Incidence and Predictors of Clinically Significant Bleedings after Transcatheter Left Atrial Appendage Closure

Background: Transcatheter left atrial appendage closure (LAAC) is performed in patients unsuitable for long-term anticoagulation, predominantly due to prior bleeding events. The study aimed to investigate the incidence and predictors of clinically significant bleeding (CSB) post-LAAC. Methods: Consecutive patients after LAAC with an Amplatzer or WATCHMAN device were analyzed (05.2014–11.2019). Bleeding was classified as CSB when associated with at least one of the following: death, ≥2 g/dL hemoglobin drop, ≥2 blood units transfusion, critical anatomic site, or hospitalization/invasive procedure. Results: Among 195 patients (age 74 (68–80), 43.1% females, HAS-BLED score 2.0 (2.0–3.0)), during median follow-up of 370 (IQR, 358–392) days, there were 15 nonprocedural CSBs in 14 (7.2%) patients. Of those, 9 (60.0%) occurred during postprocedural dual antiplatelet therapy (DAPT) (median 46 (IQR: 16–60) days post-LAAC) vs. 6 (40%) after DAPT discontinuation (median 124 (81–210) days post-LAAC), translating into annualized CSB rates of 14.0% (per patient-year on DAPT) vs. 4.6% (per patient-year without DAPT). In 92.9% (13/14) of patients, the post-LAAC nonprocedural CSB was a recurrence from the same site as bleeding pre-LAAC. In the multivariable model, admission systolic blood pressure (SBP) > 127 mmHg (HR = 10.73, 1.37–84.26, p = 0.024), epistaxis history (HR = 5.84, 1.32–25.89, p = 0.020), permanent atrial fibrillation (AF) (HR = 4.55, 1.20–17.20, p = 0.025), and prior gastrointestinal bleeding (HR = 3.35, 1.01–11.08, p = 0.048) predicted post-LAAC CSB. Conclusions: Nonprocedural CSBs after LAAC, with a similar origin as the pre-LAAC bleedings, were observed predominantly during postprocedural DAPT and predicted by elevated admission SBP, prior epistaxis, permanent AF, and gastrointestinal bleeding history. Whether a more reserved post-LAAC antiplatelet regimen and stringent blood pressure control may improve LAAC outcomes remains to be studied

Impact of Coronary Artery Calcium Characteristics on Accuracy of CT Angiography

ObjectivesThis study sought to evaluate which specific calcium characteristics impact diagnostic accuracy of coronary computed tomography angiography (CTA).BackgroundCoronary calcifications comprise one of the most significant factors interfering with diagnostic accuracy of coronary CTA. Despite this fact, there is paucity of data regarding this phenomenon.MethodsA total of 525 coronary lesions (252 calcified and 273 reference [noncalcified] lesions) within 97 arteries of 60 patients (19 women, age 63 ± 10 years) underwent assessment with both 2 × 64-slice computed tomography and intravascular ultrasound (IVUS). Nineteen calcium characteristics were determined. The main outcome was coronary CTA inaccuracy defined as the deviation of minimum lumen area within the calcification measured with coronary CTA from that measured with IVUS, in both absolute (mm2) and relative (%) terms.ResultsPresence of calcification was found to be independently correlated to coronary CTA inaccuracy in both absolute and relative terms (p < 0.001 for both). The relative (%) inaccuracy of coronary CTA was independently correlated to total calcium length (p = 0.004), total calcium volume (p = 0.008), cross section calcium thickness (p = 0.023), cross section calcium area (p = 0.023), and cross section lumen area (p = 0.001). The absolute inaccuracy of CTA was correlated to calcium length (p = 0.010), calcium volume (p = 0.017), and cross section calcium area (p < 0.001). The presence of both total calcium arc ≥47° and mean lumen diameter of ≤2.8 mm provided the best predictive accuracy for detection of excessive lumen underestimation by CTA. The best accuracy for prediction of excessive lumen overestimation provided combination of 2 of 3 features: maximum calcium density <869 HU, OR whole calcium length <2.4 mm, OR total calcium volume <6.4 mm3.ConclusionsOur results indicate which specific calcium characteristics impact accuracy of coronary CTA in lumen assessment within calcified lesions. This may provide practical assistance in predicting coronary lumen underestimation or overestimation by coronary CTA, therefore mitigating risk of diagnostic errors in clinical practice

Original article Comparison of prognostic value of epicardial blood flow and early ST-segment resolution after primary coronary angioplasty. ANIN &#8211; Myocardial Infarction Registry

Background: TIMI scale is commonly used for angiographic assessment of reperfusion effectiveness and early risk stratification in patients treated with primary angioplasty for ST-elevation myocardial infarction (STEMI). Since ST-resolution analysis allows a noninvasive insight into the reperfusion status at the myocardial tissue level, it may be a better predictor of outcome after primary angioplasty. Aim: To compare the prognostic value of the reperfusion effectiveness evaluation based on either the epicardial blood flow assessment according to the TIMI scale, or ST-segment resolution analysis in patients treated with primary coronary angioplasty for STEMI. Methods: 324 consecutive patients treated within 12 hours from the pain onset were studied. Based on the analysis of maximal ST-segment elevation/depression identified in a single ECG lead recorded after the procedure (maxSTE), patients were classified into groups of high versus medium/low risk. Independently, distinguished were groups with restored normal (TIMI 3) and abnormal (TIMI 0-2) final blood flow in infarct related artery. Results: The 30-day and one-year mortality rates were higher in the high-risk maxSTE group (25% of all patients) than in the other patients (14.8% vs. 2.5%, pWstęp: Przywrócenie prawidłowego przepływu krwi w tętnicy dozawałowej jest głównym celem pierwotnej angioplastyki wieńcowej i jest rutynowo określane za pomocą skali TIMI. Mimo że ten parametr ma uznane znaczenie prognostyczne, trwają poszukiwania innych, prostszych i nieinwazyjnych wskaźników prognostycznych. Cel: Porównanie wartości rokowniczej oceny skuteczności reperfuzji na podstawie klasyfikacji przepływu nasierdziowego wg skali TIMI z analizą normalizacji uniesionego odcinka ST u pacjentów leczonych pierwotną angioplastyką wieńcową w ostrym zespole wieńcowym z przetrwałym uniesieniem odcinka ST (STEMI). Metodyka: Zbadano 324 kolejnych pacjentów leczonych do 12 godz. od początku bólu. Na podstawie analizy wielkości maksymalnego uniesienia/obniżenia odcinka ST rejestrowanego po zabiegu w pojedynczym odprowadzeniu EKG (maxSTE), pacjentów przypisano do grup wysokiego i niskiego/średniego ryzyka. Niezależnie wyodrębniono grupy z prawidłowym (TIMI 3) i nieprawidłowym (TIMI 0&#8211;2) przepływem końcowym. Wyniki: Śmiertelność 30-dniowa i roczna w grupie wysokiego ryzyka wg maxSTE (25% pacjentów) była wyższa niż u pozostałych pacjentów (14,8% vs 2,5%,

Management of coronary disease in patients with advanced kidney disease

BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P=0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P=0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P=0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction