The safety and feasibility of live-stream proctoring for CTO procedures

OBJECTIVE

To assess the technical feasibility of a new method of educational training, based on audio-video (AV) communication between an interventional cardiologist and the cath lab staff members in one location and a remote expert proctor.

METHODS

Overall, 9 patients underwent a percutaneous coronary intervention (PCI) targeting a chronic total occlusion (CTO) between June 2021 and January 2022 at a single Belgian center using the virtual proctoring approach. For this assessment, the strategic planning of the CTO PCI and all the decisions throughout the intervention were the responsibility of the proctor. The operator was guided via an AV link, by the proctor throughout the procedure.

RESULTS

The operator performed each procedural step, guided by the remote proctor, who had continuous access to all relevant interventional details. No major adverse cardiac events (MACE) occurred during the index hospitalization or within 6 months follow-up.

CONCLUSIONS

A new method of virtual proctoring based on live AV communication is feasible, even in the case of highly complex CTO PCI procedures. This strategy also appears safe and may provide the patient the benefit of incremental expertise. This approach is facilitated by advances in AV communication and allows physicians to share expertise irrespective of location. It could increase global interaction between colleagues and facilitate sharing of knowledge, which are both key aspects in the development of CTO PCI. This preliminary experience could serve as a basis for future large studies to study the potential role and benefits of virtual proctoring for complex CTO PCI procedures.

iFR/FFR/IVUS Discordance and Clinical Implications: Results From the Prospective Left Main Physiology Registry

OBJECTIVES

This study aimed to assess discordance between results of instantaneous wave-free ratio (iFR), fractional flow reserve (FFR), and intravascular ultrasound (IVUS) in intermediate left main coronary (LM) lesions, and its impact on clinical decision making and outcome.

METHODS

We enrolled 250 patients with a 40%-80% LM stenosis in a prospective, multicenter registry. These patients underwent both iFR and FFR measurements. Of these, 86 underwent IVUS and assessment of the minimal lumen area (MLA), with a 6 mm2 cutoff for significance.

RESULTS

Isolated LM disease was recognized in 95 patients (38.0%), while 155 patients (62.0%) had both LM disease and downstream disease. In 53.2% of iFR+ and 56.7% of FFR+ LM lesions, the measurement was positive in only one daughter vessel. iFR/FFR discordance occurred in 25.0% of patients with isolated LM disease and 36.2% of patients with concomitant downstream disease (P=.049). In patients with isolated LM disease, discordance was significantly more common in the left anterior descending artery and younger age was an independent predictor of iFR-/FFR+ discordance. iFR/MLA and FFR/MLA discordance occurred in 37.0% and 29.4%, respectively. Within 1 year of follow-up, major cardiac adverse events (MACE) occurred in 8.5% and 9.7% (P=.763) of patients whose LM lesion was deferred or revascularized, respectively. Discordance was not an independent predictor of MACE.

CONCLUSIONS

Current methods of estimating LM lesion significance often yield discrepant findings, complicating therapeutic decision-making.

Clinical validation of a 13-lead electrocardiogram derived from a self-applicable 3-lead recording for diagnosis of myocardial supply ischaemia and common non-ischaemic electrocardiogram abnormalities at rest

Aims

In this study, we compare the diagnostic accuracy of a standard 12-lead electrocardiogram (ECG) with a novel 13-lead ECG derived from a self-applicable 3-lead ECG recorded with the right exploratory left foot (RELF) device. The 13th lead is a novel age and sex orthonormalized computed ST (ASO-ST) lead to increase the sensitivity for detecting ischaemia during acute coronary artery occlusion.

Methods and results

A database of simultaneously recorded 12-lead ECGs and RELF recordings from 110 patients undergoing coronary angioplasty and 30 healthy subjects was used. Five cardiologists scored the learning data set and five other cardiologists scored the validation data set. In addition, the presence of non-ischaemic ECG abnormalities was compared. The accuracy for detection of myocardial supply ischaemia with the derived 12 leads was comparable with that of the standard 12-lead ECG (P = 0.126). By adding the ASO-ST lead, the accuracy increased to 77.4% [95% confidence interval (CI): 72.4-82.3; P < 0.001], which was attributed to a higher sensitivity of 81.9% (95% CI: 74.8-89.1) for the RELF 13-lead ECG compared with a sensitivity of 76.8% (95% CI: 71.9-81.7; P < 0.001) for the 12-lead ECG. There was no significant difference in the diagnosis of non-ischaemic ECG abnormalities, except for Q-waves that were more frequently detected on the standard ECG compared with the derived ECG (25.9 vs. 13.8%; P < 0.001).

Conclusion

A self-applicable and easy-to-use 3-lead RELF device can compute a 12-lead ECG plus an ischaemia-specific 13th lead that is, compared with the standard 12-lead ECG, more accurate for the visual diagnosis of myocardial supply ischaemia by cardiologists.

Practice and long-term outcome of unprotected left main PCI: real-world data from a nationwide registry

BACKGROUND

Percutaneous coronary intervention (PCI) is increasingly performed in significant left main (LM) lesions. Left untreated, the prognosis is poor, but PCI and coronary bypass surgery (CABG) behold risks as well. Additional long-term outcome data might guide future treatment decisions.

METHODS

Between 2012 and 2019, all 6783 patients who underwent LM PCI were prospectively enrolled in a national registry. Patients with prior CABG or prior LM PCI, and patients presenting in cardiogenic shock or after out-of-hospital cardiac arrest were excluded. From the remaining 5284 patients, baseline and procedural data as well as long-term survival were assessed.

RESULTS

The annual rate of LM PCI increased from 422 (2.2% of PCIs) in 2012 to 868 in 2018 (3.0%). By 2018, 71% of the interventional cardiologists performed at least 1 LM PCI a year, though only 5 on average. Use of transradial access (TRA) in LM PCI increased from 20.4% in 2012 to 59.5% in 2019. All-cause mortality was 6.0% at 30 days and 18.5% at a mean follow-up of 33.5 months. Independent predictors of higher long-term mortality were older age, diabetes, multivessel disease, an urgent indication, a suboptimal angiographical result, and non-exclusive use of drug-eluting stents. TRAand higher operator and centre LM PCI experience were independent predictors of a lower long-term mortality.

CONCLUSION

LM PCI is associated with high short- and long-term mortality. Use of TRA and higher expertise in LM PCI were associated with better survival.

Mortality in STEMI Patients With Cardiogenic Shock: Results From a Nationwide PCI Registry and Focus on Left Main PCI

BACKGROUND

The study aims to assess real-life short- and long-term outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) complicated with cardiogenic shock (CS). Outcome after left main (LM) PCI is of particular interest.

