Strategy to optimize PeriproCeduraL AnticOagulation in structural transseptal interventions: Design and rationale of the STOP CLOT trial

BACKGROUND

Both transcatheter edge-to-edge repair (TEER) of mitral regurgitation or left atrial appendage closure (LAAC) require periprocedural anticoagulation with unfractionated heparin (UFH) that is administered either before or immediately after transseptal puncture (TSP). The optimal timing of UFH administration (before or after TSP) is unknown. The Strategy To Optimize PeriproCeduraL AnticOagulation in Structural Transseptal Interventions trial (STOP CLOT Trial) was designed to determine if early anticoagulation is effective in reducing ischemic complications without increasing the risk of periprocedural bleeding.

METHODS

The STOP CLOT trial is a multicenter, prospective, double-blind, placebo-controlled, randomized trial. A total of 410 patients scheduled for TEER or LAAC will be randomized 1:1 either early UFH administration (iv. bolus of 100 units/kg UFH or placebo, given after obtaining femoral vein access and at least 5 minutes prior to the start of the TSP) or late UFH administration (iv. bolus of 100 units/kg UFH or placebo given immediately after TSP). Prespecified preliminary statistical analysis will be performed after complete follow-up of the first 196 randomized subjects. To ensure blinding, a study nurse responsible for randomization and UFH/placebo preparation is not involved in the care of the patients enrolled into the study. The primary study endpoint is a composite of (1) major adverse cardiac and cerebrovascular events (death, stroke, TIA, myocardial infarction, or peripheral embolization) within 30 days post-procedure, (2) intraprocedural fresh thrombus formation in the right or left atrium as assessed with periprocedural transesophageal echocardiography, or (3) occurrence of new ischemic lesions (diameter ≥4 mm) on brain magnetic resonance imaging performed 2 to 5 days after the procedure. The safety endpoint is the occurrence of moderate or severe bleeding complications during the index hospitalization.

CONCLUSIONS

Protocols of periprocedural anticoagulation administration during structural interventions have never been tested in a randomized clinical trial. The Stop Clot trial may help reach consensus on the optimal timing of initiation of periprocedural anticoagulation.

CLINICAL TRIALS REGISTRATION NUMBER

The study protocol is registered at ClinicalTrials.gov, identifier NCT05305612.

Computed tomographic characteristics of congenital coronary artery fistulas in an adult population

BACKGROUND

Coronary artery fistulas (CAFs) are usually congenital coronary artery anomalies of termination.

AIMS

This study aimed to assess the prevalence, anatomic characteristics, and clinical significance of CAFs detected by computed tomography (CT) in an adult population.

METHODS

We performed 45 817 CT examinations in 39 066 subjects between 2008 and 2020. The electronic database was manually checked using specific keywords to identify patients with CAFs. The CT characteristics of CAFs were evaluated. CAF was defined as clinically significant if it was the most plausible cause of myocardial infarction, infective endocarditis, heart failure, death during follow-up, hospitalization, or if it required either percutaneous or surgical intervention.

RESULTS

Of 39 066 patients, 56 CAFs were detected in 42 subjects (20 men, 47.6%) with a prevalence of 0.11%. Most CAFs originated from the right coronary artery (RCA) (48.2%) and drained into the pulmonary artery (PA) (58.9%). CAFs terminating in the PA were more frequently multiple (P <0.001) and tortuous (P <0.001) as compared to CAFs without PA drainage. Clinically significant CAFs, identified in 7 of 42 patients, were more common in younger (P = 0.03) and male (P = 0.04) subjects and had larger lumen area and diameter at the site of origin (P = 0.03, P = 0.03, respectively).

CONCLUSIONS

In the unselected adult population undergoing coronary CT angiography, the RCA and the PA are the most common sites of origin and termination of CAFs, respectively. CAFs draining into the PA are more often multiple and tortuous. Clinically meaningful CAFs are larger and most frequently detected in younger and male patients.

Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery

Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.

Pericoronary adipose tissue density is increased in patients with recent spontaneous coronary dissection

OBJECTIVE

Inflammatory activity is one of the potential mechanisms of spontaneous coronary artery dissection (SCAD). Recently, the pericoronary adipose tissue attenuation (PCAT) derived from CT angiography (CTA) has been established as a method for measuring vascular inflammation. We aimed to characterise the pancoronary and vessel-specific PCAT in patients with and without recent SCAD.

