RESUMEN

OBJECTIVE: Sudden cardiac death or arrest describes an unexpected cardiac cause-related death or arrest that occurs rapidly out of the hospital or in the emergency room. This study aimed to reveal the relationship between coronary angiographic findings and cardiac death secondary to acute ST-elevation myocardial infarction. MATERIALS AND METHODS: Patients presenting with acute ST-elevation myocardial infarction complicated with cardiac arrest were included in the study. The severity of coronary artery disease, coronary chronic total occlusion, coronary collateral circulation, and blood flow in the infarct-related artery were recorded. Patients were divided into two groups, namely, deaths secondary to cardiac arrest and survivors of cardiac arrest. RESULTS: A total of 161 cardiac deaths and 42 survivors of cardiac arrest were included. The most frequent (46.3%) location of the culprit lesion was on the proximal left anterior descending artery. The left-dominant coronary circulation was 59.1%. There was a difference in the SYNTAX score (16.3±3.8 vs. 13.6±1.9; p=0.03) and the presence of chronic total occlusion (19.2 vs. 0%; p=0.02) between survivors and cardiac deaths. A high SYNTAX score (OR: 0.38, 95%CI: 0.27-0.53, p<0.01) was determined as an independent predictor of death secondary to cardiac arrest. CONCLUSION: The chronic total occlusion presence and SYNTAX score may predict death after cardiac arrest secondary to ST-elevation myocardial infarction.

Asunto(s)

Angiografía Coronaria , Paro Cardíaco , Infarto del Miocardio con Elevación del ST , Índice de Severidad de la Enfermedad , Humanos , Femenino , Masculino , Paro Cardíaco/mortalidad , Persona de Mediana Edad , Anciano , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/complicaciones , Factores de Riesgo , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Oclusión Coronaria/mortalidad , Oclusión Coronaria/complicaciones , Oclusión Coronaria/diagnóstico por imagen , Valor Predictivo de las Pruebas , Medición de Riesgo , Muerte Súbita Cardíaca/etiología , Muerte Súbita Cardíaca/epidemiología

RESUMEN

Cigarette smoking is a significant risk factor for coronary artery disease. However, there is insufficient evidence regarding the long-term clinical effects of smoking in Asian populations with chronic total occlusion (CTO). This study aimed to assess the effects of smoking on 5-year (median follow-up period, 4.2 ± 1.5 [interquartile range, 4.06-5.0] years) clinical outcomes in patients with CTO lesions who underwent percutaneous coronary intervention (PCI) or medical treatment (MT). We enrolled 681 consecutive patients with CTO who underwent diagnostic coronary angiography and subsequent PCI or MT. The patients were categorized into smokers (n = 304) and nonsmokers (n = 377). The primary endpoint was major adverse cardiovascular events (MACE), including a composite of all-cause death, myocardial infarction, and revascularization over a 5-year period. Propensity score matching (PSM) analysis was performed to adjust for potential baseline confounders. After PSM analysis, two propensity-matched groups (200 pairs, n = 400) were generated, and the baseline characteristics of both groups were balanced. The smokers exhibited a higher cardiovascular risk of MACE (29.5% vs. 18.5%, p = 0.010) and non-TVR (17.5 vs. 10.5%, p = 0.044) than the nonsmokers. In a landmark analysis using Kaplan-Meier curves at 1 year, the smokers had a significantly higher rate of MACE in the early period (up to 1 year) (18.8% and 9.2%, respectively; p = 0.008) compared with the nonsmokers. The Cox hazard regression analysis with propensity score adjustment revealed that smoking was independently associated with an increased risk of MACE. These findings indicate that smoking is a strong cardiovascular risk factor in patients with CTO, regardless of the treatment strategy (PCI or MT). In addition, in the subgroup analysis, the risk of MACE was most prominently elevated in the group of smokers who underwent PCI.

Asunto(s)

Fumar Cigarrillos , Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Persona de Mediana Edad , Oclusión Coronaria/complicaciones , Fumar Cigarrillos/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Anciano , Factores de Riesgo , Resultado del Tratamiento , Angiografía Coronaria , Infarto del Miocardio/etiología , Enfermedad Crónica , Puntaje de Propensión , Estudios de Seguimiento

RESUMEN

The recent results of the REVIVED-BCIS2 randomized clinical trial added further controversy on the utility of myocardial revascularization in patients with chronic coronary syndrome with reduced ejection fraction. However, coronary artery disease still represents the leading cause of heart failure with reduced ejection fraction, with the potential for functional recovery following complete revascularization due to the restoration of the so-called hibernating myocardium. We report an emblematic case of a patient with recovery of contractile function and normalization of the left bundle branch block after percutaneous coronary intervention of the right coronary artery chronic total occlusion.

