Assessment of absolute coronary flow and microvascular resistance reserve in patients with severe aortic stenosis

Introduction

The development of left ventricular hypertrophy in patients with severe aortic stenosis (AS) is accompanied by adaptive coronary flow regulation, both in epicardial and microvascular compartment, which ultimately lead to a chronic ischemic insult even in the absence of obstructive coronary artery disease. Intracoronary continuous thermodilution of saline through a dedicated infusion catheter is a novel tool that allows to measure absolute coronary flow and microvascular resistance at rest and during hyperemia and to calculate both coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR)

Purpose

We aimed to assess absolute coronary flow, microvascular resistance, CFR and MRR in patients with AS, by continuous intracoronary thermodilution, comparing these hemodynamic findings with a propensity-score matched contemporary cohort of patients without AS.

Methods

Absolute coronary blood flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and compared to 15 controls matched for age, gender, diabetes mellitus and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and LAD-specific mass were quantified by echocardiography and cardiac-CT.

Results

Patients with AS presented a significantly positive LV remodeling with lower global longitudinal strain and higher global work index compared to controls (p<0.02). Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS. Compared to matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (86 [66–107] ml/min vs 68 [52–75] ml/min, p=0.036), resulting, in lower CFR (2.30±0.69 vs 2.89±0.77, p=0.005) and MRR (2.73±0.74 vs 3.53±0.95, p=0.005) in the AS cohort compared to controls (Figure 1). No differences were found in hyperemic flow and resting and hyperemic resistances. Interestingly, hyperemic myocardial perfusion (calculated as the ratio between the absolute coronary flow in the LAD and the mass subtended by the vessel, expressed in mL/min/g), but not resting, was significantly lower in the AS group (1.9 [1.5–2.5] ml/min/g vs 2.3 [2–3.1] ml/min/g p=0.036).

Conclusions

In patients with severe aortic stenosis and non-obstructive coronary artery disease, with the progression of LVH, the compensatory mechanism of increased resting flow maintains an adequate perfusion at rest, but not during hyperemia (Figure 2). As consequence, both CFR and MRR are significantly impaired.

Funding Acknowledgement

Type of funding sources: None.

Diagnostic and prognostic role of cardiac magnetic resonance in patients with MINOCA

Background

Myocardial infarction with non-obstructed coronary arteries (MINOCA) is common in current clinical practice and cardiac magnetic resonance (CMR) plays an important role in the present management of this group of patients. However, there are still a lot of controversies concerning the etiology behind the syndrome of MINOCA. Furthermore, the prognostic value of CMR in patients with MINOCA is still undetermined.

Purpose

We aimed to determine the diagnostic and prognostic value of CMR in the management of patients with MINOCA.

Methods

A systematic review was performed to identify studies reporting the results of CMR findings in MINOCA patients (non-obstructive CAD or normal coronary arteries). Random effects models were used to determine the prevalence of different disease entities – myocarditis, myocardial infarction, Takotsubo cardiomyopathy or normal CMR findings. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the prognostic value of CMR diagnosis in the subgroup of studies that reported clinical outcomes. Major adverse clinical events (MACE) were defined based on the specific study definitions and included cardiovascular death, non-fatal myocardial infarction, and cardiovascular hospitalization.

Results

31 studies comprising 4119 patients were included. Mean age was 54.1±3.3, 59% were males. The pooled prevalence of myocarditis was 32% (95% CI 0.25 to 0.39), myocardial infarction (MI) - 21% (95% CI 0.17 to 0.24), Takotsubo cardiomyopathy −12% (95% CI 0.09 to 0.16). Normal findings were found in 23% (95% CI 0.14 to 0.35), figure 1. In a subgroup analysis of seven studies (900 patients) that reported clinical outcomes the prognostic value of the CMR was assessed. CMR diagnosis of myocarditis was not significantly associated with increased risk of MACE (pooled OR, 1.50; 95% CI, 0.46 to 4.87; p=0.459). However, both diagnosis of MI and Takotsubo were significantly associated with increased risk of combined clinical outcomes (pooled OR, 1.75; 95% CI, 1.12 to 3.59; p<0.05 and pooled OR, 2.19; 95% CI, 1.34 to 5.27; p<0.001).

