Impact of coronary calcium morphology on intravascular lithotripsy

BACKGROUND

Coronary calcification negatively impacts optimal stenting. Intravascular lithotripsy (IVL) is a new calcium modification technique.

AIMS

We aimed to assess the impact of different calcium morphologies on IVL efficacy.

METHODS

This was a prospective, multicentre study (13 tertiary referral centres). Optical coherence tomography (OCT) was performed before and after IVL, and after stenting. OCT-defined calcium morphologies were concentric (mean calcium arc >180°) and eccentric (mean calcium arc ≤180°). The primary outcomes were angiographic success (residual stenosis <20%) and the presence of fracture by OCT in concentric versus eccentric lesions.

RESULTS

Ninety patients were included with a total of 95 lesions: 47 concentric and 48 eccentric. The median number of pulses was 60 (p=1.00). Following IVL, the presence of fracture was not statistically different between groups (79.0% vs 66.0% for concentric vs eccentric; p=0.165). The number of fractures/lesion (4.2±4.4 vs 2.3±2.8; p=0.018) and ≥3 fractures/lesion (57.1% vs 34.0%; p=0.029) were more common in concentric lesions. Angiographic success was numerically but not statistically higher in the concentric group (87.0% vs 76.6%; p=0.196). By OCT, no differences were noted in final minimum lumen area (5.9±2.2 mm2 vs 6.2±2.1 mm2; p=0.570), minimum stent area (5.9±2.2 mm² vs 6.25±2.4 mm2; p=0.483), minimum stent expansion (80.9±16.7% vs 78.2±19.8%), or stent expansion at the maximum calcium site (100.6±24.2% vs 95.8±27.3%) (p>0.05 for all comparisons of concentric vs eccentric, respectively). Calcified nodules were found in 29.5% of lesions; these were predominantly non-eruptive (57%). At the nodule site, dissection was more common than fracture with stent expansion of 103.6±27.2%.

CONCLUSIONS

In this prospective, multicentre study, the effectiveness of IVL followed by stenting was not significantly affected by coronary calcium morphology.

Commissural alignment and the ACURATE neo2 transcatheter aortic valve: Impact on valve performance

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is increasingly being used to treat severe aortic stenosis in younger patients. Accordingly, lifetime management regarding future reintervention and coronary access is a concern.

AIMS

To assess the impact of commissural alignment on ACURATE neo2 transcatheter aortic valve (TAV) performance.

METHODS

COMALIGN-neo2 was an observational, retrospective study enrolling consecutive TAVR patients treated with the ACURATE neo2 (October 2021 to October 2022). The degree of commissural (mis)-alignment (CMA) with the native aortic valve commissures was determined and transvalvular gradient, effective orifice area, patient-prosthesis mismatch (PPM), and aortic regurgitation (AR) were assessed.

RESULTS

Among 825 patients, the mean age was 80.7 years and 42% were female. Commissural alignment was achieved in 60% of cases; mild (26%), moderate (9%), and severe misalignment (5%) were found less often. Severe PPM occurred more frequently in patients with severe CMA (14.7%) compared to aligned valves (p = 0.034). By multivariate analysis, severe CMA (odds ratio [OR]: 3.12, 95% confidence interval [CI] [1.09-8.90]; p = 0.033) and lack of postdilatation (OR: 3.85, [1.33-11.1]; p = 0.012) were associated with severe PPM. Higher rates of ≥mild AR (51.4%) were found in TAVs implanted with severe CMA compared to aligned (34.3%), mildly (38.1%) or moderately (36.0%) misaligned TAVs (p = 0.030). Multivariate analysis identified severe CMA (OR: 2.05, [1.05-4.02]; p = 0.037) to be an independent predictor of ≥mild AR.

CONCLUSIONS

COMALIGN-neo2 is the largest study to date assessing the impact of commissural alignment on acute TAV performance. Severe CMA with the ACURATE neo2 platform was associated with worse valve hemodynamics and increased risk for mild AR.

A Prospective, Multicenter, Real-World Registry of Coronary Lithotripsy in Calcified Coronary Arteries: The REPLICA-EPIC18 Study

BACKGROUND

Intravascular lithotripsy (IVL) has demonstrated effectiveness in the treatment of calcified lesions in selected patients with stable coronary disease.

OBJECTIVES

The authors sought to assess the performance of coronary IVL in calcified coronary lesions in a real-life, all comers, setting.

METHODS

The REPLICA-EPIC18 study prospectively enrolled consecutive patients treated with IVL in 26 centers in Spain. An independent core laboratory performed the angiographic analysis and event adjudication. The primary effectiveness endpoint assessed procedural success (successful IVL delivery, final diameter stenosis <20%, and absence of in-hospital major adverse cardiovascular events [MACE]). The primary safety endpoint measured freedom from MACE at 30 days. A predefined substudy compared outcomes between acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) patients.

RESULTS

426 patients (456 lesions) were included, 63% of the patients presenting with ACS. IVL delivery was successful in 99% of cases. Before IVL, 49% of lesions were considered undilatable. The primary effectiveness endpoint was achieved in 66% of patients, with similar rates among CCS patients (68%) and ACS patients (65%). Likewise, there were no significant differences in angiographic success after IVL between CCS and ACS patients. The rate of MACE at 30 days (primary safety endpoint) was 3% (1% in CCS and 5% in ACS patients [P = 0.073]).

CONCLUSIONS

Coronary IVL proved to be a feasible and safe procedure in a "real-life" setting, effectively facilitating stent implantation in severely calcified lesions. Patients with ACS on admission showed similar angiographic success rates but showed a trend toward higher 30-day MACE compared with patients with CCS. (REPLICA-EPIC18 study [Registry of Coronary Lithotripsy in Spain]; NCT04298307).

Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond

The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.

