Speckle tracking assessment of the atrial function in patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by small vessel vasculopathy, autoantibodies production and exaggerated extracellular matrix deposition, leading to extensive tissue fibrosis. Cardiac involvement in SSc, albeit often asymptomatic, is frequent and represents a negative prognostic factor. Speckle tracking global longitudinal strain (GLS) has proved itself to be an effective tool to identify the presence and the progression of subclinical SSc-related cardiomyopathy.

The aim of our study was to assess whether SSc-related cardiomyopathy affects not only the ventricles but also the right (RA) and left atria (LA) in patients with SSc and no overt cardiac disease nor pulmonary hypertension.

Materials and methods

Observational prospective study enrolling all consecutive patients with SSc age- and gender-matched 1:1 to healthy controls. Patients with structural heart disease, heart failure, atrial fibrillation and pulmonary hypertension were excluded.

For every patient, standard echocardiographic parameters and speckle-tracking derived variables were registered. The reservoir function (from the end of ventricular contraction to mitral valve opening), conduit function (from mitral valve opening through the onset of atrium contraction) and contraction function (from the onset of atrium contraction to the end of ventricular diastole) were assessed via GLS. Zero strain reference was set at left ventricular end diastole.

Results

Fifty-two SSc patients and 52 matched controls were consecutively enrolled. Left ventricular ejection fraction (66.5%±7.4% vs. 66.1%±5.9%; p=ns) right fractional area change (49.4%±9.6% vs. 49.2%±9.2%; p=ns) and mean sPAP (29.0%±5.3% vs. 24.4%±4.1%; p=ns) were well within the normal range and similar between SSc patients and controls. Right atrial reservoir function (35.0%±7.3% vs. 42.3%±8.5%; p=.024) and contraction function (14.8%±4.3% vs. 18.5%±4.1%; p=.034) were significantly lower in SSc patients when compared to matched controls. No difference was seen in right atrial conduit function or left atrial strain.

In patients with SSc, RA reservoir (r=.194; p=.033) and conduit function (r=.174; p=.036) were directly associated to right ventricular GLS. LA reservoir (r=.260; p=.008) and conduit function (r=.271; p=.006) were directly associated with left ventricular GLS. No association was observed between contraction function and GLS in both left and right chambers. Moreover, RA and LA reservoir (r=.358; p=.02), conduit (r=.525; p=.004) and contraction functions (r=.30; p=.0.18) were directly correlated.

Conclusions

While no significant difference was seen between cases and controls in terms of common echocardiographic parameters, RA reservoir and contraction function assessed through GLS were significantly impaired in patients with SSc. The correlation between impaired atrial and ventricular GLS in SSc may represent another indirect evidence of SSc-related heart global involvement.

Funding Acknowledgement

Type of funding sources: None.

The Common Combination of Aortic Stenosis with Mitral Regurgitation: Diagnostic Insight and Therapeutic Implications in the Modern Era of Advanced Echocardiography and Percutaneous Intervention

The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.

Contrast-Induced Nephropathy in Patients Undergoing Staged Versus Concomitant Transcatheter Aortic Valve Implantation and Coronary Procedures

Background

The impact of staged versus concomitant coronary procedures on renal function in patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) remains unclear.

Methods and Results

Three‐hundred thirty‐nine patients undergoing coronary procedures and TAVI as a staged strategy (160, 47.2%) or concomitant strategy (179, 52.8%) were retrospectively analyzed. Contrast‐induced acute kidney injury (CI‐AKI) occurred in 49 patients in the staged strategy group (30.6%) and in 18 patients (10.1%) in the concomitant strategy group (P<0.001). Among the staged strategy group, 25 (15.6%) patients developed CI‐AKI after coronary angiography or percutaneous coronary intervention, 17 (10.6%) after TAVI, and 7 (4.3%) after both the procedures. Staged strategy was associated with a higher risk of CI‐AKI (odds ratio, 3.948; P<0.001) after adjustment for multiple confounders and regardless of the baseline renal function (P for interaction=0.4) when compared with the concomitant strategy. At a median follow‐up of 24.0 months (3.0–35.3), CI‐AKI was not associated with sustained renal injury (P=0.794), irrespective of the adopted strategy. The concomitant strategy did not impact the overall early safety at 30 days follow‐up after TAVI compared to the staged strategy (P=0.609).

