2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Aggressive hydraTion in patients with ST-Elevation Myocardial infarction undergoing Primary percutaneous coronary intervention to prevenT contrast-induced nephropathy (ATTEMPT): Study design and protocol for the randomized, controlled trial, the ATTEMPT, RESCIND 1 (First study for REduction of contraSt-induCed nephropathy followINg carDiac catheterization) trial

Adequate hydration is recommended for acute ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) to prevent contrast-induced nephropathy (CIN). However, the optimal hydration regimen has not been well established in these high-risk patients. The objective of this study is to evaluate the efficacy of a preprocedural loading dose plus postprocedural aggressive hydration with normal saline guided by the left ventricular end-diastolic pressure (LVEDP) compared with general hydration for CIN prevention. The ATTEMPT study is a multicenter, open-label, investigator-driven, randomized controlled trial in China. Approximately 560 patients with STEMI undergoing primary PCI will be randomized (1:1) to receive either periprocedural general hydration (control group) or aggressive hydration (treatment group). Patients in the control group receive periprocedural general hydration with ≤500 mL normal saline (within 6 hours) at a normal rate (0.5 or 1 mL/kg · h). Patients in the treatment group receive a preprocedural loading dose (125/250 mL) of normal saline within 30 minutes and intravenous hydration at a normal rate until LVEDP is available, followed by postprocedural aggressive hydration guided by LVEDP for 4 hours and then continuous intravascular hydration at the normal rate until 24 hours after PCI. The primary end point is CIN, defined as a >25% or 0.5-mg/dL increase in serum creatinine from baseline during the first 48 to 72 hours after procedure. The ATTEMPT study has the potential to identify optimal hydration regimens for STEMI patients undergoing PCI.

Six Versus 12 Months of Dual Antiplatelet Therapy After Implantation of Biodegradable Polymer Sirolimus-Eluting Stent

Background—

There are no reports on a large-scale randomized trial exploring optimal dual antiplatelet therapy (DAPT) duration after biodegradable polymer sirolimus-eluting stent implantation. We sought to report the outcomes of a randomized substudy of the prospective Evaluate Safety and Effectiveness of the Tivoli DES and the Firebird DES for Treatment of Coronary Revascularization (I-LOVE-IT 2) trial.

Methods and Results—

In the prospective noninferiority randomized I-LOVE-IT 2 trial, 1829 patients allocated to the biodegradable polymer sirolimus-eluting stent group were also randomized to receive either 6-month (n=909) or 12-month DAPT (n=920). The primary end points of this noninferiority substudy were 12-month target lesion failure (composite of cardiac death, target vessel myocardial infarction or clinically indicated target lesion revascularization), and the major secondary end points were 12-month net adverse clinical and cerebral events (composite of all-cause death, all myocardial infarction, stroke, or major bleeding [Bleeding Academic Research Consortium type ≥3]). The 12-month target lesion failure in 6-month DAPT group was comparable with the 12-month DAPT group (6.8% versus 5.9%; difference and 95% confidence interval, 0.87% [−1.37% to 3.11%], P for noninferiority=0.0065). Further follow-up at 18 months showed that incidence of target lesion failure and net adverse clinical and cerebral events were similar between the 2 groups (7.5% versus 6.3%, log-rank P =0.32; 7.8% versus 7.3%, log-rank P =0.60; respectively), as well as their individual end point components.

Conclusions—

This study indicated noninferiority in safety and efficacy of 6-month versus 12-month DAPT after implantation of a novel biodegradable polymer sirolimus-eluting stent.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01681381.

Beyond Stenosis With Fractional Flow Reserve Via Computed Tomography and Advanced Plaque Analyses for the Diagnosis of Lesion-Specific Ischemia

In the treatment of stable coronary artery disease (CAD), the determination of stenosis severity by invasive coronary angiography (ICA) is a critical procedure, and for borderline lesions, the detection of ischemia through invasive fractional flow reserve (FFR) is the gold standard. With advances in computational fluid dynamics, FFR can now be calculated noninvasively using anatomic data from coronary computed tomographic angiography (CCTA). This technique is known as FFR_CT. The purpose of this review is to summarize the science of FFR_CT, describe its diagnostic accuracy, discuss its clinical and economic impact, and elucidate factors beyond stenosis severity that may mechanistically relate to lesion-specific ischemia. These factors include adverse atherosclerotic plaque characteristics such as positive remodelling, low-attenuation plaque, and spotty calcification, as well as aggregate plaque volume. These factors can be appreciated noninvasively by CCTA but not by ICA. The diagnostic accuracy of FFR_CT, compared with the gold standard of FFR, has been validated in 3 prospective multicentre blinded core laboratory-controlled trials, and as a result FFR_CT has been approved by the US Food and Drug Administration for clinical use. FFR_CT has also been shown in a clinical utility trial to better identify patients without obstructive CAD when compared with standard noninvasive assessment of stable CAD, thereby avoiding unnecessary angiograms. In addition, the use of FFR_CT has been shown to allow for a significant cost savings compared with traditional care. It is therefore important for cardiologists to appreciate the value of this important new methodology.

