<div><h4>Angiographic Severity of the Non-culprit Lesion and the Efficacy of Fractional Flow Reserve-guided Complete Revascularization in AMI Patients: FRAMI-AMI Substudy.</h4><i>Seung J, Choo EH, Kim CJ, Kim HK, ... Gwon HC, Hahn JY</i><br /><AbstractText><b>Background</b>: The benefit of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) for non-infarct related artery (IRA) lesions with angiographically severe stenosis in patients with acute myocardial infarction (MI) is unclear. <br /><b>Methods:</b><br/>Among 562 patients from FRAME-AMI trial who were randomly allocated into either FFR-guided or angiography-guided PCI for non-IRA lesions, the current study evaluated the relationship between non-IRA stenosis measured by quantitative coronary angiography (QCA) and the efficacy of FFR-guided PCI. The incidence of the primary endpoint (death, MI, or repeat revascularization) was compared between FFR- and angiography-guided PCI according to non-IRA stenosis severity (QCA stenosis ≥70% or <70%). <br /><b>Results:</b><br/>A total of 562 patients were assigned to FFR-guided (n=284) versus angiography-guided PCI (n=278). At a median follow-up of 3.5 years, the primary endpoint occurred in 14 patients of 181 patients with FFR-guided PCI and 31 of 197 patients with angiography-guided PCI among patients with QCA stenosis ≥70% (8.5% versus 19.2%; hazard ratio 0.41, 95% confidence interval 0.22 - 0.80, p=0.008), while occurred in 4 of 103 patients with FFR-guided PCI and 9 of 81 patients with angiography-guided PCI among those with QCA stenosis <70% (3.9% versus 11.1%, p=0.315). There was no significant interaction between treatment strategy and non-IRA stenosis severity (p for interaction=0.636). FFR-guided PCI was associated with the reduction of death and myocardial infarction in both patients with QCA stenosis ≥70% (6.7% vs. 15.1%, p=0.008) and those with QCA stenosis <70% (1.0% vs. 9.6%, p=0.042) compared to angiography-guided PCI. <b>Conclusions:</b> In patients with acute MI and multivessel disease, FFR-guided PCI tended to have a lower risk of primary endpoint than angiography-guided PCI regardless of non-IRA stenosis severity without significant interaction.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 06 Nov 2023; epub ahead of print</small></div>

<div><h4>Characterising Mechanisms of Ischemia in Patients with Myocardial Bridges.</h4><i>Sinha A, Rahman H, Rajani R, Demir OM, ... Marber M, Perera D</i><br /><AbstractText><b>Background:</b> Myocardial bridges (MBs) are prevalent and can be associated with acute and chronic ischemic syndromes. We sought to determine the substrates for ischemia in patients with angina, nonobstructive coronary arteries (ANOCA) and a MB in the left anterior descending artery. <br /><b>Methods:</b><br/>Patients with ANOCA underwent acquisition of intracoronary pressure and flow during rest, supine bicycle exercise and adenosine infusion. Coronary wave intensity analysis was performed, with perfusion efficiency defined as accelerating wave energy/total wave energy (%). Epicardial endothelial dysfunction was defined as a reduction in epicardial vessel diameter ≥20% in response to intracoronary acetylcholine infusion. Patients with ANOCA and a MB were compared to two ANOCA groups with no MB: one with coronary microvascular disease (CMD: coronary flow reserve, CFR, <2.5) and one with normal CFR (reference: CFR≥2.5). <br /><b>Results:</b><br/>92 patients were enrolled in the study (30 MB, 33 CMD and 29 reference). FFR in these three groups was 0.86±0.05, 0.92±0.04 and 0.94±0.05; CFR was 2.5±0.5, 2.0±0.3 and 3.2±0.6. Perfusion efficiency increased numerically during exercise in the reference group (65±9% to 69±13%, p=0.063), but decreased in the CMD (68±10% to 50±10%, p<0.001) and MB (66±9% to 55±9%, p<0.001) groups. The reduction in perfusion efficiency had distinct causes: in CMD this was driven by microcirculation derived energy in early diastole, whereas in MB this was driven by diminished accelerating wave energy, due to the upstream bridge, in early systole. Epicardial endothelial dysfunction was more common in the MB group (54% versus 29% reference and 38% CMD). Overall, 93% of patients with a MB had an identifiable ischemic substrate. <b>Conclusions:</b> MBs led to impaired coronary perfusion efficiency during exercise, which was due to diminished accelerating wave energy in early systole compared to the reference group. Additionally, there was a high prevalence of endothelial and microvascular dysfunction. These ischemic mechanisms may represent distinct treatment targets.