Comprehensive Assessment of Myocardial Ischemia Mechanisms in the Catheterization Laboratory: Design and Rationale of the Advanced Invasive Diagnosis Strategy for Patients with Stable Coronary Syndromes Undergoing Coronary ANGIOgraphy - the AID-ANGIO Study

BACKGROUND

The diagnostic yield of invasive coronary angiography (ICA) to identify obstructive coronary artery disease in the context of chronic coronary syndromes (CCS) is very low. Furthermore, myocardial ischemia may have a non-obstructive origin, which cannot be detected by ICA.

METHODS

AID-ANGIO is an observational, prospective, single-cohort, multicenter study, intended to evaluate the diagnostic yield of adopting a hierarchical strategy to assess obstructive and non-obstructive causes of myocardial ischemia in an all-comers population of patients with CCS at the time of ICA. The primary endpoint will investigate the additional diagnostic value of such strategy over angiography alone regarding the identification of ischemia-generating mechanisms.

SUMMARY

An estimated sample of consecutive 260 patients with CCS referred by their clinicians to ICA, will be enrolled. In a stepwise manner, a conventional ICA will be performed as the initial diagnostic tool. Those patients with severe-grade stenosis will not undergo further assessment and an obstructive origin for myocardial ischemia will be assumed. Subsequently, the remainder with intermediate-grade stenosis will be assessed with pressure guidewires. Those with a negative result from physiological evaluation and those without epicardial coronary stenosis will be further studied for ischemia of non-obstructive origin, including microvascular dysfunction and vasomotor disorders. The study will be conducted in two steps. Firstly, ICA images will be displayed to patient's referring clinicians, who will be asked to identify the existent epicardial stenosis, their angiographic severity and probable physiological relevance, together with a tentative therapeutic approach. Then, the diagnostic algorithm will continue to be applied and, considering the whole gathered information, a definite therapeutic plan will be consensually established by the interventional cardiologist and patient's referring clinicians.

CONCLUSION

The AID-ANGIO study will assess the additional diagnostic yield of a hierarchical strategy over ICA alone to identify ischemia-generating mechanisms in patients with CCS and its impact on therapeutic approach. Positive results of the study might support a streamlined invasive diagnostic process for patients with CCS.

Mid-Term Angiographic and Intracoronary Imaging Results Following Intracoronary Lithotripsy in Calcified Coronary Artery Disease: Results From Two Tertiary Referral Centres

BACKGROUND

Intracoronary lithotripsy (IVL) is a safe and effective treatment for coronary calcification. Angiographic and intracoronary imaging follow-up have not yet been described. We aimed to describe the mid-term angiographic outcomes following IVL.

METHODS

Patients successfully treated with IVL in two tertiary referral hospitals were included. Repeat angiography and intracoronary imaging was performed. Quantitative coronary angiography (QCA) and optical coherence tomography (OCT) analyses were performed using dedicated workstations.

RESULTS

Twenty patients were included; mean age 67.1 years, left anterior descending artery 55 %. Median IVL balloon size was 3.0 mm and a median of 60 pulses were delivered per vessel. Percentage stenosis by QCA was 60 % [IQR 51-70] reducing to 20 % post stenting (p < 0.001). On OCT, 88.9 % had circumferential calcium. IVL resulted in fractures in 88.9 %. Resulting minimum stent expansion was 91.75 % [IQR 81.5-108]. Follow-up was at a median of 22.7 months [IQR16.4-25.5]. Percentage stenosis by QCA was 22.5 % [IQR 14-30] and not significantly different from the index procedure (p > 0.05). Minimum stent expansion by OCT was 85 % [IQR 72-97]. Late luminal loss was 0.15 mm [IQR -0.25 to 0.69]. Binary angiographic instent restenosis (ISR) was 10 % (2 of 20 patients). OCT demonstrated a predominantly homogenous neointimal pattern with high backscatter.

CONCLUSION

Following successful IVL treatment, repeat angiography demonstrated preserved stent parameters in the majority of patients with favorable vascular healing properties by OCT. A binary restenosis rate of 10 % was observed. These results suggest durable results following IVL treatment of severe coronary calcification however larger studies are warranted.

Transcatheter aortic valve durability: a contemporary clinical review

Encouraged by randomized controlled trials demonstrating non-inferiority of transfemoral transcatheter aortic valve implantation (TAVI) compared to surgical aortic valve replacement (SAVR) across all surgical risk categories, there has been a dramatic increase in the use of TAVI in a younger patient cohort with severe aortic stenosis, endorsed by both European and American Cardiac Societies. However, the standard use of TAVI in younger, less co-morbid patients with a longer life expectancy can only be supported if there is sound data demonstrating long-term durability of transcatheter aortic valves (TAVs). In this article, we have reviewed available randomized and observational registry clinical data pertaining to TAV long-term durability, placing emphasis on trials and registries using the new standardized definitions of bioprosthetic valve dysfunction (BVD) and bioprosthetic valve failure (BVF). Despite inherent difficulties in interpreting the available data, the determination reached is that the risk of structural valve deterioration (SVD) is potentially lower after TAVI than SAVR at 5 to 10 years, and that the two treatment modalities have a similar risk of BVF. This supports the adoption of TAVI in younger patients evident in current practice. However, the routine use of TAVI in younger patients with bicuspid aortic valve stenosis should be cautioned due to insufficient long-term TAV durability data in this particular patient population. Finally, we highlight the importance of future research into the unique potential mechanisms that can potentially contribute to TAV degeneration.

Angiography-derived assessment of coronary microcirculatory resistance in patients with suspected myocardial ischaemia and non-obstructive coronary arteries

BACKGROUND

Myocardial ischaemia with non-obstructive coronary arteries (INOCA) represents a challenging and frequent, but largely underdiagnosed, condition.

AIMS

We aimed to investigate the feasibility and diagnostic value of angiography-derived coronary microcirculatory resistance in patients with INOCA syndrome.