Influence of segmented vessel size due to limited imaging resolution on coronary hyperemic flow prediction from arterial crown volume

Computational predictions of the functional stenosis severity from coronary imaging data use an allometric scaling law to derive hyperemic blood flow (Q) from coronary arterial volume (V), Q = αV(β) Reliable estimates of α and β are essential for meaningful flow estimations. We hypothesize that the relation between Q and V depends on imaging resolution. In five canine hearts, fluorescent microspheres were injected into the left anterior descending coronary artery during maximal hyperemia. The coronary arteries of the excised heart were filled with fluorescent cast material, frozen, and processed with an imaging cryomicrotome to yield a three-dimensional representation of the coronary arterial network. The effect of limited image resolution was simulated by assessing scaling law parameters from the virtual arterial network at 11 truncation levels ranging from 50 to 1,000 μm segment radius. Mapped microsphere locations were used to derive the corresponding relative Q using a reference truncation level of 200 μm. The scaling law factor α did not change with truncation level, despite considerable intersubject variability. In contrast, the scaling law exponent β decreased from 0.79 to 0.55 with increasing truncation radius and was significantly lower for truncation radii above 500 μm vs. 50 μm (P< 0.05). Hyperemic Q was underestimated for vessel truncation above the reference level. In conclusion, flow-crown volume relations confirmed overall power law behavior; however, this relation depends on the terminal vessel radius that can be visualized. The scaling law exponent β should therefore be adapted to the resolution of the imaging modality.

All-comer treatment with bioresorbable vascular scaffold

BACKGROUND

Bioresorbable vascular scaffolds (BVS) could overcome drug-eluting stents (DES) drawbacks connected with their permanent presence in the vessel wall. Studies exploring the clinical use of BVS are limited to the patients presenting with noncomplex, short and stable lesions. There are no prospective and randomized studies available in all-comer patients.

METHODS AND RESULTS

We analyzed 31 patients, who received at least one BVS (Absorb(™)) between September 1, 2012 and November 1, 2014. Median follow-up period was 424 days. In one (3.2%) patient, we performed a target vessel revascularization (TVR). The death rate was 6.5%. One (3.2%) patient, who received both BVS and a bare metal stent (BMS), died of an acute stent thrombosis 8 days after the initial procedure. One (3.2%) patient died of a non-cardiac death. We did not encounter any target lesion revascularization (TLR) or myocardial infarction (MI). The major adverse cardiac events (MACE) rate was 3.2%.

CONCLUSIONS

Implantation of BVS is a safe treatment option. Lesions should be carefully selected and prepared before BVS implantation. We need more data about the safety of BVS and BMS overlapping.

Implant success and safety of left atrial appendage closure with the WATCHMAN device: peri-procedural outcomes from the EWOLUTION registry

Aims  Left atrial appendage closure is a non-pharmacological alternative for stroke prevention in high-risk patients with non-valvular atrial fibrillation. The objective of the multicentre EWOLUTION registry was to obtain clinical data on procedural success and complications, and long-term patient outcomes, including bleeding and incidence of stroke/transient ischaemic attack (TIA). Here, we report on the peri-procedural outcomes of up to 30 days.

Methods and results  Baseline/implant data are available for 1021 subjects. Subjects in the study were at high risk of stroke (average CHADS ₂ score: 2.8 ± 1.3, CHA ₂ DS ₂ -VASc: 4.5 ± 1.6) and moderate-to-high risk of bleeding (average HAS-BLED score: 2.3 ± 1.2). Almost half of the subjects (45.4%) had a history of TIA, ischaemic stroke, or haemorrhagic stroke; 62% of patients were deemed unsuitable for novel oral anticoagulant by their physician. The device was successfully deployed in 98.5% of patients with no flow or minimal residual flow achieved in 99.3% of implanted patients. Twenty-eight subjects experienced 31 serious adverse events (SAEs) within 1 day of the procedure. The overall 30-day mortality rate was 0.7%. The most common SAE occurring within 30 days of the procedure was major bleeding requiring transfusion. Incidence of SAEs within 30 days was significantly lower for subjects deemed to be ineligible for oral anticoagulation therapy (OAT) compared with those eligible for OAT (6.5 vs. 10.2%, P = 0.042).

