Ticagrelor or Clopidogrel Monotherapy vs Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Systematic Review and Patient-Level Meta-Analysis

Importance

Among patients undergoing percutaneous coronary intervention (PCI), it remains unclear whether the treatment efficacy of P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) depends on the type of P2Y12 inhibitor.

Objective

To assess the risks and benefits of ticagrelor monotherapy or clopidogrel monotherapy compared with standard DAPT after PCI.

Data Sources

MEDLINE, Embase, TCTMD, and the European Society of Cardiology website were searched from inception to September 10, 2023, without language restriction.

Study Selection

Included studies were randomized clinical trials comparing P2Y12 inhibitor monotherapy with DAPT on adjudicated end points in patients without indication to oral anticoagulation undergoing PCI.

Data Extraction and Synthesis

Patient-level data provided by each trial were synthesized into a pooled dataset and analyzed using a 1-step mixed-effects model. The study is reported following the Preferred Reporting Items for Systematic Review and Meta-Analyses of Individual Participant Data.

Main Outcomes and Measures

The primary objective was to determine noninferiority of ticagrelor or clopidogrel monotherapy vs DAPT on the composite of death, myocardial infarction (MI), or stroke in the per-protocol analysis with a 1.15 margin for the hazard ratio (HR). Key secondary end points were major bleeding and net adverse clinical events (NACE), including the primary end point and major bleeding.

Results

Analyses included 6 randomized trials including 25 960 patients undergoing PCI, of whom 24 394 patients (12 403 patients receiving DAPT; 8292 patients receiving ticagrelor monotherapy; 3654 patients receiving clopidogrel monotherapy; 45 patients receiving prasugrel monotherapy) were retained in the per-protocol analysis. Trials of ticagrelor monotherapy were conducted in Asia, Europe, and North America; trials of clopidogrel monotherapy were all conducted in Asia. Ticagrelor was noninferior to DAPT for the primary end point (HR, 0.89; 95% CI, 0.74-1.06; P for noninferiority = .004), but clopidogrel was not noninferior (HR, 1.37; 95% CI, 1.01-1.87; P for noninferiority > .99), with this finding driven by noncardiovascular death. The risk of major bleeding was lower with both ticagrelor (HR, 0.47; 95% CI, 0.36-0.62; P < .001) and clopidogrel monotherapy (HR, 0.49; 95% CI, 0.30-0.81; P = .006; P for interaction = 0.88). NACE were lower with ticagrelor (HR, 0.74; 95% CI, 0.64-0.86, P < .001) but not with clopidogrel monotherapy (HR, 1.00; 95% CI, 0.78-1.28; P = .99; P for interaction = .04).

Conclusions and Relevance

This systematic review and meta-analysis found that ticagrelor monotherapy was noninferior to DAPT for all-cause death, MI, or stroke and superior for major bleeding and NACE. Clopidogrel monotherapy was similarly associated with reduced bleeding but was not noninferior to DAPT for all-cause death, MI, or stroke, largely because of risk observed in 1 trial that exclusively included East Asian patients and a hazard that was driven by an excess of noncardiovascular death.

A comparison between radial artery compression devices for patent hemostasis after transradial percutaneous interventions

OBJECTIVES

Patent hemostasis (PH) is essential for preventing radial artery occlusion (RAO) after trans-radial procedures; however, it remains unclear how it should be obtained. The aim of this multicenter randomized study was to evaluate whether the use of an adjustable device (AD), inflated with a pre-determined amount of air (AoA), was more effective than a non-adjustable device (non-AD) for achieving PH, thereby reducing the incidence of RAO.

METHODS

We enrolled a total of 480 patients undergoing transradial procedure at 3 Italian institutions. Before the procedure, a modified Reverse Barbeau Test (mRBT) was performed in all patients to evaluate the AoA to be eventually inflated in the AD. After the procedure, patients were randomized into 2 groups: (1) AD Group, using TR-Band (Terumo) inflated with the pre-determined AoA; and 2) non-AD Group, using RadiStop (Abbott). An RBT was performed during compression to demonstrate the achievement of PH, as well as 24 hours later to evaluate the occurrence of RAO.

RESULTS

PH was more often obtained in the AD Group compared with the non-AD Group (90% vs 64%, respectively, P less than .001), with no difference in terms of bleedings. RAO occurred more often in the non-AD Group compared with the AD Group (10% vs 3%, respectively, P less than .001). Of note, mRBT was effective at guiding AD inflation and identifying high-risk patients in whom PH was more difficult to obtain.

CONCLUSIONS

The use of AD, filled with a predetermined AoA, allowed PH significantly more often compared with non-AD, providing a significantly reduced incidence of RAO.

Cangrelor in contemporary patients with ST-segment elevation myocardial infarction pretreated with Ticagrelor: Pharmacodynamic data from the POMPEII study

Background

There are limited data to assess pharmacodynamic (PD) profiles of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) and receiving cangrelor after pretreatment with ticagrelor.

Methods

The PharmacOdynaMic effects of cangrelor in PatiEnts wIth acute or chronIc coronary syndrome undergoing percutaneous coronary intervention (POMPEII) registry (NCT04790032) is a prospective study conducted at Federico II University of Naples enrolling all patients undergoing PCI receiving cangrelor at operator's discretion. PD assessments were performed with 3 assays: (1) the gold standard light transmittance aggregometry (LTA) (20- and 5-μM adenosine diphosphate [ADP] stimuli); (2) VerifyNow P2Y12-test; (3) Multiplate electrode aggregometry (MEA), ADP-test.

Results

We analyzed 13 STEMI patients pretreated with ticagrelor within 1 h at the time they underwent primary PCI receiving cangrelor. All patients showed low maximal platelet aggregation at 30-minute during cangrelor infusion, as well as at 3 h and 4-6 h (corresponding to 1 h and 2-4 h after stopping cangrelor infusion) with no cases of high residual platelet reactivity. These results were consistent with all assays.

Conclusions

PD data show that in contemporary real-world STEMI patients pretreated within 1 h with ticagrelor undergoing primary PCI, adding cangrelor resulted in fast and potent platelet inhibition, thus suggesting that cangrelor may bridge the gap until ticagrelor reaches its effect.

CT Coronary Angiography: Technical Approach and Atherosclerotic Plaque Characterization

Coronary computed tomography angiography (CCTA) currently represents a robust imaging technique for the detection, quantification and characterization of coronary atherosclerosis. However, CCTA remains a challenging task requiring both high spatial and temporal resolution to provide motion-free images of the coronary arteries. Several CCTA features, such as low attenuation, positive remodeling, spotty calcification, napkin-ring and high pericoronary fat attenuation index have been proved as associated to high-risk plaques. This review aims to explore the role of CCTA in the characterization of high-risk atherosclerotic plaque and the recent advancements in CCTA technologies with a focus on radiomics plaque analysis.

Impact of biomarker type on periprocedural myocardial infarction in patients undergoing elective PCI

BACKGROUND

Periprocedural myocardial infarction (MI) according to the Society for Cardiovascular Angiography and Interventions (SCAI) criteria has prognostic relevance among patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether the type of cardiac biomarker used for the diagnosis of periprocedural MI plays a role in terms of event frequency and outcomes.

OBJECTIVES

To compare the characteristics of SCAI periprocedural MI based on creatine kinase-myocardial band fraction (CK-MB) vs. high-sensitivity cardiac troponin (hs-cTn) in patients undergoing elective PCI.

METHODS AND RESULTS

Between 2017 and 2021, periprocedural MI was assessed in a prospective study. The primary clinical outcome of interest was all-cause death at 1-year follow-up. A total of 1010 patients undergoing elective PCI were included. SCAI periprocedural MI based on CK-MB vs. hs-cTnI occurred in 1.8 and 13.5% of patients, respectively. hs-cTnI periprocedural MI in the absence of concomitant CK-MB criteria was associated with lower rates of ancillary criteria, including angiographic, ECG, and cardiac imaging criteria. At 1-year follow-up, periprocedural MI defined by CK-MB (adjusted hazard ratio, HR, 4.27, 95% confidence intervals, CI, 1.23-14.8; P = 0.022) but not hs-cTnI (adjusted HR 2.04, 95% CI 0.94-4.45; P = 0.072) was associated with a higher risk of all-cause death. Hs-cTnI periprocedural MI was not predictive of death unless accompanied by CK-MB criteria (adjusted HR 4.64, 95% CI 1.32-16.31; P = 0.017).

CONCLUSION

In the setting of elective PCI, using hs-cTn instead of CK-MB resulted in a substantial increase in SCAI periprocedural MI events, which were not prognostically relevant in the absence of concurrent CK-MB elevations.

Rationale and design of the PARTHENOPE trial: A two-by-two factorial comparison of polymer-free vs biodegradable-polymer drug-eluting stents and personalized vs standard duration of dual antiplatelet therapy in all-comers undergoing PCI

BACKGROUND

Over the past few decades, percutaneous coronary intervention (PCI) has undergone significant advancements as a result of the combination of device-based and drug-based therapies. These iterations have led to the development of polymer-free drug-eluting stents. However, there is a scarcity of data regarding their clinical performance. Furthermore, while various risk scores have been proposed to determine the optimal duration of dual antiplatelet therapy (DAPT), none of them have undergone prospective validation within the context of randomized trials.

DESIGN

The PARTHENOPE trial is a phase IV, prospective, randomized, multicenter, investigator-initiated, assessor-blind study being conducted at 14 centers in Italy (NCT04135989). It includes 2,107 all-comers patients with minimal exclusion criteria, randomly assigned in a 2-by-2 design to receive either the Cre8 amphilimus-eluting stent or the SYNERGY everolimus-eluting stent, along with either a personalized or standard duration of DAPT. Personalized DAPT duration is determined by the DAPT score, which accounts for both bleeding and ischemic risks. Patients with a DAPT score <2 (indicating higher bleeding than ischemic risk) receive DAPT for 3 or 6 months for chronic or acute coronary syndrome, respectively, while patients with a DAPT score ≥2 (indicating higher ischemic than bleeding risk) receive DAPT for 24 months. Patients in the standard DAPT group receive DAPT for 12 months. The trial aims to establish the noninferiority between stents with respect to a device-oriented composite end point of cardiovascular death, target-vessel myocardial infarction, or clinically-driven target-lesion revascularization at 12 months after PCI. Additionally, the trial aims to demonstrate the superiority of personalized DAPT compared to a standard approach with respect to a net clinical composite of all-cause death, any myocardial infarction, stroke, urgent target-vessel revascularization, or type 2 to 5 bleeding according to the Bleeding Academic Research Consortium criteria at 24-months after PCI.

