Clinical and angiographic outcomes following percutaneous treatment of non-occlusive vs. chronically total occluded coronary lesions

Background

Recent advancements in recanalization techniques, introduction of dedicated equipment and elaboration of systematic algorithmic approaches have significantly improved procedural success of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures. However, despite their undisputable merits in terms of procedural success, direct comparisons of mid-term clinical and angiographic outcomes following CTO and non-CTO-PCI are missing.

Purpose

The aim of this study was to assess the clinical and angiographic outcomes of patients undergoing successful CTO-PCI as compared to a propensity matched cohort of patients undergoing PCI of non-occlusive coronary lesions.

Methods

All consecutive patients undergoing successful CTO recanalization procedures at our center between 2015 and 2018 were included (N=453; 472 lesions). For matching purposes, all patients undergoing non-CTO-PCI present in our database were included (N=14733; 23458 lesions). A 1-to-1 nearest neighbour matching using baseline clinical and angiographic variables was performed to identify one patient undergoing non-CTO-PCI (N=453; 472 vessels) for each patient undergoing CTO-PCI (N=453; 472 vessels). Surveillance angiography was scheduled at 6–9 months and clinical follow-up was performed up to 12 months. The primary clinical endpoint of interest was the incidence of major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR). The secondary angiographic endpoint was in-segment binary restenosis.

Results

Patients undergoing CTO-PCI displayed a tendency towards higher degrees of binary restenosis at surveillance angiography as compared to those undergoing non-CTO-PCI (CTO vs. non-CTO: 30.5% vs. 24.0%; P=0.058), despite not meeting statistical significance. Of note, the incidence of occlusive restenosis was low and comparable between groups (2.2% vs. 1.4%; P=0.603). At 12 months follow-up, MACE occurred in 83 patients (19.7%) in the CTO-PCI and 59 patients (14.1%) in the non-CTO-PCI group (hazard ratio [HR] = 1.44; 95% confidence interval [CI]: 1.03–2.01; P=0.033). TLR rates were significantly higher following CTO- as compared to non-CTO-PCI (17.2% vs. 10.3%; HR=1.72 [1.18–2.51], P=0.005). The incidence of all-cause death (2.6% vs. 3.3%; P=0.548) and MI (0.5% vs. 1.4%; P=0.177) was not significantly different between the groups.

Conclusion

In this large, propensity-matched comparison of clinical and angiographic outcomes following CTO- vs. non-CTO-PCI, we found CTO-PCI to be associated with a higher MACE rate at 12 months, primarily driven by significantly higher TLR rates. The incidence of occlusive restenosis was low and comparable between groups.

Funding Acknowledgement

Type of funding sources: None.

Ticagrelor or prasugrel in patients with acute coronary syndrome and high bleeding risk

Background

The relative efficacy and safety of more potent P2Y12 inhibitors in patients with acute coronary syndrome (ACS) and high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI) remains unclear.

Purpose

To study the treatment effect of ticagrelor and prasugrel in PCI patients presenting with ACS and HBR.

Methods

This post-hoc analysis of the ISAR-REACT 5 trial included patients with ACS undergoing PCI, randomized to ticagrelor or prasugrel, in whom HBR was defined as per Academic Research Consortium criteria. The primary (efficacy) endpoint was the composite of all-cause death, myocardial infarction, or stroke. The secondary (safety) endpoint was Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding. Outcomes were assessed 12 months after randomisation.

Results

Out of the 3,239 patients included in this analysis, 486 fulfilled the criteria for ARC-HBR definition (HBR group; ticagrelor, n=230 and prasugrel, n=256), whilst 2,753 did not (non-HBR group; ticagrelor, n=1,375 and prasugrel, n=1,378). Compared to the non-HBR group, the HBR group had a higher risk for the primary (hazard ratio [HR]=3.57, 95% confidence interval [CI], 2.79–4.57, p<0.001), and secondary endpoint (HR=2.94 [2.17–3.99], p<0.001). In the HBR group, the primary (HR=1.09; [0.73–1.62]) and secondary (HR=1.18 [0.67–2.08]) endpoints were not statistically different between patients assigned to ticagrelor and prasugrel. In the non-HBR group, the primary endpoint (HR=1.62 [1.19–2.20]) occurred more frequently in patients assigned to ticagrelor as compared to patients assigned to prasugrel, without difference in safety (HR=1.08 [0.74–1.58]). There was no treatment allocation-by-HBR status interaction with respect to the primary (p for interaction = 0.123), or secondary (p for interaction = 0.803) endpoints.