Conclusion  Left atrial appendage closure with the WATCHMAN device has a high success rate in complete LAAC with low peri-procedural risk, even in a population with a higher risk of stroke and bleeding, and multiple co-morbidities. Improvement in implantation techniques has led to a reduction of peri-procedural complications previously limiting the net clinical benefit of the procedure.

Percutaneous assist devices in acute myocardial infarction with cardiogenic shock: Review, meta-analysis

AIM: To assess the impact of percutaneous cardiac support in cardiogenic shock (CS) complicating acute myocardial infarction (AMI), treated with percutaneous coronary intervention.

METHODS: We selected all of the studies published from January 1^st, 1997 to May 15^st, 2015 that compared the following percutaneous mechanical support in patients with CS due to AMI undergoing myocardial revascularization: (1) intra-aortic balloon pump (IABP) vs Medical therapy; (2) percutaneous left ventricular assist devices (PLVADs) vs IABP; (3) complete extracorporeal life support with extracorporeal membrane oxygenation (ECMO) plus IABP vs IABP alone; and (4) ECMO plus IABP vs ECMO alone, in patients with AMI and CS undergoing myocardial revascularization. We evaluated the impact of the support devices on primary and secondary endpoints. Primary endpoint was the inhospital mortality due to any cause during the same hospital stay and secondary endpoint late mortality at 6-12 mo of follow-up.

RESULTS: One thousand two hundred and seventy-two studies met the initial screening criteria. After detailed review, only 30 were selected. There were 6 eligible randomized controlled trials and 24 eligible observational studies totaling 15799 patients. We found that the inhospital mortality was: (1) significantly higher with IABP support vs medical therapy (RR = +15%, P = 0.0002); (2) was higher, although not significantly, with PLVADs compared to IABP (RR = +14%, P = 0.21); and (3) significantly lower in patients treated with ECMO plus IABP vs IABP (RR = -44%, P = 0.0008) or ECMO (RR = -20%, P = 0.006) alone. In addition, Trial Sequential Analysis showed that in the comparison of IABP vs medical therapy, the sample size was adequate to demonstrate a significant increase in risk due to IABP.

CONCLUSION: Inhospital mortality was significantly higher with IABP vs medical therapy. PLVADs did not reduce early mortality. ECMO plus IABP significantly reduced inhospital mortality compared to IABP.

Clinical outcomes in patients with ST-segment elevation myocardial infarction treated with everolimus-eluting stents versus bare-metal stents (EXAMINATION): 5-year results of a randomised trial

BACKGROUND

Data for the safety and efficacy of new-generation drug-eluting stents at long-term follow-up, and specifically in patients with ST-segment elevation myocardial infarction, are scarce. In the EXAMINATION trial, we compared everolimus-eluting stents (EES) with bare-metal stents (BMS) in an all-comer population with ST-segment elevation myocardial infarction. In this study, we assessed the 5-year outcomes of the population in the EXAMINATION trial.

METHODS

In the multicentre EXAMINATION trial, done in Italy, Spain, and the Netherlands, patients with ST-segment elevation myocardial infarction were randomly assigned in a 1:1 ratio to receive EES or BMS. The random allocation schedule was computer-generated and central randomisation (by telephone) was used to allocate patients in blocks of four or six, stratified by centre. Patients were masked to treatment assignment. At 5 years, we assessed the combined patient-oriented outcome of all-cause death, any myocardial infarction, or any revascularisation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00828087.

FINDINGS

1498 patients were randomly assigned to receive either EES (n=751) or BMS (n=747). At 5 years, complete clinical follow-up data were obtained for 731 patients treated with EES and 727 treated with BMS (97% of both groups). The patient-oriented endpoint occurred in 159 (21%) patients in the EES group versus 192 (26%) in the BMS group (hazard ratio 0·80, 95% CI 0·65-0·98; p=0·033). This difference was mainly driven by a reduced rate of all-cause mortality (65 [9%] vs 88 [12%]; 0·72, 0·52-0·10; p=0·047).

INTERPRETATION

Our findings should be taken as a point of reference for the assessment of new bioresorbable polymer-based metallic stents or bioresorbable scaffolds in patients with ST-segment elevation myocardial infarction.

FUNDING

Spanish Heart Foundation.

Role of cardiovascular magnetic resonance in the guidelines of the European Society of Cardiology

BACKGROUND

Despite common enthusiasm for cardiovascular magnetic resonance (CMR), its application in Europe is quite diverse. Restrictions are attributed to a number of factors, like limited access, deficits in training, and incomplete reimbursement. Aim of this study is to perform a systematic summary of the representation of CMR in the guidelines of the European Society of Cardiology (ESC).