SUMMARY

The PARTHENOPE trial is the largest randomized trial investigating the efficacy and safety of a polymer-free DES with a reservoir technology for drug-release and the first trial evaluating a personalized duration of DAPT based on the DAPT score. The study results will provide novel insights into the optimizing the use of drug-eluting stents and DAPT in patients undergoing PCI.

Lp(a) in the Pathogenesis of Aortic Stenosis and Approach to Therapy with Antisense Oligonucleotides or Short Interfering RNA

To date, no medical therapy can slow the progression of aortic stenosis. Fibrocalcific stenosis is the most frequent form in the general population and affects about 6% of the elderly population. Over the years, diagnosis has evolved thanks to echocardiography and computed tomography assessments. The application of artificial intelligence to electrocardiography could further implement early diagnosis. Patients with severe aortic stenosis, especially symptomatic patients, have valve repair as their only therapeutic option by surgical or percutaneous technique (TAVI). The discovery that the pathogenetic mechanism of aortic stenosis is similar to the atherosclerosis process has made it possible to evaluate the hypothesis of medical therapy for aortic stenosis. Several drugs have been tested to reduce low-density lipoprotein (LDL) and lipoprotein(a) (Lp(a)) levels, inflammation, and calcification. The Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9-i) could decrease the progression of aortic stenosis and the requirement for valve implantation. Great interest is related to circulating Lp(a) levels as causally linked to degenerative aortic stenosis. New therapies with ASO (antisense oligonucleotides) and siRNA (small interfering RNA) are currently being tested. Olpasiran and pelacarsen reduce circulating Lp(a) levels by 85-90%. Phase 3 studies are underway to evaluate the effect of these drugs on cardiovascular events (cardiovascular death, non-fatal myocardial injury, and non-fatal stroke) in patients with elevated Lp(a) and CVD (cardiovascular diseases). For instance, if a reduction in Lp(a) levels is associated with aortic stenosis prevention or progression, further prospective clinical trials are warranted to confirm this observation in this high-risk population.

Platelet Inhibition with Ticagrelor 60 mg Versus 90 mg Twice Daily in Elderly Patients with Acute Coronary Syndrome: Rationale and Design of the PLINY THE ELDER Trial

BACKGROUND

Elderly status is steadily increasing among patients with acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 receptor inhibitor is the cornerstone of treatment to prevent recurrent thrombotic complications in patients with ACS. However, DAPT in older patients is challenged by a concurrent heightened risk of ischemia and bleeding. The aim of this study is to evaluate the pharmacodynamic and pharmacokinetic profile of a lower dose of ticagrelor (60 mg twice daily) among elderly patients during the early phase of ACS.

STUDY DESIGN

PLINY THE ELDER (PLatelet INhibition with two different doses of potent P2y12 inhibitors in THE ELDERly population) (NCT04739384) is a prospective, randomized, open-label, crossover trial to evaluate the non-inferiority of a lower dose of ticagrelor (60 mg twice daily) compared with a standard dose (90 mg twice daily) among elderly patients with ACS undergoing percutaneous coronary intervention (PCI). A total of 50 patients, aged 75 years or more, with indication to potent P2Y12 receptor inhibitors will be randomized within 3 days from PCI for the index ACS. Patients with indication to oral anticoagulant therapy, treatment with glycoprotein IIb/IIIa inhibitors, or active bleeding will be excluded. The primary endpoint is platelet reactivity determined by P2Y12 reaction units (PRU) (VerifyNow, Accumetrics, San Diego, CA, USA) after treatment with ticagrelor 60 or 90 mg twice daily for 14 days. Secondary endpoints will include other pharmacodynamic tests of ADP-induced aggregation (light transmittance aggregometry and multiple electrode aggregometry) and determination of pharmacokinetic profile (plasma levels of ticagrelor and its metabolite AR-C124910XX) by high performance liquid chromatography-tandem mass spectrometry.

CONCLUSIONS

The PLINY THE ELDER trial will determine whether a lower dose of ticagrelor confers non-inferior platelet inhibition compared with the standard dose in the early phase of ACS among elderly patients undergoing PCI, informing future clinical investigation.

Comparison of different percutaneous revascularisation timing strategies in patients undergoing transcatheter aortic valve implantation

BACKGROUND

The optimal timing to perform percutaneous coronary interventions (PCI) in transcatheter aortic valve implantation (TAVI) patients remains unknown.

AIMS

We sought to compare different PCI timing strategies in TAVI patients.

METHODS

The REVASC-TAVI registry is an international registry including patients undergoing TAVI with significant, stable coronary artery disease (CAD) at preprocedural workup. In this analysis, patients scheduled to undergo PCI before, after or concomitantly with TAVI were included. The main endpoints were all-cause death and a composite of all-cause death, stroke, myocardial infarction (MI) or rehospitalisation for congestive heart failure (CHF) at 2 years. Outcomes were adjusted using the inverse probability treatment weighting (IPTW) method.

RESULTS

A total of 1,603 patients were included. PCI was performed before, after or concomitantly with TAVI in 65.6% (n=1,052), 9.8% (n=157) or 24.6% (n=394), respectively. At 2 years, all-cause death was significantly lower in patients undergoing PCI after TAVI as compared with PCI before or concomitantly with TAVI (6.8% vs 20.1% vs 20.6%; p<0.001). Likewise, the composite endpoint was significantly lower in patients undergoing PCI after TAVI as compared with PCI before or concomitantly with TAVI (17.4% vs 30.4% vs 30.0%; p=0.003). Results were confirmed at landmark analyses considering events from 0 to 30 days and from 31 to 720 days.

CONCLUSIONS

In patients with severe aortic stenosis and stable coronary artery disease scheduled for TAVI, performance of PCI after TAVI seems to be associated with improved 2-year clinical outcomes compared with other revascularisation timing strategies. These results need to be confirmed in randomised clinical trials.

Renin-angiotensin system inhibitors reduce cardiovascular mortality in hypertensive patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: insights from the EffecTAVI registry

Objectives

Arterial hypertension is associated with the triggering of the renin-angiotensin system, leading to left ventricle fibrosis and worse cardiovascular outcomes. In this study, patients with comorbid arterial hypertension and severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) were selected from the EffecTAVI registry to evaluate the impact of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) on cardiovascular mortality.

Methods

We enrolled 327 patients undergoing TAVI from the EffecTAVI registry. Using Kaplan-Meier event rates and study-stratified multivariable Cox proportional hazards regression models, we evaluated 2-year clinical outcomes according to the ACEI/ARB therapy status at enrollment.

Results

Among the included patients, 222 (67.9%) were on ACEIs/ARBs at baseline, whereas 105 (32.1%) were not. Treatment with ACEIs/ARBs was significantly associated with a 2-year decrease in the rate of cardiovascular mortality (HR = 0.44, 95% CI: 0.23-0.81, p = 0.009). This association remained stable after both multivariable adjustment and propensity score matching.

Conclusion

In a cohort of hypertensive patients with severe AS who were selected from the EffecTAVI registry, ACEI/ARB treatment at baseline was found to be independently associated with a lower risk of 2-year cardiovascular mortality, suggesting a potential benefit of this treatment. More trials are needed to validate this finding and to understand the full benefit of this treatment.

Echocardiographic Evaluation of Aortic Stenosis: A Comprehensive Review

Echocardiography represents the most important diagnostic tool in the evaluation of aortic stenosis. The echocardiographic assessment of its severity should always be performed through a standardized and stepwise approach in order to achieve a comprehensive evaluation. The latest technical innovations in the field of echocardiography have improved diagnostic accuracy, guaranteeing a better and more detailed evaluation of aortic valve anatomy. An early diagnosis is of utmost importance since it shortens treatment delays and improves patient outcomes. Echocardiography plays a key role also in the evaluation of all the structural changes related to aortic stenosis. Detailed evaluation of subtle and subclinical changes in left ventricle function has a prognostic significance: scientific efforts have been addressed to identify the most accurate global longitudinal strain cut-off value able to predict adverse outcomes. Moreover, in recent years the role of artificial intelligence is increasingly emerging as a promising tool able to assist cardiologists in aortic stenosis screening and diagnosis, especially by reducing the rate of aortic stenosis misdiagnosis.

Biolimus-eluting vs. other limus-eluting stents in NSTE-ACS: A pooled analysis of GLASSY and TWILIGHT

BACKGROUND

Biodegradable polymer biolimus-eluting stents (BP-BES) may be associated with better outcomes in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) compared to other current-generation limus-eluting stents (LES).

AIMS

To compare BP-BES with other current-generation LES in ACS patients undergoing PCI.

METHODS

We pooled individual data of Non-ST-segment elevation (NSTE)-ACS patients from two large randomized controlled trials (GLASSY and TWILIGHT). The BP-BES groups consisted mostly of GLASSY patients, while the control group (other current-generation LES) included exclusively TWILIGHT patients. The primary outcome was major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, or stent thrombosis; the key secondary outcome was target-vessel failure (TVF). To account for trial design differences, outcomes were assessed at 3 months (short-term) and between 3 and 12 months (long-term) after PCI and subsequently pooled to estimate the 12-month hazards.

RESULTS

Of 7107 and 6053 NSTE-ACS patients included in the short- and long-term analysis, 32.7% and 36.5% received a BP-BES, respectively. Risk of MACE associated with BP-BES versus other LES was similar at short-term (1.1% vs 1.3%, adjusted HR 0.86, 95%CI 0.53-1.38), lower at long-term (1.7% vs 3.1%, adjusted HR 0.49, 95%CI 0.34-0.72), and lower in the entire 12-month period (pooled adjusted HR 0.61, 95%CI 0.45-0.82). The cumulative 12-month risk of TVF was reduced with BP-BES (adjusted HR 0.52, 95%CI 0.38-0.70).

