Coronary Obstruction From TAVR in Native Aortic Stenosis: Development and Validation of Multivariate Prediction Model

BACKGROUND

Transcatheter aortic valve replacement (TAVR)-related coronary artery obstruction prediction remains unsatisfactory despite high mortality and novel preventive therapies.

OBJECTIVES

This study sought to develop a predictive model for TAVR-related coronary obstruction in native aortic stenosis.

METHODS

Preprocedure computed tomography and fluoroscopy images of patients in whom TAVR caused coronary artery obstruction were collected. Central laboratories made measurements, which were compared with unobstructed patients from a single-center database. A multivariate model was developed and validated against a 1:1 propensity-matched subselection of the unobstructed cohort.

RESULTS

Sixty patients with angiographically confirmed coronary obstruction and 1,381 without obstruction were included. In-hospital death was higher in the obstruction cohort (26.7% vs 0.7%; P < 0.001). Annular area and perimeter, coronary height, sinus width, and sinotubular junction height and width were all significantly smaller in the obstructed cohort. Obstruction was most common on the left side (78.3%) and at the level of the coronary artery ostium (92.1%). Coronary artery height and sinus width, but not annulus area, were significant risk factors for obstruction by logistic regression but performed poorly in predicting obstruction. The new multivariate model (coronary obstruction IF cusp height > coronary height, AND virtual valve-to-coronary distance ≤4 mm OR culprit leaflet calcium volume >600 mm3) performed well, with an area under the curve of 0.93 (sensitivity = 0.93, specificity = 0.84) for the left coronary artery and 0.94 (sensitivity = 0.92, specificity = 0.96) for the right.

CONCLUSIONS

A novel computed tomography-based multivariate prediction model that can be implemented routinely in real-world practice predicted coronary artery obstruction from TAVR in native aortic stenosis.

Association of left atrial enlargement and increased left ventricular wall thickness with arrhythmia recurrence after cryoballoon ablation for atrial fibrillation

BACKGROUND

Left atrial enlargement (LAE) predicts atrial fibrillation (AF) recurrence after cryoballoon-based pulmonary vein isolation (CB). Increased left ventricular wall thickness (LVWT) is pathophysiologically associated with LAE and atrial arrhythmias.

AIMS

To assess effect of increased LVWT on long-term outcomes of CB depending on coexistence of LAE.

METHODS

LAE was defined using either echocardiography ( > 48 cm³/m²) or multislice computer tomography (MSCT, ≥63 cm³/m²). Increased LVWT was echocardiographic septal/posterior wall thickness > 10 mm in males and > 9 mm in females. All patients achieved 2-year follow-up.

RESULTS

Of 250 patients (median [interquartile range, IQR] age of 61 [49.0-67.3] years; 30% female) with AF (40% non-paroxysmal), 66.5% had hypertension, and 27.2% underwent redo procedure. MSCT was done in 76%. During follow-up of 24.5 (IQR, 6.0-31.00) months the clinical success rate was 72%, despite 46% of patients having arrhythmia recurrence. Arrhythmia recurrence risk was increased by LAE and increased LVWT (hazard ratio [HR], 1.801; P = 0.002 and HR, 1.495; P = 0.036; respectively). The highest arrhythmia recurrence (61.9% at 2 years) was among patients with LAE and increased LVWT (33.6% of patients); intermediate (41.8%) among patients with isolated LAE; and lowest among patients with isolated increased LVWT or patients without LAE or increased LVWT (36.8% and 35.2% respectively, P = 0.004). After adjustment for body mass index (BMI), paroxysmal AF, CHA₂DS₂-VASc score, clinically-significant valvular heart disease, and cardiomyopathy, patients with LAE and concomitant increased LVWT diagnosis had a 1.8-times increased risk of arrhythmia recurrence (HR, 1.784; 95% confidence interval [CI], 1.017-3.130; P = 0.043).

CONCLUSION

Joint occurrence of LAE and increased LVWT is associated with the highest rate of arrhythmia recurrence after CB for AF.

Prognostic value of computed tomography derived measurements of pulmonary artery diameter for long-term outcomes after transcatheter aortic valve replacement

BACKGROUND

An increase in pulmonary artery diameter (PAD) on multi-detector computed tomography (MDCT) may indicate pulmonary hypertension. We assessed the prognostic value of MDCT-derived measurements of PAD on outcomes after successful transcatheter aortic valve replacement (TAVR).

METHODS

Consecutive patients treated with TAVR from February 2013 to October 2017, with a 68.8% rate of new generation valves, underwent pre-interventional MDCT with measurements of PAD (in the widest short-axis within 3 cm of the bifurcation) and ascending aortic diameter (AoD; at the level of the PAD). The PAD/AoD ratio was calculated. Patients with high-density lipoprotein cholesterol levels ≤46 mg/dl and C-reactive protein levels ≥0.20 mg/dl at baseline were identified as the frail group. One-year mortality was established for all subjects.

RESULTS

Among studied 266 patients (median age, 82.0 years; 63.5% women) those who died at 1 year (n = 34; 12.8%) had larger PAD and PAD/AoD (28.9 [5.0] vs. 26.5 [4.6] mm and 0.81 [0.13] vs. 0.76 [0.13] mm vs. the rest of the studied subjects; P = 0.005 and P = 0.02, respectively) but similar AoD. The cutoff value for the PAD to predict 1-year mortality was 29.3 mm (sensitivity, 50%; specificity, 77%; area under the curve, 0.65). Patients with PAD >29.3 mm (n = 72; 27%) had higher 1-year mortality (23.6% vs. 8.8%, log-rank P = 0.001). Baseline characteristics associated with PAD29.3 mm were a bigger body mass index, more frequent diabetes mellitus, more prior stroke/transient ischemic attacks and atrial fibrillation, and lower baseline maximal aortic valve gradient with higher pulmonary artery systolic pressure (PASP). PAD >29.3 mm and frailty, but not baseline PASP, remained predictive of 1-year mortality in the multivariable model (hazard ratio [HR], 2.221; 95%CI, 1.038-4.753; P = 0.04 and HR, 2.801; 95% CI, 1.328-5.910; P = 0.007, respectively).

CONCLUSION

PAD >29.3 mm on baseline MDCT is associated with higher 1-year mortality after TAVR, independently of echocardiographic measures of PH and frailty.

Improvement in long-term survival with acute kidney recovery after a successful transcatheter aortic valve replacement

INTRODUCTION

Chronic kidney disease (CKD) is frequent in patients treated with transcatheter aortic valve replacement. Yet, the procedure can improve kidney function, that is, it can lead to acute kidney recovery (AKR).

OBJECTIVES

The aim of the study was to assess kidney function changes after transcatheter aortic valve replacement and their impact on long‑term outcomes.

PATIENT AND METHODS

In 432 patients (median age, 83 years; female sex, 63.4% ), estimated glomerular filtration rate (eGFR) was measured before and after the procedure. Chronic kidney disease was defined as a prior diagnosis or baseline eGFR of less than 60 ml/min/1.73 m2. Median (interquartile range [IQR]) follow‑up was 44.7 (31.2-48) months.

RESULTS

Overall, 66.7% of patients had CKD. An increase in eGFR of 10% or greater at 48 hours (median [IQR], 39.8% [26.2%-51.8%]) was observed in 55.2% of patients with CKD and lasted until discharge (31.8% [17.8%-49%]) in 35.8% (the AKR group). In 17.4% of patients (64.3% with CKD), there was a drop in eGFR of 10% or greater at 48 hours, which remained at discharge in 6.5% of patients (the AKI group; median [IQR] eGFR drop, -22.8% [-40.6% to -14.9%] and -22.8% [-37.5% to -16.2%], respectively). There was a stepwise increase in AKR prevalence from CKD stage 1 and 2 (11.5%) to 4 (52%) (P = 0.03). In‑hospital mortality (P = 0.01) was highest with AKI (10.7%); intermediate with CKD but no AKR (6.6%); and lowest with neither CKD nor AKI (1.5%) or with AKR (1%). Estimated 4‑year mortality was correspondingly different (46.9%, 47.2%, 25.5%, 35.4%, respectively; P <0.001). The nonperipheral access was associated with more AKI and less AKR. Acute kidney recovery was more frequent with a history of stroke or transient ischemic attack or a newer generation self-expanding valves.

CONCLUSIONS

Transcatheter aortic valve replacement led to acute kidney recovery in a substantial number of patients with CKD and an improved 4‑year survival.

Comparison of myocardial tissue reperfusion of inferior wall and a right ventricle among patients after primary angioplasty for an inferior myocardial infarction with right ventricular infarction

BACKGROUND

Impaired myocardial tissue reperfusion affects prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and can be identified by ST-segment analysis. To date, evaluation of the myocardial tissue reperfusion of the right ventricle (RV) among the patients treated with PCI for inferior STEMI with right ventricular infarction (RVI) has not been made yet.