METHODS

Procedural, 30-day, and >30-day mortality rates were assessed in 2744 CS-STEMI patients enrolled between 2012 and 2019 in a nationwide registry involving 49 centers.

RESULTS

Procedural, 30-day, and >30-day mortality rates were 6.9%, 39.8%, and 12.6%, respectively. The mortality rates were significantly higher in the 348 patients (12.7%) who underwent LM-PCI (13.5%, 59.5%, and 18.4%, respectively). LM-PCI, a suboptimal PCI result, and transfemoral access were independent predictors of procedural and 30-day mortality. Operator experience was an independent predictor of procedural mortality, but not 30-day mortality.

CONCLUSIONS

Mortality remains high in CS-STEMI patients, especially within the first month. Patients undergoing LM-PCI are particularly at risk. Operator experience is predictive of procedural mortality.

The evolution of the CTO-PCI landscape in Belgium and Luxembourg: a four-year appraisal

BACKGROUND

To chart the evolution of the CTO-PCI landscape in Belgium and Luxembourg, the Belgian Working Group on Chronic Total Occlusions (BWGCTO) was established in 2016.

METHODS

Between May 2016 and December 2019, patients undergoing a CTO-PCI treatment were prospectively and consecutively enrolled. Twenty-one centres in Belgium and one in Luxembourg participated. Individual operators had mixed levels of expertise in treating CTO lesions. Demographic, angiographic, procedural parameters and incidence of major adverse cardiac and cerebrovascular events (MACCE) were systematically registered.

RESULTS

Over a four-year enrolment period, 1832 procedures were performed in 1733 patients achieving technical success in 1474 cases (80%), with an in-hospital MACCE rate of 2.3%. Fifty-nine (3%) cases were re-attempt procedures of which 41 (69%) were successful. High-volume centres treated more complex lesions (mean J-CTO score: 2.15 ± 1.21) as compared to intermediate (mean J-CTO score: 1.72 ± 1.23; p < 0.001) and low-volume centres (mean J-CTO score: 0.99 ± 1.21; p = 0.002). Despite this, success rates did not differ between centres (p = 0.461). Overall success rates did not differ over time (p = 0.810). High-volume centres progressively tackled more complex CTOs while keeping success rates stable. In all centres, the most applied strategy was antegrade wire escalation (83%). High-volume centres more often successfully applied antegrade dissection and re-entry and retrograde techniques in lesions with higher complexity.

CONCLUSION

With variable experience levels, operators treated CTOs with high success and relatively few complications. Although AWE remains the most used technique, it is paramount for operators to be skilled in all contemporary techniques in order to be successful in more complex CTOs.

Revascularisation of chronic total occlusions and recurrence rate of ventricular arrhythmias

BACKGROUND

The impact of revascularisation of chronic total occlusions (CTO) on the incidence of ventricular arrhythmias (VA) remains to be elucidated.

METHODS

Based on prospectively gathered data, the recurrence rate of VAs following CTO treatment was retrospectively investigated. Patients presenting with VAs as clinical indication for CTO revascularisation were retrospectively selected out of three Belgian CTO registries (i.e. Ziekenhuis Oost-Limburg, UZ Leuven and CHR de la Citadelle). Freedom of VAs was defined as absence of non-sustained or sustained tachycardias (VT), ventricular fibrillations (Vfib) and ventricular extrasystoles (VES; <2500 VES/24 h). Long-term outcome in terms of reoccurrence of VAs was evaluated by reviewing patient records.

RESULTS

Between 2011 and 2019, 912 patients underwent a CTO-PCI across three Belgian centres. In total 43 patients (5%) presented with VAs as clinical indication for CTO revascularisation. Overall follow-up was 723 (391 - 1144) days. Fourteen (33%), 18 (42%), 5 (11%) and 6 (14%) presented with >2500 VES/24 hrs, non-sustained VT, sustained VT and Vfib, respectively. In those patients with a one-year follow-up available (n = 34), overall recurrence rate of VAs was 38% (within VA group: VES: 25%, non-sustained VT: 46%; sustained VT: 25% and Vfib: 60%).

CONCLUSION

Based on this retrospective data analysis, CTO revascularisation, in patients presenting with VAs as the main clinical indication, seems to beneficially impact the incidence of VAs, which ultimately might result in improved patients' outcome.

Aortic valve implantation-induced conduction block as a framework towards a uniform electrocardiographic definition of left bundle branch block

Introduction

New-onset left bundle branch block (LBBB) following transcatheter or surgical aortic valve replacement (LBBB_AVI) implies a proximal pathogenesis of LBBB. This study compares electrocardiographic characteristics and concordance with LBBB definitions between LBBB_AVI and non-procedure-induced LBBB controls (LBBB_control).

Methods

All LBBB_AVI patients at Ghent University Hospital between 2013 and 2019 were enrolled in the study. LBBB_AVI patients were matched for age, sex, ischaemic heart disease and ejection fraction to LBBB_control patients in a 1:2 ratio. For inclusion, a non-strict LBBB definition was used (QRS duration ≥ 120 ms, QS or rS in V1, absence of Q waves in V5-6). Electrocardiograms were digitally analysed and classified according to three LBBB definitions: European Society of Cardiology (ESC), Strauss and American Heart Association (AHA).

Results

A total of 177 patients (59 LBBB_AVI and 118 LBBB_control) were enrolled in the study. LBBB_AVI patients had more lateral QRS notching/slurring (100% vs 85%, p = 0.001), included a higher percentage with a QRS duration ≥ 130 ms (98% vs 86%, p = 0.007) and had a less leftward oriented QRS axis (−15° vs −30°, p = 0.013) compared to the LBBB_control group. ESC and Strauss criteria were fulfilled in 100% and 95% of LBBB_AVI patients, respectively, but only 18% met the AHA criteria. In LBBB_control patients, concordance with LBBB definitions was lower than in the LBBB_AVI group: ESC 85% (p = 0.001), Strauss 68% (p < 0.001) and AHA 7% (p = 0.035). No differences in electrocardiographic characterisation or concordance with LBBB definitions were observed between LBBB_AVI and LBBB_control patients with lateral QRS notching/slurring.

Conclusion

Non-uniformity exists among current LBBB definitions concerning the detection of proximal LBBB. LBBB_AVI may provide a framework for more consensus on defining proximal LBBB.

Supplementary Information

The online version of this article (10.1007/s12471-021-01565-8) contains supplementary material, which is available to authorized users.