CONCLUSION

BP-BES was associated with lower 12-month risks of MACE and TVF compared to other current generation LES among NSTE-ACS patients treated with abbreviated or standard ticagrelor-based DAPT. These non-randomized findings are hypothesis-generating.

CONDENSED ABSTRACT

Differences in clinical outcomes may exist between biodegradable polymer biolimus-eluting stents (BP-BES) and other current-generation limus-eluting stent (LES) in patients with acute coronary syndrome (ACS). We pooled individual data of about 7000 Non-ST-segment elevation ACS patients undergoing PCI and treated with ticagrelor with or without aspirin from two large randomized controlled trials (GLASSY and TWILIGHT). BP-BES patients derived very largely from GLASSY and other LES patients from TWILIGHT. In this population, BP-BES compared to other current generation LES, were associated with a lower 12-month risk of major adverse cardiovascular events and target-vessel failure.

P2Y12 Inhibitor or Aspirin Monotherapy for Secondary Prevention of Coronary Events

BACKGROUND

Aspirin is the only antiplatelet agent with a Class I recommendation for long-term prevention of cardiovascular events in patients with coronary artery disease (CAD). There is inconsistent evidence on how it compares with alternative antiplatelet agents.

OBJECTIVES

This study compared P2Y12 inhibitor monotherapy vs aspirin in patients with CAD.

METHODS

We conducted a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy vs aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction, and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (the composite of the primary outcome and major bleeding). Data were pooled in a 1-step meta-analysis.

RESULTS

Patient-level data were obtained from 7 trials. Overall, 24,325 participants were available for analysis, including 12,178 patients assigned to receive P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 assigned to receive aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (HR: 0.88; 95% CI: 0.79-0.97; P = 0.012), mainly owing to less myocardial infarction (HR: 0.77; 95% CI: 0.66-0.90; P < 0.001). Major bleeding was similar (HR: 0.87; 95% CI: 0.70-1.09; P = 0.23) and net adverse clinical events were lower (HR: 0.89; 95% CI: 0.81-0.98; P = 0.020) with P2Y12 inhibitors. The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitors.

CONCLUSIONS

Given its superior efficacy and similar overall safety, P2Y12 inhibitor monotherapy might be preferred over aspirin monotherapy for long-term secondary prevention in patients with established CAD. (P2Y12 Inhibitor or Aspirin Monotherapy as Secondary Prevention in Patients With Coronary Artery Disease: An Individual Patient Data Meta-Analysis of Randomized Trials [PANTHER collaborative initiative]; CRD42021290774).

Periprocedural myocardial infarction in patients undergoing complex versus noncomplex percutaneous coronary intervention

BACKGROUND

Limited data are available on the risk of periprocedural myocardial infarction (MI) in patients undergoing complex versus noncomplex percutaneous coronary intervention (PCI).

METHODS

We assessed the risk of periprocedural MI according to the fourth Universal definition of myocardial infarction (UDMI) and several other criteria among patients undergoing elective PCI in a prospective, single-center registry. Complex PCI included at least one of the following: 3 coronary vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, treatment of chronic total occlusion, and use of rotational atherectomy.

RESULTS

Between 2017 and 2021, we included 1010 patients with chronic coronary syndrome, of whom 226 underwent complex PCI (22.4%). The rate of periprocedural MI according to the fourth UDMI was significantly higher in complex compared to noncomplex PCI patients (26.5% vs. 14.5%, p < 0.001). Additionally, periprocedural MI was higher in the complex PCI group using SCAI (4% vs. 1.1%, p = 0.009), ARC-2 (13.7% vs. 8.0%, p = 0.013), ISCHEMIA (5.8% vs. 1.7%, p = 0.002), and EXCEL criteria (4.9% vs. 2.0%, p = 0.032). SYNTAX periprocedural MI occurred at low rates in both groups (0.9% vs. 0.6%, p = 0.657). Complex PCI was an independent predictor of the fourth UDMI periprocedural MI (odds ratio [OR] 1.54, 95% confidence interval [CI]: 1.04-2.27, p = 0.031).

CONCLUSIONS

In patients with chronic coronary syndrome undergoing elective PCI, complex PCI is associated with a significantly higher risk of periprocedural MI using multiple definitions. These findings highlight the importance of considering upfront this risk in the planning of complex PCI procedures.

Impact of Preprocedural Computed Tomography on Left Atrial Appendage Closure Success: A Swiss-Apero Trial Subanalysis

BACKGROUND

The benefit related to the use of preprocedural computed tomography angiography (CCTA) on top of periprocedural echocardiography to plan percutaneous left atrial appendage closure (LAAC) procedures is still unclear.

OBJECTIVES

The authors sought to evaluate the impact of preprocedural CCTA on LAAC procedural success.

METHODS

In the investigator-initiated SWISS-APERO (Comparison of Amplatzer Amulet and Watchman Device in Patients Undergoing Left Atrial Appendage Closure) trial, patients undergoing echocardiography-guided LAAC were randomly assigned to receive the Amulet (Abbott) or Watchman 2.5/FLX (Boston Scientific) device across 8 European centers. According to the study protocol ongoing at the time of the procedure, the first operators had (CCTA unblinded group) or did not have (CCTA blinded group) access to preprocedural CCTA images. In this post hoc analysis, we compared blinded vs unblinded procedures in terms of procedural success defined as complete left atrial appendage occlusion as evaluated at the end of LAAC (short-term) or at the 45-day follow-up (long-term) without procedural-related complications.

RESULTS

Among 219 LAACs preceded by CCTA, 92 (42.1%) and 127 (57.9%) were assigned to the CCTA unblinded and blinded group, respectively. After adjusting for confounders, operator unblinding to preprocedural CCTA remained associated with a higher rate of short-term procedural success (93.5% vs 81.1%; P = 0.009; adjusted OR: 2.76; 95% CI: 1.05-7.29; P = 0.040) and long-term procedural success (83.7% vs 72.4%; P = 0.050; adjusted OR: 2.12; 95% CI: 1.03-4.35; P = 0.041).

CONCLUSIONS

In a prospective multicenter cohort of clinically indicated echocardiography-guided LAACs, unblinding of the first operators to preprocedural CCTA images was independently associated with a higher rate of both short- and long-term procedural success. Further studies are needed to better evaluate the impact of preprocedural CCTA on clinical outcomes.

Myocardial Injury After Transcatheter Aortic Valve Replacement According to VARC-3 Criteria

BACKGROUND

The Valve Academic Research Consortium (VARC)-3 definition for myocardial injury after transcatheter aortic valve replacement (TAVR) lacks of clinical validation.

OBJECTIVES

This study sought to determine the incidence, predictors, and clinical impact of periprocedural myocardial injury (PPMI) following TAVR as defined by recent VARC-3 criteria.

METHODS

We included 1,394 consecutive patients who underwent TAVR with a new-generation transcatheter heart valve. High-sensitivity troponin levels were assessed at baseline and within 24 hours after the procedure. PPMI was defined according to VARC-3 criteria as an increase ≥70 times in troponin levels (vs ≥15 times according to the VARC-2 definition). Baseline, procedural, and follow-up data were prospectively collected.

RESULTS

PPMI was diagnosed in 193 (14.0%) patients. Female sex and peripheral artery disease were independent predictors of PPMI (P < 0.01 for both). PPMI was associated with a higher risk of mortality at 30-day (HR: 2.69, 95% CI: 1.50-4.82; P = 0.001) and 1-year (for all-cause mortality, HR: 1.54; 95% CI: 1.04-2.27; P = 0.032; for cardiovascular mortality, HR: 3.04; 95% CI: 1.68-5.50; P < 0.001) follow-up. PPMI according to VARC-2 criteria had no impact on mortality.

CONCLUSIONS

About 1 out of 10 patients undergoing TAVR in the contemporary era had PPMI as defined by recent VARC-3 criteria, and baseline factors like female sex and peripheral artery disease determined an increased risk. PPMI had a negative impact on early and late survival. Further studies on the prevention of PPMI post-TAVR and implementing measures to improve outcomes in PPMI patients are warranted.

Hemodynamic Performance of Transcatheter Aortic Valves: A Comprehensive Review

Transcatheter aortic valve implantation (TAVI) is a widely adopted treatment option for patients with severe aortic stenosis. Its popularity has grown significantly in recent years due to advancements in technology and imaging. As TAVI use is increasingly expanded to younger patients, the need for long-term assessment and durability becomes paramount. This review aims to provide an overview of the diagnostic tools to evaluate the hemodynamic performance of aortic prosthesis, with a special focus on the comparison between transcatheter and surgical aortic valves and between self-expandable and balloon-expandable valves. Moreover, the discussion will encompass how cardiovascular imaging can effectively detect long-term structural valve deterioration.

Is There Still a Role for Invasive Assessment of Aortic Gradient?

Advances in technology and imaging have expanded the range of tools for diagnosing aortic stenosis (AS). The accurate assessment of aortic valve area and mean pressure gradient is crucial to determine which patients are appropriate candidates for aortic valve replacement. Nowadays, these values can be obtained noninvasively or invasively, with similar results. Contrariwise, in the past, cardiac catheterization played a major role in the evaluation of AS severity. In this review, we will discuss the historical role of the invasive assessment of AS. Moreover, we will specifically focus on tips and tricks for properly performing cardiac catheterization in patients with AS. We will also elucidate the role of invasive methods in current clinical practice and their additional value to the information provided through non-invasive techniques.

Echocardiographic Evaluation after Transcatheter Aortic Valve Implantation: A Comprehensive Review

Transcatheter aortic valve implantation (TAVI) is an increasingly popular treatment option for patients with severe aortic stenosis. Recent advancements in technology and imaging tools have significantly contributed to the success of TAVI procedures. Echocardiography plays a pivotal role in the evaluation of TAVI patients, both before and after the procedure. This review aims to provide an overview of the most recent technical advancements in echocardiography and their use in the follow-up of TAVI patients. In particular, the focus will be on the examination of the influence of TAVI on left and right ventricular function, which is frequently accompanied by other structural and functional alterations. Echocardiography has proven to be key also in detecting valve deterioration during extended follow-up. This review will provide valuable insights into the technical advancements in echocardiography and their role in the follow-up of TAVI patients.