METHODS

Patients with inferior STEMI were screened for RVI. Tissue reperfusion was evaluated by maximal residual ST-segment deviation post PCI, independently for the RV and for inferior wall. Myocardial injury was assessed by the peak creatine kinase-mb (CK-MB) value.

RESULTS

Among 456 patients with inferior STEMI, concomitant RVI occurred in 153 (33.5%) subjects (59.86±10.35 years old, 71.9% females). Tissue reperfusion of LV was present in 75 (49%), whereas 55 (35.9%) had both successful LV and RV reperfusion. Among 97 (63.4%) with successful tissue reperfusion of RV, 55 (56.7%) had associated successful tissue reperfusion of inferior wall. Adequate LV reperfusion was accompanied by RV in over 73.3% of patients (P=0.006). Mean peak CK-MB was lower in the group with adequate versus impaired RV tissue-perfusion (197±143 vs. 305±199 U/L, P=0.021 respectively).

CONCLUSIONS

Impaired reperfusion of RV is observed in more than one third of inferior STEMIs with RVI and is not strictly associated with impaired reperfusion of inferior wall and clinical or angiographic variables, therefore ST-segment analysis for RV is mandatory.

Comparison of myocardial tissue reperfusion of inferior wall and a right ventricle among patients after primary angioplasty for an inferior myocardial infarction with right ventricular infarction

BACKGROUND

Impaired myocardial tissue reperfusion affects prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and can be identified by ST-segment analysis. To date, evaluation of the myocardial tissue reperfusion of the right ventricle (RV) among the patients treated with PCI for inferior STEMI with right ventricular infarction (RVI) has not been made yet.

METHODS

Patients with inferior STEMI were screened for RVI. Tissue reperfusion was evaluated by maximal residual ST-segment deviation post PCI, independently for the RV and for inferior wall. Myocardial injury was assessed by the peak creatine kinase-mb (CK-MB) value.

RESULTS

Among 456 patients with inferior STEMI, concomitant RVI occurred in 153 (33.5%) subjects (59.86±10.35 years old, 71.9% females). Tissue reperfusion of LV was present in 75 (49%), whereas 55 (35.9%) had both successful LV and RV reperfusion. Among 97 (63.4%) with successful tissue reperfusion of RV, 55 (56.7%) had associated successful tissue reperfusion of inferior wall. Adequate LV reperfusion was accompanied by RV in over 73.3% of patients (P=0.006). Mean peak CK-MB was lower in the group with adequate versus impaired RV tissue-perfusion (197±143 vs. 305±199 U/L, P=0.021 respectively).

CONCLUSIONS

Impaired reperfusion of RV is observed in more than one third of inferior STEMIs with RVI and is not strictly associated with impaired reperfusion of inferior wall and clinical or angiographic variables, therefore ST-segment analysis for RV is mandatory.

Additive Value of High-Density Lipoprotein Cholesterol and C-Reactive Protein Level Assessment for Prediction of 2-year Mortality After Transcatheter Aortic Valve Implantation

Available prediction models are inaccurate in elderly who underwent transcatheter aortic valve implantation (TAVI). The aim of present study was to analyze the separate and combined prognostic values of baseline HDL-C and C-reactive protein (CRP) levels in patients treated successfully with TAVI who had complete 2-year follow-up. We analyzed 334 patients treated with TAVI from 01/2010 to 07/2017 who had measurements of HDL-C and CRP on admission or during qualification for the procedure. Baseline HDL-C ≤46 mg/dl (areas under the curve [AUC] = 0.657) and CRP ≥0.20 mg/dl (AUC = 0.634) were predictive of 2-year mortality. After stratification with both cutoffs, patients with low HDL-C and concomitant high CRP most often had LVEF ≤50% and were high risk as per EuroSCORE II. Those with isolated CRP elevation had the lowest frequency of LVEF ≤50%, but more sarcopenia (based on psoas muscle area). After adjustment in the multivariate analysis for other identified predictors including EuroSCORE II and statin therapy, isolated HDL-C ≤46 mg/dl (identified in 40 patients) and isolated CRP ≥0.20 mg/dl (n = 109) were both independent predictors of 2-year mortality (hazard ratio [HR] = 2.92 and HR = 2.42, respectively) compared with patients with both markers within established cutoffs (n = 105) who had the lowest 2-year mortality (9.5%). Patients with both markers exceeding cutoffs (n = 80) had the highest risk (HR = 4.53) with 2-year mortality of 42.5%. High CRP was associated with increased mortality within the first year of follow-up, whereas low HDL-C increased mortality in the second year. The combination of both markers with EuroSCORE II enhanced mortality prediction (AUC = 0.697). In conclusion, low baseline HDL-C and high CRP jointly contribute to the prediction of increased all-cause mortality after TAVI.

