Atrial septum anatomy as a predictor of ischemic neurological episodes in patients with a patent foramen ovale

BACKGROUND

The correlation between atrial septum anatomy and the risk of ischemic neurological events remains underexplored.

AIMS

This study aimed to examine both the functional and anatomical attributes of the atrial septum and identify predictors of stroke and/or transient ischemic attack (TIA) in patients diagnosed with patent foramen ovale (PFO).

METHODS

A total of 155 patients diagnosed with PFO, with a cardiological cause of neurological events, were enrolled. Transesophageal echocardiography was utilized to assess the anatomy of the PFO canal, size of the right-to-left shunt, thickness of the primary and secondary atrial septum, presence of atrial septum aneurysm, and anatomical structures of the right atrium.

RESULTS

Regression analysis showed that factors such as female sex, hypercholesterolemia, PFO canal width, and a large right-to-left shunt were significantly associated with stroke and/or TIA. Receiver operating characteristic analysis indicated that the width of the PFO canal holds a relatively weak, although significant predictive, value for ischemic neurological episodes (area under the curve = 0.7; P = 0.002). A PFO canal width of 4 mm was associated with 70% sensitivity and 55% specificity for predicting stroke and/or TIA.

CONCLUSIONS

The atrial septum's anatomy, especially the dimensions of the PFO canal and the magnitude of the right-to-left shunt, combined with specific demographic and clinical factors, are linked to ischemic neurological incidents in PFO patients.

In-Hospital Levels of Circulating MicroRNAs as Potential Predictors of Left Ventricular Remodeling Post-Myocardial Infarction

Background and Objectives: Biochemical and molecular regulation of both adaptive and pathological responses of heart tissue to ischemic injury is widely investigated. However, it is still not fully understood. Several biomarkers are tested as predictors of left ventricle (LV) remodeling after myocardial infarction (MI). The aim of this study was to assess the relationship between selected microRNAs (miRNAs) and LV function and morphology in patients after MI. Materials and Methods: Selected miRNAs related to heart failure were assessed in the acute phase of MI: miR-150-3p, miR-21-5p, miR-19b-3p, miR-155-5p, miR-22-5p. Echocardiography with 3D imaging was performed at baseline and after 6 months. Remodeling was defined as >20% increase in LV end-diastolic volume, whereas reverse remodeling was defined as >10% reduction in LV end-systolic volume. Results: Eighty patients entered the registry. Remodeling occurred in 26% and reverse remodeling was reported in 51% of patients. In the presented study, none of the analyzed miRNAs were found to be a significant LV remodeling predictor. The observed correlations between miRNAs and other circulating biomarkers of myocardial remodeling were relatively weak. Conclusions: Our analysis does not demonstrate an association between the analyzed miRNAs and LV remodeling in patients with MI.

Influence of diabetes mellitus on the invasive assessment of myocardial ischemia in patients with coronary artery disease

INTRODUCTION

Current guidelines recommend physiological evaluation of borderline coronary artery stenoses using hyperemic (fractional flow reserve [FFR]) and nonhyperemic (instantaneous wave‑free ratio [iFR] and resting full‑cycle ratio [RFR]) methods. However, comorbidities, such as diabetes mellitus (DM), may influence the results of the assessment.

OBJECTIVES

We sought to investigate the impact of DM and insulin treatment on the discordance between FFR and iFR/RFR.

PATIENTS AND METHODS

A total of 417 intermediate stenoses in 381 patients underwent FFR and iFR/RFR assessment. FFR lower than or equal to 0.8 and iFR/RFR lower than or equal to 0.89 indicated significant ischemia. The patients were categorized based on DM diagnosis and insulin treatment status.

RESULTS

Of the 381 patients, 154 (40.4%) had DM. Among these, 58 patients (37.7%) received insulin treatment. Diabetic patients had higher body mass index and glycated hemoglobin levels, and lower ejection fraction. FFR and iFR/RFR analyses were conducted in 417 vessels with available measurements for both tests. A good correlation between FFR and iFR/RFR was confirmed in both diabetic (R = 0.77) and nondiabetic (R = 0.74) patients. Discordance between FFR and iFR/RFR occurred in approximately 20% of cases, and the frequency of discordance was not affected by the diabetic status. However, insulin‑treated DM was independently associated with a higher risk of negative FFR and positive iFR/RFR discordance (odds ratio, 4.61; 95% CI, 1.38-15.4; P = 0.01). Also, the optimal cutoff value for FFR identifying significant ischemia in DM patients treated with insulin was higher (0.84) than the generally recommended value.

CONCLUSIONS

The rate of FFR and iFR/FFR discordance was similar regardless of the diabetes status, and insulin‑treated DM was associated with an increased risk of negative FFR and positive iFR/RFR discordance.

The Impact of Age on the Physiological Assessment of Borderline Coronary Stenoses

Background and Objectives: Coronary angiography is the gold standard for diagnosing coronary artery disease (CAD). In the case of borderline changes, patients require further diagnosis through ischemia assessment via one of the recommended methods of invasive evaluation. This study aimed to assess whether clinical factors influence the risk of a positive result in invasive myocardial ischemia assessment and if these potential factors change with the patient's age and the consistency of ischemia assessment. Materials and Methods: Data were collected retrospectively on all consecutive patients hospitalized in the University Hospital in Krakow between 2020 and 2021, on whom physiological assessments of coronary circulation were performed. Patients were divided into two groups: patients aged 60 or younger and patients older than 60. Results: Despite the older patients having more risk factors for CAD, their physiological assessment results of borderline lesions were similar to those of the younger patients. Positive fractional flow reserve (FFR) assessments were obtained from almost 50% of vessels. In the younger patients, cigarette use and type 2 diabetes mellitus increased the risk of a positive FFR result by 3.5 and 2.5 times, respectively. In the older patients, male gender and peripheral vascular disease significantly increased the risk of a positive FFR by 2.5 and 2 times, respectively. Conclusions: Clinical characteristics of patients undergoing physiological assessment of borderline coronary stenosis varied significantly by age. Refining the definition of borderline lesions to include age, gender, and other factors may improve the identification of patients who would benefit from physiological assessment and coronary revascularization.

Experience in patent foramen ovale closure with the CERA Lifetech occluder in patients with cryptogenic stroke

Introduction

Nowadays, percutaneous closure of patent foramen ovale (PFO) in patients after cryptogenic stroke is becoming a dominating strategy. The most commonly used and investigated device is the Amplatzer occluder. However, several other devices have been designed for transcatheter closure of PFO, which are not so well examined.

Aim

To assess the effectiveness and safety of PFO closure with the Lifetech CERA occluder.

Material and methods

A prospective, single-arm registry of patients with PFO treated with CERA occluder (Lifetech Scientific, Shenzhen, China) implantation was conducted. We assessed peri-procedural and 12-month follow-up. Patients were screened for the residual shunt in transcranial Doppler/transesophageal echocardiography.

Results

Ninety-six patients entered the registry. Most patients were women (76%) and the analyzed group was relatively young (mean age of 42.3 ±13.6 years). Before closure, most patients had a large shunt through the PFO. Procedures of PFO closure were performed under TEE guidance. All procedures were made under local anesthesia and all patients had the PFO successfully closed. No device-related complications were reported in the peri-procedural period or during follow-up. No recurrent neurological ischemic events were reported at 12 months. During follow-up we observed a 9% rate of residual shunts, which were mostly small.

Conclusions

The study confirmed excellent immediate and 12-month results of CERA occluder implantation in patients with PFO.

Influence of sex on the functional assessment of myocardial ischemia

BACKGROUND

Fractional flow reserve (FFR) and non-hyperemic resting pressure ratios, such as instantaneous wave-free ratio (iFR) and resting full-cycle ratio (RFR), are recommended for evaluating the significance of angiographically intermediate coronary stenoses. Despite their usefulness, approximately 20% of assessed lesions exhibit discordance between FFR and iFR/RFR.

AIMS

The role of sex in this discrepancy remains uncertain; thus, we aimed to investigate its impact on the discordance between FFR and iFR/RFR.

METHODS

We reviewed 417 consecutive intermediate stenotic lesions from 381 patients, stratified by sex and assessed with both FFR and iFR/RFR. FFR ≤0.80 and iFR/RFR ≤0.89 were considered positive for ischemia.

RESULTS

Of the 381 patients, 92 (24.1%) were women. Women were older, had a lower estimated glomerular filtration rate (eGFR), higher ejection fraction, and were more likely to have peripheral artery disease than men. Median FFR and iFR/RFR values were lower in men than in women (FFR 0.86 vs. 0.80; P <0.001; iFR 0.92 vs. 0.90; P = 0.049). However, overall discordance prevalence was similar for both sexes (20.6% vs. 15.1%; P = 0.22). In men, eGFR, insulin-treated diabetes mellitus, and arterial hypertension were predictors of positive FFR | negative iFR/RFR discordance, while eGFR, insulin-treated diabetes mellitus, atrial fibrillation, and chronic obstructive pulmonary disease were predictors of negative FFR | positive iFR/RFR discordance. No factors associated with either discordance were identified in women.

CONCLUSIONS

FFR and iFR/RFR results indicating significant ischemia were more common in men than women when assessing intermediate coronary stenoses. Nevertheless, sex did not predict discordant results.

Operator-patient sex discordance and periprocedural outcomes of percutaneous coronary intervention (from the ORPKI Polish National Registry)

Introduction

A recent study suggested that sex discordance between surgeons and patients negatively affects the outcomes of patients undergoing common surgical procedures.

Aim

We sought to assess whether such an impact exists for periprocedural outcomes of percutaneous coronary intervention (PCI).

Material and methods

From 2014 to 2020, data on 581,744 patients undergoing single-stage coronary angiography and PCI from 154 centers were collected. Patients were divided into four groups based on the patient and operator sex. Operator-patient sex discordance was defined as the procedure done by a male operator on a female patient or by a female operator on a male patient.

Results

Of 581,744 patients treated by 34 female and 782 male operators, 194,691 patients were sex discordant with their operator (female operator with male patient 12,479; male operator with female patient 182,212) while 387,053 were sex concordant (female operator with female patient 6,068; male operator with male patient 380,985). Among female patients, no difference in the risk of periprocedural complications, including death (0.65% vs. 0.82%; p = 0.10), between patients discordant versus concordant with operators was observed. Among male patients the risk of death (0.55% vs. 0.43%; p = 0.037) and bleeding at the puncture site (0.13% vs. 0.08%; p = 0.046) was higher in patients discordant with operators. However, the differences were no longer significant after adjustment for covariates.

Conclusions

No detrimental effect of operator-patient sex discordance on periprocedural outcomes was confirmed in all-comer patients undergoing PCI. Some of the observed differences in outcomes were primarily related to the differences in baseline risk profile.

Thrombus containing lesions strategies during primary percutaneous coronary interventions in ST-segment elevation myocardial infarction: insights from ORPKI National Registry

In the era of potent P2Y₁₂ inhibitors, according to current guidelines, treatment with glycoprotein IIb/IIIa inhibitors (GPIs) should be limited to bail-out and/or highly thrombotic situations. Similarly, the recommendation for aspiration thrombectomy (AT) is downgraded to very selective use. We examine the prevalence, and predictors of GPI and AT use in STEMI patients referred to primary percutaneous coronary intervention (PCI). Data on 116,873 consecutive STEMI patients referred to primary PCI in Poland between 2015 and 2020 were analyzed. GPIs were administered in 29.3%, AT was used in 11.6%, and combined treatment with both in 6.1%. There was a mild trend toward a decrease in GPI and AT usage during the analyzed years. On the contrary, there was a rapid growth of the ticagrelor/prasugrel usage rate from 6.5 to 48.1%. Occluded infarct-related artery at baseline and no-reflow during PCI were the strongest predictors of GPI administration (OR 2.3; 95% CI 2.22-2.38 and OR 3.47; 95% CI 3.13-3.84, respectively) and combined usage of GPI and AT (OR 4.4; 95% CI 4.08-4.8 and OR 3.49; 95% CI 3.08-3.95 respectively) in a multivariate logistic regression model. Similarly, the administration of ticagrelor/prasugrel was an independent predictor of both adjunctive treatment strategies. In STEMI patients in Poland, GPIs are selectively used in one in four patients during primary PCI, and the combined usage of GPI and AT is marginal. Despite the rapid growth in potent P2Y₁₂ inhibitors usage in recent years, GPIs are selectively used at a stable rate during PCI in highly thrombotic lesions.

Comparison of Fractional Flow Reserve with Resting Non-Hyperemic Indices in Patients with Coronary Artery Disease

Guidelines recommend using hyperemic (FFR) and non-hyperemic (iFR/RFR) methods of evaluating coronary artery stenoses in patients with coronary artery disease. However, in some cases, achieved results indicating significant ischemia may differ between those methods. Thus, we sought to identify predictors of such a discrepancy. Data were collected on all consecutive patients with chronic coronary syndrome hospitalized between 2020 and 2021. For 279 patients (417 vessels), results for both FFR and iFR/RFR were available. Values of ≤0.80 for FFR and ≤0.89 for iFR/RFR were considered positive for ischemia. Discordant measurements of FFR and iFR/RFR were observed in 80 (19.2%) patients. Atrial fibrillation was the only predictor of the overall FFR and iFR/RFR discordance - OR (95%CI) 1.90 (1.02-3.51); p = 0.040. The chance of positive FFR and negative iFR/RFR decreased independently with age - OR (95%CI) 0.96 (0.93-0.99); p = 0.024. On the contrary, insulin-treated diabetes mellitus was the predictor of negative FFR and positive iFR/RFR discrepancy - OR (95%CI) 4.61 (1.38-15.40); p = 0.013. In everyday clinical practice, iFR/FFR correlates well with FFR. However, discordance between these methods is quite common. Physicians should be aware of the risk of such discordance in patients with atrial fibrillation, advanced age, and insulin-treated diabetes mellitus.

Impact of COVID-19 Pandemic on Patients with ST-Segment-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest

Patients with ST-segment-elevation myocardial infarction (STEMI) treated during the COVID-19 pandemic might experience prolonged time to reperfusion. The delayed reperfusion may potentially aggravate the risk of out-of-hospital cardiac arrest (OHCA) in those patients. Limited access to healthcare, more reluctant health-seeking behaviors, and bystander readiness to render life-saving interventions might additionally contribute to the suggested change in the risk of OHCA in STEMI. Thus, we sought to explore the effects of the COVID-19 outbreak on treatment delay and clinical outcomes of patients with STEMI with OHCA. Overall, 5,501 consecutive patients with STEMI complicated by OHCA and treated with primary percutaneous coronary intervention with stent implantation were enrolled. A propensity score matching was used to obviate the possible impact of non-randomized design. A total of 740 matched pairs of patients with STEMI and OHCA treated before and during the COVID-19 pandemic were compared. A similar mortality and prevalence of periprocedural complications were observed in both groups. However, patients treated during the COVID-19 outbreak experienced longer delays from first medical contact to angiography (88.8 (±61.5) vs. 101.4 (±109.8) [minutes]; p = 0.006). There was also a trend toward prolonged time from pain onset to angiography in patients admitted to the hospital in the pandemic era (207.3 (±192.8) vs. 227.9 (±231.4) [minutes]; p = 0.06). In conclusion, the periprocedural outcomes in STEMI complicated by OHCA were comparable before and during the COVID-19 era. However, treatment in the COVID-19 outbreak was associated with a longer time from first medical contact to reperfusion.

Diabetes Mellitus Is Still a Strong Predictor of Periprocedural Outcomes of Primary Percutaneous Coronary Interventions in Patients Presenting with ST-Segment Elevation Myocardial Infarction (from the ORPKI Polish National Registry)

The impact of diabetes mellitus (DM) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was confirmed by several studies. However, it is unclear whether this effect is still present in large groups of unselected patients undergoing up-to-date treatment. Thus, we sought to assess the impact of DM on periprocedural outcomes of primary PCI in STEMI using data from the Polish National Registry of PCI. Data on 150,782 STEMI patients undergoing primary PCI were collected. Of them, 26,360 (17.5%) patients had DM. Patients with DM were higher-risk individuals who experienced longer reperfusion delays and were less likely to have closed infarct-related artery at baseline (TIMI 0 + 1 flow: 73.2% vs. 72.0%; p < 0.0001) and achieve optimal reperfusion after PCI (TIMI 3 flow: 91.8% vs. 88.5%; p < 0.0001). The periprocedural mortality (1.1% vs. 1.9%; p < 0.0001) was higher in patients with DM and DM was identified as an independent predictor of periprocedural death. In conclusion, despite continuous progress in STEMI treatment, DM remains a strong predictor of periprocedural mortality. However, this detrimental effect of DM may be partially explained by the overall higher risk profile of diabetic patients.

Outcomes of COVID-19 patients with STEMI undergoing primary PCI

Introduction and aim

Coronavirus disease (COVID-19) has substantial impact on acute myocardial infarction (AMI) clinical course and outcome.

In Poland during early phase of COVID-19 pandemic a network of dedicated hospitals was set to treat SARS-Cov2 positive patients. There is scarce data on STEMI patients outcome treated in this setting.

Our aim was to compare outcomes of STEMI patients treated with primary PCI in hospitals dedicated to treat COVID-19 and referral high volume haemodynamic centres.

Methods

Study was a retrospective analysis of 115 consecutive COVID-19 patients with STEMI, treated with primary PCI, admitted to 4 high volume centres (2 referral hospitals and 2 COVID dedicated sites) in southern Poland between May 2020 and November 2021. Data was obtained from patients' electronic medical records.

Results

Detailed characteristics are presented in Table 1 and 2. In general in all hospitals, patients were similar in terms of age (median 69 y.o., IQR: 60–73), with similar profile of comorbidities. All patients used acetylsalicylic acid and unfractioned heparin.

In referral centres, as compared with COVID-19 dedicated sites, there was a higher use of mechanical thrombectomy (p&lt;0.001) and adenosine (p&lt;0.001). Overall mortality rate was higher in COVID-19 centres (50% vs 25%, p=0.008). Detailed results are presented in Table 3.

Conclusions

There is a significantly higher mortality in COVID patients who develop STEMI than in patients with STEMI who were tested positive on admission.

Patients in COVID-19 hospitals had higher levels of CRP and NT-proBNP at baseline.

There are substantial differences in treatment of patients in referral centres and COVID dedicated hospitals.

Funding Acknowledgement

Type of funding sources: None.

Contemporary approach to thrombus containing lesions during primary percutaneous coronary interventions in ST-segment elevation myocardial infarction (from the ORPKI National Registry in Poland)

Background

In the era of potent P2Y12 inhibitors, according to current guidelines on ST-segment elevation myocardial infarction (STEMI), treatment with glycoprotein IIb/IIIa inhibitors (GPI) should be limited to selected bail-out or highly thrombotic situations. Similarly, aspiration thrombectomy (AT) is downgraded in current guidelines for very selective but not routine usage. Both recommendations make the treatment of thrombus containing lesions somewhat defensive, underlining the need for an individualized approach to STEMI patients. However, data concerning current clinical practice of such approach are limited.

Purpose

We examined the prevalence, procedural characteristics, and predictors of GPI administration and AT usage in all-comers contemporary STEMI patients referred to primary PCI in Poland.

Methods

We focused on 116,873 consecutive STEMI patients undergoing primary PCI in Poland between 2015 and 2020.

Results

GPIs were administered in 29.3% of patients and AT was used in 11.6%, with combined treatment with GPI and AT in 6.1% of patients. There was a slight trend towards a decrease in GPI and AT usage during the analyzed years. On the opposite, there was a rapid growth of the ticagrelor/prasugrel usage rate from 6.5% in 2015 to 48.1% in 2020 (Figure 1). Patients with periprocedural GPI administration and combined strategy with GPI and AT were younger, more often men, with history of smoking and presented with cardiogenic shock on admission. They were less likely to have diabetes, chronic kidney disease and previous stroke. Occluded infarct-related artery in baseline angiography and no-reflow during PCI were the strongest independent predictors of GPI administration and combined usage of GPI and AT in a multivariate logistic regression model. Similarly, administration of ticagrelor/prasugrel was an independent predictor of both adjunctive treatment strategies (see table for details).

Conclusions

Despite the rapid growth of potent P2Y12 inhibitors usage in Poland in recent years, GPI and AT are selectively used at a stable level during primary PCI in highly thrombotic STEMI lesions.

Funding Acknowledgement

Type of funding sources: None.

Risk factors of contrast-induced nephropathy in patients with acute coronary syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) are at high risk of contrast-induced nephropathy (CIN), which is associated with prolonged hospitalization, higher morbidity and mortality after angiographic procedures. The occurrence of CIN is regarded as a transient and reversible condition. However, the persistence of CIN until hospital discharge in patients with ACS has not been thoroughly analyzed.

AIMS

We aimed to analyze CIN persistent until hospital discharge in contemporary ACS population referred to invasive diagnostics and treatment.

METHODS

A total of 2638 consecutive patients with ACS were included in a prospective registry. The occurrence of CIN was defined as a 25% increase in serum creatinine from baseline or a 0.5 mg/dl (44 μmol/l) increase in the absolute value.

RESULTS

Criteria of CIN at hospital discharge were met in 10.7% of patients. Immediate percutaneous coronary intervention (PCI) after angiography (67% of patients) was associated with higher rates of CIN compared to patients referred for other treatment strategies (P < 0.001). The logistic regression model showed that anemia at baseline (8.7% of patients) was an independent predictor of CIN, which occurred in 17.9% of anemic patients and 10% of patients without anemia (P < 0.001). Also, ST-segment elevation myocardial infarction (STEMI) presentation and immediate PCI were independent predictors of CIN.

CONCLUSIONS

Despite intravenous fluid administration during the hospital stay, CIN persisted until hospital discharge in more than 10% of patients with ACS. Anemia at baseline, STEMI presentation, and immediate PCI strategy were independent predictors of CIN. Thus, preventive actions should be specially aimed at those groups of patients.

Frailty as a Predictor of In-Hospital Outcome in Patients with Myocardial Infarction

(1) Background: Frailty is a condition associated with aging, co-morbidity, and disability. We aimed to investigate the relationship between frailty and in-hospital outcome in patients with myocardial infarction (MI), including the occurrence of delirium, hospital-acquired pneumonia (HAP), and length of hospital stay. (2) Methods: We analyzed 55 patients ≥ 75 years old with ST-elevation and non-ST-elevation MI. Assessment with Abbreviated Mental Test Score (AMTS), Activity of Daily Living (ADL), Instrumental Activity of Daily Living (IADL) and Clinical Frailty Scale (CFS) was performed. (3) Results: In ROC analysis, IADL and CFS presented good predictive values for the occurrence of delirium (AUC = 0.81, p = 0.023, and AUC = 0.86, p = 0.009, respectively). For predicting HAP, only AMTS showed a significant value (AUC = 0.69, p = 0.036). In regression analyses, all tests presented significant predictive values for delirium. For predicting HAP, only IADL and CFS presented significant values (in an analysis adjusted for age, gender and type of MI). Frail patients (≥5 points in CFS) had longer hospital stays (10 days IQR: 8–17 vs. 8 days IQR: 7–10; p = 0.03). (4) Conclusions: While recognizing the limitations of our study associated with the relatively low sample size, we believe that our analysis shows that frailty is a predictor of poorer in-hospital outcomes in patients with MI, including higher rates of delirium, HAP and longer hospital stay.

Mid-regional pro-adrenomedullin and lactate dehydrogenase as predictors of left ventricular remodeling in patients with myocardial infarction treated with percutaneous coronary intervention

BACKGROUND

The main impact of myocardial infarction (MI) is shifting from acute mortality to adverse remodeling, chronic left ventricle (LV) dysfunction and heart failure.

OBJECTIVES

The aim of this study was to assess relationships between levels of circulating biomarkers and function of LV after MI.

PATIENTS AND METHODS

Prospective study of 80 patients with MI treated with percutaneous coronary interventions (PCI). Novel biomarkers including mid-regional pro-adrenomedullin (MR-proADM), Notch-1, syndecan-4, myeloperoxidase, S-100 protein, soluble ST-2, as well as markers of inflammatory response and tissue injury: galectin-3, C-reactive protein (CRP), lactate dihydrogenase (LDH) and interleukin-6 (IL-6) were assessed in the acute phase of MI. Echocardiography was performed at baseline and 6 months.