METHODS

Twenty-nine ESC guidelines were screened for the terms "magnetic", "MRI", "CMR", "MR" and "imaging". As 3 topics were published twice (endocarditis, pulmonary hypertension, NSTEMI), 26 guidelines were finally included. MRI in the context of non-cardiovascular examinations was not recognized. The main CMR-related conclusions and, if available, the level of evidence and the class of recommendation were extracted.

RESULTS

Fourteen of the 26 guidelines (53.8%) contain specific recommendations regarding the use of CMR. Nine guidelines (34.6%) mention CMR in the text, and 3 (11.5%) do not mention CMR. The 14 guidelines with recommendations regarding the use of CMR contain 39 class-I recommendations, 12 class-IIa recommendations, 10 class-IIb recommendations and 2 class-III recommendations. Most of the recommendations have evidence level C (41/63; 65.1%), followed by level B (16/63; 25.4%) and level A (6/63; 9.5%). The four guidelines, which absolutely contained most recommendations for CMR, were stable coronary artery disease (n = 14), aortic diseases (n = 9), HCM (n = 7) and myocardial revascularization (n = 7).

CONCLUSIONS

CMR is represented in the majority of the ESC guidelines. They contain many recommendations in favour of the use of CMR in specific scenarios. Issues regarding access, training and reimbursement have to be solved to offer CMR to patients in accordance with the ESC guidelines.

A case report of the new Polyzene™-F COBRA PzF™ Nanocoated Coronary Stent System (NCS): Addressing an unmet clinical need

Because of anticipated antiplatelet medication risks, patients who are not DES candidates or who are at particularly high risk for bleeding events have been targeted initially for treatment with the COBRA PzF Coronary Stent System. We report the case of a successful experience with a new, Polyzene™-F COBRA PzF™ Coronary Stent System, designed to impart thrombo-resistance and reduce inflammation, to achieve shorter dual antiplatelet therapy duration while reducing restenosis incidence in a high risk patient with atrial fibrillation.

Bioresorbable Scaffold vs. Second Generation Drug Eluting Stent in Long Coronary Lesions requiring Overlap: A Propensity-Matched Comparison (the UNDERDOGS study)

BACKGROUND

Randomized clinical trials on bioresorbable scaffolds (BRS) enrolled patients with simple coronary lesions. The present study was sought to give preliminary findings about safety of BRS implantation in overlap in long coronary lesions.

METHODS

From June 2012 to January 2015, we prospectively collected data from 162 consecutive patients receiving overlapping BRS implantation in the 16 participating institutions. We applied a propensity-score to match BRS-treated patients with 162 patients receiving second generation drug eluting stents (DES) in overlap. The primary endpoint was a device-oriented endpoint (DOCE), including cardiac death, target vessel myocardial infarction, and target lesion revascularization.

RESULTS

DOCE rate did not significantly differ between the two groups (5.6% in BRS group vs. 7.4% in DES group, HR 0.79, 95%CI 0.37-3.55, p=0.6). Also stent/scaffold thrombosis did not differ between groups (1.2% in BRS group vs. 1.9% in DES group, p=0.6). Occurrence of procedural-related myocardial injury was significantly higher in the BRS group (25% vs. 12%, p=0.001), although it was not related to DOCE (HR 1.1, 95%CI 0.97-1.2, p=0.2). Imaging techniques and enhanced stent visualization systems were significantly more employed in the BRS group (p=0.0001 for both). Procedure length, fluoroscopy time and contrast dye amount were significantly higher in the BRS group (p=0.001, p=0.001 and p=0.01, respectively).

CONCLUSIONS

Overlapping BRS utilization in long coronary lesions showed a comparable DOCE rate at 1year if compared to second generation DES. Further and larger studies are on demand to confirm our findings.

Risks and benefits of triple oral anti-thrombotic therapies after acute coronary syndromes and percutaneous coronary intervention

The key pathophysiological process underlying symptomatic coronary artery disease, including acute coronary syndromes (ACS), is usually a rupture or an erosion of an atherosclerotic plaque, followed by platelet activation and subsequent thrombus formation. Early clinical trials showed benefit with long-term aspirin treatment, and later-based on large clinical trials-dual anti-platelet therapy (DAPT), initially with clopidogrel, and more recently with prasugrel or ticagrelor, has become the established treatment in the post-ACS setting and after percutaneous coronary intervention (PCI). Treatment with DAPT is recommended for both ST-elevation myocardial infarction and non-ST-elevation ACS, as well as after PCI with stenting, in American and European clinical guidelines. Notwithstanding the benefits observed with DAPT, including third-generation P2Y12 receptor inhibitors plus aspirin, ACS patients remain at high risk for a recurrent cardiovascular event, suggesting that other treatment strategies, including the addition of a third oral anti-platelet agent or a novel oral anticoagulant (NOAC) to standard DAPT regimens, may provide additional benefit for post-ACS patients and for patients undergoing PCI. Adding a third anti-thrombotic agent to DAPT after an ACS event or a PCI procedure has been shown to have modest benefit in terms of ischemic event reduction, but has consistently been associated with increased bleeding complications. Therefore, the quest to optimize anti-thrombotic therapies post-ACS and post-PCI continues unabated but is tempered by the historical experiences to date that indicate that careful patient and dose selection will be critical features of future randomized trials.