Effect on Mortality of Systemic Thromboinflammatory Response After Transcatheter Aortic Valve Implantation

After transcatheter aortic valve implantation (TAVI) there is consistently identified decrease in platelets accompanied by a leucocyte (white blood cell, WBC) increase. We aimed to analyze the prognostic value of early platelet and WBC count changes (thromboinflammatory response) after successful TAVI. Among 432 consecutive patients [median 83.0 years of age, 63.4% women], platelets and WBCs were measured before and for 7 days post-TAVI. Follow-up was 36.9 (21.4 to 48.0) months. Platelet decrease (∆%Platelet-max) and parallel WBC increase (∆%WBC-max) were seen at days 1 to 3. Both ∆%Platelet-max ≤-37.6% and ∆%WBC-max >72.5% predicted mortality (area under the curve = 0.569 and area under the curve = 0.626). The 30-day and 1-year mortality (13.1% and 26.2%) were highest among 28% patients with a greater decrease in platelets and a greater increase in WBCs; intermediate (0.9% and 12.3%) among 52.5% patients with either a greater decrease in platelets or a greater increase in WBCs, but not both; and lowest (0% and 6.6%) among 19.5% patients with a lesser decrease in platelets and a lesser increase in WBCs (p <0.001). Estimated 4-year mortality rates were 53.7% versus 36.2% versus 24.5%, respectively, p <0.001. Bleeding, surgical wounds, acute kidney, and brain injury predicted a more intense thromboinflammatory response, whereas use of the newer generations had the opposite effect. In conclusion, substantial thromboinflammatory response identified after successful TAVI predicts a higher long-term mortality.

Incidence, clinical correlates, timing, and consequences of acute thrombus formation in patients undergoing the MitraClip procedure

BACKGROUND

Despite adequate heparinization, formation of fresh intracardiac thrombi during the MitraClip procedure was reported.

AIMS

We aimed to evaluate the incidence and clinical consequences of intracardiac thrombus formation during the MitraClip device implantation.

METHODS

Clinical data and transesophageal echocardiography findings obtained during MitraClip procedures in 100 consecutive patients (81 men; mean [SD] age, 67.8 [8.3] years) were reviewed. In all patients, a heparin bolus was given immediately after a successful transseptal puncture, and the activated clotting time above 250 seconds was maintained throughout the procedure.

RESULTS

Thrombus formation was documented in 9 patients (9%). In 6 patients, thrombi formed on a transseptal needle/sheath (2 attached to the sheath in the right atrium and 4 on the sheath immediately after the puncture in the left atrium), and in 3 patients, on the MitraClip device in the left atrium (2 on a steerable guiding catheter and 1 on the clip delivery system). Overall, 6 thrombi (67%) formed prior to and 3 (33%) after heparin administration. All thrombi were transient and disappeared within minutes. No periprocedural ischemic stroke, transient ischemic attack, or other embolic complications were reported. Clinical characteristics were similar in patients with and without thrombi, except for lower left ventricular ejection fraction (LVEF; mean [SD], 23% [10%] and 30% [10%], respectively; P = 0.03). In-hospital death was reported in 6 patients: 2 with a visible thrombus and 4 without (P = 0.09).

CONCLUSIONS

Transient thrombus formation is relatively common during the MitraClip procedure, especially in patients with low LVEF; however, acute clinical consequences are benign.

In‑hospital outcomes of rotational versus orbital atherectomy during percutaneous coronary intervention: a meta‑analysis

BACKGROUND

Data comparing rotational atherectomy (RA) with orbital atherectomy (OA) for calcified lesions is inconclusive and based on single observational studies in populations with limited numbers of patients.

AIMS

The aim of the study was to perform a meta‑analysis of observational studies comparing RA with OA for calcified lesions prior to percutaneous coronary intervention.