METHODS

This is an investigator-driven, prospective and blinded study. The diagnostic yield of angiography-derived index of coronary microcirculatory resistance (angio-IMR) was investigated against thermodilution-derived IMR (thermo-IMR) in patients with clinically indicated coronary angiography due to suspected myocardial ischaemia and angiographically normal or non-obstructive coronary arteries. The angio-IMR was derived from resting angiograms (contrast-flow angio-IMR [cAngio-IMR]) by an expert analyst blinded to the thermo-IMR. An independent, blinded, physiology core laboratory analysed the raw intracoronary physiology data and provided the final thermo-IMR values.

RESULTS

A total of 104 patients (108 coronary vessels) were analysed after fulfilling predefined inclusion criteria. Most patients were female (67%). Obstructive epicardial disease was angiographically (percent diameter stenosis <50%) and physiologically (fractional flow reserve>0.80) ruled out in all cases. Median thermo-IMR and cAngio-IMR were 16.6 (12.7, 23.0) and 16.8 (12.8, 23.1) units, respectively (median difference -0.31, 95% confidence interval: -1.53 to 1.00; p=0.654). cAngio-IMR showed good correlation (Pearson coefficient 0.76; p<0.001), agreement (mean bias 0.4), discriminatory power (area under the curve from the receiver operator characteristics 0.865; p<0.001) and accuracy (85%), compared to thermo-IMR (≥25 U).

CONCLUSIONS

Evaluating coronary microcirculatory resistance in patients with INOCA syndrome using cAngio-IMR is feasible and accurate. By circumventing the need of coronary instrumentation and hyperaemic drugs, this method may facilitate the assessment of coronary microcirculatory resistance in patients with suspected INOCA.

CLINICALTRIALS

gov: NCT04827498.

Procedural and Technological Innovations Facilitating Ultra-low Contrast Percutaneous Coronary Interventions

Ultra-low-dose contrast percutaneous coronary intervention (PCI) is a valuable approach in selected complex high-risk patients with renal failure. One of the objectives of ultra-low contrast PCI is to decrease the probability of developing postprocedural contrast-induced nephropathy (CIN), which predominately affects patients with baseline renal dysfunction. CIN is associated with poor clinical outcomes and increased healthcare-related costs. Another two clinical scenarios in which reduced dependence on contrast administration by the operator may contribute to improved safety are PCI in complex, high-risk indicated patients and in shock. In this review, we discuss the procedural techniques and recent technological innovations that enable ultra-low-dose contrast PCI to be performed in the cardiac cath lab.

Coronary microvascular dysfunction is associated with impaired cognitive function: the Cerebral-Coronary Connection study (C3 study)

BACKGROUND

It remains unknown whether the presence of coronary microcirculatory dysfunction (CMD) correlates with its equivalent condition in the brain, cerebral small vessel disease (CSVD). The cerebral-coronary connection (C3), a prospective blinded study, investigated the prevalence of CMD in patients with coronary artery disease (CAD) and its association with CSVD and cognitive function.

METHODS AND RESULTS

Patients with documented CAD fulfilling inclusion criteria underwent physiological assessment of epicardial vessels and the microcirculation using intracoronary pressure and Doppler. Coronary microcirculation-related indices included coronary flow reserve (CFR) and hyperaemic microvascular resistance. Brain magnetic resonance imaging, transcranial Doppler (TCD), and neurocognitive examination were performed. Overall, 67 patients were included in the study (mean age 66 years, 73% female). Patients with abnormal CFR (<2.0) (55.2%) showed higher burden of white-matter hyperintensities: 43.2 vs. 20.0% (P = 0.044). After statistical adjustment, low CFR was associated with lower grey matter volume (P = 0.024) and with parameters of white-matter microstructural damage in diffusion-tensor imaging (lower fractional anisotropy and higher mean diffusivity, P = 0.029 and P = 0.032, respectively). Low CFR was associated with higher resistive (P = 0.027) and pulsatility (P = 0.043) values on TCD, and worse neurocognitive test scores (lower mini mental state examination, P = 0.025, and slower Trail Making Test A, P = 0.034).

CONCLUSIONS

Coronary microcirculatory dysfunction is frequent in patients with CAD and correlates with CSVD, abnormal cerebral flow haemodynamics, and significant cognitive impairment. These findings support the hypothesis that microvascular dysfunction in the heart and the brain are part of a single pathological process affecting microcirculation in patients with CAD.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT04131075.

Coronary Physiology as Part of a State-of-the-Art Percutaneous Coronary Intervention Strategy: Lessons from SYNTAX II and Beyond

The use of coronary physiology allows for rational decision making at the time of PCI, contributing to better patient outcomes. Yet, coronary physiology is only one aspect of optimal revascularization. State-of-the-art PCI must also consider other important aspects such as intracoronary imaging guidance and specific procedural expertise, as tested in the SYNTAX II study. In this review, we highlight the technical aspects pertaining to the use of physiology as used in that trial and offer a glimpse into the future with emerging physiologic metrics, including functional coronary angiography, which have already established themselves as useful indices to guide decision making.

Age-related changes in the coronary microcirculation influencing the diagnostic performance of invasive pressure-based indices and long-term patient prognosis

OBJECTIVES

Investigate age-related changes in coronary microvascular function, its effect on hyperemic and non-hyperemic indices of stenosis relevance, and its prognostic implications.

BACKGROUND

Evidence assessing the effect of age on fractional flow reserve (FFR), resting mean distal intracoronary pressure/mean aortic pressure (Pd/Pa), and microcirculatory function remains scarce.

METHODS

This is a post hoc study of a large prospective international registry (NCT03690713) including 1134 patients (1326 vessels) with coronary stenoses interrogated with pressure and flow guidewires. Age-dependent correlations with functional indices were analyzed. Prevalences of FFR, resting Pd/Pa, and coronary flow reserve (CFR) classification agreement were assessed. At 5 years follow-up, the relation between resting Pd/Pa, CFR, and their age-dependent implications on FFR-guided percutaneous coronary intervention (PCI) deferral (deferred if FFR > 0.80) were investigated using vessel-oriented composite outcomes (VOCO) composed of death, myocardial infarction, and repeated revascularization.

