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Impact of Eruptive vs Noneruptive Calcified Nodule Morphology on Acute and Long-Term Outcomes After Stenting

https://doi.org/10.1016/j.jcin.2023.03.009Get rights and content

Abstract

Background

Whether an eruptive or noneruptive target lesion calcified nodule (CN) portends worse acute and long-term clinical outcomes after stenting has not been established.

Objectives

The authors sought to compare acute and long-term clinical outcomes in eruptive CN vs noneruptive CN morphology.

Methods

Using optical coherence tomography, an eruptive CN was defined as an accumulation of small calcium fragments protruding and disrupting the overlying fibrous cap, typically with small amount of thrombus. A noneruptive CN was defined as an accumulation of small calcium fragments with a smooth intact fibrous cap without an overlying thrombus. The primary endpoint was target lesion failure (TLF) including cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization in patients with ≥6-month follow-up.

Results

Among 3,231 patients with evaluable pre- and postintervention OCT, 236 patients had lesions with CNs (7.3%). After eliminating 4 secondary lesions and 6 patients without ≥6-month follow-up, 126 (54.8%) lesions with eruptive CNs and 104 (45.2%) lesions with noneruptive CNs formed the current report. Compared with noneruptive CNs, eruptive CNs were independently associated with greater stent expansion (89.2% ± 18.7% vs. 81.5% ± 18.9%; P = 0.003) after adjusting for morphologic and procedural factors. At 2 years, eruptive CNs trended toward more TLF compared with noneruptive CNs (Kaplan-Meier estimates, 19.8% vs 12.5%; P = 0.11) and significantly more target lesion revascularization (18.3% vs 9.6%; P = 0.04). In the adjusted model, eruptive CNs were independently associated with 2-year TLF (HR: 2.07; 95% CI: 1.01-4.50; P = 0.048).

Conclusions

Compared with noneruptive CN morphology, lesions with an eruptive CN appearance on optical coherence tomography had a worse poststent long-term clinical outcome despite better acute stent expansion.

Section snippets

Study population

This was a single-center, retrospective, observational study. Consecutive patients who underwent OCT-guided PCI at St. Francis Hospital from 2012 to 2021 were screened (Supplemental Figure 1) to identify the presence of a de novo native coronary artery eruptive CN or a noneruptive CN on the pre-PCI OCT image in patients with evaluable pre- and post-PCI OCT and ≥6-month clinical follow-up. The study complied with the Declaration of Helsinki, the Institutional Review Board at St. Francis Hospital

Results

From 2012 to 2021, there were 3,981 vessels in 3,231 patients who underwent OCT-guided PCI in a de novo native coronary artery lesion with evaluable pre- and post-PCI OCT images; among them, there were 284 CNs in 240 lesions in 236 vessels from 236 patients (Supplemental Figure 1). Thus, the prevalence of a CN was 5.9% (236/3981) per vessel and 7.3% (236/3231) per patient. After eliminating 6 vessels in 6 patients without a 6-month follow-up and 4 secondary lesions (only the most severe lesion

Discussion

The main findings of the present study of CN lesions were as follows: 1) stent implantation deformed an eruptive CN more readily than a noneruptive CN; 2) the type of CN, negative remodeling, greater CN circumference, and greater surrounding calcium arc were independently associated with poor stent expansion; 3) TLR dramatically increased at approximately 6 months post-PCI in the eruptive CN group compared with the noneruptive CN group; and 4) an eruptive CN, greater CN circumference, greater Δ

Conclusions

Eruptive CNs and noneruptive CNs are distinctly different lesion morphologies, with a large eruptive CN with a greater hinge motion having worse outcomes after PCI despite better stent expansion. The mechanism was angiographic evidence of reprotrusion of the eruptive CN through stent struts.

WHAT IS KNOWN? CNs have a unique morphology and the potential to develop coronary events. Pathologically, CNs have been classified into 2 types: eruptive CNs and noneruptive CNs. In addition, recent studies

Funding Support and Author Disclosures

Dr Evan Shlofmitz has been a consultant to Abbott Vascular, Medtronic, and Opsens Medical. Dr Khalique has received speaker fees from Edwards Lifesciences. Dr Cohen has received research grant support from Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic and has received a consulting income from Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic. Dr Mintz has received honoraria from Boston Scientific/Philips. Dr Richard A. Shlofmitz has been a speaker for Shockwave

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