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 06 Nov 2023; epub ahead of print</small></div>

<div><h4>Navigating the Course of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Review of Guided Approaches.</h4><i>Ammirabile N, Landolina D, Capodanno D</i><br /><AbstractText>Dual antiplatelet therapy (DAPT) is the standard approach to prevent thrombotic events in patients undergoing percutaneous coronary intervention and presenting with chronic or acute coronary syndromes. However, a sizeable proportion of patients presents with an impaired or unwarranted response to DAPT depending on genetic polymorphisms or variability in platelet response. Therefore, the concept of changing the type or dose of antiplatelet drugs based on the result of platelet function or genotype tests (ie, guided DAPT) has been introduced. The goal of guided DAPT is to intensify the antiplatelet potency in patients at high risk of thrombotic events (ie, escalation) and to decrease the antiplatelet potency in patients at high risk of bleeding (ie, de-escalation). This review aims to present an up-to-date and comprehensive overview of the latest research findings on DAPT modulation guided by either platelet function or genetic testing, discussing its current indications and future directions.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Nov 2023:e013450; epub ahead of print</small></div>

<div><h4>Drug-Coated Balloon Angioplasty for De Novo Lesions on the Left Anterior Descending Artery.</h4><i>Gitto M, Sticchi A, Chiarito M, Novelli L, ... Mangieri A, Colombo A</i><br /><b>Background</b><br />Drug-coated balloons (DCB) are an emerging tool for modern percutaneous coronary intervention (PCI), but evidence on their use for de novo lesions on large vessels is limited.<br /><b>Methods</b><br />Consecutive patients undergoing DCB-based PCI on the left anterior descending artery in 2 Italian centers from 2018 to 2022 were retrospectively enrolled and compared with patients who received left anterior descending PCI with contemporary drug-eluting stents (DES). In-stent restenosis was excluded. The DCB group included both patients undergoing DCB-only PCI and those receiving hybrid PCI with DCB and DES combined. The primary end point was target lesion failure at 2 years, defined as the composite of target lesion revascularization, cardiac death, and target vessel myocardial infarction.<br /><b>Results</b><br />We included 147 consecutive patients undergoing DCB-based treatment on the left anterior descending artery and compared them to 701 patients who received conventional PCI with DES. In the DCB group, 43 patients (29.2%) were treated with DCB only and 104 (70.8%) with a hybrid approach; DCB length was greater than stent length in 55.1% of cases. Total treated length was higher in the DCB group (65 [40-82] versus 56 [46-66] mm; <i>P</i>=0.002), while longer DESs were implanted (38 [24-62] versus 56 [46-66] mm; <i>P</i><0.001) and a higher rate of large vessels were treated (76.2% versus 83.5%; <i>P</i>=0.036) in the DES cohort. The cumulative 2-year target lesion failure incidence was not significantly different between the 2 groups (DCB, 4.1% versus DES, 9.8%; hazard ratio, 0.51 [95% CI, 0.20-1.27]; <i>P</i>=0.15). After a 1:1 propensity score matching resulting in 139 matched pairs, the DCB-based treatment was associated with a lower risk for target lesion failure at 2 years compared with DES-only PCI (hazard ratio, 0.2 [95% CI, 0.07-0.58]; <i>P</i>=0.003), mainly driven by less target lesion revascularization.<br /><b>Conclusions</b><br />A DCB-based treatment approach for left anterior descending revascularization allows a significantly reduced stent burden, thereby potentially limiting target lesion failure risk at midterm follow-up.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 24 Oct 2023:e013232; epub ahead of print</small></div>