RESULTS

Age correlated positively with FFR (r = 0.08, 95% confidence interval [CI]: 0.03 to 0.13, p =  0.005), but not with resting Pd/Pa (r = -0.03, 95% CI:-0.09 to 0.02, p = 0.242). CFR correlated negatively with age (r = -0.15, 95% CI: -0.21 to -0.10, p < 0.001) due to a significant decrease in maximal hyperemic flow in older patients. Patients over 60 years of age with FFR-guided deferred-PCI abnormal resting Pd/Pa or abnormal CFR had increased risk of VOCO (hazard ratio [HR]: 2.10, 95% CI: 1.15 to 4.36, p = 0.048; HR: 2.46, 95% CI:1.23 to 4.96, p = 0.011; respectively).

CONLUSIONS

Aging is associated with decrease in microcirculatory vasodilation, as assessed with adenosine-based methods like CFR. In patients older than 60 years in whom PCI is deferred according to FFR > 0.80, CFR and resting Pd/Pa have an incremental value in predicting future vessel-oriented patient outcomes.

Development of a new score to predict left ventricular reverse remodelling in patients with nonischemic cardiomyopathy

Background and purpose

Implantable cardioverter-defibrillator is indicated in patients with dilated non-ischemic cardiomyopathy (DCM) and severely depressed left ventricular ejection fraction (LVEF) after a wait-and-see period of 3–9 months under optimised medical therapy. However, in the first 6 months after the disease debut, around 2% of patients might suffer life-threatening arrhythmias.

The appearance of left ventricular reverse remodelling (LVRR) in patients with DCM is associated with a lower incidence of ventricular tachyarrhythmias. Therefore, it is relevant an early identification of the patients who will experience LVRR during the follow-up.

Our aim was to develop a score to predict the appearance of LVRR in patients with DCM.

Methods

From 2014 to 2021, 201 patients with DCM and LVEF ≤45% were prospectively evaluated in our tertiary care hospital. All patients underwent a transthoracic echocardiogram and 1.5 Tesla scanner cardiac magnetic resonance (MR) as part of the diagnostic workup. LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50% associated with a reduction in left ventricular end-diastolic diameter ≥10%.

Results

The median age of our cohort (n=201) was 61.6 (14.7) years, and 68% were male. Most patients (&gt;90%) were treated with beta-blockers or RASS blockers, and 72% with mineralocorticoid receptor antagonists.

During a mean follow-up period of 37.6 (33.9) months 45% of patients had LVRR.

Patients with LVRR had a lower cardiovascular mortality (3.33 vs 9.59%; p=0.153), lower mortality due to heart failure (0% vs 8.22%; p=0.023), and a lower incidence of ventricular tachyarrhythmias (1.67% vs 19.18%; p=0.001).

Table 1 shows the echocardiographic, MR and clinical characteristics of patients who experienced LVRR.

Variables significantly associated with LVRR in the univariable analysis and considered clinically relevant were included in a multivariable logistic regression analysis. The final model included the presence of right ventricular end systolic volume index (RVESVi) &gt;50 ml/m2 (2 points), left bundle brach block (LBBB) echo pattern (1 point), female gender (1 point) and tachycardiomyopathy/idiopathic/alcoholic/chemotherapy induced cardiomyopathy as the potencial cause of DCM (1 point).

The score showed a good discrimination, with an area under the ROC curve of 0.82 (95% CI 0.69 to 0.94), 84% sensitivity and 80% specificity. The presence of 3 or more points was associated with a high probability to had LVRR (0 points: 1%; 1 points: 17%; 2 points: 38%; 3 points: 64%; 4 points: 84%%; 5 points: 94% and 6 points: 98%) (Figure 1).

Conclusion

A new score with four variables (RVESV, LBBB echo pattern, female gender and tachycardiomyopathy/idiopatic/alcoholic/chemotheapy induced cardiomyopathy as potential cause) accurately predicts the probability of LVRR. Considering patients who experience LVRR have less cardiovascular events, this score may be a helpful tool for patients' risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Hyperaemic and non-hyperaemic pressure indices of coronary stenosis severity in patients with chronic kidney disease

Background

Evidence regarding the use of pressure indices for the assessment of coronary stenoses in patients with chronic kidney disease (CKD) is scarce.

Methods

We assessed the relation between eGFR, FFR and resting Pd/Pa in 1147 consecutive patients (1316 vessels) included in the International Collaboration of Comprehensive Physiologic Assessment Study. We also compared FFR and Pd/Pa against a standardized cut-off of coronary flow reserve (CFR&lt;2.0). Finally, we examined the occurrence of vessel-oriented composite outcome (VOCO: cardiac death, vessel-specific revascularization, vessel-specific myocardial infarction) across negative/positive results of both FFR and CFR in patients with and without CKD.

Results

FFR increases as renal function worsens (beta −10.5, 95% CI −20.0 to −11.03, p=0.030), a relation that was not seen with resting Pd/Pa (beta −6.14, 95% CI −19.9 to 6.78, p=0.351). Both indices had similar diagnostic accuracies for the detection of a CFR&lt;2.0 in the presence of CKD (AUC 0.629 for FFR vs 0.663 for resting Pd/Pa, p=0.192). However, CKD patients showed a higher proportion of vessels with negative FFR but low CFR (24.5% vs 13.4%, p=0.015).

CFR decreased linearly with deteriorating eGFR, and this was mainly driven by higher resting coronary flow in CKD patients (p=0.026), while hyperaemic coronary flow remained similar (p=0.403). IMR did not change significantly with eGFR (beta −0.02, 95% −0.09 to 0.05, p=0.557).

