The aim was to establish a contemporary scoring system to predict the outcome of chronic total occlusion coronary angioplasty.
Interventional treatment of chronic total coronary occlusions (CTOs) is ...a developing subspecialty. Predictors of technical success or failure have been derived from datasets of modest size. A robust scoring tool could facilitate case selection and inform decision making.
The study analyzed data from the EuroCTO registry. This prospective database was set up in 2008 and includes >20,000 cases submitted by CTO expert operators (>50 cases/year). Derivation (n = 14,882) and validation (n = 5,745) datasets were created to develop a risk score for predicting technical failure.
There were 14,882 patients in the derivation dataset (with 2,356 15.5% failures) and 5,745 in the validation dataset (with 703 12.2% failures). A total of 20.2% of cases were done retrogradely, and dissection re-entry was performed in 9.3% of cases. We identified 6 predictors of technical failure, collectively forming the CASTLE score (Coronary artery bypass graft history, Age (≥70 years), Stump anatomy blunt or invisible, Tortuosity degree severe or unseen, Length of occlusion ≥20 mm, and Extent of calcification severe). When each parameter was assigned a value of 1, technical failure was seen to increase from 8% with a CASTLE score of 0 to 1, to 35% with a score ≥4. The area under the curve (AUC) was similar in both the derivation (AUC: 0.66) and validation (AUC: 0.68) datasets.
The EuroCTO (CASTLE) score is derived from the largest database of CTO cases to date and offers a useful tool for predicting procedural outcome.
A retrograde approach improves the success rate of percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs).
The authors describe the European experience with and outcomes of ...retrograde PCI revascularization for coronary CTOs.
Follow-up data were collected from 1,395 patients with 1,582 CTO lesions enrolled between January 2008 and December 2012 for retrograde CTO PCI at 44 European centers. Major adverse cardiac and cerebrovascular events were defined as the composite of cardiac death, myocardial infarction, stroke, and further revascularization.
The mean patient age was 62.0 ± 10.4 years; 88.5% were men. Procedural and clinical success rates were 75.3% and 71.2%, respectively. The mean clinical follow-up duration was 24.7 ± 15.0 months. Compared with patients with failed retrograde PCI, successfully revascularized patients showed lower rates of cardiac death (0.6% vs. 4.3%, respectively; p < 0.001), myocardial infarction (2.3% vs. 5.4%, respectively; p = 0.001), further revascularization (8.6% vs. 23.6%, respectively; p < 0.001), and major adverse cardiac and cerebrovascular events (8.7% vs. 23.9%, respectively; p < 0.001). Female sex (hazard ratio HR: 2.06; 95% confidence interval CI: 1.33 to 3.18; p = 0.001), prior PCI (HR: 1.73; 95% CI: 1.16 to 2.60; p = 0.011), low left ventricular ejection fraction (HR: 2.43; 95% CI: 1.22 to 4.83; p = 0.011), J-CTO (Multicenter CTO Registry in Japan) score ≥3 (HR: 2.08; 95% CI: 1.32 to 3.27; p = 0.002), and procedural failure (HR: 2.48; 95% CI: 1.72 to 3.57; p < 0.001) were independent predictors of major adverse cardiac and cerebrovascular events at long-term follow-up.
The number of retrograde procedures in Europe has increased, with high percents of success, low rates of major complications, and good long-term outcomes.
A meta-analysis of all randomised controlled studies that compare outcomes of transradial versus the transfemoral route to better define best practice in patients with ST elevation myocardial ...infarction (STEMI).
A Medline and Embase search was conducted using the search terms 'transradial,' 'radial', 'STEMI', 'myocardial' and 'infarction'.
Randomised controlled studies that compare outcomes of transradial versus the transfemoral route.
A total of nine studies were identified that consisted of 2977 patients with STEMI. Interventions Studies that compare outcomes of transradial versus the transfemoral route.
The primary clinical outcomes of interest were (1) mortality; (2) major adverse cardiac events (MACE); (3) major bleeding and (4) access site complications.
Transradial PCI was associated with a reduction in mortality (OR 0.53, 95% CI 0.33 to 0.84; p=0.008), MACE (OR 0.62, 95% CI 0.43 to 0.90; p=0.012), major bleeding events (OR 0.63, 95% CI 0.35-1.12; p=0.12) and access site complications (OR 0.30, 95% CI 0.19 to 0.48; p<0.0001) compared with procedures performed through the femoral route.
This meta-analysis demonstrates a significant reduction in mortality, MACE and major access site complications associated with the transradial access site in STEMI. The meta-analysis supports the preferential use of radial access for STEMI PCI.
Background
Defining the optimal conduction of percutaneous‐coronary‐intervention (PCI) to treat bifurcation lesions has been the subject of many clinical studies showing that the applied stenting ...technique may influence clinical outcome. Accordingly, bifurcation stenting classifications and technical sequences should be standardized to allow proper reporting and comparison.
Methods
The European Bifurcation Club (EBC) is a multidisciplinary group dedicated to optimize the treatment of bifurcations and previously created a classification of bifurcation stenting techniques that is based on the first stent implantation site. Since some techniques have been abandoned, others have been refined and dedicated devices became available, EBC promoted an international task force aimed at updating the classification of bifurcation stenting techniques as well as at highlighting the best practices for most popular techniques. Original descriptive images obtained by drawings, bench tests and micro‐computed‐tomographic reconstructions have been created in order to serve as tutorials in both procedure reporting and clinical practice.