Right Coronary Artery Chronic Total Occlusion After Bypass Grafting Successfully Treated Using Reverse Controlled Antegrade and Retrograde Subintimal Tracking (CART) Technique via the Gastroepiploic Artery: A Case Report

Patient: Male, 63-year-old

Final Diagnosis: Chronic total coronary artery occlusion

Symptoms: Angina pectoris

Medication:—

Clinical Procedure: Percutaneous coronary intervention

Specialty: Cardiology

Physiology-Based Revascularization of Left Main Coronary Artery Disease

It is of critical importance to correctly assess the significance of a left main lesion. Underestimation of significance beholds the risk of inappropriate deferral of revascularization, whereas overestimation may trigger major but unnecessary interventions. This article addresses the invasive physiological assessment of left main disease and its role in deciding upon revascularization. It mainly focuses on the available evidence for fractional flow reserve and instantaneous wave-free ratio, their interpretation, and limitations. We also discuss alternative invasive physiological indices and imaging, as well as the link between physiology, ischemia, and prognosis.

Feasibility and Safety of Performing Complex Coronary Interventions by Distal Radial Artery Using the Railway Sheathless Vascular System

AIMS

The aim of this clinical study is to assess the feasibility and safety of the 7 Fr Railway sheathless access system (Cordis Corporation) for complex percutaneous coronary interventions (PCI) using distal radial artery access.

METHODS AND RESULTS

Over a 2-month period, we enrolled 20 patients (all those undergoing complex PCI) where a 7 Fr guide catheter was deemed necessary. Multiple bifurcation techniques and calcified plaque modifying tools were used. The primary endpoint was procedural success (95%) without need for access-site crossover (0%) or major adverse cardiovascular event within the first month (0%), while our secondary endpoint was the access-site complication rate (arterial spasm in 1 case [5%]).

CONCLUSION

Distal radial access with the 7 Fr Railway sheathless access system was a feasible and safe access option for complex PCI in our very high-risk study population. This approach could be a valuable option for decreasing the risk of a major bleeding event or vascular complication in cases that require a large guide catheter.

iFR uncovers profound but mostly reversible ischemia in CTOs and helps to optimize PCI results

OBJECTIVES

The study aimed to demonstrate through instant wave-free ratio (iFR) measurements that myocardium distal to a chronic total occlusion (CTO) is ischemic, that ischemia is reversible by PCI, and that iFR assessment after PCI can be used to optimize PCI results.

BACKGROUND

The greatest benefit of revascularization is found in patients with low fractional flow reserve. In patients with CTOs, iFR measurement may be more appropriate to evaluate ischemia as it does not require maximal microvascular vasodilation, which may be hampered by microvascular dysfunction.

METHODS

The iFR was measured in 81 CTO patients, both pre- and post-PCI in 63 patients, and only post-PCI in the following 18 patients. A pressure wire pullback was performed post-PCI if iFR ≤0.89.

RESULTS

The first 63 patients all had significant ischemia distal to the CTO with a median iFR of 0.33 [0.22; 0.44], improving significantly post-PCI to a median iFR of 0.93 [0.89;0.96] (p < .001). In the complete cohort, the median iFR post-PCI was 0.93 [0.86;0.96] but still ≤0.89 in 23 patients (30%). 12 of these patients had further PCI optimization because of a residual focal pressure gradient on pullback, after which only two had a final iFR ≤0.89.

CONCLUSIONS

In CTO patients with an indication for PCI, iFR consistently demonstrated profound myocardial ischemia. Successful PCI immediately relieved ischemia in 70% of patients. In the remaining 30% of cases, a manual iFR pullback proved helpful in guiding further optimization of the PCI result.

P309Aortic valve implantation-induced bundle branch block as a framework towards a more uniform electrocardiographic definition of left bundle branch block

INTRODUCTION

The electrocardiographic (ECG) pattern of true left bundle branch block (LBBB) has not been fully clarified and various definitions of LBBB exist. New-onset LBBB after transcatheter (TAVR) or surgical (SAVR) aortic valve replacement implies a proximal pathogenesis of LBBB and thus may provide a reference to characterize and define true LBBB.

PURPOSE

This study compares ECG characteristics in aortic valve implantation-induced LBBB (AVI-LBBB) to a non-procedural-induced LBBB control group (co-LBBB) in order to set a more homogenous definition for true LBBB.

METHODS

The study enrolled all patients with new-onset TAVR- and SAVR-induced LBBB between 2013 and 2019. AVI-LBBB was defined as new-onset persistent LBBB occurring within 24h after TAVR or SAVR. Patients were matched for age, sex, ischemic heart disease and left ventricular systolic function to randomly selected co-LBBB patients in a 1:2 ratio. For inclusion in both groups, a non-strict LBBB definition was used (QRSD ≥120ms, QS or rS in lead V1, absence of Q wave in leads V5-6). ECG characteristics were digitally analysed by the MUSE algorithm and confirmed by two experts. All ECG recordings were classified according to 4 different LBBB definitions: MADIT, European Society of Cardiology (ESC), Strauss and American Heart Association (AHA).

RESULTS

59 patients with AVI-LBBB (34 TAVR, 25 SAVR, median age 82 years, 42% male) were compared to 118 matched co-LBBB patients.

All patients with AVI-LBBB presented with QRS notching/slurring in the lateral leads, whereas this was present in only 85% of the co-LBBB group (p = 0.001). QRS duration (148ms vs 145ms, p = 0.074) and R wave peak time (58ms vs 62ms, p = 0.065) were not significantly different among both groups. AVI-LBBB was characterized by a more rightward QRS axis (-15° vs -30°, p = 0.013). When comparing AVI-LBBB to LBBB controls with QRS notching/slurring, a comparable QRS axis was observed.

Almost all AVI-LBBB patients met the MADIT (98%), ESC (100%) and Strauss (95%) definition. Only 18% of patients met the AHA definition, because of the low combined presence of QRS notching/slurring in all 4 lateral leads (54%) and because only 27% of patients had an R wave peak time &gt;60ms in both leads V5-6.

In the co-LBBB group, adherence to the different definitions was significantly lower compared to the AVI-LBBB group: MADIT 86% (p = 0.007), ESC 85% (p = 0.001), Strauss 68% (p &lt; 0.001) and AHA 7% (p = 0.035). Lower presence of lateral notching/slurring and more patients with smaller QRS duration (QRS duration ≥130ms, 86% vs 98%, p = 0.007) in the co-LBBB group explain these results.

