Left main coronary artery (LMCA) disease is associated with high mortality and morbidity due to a large area of jeopardized myocardium. However, the optimal revascularization strategy for patients ...with LMCA disease and left ventricular dysfunction is still unclear.
This study sought to examine long-term comparative outcomes after percutaneous coronary intervention (PCI) or a coronary artery bypass grafting (CABG) according to the severity of left ventricular dysfunction.
The authors evaluated a total of 3,488 patients with LMCA disease who underwent CABG (n = 1,355) or PCI (n = 2,133) from the IRIS-MAIN (Interventional Research Incorporation Society-Left MAIN Revascularization) registry. Left ventricular function was categorized according to left ventricular ejection fraction (LVEF) as normal function (LVEF ≥55%), mild dysfunction (LVEF ≥45% to <55%), moderate dysfunction (LVEF ≥35% to <45%), or severe dysfunction (LVEF <35%). The primary outcome was a composite of death, myocardial infarction, or stroke.
Among the overall patient population, 2,641 (75.7%) patients had normal LVEF and 403 (11.6%), 260 (7.5%), and 184 (5.3%) had mild, moderate, and severe left ventricular dysfunction at baseline, respectively. Compared with CABG, PCI was associated with a higher adjusted risk of primary outcomes in patients with moderate (hazard ratio HR: 2.23; 95% confidence interval CI: 1.17 to 4.28) or severe (HR: 2.45; 95% CI: 1.27 to 4.73) dysfunction. In contrast, PCI and CABG had similar risks of the primary outcomes in patients with normal (HR: 0.80; 95% CI: 0.59 to 1.07) or mild (HR: 1.17; 95% CI: 0.63 to 2.17) dysfunction (p for interaction = 0.004).
In the revascularization of LMCA disease, PCI was associated with an inferior primary composite outcome of death, MI, or stroke compared with CABG in patients with moderate or severe left ventricular dysfunction. However, the risk for the primary outcome was comparable between PCI and CABG in those with normal or mild left ventricular dysfunction. (Observational Study for Left Main Disease Treatment; NCT01341327)
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Transition-metal dichalcogenide materials play a major role in the state-of-the-art innovations for energy conversion because of potential applications resulting from their unique properties. These ...materials additionally show inordinate potential toward the progress of hygienic power sources to deal with increasing environmental disputes at the time of skyrocketing energy demands. Herein, we report earth-abundant, few-layered, MoSe2-bridged MoS2/cadmium sulfide (CdS) nanocomposites, which reduce photogenerated electron and hole recombination by effectively separating charge carriers to achieve a high photocatalytic efficiency. Accordingly, the MoSe2-bridged MoS2/CdS system produced effective hydrogen (193 μmol·h–1) as that of water using lactic acid as a hole scavenger with the irradiation of solar light. The presence of few-layered MoSe2 bridges in MoS2/CdS successfully separates photogenerated charge carriers, thereby enhancing the shuttling of electrons on the surface to active edge sites. To the best of our knowledge, this few-layered MoSe2-bridged MoS2/CdS system exhibits the most effective concert among altogether-reported MoS2-based CdS composites. Notably, these findings with ample prospective for the development of enormously real photocatalytic systems are due to their economically viable and extraordinary efficiency.
It is unknown whether the direct oral anticoagulant edoxaban can reduce leaflet thrombosis and the accompanying cerebral thromboembolic risk after transcatheter aortic valve replacement. In addition, ...the causal relationship of subclinical leaflet thrombosis with cerebral thromboembolism and neurological or neurocognitive dysfunction remains unclear.
We conducted a multicenter, open-label randomized trial comparing edoxaban with dual antiplatelet therapy (aspirin plus clopidogrel) in patients who had undergone successful transcatheter aortic valve replacement and did not have an indication for anticoagulation. The primary end point was an incidence of leaflet thrombosis on 4-dimensional computed tomography at 6 months. Key secondary end points were the number and volume of new cerebral lesions on brain magnetic resonance imaging and the serial changes of neurological and neurocognitive function between 6 months and immediately after transcatheter aortic valve replacement.
