<div><h4>Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review.</h4><i>Figtree GA, Vernon ST, Harmer JA, Gray MP, ... Nicholls SJ, CRE for CAD Collaborators</i><br /><AbstractText>Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.</AbstractText><br /><br />Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Coll Cardiol: 26 Sep 2023; 82:1343-1359</small></div>

<div><h4>Existing Nongated CT Coronary Calcium Predicts Operative Risk in Patients Undergoing Noncardiac Surgeries (ENCORES).</h4><i>Choi DY, Hayes D, Maidman SD, Dhaduk N, ... Donnino R, Smilowitz NR</i><br /><b>Background</b><br />Preoperative cardiovascular risk stratification before noncardiac surgery is a common clinical challenge. Coronary artery calcium scores from ECG-gated chest computed tomography (CT) imaging are associated with perioperative events. At the time of preoperative evaluation, many patients will not have had ECG-gated CT imaging, but will have had nongated chest CT studies performed for a variety of noncardiac indications. We evaluated relationships between coronary calcium severity estimated from previous nongated chest CT imaging and perioperative major clinical events (MCE) after noncardiac surgery.<br /><b>Methods</b><br />We retrospectively identified consecutive adults age ≥45 years who underwent in-hospital, major nongated surgery from 2016 to 2020 at a large academic health system composed of 4 acute care centers. All patients had nongated (contrast or noncontrast) chest CT imaging performed within 1 year before surgery. Coronary calcium in each vessel was retrospectively graded from absent to severe using a 0 to 3 scale (absent, mild, moderate, severe) by physicians blinded to clinical data. The estimated coronary calcium burden (ECCB) was computed as the sum of scores for each coronary artery (0 to 9 scale). A Revised Cardiac Risk Index was calculated for each patient. Perioperative MCE was defined as all-cause death or myocardial infarction within 30 days of surgery.<br /><b>Results</b><br />A total of 2554 patients (median age, 68 years; 49.7% women; median Revised Cardiac Risk Index, 1) were included. The median time interval from nongated chest CT imaging to nongated surgery was 15 days (interquartile range, 3-106 days). The median ECCB was 1 (interquartile range, 0-3). Perioperative MCE occurred in 136 (5.2%) patients. Higher ECCB values were associated with stepwise increases in perioperative MCE (0: 2.9%, 1-2: 3.7%, 3-5: 8.0%; 6-9: 12.6%, <i>P</i><0.001). Addition of ECCB to a model with the Revised Cardiac Risk Index improved the C-statistic for MCE (from 0.675 to 0.712, <i>P</i>=0.018), with a net reclassification improvement of 0.428 (95% CI, 0.254-0.601, <i>P</i><0.0001). An ECCB ≥3 was associated with 2-fold higher adjusted odds of MCE versus an ECCB <3 (adjusted odds ratio, 2.11 [95% CI, 1.42-3.12]).<br /><b>Conclusions</b><br />Prevalence and severity of coronary calcium obtained from existing nongated chest CT imaging improve preoperative clinical risk stratification before nongated surgery.<br /><br /><br /><br /><small>Circulation: 21 Sep 2023; epub ahead of print</small></div>

<div><h4>PRIME score for prediction of permanent pacemaker implantation after transcatheter aortic valve replacement.</h4><i>Barrett CD, Nickel A, Rosenberg MA, Ream K, ... Varosy P, Sandhu A</i><br /><b>Objectives</b><br />We sought to produce a simple scoring system that can be applied at clinical visits before transcatheter aortic valve replacement (TAVR) to stratify the risk of permanent pacemaker (PPM) after the procedure.<br /><b>Background</b><br />Atrioventricular block is a known complication of TAVR. Current models for predicting the risk of PPM after TAVR are not designed to be applied clinically to assist with preprocedural planning.<br /><b>Methods</b><br />Patients undergoing TAVR at the University of Colorado were split into a training cohort for the development of a predictive model, and a testing cohort for model validation. Stepwise and binary logistic regressions were performed on the training cohort to produce a predictive model. Beta coefficients from the binary logistic regression were used to create a simple scoring system for predicting the need for PPM implantation. Scores were then applied to the validation cohort to assess predictive accuracy.<br /><b>Results</b><br />Patients undergoing TAVR from 2013 to 2019 were analyzed: with 483 included in the training cohort and 123 included in the validation cohort. The need for a pacemaker was associated with five preprocedure variables in the training cohort: PR interval > 200 ms, Right bundle branch block, valve-In-valve procedure, prior Myocardial infarction, and self-Expandable valve. The PRIME score was developed using these clinical features, and was highly accurate for predicting PPM in both the training and model validation cohorts (area under the curve 0.804 and 0.830 in the model training and validation cohorts, respectively).<br /><b>Conclusions</b><br />The PRIME score is a simple and accurate preprocedural tool for predicting the need for PPM implantation after TAVR.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 21 Sep 2023; epub ahead of print</small></div>

<div><h4>Restoration of von Willebrand factor after transcatheter aortic valve replacement-A possible cause for posttranscatheter aortic valve replacement thrombocytopenia?</h4><i>Roth N, Heidel C, Xu C, Hubauer U, ... Jungbauer C, Debl K</i><br /><b>Objectives</b><br />The aim of the current study was to analyze the clinical and procedural predictors of thrombocytopenia and the relationship between the decrease in platelet count (DPC) and change in vWF function (ΔvWF) after transcatheter aortic valve replacement (TAVR).<br /><b>Background</b><br />TAVR often causes temporary thrombocytopenia. At the same time, TAVR leads to a restoration of von Willebrand factor (vWF) function.<br /><b>Methods</b><br />One hundred and forty-one patients with severe aortic stenosis undergoing TAVR were included in the study. Platelet count and vWF function (vWF:Ac/Ag ratio) were assessed at baseline and 6 h after TAVR. Thrombocytopenia was defined as platelet count <150/nL.<br /><b>Results</b><br />Median platelet count at baseline was 214/nL (interquartile range [IQR]: 176-261) and decreased significantly to 184/nL (IQR: 145-222) 6 h after TAVR. The number of patients with thrombocytopenia increased from 12.8% at baseline to 29.1% after 6 h. DPC 6 h after TAVR showed a significant correlation with ΔvWF (r = - 0.254, p = 0.002). Patients with DPC > 20% had significantly higher ΔvWF (10.9% vs. 6.5%, p = 0.021). Obese patients showed a significantly lower DPC (11.8% vs. 19.9%, p = 0.001). In multivariate analysis, ΔvWF 6 h after TAVR was the only significant predictor for DPC > 20% (p = 0.017).<br /><b>Conclusions</b><br />The restoration of vWF after TAVR is a significant predictor for DPC after TAVR. An increased platelet consumption due to vWF restoration could play a key role in the development of thrombocytopenia after TAVR.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Antidromic and orthodromic reciprocating tachycardias over a novel left-sided accessory pathway involving the vein of Marshall and coronary sinus musculature.</h4><i>Kanzaki Y, Morishima I, Miyazawa H, Shimojo K</i><br /><b>Introduction</b><br />Herein, we present a rare case of the successful ablation of an accessory pathway (AP) involving the Marshall Bundle (MB) and coronary sinus musculature (CSM) in a 40-year-old man with Wolff-Parkinson-White syndrome.<br /><b>Methods and results</b><br />An orthodromic reciprocating tachycardia (ORT) was inducible with the earliest atrial activation site located at the posterolateral mitral annulus. The local conduction and the cycle length of ORT was prolonged by peri-mitral ablation; however, it failed to block the AP. The atrial insertion of the AP was identified by remapping during ORT at the left atrial ridge, which was away from the mitral annulus, where ablation was successful. Together with the electrophysiological findings in CSM potentials, we conclude that the epicardial MB-CSM connection functioned as the AP in this patient.<br /><b>Conclusion</b><br />The novel variant form of AP comprised of MB and CSM should be noted. The atrial insertion of the MB may be the target of catheter ablation.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Novel approach to stenting the left anterior descending coronary artery through a retrograde approach via the left internal mammary artery graft in a patient with occlusion of the coronary ostium from a prior aortic valve replacement.</h4><i>Soud M, Feit F, Rao S, Bangalore S</i><br /><AbstractText>Total occlusion of both coronary ostia is a rare and potentially life-threatening complication following surgical aortic valve replacement. This report presents a case of a patient with known total occlusion of both coronary artery ostia following combined coronary artery bypass graft surgery and aortic valve replacement who underwent successful percutaneous coronary intervention through a retrograde approach.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular Outcomes.</h4><i>Peng AW, Dudum R, Jain SS, Maron DJ, ... Sandhu AT, Rodriguez F</i><br /><b>Background</b><br />Coronary artery calcium (CAC) is a strong predictor of cardiovascular events across all racial and ethnic groups. CAC can be quantified on nonelectrocardiography (ECG)-gated computed tomography (CT) performed for other reasons, allowing for opportunistic screening for subclinical atherosclerosis.<br /><b>Objectives</b><br />The authors investigated whether incidental CAC quantified on routine non-ECG-gated CTs using a deep-learning (DL) algorithm provided cardiovascular risk stratification beyond traditional risk prediction methods.<br /><b>Methods</b><br />Incidental CAC was quantified using a DL algorithm (DL-CAC) on non-ECG-gated chest CTs performed for routine care in all settings at a large academic medical center from 2014 to 2019. We measured the association between DL-CAC (0, 1-99, or ≥100) with all-cause death (primary outcome), and the secondary composite outcomes of death/myocardial infarction (MI)/stroke and death/MI/stroke/revascularization using Cox regression. We adjusted for age, sex, race, ethnicity, comorbidities, systolic blood pressure, lipid levels, smoking status, and antihypertensive use. Ten-year atherosclerotic cardiovascular disease risk was calculated using the pooled cohort equations.<br /><b>Results</b><br />Of 5,678 adults without ASCVD (51% women, 18% Asian, 13% Hispanic/Latinx), 52% had DL-CAC >0. Those with DL-CAC ≥100 had an average 10-year ASCVD risk of 24%; yet, only 26% were on statins. After adjustment, patients with DL-CAC ≥100 had increased risk of death (HR: 1.51; 95% CI: 1.28-1.79), death/MI/stroke (HR: 1.57; 95% CI: 1.33-1.84), and death/MI/stroke/revascularization (HR: 1.69; 95% CI: 1.45-1.98) compared with DL-CAC = 0.<br /><b>Conclusions</b><br />Incidental CAC ≥100 was associated with an increased risk of all-cause death and adverse cardiovascular outcomes, beyond traditional risk factors. DL-CAC from routine non-ECG-gated CTs identifies patients at increased cardiovascular risk and holds promise as a tool for opportunistic screening to facilitate earlier intervention.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Coll Cardiol: 19 Sep 2023; 82:1192-1202</small></div>

<div><h4>De-escalation from ticagrelor to clopidogrel in patients with acute myocardial infarction: the TALOS-AMI HBR substudy.</h4><i>Kim MC, Ahn SG, Cho KH, Sim DS, ... Chang K, Ahn Y</i><br /><b>Background</b><br />The benefits of de-escalation of P2Y<sub>12</sub> inhibition after percutaneous coronary intervention (PCI) may differ by high bleeding risk (HBR) status.<br /><b>Aims</b><br />We investigated the efficacy and safety of de-escalation from ticagrelor to clopidogrel after PCI by HBR status.<br /><b>Methods</b><br />This is a non-prespecified post hoc analysis of the TicAgrelor Versus CLOpidogrel in Stabilized Patients with Acute Myocardial Infarction (TALOS-AMI) trial. Net adverse clinical events (a composite of cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium [BARC] bleeding type 2, 3, or 5) at 1 year post-PCI were compared between the de-escalation (clopidogrel plus aspirin) and the active control (ticagrelor plus aspirin) groups by HBR status, as defined by the modification of the Academic Research Consortium (ARC) criteria.<br /><b>Results</b><br />A total of 2,625 patients in the TALOS-AMI trial were analysed. Of these, 589 (22.4%) met the modified ARC-HBR criteria. The de-escalation group had lower primary endpoint rates than the control group in both HBR (hazard ratio [HR] 0.47, 95% confidence interval [CI]: 0.26-0.84) and non-HBR (HR 0.59, 95% CI: 0.41-0.84) patients. There were no differences in treatment effect for the primary endpoint regardless of HBR status (p for interaction=0.904). BARC bleeding type 3 or 5 was less common in the de-escalation than the control group among HBR patients only (HR 0.24, 95% CI: 0.07-0.84).<br /><b>Conclusions</b><br />In stabilised acute myocardial infarction patients, unguided de-escalation from ticagrelor to clopidogrel was associated with a lower rate of net adverse clinical outcomes irrespective of HBR status. The effect of de-escalation of P2Y<sub>12</sub> inhibition on reducing haemorrhagic events was greater in patients with HBR.<br /><br /><br /><br /><small>EuroIntervention: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction Complicated by Cardiogenic Shock in a Super-aging Society.</h4><i>Nishihira K, Honda S, Takegami M, Kojima S, ... Kimura K, Yasuda S</i><br /><b>Aims</b><br />ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMICS) is associated with substantial mortality. As life expectancy increases, percutaneous coronary intervention (PCI) is being performed more frequently, even in elderly patients with acute myocardial infarction (AMI). This study sought to investigate the characteristics and impact of PCI on in-hospital mortality in patients with STEMICS.<br /><b>Methods and results</b><br />The Japan AMI Registry (JAMIR) is a retrospective, nationwide, real-world database. Among 46,242 patients with AMI hospitalized in 2011-2016, 2,760 patients with STEMICS (median age, 72 years) were studied. We compared 2,396 (86.8%) patients who underwent PCI with 364 (13.2%) patients who did not. The percentage of mechanical circulatory support use in patients with STEMICS was 69.3% and in-hospital mortality was 34.6%. Compared with patients who did not undergo PCI, patients undergoing PCI were younger and had a higher rate of intra-aortic balloon pump use. A higher proportion were male or current smokers. In-hospital mortality was significantly lower in the PCI group than in the no-PCI group (31.3% vs. 56.0%, P < 0.001). PCI was independently associated with lower in-hospital mortality (adjusted odds ratio [OR], 0.508; 95% confidence interval [CI], 0.347-0.744). In 789 (28.6%) patients aged ≥80 years, PCI was associated with fewer in-hospital cardiac deaths (adjusted OR, 0.524; 95% CI, 0.281-0.975), but was not associated with in-hospital mortality (adjusted OR, 0.564; 95% CI, 0.300-1.050).<br /><b>Conclusion</b><br />In Japan, PCI was effective in reducing in-hospital cardiac death in elderly patients with STEMICS. Age alone should not preclude potentially beneficial invasive therapy.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Anomalous right coronary artery originating from the opposite sinus of Valsalva: Fractional flow reserve and intravascular ultrasound-guided management.</h4><i>Singh A, Donnino R, Small A, Bangalore S</i><br /><AbstractText>There remains significant controversy in the risk stratification and management of patients with anomalous right coronary artery originating from the opposite sinus (R-ACAOS). We present the case of a patient with an inferior ST-elevation myocardial infarction, found to have R-ACAOS and severe atherosclerotic right coronary artery disease, treated with fractional flow reserve and intravascular ultrasound-guided percutaneous coronary intervention.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Acute Myocardial Infarction: Etiologies and Mimickers in Young Patients.</h4><i>Krittanawong C, Khawaja M, Tamis-Holland JE, Girotra S, Rao SV</i><br /><AbstractText>Acute myocardial infarction is an important cause of death worldwide. While it often affects patients of older age, acute myocardial infarction is garnering more attention as a significant cause of morbidity and mortality among young patients (<45 years of age). More specifically, there is a focus on recognizing the unique etiologies for myocardial infarction in these younger patients as nonatherosclerotic etiologies occur more frequently in this population. As such, there is a potential for delayed and inaccurate diagnoses and treatments that can carry serious clinical implications. The understanding of acute myocardial infarction manifestations in young patients is evolving, but there remains a significant need for better strategies to rapidly diagnose, risk stratify, and manage such patients. This comprehensive review explores the various etiologies for acute myocardial infarction in young adults and outlines the approach to efficient diagnosis and management for these unique patient phenotypes.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 19 Sep 2023:e029971; epub ahead of print</small></div>

<div><h4>Forecasting the Risk of Heart Failure Hospitalization After Acute Coronary Syndromes: the CORALYS HF Score.</h4><i>D\'Ascenzo F, Fabris E, DeGregorio C, Mittone G, ... Sinagra G, de Ferrari GM</i><br /><AbstractText>The present study aimed to identify patients at a higher risk of hospitalization for heart failure (HF) in a population of patients with acute coronary syndrome (ACS) treated with percutaneous coronary revascularization without a history of HF or reduced left ventricular (LV) ejection fraction before the index admission. We performed a Cox regression multivariable analysis with competitive risk and machine learning models on the incideNce and predictOrs of heaRt fAiLure After Acute coronarY Syndrome (CORALYS) registry (NCT04895176), an international and multicenter study including consecutive patients admitted for ACS in 16 European Centers from 2015 to 2020. Of 14,699 patients, 593 (4.0%) were admitted for the development of HF up to 1 year after the index ACS presentation. A total of 2 different data sets were randomly created, 1 for the derivative cohort including 11,626 patients (80%) and 1 for the validation cohort including 3,073 patients (20%). On the Cox regression multivariable analysis, several variables were associated with the risk of HF hospitalization, with reduced renal function, complete revascularization, and LV ejection fraction as the most relevant ones. The area under the curve at 1 year was 0.75 (0.72 to 0.78) in the derivative cohort, whereas on validation, it was 0.72 (0.67 to 0.77). The machine learning analysis showed a slightly inferior performance. In conclusion, in a large cohort of patients with ACS without a history of HF or LV dysfunction before the index event, the CORALYS HF score identified patients at a higher risk of hospitalization for HF using variables easily accessible at discharge. Further approaches to tackle HF development in this high-risk subset of patients are needed.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 19 Sep 2023; 206:320-329</small></div>

<div><h4>Gender-Based Differences in Outcomes After Percutaneous Coronary Intervention of Chronic Total Occlusions (Insights from a Large Single-Center Registry).</h4><i>Kyaw H, Giustino G, Kumar S, Sartori S, ... Mehran R, Sharma SK</i><br /><AbstractText>Patients who undergo percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) are at a high risk for both periprocedural and post-procedural adverse events. Whether gender-differences in outcomes exist after PCI of CTO remain unclear. Therefore, we sought to investigate gender-based differences in outcomes after CTO-PCI. All patients who underwent elective CTO intervention from January 2012 to December 2017 at The Mount Sinai Hospital (New York, New York) were included. The primary end point of interest was major adverse cardiac events defined as the composite of death, myocardial infarction, and target vessel revascularization at 1 year of follow-up. A total 1,897 patients were included, of which 368 were women (19.4%). Mean follow-up time was 174 days. Women were older (66.8 ± 11.3 years vs 62.6 ± 10.9 years) and had a higher prevalence of co-morbidities including diabetes and chronic kidney disease. There were no significant differences in the rate of successful CTO-PCI between groups (73.5% vs 73.2%, p = 0.91). Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding (4.1% vs 1.8%, p = 0.009) and acute vessel closure (1.36% vs 0.2%, p = 0.009). In multivariable-adjusted analysis, female gender was associated with higher risk of major adverse cardiac event and target vessel revascularization at 1 year. In conclusion, in this large single-center study, women who underwent percutaneous CTO revascularization experienced higher rates of periprocedural complications and worse clinical outcomes at 1 year compared with men. Further research is needed to address disparities in gender-specific outcomes of CTO-PCI.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 19 Sep 2023; 207:108-113</small></div>