Clinical Feasibility of Simultaneous Acquisition Rest (99m)Tc/Stress (201)Tl Dual-Isotope Myocardial Perfusion Single-Photon Emission Computed Tomography With Semiconductor Camera

BACKGROUND

The aim of this study was to evaluate the clinical feasibility of simultaneous acquisition of rest (99m)Tc-tetrofosmin/stress (201)Tl dual-isotope single-photon emission computed tomography with a semiconductor gamma camera.

METHODS AND RESULTS

Ninety-four patients with known or suspected coronary artery disease (CAD) were enrolled in the study. First, patients were injected with (99m)Tc-tetrofosmin (296 MBq) for rest imaging, followed by (201)Tl (74 MBq) injection during 6 min of vasodilator stress test. Immediately after the stress test, the patients underwent the first electrocardiogram (ECG)-gated simultaneous acquisition including rest and stress perfusion scans. Patients were brought back for the second simultaneous acquisition for the comparison of ECG-gated wall motion between stress and rest scan 30 min later. Coronary angiography was performed in all the patients within 3 months of this protocol. Sensitivity, specificity and accuracy on a per patient basis to detect significant coronary artery stenosis (≥75%) were 88.6%, 79.2% and 86.2%, respectively. Per coronary vessel, sensitivity, specificity and accuracy were as follows: 84.9%, 80.5% and 83% in the left anterior descending coronary artery; 75%, 93.1% and 86.2% in the left circumflex coronary artery; and 74.2%, 85.7% and 81.9% in the right coronary artery.

CONCLUSIONS

Simultaneous acquisition of rest (99m)Tc-tetrofosmin/stress (201)Tl dual-isotope protocol had high diagnostic accuracy for significant CAD. (Circ J 2016; 80: 689-695).

Treatment variation in stent choice in patients with stable or unstable coronary artery disease

AIM

Variations in treatment are the result of differences in demographic and clinical factors (e.g. anatomy), but physician and hospital factors may also contribute to treatment variation. The choice of treatment is considered important since it could lead to differences in long-term outcomes. This study explores the associations with stent choice: i.e. drug-eluting stent (DES) versus bare-metal stents (BMS) for Dutch patients diagnosed with stable or unstable coronary artery disease (CAD).

METHODS & RESULTS

Associations with treatment decisions were based on a prospective cohort of 692 patients with stable or unstable CAD. Of those patients, 442 patients were treated with BMS or DES. Multiple logistic regression analyses were performed to identify variables associated with stent choice. Bivariate analyses showed that NYHA class, number of diseased vessels, previous percutaneous coronary intervention, smoking, diabetes, and the treating hospital were associated with stent type. After correcting for other associations the treating hospital remained significantly associated with stent type in the stable CAD population.

CONCLUSIONS

This study showed that several factors were associated with stent choice. While patients generally appear to receive the most optimal stent given their clinical characteristics, stent choice seems partially determined by the treating hospital, which may lead to differences in long-term outcomes.

Everolimus-eluting bioresorbable stent vs. durable polymer everolimus-eluting metallic stent in patients with ST-segment elevation myocardial infarction: results of the randomized ABSORB ST-segment elevation myocardial infarction-TROFI II trial

AIMS

Patients with ST-segment elevation myocardial infarction (STEMI) feature thrombus-rich lesions with large necrotic core, which are usually associated with delayed arterial healing and impaired stent-related outcomes. The use of bioresorbable vascular scaffolds (Absorb) has the potential to overcome these limitations owing to restoration of native vessel lumen and physiology at long term. The purpose of this randomized trial was to compare the arterial healing response at short term, as a surrogate for safety and efficacy, between the Absorb and the metallic everolimus-eluting stent (EES) in patients with STEMI.