CONCLUSIONS

Discordance exists between various definitions in scoring AVI-LBBB. Our data show that presence of QRS notching/slurring in the lateral leads is a crucial feature of proximal LBBB, rather than QRS duration and R wave peak time. The AVI-LBBB population provides a framework towards a more uniform definition and criteria for assessing true, proximal LBBB.

Feasibility of His-bundle pacing in patients with conduction disorders following transcatheter aortic valve replacement

BACKGROUND

Conduction disorders requiring permanent pacemaker implantation occur frequently after transcatheter aortic valve replacement (TAVR). This multicenter study explored the feasibility and safety of His bundle pacing (HBP) in TAVR patients with a pacemaker indication to correct a TAVR-induced left bundle branch block (LBBB).

METHODS

Patients qualifying for a permanent pacemaker implant after TAVR were planned for HBP implant. HBP was performed using the Select Secure (3830; Medtronic) pacing lead, delivered through a fixed curve or deflectable sheath (C315HIS or C304; Medtronic). Successful HBP was defined as selective or nonselective HBP, irrespective of LBB recruitment. Successful LBBB correction was defined as selective or nonselective HBP resulting in paced QRS morphology similar to pre-TAVR QRS and paced QRS duration (QRSd) less than 120 milliseconds with thresholds less than 3.0 V at 1.0-millisecond pulse width.

RESULTS

The study enrolled 16 patients requiring a permanent pacemaker after TAVR (age 85 ± 4 years, 31% female, all LBBB; QRSd: 161 ± 14 milliseconds). Capture of the His bundle was achieved in 13 of 16 (81%) patients. HBP with LBBB correction was achieved in 11 of 16 (69%) and QRSd narrowed from 162 ± 14 to 99 ± 13 milliseconds and 134 ± 7 milliseconds during S-HBP and NS-HBP, respectively (P = .005). At implantation, mean threshold for LBBB correction was 1.9 ± 1.1 V at 1.0 millisecond. Thresholds remained stable at 11 ± 4 months follow-up (1.8 ± 0.9 V at 1.0 millisecond, P = .231 for comparison with implant thresholds). During HBP implant, one temporary complete atrioventricular block occurred.

CONCLUSION

Permanent HBP is feasible in the majority of patients with TAVR requiring a permanent pacemaker with the potential to correct a TAVR-induced LBBB with acceptable pacing thresholds.

6119Correction of transcatheter aortic valve replacement induced left bundle branch block by His bundle pacing

Background

Left bundle branch block (LBBB) occurs frequently after transcatheter aortic valve replacement (TAVR) and is associated with increased risk of permanent pacemaker implantation, heart failure hospitalization and sudden cardiac death. This pilot study explored the feasibility of TAVR-induced LBBB correction with His bundle pacing (HBP).

Methods

Patients with TAVR -induced LBBB and postoperative need for permanent pacemaker implant were planned for electrophysiology study and HBP. Patients with persistent high degree AV-block were excluded. HBP was performed using the Select Secure pacing lead, delivered through a fixed curve or a deflectable sheath. Successful HBP was defined as correction of LBBB by selective or non-selective HBP with LBBB correction thresholds less than 3.5V at 1.0ms at implant.

Results

The study enrolled 6 patients (mean age 85±2.5 years, 50% male). Mean QRS duration was 152±10ms, PR-interval 212±12ms AH-interval 166±16ms and HV-interval 62±12ms. Successful HBP was achieved in 5/6 (83%) patients. Mean QRS duration decreased from 153±11ms to 88±14ms (p=0.002). At implantation, mean threshold for LBBB correction was 1.6±1.0V (unipolar) and 2.2±1.3V (bipolar) at 1.0ms. Periprocedural, two complete AV-blocks occurred, both spontaneously resolved by the end of the procedure. Thresholds remained stable at 1 month follow up: 1.8±1.0V (unipolar) and 2.3±1.5V (bipolar) at 1.0ms.

Figure 1

Conclusion

Permanent His bundle pacing can safely correct TAVR-induced LBBB in the majority of patients. Further studies are needed to assess potential benefits of His bundle pacing over conventional right ventricular pacing in this population.

P576The first handheld device for autonomic self-detection of symptomatic acute coronary artery occlusion: feasibility, performance and implications for time-efficient self-triage of outpatients with CAD

Background

Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion (ACAO). Response time might be reduced by reliable self-detection of ACAO. Currently no self-applicable device can accurately detect ACAO. We have recently shown that an automatic algorithm based upon a three lead system (RELF method) accurately detects ACAO.

Purpose

In this multicenter observational study we tested the operational feasibility, sensitivity and specificity of our RELF method, built into a mobile handheld device, for detection of ACAO.

Methods

Patients with planned elective percutaneous coronary intervention (PCI), who were able to use a smartphone, were asked to perform random ambulatory self-recordings for at least one week. A similar self-recording was made before angioplasty and at 60 s of balloon occlusion.

Results

The operational feasibility of ambulatory self-recordings in enrolled patients with CAD was 59/64 (92.1%, 95% CI: 83.0–96.6). Of all self-recordings 91.1% (n=4567) were automatically classified as successful within one minute. The mean false positive rate during daily life conditions was 4.19% (95% CI: 3.29–5.10). Amongst 65 balloon occlusions, 63 index-tests at 60 s of occlusion were available. The sensitivity for the target conditions “ACAO”, “ACAO with ECG changes” and “ACAO with ECG changes and ST segment elevation myocardial infarction (STEMI) criteria” was respectively 55/63 (0.87; 95% CI: 0.77–0.93), 54/57 (0.95; 95% CI: 0.86–0.98) and 35/35 (1.00). The figure depicts all (n=3936) ST difference vector (STDVn) measurements obtained during ambulatory postural changes, exercise and coronary artery occlusion with and without ECG changes and/or STEMI criteria. Receiver Operator Curve (ROC) for ACAO at different cut-off values of the magnitude of STDVn was 0.973 (95% CI: 0.956–0.990).

Boxplots of all STDVn test recordings

Conclusions

Self-recording with our RELF device is feasible for the majority of patients with CAD. The sensitivity and specificity for automatic detection of the earliest phase of acute coronary artery occlusion support the concept of our RELF device for patient empowerment to reduce delay and increase survival without overloading emergency services. This is the first clinical study that confirms the proof-of-concept of self-detection of acute coronary artery occlusion in outpatients with CAD.

Acknowledgement/Funding

Ghent University, Industrial Research Fund (IOF reference: F2015/IOF-advanced/084).