<div><h4>Comparison of Paravalvular Leak in SAPIEN 3 and EVOLUT PRO Valves in Transcatheter Aortic Valve Replacement: A Multicenter Registry.</h4><i>Matta A, Regueiro A, Urena M, Nombela-Franco L, ... Carrié D, Campelo-Parada F</i><br /><AbstractText>Paravalvular leak (PVL), conduction disturbances, and vascular complications remain the most common complications after TAVR. To address these adverse outcomes, the third generation of transcatheter heart valves has been developed. The last generation prosthesis provides an outer pericardial wrap for enhanced sealing and PVL prevention. This study aimed to compare the incidence and severity of PVL and 1-year survival after TAVR using SAPIEN 3 with those using EVOLUT PRO. An observational retrospective analysis was conducted in 1,481 patients who underwent TAVR for symptomatic severe aortic stenosis in 6 different European centers. The primary end point was to assess the frequency and severity of PVL at 30 days after TAVR. The secondary end point was to compare 1-year survival using EVOLUT PRO with that using SAPIEN 3. SAPIEN 3 transcatheter heart valve was implanted in 78.3% of study participants (n = 1,160) whereas EVOLUT PRO was implanted in 21.7% (n = 321). PVL is more commonly observed in patients treated with EVOLUT PRO at prehospital discharge (55.1% vs 37.3%) and at 1-month (51% vs 41.4%) and 1-year (51.3% vs 39.3%) follow-up. This difference mainly concerns low-grade (mild/trace) PVL. The frequency of high-degree (moderate/severe) PVL was almost similar in both groups throughout the study period (5.3% vs 5.8% before hospital discharge, 4% vs 3.1% at 1 month, and 3.2% vs 4.9% at 1 year). No significant difference in survival over 1 year has been observed (hazard ratio 0.73 [0.33 to 1.63], p = 0.442) (Graphical abstract). In conclusion, the detection rate of PVL after TAVR with third-generation heart valves remains high, and there are no major differences between the devices regarding the frequency of significant (moderate/severe) PVL and survival.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 19 Sep 2023; 207:114-120</small></div>

<div><h4>The Incidence of Complication in the Perioperative Period of Rotational Atherectomy in Patients With Acute Coronary Syndrome: A Retrospective Study of Low Speed Versus High Speed.</h4><i>Wu J, Qiu G, Li H, Hu H, Ma LK</i><br /><AbstractText>The safety and efficacy of rotational atherectomy (RA) in patients with acute coronary syndrome (ACS) treated with different rotational speeds remain unclear. This was an observational retrospective registry study. Between February 2017 and January 2022, a total of 283 patients with ACS were treated with RA. The patients were divided into 2 groups: the low-speed group (130,000 to 150,000 rotations/min [rpm],182 cases) and the high-speed group (160,000 to 220,000 rpm, 101 cases) according to the maximum RA speed. The outcomes analyzed were procedural complications; incidence of heart failure, stent thrombosis, and cardiac death during hospitalization; and 30-day major cardiovascular and cerebrovascular events. Patients in the low-speed RA group had a higher incidence of vasospasm during RA (15.4% vs 6.9%, p = 0.040), whereas the incidence of slow blood flow was higher in the high-speed RA group (16.5% vs 27.7%, p = 0.031). There was no significant difference in other complications or in 30-day major cardiovascular and cerebrovascular events between the 2 groups. Moreover, logistic regression analysis identified rotational speed (160,000 to 220,000 rpm) as a predictor of slow flow during RA (odds ratio 1.900, 95% confidence interval 1.006 to 3.588, p = 0.048). For every 10,000-rpm increase in rotational speed, the risk of slow flow increased by 27% (odds ratio 1.273, 95% confidence interval 1.047 to 1.547, p = 0.015). In conclusion, patients with ACS treated with a lower RA speed (130,000 to 150,000 rpm) had a higher risk of vasospasm, whereas those treated with higher speeds (160,000 to 220,000 rpm) had a higher incidence of slow flow. High rotational speed (160,000 to 220,000 rpm) is an independent risk factor for slow flow during RA in patients with ACS.</AbstractText><br /><br />Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 19 Sep 2023; 207:121-129</small></div>

<div><h4>Impact of Frailty on Left Ventricular Assist Device Clinical Outcomes.</h4><i>Imburgio S, Udongwo N, Mararenko A, Johal A, ... Almendral J, Heaton J</i><br /><AbstractText>Frailty is a clinical syndrome prevalent in older adults and carries poor outcomes in patients with heart failure. We investigated the impact of frailty on left ventricular assist device (LVAD) clinical outcomes. The Nationwide Readmission Database was used to retrospectively identify patients with a primary diagnosis of heart failure who underwent LVAD implantation during their hospitalization from 2014 to 2020. Patients were categorized into frail and nonfrail groups using the Hospital Frailty Risk Score. Cox and logistic regression were used to predict the impact of frailty on inpatient mortality, 30-day readmissions, length of stay, and discharge to a skilled nursing facility. LVADs were implanted in 11,465 patients who met the inclusion criteria. There was more LVAD use in patients who were identified as frail (81.6% vs 18.4%, p <0.001). The Cox regression analyses revealed that LVAD insertion was not associated with increased inpatient mortality in frail patients (hazard ratio 1.15, 95% confidence interval 0.81 to 1.65, p = 0.427). Frail patients also did not experience a higher likelihood of readmissions within 30 days (hazard ratio 1.15, 95% confidence interval 0.91 to 1.44, p = 0.239). LVAD implantation did not result in a significant increase in inpatient mortality or readmission rates in frail patients compared with nonfrail patients. These data support continued LVAD use in this high-risk patient population.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 19 Sep 2023; 207:69-74</small></div>

<div><h4>Repair of Aortic Regurgitation in Young Adults: Sooner Rather Than Later.</h4><i>Barradas-Pires A, Merás P, Constantine A, Costola G, ... Rubio AM, Dimopoulos K</i><br /><AbstractText><br /><b>Background:</b><br/>Establishing surgical criteria for aortic valve replacement (AVR) in severe aortic regurgitation in young adults is challenging due to the lack of evidence-based recommendations. We studied indications for AVR in young adults with severe aortic regurgitation and their outcomes, as well as the relationship between presurgical echocardiographic parameters and postoperative left ventricular (LV) size, function, clinical events, and valve-related complications. Methods and Results Data were collected retrospectively on 172 consecutive adult patients who underwent AVR or repair for severe aortic regurgitation between 2005 and 2019 in a tertiary cardiac center (age at surgery 29 [22-41] years, 81% male). One-third underwent surgery before meeting guideline indications. Postsurgery, 65% achieved LV size and function normalization. LV ejection fraction showed no significant change from baseline. A higher presurgical LV end-systolic diameter correlated with a lack of LV normalization (odds ratio per 1-cm increase 2.81, <i>P</i><0.01). The baseline LV end-systolic diameter cut-off for predicting lack of LV normalization was 43 mm. Pre- and postoperative LV dimensions and postoperative LV ejection fraction predicted clinical events during follow-up. Prosthetic valve-related complications occurred in 20.3% during an average 5.6-year follow-up. Freedom from aortic reintervention was 98%, 96.5%, and 85.4% at 1, 5, and 10 years, respectively. <br /><b>Conclusions:</b><br/>Young adult patients with increased baseline LV end-systolic diameter or prior cardiac surgery are less likely to achieve LV normalization after AVR. Clinicians should carefully balance the long-term benefits of AVR against procedural risks and future interventions, especially in younger patients. Evidence-based criteria for AVR in severe aortic regurgitation in young adults are crucial to improve outcomes.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 18 Sep 2023:e029251; epub ahead of print</small></div>

<div><h4>Cardiovascular Risk Factors and Culprit Plaque Characteristics in Women With Acute Coronary Syndromes.</h4><i>Seegers LM, Yeh DD, Wood MJ, Yonetsu T, ... Kakuta T, Jang IK</i><br /><AbstractText>Outcomes after myocardial infarction in women remain poor. The number of cardiovascular risk factors in women increase with age, however the relation between risk factors and culprit plaque characteristics in this population is poorly understood. The aim of the study was to investigate the relation between risk factors and culprit plaque characteristics in women with acute coronary syndrome (ACS). A total of 382 women who presented with ACS and underwent pre-intervention optical coherence tomography imaging of the culprit lesion were included in this analysis. The culprit plaques were categorized as plaque rupture, plaque erosion or calcified plaque, and then stratified by age and risk factors. The predominant pathology of ACS was plaque erosion in young patients (<60 years), which decreased with age (p <0.001). Current smokers had a high prevalence of plaque rupture (60%) and lipid plaque (79%). Women with diabetes tended to have more lipid plaque (70%) even at a young age. In women with hyperlipidemia, the prevalence of lipid plaques was modest in younger ages, but rose gradually with age (p <0.001). An increasing age trend for lipid plaque was also observed in women with hypertension (p = 0.03) and current smokers (p = 0.01). In conclusion, early treatment of risk factors such as diabetes in young women might be important before accelerated progression of atherosclerosis begins as age advances. Clinical trial registration: http://www.clinicaltrials.gov, NCT01110538, NCT03479723 and NCT02041650.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 16 Sep 2023; 207:13-20</small></div>

<div><h4>Predictors of Cerebral Embolic Debris During Transcatheter Aortic Valve Replacement: The SafePass 2 First-in-Human Study.</h4><i>Grubman D, Ahmad Y, Leipsic JA, Blanke P, ... Parise H, Lansky AJ</i><br /><AbstractText>Transcatheter aortic valve replacement (TAVR) generates significant debris, and strategies to mitigate cerebral embolization are needed. The novel Emboliner embolic protection catheter (Emboline, Inc., Santa Cruz, California) is designed to capture all particles generated during TAVR. This first-in-human study sought to assess the safety and feasibility of the device and to characterize the distribution and histopathology of the debris generated during TAVR. The SafePass 2 study was a prospective, nonrandomized, multicenter, single-arm investigation of the Emboliner device. Primary end points included 30-day major adverse cardiac and cerebrovascular events (MACCE) and technical performance. Computed tomography angiography was analyzed by an independent core laboratory, and filters were sent for histopathology of captured debris. Predictors of particle number were identified using >150 µm and >500 µm size thresholds. Of 31 subjects enrolled, technical success was 100%, and 30-day MACCE was 6.5% (2 cerebrovascular accidents, with 1 attributed to subtherapeutic dosing of rivaroxaban along with atrial fibrillation and the other to possible previous small ischemic strokes on magnetic resonance imaging; neither MACCE event had a causal relation to the Emboliner). All filters contained debris, with a median of 191.0 particles >150 µm and 14.0 particles >500 µm. Histopathology revealed mostly acute thrombus and valve or arterial tissue with lesser amounts of calcified tissue. A history of atrial fibrillation predicted a greater number of particles >500 µm (p = 0.0259) and its presence on admission was associated with 4.1 times more particles >150 µm (p = 0.0130) and 8.1 times more particles >500 µm (p = 0.0086). Self-expanding valves were associated with twice the number of particles >150 µm (p = 0.0281). TASK score was positively correlated with number of particles >500 µm (p = 0.0337). The Emboliner device was safe and feasible. Emboli after TAVR appear more numerous than previously documented. Atrial fibrillation, higher TASK score, and self-expanding valve use conferred higher embolic burden. Notably, none of the tested computed tomography angiography features were able to identify with higher embolic risk. Larger-scale studies are needed to identify high-risk patients for selective embolic protection device use.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 16 Sep 2023; 207:28-34</small></div>

<div><h4>Self-Expanding Transcatheter Aortic Valves Optimize Transvalvular Hemodynamics Independent of Intra- Versus Supra-Annular Design.</h4><i>Brown JA, Yousef S, Toma C, Kliner D, ... Pompeu Sá M, Sultan I</i><br /><AbstractText>This study sought to characterize transvalvular hemodynamics during the first 30 days after transcatheter aortic valve implantation (TAVI) across various transcatheter heart valves (THVs), while adjusting for annular dimensions. This was an observational study of TAVIs from September 2021 to October 2022. The primary outcome was mean transvalvular pressure gradient (TVPG), measured using transthoracic echocardiography at day 0, day 1, and day 30 post-TAVI, and were compared across 3 THV, including the self-expandable intra-annular Portico (Abbott Vascular, Santa Clara, California) valve, the balloon-expandable SAPIEN 3 Ultra (Edwards Lifesciences, Irvine, California), and the self-expandable supra-annular Evolut Pro+ (Medtronic, Minneapolis, Minnesota). A total of 560 patients who underwent TAVI were identified, of which 106 (18.9%) received a Portico THV, 176 (31.4%) received a SAPIEN THV, and 278 (49.6%) received an Evolut THV. For Portico THV, the TVPG on day 0 increased from 6.0 (4.7 to 9.0) to 7.0 (6.0 to 10.0) by day 30 (p = 0.009). For SAPIEN THV, the TVPG on day 0 increased from 6.5 (5.0 to 8.0) to 12.0 (9.0 to 15.0) by day 30 (p <0.001). For Evolut THV, the TVPG on day 0 increased from 6.0 (5.0 to 9.0) to 7.2 (5.0 to 10.0) by day 30 (p = 0.001). Adjusting for time and annular diameter in a multivariable mixed effects model, the SAPIEN group had a significantly greater increase in TVPG over time than the Evolut reference group (p <0.001), while there was no difference in the change of TVPG over time for the Portico group vs. the Evolut group (p = 0.874). In conclusion, compared with balloon-expandable valves, self-expanding THV may optimize transvalvular hemodynamics across all annular diameters, independent of their supra-annular and intra-annular design.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 16 Sep 2023; 207:48-53</small></div>

<div><h4>Effectiveness and Safety of Remote Cardiac Rehabilitation for Patients After Acute Coronary Syndrome.</h4><i>Hilu R, Haskiah F, Khaskia A, Assali A, ... Chen J, Pereg D</i><br /><AbstractText>Cardiac rehabilitation improves cardiovascular outcomes in patients after acute coronary syndrome (ACS). Recently there has been a growing interest in remote cardiac rehabilitation (RCR) programs. We aimed to evaluate the effectiveness of RCR compared with center-based cardiac rehabilitation (CBCR). This is an observational study including patients after hospital admission for ACS. The study group included patients at low-to-moderate risk for cardiovascular complications who were referred for RCR. The control group included patients at similar risk who participated in CBCR. The primary end points were the improvement of at least 10% to 25% in exercise capacity after 6 months of cardiac rehabilitation. Included were 305 patients who completed 6 months of cardiac rehabilitation. Of them, 107 patients participated in RCR and 198 in CBCR. RCR patients were younger and more frequently males. Improvement of ≥10% in exercise capacity after 6 months was achieved more frequently in patients participating in RCR compared with CBCR (69.3% and 55% respectively, p = 0.03). A similar trend was observed for improvement of ≥25% in exercise capacity after 6 months (33.8% and 22.7% in RCR and CBCR, respectively, p = 0.05). While weight reduction and the increase in muscle mass were similar in the 2 groups, fat percent reduction was significantly greater in the RCR compared with the CBCR (2.5% and 1.4% respectively, p <0.005). We conclude that RCR program is an effective and safe option for low-risk patients after hospital admission for ACS. It enables optimizing the utilization of this important service for patients with coronary artery disease.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 16 Sep 2023; 207:54-58</small></div>

<div><h4>Cardiovascular Outcomes After Mini-Crush or Double Kissing Crush Stenting Techniques for Complex Bifurcation Lesions: The EVOLUTE-CRUSH Registry.</h4><i>Güner A, Uzun F, Demirci G, Gökçe K, ... Ertürk M, Colombo A</i><br /><AbstractText>Comparison of clinical outcomes of double kissing crush (DKC) and mini-crush (MC) techniques in patients with complex coronary bifurcation lesions is lacking. This study sought to determine the clinical results of DKC and MC stenting techniques in mid-term follow-up. This retrospective study included a total of 269 consecutive patients with complex bifurcation lesions who underwent percutaneous coronary intervention; 132 (49%) of them were treated with MC technique, whereas 137 (51%) treated with DKC technique. The primary end point was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. This is the first study to compare the cardiovascular outcomes of DKC and MC stenting techniques in patients with complex bifurcation lesions. The SYNTAX scores were similar in both groups (23 [20 to 30] vs 23 [19 to 28], p = 0.631)]. The number of balloons (6.31 ± 1.80 vs 4.42 ± 0.87, p <0.001) and guidewires (3.55 ± 0.83 vs 2.86 ± 0.74, p <0.001) used, fluoroscopy time (21.55 ± 7.05 vs 16.66 ± 4.19 minutes, p <0.001), and procedure time (80.42 ± 27.95 vs 69.61 ± 18.97 minutes, p <0.001) were significantly higher in the DKC group. The rate of composite TLF was similar in complex bifurcation patients treated with MC than those treated with the DKC technique (14% vs 12%, p = 0.453). Moreover, both groups had similar rates in terms of cardiac death or all-cause death, target vessel-related myocardial infarction, clinically driven target lesion revascularization, and stent thrombosis. In conclusion, the present study showed that both techniques of bifurcation treatment met high angiographic success with low complication and similar TLF rates.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 16 Sep 2023; 206:238-246</small></div>

<div><h4>Use of Coronary Artery Calcium Quantification and Distribution for Coronary Vascular Disease Risk Reclassification in a Primary Prevention Setting.</h4><i>Ali AH, Nakhla M, Cho L, Seballos R, ... Wang T, Desai MY</i><br /><AbstractText>In a large screening program of asymptomatic middle-aged individuals, we sought to assess the degree of risk reclassification provided by comparing multiethnic study on subclinical atherosclerosis coronary artery calcium scoring (CACS) versus atherosclerotic cardiovascular disease (ASCVD) and Reynolds risk score (RRS) score. All 5,324 consecutive patients (aged 57 ± 8 years, 76% male) who underwent CACS screening at the Cleveland Clinic as part of a primary prevention executive health between March 16 and October 21 were included. The 10-year ASCVD, RRS, and multiethnic study on subclinical atherosclerosis CACS (MESA-CACS) risk scores were calculated and categorized as <1, 1 to 4.99, 5 to 9.99, and ≥10%. Compared with ASCVD, using MESA-CACS resulted in a downgraded risk in 1,667 subjects (31%), whereas 738 (14%) had an upgrade in risk (total of 45% reclassification). Similarly, compared with RRS, using MESA-CACS resulted in an upgraded risk in 797 (15%) and a downgrade in 1,380 (26%) subjects (total of 41% reclassification). However, by further dividing by the distribution of the coronary calcification, ASCVD overestimates the risk only for patients with coronary artery calcium (CAC) in 0 or 1 coronary artery only, whereas MESA-CACS overestimates if the CAC was noted in ≥2 arteries. Similarly, RRS only overestimates the risk for patients with 0 CAC, whereas it underestimates the risk for patients with any CAC. In conclusion, the use of MESA-CACS, along with CAC distribution in primary prevention clinics, results in differential and significant reclassification of traditional scores when calculating the 10-years coronary vascular disease risk. Overall, RRS underestimates and ASCVD overestimates the cardiovascular disease risk compared with MESA-CACS.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 16 Sep 2023; 206:303-308</small></div>

<div><h4>Extrathoracic Against Intrathoracic Vascular Accesses for Transcatheter Aortic Valve Replacement: A Systematic Review With Meta-Analysis.</h4><i>Abellan C, Antiochos P, Fournier S, Skali H, ... Muller O, Lu H</i><br /><AbstractText>Alternative vascular accesses to transfemoral access for transcatheter aortic valve replacement (TAVR) can be divided into intrathoracic (IT)-transapical and transaortic- and extrathoracic (ET)-transcarotid, transsubclavian, and transaxillary. This study aimed to compare the outcomes and safety of IT and ET accesses for TAVR as alternatives to transfemoral access. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all studies comparing IT-TAVR with ET-TAVR published until April 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM), 1-year ACM, postoperative and 30-day complications. A total of 18 studies with 6,800 IT-TAVR patients and 5,032 ET-TAVR patients were included. IT accesses were associated with a significantly higher risk of in-hospital or 30-day ACM (relative risk 1.99, 95% confidence interval 1.67 to 2.36, p <0.001), and 1-year ACM (relative risk 1.31, 95% confidence interval 1.21 to 1.42, p <0.001). IT-TAVR patients presented more often with postoperative life-threatening bleeding, 30-day new-onset atrial fibrillation or flutter, and 30-day acute kidney injury needing renal replacement therapy. The risks of postoperative permanent pacemaker implantation and significant paravalvular leak were lower with IT-TAVR. ET-TAVR patients were more likely to be directly discharged home. There was no statistically significant difference regarding the 30-day risk of stroke. Compared with ET-TAVR, IT-TAVR was associated with higher risks of in-hospital or 30-day ACM, 1-year ACM and higher risks for some critical postprocedural and 30-day complications. Our results suggest that ET-TAVR could be considered as the first-choice alternative approach when transfemoral access is contraindicated.</AbstractText><br /><br />Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 15 Sep 2023; 203:473-483</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>Incidence, management, and prognostic impact of arrhythmias in patients with Takotsubo syndrome: a nationwide retrospective cohort study.</h4><i>Isogai T, Matsui H, Tanaka H, Makito K, Fushimi K, Yasunaga H</i><br /><b>Background</b><br />Arrhythmia is a major complication of Takotsubo syndrome (TTS). However, its incidence, management, and prognostic impact remain to be elucidated in a large cohort.<br /><b>Methods</b><br />We retrospectively identified 16713 patients hospitalized for TTS between July 2010 and March 2021 from the Japanese Diagnosis Procedure Combination database. Serious arrhythmias were defined as ventricular tachycardia/fibrillation (VT/VF), 2nd/3rd-degree atrioventricular block (AVB), sick sinus syndrome (SSS), or unspecified arrhythmias requiring device treatment. Patient characteristics and outcomes were compared based on the occurrence of serious arrhythmias.<br /><b>Results</b><br />The overall incidence proportion of serious arrhythmias was 6.2% (n=1036; 449 VT/VF, 283 2nd/3rd-degree AVB, 133 SSS, 55 multiple arrhythmias, 116 others), which remained stable over 11 years. The arrhythmia group was younger, more often male, and exhibited greater impairment in activities of daily living (ADLs) and consciousness than the non-arrhythmia group. Although crude in-hospital mortality was higher in the arrhythmia group (9.6% vs. 5.0%, p=0.013), the significant association between arrhythmias and mortality disappeared after adjustment for confounders (odds ratio=1.15, 95% CI=0.90-1.49). However, age, sex, ADLs, consciousness, and Charlson comorbidity index were significantly associated with mortality. In the arrhythmia group, 254 (24.5%) patients received pacemakers (18.4%) or defibrillators (6.1%), which were implanted at a median of 8 and 19 days after admission, respectively.<br /><b>Conclusions</b><br />Arrhythmias are not uncommon in TTS. Patients\' background characteristics, rather than arrhythmia itself, may be associated with in-hospital mortality. Given the reversibility of cardiac dysfunction in TTS, there may be unnecessary device implantations for arrhythmias occurring as sequelae to TTS, warranting further investigations.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Multidisciplinary cardiogenic shock team approach improves the long-term outcomes of patients suffering from refractory cardiogenic shock treated with short-term mechanical circulatory support.</h4><i>Hérion FX, Beurton A, Oddos C, Nubret K, ... Imbault J, Ouattara A</i><br /><b>Background</b><br />Short-term mechanical circulatory support (STMCS) may be used as an intentional escalation strategy to treat cardiogenic shock refractory (rCS). However, with growing technical possibilities, making the right choice at the right time can be challenging. We established a shock team in January 2013 comprising a cardiac anaesthetist-intensivist, an interventional cardiologist, and a cardiac surgeon. Since then, a diagnosis of rCS has triggered a multidisciplinary team meeting based on a common algorithm. This study aimed to compare the decision-making process for STMCS for rCS before (2007-2013) and after (2013-2019) the creation of the shock team.<br /><b>Methods</b><br />This before-and-after cohort study was conducted over a 156-month period. Post-cardiotomy rCS were excluded. The primary outcome was a 1-year survival rate.<br /><b>Results</b><br />In total, 250 consecutive adult patients were included in the analysis (84 in the control group and 166 in the shock team group). At baseline, the CardShock score was not different between the two groups (5[3-5] vs. 5[4-6], p=0.323). The 1-year survival rate was significantly higher in the shock team group compared to the control group (59% vs. 45%, p = 0.043). After a Cox regression analysis, the shock team intervention was independently associated with a significantly improved 1-year survival rate (HR: 0.592, 95% CI: 0.398-0.880, p=0.010).<br /><b>Conclusion</b><br />A multidisciplinary shock team-based decision for STMCS device implantation in rCS is associated with better 1-year survival rates.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Contemporary In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the MENATA (Middle East, North Africa, Turkey, and Asia) Chapter of the PROGRESS-CTO Registry.</h4><i>Gorgulu S, Kostantinis S, ElGuindy AM, Abi Rafeh N, ... Brilakis ES, Goktekin O</i><br /><AbstractText>Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been rapidly evolving in different parts of the world. We examined the clinical and angiographic characteristics and procedural outcomes of 1,079 consecutive CTO PCIs performed in 1,063 patients at 10 centers in the Middle East, North Africa, Turkey, and Asia regions between 2018 and 2022. The mean age was 61 ± 10 years and 82% of the patients were men. The prevalence of diabetes (49%) and previous PCI (50%) was high. The most common target vessel was the right coronary artery (51%), followed by the left anterior descending artery (33%) and the circumflex artery (15%). The mean Japanese CTO score was 2.1 ± 1.2 and mean PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) score was 1.2 ± 1.0. The technical and procedural success rates were high (91% and 90%, respectively) with a low incidence (1.6%) of in-hospital major adverse cardiac events. The incidence of perforation was 4.6% (n = 50): guidewire exit was the most common mechanism of perforation (48%) and 14 patients required pericardiocentesis (28%). Antegrade wire escalation was the most common crossing strategy used (91%), followed by retrograde approach (24%) and antegrade dissection and re-entry (12%). Median contrast volume, air kerma radiation dose, and fluoroscopy time were 300 (200 to 400) ml, 3.7 (2.0 to 6.3) Gy, and 40 (25 to 65) minutes, respectively. In conclusion, high success and acceptable complication rates are currently achieved at experienced centers in the Middle East, North Africa, Turkey, and Asia regions using a combination of crossing strategies.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 15 Sep 2023; 206:221-229</small></div>

<div><h4>Prognostic significance of the SYNTAX score and SYNTAX score II in patients with myocardial infarction treated with percutaneous coronary intervention.</h4><i>Di Maio M, Esposito L, Silverio A, Bellino M, ... Vecchione C, Galasso G</i><br /><b>Objectives</b><br />We aimed to evaluate the prognostic significance of the SYNTAX score (SS) and SYNTAX score II (SS-II) in a contemporary real-world cohort of myocardial infarction (MI) patients treated with percutaneous coronary intervention (PCI).<br /><b>Background</b><br />The role of SS and SS-II in the prognostic stratification of patients presenting with MI and undergoing PCI has been poorly investigated.<br /><b>Methods</b><br />This study included MI patients treated with PCI from January 2015 to April 2020 at the University Hospital of Salerno. Patients were divided into tertiles according to the baseline SS and SS-II values. The primary outcome measure was all-cause mortality at long-term follow-up; secondary outcome measures were cardiovascular (CV) death and MI.<br /><b>Results</b><br />Overall, 915 patients were included in this study. Mean SS and SS-II were 16.1 ± 10.0 and 31.6 ± 11.5, respectively. At propensity weighting adjusted Cox regression analysis, both SS (hazard ratio [HR]: 1.02; 95% confidence interval [CI]: 1.02-1.06; p = 0.017) and SS-II (HR: 1.08; 95% CI: 1.07-1.10; p < 0.001) were significantly associated with the risk of all-cause mortality at long-term follow-up; both SS (HR 1.04; CI 1.01-1.06; p < 0.001) and SS-II (HR 1.08; CI 1.06-1.10; p < 0.001) were significantly associated with the risk of CV death, but only SS-II showed a significant association with the risk of recurrent MI (HR 1.03; CI 1.01-1.05; p < 0.001). At 5 years, SS-II showed a significantly higher discriminative ability for all-cause mortality than SS (area under the curve: 0.82 vs. 0.64; p < 0.001). SS-II was able to reclassify the risk of long-term mortality beyond the SS (net reclassification index 0.88; 95% CI: 0.38-1.54; p = 0.033).<br /><b>Conclusions</b><br />In a real-world cohort of MI patients treated with PCI, SS-II was a stronger prognostic predictor of long-term mortality than SS.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 13 Sep 2023; epub ahead of print</small></div>

<div><h4>Ping-pong snaring of a totally dislodged stent across left main ostium: \"All is not lost\".</h4><i>Restivo A, Stanzione A, Maffeo D, Buono A</i><br /><AbstractText>Undeployed stent loss is a rare but potentially serious complication of percutaneous coronary intervention. Its management is not assisted by well-defined guidelines, and it is made even more difficult when the dislodged stent is not protected by in situ guidewire. In this work, we present the case of a total stent loss with a crushed device protruding out of the left main. In this hopeless circumstance, an innovative ping-pong technique was used to contralaterally perform a successful stent retrieval.</AbstractText><br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 13 Sep 2023; epub ahead of print</small></div>

<div><h4>Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience.</h4><i>Thompson MP, Stewart JW, Hou H, Nathan H, ... Hawkins RB, Likosky DS</i><br /><b>Background</b><br />Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting.<br /><b>Methods</b><br />A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes.<br /><b>Results</b><br />In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26-1.57]; <i>P</i><0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; <i>P</i><0.001).<br /><b>Conclusions</b><br />The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 13 Sep 2023:e009639; epub ahead of print</small></div>

<div><h4>Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome.</h4><i>David TE, Park J, Tatangelo M, Steve Fan CP, Ouzounian M</i><br /><b>Background</b><br />The usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial.<br /><b>Objectives</b><br />The purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement.<br /><b>Methods</b><br />Patients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed.<br /><b>Results</b><br />There were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve.<br /><b>Conclusions</b><br />Aortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Coll Cardiol: 12 Sep 2023; 82:1068-1076</small></div>

<div><h4>Utility of rapid atrial pacing before and after TAVR with balloon-expandable valve in  predicting permanent pacemaker implantation.</h4><i>Tan BE, Hashem A, Boppana LKT, Mohamed MS, ... Bhatt DL, Depta JP</i><br /><b>Background</b><br />High-grade or complete atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation is a known complication of transcatheter aortic valve replacement (TAVR). Wenckebach AVB induced by rapid atrial pacing (RAP) after TAVR was previously demonstrated in an observational analysis to be an independent predictor for PPM. We sought to investigate the utility of both pre- and post-TAVR RAP in predicting PPM implantation.<br /><b>Methods</b><br />In a single-center, prospective study, 421 patients underwent TAVR with balloon-expandable valves (BEV) between April 2020 and August 2021. Intraprocedural RAP was performed in patients without a pre-existing pacemaker, atrial fibrillation/flutter, or intraprocedural complete AVB to assess for RAP-induced Wenckebach AVB. The primary outcome was PPM within 30 days after TAVR.<br /><b>Results</b><br />RAP was performed in 253 patients, of whom 91.3% underwent post-TAVR RAP and 61.2% underwent pre-TAVR RAP. The overall PPM implantation rate at 30 days was 9.9%. Although there was a numerically higher rate of PPM at 30 days in patients with RAP-induced Wenckebach AVB, it did not reach statistical significance (13.3% vs. 8.4%, p = 0.23). In a multivariable analysis, RAP-induced Wenckebach was not an independent predictor for PPM implantation at 30 days after TAVR. PPM rates at 30 days were comparable in patients with or without pre-TAVR pacing-induced Wenckebach AVB (11.8% vs. 8.2%, p = 0.51) and post-TAVR pacing-induced Wenckebach AVB (10.2% vs. 5.8%, p = 0.25).<br /><b>Conclusion</b><br />In patients who underwent TAVR with BEV, there were no statistically significant differences in PPM implantation rates at 30 days regardless of the presence or absence of RAP-induced Wenckebach AVB. Due to conflicting results between the present study and the prior observational analysis, future studies with larger sample sizes are warranted to determine the role of RAP during TAVR as a risk-stratification tool for significant AVB requiring PPM after TAVR.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>Performance of the 32 mm Myval transcatheter heart valve for treatment of aortic stenosis in patients with extremely large aortic annuli in real-world scenario: First global, multicenter experience.</h4><i>Holzamer A, Bedogni F, van Wyk P, Barwad P, ... Seidler T, Hilker M</i><br /><b>Background</b><br />Extremely large aortic valve anatomy is one of the remaining limitations leading to exclusion of patients for transcatheter aortic valve replacement (TAVR).<br /><b>Aims</b><br />The newly approved Myval 32 mm device is designed for use in aortic annulus areas up to 840 mm<sup>2</sup> . Here we want to share the initial worldwide experience with the device.<br /><b>Methods and results</b><br />Retrospective data were collected from 10 patients with aortic stenosis and very large annular anatomy (mean area 765.5 mm<sup>2</sup> ), who underwent implantation with 32 mm Myval transcatheter heart valve at eight centers. Valve Academic Research Consortium-2 device success was achieved in all cases. Mild paravalvular leak was observed in three patients and two patients required new pacemaker implantation. One patient experienced retroperitoneal hemorrhage caused by the contralateral 6 F sheath and required surgical revision. No device-related complications, stroke, or death from any cause occurred within the 30-day follow-up period. In a studied cohort of 2219 consecutive TAVR-screened patients from a central European site, only 0.27% of patients showed larger anatomy than covered by the 32 mm Myval device by instructions for use without off-label use of overexpansion. This rate was significantly higher for the 34 mm Evolut Pro (1.8%) and 29 mm Sapien 3 (2.1%) devices.<br /><b>Conclusions</b><br />The Myval 32 mm prosthesis showed promising initial results in a cohort of patients who previously had to be excluded from TAVR. It is desirable that all future TAVR systems accommodate larger anatomy to allow optimal treatment of all patients.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>Trends and outcomes of combined percutaneous (TAVI+PCI) and surgical approach (SAVR+CABG) for patients with aortic valve and coronary artery disease: A National Readmission Database (NRD) analysis.</h4><i>Ullah W, Sarvepalli D, Kumar A, Zahid S, ... Filby SJ, Devireddy C</i><br /><b>Background</b><br />In patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD), the relative merits of a combined percutaneous (transcatheter aortic valve implantation [TAVI] and percutaneous coronary intervention [PCI]] versus surgical approach (surgical aortic valve replacement [SAVR] and coronary artery bypass graft [CABG]) remain unknown.<br /><b>Aims</b><br />To determine the utility of combined percutaneous versus surgical approaches in patients with severe AS and CAD.<br /><b>Methods</b><br />The National Readmission Database (NRD) (2015-2019) was queried to identify all cases of TAVI+PCI and SAVR+CABG. The adjusted odds ratios (aOR) of mortality, stroke, and its composite (major adverse cardiovascular events [MACE]) were calculated using a propensity-score matched (PSM) analysis.<br /><b>Results</b><br />A total of 89,314 (5358 TAVI+PCI, 83,956 SAVR+CABG) patients were included in the crude analysis. There was a gradual increase in the utilization of TAVI+PCI from 2016 to 2019 by 2%-4% per year. Using PSM, a subset of 11,361 (5358 TAVI+PCI, 6003 SAVR+CABG) patients with a balanced set of demographics and baseline comorbidities was selected. During index hospitalization, the adjusted odds of MACE (aOR 0.72, 95% confidence interval [CI] 0.62-0.83), and all-cause mortality (aOR 0.68, 95% CI 0.57-0.81) were significantly lower in patients undergoing TAVI+PCI compared with SAVR+CABG. However, patients undergoing TAVI+PCI had a higher incidence of MACE (aOR 1.40, 95% CI 1.05-1.87), and mortality (aOR 1.75, 95% CI 1.22-2.50) at 30-days. The risk of index-admission (aOR 0.82, 95% CI 0.62-1.09) and 30-day (aOR 0.88, 95% CI 0.51-1.51) stroke was similar between the two groups.<br /><b>Conclusion</b><br />In selected patients with severe AS and concomitant CAD, a combined percutaneous approach (TAVR+PCI) compared with SAVR+CABG may confer a lower risk of MACE and mortality during index admission but a higher incidence of 30-day complications.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>The Benefit of Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Replacement: A Multicenter Retrospective Outcome-Based Study.</h4><i>Mosleh W, Mather JF, Delago AJ, Eastman L, ... McKay RG, Young MN</i><br /><AbstractText>There is inadequate evidence regarding the role of percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). The current American Heart Association/American College of Cardiology guidelines are limited to class 2A recommendations for pre-TAVR revascularization in the setting of hemodynamically significant left main (LM), proximal left anterior descending (pLAD), or extensive bifurcation disease regardless of angina status. We performed a multicenter, retrospective, observational study assessing the benefit of PCI in patients with coronary artery disease who underwent transfemoral TAVR for severe symptomatic aortic stenosis. Patients were divided into 2 cohorts: (1) patients who did not undergo pre-TAVR PCI within the preceding 12 months (no-PCI group) and (2) patients who received pre-TAVR PCI within the preceding 12 months (PCI group). The primary outcome was defined as the composite end point of in-hospital and 30-day adverse events, including all-cause mortality, cardiac arrest, and myocardial infarction. Subgroup analyses were performed on patients with LM and/or pLAD disease and other high-risk features, including angina and heart failure. Comparisons were made between 1,809 consecutive patients (1,364 in the no-PCI group and 445 in the PCI group). There were no differences between the 2 cohorts regarding the primary composite outcome (2.0% vs 2.8%, p = 0.918) or individual secondary outcomes. Although LM/pLAD disease, New York Heart Association classes III to IV, and Society of Thoracic Surgeons risk score ≥8 were all independent predictors of the primary outcome, none of the subgroups demonstrated a benefit favoring PCI. In conclusion, there is no observed benefit from PCI within 12 months pre-TAVR in patients with severe aortic stenosis and concomitant coronary artery disease, including patients with LM/pLAD disease.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Am J Cardiol: 12 Sep 2023; 206:175-184</small></div>

<div><h4>Antiplatelet Resistance in Patients Who Underwent Coronary Artery Bypass Grafting: A Systematic Review and Meta-Analysis.</h4><i>Comanici M, Bhudia SK, Marczin N, Raja SG</i><br /><AbstractText>Antiplatelet therapy (APT) with aspirin and a P2Y12 inhibitor is commonly given to patients who underwent coronary artery bypass grafting (CABG) to reduce thrombotic events. APT resistance, the inadequate antiplatelet effect of these drugs, is a growing concern. This review aimed to assess APT resistance prevalence in patients who underwent CABG and its impact on clinical outcomes. We conducted a comprehensive search for relevant studies published to date. The included studies measured platelet function through laboratory assays and reported on clinical outcomes in patients who underwent CABG. The primary outcomes were major adverse cardiovascular events (MACEs) and mortality, whereas the secondary outcomes included acute coronary syndrome (ACS), stroke, and thromboembolic events. The meta-analysis used random-effects models, with heterogeneity assessed using the I<sup>2</sup> statistic. The initial search identified 45 studies, with 11 meeting the inclusion criteria, involving 3,122 patients. The overall prevalence of APT resistance in patients who underwent CABG was 39%. Patients with APT resistance had significantly higher risks of MACEs and death (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.06 to 2.83, p = 0.03) and postoperative myocardial infarction (OR 2.25, 95% CI 1.13 to 4.48, p = 0.02) than those without resistance. However, no significant association was found between APT resistance and stroke (OR 2.25, 95% CI 0.80 to 6.35, p = 0.12) or other thromboembolic events (OR 1.72, 95% CI 0.72 to 4.08, p = 0.22). In conclusion, APT resistance is prevalent in a significant proportion of patients who underwent CABG, increasing the risk of MACEs and postoperative myocardial infarction. These findings emphasize the need for further research to develop tailored antiplatelet strategies in this patient population.</AbstractText><br /><br />Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 12 Sep 2023; 206:191-199</small></div>

