98Mitral annular calcification, mitral valve diseases and clinical outcomes in patients undergoing transcatheter aortic valve replacement for severe aortic stenosis

Background

Mitral annular calcification (MAC) and mitral valve diseases (MVD) have been identified as strong predictors of mortality in patients undergoing transcatheter aortic valve replacement (TAVR). However, the association between MAC and MVD, and the prognostic implications in these patients remain unclear.

Purpose

This study sought to investigate the association between severity of MAC and the prevalence of MVD as well as to assess the prognostic impact of MAC depending on the presence or absence of MVD in patients undergoing TAVR.

Methods

We identified 967 patients who have comprehensive echocardiographic and computed tomographic assessment of MVD and MAC from our institutional registry that is a part of the Swiss TAVI registry (NCT01368250) between August 2007 and June 2017.

Results

Among these patients, mild or moderate MAC was present in 45.2% and severe MAC was present in 17.8%. The prevalence of MVD was significantly higher in severe MAC patients, while the prevalence in patients with mild and moderate MAC was similar to patients without MAC. Compared to patients without severe MAC and MVD, an increased risk of all-cause death at 1 year was observed in patients with severe MAC and MVD (hazard ratio [HR]: 2.81, 95% confidence interval [CI]: 1.72–4.59, p<0.001) as well as in patients with non-severe MAC and MVD (HR: 2.80, 95% CI: 1.87–4.20, p<0.001) but not in patients with severe MAC and non-MVD (HR: 0.68, 95% CI: 0.27–1.70, p=0.409). In a multivariable analysis, severe MAC concomitant with MVD was found to be an independent predictor of new permanent pacemaker implantation after TAVR (Odds ratio: 2.08, 95% CI: 1.27–3.41, p=0.004).

Conclusions

Severe MAC was associated with higher prevalence of MVD. Severe MAC concomitant with MVD was associated with increased risks of mortality at 1 year and conduction abnormalities after TAVR, whereas severe MAC without MVD was not.

P1968Five-year outcomes in patients with diabetes mellitus treated with biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents

Background

Patients with diabetes mellitus (DM) remain at higher risk for adverse events after percutaneous coronary intervention (PCI) compared with non-diabetic individuals. Among available drug-eluting stents (DES), thin-strut durable polymer everolimus-eluting stents (DP-EES) were shown to provide the best safety and efficacy profile in diabetics. Whether biodegradable polymer DES provide additional long-term clinical benefit compared with DP-EES among diabetic patients remains uncertain.

Purpose

To compare the long-term performance of ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus DP-EES for PCI in patients with insulin-requiring and non-insulin-requiring DM.

Methods

We performed a prespecified subgroup analysis of the randomized, multicenter, non-inferiority BIOSCIENCE trial (NCT01443104). Patients with stable coronary artery disease or acute coronary syndrome were randomly assigned to treatment with ultrathin-strut BP-SES or thin-strut DP-EES. Patients were further divided according to diabetic status. The primary endpoint was target lesion failure (TLF), a composite of cardiac death, target-vessel myocardial infarction (MI) and clinically-indicated target lesion revascularization (TLR), within 12 months.

Results

Among 2'119 patients enrolled between March 2012 and May 2013, 486 (22.9%) presented with DM (insulin-requiring, 33.1%). Compared with non-diabetics, patients with DM were older and had a greater baseline cardiac risk profile, including higher prevalence of hypertension, hypercholesterolaemia, peripheral artery disease, chronic renal failure and prior PCI, coronary artery bypass graft surgery, or stroke. At 5 years, TLF occurred similarly in 74 patients (cumulative incidence, 31.0%) treated with BP-SES and 57 patients (25.8%) treated with DP-EES (RR 1.23; 95% CI 0.87–1.73; p=0.24) in diabetics, and in 124 patients (16.8%) treated with BP-SES and 132 patients (16.8%) treated with DP-EES (RR 0.98; 95% CI 0.77–1.26; p=0.90) in non-diabetics (p for interaction=0.31). Cumulative incidences of cardiac death (14.9% vs. 9.5%; p=0.10), target-vessel MI (11.4% vs. 11.0%; p=0.81), clinically-indicated TLR (16.9% vs. 15.8%; p=0.68), and definite thrombosis (3.0% vs. 2.5%; p=0.63) at 5 years were similar among diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES. Overall, there was no interaction between diabetic status and treatment effect of BP-SES versus DP-EES.