Feasibility and performance of a device for automatic self-detection of symptomatic acute coronary artery occlusion in outpatients with coronary artery disease: a multicentre observational study

BACKGROUND

Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion. Response time might be reduced by reliable self-detection. We aimed to formally assess the proof-of-concept and accuracy of self-detection of acute coronary artery occlusion by patients during daily life situations and during the very early stages of acute coronary artery occlusion.

METHODS

In this multicentre, observational study, we tested the operational feasibility, specificity, and sensitivity of our RELF method, a three-lead detection system with an automatic algorithm built into a mobile handheld device, for detection of acute coronary artery occlusion. Patients were recruited continuously by physician referrals from three Belgian hospitals until the desired sample size was achieved, had been discharged with planned elective percutaneous coronary intervention, and were able to use a smartphone; they were asked to perform random ambulatory self-recordings for at least 1 week. A similar self-recording was made before percutaneous coronary intervention and at 60 s of balloon occlusion. Patients were clinically followed up until 1 month after discharge. We quantitatively assessed the operational feasibility with an automated dichotomous quality check of self-recordings. Performance was assessed by analysing the receiver operator characteristics of the ST difference vector magnitude. This trial is registered with ClinicalTrials.gov, number NCT02983396.

FINDINGS

From Nov 18, 2016, to April 25, 2018, we enrolled 64 patients into the study, of whom 59 (92%) were eligible for self-applications. 58 (91%) of 64 (95% CI 81·0-95·6) patients were able to perform ambulatory self-recordings. Of all 5011 self-recordings, 4567 (91%) were automatically classified as successful within 1 min. In 65 balloon occlusions, 63 index tests at 60 s of occlusion in 55 patients were available. The mean specificity of daily life recordings was 0·96 (0·95-0·97). The mean false positive rate during daily life conditions was 4·19% (95% CI 3·29-5·10). The sensitivity for the target conditions was 0·87 (55 of 63; 95% CI 0·77-0·93) for acute coronary artery occlusion, 0·95 (54 of 57; 0·86-0·98) for acute coronary artery occlusion with electrocardiogram (ECG) changes, and 1·00 (35 of 35) for acute coronary artery occlusion with ECG changes and ST-segment elevation myocardial infarction criteria (STEMI). The index test was more sensitive to detect a 60 s balloon occlusion than the STEMI criteria on 12-lead ECG (87% vs 56%; p<0·0001). The proportion of total variation in study estimates due to heterogeneity between patients (I²) was low (12·6%). The area under the receiver operator characteristics curve was 0·973 (95% CI 0·956-0·990) for acute coronary artery occlusion at different cutoff values of the magnitude of the ST difference vector. No patients died during the study.

INTERPRETATION

Self-recording with our RELF device is feasible for most patients with coronary artery disease. The sensitivity and specificity for automatic detection of the earliest phase of acute coronary artery occlusion support the concept of our RELF device for patient empowerment to reduce delay and increase Survival without overloading emergency services.

FUNDING

Ghent University, Industrial Research Fund.

Validation of a Novel System for Co-Registration of Coronary Angiographic and Intravascular Ultrasound Imaging

INTRODUCTION

Intravascular ultrasound (IVUS) is a useful adjunct to guide percutaneous coronary intervention (PCI). Correlating IVUS images with angiographic findings can be challenging. We evaluated the utility of a novel co-registration system for IVUS and coronary angiography.

METHODS AND RESULTS

A 3-D virtual catheter trajectory was constructed from separate angiographic imaging runs using bespoke software. Intravascular ultrasound images were obtained using a commercially available mechanical rotational transducer with motorized pullback. Co-registration of ultrasound and angiographic images was then performed retrospectively based on the length of pullback, the 3-D trajectory and the start position of the catheter. Validation was performed in a spherical phantom model and in vivo in the coronary circulation of patients undergoing coronary angiography and intravascular imaging for clinical purposes. 111 paired angiographic and IVUS runs were performed in 3 phantom models. The differences between the reference length and the length measured on the 3D reconstructed path was -0.01 ± 0.40 mm. Intra-observer variability was 0.4%. We enrolled 25 patients in 3 European hospitals and performed 35 co-registration attempts with an 86% success rate. 71 landmarks were selected by the first operator, 68 by the second. Differences between angiographic and IVUS landmarks were -0.22 ± 0.72 mm and 0.05 ± 1.01 mm, respectively. Inter-observer variability was 0.23 ± 0.63 mm.

CONCLUSION

We present a novel method for the co-registration of IVUS and coronary angiographic images. This system performed well in a phantom model and using images obtained from the human coronary circulation.

CLASSIFICATIONS

Innovation, intravascular ultrasound, other technique.

Assessing the landscape of percutaneous coronary chronic total occlusion treatment in Belgium and Luxembourg: the Belgian Working Group on Chronic Total Occlusions (BWGCTO) registry

Background: Important developments in materials, devices, and techniques have improved outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), and resulted in a growing interest in CTO-PCI. The Belgian Working Group on Chronic Total Occlusions (BWGCTO) working group aims to assess the evolution within the CTO-PCI landscape over the next years. Methods: From May 2016 onwards, patients undergoing CTO-PCI were included in the BWGCTO registry by 15 centres in Belgium and Luxemburg. Baseline, angiographic, and procedural data were collected. Here, we report on the one-year in-hospital outcomes. Results: Over the course of one year, 411 procedures in 388 patients were included with a mean age of 64 ± 11 years. The majority were male (81%). Relatively complex CTOs were treated (Japanese CTO score =2.2 ± 1.2) with a high procedure success rate (82%). Patient- and lesion-wise success rates were 83 and 85%, respectively. Major adverse in-hospital events were acceptably low (3.4%). Antegrade wire escalation technique was applied most frequently (82%). On the other hand, antegrade dissection and re-entry and retrograde strategies were more frequently applied in higher volume centres and successful for lesions with higher complexity. Conclusion: Satisfactory procedural outcomes and a low rate of adverse events were obtained in a complex CTO population, treated by operators with variable experience levels. Antegrade wire escalation was the preferred strategy, regardless of operator volume.

DOSIMETRY DURING PERCUTANEOUS CORONARY INTERVENTIONS OF CHRONIC TOTAL OCCLUSIONS

Percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTO) increase the risk of high radiation exposure for both the patient and the cardiologist. This study evaluated the maximum dose to the patients' skin (MSD) and the exposure of the cardiologists during CTO-PCI. Moreover, the efficiency of radioprotective drapes to reduce cardiologist exposure was assessed. Patient dose was measured during 31 procedures; dose to the cardiologist's extremities were measured during 65 procedures, among which 31 were performed with radioprotective drapes. The MSD was high (median: 1254 mGy; max: 6528 mGy), and higher than 2 Gy for 33% of the patients. The dose to the cardiologists' extremities per procedure was also of concern (median: 25-465 μSv), particularly to the left eye (median: 68 μSv; max: 187 μSv). Radioprotective drapes reduced the exposure to physician's upper limbs and eyes; especially to the left side (from -28 to -49%).