METHODS

Electronic databases were searched for studies comparing short‑term outcomes of RA with OA prior to percutaneous coronary intervention. Risk ratios (RRs) or mean differences (MD) and 95% confidence intervals (CIs) were calculated using a random‑effects model.

RESULTS

Meta‑analysis included 6 retrospective studies with 1590 patients treated with RA and 721 with OA. The latter was associated with shorter fluoroscopy time (MD, -3.40 min; 95% CI, -4.76 to -2.04; P <0.001, I2 = 0%), but contrast use was similar (MD, -2.78 ml; 95% CI, -16.04 to 10.47; P = 0.68; I2 = 67%). Although coronary dissection occurred 4‑fold more frequently with OA (RR, 3.87; 95% CI, 1.37-10.93; P = 0.01; I2 = 0%), perforations (RR, 2.73; 95% CI, 0.46-16.30, P = 0.27; I2 = 41), tamponade (RR, 1.78; 95% CI, 0.37-8.58; P = 0.47; I2 = 0%), and slow or no‑reflow phenomenon (RR, 0.81; 95% CI, 0.35-1.84; P = 0.61; I2 = 0%) occurred with similar frequency. The risk of 30‑day or in‑hospital myocardial infarction was lower in OA as compared with RA (RR, 0.67; 95% CI, 0.47-0.94; P = 0.02; I2 = 0%), yet the risk of in‑hospital mortality (RR, 0.73; 95% CI, 0.11-4.64; P = 0.74; I2 = 43%) and length of stay (MD, -0.27 days; 95% CI, -0.76 to -0.23; P = 0.29; I2 = 0%) did not differ.

CONCLUSIONS

Orbital atherectomy was associated with a lower risk of early myocardial infarction. However, a higher rate of coronary dissections produced by OA did not translate into increased risk of perforations, slow or no‑reflow phenomenon, or in‑hospital mortality.

The Impact of Plaque Rupture on Mismatch Between Intravascular Ultrasound Minimal Lumen Area and Fractional Flow Reserve Measured in an Angiographically Borderline Left Main With Complex Left Anterior Descending Involvement

Plaque rupture is known to affect the mismatch between anatomy and physiology. In this case, we relied on fractional flow reserve along with the tomographic perspective of intravascular ultrasound.

Importance of Right Marginal Branch Protection During Primary Angioplasty in Inferior STEMI With Right Ventricular Involvement

We document the high effectiveness of an extra guidewire insertion aimed at mechanical lumen protection of the right marginal branch from displaced thrombus, which frequently occurs during proximal right coronary artery stenting.

Angiographic appearance of the HeartMate 3™

The use of Left Ventricular Assist Devices (LVADs) has substantially increased in recent years, being a valid therapeutic option for a growing population of patients with advanced heart failure. A 54 year old male had had the HeartMate 3™ implanted in a prepericardiac location due to end-stage congestive heart failure. We present the angiographic data of our patient.

Higher admission glycaemia independently of diagnosed or unrecognised diabetes mellitus is a risk factor for failed myocardial tissue reperfusion and higher mortality after primary angioplasty

BACKGROUND AND AIM

Admission hyperglycaemia worsens reperfusion in ST-segment elevation myocardial infarction (STEMI). ST-segment elevation resolution parallels myocardial tissue reperfusion and predicts the outcome of primary percutaneous coronary intervention (pPCI).

METHODS

We investigated whether higher glycaemia on admission impairs tissue-level reperfusion after pPCI for STEMI, as-sessed with the single-lead Schröder method of ST-segment resolution analysis (maxSTE).

RESULTS

Among 323 patients (60.4 ± 11.5 years, 27.8% female), 13.4% of nondiabetic subjects and 58.2% of those with known diabetic history (17%) were admitted with glycaemia > 11.1 mmol/L. Failed tissue reperfusion, recognised if high-risk maxSTE criteria were fulfilled, was present among 25% of patients. The overall 180-day mortality rate was 6.8% (n = 22). Admission glycaemia ≥ 8.75 mmol/L appeared as the single risk factor for failed tissue reperfusion (ROC area = 0.638, standard error = 0.038, p < 0.001). Even after adjustment for diabetes history, patients with admission glycaemia ≥ 8.75 mmol/L (44.5%) had 2.36-fold higher risk (95% confidence interval [CI] 1.25-4.46, p = 0.008) of failed tissue reperfusion. After exclusion of patients with known diabetes and those with acute blood glucose level > 11.1 mmol/L (28%), admission glycaemia remained an independent predictor of failed tissue reperfusion (odds ratio [OR] 1.32, 95% CI 1.03-1.69, p = 0.028). Admission glycae-mia and failed tissue reperfusion (high- vs. low-risk maxSTE category) were the independent predictors of 180-day mortality (OR 1.18, 95% CI 1.05-1.32, p = 0.004 and OR 3.84, 95% CI 1.12-13.21, p = 0.033, respectively).