<div><h4>Association Between Polyvascular Disease and Transcatheter Aortic Valve Replacement Outcomes: Insights from the STS/ACC TVT Registry.</h4><i>Bansal K, Soni A, Shah M, Kosinski AS, ... Elmariah S, Kolte D</i><br /><AbstractText><b>Background:</b> Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Polyvascular disease (PVD), defined as involvement of ≥2 vascular beds (VB) i.e., coronary, cerebrovascular, or peripheral, portends a poor prognosis in patients with ASCVD; however, data on the association of PVD with outcomes of patients undergoing TAVR are limited. <br /><b>Methods:</b><br/>The Society of Thoracic Surgeons and the American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry was analyzed to identify patients who underwent TAVR from November 2011 through March 2022. Exposure of interest was PVD. Primary outcome was all-cause mortality. Secondary outcomes included major vascular complications, major/life-threatening bleeding, myocardial infarction (MI), transient ischemic attack (TIA)/stroke, and valve and non-valve related readmissions. Outcomes were assessed at 30 days and 1 year. <br /><b>Results:</b><br/>Of 443,790 patients who underwent TAVR, PVD was present in 150,823 (34.0%) [111,425 (25.1%) with 2VB-PVD and 39,398 (8.9%) with 3VB-PVD]. On multivariable analysis, PVD was associated with increased all-cause mortality at 1 year (hazard ratio [HR] 1.17; 95% CI, 1.14-1.20). There was an incremental increase in 1-year mortality with increasing number of VB involved (no PVD [ref.], 2VB-PVD, HR 1.12; 95% CI, 1.09-1.15, and 3VB-PVD, HR 1.31; 95% CI, 1.26-1.36). Patients with vs. without PVD had higher rates of major vascular complications, major/life-threatening bleeding, TIA/stroke, and non-valve related readmissions at 30 days and 1 year. <b>Conclusions:</b> PVD is associated with worse outcomes after TAVR, and the risk is highest in patients with 3VB-PVD.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Outcomes Following Transcatheter Aortic Valve Replacement for Aortic Stenosis in Patients With Type 0 Bicuspid, Type 1 Bicuspid, and Tricuspid Aortic Valves.</h4><i>He J, Xiong TY, Yao YJ, Peng Y, ... Feng Y, Chen M</i><br /><b>Background</b><br />Data concerning the outcomes of transcatheter aortic valve replacement in type 0 bicuspid aortic stenosis (AS) are scarce. The study aims to compare the outcomes of transcatheter aortic valve replacement for AS in patients with type 0 bicuspid, type 1 bicuspid, and tricuspid aortic valve anatomy.<br /><b>Methods</b><br />We enrolled consecutive patients undergoing transcatheter aortic valve replacement for severe AS between 2012 and 2022 in this single-center retrospective cohort study. The primary outcome was mortality, while secondary outcomes included in-hospital complications such as stroke and pacemaker implantation and transcatheter heart valve hemodynamic performance.<br /><b>Results</b><br />The number of patients with AS with type 0 bicuspid, type 1 bicuspid, and tricuspid aortic valve anatomy was 328, 302, and 642, respectively. Self-expanding transcatheter heart valves were used in the majority of patients (n=1160; 91.4%). In the matched population, differences in mortality (30 days: 4.2% versus 1.7% versus 1.7%, <i>P</i><sub>overall</sub>=0.522; 1 year: 10% versus 2.3% versus 6.2%, <i>P</i><sub>overall</sub>=0.099) and all stroke (30 days: 1.0% versus 0.9% versus 0.0%, <i>P</i><sub>overall</sub>=0.765; 1 year: 1.4% versus 1.6% versus 1.3%, <i>P</i><sub>overall</sub>=NS) were nonsignificant, and the incidence of overall in-hospital complications was comparable among groups. Ascending aortic diameter was the single predictor of 1-year mortality in type 0 bicuspid patients (hazard ratio, 1.59 [95% CI, 1.03-2.44]; <i>P</i>=0.035). The proportion of patients with a mean residual gradient ≥20 mm Hg was the highest in those with type 0 bicuspid anatomy, although the need for permanent pacemaker implantation was the lowest in this group.