Microvascular dysfunction and absolute coronary blood flow after percutaneous coronary intervention of a chronic total occlusion

 

The development of a coronary chronic total occlusion (CTO) causes changes in the distal epicardial vascular bed and in the microvasculature tributary of the occluded vessel. Studies with positron emission tomography showed an increase in myocardial blood flow and coronary flow reserve (CFR) after percutaneous coronary intervention (PCI) of a CTO (1). These changes are not immediate after PCI, since they usually involve a process of weeks-months (2).

The FLOW-CTO study aims to evaluate the evolution of microvascular resistance and absolute coronary blood flow (ABF) after PCI of a CTO.

The study consecutively included patients in 4 national centers in Spain. In these patients, a coronary physiology study was performed, immediately after PCI and at 6 months follow-up. Fractional flow reserve (FRR), CFR and index of microcirculatory resistance (IMR) were determined. ABF and microvascular resistances were determined by continuous thermodilution during maximal hyperemia induced by serum infusion (3). Coronary microvascular dysfunction (MVD) was defined as an IMR ≥25 and/or an CFR <2.0, in the presence of an FFR >0.80. We present data from the baseline study immediately after PCI of a CTO in the first 49 patients.

Most patients were male (90%), with a median age of 62 years-old [IQR 56–69]. The prevalence of hypertension, dyslipidemia and diabetes were 71, 67 and 41%, respectively. The median left ventricular ejection fraction was 55% [IQR 45–60]. Eighty-six percent of the patients had exertional angina and 14% had history of congestive heart failure.

The most frequently involved vessel was the right coronary artery (55%). The most used technique was antegrade guidewire escalation (74%). The median length of the devices implanted was 59±25 mm. The mean percentage of residual stenosis was 8±4%.

Despite the good angiographic result, 20% of the lesions had an FFR value ≤0.80. Of those patients with a non-significant FFR value (>0.80), 54% had signs of MVD. Those patients with an elevated IMR (≥25) showed a non-significant trend towards a lower ABF (143±79 vs. 192±59 mL/min; p=0.1043), with significantly higher microvascular resistance (694±206 vs. 471±166 mmHg/(l/min); p=0.0328). Those patients with a reduced CFR (<2.0) had lower ABF (166±57 vs. 207±64 ml/min; p=0.0460) and a non-significant trend towards a higher microvascular resistance (535±240 vs. 466±195 mmHg/(l/min); p=0.3419). Diabetes mellitus was identified as a predictor of an elevated IMR (OR 6.3, 95% CI 1.1–13; p=0.046) or reduced CFR (OR 5.7, 95% CI 1.4–22, p=0.013).

In our study, more than half of the patients presented signs of MVD immediately after PCI of a CTO. Despite an optimal angiographic result, in a fifth of the cases we found a significant alteration of the parameters that evaluate the epicardial circulation. Diabetes mellitus was found as a predictor of MVD after PCI of a CTO.

Funding Acknowledgement

Type of funding sources: None.

Real-World Multicenter Coronary Lithotripsy Registry: Long-Term Clinical Follow-Up

OBJECTIVES

Coronary lithotripsy (CL) works by fracturing the calcified plaque, allowing mean area gain, enhancing vessel compliance, and facilitating stent deployment. This study reports the safety, effectiveness, and durability of the clinical benefit of CL at long-term follow-up of a real-world multicenter registry.

METHODS

This was a prospective, multicenter, single-arm study that included consecutive patients with calcified lesions undergoing CL from August, 2018 to October, 2020 with a clinical follow-up of 20 months (interquartile range, 14.5-25). Exclusion criteria were a target lesion located in a vessel <2.5 mm and/or the presence of dissection prior to CL. The primary endpoint was the rate of major adverse cardiovascular event (MACE, defined as death or target-lesion revascularization [TLR] or myocardial infarction [MI]) at follow-up.

RESULTS

This registry included 109 patients (128 lesions). The population was elderly (mean age, 74 years old), with high rates of diabetic patients (58%), renal insufficiency (32%), and multivessel disease (76%). Most of the lesions were predilated with semicompliant/noncompliant balloons (25 with cutting balloon). Rotational atherectomy was used in 20 lesions. On average, CL required the use of 1 balloon delivering a mean of 60 pulses. Twelve patients presented with ST-segment-elevation MI and a culprit calcified coronary lesion undergoing CL. Successful CL was achieved in 99% of cases. There were few procedural complications, with 30-day freedom from MACE rate of 98%. The MACE rate at long-term follow-up was 5.6%.

