of 4.9 mm2.

Safety and efficacy of dedicated guidewire, microcatheter, and guide catheter extension technologies for chronic total coronary occlusion revascularization: Primary results of the Teleflex Chronic Total Occlusion Study

BACKGROUND

Description of procedural outcomes using contemporary techniques that apply specialized coronary guidewires, microcatheters, and guide catheter extensions designed for chronic total occlusion (CTO) percutaneous revascularization is limited.

METHODS

A prospective, multicenter, single-arm study was conducted to evaluate procedural and in-hospital outcomes among 150 patients undergoing attempted CTO revascularization utilizing specialized guidewires, microcatheters and guide extensions. The primary endpoint was defined as successful guidewire recanalization and absence of in-hospital cardiac death, myocardial infarction (MI), or repeat target lesion revascularization (major adverse cardiac events, MACE).

RESULTS

The prevalence of diabetes was 32.7%; prior MI, 48.0%; and previous bypass surgery, 32.7%. Average (mean ± standard deviation) CTO length was 46.9 ± 20.5 mm, and mean J-CTO score was 1.9 ± 0.9. Combined radial and femoral arterial access was performed in 50.0% of cases. Device utilization included: support microcatheter, 100%; guide catheter extension, 64.0%; and mean number of study guidewires/procedure was 4.8 ± 2.6. Overall, procedural success was achieved in 75.3% of patients. The rate of successful guidewire recanalization was 94.7%, and in-hospital MACE was 19.3%. Achievement of TIMI grade 2 or 3 flow was observed in 93.3% of patients. Crossing strategies included antegrade (54.0%), retrograde (1.3%) and combined antegrade/retrograde techniques (44.7%). Clinically significant perforation resulting in hemodynamic instability and/or requiring intervention occurred in 16 (10.7%) patients.

CONCLUSIONS

In a multicenter, prospective registration study, favorable procedural success was achieved despite high lesion complexity using antegrade and retrograde guidewire maneuvers and with acceptable safety, yet with comparably higher risk than conventional non-CTO PCI.

Complications during chronic total occlusion percutaneous coronary intervention: a sign- and symptom-based approach to early diagnosis and treatment

Coronary chronic total occlusions (CTO) are frequently found in patients undergoing coronary angiography. Despite their high prevalence and indication for revascularization in a relevant proportion of cases, CTO recanalization is attempted only in a minority of cases. This is due to higher risk of procedural complications compared to non-CTO interventions and because the CTO-PCIs are the most complex procedures in interventional cardiology. In particular, the perceived higher risk of complications during CTO intervention might discourage new operators from engaging in this challenging field. The aim of this work is to review the potential complications of CTO percutaneous coronary intervention, and to provide an algorithmic, sign- and symptom-based approach to facilitate early recognition and effective management.

Implications of Periprocedural Myocardial Biomarker Elevations and Commonly Used MI Definitions After Left Main PCI

OBJECTIVES

The aim of this study was to: 1) assess the relationship of different thresholds of creatine kinase-myocardial band (CK-MB) and cardiac troponin with subsequent mortality; and 2) evaluate the prognostic significance of periprocedural myocardial infarction (PMI) according to various definitions of myocardial infarction in patients with left main (LM) coronary artery disease.

BACKGROUND

The magnitude of postprocedural biomarker elevation representing a clinically meaningful PMI after percutaneous coronary intervention (PCI) is controversial.

METHODS

A total of 4,013 consecutive patients undergoing LM PCI at a single center from January 2004 to December 2016 were enrolled. CK-MB and cardiac troponin I (cTnI) were routinely collected at baseline and at frequent intervals between 8 and 48 hours after PCI. The primary and secondary outcomes were the covariate-adjusted 3-year rates of cardiovascular (CV) and all-cause mortality, respectively.

RESULTS

The 3-year rate of CV mortality progressively increased with higher peak CK-MB values. CV mortality was first independently predicted by postprocedural CK-MB 3 to 5 times the upper reference limit (URL) (adjusted hazard ratio [aHR]: 2.93; 95% confidence interval [CI]: 1.02-8.40), whereas all-cause death was independently predicted only by CK-MB ≥ 10 × URL (aHR: 3.25; 95% CI: 1.37-7.70). In contrast, no level of peak postprocedural cTnI was associated with CV or all-cause death. PMI by the Society for Cardiovascular Angiography and Interventions (SCAI), Academic Research Consortium-2 (ARC-2), and fourth universal definition of myocardial infarction (UDMI) occurred in 1.3%, 3.1%, and 5.1% of patients, respectively. The SCAI definition was significantly associated with 3-year CV mortality (aHR: 4.93; 95% CI: 1.92-12.69) and all-cause mortality (aHR: 3.11; 95% CI: 1.33-7.27), whereas the ARC-2 and fourth UDMI definitions were not.

CONCLUSIONS

In a large cohort of consecutive patients undergoing LM PCI, intermediate (≥3 × URL) and high (≥10 × URL) levels of peak postprocedural CK-MB independently predicted 3-year CV and all-cause mortality, respectively, whereas even large elevations of post-PCI cTnI did not. The SCAI definition (but not the ARC-2 or fourth UDMI) of PMI was independently associated with mortality after LM PCI.