Conclusions

In patients with ACS undergoing PCI, HBR status increased both ischemic and bleeding risks without significant impact on the relative efficacy or safety of ticagrelor versus prasugrel. These results warrant confirmation in larger cohorts.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Center for Cardiovascular Research (DZHK)Deutsches Herzzentrum München

Ticagrelor or prasugrel in patients with acute coronary syndrome and prior myocardial infarction

Objectives

To investigate the efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndrome (ACS) and prior myocardial infarction (MI).

Background

The efficacy and safety of ticagrelor versus prasugrel in ACS patients with prior MI remains unstudied.

Methods

Patients with ACS scheduled for an invasive strategy and randomized to ticagrelor or prasugrel in the ISAR-REACT 5 trial with available information concerning prior MI were included in the present analysis. The primary endpoint was the composite of all-cause death, myocardial infarction, or stroke; the secondary endpoint was Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding. Endpoints were assessed 12 months after randomization.

Results

A total of 4,015 patients were included in this analysis (prior MI= 631 patients; no prior MI = 3,384 patients). As compared to patients without prior MI, the primary endpoint occurred more frequently in patients with prior MI (12.6% vs. 7.2%; hazard ratio [HR] = 1.78, 95% confidence interval [CI] 1.38–2.29; p= <0.001) without significant difference in terms of secondary endpoint between groups (5.8% vs. 5.7%; HR=1.02 [0.71–1.45]; p=0.921). Patients with prior MI randomized to ticagrelor versus prasugrel displayed higher risk for primary (HR=1.62 [1.03–2.55]) but not secondary endpoint (HR=1.28 [0.56–2.91]). Patients without prior MI randomized to ticagrelor or prasugrel displayed no significant difference in terms of primary (HR=1.28 [0.99–1.65]) or secondary endpoints (HR=1.13 [0.82–1.55]). There was no treatment assignment-by-prior MI status interaction with respect to the primary (p for interaction = 0.373) and the secondary (p for interaction= 0.786) endpoints.

Conclusions

Patients with ACS and prior MI are at higher risk for recurrent ischemic but not bleeding events. The history of MI does not affect the relative efficacy and safety of ticagrelor versus prasugrel in patients with ACS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Center for Cardiovascular Research (DZHK)Deutsches Herzzentrum München

[Technical armamentarium for chronic total occlusion of coronary vessels]

Percutaneous revascularization of chronic total occlusion (CTO) of coronary vessels represents a major challenge for contemporary interventional cardiologists. In the last decade there has been an unprecedented effort towards the standardization of revascularization procedures for CTO of coronary vessels. This endeavour has been possible by virtue of the growing interest of various cardiological societies for this patient group. Along with supportive endovascular technologies and percutaneous devices specifically dedicated to this interventional target, the increasing experience of interventionalists enabled continuously growing success for revascularization of CTO of coronary vessels. This review article highlights the currently available tools as well as technologies, techniques and strategies for the percutaneous recanalization of CTO of coronary vessels.

Influence of treatment modality and neointimal characteristics on optical coherence tomography on clinical outcomes of in-stent restenosis

Background

In-stent restenosis (ISR) represents the more frequent modality of stent failure. The currently recommended treatment strategies are represented by repeat drug-eluting stent (DES) implantation or drug-coated balloon (DCB) angioplasty. Optical coherence tomography can display important information regarding mechanisms of stent failure as well as neointimal characterization.