RESULTS

Adverse remodeling, defined as >20% increase in LV end-diastolic volume occurred in 26% of patients. Reverse remodeling (>10% reduction in LV end-systolic volume) was observed in 52% of patients. In a univariable analysis higher levels of MR-proADM and LDH were predictors of adverse remodeling and higher levels of MR-proADM, LDH, CRP and Il-6 were negative predictors of reverse remodeling. In a multivariable model LDH remained an independent predictor of adverse remodeling (OR: 3.13; 95%CI: 1.42-8.18; P=0.003) and negative predictor of reverse remodeling (OR: 0.37; 95%CI: 0.17-0.8; P=0.005).

CONCLUSIONS

LDH and MR-proADM seem to be promising biomarkers of adverse remodeling. On the other hand, higher levels of these biomarkers were associated with reduced chance of occurrence of favorable reverse remodeling in MI patients. However, further studies on larger groups of patients are necessary to confirm this data.

Treatment delay and clinical outcomes in patients with ST-elevation myocardial infarction during the COVID-19 pandemic

Background

The COVID-19 pandemic negatively affected access to health-care system and timeline of treatment. The fear of contamination might potentially forbear from accessing the emergency system.mFurthermore, pandemic-specific protocols require additional time to prepare medical stuff and catheterization laboratory before procedure. Thus, patients with ST-segment elevation myocardial infarction (STEMI) might be exposed to a longer delay for revascularization and higher risk of mortality.

Purpose

The aim of this study was to evaluate treatment delay and clinical outcomes in COVID-19 positive and negative patients with STEMI treated with percutaneous coronary intervention (PCI) during on- and off hours.

Methods

All consecutive patients with STEMI treated with PCI and stent implantation between 1st March 2020 and 31st December 2020 were enrolled into analysis. To overcome potential bias related to the non-randomized design a propensity score match (PSM) was used to compare COVID-19 positive and negative patients for both working frames hours. The study group consisted of 877 matched pairs treated during regular hours (everyday 7:00AM-16:59PM) and 418 matched pairs with PCI performed during off-hours (everyday 17:00PM and 06:59AM) in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry).

Results

After PSM there were no differences between COVID-19 positive and negative patients in baseline characteristics during both on- and off-hours. However, patients diagnosed with COVID-19 were admitted with cardiac arrest more frequently as compared to COVID-19 negative patients during regular working hours (180 (20.5%) vs. 64 (7.30%); p=0.001). There were no differences in radiation doses and total amount of contrast between both groups. Similarly, no differences in rate of periprocedural complications were observed despite of time of intervention, including stroke, access-site-related bleeding, allergic reaction and coronary artery perforation. Furthermore, there were no differences in periprocedural mortality between both groups (on-hours: COVID-19 negative vs. COVID-19 positive: 17 (1.9%) vs. 11 (1.3%),p=0.3; off-hours: COVID-19 negative vs. COVID-19 positive: 4 (1.0%) vs. 7 (1.7%),p=0.5). However, COVID-19 positive patients were exposed to longer time from first medical contact to angiography during both on-hours (133.76 (±137.10) vs. 117.14 (±135.83) [min]; p=0.001) and off-hours (148.08 (±201.56) vs. 112.19 (±138.72) [min]; p=0.003). Time from pain to first medical contact remained similar during both working frame hours (On-hours and off-hours, respectively: p=0.7 and p=0.9).

Conclusions

Patients diagnosed with COVID-19 might experience a longer time from first medical contact to revascularization. There was no impact of COVID-19 diagnosis on rate of periprocedural mortality or periprocedural complication, irrespective of time of intervention. System-level changes might be crucial to improve health-care during COVID-19 pandemic.

Funding Acknowledgement

Type of funding sources: None.

Treatment Delay and Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction during the COVID-19 Pandemic

Pandemic-specific protocols require additional time to prepare medical staff and catheterization laboratories. Thus, we sought to investigate treatment delay and clinical outcomes in COVID-19 positive and negative patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) during on- and off-hours. All consecutive patients with STEMI treated with PCI between 1 March and 31 December 2020 were enrolled in the analysis. A propensity score match was used to compare COVID-19 positive and negative patients for on- and off-hours. The study group was comprised of 877 paired patients treated during regular hours (every day 7:00 a.m. to 16:59 p.m.) and 418 matched pairs with PCI performed during off-hours (every day 17:00 p.m. to 06:59 a.m.) (ORPKI Polish National Registry). No difference in periprocedural mortality was observed between the two groups (on-hours: COVID-19 negative vs. COVID-19 positive: 17 (1.9%) vs. 11 (1.3%); p = 0.3; off-hours: COVID-19 negative vs. COVID-19 positive: 4 (1.0%) vs. 7 (1.7%); p = 0.5). Additionally, a similar rate of periprocedural complications was reported. Patients diagnosed with COVID-19 were exposed to longer time from first medical contact to angiography (on-hours: 133.8 (±137.1) vs. 117.1 (±135.8) (min); p = 0.001) (off-hours: 148.1 (±201.6) vs. 112.2 (±138.7) (min); p = 0.003). However, there was no influence of COVID-19 diagnosis on mortality and the prevalence of other periprocedural complications irrespective of time of intervention.

Radial approach reduces mortality in patients with ST-segment elevation myocardial infarction and cardiogenic shock

INTRODUCTION

The beneficial outcome of the radial (RA) over femoral approach (FA) in ST-segment elevation myocardial infarction (STEMI) has been widely demonstrated. However, most of the studies excluded patients with STEMI and cardiogenic shock (CS).

OBJECTIVES

We sought to evaluate periprocedural outcomes of percutaneous coronary intervention (PCI) with RA and FA in patients with STEMI complicated by CS using data from the Polish National PCI Registry (ORPKI).

PATIENTS AND METHODS

A total of 3,565 consecutive patients with STEMI and CS treated with emergent PCI and stent implantation were included. Data was collected prospectively between 2014 and 2018 from 151 tertiary primary-PCI centers in Poland. To avoid possible selection bias, a propensity score matching (PSM) was used to create 945 matched pairs treated via RA or FA.

RESULTS

No differences were reported in baseline characteristics, clinical presentation and delays in treatment between RA and FA after the PSM. Similar radiation doses and the total amount of contrast were used in both groups. A similar rate of periprocedural complications was observed in both RA and FA. However, RA was associated with reduced periprocedural mortality (9.4% (89) vs. 18.6% (176); P=0.001) and lower incidence of cardiac arrest (9.7% (92) vs. 16.1% (152); P=0.001). In multivariable analysis, FA was the strongest independent predictor for increased periprocedural mortality (OR 2.087, 95% CI 1.629-2.674; P=0.001).

CONCLUSIONS

The radial approach was associated with lower periprocedural mortality compared with FA in patients with STEMI complicated by CS. RA seems to be a valuable option in technically feasible situations.

Percutaneous coronary intervention during on- and off-hours in patients with ST-segment elevation myocardial infarction

OBJECTIVE

There are conflicting data on the clinical outcomes of percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) based on the time of admission to the catheterization laboratory. Thus, we aimed to assess clinical outcomes in an unselected cohort of consecutive patients with STEMI treated with PCI during on-and-off hours of work.

METHODS

A total of 99,783 patients were included in the analysis. Patients were divided using the most frequently used definition: On-hours (Monday-Friday 07:00 AM-04:59 PM); off-hours (Monday-Friday 05:00 PM-06:59 AM, Saturday, Sunday, and nonworking holidays) (37,469 matched pairs). To avoid potential preselection bias, a propensity score was calculated to compare on-and-off hour groups.

RESULTS

Higher radiation doses were observed for PCIs performed during off-hours (1055.2(±1006.5) vs. 1081.6(±1003.25)[mGy] and p = 0.001). A similar prevalence of periprocedural complications was observed during on- and off-hours. However, there was a higher mortality rate during off-hours than during regular working hours (1.17% (439) vs. 1.49% (559) and p = 0.001).

CONCLUSIONS

Primary PCIs in STEMI performed during off-hours might be associated with a higher rate of periprocedural mortality and higher radiation doses than procedures conducted during regular working hours.

Long-term outcomes of percutaneous coronary interventions within coronary artery bypass grafts

INTRODUCTION

The long-term outcomes of percutaneous coronary interventions (PCIs) within coronary artery bypasses are still poor as compared to those within native coronary arteries. Thus, we aimed to assess predictors of long-term clinical outcomes after PCIs of coronary bypasses.

