Mitral valve gradient changes associate with outcomes of patients undergoing transcatheter edge-to-edge repair

INTRODUCTION

Transcatheter edge-to-edge repair (TEER) is typically used to treat mitral regurgitation (MR) in patients with high surgical risk. Increased post-procedural mitral valve gradient (MVG) may impact mortality and hospitalizations. We aim to evaluate and compare the absolute postprocedural MVG and the change in the MVG effect on outcomes for patients undergoing TEER therapy.

METHODS

Patients who underwent TEER for severe MR were divided into two groups, initially by postprocedural absolute MVG, TTE-based at discharge, and then by the difference between preprocedural and postprocedural MVG. Primary endpoints included all-cause mortality and heart failure hospitalization (HFH) during one year after the procedure.

RESULTS

The study included 100 patients. The mean MVG increased from 3.39 mmHg immediately after the procedure to 4.83 mmHg the following day, an increase of 1.44 mmHg (p < 0.001). First stratification was by MVG on the day following the procedure - MVG ≤5 mmHg (n = 70) and MVG >5 mmHg (n = 30). There was no significant difference in rates of survival (88.6%, 93.3%, p = 0.716) or HFH (18.6%, 33.3%, p = 0.178). Second stratification was by the difference in preprocedural and postprocedural MVG- delta MVG <3 mmHg (n = 55) and delta MVG ≥3 mmHg (n = 45). While survival rates did not significantly differ (87.3% vs. 93.3%, p = 0.503), delta MVG ≥3 mmHg correlated with higher HFH rates (12.7% vs. 35.6%, p = 0.014).

CONCLUSIONS

The MVG of patients undergoing TEER usually increases on the day after the procedure compared to the immediate post-procedure MVG. Higher delta MVG is associated with higher HFH rate.

Performance of a novel artificial intelligence software developed to derive coronary fractional flow reserve values from diagnostic angiograms

BACKGROUND

Although invasive measurement of fractional flow reserve (FFR) is recommended to guide revascularization, its routine use is underutilized. Recently, a novel non-invasive software that can instantaneously produce FFR values from the diagnostic angiograms, derived completely from artificial intelligence (AI) algorithms has been developed. We aim to assess the accuracy and diagnostic performance of AI-FFR in a real-world retrospective study.

METHODS

Retrospective, three-center study comparing AI-FFR values with invasive pressure wire-derived FFR obtained in patients undergoing routine diagnostic angiography. The accuracy, sensitivity, and specificity of AI-FFR were analyzed.

RESULTS

A total of 304 vessels from 297 patients were included. Mean invasive FFR was 0.86 vs. 0.85 AI-FFR (mean difference: -0.005, P  = 0.159). The diagnostic performance of AI-FFR demonstrated sensitivity of 91%, specificity 95%, positive predictive value 83% and negative predictive value 97%. Overall accuracy was 94% and the area under curve was 0.93 (95% CI 0.88-0.97). 105 lesions fell around the cutoff value (FFR = 0.75-0.85); in this sub-group, AI-FFR demonstrated sensitivity of 95%, and specificity 94%, with an AUC of 0.94 (95% CI 88.2-98.0). AI-FFR calculation time was 37.5 ± 7.4 s for each angiographic video. In 89% of cases, the software located the target lesion and in 11%, the operator manually marked the target lesion.

CONCLUSION

AI-FFR calculated by an AI-based, angio-derived method, demonstrated excellent diagnostic performance against invasive FFR. AI-FFR calculation was fast with high reproducibility.

A novel robotic radiation shielding device for electrophysiologic procedures: A prospective study

BACKGROUND

A robotic Radiaction Shielding System (RSS) was developed to provide a full-body protection to all medical personnel during fluoroscopy-guided procedures, by encapsulating the imaging beam and blocking scattered radiation.

OBJECTIVES

We aimed to evaluate its efficacy in real-world electrophysiologic (EP) laboratory- both during ablations and cardiovascular implantable electronic devices (CIED) procedures.

METHODS

A prospective controlled study comparing consecutive real-life EP procedures with and without RSS using highly sensitive sensors in different locations.

RESULTS

Thirty-five ablations and 19 CIED procedures were done without RSS installed and 31 ablations and 24 CIED procedures (17 with usage levels ≥70%) were done with RSS. Overall, there was 95% average usage level for ablations and 88% for CIEDs. For all procedures with ≥70% usage level and for all sensors, the radiation with RSS was significantly lower than radiation without RSS. For ablations, there was 87% reduction in radiation with RSS (76%-97% for different sensors). For CIEDs, there was 83% reduction in radiation with RSS (59%-92%). RSS usage did not increase procedure time and radiation time. User feedback showed a high-level of integration in the clinical workflow and safety profile for all types of EP procedures.

CONCLUSIONS

For both CIED and ablation procedures the radiation with RSS was significantly lower than without RSS. Higher usage level brings higher reduction rates. Thus, RSS may have an important role in full-body protection to all medical personnel from scattered radiation during EP and CIED procedures. Until more data is available, it is recommended to maintain existing standard shielding.

Urgent transcatheter edge-to-edge repair for severe mitral regurgitation with flail leaflet in critically Ill patients

Introduction

Degenerative mitral valve disease (DMR) is a common valvular disorder, with flail leaflets due to ruptured chordae representing an extreme variation of this pathology. Ruptured chordae can present as acute heart failure which requires urgent intervention. While mitral valve surgery is the preferred mode of intervention, many patients have significantly elevated surgical risk and are sometimes considered inoperable. We aim to characterize patients with ruptured chordae undergoing urgent transcatheter edge-to-edge repair (TEER), and to analyze their clinical and echocardiographic outcomes.

