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).

Influence of the speed of deflation of the stent delivery system in the myocardial blush and ST-segment resolution in primary angioplasty: a randomized study

Introduction

Distal embolization may compromise the results of primary angioplasty. Our aim is to analyze the influence of the speed of deflation of the stent delivery system on the myocardial blush ≥2 and on the ST-Segment resolution ≥70%.

Methods

From December 2016 to February 2019, all consecutive patients with ST-elevation myocardial infarction who underwent urgent coronary angiography at our institution who were susceptible of thrombectomy, IIB-IIIA inhibitors and direct stenting were randomized 1:1 to fast deflation of the stent delivery system (group 1, n=103) or to slow deflation at 1 atm/second (group 2, n=107). Pre- and postdilatation was not allowed per protocol. The primary outcomes were the myocardial blush ≥2 and the ST-Segment resolution ≥70% while the size of myocardial damage, ejection fraction at discharge and at 12 months and total and cardiovascular mortality at 12 months were the secondary outcomes. A multivariate analysis was performed to analyze the influence of the speed of deflation of the stent delivery system in both primary end-points in case of possible imbalances among groups despite the randomization.

Results

Both groups represented 47% of the 447 procedures of primary angioplasty performed in that period. Baseline characteristics of the whole cohort: female gender 46 (21.9%), age 59.5±10.6 years, diabetes 35 (16.7%), Killip class IV 5 (2.4%), total ischemic time 177.5 (124–275) minutes and door to balloon time 84 (66–120.5) minutes. There were not differences in clinical or angiographic characteristics between both groups, although there was a non-significant trend towards larger reference vessel diameter in the slow deflation group (2.74±0.42 vs. 2.86±0.47, p=0.07). The study was prematurely stopped with 50% of the calculated sample size due to futility. The primary endpoint of myocardial blush ≥2 occurred in 77 (74.7%) vs. 79 (75.2%), p=0.93 and ST-Segment resolution ≥70% in 54 (53.9%) vs. 59 (55.5%), p=0.75 in group 1 and 2, respectively, without differences in any of the secondary endpoints. The speed of deflation of the stent delivery system did not show any influence on the MB or ST-Segment resolution ≥70% in the multivariate analysis. Predictors of myocardial blush ≥2 were systolic blood pressure at admission, creatinine clearance &lt;60 ml/min and maximal diameter postprocedure. Diabetes, previous infarction, left anterior descending, TIMI ≥2 before intervention, TIMI 3 after intervention and collateral supply grade ≥2 were predictors of ST segment resolution≥70% with an area under the curve of 0.71 (0.63–0.80) and 0.75 (0.68–0.82), respectively.

Conclusions

In our series, the speed of deflation of the stent delivery system in primary angioplasty did not modified the myocardial blush ≥2 or ST-Segment resolution ≥70% and neither showed any influence in clinical outcomes, size of myocardial infarction by biomarkers and ejection fraction.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Laboratories

No Differences in Levels of Circulating Progenitor Endothelial Cells or Circulating Endothelial Cells Among Patients Treated With Ticagrelor Compared With Clopidogrel During Non- ST -Segment-Elevation Myocardial Infarction

Background

Ticagrelor use during acute coronary syndromes demonstrated a decrease in all‐cause mortality in the PLATO (Platelet Inhibition and Patient Outcomes) trial. This effect has been attributed to a non–platelet‐derived improvement in endothelial function. The aim of this study was to determine differences in the number of endothelial progenitor cells and/or circulating endothelial cells found in peripheral blood in patients treated with either ticagrelor or clopidogrel during non–ST‐segment–elevation myocardial infarction.

Methods and Results

In this multicenter, randomized study (NCT02244710), patients were considered for inclusion after non–ST‐segment–elevation myocardial infarction whenever they were P2Y₁₂‐inhibitor naïve. Ticagrelor and clopidogrel were allocated at a 1:1 ratio. Blood samples for determining endothelial progenitor cells and circulating endothelial cells were extracted before the antiplatelet loading dose, 48 hours after presentation of index symptoms, and 1 month after the event. A multichannel cytometer was used for optimal cell characterization. A total of 96 patients fulfilled the inclusion criteria. Circulating endothelial cell levels corrected by white blood cells were as follows at baseline, 48 hours, and 1 month: 44 (28–64), 50 (33–63), and 38 (23–62) cells/mL, respectively, for clopidogrel and 38 (29–60), 45 (32–85), and 35 (24–71) cells/mL, respectively, for ticagrelor (P=0.6). Endothelial progenitor cell levels were 29 (15–47), 27 (15–33), and 18 (10–25) cells/mL, respectively, for clopidogrel and 20 (11–33), 22 (12–32), and 18 (11–29) cells/mL, respectively, for ticagrelor (P=0.9). No differences in intraindividual changes were found.

Conclusions

Patients treated with ticagrelor during non–ST‐segment–elevation myocardial infarction, in comparison to clopidogrel, showed similar levels of endothelial progenitor cells and circulating endothelial cells. These data suggest that the endothelial protective effect mediated by ticagrelor is not related to bone marrow physiology modulation.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02244710.

Percutaneous paravalvular leak closure after CoreValve transcatheter aortic valve implantation using an arterio-arterial loop

Significant periprosthetic aortic regurgitation after transcatheter aortic valve implantation has become a major concern of this technique given its association with impaired survival. We report the successful closure of such defect using a vascular occlusion device with the creation of an arterio-arterial loop to gain enough support to advance the delivery sheath into de the left ventricle.

Double Guide Catheter Technique for Sealing an Iatrogenic Coronary Perforation

Introduction:

Coronary vessel perforation is one of the most feared complications of coronary angioplasty. The treatment of this complication relies mostly on the implantation of covered stents. However, due to their design, covered stents are difficult to advance in a tortuous or calcified vessel.

Case Presentation:

We present a case of a grade III coronary perforation in which the double guiding catheter technique helped us to deliver the graft stent.

Conclusions:

The double-guiding technique is useful in emergency situations to increase the safety and efficacy of sealing a coronary perforation.

Third CoreValve™ insertion for treatment of a severe paravalvular leak after a failed valve-in-valve procedure

An 83-year-old high-risk gentleman diagnosed with severe symptomatic aortic stenosis was scheduled for TAVR. A 31 mm CoreValve was implanted but severe paravalvular leak was noted. A valve-in-valve procedure was performed. However, the valve frame was partially dislodged into de ascending aorta. We report our strategy to solve this severe leak after a failed valve-in-valve procedure.

Timely reperfusion for ST-segment elevation myocardial infarction: Effect of direct transfer to primary angioplasty on time delays and clinical outcomes

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them, prehospital diagnosis and direct transfer to the cath lab, by-passing the emergency department of hospitals, has emerged as an attractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.

Effect of early metoprolol on infarct size in ST-segment-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: the Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction (METOCARD-CNIC) trial

BACKGROUND

The effect of β-blockers on infarct size when used in conjunction with primary percutaneous coronary intervention is unknown. We hypothesize that metoprolol reduces infarct size when administered early (intravenously before reperfusion).

METHODS AND RESULTS

Patients with Killip class II or less anterior ST-segment-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention within 6 hours of symptoms onset were randomized to receive intravenous metoprolol (n=131) or not (control, n=139) before reperfusion. All patients without contraindications received oral metoprolol within 24 hours. The predefined primary end point was infarct size on magnetic resonance imaging performed 5 to 7 days after STEMI. Magnetic resonance imaging was performed in 220 patients (81%). Mean ± SD infarct size by magnetic resonance imaging was smaller after intravenous metoprolol compared with control (25.6 ± 15.3 versus 32.0 ± 22.2 g; adjusted difference, -6.52; 95% confidence interval, -11.39 to -1.78; P=0.012). In patients with pre-percutaneous coronary intervention Thrombolysis in Myocardial Infarction grade 0 to 1 flow, the adjusted treatment difference in infarct size was -8.13 (95% confidence interval, -13.10 to -3.16; P=0.0024). Infarct size estimated by peak and area under the curve creatine kinase release was measured in all study populations and was significantly reduced by intravenous metoprolol. Left ventricular ejection fraction was higher in the intravenous metoprolol group (adjusted difference, 2.67%; 95% confidence interval, 0.09-5.21; P=0.045). The composite of death, malignant ventricular arrhythmia, cardiogenic shock, atrioventricular block, and reinfarction at 24 hours in the intravenous metoprolol and control groups was 7.1% and 12.3%, respectively (P=0.21).

CONCLUSIONS

In patients with anterior Killip class II or less ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, early intravenous metoprolol before reperfusion reduced infarct size and increased left ventricular ejection fraction with no excess of adverse events during the first 24 hours after STEMI.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT01311700. EUDRACT number: 2010-019939-35.

Techniques and material used in the percutaneous treatment of chronic coronary occlusions. Data from the CIBELES study

INTRODUCTION

In recent years, various specific techniques and materials have been developed for the treatment of coronary chronic total occlusions (CTO).