CONCLUSION

This is the first real-world, multicenter registry that confirms the safety and long-term efficacy of percutaneous coronary intervention for calcified lesions using CL in an unselected and high-risk population with a low long-term follow-up MACE rate.

Post-COVID-19 syndrome: prospective evaluation of clinical and functional outcomes

Introduction

Coronavirus disease 2019 (COVID-19) is a highly pathogenic coronavirus characterized by by systemic inflammatory response with endothelial damage and a dysregulated coagulation system. Despite most patients survive the acute setting of COVID-19, their long-term clinical sequelae are highly unclear. We have sought to identify the impact of post-COVID-19 syndrome on mid-term follow-up and gain some additional insights about the potential explanation for persistence of dyspnea.

Methods

This is a 3-month prospective cohort study of previously hospitalised COVID-19 patients recruited from a single Spanish center, a small outpatient group without prior hospitalisation was also evaluated. Patients underwent serial testing with cardio-pulmonary exercise test (CPET), transthoracic echocardiogram, pulmonary lung test, six-minute walking test, serum biomarker analysis and quality of life questionaries. They were classify according to the presence of persistent dyspnea. Primary study outcome was predicted peak oxygen consumption (V02) according to CPET and predicted carbon monoxide diffusion capacity.

Results

Our study included 41 (58.6%) patients with dyspnea and 29 (41.4%) asymptomatic. Symptomatic patients had a higher proportion of females (73.2% vs. 51.7%), but comparable age and prevalence of cardiovascular risk factors. We did not observe differences among the assessed variables in transthoracic echocardiogram and pulmonary function test. Patients who referred dyspnea had smaller predicted peak O2 consumption (77.8 [64–92.5] vs. 99 [88–105]: p<0.001), total distance in the 6-minute walking test (535 [467–600] vs. 611 [550–650] meters; p=0.001), and quality of life (KCCQ-23 60.1±18.6 vs. 82.8±11.3; p<0.001). Additionally, abnormalities in CPET were suggestive of a ventilation/perfusion misthmach or hyperventilatory syndrome characterized by impaired ventilatory efficiency with a greater VE/VCO2 slope (32 [28.1–37.4] vs. 29.4 [26.9–31.4]; p=0.022) and low PETCO2 (34 [32–39] vs. 38 [36–40]; p=0.025).

Interpretation

In this study >50% of COVID-19 survivors present a symptomatic functional impairment irrespective of age or prior hospitalization. Compared to asymptomatic patients, among those who referred dyspnea our findings suggest potential ventilatory inefficiency.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Gerencia Regional de Salud de Castilla y Leόn; Grant from the Spanish Society of Cardiology Tabla de resultados

Clinical profile and predictors of in-hospital mortality among older patients hospitalised for COVID-19

BACKGROUND

the coronavirus disease 2019 (COVID-19) is characterized by poor outcomes and mortality, particularly in older patients.

METHODS

post hoc analysis of the international, multicentre, 'real-world' HOPE COVID-19 registry. All patients aged ≥65 years hospitalised for COVID-19 were selected. Epidemiological, clinical, analytical and outcome data were obtained. A comparative study between two age subgroups, 65-74 and ≥75 years, was performed. The primary endpoint was all cause in-hospital mortality.

RESULTS

about, 1,520 patients aged ≥65 years (60.3% male, median age of 76 [IQR 71-83] years) were included. Comorbidities such as hypertension (69.2%), dyslipidaemia (48.6%), cardiovascular diseases (any chronic heart disease in 38.4% and cerebrovascular disease in 12.5%), and chronic lung disease (25.3%) were prevalent, and 49.6% were on ACEI/ARBs. Patients aged 75 years and older suffered more in-hospital complications (respiratory failure, heart failure, renal failure, sepsis) and a significantly higher mortality (18.4 vs. 48.2%, P < 0.001), but fewer admissions to intensive care units (11.2 vs. 4.8%). In the overall cohort, multivariable analysis demonstrated age ≥75 (OR 3.54), chronic kidney disease (OR 3.36), dementia (OR 8.06), peripheral oxygen saturation at admission <92% (OR 5.85), severe lymphopenia (<500/mm3) (OR 3.36) and qSOFA (Quick Sequential Organ Failure Assessment Score) >1 (OR 8.31) to be independent predictors of mortality.