Methods

We screened all patients who underwent TEER at a tertiary referral center in Israel. We included patients with DMR with flail leaflet due to ruptured chordae and categorized them into elective and critically ill groups. We evaluated the echocardiographic, hemodynamic, and clinical outcomes of these patients.

Results

The cohort included 49 patients with DMR due to ruptured chordae and flail leaflet, who underwent TEER. Seventeen patients (35%) underwent urgent intervention and 32 patients (65%) underwent an elective procedure. In the urgent group, the average age of the patient was 80.3, with 41.8% being female. Fourteen patients (82%) received noninvasive ventilation, and three patients (18%) required invasive mechanical ventilation. One patient died due to tamponade, while echo evaluation of the other 16 patients demonstrated successful reduction of ≥2 in the MR grade. Left atrial V wave decreased from 41.6 mmHg to 17.9 mmHg (p < 0.001), and the pulmonic vein flow pattern changed from reversal (68.8%) to a systolic dominant flow in all patients (p = 0.001). After the procedure, 78.5% of patients improved to New York Heart Association (NYHA) class I or II (p < 0.001). There was no significant difference in the overall mortality between the urgent and elective groups, with similar 6 months survival rates for each group.

Conclusion

Urgent TEER in patients with ruptured chordae and flail leaflets can be safe and feasible with favorable hemodynamic, echocardiographic, and clinical outcomes.

First-in-Human Dedicated Leaflet Splitting Device for Prevention of Coronary Obstruction in Transcatheter Aortic Valve Replacement

BACKGROUND

Coronary artery obstruction is a life-threatening complication of transcatheter aortic valve replacement (TAVR) procedures. Current preventive strategies are suboptimal.

OBJECTIVES

The aim of this study was to describe bench testing and clinical experience with a novel device that splits valve leaflets that are at risk for causing coronary obstruction after TAVR, allowing normal coronary flow.

METHODS

The ShortCut device was initially tested in vitro and preclinically in a porcine model for functionality and safety. The device was subsequently offered to patients at elevated risk for coronary obstruction. Risk for coronary obstruction was based on computed tomography-based anatomical characteristics. Procedure success was determined as patient survival at 30 days with a functioning new valve, without stroke or coronary obstruction.

RESULTS

Following a successful completion of bench testing and preclinical trial, the device was used in 8 patients with failed bioprosthetic valves (median age 81 years; IQR: 72-85 years; 37.5% man) at 2 medical centers. A total of 11 leaflets were split: 5 patients (63.5%) were considered at risk for left main obstruction alone, and 3 patients (37.5%) were at risk for double coronary obstruction. All patients underwent successful TAVR without evidence of coronary obstruction. All patients were discharged from the hospital in good clinical condition, and no adverse neurologic events were noted. Procedure success was 100%.

CONCLUSIONS

Evaluation of the first dedicated transcatheter leaflet-splitting device shows that the device can successfully split degenerated bioprosthetic valve leaflets. The procedure was safe and successfully prevented coronary obstruction in patients at risk for this complication following TAVR.

Large multinational evaluation of time to reintervention in patients undergoing bioprosthetic valve implantation during open heart surgery

Introduction

Bioprosthetic valves are increasingly utilized during open heart surgery in favor of mechanical valves. These tissue valves are prone for structural valve degeneration and failure, especially in young patients. Transcatheter aortic valve implantation (TAVI) is an appealing approach in these patients.

Purpose

To describe independent correlates for early need for reintervention.

Method

We used a large multicenter registry of patients (&gt;45 years of age) with failed bioprosthetic surgical valves undergoing TAVI valve-in-valve (VinV) in either aortic or the mitral positions. Early reintervention was (&lt;5 years between open-heart surgery and VinV). Multi-variable properties that were included: patient gender, age at open-heart surgery, valve size, baseline renal failure, position of valve implantation, and bioprosthetic valve label size.

Results

A total of 3,324 patients were included in the study (age at the time of open heart surgery 68.9+7.9 years). Median time to TAVI was 9 years (IQR 6–13 years). A total of 632 (19%) patients experienced early valve degeneration with median time to TAVI of only 3 years [IQR 1–5]. Patients with early degeneration were older than those without early degeneration (mean age at surgery was 72.8±9 years vs. 68.9±8 years; p&lt;0.001). in addition, significant linear relation between older patient age and early valve degeneration (p for trend &lt;0.001). Re-intervention in the mitral position was more common in the group of patients with early degeneration (24.4% vs 18.2% without early degeneration; p&lt;0.001) Patient age and mitral valve position were independently associated with increased rate of early degeneration (OR 1.09 [1.08–1.11], p&lt;0.001; OR 1.62 [1.31–2.01]; p&lt;0.001 respectively).

Conclusions

In this large multicenter analysis of patients undergoing TAVR for failed bioprosthetic valves we identified old patient age and mitral valve (vs. aortic) as independent correlates for early intervention. A discrepancy with known association of young age and rapid bioprosthetic valve degeneration is to be determined.

Funding Acknowledgement

Type of funding sources: None.

Large comprehensive evaluation of new- vs. old-generation ACURATE neo self-expanding valve during TAVI procedures: a decrease in paravalvular leakage with an increase in post-procedural gradients?