<div><h4>Early Computed Tomography Coronary Angiography and Preventative Treatment in Patients with Suspected Acute Coronary Syndrome A secondary analysis of the RAPID-CTCA trial.</h4><i>Wang KL, Meah MN, Bularga A, Oatey K, ... Gray AJ, RAPID-CTCA Investigators</i><br /><b>Background</b><br />Computed tomography coronary angiography (CTCA) offers detailed assessment of the presence of coronary atherosclerosis and helps guide patient management. We investigated influences of early CTCA on the subsequent use of preventative treatment in patients with suspected acute coronary syndrome.<br /><b>Methods</b><br />In this secondary analysis of a multicentre randomised controlled trial of early CTCA in intermediate-risk patients with suspected acute coronary syndrome, prescription of aspirin, P2Y<sub>12</sub> receptor antagonist, statin, renin-angiotensin system blocker, and beta-blocker therapies from randomisation to discharge were compared within then between those randomised to early CTCA or to standard of care only. Effects of CTCA findings on adjustment of these therapies were further examined.<br /><b>Results</b><br />In 1743 patients (874 randomised to early CTCA and 869 to standard of care only), prescription of P2Y<sub>12</sub> receptor antagonist, dual antiplatelet, and statin therapies increased more in the early CTCA group (between-group difference: 4.6% (95% confidence interval, 0.3 to 8.9), 4.5% (95% confidence interval, 0.2 to 8.7), and 4.3% (95% confidence interval, 0.2 to 8.5), respectively), whereas prescription of other preventative therapies increased by similar extent in both study groups. Amongst patients randomised to early CTCA, there were additional increments of preventative treatment in those with obstructive coronary artery disease and higher rates of reductions in antiplatelet and beta-blocker therapies in those with normal coronary arteries.<br /><b>Conclusions</b><br />Prescription patterns of preventative treatment varied during index hospitalisation in patients with suspected acute coronary syndrome. Early CTCA facilitated targeted individualisation of these therapies based on the extent of coronary artery disease.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Am Heart J: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>Comparison of Recurrent With First-Time In-Stent Restenosis.</h4><i>Zhang H, Zhang Y, Tian T, Wang T, ... Yang W, Song L</i><br /><AbstractText>Recurrent in-stent restenosis (Re-ISR) remains a therapeutic challenge. We aimed to investigate the clinical characteristics, treatment, and long-term outcomes in patients with Re-ISR compared with those with first-time ISR (First-ISR). This retrospective study consecutively enrolled patients who underwent percutaneous coronary intervention (PCI) for ISR in Fuwai Hospital between January 2017 and December 2018. Re-ISR was defined as a second event of ISR after a previous successful treatment of the ISR lesion. The primary outcome was defined as a composite of all-cause death, spontaneous myocardial infarction, and repeat revascularization. A total of 2,006 patients (2,154 lesions) with ISR underwent successful PCI were enrolled and categorized into 2 groups: the Re-ISR group (246 patients/259 lesions) and the First-ISR group (1,760 patients/1,895 lesions). During a mean follow-up of 36 months, the primary outcomes occurred in 80 patients (32.5%) in the Re-ISR group and 349 patients (19.3%) in the First-ISR group (p <0.001 by log-rank test), major driven by spontaneous myocardial infarction (4.9% vs 2.7%, p = 0.049) and repeat revascularization (30.1% vs 16.5%, p <0.001). The multivariable Cox regression analysis revealed that Re-ISR was independently associated with a higher rate of major adverse cardiovascular events (adjusted hazard ratio 1.88, 95% confidence interval 1.39 to 2.53, p <0.001) and repeated revascularization (adjusted hazard ratio 2.09, 95% confidence interval 1.53 to 2.84, p <0.001). The relation remained consistent after the propensity score analysis. In conclusion, in the present cohort of patients who underwent PCI for ISR, Re-ISR was significantly associated with a higher risk of long-term outcomes than First-ISR.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 12 Sep 2023; 206:168-174</small></div>

<div><h4>Temporal trends of case-fatality in patients undergoing dual-injection coronary chronic total occlusion recanalization.</h4><i>Blessing R, Keller K, Dimitriadis Z, Münzel T, Gori T, Hobohm L</i><br /><b>Aims</b><br />Recently, interventional techniques and material to treat chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) have evolved significantly. Nevertheless, it is still unknown whether this progress improved treatment success and patients\' outcome. In a nationwide sample, we sought to analyze trends of patients\' characteristics, complications and in-hospital case-fatality of patients undergoing CTO revascularization in Germany.<br /><b>Methods and results</b><br />We analyzed data on characteristics, treatments, and in-hospital outcomes for all coronary artery disease (CAD) patients (ICD-code I25) undergoing dual-injection CTO recanalization (OPS procedural code: 8-839.9) in Germany from 2009 to 2020. Overall, 4,998,457 inpatients aged ≥ 18 years with diagnosis of CAD were treated in German hospitals in this period. Among these, 52,879 patients (1.1%) underwent CTO recanalization. Annual number of CTO PCIs increased from 1263 in 2009 to 6435 in 2020 (β 3.48 [95% CI 3.44-3.52]; p < 0.001) in parallel with a significant decrease of case-fatality (2.2% in 2009 to 1.4% in 2020; β  - 0.60 [95% CI  - 0.82 to  - 0.39]; p < 0.001). Overall, 754 (1.4%) patients with CTO recanalization died during the in-hospital stay and in-hospital case-fatality grew exponentially with age (β 0.82 [95% CI 0.73-0.90]; p < 0.001). Significant predictors of in-hospital case fatality with an OR > 3 were cancer, stroke, hemopericardium, acute renal failure, pulmonary embolism and shock.<br /><b>Conclusion</b><br />Annual number of CTO procedures performed in Germany increased from 2009 to 2020 with a concomitant anti-proportional decrease in the case-fatality. Our findings may help to draw more attention to predictors of in-hospital case fatality in patients hospitalized for CTO recanalization.<br /><br />© 2023. The Author(s).<br /><br /><small>Clin Res Cardiol: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Patient-specific commissural alignment for ACURATE neo2 implantation in degenerated surgical bioprostheses.</h4><i>Curio J, Khokhar AA, Beneduce A, Mylotte D, ... Giannini F, Dudek D</i><br /><AbstractText>Valve-in-valve TAVI to treat failing surgical aortic valves (SAVs) is increasingly performed, and commissural alignment is a key technical aspect in such procedures. Surgeons optimize valve alignment, accounting for potential coronary eccentricity and achieving a patient-specific optimized commissural orientation, representing the ideal target for TAVI alignment. Therefore, here we present a dedicated stepwise valve-in-valve implantation technique using the ACURATE neo2. In a specific SAV postoverlap view, isolating one surgical post to the right of the screen representing the target for alignment, rotational orientation of the TAVI commissures, matching the SAV orientation, is achieved and verified before implantation. This technique has been tested in a patient-specific three-dimensionally-printed aortic root anatomy, attached to a pulsatile flow simulator, allowing for native-like simulation of coronary cannulations under fluoroscopy, and enabling detailed assessment with fluoroscopic as well as direct videographic visualization. Furthermore, the technique is exemplified by providing an educational clinical case example.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Endovascular maneuvers for contralateral stent graft limb misplacement in endovascular aortic repair.</h4><i>Schulte K, Zdoroveac A, Gürke L, Isaak A</i><br /><AbstractText>Cannulation and placement of the contralateral stent graft limb during endovascular aortic repair (EVAR) procedure are crucial steps as mispositioning may lead to conversion to open aortic repair. Endovascular bail-out strategies for stent graft relocation in EVAR are underreported though detailed knowledge may facilitate application and prevent conversion. We present three endovascular bail-out strategies for repositioning of a mispositioned contralateral stent graft limb. (1) Retraction of the mispositioned component with an inflated reliant balloon and placement of an interposition stent graft after successful cannulation; (2) Push-maneuver of the mispositioned stent graft into the infrarenal aortic aneurysm with an inflated reliant balloon supported by a large lumen introducer sheath and (3) Parallel placement of a second contralateral stent graft limb displacing the mispositioned one against the atrial wall in cases with adequate vessel diameter. Prevention of stent graft mispositioning by applying recognized tests to ensure correct placement are essential, following the slogan: check twice, deploy once.</AbstractText><br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Gender Differences in Long-Term Outcomes of Young Patients Who Underwent Percutaneous Coronary Intervention: Long-Term Outcome Analysis from a Multicenter Registry in Japan.</h4><i>Kuno T, Miyamoto Y, Sawano M, Kodaira M, ... Fukuda K, Kohsaka S</i><br /><AbstractText>Young patients who underwent percutaneous coronary intervention (PCI) have shown worse long-term outcomes but remain inadequately investigated. We analyzed 1,186 consecutive young patients (aged ≤55 years) from the Keio Cardiovascular PCI registry who were successfully discharged after PCI (2008 to 2019) and compared them to 5,048 older patients (aged 55 to 75 years). The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting within 2 years after discharge. In the young patients, the mean age was 48.4 ± 5.4 years, acute coronary syndrome cases accounted for 69.6%, and 92 (7.8%) were female. Body mass index; hemoglobin levels; and proportions of smoking, hyperlipidemia, and ST-elevation myocardial infarction were lower and dialysis or active cancer proportions were higher in young female patients than male patients. A higher number of young female than male patients reached the primary end point and all-cause death (15.2% vs 7.1%, p = 0.01; 4.3% vs 1.0%, p = 0.023), mainly because of noncardiac death (4.3% versus 0.5%, p = 0.001). After covariate adjustment, the primary end point rates were higher among young women than men (hazard ratio 2.00, 95% confidence interval 1.03 to 3.89, p = 0.042). Gender did not predict the primary end point among older patients (vs men; hazard ratio 0.84, 95% confidence interval 0.67 to 1.06, p = 0.14). In conclusion, young women showed worse outcomes during the 2-year post-PCI follow-up, but this gender difference was absent in patients aged 55 to 75 years.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 11 Sep 2023; 206:151-160</small></div>

<div><h4>Histology, OCT, and Micro-CT Evaluation of Coronary Calcification Treated With Intravascular Lithotripsy: Atherosclerotic Cadaver Study.</h4><i>Kawai K, Sato Y, Hokama JY, Kawakami R, ... Virmani R, Finn AV</i><br /><b>Background</b><br />Although intravascular lithotripsy (IVL) has been an emerging novel option to treat vascular calcification, the specific effects on histology have not been systematically examined.<br /><b>Objectives</b><br />The authors examined the histologic effects of IVL on coronary calcified lesions from human autopsy hearts and evaluated the diagnostic ability of optical coherence tomography (OCT) and micro-computed tomography (CT) to detect calcium fracture as identified by the gold standard histology.<br /><b>Methods</b><br />Eight coronary lesions were treated with IVL, and 7 lesions were treated with 10 atm inflation using an IVL catheter balloon without lithotripsy pulses (plain old balloon angioplasty [POBA]). OCT and micro-CT imaging were performed before and after treatment, and the presence of calcium fracture was assessed. The frequency and size of fractures were measured and compared with the corresponding histology.<br /><b>Results</b><br />All 15 treated lesions were diagnosed as sheet calcium by histology. Histological evidence of calcium fracture was significantly greater in the IVL group compared with the POBA group (62.5% vs 0.0%; P = 0.01). Calcified lesions with fracture had a larger maximum arc degree of calcification (median 145.6 [IQR: 134.4-300.4] degrees vs 107.0 [IQR: 88.9-129.1] degrees; P = 0.01). Micro-CT and histology showed an excellent correlation for fracture depth (R<sup>2</sup> = 0.83; P < 0.0001), whereas OCT showed less correlation (R<sup>2</sup> = 0.37; P = 0.11). The depth of fractures measured by OCT were significantly shorter than with those measured by histology (0.49 [IQR: 0.29-0.77] mm vs 0.88 [IQR: 0.64-1.07] mm; P = 0.008).<br /><b>Conclusions</b><br />IVL demonstrated a histologically superior fracturing effect on coronary calcified lesions compared with POBA. OCT failed to identify the presence of some calcium fractures and underestimated the depth of fracture when compared with micro-CT.<br /><br />Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Interv: 11 Sep 2023; 16:2097-2108</small></div>

<div><h4>Outcomes Based on Angiographic vs Functional Significance of Complex 3-Vessel Coronary Disease: FAME 3 Trial.</h4><i>Kobayashi Y, Takahashi T, Zimmermann FM, Otsuki H, ... Fearon WF, FAME 3 Trial Investigators</i><br /><b>Background</b><br />The functional SYNTAX score (FSS), which incorporates functional information as assessed by fractional flow reserve (FFR), is a better predictor of outcome after percutaneous coronary intervention (PCI) in patients with less complex coronary artery disease (CAD).<br /><b>Objectives</b><br />This study sought to test the prognostic value of the FSS in patients with complex CAD eligible for coronary artery bypass grafting (CABG).<br /><b>Methods</b><br />The FAME 3 (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3) trial compared FFR-guided PCI with CABG in patients with angiographic 3-vessel CAD. In this prespecified substudy, the angiographic core laboratory calculated the SYNTAX score (SS) and then the FSS by eliminating lesions that were not significant based on FFR. Outcomes in the PCI patients based on the FSS and the SS were compared to each other and to the patients treated with CABG.<br /><b>Results</b><br />The FSS reclassified more than one-quarter of patients from an SS >22 to an FSS ≤22. In the 50% of PCI patients who had an FSS ≤22, the primary endpoint occurred at a similar rate to patients treated with CABG (P = 0.77). The primary endpoint in patients without functionally significant 3-vessel CAD was similar to the CABG group (P = 0.97). The rate of myocardial infarction and revascularization among all deferred lesions was 0.5% and 3.2%, respectively.<br /><b>Conclusions</b><br />By measuring the FSS, one can identify 50% of patients who have a similar outcome at 1 year with PCI compared with CABG. Lesions deferred from PCI based on FFR have a low event rate.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Interv: 11 Sep 2023; 16:2112-2119</small></div>

<div><h4>Direct Comparison of Rotational vs Orbital Atherectomy for Calcified Lesions Guided by Optical Coherence Tomography.</h4><i>Okamoto N, Egami Y, Nohara H, Kawanami S, ... Nishino M, Tanouchi J</i><br /><b>Background</b><br />There are several retrospective studies comparing rotational atherectomy (RA) and orbital atherectomy (OA), but all percutaneous coronary interventions (PCIs) in those studies were not performed under intracoronary imaging guidance.<br /><b>Objectives</b><br />This study sought to compare the efficacy and safety of optical coherence tomography (OCT)-guided PCI with RA vs OA.<br /><b>Methods</b><br />The DIRO (To directly compare RA and OA for calcified lesions, a prospective randomized trial) trial was conducted. We enrolled patients with de novo calcified lesions (arc >180°) assessed by OCT or angiographically moderate or severe calcifications if the OCT catheter could not cross the lesion before any intervention. Eligible patients were randomly 1:1 allocated to lesion preparation with RA vs OA. Stent expansion was defined as the minimum stent area divided by the distal reference area multiplied by 100. Tissue modification was assessed using preatherectomy and postatherectomy OCT images. Procedural outcomes including periprocedural myocardial infarctions were evaluated. Furthermore, clinical events and vascular healing evaluated by OCT at 8 months postprocedure were assessed.<br /><b>Results</b><br />The stent expansion was significantly greater in the RA group vs the OA group (99.5% vs 90.6%; P = 0.02). The maximum atherectomy area was significantly larger in the RA group than in the OA group (1.34 [IQR: 1.02-1.89] mm<sup>2</sup> vs 0.83 [IQR: 0.59-1.11] mm<sup>2</sup>; P = 0.004). The procedural outcomes and clinical events at 8 months did not differ between the groups. The vascular healing was sufficient in both groups.<br /><b>Conclusions</b><br />The prospective randomized DIRO trial revealed that RA could produce a more favorable tissue modification, which may lead to a larger stent expansion than OA in heavily calcified lesions.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Interv: 11 Sep 2023; 16:2125-2136</small></div>

<div><h4>Late Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention in the Workup Pre-TAVR.</h4><i>Avvedimento M, Campelo-Parada F, Munoz-Garcia E, Nombela-Franco L, ... Faroux L, Rodés-Cabau J</i><br /><b>Background</b><br />In patients undergoing percutaneous coronary intervention (PCI) in the work-up pre-transcatheter aortic valve replacement (TAVR), the incidence and clinical impact of late bleeding events (LBEs) remain largely unknown.<br /><b>Objectives</b><br />This study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of LBEs in patients undergoing PCI in the work-up pre-TAVR.<br /><b>Methods</b><br />This was a multicenter study including 1,457 consecutive patients (mean age 81 ± 7 years; 41.5% women) who underwent TAVR and survived beyond 30 days. LBEs (>30 days post-TAVR) were defined according to the Valve Academic Research Consortium-2 criteria.<br /><b>Results</b><br />LBEs occurred in 116 (7.9%) patients after a median follow-up of 23 (IQR: 12-40) months. Late bleeding was minor, major, and life-threatening or disabling in 21 (18.1%), 63 (54.3%), and 32 (27.6%) patients, respectively. Periprocedural (<30 days post-TAVR) major bleeding and the combination of antiplatelet and anticoagulation therapy at discharge were independent factors associated with LBEs (P ≤ 0.02 for all). LBEs conveyed an increased mortality risk at 4-year follow-up compared with no bleeding (43.9% vs 36.0; P = 0.034). Also, LBE was identified as an independent predictor of all-cause mortality after TAVR (HR: 1.39; 95% CI: 1.05-1.83; P = 0.020).<br /><b>Conclusions</b><br />In TAVR candidates with concomitant significant coronary artery disease requiring percutaneous treatment, LBEs after TAVR were frequent and associated with increased mortality. Combining antiplatelet and anticoagulation regimens and the occurrence of periprocedural bleeding determined an increased risk of LBEs. Preventive strategies should be pursued for preventing late bleeding after TAVR, and further studies are needed to provide more solid evidence on the most safe and effective antithrombotic regimen post-TAVR in this challenging group of patients.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Interv: 11 Sep 2023; 16:2153-2164</small></div>

<div><h4>Changes of left atrial morphology and function evaluated with four-dimensional automated left atrial quantification echocardiography in patients with coronary slow flow phenomenon and preserved left ventricular ejection fraction.</h4><i>Xing Y, Zhang Y, Zhao R, Shi J, ... Chen L, Pan C</i><br /><b>Background</b><br />Coronary slow flow phenomenon (CSFP) can cause left ventricular diastolic dysfunction (LVDD). In multiple studies, the left atrial (LA) strain has been reported to be an excellent parameter for assessing LVDD. The 4-dimensional automated LA quantification (4D Auto LAQ) dedicated to the LA was recently available. Our study aimed to evaluate subclinical changes in LA morphology and function with 4D Auto LAQ in patients with CSFP and preserved left ventricular ejection fraction (LVEF).<br /><b>Methods</b><br />Forty-eight patients with CSFP confirmed with coronary angiography and 46 age and gender-matched controls with normal coronary flow were enrolled. The thrombolysis in myocardial infarction frame count (TFC) method was used to record coronary blood flow velocities for each major coronary artery. LA volume, LA longitudinal and circumferential strains during each of the three LA phases (reservoir, conduit, and contraction), LA total emptying fraction (LATEF), LA active emptying fraction (LAAEF), and LA passive emptying fraction (LAPEF) were quantified with 4D Auto LAQ analysis.<br /><b>Results</b><br />Compared with controls, LA longitudinal reservoir strain (LASr), LA longitudinal strain during the conduit phase (LAScd), LA contraction strain (LASct), LA conduit circumferential strain (LAScd-c), LATEF, LAPEF decreased significantly in individuals with CSFP. Of the 4D- LAQ parameters, only LASr [odds ratio (OR): 0.773, P < 0.001] and LATEF [OR: 0.762, P < 0.001] were associated with CSFP in multivariate analysis. A LASr ≤23.00% can differentiate CSFP from controls [sensitivity, 66.7%; specificity, 93.5%; area under the curve (AUC), 0.823; P < 0.001]. A LASr of ≤19.00% could predict the elevation of LV filling pressure in the CSFP cohort [sensitivity, 76.9%; specificity, 74.3%; area under the curve (AUC), 0.792; P < 0.001]. LASr was the only index to demonstrate significant changes compared to controls in single-vessel CSFP. Compared to the right coronary artery (RCA) and left circumflex (LCX), TFC of the left anterior descending (LAD) artery was the only independent variable of LASr (Standardized Coefficients: -0.386, P = 0.037).<br /><b>Conclusions</b><br />Impairment of LA reservoir function reflected by changes of LASr and LATEF can be seen in patients with CSFP. LASr could predict the elevation of LV filling pressure in CSFP individuals. LASr is more sensitive than LATEF in detecting LA reservoir dysfunction in single-vessel CSFP. CSFP in LAD exerts a more prominent influence on LASr than RCA or LCX.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 09 Sep 2023:131351; epub ahead of print</small></div>