METHODS

The study comprised patients with SCAD referred to a tertiary centre between 2017 and 2022 who underwent CTA and were compared with individuals with no prior SCAD. PCAT was analysed on end-diastolic CTA reconstructions along proximal 40 mm of all major coronary vessels as well as the SCAD-related vessel. We analysed 48 patients with recent SCAD (median 6.1 (IQR 3.5-14.9) months since SCAD, 95.8% female) and 48 patients in the group without SCAD.

RESULTS

Pancoronary PCAT was higher in patients with SCAD compared with those without SCAD (-80.6±7.9 vs -85.3 HU±6.1, p=0.002). Vessel-specific PCAT in patients with SCAD compared with patients without SCAD was higher for both the RCA (-80.9±9.5 vs -87.1±6.9 HU, p=0.001) and the LCA (-80.3±7.8 vs -83.4±7.2 HU, p=0.04). In patients with SCAD, PCAT of the SCAD-related vessel was not significantly different from averaged PCAT of unaffected vessels (-81.2±9.2 vs -80.6±7.6, p=0.74). There was no association between PCAT and the interval from SCAD to CTA.

CONCLUSIONS

Patients with recent SCAD have higher PCAT compared with patients without SCAD, suggesting an increased perivascular inflammatory activity. This association is not restricted to the dissected vessel.

Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery

Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.

Clinical use of intracoronary imaging modalities in Poland. Expert opinion of the Association of Cardiovascular Interventions of the Polish Cardiac Society

The article presents the most common, current indications for the use of intravascular invasive imag-ing diagnostic techniques, i.e. intravascular ultrasound and optical coherence tomography in Polish invasive cardiology centers. The application of the above-mentioned techniques in the diagnosis of stenosis of the left main coronary artery, optimization of stent implantation procedures, treatment of calcified lesions, and other clinically important issues are discussed.

Efficacy and safety of coronary computed tomography angiography in patients with a high clinical likelihood of obstructive coronary artery disease

BACKGROUND

The CAT-CAD trial showed that coronary computed tomography angiography (CTA) in patients with a high prevalence of coronary artery disease (CAD) and indications for invasive coronary angiography (ICA) reduces the number of patients undergoing ICA by two thirds and nearly eradicates non-actionable ICAs. However, the long-term benefits of this non-invasive strategy remain unknown.

AIMS

To evaluate the long-term efficacy and safety of a non-invasive strategy employing coronary CTA vs. ICA as the first-line imaging test in stable patients with a high clinical likelihood of obstructive CAD.

METHODS

The long-term outcomes were evaluated during 36 months following randomization and included the efficacy outcome, analyzed as the composite of major adverse cardiovascular events (MACE): all-cause death, acute coronary syndrome, unplanned coronary revascularization, urgent hospitalization for cardiovascular reason, stroke, and the safety outcome, analyzed as a cumulative incidence of serious adverse events.

RESULTS

120 participants with a mean age of 60.6 (7.9) years (female, 35.0%) were randomized with an allocation ratio of 1:1 to coronary CTA and direct ICA as the first-line anatomical test for suspected obstructive CAD. There were no significant differences between both diagnostic strategies neither in terms of the long-term efficacy (MACE occurrence: 15.5% in coronary CTA group vs. 16.7% in ICA group; log-rank P = 0.89) nor the long-term safety (cumulative number of serious adverse events: respectively 36 vs. 38; P = 0.79).

CONCLUSIONS

Long-term follow-up of the randomized CAT-CAD trial confirms that the strategy employing coronary CTA is an effective and safe, non-invasive, outpatient-based alternative to ICA for patients with a high clinical likelihood of obstructive CAD.

Percutaneous tricuspid edge-to-edge repair - patient selection, imaging considerations, and the procedural technique. Expert opinion of the Working Group on Echocardiography and Association of CardioVascular Interventions of the Polish Cardiac Society

Tricuspid regurgitation (TR) is a common acquired valvular heart disease (VHD). TR has progressive character and is associated with impaired long-term survival in both symptomatic and asymptomatic subjects. Despite this knowledge, the overall number of tricuspid valve surgeries is very low worldwide and many patients with clear indications for intervention are left untreated. The development of less invasive transcatheter techniques may offer new treatment options in this growing population of patients. Out of various percutaneous methods proposed, tricuspid edge-to-edge repair has recently gained considerable attention. The article summarizes available data regarding this new treatment method.

Mechanisms, Prevention and Treatment of Saphenous Vein Graft Disease

Saphenous vein grafts are imperfect yet indispensable conduits commonly used for coronary artery bypass grafting. Their degeneration ultimately leading to occlusion results from the pathological response of the vein to altered blood rheology and several types of vascular injury. Surgical techniques minimizing vessel damage, and prolonged antiplatelet and lipid-lowering treatment are established methods of mitigating the degeneration process hence preventing graft occlusions. Percutaneous interventions in degenerated vein grafts carry high risk of embolization, periprocedural myocardial infarction and restenosis. Thus, native vessel should be the preferred treatment target in case of graft failure whenever technically feasible.

Comparison of myocardial tissue reperfusion of inferior wall and a right ventricle among patients after primary angioplasty for an inferior myocardial infarction with right ventricular infarction

BACKGROUND

Impaired myocardial tissue reperfusion affects prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and can be identified by ST-segment analysis. To date, evaluation of the myocardial tissue reperfusion of the right ventricle (RV) among the patients treated with PCI for inferior STEMI with right ventricular infarction (RVI) has not been made yet.

METHODS

Patients with inferior STEMI were screened for RVI. Tissue reperfusion was evaluated by maximal residual ST-segment deviation post PCI, independently for the RV and for inferior wall. Myocardial injury was assessed by the peak creatine kinase-mb (CK-MB) value.

RESULTS

Among 456 patients with inferior STEMI, concomitant RVI occurred in 153 (33.5%) subjects (59.86±10.35 years old, 71.9% females). Tissue reperfusion of LV was present in 75 (49%), whereas 55 (35.9%) had both successful LV and RV reperfusion. Among 97 (63.4%) with successful tissue reperfusion of RV, 55 (56.7%) had associated successful tissue reperfusion of inferior wall. Adequate LV reperfusion was accompanied by RV in over 73.3% of patients (P=0.006). Mean peak CK-MB was lower in the group with adequate versus impaired RV tissue-perfusion (197±143 vs. 305±199 U/L, P=0.021 respectively).

CONCLUSIONS

Impaired reperfusion of RV is observed in more than one third of inferior STEMIs with RVI and is not strictly associated with impaired reperfusion of inferior wall and clinical or angiographic variables, therefore ST-segment analysis for RV is mandatory.

Comparison of myocardial tissue reperfusion of inferior wall and a right ventricle among patients after primary angioplasty for an inferior myocardial infarction with right ventricular infarction

BACKGROUND

Impaired myocardial tissue reperfusion affects prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) and can be identified by ST-segment analysis. To date, evaluation of the myocardial tissue reperfusion of the right ventricle (RV) among the patients treated with PCI for inferior STEMI with right ventricular infarction (RVI) has not been made yet.

METHODS

Patients with inferior STEMI were screened for RVI. Tissue reperfusion was evaluated by maximal residual ST-segment deviation post PCI, independently for the RV and for inferior wall. Myocardial injury was assessed by the peak creatine kinase-mb (CK-MB) value.

RESULTS

Among 456 patients with inferior STEMI, concomitant RVI occurred in 153 (33.5%) subjects (59.86±10.35 years old, 71.9% females). Tissue reperfusion of LV was present in 75 (49%), whereas 55 (35.9%) had both successful LV and RV reperfusion. Among 97 (63.4%) with successful tissue reperfusion of RV, 55 (56.7%) had associated successful tissue reperfusion of inferior wall. Adequate LV reperfusion was accompanied by RV in over 73.3% of patients (P=0.006). Mean peak CK-MB was lower in the group with adequate versus impaired RV tissue-perfusion (197±143 vs. 305±199 U/L, P=0.021 respectively).

CONCLUSIONS

Impaired reperfusion of RV is observed in more than one third of inferior STEMIs with RVI and is not strictly associated with impaired reperfusion of inferior wall and clinical or angiographic variables, therefore ST-segment analysis for RV is mandatory.