Background

Contemporary data comparing new- versus old-generation transcatheter heart valve (THV) devices are lacking regarding several THV devices. We aimed to compare the safety and efficacy of old-generation device (OGD) ACURATE neoTM versus the newer generation device (NGD) ACURATE neo2TM THVs (Boston Scientific) in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods

An analysis of patients undergoing transfemoral TAVI with old-generation device ACURATE neoTM versus newer generation device ACURATE neo2TM from 2016 to 2021. The primary end-point was early safety events at 30-days post-valve implantation. Significant post-implantation paravalvular leakage (PVL) was considered as ≥moderate.

Results

A total of 249 patients were included in the evaluation; mean age was 81±7.2, and 95 (38.2%) were males. Of the total population 87 (35%) underwent TAVI with the NGD. Early safety events occurred in 21.8% NGD versus 19.1% in OGD (RR= 0.67, P=0.13). Permanent pacemakers were implanted within 30 days in 4.6% versus 6.2% in NGD versus OGD respectively (RR=1.343, P=0.77). Major vascular complications occurred in 5.7% in NGD versus 9.4% in OGD 9.4% (RR=1.6, P=0.46). More than mild PVL occurred significantly more often in OGD (P&lt;0.0001). Echocardiographic mean gradient post-procedure was 9 mmHg± 5 in OGD versus 11±4 mmHg in the NGD (P=0.0159).

Conclusion

New-generation ACURATE neo2TM devices were associated with less significant PVL. However, this new generation valve was also associated with higher residual gradients. This trend of decrease in PVL with an increase in gradients will be further studied.

Funding Acknowledgement

Type of funding sources: None.

Urgent Transcatheter Edge-to-Edge Repair for Severe Mitral Regurgitation in Patients with Refractory Cardiogenic Shock

Introduction Patients suffering from cardiogenic shock (CS) and mitral regurgitation (MR) demonstrate worse prognosis, with higher mortality rates. We sought to evaluate the effectiveness of urgent valve intervention of the mitral valve, using transcatheter edge-to-edge repair (TEER) procedures in patients presenting with CS in a tertiary Intensive Coronary Care Unit (ICCU). Methods and Results Patients with unremitting CS and severe MR were selected for urgent TEER. Baseline clinical and echocardiographic characteristics were recorded, as well as procedural success (MR severity and hemodynamics), and 30-days and 6-month mortality. Urgent TEER was done in 13 patients, whose average age was 70 years; 12 (92%) of the patients were male. All 13 patients had suffered previous ischemic heart disease—12 (92%) with either acute severe MR or worsening of previously known MR by an acute ischemic event. Using the SCAI criteria, 8 patients (61%) were classified as ‘E’ (Extreme) category; 4 (31%) were classified as ‘C’. At 30 days, 12 out of the 13 patients survived (corresponding to an 8% mortality rate); all of those 12 patients remained alive at 6 months post-admission/procedure. Conclusions The use of TEER was associated with greater 30-day and 6-month survival rates, compared to the worldwide mortality rates of patients admitted with CS. This finding may change the previous paradigm that CS and MR are associated with the worst outcome, and we might be able to offer these patients a safe and effective therapeutic option.

Prospective evaluation of commissural alignment of balloon-expandable transcatheter heart valves utilizing pre- and post-procedure computed-tomogrpahy

Background

Previous studies suggested that bioprosthetic valve commissural alignment may improve device performance and clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). However, no cath-lab method for correct commissural alignment of balloon-expandable valves was described to-date. Our aim is to evaluate the impact of a predefined patient specific crimped SAPIEN 3 orientation on its final implant orientation in relation to original valve commissures and overlap with coronary arteries as demonstrated by cardiac computed tomography (CT) in tricuspid aortic valve stenosis patients.

Methods and results

A prospective study of patients undergoing TAVI with SAPIEN 3 (Edwards Lifesciences), including post procedure cardiac CT. Patients were divided to 2 groups, a planned group in which the SAPIEN 3 was crimped before implantation in a pre-defined position, and a control group with conventional valve deployment. All patients underwent pre and post TAVI cardiac CT, which were evaluated by cardiac imaging experts that were blinded to the method of valve deployment. Twenty-eight patients were prospectively evaluated before and after TAVI with SAPIEN 3. All patients had elevated risk for open-heart surgery (age 77.6±7.9 years, 68% male, STS PROM 4.4%±3.4%). Fifteen patients were included in the active alignment group vs. thirteen patients in the control. Patients in the active alignment group had a trend for more correct commissural alignment (73.3% vs. 38.5%, p=0.06). There was no statistically significant difference in patient characteristics, echocardiographic measures or in anatomical CT features between the active commissural alignment and control groups.

Conclusion

This is probably the first study that shows that patient-specific initial crimped orientation of balloon-expandable TAVI may improve our ability to have correct commissural alignment of the implanted valve. Our prospective study continues to recruit patients and updated study results will be presented.

Funding Acknowledgement

Type of funding sources: None.

Platelet reactivity and immature platelets in patients with Covid-19

Background

Coronavirus disease 2019 (Covid-19) is associated with high incidence of thromboembolic events, both venous and arterial. Currently, there are no clinical or laboratory markers to guide antithrombotic therapy in COVID-19 patients. Immature platelets represent a population of hyper-reactive platelets associated with arterial thrombotic events.

Objectives

To determine indices of immature platelets and platelet reactivity in Covid-19 patients.