Conclusion

In patients with MINOCA CMR brings important diagnostic and prognostic role. The pooled prevalence of myocarditis was 32%, of MI – 21% and of Takotsubo – 12%. The CMR diagnosis of MI and Takotsubo was associated with increased risk of MACE.

Funding Acknowledgement

Type of funding sources: None.

Repeatability of bolus and continuous thermodilution for assessing coronary microvasculatory function

Introduction

The bolus thermodilution-derived index of microcirculatory resistance (IMR) has emerged over years as the standard of reference to invasively define coronary microvascular dysfunction (CMD). However, the technique still presents some limitations, mainly related to the fact that manual injection of saline bolus accounts for some variance in the measurements. Continuous intracoronary thermodilution has been recently introduced as a tool to directly quantify absolute coronary flow and microvascular resistance both at rest and during hyperemia and has shown to be safe and operator independent. Microvascular resistance reserve (MRR), derived from continuous thermodilution, has been validated as novel index specific for microcirculation and independent from myocardial mass.

Purpose

To compare head-to-head the intra-observer repeatability of bolus and continuous thermodilution for assessing microvascular function.

Methods

Patients undergoing coronary angiography in the absence of obstructive coronary artery disease were prospectively enrolled. Bolus and continuous intracoronary thermodilution measurements were performed in duplicates in the left anterior descending artery (LAD). Patients were randomly assigned in a 1:1 ratio to undergo first bolus thermodilution or first continuous thermodilution assessment.

Results

A total of 102 patients were enrolled. Average FFR was 0.86±0.06. Coronary Flow Reserve (CFR) calculated with continuous thermodilution (CFRthermo) was significantly lower than bolus thermodilution-derived CFR (CFRbolus) (2.63±0.65 and 3.29±1.17, respectively, p<0.001). CFRthermo showed a lower variability and a higher agreement than CFRbolus (variability 12.74±10.41% vs 31.26±24.85%, respectively, p<0.001; ICC= 0.78 (0.70–0.85) and 0.48 (0.32–0.62), respectively, p<0.001, Figure 1). Both MRR and IMR showed a good agreement (ICC 0.81 (0.74–0.87) and 0.80 (0.71–0.86)) but the variability of the MRR was significantly lower (12.44±10.06% vs 24.24±19.27, respectively, p<0.001, Figure 1). Reproducibility data of all indices derived from duplicated measurements of bolus and continuous thermodilution are reported in Table 2.

Conclusion

Continuous intracoronary thermodilution has a higher repeatability than bolus thermodilution in the assessment of CMD.

Funding Acknowledgement

Type of funding sources: None.

Impact of aortic regurgitation on long-term outcomes in heart failure with preserved ejection fraction

Background

Aortic Regurgitation (AR) may aggravate the clinical course in patients with heart failure and preserved ejection fraction (HFpEF) by increasing filling pressures and triggering LV remodelling.

Objective

To assess AR's prevalence and long-term prognostic implications in patients with HFpEF.

Methods

The study population consisted of 458 consecutive patients (age 77.5±9.2 y, 57.9% females) hospitalized with de novo or worsened HFpEF. Patients with more than moderate aortic and/or mitral valve disease were excluded. Data on cardiovascular death, HF re-hospitalization and their composite (MACE) were collected.

Results

Out of 309 (67.5%) patients with any AR, 156 (34.0%) and 153 (33.5%) had mild-AR and moderate-AR, respectively. The remaining 149 (32.5%) individuals had no-AR. Patients with versus without AR were significantly older with larger LV and LA volumes and a higher prevalence of diastolic dysfunction (all p<0.05). During a median follow-up of 33±25 months, a total of 114 patients (24.9%) died from cardiovascular causes, 126 patients (27.5%) were re-hospitalized for HF, while 272 (59.4%) had the composite endpoint (MACE). In multivariable Cox regression analysis, any AR emerged as an only independent predictor of MACE (HR=1.90, 95% CI 1.26–2.87, p=0.002). Mild-AR and Moderate AR increased the risk of MACE by 77% and 92%, respectively, compared to the No-AR (Figure).