The incidence of VOCO was higher in patients with CKD and FFR&gt;0.80 when compared to non-CKD patients and FFR&gt;0.80 (12.7% vs 6.90%, p=0.062). Prognosis was worse for those with CKD, negative FFR and CFR&lt;2.0 (20.59% vs. 8.44% in non-CKD, p=0.038).

Conclusions

The assessment of a given coronary stenosis in patients with CKD with either FFR or resting Pd/Pa is equivalent when compared to underlying coronary flow. In CKD, impaired CFR is caused by a state of increased resting flow. The assessment of CFR on top of standard pressure wire examination significantly improves prognostic stratification in CKD patients.

Funding Acknowledgement

Type of funding sources: None.

Invasive evaluation of coronary microvascular dysfunction

Coronary microvascular dysfunction (CMD) is a prevalent cause of ischemic heart disease and is associated with poorer quality of life and worse patient outcomes. Both functional and structural abnormalities of the microcirculation can generate ischemia in the absence of epicardial stenosis or worsen concomitant obstructive coronary artery disease (CAD). The invasive assessment of CMD allows for the evaluation of the entirety of the coronary vascular tree, from the large epicardial vessels to the microcirculation, and enables the study of vasomotor function through vasoreactivity testing. The standard evaluation of CMD includes vasomotor assessment with acetylcholine, as well as flow- and resistance-derived indices calculated with either thermodilution or Doppler guidewires. Tailored treatment based upon the information gathered from the invasive evaluation of CMD has been demonstrated to reduce the burden of angina; therefore, a thorough understanding of these procedures is warranted with the aim of improving the quality of life of the patient. This review summarizes the most widespread approaches for the invasive evaluation of CMD, with a focus on patients with ischemia and non-obstructive CAD.

Transcatheter versus surgical aortic valve replacement in patients with morbid obesity: a multicentre propensity score-matched analysis

BACKGROUND

Morbidly obese (MO) patients are increasingly undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). However, the best therapeutic strategy for these patients remains a matter for debate.

AIMS

Our aim was to compare the periprocedural and mid-term outcomes in MO patients undergoing TAVR versus SAVR.

METHODS

A multicentre retrospective study including consecutive MO patients (body mass index ≥40 kg/m², or ≥35 kg/m² with obesity-related comorbidities) from 18 centres undergoing either TAVR (n=860) or biological SAVR (n=696) for severe AS was performed. Propensity score matching resulted in 362 pairs.

RESULTS

After matching, periprocedural complications, including blood transfusion (14.1% versus 48.1%; p<0.001), stage 2-3 acute kidney injury (3.99% versus 10.1%; p=0.002), hospital-acquired pneumonia (1.7% versus 5.8%; p=0.005) and access site infection (1.5% versus 5.5%; p=0.013), were more common in the SAVR group, as was moderate to severe patient-prosthesis mismatch (PPM; 9.9% versus 39.4%; p<0.001). TAVR patients more frequently required permanent pacemaker implantation (14.4% versus 5.6%; p<0.001) and had higher rates of ≥moderate residual aortic regurgitation (3.3% versus 0%; p=0.001). SAVR was an independent predictor of moderate to severe PPM (hazard ratio [HR] 1.80, 95% confidence interval [CI]: 1.25-2.59; p=0.002), while TAVR was not. In-hospital mortality was not different between groups (3.9% for TAVR versus 6.1% for SAVR; p=0.171). Two-year outcomes (including all-cause and cardiovascular mortality, and readmissions) were similar in both groups (log-rank p>0.05 for all comparisons). Predictors of all-cause 2-year mortality differed between the groups; moderate to severe PPM was a predictor following SAVR (HR 1.78, 95% CI: 1.10-2.88; p=0.018) but not following TAVR (p=0.737).

CONCLUSIONS

SAVR and TAVR offer similar mid-term outcomes in MO patients with severe AS, however, TAVR offers some advantages in terms of periprocedural morbidity.

Neurological outcomes of transcatheter aortic valve implantation with or without cerebral embolic protection devices: A meta-analysis

INTRODUCTION

Cerebral embolic protection devices (CEPDs) are designed to prevent embolization of debris during transcatheter aortic valve implantation (TAVI). Current evidence from randomized clinical trials (RCTs) and observational studies is controversial.

AIMS

The purpose of this meta-analysis was to study the influence of CEPDs on stroke, silent ischemic lesions and neurocognitive function.

METHODS

A systematic search was conducted including RCTs or adjusted observational studies comparing TAVI with or without CEPDs. Pooled odds ratios, risk ratios or standardized mean differences with 95% confidence intervals were calculated using the inverse of variance method. Risk of bias sensitivity analyses and meta regression for CEPD type were also conducted.

RESULTS

Five RCTs and five adjusted observational studies were included (n= 159,865). Mean age of the patients was 81.1 (SD 1.04) years in CEPDs and 81 (SD 1.86) in non-CEPD. The overall quality of evidence using the GRADE system for each endpoint was low to very low, mainly due to serious risk of bias, inconsistency and imprecision. Random effects meta-analysis detected no significant differences between CEPD and non-CEPD (OR= 0.74; 95% CI 0.51-1.07; P= 0.105; I²= 82.1%) for 30-day stroke. This finding was consistent in meta regression for CEPD type and subgroup analyses by study type and CEPD type. No significant differences between groups were observed in cerebral DW-MRI assessment and neurocognitive function evaluation.

CONCLUSION

In the present meta- analysis of five RCTs and five adjusted observational studies, the use of a CEPD during TAVI was not associated with a significant benefit on 30- day stroke, total lesion volume per patient, number of ischemic lesions per patient and neurocognitive function assessments.

Development of atrioventricular and intraventricular conduction disturbances in patients undergoing transcatheter aortic valve replacement with new generation self-expanding valves: A real world multicenter analysis

BACKGROUND

High degree cardiac conduction disturbances (HDCD) remain a major complication after transcatheter aortic valve replacement (TAVR), especially with self-expandable valves (SEV). Our aim was to investigate peri-procedural and in-hospital modification of atrioventricular and intracardiac conduction associated to new generation SEV implantation, and the development of new HDCD resulting in permanent pacemaker implantation (PPM) in patients undergoing TAVR.