Methods

This prospective study compared consecutive COVID-19 patients (n=47, median age = 56 years) to patients with acute myocardial infarction (AMI, n=100, median age = 59 years) and a group of stable patients with cardiovascular risk factors (n=64, median age=68 years). Immature platelet fraction (IPF) and immature platelet count (IPC) were determined by the Sysmex XN-3000 auto-analyzer on admission and at subsequent time-points.

Results

IPF% on admission was higher in the Covid-19 group than the stable group and similar to the AMI group (4.8% [IQR 3.4–6.9], 3.5% [2.7–5.1], 4.55% [3.0–6.75], respectively, p=0.005 for Covid-19 vs. stable). IPC on admission was also higher in the Covid-19 group than the stable group and similar to the AMI group (10.8×109/L [8.3–18.1], 7.35×109/L [5.3–10.5], 10.7×109/L [7.7–16.8], respectively, P&lt;0.0001 for Covid-19 vs. stable). The maximal IPF% among the Covid-19 group was higher than the stable group and similar to the AMI group. The maximal IPC in the Covid-19 group was higher than the maximal IPC in both the stable and AMI groups (Covid-19: 14.4×109/L [9.4–20.9], AMI: 10.9×109/L [7.6–15.2], P=0.0035, Stable: 7.55×109/L [5.55–10.5], P&lt;0.0001).

Conclusions

Patients with Covid-19 have increased immature platelets indices compared to stable patients with cardiovascular risk factors, and as the disease progresses also compared to AMI patients. Enhanced platelet turnover and reactivity may, therefore, have a role in the development of thrombotic events in Covid-19 patients.

Funding Acknowledgement

Type of funding sources: None. IPF in COVID-19, AMI and stable groups

Immature platelets in patients with Covid-19: association with disease severity

Background

Coronavirus disease 2019 (Covid-19) is associated with a high incidence of thromboembolic events, both venous and arterial. Currently, there are no clinical or laboratory markers to guide risk-stratification or antithrombotic therapy in Covid-19 patients. Circulating immature platelets represent a population of hyper-reactive platelets, which are associated with arterial thrombotic events.

Objectives

To assess whether the proportion of immature platelets in the circulation is associated with disease severity in patients with Covid-19

Methods

This prospective study evaluated consecutive patients with COVID-19 admitted with various degrees of disease severity, as determined by the standard Covid-19 severity Score. Disease severity was evaluated during hospitalization. Immature platelet fraction (IPF) absolute number and percentage were measured on admission and at additional time points during the hospital course using the SysmexXN-3000 auto-analyzer. The maximal values of IPF% and absolute IPF was analyzed according to disease severity.

Results

A total of 136 consecutive patients with Covid-19 were recruited. Mean age was 60±19 years for patients with mild and moderate disease and 69±14 years for patients with severe disease, 52% with mild and moderate disease and 48% with severe disease were woman, 11% with mild and moderate disease and 20% with severe disease with concurrent cardiovascular disease

The median of IPF% was higher in the severe COVID-19 group compared to patients with mild or moderate disease [4.2 (IQR 2.73–6.45) vs 5.8 (IQR 3.9–8.7), P=0.01, Figure 1)]. The median of IPF absolute number was also significantly higher in patients with severe disease comparing to patients with mild or moderate disease (4.2 (2.85–6.1) vs 5.1 (IQR 3.65–7.35), P&lt;0.0001, Figure 2].

Conclusions

Patients with severe Covid-19 have a higher level of IPF in the circulation than patients with mild or moderate disease. IPF may serve as a reliable prognostic marker for in-hospital disease severity in patients with Covid-19

Funding Acknowledgement

Type of funding sources: None. Figure 1. IPF% (median, 95% confidence interval)Figure 2. IPF# (median, 95% confidence interval)

Immature platelets in patients with Covid-19: association with disease severity

Coronavirus disease 2019 (Covid-19) is associated with a high incidence of venous and arterial thromboembolic events. Currently, there are no clinical or laboratory markers that predict thrombotic risk. Circulating immature platelets are hyper-reactive platelets, which are associated with arterial thrombotic events. The aim of this study was to assess whether the proportion of circulating immature platelets is associated with disease severity in Covid-19 patients. Patients admitted with Covid-19 disease were prospectively assessed. Immature platelet count (IPC) and immature platelet fraction (IPF) were measured at admission and at additional time points during the hospital course using the Sysmex XN-3000 auto-analyzer. A total of 136 consecutive patients with Covid-19 were recruited [mean age 60 ± 19 years, 49% woman, 56 (41%) had mild-moderate disease and 80 (59%) had severe disease at presentation]. The median IPF% was higher in patients with severe compared to mild-moderate disease [5.8 (3.9-8.7) vs. 4.2 (2.73-6.45), respectively, p = 0.01]. The maximal IPC value was also higher in patients with severe disease [15 (10.03-21.56), vs 10.9 (IQR 6.79-15.62), respectively, p = 0.001]. Increased IPC was associated with increased length of hospital stay. Patients with severe Covid-19 have higher levels of IPF than patients with mild-moderate disease. IPF may serve as a prognostic marker for disease severity in Covid-19 patients.