Impact of periprocedural myocardial injury on long-term clinical outcomes of chronic total occlusion patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis

Background:

Several studies have evaluated the long-term clinical outcomes of periprocedural myocardial injury for chronic total occlusions patients. However, the results of these studies were inconsistent. To determine whether the periprocedural myocardial injury has adverse effects on long-term clinical outcomes in chronic total occlusion patients undergoing percutaneous coronary intervention.

Methods:

We searched Cochrane Library, PubMed, and Embase for eligible articles from their date of inception up to March 2019. Long-term clinical outcomes included major adverse cardiac events, all-cause death, cardiac death, myocardial infarction, and target vessel revascularization. Odds ratios with 95% confidence intervals were calculated as summary statistics by using Review Manager software.

Results:

A total of 8 observational studies involving 5879 chronic total occlusions patients were included in this meta-analysis. These results of this meta-analysis indicated that periprocedural myocardial injury was associated with a higher risk of major adverse cardiac events (odds ratio, 1.94; 95% confidence interval, 1.22–3.08; P = 0.005), a higher risk of all-cause death (odds ratio, 1.30; 95% confidence interval, 1.02–1.64; P = 0.03), a higher risk of cardiac death (odds ratio, 2.59; 95% confidence interval, 1.41–4.78; P = 0.002), a higher risk of myocardial infarction (odds ratio, 3.07; 95% confidence interval, 1.90–4.98; P < 0.00001), and a higher risk of target vessel revascularization (odds ratio, 2.07; 95% confidence interval, 1.35–3.16; P=0.0008) than non-periprocedural myocardial injury.

Conclusion:

Periprocedural myocardial injury was associated with significantly increased risk of major adverse cardiac events, all-cause death, cardiac death, myocardial infarction, and target vessel revascularization in chronic total occlusion patients undergoing percutaneous coronary intervention at long-term follow-up.

Stenting techniques for coronary bifurcation lesions: Evidence from a network meta-analysis of randomized clinical trials

OBJECTIVES

We conducted a systematic review and network meta-analysis of available randomized clinical trials (RCTs) to compare cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions.

BACKGROUND

Although provisional stenting of the main branch and balloon angioplasty of the side branch is considered the standard approach, the use of two stents is often pursued with a wide variety of bifurcation stenting techniques available.

METHODS

We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov from inception to December 2018. We performed a frequentist network meta-analysis to estimate relative risks (RR) of death, major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST) among different two stent bifurcation techniques.

RESULTS

We identified 14 studies, yielding data on 4,285 patients. Double Kissing (DK) Crush and Mini-crush were associated with significant reductions in MACE, TVR, and TLR when compared with the Provisional stenting (RR 0.31-0.55 [all p < .01] and RR 0.42-0.45 [all p < .02], respectively) and with the remaining bifurcation techniques (RR 0.44-0.55 [all p < .05] for DK Crush and RR 0.37-0.45 [all p < .05] for Mini-crush). In addition, Culotte and Crush were associated with an increased risk for ST compared to Provisional stenting (RR 3.25-4.27 [both p < .05]) and to DK crush (RR 3.02-3.99 [both p < .05]).

CONCLUSIONS

DK crush and mini-crush were found to be associated with fewer events and complications compared to the other techniques reviewed, including the Provisional approach. Further, Culotte and Crush were associated with an increased risk of stent thrombosis when compared to the Provisional approach.

Definitions and Clinical Trial Design Principles for Coronary Artery Chronic Total Occlusion Therapies: CTO-ARC Consensus Recommendations

Over the past 2 decades, chronic total occlusion (CTO) percutaneous coronary intervention has developed into its own subspecialty of interventional cardiology. Dedicated terminology, techniques, devices, courses, and training programs have enabled progressive advancements. However, only a few randomized trials have been performed to evaluate the safety and efficacy of CTO percutaneous coronary intervention. Moreover, several published observational studies have shown conflicting data. Part of the paucity of clinical data stems from the fact that prior studies have been suboptimally designed and performed. The absence of standardized end points and the discrepancy in definitions also prevent consistency and uniform interpretability of reported results in CTO intervention. To standardize the field, we therefore assembled a broad consortium comprising academicians, practicing physicians, researchers, medical society representatives, and regulators (US Food and Drug Administration) to develop methods, end points, biomarkers, parameters, data, materials, processes, procedures, evaluations, tools, and techniques for CTO interventions. This article summarizes the effort and is organized into 3 sections: key elements and procedural definitions, end point definitions, and clinical trial design principles. The Chronic Total Occlusion Academic Research Consortium is a first step toward improved comparability and interpretability of study results, supplying an increasingly growing body of CTO percutaneous coronary intervention evidence.

Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction

Coronary chronic total occlusion (CTO) has gained increasing clinical attention as the most advanced form of coronary artery disease. Prior studies already indicated a clear association of CTO with adverse clinical outcomes, especially in patients with acute myocardial infarction (AMI) and concomitant CTO of the non-infarct-related coronary artery (non-IRA). Nevertheless, the prognostic impact of percutaneous coronary intervention (PCI) of CTO in the acute setting during AMI is still controversial. Due to the complexity of the CTO lesion, CTO-PCI leads to an increased risk of complications compared to non-occlusive coronary lesions. Therefore, this review outlines the prognostic impact of CTO-PCI in patients with AMI. In addition, the prognostic impact of periprocedural myocardial infarction caused by CTO-PCI will be discussed.