Asunto(s)

Bloqueo de Rama , Intervención Coronaria Percutánea , Disfunción Ventricular Izquierda , Humanos , Bloqueo de Rama/fisiopatología , Bloqueo de Rama/terapia , Intervención Coronaria Percutánea/métodos , Masculino , Oclusión Coronaria/cirugía , Oclusión Coronaria/complicaciones , Oclusión Coronaria/terapia , Anciano , Índice de Severidad de la Enfermedad , Revascularización Miocárdica/métodos

RESUMEN

Dextrocardia is a very rare congenital malposition, and most cardiologists are not familiar with the radiographic angiograms of this condition. Here, we first report a case of dextrocardia with a chronic total occlusion (CTO) lesion undergoing retrograde percutaneous coronary intervention (PCI). Significant difficulties in lesion interpretation and device manipulation were encountered with the original angiograms. These challenges were not significantly improved until we adopted the double-inversion technique. The procedure was finally accomplished by using the kissing wire technique with a poor angle of attack. Retrograde CTO PCI for patients with dextrocardia is feasible with adequate techniques.

Asunto(s)

Angiografía Coronaria , Oclusión Coronaria , Dextrocardia , Intervención Coronaria Percutánea , Humanos , Dextrocardia/complicaciones , Dextrocardia/diagnóstico por imagen , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/cirugía , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/complicaciones , Masculino , Enfermedad Crónica , Anciano , Persona de Mediana Edad

RESUMEN

Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.

Asunto(s)

Infarto del Miocardio , Placa Aterosclerótica , Humanos , Infarto del Miocardio/etiología , Infarto del Miocardio/patología , Placa Aterosclerótica/patología , Oclusión Coronaria/etiología , Oclusión Coronaria/complicaciones , Animales , Factores de Riesgo

RESUMEN

BACKGROUND: Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage. CASE PRESENTATION: A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful. CONCLUSION: We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

Asunto(s)

Embolización Terapéutica , Humanos , Masculino , Persona de Mediana Edad , Embolización Terapéutica/métodos , Hemorragia/terapia , Hemorragia/inducido químicamente , Intervención Coronaria Percutánea , Hematoma/terapia , Contrapulsador Intraaórtico , Angiografía Coronaria , Tomografía Computarizada por Rayos X , Fibrinolíticos/uso terapéutico , Infarto del Miocardio/terapia , Infarto del Miocardio/complicaciones , Oclusión Coronaria/terapia , Oclusión Coronaria/complicaciones

Asunto(s)

Infarto de la Pared Anterior del Miocardio , Oclusión Coronaria , Ventrículos Cardíacos , Trombosis , Humanos , Infarto de la Pared Anterior del Miocardio/diagnóstico por imagen , Infarto de la Pared Anterior del Miocardio/tratamiento farmacológico , Infarto de la Pared Anterior del Miocardio/etiología , Ecocardiografía , Electrocardiografía , Ventrículos Cardíacos/diagnóstico por imagen , Trombosis/diagnóstico por imagen , Trombosis/tratamiento farmacológico , Trombosis/etiología , Anciano , Femenino , Oclusión Coronaria/complicaciones , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/tratamiento farmacológico , Angiografía Coronaria

RESUMEN

Left main occlusion presenting as ST-segment elevation myocardial infarction is an exceedingly morbid condition. This article reports a case of cardiac arrest in a patient after a treadmill stress test. Coronary angiography revealed 100% occlusion of the left main coronary artery. Left ventricular unloading with the Impella CP heart pump (ABIOMED/Johnson & Johnson MedTech) was used, after which epicardial blood flow was restored without angioplasty. The patient underwent surgical revascularization. Despite a prolonged revascularization time, there was no evidence of severe myocardial injury postoperatively.