Acute advanced aortic stenosis

Acute decompensation often represents the onset of symptoms associated with severe degenerative aortic stenosis (AS) and usually complicates the clinical course of the disease with a dismal impact on survival and quality of life. Several factors may derange the faint balance between left ventricular preload and afterload and precipitate the occurrence of symptoms and signs of acute heart failure (HF). A standardized approach for the management of this condition is currently lacking. Medical therapy finds very limited application in this setting, as drugs usually indicated for the control of acute HF might worsen hemodynamics in the presence of AS. Urgent aortic valve replacement is usually performed by transcatheter than surgical approach whereas, over the last decades, percutaneous balloon valvuloplasty gained renewed space as bridge to definitive therapy. This review focuses on the pathophysiological aspects of acute advanced AS and summarizes current evidence on its management.

Antithrombotic Therapy in Peripheral Artery Disease: Current Evidence and Future Directions

Patients with peripheral artery disease (PAD) are at an increased risk of major adverse cardiovascular events, and those with disease in the lower extremities are at risk of major adverse limb events primarily driven by atherothrombosis. Traditionally, PAD refers to diseases of the arteries outside of the coronary circulation, including carotid, visceral and lower extremity peripheral artery disease, and the heterogeneity of PAD patients is represented by different atherothrombotic pathophysiology, clinical features and related antithrombotic strategies. The risk in this diverse population includes systemic risk of cardiovascular events as well as risk related to the diseased territory (e.g., artery to artery embolic stroke for patients with carotid disease, lower extremity artery to artery embolism and atherothrombosis in patients with lower extremity disease). Moreover, until the last decade, clinical data on antithrombotic management of PAD patients have been drawn from subanalyses of randomized clinical trials addressing patients affected by coronary artery disease. The high prevalence and related poor prognosis in PAD patients highlight the pivotal role of tailored antithrombotic therapy in patients affected by cerebrovascular, aortic and lower extremity peripheral artery disease. Thus, the proper assessment of thrombotic and hemorrhagic risk in patients with PAD represents a key clinical challenge that must be met to permit the optimal antithrombotic prescription for the various clinical settings in daily practice. The aim of this updated review is to analyze different features of atherothrombotic disease as well as current evidence of antithrombotic management in asymptomatic and secondary prevention in PAD patients according to each arterial bed.

Management of Non-Culprit Lesions in STEMI Patients with Multivessel Disease

Multivessel disease is observed in approximately 50% of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Data from randomized clinical trials has shown that complete revascularization in the STEMI setting improves clinical outcomes by reducing the risk of reinfarction and urgent revascularization. However, the timing and modality of revascularization of non-culprit lesions are still debated. PCI of non-culprit lesions can be performed during the index primary PCI or as a staged procedure and can be guided by angiography, functional assessment, or intracoronary imaging. In this review, we summarize the available evidence about the management of non-culprit lesions in STEMI patients with or without cardiogenic shock.

Dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials

AIMS

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) is still debated. The current study, using the totality of existing evidence, evaluated the impact of an abbreviated DAPT regimen in HBR patients.

METHODS AND RESULTS

A systematic review and meta-analysis was performed to search randomized clinical trials comparing abbreviated [i.e. very-short (1 month) or short (3 months)] with standard (≥6 months) DAPT in HBR patients without indication for oral anticoagulation. A total of 11 trials, including 9006 HBR patients, were included. Abbreviated DAPT reduced major or clinically relevant non-major bleeding [risk ratio (RR): 0.76, 95% confidence interval (CI): 0.61-0.94; I2 = 28%], major bleeding (RR: 0.80, 95% CI: 0.64-0.99, I2 = 0%), and cardiovascular mortality (RR: 0.79, 95% CI: 0.65-0.95, I2 = 0%) compared with standard DAPT. No difference in all-cause mortality, major adverse cardiovascular events, myocardial infarction, or stent thrombosis was observed. Results were consistent, irrespective of HBR definition and clinical presentation.

CONCLUSION

In HBR patients undergoing PCI, a 1- or 3-month abbreviated DAPT regimen was associated with lower bleeding and cardiovascular mortality, without increasing ischaemic events, compared with a ≥6-month DAPT regimen.

STUDY REGISTRATION

PROSPERO registration number CRD42021284004.

P2Y12 Inhibitor Monotherapy or Dual Antiplatelet Therapy After Complex Percutaneous Coronary Interventions

BACKGROUND

It remains unclear whether P2Y₁₂ inhibitor monotherapy preserves ischemic protection while limiting bleeding risk compared with dual antiplatelet therapy (DAPT) after complex percutaneous coronary intervention (PCI).

OBJECTIVES

We sought to assess the effects of P2Y₁₂ inhibitor monotherapy after 1-month to 3-month DAPT vs standard DAPT in relation to PCI complexity.

METHODS

We pooled patient-level data from randomized controlled trials comparing P2Y₁₂ inhibitor monotherapy and standard DAPT on centrally adjudicated outcomes after coronary revascularization. Complex PCI was defined as any of 6 criteria: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, or chronic total occlusion. The primary efficacy endpoint was all-cause mortality, myocardial infarction, and stroke. The key safety endpoint was Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding.

RESULTS

Of 22,941 patients undergoing PCI from 5 trials, 4,685 (20.4%) with complex PCI had higher rates of ischemic events. The primary efficacy endpoint was similar between P2Y₁₂ inhibitor monotherapy and DAPT among patients with complex PCI (HR: 0.87; 95% CI: 0.64-1.19) and noncomplex PCI (HR: 0.91; 95% CI: 0.76-1.09; P_interaction = 0.770). The treatment effect was consistent across all the components of the complex PCI definition. Compared with DAPT, P2Y₁₂ inhibitor monotherapy consistently reduced BARC 3 or 5 bleeding in complex PCI (HR: 0.51; 95% CI: 0.31-0.84) and noncomplex PCI patients (HR: 0.49; 95% CI: 0.37-0.64; P_interaction = 0.920).

CONCLUSIONS

P2Y₁₂ inhibitor monotherapy after 1-month to 3-month DAPT was associated with similar rates of fatal and ischemic events and lower risk of major bleeding compared with standard DAPT, irrespective of PCI complexity. (PROSPERO [P2Y12 Inhibitor Monotherapy Versus Standard Dual Antiplatelet Therapy After Coronary Revascularization: Individual Patient Data Meta-Analysis of Randomized Trials]; CRD42020176853).

Stroke volume index and transvalvular flow rate trajectories in severe aortic stenosis treated with TAVR

AIMS

The prognostic impact of flow trajectories according to stroke volume index (SVi) and transvalvular flow rate (FR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) remains poorly assessed. We evaluated and compared SVi and FR prior and after TAVR for severe AS.

METHODS AND RESULTS

Patients were categorized according to SVi (<35 mL/m2) and FR (<200 mL/s). The association of pre- and post-TAVR SVi and FR with all-cause mortality up to 3 years was assessed with multivariable Cox regression models. Among 980 patients with pre-TAVR flow assessment, SVi was reduced in 41.3% and FR in 48.1%. Baseline flow status was not an independent mortality predictor [SVi: hazard ratio (HR) 1.22, 95% confidence interval (CI) 0.85-1.82, FR: HR 0.78, 95% CI 0.48-1.27]. Among 731 patients undergoing early (5 days, interquartile range 2-29) post-TAVR flow assessment, SVi recovered in 40.1% and FR in 49.0% patients with baseline low flow. Reduced FR following TAVR was an independent predictor of mortality (HR 1.67, 95% CI 1.02-2.74), whereas SVi was not (HR 0.97, 95% CI 0.53-1.78). Three-year estimated mortality in patients with recovered FR was lower than that in patients with reduced FR (13.3 vs. 37.7% vs, P = 0.003) and similar to that in patients with normal baseline FR (P = 0.317).

CONCLUSION

Baseline flow status was not an independent predictor of mid-term mortality among all-comers with severe AS undergoing TAVR. Flow recovery early after TAVR was frequent. Post-TAVR FR, but not SVi, was independently associated with mid-term all-cause mortality. By impacting flow status, AV replacement modifies the association of flow status with outcomes.

P2Y12 Inhibitors Monotherapy in Patients Undergoing Complex vs Non-Complex Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Trials

BACKGROUND

Monotherapy with P2Y12 inhibitors (P2Y12i) is emerging as alternative strategy to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). However, early withdrawal of aspirin as part of P2Y12i monotherapy regimens may pose concerns in high-risk patients, such as those undergoing complex PCI. Our aim was to evaluate the efficacy and safety of P2Y12i monotherapy after a short course of DAPT (1-3-month) compared with standard DAPT (≥12-month) according to PCI complexity.

METHODS

We performed a meta-analysis of randomized trials using random effects models to combine hazard ratios (HRs) with 95% confidence intervals (CIs). Within-trial interactions were pooled to estimate heterogeneity between complex and noncomplex PCI strata. The study protocol was registered in the PROSPERO (CRD42021291027).

RESULTS

We identified 5 trials including 31,627 patients, of whom 8,328 (26.3%) underwent complex PCI. P2Y12i monotherapy compared with standard DAPT was associated with a similar risk of all-cause death, stent thrombosis, and stroke, with no evidence for interaction between complex and noncomplex PCI. We found heterogeneity in the treatment effect of P2Y12i monotherapy vs standard DAPT with respect to myocardial infarction (P-interaction = 0.027). Compared with standard DAPT, P2Y12i monotherapy decreased the risk of myocardial infarction in complex PCI (HR 0.77, 95%CI 0.60-0.99, P = .042), but not in noncomplex PCI patients (HR 1.09, 95%CI 0.90-1.30, P = .382). The risk of major bleeding was significantly reduced by P2Y12i monotherapy with a consistent treatment effect (P-interaction = 0.699) in both complex and noncomplex PCI strata.

CONCLUSIONS

Patients undergoing complex PCI may derive more benefit and less harm from P2Y12i monotherapy after early aspirin withdrawal compared with standard DAPT.

Myocardial mass affects diagnostic performance of non-hyperemic pressure-derived indexes in the assessment of coronary stenosis

Background Several non-hyperemic pressure-derived Indexes (NHPI) have been introduced for the assessment of coronary stenosis, showing a good correlation with fractional flow reserve (FFR). Notably, either the assessment of NHPI during adenosine administration (NHPI_ADO) or the Hybrid Approach (NHPI_HA), combining NHPI with FFR, have been showed to increase the accuracy of such indexes. It remains unclear whether diagnostic performance might be affected by the extent of the subtended myocardial mass.