Myocardial damage associated with elective percutaneous coronary intervention in Chinese patients: a retrospective study

Objective

To determine the prevalence of percutaneous coronary intervention (PCI) related myocardial damage (injury or myocardial infarction), investigate several cardiac biomarkers, explore possible risk factors and assess survival in patients undergoing elective PCI.

Methods

Patients >18 years of age who had undergone an elective PCI at Huashan hospital in Shanghai, China from October 2016 to June 2017 and had baseline and post-PCI results available for four cardiac biomarkers (cTnT, CK-MB mass, hs-CRP and NT-ProBNP) were eligible. Patients were separated into two groups according to whether or not they had PCI related myocardial damage.

Results

Of the 143 patients who were eligible for the study, 75 (52%) were classified as ‘controls,’ and 68 (48%) had PCI related myocardial damage. Of the 68 patients, 64 (45%) had PCI related myocardial injury and 4 (3%) had PCI related myocardial infarction. Elderly Chinese patients, with high systolic blood pressure on admission and who required multiple coronary segments for PCI had a high risk of myocardial damage. Relative cTnT or relative CK-MB mass may be useful cardiac biomarkers for monitoring PCI related myocardial damage, especially at 24h post-PCI. There was no significant difference in survival rates between controls and those with myocardial complications.

Conclusions

PCI related myocardial damage is common but appears to have no impact on prognosis. Senior age, high systolic blood pressure and multiple coronary segments for PCI are risk factors.

Long-term outcomes of percutaneous or surgical treatment in left main disease

INTRODUCTION

Long-term efficacy and safety of either surgical or percutaneous treatment left main coronary artery disease treatment is lacking.

EVIDENCE ACQUISITION

We conducted a systematic review and meta-analysis of the most updated randomized clinical trials that compared the efficacy of coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the Left Main Coronary Artery (LMCA) disease. It was also conducted a systematic search of PubMed, Google Scholar, reference lists of relevant articles, and Medline. The search utilized the following terms: "left main PCI versus CABG," "drug-eluting stents," "bypass surgery" and "left main stenting." The search of articles compatible with our inclusion and exclusion criteria was performed from inception through April 2020 and returned a combined total of 304 articles.

EVIDENCE SYNTHESIS

We identified 6 studies, providing data on 5812 patients. The mean follow-up was 6.7 years. PCI was associated with an increased risk of major vascular events (MACE) (IRR 1.24, 95% CI [1.03-1.67], P<0.01), and coronary revascularization (IRR 1.69, 95% CI [1.42-2.03], P<0.01) compared to CABG. Furthermore, all-cause death, MI and stroke events were not statistically different between the two therapeutic revascularization methodologies (IRR 1.06, 95% CI [0.90-1.24], P=0.47, IRR 1.35, 95% CI [0.84-2.16], P=0.03 and IRR 0.66, 95% CI [0.43-1.01], P=0.05, respectively).

CONCLUSIONS

LMCA PCI has an overall same survival compared to CABG in the long term follow-up. Nevertheless, MACE and revascularization events were more frequent in PCI compared to CABG.

Determinants and prognostic implication of periprocedural myocardial injury after successful recanalization of coronary chronic total occlusion

Periprocedural myocardial injury (PMI) has been generally associated with major adverse cardiac events (MACE), however, limited studies addressed its clinical implications following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). To evaluate the determinants and prognostic implication of PMI following CTO-PCI. Retrospective single-centre study of 125 consecutive patients undergoing CTO-PCI was attempted between December 2013 and December 2017. Angiographic success was achieved in 115 patients (92.0%) and cTn-I values were obtained 12-24 h following PCI. PMI was defined as an elevation of cTn-I above 5 times the 99th-percentile upper reference limit. Baseline demographic, clinical, angiographic and procedural characteristics were compared. Multivariate analysis was performed to determine the predictors of PMI and the correlates of PMI and 1-year MACE, a composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. Overall, mean age was 67 ± 17 years; 25 patients (21.7%) were female; and PMI occurred in 41 patients (35.7%). Multivessel coronary artery disease (MVD) (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.09-10.67; p = 0.04) and procedural complications (a composite of iatrogenic coronary artery dissection/haematoma or perforation) (OR, 19.08; 95% CI, 3.77-96.65; p < 0.01) predicted PMI. Significant collateralization (Rentrop 3) (hazard ratio, [HR], 0.19; 95% CI, 0.06-0.64; p < 0.01) and procedural complications (HR, 8.86; 95% CI, 2.66-29.46; p < 0.01) were independently associated with 1-year MACE, while PMI was not (p = 0.26). In this contemporary cohort, PMI following successful CTO-PCI was a common finding and was predicted by MVD and procedural complications. PMI was not independently associated with 1-year MACE.