MATERIAL AND METHODS

We enrolled 194 patients after PCIs of coronary artery bypasses at the mean age of 69.5 ±8.3 years (73.2% male). The primary study endpoint was a combination of target-vessel revascularization (TVR), target-lesion revascularization (TLR), myocardial infarction (MI), stroke, coronary artery bypass grafting (CABG) and death. The mean follow-up was 964 ±799.1 days and was completed among 156 patients. Multivariate analysis was used to assess determinants of study endpoints during follow-up. Moreover, we compared survival curves according to the type of PCI and presence of anti-embolic protection.

RESULTS

The primary endpoint of the study occurred in 59.7% of patients after the mean time of 669.6 ±598.7 days. The TVR occurred in 37.9% of individuals, TLR in 24.2%, MI in 26.3%, stroke in 4.2%, CABG in 2.1% and death in 30.5% of patients. In Cox multivariate analysis, PCI of two or more bypasses (p < 0.01), post-dilatation (p < 0.05) and no-reflow (p < 0.05) were the independent determinants of the primary study endpoint. No significant impact of anti-embolic protection devices on long-term outcomes was observed.

CONCLUSIONS

Percutaneous coronary interventions of two or more bypasses, post-dilatation and no-reflow are predictors of worse outcome in patients undergoing PCI within coronary artery bypass grafts.

Concomitant multi-vessel disease is associated with a lower procedural death rate in patients treated with percutaneous coronary interventions within the left main coronary artery (from the ORPKI registry)

INTRODUCTION

In this study, we aimed to distinguish differences in the procedural complication rate in a group of patients undergoing percutaneous coronary interventions (PCI) of the left main coronary artery (LMCA) between patients with isolated LMCA disease and multi-vessel disease (MVD) with LMCA involvement and to identify their predictors.

MATERIAL AND METHODS

We assessed 221,187 patients from the Polish Cardiovascular Intervention Society national registry (ORPKI) regarding all PCI procedures performed in Poland in 2015 and 2016. We extracted data of 1,819 patients with isolated LMCA disease and 3,718 patients with MVD and LMCA involvement. We compared those two groups in terms of procedural complications and their predictors.

RESULTS

The overall rate of procedural complications was significantly higher in patients treated with LMCA PCI both in the group of patients with isolated LMCA (6.5%) and the group with MVD with LMCA involvement (7.3%) compared to the non-LMCA PCI group (1.9%, p = 0.002). Multivariate analysis confirmed that MVD with LMCA involvement is an independent predictor of decreased risk of procedural death in the overall group of patients undergoing PCI of the LMCA (odds ratio: 0.583; 95% confidence interval: 0.4-0.848; p = 0.005).

CONCLUSIONS

The MVD involvement in patients treated with PCI of the LMCA may play a protective role. Patients with isolated LMCA involvement undergoing PCI should be subjected to special care and protected by various methods, such as devices to support left ventricle function.

Comparison of safety and effectiveness between the right and left radial artery approach in percutaneous coronary intervention

INTRODUCTION AND OBJECTIVES

There is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in "real-world" patients with either stable angina or acute coronary syndrome (ACS).

METHODS

To overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry).

RESULTS

The rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0±947.1 mGy vs 1007.4±983.5 mGy, P=.001; ACS: 1212.7±1005.5 mGy vs 1053.5±1029.7 mGy, P=.001). More contrast was used in LRA procedures but only in ACS patients (174.2±75.4mL vs 167.2±72.1mL, P=.001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P=.008), no-reflow phenomenon (0.65% vs 0.49%, P=.005), and puncture site bleeding (0.09% vs 0.05%, P=.04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P=.90).

CONCLUSIONS

Our finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients.

Percutaneous coronary intervention during on- and off-hours in patients with ST-segment elevation myocardial infarction

Introduction

There are conflicting data on the clinical outcomes of percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) based on time of intervention. Concerns have been postulated regarding equally effective in-hospital outcomes for STEMI patients treated with PCI during normal working hours as compared to group treated off-hours.

Purpose

The aim of this study was to assess clinical outcomes in “real-world” patients with STEMI treated with PCI during off-hours and regular hours of work.

Methods

To avoid possible bias related to the non-randomized design, a propensity score was calculated to compare off- and on-hours groups. The study group consisted of 37, 469 matched pairs in STEMI treated with PCI and stent implantation between 2014 and 2018 during regular hours (weekdays 7:00 AM to 16:59 PM) and off-hours (weekdays between 17:00 PM and 06:59AM, weekends, and holidays) in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry).

Results

No differences were reported between both groups in baseline characteristics after the propensity score match (PSM). There were no differences in time from pain to first contact (p=0.2) and door to balloon time between both groups (p=0.7). After PSM higher radiation dose was observed in off-hours group (1055.18 (±1006.52) vs. 1081.59 (±1003.25)[mGy]; p=0.001). However, there was no difference in total amount of contrast (on-hours vs. off-hours: 175.69 (±74.71) vs. 176.48 (±74.41)[ml]; p=0.1, respectively). Similar rate of periprocedural complications was observed between both groups of patients, includind stroke, access-site-related bleeding, allergic reaction and coronary artery perforation. However, procedures performed during off-hours were associated with higher incidence of periprocedural death (1.17% (439) vs. 1.49% (559); p=0.001) and periprocedural cardiac arrest (1.76% (658) vs.1.97% (740); p=0.001) as compared to PCI conducted within normal working hours.

Conclusions

Percutaneous coronary intervention in STEMI performed durgin off-hours might be associated with higher rate of periprocedural mortality and higher radiation dose as compared to procedures conducted during regular working hours.

Funding Acknowledgement

Type of funding source: None

Direct Rapid Left Ventricular Wire Pacing during Balloon Aortic Valvuloplasty

Background: Rapid ventricular pacing is mandatory for optimal balloon positioning during aortic valvuloplasty (BAV) in patients with severe aortic stenosis. We aimed to assess the safety and efficacy of direct left ventricular (LV) guidewire pacing in comparison with regular pacing induced by temporary pacemaker (PM) placement in the right ventricle. Methods: Direct rapid LV pacing was provided with a 0.035″ guidewire. Baseline clinical characteristics, echocardiographic and procedural data, as well as complication rates, were compared between the two groups. Results: A total of 202 patients undergoing BAV were enrolled (49.5% with direct LV guidewire pacing). The pacing success rate was 100%. In the direct LV guidewire pacing group, we found a lower radiation dose, shorter fluoroscopy and overall procedural time (0.16 vs. 0.28 Gy, p = 0.02; 5.4 vs. 10.3 min, p = 0.01; 17 vs. 25 min, p = 0.01; respectively). In addition, the complication rate was lower in that group (cardiac tamponades, vascular access site complications, blood transfusions rate, and in-hospital mortality: 0% vs. 3.9%; 4.0% vs. 15.7%; 2.0% vs. 12.7%; 2.0% vs. 9.8%, p = 0.01 for all, respectively). Conclusions: Direct rapid LV guidewire pacing is a simple, safe and effective option for BAV with a reduced complication rate compared to a temporary PM placed in the right ventricle.

Prevalence and Predictors of Coronary Artery Perforation During Percutaneous Coronary Interventions (from the ORPKI National Registry in Poland)

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). With a growing number of PCIs in complex lesions, the problem of CAP becomes even more important nowadays. Data on CAP rates in Poland are lacking. Presented study is an analysis of 344,517 consecutive patients treated with PCI between 2014 and 2017. Data were gathered from the Polish National PCI Registry (ORPKI). During 4 years of data collection CAP was observed in 595 (0.17%) cases. Patients diagnosed with CAP were older (69 years Q1:63; Q3:78 vs 66 years Q1:60; Q3:75; p <0.001), more often female (44% vs 32%; p <0.001), with arterial hypertension (77% vs 71%; p = 0.002), and chronic kidney disease (8.9% vs 5.4%; p <0.001). In the CAP group, a higher rate of PCIs within chronic total occlusions (8.7% vs 2.3%; p <0.001) and saphenous vein graft lesions (2.7% vs 1.3%; p = 0.002), as well as rotational atherectomy procedures (2.2% vs 0.4%; p <0.001) was observed. Patients with CAP had higher rate of no-reflow phenomenon (5.5% vs 0.5%; p <0.001) and greater periprocedural mortality (4.2% vs 0.5%; p <0.001). In conclusion, our study confirms that CAP is more common during complex PCI procedures in high-risk patients. CAP occurrence is associated with worse immediate outcomes including increased periprocedural mortality.