Conclusion

In a prespecified subgroup analysis of the BIOSCIENCE trial, we found no difference in clinical outcomes throughout five years between diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES.

Acknowledgement/Funding

BIOSCIENCE was an investigator-initiated trial supported by a dedicated research grant from Biotronik, Bülach, Switzerland

P6440The perils of polyvascular disease with concomitant type 2 diabetes in a real-world cohort of patients with acute coronary syndrome

Background

Despite substantial improvement in type 2 diabetes (DM2) care, the burden of recurrent cardiovascular (CV) events remains high. Polyvascular disease (PVD), has recently emerged as a potential marker of heightened residual ischemic risk in DM2 patients, that are likely to derive a greater absolute risk reduction from more intense, individualized therapy.

Purpose

We sought to assess the relationship between DM2, PVD and CV outcomes among 2,168 all-comers patients admitted to four Swiss University Hospital for acute coronary syndrome (ACS) and enrolled in the prospective multicenter SPUM registry (NCT 01000701).

Methods

PVD was defined as concomitant peripheral artery disease, stroke or transient ischemic attack, or both. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE: Stroke, myocardial infarction, CV death). Adjusted Cox proportional hazards regression models were implemented to determine the risk associated with PVD disease in DM2 and outcomes, and intention-to-treat analysis was performed.

Results

Out of 2,168 ACS patients, 396 patients (18.3%) had DM2; of these 62 (15%) had PVD. Despite compared with the general ACS population, those with PVD + DM2 were more likely to have a complex history of CV disease, such as previous MI (27.4% vs 14.7%, p=0.021), prior percutaneous (37.1% vs 17%, p<0.001) or surgical (24.2% vs 5.1%, p<0.001) coronary revascularization, one third was not on statin therapy. At 1 year, patients with PVD + DM2 had a higher rate of MACCE compared to those presenting with PVD or DM2 alone. Rates of the single components of the primary endpoint and all-cause of death were all significantly higher in patients with PVD + DM2 vs. PVD or DM2 alone (Fig. 1A, all p<0.001). This enhanced risk persisted after adjustment for significant baseline differences, with a 34% (Adj. HR 1.34, 95% CI 1.15–1.49, p=0.02) increase in MACCE and a 44% increment of all cause of death (Adj. HR 1.44, 95% CI 1.06–1.54, p=0.02, Fig. 1B).

Outcomes by PVD and DM2 status.

Conclusions

Among a real-world cohort of ACS-patients, the coexistence of PVD and DM2 highlights the highest CV risk phenotype, being associated with significant increased rates of MACCE and all-cause of death. These observations might help clinicians to furtherly stratify the very high risk population and to identify patients who may derive the greatest benefit from more intense secondary prevention therapies.

Evolocumab for Early Reduction of LDL Cholesterol Levels in Patients With Acute Coronary Syndromes (EVOPACS)

BACKGROUND

Although guidelines recommend in-hospital initiation of high-intensity statin therapy in patients with acute coronary syndromes (ACS), low-density lipoprotein cholesterol (LDL-C) target levels are frequently not attained. Evolocumab, a rapidly acting, potent LDL-C-lowering drug, has not been studied in the acute phase of ACS.

OBJECTIVES

The purpose of this study was to assess the feasibility, safety, and LDL-C-lowering efficacy of evolocumab initiated during the in-hospital phase of ACS.

METHODS

The authors conducted an investigator-initiated, randomized, double-blind, placebo-controlled trial involving 308 patients hospitalized for ACS with elevated LDL-C levels (≥1.8 mmol/l on high-intensity statin for at least 4 weeks; ≥2.3 mmol/l on low- or moderate-intensity statin; or ≥3.2 mmol/l on no stable dose of statin). Patients were randomly assigned 1:1 to receive subcutaneous evolocumab 420 mg or matching placebo, administered in-hospital and after 4 weeks, on top of atorvastatin 40 mg. The primary endpoint was percentage change in calculated LDL-C from baseline to 8 weeks.