Purpose

Aim of the present study was to determine the impact of treatment modality (DES vs. DCB) as well as neointimal characteristics (homogeneous vs. non-homogeneous) as determined by intravascular OCT, on clinical outcomes and explore whether there is an interaction between neointimal pattern of ISR and treatment modality.

Methods

Patients presenting with ischemic symptoms and/or evidence of myocardial ischemia in three European centers and undergoing intravascular OCT prior to percutaneous coronary intervention (PCI) for ISR, were retrospectively included in this study. Characterization of neointimal tissue was performed at the frame displaying the maximal %AS as well as the 5 preceding and following analyzed frames. Each frame was subdivided in 4 quadrants (90°) and the neointimal characteristics separately characterized for each of them. Based on its optical characteristics, neointimal tissue was categorized as homogeneous, heterogeneous, layered or neoatherosclerosis.

Based on the dominant neointimal type, the study population was divided in two groups, (predominantly homogeneous and non-homogeneous). Primary endpoints of the study were represented by major adverse cardiac events (MACE) and its idividual components (death, cardiac death, myocardial infarction and target lesion revascularization (TLR)) at 2 years follow-up.

Results

A total of 197 patients undergoing OCT prior to PCI for ISR were included in this study. 100 patients were classified as having predominantly homogeneous and 97 as having predominantly non-homogeneous neointima.

No association was found between predominant OCT pattern (homogenous vs. non-homogenous) and MACE at 2 years follow-up (HR=1.01, 95% CI: 0.59–1.75; p=0.94), or the individual MACE components. Analogously, no significant differences in terms of MACE at 2 years were found between predominantly homogeneous vs. non-homogeneous neointima in the patient subgroup receiving a DES (p=0.10) and in that undergoing DCB treatment (p=0.11).

However, a significant interaction was found between neointimal tissue pattern and treatment modality in terms of MACE (p=0.02) aa well as death or MI (p=0.016). Predominantly non-homogeneous neointima in patients treated with DCB was associated with a higher incidence of MACE.

Conclusions

Our results indicate that there is a significant interaction between treatment modality of ISR (DES vs. DCB) and neointimal pattern as determined by intravascular OCT. These results land initial support to an OCT-guided treatment of ISR and should be confirmed by larger trials.

Funding Acknowledgement

Type of funding source: None

Angiographic and clinical outcomes of patients treated with everolimus-eluting bioresorbable stents in routine clinical practice: Results of the ISAR-ABSORB registry

OBJECTIVES

We aimed to analyze angiographic and clinical results of patients undergoing BRS implantation in a real-world setting.

BACKGROUND

Angiographic and clinical outcome data from patients undergoing implantation of drug-eluting bioresorbable stents (BRS) in routine clinical practice is scant.

METHODS

Consecutive patients undergoing implantation of everolimus-eluting BRS at two high-volume centers in Munich, Germany were enrolled. Data were collected prospectively. All patients were scheduled for angiographic surveillance 6-8 months after stent implantation. Quantitative coronary angiographic analysis was performed in a core laboratory. Clinical follow-up was performed to 12 months and events were adjudicated by independent assessors.

RESULTS

A total of 419 patients were studied. Mean age was 66.6 ± 10.9 years, 31.5% had diabetes mellitus, 76.1% had multivessel disease, and 39.0% presented with acute coronary syndrome; 49.0% of lesions were AHA/ACC type B2/C, 13.1% had treatment of bifurcation lesions. Mean reference vessel diameter was 2.89 ± 0.46 mm. At angiographic follow-up in-stent late loss was 0.26 ± 0.51 mm, in-segment diameter stenosis was 27.5 ± 16.1, and binary angiographic restenosis was 7.5%. At 12 months, the rate of death, myocardial infarction, or target lesion revascularization was 13.1%. Definite stent thrombosis occurred in 2.6%.

CONCLUSIONS

The use of everolimus-eluting BRS in routine clinical practice is associated with high antirestenotic efficacy in patients undergoing angiographic surveillance. Overall clinical outcomes at 12 months are satisfactory though stent thrombosis rates are not insignificant. Further study with longer term follow-up and larger numbers of treated patients is required before we can be sure of the role of these devices in clinical practice.