P4597Impact of operator experience with radial approach for clinical outcome on percutaneous coronary intervention in acute coronary syndrome performed with femoral artery access site

Introduction

Radial approach (RA) for percutaneous coronary intervention (PCI) is associated with reduced mortality and access site complications. The routine use of the RA in patients should be strongly considered, keeping in mind the learning curve associated with the technique. However, promotion of RA may interfere with the equally important goal of maintaining proficiency in the femoral approach (FA), which is essential in a variety of procedures as well as when RA fails. There is possible risk of higher rate of complications in PCI with FA performed by operators mainly using radial artery as access site.

Purpose

The aim of this study was to evaluate impact of experience and proficiency with RA for clinical outcomes on PCI via FA in “real-world” patients with acute coronary syndrome (ACS).

Methods

A total of 539 invasive cardiologists performing PCI in 151 invasive cardiology centers on the Polish territory between 2014 and 2017 were included in study analysis. Proficiency threshold has been set at >400 procedures during four consecutive years per individual operator. They were categorized to quartiles according to total volume of radial artery utilization during all PCIs. Procedures performed on patients with Killip-Kimball class IV on admission to catheterisation laboratory were excluded from analysis.

Results

The most of the operators performed >75% of all procedures via radial artery (326 (60.5%)), 112 (20.8%) used RA in 50–75% of cases, 67 (12.4%) in 25–50% of all PCIs and only 34 (6.3%) invasive cardiologist were using RA in less than 25% of all procedures. Mortality during PCI via FA was higher in group of invasive cardiologist with >75% of all procedures performed with radial access (>75% vs. 50–75% vs. 25–50% vs. <25%: 1.63% (±2.52%) vs. 0.93% (±1.05%) vs. 0.68% (±0.73%) vs. 0.31% (±0.40%); p=0.01). A trend towards higher rate of bleeding at the puncture site during PCI procedures with femoral artery were reported in groups of operators with higher expertise in RA (>75% vs. 50–75% vs. 25–50% vs. <25%: 0.43% (±1.09%) vs. 0.14% (±0.36%) vs. 0.21% (±0.45%) vs. 0.14% (±0.37%); p=0.09).

Conclusions

Higher experience in radial access might be linked to worse outcome in PCI via FA in ACS settings. Femoral artery is important vascular approach and should not be abandoned while learning procedures with radial artery utilization.

Acknowledgement/Funding

None

P5536Comparison of safety and effectiveness between right and left radial artery approach in percutaneous coronary intervention for acute coronary syndrome. Propensity score analysis of data from the ORPKI

Introduction

The use of the radial approach (RA) for percutaneous coronary intervention (PCI) has gradually increased. Several studies demonstrated that radial artery is associated with significant reduction in major adverse cardiac events for both coronary angiography and PCI in acute coronary syndrome (ACS). However, it is still unclear if the side of RA has influence on clinical outcomes in an all-comer population in ACS settings.

Purpose

We sought to evaluate safety, feasibility, and clinical outcomes of right radial approach (RRA) compared to left radial approach (LRA) during PCI in “real-world” patients with ACS.

Methods

A total of 234,087 consecutive patients with ACS treated with PCI and stent implantation via radial approach between 2014 and 2017 in 151 invasive cardiology centers on the Polish territory. Data was based on the ORPKI Polish National Registry. Patients treated with RRA and LRA were compared using a propensity score analysis to avoid possible selection bias. The analysis was done in an “as-treated” manner.

Results

Procedure was conducted using RRA and LRA in 180,378 (77.1%) and 53,709 (22.9%) patients, respectively. After propensity score matching higher total amount of contrast (174.28 (±75.56) vs. 166.95 (±70.57) [ml]; P=0.001) and radiation doses were reported in PCI with left radial artery utilization (1210.21 (±1003.53) vs. 1054.07 (±1024.17) [mGy]; p=0.001). No differences were observed between RRA and LRA in rate of periprocedural adverse events such as myocardial infarction (0.08% vs. 0.08%; p=0.9) stroke (0.02% vs. 0.01%; p=0.1), no-reflow phenomenon (0.64%vs. 0.56%; p=0.1) and death (0.25% vs. 0.24%; p=0.7). A trend towards a lower rate of access-site-related bleeding during PCI was observed in RRA group (0.08% vs. 0.05%; p=0.066). Coronary artery perforation (0.21% vs. 0.16%; p=0.05) and cardiac arrest (0.56% vs 0.42%; p=0.01) were reported more often during PCI conducted with LRA.

Conclusions

Both radial approaches seems to be equally effective in the setting of PCI in ACS. However, utilization of left radial artery was associated with trend toward increased risk of access-site bleeding and higher rate of periprocedural complications as compared to RRA. Higher amount of contrast and radiation doses used in LRA procedures might be equivalent of generally lower experience with this access site.

Acknowledgement/Funding

None

P4706Sex-related differences in clinical outcomes after percutaneous transluminal angioplasty in patients with peripheral artery disease

Aim

There are inconsistent data on the sex-related differences in clinical outcomes after percutaneous transluminal angioplasty (PTA) in patients with peripheral artery disease (PAD). We aimed to investigate sex-related differences in clinical outcomes after PTA.

Methods

A total of 939 consecutive patients undergoing PTA were enrolled in two large volume centers. Patients were stratified by gender. Baseline characteristics, procedural and long-term clinical outcomes were compared between women and men.

Results

Women represented 37.4% of the study population. Women, compared to men, had more often hypertension (92% vs 86%, p=0.001) and diabetes (54% vs 46%, p=0.02). However, men presented more often with chronic obstructive pulmonary disease (14.8% vs 6.8%, p=0.0003), coronary artery disease (45.4% vs 32.7%, p=0.0001), smoking (60.4% vs 45%, p=0.007) and previous PTA (25% vs 17%, p=0.005). There were no differences in 120-month all-cause mortality between groups (women vs. men: 29% vs. 21%, p=0.6). Men were at higher risk of re-PTA at 5-year follow-up (40% vs. 49%; p=0.03). Moreover, male sex was an independent predictor of re-PTA (age-adjusted odds ratio (OR) (95% CI): 1.276 (1.015–1.614), p=0.03). In multivariable Cox regression analysis, a superficial femoral artery chronic total occlusion (SFA-CTO) (hazard ratio [HR]) (95% confidence interval [CI]): 1.68 (1.12–2.5), body mass index (BMI) (hazard ratio (HR)) (95% CI): 0.93 (0.87–0.99), baseline creatinine level hazard ratio (HR)) (95% CI): 0.95 (0.88–0.99) were identified as independent factors of re-PTA in women.

Figure 1. Months to re-PTA for grouping variable male.

Conclusion

Male sex was identified as an independent predictor of re-PTA. SFA-CTO, BMI and baseline creatinine level were associated with re-PTA in women.

Long-term clinical outcomes of direct absorb bioresorbable vascular scaffold implantation in acute coronary syndrome

BACKGROUND

Preferred technique for bioresorbable vascular scaffold (BVS) implantation included high pressure predilation. Data about direct BVS implantation in acute coronary syndrome (ACS) patients are scarce.

METHODS

Analysis of 90 consecutive patients with acute myocardial infarction (MI) treated with primary PCI with Absorb deployment between 2013-2016 in a single center. In 45 patients, scaffolds were implanted in the direct technique, other 45 patients underwent Absorb deployment after balloon predilation.

RESULTS

Follow-up was available in 100% of patients with mean duration of 32±11 months. No cardiac death or scaffold thrombosis were observed in both groups. In the direct group, no target lesion revascularization (TLR) was reported. In the predilation arm, TLR occurred in 4 (9%) patients (P=0.12). Target vessel revascularization (TVR) was observed in 1 (2%) case in the direct group and in 6 (13%) patients from the predilation group (P=0.11). Target vessel MI was reported in one patient from each group. In an intention to treat analysis, we observed significantly higher rates of TVR (15% vs. 2%; P<0.043) and TLR (10% vs. 0%; P=0.038) in the predilation arm. Kaplan-Meier survival analysis did not show significant differences in TLR, TVR and device oriented composite endpoint (a combination of cardiac death, target vessel MI and ischemia driven TLR) between patients treated with both methods.