Additive Value of High-Density Lipoprotein Cholesterol and C-Reactive Protein Level Assessment for Prediction of 2-year Mortality After Transcatheter Aortic Valve Implantation

Available prediction models are inaccurate in elderly who underwent transcatheter aortic valve implantation (TAVI). The aim of present study was to analyze the separate and combined prognostic values of baseline HDL-C and C-reactive protein (CRP) levels in patients treated successfully with TAVI who had complete 2-year follow-up. We analyzed 334 patients treated with TAVI from 01/2010 to 07/2017 who had measurements of HDL-C and CRP on admission or during qualification for the procedure. Baseline HDL-C ≤46 mg/dl (areas under the curve [AUC] = 0.657) and CRP ≥0.20 mg/dl (AUC = 0.634) were predictive of 2-year mortality. After stratification with both cutoffs, patients with low HDL-C and concomitant high CRP most often had LVEF ≤50% and were high risk as per EuroSCORE II. Those with isolated CRP elevation had the lowest frequency of LVEF ≤50%, but more sarcopenia (based on psoas muscle area). After adjustment in the multivariate analysis for other identified predictors including EuroSCORE II and statin therapy, isolated HDL-C ≤46 mg/dl (identified in 40 patients) and isolated CRP ≥0.20 mg/dl (n = 109) were both independent predictors of 2-year mortality (hazard ratio [HR] = 2.92 and HR = 2.42, respectively) compared with patients with both markers within established cutoffs (n = 105) who had the lowest 2-year mortality (9.5%). Patients with both markers exceeding cutoffs (n = 80) had the highest risk (HR = 4.53) with 2-year mortality of 42.5%. High CRP was associated with increased mortality within the first year of follow-up, whereas low HDL-C increased mortality in the second year. The combination of both markers with EuroSCORE II enhanced mortality prediction (AUC = 0.697). In conclusion, low baseline HDL-C and high CRP jointly contribute to the prediction of increased all-cause mortality after TAVI.

Effect on Mortality of Systemic Thromboinflammatory Response After Transcatheter Aortic Valve Implantation

After transcatheter aortic valve implantation (TAVI) there is consistently identified decrease in platelets accompanied by a leucocyte (white blood cell, WBC) increase. We aimed to analyze the prognostic value of early platelet and WBC count changes (thromboinflammatory response) after successful TAVI. Among 432 consecutive patients [median 83.0 years of age, 63.4% women], platelets and WBCs were measured before and for 7 days post-TAVI. Follow-up was 36.9 (21.4 to 48.0) months. Platelet decrease (∆%Platelet-max) and parallel WBC increase (∆%WBC-max) were seen at days 1 to 3. Both ∆%Platelet-max ≤-37.6% and ∆%WBC-max >72.5% predicted mortality (area under the curve = 0.569 and area under the curve = 0.626). The 30-day and 1-year mortality (13.1% and 26.2%) were highest among 28% patients with a greater decrease in platelets and a greater increase in WBCs; intermediate (0.9% and 12.3%) among 52.5% patients with either a greater decrease in platelets or a greater increase in WBCs, but not both; and lowest (0% and 6.6%) among 19.5% patients with a lesser decrease in platelets and a lesser increase in WBCs (p <0.001). Estimated 4-year mortality rates were 53.7% versus 36.2% versus 24.5%, respectively, p <0.001. Bleeding, surgical wounds, acute kidney, and brain injury predicted a more intense thromboinflammatory response, whereas use of the newer generations had the opposite effect. In conclusion, substantial thromboinflammatory response identified after successful TAVI predicts a higher long-term mortality.

Incidence, clinical correlates, timing, and consequences of acute thrombus formation in patients undergoing the MitraClip procedure

BACKGROUND

Despite adequate heparinization, formation of fresh intracardiac thrombi during the MitraClip procedure was reported.

AIMS

We aimed to evaluate the incidence and clinical consequences of intracardiac thrombus formation during the MitraClip device implantation.

METHODS

Clinical data and transesophageal echocardiography findings obtained during MitraClip procedures in 100 consecutive patients (81 men; mean [SD] age, 67.8 [8.3] years) were reviewed. In all patients, a heparin bolus was given immediately after a successful transseptal puncture, and the activated clotting time above 250 seconds was maintained throughout the procedure.