One-Year Clinical Outcomes of the Hybrid CTO Revascularization Strategy After Hospital Discharge: A Subanalysis of the Multicenter RECHARGE Registry

OBJECTIVES

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) has historically been associated with higher event rates during follow-up. The hybrid algorithm and contemporary wiring and dissection re-entry (DR) techniques can potentially improve long-term outcomes after CTO-PCI. This study assessed the long-term clinical outcomes of the hybrid CTO practice, when applied by operators with varying experience levels.

METHODS

We examined the 1-year clinical events after hospital discharge of the RECHARGE population, according to technical outcome and final technique. The primary endpoint was major adverse cardiac event (MACE) rate. Centers that provided ≥90% complete 12-month follow-up were included.

RESULTS

Follow-up data of 1067 out of 1165 patients (92%) were provided by 13 centers. Mean follow-up duration was 362.8 ± 0.9 days. One-year MACE-free survival rate was 91.3% (974/1067). MACE included death (1.9%; n = 20), myocardial infarction (1.4%; n = 15), target-vessel failure (5.9%; n = 63), and target-vessel revascularization (TVR) (5.5%; n = 59). Non-TVR was performed in 6.7% (n = 71). MACE was significantly in favor of successful CTO-PCI (8.0% vs 13%; P=.04), even after adjusting for baseline differences (adjusted hazard ratio, 0.59; 95% confidence interval, 0.36-0.98; P=.04). Other events, including individual MACE components, were comparable with respect to technical outcome and final technique (DR vs non-DR techniques).

CONCLUSIONS

The use of the hybrid algorithm with contemporary techniques by moderate to highly experienced operators for CTO-PCI is safe and associated with a low 1-year event rate. Successful procedures are associated with a better MACE rate. DR techniques can be used as first-line strategies alongside intimal wiring techniques without compromising clinical outcomes.

Fully Transradial Versus Transfemoral Approach for Percutaneous Intervention of Coronary Chronic Total Occlusions Applying the Hybrid Algorithm

Background—

Small observational studies demonstrate the feasibility of transradial approach for chronic total occlusion (CTO) percutaneous coronary intervention. The aim of the current study is to assess technical success, complication rates, and procedural efficiency in fully transradial approach (fTRA) and transfemoral approach (TFA) in a large prospective European registry adopting the hybrid algorithm for CTO percutaneous coronary intervention (Registry of CrossBoss and Hybrid Procedures in France, the Netherlands, Belgium and United Kingdom, RECHARGE registry).

Methods and Results—

We analyzed 1253 CTO percutaneous coronary intervention procedures performed according to the hybrid protocol in 17 European centers, comparing fTRA (single or biradial access) and TFA (single or bifemoral or combined radial and femoral access). fTRA was applied in 306 (24%) and TFA in 947 (76%) cases. The average Japanese CTO score was 2.1±1.2 in fTRA and 2.3±1.1 in TFA ( P =0.06). Technical success was achieved in 85% in fTRA and 86% in TFA ( P =0.51). Technical success was comparable for fTRA and TFA in different Japanese CTO score subgroups after multivariable analysis and after propensity adjustment. In-hospital major adverse cardiac and cerebral events occurred in 2.0% in fTRA and 2.9% in TFA ( P =0.40). Major access site bleeding occurred in 0.3% in fTRA and 0.5% in TFA ( P =0.66). fTRA compared with TFA had similar procedural duration (80 minutes [54–120 minutes] versus 90 minutes [60–121 minutes]; P =0.07), similar radiation dose (dose area product 89 Gray×cm 2 [52–163 Gray×cm 2 ] versus 101 Gray×cm 2 [59–171 Gray×cm 2 ]; P =0.06), and lower contrast agent use (200 mL [150–310 mL] versus 250 mL [200–350 mL]; P <0.01).

Conclusions—

fTRA CTO percutaneous coronary intervention is a valid alternative to TFA with a high rate of success, low complication rates, and no decrease in procedural efficiency.

Percutaneous coronary interventions of chronic total -occlusions; a review of clinical indications, treatment strategy and current practice

Chronic total occlusions (CTOs) are commonly encountered in patients undergoing coronary angiography, but percutaneous coronary intervention (PCI) for CTO is currently infrequently performed owing to the perception of limited clinical benefit, high complexity and cost of intervention, and perceived risk of complications. Numerous observational studies have demonstrated that successful CTO revascularization is associated with better cardiovascular outcomes and enhanced quality of life (QOL). However, in the absence of randomized trials, its prognostic benefit remains debated. Nevertheless, over the past decade the interest in CTO-PCI has exponentially grown due to important developments in dedicated equipment and techniques, resulting in high success and low complication rates. A number of factors must be taken into consideration in selecting patients for CTO-PCI, including presence of symptoms attributable to the CTO, extent of ischaemia distal to the occlusion, and degree of myocardial viability. In this review, we focus on the impact of CTO revascularization on clinical outcomes and QOL and on appropriate patient selection. Data regarding efficacy and safety of recent advances in PCI-CTO techniques will be discussed. Steps involved in setting up a dedicated CTO program will be outlined and the current CTO landscape in Belgium will be briefly highlighted. The overall aim of this review is to promote a more balanced approach to management of patients with a CTO.

Antegrade Dissection and Reentry as Part of the Hybrid Chronic Total Occlusion Revascularization Strategy

Background—

Development of the CrossBoss and Stingray devices for antegrade dissection and reentry (ADR) of chronic total occlusions has improved historically suboptimal outcomes. However, the outcomes, safety, and failure modes of the technique have to be studied in a larger patient cohort. This preplanned substudy of the RECHARGE registry (Registry of CrossBoss and Hybrid Procedures in France, the Netherlands, Belgium and United Kingdom) aims to evaluate the value and use of ADR and determine its future position in contemporary chronic total occlusion intervention.