[New ESH/ESC guidelines on arterial hypertension : what is new and what indications remain for renal denervation?]

Arterial hypertension is one of the most common diseases in the western world and one of the most important risk factors for other cardiovascular diseases. Despite widespread therapeutic options, there is still a large proportion of patients with uncontrolled hypertension. The new European guidelines on hypertension give clear lines of action for diagnosis and treatment sorted into appropriate evidence levels based on current scientific data. Such evidence is still unclear for renal denervation so that no clear recommendations can be given.

Combined immunophenotyping and fluorescence in situ hybridization with chromosome-specific DNA probes allows quantification and differentiation of ex vivo generated dendritic cells, leukemia-derived dendritic cells and clonal leukemic cells in patients with acute myeloid leukemia

Antileukemic T-cell responses induced by leukemia-derived dendritic cells (DC(leu)) are variable, due to varying DC/DC(leu) composition/quality. We studied DC/DC(leu) composition/quality after blast culture in four DC media by flow cytometry (FC) and combined fluorescence in situ hybridization/immunophenotyping analysis (FISH-IPA). Both methods showed that DC methods produce variable proportions of DC subtypes. FISH-IPA is an elaborate method to study clonal aberrations in blast/DC cells on slides, however without preselection of distinct cell populations for FISH analysis. FISH-IPA data proved previous FC data: not every clonal/blast cell is converted to DC(leu) (resulting in various proportions of DC(leu)) and not every detectable DC is of clonal/leukemic origin. Preselection of the best of four DC methods for "best" DC/DC(leu) generation is necessary. DC(leu) proportions correlate with the antileukemic functionality of DC/DC(leu)-stimulated T-cells, thereby proving the necessity of studying the quality of DC/DC(leu) after culture. FC is the superior method to quantify DC/DC(leu), since a blast phenotype is available in every given patient, even with low/no proportions of clonal aberrations, and can easily be used to study cellular compositions after DC culture.

Serum-free generation and quantification of functionally active Leukemia-derived DC is possible from malignant blasts in acute myeloid leukemia and myelodysplastic syndromes

Functional dendritic cells (DC) are professional antigen presenting cells (APC) and can be generated in vitro from leukemic cells from acute myeloid leukemia AML patients, giving rise to APC of leukemic origin presenting leukemic antigens (DC(leu)). We have already shown that DC can be successfully generated from AML and myeloplastic syndromes (MDS) cells in serum-free 'standard' medium (X-vivo + GM-CSF + IL-4 +TNFalpha + FL) in 10-14 days. In this study, we present that DC counts generated from mononuclear cells (MNC) varied between 20% (from 55 MDS samples), 34% (from 100 AML samples) and 25% (from 38 healthy MNC samples) medium. Between 53% and 58% of DC are mature CD83+ DC. DC harvests were highest in monocytoid FAB types (AML-M4/M5, MDS-CMML) and independent from cytogenetic risk groups, demonstrating that DC-based strategies can be applied for patients with all cytogenetic risk groups. Proof of the clonal derivation of DC generated was obtained in five AML and four MDS cases with a combined FISH/immunophenotype analysis (FISH-IPA): The clonal numerical chromosome aberrations of the diseases were regularly codetectable with DC markers; however, not with all clonal cells being convertible to leukemia-derived DC(leu) (on average, 53% of blasts in AML or MDS). To the contrary, not all DC generated carried the clonal aberration (on average, 51% of DC). In 41 AML and 13 MDS cases with a suitable antigen expression, we could confirm FISH-IPA data by Flow cytometry: although DC(leu) are regularly detectable, on average only 57% of blasts in AML and 64% of blasts in MDS were converted to DC(leu). After coculture with DC in mixed lymphocyte reactions (MLR), autologous T cells from AML and MDS patients proliferate and upregulate costimulatory receptors. The specific lysis of leukemic cells by autologous T cells could be demonstrated in three cases with AML in a Fluorolysis assay. In six cases with only few DC(leu) or few vital T cells available after the DC/MLR procedure, no lysis of allogeneic or autologous leukemic cells was seen, pointing to the crucial role of both partners in the lysis process. We conclude: (1) the generation of DC is regularly possible in AML and also in MDS under serum-free conditions. (2) Clonal/leukemia-derived DC(leu) can be regularly generated from MDS and AML-MNC; however, not with all blasts being converted to DC(leu) and not all DC generated carrying leukemic markers. We recommend to select DC(leu) for vaccinations or ex vivo T-cell activations to avoid contaminations with non-converted blasts and non-leukemia-derived DC and to improve the harvest of specific, anti-leukemic T cells. DC and DC-primed T cells could provide a practical strategy for the immunotherapy of AML and MDS.