Advances in mammalian target of rapamycin kinase inhibitors: application to devices used in the treatment of coronary artery disease

Mammalian target of rapamycin (mTOR) inhibitors have been applied to vascular coronary devices to avoid neointimal growth and have become the predominant pharmacological agents used to prevent restenosis. mTOR inhibitors can affect not only proliferating vascular smooth muscle cells but also endothelial cells and therefore can result in delayed healing of the vessel including endothelialization. Emerging evidence suggests accelerated atherosclerosis due to the downstream negative effects on endothelial barrier functional recovery. The development of neoatherosclerosis within the neointima of drug-eluting stents can result in late thrombotic events. This type of problematic healing response may open the way for specific mTOR kinase inhibitors, such as ATP-competitive mTOR inhibitors. These inhibitors demonstrate a better healing profile than traditional limus-based drug-eluting stent and their clinical efficacy remains unknown.

P3607Temporal trends in the characteristics, management, and clinical outcomes of patients with prior myocardial infarction who are admitted with an acute coronary syndrome

Background

Patients with prior myocardial infarction (MI) are at increased risk for recurrent cardiovascular events. Advances in treatment in the last decade has improved prognosis of patients with acute coronary syndrome (ACS), yet it is not known whether similar trends exist in patients with prior MI who are admitted with an ACS, a particularly high-risk group.

Methods

Patients admitted with ACS who were enrolled in the ACS Israeli Surveys (ACSIS). Patients were stratified by early (2000–2008) and late (2010–2016) time-periods and by prior MI status. Clinical outcomes included 30-d MACE (death, MI, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality.

Results

A total of 15,211 ACS patients were included, of whom 4627 (30%) had a prior MI. These patients were older (67y vs. 63y), more commonly male, had more prior comorbidities, and a higher proportion had a GRACE score>140 (38.4% vs 12.2%). Patients with prior MI received more prior medications such as aspirin, statins, antihypertensives and hypoglycemics. During time, utilization of guideline-recommended therapies such as P2Y12 inhibitors, statins, and PCI had significantly improved in patients with prior MI. However, compared with patients without prior MI, they were still treated less commonly by PCI (61% vs. 74%). Overall, patients with prior MI had a higher 30-d MACE (13.7% vs 17.2%, p<0.001) and 1-year mortality (8.2% vs. 13.1%, p<0.001). In patients with prior MI, during time, 30d MACE nearly halved (22.7% to 11.8%) and 1-year mortality also decreased (15.5% to 10.7%). Upon adjustment, prior MI was independently associated with 1-year mortality (HR 1.13, 95% CI 1.01–1.26, p=0.04) and the late time-period was associated with reduced 1-year mortality (HR 0.75, 95% CI 0.65–0.84, p<0.001).

Conclusion

Patients with prior MI have a worse prognosis after ACS despite being treated with prior medications and improvement in guideline-based therapies. Although still undertreated, their clinical outcome has significantly improved throughout the years.

Direct Targeting of the mTOR (Mammalian Target of Rapamycin) Kinase Improves Endothelial Permeability in Drug-Eluting Stents-Brief Report

Objective- Drug-eluting stents eluting canonical mTOR (mammalian target of rapamycin) inhibitors are widely used to treat coronary artery disease but accelerate the development of atherosclerosis within the stent (neoatherosclerosis)-a leading cause of late stent failure. We recently showed that canonical mTOR inhibitors bind FKBP12.6 (12.6-kDa FK506-binding protein 12), displace it from calcium release channels, resulting in activation of PKCα (protein kinase Cα) and dissociation of p-120-catenin (p120) from VE-CAD (vascular endothelial cadherin; promoting endothelial barrier dysfunction [EBD]). However, the relevance of these findings to drug-eluting stents remains unknown. Newer generation direct mTOR kinase inhibitors do not bind FKBP12.6 and offer the potential of improving endothelial barrier function while maintaining antirestenotic efficacy, but their actual effects are unknown. We examined the effects of 2 different pharmacological targeting strategies-canonical mTOR inhibitor everolimus and mTOR kinase inhibitors Torin-2-on EBD after stenting. Approach and Results- Using the rabbit model of stenting and a combination of Evans blue dye, confocal and scanning electron microscopy studies, everolimus-eluting stents resulted in long-term EBD compared with bare metal stents. EBD was mitigated by using stents that eluted mTOR kinase inhibitors (Torin-2-eluting stent). At 60 days after stent placement, everolimus-eluting stents demonstrated large areas of Evans blue dye staining and evidence of p120 VE-CAD dissociation consistent with EBD. These findings were absent in bare metal stents and significantly attenuated in Torin-2-eluting stent. As proof of concept of the role of EBD in neoatherosclerosis, 100 days after stenting, animals were fed an enriched cholesterol diet for an additional 30 days. Everolimus-eluting stents demonstrated significantly more macrophage infiltration (consistent with neoatherosclerosis) compared with both bare metal stents and Torin-2-eluting stent. Conclusions- Our results pinpoint interactions between FKBP12.6 and canonical mTOR inhibitors as a major cause of vascular permeability and neoatherosclerosis, which can be overcome by using mTOR kinase inhibitors. Our study suggests further refinement of molecular targeting of the mTOR complex may be a promising strategy (Graphic Abstract).

Pathological mechanisms of left main stent failure

BACKGROUND

Despite the increasing use of left main (LM) percutaneous coronary intervention (LM-PCI), there have been no pathological studies devoted to understanding the causes of LM stent failure. We aimed to systematically determine the pathological mechanisms of LM stent failure.