Conclusions

Performing coronary procedures with a staged strategy before TAVI was associated with a higher risk of CI‐AKI compared with a concomitant strategy. Moreover, a concomitant strategy did not increase the risk of procedure‐related complications.

Real World Performance Evaluation of Transcatheter Aortic Valve Implantation

Background: The aim of this research is to describe the performance over time of transcatheter aortic valve implantations (TAVIs) in a high-volume center with a contemporary, real-world population. Methods: Patients referred for TAVIs at the University Hospital of Verona were prospectively enrolled. By cumulative sum failures analysis (CUSUM), procedural-control curves for standardized combined endpoints—as defined by the Valve Academic Research Consortium-2 (VARC-2)—were calculated and analyzed over time. Acceptable and unacceptable limits were derived from recent studies on TAVI in intermediate and low-risk patients to fit the higher required standards for current indications. Results: A total of 910 patients were included. Baseline risk scores significantly reduced over time. Complete procedural control was obtained after approximately 125 and 190 cases for device success and early safety standardized combined endpoints, respectively. High risk patients (STS ≥ 8) had poorer outcomes, especially in terms of VARC-2 clinical efficacy, and required a higher case load to maintain in-control and proficient procedures. Clinically relevant single endpoints were all influenced by operator’s experience as well. Conclusions: Quality-control analysis for contemporary TAVI interventions based on standardized endpoints suggests the need for relevant operator’s experience to achieve and maintain optimal clinical results, especially in higher-risk subjects.

Coronary Microvascular Dysfunction Assessed by Pressure Wire and CMR After STEMI Predicts Long-Term Outcomes

OBJECTIVES

This study sought to evaluate the long-term prognostic implications of coronary microvascular dysfunction (CMD) when assessed with both cardiovascular magnetic resonance (CMR) and index of microcirculatory resistance (IMR) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).

BACKGROUND

Post-ischemic CMD can be assessed using the pressure-wire based IMR and/or by the presence of microvascular obstruction (MVO) on CMR.

METHODS

A total of 198 patients with STEMI underwent IMR and MVO assessment. Patients were classified as follows: Group 1, no significant CMD (low IMR [≤40 U] and no MVO); Group 2, CMD with either high IMR (>40 U) or MVO; Group 3, CMD with both IMR >40 U and MVO. The primary endpoint was the composite of all-cause mortality, diagnosis of new heart failure, cardiac arrest, sustained ventricular tachycardia/fibrillation, and cardioverter defibrillator implantation.

RESULTS

CMD with both high IMR and MVO was present in 23.7% of the cases (Group 3) and CMD with either high IMR or MVO was observed in 40.9% of cases (Group 2). At a median follow-up of 40.1 months, the primary endpoint occurred in 34 (17%) cases. At 1 year of follow-up, Group 3 (hazard ratio [HR]: 12.6; 95% confidence interval [CI]: 1.6 to 100.6; p = 0.017) but not Group 2 (HR: 7.2; 95% CI: 0.9 to 57.9; p = 0.062) had worse clinical outcomes compared with those with no significant CMD in Group 1. However, in the long-term, patients in Group 2 (HR: 4.2; 95% CI: 1.4 to 12.5; p = 0.009) and those in Group 3 (HR: 5.2; 95% CI: 1.7 to 16.2; p = 0.004) showed similar adverse outcomes, mainly driven by the occurrence of heart failure.

