TCT-319 Use of Limited Antegrade Subintimal Tracking Technique in Chronic Total Occlusion Percutaneous Coronary Intervention

Background: There are limited data on the limited antegrade subintimal tracking (LAST) crossing technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We analyzed the frequency of use and outcomes of LAST among 2,003 CTO PCIs performed with antegrade dissection and re-entry (ADR) in the PROGRESS-CTO Registry between 2012 and 2021 at 39 centers. Results: LAST was used in 144 cases (7.2%), primary LAST in 113 (5.6%), and secondary LAST in 31 cases (1.5%). The Stingray system was used in 905 cases (45.2%), subintimal tracking and re-entry (STAR) in 333 cases (16.6%), and contrast-guided STAR in 29 cases (1.4%). The mean patient age was 64.2 ± 10 years, 86% were men, and 34.9% had prior coronary artery bypass graft surgery. Cases in which LAST was used were less complex with a lower J-CTO score (2.50 ± 1.32 vs. 2.95 ± 1.10, P \u3c 0.001). There was no difference in technical (75.0% vs 78.4%, P = 0.337) and procedural success (72.2% vs 75.5%, P = 0.384) and major cardiac adverse events (MACEs) (2.08% vs 3.55%, P = 0.352) between LAST and non-LAST cases. However, cases in which the LAST technique was used required less procedure and fluoroscopy time (Figure 1A). A primary LAST technique was associated with higher technical and procedural success rates and a similar MACE rate compared with a secondary LAST technique (Figure 1B). Conclusion: LAST is used in 7.2% of ADR CTO PCI cases and is associated with similar technical and procedural success rates and major complication rates but lower procedural and fluoroscopy time compared with ADR cases that did not use LAST

p38-MAPK is involved in restoration of the lost protection of preconditioning by nicorandil in vivo

Nicorandil, a selective mitochondrial KATP channel opener, reinstates the waned protection after multiple cycles of preconditioning. In this study, we determined the signal transduction activated in heart after 3 or 8 cycles of preconditioning and prolonged ischemia in rabbits treated with placebo or nicorandil. In a first series (eight groups) we evaluated the (%) infarct to risk ratio after 30 min ischemia/3 h reperfusion and in a second series (six groups), we assessed the intracellular levels of cyclic GMP (c-GMP), protein kinase C (PKC) activity and p38-mitogen activated protein kinase (p38-MAPK) phosphorylation from heart samples taken during the long ischemia. Cardioprotection by 3 cycles of preconditioning (11.7 ± 3.8% vs 45.9 ± 5.2% in the control, P < 0.001) was lost after 8 cycles (43.9 ± 5.1%, P = NS vs control). Nicorandil restored it to the levels of classic preconditioning (13.7 ± 2.4% vs 40.8 ± 3.5% in respective controls, P < 0.001). This was reversed by the p38-MAPK inhibitor SB203580 (48.8 ± 5.1%) which had no protective effect in the control group (44.6 ± 5.8%). In the placebo-treated rabbits, intracellular c-GMP and PKC were increased only in the group subjected to 3 cycles of preconditioning. Despite that nicorandil equalizes the intracellular levels of c-GMP, PKC and activated p38-MAPK at the long ischemia, specific alterations of p38-MAPK phosphorylation differentiate the protected groups. Our data delineate the signal transduction mechanism mediating the beneficial effect of nicorandil and imply that the recapture of the lost protection is due to a dynamic process of the intracellular mediators accompanied by an increase in p38-MAPK phosphorylation and not to an instantaneous event. © 2007 Elsevier B.V. All rights reserved

Ticagrelor versus clopidogrel in patients with STEMI treated with thrombolysis: The MIRTOS trial