<div><h4>Clinical characteristics and outcomes in patients with acute type a aortic intramural hematoma.</h4><i>Kanagami T, Saito Y, Hashimoto O, Nakayama T, ... Himi T, Kobayashi Y</i><br /><b>Background</b><br />Although type A acute aortic dissection (AAD) including classic double-channel aorta and intramural hematoma (IMH) is a life-threatening condition, the prognostic impact and predictors of IMH remain to be established. The present study evaluated the prevalence, baseline characteristics, and outcomes of IMH as compared with classic non-thrombosed type A AAD.<br /><b>Methods</b><br />This multicenter registry in Japan retrospectively included 703 patients with type A AAD. IMH was defined as a crescentic or circular area along the ascending aortic wall without contrast enhancement on computed tomography (CT). Non-thrombosed type A AAD was defined as the classic double-channel ascending aorta on contrast-enhanced CT. The primary endpoint was in-hospital mortality.<br /><b>Results</b><br />Of the 703 patients with type A AAD, 312 (44.3%) had IMH. Older age was an only baseline patient factor significantly associated with the presence of IMH in the multivariable analysis. The longitudinal extent of dissection was greater in patients with classic non-thrombosed AAD than those with IMH, resulting in an increased risk of end-organ malperfusion in the classic AAD group. During the hospitalization, 41 (13.1%) and 85 (21.7%) patients with and without IMH died (p < 0.001). IMH was associated with lower in-hospital mortality in a multivariable model, irrespective of age and the implementation of surgery.<br /><b>Conclusions</b><br />The present study showed that IMH on CT was frequent among patients with type A AAD. Although IMH was more likely to be present in the elderly, its effect on the better survival was independent of age and surgical treatment.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 09 Sep 2023:131355; epub ahead of print</small></div>

<div><h4>Hybrid approach to pulmonary vein stenting after Fontan palliation.</h4><i>Critchfield DR, Chamberlain RC, Turek JW, Fleming GA</i><br /><AbstractText>Pulmonary vein stenosis is poorly tolerated in patients who have undergone Fontan palliation and typically requires surgical or transcatheter intervention. Percutaneous transcatheter approaches to intervention can be technically difficult due to challenging anatomy. A hybrid per-atrial transcatheter approach for stenting pulmonary veins provides a direct approach to the pulmonary veins and has the potential to improve safety and efficacy of this complex intervention. We describe our experience with hybrid per-atrial pulmonary vein stenting in three patients with pulmonary vein stenosis following Fontan palliation.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Long-Term Outcomes of Patients Undergoing Aortic Root Replacement With Mechanical Versus Bioprosthetic Valves: Meta-Analysis of Reconstructed Time-to-Event Data.</h4><i>Sá MP, Tasoudis P, Jacquemyn X, Van den Eynde J, ... Serna-Gallegos D, Sultan I</i><br /><AbstractText><br /><b>Background:</b><br/>An aspect not so clear in the scenario of aortic surgery is how patients fare after composite aortic valve graft replacement (CAVGR) depending on the type of valve (bioprosthetic versus mechanical). We performed a study to evaluate the long-term outcomes of both strategies comparatively. Methods and Results Pooled meta-analysis of Kaplan-Meier-derived time-to-event data from studies with follow-up for overall survival (all-cause death), event-free survival (composite end point of cardiac death, valve-related complications, stroke, bleeding, embolic events, and/or endocarditis), and freedom from reintervention. Twenty-three studies met our eligibility criteria, including 11 428 patients (3786 patients with mechanical valves and 7642 patients with bioprosthetic valve). The overall population was mostly composed of men (mean age, 45.5-75.6 years). In comparison with patients who underwent CAVGR with bioprosthetic valves, patients undergoing CAVGR with mechanical valves presented no statistically significant difference in the risk of all-cause death in the first 30 days after the procedure (hazard ratio [HR], 1.24 [95% CI, 0.95-1.60]; <i>P</i>=0.109), but they had a significantly lower risk of all-cause mortality after the 30-day time point (HR, 0.89 [95% CI, 0.81-0.99]; <i>P</i>=0.039) and lower risk of reintervention (HR, 0.33 [95% CI, 0.24-0.45]; <i>P</i><0.001). Despite its increased risk for the composite end point in the first 6 years of follow-up (HR, 1.41 [95% CI, 1.09-1.82]; <i>P</i>=0.009), CAVGR with mechanical valves is associated with a lower risk for the composite end point after the 6-year time point (HR, 0.46 [95% CI, 0.31-0.67]; <i>P</i><0.001). <br /><b>Conclusions:</b><br/>CAVGR with mechanical valves is associated with better long-term outcomes in comparison with CAVGR with bioprosthetic valves.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 08 Sep 2023:e030629; epub ahead of print</small></div>

<div><h4>Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single-center study.</h4><i>Chaturvedi A, Moroni F, Axline M, Tomdio A, Mojadidi MK, Gertz Z</i><br /><b>Introduction</b><br />Certain patent foramen ovale (PFO) characteristics, such as a large right-to-left shunt (RLS) or atrial septal aneurysm, identify patients who may receive the highest clinical benefit from percutaneous PFO closure. This study aimed to compare intracardiac echocardiography (ICE) with standard echocardiographic imaging in the evaluation of high-risk PFO characteristics and RLS severity in patients with PFO-associated stroke.<br /><b>Methods</b><br />We conducted a retrospective review of all patients aged ≥18 years who underwent percutaneous PFO closure for PFO-associated stroke and received all three ultrasound-based cardiac imaging modalities and had interpretable results (N = 51). We then compared RLS severity, high-risk PFO characteristics, and the proportion of patients with a higher likelihood of PFO-associated stroke by ICE versus transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE).<br /><b>Results</b><br />The final cohort had a mean (±SE) age of 48.4 (±1.8) years and was predominantly female (58.8%). ICE was more likely to identify a large RLS versus TTE/TEE combined (66.7% vs. 45.1%; p = 0.03). The use of ICE resulted in significantly more patients being reclassified as having a higher likelihood of PFO-associated stroke (TTE vs. TEE vs. ICE: 10.4% vs. 14.6% vs. 25%; p = 0.03). A high-quality bubble study was found to be the single most important factor associated with identifying a larger RLS across all modalities (ρ [p]; TTE: 0.49 [<0.001], TEE: 0.60 [<0.001], ICE: 0.32 [0.02]). The presence of a hypermobile septum was associated with significantly greater RLS on ICE (ρ [p]: 0.3 [0.03]), especially with poor quality bubble studies (ρ [p]: 0.49 [0.02]).<br /><b>Conclusion</b><br />In this observational study of patients with PFO-associated stroke, ICE detected a large RLS more frequently than TTE and TEE; and reclassified some patients as having a higher likelihood of PFO-associated stroke.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>A preliminary study of minimal left atrial appendage occlusion using Watchman under the guidance of fluoroscopy.</h4><i>Ruan ZB, Li W, Jin K, Ding XW, ... Ren Y, Zhu L</i><br /><b>Background</b><br />Left atrial appendage occlusion (LAAO) has been considered an alternative treatment to prevent embolic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, it carries a risk of general anesthesia or esophageal injury if guided by transesophageal echocardiography (TEE).<br /><b>Aims</b><br />We aimed to investigate the feasibility and safety of minimal LAAO (MLAAO) using Watchman under fluoroscopy guidance alone in patients with NVAF.<br /><b>Methods</b><br />A total of 249 consecutive patients with NVAF who underwent LAAO using the WATCHMAN device were divided into two groups: the Standard LAAO (SLAAO) group and the MLAAO group. Procedural characteristics and follow-up results were compared between the two groups.<br /><b>Results</b><br />There was no statistically significant difference in the rate of successful device implantation (p > 0.05). Fluoroscopy time, radiation exposure dose, and contrast medium usage in the MLAAO group were higher than those in the SLAAO group (p < 0.001). The procedure time and hospitalization duration were significantly lower in the MLAAO group than those in the SLAAO group (p < 0.001). The occluder compression ratio, measured with fluoroscopy, was lower than that measured with TEE (17.63 ± 3.75% vs. 21.69 ± 4.26%, p < 0.001). Significant differences were observed between the SLAAO group and the MLAAO group (p < 0.05) in terms of oropharyngeal/esophageal injury, hypotension, and dysphagia. At 3 months after LAAO, the MLAAO group had a higher incidence of residual flow within 1-5 mm compared to the SLAAO group, although the difference was not statistically significant.<br /><b>Conclusion</b><br />MLAAO guided by fluoroscopy, instead of TEE, without general anesthesia simplifies the operational process and may be considered safe, effective, and feasible, especially for individuals who are unable to tolerate or unwilling to undergo TEE or general anesthesia.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Impact of preprocedural anemia on in-hospital and follow-up outcomes of chronic total occlusion percutaneous coronary intervention.</h4><i>Rempakos A, Kostantinis S, Simsek B, Karacsonyi J, ... Brilakis ES, Gorgulu S</i><br /><b>Background</b><br />The impact of preprocedural anemia on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.<br /><b>Methods</b><br />We examined the clinical and angiographic characteristics and procedural outcomes of 8633 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023. Anemia was defined as a hemoglobin level of <13 g/dL in men and <12 g/dL in women.<br /><b>Results</b><br />Anemia was present in 1652 (19%) patients undergoing CTO PCI. Anemic patients had a higher incidence of comorbidities, such as diabetes mellitus, hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease. CTOs in anemic patients were more likely to have complex angiographic characteristics, including smaller diameter, longer length, moderate to severe calcification, and moderate to severe proximal tortuosity. Anemic patients required longer procedure (119 vs. 107 min; p < 0.001) and fluoroscopy (45 vs. 40 min; p < 0.001) times but received similar contrast volumes. Technical success was similar between the two groups. In-hospital major adverse cardiac events (MACE) rates were higher in patients with anemia; however, this association was no longer significant after adjusting for confounding factors. Baseline anemia was independently associated with follow-up MACE (adjusted hazard ratio [HR]: 1.63; 95% confidence interval [CI]: 1.07-2.49; p = 0.023) and all-cause mortality (adjusted HR: 3.03; 95% CI: 1.41-6.49; p = 0.004).<br /><b>Conclusions</b><br />Preprocedural anemia is associated with more comorbidities, higher lesion complexity, longer procedure times, and higher follow-up MACE and mortality after CTO PCI.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Long-term clinical outcomes following successful percutaneous coronary intervention in patients with extremely long coronary chronic total occlusion lesions.</h4><i>Ahn J, Yu H, Rha SW, Choi BG, ... Kang DO, Choi CU</i><br /><b>Background</b><br />Lesion length is related to worse clinical outcomes following percutaneous coronary intervention (PCI) for the treatment of chronic total occlusion (CTO). However, the data to confirm the association between extremely long lesions and clinical hard endpoints have been limited. Therefore, we investigated the impact of extremely long CTO lesions (≥50 mm, treated lesion length) on the long-term clinical outcomes following successful PCI.<br /><b>Methods</b><br />A total of 333 consecutive patients with CTO who underwent successful PCI with drug-eluting stents (DESs) were allocated to either the extremely long or the short CTO group according to their CTO lesion length. The 5-year clinical outcomes were compared between the two groups. The incidence of myocardial infarction, cardiac death (CD), revascularization, and major adverse cardiovascular events (MACE) was higher in the extremely long CTO group. The 5-year clinical outcomes were analyzed using the Cox hazard ratio (HR) model.<br /><b>Results</b><br />In the entire study population, the extremely long CTO lesion was an independent predictor for higher rate of revascularization, MACE, CD, or mortality.<br /><b>Conclusions</b><br />In our study, CTO patients with extremely long lesions (≥50 mm) who underwent successful PCI were associated with a higher risk of worse long-term clinical outcomes, including hard clinical endpoints such as CD and mortality even in the DESs era.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Aspirin Versus Warfarin after Transcatheter Aortic Valve Replacement in Low-Risk Patients: 2-Year Follow-Up.</h4><i>Merdler I, Rogers T, Case BC, Bhogal S, ... Weissman G, Waksman R</i><br /><AbstractText>Subclinical leaflet thrombosis occurs with transcatheter heart valves (THVs) and could be associated with structural valve deterioration. The current guidelines recommend the use of antiplatelet agents after transcatheter aortic valve replacement (TAVR) but not the routine use of oral anticoagulation. Our study examines the effects of short-term warfarin therapy on THV hemodynamics at 24 months after TAVR in low-risk patients. Low-risk patients who underwent TAVR were randomly allocated 1:1 to receive low-dose aspirin (n = 50) or low-dose aspirin plus warfarin (n = 44). After 30 days of treatment, ongoing medication regimens, including anticoagulation, were at the physicians\' discretion. Follow-up after a period of 24 months was available for clinical and echocardiographic outcomes. At the 24-month mark, follow-up echocardiography of the randomly allocated patients revealed just 1 additional case of new structural valve deterioration in the aspirin group (compared with the occurrence within 30 days), based on the Valve Academic Research Consortium 3 definitions. There were also no differences in mean pressure gradients (11.5 ± 0.5 mm Hg vs 11.05 ± 4.0 mm Hg, p = 0.6) or peak velocity (2.2 ± 0.5 m/s vs 2.1 ± 0.4 m/s, p = 0.7) between the groups. A composite end point (mortality, stroke, and myocardial infarction) did not show any difference between the groups at long-term follow-up (p = 0.07). In conclusion, in low-risk patients who underwent TAVR, short-term anticoagulation with warfarin did not impact clinical outcomes or THV hemodynamics by echocardiography at 24 months.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 08 Sep 2023; 206:108-115</small></div>

<div><h4>Impact of Acute Myocardial Infarction Type on Prognosis in Female Patients With Cardiogenic Shock.</h4><i>Jeon BK, Jang WJ, Park IH, Oh JH, ... Jeong JO, Park SD</i><br /><AbstractText>There are limited data about mid-term prognosis according to acute myocardial infarction (AMI) type in female patients with AMI complicated by cardiogenic shock (CS). In this study, we evaluated the impact of AMI type on prognosis in female patients who underwent percutaneous coronary intervention (PCI) for AMI complicated by CS. A total of 184 female patients who underwent PCI for AMI complicated by CS were enrolled from 12 centers in the Republic of Korea. Patients were divided into 2 groups according to AMI type: the ST-segment elevation myocardial infarction (n = 114) and the non-ST-segment elevation myocardial infarction (n = 70) group. Primary outcome was a major adverse cardiac event (MACE) (defined as a composite of cardiac death, myocardial infarction, or repeat revascularization). Propensity-score matching analysis was performed to reduce selection bias and potential confounding factors. During 12-month follow-up, a total of 73 MACEs occurred (ST-segment elevation myocardial infarction group, 47 [41.2%] vs non-ST-segment elevation myocardial infarction group, 26 [37.1%], p = 0.643). Multivariate analysis revealed no significant difference in the incidence of MACE at 12 months between the 2 groups (adjusted hazard ratio 1.16, 95% confidence interval 0.70 to 2.37, p = 0.646). After propensity-score matching, the incidence of MACE at 12 months remained similar between the 2 groups (hazard ratio 1.31, 95% confidence interval 0.69 to 2.52, p = 0.413). The similarity in MACEs between the 2 groups was consistent across a variety of subgroups. In conclusion, after adjusting for baseline differences, AMI clinical type did not appear to increase the risk of MACEs at 12 months in female patients who underwent emergency PCI for AMI complicated by CS.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 08 Sep 2023; 206:116-124</small></div>

<div><h4>OECD indicator \'AMI 30-day mortality\' is neither comparable between countries nor suitable as indicator for quality of acute care.</h4><i>Stolpe S, Kowall B, Werdan K, Zeymer U, ... Schneider S, Stang A</i><br /><b>Background</b><br />Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation.<br /><b>Methods</b><br />Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators \'AMI 30-day mortality using unlinked data\' and \'average length of stay after AMI\' were used to describe the association between these variables graphically and by linear regression.<br /><b>Results</b><br />Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R<sup>2</sup> = 0.56). AMI mortality reported from registries is distorted by different underlying populations.<br /><b>Conclusion</b><br />Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.<br /><br />© 2023. The Author(s).<br /><br /><small>Clin Res Cardiol: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>PAR4 Inhibition Reduces Coronary Artery Atherosclerosis and Myocardial Fibrosis in SR-B1/LDLR Double Knockout Mice.</h4><i>Lee SK, Malik R, Zhou J, Wang W, ... Ramachandran R, Trigatti BL</i><br /><b>Background</b><br />SR-B1 (scavenger receptor class B type 1)/LDLR (low-density lipoprotein receptor) double knockout mice fed a high-fat, high-cholesterol diet containing cholate exhibit coronary artery disease characterized by occlusive coronary artery atherosclerosis, platelet accumulation in coronary arteries, and myocardial fibrosis. Platelets are involved in atherosclerosis development, and PAR (protease-activated receptor) 4 has a prominent role in platelet function in mice. However, the role of PAR4 on coronary artery disease in mice has not been tested.<br /><b>Methods</b><br />We tested the effects of a PAR4 inhibitory pepducin (RAG8) on diet-induced aortic sinus and coronary artery atherosclerosis, platelet accumulation in atherosclerotic coronary arteries, and myocardial fibrosis in SR-B1/LDLR double knockout mice. SR-B1/LDLR double knockout mice were fed a high-fat, high-cholesterol diet containing cholate and injected daily with 20 mg/kg of either the RAG8 pepducin or a control reverse-sequence pepducin (SRQ8) for 20 days.<br /><b>Results</b><br />Platelets from the RAG8-treated mice exhibited reduced thrombin and PAR4 agonist peptide-mediated activation compared with those from control SRQ8-treated mice when tested ex vivo. Although aortic sinus atherosclerosis levels did not differ, RAG8-treated mice exhibited reduced coronary artery atherosclerosis, reduced platelet accumulation in atherosclerotic coronary arteries, and reduced myocardial fibrosis. These protective effects were not accompanied by changes in circulating lipids, inflammatory cytokines, or immune cells. However, RAG8-treated mice exhibited reduced VCAM-1 (vascular cell adhesion molecule 1) protein levels in nonatherosclerotic coronary artery cross sections and reduced leukocyte accumulation in atherosclerotic coronary artery cross sections compared with those from SRQ8-treated mice.<br /><b>Conclusions</b><br />The PAR4 inhibitory RAG8 pepducin reduced coronary artery atherosclerosis and myocardial fibrosis in SR-B1/LDLR double knockout mice fed a high-fat, high-cholesterol diet containing cholate. Furthermore, RAG8 reduced VCAM-1 in nonatherosclerotic coronary arteries and reduced leukocyte and platelet accumulation in atherosclerotic coronary arteries. These findings identify PAR4 as an attractive target in reducing coronary artery disease development, and the use of RAG8 may potentially be beneficial in cardiovascular disease.<br /><br /><br /><br /><small>Arterioscler Thromb Vasc Biol: 07 Sep 2023; epub ahead of print</small></div>

<div><h4>Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta-analysis.</h4><i>Fujisaki T, Kuno T, Iwagami M, Miyamoto Y, ... Latib A, Kohsaka S</i><br /><b>Background</b><br />Contemporary dual antiplatelet therapy (DAPT) strategies, such as short-term DAPT or de-escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients.<br /><b>Methods</b><br />PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short-term, uniform de-escalation, and guided-selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta-analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding.<br /><b>Results</b><br />Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de-escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y<sub>12</sub> inhibitors. The short-term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y<sub>12</sub> inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies.<br /><b>Conclusions</b><br />Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 07 Sep 2023; epub ahead of print</small></div>

<div><h4>Balloon-assisted subintimal entry (BASE) in chronic total occlusion percutaneous coronary interventions.</h4><i>Alexandrou M, Rempakos A, Al Ogaili A, Choi JW, ... Burke MN, Brilakis ES</i><br /><b>Background</b><br />There is limited data on the use of the balloon-assisted subintimal entry (BASE) technique in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).<br /><b>Methods</b><br />We analyzed the baseline clinical and angiographic characteristics and outcomes of 155 CTO PCIs that utilized the BASE technique at 31 US and non-US centers between 2016 and 2023.<br /><b>Results</b><br />The BASE technique was used in 155 (7.9%) of 1968 antegrade dissection and re-entry (ADR) cases performed during the study period. The mean age was 66 ± 10 years, 88.9% of the patients were men, and the prevalence of diabetes (44.6%), hypertension (90.5%), and dyslipidemia (88.7%) was high. Compared with 1813 ADR cases that did not use BASE, the target vessel of the BASE cases was more commonly the RCA and less commonly the LAD. Lesions requiring BASE had longer occlusion length (42 ± 23 vs. 37 ± 23 mm, p = 0.011), higher Japanese CTO (J-CTO) (3.4 ± 1.0 vs. 3.0 ± 1.1, p < 0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention chronic total occlusion) (1.8 ± 1.0 vs. 1.5 ± 1.0, p = 0.008) scores, and were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate to severe calcification, and proximal tortuosity. Technical (71.6% vs. 75.5%, p = 0.334) and procedural success (71.6% vs. 72.8%, p = 0.821), as well as major adverse cardiac events (MACE) (1.3% vs. 4.1%, p = 0.124), were similar in ADR cases that used BASE and those that did not.<br /><b>Conclusions</b><br />The BASE technique is used in CTOs with longer occlusion length, higher J-CTO score, and more complex angiographic characteristics, and is associated with moderate success but also low MACE.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 07 Sep 2023; epub ahead of print</small></div>

<div><h4>Percutaneous ventricular assist device for higher-risk percutaneous coronary intervention in surgically ineligible patients: Indications and outcomes from the OPTIMUM study.</h4><i>Hirai T, Grantham JA, Kandzari DE, Ballard W, ... Salisbury AC, OPTIMUM Study Group</i><br /><b>Background</b><br />Indications and outcomes for percutaneous ventricular assist device (pVAD) use in surgically ineligible patients undergoing percutaneous coronary intervention (PCI) remain poorly characterized.<br /><b>Aims</b><br />We sought to describe the use and timing of pVAD and outcome in surgically ineligible patients.<br /><b>Methods</b><br />Among 726 patients enrolled in the prospective OPTIMUM study, clinical and health status outcomes were assessed in patients who underwent pVAD-assisted PCI and those without pVAD.<br /><b>Results</b><br />Compared with patients not receiving pVAD (N = 579), those treated with pVAD (N = 142) more likely had heart failure, lower left ventricular ejection fraction (30.7 ± 13.6 vs. 45.9 ± 15.5, p < 0.01), and higher STS 30-day predicted mortality (4.2 [2.1-8.0] vs. 3.3 [1.7-6.6], p = 0.01) and SYNTAX scores (36.1 ± 12.2, vs. 31.5 ± 12.1, p < 0.01). While the pVAD group had higher in-hospital (5.6% vs. 2.2%, p = 0.046), 30-day (9.0% vs. 4.0%, p = 0.01) and 6-month (20.4% vs. 11.7%, p < 0.01) mortality compared to patients without pVAD, this difference appeared to be largely driven by significantly higher mortality among the 20 (14%) patients with unplanned pVAD use (30% in-hospital mortality with unplanned PVAD vs. 1.6% with planned, p < 0.01; 30-day mortality, 38.1% vs. 4.5%, p < 0.01). The degree of 6-month health status improvement among survivors was similar between groups.<br /><b>Conclusion</b><br />Surgically ineligible patients with pVAD-assisted PCI had more complex baseline characteristics compared with those without pVAD. Higher mortality in the pVAD group appeared to be driven by very poor outcomes by patients with unplanned, rescue pVAD.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 07 Sep 2023; epub ahead of print</small></div>

<div><h4>High Bleeding Incidence in Unselected Hospitalized Suspected Non-ST-Segment Elevation Myocardial Infarction Patients Aged Under 65 Years.</h4><i>Kesti H, Mäkinen H, Mattila K, Jaakkola S, Lintu M, Porela P</i><br /><AbstractText>High bleeding risk (HBR) is commonly encountered among patients with acute coronary syndrome (ACS), and bleeding complications are associated with worse prognosis. Data on bleeding events of patients with ACS are based almost exclusively on percutaneous coronary intervention registries. Enrolling only patients suitable for invasive procedures might have skewed the observed bleeding incidence. We sought to investigate bleeding incidence in unselected patients with ACS. Patients were retrospectively enrolled between January and June 2019 from the emergency department of a tertiary hospital. All consecutive hospitalized adults with suspected non-ST-segment elevation myocardial infarction were included. Data was gathered by a database search and verified using electronic patient records. Bleeding risk was assessed according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition. The primary end point was a composite of post- discharge Bleeding Academic Research Consortium type 2, 3, and 5 bleeding during 1-year follow-up. Of the 209 included patients, 15 (7.2%) suffered a bleeding event. There were more bleeding events among dual antiplatelet therapy (DAPT) users as compared with those without DAPT (10.7% vs 3.1%, p = 0.033). Among HBR patients, 6.1% and in non-HBR patients 8.1% suffered a bleeding event (p = 0.579). Notably, major bleeding (Bleeding Academic Research Consortium type 3) incidence was highest in patients <65 years and without DAPT use. In conclusion, unselected suspected non-ST-segment elevation myocardial infarction patients aged <65 years had surprisingly high bleeding incidence, regardless of ARC-HBR status or DAPT use.</AbstractText><br /><br />Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 07 Sep 2023; 206:101-104</small></div>

<div><h4>Intensive Statin Therapy Versus Upfront Combination Therapy of Statin and Ezetimibe in Patients With Acute Coronary Syndrome: A Propensity Score Matching Analysis Based on the PL-ACS Data.</h4><i>Lewek J, Niedziela J, Desperak P, Dyrbuś K, ... Gąsior M, Banach M</i><br /><AbstractText><br /><b>Background:</b><br/>We aimed to compare statin monotherapy and upfront combination therapy of statin and ezetimibe in patients with acute coronary syndromes (ACSs). Methods and Results The study included consecutive patients with ACS included in the PL-ACS (Polish Registry of Acute Coronary Syndromes), which is a national, multicenter, ongoing, prospective observational registry that is mandatory for patients with ACS hospitalized in Poland. Data were matched using the Mahalanobis distance within propensity score matching calipers. Multivariable stepwise logistic regression analysis, including all variables, was next used in propensity score matching analysis. Finally, 38 023 consecutive patients with ACS who were discharged alive were included in the analysis. After propensity score matching, 2 groups were analyzed: statin monotherapy (atorvastatin or rosuvastatin; n=768) and upfront combination therapy of statin and ezetimibe (n=768 patients). The difference in mortality between groups was significant during the follow-up and was present at 1 (5.9% versus 3.5%; <i>P</i>=0.041), 2 (7.8% versus 4.3%; <i>P</i>=0.019), and 3 (10.2% versus 5.5%; <i>P</i>=0.024) years of follow-up in favor of the upfront combination therapy, as well as for the overall period. For the treatment, rosuvastatin significantly improved prognosis compared with atorvastatin (odds ratio [OR], 0.790 [95% CI, 0.732-0.853]). Upfront combination therapy was associated with a significant reduction of all-cause mortality in comparison with statin monotherapy (OR, 0.526 [95% CI, 0.378-0.733]), with absolute risk reduction of 4.7% after 3 years (number needed to treat=21). <br /><b>Conclusions:</b><br/>The upfront combination lipid-lowering therapy is superior to statin monotherapy for all-cause mortality in patients with ACS. These results suggest that in high-risk patients, such an approach, rather than a stepwise therapy approach, should be recommended.</AbstractText><br /><br /><br /><br /><small>J Am Heart Assoc: 06 Sep 2023:e030414; epub ahead of print</small></div>

<div><h4>Collateral grading systems in retrograde percutaneous coronary intervention of chronic total occlusions.</h4><i>Somsen YBO, de Winter RW, Giunta R, Schumacher SP, ... Henriques JP, Knaapen P</i><br /><b>Background</b><br />The Japanese Channel (J-Channel) score was introduced to aid in retrograde percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTOs). The predictive value of the J-Channel score has not been compared with established collateral grading systems such as the Rentrop classification and Werner grade.<br /><b>Aims</b><br />To investigate the predictive value of the J-Channel score, Rentrop classification and Werner grade for successful collateral channel (CC) guidewire crossing and technical CTO PCI success.<br /><b>Methods</b><br />A total of 600 prospectively recruited patients underwent CTO PCI. All grading systems were assessed under dual catheter injection. CC guidewire crossing was considered successful if the guidewire reached the distal segment of the CTO vessel through a retrograde approach. Technical CTO PCI success was defined as thrombolysis in myocardial infarction flow grade 3 and residual stenosis <30%.<br /><b>Results</b><br />Of 600 patients, 257 (43%) underwent CTO PCI through a retrograde approach. Successful CC guidewire crossing was achieved in 208 (81%) patients. The predictive value of the J-Channel score for CC guidewire crossing (area under curve 0.743) was comparable with the Rentrop classification (0.699, p = 0.094) and superior to the Werner grade (0.663, p = 0.002). Technical CTO PCI success was reported in 232 (90%) patients. The Rentrop classification exhibited a numerically higher discriminatory ability (0.676) compared to the J-Channel score (0.664) and Werner grade (0.589).<br /><b>Conclusions</b><br />The J-channel score might aid in strategic collateral channel selection during retrograde CTO PCI. However, the J-Channel score, Rentrop classification, and Werner grade have limited value in predicting technical CTO PCI success.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 06 Sep 2023; epub ahead of print</small></div>

<div><h4>Ultrasound Guidance for Vascular Access for Coronary Angiogram: A Meta-Analysis of Randomized Controlled Trials.</h4><i>Fishkin T, Isath A, Virk HUH, Bandyopadhyay D, ... Jneid H, Krittanawong C</i><br /><AbstractText>Obtaining vascular access during percutaneous coronary intervention is necessary to facilitate the procedure but carries procedural risks that impact patient outcomes. Historically, vascular access has been accomplished using anatomic landmarks, pulsation, and/or fluoroscopic guidance. Ultrasound (US) guidance has emerged as a modality for achieving vascular access in a multitude of interventional procedures including those in the cardiac catheterization laboratory. US use has been demonstrated in randomized controlled trials and meta-analyses to be associated with an increased success rate for vascular access with fewer complications, although the data are mixed. We aimed to re-evaluate the totality of evidence in an updated meta-analysis to compare the ease of access and complications rates between US-guided and manual vascular access. A meta-analysis of 8 randomized controlled trials including 5,170 patients was performed. The primary outcome evaluated was the rate of access failure, and the secondary outcomes included hematomas and access site bleeding. US-guided arterial access was associated with a significantly higher rate of first-attempt success and a decreased risk of venipuncture. US use had a trend toward a lower total number of attempts, but the results were not significant. This updated meta-analysis further supports the use of US for vascular access for coronary angiography because of higher rates of first-attempt success and reduced venipuncture. However, there was no significant difference in vascular complications such as hematoma, pseudoaneurysm, and bleeding complications. Because of the high morbidity of bleeding complications associated with coronary angiography, further research should be done to reduce these complications.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 06 Sep 2023; 206:70-72</small></div>

<div><h4>Prognostic Impact of Drug-Coated Balloons in Patients With Diabetes Mellitus: A Propensity-Matched Study.</h4><i>Verdoia M, Zilio F, Gioscia R, Viola O, ... Rognoni A, De Luca G</i><br /><AbstractText>Patients with diabetes mellitus (DM) are at higher risk of restenosis and stent thrombosis after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) positioning. Whether drug-coated balloons (DCB) can offer any benefit in this subset of patients has been seldom cleared out and was the aim of the present propensity-matched cohort study, that compared the prognostic impact of DCB versus DES in patients with DM who underwent PCI. Patients with DM enrolled in the NOvara-BIella-TREnto (NOBITRE) Registry were identified and matched according to propensity score, to a control population of patients with DM treated with DES. The primary study end point was the occurrence of major adverse cardiovascular events (MACEs). A total of 150 patients were identified in the DCB group and matched with 150 DES-treated patients. Patients treated with DCB displayed more often a previous cardiovascular history and received a more complete pharmacological therapy. Target vessel diameter and the percentage of stenosis were lower in patients with DCB, whereas binary in-stent restenosis was more common (p <0.001, p = 0.003, and p <0.001, respectively). Paclitaxel-eluting balloon represented the most common strategy in the DCB group, whereas Zotarolimus-eluting stents were used in half of the DES population. At a median follow-up of 545.5 days, MACE occurred in 54 (19.4%) of patients, with no difference according to the PCI strategy (21.6% vs 17.3%, adjusted hazard ratio [95% confidence interval] 1.51 [0.46 to 4.93], p = 0.50). Major ischemic end points were slightly increased in patients treated with DCB, whereas overall death was significantly reduced (3.6% vs 10.9%; adjusted hazard ratio [95% confidence interval] 0.27 [0.08 to 0.91], p = 0.03). In conclusion, the present propensity-matched study shows that, in patients with DM who underwent PCI for in-stent restenosis or de novo lesions, the use of DCB is associated with a similar rate of MACE and a modest increase in target lesion failure, but a significantly improved survival as compared with DES.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 06 Sep 2023; 206:73-78</small></div>

<div><h4>Trends and Inhospital Outcomes of Intravascular Imaging on Single-Vessel Coronary Chronic Total Occlusion Treated With Percutaneous Coronary Intervention.</h4><i>Park DY, Hu JR, Kanitsoraphan C, Al-Ogaili A, ... Nanna MG, Vij A</i><br /><AbstractText>Intravascular imaging (IVI), including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), improves outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs). We sought to quantify temporal trends in the uptake of IVI for CTO-PCI in the United States. We identified adults who underwent single-vessel PCI for CTO between 2008 and 2020. We quantified yearly trends in the number of IVUS-guided and OCT-guided single-vessel CTO-PCIs by Cochran-Armitage and linear regression tests. We also examined the rates of inhospital mortality and other prespecified inhospital outcomes in patients who underwent CTO-PCIs with and without IVI, using logistic regression. Our study included a total of 151,998 PCIs on single-vessel CTOs, with the absolute number of CTO-PCIs decreasing from 12,345 in 2008 to 8,525 in 2020 (p trend <0.001). IVUS use has increased dramatically from 6% in 2008 to 18% in 2020 for single-vessel CTO-PCIs (p trend <0.001). Rates of OCT use have increased as well, from 0% in 2008 to 7% in 2020 (p trend <0.001). There was no difference in inhospital mortality between patients who underwent CTO-PCI with and without IVI (p logistic = 0.60). In the largest national analysis of single-vessel CTO-PCI trends to date, we found that the use of IVUS has increased substantially accompanied by a similar but lesser increase in the use of OCT. There were no differences in rates of inhospital mortality between patients who underwent single-vessel CTO-PCIs with and without IVI.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 06 Sep 2023; 206:79-85</small></div>

<div><h4>Mortality Trends After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.</h4><i>Thrane PG, Olesen KKW, Thim T, Gyldenkerne C, ... Kristensen SD, Maeng M</i><br /><b>Background</b><br />Observational studies have reported that mortality rates after ST-segment elevation myocardial infarction (STEMI) have been stable since 2006 to 2010.<br /><b>Objectives</b><br />The aim of this study was to evaluate the temporal trends in 1-year, 30-day, and 31- to 365-day mortality after STEMI in Western Denmark where primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003.<br /><b>Methods</b><br />Using the Western Denmark Heart Registry, the study identified first-time PCI-treated patients undergoing primary PCI (pPCI) for STEMI from 2003 to 2018. Based on the year of pPCI, patients were divided into 4 time-interval groups and followed up for 1 year using the Danish national health registries.<br /><b>Results</b><br />A total of 19,613 patients were included. Median age was 64 years, and 74% were male. One-year mortality decreased gradually from 10.8% in 2003-2006, 10.4% in 2007-2010, 9.1% in 2011-2014, to 7.7% in 2015-2018 (2015-2018 vs 2003-2006: adjusted HR [aHR]: 0.71; 95% CI: 0.62-0.82). The largest absolute mortality decline occurred in the 0- to 30-day period with a 2.3% reduction (aHR: 0.69; 95% CI: 0.59-0.82), and to a lesser extent in the 31- to 365-day period (risk reduction: 1.0%; aHR: 0.71; 95% CI: 0.56-0.90).<br /><b>Conclusions</b><br />In a high-income European country with a fully implemented pPCI strategy, 1-year mortality in pPCI-treated patients with STEMI decreased substantially between 2003 and 2018. Approximately three-quarters of the absolute mortality reduction occurred within the first 30 days after pPCI. These results indicate that optimization of early management of pPCI-treated patients with STEMI offers great opportunities for improving overall survival in contemporary clinical practice.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Coll Cardiol: 05 Sep 2023; 82:999-1010</small></div>