METHODS

We enrolled consecutive patients with an intermediate coronary stenosis assessed with NHPI and FFR. NHPI were also measured during adenosine (ADO) administration (NHPI_ADO). The amount of jeopardized myocardium was assessed using the Duke Jeopardy Score (DJS). With FFR as reference, we assessed the accuracy of NHPI, NHPI_ADO and NHPI_HA according to the extent of the subtended myocardium.

RESULTS

One-hundred-seventy stenoses from 151 patients were grouped according to the DJS as follows: A) Small Extent (SE, n = 82); B) Moderate Extent (ME, n = 53); C) Large Extent (LE, n = 35). As compared with FFR, NHPI showed a significantly different accuracy, as assessed by the Youden's index, according to the extent of the jeopardized myocardium (SE: 0.39 ± 0.05, ME: 0.68 ± 0.06, LE: 0.28 ± 0.06, p < 0.001). Conversely, both the NHPI_ADO (SE: 0.76 ± 0.02, ME: 0.88 ± 0.02, LE: 0.82 ± 0.02, p = 0.72) and NHPI_HA (SE: 0.82 ± 0.07, ME: 0.84 ± 0.02, LE: 0.88 ± 0.02, p = 0.70) allowed for a better diagnostic accuracy regardless of the amount of myocardium subtended.

CONCLUSIONS

Diagnostic performance of NHPI might be affected by the extent of myocardial territory subtended by the coronary stenosis. A hybrid approach might be useful to overcome this limitation.

1005 STROKE VOLUME INDEX AND TRANSVALVULAR FLOW RATE TRAJECTORIES IN SEVERE AORTIC STENOSIS TREATED WITH TAVR

Aims

The prognostic impact of flow trajectories according to stroke volume index (SVi) and transvalvular flow rate (FR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) remains poorly assessed. We evaluated and compared SVi and FR prior and after TAVR for severe AS.

Methods and results

Patients were categorized according to SVi (&lt;35 ml/m2) and FR (&lt;200 ml/sec). The association of pre- and post-TAVR SVi and FR with all-cause mortality up to 3 years was assessed with multivariable Cox regression models. Among 980 patients with pre-TAVR flow assessment, SVi was reduced in 41.3% and FR in 48.1%. Baseline flow status was not an independent mortality predictor (SVi: HR 1.39, 95%CI 0.81-2.40, FR: HR 0.86, 95%CI 0.51-1.46). Among 731 patients undergoing early (5 days, IQR 2-29) post-TAVR flow assessment, SVi recovered in 40.1% and FR in 49.0% patients with baseline low-flow. Reduced FR following TAVR was an independent predictor of mortality (HR 2.08, 95%CI 1.07-4.04) while SVi was not (HR 0.68, 95%CI 0.34-1.36). Three-year estimated mortality in patients with recovered FR was lower as compared to patients with reduced FR (13.3% vs 37.7% vs, p=0.003) and similar to patients with normal baseline FR (p=0.317).

Conclusions

Baseline flow status was not an independent predictor of mid-term mortality among all-comers with severe AS undergoing TAVR. Flow recovery early after TAVR was frequent. Post-TAVR FR, but not SVi, was independently associated with mid-term all-cause mortality. By impacting flow status, AV replacement modifies the association of flow status with outcomes.

689 IMPACT OF RENIN-ANGIOTENSIN SYSTEM INHIBITORS ON CLINICAL OUTCOME IN HYPERTENSIVE PATIENTS WITH SEVERE AORTIC STENOSIS UNDERGOING TRANSCATHETER AORTIC VALVE IMPLANTATION: INSIGHT FROM THE EFFECTAVI REGISTRY

Aims

Left ventricular pressure overload is connected with cardiac renin–angiotensin system activation, which may lead to myocardial fibrosis and poorer clinical outcomes. Hypertensive patients with symptomatic, severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) in the EffecTAVI registry were evaluated for the association between baseline treatment with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) and clinical outcomes.

Methods and results

The research comprised 373 patients with moderate, high, or prohibitive risk who had TAVI in the EffecTAVI registry (NCT05235555). Using Kaplan–Meier event rates and study-stratified multivariable Cox proportional hazards regression models, we evaluated clinical outcomes at 2 years according to ACEi/ARB therapy status at baseline. Among the 327 patients with hypertension included in the present study, 222 (67.9%) were treated with ACEI/ARB at baseline, whereas 105 (32.1%) were not. Treatment with ACEI/ARB was related with decreased all-cause mortality (HR=0.46, 95% CI 0.25-0.90, p=0.011), although this association was not statistically significant after multivariable adjustment for important covariates. Analyzing pre-procedural ACEi and ARBs separately, ARBs administration was related with a 58% decrease in all-cause mortality (HR=0.42, 95% CI 0.18-0.98, p=0.04), which was confirmed in multivariate analysis.

Conclusion

In a small cohort of hypertensive patients with severe symptomatic AS from the EffecTAVI registry, ARBs treatment at baseline was independently associated with a lower risk of 2-year all-cause mortality.

730 P2Y12 INHIBITORS MONOTHERAPY IN PATIENTS UNDERGOING COMPLEX VS NON-COMPLEX PERCUTANEOUS CORONARY INTERVENTION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Monotherapy with P2Y12 inhibitors (P2Y12i) is emerging as alternative strategy to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). However, early withdrawal of aspirin as part of P2Y12i monotherapy regimens may pose concerns in high-risk patients, such as those undergoing complex PCI. Thus, we aimed to evaluate the efficacy and safety of P2Y12i monotherapy compared with standard DAPT according to PCI complexity.

Methods

We performed a meta-analysis of randomized trials using random effects models to combine hazard ratios (HRs) with 95% confidence intervals (CIs). No restrictions were applied to the type of P2Y12 receptor inhibitor or to the definition of complex PCI. Within-trial interactions were pooled to estimate heterogeneity between complex and noncomplex PCI strata. The study protocol was registered in the PROSPERO (CRD42021291027).

Results

After screening of 7,502 unique citations, we included in the analysis 5 randomized clinical trial enrolling 31,627 patients, of whom 8,328 (26.3%) underwent complex PCI (Table 1) Risk estimates for efficacy and safety outcomes associated with P2Y12i monotherapy and standard DAPT across studies included in the analysis, stratified by complex and noncomplex PCI, are reported in Figure 1. P2Y12i monotherapy compared with standard DAPT was associated with a similar risk of all-cause death, stent thrombosis, and stroke, with no evidence for interaction between complex and noncomplex PCI. We found heterogeneity in the treatment effect of P2Y12i monotherapy vs. standard DAPT with respect to myocardial infarction (P-interaction=0.027). Compared with standard DAPT, P2Y12i monotherapy decreased the risk of myocardial infarction in complex PCI (HR 0.77, 95%CI 0.60-0.99, P=0.042), but not in noncomplex PCI patients (HR 1.09, 95%CI 0.90-1.30, P=0.382). The risk of major bleeding was significantly reduced by P2Y12i monotherapy with a consistent treatment effect (P-interaction=0.699) in both complex and noncomplex PCI strata.

Conclusions

Patients undergoing complex PCI may derive more benefit and less harm from P2Y12i monotherapy after early aspirin withdrawal compared with standard DAPT, resulting in decreased risks of myocardial infarction and bleeding.

1019 SAFETY OF PLUG-BASED AND SUTURE-BASED VASCULAR CLOSURE DEVICES IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT: A MULTICENTER OBSERVATIONAL STUDY

Background

Transcatheter aortic valve replacement (TAVR), is the treatment of choice for most patients with aortic stenosis. Transfemoral access remains the most widely used peripheral vascular approach for TAVR and dedicated plug-based or suture-based vascular closure devices are available to achieve femoral hemostasis. However, the comparative safety of such strategies is controversial in patients undergoing transfemoral TAVR.

Objectives

in this study, we aimed to evaluate the rates of vascular access complications according to the use of plug-based or suture-based vascular closure in patients undergoing TAVR.

Methods

Data were retrospectively collected from two high-volume TAVR centers from September 2009 to March 2022. Patients were categorized according to the use of plug-based or suture-based vascular closure devices. The plug-based platform used was MANTA (Teleflex), while the suture-based devices were the Perclose ProGlide™ or the Prostar™ Systems (Abbott Vascular). Baseline demographic, clinical, and echocardiographic variables were compared between these groups using an independent-sample Student's t-test for continuous variables, presented as mean±SD, and the chi-square test for categorical or binary variables, presented as number and percentage, as appropriate. The odds ratio (OR) for vascular complications was calculated using a multivariate logistic regression model including as dependent variables all relevant baseline and procedural characteristics. The closure device variable was included in the multivariate model using the Prostar™ XL device group as reference. Vascular complications were adjudicated according to the Valve Academic Research Consortium definitions 3.

Results

Out of 874 patients, hemostasis was achieved with Prostar™ XL PVS in 120 (13.7%) patients, with Perclose ProGlide™ in 525 (60.1%), and with MANTA 229 (26.2%). No differences in age and common cardiovascular risk factors were observed between the group except for the prevalence of peripheral arterial disease (30.6% vs. 17.0%, p&lt;0.0001) and dyslipidemia (58.9% vs. 68.6%, p=0.01) as well as for the echo and procedural variables except for the Euroscore II that was lower in the plug-based group (6.0±5.6 vs. 5.1±4.68), and for the higher use of new generation devices (79.1% vs. 98.3%, p&lt;0.0001). After adjustment for common cardiovascular risk factors and procedural features, no differences were observed for total vascular complications [OR: 0.68 (95% confidence interval (CI): 0.33 to 1.38) and OR: 0.60 (95% CI: 0.33 to 1.53), for Perclose ProGlide™ and MANTA groups, respectively]. Likewise, no substantial differences were observed for major and minor vascular complications.

Conclusions

Both suture-based and plug-based devices have comparable outcomes with regard to the risk of vascular complications. Further randomized clinical trials are warranted to confirm this observation in high-risk sub-group patients with for example heavily calcified access or obesity.