CONCLUSIONS

Post-ischemic CMD predicts a more than 4-fold increase in long-term risk of adverse outcomes, mainly driven by the occurrence of heart failure. Defining CMD by either invasive IMR >40 U or by CMR-assessed MVO showed similar risk of adverse outcomes.

Novel device-based therapies to improve outcome in ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (PPCI) has dramatically changed the outcome of patients with ST-elevation myocardial infarction (STEMI). However, despite improvements in interventional technology, registry data show little recent change in the prognosis of patients who survive STEMI, with a significant incidence of cardiogenic shock, heart failure, and cardiac death. Despite a technically successful PPCI procedure, a variable proportion of patients experience suboptimal myocardial reperfusion. Large infarct size and coronary microvascular injury, as the consequence of ischaemia-reperfusion injury and distal embolization of atherothrombotic debris, account for suboptimal long-term prognosis of STEMI patients. In order to address this unmet therapeutic need, a broad-range of device-based treatments has been developed. These device-based therapies can be categorized according to the pathophysiological pathways they target: (i) techniques to prevent distal atherothrombotic embolization, (ii) techniques to prevent or mitigate ischaemia/reperfusion injury, and (iii) techniques to enhance coronary microvascular function/integrity. This review is an overview of these novel technologies with a focus on their pathophysiological background, procedural details, available evidence, and with a critical perspective about their potential future implementation in the clinical care of STEMI patients.

Effect of Sex on Outcomes of Coronary Rotational Atherectomy Percutaneous Coronary Intervention (From the European Multicenter Euro4C Registry)

Data regarding the potential influence of gender on outcomes of rotational atherectomy (RA) percutaneous coronary intervention (PCI) are scarce and conflicting. Using the Euro4C registry, an international prospective multicentric registry of RA PCI, we evaluated the influence of gender on clinical outcomes of RA PCI. Between October 2016 and July 2018, 966 patients were included. In them, 267 (27.6%) were females. Female patients were older than males (77.7 years old ± 9.8 vs 73.3 ± 9.5 years old respectively, p < 0.001) had a poorer renal function (43,1% of females had a GFR < 60 ml/min:1.73m² vs 30.4% of males, p < 0.001) and were more frequently admitted for an acute coronary syndrome (32.2% vs 22.3% p = 0.002). During RA procedure, women were less likely to be treated by radial approach (65.0% vs 74.4%, p = 0.004). In-hospital major adverse cardiac event rate-defined as cardiovascular death, myocardial infarction, stroke/transient ischemic attack, target lesion revascularization, and coronary artery bypass grafting surgery-was higher in the female group (7.1% vs 3.7%, p = 0.043). However, coronary perforation, dissection, slow/low flow and tamponade did not significantly differ in gender, neither did cardiovascular medications at discharge. At 1 year follow-up, rate of major adverse cardiac event was 18.4% in the female group vs 11.2% in the male group (adjusted Hazard Ratio 1.82 [1.24 to 2.67], p = 0.002). No significant bleeding differences were observed in gender, neither in hospital, nor during follow-up. In conclusion women had worse clinical outcomes following RA PCI during hospitalization and at 1 year follow-up than did men.

Early Postoperative Thrombosis of Transcatheter Aortic Valve-in-Valve Prosthesis

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has been popularized as an attractive alternative to redo surgical aortic valve replacement for bioprosthetic valve dysfunction. Acute valve thrombosis has been occasionally described after ViV-TAVR. Lack of anticoagulant therapy has been always considered a crucial risk factor. This report describes a rare case of early postoperative fatal ViV-TAVR thrombosis despite adequate anticoagulation in addition to dual antiplatelet therapy.

Extravalvular Cardiac Damage and Renal Function Following Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

BACKGROUND

In this study we sought to determine the differences in incidence of acute kidney injury (AKI) and acute kidney recovery (AKR) among patients undergoing transcatheter aortic valve implantation (TAVI), according to the degree of extravalvular cardiac damage (EVCD).