Clinical Outcomes and Angiographic Results of Bailout Stenting for Guide Catheter-Induced Iatrogenic Coronary Artery Dissection - Impact of Stent Type

BACKGROUND

Guide catheter-induced iatrogenic coronary artery dissection is a rare but feared complication. When it occurs, bailout stenting is widely performed; however, its prognosis and the impact of stent type remains unclear.Methods and Results:The study population consisted of 77,257 consecutive patients (coronary angiography, 55,864; percutaneous coronary intervention, 21,393) between 2000 and 2015. We investigated the incidence, clinical outcomes, and angiographic results after bailout stenting and compared by stent type: bare-metal stent (BMS) and drug-eluting stent (DES). Iatrogenic coronary artery dissection occurred in 105 patients (incidence rate, 0.14%). All cases of iatrogenic coronary artery dissection that were recognized as requiring bailout procedure could be managed by stent implantation, and no patients died during bailout procedure. The 5-year cumulative incidences of cardiac death, target lesion revascularization, and major adverse cardiac events were 11.3%, 10.3%, and 21.0%, respectively. The binary restenosis rate was 10.4%, and it was not significantly different between BMS and DES implantation. In lesions with preprocedural stenosis, however, it was significantly lower in the DES group than in the BMS group. On the other hand, coronary artery dissection recurred in 8 patients, which was observed only after DES implantation.

CONCLUSIONS

The immediate and long-term outcomes of bailout stenting for iatrogenic coronary artery dissection were acceptable. Although DES may be favorable for stenotic lesions, coronary artery dissection can recur after DES implantation.

A Contemporary Definition of Periprocedural Myocardial Injury After Percutaneous Coronary Intervention of Chronic Total Occlusions

OBJECTIVES

The aim of this study was to assess the prognostic impact of post-procedural troponin T increase and mortality in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) to define the threshold at which procedure-related myocardial injury drives mortality.

BACKGROUND

Coronary CTO recanalization represents the most technically challenging PCI. The complexity harbors a significant increased risk for complications with CTO PCI with compared with non-CTO PCI. However, there are evidenced biomarker cutoff levels that help identify those patients at risk for unfavorable clinical outcomes.

METHODS

A total of 3,712 consecutive patients undergoing PCI for at least 1 CTO lesion were enrolled, and comprehensive troponin T measurements were performed 6, 8, and 24 h after the procedure. All-cause mortality was defined as the primary study endpoint.

RESULTS

Using spline curve analysis, a more than 18-fold increase of troponin above the upper reference limit was significantly associated with mortality. In a Cox regression analysis, the crude hazard ratio was 2.32 (95% confidence interval: 1.83 to 2.93; p < 0.001) for a ≥18-fold increase compared with patients with post-procedural troponin increase <18-fold of the upper reference limit. Results remained virtually unchanged after bootstrap- or clinical confounder-based adjustment.

CONCLUSIONS

This large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in patients with CTOs. A threshold was defined for procedure-related myocardial injury in patients with CTOs to differentiate them from those without CTOs that may help guide post-procedural clinical care in this high-risk patient population.

Improving the Design of Future PCI Trials for Stable Coronary Artery Disease: JACC State-of-the-Art Review

The role of percutaneous coronary interventions in addition to medical therapy for patients with stable coronary artery disease continues to be debated in routine clinical practice, despite more than 2 decades of randomized controlled trials. The residual uncertainty arises from particular challenges facing revascularization trials. Which endpoint do doctors care about, and which do patients care about? Which participants should be enrolled? What background medical therapy should we use? When is placebo control relevant? In this paper, we discuss how these questions can be approached and examine the merits and disadvantages of possible options. Engaging multiple stakeholders, including patients, researchers, regulators, and funders, to ensure the design elements are methodologically valid and clinically meaningful should be an aspirational goal in the development of future trials.

Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Intervention

The retrograde approach has increased the success rate of chronic total occlusion percutaneous coronary intervention but has also been associated with a higher risk of complications. The retrograde approach is usually performed in complex lesions, in which the antegrade approach is not feasible or has failed previously. Using a systematic 10-step approach can maximize the likelihood of success and minimize the risks of retrograde chronic total occlusion interventions.

Outcomes with retrograde versus antegrade chronic total occlusion revascularization

OBJECTIVES

The aim of the study was to evaluate the outcomes of retrograde versus antegrade approach in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

The retrograde approach has increased the success rate of CTO PCI but has been associated with a higher risk for complications.

METHODS

We conducted a meta-analysis of studies published between 2000 and August 2019 comparing the in-hospital and long-term outcomes with retrograde versus antegrade CTO PCI.

