Characteristics and outcome in cardiogenic shock according to vascular access site for percutaneous coronary intervention

Aims The optimal vascular access site for percutaneous coronary interventions (PCIs) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) remains uncertain. While observational data favour transradial access (TRA) due to lower complication rates and mortality, transfemoral access (TFA) PCI offers advantages such as shorter access and procedure times, along with quicker escalation to mechanical circulatory support (MCS). In this study, we aimed to investigate factors associated with a transfemoral approach and compare mortality rates between TRA and TFA in AMI-CS patients undergoing PCI. Methods Data from a nationwide registry of AMI-CS patients undergoing PCI (2017–2021) were analysed. We compared patient and results demographics, procedural details, and outcomes between TRA and TFA groups. Logistic regression identified access site factors and radial-to-femoral crossover predictors. Propensity score–matched (PSM) analysis examined the impact of access site on mortality. Of the 1562 patients, 45% underwent TRA PCI, with an increasing trend over time. Transfemoral access patients were more often female, had a history of coronary artery bypass grafting, lower blood pressure, higher resuscitation and intubation rates, and elevated lactate levels. After PSM, 30-day mortality was lower in TRA (33% vs. 46%, P &lt; 0.001). Predictors for crossover included left coronary artery interventions, multivessel PCI, and MCS initiation. Conclusion Significant differences exist between TRA and TFA PCI in AMI-CS. Transfemoral access was more common in patients with worse haemodynamics and was associated with higher 30-day mortality compared with TRA. This mortality difference persisted in the PSM analysis.[Figure</p

Recovery and prognostic value of myocardial strain in ST-segment elevation myocardial infarction patients with a concurrent chronic total occlusion

Objectives: Global left ventricular (LV) function is routinely used to assess cardiac function; however, myocardial strain is able to identify more subtle dysfunction. We aimed to determine the recovery and prognostic value of featuring tracking (FT) cardiovascular magnetic resonance (CMR) strain in ST-segment elevation myocardial infarction (STEMI) patients with a concurrent chronic total occlusion (CTO). Methods: In the randomized EXPLORE trial, there was no significant difference in global LV functio

Rationale and design of EXPLORE: a randomized, prospective, multicenter trial investigating the impact of recanalization of a chronic total occlusion on left ventricular function in patients after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction

<p>Abstract</p> <p>Background</p> <p>In the setting of primary percutaneous coronary intervention, patients with a chronic total occlusion in a non-infarct related artery were recently identified as a high-risk subgroup. It is unclear whether ST-elevation myocardial infarction patients with a chronic total occlusion in a non-infarct related artery should undergo additional percutaneous coronary intervention of the chronic total occlusion on top of optimal medical therapy shortly after primary percutaneous coronary intervention. Possible beneficial effects include reduction in adverse left ventricular remodeling and preservation of global left ventricular function and improved clinical outcome during future coronary events.</p> <p>Methods/Design</p> <p>The Evaluating Xience V and left ventricular function in Percutaneous coronary intervention on occLusiOns afteR ST-Elevation myocardial infarction (EXPLORE) trial is a randomized, prospective, multicenter, two-arm trial with blinded evaluation of endpoints. Three hundred patients after primary percutaneous coronary intervention for ST-elevation myocardial infarction with a chronic total occlusion in a non-infarct related artery are randomized to either elective percutaneous coronary intervention of the chronic total occlusion within seven days or standard medical treatment. When assigned to the invasive arm, an everolimus-eluting coronary stent is used. Primary endpoints are left ventricular ejection fraction and left ventricular end-diastolic volume assessed by cardiac Magnetic Resonance Imaging at four months. Clinical follow-up will continue until five years.</p> <p>Discussion</p> <p>The ongoing EXPLORE trial is the first randomized clinical trial powered to investigate whether recanalization of a chronic total occlusion in a non-infarct related artery after primary percutaneous coronary intervention for ST-elevation myocardial infarction results in a better preserved residual left ventricular ejection fraction, reduced end-diastolic volume and enhanced clinical outcome.</p> <p>Trial registration</p> <p>trialregister.nl NTR1108.</p

Less bleeding by omitting aspirin in non-ST-segment elevation acute coronary syndrome patients: Rationale and design of the LEGACY study