<div><h4>Wire-based antegrade dissection re-entry technique for coronary chronic total occlusions percutaneous revascularization: Experience from the ERCTO Registry.</h4><i>Galassi AR, Vadalà G, Maniscalco L, Gasparini G, ... Mashayekhi K, di Mario C</i><br /><b>Background</b><br />The recent development and widespread adoption of antegrade dissection re-entry (ADR) techniques have been underlined as one of the antegrade strategies in all worldwide CTO consensus documents. However, historical wire-based ADR experience has suffered from disappointing long-term outcomes.<br /><b>Aims</b><br />Compare technical success, procedural success, and long-term outcome of patients who underwent wire-based ADR technique versus antegrade wiring (AW).<br /><b>Methods</b><br />One thousand seven hundred and ten patients, from the prospective European Registry of Chronic Total Occlusions (ERCTO), underwent 1806 CTO procedures between January 2018 and December 2021, at 13 high-volume ADR centers. Among all 1806 lesions attempted by the antegrade approach, 72% were approached with AW techniques and 28% with wire-based ADR techniques.<br /><b>Results</b><br />Technical and procedural success rates were lower in wire-based ADR than in AW (90.3% vs. 96.4%, p < 0.001; 87.7% vs. 95.4%, p < 0.001, respectively); however, wire-based ADR was used successfully more often in complex lesions as compared to AW (p = 0.017). Wire-based ADR was used in most cases (85%) after failure of AW or retrograde procedures. At a mean clinical follow-up of 21 ± 15 months, major adverse cardiac and cerebrovascular events (MACCEs) did not differ between AW and wire-based ADR (12% vs. 15.1%, p = 0.106); both AW and wire-based ADR procedures were associated with significant symptom improvements.<br /><b>Conclusions</b><br />As compared to AW, wire-based ADR is a reliable and effective strategy successfully used in more complex lesions and often after the failure of other techniques. At long-term follow-up, patient\'s MACCEs and symptoms improvement were similar in both antegrade techniques.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Contrast media volume reduction with the DyeVert system to prevent acute kidney injury in stable patients undergoing coronary procedures.</h4><i>Paolucci L, De Micco F, Bezzeccheri A, Scarpelli M, ... Focaccio A, Briguori C</i><br /><b>Background</b><br />Contrast associated acute kidney injury (CA-AKI) can lead to an increased risk of adverse events. Contrast media (CM) volume reduction has been advocated as a pivotal strategy to prevent CA-AKI in stable patients undergoing percutaneous coronary procedures.<br /><b>Aims</b><br />To compare the effectiveness of CM volume reduction with the DyeVert<sup>TM</sup> system versus conventional strategy in reducing the risk of CA-AKI.<br /><b>Methods</b><br />We prospectively collected data from 136 patients with stable coronary artery disease at high risk of CA-AKI treated with left ventricular end diastolic pressure (LVEDP)- guided hydration and undergoing interventions with the use of the DyeVert<sup>TM</sup> (Osprey Medical Inc.) system. Patients previously enrolled in the LVEDP-guided hydration arm of the \"Renal Insufficiency Following Contrast MEDIA Administration triaL III\" (REMEDIAL III) were considered as controls. Propensity score was used to perform 1:1 matching to adjust for major confounders. The primary outcome was the occurrence of CA-AKI, as defined by an absolute increase of creatinine values ≥0.3 mg/dL at 48 h.<br /><b>Results</b><br />Patients in the DyeVert group were treated with a significant lower CM volume (median: 47.5 vs. 84.0 mL, p < 0.001). The trend in creatinine increase was lower (p = 0.004) and the Δ of creatinine (0-48 h) showed a higher drop (-0.18 vs. -0.10 mg/dL, p = 0.036) in the DyeVert group. The risk of CA-AKI was significantly lower in DyeVert group compared to control group (5.1% vs. 16.8%; odds ratio 0.27, 95% confidence interval [0.12-0.61]).<br /><b>Conclusions</b><br />CM volume reduction with the DyeVert<sup>TM</sup> system seems to be superior to conventional strategies in reducing the occurrence of CA-AKI.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Mid-term outcomes and hemodynamic performance of transcatheter aortic valve implantation in bicuspid aortic valve stenosis: Insights from the bicuSpid TAvi duraBILITY (STABILITY) registry.</h4><i>Fiorina C, Massussi M, Ancona M, Montorfano M, ... Tamburino C, Adamo M</i><br /><b>Background</b><br />Limited data are available on transcatheter heart valves (THVs) durability in bicuspid aortic valve (BAV) stenosis.<br /><b>Aims</b><br />To evaluate evaluating 4-year clinical and echocardiographic outcomes of patients with BAV undergoing transcatheter aortic valve implantation (TAVI).<br /><b>Methods</b><br />The bicuSpid TAvi duraBILITY (STABILITY) registry is an Italian multicentre registry including all consecutive patients with BAV and severe aortic stenosis (AS), treated by means of TAVI between January 2011 and December 2017. Outcomes of interest were all-cause death at 4-year, over time changes in echocardiographic measurements, and THV durability according to the valve aortic research consortium (VARC)-3 update definitions.<br /><b>Results</b><br />Study population included 109 patients (50% females; mean age 78 ± 7.5 years) with a mean Society of Thoracic Surgeons Predicted Risk of Mortality score of 5.1 ± 4.3%. Median follow-up (FU) duration was 4.1 years [interquartile range: 2.8-5.1]. The overall cumulative incidence of all-cause death by Kaplan-Meier estimates at 4 years was 32%. Compared to baseline, a significant decrease in transprosthetic mean gradient was obtained after TAVI (54 ± 16 vs. 10 ± 5 mmHg; p < 0.001), whereas a significant increase was observed at 4-year (13 ± 6.4 mmHg, p = 0.03). Cumulative incidence of hemodynamic valve dysfunction (HVD) was 4%. Six patients met HVD criteria: three moderate and three severe HVD. All three cases of severe HVD were clinically relevant (bioprosthetic valve failure [BVF]) with two patients receiving a reintervention (TAVI in TAVI), and one patient experiencing a valve-related death due to endocarditis.<br /><b>Conclusions</b><br />The STABILITY registry suggests that in patients with severe AS and BAV undergoing TAVI, postprocedural clinical benefits might last, over time, up to 4-year FU. The low rates of severe HVD and BVF may support the hypothesis of good THV durability also in BAV recipient.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Impact of diabetes on long-term outcomes of bifurcation percutaneous coronary intervention. An analysis from the BIFURCAT registry.</h4><i>Bruno F, Kang J, Elia E, Han JK, ... Koo BK, D\'Ascenzo F</i><br /><b>Background</b><br />It is still unclear the impact of diabetes mellitus (DM) in complex coronary lesions treated with percutaneous coronary intervention (PCI) which themselves are at increased incidence of adverse events.<br /><b>Methods</b><br />BIFURCAT registry encompassed patients treated with PCI for coronary bifurcation lesion from the COBIS III and the RAIN registry. The primary endpoint was the occurrence of major cardiovascular adverse event (MACE), a composite and mutual exclusive of all-cause death or myocardial infarction (MI) or target-lesion revascularization (TLR). A total of 5537 patients were included in the analysis and 1834 (33%) suffered from DM.<br /><b>Results</b><br />After a median follow-up of 21 months, diabetic patients had a higher incidence of MACE (17% vs. 9%, p < 0.001), all-cause mortality (9% vs. 4%, p < 0.001), TLR (5% vs. 3%, p = 0.001), MI (4% vs. 2%, p < 0.001), and stent thrombosis (ST) (2% vs. 1%, p = 0.007). After multivariate analysis, diabetes remained significantly associated with MACE (hazard ratio [HR]: 1.37; confidence interval [CI]: 1.13-1.65; p = 0.001), all-cause death (HR: 1.65; 95% CI: 1.24-2.19, p = 0.001), TLR (HR: 1.45; CI: 1.03-2.04; p = 0.031) and ST (HR: 1.73, CI: 1.04-2.88; p = 0.036), but not with MI (HR: 1.34; CI: 0.93-1.92; p = 0.11). Among diabetics, chronic kidney disease (HR: 2.99; CI: 2.21-4.04), baseline left ventricular ejection fraction (HR: 0.98; CI: 0.97-0.99), femoral access (HR: 1.62; CI: 1.23-2.15), left main coronary artery (HR: 1.44; CI: 1.06-1.94), main branch diameter (HR: 0.79; CI: 0.66-0.94) and final kissing balloon (HR: 0.70; CI: 0.52-0.93) were independent predictors of MACE at follow-up.<br /><b>Conclusions</b><br />Patients with DM treated with PCI for coronary bifurcations have a worse prognosis due to higher incidence of MACE, all-cause mortality, TLR and ST compared to the non-diabetics.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Coronary intravascular lithotripsy and rotational atherectomy for severely calcified stenosis: Results from the ROTA.shock trial.</h4><i>Blachutzik F, Meier S, Weissner M, Schlattner S, ... Nef H, ROTA.shock Investigators</i><br /><b>Background</b><br />Severely calcified coronary lesions present a particular challenge for percutaneous coronary intervention.<br /><b>Aims</b><br />The aim of this randomized study was to determine whether coronary intravascular lithotripsy (IVL) is non-inferior to rotational atherectomy (RA) regarding minimal stent area (MSA).<br /><b>Methods</b><br />The randomized, prospective non-inferiority ROTA.shock trial enrolled 70 patients between July 2019 and November 2021. Patients were randomly (1:1) assigned to undergo either IVL or RA before percutaneous coronary intervention of severely calcified coronary lesions. Optical coherence tomography was performed at the end of the procedure for primary endpoint analysis.<br /><b>Results</b><br />The primary endpoint MSA was lower but non-inferior after IVL (mean: 6.10 mm<sup>2</sup> , 95% confidence interval [95% CI]: 5.32-6.87 mm<sup>2</sup> ) versus RA (6.60 mm<sup>2</sup> , 95% CI: 5.66-7.54 mm<sup>2</sup> ; difference in MSA: -0.50 mm<sup>2</sup> , 95% CI: -1.52-0.52 mm<sup>2</sup> ; non-inferiority margin: -1.60 mm<sup>2</sup> ). Stent expansion was similar (RA: 0.83 ± 0.10 vs. IVL: 0.82 ± 0.11; p = 0.79). There were no significant differences regarding contrast media consumption (RA: 183.1 ± 68.8 vs. IVL: 163.3 ± 55.0 mL; p = 0.47), radiation dose (RA: 7269 ± 11288 vs. IVL: 5010 ± 4140 cGy cm<sup>2</sup> ; p = 0.68), and procedure time (RA: 79.5 ± 34.5 vs. IVL: 66.0 ± 19.4 min; p = 0.18).<br /><b>Conclusion</b><br />IVL is non-inferior regarding MSA and results in a similar stent expansion in a random comparison with RA. Procedure time, contrast volume, and dose-area product do not differ significantly.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Prosthesis-patient mismatch after transcatheter implantation of contemporary balloon-expandable and self-expandable valves in small aortic annuli.</h4><i>Leone PP, Regazzoli D, Pagnesi M, Costa G, ... Latib A, TAVI-SMALL Investigators</i><br /><b>Background</b><br />Evidence of clinical impact of PPM after TAVI is conflicting and might vary according to the type of valve implanted.<br /><b>Aims</b><br />To assess the clinical impact of prosthesis-patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI) with balloon-expandable (BEV) and self-expandable valves (SEV) in patients with small annuli.<br /><b>Methods</b><br />TAVI-SMALL 2 enrolled 628 patients in an international retrospective registry, which included patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm<sup>2</sup> ) treated with transfemoral TAVI at 16 high-volume centers between 2011 and 2020. Analyses were performed comparing patients with less than moderate (n = 452), moderate (n = 138), and severe PPM (n = 38). Primary endpoint was incidence of all-cause mortality. Predictors of all-cause mortality and PPM were investigated.<br /><b>Results</b><br />At a median follow-up of 380 days (interquartile range: 210-709 days), patients with severe PPM, but not moderate PPM, had an increased risk of all-cause mortality when compared with less than moderate PPM (log-rank p = 0.046). Severe PPM predicted all-cause mortality in patients with BEV (hazard ratio [HR]: 5.20, 95% confidence interval [CI]: 1.27-21.2) and intra-annular valves (IAVs, HR: 4.23, 95% CI: 1.28-14.02), and it did so with borderline significance in the overall population (HR: 2.89, 95% CI: 0.95-8.79). Supra-annular valve (SAV) implantation was the only predictor of severe PPM (odds ratio: 0.33, 95% CI: 0.13-0.83).<br /><b>Conclusions</b><br />Patients with small aortic annuli and severe PPM after TAVI have an increased risk of all-cause mortality at early term follow-up, especially after IAV or BEV implantation. TAVI with SAV protected from severe PPM.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Coils embolization use for coronary procedures: Basics, indications, and techniques.</h4><i>Loh SX, Brilakis E, Gasparini G, Agostoni P, ... Stone GW, Egred M</i><br /><AbstractText>The use of coils is fundamental in interventional cardiology and can be lifesaving in selected settings. Coils are classified by their materials into bare metal, fiber coated, and hydrogel coated, or by the deliverability method into, pushable or detachable coils. Coils are delivered through microcatheters and the choice of coil size is important to ensure compatibility with the inner diameter of the delivery catheter, firstly to be able to deliver and secondly to prevent the coil from being stuck and damaged. Clinically, coils are used in either acute or in elective setting. The most important acute indication is typically the sealing coronary perforation. In the elective settings, coils can be used for the treatment of certain congenital cardiac abnormalities, aneurysms, fistulas or in the treatment of arterial side branch steal syndrome after CABG. Coils must always be delivered under fluoroscopy guidance. There are some associated complications with coils that can be acute or chronic, that nictitates regular followed-up. There is a need for education, training and regular workshops with hands-on to build the experience to use coils in situations that are infrequently encountered.</AbstractText><br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Clinical value of CT-derived simulations of transcatheter-aortic-valve-implantation in challenging anatomies the PRECISE-TAVI trial.</h4><i>Hokken TW, Wienemann H, Dargan J, Ginkel DV, ... Adam M, Van Mieghem NM</i><br /><b>Background</b><br />Preprocedural computed tomography planning improves procedural safety and efficacy of transcatheter aortic valve implantation (TAVI). However, contemporary imaging modalities do not account for device-host interactions.<br /><b>Aims</b><br />This study evaluates the value of preprocedural computer simulation with FEops HEARTguide<sup>TM</sup> on overall device success in patients with challenging anatomies undergoing TAVI with a contemporary self-expanding supra-annular transcatheter heart valve.<br /><b>Methods</b><br />This prospective multicenter observational study included patients with a challenging anatomy defined as bicuspid aortic valve, small annulus or severely calcified aortic valve. We compared the heart team\'s transcatheter heart valve (THV) planning decision based on (1) conventional multislice computed tomography (MSCT) and (2) MSCT imaging with FEops HEARTguide<sup>TM</sup> simulations. Clinical outcomes and THV performance were followed up to 30 days.<br /><b>Results</b><br />A total of 77 patients were included (median age 79.9 years (IQR 74.2-83.8), 42% male). In 35% of the patients, preprocedural planning changed after FEops HEARTguide<sup>TM</sup> simulations (change in valve size selection [12%] or target implantation height [23%]). A new permanent pacemaker implantation (PPI) was implanted in 13% and >trace paravalvular leakage (PVL) occurred in 28.5%. The contact pressure index (i.e., simulation output indicating the risk of conduction abnormalities) was significantly higher in patients with a new PPI, compared to those without (16.0% [25th-75th percentile 12.0-21.0] vs. 3.5% [25th-75th percentile 0-11.3], p < 0.01) The predicted PVL was 5.7 mL/s (25th-75th percentile 1.3-11.1) in patients with none-trace PVL, 12.7 (25th-75th percentile 5.5-19.1) in mild PVL and 17.7 (25th-75th percentile 3.6-19.4) in moderate PVL (p = 0.04).<br /><b>Conclusion</b><br />FEops HEARTguide<sup>TM</sup> simulations may provide enhanced insights in the risk for PVL or PPI after TAVI with a self-expanding supra-annular THV in complex anatomies.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 05 Sep 2023; epub ahead of print</small></div>

<div><h4>Outcomes of Acute Myocardial Infarction in Female Patients With Type 1 Diabetes Mellitus.</h4><i>Santana JC, Dangl M, Albosta M, Colombo R</i><br /><AbstractText>There is a paucity of data on acute myocardial infarction (AMI) outcomes for female patients with type 1 diabetes (T1DM) compared with men. The National Inpatient Sample Database was queried from 2011 to 2019 for relevant International Classification of Diseases, Ninth and Tenth Revision procedural and diagnostic codes. Hospitalizations with an admitting diagnosis of non-ST-elevation myocardial infarction or ST-elevation myocardial infarction were compared between male and female patients with T1DM. A multivariate logistic regression adjusting for baseline characteristics and primary diagnosis was performed. A p <0.001 was considered significant. A total of 50,020 hospitalizations for AMI in patients with T1DM were identified, of which 23,980 (47.9%) were women. The baseline characteristics are listed in Table 1. Women experienced similar rates of all-cause and inhospital mortality (5.0% vs 4.7%, p = 0.082). However, after adjusting for baseline characteristics and primary diagnosis, women had higher odds of mortality (adjusted odds ratio [aOR] 1.26, 95% confidence interval [CI] 1.15 to 1.38). Women were less likely to undergo cardiac catheterization (65.7% vs 68.2%; aOR 0.90, 95% CI 0.86 to 0.94) and coronary artery bypass grafting (5.6% vs 6.9%; aOR 0.76, 95% CI 0.70 to 0.82, p <0.001 for both). There was no difference in the use of percutaneous coronary intervention (41.0% vs 41.9%; aOR 1.01, 95% CI 0.97 to 1.05, p = 0.042). The female gender is not protective against AMI in patients with T1DM. Women with T1DM, on average, experience AMI at the same age as men, are less likely to undergo surgical revascularization, and have higher odds of mortality.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 05 Sep 2023; 206:12-13</small></div>

<div><h4>Impact of Chronic Coronary Artery Disease and Revascularization Strategy in Patients with Severe Aortic Stenosis Who Underwent Transcatheter Aortic Valve Implantation.</h4><i>Aurigemma C, Massussi M, Fraccaro C, Adamo M, ... Tarantini G, OBSERVANT II Research Group</i><br /><AbstractText>The prognostic impact of coronary artery disease (CAD) after transcatheter aortic valve implantation (TAVI) is controversial. The aim of this study is to investigate the impact of CAD and different revascularization strategies on clinical outcomes in patients who underwent TAVI with third generation devices. Patients enrolled in the national observational Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment II study were stratified according to the presence of CAD (CAD+, n = 1,130) versus no CAD (CAD-, n = 1,505), and compared using a propensity matched analysis. CAD+ group was further stratified according to the revascularization strategy: no revascularization (n = 331), revascularization performed >90 days before index-TAVI (n = 417) and coronary revascularization performed <90 days before index-TAVI or during TAVI (n = 382). In-hospital, 30-day and 1-year clinical outcomes were estimated. The mean age of the overall population was 81.8 years; 54.9% of patients were female. Propensity score matching yielded 813 pairs and their 30-day all-cause mortality was comparable (p = 0.480). Major periprocedural adverse events were also similar between the groups. At 1-year follow-up, the rate of major adverse cardiac and cerebrovascular events (MACCEs) and all-cause mortality were similar between the groups (p = 0.732 and p = 0.633, respectively). Conversely, patients with CAD experienced more often myocardial infarction and need for percutaneous coronary intervention at 1 year (p = 0.007 and p = 0.001, respectively). Neither CAD nor revascularization strategy were independent predictors of 1-year MACCE. About 40% of patients presenting with severe AS and who underwent TAVI had concomitant CAD. The presence of CAD had no impact on all-cause mortality and MACCE 1-year after TAVR. However, CAD carries a higher risk for acute myocardial infarction and need of percutaneous coronary intervention during follow-up.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 05 Sep 2023; 206:14-22</small></div>

<div><h4>Temporal variations in ischemic and bleeding event risks after acute coronary syndrome during dual antiplatelet therapy.</h4><i>Fujii T, Kasai S, Kawamura Y, Yoshimachi F, Ikari Y</i><br /><b>Background</b><br />This study estimates the temporal risk variations of ischemic and bleeding events during dual antiplatelet therapy (DAPT) among patients stratified according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria, suggesting the optimal period for DAPT after acute coronary syndrome (ACS).<br /><b>Methods</b><br />A total of 1264 ACS patients receiving either clopidogrel or prasugrel with aspirin were classified by ARC-HBR; HBR (n = 574) and non-HBR groups (n = 690). This study was designed as a multicenter observation to evaluate the primary endpoints of ischemic, including cardiovascular death, myocardial infarction, or ischemic stroke, and bleeding events, defined as Bleeding Academic Research Consortium type 3/5. The temporal risk variations were estimated using the Cox hazard and Royston-Parmar models.<br /><b>Results</b><br />Ischemic and bleeding events were observed in 9.4% and 7.4%, respectively, during an average observation period of 313 days. The HBR group had a higher incidence of both events than the non-HBR group (15.3% vs. 4.5%, P < 0.01 for ischemic; 11.9% vs. 3.8%, P < 0.01 for bleeding). The estimated risk curves for both events revealed peaks and steep declines in the first few days, followed by constant declines. The peak of risk was higher for bleeding than for ischemic events, but this relationship reversed early, with ischemic events displaying a higher risk in both the HBR and non-HBR groups until at least 60 days.<br /><b>Conclusions</b><br />A 60-day period of DAPT is appropriate to balance the risks of adverse events after ACS, regardless of ARC-HBR criteria.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 05 Sep 2023:131340; epub ahead of print</small></div>