Aims: We aimed to demonstrate whether coronary microvascular function is improved after ticagrelor administration compared to clopidogrel administration in STEMI subjects undergoing thrombolysis. Methods and results: MIRTOS is a multicentre study of ticagrelor versus clopidogrel in STEMI subjects treated with fibrinolysis. We enrolled 335 patients <75 years old with STEMI eligible for thrombolysis, of whom 167 were randomised to receive clopidogrel and 168 to receive ticagrelor together with thrombolysis. Primary outcome was the difference in post-PCI corrected TIMI frame count (CTFC). All clinical events were recorded in a three-month follow-up period. From the 335 patients who were randomised, 259 underwent PCI (129 clopidogrel and 130 ticagrelor) and 154 angiographies were analysable for the study primary endpoint. No significant difference was found between the clopidogrel (n=85) and ticagrelor (n=69) groups for CTFC (24.33±17.35 vs 28.33±17.59, p=0.10). No significant differences were observed in MACE and major bleeding events between randomisation groups (OR 2.0, 95% CI: 0.18-22.2, p=0.99). Conclusions: Thrombolysis with ticagrelor in patients <75 years old was not able to demonstrate superiority compared to clopidogrel in terms of microvascular injury, while there was no difference between the two groups in MACE and major bleeding events. Trial Registration. ClinicalTrials.gov Identifier: NCT02429271. EudraCT Number 2014-004082-25. © Europa Digital & Publishing 2021. All rights reserved

Trends of Antithrombotic Treatment in Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights from the GReek-AntiPlatElet Atrial Fibrillation (GRAPE-AF) Registry

Purpose: Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) are a high-risk subset of patients, whose optimal antithrombotic treatment strategy, involving a combination of anticoagulant and antiplatelet agents, has not been well defined. Our study aims to investigate contemporary “real-world” trends of antithrombotic treatment strategies in AF patients undergoing PCI, as well as identify factors affecting decision-making at hospital discharge. Methods: “Real-world” data were retrieved from the GReek-AntiPlatElet Atrial Fibrillation (GRAPE-AF) registry, a contemporary, nationwide, multicenter, observational study of AF patients undergoing PCI. Characteristics of patients discharged on triple antithrombotic therapy (TAT) or dual antithrombotic therapy (DAT) were compared in order to identify factors that could influence treatment decisions. Results: A total of 654 patients were enrolled (42% with stable coronary artery disease, 58% with acute coronary syndrome). TAT was adopted in 49.9% and DAT in 49.2% of patients at discharge. Regarding anticoagulants, the vast majority of patients (92.9%) received non-vitamin K antagonist oral anticoagulants (NOACs) and only 7.1% received vitamin K antagonists (VKAs). Dyslipidemia, insulin-dependent diabetes mellitus, prior myocardial infarction, acute coronary syndrome at presentation, and regional variations were predictive of TAT adoption, whereas the use of NOACs or ticagrelor was predictive of DAT adoption. Conclusion: Contemporary “real-world” data concerning antithrombotic treatment in AF patients undergoing PCI indicate a strong shift towards the use of NOACs instead of VKAs, along with a large subset of patients adopting an aspirin-free strategy early after index PCI, with clinical as well as treatment characteristics affecting decision-making. Trial registration: ClinicalTrials.gov Identifier: NCT03362788 (First Posted: December 5, 2017) © 2020, Springer Science+Business Media, LLC, part of Springer Nature

Outcomes of “Investment Procedures” in Chronic Total Occlusion Interventions

Background: In cases of failed re-entry into the distal true lumen during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification to restore some antegrade flow may facilitate subsequent lesion recanalization (“investment procedure”). Methods: We examined the subsequent outcomes of 58 CTO PCI “investment procedures” of 4,657 CTO PCIs in total (1.2%) from a large, multicenter registry between years 2012 and 2019. Results: Mean patient age was 67 ± 9 years, and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%), and diabetes (48%); prior PCI (61%); and prior coronary artery bypass surgery (47%). The target CTO lesions were highly complex as illustrated by the high frequency of proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score 3.2 ± 1.1. The rate of technical and procedural success achieved during subsequent CTO PCI was high (85% and 82%, respectively) with an acceptable rate of in-hospital major adverse cardiac events (3.3%). Median subsequent procedure time was 148 min (101, 221 min), median contrast volume was 188 ml (150, 262 ml), and median air kerma radiation dose was 2.5 Gy (1.4, 4.2 Gy) (Figure). [Figure presented] Conclusion: “Investment procedures” as bailout strategy in CTO PCI are associated with likelihood for successful revascularization during repeat CTO PCI attempt