METHODS AND RESULTS

Three-hundred forty-four consecutive patients with severe aortic stenosis who underwent TAVR with a new generation SEV [Evolut-R/Pro (n = 130), Acurate-neo (n = 79), Portico (n = 75) and Allegra (n = 60)] were included. An analysis of baseline, post-TAVR and pre-discharge ECG and procedural aspects were centrally performed. A significant increase in baseline PR interval (169.6 ± 28.2 ms) and QRS complex width (101.7 ± 25.9 ms) was noted immediately post-TAVR (188.04 ± 34.49; 129.55 ± 30.02 ms), with a partial in-hospital reversal (179.4 ± 30.1; 123.06 ± 30.94 ms), resulting in a net increase at hospital discharge of 12.6 ± 38.8 ms and 21.4 ± 31.6 ms (p < 0.001), respectively. The global incidence of new onset persistent HDCD at hospital discharge was 46.3%, with 17.7% of patients requiring PPM. Independent predictors of new onset HCDC at hospital discharge were valve recapture (OR: 2.8; 95% IC: 1.1-7.2, p = 0.033) and implantation depth ≥ 6 mm (OR: 1.9 05% IC 1.1-3.3, p = 0.015), while higher implantation (<3 mm (OR: 0.3, 95% IC 0.1-0.7, p = 0.014) and use of Acurate-Neo valve (OR: 0.4; 95% IC 0.2-0.8, p = 0.009) were protective factor.

CONCLUSIONS

New generation self-expanding aortic valves were associated with a significant increase in PR and QRS interval at hospital discharge leading to a very high rate of HDCD. While valve recapture and implantation depth were independent predictors for the occurrence of HDCD, use of Accurate-Neo valve was a protective factor.

In-vivo evidence of systemic endothelial vascular dysfunction in COVID-19

Background

Endothelial dysfunction is one of the underlying mechanisms to vascular and cardiac complications in patients with COVID-19. We sought to investigate the systemic vascular endothelial function and its temporal changes in COVID-19 patients from a non-invasive approach with reactive hyperemia peripheral arterial tonometry (PAT).

Methods

This is a prospective, observational, case-control and blinded study. The population was comprised by 3 groups: patients investigated during acute COVID-19 (group 1), patients investigated during past COVID-19 (group 2), and controls 1:1 matched to COVID-19 patients by demographics and cardiovascular risk factors (group 3). The natural logarithmic scaled reactive hyperemia index (LnRHI), a measure of endothelium-mediated dilation of peripheral arteries, was obtained in all the participants and compared between study groups.

Results

144 participants were enrolled (72 COVID-19 patients and 72 matched controls). Median time from COVID-19 symptoms to PAT assessment was 9.5 and 101.5 days in groups 1 and 2, respectively. LnRHI was significantly lower in group 2 compared to both group 1 and controls (0.53 ± 0.23 group 2 vs. 0.72 ± 0.26 group 1, p = 0.0043; and 0.79 ± 0.23 in group 3, p < 0.0001). In addition, within group 1, it was observed a markedly decrease in LnRHI from acute COVID-19 to post infection stage (0.73 ± 0.23 vs. 0.42 ± 0.26, p = 0.0042).

Conclusions

This study suggests a deleterious effect of SARS-CoV-2 infection on systemic vascular endothelial function. These findings open new venues to investigate the clinical implication and prognostic role of vascular endothelial dysfunction in COVID-19 patients and post-COVID syndrome using non-invasive techniques.

Assessment of vascular endothelial function in COVID-19 patients

Background

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) uses angiotensin-converting enzyme 2 (ACE2) receptor as a means to enter the host. High density of ACE2 receptor in vascular endothelial cells may explain why vascular complications related to endothelial dysfunction occur in COVID-19. However, in vivo assessment of vascular endothelial function during COVID-19 has not been reported.

Objective

To investigate the vascular endothelial function and its temporal changes in COVID-19 patients.

Methods

In this prospective blinded study, systemic endothelial function was assessed using plethysmography-derived peripheral arterial tonometry (PAT). The reactive hyperemia index (LnRHI), a measure of endothelium-mediated hyperaemia, and the augmentation index, a measure of arterial vascular stiffness, were measured in 102 individuals across three study groups using PAT: group 1 (active infection), constituted by 20 patients hospitalised due to acute COVID-19; group 2 (past infection), constituted by 52 patients who had recovered from COVID-19; and group 3 (controls), constituted by 30 healthcare workers not infected by SARS-CoV-2. Additionally, among group 1, PAT assessment was repeated in 14 patients several weeks after recovery from acute COVID-19. PAT studies were analysed at a blinded fashion with respect to the assigned study group.

Results

Lower resting PAT amplitude was found in acute COVID-19 patients compared to the other groups (ratio of arterial tone signal between hyperemia to resting condition was 1.5 [interquartile range, 1.1] in group 1, 1.3 [0.3] in group 2 and 1.2 [0.3] in group 3, p=0.041). On the contrary, no significant differences between groups were found with respect to the hyperemic PAT amplitude (867.9 [486.1] in group 1, 944.7 [748.1] in group 2 and 819.3 [639.6] in group 3, p=0.444). Due to the lower resting PAT amplitude, there was a paradoxically significantly increased LnRHI during acute COVID-19 compared to past infection and controls (0.73 [0.32] vs. 0.53 [0.31] vs. 0.44 [0.23], respectively; p=0.013) (Figure A). Furthermore, among group 1 patients, LnRHI normalised markedly from acute COVID-19 to past infection stage (0.73 [0.32] vs. 0.49 [0.28], respectively; p=0.005) (Figure B). Augmentation index was significantly higher during acute COVID-19 compared to past COVID-19 and controls (9.6 [19.1] in group 1, 6.97 [18.6] in group 2 and −0.35 [20.53] in group 3; p=0.045 for COVID groups vs. controls).