Methods and Results—

Patients were selected if an ADR strategy was applied. Outcomes, safety, and failure modes of the technique were assessed. The ADR technique was used in 23% (n=292/1253) of the RECHARGE registry and was mainly applied for complex lesions (Japanese chronic total occlusion score=2.7±1.1). ADR was the primary strategy in 30% (n=88/292), of which 67% were successful. Bail-out ADR strategies were successful in 63% (n=133/210). The Controlled ADR (ie, combined CrossBoss-Stingray) subtype was applied most frequently (32%; n=93/292) and successfully (81%; n=75/93). Overall per-lesion success rate was 78% (n=229/292), after use of additional bail-out strategies. The inability to reach the distal target zone (n=48/100) or to reenter (n=43/100) most commonly led to failure. ADR-associated major events occurred in 3.4% (n=10/292).

Conclusions—

Although mostly applied as a bail-out strategy for complex lesions, the frequency, outcomes, and low complication rate of the ADR technique and its subtypes confirm the benefit and value of the technique in hybrid chronic total occlusion percutaneous coronary intervention, especially when antegrade wiring or retrograde approaches are not feasible.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT02075372.

Air pollution and ST-elevation myocardial infarction: A case-crossover study of the Belgian STEMI registry 2009-2013

BACKGROUND

Previous studies have shown that air pollution particulate matter (PM) is associated with an increased risk for myocardial infarction. The effects of air pollution on the risk of ST-elevation myocardial infarction (STEMI), in particular the role of gaseous air pollutants such as NO₂ and O₃ and the susceptibility of specific populations, are still under debate.

METHODS

All patients entered in the Belgian prospective STEMI registry between 2009 and 2013 were included. Based on a validated spatial interpolation model from the Belgian Environment Agency, a national index was used to address the background level of air pollution exposure of Belgian population. A time-stratified and temperature-matched case-crossover analysis of the risk of STEMI was performed.

RESULTS

A total of 11,428 STEMI patients were included in the study. Each 10μg/m³ increase in PM10, PM2.5 and NO₂ was associated with an increased odds ratio (ORs) of STEMI of 1.026 (CI _95%: 1.005-1.048), 1.028 (CI _95%: 1.003-1.054) and 1.051 (CI _95%: 1.018-1.084), respectively. No effect of O₃ was found. STEMI was associated with PM10 exposure in patients ≥75y.o. (OR: 1.046, CI _95%: 1.002-1.092) and with NO₂ in patients ≤54y.o. (OR: 1.071, CI _95%: 1.010-1.136). No effect of air pollution on cardiac arrest or in-hospital STEMI mortality was found.

CONCLUSION

PM2.5 and NO₂ exposures incrementally increase the risk of STEMI. The risk related to PM appears to be greater in the elderly, while younger patients appear to be more susceptible to NO₂ exposure.

How to measure quality of care in patients presenting with STEMI? A single-centre experience

OBJECTIVE

The evaluation of the quality of care delivered to patients with acute coronary syndromes is becoming increasingly important. Due to novel regulations permitting the installation of new catheterization laboratories in Belgium, the Flemish government initiated a project to measure quality of care in patients with an ST-elevated myocardial infarction (STEMI) by measuring four quality indicators: prescription of ACE inhibitor, beta blocker or aspirin on discharge and unadjusted mortality. However, we are not convinced that these four indicators will provide sufficient information on the quality of care in our hospitals. Hence, we performed a retrospective analysis on a larger set of parameters and evaluated their applicability as indicators of quality of care.

METHODS

We measured 38 indicators in 153 patients (69 transferred and 84 on-site) with a STEMI who presented at, or were transferred to the UZ Brussels in 2013 and received percutaneous coronary intervention (PCI).

RESULTS

The unadjusted overall mortality was 7.2% (n = 11/153). Important differences in unadjusted mortality were observed between the on-site and transferred patients (10.7%, n = 9 vs 2.9%, n = 2, P = 0.112), which were attributed to the initial condition at presentation and a larger proportion of cardiogenic shocks in the on-site group. Discharge medication highly corresponded with the ESC guidelines.

CONCLUSION

We demonstrate that the proposed quality indicators do not provide sufficient information to compare hospitals and that it is of utmost importance to weigh the mortality according to risk profile.

[Many possible causes of variant angina]

BACKGROUND

Variant angina, or vasospastic angina, is a form of angina caused by vasospasm of the coronary arteries, probably caused by endothelial dysfunction. This form of angina is provoked by non-classical risk factors such as stress, alcohol use, use of sympathomimetics and low environmental temperatures, but also by smoking. Treatment is based on elimination of risk factors and vasodilator therapy with nitrates and long-acting calcium antagonists.

CASE DESCRIPTION

We present a 68-year-old woman with recurring thoracalgia at rest and during exercise, suggestive of severe variant angina in more than one coronary artery. Despite elimination of risk factors and administration of vasodilatory therapy the treatment was initially insufficient. It eventually emerged that the probable cause was frequent use of a vasoconstrictive nasal spray, although this was not described in literature, and not originally mentioned by the patient.

CONCLUSION

A thorough case history is of vital importance in a patient presenting with a history suggestive of variant angina. Even undescribed and apparently less important risk factors can be responsible for persistence of symptoms, and can lead to an applied treatment not producing the desired result.

Left ventricular function and clinical outcome in transient left ventricular ballooning syndrome

BACKGROUND

It is unknown if the severity of left ventricular dysfunction in patients with transient left ventricular ballooning syndrome (TLVBS) adversely affects clinical outcome. Furthermore, it remains unclear if the patterns of ventricular involvement are distinct patterns or if they represent varying stages of ventricular involvement.

METHODS AND RESULTS

All patients with TLVBS who presented to our hospital from August 1998 to August 2012 were prospectively identified and entered into a clinical database. Available ventriculograms were reviewed, the ejection fraction (EF) calculated and a new severity score of left ventricular (LV) involvement was developed to determine the degree of LV dysfunction. The incidence of in-hospital mortality, cardiogenic shock and major cardiac events (heart failure/pulmonary oedema or major cardiac arrhythmia) was recorded. In total, 145 TLVBS episodes were identified in 139 patients. Age at presentation was 67 ± 12 years and 89% (n = 123) of patients were female. Patients who developed cardiogenic shock or other acute cardiac events had a worse LVEF compared to those who did not (P < 0.01 and P = 0.05, respectively). In-hospital mortality was not related to worse EF (P = 0.58). In-hospital and 1-year mortality rates were 6.9% and 12.6%, respectively. Median time from symptom onset to clinical diagnosis was similar between the apical ballooning (n = 104; 12 [3-30] hours) and the mid-ventricular ballooning group (n = 25; 11 [4-35] hours, P = 0.97).

CONCLUSIONS

In TLVBS patients the severity of LV dysfunction determines the incidence of cardiogenic shock and early cardiac events. Apical and mid-ventricular forms of TLVBS appear to be distinct patterns.