CONCLUSION

patients aged ≥65 years hospitalised for COVID-19 had high rates of in-hospital complications and mortality, especially among patients 75 years or older. Age ≥75 years, dementia, peripheral oxygen saturation <92%, severe lymphopenia and qSOFA scale >1 were independent predictors of mortality in this population.

Impact of the presence of heart disease, cardiovascular medications and cardiac events on outcome in COVID-19

BACKGROUND

Cardiovascular risk factors and usage of cardiovascular medication are prevalent among coronavirus disease 2019 (COVID-19) patients. Little is known about the cardiovascular implications of COVID-19. The goal herein, was to evaluate the prognostic impact of having heart disease (HD) and taking cardiovascular medications in a population diagnosed of COVID-19 who required hospitalization. Also, we studied the development of cardiovascular events during hospitalization.

METHODS

Consecutive patients with definitive diagnosis of COVID-19 made by a positive real time- -polymerase chain reaction of nasopharyngeal swabs who were admitted to the hospital from March 15 to April 14 were included in a retrospective registry. The association of HD with mortality and with mortality or respiratory failure were the primary and secondary objectives, respectively.

RESULTS

A total of 859 patients were included in the present analysis. Cardiovascular risk factors were related to death, particularly diabetes mellitus (hazard ratio in the multivariate analysis: 1.810 [1.159- -2.827], p = 0.009). A total of 113 (13.1%) patients had HD. The presence of HD identified a group of patients with higher mortality (35.4% vs. 18.2%, p < 0.001) but HD was not independently related to prognosis; renin-angiotensin-aldosterone system inhibitors, calcium channel blockers, diuretics and beta-blockers did not worsen prognosis. Statins were independently associated with decreased mortality (0.551 [0.329-0.921], p = 0.023). Cardiovascular events during hospitalization identified a group of patients with poor outcome (mortality 31.8% vs. 19.3% without cardiovascular events, p = 0.007).

CONCLUSIONS

The presence of HD is related to higher mortality. Cardiovascular medications taken before admission are not harmful, statins being protective. The development of cardiovascular events during the course of the disease is related to poor outcome.

Comparison of Figulla Flex® and Amplatzer™ devices for atrial septal defect closure: A meta-analysis

BACKGROUND

Atrial septal defect (ASD) is one of the most common congenital heart diseases. Percutaneous closure is the preferred treatment, but certain complications remain a concern. The most common devices are AMPLATZER™ (ASO) (St. Jude Medical, St. Paul, MN, USA) and Figulla Flex® septal occluders (FSO) (Occlutech GmbH, Jena, Germany). The present study aimed to assess main differences in outcomes.

METHODS

A systematic search in Pubmed and Google scholarship was performed by two independent reviewers for any study comparing ASO and FSO. Searched terms were "Figulla", "Amplatzer", and "atrial septal defect". A random-effects model was used.

RESULTS

A total of 11 studies including 1770 patients (897 ASO; 873 FSO) were gathered. Baseline clinical and echocardiographic characteristics were comparable although septal aneurysm was more often reported in patients treated with ASO (32% vs. 25%; p = 0.061). Success rate (94% vs. 95%; OR: 0.81; 95% CI: 0.38-1.71; p = 0.58) and peri-procedural complications were comparable. Procedures were shorter, requiring less fluoroscopy time with an FSO device (OR: 0.59; 95% CI: 0.20-0.97; p = 0.003). Although the global rate of complications in long-term was similar, the ASO device was associated with a higher rate of supraventricular arrhythmias (14.7% vs. 7.8%, p = 0.009).

CONCLUSIONS

Percutaneous closure of ASD is a safe and effective, irrespective of the type of device. No differences exist regarding procedural success between the ASO and FSO devices but the last was associated to shorter procedure time, less radiation, and lower rate of supraventricular arrhythmias in follow-up. Late cardiac perforation did not occur and death in the follow-up was exceptional.