METHODS AND RESULTS

ABSORB-STEMI TROFI II was a multicentre, single-blind, non-inferiority, randomized controlled trial. Patients with STEMI who underwent primary percutaneous coronary intervention were randomly allocated 1:1 to treatment with the Absorb or EES. The primary endpoint was the 6-month optical frequency domain imaging healing score (HS) based on the presence of uncovered and/or malapposed stent struts and intraluminal filling defects. Main secondary endpoint included the device-oriented composite endpoint (DOCE) according to the Academic Research Consortium definition. Between 06 January 2014 and 21 September 2014, 191 patients (Absorb [n = 95] or EES [n = 96]; mean age 58.6 years old; 17.8% females) were enrolled at eight centres. At 6 months, HS was lower in the Absorb arm when compared with EES arm [1.74 (2.39) vs. 2.80 (4.44); difference (90% CI) -1.06 (-1.96, -0.16); Pnon-inferiority < 0.001]. Device-oriented composite endpoint was also comparably low between groups (1.1% Absorb vs. 0% EES). One case of definite subacute stent thrombosis occurred in the Absorb arm (1.1% vs. 0% EES; P = ns).

CONCLUSION

Stenting of culprit lesions with Absorb in the setting of STEMI resulted in a nearly complete arterial healing which was comparable with that of metallic EES at 6 months. These findings provide the basis for further exploration in clinically oriented outcome trials.

Mechanisms of Very Late Drug-Eluting Stent Thrombosis Assessed by Optical Coherence Tomography

BACKGROUND

The pathomechanisms underlying very late stent thrombosis (VLST) after implantation of drug-eluting stents (DES) are incompletely understood. Using optical coherence tomography, we investigated potential causes of this adverse event.

METHODS AND RESULTS

Between August 2010 and December 2014, 64 patients were investigated at the time point of VLST as part of an international optical coherence tomography registry. Optical coherence tomography pullbacks were performed after restoration of flow and analyzed at 0.4 mm. A total of 38 early- and 20 newer-generation drug-eluting stents were suitable for analysis. VLST occurred at a median of 4.7 years (interquartile range, 3.1-7.5 years). An underlying putative cause by optical coherence tomography was identified in 98% of cases. The most frequent findings were strut malapposition (34.5%), neoatherosclerosis (27.6%), uncovered struts (12.1%), and stent underexpansion (6.9%). Uncovered and malapposed struts were more frequent in thrombosed compared with nonthrombosed regions (ratio of percentages, 8.26; 95% confidence interval, 6.82-10.04; P<0.001 and 13.03; 95% confidence interval, 10.13-16.93; P<0.001, respectively). The maximal length of malapposed or uncovered struts (3.40 mm; 95% confidence interval, 2.55-4.25; versus 1.29 mm; 95% confidence interval, 0.81-1.77; P<0.001), but not the maximal or average axial malapposition distance, was greater in thrombosed compared with nonthrombosed segments. The associations of both uncovered and malapposed struts with thrombus were consistent among early- and newer-generation drug-eluting stents.

CONCLUSIONS

The leading associated findings in VLST patients in descending order were malapposition, neoatherosclerosis, uncovered struts, and stent underexpansion without differences between patients treated with early- and new-generation drug-eluting stents. The longitudinal extension of malapposed and uncovered stent was the most important correlate of thrombus formation in VLST.

Oral Antiplatelet Therapy in Coronary Disease

Ischemic heart disease is the major isolated cause of death worldwide, responsible for 7,249,000 deaths in 2008, 12.7% of deaths from any causes. The inhibition of platelet activation and aggregation is an important therapeutic target. Cyclooxygenase inhibitors and thienopyridines are currently the 2 most used pharmacological classes, but novel antiplatelet agents have currently an important role. The most recent thienopyridine, prasugrel, allows an irreversible inhibition of the P2Y12 platelet receptor associated to a faster and more consistent onset of action rather the previous antiplatelet agents of the same class. Cyclopentyl-triazolo-pyrimidines, a newer pharmacological class from which ticagrelor is an example, also act at the P2Y12 platelet receptor, and like prasugrel, ticagrelor inhibits platelet aggregation in a fast and consistent manner, however, in a reversible way. This article aims to conduct a review on the literature about the most recent information and guidelines on oral antiplatelet agents available for the management of coronary disease.

Stenting of coronary bifurcation lesions: a literature and technical review

Newer generation drug-eluting stents have improved outcomes in various subsets of coronary lesions including bifurcation lesions. This article reviews the current literature on various issues in bifurcation percutaneous coronary intervention (PCI). Generally, the provisional approach of placing one stent in the main vessel is the preferred first-line treatment for most bifurcation lesions. However, some lesions require 2-stenting. It is unknown whether 2nd-generation DES have improved outcomes with 2-stenting. The use of fractional flow reserve (FFR) for the assessment of functional significance of the jailed side branch can help avoid unnecessary stenting in complex lesions. Skilled techniques in every step of the 2-stenting process and meticulous use of imaging techniques including IVUS or OCT are warranted to obtain optimal angiographic and clinical results. Dedicated bifurcation stents are feasible treatment options and may change future concepts in bifurcation PCI, although larger trials with control groups are required in order to widely apply these techniques into daily routine practice.