Conclusions

In patients with HFpEF, mild-to-moderate AR is highly prevalent, and it seems to identify individuals with worse long-term outcomes. This suggests that even mild AR should be considered a high-risk prognostic marker in patients with HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Infarct size, inflammatory burden and admission hyperglycemia in diabetic patients with acute myocardial infarction treated with SGLT2-inhibitors: a multicenter international registry

Background

Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) currently receive intense clinical interest in patients with and without diabetes mellitus (DM) with pleiotropic beneficial effects. Nowadays, the inflammation response in the setting of acute myocardial infarction (AMI) has been proposed as a potential pharmacological intervention target. In this setting, we tested the hypothesis that the SGLT2-I displays anti-inflammatory effect along with glucose-lowering properties. We investigated the relationship between stress hyperglycemia, inflammation burden and infarct size in a cohort of type 2 diabetic AMI patients treated with SGLT2-I versus other oral anti-diabetic (OAD) agents alone.

Methods

In this multicenter international registry, all diabetic patients with AMI treated with percutaneous coronary intervention (PCI) between 2018 and 2021 were enrolled. Based on the admission anti-diabetic therapy, patients were divided into those receiving SGLT2-I versus other OAD agents alone. Patients on insulin therapy alone or combined with OAD agents were excluded from the study. The following inflammatory markers were evaluated at different time points: total white blood cell, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-platelet ratio (NPR), C-reactive protein. Infarct size was assessed by peak troponin levels and echocardiographic parameters.

Results

The final study population consisted of 583 patients hospitalized for AMI (both STEMI and NSTEMI) classified as SGLT2-I users (n=98) versus other OAD agents alone (n=485). Admission hyperglycemia was more prevalent among the other OAD agents group. Reduced infarct size was detected in patients treated with SGLT2-I compared to those treated with other OAD agents alone. Both at admission, and after 24 hours, inflammatory indices were significantly higher in patients treated with other OAD agents alone, with a significant increase in neutrophils levels at 24 hours, compared to the SGLT2-I group. In multivariate analysis, SGLT2-I emerged as a significant predictor of reduced inflammatory response (OR 0.45, 95% CI 0.27–0.75, p=0.002), together with peak troponin values, independently of age, admission creatinine values and admission glycemia.

Conclusions

Type 2 Diabetic patients hospitalized for AMI and receiving SGLT2-I exhibited modest inflammatory response and myocardial damage/infarct size compared to other OAD agents alone, independently of glucose-metabolic control. Our findings pave the way for new pathophysiological and therapeutic insights regarding the cardioprotective effect of SGLT2-I in the setting of coronary artery disease.

Funding Acknowledgement

Type of funding sources: None.

Outcomes benefit in asymptomatic patients with moderate aortic valve stenosis followed up in heart valve clinics

Background

The management of patients with asymptomatic moderate aortic stenosis (AS), particularly the follow-up and the choice between early intervention vs watchful waiting, remains debated. A progressively increasing number of patients with valvular heart disease (VHD) were diagnosed and followed in an ambulatory setting with a dedicated cardiologist and cardiac imaging specialist: the Heart Valve Clinics (HVC). However, the number of patients with VHD is that high, that these patients are also followed by routine cardiac care consultations (standard-of-care).

Purpose

To determine the benefit of a HVC approach and outcomes compared to standard-of-care for patients with moderate asymptomatic AS.

Methods

From November 2014 a HVC environment was introduced at our Cardiovascular Center, to follow patients with moderate and severe VHD by an imaging and valve specialist. Patients who received at least one visit in the Ambulatory HVC were included in a prospective registry. All consecutive patients with aortic valve velocity max>3 cm/sec diagnosed with 2-D echocardiography according to the ESC Guidelines were included in this study. Exclusion criteria included more than moderate aortic regurgitation and prior aortic valve replacement (AVR). Natural history, need for AVR, and survival of patients with baseline moderate AS were assessed at follow up. Cox proportional hazard model, Kaplan-Meier survival curves and propensity score matching where used to assess the HVC approach effect on the mortality.