OBJECTIVE

To evaluate the current situation in the treatment of CTO (techniques and material) in our setting.

METHODS

We evaluated data on techniques and material used in the CIBELES (ChronIc coronary occlusion treated By EveroLimus Eluting Stent) trial, a randomized comparison of sirolimus- and everolimus-eluting stents in 207 patients with CTO in 13 centers in Spain and Portugal.

RESULTS

A radial approach was used in 23% of patients, and retrograde techniques were used in only 5%. A high number of balloons were used (2.2±0.9 per patient). Microcatheters were used in 33% of patients, and post-dilatation balloons in only 25%. The mean number of stents implanted per patient was 2.1±1.0, with a mean total stent length of 49±24 mm. Other devices and techniques used were: Tornus penetration catheter in 4% of patients, rotational atherectomy in 2%, and cutting balloon in 1%. Intracoronary ultrasound was used in only 6% of patients. In 34% of cases, operators used guidewires that were not specifically for CTO. Considerable variability between centers was detected in the use of different techniques, the highest and lowest variability being observed in the use of intracoronary ultrasound and the use of CTO guidewires, respectively.

CONCLUSIONS

In the CIBELES trial, techniques and devices specifically designed for the treatment of CTO were used in a relatively low proportion of patients. Considerable variability between centers was detected.

Preclinical evaluation of coronary stents: focus on safety issues

In recent years, we have witnessed a revolution in the treatment of coronary artery disease. The development and improvement of drug eluting stents (DES) have lowered the incidence of restenosis to one-digit figures. In the search for a superior efficacy, animal models have played a key role. The classical swine model of coronary stenting remains the preferred model to measure restenosis, although the rabbit iliac artery stenting has become an accepted alternative. After widespread clinical use of DES, an unforeseen complication arose: late stent thrombosis. In a back-to-bench step, some data from animal models helped to explain the phenomenon. A delayed and incomplete vascular healing was detected. Toxic and hypersensitivity reactions to polymers and/or drugs seem to be the underlying causes. So, translational research focused on the safety aspect of these devices: development of better drug carriers as absorbable polymers or fully bioresorbable scaffolds, selection of different drugs and assessment of the re-endothelialization process. We review and evaluate the efficacy and safety of coronary stents in different animal models. Further improvements in this field such as, the selection of better animal models (e.g. hyperlipidemic, diabetic, atherosclerotic) that closely mimic the clinical setting and longer follow-up periods to detect late complications are also discussed.

Vasomotor response to different endothelium-dependent vasodilators in an animal model

BACKGROUND AND OBJECTIVES

Incomplete re-endothelialization of stents can be revealed as paradoxical vasoconstriction with endothelium-dependent vasodilators. As no consensus exists about the best method or agent, our objective is to analyze the response to different drugs in a coronary swine model.

METHODS

Twenty-seven stents were implanted in 9 domestic swine. The vessel diameter of proximal and distal segments (≥5 mm) was assessed immediately post implantation. Different endothelium-dependent vasodilators were used: intracoronary (IC) acetylcholine, 20 μg (A2) and 40 μg (A4), IC serotonin (S), 100 μg, and isoproterenol (I), intravenous infusion. The results are presented as constriction (%) compared with maximal vasodilation with IC nitroglycerin (N, 200 μg).

RESULTS

In 10 vessels (37%), A4 provoked an occlusive spasm. Acetylcholine induced a higher degree of vasoconstriction (A4, 42 ± 39%; A2, 16 ± 14%) than the rest of the agonists (S, 6 ± 12%; I, 6 ± 11%; P<.01). The constriction rate was not related to the induced hemodynamic changes.

CONCLUSIONS

After focal endothelial denudation in a coronary swine model, the constriction rate induced by different endothelium-dependent vasodilators is highly variable. The highest value is observed after IC acetylcholine bolus. The constriction rate does not correlate with the observed hemodynamic changes.