RESULTS

Most patients (78.2%) had not been on previous statin treatment. Mean LDL-C levels decreased from 3.61 to 0.79 mmol/l at week 8 in the evolocumab group, and from 3.42 to 2.06 mmol/l in the placebo group; the difference in mean percentage change from baseline was -40.7% (95% confidence interval: -45.2 to -36.2; p < 0.001). LDL-C levels <1.8 mmol/l were achieved at week 8 by 95.7% of patients in the evolocumab group versus 37.6% in the placebo group. Adverse events and centrally adjudicated cardiovascular events were similar in both groups.

CONCLUSIONS

In this first randomized trial assessing a PCSK9 antibody in the very high-risk setting of ACS, evolocumab added to high-intensity statin therapy was well tolerated and resulted in substantial reduction in LDL-C levels, rendering >95% of patients within currently recommended target levels. (EVOlocumab for Early Reduction of LDL-cholesterol Levels in Patients With Acute Coronary Syndromes [EVOPACS]; NCT03287609).

Does isolated mitral annular calcification in the absence of mitral valve disease affect clinical outcomes after transcatheter aortic valve replacement?

Aims 

Mitral annular calcification (MAC) has been associated with adverse outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) but has been investigated in isolation of co-existent mitral regurgitation or mitral stenosis, which may represent important confounders. This study sought to investigate the effect of MAC with and without concomitant mitral valve disease (MVD) on clinical outcomes in patients treated with TAVR.

Methods and results 

Computed tomography (CT) and echocardiographic data in consecutive TAVR patients enrolled into a prospective registry were categorized according to presence or absence of severe MAC and significant MVD, respectively. A total of 967 patients with adequate CT and echocardiography data were included between 2007 and 2017. Severe MAC was found in 172 patients (17.8%) and associated with MVD in 87 patients (50.6%). Compared to TAVR patients without severe MAC or MVD, all-cause mortality at 1 year was significantly increased among patients with severe MAC in combination with MVD [adjusted hazard ratio (HRadj): 1.97, 95% confidence interval (CI): 1.12–3.44, P = 0.018] and patients with isolated MVD (HRadj: 2.33, 95% CI: 1.56–3.47, P &lt; 0.001), but not in patients with isolated severe MAC in the absence of MVD (HRadj: 0.52, 95% CI: 0.21–1.33, P = 0.173).

Conclusion 

We found no effect of isolated MAC on clinical outcomes following TAVR in patients with preserved mitral valve function. Patients with MVD had an increased risk of death at 1 year irrespective of MAC.

Long-Term Effect of Ultrathin-Strut Versus Thin-Strut Drug-Eluting Stents in Patients With Small Vessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

Background:

Randomized trials evaluating the Orsiro biodegradable polymer sirolimus-eluting stent (BP-SES; 60 and 80 μm strut thickness for stent diameters ≤3 and >3 mm, respectively) did not stratify according to vessel size and failed to specify the impact of ultrathin-strut thickness on long-term clinical outcomes compared with durable polymer everolimus-eluting stents (DP-EES). We sought to assess the long-term effect of ultrathin-strut (60 μm) BP-SES versus thin-strut (81 μm) DP-EES on long-term outcomes in patients undergoing percutaneous coronary revascularization for small vessel disease.

Methods:

In a subgroup analysis of the randomized, multicenter, noninferiority BIOSCIENCE trial, patients with stable coronary artery disease or acute coronary syndrome randomly assigned to treatment with BP-SES or DP-EES were stratified according to vessel size (≤3 mm versus >3 mm) as a surrogate to compare patients treated with ultrathin-strut versus thin-strut drug-eluting stent. The primary end point was target lesion failure, a composite of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization, within 5 years.

Results:

Among 2109 patients, 1234 (59%) were treated for small vessel disease. At 5 years, target lesion failure occurred in 124 patients (cumulative incidence, 22.3%) treated with ultrathin-strut BP-SES and 109 patients (18.3%) treated with thin-strut DP-EES (rate ratio, 1.22; 95% CI, 0.94–1.58; P =0.13). Cumulative incidences of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization and definite stent thrombosis at 5 years were similar in patients treated with ultrathin-strut BP-SES and thin-strut DP-EES. After adjustment for potential confounders, there was no significant interaction between vessel size and treatment effect of BP-SES versus DP-EES.

Conclusions:

We found no significant difference in clinical outcomes throughout 5 years between patients with small vessel disease treated with ultrathin-strut BP-SES versus thin-strut DP-EES.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01443104.

Electrocardiographic predictors of mortality in patients after percutaneous coronary interventions - a nested case-control study

Background: The outcome of patients undergoing percutaneous coronary interventions (PCIs) varies considerably. Several ECG parameters have recently emerged (PQ interval, P-wave, T-peak-to-T-end interval, T-wave, T/R ratio, J-wave) beyond traditional markers (rhythm, QRS, Q-wave, QT interval, ST segment) and were attributed important prognostic value in the setting of coronary artery disease. The present study integrated for the first time these ECG parameters altogether with the aim to determine their role in predicting patients' outcome after a PCI. Methods: A total of 3342 patients were enrolled in the present study between 2009 and 2013. In a nested case-control design, 644 patients who died within a year post-PCI (cases) were matched 1:4 with patients alive at that particular date (controls). Results: Our data showed that only the presence of a longer QT interval (heart rate-corrected using Bazett formula) was associated with increased risk of death after adjusting for multiple clinical and angiographic risk factors (adjusted OR 1.07; 95%CI 1.01-1.12, p = .022). Conclusion: Our study emphasises the prognostic importance of the QT interval in identifying patients at increased risk of death during the first year after PCI. Clinical Trial Registration - URL: https://www.clinicaltrials.gov . Unique identifier: NCT02241291.

Prognostic value of elevated lipoprotein(a) in patients with acute coronary syndromes

BACKGROUND

Minimal lipoprotein(a) [Lp(a)] target values are advocated for high-risk cardiovascular patients. We investigated the prognostic value of Lp(a) in the acute setting of patients with acute coronary syndromes (ACS).

MATERIALS AND METHODS

Plasma levels of Lp(a) were collected at time of angiography from 1711 patients hospitalized for ACS in a multicentre Swiss prospective cohort. Associations between elevated Lp(a) ≥30 mg/dL (cut-off corresponding to the 75th percentile of the assay) or Lp(a) tertiles at baseline, and major adverse cardiovascular events (MACE) at 1 year, defined as a composite of cardiac death, myocardial infarction or stroke, were assessed using hazard ratios (HR) and 95% confidence intervals (CI) adjusting for traditional cardiovascular risk factors (age, sex, smoking, diabetes, hypertension, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C] and triglycerides.

RESULTS

Lp(a) levels range between 2.5 and 132 mg/dL with a median value of 6 mg/dL and a mean value of 14.2 mg/dL. A total of 276 patients (23.0%) had Lp(a) plasma levels ≥30 mg/dL. Patients with elevated Lp(a) were more likely to be of female gender and to have higher levels of total cholesterol, LDL-C, HDL-C and triglycerides. Higher Lp(a) was associated with failure to reach the LDL-C target <1.8 mmol/L at 1 year (HR 1.71, 95% CI 1.13-2.58, P = 0.01). No association was found between elevated Lp(a) and MACE at 1 year (HR 1.05, 95% CI 0.64-1.73), nor for Lp(a) tertiles (HR 0.82, 95% CI 0.52-1.28, P > 0.20) or standardized continuous variables (0.98, 95% CI 0.82-1.19 for each increase of standard deviation).

CONCLUSIONS

Our real-world data suggest high Lp(a) levels at time of angiography are not predictive for cardiovascular outcomes in patients otherwise medically well controlled, but might be useful to identify patients who would not be on LDL-C targets 1 year after ACS.

Habitat selection can reduce effects of extreme climatic events in a long-lived shorebird

Changes in the frequency of extreme climatic events (ECEs) can have profound impacts on individual fitness by degrading habitat quality. Organisms may respond to such changes through habitat selection, favouring those areas less affected by ECEs; however, documenting habitat selection in response to ECEs is difficult in the wild due to the rarity of such events and the long-term biological data required. Sea level rise and changing weather patterns over the past decades have led to an increase in the frequency of coastal flooding events, with serious consequences for ground nesting shorebirds. Shorebirds therefore present a useful natural study system to understand habitat selection as a response to ECEs. We used a 32-year study of the Eurasian oystercatcher (Haematopus ostralegus) to investigate whether habitat selection can lead to an increase in nest elevation and minimize the impacts of coastal flooding. The mean nest elevation of H. ostralegus has increased during the last three decades. We hypothesized that this change has been driven by changes in H. ostralegus territory settlement patterns over time. We compared various possible habitat selection cues to understand what information H. ostralegus might use to inform territory settlement. There was a clear relationship between elevation and territory settlement in H. ostralegus. In early years, settlements were more likely at low elevations but in more recent years the likelihood of settlement was similar between high and low elevation areas. Territory settlement was associated with conspecific fledgling output and conspecific density. Settlement was more likely in areas of high density and areas with high fledgling output. This study shows that habitat selection can minimize the effects of increasingly frequent ECEs. However, it seems unlikely that the changes we observe will fully alleviate the consequences of anthropogenic climate change. Rates of nest elevation increase were insufficient to track current increases in maximum high tide (0.5 vs. 0.8 cm/year). Furthermore, habitat selection cues that rely on information from previous breeding seasons (e.g. conspecific fledgling output) may become ineffective as ECEs become more frequent and environmental predictability is diminished.

Prognostic value of total testosterone levels in patients with acute coronary syndromes

BACKGROUND

Endogenous testosterone levels decrease in men with aging. Controversies persist regarding the screening and treatment of low testosterone levels in patients with acute coronary syndromes (ACS).

METHODS AND RESULTS

Total serum testosterone levels were measured in 1054 men hospitalized for ACS that were part of a Swiss prospective cohort. Total testosterone levels were classified first in tertiles and using the cut-off of 300 ng/dL. Primary endpoint was all-cause mortality at one year. Cox regression models adjusting for the GRACE score (composite of age, heart rate systolic blood pressure, creatinine, cardiac arrest at admission, ST segment deviation, abnormal troponin enzyme and Killip classification), preexisting diabetes and inflammation (high-sensitivity C-reactive protein). A total of 430 men (40.8%) had total testosterone levels ≤300 ng/dL. Low total testosterone levels were correlated with lower high-density lipoprotein cholesterol and higher triglycerides, high-sensitivity C-reactive protein, high-sensitivity troponin T, N-terminal-pro B-type natriuretic peptide and glucose levels (all p < 0.01). Patients in the lowest testosterone tertile had a mortality rate at one-year of 5.4% compared with 2.9% in the highest tertile with an unadjusted hazard ratio of 1.92 (95% confidence interval 0.96-1.90, p = 0.095) and adjusted hazard ratio of 1.26 (95% confidence interval 0.57-2.78, p = 0.565). In an exploratory analysis, the highest mortality rate (10.3%) was observed in men aged >65 years old belonging to the lowest testosterone tertile.

CONCLUSION

In this large population of men with ACS, we found a prevalence of low total endogenous testosterone levels of almost 40%. However, low testosterone levels were not significantly associated with mortality after adjustment for high-risk confounders.

Impact of left ventricular function on clinical outcomes among patients with coronary artery disease

AIMS

To investigate the clinical relevance of contemporary cut-offs of left ventricular ejection fraction (LVEF) including an intermediate phenotype with mid-range reduced ejection fraction among patients with coronary artery disease undergoing percutaneous coronary intervention.