Results
An updated Main‐Across‐Distal‐Side (MADS)‐2, classification of bifurcation stenting techniques has been realized and is reported in the present article allowing standardized procedure reporting in both clinical practice and scientific studies. The EBC‐promoted task force deeply discussed, agreed on and described (using original drawings and bench tests) the optimal steps for the following major bifurcation stenting techniques: (a) 1‐stent techniques (“provisional” and “inverted provisional”) and (b) 2‐stent techniques (“T/TAP,” “culotte,” and “DK‐crush”).
Conclusions
The present EBC‐promoted paper is intended to facilitate technique selection, reporting and performance for PCI on bifurcated lesions during daily clinical practice.
Percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTO) improves clinical symptoms and quality of life. The longer-term safety of PCI compared to optimal medical therapy ...(OMT) remains uncertain.
We sought to evaluate the long-term safety of PCI for CTO in a randomised trial as compared to OMT.
A total of 396 patients with a symptomatic CTO were enrolled into a randomised, multicentre clinical trial comparing PCI and OMT. Half of the patients had a single CTO; the others had multivessel disease. Non-CTO lesions were treated prior to randomisation (2:1 ratio). During follow-up, crossover from OMT to PCI occurred in 7.3% (1 year) and 17.5% (3 years) of patients.
At 3 years, the incidence of cardiovascular death or nonfatal myocardial infarction was not significantly different between the groups (OMT 3.7% vs PCI 6.2%; p=0.29). By per-protocol analysis, the difference remained non-significant (OMT 5.7% vs PCI 4.7%; p=0.67). Overall, major adverse cardiovascular events (MACE) were more frequent with OMT (OMT 21.2% vs PCI 11.2%), largely because of ischaemia-driven revascularisation. The rates of stroke or hospitalisation for bleeding were not different between the groups.
At 3 years there was no difference in the rate of cardiovascular death or myocardial infarction between PCI or OMT among patients with a remaining single coronary CTO. The MACE rate was higher in the OMT group due largely to ischaemia-driven revascularisation. CTO PCI appears to be a safe option for patients with a single remaining significant coronary CTO. CinicalTrials.gov: NCT01760083.
Aims
The aim was to assess the effect of a telemonitoring programme vs. standard care (SC) in preventing all‐cause deaths or unplanned hospitalisations in heart failure (HF) at 18 months.
Methods and ...results
OSICAT was a randomised, multicentre, open‐label French study in 937 patients hospitalised for acute HF ≤12 months before inclusion. Patients were randomised to telemonitoring (daily body weight measurement, daily recording of HF symptoms, and personalised education) (n = 482) or to SC (n = 455). Mean ± standard deviation number of events for the primary outcome was 1.30 ± 1.85 for telemonitoring and 1.46 ± 1.98 for SC rate ratio 0.97, 95% confidence interval (CI) 0.77–1.23; P = 0.80. In New York Heart Association (NYHA) class III or IV HF, median time to all‐cause death or first unplanned hospitalisation was 82 days in the telemonitoring group and 67 days in the SC group (P = 0.03). After adjustment for known predictive factors, telemonitoring was associated with a 21% relative risk reduction in first unplanned hospitalisation for HF hazard ratio (HR) 0.79, 95% CI 0.62–0.99; P = 0.044); the relative risk reduction was 29% in patients with NYHA class III or IV HF (HR 0.71, 95% CI 0.53–0.95; P = 0.02), 38% in socially isolated patients (HR 0.62, 95% CI 0.39–0.98; P = 0.043), and 37% in patients who were ≥70% adherent to body weight measurement (HR 0.63, 95% CI 0.45–0.88; P = 0.006).
Conclusion
Telemonitoring did not result in a significantly lower rate of all‐cause deaths or unplanned hospitalisations in HF patients. The pre‐specified subgroup results suggest the telemonitoring approach improves clinical outcomes in selected populations but need further confirmation.
Abstract
Aims
There are only very few data on the prognostic value of stress cardiovascular magnetic resonance (CMR) in elderly people, while life expectancy of the general population is steadily ...increasing. Therefore, this study aims to assess the prognostic value of vasodilator stress perfusion CMR in elderly >75 years.
Methods and results
Between 2008 and 2017, we included consecutive elderly >75 years without known coronary artery disease (CAD) referred for dipyridamole stress CMR. They were followed for the occurrence of major adverse cardiovascular events (MACE) including cardiac death or non-fatal myocardial infarction. Univariate and multivariate analyses were performed to determine the prognostic value of ischaemia or late gadolinium enhancement. Of 754 elderly individuals (82.0 ± 3.9 years, 48.4% men), 659 (87.4%) completed the follow-up with median follow-up of 4.7 years. Using Kaplan–Meier analysis, the presence of myocardial ischaemia was associated with the occurrence of MACE hazard ratio (HR) 5.38, 95% confidence interval (CI): 3.56–9.56; P < 0.001. In a multivariable Cox regression including clinical characteristics and CMR indexes, inducible ischaemia was an independent predictor of a higher incidence of MACE (HR 4.44, 95% CI: 2.51–7.86; P < 0.001). In patients without ischaemia, the occurrence of MACE was lower in women when compared with men (P < 0.01).
Conclusion
Stress CMR is safe and has discriminative prognostic value in elderly, with a significantly lower event rate of future cardiovascular event or death in subjects without ischaemia or infarction.
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