METHODS AND RESULTS

From the CVPath Stent registry, a total of 46 lesions were identified to have LM-PCI. Pathologic stent failure (PSF) was defined as stent thrombosis, restenosis and in-stent chronic total occlusion (CTO). Failed and patent LM stented lesions were pathologically assessed to determine predictors of PSF. Malapposition and uncovered struts were numerically greater in the LM ostium, body, and bifurcation while neointimal thickness was relatively greater in bifurcation and proximal circumflex. In this study cohort, half of the lesions (n = 23) showed PSF. Stent thrombosis (ST, n = 18) was the major mode of PSF followed by in-stent CTO (n = 4) and restenosis (n = 1). Failed lesions showed significantly greater prevalence of malapposition >20% of struts/section (65% vs. 13%, P < 0.01), stent struts crossing an ostial side branch >30% of the circumference (48% vs. 13%, P < 0.01) and uncovered struts >30% (57% vs. 18%, P = 0.03). In multivariate analysis, the prevalence of malapposition >20% was the strongest risk factor for PSF (Odds ratio 8.0, 95% confidence interval 1.8-45.4, P < 0.01) followed by struts crossing an ostial side branch >30% (Odds ratio 4.2, 95% confidence interval 0.8-24.7, P = 0.09).

CONCLUSION

Our data demonstrate the main pathological predictors for LM stent failure are malapposition and struts crossing an ostial side branch and suggest that imaging-guided PCI may be important.

Vascular Permeability Assay in Human Coronary and Mouse Brachiocephalic Arteries

Coronary artery disease remains an important cause of morbidity and mortality. Previous work, including ours, has focused on the role of intraplaque hemorrhage, particularly from immature microvessel angiogenesis, as an important contributor to plaque progression via increases in vascular permeability leading to further intraplaque hemorrhage, which increases red cell membrane-derived free cholesterol in plaque content and inflammatory cell recruitment. Evans Blue Dye (EBD) assay is widely used as a standard assay for vasculature permeability. However, the method has not been established in fresh human coronary artery autopsy samples to evaluate intraplaque microvessel permeability and angiogenesis. In this protocol, we describe a method to evaluate human coronary samples for microvascular permeability, including procedures to perfuse coronary arteries, collection of artery samples for histological analysis and immunostaining as well as the use of appropriate methodology to analyze the images. An optional procedure is also provided for the use of FITC-dextran in mouse model to evaluate vascular permeability. These Evans Blue Dye procedures may be useful in providing functional measure of the endothelium integrity and permeability in both human samples and animal models in various pathological conditions.

CD163+ macrophages promote angiogenesis and vascular permeability accompanied by inflammation in atherosclerosis

Intake of hemoglobin by the hemoglobin-haptoglobin receptor CD163 leads to a distinct alternative non-foam cell antiinflammatory macrophage phenotype that was previously considered atheroprotective. Here, we reveal an unexpected but important pathogenic role for these macrophages in atherosclerosis. Using human atherosclerotic samples, cultured cells, and a mouse model of advanced atherosclerosis, we investigated the role of intraplaque hemorrhage on macrophage function with respect to angiogenesis, vascular permeability, inflammation, and plaque progression. In human atherosclerotic lesions, CD163+ macrophages were associated with plaque progression, microvascularity, and a high level of HIF1α and VEGF-A expression. We observed irregular vascular endothelial cadherin in intraplaque microvessels surrounded by CD163+ macrophages. Within these cells, activation of HIF1α via inhibition of prolyl hydroxylases promoted VEGF-mediated increases in intraplaque angiogenesis, vascular permeability, and inflammatory cell recruitment. CD163+ macrophages increased intraplaque endothelial VCAM expression and plaque inflammation. Subjects with homozygous minor alleles of the SNP rs7136716 had elevated microvessel density, increased expression of CD163 in ruptured coronary plaques, and a higher risk of myocardial infarction and coronary heart disease in population cohorts. Thus, our findings highlight a nonlipid-driven mechanism by which alternative macrophages promote plaque angiogenesis, leakiness, inflammation, and progression via the CD163/HIF1α/VEGF-A pathway.

Safety of Zilver PTX Drug-Eluting Stent Implantation Following Drug-Coated Balloon Dilation in a Healthy Swine Model

Purpose: To compare the safety of Zilver PTX drug-eluting stents (DES) following drug-coated balloon (DCB) angioplasty or conventional balloon angioplasty (BA) in a healthy porcine iliofemoral artery model. Methods: DES implantation following DCB (DCB+DES) or BA (BA+DES) was assessed by angiography and histology in the nondiseased iliofemoral arteries of 20 animals, with sacrifice at 1, 3, and 6 months. Safety assessment compared quantitative measures of vessel integrity (eg, preservation of artery geometry, structure, and lumen dimensions; absence of aneurysm; malapposition) and histological parameters (eg, excessive inflammation). The percentage of uncovered struts could not be >30% per section and the endothelial cell loss had to be <50%. The vascular and skeletal muscle changes in the downstream regions were also assessed histologically for evidence of emboli. Results: No significant differences in safety parameters, including inflammation and endothelial cell loss, were observed between the 2 groups at all time points. Percentage of fibrin was significantly higher in DCB+DES at 3 months [20.0% (IQR 11.6, 28.4) vs BA+DES 4.2% (IQR 1.4, 9.6), respectively; p=0.04], with consistent trends between groups at all time points. Medial smooth muscle cell loss peaked at 1 month and was not statistically different between groups at any time point, although the loss was greater in the DCB+DES group. Sections with arterioles exhibiting paclitaxel-associated fibrinoid necrosis in downstream tissues were observed exclusively in the DCB group at 1 month (14.3% of sections) and 3 months (11.5%). Conclusion: This preclinical study suggests that Zilver PTX stent implantation is a safe strategy after DCB angioplasty and might be considered for patients who require stenting after DCB treatment.

