Journal: Circ Cardiovasc Interv

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Abstract

Ticagrelor Monotherapy Versus Ticagrelor With Aspirin in Acute Coronary Syndrome Patients With a High Risk of Ischemic Events.

Lee SJ, Lee YJ, Kim BK, Hong SJ, ... Hong MK, Jang Y
Background
In patients with acute coronary syndrome (ACS) with a high risk of ischemia, the impact of ticagrelor monotherapy after short-term dual antiplatelet therapy (DAPT) has not been clearly elucidated.
Methods
This post hoc analysis of the TICO trial (Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome) compared the impact of ticagrelor monotherapy after 3-month DAPT versus ticagrelor-based 12-month DAPT in patients with high-ischemic risk ACS, defined as any of the following: number of stents implanted ≥3, total stent length >60 mm, complex procedures (chronic total occlusion, left main occlusion, or bifurcation plaques remedied using the 2-stent technique), or a history of diabetes or chronic kidney disease. Ischemic (composite of death, myocardial infarction, stent thrombosis, stroke, and target vessel revascularization) and bleeding outcomes (major bleeding) were evaluated at 12 months.
Results
Of the total population (N=3056), 1473 (48.2%) patients were identified as having high-ischemic risk ACS. The rate of the ischemic outcome was significantly higher in high-ischemic risk ACS patients than in nonhigh-ischemic risk ACS patients (3.9% versus 1.9%, hazard ratio, 2.14 [95% CI, 1.37-3.35], P=0.001). Furthermore, the risk of major bleeding (3.2% versus 1.5%, hazard ratio, 2.23 [95% CI, 1.36-3.68], P=0.001) and the composite ischemic and bleeding outcome (6.6% versus 3.3%, hazard ratio, 2.02 [95% CI, 1.44-2.84], P<0.001) were also higher in the high-risk ACS population. In ACS patients with or without high-ischemic risk, the effect of ticagrelor monotherapy after 3-month DAPT, as compared to that of 12-month DAPT, was consistent with ischemic (Pint=0.718), bleeding (Pint=0.092), and composite outcomes (Pint=0.094) without significant interactions.
Conclusions
There were no significant heterogeneities in the impact of ticagrelor monotherapy after 3-month DAPT compared with that of ticagrelor-based 12-month DAPT on clinical outcomes according to the presence of high-ischemic risk.
Registration
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02494895.



Circ Cardiovasc Interv: 19 Jul 2021:CIRCINTERVENTIONS121010812; epub ahead of print
Lee SJ, Lee YJ, Kim BK, Hong SJ, ... Hong MK, Jang Y
Circ Cardiovasc Interv: 19 Jul 2021:CIRCINTERVENTIONS121010812; epub ahead of print | PMID: 34281363
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Abstract

Efficacy and Safety of Percutaneous Pulmonary Artery Subtotal Occlusion and Chronic Total Occlusion Intervention in Chronic Thromboembolic Pulmonary Hypertension.

Gerges C, Friewald R, Gerges M, Shafran I, ... Klepetko W, Lang IM
Background
Balloon pulmonary angioplasty (BPA) is an emerging percutaneous therapy for patients with inoperable chronic thromboembolic pulmonary hypertension, and patients with mean pulmonary artery pressure ≤30 mm Hg have an excellent survival. Common vascular lesion types are ring-like stenoses (type A), web lesions (type B), subtotal occlusions (type C), chronic total occlusions (CTOs; type D), and tortuous lesions (type E). Occlusive lesions (ie, subtotal occlusions and CTOs) are the most challenging. Risk and benefit of pulmonary occlusive lesion intervention in chronic thromboembolic pulmonary hypertension has not been studied. We evaluated the impact of percutaneous pulmonary artery subtotal occlusion and CTO intervention on BPA treatment response.
Methods
One hundred twenty patients underwent 712 BPA procedures between April 2014 and October 2019 at the Medical University of Vienna. Clinical features and hemodynamics were assessed at baseline and 6 to 12 months after the last BPA session.
Results
A total of 2542 lesions were targeted: 720 occlusions (28.3%; 352 CTOs and 368 subtotal occlusions) and 1822 nonocclusion lesions (71.7%). Complications occurred in 6.0% of all procedures (severe complications in 0.4% of all procedures). The overall success rate for recanalization of occlusions was 81% (subtotal occlusions [type C lesions], 98%; CTOs [type D lesions], 50%). Number of successfully treated lesions of any type (β, -0.86 [-1.19 to -0.53]; P<0.001), number of successfully treated occlusions (β, -2.17 [-3.38 to -0.97]; P=0.001), and number of successfully treated nonocclusion lesions (β, -0.81 [-1.25 to -0.37]; P<0.001) emerged as predictors of relative change in the mean pulmonary artery pressure. The impact on relative change in the mean pulmonary artery pressure was higher for CTOs (β, -5.88 [-10.49 to -1.26]; P=0.014) than for subtotal occlusions (β, -2.51 [-4.18 to -0.83]; P=0.004).
Conclusions
The number of successfully treated vascular lesions predicts treatment response to BPA. The number of successfully recanalized occlusions (particularly CTOs) appears to have the strongest impact on change in mean pulmonary artery pressure, highlighting the importance of advanced BPA technique.