891 EARLY EVOLUTION OF CARDIAC DAMAGE STAGING FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT: PREVALENCE, CLINICAL PATTERNS AND PROGNOSTIC SIGNIFICANCE

Background

The early evolution of extravalvular cardiac damage following transcatheter aortic valve replacement (TAVR) as assessed by a previous validated score system remains unstudied. We sought to assess the patterns of early cardiac damage change among patients with severe aortic stenosis (AS) undergoing TAVR and its prognostic implications.

Methods

The RECOVERY-TAVR is a multi-center, international retrospective registry including all consecutive patients undergoing TAVR in thirteen high-volume centers. All the enrolled patients with available paired echocardiography assessment pre- and post TAVR were included in this sub-analysis. Patients were categorized according to the extension of cardiac damage based on a previous published and validated classification (stage 0, no damage; stage 1, left ventricular damage; stage 2, left atrial or mitral valve damage; stage 3, pulmonary vasculature or tricuspid valve damage; and stage 4, right ventricular damage). The primary endpoint was a composite of all-cause mortality or first heart failure hospitalization at 1 year. The association of cardiac damage stage evaluated prior and following TAVR along with the staging evolution was assessed with multivariate Cox regression model (that include hemoglobin, NYHA class and max aortic valve gradient) for the primary outcome.

Results

Of 1331 Patients included in the RECOVERY-TAVR registry with a full echocardiographic pre-TAVR assessment, 892 patients with available paired echocardiography exams were finally included in this analysis (pre-TAVR assessment: median 8 days prior to TAVR; post-TAVR assessment: median 7 days post-TAVR). 63 (7.1%) had stage 0/1, 433 (48.2%) had stage 2, 235 (26.3%) had stage 3 and 161 (18%) had stage 4 myocardial damage. Pre-TAVR myocardial damage staging was associated with the primary outcome (Adj-HR for myocardial stage increase: HR 1.40, 95% CI 1.01–1.93). Following TAVR 274 (30.7%) patients experienced myocardial damage improvement and 161 (18.1%) myocardial damage worsening. Post-TAVR myocardial damage staging was more strongly associated with the primary outcome (HR 1.55, 95%CI 1.14–2.10) as compared to pre-TAVR assessment. Male Sex (p = 0.044) and post-procedural permanent pacemaker implantation (p = 0.044) was associated with myocardial damage worsening, while the use of a balloon-expandable valve (p = 0.011) was associated with myocardial damage improvement. Early myocardial damage worsening (HR 1.89, 95%CI 1.12–3.21), but not early myocardial damage improvement (HR 0.86, 95%CI 0.54–1.37) was associated with the primary outcome.

Conclusion

In patients undergoing TAVR, the extent of extravalvular cardiac damage prior to and early after TAVR has an independent prognostic value while early myocardial damage worsening following TAVR portends a poor prognosis. Whether strategies to improve procedural success and treatments addressing extravalvular myocardial damage early following TAVR may improve outcomes has to be prospectively assessed.

893 FUNCTIONAL ASSESSMENT OF INTERMEDIATE CORONARY ARTERY STENOSIS

Background

FFR represents the gold standard to functionally assess the ischemic potential of intermediate coronary artery stenoses particularly in patients presenting with multivessel disease. However, it is still underused in the current practice. Less invasive techniques have been identified for the evaluation of intermediate stenosis. The Quantitative flow ratio (QFR), based on the angiography with 3D-reconstruction of the coronary artery and computational fluid dynamics, has been showed to well correlate with the FFR. The Angiography-DeriveD hEmoDynamic index (ADDED Index) has also been validated to assess the ischemic potential of intermediate coronary stenosis and was also found to well correlate with FFR. It considers the jeopardized subtended myocardium and the minimal lumen diameter calculated at the angiography. This study aimed to compare the ADDED Index with QFR in terms of diagnostic accuracy.

Methods

A retrospective observational study was conducted. We included all patients presenting with an intermediate stenosis assessed with QFR. Both QFR and ADDED Index were calculated. Correlation was studied using Pearson's r test and linear regression. Receiver operator characteristics curve analysis was also performed.

Results

A total of 54 patients presenting with either stable angina or acute coronary syndromes were enrolled and finally 62 intermediate stenoses were included. A significant correlation between the ADDED Index and QFR was found (r2=0,32, p &lt;0.001) (Figure 1). At ROC analysis, and with the QFR as reference, the ADDED Index showed a significant and very high area under the curve (0.99 (0.99-1.00), p&lt;0.001), Figure 2) suggesting the high accuracy for the assessment of the ischemic potential of intermediate coronary artery stenoses.

Conclusion

ADDED Index was found similar to the QFR in terms of accuracy for the functional assessment of intermediate coronary artery stenoses.

351 MULTIPLE PHARMACODYNAMIC ASSESSMENTS OF CANGRELOR EFFECTS IN ELECTIVE COMPLEX PCI: DATA FROM PHARMACODYNAMIC EFFECTS OF CANGRELOR IN PATIENTS WITH ACUTE OR CHRONIC CORONARY SYNDROME UNDERGOING PERCUTANEOUS CORONARY INTERVENTION REGISTRY

Aims

Complex percutaneous coronary intervention (PCI) patients have greater risk of peri-procedural complications, with potential to be associated with poor short-term and late prognosis. Cangrelor is an intravenous P2Y12 receptor inhibitor characterized by rapid onset and offset effect of platelet inhibition which reduced the risk of thrombotic complications. Cangrelor use is currently approved in patients naïve from oral P2Y12 inhibitors with chronic (CCS) or acute coronary syndrome (ACS) undergoing PCI with a IIb recommendation by European guidelines. Yet, the process of switching from cangrelor to oral P2Y12 inhibitor remains uncertain.

Methods and Results

POMPEII study (NCT04790032) is a prospective registry conducted at Federico II University of Naples enrolling all patients undergoing PCI and receiving cangrelor administration. Pharmacodynamic (PD) assessments were performed at baseline, at 30 minutes, 3 hours and 4-6 hours after cangrelor initiation with 3 assays: 1) the gold standard light transmittance aggregometry (LTA) (20- and 5-µM adenosine diphosphate [ADP] stimuli); 2) VerifyNow P2Y12-test; 3) Multiplate electrode aggregometry (MEA), ADP-test. We enrolled 41 patients undergoing elective complex PCI. All patients were P2Y12 inhibitor naïve and received aspirin, unfractionated heparin, and cangrelor (30-µg/kg bolus followed by 4-µg/kg/min infusion for 2 hours) prior to the start of PCI per standard of care. All patients showed low P2Y12 reactivity at 30 minutes during cangrelor infusion with a mean inhibition of platelet aggregation (IPA, %) of 55.7±18.0% at LTA 20-µM ADP test (34% with IPA ≤50%, 19.5% with IPA≥70%, 4.9% with IPA ≥80% and none IPA ≥90%). High residual platelet reactivity (HRPR) was observed in 1 case (2.4%) as shown by LTA (both 20- and 5-µM ADP stimuli) but not confirmed by VerifyNow and MEA. HRPR was observed in 55% at at 3h and 22.5% at 4-6h at LTA 20-µM and consistently with other assays. All patients with HRPR after cangrelor stop had received clopidogrel as switching drug, while no HRPR was observed in the 4 patients switching to ticagrelor.

Conclusions

Cangrelor showed to be effective and safe in patients undergoing complex PCI at high thrombotic risk. The switch from cangrelor to clopidogrel could expose patients to a variable period of on-treatment HRPR with inadequate platelet inhibition probably due to the fast offset of cangrelor effect and delay of oral drug effect, while the use of ticagrelor soon after cangrelor start might be ideal to cover the gap. This might be of relevance in such a delicate clinical setting.

869 SUCCESSFUL TREATMENT OF COMBINED ANNULAR RUPTURE DURING TRANSCATHETER AORTIC VALVE IMPLANTATION: A CASE REPORT

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with severe, symptomatic aortic stenosis. Despite being less invasive than conventional open-chest surgery, TAVI remains associated with rare but serious complications such as vascular injury, stroke, coronary obstruction, cardiac perforation and annular rupture. We report a case of a combined annular rupture successful treated by emergent surgery. Case presentation: A low-risk (EuroSCORE:1.14%) 73-year-old male presenting with high-gradient, normal-flow severe aortic stenosis (AS) was referred to our centre. He had preserved left ventricular ejection fraction and heavily calcified aortic valve. The Heart Team recommended isolated surgical aortic valve replacement, but the patient refused this option. We decided to perform transfemoral-TAVI with a 26 mm Edwards valve which was deployed after predilatation with a 23 mm balloon. Immediately after valve deployment, the angiography revealed contrast leakage at the level of the Valsalva sinuses. The patient developed hypotension due to cardiac tamponade which was immediately managed with pericardial drainage. A bailout cardiac surgery was required to remove the TAVI prosthesis and the native aortic leaflets. A left ventricular outflow tract (LVOT) rupture was observed in addition to supra- annular and intra-annular injury. Repair of the left ventricle with a pericardial patch and implantation of a surgical bioprosthesis (Dafodil Meril 21 mm) were performed. No complications occurred post-operatively Annular rupture occurs in about 1% of all TAVI procedures and may involve the region of the aortic root and LVOT. According to the anatomical location of the injury, it can be classified into 4 types: intra-annular, sub-annular, supra-annular, and combined rupture. Annular rupture has been mainly observed after the use of balloon-expandable valves and only exceptionally after TAVI with self- expandable prosthesis. Nevertheless, the following anatomic characteristics are associated with an increased incidence of this catastrophic event: small aortic valve annulus (&lt;20 mm), a narrow aortic root, heavy calcifications of aortic valve leaflets, annulus, LVOT and sinuses of Valsalva, bicuspid valve, short distance from a coronary artery to the annulus and LV hypertrophy. The voluminous amount of calcification located in the landing zone in addition to the force applied during the balloon expansion may be the main mechanism of this catastrophic complication. Clinical presentation is dramatic and emergent surgery can be the sole solution. Alternative bailout treatments, such as placing a second transcatheter valve to close the rupture have been occasionally reported. A precise preprocedural analysis of the device landing zone is mandatory. This includes determination of the size, morphology of all anatomical structures and a careful identification of possible factors for annular rupture. Moreover, in these cases, the availability of cardiac surgery onsite is pivotal to save patient's life. As more and younger patient will undergo TAVI in next years, our report highlightsthe need to optimize preprocedural planning and prosthesis selection. Improvements in devices, procedural techniques, and imaging tools may simplify TAVI and reduce possible complications.