Asunto(s)

Angiografía Coronaria , Circulación Coronaria , Corazón Auxiliar , Infarto del Miocardio con Elevación del ST , Función Ventricular Izquierda , Humanos , Persona de Mediana Edad , Circulación Coronaria/fisiología , Oclusión Coronaria/fisiopatología , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/cirugía , Oclusión Coronaria/complicaciones , Electrocardiografía , Revascularización Miocárdica/métodos , Pericardio/fisiopatología , Diseño de Prótesis , Recuperación de la Función , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/cirugía , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento , Función Ventricular Izquierda/fisiología , Femenino

RESUMEN

BACKGROUND: The EXPLORE (Evaluating Xience and Left Ventricular Function in PCI on Occlusions After STEMI) trial was the first and only randomized trial investigating chronic total occlusion (CTO) percutaneous coronary intervention (PCI) early after primary PCI for ST-segment-elevation myocardial infarction, compared with medical therapy for the CTO. We performed a 10-year follow-up of EXPLORE to investigate long-term safety and clinical impact of CTO PCI after ST-segment-elevation myocardial infarction, compared with no-CTO PCI. METHODS AND RESULTS: In EXPLORE, 302 patients post-ST-segment-elevation myocardial infarction with concurrent CTO were randomized to CTO PCI within ≈1 week or no-CTO PCI. We performed an extended clinical follow-up for the primary end point of major adverse cardiac events, consisting of cardiovascular death, coronary artery bypass grafting, or myocardial infarction. Secondary end points included all-cause death, angina, and dyspnea. Median follow-up was 10 years (interquartile range, 8-11 years). The primary end point occurred in 25% of patients with CTO PCI and in 24% of patients with no-CTO PCI (hazard ratio [HR], 1.11 [95% CI, 0.70-1.76]). Cardiovascular mortality was higher in the CTO PCI group (HR, 2.09 [95% CI, 1.10-2.50]), but all-cause death was similar (HR, 1.53 [95% CI, 0.93-2.50]). Dyspnea relief was more frequent after CTO PCI (83% versus 65%, P=0.005), with no significant difference in angina. CONCLUSIONS: This 10-year follow-up of patients post-ST-segment-elevation myocardial infarction randomized to CTO PCI or no-CTO PCI demonstrated no clinical benefit of CTO PCI in major adverse cardiac events or overall mortality. However, CTO PCI was associated with a higher cardiovascular mortality compared with no-CTO PCI. Our long-term data support a careful weighing of effective symptom relief against an elevated cardiovascular mortality risk in CTO PCI decisions. REGISTRATION: URL: https://www.trialregister.nl; Unique identifier: NTR1108.

Asunto(s)

Oclusión Coronaria , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Masculino , Femenino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/terapia , Oclusión Coronaria/mortalidad , Oclusión Coronaria/complicaciones , Persona de Mediana Edad , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/complicaciones , Anciano , Resultado del Tratamiento , Enfermedad Crónica , Factores de Tiempo , Estudios de Seguimiento , Factores de Riesgo

RESUMEN

AIMS: Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation. METHODS AND RESULTS: The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151). CONCLUSION: Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

Asunto(s)

Ablación por Catéter , Oclusión Coronaria , Desfibriladores Implantables , Isquemia Miocárdica , Prevención Primaria , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Oclusión Coronaria/mortalidad , Oclusión Coronaria/terapia , Oclusión Coronaria/prevención & control , Oclusión Coronaria/complicaciones , Resultado del Tratamiento , Estudios Prospectivos , Isquemia Miocárdica/complicaciones , Isquemia Miocárdica/mortalidad , Taquicardia Ventricular/prevención & control , Taquicardia Ventricular/terapia , Taquicardia Ventricular/mortalidad , Cardiomiopatías/mortalidad , Cardiomiopatías/complicaciones , Cardiomiopatías/terapia , Muerte Súbita Cardíaca/prevención & control , Muerte Súbita Cardíaca/etiología , Factores de Riesgo , Cardioversión Eléctrica/instrumentación , Cardioversión Eléctrica/efectos adversos , Cardioversión Eléctrica/mortalidad , Infarto del Miocardio/mortalidad , Infarto del Miocardio/prevención & control , Infarto del Miocardio/complicaciones , Enfermedad Crónica , Factores de Tiempo

RESUMEN

BACKGROUND: Chronic total coronary occlusions (CTO) substantially increase the risk for sudden cardiac death. Among patients with chronic ischemic heart disease at risk for sudden cardiac death, an implantable cardioverter defibrillator (ICD) is the favored therapy for primary prevention of sudden cardiac death. This study sought to investigate the impact of CTOs on the risk for appropriate ICD shocks and mortality within a nationwide prospective cohort. METHODS AND RESULTS: This is a subanalysis of the nationwide Dutch-Outcome in ICD Therapy (DO-IT) registry of primary prevention ICD recipients in The Netherlands between September 2014 and June 2016 (n=1442). We identified patients with chronic ischemic heart disease (n=663) and assessed available coronary angiograms for CTO presence (n=415). Patients with revascularized CTOs were excluded (n=79). The primary end point was the composite of all-cause mortality and appropriate ICD shocks. Clinical follow-up was conducted for at least 2 years. A total of 336 patients were included, with an average age of 67±9 years, and 20.5% was female (n=69). An unrevascularized CTO was identified in 110 patients (32.7%). During a median follow-up period of 27 months (interquartile range, 24-32), the primary end point occurred in 21.1% of patients with CTO (n=23) compared with 11.9% in patients without CTO (n=27; P=0.034). Corrected for baseline characteristics including left ventricular ejection fraction, and the presence of a CTO was an independent predictor for the primary end point (hazard ratio, 1.82 [95% CI, 1.03-3.22]; P=0.038). CONCLUSIONS: Within this nationwide prospective registry of primary prevention ICD recipients, the presence of an unrevascularized CTO was an independent predictor for the composite outcome of all-cause mortality and appropriate ICD shocks.