<div><h4>Prediction of clinical outcomes after percutaneous coronary intervention: Machine-learning analysis of the National Inpatient Sample.</h4><i>Galimzhanov A, Matetic A, Tenekecioglu E, Mamas MA</i><br /><b>Background</b><br />This study aimed to develop a multiclass machine-learning (ML) model to predict all-cause mortality, ischemic and hemorrhagic events in unselected hospitalized patients undergoing percutaneous coronary intervention (PCI).<br /><b>Methods</b><br />This retrospective study included 1,815,595 unselected weighted hospitalizations undergoing PCI from the National Inpatient Sample (2016-2019). Five most common ML algorithms (logistic regression, support vector machine (SVM), naive Bayes, random forest (RF), and extreme gradient boosting (XGBoost)) were trained and tested with 101 input features. The study endpoints were different combinations of all-cause mortality, ischemic cerebrovascular events (CVE) and major bleeding. An area under the curve (AUC) with 95% confidence interval (95% CI) was selected as a performance metric.<br /><b>Results</b><br />The study population was split to a training cohort of 1,186,880 PCI discharges, validation cohort (for calibration) of 296,725 hospitalizations and a test cohort of 331,990 PCI discharges. A total of 98,180 (5.4%) hospital entries included study outcomes. Logistic regression, SVM, naive Bayes, and RF model demonstrated AUCs of 0.83 (95% CI 0.82-0.84), 0.84 (95% CI 0.83-0.86), 0.81 (95% CI 0.80-0.82), and 0.83 (95% CI 0.81-0.84), retrospectively. The XGBoost classifier performed the best with an AUC of 0.86 (95% CI 0.85-0.87) with excellent calibration. We then built a web-based application that provides predictions based on the XGBoost model.<br /><b>Conclusion</b><br />We derived the multi-task XGBoost classifier based on 101 features to predict different combinations of all-cause death, ischemic CVE and major bleeding. Such models may be useful in benchmarking and risk prediction using routinely collected administrative data.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 05 Sep 2023:131339; epub ahead of print</small></div>

<div><h4>Biomarkers as Prognostic Markers for Aortic Stenosis: A Review.</h4><i>Sarkar A, Chowdhury S, Kumar A, Khan B, ... Hajra A, Aronow WS</i><br /><AbstractText>Aortic stenosis (AS) is the most frequent valvular heart disease among the older individuals. Current guidelines indicate intervention for patients with symptomatic or fast progressive severe AS and asymptomatic patients with a reduced left ventricular (LV) ejection fraction by 50%. Interestingly, myocardial damage may have already happened by the time symptoms appear or LV function deteriorates. Serum biomarkers can be an early indicator to show LV function decline and AS progression even before clinical symptom onset. Studies have shown that cardiac biomarkers have prognostic value in patients with AS. Hence, cardiac biomarkers can be helpful in determining the optimum time to intervene. Transcatheter aortic valve replacement is a less invasive alternative to conventional surgical aortic valve replacement. The elevation of cardiac biomarkers at discharge has been associated with 2-year mortality after transcatheter aortic valve replacement. The correlation between biomarkers and AS-associated morbidity and mortality is an area to explore further. The authors of this review article have discussed the role of cardiac biomarkers in patients with AS for better risk stratification and identification of patients who would benefit from early intervention.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 05 Sep 2023; 206:53-59</small></div>

<div><h4>High-Risk Plaques on Coronary Computed Tomography Angiography: Correlation With Optical Coherence Tomography.</h4><i>Kinoshita D, Suzuki K, Usui E, Hada M, ... Kakuta T, Jang IK</i><br /><b>Background</b><br />Although patients with high-risk plaque (HRP) on coronary computed tomography angiography (CTA) are reportedly at increased risk for future cardiovascular events, individual HRP features have not been systematically validated against high-resolution intravascular imaging.<br /><b>Objective</b><br />The aim of this study was to correlate HRP features on CTA with plaque characteristics on optical coherence tomography (OCT).<br /><b>Methods</b><br />Patients who underwent both CTA and OCT before coronary intervention were enrolled. Plaques in culprit vessels identified by CTA were evaluated with the use of OCT at the corresponding sites. HRP was defined as a plaque with at least 2 of the following 4 features: positive remodeling (PR), low-attenuation plaque (LAP), napkin-ring sign (NRS), and spotty calcification (SC). Patients were followed for up to 3 years.<br /><b>Results</b><br />The study included 448 patients, with a median age of 67 years and of whom 357 (79.7%) were male, and 203 (45.3%) presented with acute coronary syndromes. A total of 1,075 lesions were analyzed. All 4 HRP features were associated with thin-cap fibroatheroma. PR was associated with all OCT features of plaque vulnerability, LAP was associated with lipid-rich plaque, macrophage, and cholesterol crystals, NRS was associated with cholesterol crystals, and SC was associated with microvessels. The cumulative incidence of the composite endpoint (target vessel nontarget lesion revascularization and cardiac death) was significantly higher in patients with HRP than in those without HRP (4.7% vs 0.5%; P = 0.010). (Massachusetts General Hospital and Tsuchiura Kyodo General Hospital Coronary Imaging Collaboration; NCT04523194) <br /><b>Conclusions:</b><br/>All 4 HRP features on CTA were associated with features of vulnerability on OCT.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>JACC Cardiovasc Imaging: 04 Sep 2023; epub ahead of print</small></div>

<div><h4>Coronary microvascular dysfunction is a hallmark of all subtypes of MINOCA.</h4><i>Milzi A, Dettori R, Lubberich RK, Reith S, ... Marx N, Burgmaier M</i><br /><b>Introduction</b><br />Myocardial infarction without obstructive coronary artery disease (MINOCA) is a heterogeneous clinical condition presenting with myocardial necrosis not due to an obstruction of a major coronary artery. Recently, a relevant role of coronary microvascular dysfunction (CMD) in the pathogenesis of MINOCA has been suggested; however, data on this are scarce. Particularly, it is unclear if CMD is equally present in all subtypes of MINOCA or differentially identifies one or more of these conditions. Therefore, the aim of this study was to assess CMD in all three coronary vessels of MINOCA patients, relating it with the clinical subtype.<br /><b>Methods</b><br />We retrospectively assessed coronary microvascular function in all three coronary territories by means of angiography-based index of microvascular resistance (aIMR) in 92 patients (64 with working diagnosis of MINOCA, 28 control patients). To further assess the association of CMD with MINOCA subtypes, MINOCA patients were subdivided according to clinical data in coronary cause (n = 13), takotsubo (n = 13), infiltrative or inflammatory cardiomyopathy (n = 9) or unclear (n = 29).<br /><b>Results</b><br />Patients with working diagnosis of MINOCA showed a significantly elevated average aIMR compared to control patients (30.5 ± 7.6 vs. 22.1 ± 5.9, p < 0.001) as a marker of a relevant CMD; these data were consistent in all vessels. Among MINOCA subtypes, no significant difference in average aIMR could be detected between patients with coronary cause (33.2 ± 6.6), takotsubo cardiomyopathy (29.2 ± 6.9), infiltrative or inflammatory cardiomyopathy (28.1 ± 6.8) or unclear cause (30.6 ± 8.5; p = 0.412). Interestingly, aIMR was significantly elevated in the coronary vessel supplying the diseased myocardium compared with other vessels (31.9 ± 11.4 vs. 27.8 ± 8.2, p = 0.049).<br /><b>Conclusion</b><br />Coronary microvascular dysfunction is a hallmark of all MINOCA subtypes. This study adds to the pathophysiological understanding of MINOCA and sheds light into the role of CMD in MINOCA.<br /><br />© 2023. The Author(s).<br /><br /><small>Clin Res Cardiol: 02 Sep 2023; epub ahead of print</small></div>

<div><h4>Outcomes Prediction in Complex High-Risk Indicated Percutaneous Coronary Interventions in the Older Patients.</h4><i>Marschall A, Martí Sánchez D, Ferreiro JL, Lopez Palop R, ... Gutierrez-Barrios A, de la Torre Hernandez JM</i><br /><AbstractText>Complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) is a poorly defined concept, which has not been validated in an older population before. This study aimed to evaluate the predictive value of the CHIP-PCI score in a large cohort of elderly patients and to identify potential further risk factors. This is a pooled analysis of 3 registries that included patients aged ≥75 years who underwent percutaneous coronary intervention from 2012 to 2019: the multicenter prospective EPIC05-Sierra 75 study, the multicenter retrospective PACO-PCI (EPIC-15) registry, and the single-center, prospective Elderly-HCD registry. A total of 2,725 patients with a mean age of 81 ± 4 years were included in the study; 269 patients (10%) met the primary end point of 1-year major adverse cardiac and cerebrovascular events (MACCEs), and 51 patients (2%) had in-hospital MACCEs. Of the 12 investigated original CHIP-PCI score variables, 5 were independent predictors: previous myocardial infarction, left ventricular ejection fraction <30%, chronic kidney disease, left main coronary artery percutaneous coronary intervention, and nonradial access. Furthermore, diabetes mellitus, anemia, and severe calcification showed to be significant predictors of MACCEs. The additional variables improved the discriminatory value of the CHIP-PCI score for 1-year MACCEs (modified CHIP-PCI score: area under the curve [AUC] 0.647 vs original CHIP-PCI score: AUC 0.598, p = 0.02) and in-hospital MACCEs (AUC 0.729 vs 0.657, p = 0.003, respectively). In conclusion, the CHIP-PCI score retains its prognostic value in older patients for in-hospital MACCEs; however, it is of limited value at 1-year follow-up. The modified CHIP-PCI score, including the 5 patient-related and 3 procedure-related factors, significantly improved its discriminatory potential.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 02 Sep 2023; 205:465-472</small></div>

<div><h4>Effect of PCSK9 antibodies on coronary plaque regression and stabilization derived from intravascular imaging in patients with coronary artery disease: A meta-analysis.</h4><i>Liu S, Wang P, Liu C, Jin M, ... Liu Z, Fu Z</i><br /><b>Background</b><br />Despite extensive evidence demonstrating the beneficial effects of the additional PCSK9 antibodies with high-density statins treatment on cardiovascular clinical outcomes, the potent causes underlying these effects remain elusive. This meta-analysis aimed at exploring the underlying causes to assess the effect of PCSK9 antibodies on the regression and stabilization of coronary plaque derived from intravascular imaging in statin-treated patients with coronary artery disease (CAD).<br /><b>Methods</b><br />PubMed, Embase, and Cochrane Library were searched from inception to February 1, 2023, for randomized controlled trials (RCTs), nonrandomized studies without language restrictions if they described the association between PCSK9 antibodies with coronary plaque regression and stabilization evaluated by intravascular imaging in statin-treated patients with CAD. Meta-analyses were performed for mean difference (MD) and odds ratio (OR) using a random-effects model. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.<br /><b>Results</b><br />A total of 9 studies (7 RCTs and 2 non-RCTs) with 2290 CAD patients were identified and included. Among statin-treated CAD patients, the addition use of PCSK9 antibodies was associated with IVUS-derived percent atheroma volume (PAV) (4 studies with 1875 participants; MD, -1.26; 95% CI, -1.51 to -1.00; P < 0.01), total atheroma volume (TAV) (4 studies with 1875 participants; MD, -7.23; 95% CI, -11.28 to -3.18; P < 0.01), incidence of PAV regression (4 studies with 1875 participants; OR, 2.24; 95% CI, 1.81 to 2.77; P < 0.01) and incidence of TAV regression (3 studies with 1256 participants; OR, 1.66; 95% CI, 1.33 to 2.09; P < 0.01) in Caucasians instead of Asians from multiple countries; OCT-derived minimum fibrous cap thickness (FCT) (6 studies with 841 participants; MD, 25.16; 95% CI, 14.06 to 36.27; P < 0.01), incidence of thin-capped fibroatheroma (TCFA) regression (2 studies with 222 participants; OR, 2.56; 95% CI, 1.42 to 4.61; P < 0.01) and maximum lipid arc (4 studies with 280 participants; MD, -14.96; 95% CI, -22.10 to -7.83; P < 0.01) in Asians and Caucasians without races restrictions.<br /><b>Conclusions</b><br />PCSK9 antibodies resulted in significantly greater coronary plaque regression and stabilization in statin-treated CAD patients, mostly Caucasians from multiple countries. Further studies are needed to assess the effect for Asian patients.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 02 Sep 2023:131330; epub ahead of print</small></div>

<div><h4>Rotational atherectomy of calcified coronary lesions: current practice and insights from two randomized trials.</h4><i>Allali A, Abdel-Wahab M, Elbasha K, Mankerious N, ... Toelg R, Richardt G</i><br /><AbstractText>With growing experience, technical improvements and use of newer generation drug-eluting stents (DES), recent data showed satisfactory acute and long-term results after rotational atherectomy (RA) in calcified coronary lesions. The randomized ROTAXUS and PREPARE-CALC trials compared RA to balloon-based strategies in two different time periods in the DES era. In this manuscript, we assessed the technical evolution in RA practice from a pooled analysis of the RA groups of both trials and established a link to further recent literature. Furthermore, we sought to summarize and analyze the available experience with RA in different patient and lesion subsets, and propose recommendations to improve RA practice. We also illustrated the combination of RA with other methods of lesion preparation. Finally, based on the available evidence, we propose a simple and practical approach to treat severely calcified lesions.</AbstractText><br /><br />© 2022. The Author(s).<br /><br /><small>Clin Res Cardiol: 01 Sep 2023; 112:1143-1163</small></div>

<div><h4>Prospective, single-centre evaluation of the safety and efficacy of percutaneous coronary interventions following a decision tree proposing a no-stent strategy in stable patients with coronary artery disease (SCRAP study).</h4><i>Meunier L, Godin M, Souteyrand G, Mottin B, ... Waliszewski M, Allix-Béguec C</i><br /><b>Aim</b><br />We evaluated a decision algorithm for percutaneous coronary interventions (PCI) based on a no-stent strategy, corresponding to a combination of scoring balloon angioplasty (SCBA) and drug-coated balloon (DCB), as a first line approach. Stents were used only in unstable patients, or in case of mandatory bailout stenting (BO-stent).<br /><b>Methods</b><br />From April 2019 to March 2020, 984 consecutive patients, including 1922 lesions, underwent PCI. The 12-month primary end-point was a composite of major adverse cardiac events (MACE) defined as all-cause death, nonfatal myocardial infarction, nonfatal stroke, and target lesion revascularization. Patients were classified into conventional or no-stent strategy groups according to the PCI strategy. In the no-stent strategy group, they were further classified into BO-stent or DCB-only groups. Their metal index was calculated by stent length divided by the total lesion length.<br /><b>Results</b><br />The no-stent strategy was applied in 85% of the patients, and it was successful for 65% of them. MACE occurred in 7.1% of the study population, including 4.2% of all-cause death. Target lesion revascularization was required in 1.4%, 3.6%, and 1.5% of patients in the conventional DES, BO-stent, and DCB-only groups, respectively. MACE occurred more often in the elderly and in those treated with at least one stent (metal index greater than 0).<br /><b>Conclusions</b><br />The no-stent strategy, i.e., revascularization of coronary lesions by SCBA followed by DCB and with DES bailout stenting, was effective and safe at 1 year. This PCI approach was applicable on a daily practice in our cath lab.<br /><b>Trial registration</b><br />This study was registered with clinicaltrials.gov (NCT03893396, first posted on March 28, 2019). Feasibility, safety and efficacy of percutaneous coronary interventions following a decision tree proposing a no-stent strategy in stable patients with coronary artery disease. DES: drug eluting stent; SCBA: scoring balloon angioplasty; BO-stent: at least one stent; DCB: drug coated balloon; BMS: bare metal stent; Bailout (dash lines); MACE: major adverse cardiac event.<br /><br />© 2022. The Author(s).<br /><br /><small>Clin Res Cardiol: 01 Sep 2023; 112:1164-1174</small></div>

<div><h4>Incidence and predictors of radial artery occlusion following transradial coronary angiography: the proRadial trial.</h4><i>Schlosser J, Herrmann L, Böhme T, Bürgelin K, ... Neumann FJ, Hochholzer W</i><br /><b>Objectives</b><br />This study investigated the contemporary incidence and predictors of radial artery occlusion as well as the effectiveness of antithrombotic treatment for radial artery occlusion following transradial coronary angiography.<br /><b>Background</b><br />The radial artery is the standard access for coronary angiography and even complex interventions. Postprocedural radial artery occlusion is still a common and significant complication.<br /><b>Methods</b><br />This prospective study enrolled 2004 patients following transradial coronary angiography. After sheath removal, hemostasis was obtained in a standardized fashion. Radial artery patency was evaluated by duplex ultrasonography in all patients. In case of occlusion, oral anticoagulation was recommended and patients were scheduled for a 30-day follow-up including Doppler ultrasonography.<br /><b>Results</b><br />A new-diagnosed radial occlusion was found in 4.6% of patients. The strongest independent predictors of radial occlusion were female sex and active smoking status. In the subgroup of patients with percutaneous coronary interventions, female sex followed by sheath size > 6 French were the strongest predictors of radial occlusion. 76 of 93 patients with radial occlusion received an oral anticoagulation for 30 days. However, reperfusion at 30 days was found in 32% of patients on oral anticoagulation.<br /><b>Conclusion</b><br />The incidence of radial artery occlusion following coronary angiography in contemporary practice appears with 4.6% to be lower as compared to previous cohorts. Female sex and smoking status are the strongest independent predictors of radial occlusion followed by procedural variables. The limited effectiveness of oral anticoagulation for treatment of radial artery occlusion suggests a primarily traumatic than thrombotic mechanism of this complication.<br /><br />© 2022. The Author(s).<br /><br /><small>Clin Res Cardiol: 01 Sep 2023; 112:1175-1185</small></div>

<div><h4>Paclitaxel drug-coated balloon-only angioplasty for de novo coronary artery disease in elective clinical practice.</h4><i>Merinopoulos I, Gunawardena T, Corballis N, Bhalraam U, ... Vassiliou VS, Eccleshall SC</i><br /><b>Objective</b><br />We aimed to investigate the safety of drug-coated balloon (DCB)-only angioplasty compared to drug-eluting stent (DES), as part of routine clinical practice.<br /><b>Background</b><br />The recent BASKETSMALL2 trial demonstrated the safety and efficacy of DCB angioplasty for de novo small vessel disease. Registry data have also demonstrated that DCB angioplasty is safe; however, most of these studies are limited due to long recruitment time and a small number of patients with DCB compared to DES. Therefore, it is unclear if DCB-only strategy is safe to incorporate in routine elective clinical practice.<br /><b>Methods</b><br />We compared all-cause mortality and major cardiovascular endpoints (MACE), including unplanned target lesion revascularisation (TLR) of all patients treated with DCB or DES for first presentation of stable angina due to de novo coronary artery disease between 1st January 2015 and 15th November 2019. Data were analysed with Cox regression models and cumulative hazard plots.<br /><b>Results</b><br />We present 1237 patients; 544 treated with DCB and 693 treated with DES for de novo, mainly large-vessel coronary artery disease. On multivariable Cox regression analysis, only age and frailty remained significant adverse predictors of all-cause mortality. Univariable, cumulative hazard plots showed no difference between DCB and DES for either all-cause mortality or any of the major cardiovascular endpoints, including unplanned TLR. The results remained unchanged following propensity score-matched analysis.<br /><b>Conclusion</b><br />DCB-only angioplasty, for stable angina and predominantly large vessels, is safe compared to DES as part of routine clinical practice, in terms of all-cause mortality and MACE, including unplanned TLR.<br /><br />© 2022. The Author(s).<br /><br /><small>Clin Res Cardiol: 01 Sep 2023; 112:1186-1193</small></div>