CONCLUSIONS

Direct Absorb implantation in patients with ACS may be feasible and safe.

Characteristics of patients presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA) in Poland: data from the ORPKI national registry

Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is an important clinical problem especially in the era of extensive utilization of coronary angiography in MI patients. Its pathophysiology is poorly understood which makes diagnostics and treatment of MINOCA challenging in everyday clinical practice. The aim of the study was to assess characteristics of MINOCA patients in Poland based on data from the Polish National ORPKI Registry. In 2016, 49,893 patients with non-ST-segment elevation (NSTEMI) or ST-segment elevation (STEMI) myocardial infarction entered the ORPKI registry. MINOCA was defined as a non-obstructive coronary artery disease (CAD) and a lack of previous coronary revascularization. MINOCA was identified in 3924 (7.8%) patients and clinical presentation was more often NSTEMI than STEMI (MINOCA: 78 vs. 22%; obstructive CAD 51.1 vs. 48.9%; p < 0.0001). MINOCA patients were younger and more often females with significantly lower rates of diabetes, smoking, arterial hypertension, kidney disease, previous MI and previous stroke comparing to patients with obstructive CAD. Myocardial bridge was visualized in angiography more often in the MINOCA group (2.2 vs. 0.4%; p < 0.0001). Additional coronary assessment inducing fractional flow reserve, intravascular ultrasound, optical coherence tomography was marginally (< 1%) used in both groups. Periprocedural mortality was lower in MINOCA group (0.13% vs. 0.95%; p < 0.0001). MINOCA patients represent a significant proportion of MI patients in Poland. Due to multiple potential causes, MINOCA should be considered rather as a working diagnosis after coronary angiography and further efforts should be taken to define the cause of MI in each individual patient.

Safety of bivalirudin versus unfractionated heparin in endovascular revascularization of peripheral arteries in short- and long-term follow-up

INTRODUCTION

Patients with peripheral artery disease (PAD) are considered as a high-risk group for hemorrhagic events.

AIM

To assess the safety of bivalirudin vs. unfractionated heparin (UFH) in percutaneous peripheral interventions (PPI) in short- and long-term follow-up.

MATERIAL AND METHODS

The retrospective single-center, observational study included 160 patients, undergoing PPI. Patients were divided into 2 groups based on the use of anticoagulation - unfractionated heparin (UFH group) or bivalirudin (Biv. group) - and observed up to 5 years.

RESULTS

The UFH group consisted of 101 patients and the Biv. group consisted of 59. We registered the following end points during in-hospital observation: 1 death (0.63% Biv, p = 0.18), 12 hematomas at puncture site (0.63% Biv. vs. 7.05% UFH, p = 0.04), 2 pseudoaneurysms (1.27% UFH, p = 0.29), thrombosis (0.63% UFH, p = 0.45), 1 bleeding from puncture site (0.63% UFH, p = 0.45). The total number of hemorrhagic complications was 1.24% in the Biv. group and 8.07% in the UFH group (p = 0.04). During long-term follow-up of 65.7 ±36.4 months the all-cause mortality rate was higher in the Biv. group (8.59% Biv vs. 0% in UFH group, p = 0.009). Regression analysis showed that bivalirudin administration is a risk factor for increased mortality risk (p = 0.003, OR = 15, 95% CI: 3.3-107.8).

CONCLUSIONS

Usage of UFH was associated with a higher number of hemorrhagic complications, especially hematomas at the puncture site in comparison to patients receiving bivalirudin.

Impact of Coronary Artery Disease and Diabetes Mellitus on the Long-Term Follow-Up in Patients after Retrograde Recanalization of the Femoropopliteal Arterial Region

The most relevant comorbidities in patients with peripheral artery disease (PAD) are coronary artery disease (CAD) and diabetes mellitus (DM). However, data of long-term follow-up of patients with chronic total occlusion (CTO) are scarce. The aim of the study was to assess the impact of CAD and DM on long-term follow-up patients after superficial femoral artery (SFA) CTO retrograde recanalization. In this study, eighty-six patients with PAD with diagnosed CTO in the femoropopliteal region and at least one unsuccessful attempt of antegrade recanalization were enrolled in 2 clinical centers. Mean time of follow-up in all patients was 47.5 months (±40 months). Patients were divided into two groups depending on the presence of CAD (CAD group: n = 45 vs. non-CAD group: n = 41) and DM (DM group: n = 50 vs. non-DM group: n = 36). In long-term follow-up, major adverse peripheral events (MAPE) occurred in 66.6% of patients with CAD vs. 36.5% of patients without CAD and in 50% of patients with DM vs. 55% of non-DM subjects. There were no statistical differences in peripheral endpoints in both groups. However, there was a statistically significant difference in all-cause mortality: in the DM group, there were 6 deaths (12%) (P value = 0.038). To conclude, patients after retrograde recanalization, with coexisting CTO and DM, are at higher risk of death in long-term follow-up.

Chronic obstructive pulmonary disease and periprocedural complications in patients undergoing percutaneous coronary interventions

Background

The relationship between chronic obstructive pulmonary disease (COPD) and periprocedural complications of percutaneous coronary interventions (PCIs) is influenced by several factors. We aimed to investigate the association between COPD, its complication type and rate in patients undergoing PCI.

Methods

Data were prospectively collected using the Polish Cardiovascular Intervention Society national registry (ORPKI) on all PCIs performed in Poland between January 2015 and December 2016. COPD was present in 5,594 of the 221,187 patients undergoing PCI. We assessed the frequency and predictors of periprocedural complications in PCI.

Results

Patients with COPD were elder individuals (70.3 ± 9.9 vs. 67 ± 10.8 years; p < 0.05). We noted 145 (2.6%) periprocedural complications in the COPD group and 4,121 (1.9%) in the non-COPD group (p < 0.001). The higher incidence of periprocedural complications in the COPD patients was mainly attributed to cardiac arrest (p = 0.001), myocardial infarctions (p = 0.002) and no-reflows (p < 0.001). COPD was not an independent predictor of all periprocedural complications. On the other hand, COPD was found to be an independent predictor of increased no-reflow risk (odds ratio [OR] 1.447, 95% CI 1.085–1.929; p = 0.01), and at the same time, of decreased risk of periprocedural allergic reactions (OR 0.117, 95% CI 0.016–0.837; p = 0.03).

Conclusions

In conclusion, periprocedural complications of PCIs are more frequent in patients with COPD. COPD is an independent positive predictor of no-reflow and a negative predictor of periprocedural allergic reactions.

Predictors of syncope in patients with severe aortic stenosis: The role of orthostatic unload test

BACKGROUND

There is a paucity of data regarding response of cerebral blood flow to the postural unloading maneuver and its impact on the risk of syncope in patients with aortic stenosis (AS). The aim of the present study was to assess effects of orthostatic stress test on changes in carotid and vertebral artery blood flow and its association with syncope in patients with severe AS.

METHODS

108 patients were enrolled (72 with and 36 patients without syncope) with severe isolated severe AS. Peak systolic blood-flow velocity (PSV) and end-diastolic velocity in the carotid arteries and vertebral arteries were measured by duplex ultrasound in the supine position and at 1-2 min after the assumption of the standing position.

RESULTS

The orthostatic stress test induced a significant decrease in carotid and vertebral arterial flow velocities in all examined arteries (p < 0.001). The median (interquartile range) of mean change in PSV for carotid arteries was higher for patients with syncope (syncope [-] vs. syncope [+]: -0.6 cm/s [-1.8, 1.0] vs. -7.3 cm/s [-9.5, -2.0]; p < 0.001) and similarly for vertebral arteries (-0.5 cm/s [-2.0, 0.5] vs. -4.8 cm/s [-6.5, -1.3]; p < 0.001, respectively). Age, aortic valve area, and mean change in PSV for carotid arteries were independently associated with syncope.

CONCLUSIONS

In patients with AS, a decrease in carotid and vertebral arterial flow velocities in the standing position was observed and was associated with syncope. The present findings may support the value of an orthostatic test in identifying patients with severe AS and a high risk of syncope.