Asunto(s)

Oclusión Coronaria , Desfibriladores Implantables , Humanos , Femenino , Persona de Mediana Edad , Anciano , Oclusión Coronaria/complicaciones , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Arritmias Cardíacas , Desfibriladores Implantables/efectos adversos , Volumen Sistólico , Incidencia , Función Ventricular Izquierda , Muerte Súbita Cardíaca/epidemiología , Muerte Súbita Cardíaca/etiología , Muerte Súbita Cardíaca/prevención & control , Sistema de Registros , Factores de Riesgo

RESUMEN

BACKGROUND: Notwithstanding readily available revascularization, significant advancements in mechanical circulatory support, and pharmacological progress, cardiogenic shock (CS) secondary to unprotected left main culprit lesion-related acute myocardial infarction (ULMCL-related AMI) is associated with very high mortality. In this population, chronic total occlusion (CTO) is relatively frequent. AIMS: This study sought to assess the association between the presence of CTO and 12-month mortality in patients with CS due to ULMCL-related AMI. RESULTS: The study included consecutive patients admitted for AMI-related CS with ULMCL who underwent percutaneous coronary intervention (PCI) and were enrolled in the prospective Polish Registry of Acute Coronary Syndromes (PL-ACS) between January 2017 and December 2021. The patients were stratified into two groups based on the presence of at least one CTO. The primary endpoint was all-cause death at 12 months. Of the 250 included patients, 60 (24%) patients had one or more CTOs of a major coronary artery (+CTO), and in 190 (76%) patients, the presence of CTO was not observed (-CTO). The 12-month mortality rates for the +CTO and -CTO patients were 85% and 69.8%, respectively (P log-rank = 0.03). After multivariable adjustment for differences in the baseline characteristics, the presence of CTO remained significantly associated with higher 12-month mortality (hazard ratio, 1.423; 95% CI, 1.027-1.973; P = 0.034). CONCLUSIONS: Our analysis showed that in patients with CS due to ULMCL-related AMI treated with PCI, the presence of CTO is associated with worse 12-month prognosis.

Asunto(s)

Síndrome Coronario Agudo , Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Choque Cardiogénico/etiología , Oclusión Coronaria/complicaciones , Oclusión Coronaria/cirugía , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/cirugía , Resultado del Tratamiento , Estudios Prospectivos , Vasos Coronarios , Polonia , Pronóstico , Sistema de Registros , Enfermedad Crónica

RESUMEN

Arrhythmic sudden cardiac death (SCD) is an important cause of mortality following myocardial infarction (MI). The rabbit has similar cardiac electrophysiology to humans and is therefore an important small animal model to study post-MI arrhythmias. The established approach of surgical coronary ligation results in thoracic adhesions that impede epicardial electrophysiological studies. Adhesions are absent following a percutaneously induced MI, which is also associated with reduced surgical morbidity and so represents a clear refinement of the approach. Percutaneous procedures have previously been described in large rabbits (3.5-5.5 kg). Here, we describe a novel method of percutaneous MI induction in smaller rabbits (2.5-3.5 kg) that are readily available commercially. New Zealand White rabbits (n = 51 males, 3.1 ± 0.3 kg) were anesthetized using isoflurane (1.5-3%) and underwent either a percutaneous MI procedure involving microcatheter tip deployment (≤1.5 Fr, 5 mm), coronary ligation surgery, or a sham procedure. Electrocardiography (ECG) recordings were used to confirm ST-segment elevation indicating coronary occlusion. Blood samples (1 and 24 h) were taken for cardiac troponin I (cTnI) levels. Ejection fraction (EF) was measured at 6-8 wk. Rabbits were then euthanized (Euthatal) and hearts were processed for magnetic resonance imaging and histology. Mortality rates were similar in both groups. Scar volume, cTnI, and EF were similar between both MI groups and significantly different from their respective sham controls. Thus, percutaneous coronary occlusion by microcatheter tip deployment is feasible in rabbits (2.5-3.5 kg) and produces an MI with similar characteristics to surgical ligation with lower procedural trauma and without epicardial adhesions.NEW & NOTEWORTHY Surgical coronary ligation is the standard technique to induce myocardial infarction (MI) in rabbits but is associated with procedural trauma and the generation of thoracic adhesions. Percutaneous coronary occlusion avoids these shortcomings and is established in pigs but has only been applicable to large rabbits because of a mismatch between the equipment used and target vessel size. Here, we describe a new scalable approach to percutaneous MI induction that is safe and effective in 2.5-3.5-kg rabbits.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos , Oclusión Coronaria , Infarto del Miocardio , Intervención Coronaria Percutánea , Humanos , Masculino , Conejos , Animales , Porcinos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Vasos Coronarios/patología , Infarto del Miocardio/patología , Corazón , Oclusión Coronaria/complicaciones , Oclusión Coronaria/diagnóstico por imagen , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Arritmias Cardíacas/complicaciones , Intervención Coronaria Percutánea/efectos adversos