METHODS

From the Verona Valvular Heart Disease Registry, 674 symptomatic severe aortic stenosis (AS) patients were selected and retrospectively analysed. Using echocardiographic data, patients were classified based on the degree of EVCD.

RESULTS

After dichotomized analysis, patients in EVCD stage 3 or 4 reported a significantly higher rate of AKI (29.5% vs 11.2%; P < 0.001). Using a multivariate analysis model, higher EVCD stage, lower glomerular filtrate rate (GFR) at admission, and amount of contrast used were found to be independent predictors of AKI, whereas stage of cardiac damage and GFR were found to be independent predictors of AKR. For the overall population after multivariate analysis AKI was associated with a higher incidence of 12-month all-cause mortality (hazard ratio, 2.142; 95% confidence interval, 1.082-4.239; P = 0.029) with a significant impact in the advanced cardiac damage stages, but not in the early stages (P for interaction = 0.006). AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months.

CONCLUSIONS

Increase in EVCD stage was associated with a higher rate of AKI after TAVI. AKI had a negative impact on long-term clinical outcomes but only in patients with advanced cardiac damage. AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months.

Refractory vasospastic angina in a patient with fibromuscular dysplasia: A case report

A 49-year-old woman affected by fibromuscular dysplasia (FMD) of the carotid artery with recurrent coronary vasospasm, refractory to medical therapy was admitted for anginal pain. Coronary involvement related to FMD is uncommon and its diagnosis "in vivo" still represents a challenge. Although a clear association between FMD and spontaneous coronary artery dissections is described, the presentation as severe coronary vasospasm is rare and it is associated with unfavorable outcome, especially when treated by means of percutaneous coronary intervention. The use of intravascular ultrasound played a key role in choosing the appropriate strategy for the management of the patient. <Learning objective: During the past years fibromuscular dysplasia (FMD) has been recognized as an underdiagnosed underlying pathology possibly associated with acute coronary syndromes, especially in the setting of young women. Coronary involvement has been recently associated with vasospasm, reported in previous cases as severe refractory vasospasm. Intravascular imaging techniques are able to detect FMD structural coronary abnormalities, aiming for clinicians to choose the appropriate strategy for the management of the patient.>.

Aortic valve replacement: validation of the Toronto Aortic Stenosis Quality of Life Questionnaire

Aims

There is no quality of life tool specifically developed for patients with severe aortic stenosis (AS) to assess how this chronic condition and its treatment affect patients. The Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ) has been developed to overcome this gap. The results of the validation of the TASQ in patients undergoing treatment for severe AS are presented.

Methods and results

Prospective study at 10 centres in Europe and Canada, which enrolled 274 patients with severe symptomatic AS undergoing surgical or transcatheter aortic valve replacement. Mean TASQ score at baseline was 71.2 points and increased to 88.9 three months after aortic valve implantation (P < 0.001). Increases were seen for the emotional impact (32.0 to 39.0; P < 0.001), physical limitations (14.8 to 22.0; P < 0.001), and physical symptoms (8.5 vs. 11.0; P < 0.001) domains. Internal consistency was good/excellent for overall TASQ score (α = 0.891) and for the physical limitation, emotional impact, and social limitation domains (α = 0.815–0.950). Test–retest reliability was excellent or strong for the overall TASQ (intraclass correlation coefficient of 0.883) and for the physical symptoms, physical limitation, emotional impact, and social limitation domains (intraclass correlation coefficient of 0.791–0.895). Responsiveness was medium overall (Cohen's d = 0.637) and medium/large for physical symptoms, emotional impact, and physical limitations (0.661–0.812). Sensitivity to change was significant for physical symptoms, physical limitations (both P < 0.001), emotional impact (P = 0.003), and social limitations (P = 0.038).

Conclusions

The TASQ is a new, brief, self‐administered, and clinically relevant health‐specific tool to measure changes in quality of life in patients with AS undergoing an intervention.