Circ Cardiovasc Interv: 15 Jul 2021:CIRCINTERVENTIONS120010243; epub ahead of print
Gerges C, Friewald R, Gerges M, Shafran I, ... Klepetko W, Lang IM
Circ Cardiovasc Interv: 15 Jul 2021:CIRCINTERVENTIONS120010243; epub ahead of print | PMID: 34266313
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Abstract

Incidence and Clinical Significance of Worsening Tricuspid Regurgitation Following Surgical or Transcatheter Aortic Valve Replacement: Analysis From the PARTNER IIA Trial.

Cremer PC, Wang TKM, Rodriguez LL, Lindman BR, ... Jaber WA, PARTNER II Investigators
Background
Aortic valve replacement (AVR) is recommended for severe symptomatic aortic stenosis. However, the incidence of worsening tricuspid regurgitation (TR) following transcatheter compared with surgical AVR (TAVR, SAVR), and the impact of worsening TR on outcomes, is ill-defined. Accordingly, among patients randomized to TAVR or SAVR, we describe the differential incidence of worsening TR and its association with survival.
Methods
From the PARTNER IIA trial (Placement of Aortic Transcatheter Valves IIA), 1334 patients were included with baseline and 30-day postprocedure core-lab echocardiograms. Worsening TR was defined as deterioration of ≥1 grade from baseline to 30 days. Outcomes included cardiovascular and all-cause death between 30 days and 2 years. Multivariable logistic regression was performed to identify associations with worsening TR; survival analyses were performed to assess associations with mortality.
Results
Worsening TR occurred in 17.3% (125/721) of TAVR and 27.0% (165/611) of SAVR patients. On multivariable analysis, SAVR (odds ratio, 2.09 [95% CI, 1.40-3.11]), female sex (odds ratio, 2.22 [95% CI, 1.44-3.42]), atrial fibrillation (odds ratio, 1.61 [95% CI, 1.03-2.51]), and right ventricular enlargement (odds ratio, 2.25 [95% CI, 1.17-4.31]) were associated with worsening TR. Cardiovascular and all-cause death occurred in 9.0% (26/290) and 17.9% (52/290) of patients with worsening TR, compared with 4.8% (50/1042) and 10.9% (114/1042) without worsening TR, respectively. In patients with worsening TR, cardiovascular and all-cause death were similar in TAVR compared with SAVR, (hazard ratio, 1.09 [95% CI, 0.55-2.16]) and (hazard ratio, 1.07 [95% CI, 0.62-1.87]), respectively. After adjustment, worsening TR was independently associated with cardiovascular (hazard ratio, 3.62 [95% CI, 2.08-6.29]) and all-cause death (hazard ratio, 2.11 [95% CI, 1.37-3.27]).
Conclusions
Worsening TR is associated with female sex, atrial fibrillation, right ventricular enlargement, and SAVR. Regardless of mode of AVR, worsening TR is similarly associated with a poor prognosis. Future studies should focus on whether preventing or treating worsening TR improves outcomes.
Registration
URL: https://www.clinicaltrials.gov; Unique identifier: NCT01314313.



Circ Cardiovasc Interv: 15 Jul 2021:CIRCINTERVENTIONS120010437; epub ahead of print
Cremer PC, Wang TKM, Rodriguez LL, Lindman BR, ... Jaber WA, PARTNER II Investigators
Circ Cardiovasc Interv: 15 Jul 2021:CIRCINTERVENTIONS120010437; epub ahead of print | PMID: 34266311
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Abstract

Hypothermia for Reduction of Myocardial Reperfusion Injury in Acute Myocardial Infarction: Closing the Translational Gap.