RESULTS

Twelve observational studies (10,240 patients) met our inclusion criteria (retrograde approach 2,789 patients, antegrade approach 7,451 patients). Lesions treated with the retrograde approach had higher J-CTO score (2.8 vs. 1.9, p < .001). Retrograde CTO PCI was associated with a lower success rate (80.9% vs. 87.4%, p < .001). Both approaches had similar in-hospital mortality, urgent revascularization, and cerebrovascular events. Retrograde CTO PCI was associated with higher risk of in-hospital myocardial infarction (MI; odds ratio [OR] 2.37, 95% confidence intervals [CI] 1.7, 3.32, p < .001), urgent pericardiocentesis (OR 2.53, 95% CI 1.41-4.51, p = .002), and contrast-induced nephropathy (OR 2.12, 95% CI 1.47-3.08; p < .001). During a mean follow-up of 48 ± 31 months retrograde crossing had similar mortality (OR 1.79, 95% CI 0.84-3.81, p = .13), but a higher incidence of MI (OR 2.07, 95% CI 1.1-3.88, p = .02), target vessel revascularization (OR 1.92, 95% CI 1.49-2.46, p < .001), and target lesion revascularization (OR 2.08, 95% CI 1.33-3.28, p = .001).

CONCLUSIONS

Compared with antegrade CTO PCI, retrograde CTO PCI is performed in more complex lesions and is associated with a higher risk for acute and long-term adverse events.

Outcomes With Deferred Versus Performed Revascularization of Coronary Lesions With Gray-Zone Fractional Flow Reserve Values

BACKGROUND

Management of coronary lesions with fractional flow reserve values in the gray zone (0.75-0.80) remains controversial due to conflicting data on the performance versus deferral of revascularization.

METHODS

We performed a systematic review and meta-analysis of 7 observational studies including 2683 patients that compared the outcomes of deferred versus performed revascularization of coronary lesions with gray-zone fractional flow reserve values.

RESULTS

During a mean follow-up of 31±9 months, the incidence of major adverse cardiovascular events (12.54 % versus 11.25%; odds ratio [OR], 1.64 [95% CI, 0.78-3.44]; P=0.19, I2=84%), cardiac mortality (1.25% versus 0.72%; OR, 1.78 [95% CI, 0.58-5.46]; P=0.31, I2=18%), and myocardial infarction (1.28% versus 2.66%; OR, 0.79 [95% CI, 0.22-2.79]; P=0.71, I2=65%) was similar with deferral versus performance of revascularization in coronary lesions with gray-zone fractional flow reserve. Deferral of revascularization was associated with a higher incidence of target vessel revascularization (9.12% versus 5.78%; OR, 1.85 [95% CI, 1.03-3.33]; P=0.04, I2=62%). When the analysis was limited only to studies that used percutaneous coronary intervention for revascularization, deferred revascularization remained associated with a higher risk of target vessel revascularization (18% versus 7.3%; OR, 3.04 [95% CI, 1.53-6.02]; P<0.001) and was associated with a higher risk of major adverse cardiovascular event (23.2% versus 13.4%; OR, 3.38 [95% CI, 1.92-5.95]; P<0.001).

CONCLUSIONS

In lesions with gray-zone fractional flow reserve, revascularization was associated with a similar incidence of major adverse cardiovascular event but a lower incidence of target vessel revascularization over a mean follow-up of approximately 2.5 years.

CLINICAL TRIAL REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/. Unique identifier: CRD42019128076.

Prognostic Impact of Periprocedural Myocardial Infarction in Patients Undergoing Elective Percutaneous Coronary Interventions

BACKGROUND

The magnitude of prognostically relevant myocardial injury after percutaneous coronary interventions remains poorly defined. The Society for Cardiovascular Angiography and Interventions (SCAI) proposed marked biomarker elevations to define periprocedural myocardial infarction (PMI). These consensus-based thresholds have not been validated in the era of high-sensitivity cardiac troponins. We sought to assess the prognostic impact of SCAI-defined PMI and explore optimal prognostic thresholds of high-sensitivity cardiac troponin T (hs-cTnT) after elective percutaneous coronary interventions.

METHODS AND RESULTS

We evaluated patients who underwent elective percutaneous coronary interventions at 2 tertiary care centers with serial hs-cTnT measurements. PMI was defined as peak postprocedural hs-cTnT >70× upper reference limit (URL) in patients with nonelevated (≤1× URL) baseline levels; or incremental increase >70× URL in patients with elevated baseline levels. The primary outcome was 1-year all-cause mortality. Of 8140 patients, 220 (2.7%) died within 1 year. In multivariable analyses, patients with SCAI-defined PMI (n=140; 1.7%) had a higher risk of 1-year mortality (12.9% versus 2.5%, adjusted hazard ratio 4.10, 95% CI 2.51-6.68; P<0.001) as well as cardiac mortality (11.4% versus 2.1%, adjusted hazard ratio 4.21, 95% CI 2.50-7.11; P<0.001). Based on receiver operating characteristics analysis, the optimal prognostic threshold of hs-cTnT was >10×URL, observed in 14.6% of patients. This threshold showed lower specificity (85.7% versus 98.4%) but higher sensitivity (25.4% versus 8.2%) and better overall performance for prediction of 1-year mortality compared with the SCAI-defined cutoff value of troponin.

CONCLUSIONS

In patients undergoing elective percutaneous coronary interventions, SCAI-defined PMI emerged as an independent, highly specific, but insensitive predictor of 1-year mortality. Optimal trade-off between sensitivity and specificity was observed at a lower threshold of hs-cTnT (10× URL) in this cohort.