RESULTS

Thrombus formation was documented in 9 patients (9%). In 6 patients, thrombi formed on a transseptal needle/sheath (2 attached to the sheath in the right atrium and 4 on the sheath immediately after the puncture in the left atrium), and in 3 patients, on the MitraClip device in the left atrium (2 on a steerable guiding catheter and 1 on the clip delivery system). Overall, 6 thrombi (67%) formed prior to and 3 (33%) after heparin administration. All thrombi were transient and disappeared within minutes. No periprocedural ischemic stroke, transient ischemic attack, or other embolic complications were reported. Clinical characteristics were similar in patients with and without thrombi, except for lower left ventricular ejection fraction (LVEF; mean [SD], 23% [10%] and 30% [10%], respectively; P = 0.03). In-hospital death was reported in 6 patients: 2 with a visible thrombus and 4 without (P = 0.09).

CONCLUSIONS

Transient thrombus formation is relatively common during the MitraClip procedure, especially in patients with low LVEF; however, acute clinical consequences are benign.

In‑hospital outcomes of rotational versus orbital atherectomy during percutaneous coronary intervention: a meta‑analysis

BACKGROUND

Data comparing rotational atherectomy (RA) with orbital atherectomy (OA) for calcified lesions is inconclusive and based on single observational studies in populations with limited numbers of patients.

AIMS

The aim of the study was to perform a meta‑analysis of observational studies comparing RA with OA for calcified lesions prior to percutaneous coronary intervention.

METHODS

Electronic databases were searched for studies comparing short‑term outcomes of RA with OA prior to percutaneous coronary intervention. Risk ratios (RRs) or mean differences (MD) and 95% confidence intervals (CIs) were calculated using a random‑effects model.

RESULTS

Meta‑analysis included 6 retrospective studies with 1590 patients treated with RA and 721 with OA. The latter was associated with shorter fluoroscopy time (MD, -3.40 min; 95% CI, -4.76 to -2.04; P <0.001, I2 = 0%), but contrast use was similar (MD, -2.78 ml; 95% CI, -16.04 to 10.47; P = 0.68; I2 = 67%). Although coronary dissection occurred 4‑fold more frequently with OA (RR, 3.87; 95% CI, 1.37-10.93; P = 0.01; I2 = 0%), perforations (RR, 2.73; 95% CI, 0.46-16.30, P = 0.27; I2 = 41), tamponade (RR, 1.78; 95% CI, 0.37-8.58; P = 0.47; I2 = 0%), and slow or no‑reflow phenomenon (RR, 0.81; 95% CI, 0.35-1.84; P = 0.61; I2 = 0%) occurred with similar frequency. The risk of 30‑day or in‑hospital myocardial infarction was lower in OA as compared with RA (RR, 0.67; 95% CI, 0.47-0.94; P = 0.02; I2 = 0%), yet the risk of in‑hospital mortality (RR, 0.73; 95% CI, 0.11-4.64; P = 0.74; I2 = 43%) and length of stay (MD, -0.27 days; 95% CI, -0.76 to -0.23; P = 0.29; I2 = 0%) did not differ.

CONCLUSIONS

Orbital atherectomy was associated with a lower risk of early myocardial infarction. However, a higher rate of coronary dissections produced by OA did not translate into increased risk of perforations, slow or no‑reflow phenomenon, or in‑hospital mortality.

Long-term follow-up and safety assessment of angiogenic gene therapy trial VIF-CAD: Transcatheter intramyocardial administration of a bicistronic plasmid expressing VEGF-A165/bFGF cDNA for the treatment of refractory coronary artery disease

There have been a number of angiogenic gene therapy trials, yielding mixed results as to efficacy, but demonstrating uniform short-term treatment safety. Data regarding long-term safety of angiogenic gene therapy are limited. Double-blind VIF-CAD trial (NCT00620217) assessed myocardial perfusion and clinical data in 52 refractory coronary artery disease (CAD) patients randomized into treatment (VIF; n = 33) and Placebo (n = 19) arms. VIF group received electromechanical system NOGA-guided intramyocardial injections of VEGF-A165/bFGF plasmid (VIF) into ischemic regions, while the Placebo group-placebo plasmid injections. Full 1-year follow-up data have been published. This study presents the results of over 10-year (median 133 months, range 95-149) safety follow-up of VIF-CAD patients. Overall, 12 (36.4%) patients died in VIF and 8 (42.1%) in Placebo group (P = .68). Cardiovascular mortality was 12/33 (36.4%) in the VIF group and 6/19 (31.6%) in Placebo group (P = .73). Two Placebo patients died due to malignancies, but no VIF patients (P = .17). The Kaplan-Meier curves of combined endpoint: cardiovascular mortality, myocardial infarction and stroke were similar for both patient groups (P = .71). Odds ratio of Placebo group increasing (reaching a worse) their CCS class versus VIF was non-significant (OR 1.28, 95% CI = 0.66-2.45; P = .47). However, CCS class improved in time irrespectively of treatment-OR of reaching a less favorable CCS class per each year of follow-up was 0.74 (95% CI 0.685-0.792; P < .0001, pooled data). There were no differences in readmission rates. Intramyocardial VEGF-A165/bFGF plasmid administration appears safe, with no evidence of an increase in the incidence of death, malignancy, myocardial infarction or stroke during 10-year follow-up in this limited patient population.