Very Late Pathological Responses to Cobalt-Chromium Everolimus-Eluting, Stainless Steel Sirolimus-Eluting, and Cobalt-Chromium Bare Metal Stents in Humans

Background

The “very late” clinical outcomes for durable polymer drug‐eluting stents and bare metal stents (BMSs) have been shown to be dissimilar in clinical studies. Conceptually, the long‐term vascular compatibility of BMSs is still regarded to be superior to drug‐eluting stents; however, no pathologic study to date has specifically addressed this issue. We evaluated the very late (≥1 year) pathologic responses to durable polymer drug‐eluting stents (cobalt–chromium [CoCr] everolimus‐eluting stents [EESs] and stainless steel sirolimus‐eluting stents [SS‐SESs]) versus BMSs (CoCr‐BMSs).

Methods and Results

From the CVPath stent registry, we studied a total of 119 lesions (40 CoCr‐EESs, 44 SS‐SESs, 35 CoCr‐BMSs) from 92 autopsy cases with a duration ranging from 1 to 5 years. Sections of stented coronary segments were pathologically analyzed. Inflammation score and the percentage of struts with giant cells were lowest in CoCr‐EESs (median inflammation score: 0.6; median percentage of struts with giant cells: 3.8%) followed by CoCr‐BMSs (median inflammation score: 1.3 [P<0.01]; median percentage of struts with giant cells: 8.9% [P=0.02]) and SS‐SESs (median inflammation score: 1.7 [P<0.01]; median percentage of struts with giant cells: 15.3% [P<0.01]). Polymer delamination was observed exclusively in SS‐SESs and was associated with increased inflammatory and giant cell reactions. The prevalence of neoatherosclerosis with CoCr‐EESs (50%) was significantly less than with SS‐SESs (77%, P=0.02) but significantly greater than with CoCr‐BMSs (20%, P<0.01).

Conclusions

CoCr‐EESs, SS‐SESs, and BMSs each demonstrated distinct vascular responses. CoCr‐EESs demonstrated the least inflammation, near‐equivalent healing to BMSs, and lower neointimal formation. These results challenge the belief that BMSs have superior biocompatibility compared with some polymeric coated drug‐eluting stents and may have implications for future stent design.

Endothelial Barrier Protein Expression in Biodegradable Polymer Sirolimus-Eluting Versus Durable Polymer Everolimus-Eluting Metallic Stents

OBJECTIVES

This study sought to investigate endothelial coverage and barrier protein expression following stent implantation.

BACKGROUND

Biodegradable polymer drug-eluting stents (BP-DES) have been purported to have biological advantages in vessel healing versus durable polymer DES (DP-DES), although clinical trial data suggest equipoise.

METHODS

Biodegradable polymer-sirolimus-eluting stents (BP-SES), durable polymer-everolimus-eluting stents (DP-EES), and bare-metal stents (BMS) were compared. In the rabbit model (28, 45, and 120 days), stented arteries underwent light microscopic analysis and immunostaining for the presence of vascular endothelium (VE)-cadherin, an endothelial barrier protein, and were subjected to confocal microscopy and scanning electron microscopy. A cell culture study in stented silicone tubes was performed to assess cell proliferation.

RESULTS

Light microscopic assessments were similar between BP-SES and DP-EES. BMS showed nearly complete expression of VE-cadherin at 28 days, whereas both DES showed significantly less with results favoring BP-SES versus DP-EES (39% coverage in BP-SES, 22% in DP-EES, 95% in BMS). Endothelial cell morphologic patterns differed according to stent type with BMS showing a spindle-like shape, DP-EES a cobblestone pattern, and BP-SES a shape in between. VE-cadherin-negative areas showed greater surface monocytes regardless of type of stent. Cell proliferation was suppressed in both DES with numerically less suppression in BP-SES versus DP-EES.

CONCLUSIONS

This is the first study to examine VE-cadherin expression after DES. All DES demonstrated deficient barrier expression relative to BMS with results favoring BP-SES versus DP-EES. These findings may have important implications for the development of neoatherosclerosis in different stent types.

Clinical implications of blood-material interaction and drug eluting stent polymers in review

INTRODUCTION

Despite advances in drug-eluting stent (DES) technology, stent thrombosis (ST) remains the most feared complication with high morbidity and mortality. Areas covered: Stent related factors certainly play a role in the pathophysiology of ST and more recent data suggest coating technologies have the potential to favorable modify this risk though blood material interactions. Of the polymer coatings used in DES, fluorinated polymers in particular have shown significant promise in modifying the risk of ST through their preferential interactions with albumin which is believed to prevent the adhesion and aggregation of platelets to the stent surface and thus minimize thrombus formation. Preclinical data from the porcine arteriovenous fistula model and clinical data from large network meta-analysis support a role for fluorinated polymers in reducing ST. Expert commentary: The search for more biocompatible anti-thrombotic polymer coatings continues and it is likely that further modification of stent based surfaces will revolutionize the field of interventional cardiology by one day obviating the need for systemic anti-platelet therapies in patients receiving intravascular devices.