El Farissi M, Keulards DCJ, Zelis JM, van \'t Veer M, ... Pijls NHJ, Otterspoor LC
Myocardial reperfusion injury-triggered by an inevitable inflammatory response after reperfusion-may undo a considerable part of the myocardial salvage achieved through timely percutaneous coronary intervention in patients with acute myocardial infarction. Because infarct size is strongly correlated to mortality and risk of heart failure, the importance of endeavors for cardioprotective therapies to attenuate myocardial reperfusion injury and decrease infarct size remains undisputed. Myocardial reperfusion injury is the result of several complex nonlinear phenomena, and for a therapy to be effective, it should act on multiple targets involved in this injury. In this regard, hypothermia remains a promising treatment despite a number of negative randomized controlled trials in humans with acute myocardial infarction so far. To turn the tide for hypothermia in patients with acute myocardial infarction, sophisticated solutions for important limitations of systemic hypothermia should continue to be developed. In this review, we provide a comprehensive overview of the pathophysiology and clinical expression of myocardial reperfusion injury and discuss the current status and possible future of hypothermia for cardioprotection in patients with acute myocardial infarction.



Circ Cardiovasc Interv: 15 Jul 2021:CIRCINTERVENTIONS120010326; epub ahead of print
El Farissi M, Keulards DCJ, Zelis JM, van 't Veer M, ... Pijls NHJ, Otterspoor LC
Circ Cardiovasc Interv: 15 Jul 2021:CIRCINTERVENTIONS120010326; epub ahead of print | PMID: 34266310
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Abstract

Transcatheter Aortic Valve Replacement for Bicuspid Aortic Valve Stenosis: A Practical Operative Overview.

Tarantini G, Fabris T
The bicuspid aortic valve (BAV) represents a complex anatomic scenario for transcatheter aortic valve replacement (TAVR) because of its unique technical challenges. As TAVR is moving towards younger and lower-risk populations, the proportion of BAV patients undergoing TAVR is expected to rise. Initial experiences of TAVR with first-generation transcatheter heart valves in high surgical risk patients with BAV stenosis showed higher rates of device failure and periprocedural complications as compared to tricuspid anatomy. The subsequent advances in imaging techniques and understanding of BAV anatomy, new iterations of transcatheter heart valves, and growing operators\' experience yielded better outcomes. However, in the lack of randomized trials and rigorous evidence, the field of TAVR in BAV has been driven by empirical observations, with wide variability in transcatheter heart valve sizing and implantation techniques across different centers and operators. Thus, in this review article, we provide a fully illustrated overview of operative periprocedural steps for TAVR in BAV stenosis, though recognizing that it still remains anecdotal.



Circ Cardiovasc Interv: 29 Jun 2021; 14:e009827
Tarantini G, Fabris T
Circ Cardiovasc Interv: 29 Jun 2021; 14:e009827 | PMID: 34130478
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Abstract

Coronary Artery Disease Evaluation and Management Considerations for High Risk Occupations: Commercial Vehicle Drivers and Pilots.

Sutton NR, Banerjee S, Cooper MM, Arbab-Zadeh A, ... Rao SV, Blumenthal RS
Optimal treatment of stable ischemic heart disease for those in the transportation industry is considered in the context of the individual\'s health, as well as with the perspective that sudden impairment could have catastrophic consequences for others. This article focuses on two high risk occupations that one may encounter in practice: commercial motor vehicle drivers and commercial pilots. This article discusses coronary heart disease in patients in high risk occupations and covers current guideline recommendations for screening, treatment, and secondary prevention. The importance of the complimentary perspectives of the regulatory agency, medical examiners, physicians, and pilot or driver are considered in this narrative review, as are considerations for future guideline updates.



Circ Cardiovasc Interv: 30 May 2021; 14:e009950
Sutton NR, Banerjee S, Cooper MM, Arbab-Zadeh A, ... Rao SV, Blumenthal RS
Circ Cardiovasc Interv: 30 May 2021; 14:e009950 | PMID: 34092098
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Abstract

Calcium Modification Techniques in Complex Percutaneous Coronary Intervention.

Shah M, Najam O, Bhindi R, De Silva K
Percutaneous coronary intervention is the most common mode of revascularization and is increasingly undertaken in high-risk subsets, including the elderly. The presence of coronary artery calcification is increasingly observed and significantly limits technical success. The mechanisms for this are multi-factorial, including increased arterial wall stiffness and impaired delivery of devices, leading to suboptimal stent delivery, deployment, and expansion which are harbingers for increased risk of in-stent restenosis and stent thrombosis. Although conventional balloon pretreatment techniques aim to mitigate this risk by modifying the lesion before stent placement, many lesions remain resistant to conventional strategies, due to the severity of calcification. There have been several substantial technological advancements in calcium modification methods in recent years, which have allowed improved procedural success with low periprocedural complication rates. This review will summarize the current adjunctive modification technologies that can be employed to improve technical outcomes in percutaneous coronary intervention in calcific disease and the evidence supporting these tools.



Circ Cardiovasc Interv: 29 Apr 2021; 14:e009870
Shah M, Najam O, Bhindi R, De Silva K
Circ Cardiovasc Interv: 29 Apr 2021; 14:e009870 | PMID: 33441017
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