Results

A total of 2130 patients were included (1879 in the standard-of-care group and 251 in the Ambulatory HVC group). 1187 (55.7%) were male, and the mean (SD) age was 77.2±12.2 years. A total of 919 patients (43.1%) had severe AS (aortic valve area <1.0 cm2). Mean clinical follow-up was 1.2±2.4 years. A total of 822 patients (38.6%) died during the follow up and 114 patients (55.6%) underwent AVR during the study period. After using 1:1, nearest neighbour, without replacement propensity score matching, baseline characteristics between the two groups were balanced. The introduction of Ambulatory HVC was associated with a reduction of adjusted all-cause mortality compared to the standard-of-care group (HR=0.53, 95% CI 0.35–0.82, p=0.004) (Figure1). At multivariable analysis, the Ambulatory HVC pathway was a significant predictor of reduced all-cause of death (HR=0.46, 95% CI 0.33–0.65, p<0.001), together with younger age and higher GFR, independently of AVA, tricuspid regurgitation gradient, LVEF and chronic obstructive pulmonary disease.

Conclusions

Patients with moderate AS followed up in HVC had lower rate of all-cause of death compared to the standard-of-care group. The Ambulatory HVC was a significant predictor of reduced all-cause of death and was associated with more efficient patient management and lower mortality. Dedicated HVC have the potential to improve patient care and clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Ambulatory pulmonary vein isolation workflow using suture-mediated vascular closure devices: a prospective observational cohort study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Cardiovascular Abbott D. Fabbricatore is supported by a research grant from the CardioPaTh PhD Program

Background

Pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) is an increasingly performed procedure worldwide, presenting an attractive opportunity for performing it in a day care setting.[1] The main reason for delayed discharge are the potential vascular complications that may occur.[2–5] There is still a lack of knowledge considering the usage of vascular closure devices in the electrophysiological field.

Purpose

The aim of the study was to evaluate feasibility, safety, and efficacy of a suture-mediated vascular closure device in ambulatory management after PVI.

Methods

Prospective single-centre cohort study on 50 patients admitted for PVI from January 2020 to May 2021. At the end of the procedure, a suture-mediated vascular closure system was used for each vascular access. The feasibility of an ambulatory PVI strategy was assessed as the percentage of patients being able to be discharged the same day of the procedure. Outcomes were defined as acute rate of vascular device closure performance, postprocedural time to haemostasis, time to ambulation and time to discharge. Vascular complications, analysed on the total number of patients enrolled, were assessed during the 30-days follow-up.

Results

A total of 48/50 (96%) patients were discharged at the same day of the procedure. Haemostasis was reached within 1 minute after the deployment of the device in 30 patients (60%). During the post-operative stay, two patients had minor bleeding without necessity of intervention and one patient was kept in supine position until an ultrasound evaluation resulted negative. Mean and median time to be deemed suitable for discharge in the 48 patients who reached the primary endpoint were 4:55 (±00:54) and 4:48 (2:50-7:30) hours respectively. Mean and median time to discharge were 5:48 (± 1:03) and 5:51 (3:38-7:57) hours respectively. Patient satisfaction was queried and resulted excellent. No major vascular complications were observed during 30-days follow up. Minor complications occurred in 4 patients and were three minor superficial haematomas (<6 cm) and one transient access site related nerve injury.

Conclusion

The use of a closure device for femoral venous accesses after PVI led to a safe discharge of patients within 6 hours from the intervention in 96% of the population. The ambulatory management described in the abstract could be useful for minimizing the overcrowding of healthcare facilities and reduce the post-operative recovery time and management. Additionally, patients were satisfied with the treatment received. Randomised trials are needed for further evaluate the efficacy of this approach.

Performance of non-invasive myocardial work to predict the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF)

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Dr. Paolisso, Dr. Esposito, Dr. Fabbricatore are supported by a research grant from the CardioPaTh PhD Program of University of Naples Federico II

Background

Non-invasive myocardial work (MW) is a validated index of left ventricular (LV) systolic performance, incorporating afterload and myocardial metabolism. The role of MW in predicting the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF) is still unknown.

Purpose

To investigate the diagnostic performance of MW to predict the first de novo HFpEF hospitalization in ambulatory individuals with preserved LVEF.

Methods

Twenty-nine patients with trans-thoracic echocardiography performed at least 6 months before the first HFpEF hospitalization were compared with 29 matched controls. MW was derived as the area of pressure-strain loop using speckle-tracking and brachial artery blood pressure. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were collected. First HFpEF hospitalization and its combination with cardiovascular death (MACE) and all-cause of death (MAE) were assessed.