Cobalt-chromium stents in long lesions of large vessels: clinical and angiographic results

Although drug-eluting stents have reduced the restenosis rate, some patients are not good candidates for prolonged double-antiplatelet therapy. Our goal was to learn the results of implanting cobalt-chromium stents in long lesions of large vessels.All consecutive patients with ≥1 lesion treated with a cobalt-chromium stent ≥28 mm in length and ≥3.5 mm in diameter during a 12-month period in 2 centers were monitored clinically and angiographically to determine the clinical status, restenosis rate, pattern of restenosis, and need for revascularization.The series comprised 78 patients with 81 lesions, mean age, 62.6 ± 15.2 yr; diabetes mellitus,19.2%; and primary or rescue intervention, 20.6%. Target vessels were the left anterior descending coronary artery, 12 (14.8%); left circumflex coronary artery, 12 (14.8%); and right coronary artery, 57 (70.4%). The mean lesion length was 35.18 ± 12.65 mm. The proximal reference diameter after percutaneous coronary intervention was 3.64 ± 0.54 mm; the distal, 3.2 ± 0.43 mm; and the mean, 3.42 ± 0.44 mm. The mean stent length was 38.05 ± 12.78 mm (range, 28-90 mm). The binary restenosis rate was 23% (15/64), with pattern IB in 2 cases, IC in 5, II in 7, and IV in 1. Revascularization was needed in 6 patients.In treating long lesions of large vessels, we found that cobalt-chromium stents achieved a moderate rate of target-vessel restenosis and a low rate of repeat revascularization. The pattern of restenosis was focal in almost half of the cases, and, in most remaining cases, restenosis affected short segments of the vessel.

Influence of platelet reactivity and response to clopidogrel on myocardial damage following percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndrome

INTRODUCTION

A wide variability in the response to clopidogrel and magnitude of post-treatment platelet reactivity has been described. However, this has been demonstrated by light transmittance aggregometry, a method too laborious for daily practice. Point-of-care devices may overcome this limitation, but little is known on the predictive value of such measurements. Our objective was to determine the relationship between platelet reactivity and the incidence of myocardial damage following percutaneous coronary intervention (PCI) in patients with Non-ST-segment Elevation Acute Coronary Syndrome (NSTEACS).

MATERIALS AND METHODS

This prospective study included 93 patients with NSTEACS and PCI. All patients received a loading dose of 300 mg of clopidogrel and 250 mg of aspirin. Myocardial damage was defined as any elevation above upper limit of normal or previous levels of troponin T, assessed every 6 h for at least 24 h following PCI. Platelet reactivity not related to clopidogrel (BASE reactivity), related to P2Y12 inhibition (P2Y12 reactivity) and inhibition of platelet aggregation (IPA) were assessed immediately pre-PCI with the VerifyNow device.

RESULTS

Myocardial damage was detected in 60 patients (64.5%). Higher BASE reactivity was associated with myocardial damage (287.8+/-62.6 vs. 260+/-55.9 units, p=0.043) while a trend was found for P2Y12 reactivity (173.4+/-70.3 vs. 149.2+/-58.4 units, p=0.109). No relationship was detected for IPA. Multivariate logistic regression analysis confirmed that BASE reactivity (p=0.04) and P2Y12 reactivity (p=0.03) were independent predictors of myocardial damage.

CONCLUSIONS

Platelet reactivity before PCI appears to be better predictor of myocardial damage than does response to clopidogrel.

[Direct stent implantation in acute myocardial infarction. The DISCO 3 study]

INTRODUCTION AND OBJECTIVES

An association has been reported between direct stenting in primary angioplasty and low incidences of the no-reflow phenomenon and distal embolization. The aims of this study were to determine the proportion of patients who can be treated by direct stent implantation and to identify factors that establish when the technique should be used in acute myocardial infarction in clinical practice.

PATIENTS AND METHOD

This prospective descriptive and multicenter study (DISCO 3) included 189 patients. Angiographic reperfusion parameters were recorded and resolution of the ST-segment elevation was monitored. Adverse clinical events, such as death, non-fatal reinfarction and repeat revascularization of the culprit vessel, were recorded at discharge, and after one and six months.

RESULTS

Direct stenting was performed in 56% of patients, and stenting after predilatation in 44%. The main predictors of direct stenting were short postinfarction delay, non-zero initial TIMI flow, and preinfarction angina. The most common reasons for balloon predilatation were TIMI flow zero on traversing the lesion with a guidewire (92%), involvement of a major bifurcation or tortuous vessel, and severe calcification. Indices of myocardial reperfusion were better with direct stenting: TIMI myocardial perfusion grade 2-3 flow was present in 84% vs 69% (P=.005), and > 70% ST-segment resolution occurred in 66% vs 42% (P=.003). No difference in adverse clinical events was found.

CONCLUSIONS

Direct stenting is feasible for treating acute myocardial infarction in more than half of patients. The lesions should not be severely calcified nor involve tortuous vessels, and there should be sufficient flow following passage of a guidewire to define the lesion's characteristics.