A total of 229 patients were included in the final intention-to-treat population. There was a trend toward a lower incidence of leaflet thrombosis in the edoxaban group compared with the dual antiplatelet therapy group (9.8% versus 18.4%; absolute difference, -8.5% 95% CI, -17.8% to 0.8%;
=0.076). The percentage of patients with new cerebral lesions on brain magnetic resonance imaging (edoxaban versus dual antiplatelet therapy, 25.0% versus 20.2%; difference, 4.8%; 95% CI, -6.4% to 16.0%) and median total new lesion number and volume were not different between the 2 groups. In addition, the percentages of patients with worsening of neurological and neurocognitive function were not different between the groups. The incidence of any or major bleeding events was not different between the 2 groups. We found no significant association between the presence or extent of leaflet thrombosis with new cerebral lesions and a change of neurological or neurocognitive function.
In patients without an indication for long-term anticoagulation after successful transcatheter aortic valve replacement, the incidence of leaflet thrombosis was numerically lower with edoxaban than with dual antiplatelet therapy, but this was not statistically significant. The effects on new cerebral thromboembolism and neurological or neurocognitive function were also not different between the 2 groups. Because the study was underpowered, the results should be considered hypothesis generating, highlighting the need for further research.
URL: https://www.
gov. Unique identifier: NCT03284827.
Artificial intelligence-based quantitative coronary angiography (AI-QCA) has been developed to provide a more objective and reproducible data about the severity of coronary artery stenosis and the ...dimensions of the vessel for intervention in real-time, overcoming the limitations of significant inter- and intraobserver variability, and time-consuming nature of on-site QCA, without requiring extra time and effort. Compared with the subjective nature of visually estimated conventional CAG guidance, AI-QCA guidance provides a more practical and standardized angiography-based approach. Although the advantage of intravascular imaging-guided PCI is increasingly recognized, their broader adoption is limited by clinical and economic barriers in many catheterization laboratories.
The FLASH (fully automated quantitative coronary angiography versus optical coherence tomography guidance for coronary stent implantation) trial is a randomized, investigator-initiated, multicenter, open-label, noninferiority trial comparing the AI-QCA-assisted PCI strategy with optical coherence tomography-guided PCI strategy in patients with significant coronary artery disease. All operators will utilize a novel, standardized AI-QCA software and PCI protocol in the AI-QCA-assisted group. A total of 400 patients will be randomized to either group at a 1:1 ratio. The primary endpoint is the minimal stent area (mm2), determined by the final OCT run after completion of PCI. Clinical follow-up and cost-effectiveness evaluations are planned at 1 month and 6 months for all patients enrolled in the study.
Enrollment of a total of 400 patients from the 13 participating centers in South Korea will be completed in February 2024. Follow-up of the last enrolled patients will be completed in August 2024, and primary results will be available by late 2024.
The FLASH is the first clinical trial to evaluate the feasibility of AI-QCA-assisted PCI, and will provide the clinical evidence on AI-QCA assistance in the field of coronary intervention.
URL: https://www.clinicaltrials.gov. Unique identifier: NCT05388357.
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Aims
Few studies have reported data on the optimal timing of left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA‐ECMO) for cardiac arrest or shock. This study ...evaluated the feasibility of an early LV unloading strategy compared with a conventional strategy in VA‐ECMO.
Methods and results
Between December 2018 and August 2022, 60 patients at two institutions were randomized in a 1:1 ratio to receive early (n = 30) or conventional (n = 30) LV unloading strategies. The early LV unloading strategy was defined as LV unloading performed at the time of VA‐ECMO insertion. LV unloading was performed using a percutaneous transseptal left atrial cannulation via the femoral vein incorporated into the ECMO venous circuit. The early and conventional LV unloading groups included 29 (96.7%) and 23 (76.7%) patients, respectively (median time from VA‐ECMO insertion to LV unloading: 48.4 h, interquartile range 47.8–96.5 h). The groups showed no significant differences in the rate of VA‐ECMO weaning as the primary endpoint (70.0% vs. 76.7%; relative risk 0.91; 95% confidence interval 0.67–1.24; p = 0.386) and survival to discharge (53.3% vs. 50.0%, p = 0.796). However, the pulmonary congestion score index at 48 h after LV unloading was significantly improved only in the early LV unloading group (2.0 ± 0.7 vs. 1.7 ± 0.6 at baseline vs. at 48 h; p = 0.008).