Results

At baseline, future HFpEF patients showed lower GWI, GCW, GWE and higher GWW than controls (all p < 0.05).  At admission versus baseline, GWE significantly decreased, and GWW increased in the HFpEF group (p < 0.05), whereas no significant difference was observed in the controls over time. GWW, with a cut-off of 170 mmHg%, showed the largest AUC to predict first HFpEF hospitalization (AUC = 0.80, 95% CI 0.69–0.91, p < 0.001), MACE (AUC = 0.80, 95% CI 0.66–0.90, p < 0.001) and MAE (AUC = 0.79, 95% CI 0.62–0.88, p = 0.001). GWW > 170 mmHg% was associated with a 4-fold increase of MACE (HR = 4.5, 95% CI 1.59–13.12, p = 0.005) and a 3-fold higher risk of MAE (HR = 2.9, 95% CI 1.24–6.6, p = 0.014).

Conclusions

In ambulatory patients with preserved LVEF and risk factors, GWW showed high accuracy to predict the first HFpEF hospitalization and its combination with mortality. The GWW routine assessment may be clinically helpful in patients with dyspnea. Abstract Figure 1: Serial changes of LARs, LV GLS  Abstract Figure 2:Kaplan–Meier survival curves fo

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

BACKGROUND

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either RA or IVL.

METHODS

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥ 0.90.

RESULTS

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65 ± 0,13 RA and 0,67 ± 0,11 IVL). After PCI, in-stent pressure gradients were significantly lower in the IVL group (0.032 ± 0.026 vs 0.043 ± 0.026 in the RA group, p = 0.024). The proportions of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p = 0.669).

CONCLUSIONS

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

Background

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions is associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using dedicated calcium modifying techniques such as RA or IVL has been advocated. Studies comparing these technologies are lacking.

Objectives

To compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either rotational atherectomy (RA) or intravascular lithotripsy (IVL).

Methods

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad, calculated as the difference between the vFFR at the proximal minus distal edge of the stent). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥0.90.

Results

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65±0,13 RA and 0,67±0,11 IVL). After PCI, in-stent pressure gradient was significantly lower in the IVL group (0.032±0.026 vs 0.043±0.026 in the RA group, p=0.024). The proportion of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p=0.669)

Conclusions

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Funding Acknowledgement

Type of funding sources: None. In stent gradients after RA and IVL

Baseline troponin-T is powerful predictor of mortality after coronary bifurcation stenting

Introduction

Considerable progress has been made in the treatment of coronary bifurcation stenosis. Anatomical characteristics of the lesion, however, fail to give information about the functional significance of the bifurcation stenosis. There is no study that systematically establishes the baseline functional significance of coronary stenosis and its effect on procedural and clinical outcomes.

Methods

Patients with significant angiographically bifurcation lesions defined as diameter stenosis >50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). If FFR was ≤0.80 the lesion was considered functionally significant, and patients underwent PCI. For the group with FFR >0.80 – intervention was deferred. All patients were followed-up for vital status every 3 months. Cox regression analysis was performed to identify independent predictors of all-cause and cardiovascular death. The local ethics committee approved the study and patients signed informed consent for participation into registry.

Results

For mean follow-up of 38±18 months (median 40, IQR 23–55 months) all-cause mortality was numerically lower: 8.5% (n=7/82) in deferred group and 12.6% in stented group (n=11/76, p=0.387). The cardiac mortality was also numerically lower, but statistically not significant (9.8%, n=8/82 vs. 11.5%, n=10/88, p=0.714). On multivariate model, independent predictors were mitral regurgitation >1st degree – HR=1.778 (CI 1.100–2.874, p=0.019); dyslipidemia HR=0.765 (CI 0.594–0.985, p=0.038); hemoglobin concentration – HR=0.976 (CI 0.964–0.988, p<0.001); pre-PCI serum troponin ≥0.010 ng/ml – HR=2.702 (CI 1.451–5.032, p=0.002). On multivariate analysis, the following factors were identified as independent predictors of cardiac mortality: age – HR=1.035 (CI 1.009–1.062, p=0.009); diabetes – HR=1.789 (CI 1.089–2.962, p=0.024); dyslipidemia treated with statin – HR=0.667 (CI 0.515–0.863, p=0.002); LV posterior wall thickness – HR=1.230 (CI 1.062–1.424, p=0.006); mitral regurgitation more than 1st degree – HR=1.763 (CI 1.065–2.917, p=0.027); troponin pre-PCI ≥0.010 ng/ml – HR=2.498 (CI 1.228–5.081, p=0.011); true bifurcation lesion – HR=1.820 (CI 1.026–3.229, p=0.040); SBBARI score <10% – HR=1.715 (CI 1.049–2.804, p-0.031).