<br /><b>Conclusions</b><br />Major clinical outcomes of transcatheter aortic valve replacement for AS in patients with type 0 bicuspid, type 1 bicuspid, and tricuspid aortic valve anatomy are equivalent at short- and mid-term follow-up. These observations merit further exploration in prospective international registries and randomized controlled trials.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 17 Oct 2023:e013083; epub ahead of print</small></div>

<div><h4>Outcomes in High-Risk Pulmonary Embolism Patients Undergoing FlowTriever Mechanical Thrombectomy or Other Contemporary Therapies: Results From the FLAME Study.</h4><i>Silver MJ, Gibson CM, Giri J, Khandhar S, ... Butros P, Horowitz JM</i><br /><b>Background</b><br />Hemodynamically unstable high-risk, or massive, pulmonary embolism (PE) has a reported in-hospital mortality of over 25%. Systemic thrombolysis is the guideline-recommended treatment despite limited evidence. The FLAME study (FlowTriever for Acute Massive PE) was designed to generate evidence for interventional treatments in high-risk PE.<br /><b>Methods</b><br />The FLAME study was a prospective, multicenter, nonrandomized, parallel group, observational study of high-risk PE. Eligible patients were treated with FlowTriever mechanical thrombectomy (FlowTriever Arm) or with other contemporary therapies (Context Arm). The primary end point was an in-hospital composite of all-cause mortality, bailout to an alternate thrombus removal strategy, clinical deterioration, and major bleeding. This was compared in the FlowTriever Arm to a prespecified performance goal derived from a contemporary systematic review and meta-analysis.<br /><b>Results</b><br />A total of 53 patients were enrolled in the FlowTriever Arm and 61 in the Context Arm. Context Arm patients were primarily treated with systemic thrombolysis (68.9%) or anticoagulation alone (23.0%). The primary end point was reached in 9/53 (17.0%) FlowTriever Arm patients, significantly lower than the 32.0% performance goal (<i>P</i><0.01). The primary end point was reached in 39/61 (63.9%) Context Arm patients. In-hospital mortality occurred in 1/53 (1.9%) patients in the FlowTriever Arm and in 18/61 (29.5%) patients in the Context Arm.<br /><b>Conclusions</b><br />Among patients selected for mechanical thrombectomy with the FlowTriever System, a significantly lower associated rate of in-hospital adverse clinical outcomes was observed compared with a prespecified performance goal, primarily driven by low all-cause mortality of 1.9%.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT04795167.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Oct 2023; 16:e013406</small></div>

<div><h4>Impact of Calcium Eccentricity on the Safety and Effectiveness of Coronary Intravascular Lithotripsy: Pooled Analysis From the Disrupt CAD Studies.</h4><i>Ali ZA, Kereiakes DJ, Hill JM, Saito S, ... Stone GW, Shlofmitz RA</i><br /><b>Background</b><br />Coronary intravascular lithotripsy (IVL) safely facilitates successful stent implantation in severely calcified lesions. This analysis sought to determine the relative impact of lesion calcium eccentricity on the safety and effectiveness of IVL using high-resolution optical coherence tomography imaging.<br /><b>Methods</b><br />Individual patient-level data (n=262) were pooled from 4 distinct international prospective studies (Disrupt CAD I, II, III, and IV) and analyzed by an independent optical coherence tomography core laboratory. IVL performance in eccentric versus concentric calcification was analyzed by dividing calcified lesions into quartiles (≤180° [most eccentric], 181°-270°, 271°-359°, and 360° [concentric]) by maximum continuous calcium arc.