In-hospital and follow-up outcomes after chronic total occlusion percutaneous coronary intervention according to left ventricular ejection fraction: Insights from the PROGRESS-CTO Registry

Background: Outcomes of chronic total occlusion percutaneous coronary intervention (CTO PCI) according to baseline left ventricular ejection fraction (LVEF) have received limited study. Methods: We compared clinical, angiographic, procedural characteristics and outcomes of 1,441 CTO PCIs performed in patients with known ejection fraction and available follow-up. We compared patients with LVEF ≥50% (N=834), LVEF 35%-49% (N=434) and LVEF \u3c35% (N=173). Results: Left anterior descending CTO was significantly more common in the low LVEF group (24% vs 25% vs 42%, p\u3c0.001). The J-CTO score was similar (2.4 ± 1.3 vs 2.5 ± 1.2 vs 2.4 ± 1.2, p = 0.5), as was procedural success (85% vs 83% vs 88%, p = 0.5) with the incidence of in-hospital major adverse cardiovascular events being numerically but not statistically higher in the LVEF\u3c35% group (2% vs 3.5% vs. 4.6%, p = 0.12). The composite endpoint of death, myocardial infarction (MI) and revascularization at 1 year was more common in the LVEF\u3c35% group (13% vs 17% vs 25 %, plog-rank = 0.001) (Figure). There was a significant difference in 1-year mortality (12.8% vs 16.8% vs 24.6%, p \u3c 0.001), but not in MI (1.9% vs 4.4% vs 5.6%, p = 0.07) and revascularization rates (7.4% vs 8.9% vs 10.7%, p = 0.8). Conclusions: CTO PCI can be performed with high success rates and acceptable in-hospital complication rates irrespectively of LVEF, but patients with LVEF\u3c35% have worse one-year outcomes

TCT-72 Primary Versus Secondary Retrograde Approach in Chronic Total Occlusion Interventions

Background: The retrograde approach to coronary chronic total occlusions (CTOs) can be used as the initial crossing strategy (primary retrograde) or after failure of antegrade crossing attempts (secondary retrograde). Methods: We compared baseline clinical and angiographic characteristics and procedural outcomes of primary versus secondary retrograde crossing for CTO percutaneous coronary intervention (PCI) among 2,789 procedures performed at 34 centers between 2012 and 2021. Results: Retrograde CTO PCI was performed as the primary crossing strategy in 1,086 cases (38.9%) and as a secondary approach in 1,703 cases (61.1%). Patients in the primary group had slightly lower left ventricular ejection fraction (49.1% vs 50.4%; P = 0.018), were more likely to have had previous coronary artery bypass graft surgery (52.9% vs 38.4%; P \u3c 0.001) and had higher J-CTO (3.31 ± 0.98 vs 2.99 ± 1.09; P \u3c 0.001) and PROGRESS-CTO (1.47 ± 0.92 vs 1.29 ± 0.99; P \u3c 0.001) scores. Technical (81.4% vs 77.3%; P = 0.01) and procedural (78.6% vs 74.1%; P = 0.006) success rates were higher in the primary retrograde group, with no difference in in-hospital major adverse events (4.3% vs 4.0%; P = 0.66). Contrast volume (250 [176,347] mL vs 270[190,367] mL; P \u3c 0.001) and procedure time (175 [127,233] min vs 180 [142,236] min; P \u3c 0.001) were lower in the primary group. Conclusion: Use of retrograde approach as primary crossing strategy is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with secondary retrograde CTO PCI

Hospital attendance and admission trends for cardiac diseases during the COVID-19 outbreak and lockdown in Greece