Conclusions
Compared with the conventional approach, early LV unloading did not improve the VA‐ECMO weaning rate, despite the rapid improvement in pulmonary congestion. Therefore, the results of this study do not support the application of this strategy after VA‐ECMO insertion.
Patients with significant pulmonary oedema or aortic valve (AV) closure during venoarterial extracorporeal membrane oxygenation (VA‐ECMO) were randomized to early left ventricular (LV) unloading or conventional strategy groups (1:1). The primary endpoint was the rate of weaning from VA‐ECMO during index admission. The early LV unloading strategy did not increase the weaning rate from VA‐ECMO compared with the conventional approach. CV, cardiovascular; HT, heart transplantation; ICU, intensive care unit; LVAD, left ventricular assist device.
This study compared the 3-year outcomes of intracoronary imaging-guided pre-dilation, stent sizing, and post-dilation (iPSP) for patients with complex coronary artery lesions.
The long-term effects ...of the optimal drug-eluting stent implantation technique in complex coronary artery disease have not been evaluated.
From the IRIS-DES (Interventional Cardiology Research In-cooperation Society-Drug-Eluting Stents) registry, the study evaluated 9,525 patients who underwent percutaneous coronary intervention for left main, bifurcation, long or diffuse (>30 mm), or angiographically severely calcified lesions. The primary outcome was a composite of cardiac death, target vessel myocardial infarction, and target vessel revascularization. The inverse probability of treatment weighting method was used to adjust for confounding factors.
At the index procedure, intravascular ultrasound assessment PSP were performed in 8,522 (89.5%) patients, 5,141 (54.0%) patients, and 5,531 (58.1%) patients, respectively; overall, 3,374 (35.4%) patients underwent stent implantation using all 3 parts of the iPSP strategy and were defined as the iPSP group. At 3 years, the adjusted rate of the primary outcome was significantly lower in iPSP group (5.6% vs 7.9%; adjusted hazard ratio: 0.71; 95% confidence interval: 0.63 to 0.81; p < 0.001).
Among patients undergoing drug-eluting stent implantation in complex coronary artery stenosis, iPSP was associated with a lower risk of cardiac events at 3 years. Therefore, physicians should apply iPSP more actively for the treatment of complex coronary artery stenoses, even in the current era. (Evaluation of the First, Second, and New Drug-Eluting Stents in Routine Clinical Practice IRIS-DES; NCT01186133).
There is insufficient data regarding the comparative efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) regarding myocardial infarction (MI). Our ...systematic review included randomized controlled trials that compared CABG versus PCI with stents in patients with multivessel or left main coronary artery disease (CAD). Included trials should have had reported event number of MI and a clinical follow-up of one or more years. Data were pooled using a random-effects model. The primary end point was MI at the longest available follow-up in the intention-to-treat population. Fifteen trials with a total of 13,592 patients treated with either CABG (n = 6,596) or PCI (n = 6,996) were included. After a weighted follow-up of 4.5 years, patients treated with CABG had a significantly lower risk of MI than those treated with PCI (risk ratio RR 0.75, 95% confidence interval CI 0.58 to 0.96, p = 0.024). The lower risk of MI with CABG as compared with PCI was more evident during a longer duration of follow-up (≥3 years, RR 0.69, 95% CI 0.52 to 0.91, p = 0.008; ≥5 years, RR 0.64, 95% CI 0.48 to 0.86, p = 0.003) and in the diabetic population (RR 0.55, 95% CI 0.44 to 0.70, p <0.001). The magnitude of risk reduction was similar across patients with multivessel (RR 0.72, 95% CI 0.53 to 0.99) and left main CAD (RR 0.74, 95% CI 0.47 to 1.15). In conclusion, the present meta-analysis of studies involving patients with multivessel or left main CAD suggests a significant benefit of CABG over PCI concerning the risk of future MI.
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