Prognostic Implications of Diastolic Dysfunction Change in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

BACKGROUND

The association between a change in diastolic function (DF) and long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) is unknown. The aim of this study was to investigate the prognostic effect of changes in diastolic dysfunction in patients undergoing PCI.Methods and Results:Consecutive patients who underwent PCI and echocardiography before and after revascularization were prospectively included. Major adverse cardiac event (MACE) was defined as a composite of cardiac death, myocardial infarction, and repeat revascularization. A total of 1,235 patients were identified. Baseline diastolic dysfunction was present in 1,033 patients (83.6%). At follow-up echocardiography, DF had worsened in 219 (17.8%) patients and was unchanged in 623 patients (50.4%). The risk of MACE was significantly higher in the worsened DF group compared with the unchanged DF group (adjusted hazard ratio [aHR]: 2.15; 95% confidence interval [CI]: 1.59 to 2.90; P<0.001) and the improved or normal DF group (aHR: 2.20; 95% CI, 1.49 to 3.27; P<0.001). Patients with worsened DF consistently had a higher risk of MACE in various subgroups, especially irrespective of left ventricular systolic function.

CONCLUSIONS

Aggravation of DF was independently associated with an increased risk of MACE in patients undergoing PCI. Evaluating changes in DF after PCI is a simple but useful method for predicting long-term clinical outcomes.

Periprocedural myocardial infarction in chronic total occlusion: The challenge of precise diagnosis and prognostication

Myonecrosis following PCI is a frequent impediment that may impact cardiac prognosis. The frequency of periprocedural myocardial infarction (PMI) in CTO-PCI is dependent on MI definition (biomarker and threshold), lesions characteristics, and PCI course. This study identified predictors of PMI during CTO-PCI and it showed that PMI and peak CK-MB level were associated with worse clinical outcomes.

Clinical implications of periprocedural myocardial injury in patients undergoing percutaneous coronary intervention for chronic total occlusion: role of antegrade and retrograde crossing techniques

AIMS

Periprocedural myocardial injury (PMI) is frequently observed after percutaneous coronary interventions (PCI) for chronic total occlusion (CTO). We aimed to investigate the prognostic impact of PMI with the antegrade as compared to the retrograde crossing technique.

METHODS AND RESULTS

A total of 1,909 patients undergoing CTO PCI were stratified according to the presence/absence of PMI (elevation of cardiac troponin T [cTnT] >5x99th percentile of normal), and divided according to tertiles of the difference between peak and baseline cTnT within 24 hours (∆cTnT). The primary endpoint was all-cause mortality at a median follow-up of 3.1 (interquartile range 3.0-4.4) years. PMI occurred in 19.4% and 25.4% after antegrade (n=1,447) and retrograde (n=462) procedures (p<0.001). PMI was significantly associated with mortality after antegrade (adjusted HR 1.39, 95% CI: 1.02-1.88, p=0.04), but not retrograde CTO PCI (adjusted HR 0.93, 95% CI: 0.53-1.63, p=0.80, pint=0.02). With the antegrade, but not with the retrograde approach, mortality also increased with tertiles of ∆cTnT (T1: 11.0%, T2: 18.6%, T3: 21.6%, log-rank p<0.001).

CONCLUSIONS

Periprocedural myocardial injury was significantly associated with all-cause mortality following antegrade, but not retrograde CTO PCI. Hence, the higher risk of PMI following retrograde procedures did not translate into worse survival.

Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis

With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.

Chronic Total Occlusion Interventions: Update on Current Tips and Tricks

PURPOSE OF REVIEW

To summarize novel techniques and developments in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

RECENT FINDINGS

Using an algorithmic, step-by-step approach can help overcome several complex CTO lesions subsets, such as proximal cap ambiguity, ostial location, in-stent occlusion, bifurcations, balloon uncrossable and undilatable lesions. Similarly, an algorithmic approach can help prevent and optimally treat CTO PCI-related complication, such as perforation, radiation, and contrast-induced nephropathy. Continual update and reassessment of each operator's algorithm for performing CTO PCI can lead to improved outcomes.

Safety and efficacy of dedicated guidewire and microcatheter technology for chronic total coronary occlusion revascularization: principal results of the Asahi Intecc Chronic Total Occlusion Study

BACKGROUND

Limited study has detailed the procedural outcomes and utilization of contemporary coronary guidewires and microcatheters designed for chronic total occlusion (CTO) percutaneous revascularization and with application of modern techniques.

PATIENTS AND METHODS

A prospective, multicenter, single-arm trial was conducted to evaluate procedural and in-hospital outcomes among 163 patients undergoing attempted CTO revascularization with specialized guidewires and microcatheters. The primary endpoint was defined as successful guidewire recanalization and absence of in-hospital cardiac death, myocardial infarction, or repeat target vessel revascularization (major adverse cardiac events).