Impact of COVID-19 pandemic on timing and early clinical outcomes of transcatheter aortic valve implantation

BACKGROUND

We sought to investigate the applicability and outcomes of a novel system to manage patients requiring transcatheter aortic valve implantation (TAVI) at a tertiary level hospital during the coronavirus disease-2019 (COVID-19) pandemic.

METHODS

To analyse the impact of hospitalisation pathways during the pandemic on clinical outcomes of TAVI patients, the study population was divided into two groups (pre-pandemic and pandemic groups) and all perioperative/follow-up data were compared. The primary endpoint was all-cause mortality at 30 days; secondary endpoints included procedural success and short-term complications.

RESULTS

A total of 315 patients received TAVI during the study period. Pandemic group (n = 77) showed a more complex baseline clinical profile (NYHA class III-IV, 70.1% vs. 56.3%; p = 0.03). The overall time to procedure was significantly longer during pandemic (56.9 ± 68.3 vs.37.7 ± 25.4; p = 0.004) while intensive care unit stay was shorter (2.2 ± 1.4 vs. 3.7 ± 3.9, p < 0.05). Hospitalisation length was similar in both groups as well as all-cause mortality rate and the incidence of major periprocedural complications. No case of infection by COVID-19 was reported among patients during the hospital stay.

CONCLUSIONS

Comparative analysis of early clinical outcomes showed that COVID-19 pandemic did not affect the safety and effectiveness of TAVI as similar rates of procedural complications and all-cause mortality were reported than before February 2020. Despite the increased time lag between diagnosis and procedure and a more complex clinical profile of patients at baseline, the revised pathway of hospitalisation allowed to resume inpatient procedures while not affecting patients' and healthcare workers' safety.

Management of Myocardial Revascularization in Patients With Stable Coronary Artery Disease Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND

The best management of stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear due to the marked inconsistency of the available evidence.

METHODS

The REVASC-TAVI registry (Management of Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation With Coronary Artery Disease) collected data from 30 centers worldwide on patients undergoing TAVI who had significant, stable CAD at preprocedural work-up. For the purposes of this analysis, patients with either complete or incomplete myocardial revascularization were compared in a propensity score matched analysis, to take into account of baseline confounders. The primary and co-primary outcomes were all-cause death and the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure, respectively, at 2 years.

RESULTS

Among 2407 patients enrolled, 675 pairs of patients achieving complete or incomplete myocardial revascularization were matched. The primary (21.6% versus 18.2%, hazard ratio' 0.88 [95% CI, 0.66-1.18]; P=0.38) and co-primary composite (29.0% versus 27.1%, hazard ratio' 0.97 [95% CI, 0.76-1.24]; P=0.83) outcome did not differ between patients achieving complete or incomplete myocardial revascularization, respectively. These results were consistent across different prespecified subgroups of patients (< or >75 years of age, Society of Thoracic Surgeons score > or <4%, angina at baseline, diabetes, left ventricular ejection fraction > or <40%, New York Heart Association class I/II or III/IV, renal failure, proximal CAD, multivessel CAD, and left main/proximal anterior descending artery CAD; all P values for interaction >0.10).

CONCLUSIONS

The present analysis of the REVASC-TAVI registry showed that, among TAVI patients with significant stable CAD found during the TAVI work-up, completeness of myocardial revascularization achieved either staged or concomitantly with TAVI was similar to a strategy of incomplete revascularization in reducing the risk of all cause death, as well as the risk of death, stroke, myocardial infarction, and rehospitalization for heart failure at 2 years, regardless of the clinical and anatomical situations.

P2Y12 inhibitors monotherapy in patients undergoing complex vs. non-complex percutaneous coronary intervention: a meta-analysis of randomized trials

Background

Monotherapy with P2Y12 inhibitors (P2Y12i) is emerging as alternative strategy to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). However, early withdrawal of aspirin as part of P2Y12i monotherapy regimens may pose concerns in high-risk patients, such as those undergoing complex PCI.

Purpose

To evaluate the efficacy and safety of P2Y12i monotherapy after a short course of DAPT (1- to 3-month) compared with standard DAPT (≥12-month) according to PCI complexity.

Methods

We performed a meta-analysis of randomized trials using random effects models to combine hazard ratios (HRs) with 95% confidence intervals (CIs). No restrictions were applied to the type of P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) or to the definition of complex PCI. Within-trial interactions were pooled to estimate heterogeneity between complex and noncomplex PCI strata. The study protocol was registered in the PROSPERO (CRD42021291027).

Results

We screened 7,502 unique citations, of which 2,948 were screened at title and abstract level and 576 were judged potentially eligible for full-text assessment. We included in the analysis five trials (1–5) enrolling 31,627 patients, of whom 8,328 (26.3%) underwent complex PCI; characteristics of trials and patient populations are summarized in Table 1. Risk estimates for efficacy and safety outcomes associated with P2Y12i monotherapy and standard DAPT across studies included in the analysis, stratified by complex and noncomplex PCI, are reported in Figure 1. P2Y12i monotherapy compared with standard DAPT was associated with a similar risk of all-cause death, stent thrombosis, and stroke, with no evidence for interaction between complex and noncomplex PCI. We found heterogeneity in the treatment effect of P2Y12i monotherapy vs. standard DAPT with respect to myocardial infarction (P-interaction=0.027). Compared with standard DAPT, P2Y12i monotherapy decreased the risk of myocardial infarction in complex PCI (HR 0.77, 95% CI 0.60–0.99, P=0.042), but not in noncomplex PCI patients (HR 1.09, 95% CI 0.90–1.30, P=0.382). The risk of major bleeding was significantly reduced by P2Y12i monotherapy with a consistent treatment effect (P-interaction=0.699) in both complex and noncomplex PCI strata.

Conclusions

Patients undergoing complex PCI may derive more benefit and less harm from P2Y12i monotherapy after early aspirin withdrawal compared with standard DAPT, resulting in decreased risks of myocardial infarction and bleeding.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of global work efficiency in patients undergoing transcatheter aortic valve implantation

Background

Non-invasive myocardial work (MW) quantification has emerged in the last years as an alternative echocardiographic tool for myocardial function assessment. Its role in patients with severe aortic stenosis (AS) after aortic valve implantation (TAVI) has not been adequately investigated.

Purpose

We aimed to evaluate MW indices as early echocardiographic markers of LV reverse remodeling within a month after TAVI and their prognostic value.

Methods and results

We conducted a single-centre prospective study, enrolling 88 consecutive patients (mean age 79.9±6.4 years, 35% males) with AS undergoing TAVI between April 2018 and 2021, selected from the EffecTAVI registry. Exclusion criteria were prior valve surgery, atrial fibrillation, left bundle branch block (LBBB) at baseline and and suboptimal quality of imaging. Echocardiographic assessment was performed before TAVI and at 30-day follow-up, including quantification of 2D global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE). LV peak systolic pressure was estimated non-invasively from the sum of systolic blood pressure and trans-aortic mean gradient. One month after the procedure, there was a significant improvement of LV GLS (−18.4±4.2 vs −19.5±4.2%, before and after TAVI respectively, p=0.006), a significant reduction of GWI (2406±567 vs 1908±479 mmHg%, p&lt;0.001), GCW (2783±616 vs 2202±463 mmHg%, p&lt;0.001), and GWW (238±203 vs 173±127 mmHg%, p=0.002). Conversely, MWE did not change early after intervention (90.4±6.2 vs 91.4±5.1%, p=0.113). After TAVI, 32 patients (36.4%) developed LV dyssynchrony due to LBBB or pacemaker implantation. When the population was divided according to the presence or absence of LV dyssynchrony at 30-day follow-up, a significant reduction in GWW was found only in the those without dyssynchrony (241±229 vs 142±103 mmHg% before and after TAVI, p&lt;0.001). Consistently, in this subgroup, MWE significantly improved after TAVI (90±7 vs 93±5%, p=0.001), while a trend of MWE reduction was observed in patients who developed dyssynchrony after TAVI (91±5 vs 89±5%, p=0.110). In the overall population, a 30-day value of MWE≤92% was associated with an increased rate of cardiovascular events (composite of all-cause death and rehospitalization for heart failure) at 1-year follow-up (29.5% vs 4.8%, long rank p=0.003). In multivariable Cox-regression analysis, adjusted for confounders, GWE after TAVI (HR: 0.892, CI: 0.817–0.974; p=0.011) was independently associated with events at 1-year follow-up.

Conclusions

In patients with severe AS undergoing TAVI a significant reduction of GWW and improvement of MWE can be detected only in those who do not develop LV dyssynchrony. In this setting, MWE≤92% early after TAVI is associated with poor outcome. Thus, MWE could represent an alternative tool for myocardial function assessment and prognostic evaluation in patients receiving TAVI.

Funding Acknowledgement

Type of funding sources: None.

Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management

The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex-oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management.

One-Month Dual Antiplatelet Therapy After Bioresorbable Polymer Everolimus-Eluting Stents in High Bleeding Risk Patients

Background

It is unknown whether contemporary drug‐eluting stents have a similar safety profile in high bleeding risk patients treated with 1‐month dual antiplatelet therapy following percutaneous coronary interventions.

Methods and Results

We performed an interventional, prospective, multicenter, single‐arm trial, powered for noninferiority with respect to an objective performance criterion to evaluate the safety of percutaneous coronary interventions with Synergy bioresorbable‐polymer everolimus‐eluting stent followed by 1‐month dual antiplatelet therapy in patients with high bleeding risk. In case of need for an oral anticoagulant, patients received an oral anticoagulant in addition to a P2Y₁₂ inhibitor for 1 month, followed by an oral anticoagulant only. The primary end point was the composite of cardiac death, myocardial infarction, or definite or probable stent thrombosis at 1‐year follow‐up. The study was prematurely interrupted because of slow recruitment. From April 2017 to October 2019, 443 patients (age, 74.8±9.2 years; women, 29.1%) at 10 Italian centers were included. The 1‐year primary outcome occurred in 4.82% (95% CI, 3.17%–7.31%) of patients, meeting the noninferiority compared with the predefined objective performance criterion of 9.4% and the noninferiority margin of 3.85% (P_{noninferiority}<0.001) notwithstanding the lower‐than‐expected sample size. The rates of cardiac death, myocardial infarction, and definite or probable stent thrombosis were 1.88% (95% CI, 0.36%–2.50%), 3.42% (95% CI, 2.08%–5.62%), and 0.94% (95% CI, 0.35%–2.49%), respectively.