BACKGROUND: Early aspirin withdrawal, also known as P2Y12-inhibitor monotherapy, following percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) can reduce bleeding without a trade-off in efficacy. Still the average daily bleeding risk is highest during the first months and it remains unclear if aspirin can be omitted immediately following PCI. METHODS: The LEGACY study is an open-label, multicenter randomized controlled trial evaluating the safety and efficacy of immediate P2Y12-inhibitor monotherapy versus dual antiplatelet therapy (DAPT) for 12 months in 3,090 patients. Patients are randomized immediately following successful PCI for NSTE-ACS to 75-100 mg aspirin once daily versus no aspirin. The primary hypothesis is that immediately omitting aspirin is superior to DAPT with respect to major or minor bleeding defined as Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, while maintaining noninferiority for the composite of all-cause mortality, myocardial infarction and stroke compared to DAPT. CONCLUSIONS: The LEGACY study is the first randomized study that is specifically designed to evaluate the impact of immediately omitting aspirin, and thus treating patients with P2Y12-inhibitor monotherapy, as compared to DAPT for 12 months on bleeding and ischemic events within 12 months following PCI for NSTE-ACS

Prognostic factors in primary and elective percutaneous coronary intervention

Percutane coronaire interventie (PCI), de behandeling van vernauwingen in de kransslagaders met katheters via lies of pols, wordt jaarlijks bij meer dan dertigduizend patiënten in Nederland verricht. Bij een acuut hartinfarct, als een van de kransslagaders ineens door een stolsel wordt afgesloten, blijkt de aanwezigheid van een chronisch verstopte kransslagader, die tot dan toe geen problemen veroorzaakte, het overlijdensrisico te verhogen. Bimmer Claessen toont aan dat chronisch verstopte kransslagaders effectief behandeld kunnen worden met PCI

Impact of Collateral Circulation on Survival in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention With a Concomitant Chronic Total Occlusion

This study sought to compare long-term clinical outcome in ST-segment elevation myocardial infarction (STEMI) patients with a concomitant chronic total occlusion (CTO) with well-developed versus poorly developed collaterals toward the CTO. In STEMI patients, presence of a CTO is associated with increased morbidity and mortality. CTOs are often (partially) perfused by collateral vessels. Therefore, when the infarct-related artery (IRA) is the main donor vessel for the collateral blood supply of the CTO, infarct size may increase significantly. Well-developed collaterals to the infarct related vessel have been associated with improved clinical outcome after STEMI. However, the impact of well-developed collaterals toward a concomitant CTO in STEMI patients is unknown. Consecutive STEMI patients with a CTO in a non-IRA presenting for primary percutaneous coronary intervention (PCI) were divided according to the presence of angiographic, well-developed (grade 2 to 3) or poorly developed collaterals (grade 0 to 1). Between 2000 and 2012 we included 413 STEMI patients with a single concomitant CTO. Well-developed collaterals to the CTO were present in 53%. Associated with poorly developed collaterals to the CTO were cardiogenic shock (hazard ratio [HR]: 1.8; 95% confidence interval [CI]: 1.11 to 3.07; p = 0.02), CTO located in the left circumflex artery (HR: 1.9; 95% CI: 1.00 to 3.43; p = 0.05), CTO diameter ≤2.5 mm (HR: 2.1; 95% CI: 1.07 to 4.12; p = 0.03), and CTO tapering (HR: 1.9; 95% CI: 1.21 to 2.85; p <0.001). Patients with well-developed collaterals to the CTO had a better 5-year survival compared to those with poorly developed collaterals (74% vs. 63%; p = 0.01). The presence of well-developed collaterals to the CTO was independently associated with improved survival (HR: 1.5; 95% CI: 1.03 to 2.10; p = 0.04). In STEMI patients with a CTO in a non-IRA, the presence of well-developed collaterals to the CTO is associated with improved surviva

Identification and treatment of the vulnerable coronary plaque

Acute coronary syndrome mostly arises from rupture or erosion of a vulnerable plaque. Vulnerable plaques typically appear as lipid-rich plaques with a thin cap, called thin-cap fibroatheromas. Various intracoronary imaging techniques can be used to detect vulnerable plaques, such as intravascular ultrasound (IVUS), optical coherence tomography (OCT) and near-infrared spectroscopy (NIRS), each visualizing different high-risk plaque characteristics. IVUS and its post-processing techniques, such as virtual histology IVUS, can primarily be used to identify calcified and soft plaques, while OCT is also able to quantitatively measure the cap thickness. The addition of NIRS allows the exact measurement of lipid content in the plaque. Non-invasive imaging techniques to identify vulnerable plaques, such as computed tomography, are less often used but are evolving and may be of additional diagnostic use, especially when prophylactic treatments for vulnerable plaques are further established. Pharmacological treatment with lipid-lowering or anti-inflammatory medication leads to plaque stabilization and reduction of cardiovascular events. Moreover, the implantation of a stent or scaffold for the local treatment of vulnerable plaques has been found to be safe and to stabilize high-risk plaque features. The use of drug-coated balloons to treat vulnerable plaques is the subject of ongoing research. Future studies should focus on non-invasive imaging techniques to adequately identify vulnerable plaques and further randomized clinical studies are necessary to find the most appropriate treatment strategy for vulnerable plaques