<br /><b>Results</b><br />In the 230 patients with clear imaging field on optical coherence tomography, there were no differences in preprocedure minimum lumen area, diameter stenosis, or maximum calcium thickness. The calcium length and volume index increased progressively with increasing mean and maximum continuous calcium arc (ie, concentricity). Conversely, the minimum calcium thickness decreased progressively with increasing concentricity. Post-procedure, the number of calcium fractures, fracture depth, and fracture width increased with increasing concentricity, with a 4-fold increase in the number of fractures in lesions with 360° of calcium arc compared with ≤180°. This increase in IVL-induced calcium fracture with increasing calcium burden and concentricity facilitated stent expansion and luminal gain such that there were no significant differences across quartiles.<br /><b>Conclusions</b><br />IVL induced calcium fractures proportional to the magnitude of coronary artery calcium, including in eccentric calcium, leading to consistent improvements in stent expansion and luminal gain in both eccentric and concentric calcified coronary lesions.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Oct 2023; 16:e012898</small></div>

<div><h4>Clinical Features and Outcomes Among Patients With Refractory Out-of-Hospital Cardiac Arrest and an Initial Shockable Rhythm.</h4><i>Zheng WC, Zheng MC, Ho FCS, Noaman S, ... Kaye DM, Chan W</i><br /><b>Background</b><br />Clinical features among patients with refractory out-of-hospital cardiac arrest (OHCA) and initial shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia are not well-characterized.<br /><b>Methods</b><br />We compared clinical characteristics and coronary angiographic findings between patients with refractory OHCA (incessant ventricular fibrillation/pulseless ventricular tachycardia after ≥3 direct-current shocks) and those without refractory OHCA.<br /><b>Results</b><br />Between 2014 and 2018, a total of 204 patients with ventricular fibrillation/pulseless ventricular tachycardia OHCA (median age 62; males 78%) were divided into groups with (36%, 74/204) and without refractory arrest (64%, 130/204). Refractory OHCA patients had longer cardiopulmonary resuscitation (23 versus 15 minutes), more frequently required ≥450 mg amiodarone (34% versus 3.8%), and had cardiogenic shock (80% versus 55%) necessitating higher adrenaline dose (4.0 versus 1.0 mg) and higher rates of mechanical ventilation (92% versus 74%; all <i>P</i><0.01). Of 167 patients (82%) selected for coronary angiography, 33% (n=55) had refractory OHCA (<i>P</i>=0.035). Significant coronary artery disease (≥1 major vessel with >70% stenosis) was present in >70% of patients. Refractory OHCA patients frequently had acute coronary occlusion (64% versus 47%), especially left circumflex (20% versus 6.4%) and graft vessel (7.3% versus 0.9%; all <i>P</i><0.05) compared with those without refractory OHCA. Refractory OHCA group had higher in-hospital mortality (45% versus 30%, <i>P</i>=0.036) and greater new requirement for dialysis (18% versus 6.3%, <i>P</i>=0.011). After adjustment, refractory OHCA was associated with over 2-fold higher odds of in-hospital mortality (odds ratio, 2.28 [95% CI, 1.06-4.89]; <i>P</i>=0.034).<br /><b>Conclusions</b><br />Refractory ventricular fibrillation/pulseless ventricular tachycardia OHCA was associated with more intensive resuscitation, higher rates of acute coronary occlusion, and poorer in-hospital outcomes, underscoring the need for future studies in this extreme-risk subgroup.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 26 Sep 2023:e013007; epub ahead of print</small></div>