RESUMEN

Although a chronic total occlusion (CTO) in the setting of an acute coronary syndrome is associated with greater risk, the prognosis of patients with a CTO and stable coronary artery disease (CAD) remains unknown. This study aimed to investigate adverse event rates in patients with stable CAD with and without a CTO. In 3,597 patients with stable CAD (>50% coronary luminal stenosis) who underwent cardiac catheterization, all-cause mortality, cardiovascular mortality, and the composite major adverse cardiac event (MACE) rates for cardiovascular death, myocardial infarction, and heart failure hospitalization were evaluated. Cox proportional hazards and Fine and Gray subdistribution hazard models were used to compare event-free survival in patient subsets after adjustment for covariates. Event rates were higher in patients with CTOs than in those without CTOs after adjusting for demographic and clinical characteristics (cardiovascular death hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.05 to 1.57, p = 0.012). Patients with CTO revascularization had lower event rates than those of patients without CTO revascularization (cardiovascular death HR 0.43, CI 0.26 to 0.70, p = 0.001). Those with nonrevascularized CTOs were at particularly great risk when compared with those without CTO (cardiovascular death HR 1.52, CI 1.25 to 1.84, p <0.001). Moreover, those with revascularized CTOs had similar event rates to those of patients with CAD without CTOs. Patients with CTO have higher rates of adverse cardiovascular events than those of patients with significant CAD without CTO. This risk is greatest in patients with nonrevascularized CTO.

Asunto(s)

Enfermedad de la Arteria Coronaria , Oclusión Coronaria , Estenosis Coronaria , Infarto del Miocardio , Intervención Coronaria Percutánea , Humanos , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/cirugía , Oclusión Coronaria/complicaciones , Factores de Riesgo , Angiografía Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/complicaciones , Estenosis Coronaria/complicaciones , Enfermedad Crónica , Intervención Coronaria Percutánea/efectos adversos , Resultado del Tratamiento

RESUMEN

BACKGROUND: Acute total occlusion (ATO) is diagnosed in a substantial proportion of patients with non-ST-elevation myocardial infarction (NSTEMI). We compared procedural outcomes and long-term mortality in patients with STEMI with NSTEMI with vs. without ATO. METHODS AND RESULTS: We included patients with acute myocardial infarction (AMI) undergoing invasive coronary angiography between 2004 and 2019 at our centre. Acute total occlusion was defined as thrombolysis in myocardial infarction (TIMI) 0-1 flow in the infarct-related artery or TIMI 2-3 flow with highly elevated peak troponin (>100-folds the upper reference limit). Association between presentation and long-term mortality was evaluated using multivariable adjusted Cox regression analysis. From 2269 AMI patients (mean age 66 ± 13.2 years, 74% male), 664 patients with STEMI and 1605 patients with NSTEMI (471 [29.3%] with ATO) were included. ATO(+)NSTEMI patients had a higher frequency of cardiogenic shock and no reflow than ATO(-)NSTEMI with similar rates compared with STEMI patients (cardiogenic shock: 2.76 vs. 0.27 vs. 2.86%, P < 0.0001, P = 1; no reflow: 4.03 vs. 0.18 vs. 3.17%, P < 0.0001, P = 0.54). ATO(+)NSTEMI and STEMI were associated with 60 and 55% increased incident mortality, respectively, as compared with ATO(-)NSTEMI (ATO(+)NSTEMI: 1.60 [1.27-2.02], P < 0.0001, STEMI: 1.55 [1.24-1.94], P < 0.0001). Likewise, left ventricular ejection fraction (48.5 ± 12.7 vs. 49.1±11 vs. 50.6 ± 11.8%, P = 0.5, P = 0.018) and global longitudinal strain (-15.2 ± -5.74 vs. -15.5 ± -4.84 vs. -16.3 ± -5.30%, P = 0.48, P = 0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI. CONCLUSION: Non-ST-elevation myocardial infarction patients with ATO have unfavourable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides a more appropriate classification of AMI than differentiation into STEMI vs. NSTEMI.