Diabetes and periprocedural outcomes in patients treated with rotablation during percutaneous coronary interventions

BACKGROUND

This study is to assess differences in periprocedural outcomes among diabetic and non-diabetic patients treated with percutaneous coronary intervention (PCI) and rotational atherectomy (RA).

METHODS

Under assessment were 221,187 patients from the Polish Cardiovascular Intervention Society national registry (ORPKI) including all PCIs performed in Poland in 2015 and 2016. Data was extracted of 975 patients treated with RA - 336 (34.5%) diabetics and 639 (65.5%) non-diabetics. Periprocedural complications were defined as overall rate or particular complications such as deaths, no-reflows, perforations, dissections, cerebral strokes or bleedings.. Multivariate analysis was performed to assess predictors of periprocedural complications.

RESULTS

The mean age was similar in diabetics and non-diabetics (70.9 ± 9.0 vs. 72.1 ± 9.9; p = 0.06). Diabetics were more often females (p < 0.01), with arterial hypertension (p < 0.01), kidney failure (p < 0.01) and prior myocardial infarction (p = 0.01). No significant differences were observed in overall or individual periprocedural complications and angiographic success was expressed as thrombolysis in myocardial infarction grade 3 flow after PCI. At baseline, de-novo lesions accounted for 96.5% in diabetics and 99% in non-diabetics (p < 0.01), while overall rate of restenosis was 3.5% and 1%, respectively (p < 0.01). Diabetes was an independent predictor of periprocedural complications in the overall group of patients treated with PCI (OR 1.11, 95% CI 1.04-1.194; p < 0.001).

CONCLUSIONS

The negative impact of diabetes on the incidence of periprocedural complications and angiographic effectiveness in the group of patients treated with RA is mitigated in the comparison to the non-RA group.

Impact of On-Site Surgical Backup on Periprocedural Outcomes of Primary Percutaneous Interventions in Patients Presenting With ST-Segment Elevation Myocardial Infarction (From the ORPKI Polish National Registry)

Conflicting data exist regarding the associations between on-site surgical backup and outcomes after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Thus, we sought to assess the impact of such a backup on periprocedural outcomes of primary PCI using data from the Polish National Registry of PCI. From 2014 to 2016 data on 66,707 patients presenting with STEMI undergoing primary PCI from 154 centers were collected. Patients were divided into 2 groups based on the presence of on-site surgical backup. Of 66,707 patients, 15,040 (22.6%) patients were treated in 28 centers with on-site surgical backup. On-site surgical backup was associated with a higher center PCI annual volume (662.4 ± 301.8 vs 1098.7 ± 483.5; p <0.001), but a lower operator PCI annual volume (226.7 ± 126.0 vs 207.8 ± 96.6; p <0.001). The periprocedural mortality (1.60% vs 1.09%; p <0.001) was lower in patients from centers with on-site cardiac surgery and both on-site surgical backup (odds ratio [95% confidence interval], 0.618 [0.517; 0.738]; p <0.001) and the mean number of PCIs by operator per year (odds ratio per 10 [95% confidence interval], 0.990 [0.984; 0.996]; p = 0.001] were independent predictors of periprocedural death. In conclusion, results of our study suggest that periprocedural mortality in patients undergoing primary PCI for STEMI is lower in centers than without on-site cardiac surgical backup. Whether this effect on mortality is attributable to such backup itself and/or whether surgical backup is a marker of overall better medical care and adherence to professional guidelines, this needs clarification in further studies.

Contemporary use of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction referred to primary percutaneous coronary interventions in Poland: Data from ORPKI national registry

According to guidelines, it is recommended to give P2Y₁₂ inhibitors (preferably ticagrelor or prasugrel) at the time of first medical contact in patients with STEMI. However, in real life antiplatelet treatment strategies are different among countries. We analyzed data on antiplatelet treatment in STEMI patients included into Polish ORPKI national registry. A total of 23,139 STEMI patients from 153 invasive cardiology centers were reported in ORPKI registry between September 2015 and August 2016. Finally 19,437 patients from 122 centers (immediate PCI in 94%) were included into the analysis (lack of ticagrelor or prasugrel usage reported in 31 centers). The dominant P2Y₁₂ inhibitor was clopidogrel (69%) with a high rate of precathlab administration (51.3%). Ticagrelor was administered in 10.1% of patients (2.3% during precathlab phase) and prasugrel in 1.1% (0.4% precathlab). The periprocedural switch from clopidogrel to newer generation oral P2Y₁₂ inhibitors was rare (to ticagrelor: 2%; to prasugrel: 0.15%). Analysis of data from top 10 centers with the highest rate of newer generation P2Y₁₂ inhibitors usage (1295 patients) revealed ticagrelor administration in 43.1% (prasugrel in 3%). During precathlab phase higher proportion of ticagrelor instead of clopidogrel (ticagrelor 17.9%, clopidogrel 29.8%) and higher rate of periprocedural switch from clopidogrel to ticagrelor (11.9%) was found comparing to all centers data (p < 0.001 for all). The strategy of precathlab administration of P2Y₁₂ inhibitors applies to about half of STEMI patients in Poland. Generally, ticagrelor or prasugrel use is low, and not equally distributed among centers. In centers with high usage, ticagrelor is main newer generation P2Y₁₂ inhibitor for precathlab and periprocedural administration.

Direct Absorb bioresorbable scaffold implantation in acute coronary syndrome

BACKGROUND

Direct stent implantation is a preferred technique for primary percutaneous coronary intervention (PCI). For the deployment of a bioresorbable vascular scaffold (BVS), the current guidelines recommend aggressive predilatation. Data about direct BVS implantation in patients with acute coronary syndrome (ACS) are scarce.

AIM

We sought to assess procedural characteristics and immediate outcomes of direct Absorb BVS implantation in ACS patients.

METHODS

A total of 91 patients with acute myocardial infarction (MI) requiring urgent coronary revascularisation were enrolled. Among them, 50 patients underwent an attempt of direct Absorb implantation. The control group consisted of 41 patients treated with PCI with BVS deployment after elective predilatation.

RESULTS

In the direct group BVS deployment was successful in 91% of lesions, and in the remaining 9% of lesions direct implantation failed. In the control group scaffolds were successfully deployed after predilatation in 98% of lesions. In one case Absorb implantation failed even after balloon angioplasty. Type C lesions with severe tortuosity and angulation > 90° were associated with failure in direct Absorb deployment. Quantitative coronary analysis showed similar final percentages of diameter stenosis in the study and control groups. Flow analyses did not show significant differences between both methods. During hospitalisation no recurrent MI, scaffold thrombosis, or target lesion revascularisation was reported in either group.

CONCLUSIONS

Direct Absorb implantation in ACS patients may be feasible in a suitable lesion anatomy.

Predictors of periprocedural complications in patients undergoing percutaneous coronary interventions within coronary artery bypass grafts

BACKGROUND

During the first decade following the coronary bypass grafting, at least ten percent of the patients require percutaneous coronary interventions (PCI) due to graft failure. Saphenous vein grafts (SVG) are innately at a higher risk of periprocedural complications. The present study aimed to investigate predictors of periprocedural complications of PCI within coronary artery bypass grafts.

METHODS

This study analyzed data gathered in the Polish National Registry (ORPKI) between January 2015 and December 2016. Of the 221,195 patients undergoing PCI, data on 2,616 patients after PCI of SVG and 442 patients after internal mammary artery (IMA) were extracted. The dissimilarities in periprocedural complications between the SVG, IMA and non-IMA/SVG groups and their predictors were investigated.

RESULTS

Patients in the SVG group were older (p < 0.001), with a higher burden of concomitant disease and differing clinical presentation. The rate of de-novo lesions was lower, while restenosis was higher at baseline in the SVG (p < 0.001). The rate of no-reflows (p < 0.001), perforations (p = 0.01) and all periprocedural complications (p < 0.01) was higher in the SVG group, while deaths were lower (p < 0.001). Among the predictors of no-reflows, it was found that acute coronary syndromes (ACS), thrombectomy and past cerebral stroke, while the complications included arterial hypertension, Thrombolysis in Myocardial Infarction (TIMI) flow before PCI and thrombectomy.

CONCLUSIONS

Percutaneous coronary interventions of SVG is associated with increased risk of specific periprocedural complications. The ACS, slower TIMI flow before PCI and thrombectomy significantly increase the periprocedural complication rate in patients undergoing PCI of SVG.