<div><h4>Hybrid Closure of Postinfarction Apical Ventricular Septal Defect Using Septal Occluder Device and Right Ventricular Free Wall: The Apical BASSINET Concept.</h4><i>Ueyama HA, Leshnower BG, Inci EK, Keeling WB, ... Greenbaum AB, Babaliaros VC</i><br /><b>Background</b><br />Postinfarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction. Surgical repair still has poor outcomes. This report describes clinical outcomes after a novel hybrid transcatheter/surgical repair in patients with apical VSD.<br /><b>Methods</b><br />Seven patients with postmyocardial infarction apical VSD underwent hybrid transcatheter repair via subxiphoid surgical access. A transcatheter occluder (Amplatzer Septal Occluder) with a trailing premounted suture was deployed through the right ventricular wall and through the ventricular septum into the left ventricular apex. The trailing suture was used to connect an anchor external to the right ventricular wall. Tension on the suture then collapses the right ventricular free wall against the septum and left ventricular occluder, thereby obliterating the VSD. Outcomes were compared with 9 patients who underwent surgical repair using either patch or primary suture closure.<br /><b>Results</b><br />All patients had significant left-to-right shunt (Qp:Qs 2.5:1; interquartile range [IQR, 2.1-2.6] hybrid repair versus 2.0:1 [IQR, 2.0-2.5] surgical repair), and elevated right ventricular systolic pressure (62 [IQR, 46-71] versus 49 [IQR, 43-54] mm Hg, respectively). All had severely depressed stroke volume index (22 versus 21 mL/m<sup>2</sup>) with ≈45% in each group requiring mechanical support preprocedurally. The procedure was done 15 (IQR, 10-50) versus 24 (IQR, 10-134) days postmyocardial infarction, respectively. Both groups of patients underwent repair with technical success and without intraprocedural death. One patient in the hybrid group and 4 in the surgical group developed multiorgan failure. The hybrid group had a higher survival at discharge (86% versus 56%) and at 30 days (71% versus 56%), but similar at 1 year (57% versus 56%). During follow-up, 1 patient in each group required reintervention for residual VSD (hybrid: 9 months versus surgical: 5 days).<br /><b>Conclusions</b><br />Early intervention with a hybrid transcatheter/surgical repair may be a viable alternative to traditional surgery for postinfarction apical VSD.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 21 Sep 2023:e013243; epub ahead of print</small></div>

<div><h4>Integrated Assessment of Computational Coronary Physiology From a Single Angiographic View in Patients Undergoing TAVI.</h4><i>Fezzi S, Ding D, Scarsini R, Huang J, ... Ribichini F, Tu S</i><br /><b>Background</b><br />Angiography-derived computational physiology is an appealing alternative to pressure-wire coronary physiology assessment. However, little is known about its reliability in the setting of severe aortic stenosis. This study sought to provide an integrated assessment of epicardial and microvascular coronary circulation by means of single-view angiography-derived physiology in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).<br /><b>Methods</b><br />Pre-TAVI angiographic projections of 198 stenotic coronary arteries (123 patients) were analyzed by means of Murray\'s law-based quantitative flow ratio and angiography microvascular resistance. Wire-based reference measurements were available for comparison: fractional flow reserve (FFR) in all cases, instantaneous wave-free ratio in 148, and index of microvascular resistance in 42 arteries.<br /><b>Results</b><br />No difference in terms of the number of ischemia-causing stenoses was detected between FFR ≤0.80 and Murray\'s law-based quantitative flow ratio ≤0.80 (19.7% versus 19.2%; <i>P</i>=0.899), while this was significantly higher when instantaneous wave-free ratio ≤0.89 (44.6%; <i>P</i>=0.001) was used. The accuracy of Murray\'s law-based quantitative flow ratio ≤0.80 in predicting pre-TAVI FFR ≤0.80 was significantly higher than the accuracy of instantaneous wave-free ratio ≤0.89 (93.4% versus 77.0%; <i>P</i>=0.001), driven by a higher positive predictive value (86.9% versus 50%). Similar findings were observed when considering post-TAVI FFR ≤0.80 as reference. In 82 cases with post-TAVI angiographic projections, Murray\'s law-based quantitative flow ratio values remained stable, with a low rate of reclassification of stenosis significance (9.9%), similar to FFR and instantaneous wave-free ratio. Angiography microvascular resistance demonstrated a significant correlation (Rho=0.458; <i>P</i>=0.002) with index of microvascular resistance, showing an area under the curve of 0.887 (95% CI, 0.752-0.964) in predicting index of microvascular resistance ≥25.