Conclusion

Baseline high-sensitive troponin T value is a strong predictor for both all cause and cardiac mortality in patients undergoing coronary bifurcation lesion PCI.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alexandrovska University Hospital

P1963The determinants of functional significance of coronary bifurcation lesions and its implications on clinical follow up to 48 months (insights from FIESTA registry)

Background

There is no study up-to-now to determine the rate of functionally significant coronary bifurcation lesions, which have to be intervened and what are the clinical consequences of the FFR case selection strategy.

Methods

We analyzed patients from FIESTA registry, which was continuation of FIESTA study (Ffr vs. IcEcgSTA, ClinicalTrials.gov Identifier: NCT01724957). Patients with stable angina were included (if there were other coronary stenoses they were threated first after checking by FFR for functional significance). The inclusion criterions were angiographic bifurcation lesions in a native coronary artery with diameter ≥2.5 mm and ≤4.5 mm and SB diameter ≥2.0 mm. We excluded patients with ST-segment elevation myocardial infarction, left main, hemodynamic instability and those with non-cardiac co-morbidity conditions with a life expectancy of less than one year. PCI was performed according to the current guidelines. Provisional stenting was the default strategy in all patients. Two guidewires were inserted into both distal MB and SB. Initial FFR was performed using the PrimeWire or PrimeWire Prestige (Volcano Corp., USA). For all FFR measurements, intracoronary adenosine was given in increasing doses of 60 mcg, 120 mcg, and 240 mcg. The minimum value of FFR measurements was taken for analysis. All patients received double antiplatelet therapy with ADP-antagonist and aspirin for at least 12 months.

Results

A 130 consecutive patients with coronary bifurcation stenoses were included – 57 had positive FFR<.80 in main vessel of bifurcation lesion (44% functionally significant lesions). The mean age was 67±10 years, 66% males, 96% hypertensive, 39% diabetic, 96% dyslipidemic (or on treatment with statin), 55% smokers, 22% with previous myocardial infarction, 51% with previous PCI. The residual SYNTAX score before FFR bifurcation assessment was 13±4 (FFR<.80) vs. 8±3 (FFR≥0.80), p<0.001. Univariate predictors of bifurcation FFR<.80 were: proximal (MV%DS) or distal (MB%DS) main vessel stenosis ≥85% (derived from ROC analysis with overall accuracy 77% and 72%, accordingly), lesion length, SYNTAX score, triglyceride concentration, previous MI on lateral wall and carotid artery disease. On multivariate logistic analysis only MV%DS>85% (OR=8.929, CI 2.887–27.619, p<0.001), MB%DS>85% (OR=3.831, CI 1.349–10.883, p=0.012) and SYNTAX score≥12 (OR=16.466, CI 5.225–15.889, p<0.001). At median follow-up of 26 months (IQR 17–35) the all-cause mortality was 17.5% in FFR positive bifurcations vs. 4.1% in FFR negative lesions (log-rank =.067).

Conclusions

Less than a half of angiographically significant coronary bifurcation lesions are functionally significant and require stent implantation. The functional significance was related with higher degree stenosis in main vessel and overall disease severity estimated with SYNTAX score. A trend to lower mortality was noted in group with non-significant FFRs.

The Bulgarian country profile: the dynamics of some inequalities in health

The Bulgarian health-care system was based on the concept of equal access and treatment. In its early stages health improved and disparities between urban and rural areas and districts diminished. New problems, institutional rigidities and policy reversals led later to the concentration of health resources in the towns and cities and to a deterioration in rural health. Sharp disparities in reported health status exist between occupational, educational and income groups. Life expectancy has fallen. Some health problems arise from urbanization, industrialization and heavy internal migration. Others clearly derive from dysfunction in the health system itself, its narrow concept of health, the inability of health plans to adapt to changing problems and needs and the emergence of privilege in access and quality of care.