Conclusions

Among high bleeding risk patients undergoing percutaneous coronary interventions with the Synergy bioresorbable‐polymer everolimus‐eluting stent, a 1‐month dual antiplatelet therapy regimen is safe, with low rates of ischemic and bleeding events.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03112707.

143 Incidence, predictors, and clinical impact of transient left bundle branch block in patients undergoing transcatheter aortic valve implantation

Aims

This study aims to evaluate the incidence and prognostic impact of transient left bundle branch block (LBBB) in patients undergoing transcatheter aortic valve implantation (TAVI) with balloon-expandable or self-expanding valves. Clinical, echocardiographic and electrocardiographic predictors of transient LBBB were also investigated.

Methods and results

197 patients treated with TAVI at Federico II University hospital, Naples, Italy were enrolled. Electrocardiograms (ECGs) were obtained before and after TAVI procedure, at discharge and at 30-day follow-up. ECGs were anonymously digitalized and analysed by five cardiologists. Transient LBBB was defined as LBBB regressed within 30 days after procedure. All ECGs for each patient were analysed by the same cardiologist. The primary endpoint of the study was all-cause mortality and permanent pacemaker implantation (PPI) at 1-month after TAVI. Secondary endpoints included cerebrovascular accidents, acute myocardial infarction, vascular complications, acute kidney injury, endocarditis, and re-hospitalization for all causes. Out of 197 patients enrolled, 54 (27.4%) developed transient LBBB. Among patients with transient LBBB, 70.4% were female. Mean age was higher in transient LBBB group compared with control group (81.0 ± 6.4 years, vs. 78. 6 ± 6.5 years; P = 0.022). From logistic analysis, peak transvalvular gradient (OR: 1.01, 95% CI: 0.93–1.00; P &lt; 0.034) and left ventricular ejection fraction (LVEF) (OR: 0.96, 95% CI: 0.93–0.99, P &lt; 0.012) were identified as predictive factors of transient LBBB. No differences between the two studied groups were observed in primary and secondary endpoints (all-cause mortality: 1.9% vs. 0.7%; P = 0.46; PPI: 9.6% vs. 12%; P = 0.80).

Conclusions

Peak transvalvular gradient and LVEF predict onset of transient LBBB, a common conduction disturbance after TAVI. Onset of transient LBBB does not correlate with worse clinical outcomes at 30 days.

652 Myocardial work in patients undergoing transcatheter aortic valve implantation: clinical value and implications for outcome

Aims

Non-invasive myocardial work (MW) quantification has emerged in the last years as an alternative echocardiographic tool for myocardial function assessment. This new parameter provides a less loading-dependent evaluation of myocardial performance through the combined assessment of global longitudinal strain (GLS) and non-invasive left ventricle (LV) pressures. The role of MW as a marker of cardiac dysfunction and reverse remodelling in patients with severe aortic stenosis (AS) after aortic valve implantation (TAVI) has not been adequately investigated. This study aims to evaluate MW indices as early echocardiographic markers of LV reverse remodelling within a month after TAVI and their prognostic value.

Methods and results

We conducted a single-centre prospective study, enrolling 70 consecutive patients (mean age 80.1 ± 5.5 years) with severe AS undergoing TAVI between 2018 and 2020, selected from the EffecTAVI registry. Exclusion criteria were prior valve surgery, severe mitral stenosis, permanent atrial fibrillation, left bundle branch block (LBBB) at baseline, and suboptimal quality of speckle-tracking image analysis. Echocardiographic assessment was performed before TAVI and at 30-day follow-up. Clinical, demographic, and resting echocardiographic data were recorded, including quantification of 2D global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). LV peak systolic pressure was estimated non-invasively from the sum of systolic blood pressure and trans-aortic mean gradient. One month after the procedure, there was a significant improvement of LV GLS (−17.94 ± 4.24% vs. −19.35 ± 4.31%, before and after TAVI respectively, P = 0.002), as well as a significant reduction of GWI (2430 ± 586 mmHg% vs. 1908 ± 472 mmHg%, P &lt; 0.001), GCW (2828 ± 626 mmHg% vs. 2206 ± 482 mmHg%, P &lt; 0.001), and GWW (238 ± 207 mmHg% vs. 171 ± 118 mmHg%, P = 0.006). Conversely, MWE did not significantly change early after intervention (90.53 ± 6.05% vs. 91.45 ± 5.05%, P = 0.204). After TAVI, 30 patients (42.8%) developed LV dyssynchrony due to LBBB or pacemaker implantation. When the population was divided according to the presence or absence of LV dyssynchrony at 30-day follow-up, a significant reduction in GWW was found only in those without dyssynchrony (244 ± 241 vs. 141 ± 110 mmHg% with and without dyssynchrony respectively, P = 0.002). Consistently, in this subgroup, MWE significantly improved post-TAVI (90 ± 7 vs. 93 ± 5%, P = 0.002), while a trend of MWE reduction was observed in patients who developed dyssynchrony post-TAVI (91 ± 4 vs. 89 ± 5%, P = 0.164). In the overall population, a baseline value of MWE&lt; 92% was associated with an increased rate of cardiovascular events (composite of all-cause death and rehospitalization for heart failure) at 1-year follow-up (22.2 vs. 3.1%, long rank, P = 0.016).

Conclusions

In patients with severe AS undergoing TAVI a significant reduction of GWW and improvement of MWE can be detected only in those who did not develop LV dyssynchrony. In this setting, MWE lower than 92% at baseline is associated with poor outcome. Thus, MWE could represent an alternative tool for myocardial function assessment in patients receiving TAVI.

134 Impact of COVID-19 pandemic on timing and early clinical outcomes of transcatheter aortic valve implantation

Aims

COVID-19 pandemic deeply changed the management of patients with aortic stenosis. Many cardiac societies have drawn up guidelines for the optimal management of this population but applicability of such recommendations in the current clinical practice and their impact on clinical outcomes has not been adequately investigated.

Methods and results

A single-centre retrospective study included 315 patients undergoing transcatheter aortic valve implantation (TAVI) between April 2017 and June 2021. To analyse the impact of hospitalization pathways during the pandemic on clinical outcomes of TAVI patients, study population was divided into two groups (pre-pandemic and pandemic groups) and all perioperative/follow-up data were compared. The primary endpoint was all-cause mortality at 30 days; secondary endpoints included procedural success and short- term complications. Pandemic group patients showed a more complex baseline clinical profile (NYHA III–IV, 70.1% vs. 56.3%; P = 0.03). The overall time to procedure was significantly longer during pandemic (56.9 ± 68.3 vs.37.7 ± 25.4; P = 0.004) while intensive care unit stay was shorter (2.2 ± 1.4 vs. 3.3 ± 3.5). Hospitalization length was similar in both group as well as all-cause mortality rate and the incidence of major periprocedural complications.

Conclusions

COVID-19 pandemic did not affect the safety and effectiveness of TAVI as similar rates of procedural complications and all-cause mortality were reported than before February 2020. Despite the increased time lag between diagnosis and procedure and a more complex clinical profile of patients at baseline, the revised pathway of hospitalization allowed to resume inpatient procedures while not affecting patients’ and healthcare workers’ safety.

777 Prehospital ECG in patients with acute myocardial infarction during the COVID-19 pandemic

Aims

Primary percutaneous coronary intervention (PCI) represents the preferred revascularization strategy among patients with acute ST-segment elevation myocardial infarction (STEMI). A decline in the rates of primary PCI has been observed globally during the outbreak of coronavirus disease-19 (COVID-19). Fear of exposure to in-hospital infection has been hypothesized as the main mechanism of this phenomenon, also contributing to a delayed presentation of patients with STEMI. However, a formal assessment of initial electrocardiograms (ECGs) among STEMI patients during the COVID-19 pandemic is still lacking. We therefore compared pre-hospital ECGs of STEMI patients hospitalized in Italy after the first reported case of COVID-19 on 21 February 2020 with data from the same period in 2019 to identifying potential changes between the two periods.

Methods and results

Prehospital ECGs were obtained from the STEMI care network in the Campania region. Deidentified ECGs were analysed by two expert reviewers who were blinded to date of recording. Pathological Q-waves were defined as a Q-wave with a duration ≥40 ms and/or depth ≥25% of the R-wave in the same lead or the presence of a Q-wave equivalent. These criteria have been shown to be associated with final infarct size at cardiac magnetic resonance. For all conventional STEMI, the timing of STEMI onset was estimated with the Anderson-Wilkins (AW) acuteness score, ranging from 1 (least acute) to 4 (most acute). From 21 February 2020 to 16 April 2020, a total of 3239 pre-hospital ECGs were recorded by the emergency medical system and 167 (5.15%) were classified as STEMI. During the same period in 2019, 3505 pre-hospital ECGs were recorded, and 196 (5.59%) were classified as STEMI. There was no difference between the two study periods in terms of age, gender, type, and location of STEMI (Table 1). Pathological Q-waves were present in 54.5% of ECGs recorded during the COVID-19 period compared with 22.1% of ECGs recorded in the same period in 2019 (risk difference 32.3, 95% confidence intervals [CI]: 21.2–43.5 percentage points). There was also an increase in the mean number of Q-waves during the COVID-19 compared with the control period (1.4 vs. 0.9; P < 0.001). These findings remained similar when QS- and qR complexes were analysed separately. Consistently, the AW score was significantly lower during the COVID-19 period (2.4 vs. 2.8; P < 0.001).

Conclusions

Prehospital ECGs of STEMI patients during the COVID-19 pandemic presented more frequently with signs of late ischemia compared with the equivalent period in 2019. Approximately, one out of two patients had already pathological Q-waves in the initial ECG. The AW acuteness score is superior to patient history (historical timing) in predicting myocardial salvage and mortality after reperfusion in STEMI patients, thus explaining the higher mortality rate and the increased risk of infarct-related complications observed during the COVID-19 pandemic.