<br /><b>Conclusions</b><br />Angiography-derived physiology provides a valid, reliable, and systematic assessment of the coronary circulation in a complex scenario, such as severe aortic stenosis.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 15 Sep 2023:e013185; epub ahead of print</small></div>

<div><h4>Adoption and Diffusion of Transcarotid Artery Revascularization in Contemporary Practice.</h4><i>Columbo JA, Stone DH, Martinez-Camblor P, Goodney PP, O\'Malley AJ</i><br /><b>Background</b><br />In 2015, the FDA approved transcarotid artery revascularization (TCAR) as an alternative to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS) for high-risk patients with carotid stenosis. This was granted in the absence of level 1 evidence to support TCAR. We aimed to document trends in TCAR utilization, its diffusion over time, and the clinical phenotypes of patients undergoing TCAR, CEA, and TF-CAS.<br /><b>Methods</b><br />We used the Vascular Quality Initiative to study patients who underwent TCAR. We calculated the number of TCARs performed and the percent of TCAR utilization versus CEA/TF-CAS. Using data from before TCAR was widespread, we calculated propensity scores for patients to receive CEA. We applied this model to patients undergoing carotid revascularization from 2016 to 2022 and grouped patients by the procedure they ultimately underwent, examining overlap in score distribution to measure patient similarity. We measured the trend of in-hospital stroke/death after TCAR.<br /><b>Results</b><br />We studied 31 447 patients who underwent TCAR from January 1, 2016 to March 31, 2022. The number of centers performing TCAR increased from 29 to 606. In 2021, TCAR represented 22.5% of carotid revascularizations at centers offering all 3 procedures. The percentage of patients that underwent TCAR who met approved high-risk criteria decreased from 88.5% to 80.9% (<i>P</i><0.001). Those with a prior ipsilateral carotid procedure decreased from 20.6% in 2016 to 12.0% in 2021 (<i>P</i><0.001). Patients undergoing TCAR after stroke increased from 19.7% to 30.7% (<i>P</i><0.001). Propensity-score overlap was 55.4% for TCAR/CEA, and 58.6% for TCAR/TF-CAS, demonstrating that TCAR patients have a clinical phenotype mixed between those who undergo CEA and TF-CAS. The average in-hospital stroke/death risk after TCAR was 2.3% in 2016 and 1.7% in 2022 (<i>P</i> trend: 0.954).<br /><b>Conclusions</b><br />TCAR now represents nearly 1-in-4 procedures at centers offering it. TCAR was increasingly performed among standard-risk patients and as a first-line procedural option after stroke. The absence of level 1 evidence underscores the importance of high-quality registry-based analyses to document TCAR\'s real-world outcomes and durability.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Sep 2023; 16:e012805</small></div>

<div><h4>Sex-Specific Differences in Potent P2Y Inhibitor Use in British Cardiovascular Intervention Society Registry STEMI Patients.</h4><i>Burgess SN, Shoaib A, Sharp ASP, Ludman P, ... Kinnaird T, Mamas MA</i><br /><b>Background</b><br />Sex-based outcome differences for women with ST-segment-elevation myocardial infarction (STEMI) have not been adequately addressed, and the role played by differences in prescription of potent P2Y<sub>12</sub> inhibitors (P-P2Y<sub>12</sub>) is not well defined. This study explores the hypothesis that disparities in P-P2Y<sub>12</sub> (prasugrel or ticagrelor) use may play a role in outcome disparities for women with STEMI.<br /><b>Methods</b><br />Data from British Cardiovascular Intervention Society national percutaneous coronary intervention database were analyzed, and 168 818 STEMI patients treated with primary percutaneous coronary intervention from 2010 to 2020 were included.