A new method for real-time co-registration of 3D coronary angiography and intravascular ultrasound or optical coherence tomography

We present a new clinically practical method for online co-registration of 3D quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS) or optical coherence tomography (OCT). The workflow is based on two modified commercially available software packages. Reconstruction steps are explained and compared to previously available methods. The feasibility for different clinical scenarios is illustrated. The co-registration appears accurate, robust and induced a minimal delay on the normal cath lab activities. This new method is based on the 3D angiographic reconstruction of the catheter path and does not require operator's identification of landmarks to establish the image synchronization.

The apical nipple sign: a useful tool for discriminating between anterior infarction and transient left ventricular ballooning syndrome

AIMS

Even after coronary angiography, transient left ventricular ballooning syndrome (TLVBS) can be misdiagnosed as ST-elevation myocardial infarction (STEMI) caused by transient thrombotic occlusion of the left anterior descending artery, as the appearance of the left ventricular angiograms is often very similar. As prognosis and antithrombotic treatment of these two conditions differ widely, it is desirable to make a correct diagnosis as early as possible.

METHODS

Between January 1998 and August 2012, we identified 145 patients diagnosed with TLVBS in a single tertiary hospital, based on the Mayo criteria and (near) normalization of left ventricular function over weeks. For 119 of these patients, coronary and left ventricular angiograms were available for detailed study.

RESULTS

In 27 (22.7%) patients, mid-ventricular ballooning was observed, with preserved contractility of the apex, while in 92 (77.3%) typical apical ballooning was seen, with extensive akinesis of the apex. In 28 of the patients with typical apical ballooning (30.4%), we observed the presence of a very small zone with preserved contractility in the most apical portion of the left ventricle. We coined this phenomenon 'apical nipple sign'. For comparison, we reviewed the left ventricular angiograms of 405 patients who had been treated for anterior STEMI by emergency percutaneous intervention on the left anterior descending artery in our hospital between February 2007 and October 2012. On careful review, the apical nipple sign was not seen in any of these.

CONCLUSION

While discrimination between TLVBS and anterior STEMI is warranted as early as possible after admission, this is very difficult, especially in the majority of cases presenting with the classical apical ballooning phenotype. By observing the herein-described apical nipple sign, the attending physician can make the diagnosis of TLVBS with virtual certainty in almost one-third of cases.

Acute procedural and six-month clinical outcome in patients treated with a dedicated bifurcation stent for left main stem disease: the TRYTON LM multicentre registry

AIMS

Tryton side branch (SB) reverse culotte stenting has been employed for the treatment of left main (LM) stem bifurcations in patients at high risk for bypass surgery. The aim of this study was to assess acute angiographic results and six-month clinical outcome after implantation of the Tryton stent in the LM.

METHODS AND RESULTS

We studied 52 consecutive patients with LM disease treated in nine European centres. Angiographic and clinical data analysis was performed centrally. Fifty-one of 52 patients (age 68±11 yrs, 75% male, 42% unstable angina, SYNTAX score 20±8) were successfully treated with the Tryton stent. Medina class was 1,1,1 in 33 (63%), 1,0,1 in 7 (13%), 1,1,0 in 3 (6%), 0,1,1 in 8 (4%) and 0,0,1 in 1 (2%). The Tryton stent on a stepped balloon (diameter 3.5-2.5 mm) was used in 41/51 (80%) of cases. The mean main vessel stent diameter was 3.4±0.4 mm with an everolimus-eluting stent employed in 30/51 (59%) of cases. Final kissing balloon dilatation was performed in 48/51 (94%). Acute gain was 1.52±0.86 mm in the LM and 0.92±0.47 mm in the SB. The angiographic success rate was 100%; the procedural success rate reached 94%. Periprocedural MI occurred in three patients. At six-month follow-up, the TLR rate was 12%, MI 10% and cardiac death 2%. The hierarchical MACE rate at six months was 22%. No cases of definite stent thrombosis occurred.

CONCLUSIONS

The use of the Tryton stent for treatment of LM bifurcation disease in combination with a conventional drug-eluting stent is feasible and achieves an optimal angiographic result. Safety of the procedure and six-month outcome are acceptable in this high-risk lesion PCI. Further safety and efficacy studies with long-term outcome assessment of this strategy are warranted.

Risk assessment for percutaneous coronary intervention of the unprotected left main coronary artery in a real-world population

BACKGROUND

Available clinical and angiographic scoring systems fail to predict clinical outcomes in real-world patients undergoing revascularization of the unprotected left main coronary artery (ULMCA).

METHODS

We prospectively assessed major adverse cardiac and cerebrovascular events (MACCE) in a real-world population undergoing percutaneous coronary intervention (PCI) for ULMCA disease. Cumulative risk-adjusted mortality in our patients was compared with expected mortality at 30 days based on logistic EuroSCORE and SYNTAX SCORE. Similarly, we plotted cumulative risk-adjusted MACCE at 1 year based on SYNTAX SCORE. Finally, both scores were combined in 1 year Global Risk Charts, including the use of drug-eluting stents (DES), diabetic status, and several factors precluding coronary surgery.

RESULTS

Over a 12-year period, 240 patients underwent elective (76%) or urgent (24%) PCI of the ULMCA. Median logistic EuroSCORE and SYNTAX SCORE were 8.7% (3.5; 21) and 23% (14; 31). During the first year of follow-up, 89 patients presented MACCE (37.1%) (46 deaths [19.2%], 18 acute myocardial infarctions [7.5%], 45 revascularizations [18.8%] and 4 strokes [1.7%]). Cumulative risk-adjusted mortality based on individual logistic EuroSCORE and SYNTAX SCORE pointed towards significant overestimation (+19 deaths) and underestimation (-35 deaths) of risk by these respective scoring systems. Similarly, the anatomic SYNTAX SCORE largely underestimated cumulative risk-adjusted MACCE (-60 MACCE). The Global Risk Charts provided a more balanced view on 1-year clinical outcome.

CONCLUSION

An integrated risk evaluation combining EuroSCORE, SYNTAX SCORE, diabetic status, stent type and general condition, may predict outcomes more accurately awaiting validation in a larger and multicentre setting.

Iatrogenic left main coronary artery dissection

We present a case of iatrogenic left main coronary artery dissection, successfully treated by prompt bail-out stenting, and provide a brief discussion on its occurrence and treatment, as well as the immediate and long-term outcome of percutaneous coronary intervention, including our own single-centre experience, for this potentially catastrophic complication.