Higher admission glycaemia independently of diagnosed or unrecognised diabetes mellitus is a risk factor for failed myocardial tissue reperfusion and higher mortality after primary angioplasty

BACKGROUND AND AIM

Admission hyperglycaemia worsens reperfusion in ST-segment elevation myocardial infarction (STEMI). ST-segment elevation resolution parallels myocardial tissue reperfusion and predicts the outcome of primary percutaneous coronary intervention (pPCI).

METHODS

We investigated whether higher glycaemia on admission impairs tissue-level reperfusion after pPCI for STEMI, as-sessed with the single-lead Schröder method of ST-segment resolution analysis (maxSTE).

RESULTS

Among 323 patients (60.4 ± 11.5 years, 27.8% female), 13.4% of nondiabetic subjects and 58.2% of those with known diabetic history (17%) were admitted with glycaemia > 11.1 mmol/L. Failed tissue reperfusion, recognised if high-risk maxSTE criteria were fulfilled, was present among 25% of patients. The overall 180-day mortality rate was 6.8% (n = 22). Admission glycaemia ≥ 8.75 mmol/L appeared as the single risk factor for failed tissue reperfusion (ROC area = 0.638, standard error = 0.038, p < 0.001). Even after adjustment for diabetes history, patients with admission glycaemia ≥ 8.75 mmol/L (44.5%) had 2.36-fold higher risk (95% confidence interval [CI] 1.25-4.46, p = 0.008) of failed tissue reperfusion. After exclusion of patients with known diabetes and those with acute blood glucose level > 11.1 mmol/L (28%), admission glycaemia remained an independent predictor of failed tissue reperfusion (odds ratio [OR] 1.32, 95% CI 1.03-1.69, p = 0.028). Admission glycae-mia and failed tissue reperfusion (high- vs. low-risk maxSTE category) were the independent predictors of 180-day mortality (OR 1.18, 95% CI 1.05-1.32, p = 0.004 and OR 3.84, 95% CI 1.12-13.21, p = 0.033, respectively).

CONCLUSIONS

Higher admission glycaemia in patients treated with pPCI for STEMI predicts failed myocardial tissue reperfusion and 180-day mortality, independently of prior or acute diabetic status.

Coronary computed tomography angiography for the assessment of SYNTAX score

BACKGROUND

Coronary computed tomography angiography (CCTA) is applied in a growing number of clinical indications. This imaging modality is often regarded as a surrogate of invasive coronary angiography (ICA). In this paper we evaluate the applicability of CCTA alone in the assessment of the SYNTAX score.

AIM

To evaluate the feasibility of calculating the SYNTAX score (SXScore) using CCTA alone instead of ICA.

METHODS

Ninety consecutive patients with multivessel or left main (LM) coronary artery disease diagnosed with ICA, in whom prior CCTA scan was available, were included in a post-hoc analysis. First, the SXScore was calculated twice in ten-week intervals by two experienced observers using ICA for each patient. Then the SXScore was calculated twice using CCTA following the same regimen for each patient. Weighted kappa statistic was used to assess the intra-modality and inter-modality reproducibility of the SXScore.

RESULTS

Ninety patients, aged 63.8 ± 8.9 years, 60% male, 64.4% with two-vessel disease, and 35.6% with three-vessel or LM disease met the inclusion criteria. 287 lesions were identified by ICA and 280 by CCTA (p = 0.56). Median total SXScore was 11.5 (10.2–14.0) as calculated by ICA and 16.0 (14.3–19.4) by CCTA (p < 0.001), and the results were moderately correlated (R = 0.38). Inter-modality agreement between ICA and CCTA for SXScore tertiles was moderate (kappa = 0.40). The intra-modality reproducibility of ICA and CCTA for SXScore tertiles was 0.47 and 0.51, respectively.