<br /><b>Results</b><br />Among the included women (43 131; 25.54%) and men (125 687; 74.45%), P-P2Y<sub>12</sub> inhibitors were prescribed less often to women (51.71%) than men (55.18%; <i>P</i><0.001). Women were more likely to die in hospital than men (adjusted odds ratio, 1.213 [95% CI, 1.141-1.290]). Unadjusted mortality was higher among women treated with clopidogrel (7.57%), than P-P2Y<sub>12</sub>-treated women (5.39%), men treated with clopidogrel (4.60%), and P-P2Y<sub>12</sub>-treated men (3.61%; <i>P</i><0.001). The strongest independent predictor of P-P2Y<sub>12</sub> prescription was radial access (adjusted odds ratio, 2.368 [95% CI, 2.312-2.425]), used in 67.93% of women and 74.38% of men (<i>P</i><0.001). Two risk adjustment models were used. Women were less likely to receive a P-P2Y<sub>12</sub> (adjusted odds ratio, 0.957 [95% CI, 0.935-0.979]) with risk adjustment for baseline characteristics alone, when procedural factors including radial access were included in the model differences were not significant (adjusted odds ratio, 1.015 [95% CI, 0.991-1.039]).<br /><b>Conclusions</b><br />Women were less likely to be prescribed prasugrel or ticagrelor, were less likely to have radial access, and had a higher mortality when being treated for STEMI. Improving rates of P-P2Y<sub>12</sub> use and radial access may decrease outcome disparities for women with STEMI.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Sep 2023; 16:e012447</small></div>

<div><h4>Complete Revascularization Versus Culprit-Lesion-Only PCI in STEMI Patients With Diabetes and Multivessel Coronary Artery Disease: Results From the COMPLETE Trial.</h4><i>Oqab Z, Kunadian V, Wood DA, Storey RF, ... Cairns JA, Mehta SR</i><br /><b>Background</b><br />In the COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI), a strategy of complete revascularization reduced the risk of major cardiovascular events compared with culprit-lesion-only percutaneous coronary intervention in patients presenting with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Patients with diabetes have a worse prognosis following STEMI. We evaluated the consistency of the effects of complete revascularization in patients with and without diabetes.<br /><b>Methods</b><br />The COMPLETE trial randomized a strategy of complete revascularization, consisting of angiography-guided percutaneous coronary intervention of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only percutaneous coronary intervention (guideline-directed medical therapy alone). In prespecified analyses, treatment effects were determined in patients with and without diabetes on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Interaction <i>P</i> values were calculated to evaluate whether there was a differential treatment effect in patients with and without diabetes.<br /><b>Results</b><br />Of the 4041 patients enrolled in the COMPLETE trial, 787 patients (19.5%) had diabetes. The median HbA1c (glycated hemoglobin) was 7.7% in the diabetes group and 5.7% in the nondiabetes group. Complete revascularization consistently reduced the first coprimary outcome in patients with diabetes (hazard ratio, 0.87 [95% CI, 0.59-1.29]) and without diabetes (hazard ratio, 0.70 [95% CI, 0.55-0.90]), with no evidence of a differential treatment effect (interaction <i>P</i>=0.36). Similarly, for the second coprimary outcome, no differential treatment effect (interaction <i>P</i>=0.27) of complete revascularization was found in patients with diabetes (hazard ratio, 0.61 [95% CI, 0.43-0.87]) and without diabetes (hazard ratio, 0.48 [95% CI, 0.39-0.60]).<br /><b>Conclusions</b><br />Among patients presenting with STEMI and multivessel disease, the benefit of complete revascularization over a culprit-lesion-only percutaneous coronary intervention strategy was consistent regardless of the presence or absence of diabetes.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Sep 2023; 16:e012867</small></div>