Conclusions

Non-invasive assessment of systemic vascular endothelial function with PAT revealed significant differences between subjects with acute COVID-19, past COVID-19 and controls. Lower baseline PAT amplitude and high augmentation index suggest vasoconstriction at rest during the acute phase of COVID-19. These findings open new research opportunities to investigate the prognostic value of PAT in COVID-19 patients.

Funding Acknowledgement

Type of funding sources: None.

Myocardial ischaemia of non-obstructive origin as a cause of new onset anginal chest pain in the long COVID syndrome

Background

New-onset chest pain occurs in around 20% of patients with long COVID syndrome (LCS). Being the vascular endothelium one of the targets of the SARS-CoV-2 virus, we hypothesized that new onset anginal symptoms in LCS could be due to endothelium dysfunction and other non-obstructive causes of myocardial ischaemia.

Methods

We investigated 11 consecutive patients who developed new onset anginal chest pain, suggestive of myocardial ischaemia, after documented SARS-CoV-2 infection. Intracoronary assessment included endothelium-dependent evaluation with acetylcholine testing (Ach), and endothelium-independent assessment with coronary flow reserve (CFR) and microcirculatory resistance (MR). Criteria for positiveness of these tests and medical treatment recommendation were obtained from 2019 ESC guidelines and 2020 EAPCI consensus document on ischaemia with non-obstructive coronary arteries (INOCA).

Results

Mean patient age was 56 years (SD ± 15); 10 (91%) were female. In the acute COVID-19 phase, 4 patients (36%) had had pulmonary infiltrates and 2 (18%) required hospitalization. Conclusive non-invasive tests were obtained in 7 (64%), showing exercise-related myocardial ischaemia in 6 (86%). Coronary angiography ruled out obstructive epicardial stenoses in all the patients. Ach testing revealed abnormal endothelium-dependent responses in 9 (82%) patients: 5 (56%) had epicardial vessel and 4 (44%) microvascular spasm. Endothelium-independent assessment was abnormal in 6 (54%) cases, with abnormal CFR in 2 (33%), abnormal MR in 2 (33) and both abnormal CFR and MR in 2 (33%) patients. The most frequent endotype was combined endothelium dependent- and independent abnormalities (6/9, 67%). Stratified medical treatment according to endotype led to significant improvement in Seattle Angina Scores for angina frequency (+22 points, p=0.013) and a notable trend towards angina stability (+25 points, p=0.093) at a mean follow-up time of 222 days.

Conclusions

Myocardial ischaemia of non-obstructive origin is common in patients with chest pain and LCS. Vasomotor abnormalities related to endothelial dysfunction occurred in 82% of patients, frequently associated to impaired microvascular vasodilation or high microvascular resistance. Stratified medical treatment led to significant improvement in angina stability and frequency.

Funding Acknowledgement

Type of funding sources: None.

Cardiac mechanics as predictors of left ventricular reverse remodelling in patients with dilated non-ischemic cardiomyopathy

Background and purpose

The appearance of left ventricular reverse remodelling (LVRR) is associated with a better prognosis in patients with dilated non-ischemic cardiomyopathy (DCM).

Our aim was to identify cardiac imaging parameters, including speckle tracking by transthoracic echocardiography (TTE) and feature tracking by CMR, associated with LVRR in a prospective cohort of patients with DCM.

Methods

From 2014 to 2021, 182 patients with DCM and left ventricle ejection fraction (LVEF) &lt;40% were prospectively evaluated in our hospital.

LVRR was defined as an increase in LVEF ≥10 points or absolute LVEF ≥50%, associated with a reduction in left ventricular end- diastolic diameter ≥10%.

Patients underwent multimodality imaging evaluation including CMR with a 1.5 Tesla scanner, and TTE. Cardiac mechanics, including global longitudinal strain (GLS), strain rate (SR) and mechanical dispersion (MD) were measured.

Results

Median age of our cohort was 62.3 (14.4) years, and 67.7% were male.

Most patients (&gt;90%) were treated with beta-blockers or RASS blockers, and 67% with mineralocorticoid receptor antagonists. 30% had cardiac resynchronization therapy (CRT) and 37% had ICD as primary prevention. Mean LVEF was 31.3%. During a mean follow-up period of 35.9 (35.4) months, 38.3% of patients had LVRR.

Age and gender distribution were similar in both groups. Regarding cardiovascular risk factors and pharmacological treatment, no differences were found between patients with and without LVRR. Baseline CRT therapy was not associated with LVRR (22.6% vs 34.7%; p=0.249). However, there was a trend towards higher LVRR in those who received CRT during follow-up 18.8% vs 0%; p=0.069).

Patients who experienced LVRR had lower basal LVEF (23.4% vs 29%; p&lt;0.008), as well as poorer RV function, including lower RVEF (40.5% vs 51%; p=0.006) and lower TAPSE (16 mm vs 19 mm; p=0.021). Regarding cardiac mechanics, those patients with lower GLS (−9% vs −12%; p=0.001), and higher MD (73 mm vs 55 mm; p=0,050) had LVRR more frequently during follow-up. The presence of a left bundle branch block (LBBB) contraction pattern by strain was associated with higher rate of LVRR (83.3% vs 30.4%; p=0.011). The burden of fibrosis measured by LGE with CMR was not associated with LVRR (14% vs 12%; p=NS).

Patients with LVRR had a lower cardiovascular mortality (3.3 vs 14.3%; p=0.117), lower mortality due to heart failure (0% vs 12.2%; p=0.046), less heart failure hospitalizations (20% vs 46.9%; p=0.016), and a lower incidence of ventricular tachyarrhythmias (3.3% vs 18.4%; p=0.051).