Asunto(s)

Causas de Muerte , Angiografía Coronaria , Oclusión Coronaria , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Masculino , Femenino , Anciano , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/cirugía , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/complicaciones , Oclusión Coronaria/mortalidad , Estudios Retrospectivos , Causas de Muerte/tendencias , Tasa de Supervivencia/tendencias , Estudios de Seguimiento , Infarto del Miocardio sin Elevación del ST/mortalidad , Factores de Tiempo , Persona de Mediana Edad , Electrocardiografía

RESUMEN

Excessive calcium-phosphorus product (Ca-P product) in patients with chronic kidney disease (CKD) is associated with coronary artery calcification and coronary artery disease, but the relation between Ca-P product and coronary artery disease in non-CKD populations has rarely been reported. Therefore, we designed a cross-sectional study to investigate the role of Ca-P product in total coronary artery occlusion (TCAO) in a non-CKD population. We reviewed 983 patients who underwent coronary angiography at Guangyuan Central Hospital from February 2018 to January 2020. Ca-P product (mg2/dl2) was calculated as Ca (mmol/L) × 4 × P (mmol/L) × 3.1 and was analyzed as a continuous and tertiary variable. TCAO was defined as complete occlusion of any coronary artery by coronary angiography (thrombolysis in myocardial infarction flow grade 0). Statistical analysis was performed using univariate and multivariate logistic regression models and restricted cubic splines. Univariate logistic regression analysis showed a statistically significant association between Ca-P product and TCAO (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.95 to 0.99, p <0.001). After stepwise adjustment for covariates, the risk of TCAO was reduced by 40% in the high versus low Ca-P group (OR 0.6, 95% CI 0.38 to 0.95, p = 0.031), and the risk of TCAO was predicted to decrease by 4% (OR 0.96, 95% CI 0.94 to 0.99, p = 0.006) for each unit increase in Ca-P product. Restricted cubic splines showed a nonlinear relation between Ca-P product and TCAO, with a significant decrease in the risk of TCAO after reaching 27.46 (nonlinear p = 0.047). In conclusion, in non-CKD populations, a higher Ca-P product (≥27.46 mg2/dl2) may help avoid TCAO.

Asunto(s)

Enfermedad de la Arteria Coronaria , Oclusión Coronaria , Insuficiencia Renal Crónica , Humanos , Calcio , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/complicaciones , Oclusión Coronaria/complicaciones , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/epidemiología , Estudios Transversales , Fósforo , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/epidemiología , Factores de Riesgo

RESUMEN

INTRODUCTION: Chronic total occlusion (CTO) is defined as a near-total blockage of a coronary artery and often occurs in arteries that are not directly responsible for the event, known as non-infarct-related arteries (NIRA). Cardiogenic shock (CS) is a complication of ST-elevated myocardial infarction (STEMI) that carries significant mortality. We performed a meta-analysis to find an association between mortality in patients undergoing PCI for STEMI that have superimposed CS, with the presence of CTO in the NIRA. MATERIALS AND METHODOLOGY: A comprehensive literature search was conducted using PubMed, EMBASE, Google Scholar and clinicaltrials.gov from inception till October 2023 to retrieve studies that compare the presence of CTO with the absence of CTO in NIRA in STEMI with CS patients undergoing PCI. The primary endpoint was 30-day mortality and the secondary endpoints were risk of all-cause mortality (ACM) and repeat myocardial infarction (MI). Forest plots were generated using the random effects model by pooling odds ratios (ORs) with a 95 % confidence interval. Statistical significance was set at p < 0.05. RESULTS: 5 observational studies with a total of 5186 patients (1031 with CTO in NIRA and 4155 with no CTO in NIRA) were included. The presence of CTO in NIRA was associated with higher odds of 30-day mortality [OR: 3.10; 95 % CI: 1.52, 6.32; p < 0.002], and ACM [OR: 2.37; 95 % CI: 1.83, 3.08; p < 0.00001]. The odds of repeat MI were comparable between the two groups [OR: 1.61, 95 % CI: 0.03, 74.36, p = 0.81]. CONCLUSIONS: The presence of CTO in the NIRA serves as an independent indicator of unfavorable clinical outcomes including increased risk of 30-day mortality and all-cause mortality. The risk of repeat MI was comparable between the two groups. Large-scale, multicenter trials are warranted to identify the most effective management approach for these patients.