CONCLUSIONS

Inter-modality agreement between CCTA and ICA for calculation of SXSscore is moderate but only slightly worse than intra-modality reproducibility for angiographic alone evaluation. Most of the observed variability can be assigned to the characteristic of the SXScore itself, not to the choice of imaging method. However, the application of CCTA for the assessment of SXScore should be used cautiously.

Workstation-Based Calculation of CTA-Based FFR for Intermediate Stenosis

OBJECTIVES

This study sought to evaluate the proportion of patients with intermediate coronary stenosis diagnosed on computed tomography angiography (CTA), which may be saved from any further testing due to use of CTA-based fractional flow reserve (FFR).

BACKGROUND

Coronary CTA often results in diagnosis of intermediate stenosis, triggering further physiological testing. CTA-based FFR (CTA-FFR) is a promising diagnostic tool, which may obviate the need for further testing. However, the specific thresholds for CTA-FFR values predicting ischemic versus nonischemic FFR with acceptable confidence are unknown, obscuring clinical utility of the diagnostic strategy using CTA-FFR.

METHODS

We analyzed 96 lesions (mean CTA stenosis: 69.7 ± 11.7%) in 90 patients (63.4 ± 8.2 years, 32% were men) who underwent CTA for suspected CAD and were diagnosed with at least 1 intermediate coronary stenosis (50% to 90%) scheduled for further physiological testing. All patients underwent routine invasive FFR and CTA-FFR evaluation. The objective was to determine the proportion of patients falling between the lower and upper CTA-FFR thresholds that predict ischemic and nonischemic stenosis, respectively (on the basis of an invasive FFR cutpoint of ≤0.80), with ≥90% accuracy.

RESULTS

The invasive FFR ≤0.8 was observed in 41 of 96 lesions (42.7%). According to Bland-Altman analysis, the CTA-FFR underestimated FFR by 0.01 and the 95% limits of agreement were ±0.19. Receiver-operating characteristic area under the curve was significantly higher for CTA-FFR than that for CTA (per lesion 0.835 vs. 0.660, respectively; p = 0.007). The CTA-FFR thresholds for which the positive and negative predictive values were each ≥90% (corresponding to an FFR of ≤0.80) were >0.87 or <0.74, respectively, encompassing 49 lesions (51%) and 45 of 90 patients.

CONCLUSIONS

In around one-half of the patients diagnosed with intermediate stenosis, coronary CTA-based FFR may confidently discriminate between ischemic versus nonischemic stenoses. Our findings require validation in an independent cohort.

Impact of coronary artery calcium characteristics on accuracy of CT angiography

OBJECTIVES

This study sought to evaluate which specific calcium characteristics impact diagnostic accuracy of coronary computed tomography angiography (CTA).

BACKGROUND

Coronary calcifications comprise one of the most significant factors interfering with diagnostic accuracy of coronary CTA. Despite this fact, there is paucity of data regarding this phenomenon.

METHODS

A total of 525 coronary lesions (252 calcified and 273 reference [noncalcified] lesions) within 97 arteries of 60 patients (19 women, age 63 ± 10 years) underwent assessment with both 2 × 64-slice computed tomography and intravascular ultrasound (IVUS). Nineteen calcium characteristics were determined. The main outcome was coronary CTA inaccuracy defined as the deviation of minimum lumen area within the calcification measured with coronary CTA from that measured with IVUS, in both absolute (mm(2)) and relative (%) terms.

RESULTS

Presence of calcification was found to be independently correlated to coronary CTA inaccuracy in both absolute and relative terms (p < 0.001 for both). The relative (%) inaccuracy of coronary CTA was independently correlated to total calcium length (p = 0.004), total calcium volume (p = 0.008), cross section calcium thickness (p = 0.023), cross section calcium area (p = 0.023), and cross section lumen area (p = 0.001). The absolute inaccuracy of CTA was correlated to calcium length (p = 0.010), calcium volume (p = 0.017), and cross section calcium area (p < 0.001). The presence of both total calcium arc ≥47° and mean lumen diameter of ≤2.8 mm provided the best predictive accuracy for detection of excessive lumen underestimation by CTA. The best accuracy for prediction of excessive lumen overestimation provided combination of 2 of 3 features: maximum calcium density <869 HU, OR whole calcium length <2.4 mm, OR total calcium volume <6.4 mm(3).