METHODS AND RESULTS

Patient-level data were summarized from five randomized clinical trials in which 6198 patients underwent clinically indicated percutaneous coronary intervention in different clinical settings. We assessed all-cause mortality as primary endpoint at five-year follow-up. According to the proposed LVEF cut-offs, 3816 patients were included in the preserved LVEF group (LVEF ≥ 50%), 1793 in the mid-range reduced LVEF group (LVEF 40-49%) and 589 patients in the reduced LVEF group (LVEF < 40%). Patients in the reduced LVEF group were at increased risk for the primary outcome of all-cause mortality compared with both, preserved and mid-range LVEF throughout five years of follow-up (adjusted hazard ratio 2.39 (95% confidence interval 1.75-3.28, p < 0.001) and 1.68 (95% confidence interval 1.34-2.10, p < 0.001), respectively). The risk of cardiac death and the composite endpoint of cardiac death, myocardial infarction, or stroke were higher for patients in the reduced LVEF group compared with the preserved and mid-range reduced LVEF groups, but also for the mid-range LVEF compared with preserved LVEF group (adjusted p < 0.05 for all comparisons) throughout five years. Irrespective of clinical presentation at baseline (stable coronary artery disease or acute coronary syndrome), patients with reduced or mid-range LVEF were at increased risk of all-cause mortality and cardiac death up to five years compared with the other group (adjusted p < 0.05 for all comparisons).

CONCLUSION

Patients with reduced LVEF <40% or mid-range LVEF 40-49% in the context of coronary artery disease undergoing clinically indicated percutaneous coronary intervention are at increased risk of all-cause mortality, cardiac death and the composite of cardiac death, stroke and myocardial infarction throughout five years of follow-up. The recently proposed LVEF cut-offs contribute to the differentiation and risk stratification of patients with ischaemic heart disease.

Impact of valvular resistance on aortic regurgitation after transcatheter aortic valve replacement according to the type of prosthesis

BACKGROUND

The impact of aortic valvular resistance (VR) on the degree of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR) remains unclear. The objective of the study was to investigate the relationship between VR and paravalvular AR after TAVR.

METHODS

Between August 2007 and December 2015, 708 TAVR patients had sufficient data to calculate VR before the intervention and were eligible for the present analysis. The patient population was dichotomized according to VR. The association between VR and post-TAVR AR was separately assessed by prosthesis type.

RESULTS

Among patients with low VR (LVR; < 238 dynes/cm⁵), 176 (49.7%) patients were treated with balloon-expandable (BE) valves and 178 (51.3%) patients with self-expandable (SE) transcatheter valves. Among patients with high VR (HVR ≥ 238), 147 (41.5%) and 207 (68.5%) patients received BE and SE, respectively. Baseline characteristics were similar in both groups irrespective of the type of valve. Patients with HVR had a 2.5-fold risk of ≥ moderate post-TAVR AR compared to patients with LVR. Both, HVR (HR_adj 2.45, 95% CI 1.33-4.51) and the use of SE (HR_adj 3.11, 95% CI 1.66-5.82), emerged as independent predictors of ≥ moderate post-TAVR AR. Moderate or greater post-AR was consistently predicted in patients treated with SE (HR_adj 2.42, 95% CI 1.22-4.80) irrespective of the level of VR.

CONCLUSIONS

HVR is associated with a nearly 2.5-fold increased risk of moderate or greater post-TAVR AR and is an independent predictor of post-TAVR AR.

Implications of the local haemodynamic forces on the phenotype of coronary plaques

AIM

To examine the effect of endothelial shear stress (ESS) on the dynamic changes in plaque phenotype.

METHODS

Patients with myocardial infarction that had intravascular ultrasound-virtual histology (IVUS-VH) and optical coherence tomography (OCT) at baseline and 13-month follow-up were studied. The IVUS-VH data were used to reconstruct the nonculprit vessels, and in the obtained models the ESS was estimated in 3 mm segments. Plaque morphology was derived in each segment from IVUS-VH and OCT. Disease progression was defined as the presence of ≥2 out of the following criteria: reduction in lumen area, increase in plaque burden and change of plaque morphology to a more vulnerable phenotype. Linear mixed effects models were used to assess the effect of ESS in different phenotypes.

RESULTS

Sixty-eight vessels were included in the analysis. Low ESS was associated with plaque progression in all phenotypes. The effect of ESS on plaque burden (p for interaction=0.467) and phenotype (p for interaction=0.188) was similar in all plaque types, whereas the effect of ESS on the changes in lumen dimensions was more prominent in disease-free (β=0.70, p<0.001) than fibrotic/fibrocalcific (β=0.28, p<0.001) or lipid-rich plaques (β=0.15, p=0.015). Standalone IVUS-VH misclassified plaque morphology in one-third of the cases leading to erroneous estimations about the effect of ESS on plaque evolution in different phenotypes.

CONCLUSIONS

The effect of ESS on plaque progression is similar in all phenotypes and cannot be accurately assessed by standalone IVUS-VH which often misclassifies plaque morphology. Therefore, multimodality imaging should be considered to examine the implications of ESS on plaque evolution.

CLINICAL TRIAL REGISTRATION

NCT00962416; Post-results.

Rationale and design of a prospective substudy of clinical endpoint adjudication processes within an investigator-reported randomised controlled trial in patients with coronary artery disease: the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY)

INTRODUCTION

The GLOBAL LEADERS is an open-label, pragmatic and superiority randomised controlled trial designed to challenge the current treatment paradigm of dual antiplatelet therapy (DAPT) for 12 months followed by aspirin monotherapy among patients undergoing percutaneous coronary intervention. By design, all study endpoints are investigator reported (IR) and not subject to formal adjudication by an independent Clinical Event Committee (CEC), which may introduce detection, reporting or ascertainment bias.

METHODS AND ANALYSIS

We designed the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY) to prospectively implement, in a large sample of patients enrolled within the GLOBAL LEADERS trial (7585 of 15 991, 47.5%), an independent adjudication process of reported and unreported potential endpoints, using standardised CEC procedures, in order to assess whether 23-month ticagrelor monotherapy (90 mg twice daily) after 1-month DAPT is non-inferior to a standard regimen of DAPT for 12 months followed by aspirin monotherapy for the primary efficacy endpoint of death, non-fatal myocardial infarction, non-fatal stroke or urgent target vessel revascularisation and superior for the primary safety endpoint of type 3 or 5 bleeding according to the Bleeding Academic Research Consortium criteria.This study will comprehensively assess the comparative safety and efficacy of the two tested antithrombotic strategies on CEC-adjudicated ischaemic and bleeding endpoints and will provide insights into the role of a standardised CEC adjudication process on the interpretation of study findings by quantifying the level of concordance between IR-reported and CEC-adjudicated events.

ETHICS AND DISSEMINATION

GLASSY has been approved by local ethics committee of all study sites and/or by the central ethics committee for the country depending on country-specific regulations. In all cases, they deemed that it was not necessary to obtain further informed consent from individual subjects.

TRIAL REGISTRATION NUMBER

NCT01813435.

Design and rationale of the Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Standard DAPT Regimen (MASTER DAPT) Study

BACKGROUND

The optimal duration of antiplatelet therapy in high-bleeding risk (HBR) patients with coronary artery disease treated with newer-generation drug-eluting bioresorbable polymer-coated stents remains unclear.

DESIGN

MASTER DAPT (clinicaltrial.govNCT03023020) is an investigator-initiated, open-label, multicenter, randomized controlled trial comparing an abbreviated versus a standard duration of antiplatelet therapy after bioresorbable polymer-coated Ultimaster (TANSEI) sirolimus-eluting stent implantation in approximately 4,300 HBR patients recruited from ≥100 interventional cardiology centers globally. After a mandatory 30-day dual-antiplatelet therapy (DAPT) run-in phase, patients are randomized to (a) a single antiplatelet regimen until study completion or up to 5 months in patients with clinically indicated oral anticoagulation (experimental 1-month DAPT group) or (b) continue DAPT for at least 5 months in patients without or 2 in patients with concomitant indication to oral anticoagulation, followed by a single antiplatelet regimen (standard antiplatelet regimen). With a final sample size of 4,300 patients, this study is powered to assess the noninferiority of the abbreviated antiplatelet regimen with respect to the net adverse clinical and major adverse cardiac and cerebral events composite end points and if satisfied for the superiority of abbreviated as compared to standard antiplatelet therapy duration in terms of major or clinically relevant nonmajor bleeding. Study end points will be adjudicated by a blinded Clinical Events Committee.