Leukemia-Derived Dendritic Cells can be Generated from Blood or Bone Marrow Cells from Patients with Acute Myeloid Leukaemia: A Methodological Approach under Serum-Free Culture Conditions

Functional dendritic cells (DC) are professional antigen-presenting cells (APC) and can be generated in vitro from healthy as well as from leukaemic cells from acute myeloid leukemia (AML) patients giving rise to APC of leukaemic origin-presenting leukaemic antigens. We describe the generation and characterization of DC from different mononuclear cell (MNC) fractions from 50 AML patients under different serum-free culture conditions, determine the optimal culture conditions and compare the results with that from 23 healthy donors. In parallel cultures, we compared DC harvests after 7- or 14-day culture, with total or adherent MNC or T-cell depleted MNC or peripheral blood (PB) or bone marrow-MNC (BM-MNC), thawn or fresh MNC, in Xvivo or CellGro serum-free media, +/-10% autologous plasma or +/-FL. In detail, we could show that AML-DC harvests were higher after 10-14 days culture (healthy DC: 7 days); total or adherent PB or BM-MNC fractions yield comparable DC counts, however, from magnetic cell sorting (MACS)-depleted MNC fractions or thawn MNC lower DC counts can be generated. Whereas the addition of FL increases the DC harvest, the addition of autologous plasma in many cases has inhibitory influence on DC maturation. CellGro and Xvivo media yield comparable DC counts. Optimal harvest of vital and mature DC from AML samples was obtained with a granulocyte/macrophage-colony stimulating factor, interleukin-4, FL and tumour necrosis factor-alpha-containing serum-free Xvivo medium after 10-14 days of culture (36/26% DC; 38/64% vital DC; 46/51% mature DC were generated from AML/healthy MNC samples). Surface marker profiles (e.g. costimulatory antigen expressing) of DC obtained from AML samples were comparable with that of healthy DC. The leukaemic derivation of AML-DC was demonstrated by the persistence of the clonal cytogenetic aberration in the DC or by coexpression of leukaemic antigens on DC. Autologous T-cell activation of leukaemia-derived DC was demonstrated in cases with AML. Autologous T cells proliferate and upregulate DC-contact-relevant antigens. We demonstrate that the generation of leukaemia-derived DC is feasable in AML under serum-free culture conditions giving rise to DC with comparable characteristics as healthy DC and offering an anti-leukaemia-directed immunotherapeutical vaccination strategy in AML.

Leukaemia-Derived Dendritic Cells Can Be Generated From Blood or Bone Marrow Cells From Patients With Myelodysplasia: A Methodological Approach Under Serum-Free Culture Conditions