Objectives: The coronavirus disease 2019 (COVID-19) outbreak, along with implementation of lockdown and strict public movement restrictions, in Greece has affected hospital visits and admissions. We aimed to investigate trends of cardiac disease admissions during the outbreak of the pandemic and possible associations with the applied restrictive measures. Study design: This is a retrospective observational study. Methods: Data for 4970 patients admitted via the cardiology emergency department (ED) across 3 large-volume urban hospitals in Athens and 2 regional/rural hospitals from February 3, 2020, up to April 12 were recorded. Data from the equivalent (for the COVID-19 outbreak) time period of 2019 and from the postlockdown time period were also collected. Results: A falling trend of cardiology ED visits and hospital admissions was observed starting from the week when the restrictive measures due to COVID-19 were implemented. Compared with the pre–COVID-19 outbreak time period, acute coronary syndrome (ACS) [145 (29/week) vs. 60 (12/week), −59%, P < 0.001], ST elevation myocardial infarction [46 (9.2/week) vs. 21 (4.2/week), −54%, P = 0.002], and non-ST elevation ACS [99 cases (19.8/week) vs. 39 (7.8/week), −60% P < 0.001] were reduced at the COVID-19 outbreak time period. Reductions were also noted for heart failure worsening and arrhythmias. The ED visits in the postlockdown period were significantly higher than in the COVID-19 outbreak time period (1511 vs 660; P < 0.05). Conclusion: Our data show significant drops in cardiology visits and admissions during the COVID-19 outbreak time period. Whether this results from restrictive measures or depicts a true reduction of cardiac disease cases warrants further investigation. © 2020 The Royal Society for Public Healt

Utilization of the hybrid approach for percutaneous coronary interventions for chronic total occlusions: Update from a multicenter global registry

BACKGROUND We sought to examine thecontemporary outcomes of chronic total occlusion (CTO) percutaneous coronary interventions (PCI). METHODS We examined the clinical, angiographic and procedural characteristics of 2,733 CTO interventions of 2677 patients that were performed in 18 centers from the United States and Europe. RESULTS Mean age was 65±10 years and 85% of thepatients were men. There was a high prevalence ofdiabetes (44%), prior myocardial infarction (46%), prior coronary artery bypass surgery (33%), and prior PCI (66%). The most common target vessels were theright coronary artery (55%), left anterior descending artery (24%), and left circumflex artery (20%). Themean J-CTO and PROGRESS-CTO score was 2.5±1.3 and 1.4±1.0, respectively. The overall technical and procedural success rate was 88% and 86% respectively and the rate of in-hospital major complications was 2.9%. The initial crossing strategy was successful in 55% (Figure). The final successful crossing strategy was antegrade wire escalation in 50%, retrograde in 28%, and antegrade dissection reentry in 22%. Median contrast volume, air kerma radiation dose, procedure and fluoroscopy time were 270 (200-365) ml, 2.9 (1.7-4.8) Gray, 125 (82-191) and 46 (29-76) minutes, respectively. CONCLUSION Application of the hybrid approach for CTO PCI is associated with high technical success and low major adverse complication rates among various operators and patient populations. (Figure presented)

Retrograde CTO PCI of native coronary arteries via left internal mammary artery grafts: Insights from a multicenter US registry

BACKGROUND Retrograde percutaneous interventions (PCI) of native coronary artery chronic total occlusions (CTOs) via left internal mammaryartery (LIMA) grafts have received limited study. METHODS We compared the clinical and procedural characteristics and outcomes of retrograde CTO PCIthrough LIMA grafts vs. via other vessels in acontemporary multicenter registry. RESULTS The LIMA was used as collateral channel in 20 of 990 retrograde CTO PCIs (2.0%) performed at 18 USCenters. The mean age of the study patients was 69±7 years, and 95% were men. The most common CTO target vessel was the right coronary artery (55%). The mean J-CTO score in the LIMA group was high (3.45±0.76). The technical and procedural success rate of retrograde PCI via LIMA grafts was 70% and 70%, respectively, vs. 81.0% and 78.2% (p=0.247, and p=0.412), respectively for retrograde via other conduits (Figure). The incidence of major in-hospital complications was also similar between the LIMA and non- LIMA retrograde groups (5% vs. 6%, p=1.000). Use of guide catheter extensions (40% vs. 28%, p=0.217), intravascular ultrasound (45% vs. 31%, p=0.197), and left ventricular assist devices (24% vs. 10%, p=0.769) were numerically higher in retrogradeCTO PCIs via LIMA grafts. CONCLUSION RetrogradeCTO PCI is infrequently performed via LIMA graftsand is associated with numerically lower success but similar major in-hospital complication rates as retrograde CTO PCI performed via other vessels. (Figure presented)