Conclusions

LVRR in patients with DCM receiving optimized medical therapy is associated with a better prognosis. Imaging parameters, including a lower basal LVEF, RVEF, GLS and higher MD, as well as LBBB echo pattern, were associated with a higher frequency of LVRR, and might help to identify patients who could benefit from CRT/and may be helpful to stratify patients's risk.

Funding Acknowledgement

Type of funding sources: None.

Safety of coronary revascularization deferral based on fractional flow reserve and instantaneous wave-free ratio in patients with chronic kidney disease

Background

The safety of revascularization deferral according to pressure wire examination in patients with chronic kidney disease (CKD) has not been fully established.

Methods

From a retrospective cohort of 439 patients in whom revascularization was deferred after physiological assessment, we examined the incidence of patient-oriented composite endpoint (POCE: all-cause death, myocardial infarction [MI] and unplanned revascularization) in patients with CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m²) and without it.

Results

At 4 years of follow-up, the primary endpoint was met by 25.0% of patients with CKD and by 14.4% of patients without CKD (hazard ratio [HR] 1.56, 95% confidence interval [CI] 0.96–2.53, p = 0.071). The incidence of POCE was even higher in patients with an eGFR < 30 mL/min/1.73 m²: 43.8% (HR 3.10, 95% CI 1.08–8.92, p = 0.036). However, no differences were observed in the incidence of MI (4.2% vs. 4.4% in non-CKD), target vessel revascularization (5.8% vs. 5.9%), and target vessel MI (0.8% vs. 4.6%).

Conclusions

Patients with CKD in whom pressure-wire evaluation led to deferral of coronary revascularization develop more POCE in the long term, compared to patients with normal renal function. However, the increase in POCE in patients with CKD was seldom related to deferred vessels, thus suggesting an epiphenomenon of an intrinsically higher cardiovascular risk of CKD patients.

Clinical Profile and 30-Day Mortality of Invasively Managed Patients with Suspected Acute Coronary Syndrome During the COVID-19 Outbreak

The COVID-19 pandemic severely disrupted cardiovascular care during the spring of 2020 in Europe. Our study analyzed the clinical profile, COVID-19 impact, and 30-day prognosis of invasively managed patients with acute coronary syndrome (ACS) compared to a historical cohort.All invasively managed ACS patients from March 1st to April 30th, 2020 were compared to a cohort from the same timeframe of 2019 (n = 316). COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test (CoV+). The primary outcome was all-cause 30-day mortality and multivariable predictors of this outcome.A 40.4% reduction in ACS patients was noted (198 cases in 2019 to 118 in 2020), and 11% of 2020 ACS patients were CoV+. Baseline characteristics were similar between groups. There were significantly more in-hospital patients with ACS (15.3% versus 6.1%, P = 0.007), and fewer patients were found to have a culprit lesion (58.5% versus 74.2%, P = 0.004) in 2020 compared to 2019. Thirty-day mortality in 2020 (7%) was not different from that in 2019 (4.2%), P = 0.294, but it was significantly higher in CoV+ patients (23.1%) compared to that in negative SARS-CoV-2 PCR test (CoV-) patients (5%), P = 0.047, in the 2020 group. In the multivariate analysis, CoV+ was an independent mortality predictor (OR = 9.8, 95% CI = 1.48-64.78), along with the left ventricular ejection fraction (LVEF) (OR = 0.91, 95% CI = 0.86-0.97), P = 0.0006.This study found increased 30-day mortality of invasively managed CoV+ ACS patients compared to that of CoV- patients during the 2020 COVID-19 spring outbreak. In the multivariable analysis, a SARS-CoV-2 positive test was independently associated with 30-day mortality. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are warranted.

P3741Incidence and outcomes of delirium in patients undergoing transcatheter aortic valve replacement

Introduction and objective

Delirium is a frequent problem in the intensive care unit (ICU), often underdiagnosed, and is associated with increased mortality. We sought to evaluate the incidence and implact on prognosis of delirium in patients admitted to ICU after transcatheter aortic valve replacemente (TAVR).

Methods

We included 294 patients admitted to ICU from February 2013 to December 2017 after transfemoral aortic valve implantation. Incidence of delirium was assessed using DSM-IV diagnostic criteria. Risk factors were evaluated, as well as overall mortality and incidence of hospital readmissions.

Results

The mean clinical follow-up was 526 days. Delirium was diagnosed in 60 patients (20.4%). In most cases (78.3%), it occurred in the first 24 hours after the procedure. Age, cognitive impairment and peripheral artery disease were risk factors for the development of Delirum, without finding differences by sex, cardiovascular risk factors (except dyslipidemia) or the usual treatment with benzodiazepines or neuroleptics. Severe bleeding during the procedure was also associated with a higher incidence, but no risk augmentation was seen with the use of general anaesthesia, the urgency of the procedure, use of a transient pacemaker for more than 24 hours after the intervention or the development of a peripheral vascular complication during admission (both related to patient immobility).

The development of Delirium was associated with longer hospital stay (10.8 vs 7.9 days, p=0.004) and with higher mortality (38.8% vs 20.4%, p=0.007). No differences were found in hospital readmissions during follow-up (54.3% vs 48.2%, p=0.453).

Conclusion

Delirium is a frequent complication after TAVR. Age, cognitive impairment and peripheral arteriy disease were risk factors for its development, but no factors that determine patient immobility, use of general anesthesia or the urgency of the procedure. Delirum after TAVR is associated with longer in-hospital stay and with higher mortality.

Intracoronary Lithotripsy in Percutaneous Treatment of Calcific Left Main Coronary Stenoses

Adequate plaque preparation in heavily calcific left main coronary stenoses is mandatory to ensure adequate stent implantation. Intravascular lithotripsy (IVL) is a potential alternative to atherectomy techniques for this purpose. The authors present 2 cases treated with IVL in a successful manner in the left main coronary artery.