Functional dendritic cells (DC) are professional antigen-presenting cells (APC) and can be generated in vitro from healthy as well as from leukaemic cells from AML patients giving rise to APC of leukaemic origin presenting leukaemic antigens. In a comparative methodological analysis of 50 AML samples, we could already show that leukaemia-derived DC can regularly be generated under serum-free culture conditions. In this study, we describe the generation and characterization of DC from different mononuclear cell (MNC) fractions from 24 myelodysplastic syndrome (MDS) patients under those different serum-free culture conditions, determine the optimal culture conditions and compare the results with that from 23 healthy donors. In parallel cultures, we compared DC harvests after 7- or 14-day culture, with total or adherent MNC or T-cell-depleted MNC or PB or BM-MNC, thawn or fresh MNC, in Xvivo or CellGro serum-free media, +/-10% autologous plasma or +/-FL. In detail, we could show that MDS-DC harvests compared to healthy DC were higher after 10- to 14-day culture; total or adherent PB or BM-MNC fractions yield comparable DC counts; however, from MACS-depleted MNC fractions or thawn MNC lower DC counts can be generated. Whereas the addition of FL increases the DC harvest, the addition of autologous plasma in many cases has inhibitory influence on DC maturation, CellGro and Xvivo media yield comparable DC counts. Optimal harvest of vital and mature DC from MDS samples was obtained with a GM-CSF, IL-4, FL and TNF-alpha containing serum-free Xvivo medium after 10-14 days of culture (18/26% DC; 54/64% vital DC; 59/51% mature DC were generated from MDS/healthy MNC samples). Surface marker profiles (e.g. costimulatory antigen expression) of DC obtained from MDS samples were comparable with that of healthy DC. The leukaemic derivation of MDS-DC was demonstrated by the persistence of the clonal cytogenetic aberration in the DC or by coexpression of leukaemic antigens on DC. Autologous T-cell activation of leukaemia-derived DC was demonstrated in cases with MDS. Autologous T cells proliferate and upregulate DC-contact-relevant antigens. We are the first who demonstrate that the generation of leukaemia-derived DC is feasible not only in AML but also in MDS under serum-free culture conditions giving rise to DC with comparable characteristics as healthy DC and offering an antileukaemia-directed immunotherapeutical vaccination strategy in AML and MDS.

Microlenses fabricated by ultraviolet excimer laser irradiation of poly(methyl methacrylate) followed by styrene diffusion

A new technique of microlens array fabrication based on the use of excimer laser radiation is described. Poly(methyl methacrylate) (PMMA) substrates are treated with many low-energy KrF laser pulses and exposed to styrene vapor. The irradiated material swells, producing spherical microlenses that are stabilized by UV polymerization. The chemistry of this process and the optical quality of the lenses are discussed.

Monolithic integration of microlens arrays and fiber holder arrays in poly(methyl methacrylate) with fiber self-centering

For many fiber applications the precise spacing from one fiber to another and the collimation of the outgoing light are important subjects. In the case of three-dimensional arrangements, such as fiber arrays, the complexity increases. The method of proton irradiation of poly(methyl methacrylate) permits the fabrication of slightly fan-shaped fiber holder arrays that can correct inhomogeneities of the fiber diameters in the micrometer range. Even a three-dimensional monolithic integration of fiber holders and corresponding microlenses can be achieved.

Application of three-dimensional micro-optical components formed by lithography, electroforming, and plastic molding

Micro-optics is usually associated with planar waveguides or integrated optical circuits. In this case the propagation of light is restricted to one or two dimensions, and the three-dimensional nature of light propagation is disregarded. We present a method of fabricating three-dimensional micro-optical components by the so-called LIGA process, a lithography, electroforming, and plastic molding process in which poly(methyl methacrylate) is structured by high-energy synchrotron radiation. We demonstrate an experimental system of image formation that uses microprisms and microlenses for a threedimensional microintegration of optical components.

Microlenses in polymethyl methacrylate with high relative aperture

Lens arrays with relative apertures as high as 1 can be fabricated in polymethyl methacrylate with a high-energy H+b eam and diffusion of styrene in the irradiatedd omains.

H(+) lithography for 3-D integration of optical circuits

Optical structures in polymethylmethacrylate can be generated with a high energy H(+) beam. The depth of the structures is up to 1 mm. We describe this new technique and demonstrate first results.

Highly parallel arithmetic algorithms for a digital optical processor using symbolic substitution logic

Symbolic substitution logic is a powerful tool for realizing optical arithmetic in a digital optical processor, because it is matched to the parallelism of optics and to the properties of optical switching devices. Working with such processor enables the use of very efficient parallel algorithms. We have investigated the implemention of the basic arithmetic operations: addition, subtraction, multiplication, and division.