RESULTS

The prevalence of diabetes was 42.9%; prior myocardial infarction, 41.1%; and previous bypass surgery, 36.8%. Average (mean±SD) CTO length was 41±29 mm, and mean Japanese CTO score was 2.6±1.3. A guidewire support catheter was used in 91.7% of cases, and the mean number of CTO-specific guidewires per procedure was 3.1±2.9. Overall, procedural success was observed in 73.0% of patients. The rate of successful guidewire recanalization was 89.0%, and absence of in-hospital major adverse cardiac event was 81.0%. Methods included antegrade (45.4%), retrograde (5.5%) and combined antegrade/retrograde techniques (49.1%). Total mean procedure time was 119±68 min; mean radiation dose, 2613±1881 mGy; and contrast utilization, 287±142 ml. Clinically significant perforation resulting in hemodynamic instability and/or requiring intervention occurred in 13 (8.0%) patients.

CONCLUSION

In this multicenter, prospective registration trial representing contemporary technique, favorable procedural success and early clinical outcomes inform technique and strategy using dedicated CTO guidewires and microcatheters in a high lesion complexity patient population.

Predictive value of baseline C-reactive protein for periprocedural myocardial infraction of higher risk stratifications: A retrospective cohort clinical study

Objective:

It is controversial whether preprocedural elevated high sensitivity C-reactive protein (CRP) could increase the incidence of periprocedural myocardial infraction (PMI) of higher risk stratifications. The primary aim of this study was to evaluate whether preoperative elevated CRP level was related to the incidence of PMI in patients who underwent percutaneous coronary intervention (PCI).

Methods:

A total of 4.426 patients [66 y (59, 75); 72.3% males] with normal preprocedural cardiac enzymes were prospectively divided into two groups; the elevated CRP group was defined as CRP >3 mg/L, which was approximately 30.4% of the patients. The relationship between CRP and the incidence of PMI was established by multivariate logistic regression analysis, and multivariate linear regression analysis was used to assess the correlation between CRP and the severity of myocardial injury.

Results:

The incidence rates were similar between the two groups with periprocedural myocardial minor necrosis (34.23% versus 32.74%, p=0.607), but significantly differed based on the 2007 (defined as cardiac enzymes >3-fold elevations), 31.25% in high CRP group versus 26.25% in low group [odds ratio (OR) 1.19; p=0.046] and the 2012 universal PMI (defined as cardiac enzymes >5-fold elevations with at least one clinical evidence, such as chest pain, ECG changes or imaging diagnosis of heart ischemia), 19.79% versus 15.35% (OR 1.26, p=0.023); besides, the PMI ratios increased in line with the elevation of CRP (p=0.006 for the 2007 and p=0.011 for the 2012 universal PMI). However, no significant linear relationship was found between CRP and high sensitivity cardiac troponin I peak post-PCI.

Conclusion:

Elevated baseline CRP was an independent risk factor for the incidence of the 2007 and the 2012 universal PMI rather than minor necrosis. However, CRP may not correlate with the severity of minor myocardial necrosis in patients with PMI.

Intravascular Ultrasound and Angioscopy Assessment of Coronary Plaque Components in Chronic Totally Occluded Lesions

BACKGROUND

The in vivo lesion morphologies and plaque components of coronary chronic total occlusion (CTO) lesions remain unclear.Methods and Results:We investigated 57 consecutive CTO lesions in 57 patients with stable angina pectoris undergoing elective percutaneous coronary intervention with intravascular ultrasound (IVUS) and coronary angioscopy (CAS) examination. All CTO lesions were classified according to the proximal angiographic lumen pattern; tapered-type (T-CTO) and abrupt-type (A-CTO). The differences in the intracoronary images of these lesion types were evaluated according to the location within the CTO segment. A total of 35 lesions (61.4%) were T-CTO. T-CTO lesions had higher frequencies of red thrombi (proximal 71.4%; middle 74.3%; distal 31.4%; P<0.001) and bright-yellow plaques (yellow-grade 2-3) (48.6%; 74.3%; 2.9%; P<0.001) at the proximal or middle than at the distal subsegment; A-CTO lesions showed no significant differences among the 3 sub-segments. At the middle subsegment, T-CTO lesions showed higher frequencies of positive remodeling (51.4% vs. 18.2%, P=0.01) and bright-yellow plaques (74.3% vs. 13.6%, P<0.001) compared with A-CTO lesions. Multivariate analysis identified bright-yellow plaque as an independent predictor (odds ratio, 7.25; 95% confidence interval, 1.25-42.04; P=0.03) of the occurrence of periprocedural myocardial necrosis.

CONCLUSIONS

The combination of IVUS and CAS analysis may be useful for identifying lesion morphology and plaque components, which may help clarify the pathogenetic mechanism of CTO lesions.

Incidence, predictors and longer-term impact of troponin elevation following hybrid chronic total occlusion percutaneous coronary intervention

OBJECTIVES

We examined the incidence of periprocedural cardiac enzyme rise (PCER) [troponin T (TnT) or high-sensivity (hs)TnT >5× the upper limit of normal (ULN)] and periprocedural myocardial infarction (PMI), predictors of PCER and impact of PCER on the longer-term major adverse cardiac events (MACE) following hybrid chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

BACKGROUND

PCER and PMI after CTO PCI, risk factors for PCER and its impact on longer-term MACE are not fully understood.

METHODS

Among 469 CTO PCI cases performed between 01/2010 and 12/2015, next-day TnT or hsTnT was measured in 455 (97%). We examined the incidence of PCER and PMI (with clinical context or TnT ≥70× ULN). In 269 successful cases who had TnT measured, longer-term MACE (death, MI or target-vessel revascularisation/re-occlusion) were assessed.