CONCLUSIONS

The MASTER DAPT study is the first randomized controlled trial aiming at ascertaining the optimal duration of antiplatelet therapy in HBR patients treated with sirolimus-eluting bioresorbable polymer-coated stent implantation.

Mechanical complications in patients with ST-segment elevation myocardial infarction: A single centre experience

Background

The study aims to assess characteristics and outcomes of patients suffering a mechanical complication (MC) after ST-segment elevation myocardial infarction (STEMI) in a contemporary cohort of patients in the percutaneous coronary intervention era.

Methods and results

This retrospective single-center cohort study encompasses 2508 patients admitted with STEMI between March 9, 2009 and June 30, 2014. A total of 26 patients (1.1%) suffered a mechanical complication: ventricular septal rupture (VSR) in 17, ventricular free wall rupture (VFWR) in 2, a combination of VSD and VFWR in 2, and papillary muscle rupture (PMR) in 5 patients. Older age (74.5 ± 10.4 years versus 63.9 ± 13.1 years, p < 0.001), female sex (42.3% versus 23.3%, p = 0.034), and a longer latency period between symptom onset and angiography (> 24h: 42.3% versus 16.2%, p = 0.002) were more frequent among patients with MC as compared to patients without MC. The majority of MC patients had multivessel disease (77%) and presented in cardiogenic shock (Killip class IV: 73.1%). Nine patients (7 VSR, 2 VFWR & VSR) were treated conservatively and died. Out of the remaining 10 VSR patients, four underwent surgery, three underwent implantation of an occluder device, and another three patients had surgical repair following occluder device implantation. All patients with isolated VFWR and PMR underwent emergency surgery. At 30 days, mortality for VSR, VFWR, VFWR & VSR and PMR amounted to 71%, 50%, 100% and 0%, respectively.

Conclusions

Despite advances in the management of STEMI patients, mortality of mechanical complications stays considerable in this contemporary cohort. Older age, female sex, and a prolonged latency period between symptom onset and angiography are associated with the occurrence of these complications.

Prognostic Relevance of Left Ventricular Myocardial Performance After Transcatheter Aortic Valve Replacement

BACKGROUND

The left-ventricular myocardial performance index Tei is an echocardiographic parameter that incorporates the information of systolic and diastolic time intervals. While the prognostic value of selected systolic and diastolic parameters is well established after transcatheter aortic valve replacement, the role of Tei has not been evaluated in this setting.

METHODS AND RESULTS

Between August 2007 and December 2015, consecutive patients with symptomatic, severe aortic stenosis and transthoracic echocardiography pre- and post-transcatheter aortic valve replacement were considered eligible for this analysis. The primary end point was all-cause mortality at 1 year after transcatheter aortic valve replacement. Of 824 patients with echocardiographic images to calculate Tei, pre-Tei was normal (<0.45) in 639 and high (≥0.45) in 185, whereas post-Tei was normal in 602 and high in 120, respectively. After adjustment for confounding factors, high pre-Tei was associated with an increased risk of all-cause mortality at 30 days (adjusted hazard ratio [HR_adj] 3.62; 95% CI, 1.89-6.91) and 1 year (HR_adj 2.56; 95% CI, 1.78-3.69). Similarly, post-Tei was associated with an increased risk of mortality between 30 days and 1-year follow-up (HR_adj 6.70; 95% CI, 4.22-10.63). At multivariable analysis Tei emerged as an independent predictor of early (pre-Tei index per 0.1-HR_adj 1.40; 95% CI, 1.23-1.60) and late mortality (post-Tei index per 0.1-HR_adj 1.40; 95% CI, 1.31-1.50), respectively.

CONCLUSIONS

The left-ventricular myocardial performance index Tei is associated with impaired clinical outcomes during short- and longer-term follow-up after transcatheter aortic valve replacement.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01368250.