Asunto(s)

Oclusión Coronaria , Infarto del Miocardio , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Infarto del Miocardio con Elevación del ST/complicaciones , Infarto del Miocardio con Elevación del ST/cirugía , Intervención Coronaria Percutánea/efectos adversos , Oclusión Coronaria/complicaciones , Oclusión Coronaria/cirugía , Infarto del Miocardio/complicaciones , Vasos Coronarios , Resultado del Tratamiento , Enfermedad Crónica , Factores de Riesgo

RESUMEN

Whether percutaneous coronary intervention for chronic total occlusion (CTO-PCI) in diabetic patients offers more benefits compared with initial medical therapy (CTO-MT) is unclear. In this study, diabetic patients with one CTO (clinical manifestations: stable angina or silent ischemia) were enrolled. Consecutively, enrolled patients (n = 1605) were assigned to different groups: CTO-PCI (1044 [65.0%]) and initial CTO-MT (561 [35%]). After a median follow-up of 44 months, CTO-PCI tended to be superior to initial CTO-MT in major adverse cardiovascular events (adjusted hazard-ratio [aHR]: .81, 95% conference-interval: .65-1.02) and significantly superior in cardiac death (aHR: .58 [.39-.87]) and all-cause death (aHR: .678[.473-.970]). Such superiority mainly attributed to a successful CTO-PCI. CTO-PCI tended to be performed in patients with younger age, good collaterals, left anterior descending branch CTO, and right coronary artery CTO. While, those with left circumflex CTO and severe clinical/angiographic situations were more likely to be assigned to initial CTO-MT. However, none of these variables influenced the benefits of CTO-PCI. Thus, we concluded that for diabetic patients with stable CTO, CTO-PCI (mainly successful CTO-PCI) offered patients survival benefits over initial CTO-MT. These benefits were consistent regardless of clinical/angiographic characteristics.

Asunto(s)

Oclusión Coronaria , Diabetes Mellitus , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/efectos adversos , Oclusión Coronaria/complicaciones , Oclusión Coronaria/terapia , Vasos Coronarios , Enfermedad Crónica , Resultado del Tratamiento , Factores de Riesgo , Angiografía Coronaria , Sistema de Registros

RESUMEN

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) are relatively common findings in patients with type 2 diabetes mellitus (T2DM). However, the indication for percutaneous coronary intervention (PCI) and its clinical benefit in these patients remain controversial. METHODS: A single-center retrospective cohort study with prospectively collected outcomes was carried out with CTO patients undergoing PCI in 2019 and 2020. Patients were divided into two groups according to previous T2DM diagnosis (T2DM and non-T2DM). The primary outcome was recurrence of angina and/or heart failure symptoms and secondary outcomes were myocardial infarction and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome (total symptom recurrence) occurred in 16.6% of the sample, with no difference between groups (non-T2DM 13.6% vs. T2DM 21.2%, p=0.194) in a two-year follow-up. Angina recurrence was significantly more frequent in T2DM patients (15.2%, p=0.043). The presence of T2DM was not an independent predictor of symptom recurrence (p=0.429, HR 1.37, 95% CI 0.62-2.98). Myocardial infarction and all-cause mortality were also not different between groups (T2DM 1.5%, p=0.786 and 4.5%, p=0.352, respectively, on survival analysis). Independent predictors of all-cause mortality were left ventricular function and creatine clearance (p=0.039, HR 0.92, 95% CI 0.85-0.99 and p=0.013, HR 0.96, 95% CI 0.93-0.99, respectively). CONCLUSIONS: T2DM did not influence outcomes in CTO patients undergoing PCI, and its presence should not be a limiting factor in deciding on CTO revascularization.

