P2Y12 inhibitor monotherapy versus dual antiplatelet therapy in patients with acute coronary syndromes undergoing coronary stenting: rationale and design of the NEOMINDSET Trial

Dual antiplatelet therapy (DAPT) is currently the standard of care after percutaneous coronary intervention (PCI). Recent studies suggest that reducing DAPT to 1-3 months followed by an aspirin-free single antiplatelet therapy (SAPT) strategy with a potent P2Y₁₂ inhibitor is safe and associated with less bleeding. However, to date, no randomised trial has tested the impact of initiating SAPT immediately after PCI, particularly in patients with acute coronary syndromes (ACS). NEOMINDSET is a multicentre, randomised, open-label trial with a blinded outcome assessment designed to compare SAPT versus DAPT in 3,400 ACS patients undergoing PCI with the latest-generation drug-eluting stents (DES). After successful PCI and up to 4 days following hospital admission, patients are randomised to receive SAPT with a potent P2Y₁₂ inhibitor (ticagrelor or prasugrel) or DAPT (aspirin plus a potent P2Y₁₂ inhibitor) for 12 months. Aspirin is discontinued immediately after randomisation in the SAPT group. The choice between ticagrelor and prasugrel is at the investigator's discretion. The primary hypothesis is that SAPT will be non-inferior to DAPT with respect to the composite endpoint of all-cause mortality, stroke, myocardial infarction or urgent target vessel revascularisation, but superior to DAPT on rates of bleeding defined by Bleeding Academic Research Consortium 2, 3 or 5 criteria. NEOMINDSET is the first study that is specifically designed to test SAPT versus DAPT immediately following PCI with DES in ACS patients. This trial will provide important insights on the efficacy and safety of withdrawing aspirin in the early phase of ACS. (ClinicalTrials.gov: NCT04360720).

Pure Aortic Regurgitation Complicated by Membranous Interventricular Septum Aneurysm Treated With Transcatheter Aortic Valve Replacement

An 89-year-old woman with severe aortic regurgitation and an aneurysmal interventricular membranous septum extending into the aortic annulus underwent successful transcatheter aortic valve replacement. A challenging case because of the risk of valve mispositioning complications attributed to the co-occurrence of pure aortic regurgitation (very low calcium burden) with an aneurysmal interventricular membranous septum. (Level of Difficulty: Intermediate.).

Incidence, Predictor, and Clinical Outcomes of Multiple Resheathing With Self-Expanding Valves During Transcatheter Aortic Valve Replacement

Background

No study has evaluated the impact of the additional manipulation demanded by multiple resheathing (MR) in patients undergoing transcatheter aortic valve replacement with repositionable self‐expanding valves.

Methods and Results

This study included a real‐world, multicenter registry involving 16 centers from Canada, Germany, Latin America, and Spain. All consecutive patients who underwent transcatheter aortic valve replacement with the Evolut R, Evolut PRO, and Portico valves were included. Patients were divided according to the number of resheathing: no resheathing, single resheathing (SR), and MR. The primary end point was device success. Secondary outcomes included procedural complications, early safety events, and 1‐year mortality. In 1026 patients, the proportion who required SR and MR was 23.9% and 9.3%, respectively. MR was predicted by the use of Portico and moderate/severe aortic regurgitation at baseline (both with P<0.01). Patients undergoing MR had less device success (no resheathing=89.9%, SR=89.8%, and MR=80%; P=0.01), driven by more need for a second prosthesis and device embolization. At 30 days, there were no differences in safety events. At 1 year, more deaths occurred with MR (no resheathing=10.5%, SR=8.0%, and MR=18.8%; P=0.014). After adjusting for baseline differences and center experience by annual volume, MR associated with less device success (odds ratio, 0.42; P=0.003) and increased 1‐year mortality (hazard ratio, 2.06; P=0.01). When including only the Evolut R/PRO cases (N=837), MR continued to have less device success (P<0.001) and a trend toward increased mortality (P=0.05).

Conclusions

Repositioning a self‐expanding valve is used in a third of patients, being multiple in ≈10%. MR, but not SR, was associated with more device failure and higher 1‐year mortality, regardless of the type of valve implanted.

Male gender and smoking are related to single, but not to multiple, human aortic aneurysms

There is scanty information concerning multiple aortic aneurysms. Thus, we verified if clinical or pathological characteristics are different in patients with multiple (two or more) aortic aneurysms in comparison with those with only one.

MATERIAL AND METHODS

We selected at the necropsy files of the Heart Institute, São Paulo University School of Medicine, the last 100 cases with aortic aneurysms, comparing between the two groups: sex, age, presence of systemic arterial hypertension, diabetes, dyslipedemia, history of smoking habit, cause of the aneurysm, cause of death, and if the diagnosis was reached during life. Age was analysed by Mann-Whitney test, and the other variables by chi-square or Fisher's exact test.

RESULTS

Multiple aneurysms corresponded to 14% of cases. The proportion of women among patients with multiple aneurysms was higher than among those with single aneurysm (64.3% versus 20.9%, P<.01), even if only cases with atherosclerosis were taken into consideration (women among multiple-6/10, 60.0%; among single-14/70, 20.0%; P=.01). Smoking was less reported in cases with multiple (4/14, 28.6%) than with single aneurysm (53/86, 61.6%; P=.04); considering cases with atherosclerosis, such difference decreases (40.0% of multiple versus 68.6% of single, P=.09).

CONCLUSION

although atherosclerosis is present in most cases of both single and multiple aortic aneurysms, male gender and smoking, considered highly influential in such lesions, are less frequent in patients with multiple than in patients with single aneurysms. Thus mechanisms underlying multiple aortic aneurysms are probably different from those related to single, more common aneurysms.