Obesity paradox in 12,381 patients undergoing transfemoral transcatheter aortic valve implantation: from the CENTER-collaboration

Background

Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic aortic valve stenosis. The majority of patients treated are overweight or obese. Obesity has traditionally been linked to reduced survival and worse cardiovascular outcomes. However, an “obesity paradox” has been described in some diseases, with improved survival of obese patients after invasive and surgical procedures.

Methods

The CENTER-collaboration included data from 10 registries or clinical trials of patients undergoing transfemoral TAVI from 2007 to 2018. Patients were divided in four groups according to body mass index (BMI): underweight: BMI &lt;18.5 kg/m2, normal weight: BMI 18.5 to 24.9 kg/m2, overweight: BMI 25 to 29.9 kg/m2, and obese: BMI ≥30 kg/m2. The primary endpoints of this analysis were differences in 30-day all-cause mortality and stroke after TAVI.

Results

Of the 12,381 patients analysed, 2% (n=205) were underweight, 29% (n=3552) had normal weight, 44% (n=5460) were overweight and 25% (n=3140) obese. Older patients had lower BMI (median of 84 years for underweight and 81 years for obese patients, p&lt;0.001). Cardiovascular risk factors such as hypertension, diabetes mellitus and dyslipidaemia increased progressively with increase of BMI category. As to clinical outcomes, there were no differences for stroke rates across BMI groups. In-hospital mortality was highest in patients who were underweight, namely 8.4%, compared to normal weight, overweight and obese patients (6.2%, 4.3% and 4.6% respectively, p&lt;0.001) as was 30-day mortality (9.8% compared to 6.9%, 5.3% and 5.2% respectively, p=0.001). On the other hand, extremely obese patients (BMI ≥40.0 kg/m2) also had worse prognosis, with a 30-day mortality of 7.6%.

Conclusions

In this global analysis of more than 12 000 patients undergoing transfemoral TAVI, overweight and obese patients had better in-hospital and 30-day survival than normal weight patients, confirming the obesity paradox. There was an inverted J-shaped relationship of body mass index with prognosis, with higher mortality rates for underweight and extremely obese patients.

Mortality and stroke per BMI category

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Dutch Heart Foundation; Netherlands Organisation for Health Research and Development

Beneficial effects of DAAs on cardiac function and structure in hepatitis C patients with low-moderate liver fibrosis

Hepatitis C virus (HCV)-related chronic infection has been associated with a higher incidence of cardiovascular diseases. An altered morphology and function of both left and right heart have been described in HCV patients; however, the causality of the association is still debated. Ninety-eight nonobese and nondiabetic HCV patients (59.5 ± 12.0 years; males 52%) with Fibroscan-Transient Elastography assessed low-moderate liver fibrosis that achieved sustained viral response at 12 and 24 weeks after DAAs (direct-acting antivirals) participated. 56 were matched with 52 control subjects for age, sex and cardiovascular risk factors at baseline. A trans-thoracic echocardiography was performed in each subject at baseline (T0) and repeated in all HCV patients after eradication (6 months later eligibility, T1). TNF-α and IL-10 were measured at baseline and at T1. A concentric remodelling of the left heart in HCV participants was identified, whereas tricuspidal annular plane systolic excursion, right indexed atrial volume, right basal ventricular diameter, inferior vena cava diameter and pulmonary arterial pressure were higher in HCV participants compared to matched controls. After virus eradication, left indexed atrial volume and all right cardiac chambers measures were lower than baseline. A significant reduction of TNF-α was shown at T1, while IL-10 did not change. This study shows a concentric remodelling of the left ventricle and structural modifications in the right sections in HCV patients compared to controls. Virus eradication with DAAs was associated with a reduction of the main right atrioventricular parameters indicating a direct involvement of the HCV in cardiac changes.

Management and Outcomes of Transvenous Pacing Leads in Patients Undergoing Transcatheter Tricuspid Valve Replacement

OBJECTIVES

The aim of this study was to determine the prevalence of pacemaker lead-related complications following transcatheter tricuspid valve replacement (TTVR).

BACKGROUND

The rate of permanent pacemaker implantation following tricuspid valve (TV) surgery is high, and many patients have transvenous leads. The feasibility, safety, and outcomes of subsequently performing TTVR in the setting of transvenous pacemaker leads have not been established.

METHODS

The VIVID (Valve-in-Valve International Database) registry was used to review 329 patients who underwent TTVR following TV repair or replacement. Patients were subdivided into 3 cohorts for intergroup comparisons: no lead, epicardial lead, and transvenous lead (entrapped or not entrapped during the TTVR procedure).

RESULTS

Of 329 patients who underwent TTVR, 128 (39%) had prior pacing systems in place, 70 with epicardial and 58 with transvenous leads. A total of 31 patients had leads passing through the TV. Three patients had the right ventricular (RV) lead extracted prior to TTVR. The remaining 28 patients had the RV lead entrapped between the transcatheter TV implant and the surgical valve (n = 22) or the repaired TV (n = 6). One patient had displacement of the RV lead during the procedure, and 2 experienced lead failure during follow-up. Overall, there was no significant difference in the cumulative incidences of competing outcomes (death, TV reintervention, TV dysfunction) between patients with and those without pacing leads or entrapped RV leads.

CONCLUSIONS

TTVR in the setting of trans-TV pacemaker leads without lead extraction or re-replacement can be performed safely with a low risk for complications, offering an alternative to surgical TV replacement.

Transfemoral TAVR in Nonagenarians: From the CENTER Collaboration

OBJECTIVES

This study aimed to compare differences in patient characteristics and clinical outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) versus patients younger than 90 years of age and to test the predictive accuracy of the logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation), the EuroSCORE II, and the STS-PROM (Society of Thoracic Surgeons Predicted Risk of Mortality) for mortality after TAVR in nonagenarians.

BACKGROUND

The prevalence of severe aortic valve stenosis is increasing due to the rising life expectancy. However, there are limited data evaluating outcomes in patients older than 90 years of age. Moreover, the predictive accuracy of risk scores for mortality has not been evaluated in nonagenarian patients undergoing transfemoral TAVR.

METHODS

The CENTER (Cerebrovascular EveNts in Patients Undergoing TranscathetER Aortic Valve Implantation) collaboration (N = 12,381) is an international collaboration consisting of 3 national registries, 6 local or multicenter registries, and 1 prospective clinical study, selected through a systematic online search. The primary endpoint of this study was the difference in 30-day all-cause mortality and stroke after TAVR in nonagenarians versus patients younger than 90 years of age. Secondary endpoints included differences in baseline characteristics, in-hospital outcomes, and the differences in predictive accuracy of the logistic EuroSCORE, the EuroSCORE II, and STS-PROM.

RESULTS

A total of 882 nonagenarians and 11,499 patients younger than 90 years of age undergoing transfemoral TAVR between 2007 and 2018 were included. Nonagenarians had considerably fewer comorbidities than their counterparts. Nevertheless, rates of 30-day mortality (9.9% vs. 5.4%; relative risk [RR]: 1.8; 95% confidence interval [CI]: 1.4 to 2.3; p = 0.001), in-hospital stroke (3.0% vs. 1.9%; RR: 1.5; 95% CI: 1.0 to 2.3; p = 0.04), major or life-threatening bleeding (8.1% vs. 5.5%; RR: 1.6; 95% CI: 1.1 to 2.2; p = 0.004), and new-onset atrial fibrillation (7.9% vs. 5.2%; RR: 1.6; 95% CI: 1.1 to 2.2; p = 0.01) were higher in nonagenarians. The STS-PROM adequately estimated mortality in nonagenarians, with an observed-expected mortality ratio of 1.0.