CONCLUSIONS

Higher admission glycaemia in patients treated with pPCI for STEMI predicts failed myocardial tissue reperfusion and 180-day mortality, independently of prior or acute diabetic status.

Percutaneous Edwards SAPIEN(™) valve implantation for significant pulmonary regurgitation after previous surgical repair with a right ventricular outflow patch

BACKGROUND

Current indications for percutaneous pulmonary valve implantation (PPVI) are limited to patients who had their outflow tracts repaired with the use of a "full" condui-homograft. Patients after a patch repair are believed to have an unfavorable anatomy for PPVI.

OBJECTIVES

To evaluate a novel use of Edwards SAPIEN(TM) valve for percutaneous treatment of moderate and severe pulmonary regurgitation after tetralogy of Fallot (TF) repair with a right ventricular outflow (RVOT) patch.

METHODS

PPVI was intended in 10 patients (age 21-39 years, 2 ♂) with regurgitant fraction of 30-59%, measured by cardiac magnetic resonance imaging (CMRI) 16-30 years after repair with a RVOT patch. Balloon test-inflations were used for definitive measurements and location of the landing site for the valve. All RVOTs were prestented.

RESULTS

Successful valve implantation was achieved in nine patients. In one patient a bare-metal stent used for prestenting embolized into pulmonary artery. A 26-mm valve was implanted in seven and a 23-mm in two patients. CMRI at 1-2 month follow-up (n = 8) demonstrated both, sustained relief of pulmonary incompetence (regurgitant fraction = 0-14%) and significant decrease of the right ventricular end-diastolic volume indexes (from 169.9 ± 43.8 to 140.0 ± 40.3 ml/m(2) , P < 0.001). At that follow-up no adverse event occurred. No stent fractures were observed.

CONCLUSIONS

We report the first case series of patients with significant PR after a RVOT patch repair, successfully treated with a percutaneous Edwards SAPIEN(TM) valve implantation. The procedure is technically feasible and may be offered to patients with the outflow tracts larger than those limited by the Melody(®) system available currently.

Impact of different re-stenting strategies on expansion of a drug-eluting stent implanted to treat bare-metal stent restenosis

We used intravascular ultrasound (IVUS) to compare the expansion of drug-eluting stents (DES) implanted to treat bare-metal stent (BMS) restenosis after 3 common re-stenting strategies. A total of 80 consecutive BMS restenotic targets were re-stented either directly (n = 30, group 1) or after low-pressure (<8 atm) pre-dilation with an undersize regular balloon (n = 16, group 2) or after high-pressure (>12 atm) pre-dilation with a semicompliant balloon the same or greater diameter as the original BMS diameter (n = 34, group 3). More patients from groups 2 and 3 had diabetes mellitus. The targets in group 1 were more proximal and focal. Lesions from groups 2 and 3 were more severe. The size and deployment pressure of the DESs and the achieved angiographic results were all similar. The post-intervention minimum stent area and the percentage of expansion of DES (minimum stent area/distal reference lumen area x 100%) were, however, both significantly larger in group 3 (6.4 +/- 1.5 mm(2) in group 3 vs 5.6 +/- 1.6 mm(2) in group 1 vs 4.4 +/- 1.4 mm(2) in group 2, p <0.001; and 88 +/- 30% in group 3 vs 74 +/- 14% in group 1 vs 73 +/- 23% in group 2, p = 0.021). A post-intervention minimum stent area <5.0 mm(2) was seen in only 3 lesions in group 3 (8.8%) versus 14 in group 1 (46.7%) and 11 in group 2 (68.8%; adjusted odds ratio 0.11, 95% confidence interval 0.03 to 0.38, p <0.001). Overall, the acute lumen gain was mainly from BMS re-expansion; however, the BMS volume increased the most in group 3 (p <0.001). In conclusion, high-pressure pre-dilation leads to superior post-intervention expansion of DESs implanted to treat BMS restenosis, regardless of the original expansion because of the greater BMS re-expansion.