Asunto(s)

Oclusión Coronaria , Diabetes Mellitus Tipo 2 , Infarto del Miocardio , Intervención Coronaria Percutánea , Humanos , Masculino , Persona de Mediana Edad , Anciano , Femenino , Intervención Coronaria Percutánea/efectos adversos , Oclusión Coronaria/cirugía , Oclusión Coronaria/complicaciones , Oclusión Coronaria/diagnóstico , Diabetes Mellitus Tipo 2/complicaciones , Estudios Retrospectivos , Enfermedad Crónica , Infarto del Miocardio/etiología , Resultado del Tratamiento , Factores de Riesgo

RESUMEN

Introducción y objetivos: Las oclusiones coronarias crónicas totales (OCT) que afectan a lesiones en bifurcación representan un subconjunto de lesiones difíciles de tratar y poco estudiadas en la literatura. Este estudio analiza la incidencia, la estrategia de tratamiento, los resultados hospitalarios y las complicaciones de la intervención coronaria percutánea (ICP) de las OCT en bifurcación (OCT-BIF). Métodos: Se evaluaron los datos de 607 pacientes consecutivos con OCT tratados en el Institut Cardiovasculaire Paris Sud (ICPS), Massy, Francia, entre enero de 2015 y febrero de 2020. Se compararon 2 subgrupos de pacientes (OCT-BIF, n=245; OCT-no BIF, n=362) en cuanto a estrategia de procedimiento, resultado hospitalario y tasa de complicaciones. Resultados: La media de edad de los pacientes fue 63,2±10,6 años; el 79,6% eran varones. Las lesiones en bifurcación estuvieron implicadas en el 40,4% de los procedimientos. La complejidad general de la lesión fue alta (valores medios de las puntuaciones J-CTO, 2,30 ± 1,16, y PROGRESS CTO, 1,37±0,94). El stent condicional fue la estrategia preferida para el tratamiento de las lesiones en bifurcación (93,5%). Los pacientes OCT-BIF presentaban una mayor complejidad de la lesión según la puntuación J-CTO (2,42±1,02 frente a 2,21±1,23 de los pacientes OCT-no BIF; p=0,025) y la puntuación PROGRESS CTO (1,60±0,95 frente a 1,22±0,90 de los pacientes OCT-no BIF; p<0,001). El éxito de la intervención fue del 78,9% y no se vio afectado por la presencia de bifurcación (el 80,4% en el grupo de OCT-BIF y el 77,8% en el grupo de OCT-no BIF; p=0,447) ni por el lugar de la bifurcación (OCT-BIF en segmento proximal, el 76,9%; OCT-no BIF en segmento medio, el 83,8%; OCT-BIF en segmento distal, el 85%; p=0,204). Las tasas de complicaciones fueron similares en ambos grupos...(AU)

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Introduction and objectives: Coronary chronic total occlusions (CTO) involving bifurcation lesions are a challenging lesion subset that is understudied in the literature. This study analyzed the incidence, procedural strategy, in-hospital outcomes and complications of percutaneous coronary interventions (PCI) for bifurcation-CTO (BIF-CTO). Methods: We assessed data from 607 consecutive CTO patients treated at the Institut Cardiovasculaire Paris Sud (ICPS), Massy, France between January 2015 and February 2020. Procedural strategy, in-hospital outcomes and complication rates were compared between 2 patient subgroups: BIF-CTO (n=245=and non–BIF-CTO (n=362). Results: The mean patient age was 63.2±10.6 years; 79.6% were men. Bifurcation lesions were involved in 40.4% of the procedures. Overall lesion complexity was high (mean J-CTO score 2.30±1.16, mean PROGRESS-CTO score 1.37±0.94). The preferred bifurcation treatment strategy was a provisional approach (93.5%). BIF-CTO patients presented with higher lesion complexity, as assessed by J-CTO score (2.42±1.02 vs 2.21±1.23 in the non–BIF-CTO patients, P=.025) and PROGRESS-CTO score (1.60±0.95 vs 1.22±0.90 in the non–BIF-CTO patients, P<.001). Procedural success was 78.9% and was not affected by the presence of bifurcation lesions (80.4% in the BIF-CTO group, 77.8% in the non–BIF-CTO-CTO group, P=.447) or the bifurcation site (proximal BIF-CTO 76.9%, mid–BIF-CTO 83.8%, distal BIF-CTO 85%, P=.204). Complication rates were similar in BIF-CTO and non–BIF-CTO. Conclusions: The incidence of bifurcation lesions is high in contemporary CTO PCI. Patients with BIF-CTO present with higher lesion complexity, with no impact on procedural success or complication rates when the predominant strategy is provisional stenting.(AU)

Asunto(s)

Humanos , Masculino , Femenino , Oclusión Coronaria/complicaciones , Resultado del Tratamiento , Incidencia , Intervención Coronaria Percutánea/estadística & datos numéricos , Stents , Enfermedades Cardiovasculares , Francia/epidemiología , Estudios Retrospectivos , Oclusión Coronaria/terapia