Cost-minimization analysis of three decision strategies for cardiac revascularization: results of the "suspected CAD" cohort of the european cardiovascular magnetic resonance registry

BACKGROUND

Coronary artery disease (CAD) continues to be one of the top public health burden. Perfusion cardiovascular magnetic resonance (CMR) is generally accepted to detect CAD, while data on its cost effectiveness are scarce. Therefore, the goal of the study was to compare the costs of a CMR-guided strategy vs two invasive strategies in a large CMR registry.

METHODS

In 3'647 patients with suspected CAD of the EuroCMR-registry (59 centers/18 countries) costs were calculated for diagnostic examinations (CMR, X-ray coronary angiography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive CXA and revascularization at the discretion of the treating physician (=CMR + CXA-strategy). In the hypothetical invasive arm, costs were calculated for an initial CXA and a FFR in vessels with ≥50% stenoses (=CXA + FFR-strategy) and the same proportion of revascularizations and complications were applied as in the CMR + CXA-strategy. In the CXA-only strategy, costs included those for CXA and for revascularizations of all ≥50% stenoses. To calculate the proportion of patients with ≥50% stenoses, the stenosis-FFR relationship from the literature was used. Costs of the three strategies were determined based on a third payer perspective in 4 healthcare systems.

RESULTS

Revascularizations were performed in 6.2%, 4.5%, and 12.9% of all patients, patients with atypical chest pain (n = 1'786), and typical angina (n = 582), respectively; whereas complications (=all-cause death and non-fatal infarction) occurred in 1.3%, 1.1%, and 1.5%, respectively. The CMR + CXA-strategy reduced costs by 14%, 34%, 27%, and 24% in the German, UK, Swiss, and US context, respectively, when compared to the CXA + FFR-strategy; and by 59%, 52%, 61% and 71%, respectively, versus the CXA-only strategy. In patients with typical angina, cost savings by CMR + CXA vs CXA + FFR were minimal in the German (2.3%), intermediate in the US and Swiss (11.6% and 12.8%, respectively), and remained substantial in the UK (18.9%) systems. Sensitivity analyses proved the robustness of results.

CONCLUSIONS

A CMR + CXA-strategy for patients with suspected CAD provides substantial cost reduction compared to a hypothetical CXA + FFR-strategy in patients with low to intermediate disease prevalence. However, in the subgroup of patients with typical angina, cost savings were only minimal to moderate.

Periprocedural effects of statins on the incidence of contrast-induced acute kidney injury: A systematic review and trial sequential analysis

BACKGROUND

Contrast-induced acute kidney injury (CI-AKI) is a potential complication in coronary angiography (CAG) and percutaneous coronary interventions (PCI). Prior randomized controlled trials (RCTs) have suggested that statins may play a role in reducing rates of CI-AKI, however it is not clear how firm the current evidence is.

OBJECTIVES

The aim of this study was to conduct a meta-analysis and trial sequential analysis to determine the effects of statins in lowering CI-AKI rates in CAG and PCI.

METHODS

A systematic literature search was performed to include all RCTs comparing statins (treatment arm) versus low-dose statins or placebo (control arm) as pretreatment for CAG and/or PCI. A traditional meta-analysis and several subgroup analyses were conducted using traditional meta-analysis with relative risk (RR), trial sequential analysis, and meta-regression analysis.

RESULTS

14 RCTs met our inclusion criteria giving a total of 2992 statin treated (49.6%) and 3041 control patients (50.4%). There was a significant reduction in CI-AKI in the statin group compared to controls (3.7% vs 8.3%, RR, 0.46; p=<0.00001). Trial sequential analysis using a relative risk reduction threshold of 20%, power 80% and type 1 error of 5%, indicated that the evidence is firm. A greater risk reduction in CI-AKI in the statin group significantly correlated with higher estimated glomerular filtration rate (eGFR; p=0.003) CONCLUSIONS: The present trial sequential analysis provides support for statins in reducing the incidence of CI-AKI in patients undergoing CAG/PCI. This effect appeared to be greater in patients with higher eGFR.