RESULTS

Overall, 420 CTOs (92.3%) were treated successfully. PCER was documented in 34%, while PMI in 2.9%. By multivariable analyses, higher J-CTO score (OR = 1.3 per point; P = 0.002), lower creatinine clearance (OR = 1.01 per each cc/min decrease; P < 0.0001) and recent MI (OR = 2.4; P = 0.007) were independent pre-PCI risk factors for PCER. Among procedural variables, retrograde approach (OR = 1.9; P = 0.014) and procedure duration (OR = 1.2 per 30 min; P = 0.007) were associated with PCER. At a median follow-up of 396 days following successful CTO PCI, PCER was not associated with higher MACE (9.3% vs. 8.1%; P = 0.60), and was not a predictor of MACE in multivariable analysis.

CONCLUSIONS

PCER following hybrid CTO PCI is detected in 1/3 of patients. However, true PMI occurs in 2.9%. PCER does not predict adverse long-term outcomes.

Incidence, predicting factors, and clinical outcomes of periprocedural myocardial infarction after percutaneous coronary intervention for chronic total occlusion in the era of new-generation drug-eluting stents

OBJECTIVE

This study aimed to examine predictors and clinical outcomes of periprocedural myocardial infarction (PMI) after chronic total occlusion (CTO) intervention.

BACKGROUND

There are limited data on the clinical implications of PMI after CTO intervention in the new-generation drug-eluting stent (DES) era.

METHODS

We enrolled 337 patients who underwent CTO intervention and met the study criteria. We evaluated the incidence and predictors of PMI, defined as an increase in creatine kinase-MB ≥3× the upper limit of normal (ULN) after intervention and compared the occurrence rates of major adverse cardiac and cerebrovascular events (MACCE, defined as the composite of cardiac death, myocardial infarction, stent thrombosis, target-vessel revascularization, or cerebrovascular accidents) between the PMI and non-PMI groups.

RESULTS

PMI occurred in 23 (6.8%) patients after CTO intervention. Significant independent predictors were previous bypass surgery [odds ratio (OR) = 5.52, 95% confidence interval (CI) = 1.17-25.92; P = 0.03], Japan-CTO score ≥3 (OR = 7.06, 95%CI = 2.57-19.39; P < 0.001), side branch occlusion (OR = 4.21, 95%CI = 1.13-15.66; P = 0.03), and longer procedure time (OR = 4.18, 95%CI = 1.35-12.99; P = 0.01). During a median follow-up of 29.6 months, the PMI group had a significantly higher MACCE rate than the non-PMI group (23.7 vs. 5.6%, P = 0.008 by log-rank test). PMI was an independent predictor of MACCE (HR = 4.26, 95%CI = 1.35-13.43; P = 0.01). The MACCE rate gradually increased in a CK-MB-dependent fashion and was highest in patients with ≥10× ULN (P = 0.005).

CONCLUSION

Previous bypass surgery, high Japan-CTO score, side branch occlusion, and longer procedure time were strongly related to PMI occurrence after CTO intervention. PMI was significantly associated with worse clinical outcomes in the new-generation DES era.

Effects of trimetazidine on periprocedural microRNA-21 expression by CD4+ T lymphocytes in patients with unstable angina pectoris

Objective

Post-percutaneous coronary intervention (PCI) myocardial injury is related to the CD4+ T lymphocyte-mediated inflammatory response. microRNA-21 expression is associated with CD4+ T lymphocyte activation. The pre-PCI use of trimetazidine prevents periprocedural myocardial injury and reduces inflammatory cytokine levels. This study aimed to assess the effects of trimetazidine on periprocedural microRNA-21 expression by CD4+ T lymphocytes in patients with unstable angina pectoris.

Methods

A total of 252 patients with unstable angina pectoris were randomized to the trimetazidine (60 mg/d, administered 3 days before PCI, n=128) and control (no trimetazidine, n=124) groups. Serum CK-MB, cTnI, and hs-CRP levels were tested pre-PCI and 16-24 h post-PCI. Peripheral blood CD4+ T lymphocytes were isolated by magnetic activated cell sorting. Quantitative polymerase chain reaction was used to assess microRNA-21 and PDCD4 mRNA expression levels in CD4+ T lymphocytes, and western blot was used to evaluate PDCD4 protein expression. Enzyme-linked immunosorbent assay was used to assess serum TNF-α and IL-10 levels.

Results

Compared with the control group, the trimetazidine group had a lower frequency of patients with post-PCI serum CK-MB and cTnI levels higher than normal values; the trimetazidine group had also significantly lower serum hs-CRP and TNF-α levels, and higher IL-10 levels post-PCI. Finally, the trimetazidine group had significantly lower PDCD4 expression and higher microRNA-21 levels in CD4+ T lymphocytes post-PCI.

Conclusions

Trimetazidine reduces the incidence of periprocedural myocardial injury, possibly by increasing microRNA-21 levels in CD4+ T lymphocytes and inhibiting PDCD4-mediated inflammatory response.