A prospective randomized controlled study of the effect of short coincubation of gametes during insemination on zona pellucida thickness

A prospective, randomized study was conducted to evaluate the thickness, of zona pellucida (ZP) after brief or standard exposure of human oocytes to spermatozoa, and to determine the correlation between ZP thickness, fertilization rate and embryo quality. The mean ZP thickness 48 h after insemination was found to be significantly less in fertilized oocytes than in non-fertilized oocytes in all treated groups (13.72 +/- 3.0 microns and 15.08 +/- 2.5 microns, respectively; p < 0.007). Zona pellucida thickness correlated positively with embryo quality. Brief exposure of gametes was found to influence ZP thickness. The ZP was significantly thinner after brief and intracytoplasmic sperm injection (ICSI) exposure of oocytes to spermatozoa than after standard in vitro fertilization (IVF). The mean ZP thickness 24 and 48 h after fertilization was significantly greater in standard IVF (16.43 +/- 2.8 microns and 15.22 +/- 2.7 microns, respectively) than in either the brief exposure or ICSI groups (12.78 +/- 2.4 microns and 13.01 +/- 3.5 microns vs. 13.46 +/- 2.2 microns and 13.16 +/- 2.4 microns; p < 0.0001).

Whose evidence? Lessons from the philosophy of science and the epistemology of medicine

OBJECTIVE

To demonstrate the inadequacies of empiricism as a scientific foundation for evidence-based approaches to psychiatry.

METHOD

The principles of empiricism are reviewed in the light of developments in the philosophy of science and phenomenology. Case studies are selected from the history of physical sciences, biological science and clinical sciences (pathology, neuroscience, psychosocial science and psychopathology), paying particular attention to the role of observation in theory construction.

RESULTS

The principles of empiricism, particularly its view of the nature of observation as the basis of evidence do not reflect the historical reality of scientific theorizing and practice. Science has constructed alternative models of its own activity that do justice to the complexities of its subject matter, including the world of human experience and mental illness.

CONCLUSIONS

A failure to recognize both the limitations of empiricism in science and the conceptual richness of alternative formulations that accord more closely with the complexity of psychiatry's domain will result in a naïve model of science and inadequate understanding of the limitations of 'evidence' that guide the training, clinical practice and research in our profession. The consequences will be the intellectual, clinical and ethical impoverishment of psychiatry.

Multitude of ion channels in the regulation of transmitter release

The presynaptic nerve terminal is of key importance in communication in the nervous system. Its primary role is to release transmitter quanta on the arrival of an appropriate stimulus. The structural basis of these transmitter quanta are the synaptic vesicles that fuse with the surface membrane of the nerve terminal, to release their content of neurotransmitter molecules and other vesicular components. We subdivide the control of quantal release into two major classes: the processes that take place before the fusion of the synaptic vesicle with the surface membrane (the pre-fusion control) and the processes that occur after the fusion of the vesicle (the post-fusion control). The pre-fusion control is the main determinant of transmitter release. It is achieved by a wide variety of cellular components, among them the ion channels. There are reports of several hundred different ion channel molecules at the surface membrane of the nerve terminal, that for convenience can be grouped into eight major categories. They are the voltage-dependent calcium channels, the potassium channels, the calcium-gated potassium channels, the sodium channels, the chloride channels, the non-selective channels, the ligand gated channels and the stretch-activated channels. There are several categories of intracellular channels in the mitochondria, endoplasmic reticulum and the synaptic vesicles. We speculate that the vesicle channels may be of an importance in the post-fusion control of transmitter release.

The doctor's troubled marriage

BACKGROUND

Reports about the health of doctors have included claims of an increased risk of unhappy marital and family relationships. Recent studies cast doubt on these pessimistic conclusions but certain patterns of troubled marriages seem to exist as do certain stressors, to which doctors may be particularly susceptible.

OBJECTIVE

To describe the individual and interpersonal dynamics of problematic marriages commonly encountered among medical practitioners and to review some common stressors in medical marriages in general.

DISCUSSION

Three commonly encountered patterns of troubled marriages are described and the ways they develop in the context of medical training and practice. The large increase in the number of women doctors in the past 20 years has brought new challenges to women and men seeking to balance their family and professional commitments.

Diagnosis and serious mental illness

We examine some limitations of the psychiatric diagnosis, particularly in the assessment of the seriousness of a patient's mental illness. The bureaucratic or technocratic use of the concept "serious mental illness' is contrasted with the perspective of the clinician who provides ongoing patient care. A decline in the clinical skills of psychiatrists is likely if proposed mental health reforms regulate psychiatric practice according to bureaucratic and technocratic definitions of serious mental illness rather than the realities of the clinical encounter between patient and doctor.

Working with the family: the role of values

In this paper, we have examined that ethical aspect of working with families which stresses the relevance of values. Given that values are at the heart of both the family's and the therapists's view of the world, we see it as crucial for them to be addressed in the course of assessment and treatment. A variety of approaches have been adopted by clinicians ranging from those who regard ethics as a cornerstone of therapy to more compartmentalized positions, whereby specific sociopolitical themes like racism, poverty, and sexism are highlighted. Whatever model is preferred, the essential task is to accept that values are a necessary feature of therapeutic work and require negotiation. Failure to do so may have adverse repercussions on the therapist-family relationship, even to the point of jeopardizing therapy. Guidelines can be articulated to forestall such unfortunate consequences. We have attempted to identify these in the hope of clarifying for therapists the necessary steps they need to take to safeguard the family's interests and achieve an optimal ethical (and clinical) outcome.