Medical Therapy With Versus Without Revascularization in Stable Patients With Moderate and Severe Ischemia: The Case for Community Equipoise

All patients with stable ischemic heart disease (SIHD) should be managed with guideline-directed medical therapy (GDMT), which reduces progression of atherosclerosis and prevents coronary thrombosis. Revascularization is also indicated in patients with SIHD and progressive or refractory symptoms, despite medical management. Whether a strategy of routine revascularization (with percutaneous coronary intervention or coronary artery bypass graft surgery as appropriate) plus GDMT reduces rates of death or myocardial infarction, or improves quality of life compared to an initial approach of GDMT alone in patients with substantial ischemia is uncertain. Opinions run strongly on both sides, and evidence may be used to support either approach. Careful review of the data demonstrates the limitations of our current knowledge, resulting in a state of community equipoise. The ongoing ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) is being performed to determine the optimal approach to managing patients with SIHD, moderate-to-severe ischemia, and symptoms that can be controlled medically. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Optical frequency domain imaging vs. intravascular ultrasound in percutaneous coronary intervention (OPINION trial): Study protocol for a randomized controlled trial

BACKGROUND

Optical coherence tomography is becoming increasingly widespread as an adjunctive intravascular diagnostic technique in percutaneous coronary intervention (PCI), because of its ability to visualize coronary structures at high resolution. Several studies have reported that intravascular ultrasound (IVUS) guidance in PCI might be helpful to reduce subsequent stent thrombosis, restenosis, repeat revascularization, myocardial infarction, and cardiac death. The OPtical frequency domain imaging vs. INtravascular ultrasound in percutaneous coronary InterventiON (OPINION) trial is aimed at evaluating the impact of optical frequency domain imaging (OFDI) guidance in PCI on clinical outcomes compared with IVUS guidance.

METHODS AND DESIGN

The OPINION trial is a multicenter, prospective, randomized, controlled, open-label, parallel group, non-inferiority trial in Japan. The eligible patients are randomly assigned to receive either OFDI-guided PCI or IVUS-guided PCI. PCI is performed using the biolimus-eluting stent in accordance with a certain criteria of OFDI and IVUS for optimal stent deployment. All patients will undergo a follow-up angiography at 8 months. The primary endpoint is target vessel failure composed of cardiac death, myocardial infarction attributed to the target vessel, and clinically-driven target vessel revascularization at 12 months.

CONCLUSION

When completed, the OPINION trial will contribute to define the clinical value of the OFDI guidance in PCI.

Safety and performance of the second-generation drug-eluting absorbable metal scaffold in patients with de-novo coronary artery lesions (BIOSOLVE-II): 6 month results of a prospective, multicentre, non-randomised, first-in-man trial

BACKGROUND

Absorbable scaffolds were designed to overcome the limitations of conventional, non-absorbable metal-based drug-eluting stents. So far, only polymeric absorbable scaffolds are commercially available. We aimed to assess the safety and performance of a novel second-generation drug-eluting absorbable metal scaffold (DREAMS 2G) in patients with de-novo coronary artery lesions.

METHODS

We did this prospective, multicentre, non-randomised, first-in-man trial at 13 percutaneous coronary intervention centres in Belgium, Brazil, Denmark, Germany, Singapore, Spain, Switzerland, and the Netherlands. Eligible patients had stable or unstable angina or documented silent ischaemia, and a maximum of two de-novo lesions with a reference vessel diameter between 2·2 mm and 3·7 mm. Clinical follow-up was scheduled at months 1, 6, 12, 24, and 36. Patients were scheduled for angiographic follow-up at 6 months, and a subgroup of patients was scheduled for intravascular ultrasound, optical coherence tomography, and vasomotion assessment. All patients were recommended to take dual antiplatelet treatment for at least 6 months. The primary endpoint was in-segment late lumen loss at 6 months. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01960504.

FINDINGS

Between Oct 8, 2013, and May 22, 2015, we enrolled 123 patients with 123 coronary target lesions. At 6 months, mean in-segment late lumen loss was 0·27 mm (SD 0·37), and angiographically discernable vasomotion was documented in 20 (80%) of 25 patients. Intravascular ultrasound assessments showed a preservation of the scaffold area (mean 6·24 mm(2) [SD 1·15] post-procedure vs 6·21 mm(2) [1·22] at 6 months) with a low mean neointimal area (0·08 mm(2) [0·09]), and optical coherence tomography did not detect any intraluminal mass. Target lesion failure occurred in four (3%) patients: one (<1%) patient died from cardiac death, one (<1%) patient had periprocedural myocardial infarction, and two (2%) patients needed clinically driven target lesion revascularisation. No definite or probable scaffold thrombosis was observed.

INTERPRETATION

Our findings show that implantation of the DREAMS 2G device in de-novo coronary lesions is feasible, with favourable safety and performance outcomes at 6 months. This novel absorbable metal scaffold could be an alternative to absorbable polymeric scaffolds for treatment of obstructive coronary disease.

FUNDING

Biotronik AG.