CONCLUSIONS

Our results indicate which specific calcium characteristics impact accuracy of coronary CTA in lumen assessment within calcified lesions. This may provide practical assistance in predicting coronary lumen underestimation or overestimation by coronary CTA, therefore mitigating risk of diagnostic errors in clinical practice.

Ischaemia modified albumin in patients with acute coronary syndrome and negative cardiac troponin I

BACKGROUND

Approximately 40-60% of patients with acute coronary syndrome (ACS) have normal cardiac troponin I (cTnI) concentrations on admission. Ischaemia modified albumin (IMA) has been suggested as a new biomarker of myocardial ischaemia.

METHODS

A total of 43 patients presenting with symptoms suggestive of ACS but with normal (< 0.1 μg/L) cTnI concentrations and 45 healthy subjects were studied. The patients from the study group were divided into two groups: STEMI (n = 28) and NSTEMI (n = 15). All these patients were undergoing percutaneous coronary intervention (PCI) with stenting. The concentrations of cTnI, myoglobin and IMA were determined on admission and 4 h after PCI.

RESULTS

Mean (SD) IMA concentrations were higher in patients with ACS (114.39 ± 25.18 U/ml) as compared to the control group (96.24 ± 6.28 U/ml, p < 0.005). IMA concentrations ≥ 104.0 U/ml demonstrated 72.1% sensitivity and 75.6% specificity for the diagnosis of ACS. The area under the receiver operator characteristic curve was 0.766 (95% CI 0.664-0.868) for ACS patients (NSTEMI + STEMI). In both groups increased median (IQR) cTnI concentration after PCI was observed (STEMI patients to 65.4 (10.9-106.9) μg/L and NSTEMI to 17.6 (0.77-84.0) μg/L). In contrast, no increase in IMA concentration was observed.

CONCLUSIONS

IMA may be a useful biomarker for the identification of ACS patients presenting with typical acute chest pain and/or abnormal electrocardiograms but negative cTnI.

Adrenomedullin concentrations at two time points following myocardial infarction and prediction of mid-term outcomes

INTRODUCTION

Adrenomedullin (ADM) is a vasopeptide with multiple actions in the cardiovascular system and a potentially powerful tool in comparison to some of the well-established unimodal biomarkers of risk stratification in myocardial infarction (MI). Previous studies on ADM in acute MI were based on single assessment. Therefore the aim of the study was to examine the relation between ADM plasma concentrations assessed at different time points following MI and outcomes.

MATERIAL AND METHODS

The study included 127 patients with acute MI treated with percutaneous coronary intervention and 60 healthy individuals as controls. Adrenomedullin concentration was assessed at baseline in all study subjects and 48 h after admission in patients with MI. The primary endpoint consisted of all-cause death, nonfatal myocardial infarction, stroke and the need of target vessel revascularization at 6-month follow-up.

RESULTS

Mean ADM plasma concentration on admission was higher in patients with MI than in controls (30.3 ±14.3 pmol/l vs. 14.6 ±4.7 pmol/l, p < 0.0001). There was no significant difference between ADM concentration after 48 h (30.6 ±12.3 pmol/l) and on admission. The primary endpoint occurred in 9.4% of patients with MI. Multivariable analysis showed that ADM concentration at 48 h after admission (OR = 2.121, 95% CI 1.180-3.810 for every increase of 10 pmol/l, p = 0.012) was the only independent predictor of the primary endpoint.

CONCLUSIONS

In patients with acute MI adrenomedullin plasma concentration assessed at 48 h after admission, but not ADM concentration at baseline, is an independent predictor of major adverse cardiovascular events at mid-term follow-up.

Computed tomography angiography for visualisation of distal coronary arteries and selection for surgical revascularisation in a patient with acute myocardial infarction

Patients with symptomatic multivessel coronary artery disease rejected for coronary revascularisation have adverse prognosis. We describe a 61 year-old male with non-ST-elevation myocardial infarction who was considered unsuitable for coronary revascularisation based on the conventional angiography findings. Unlike conventional angiography, computed tomography angiography visualised distal coronary segments and the patient underwent successful coronary artery bypass grafting.