CONCLUSIONS

In this large, global, patient-level analysis, mortality after transfemoral TAVR was 2-fold higher in nonagenarians compared with patients younger than 90 years of age, despite the lower prevalence of baseline comorbidities. Moreover, nonagenarians had a higher risk of in-hospital stroke, major or life-threatening bleeding, and new-onset atrial fibrillation. The STS-PROM was the only surgical risk score that accurately predicted the risk of mortality in nonagenarians.

Predictors of patent and occlusive hemostasis after transradial coronary procedures

OBJECTIVES

To assess the independent predictors of patent and occlusive hemostasis (PH and OH, respectively) during radial hemostasis after coronary procedures.

BACKGROUND

Radial artery occlusion (RAO) is a thrombotic complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Sheath-vessel diameter ratio, postprocedure compression time, occlusive hemostasis, inadequate, and excessive anticoagulation are all predictors of RAO.

METHODS

As a part of a previously published study investigating the relationship between residual anticoagulation and risk of RAO, 837 patients undergoing transradial diagnostic coronary angiography or percutaneous coronary interventions were enrolled. Cumulative heparin dose used during the procedure and ACT measured before sheath removal were recorded. PH with reverse Barbeau test was attempted in all patients (NCT02762344).

RESULTS

PH was less frequently obtained for increasing cumulative heparin dose and ACT values (p < .0001 and p = .0034, respectively). At logistic regression analysis both cumulative heparin dose and ACT values were independent predictors of OH (OR 1.017, 95% IC 1.011-1.023 p < .0001 and OR 1.004, 95% IC 1.001-1.006, p = .0004) while adjusted probability for RAO showed exponential relationship with both parameters.

CONCLUSIONS

The level of anticoagulation is strongly related to the incidence of RAO, and should be taken into account when choosing hemostasis protocol.

Why, When and How Should Clinicians Use Physiology in Patients with Acute Coronary Syndromes?

Current data support the use of coronary physiology in patients with acute coronary syndrome (ACS). In patients with ST-elevation MI, the extent of myocardial damage and microvascular dysfunction create a complex conundrum to assimilate when considering clinical management and risk stratification. In this setting, the index of microcirculatory resistance emerged as an accurate tool to identify patients at risk of suboptimal myocardial reperfusion after primary percutaneous coronary intervention who may benefit from novel adjunctive therapies. In the context of non-ST-elevation ACS, coronary physiology should be carefully interpreted and often integrated with intracoronary imaging, especially in cases of ambiguous culprit lesion. Conversely, the functional assessment of bystander coronary disease is favoured by the available evidence, aiming to achieve complete revascularisation. Based on everyday clinical scenarios, the authors illustrate the available evidence and provide recommendations for the functional assessment of infarct-related artery and non-culprit lesions in patients with ACS.

Long-term variations of FFR and iFR after transcatheter aortic valve implantation

Long-term variations of fractional flow reserve (FFR) and instantaneous wave-free-ratio (iFR) after transcatheter aortic valve implantation (TAVI) have not been previously assessed. A total of 23 coronary lesions in 14 patients with aortic stenosis (AS) underwent physiology assessment at baseline, immediately after TAVI and at 14(7-29) months of follow-up. The angiographic severity of the lesions did not progress at follow-up (54[45-64] vs 54[49-63], p = .53). Overall, FFR (0.87[0.85-0.92] vs 0.88[0.82-0.92], p = .45) and iFR (0.88[0.85-0.96] vs 0.91[0.86-0.97], p = .30) did not change significantly compared with the baseline. FFR decreased in 3(13%) lesions with abnormal baseline value, whereas it remained stable in lesions with FFR > 0.80. Conversely, iFR did not show a systematic trend at long-term after TAVI. However, iFR demonstrated a higher reclassification rate at follow-up compared with FFR (p = .02). In conclusions, in this exploratory study, only minor variations of coronary physiology indices were observed at long-term after TAVI. Nevertheless, caution should be exercised in the interpretation of borderline FFR and iFR values in severe AS.