Publications by authors named "Adrian P Banning"

222 Publications

Survival relative to pacemaker status after transcatheter aortic valve implantation.

Catheter Cardiovasc Interv 2021 Jan 27. Epub 2021 Jan 27.

Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.

Objectives: To determine whether a permanent pacemaker (PPM) in situ can enhance survival after transcatheter aortic valve implantation (TAVI), in a predominantly inoperable or high risk cohort.

Background: New conduction disturbances are the most frequent complication of TAVI, often necessitating PPM implantation before hospital discharge.

Methods: We performed an observational cohort analysis of the UK TAVI registry (2007-2015). Primary and secondary endpoints were 30-day post-discharge all-cause mortality and long-term survival, respectively.

Results: Of 8,651 procedures, 6,815 complete datasets were analyzed. A PPM at hospital discharge, irrespective of when implantation occurred (PPM 1.68% [22/1309] vs. no PPM 1.47% [81/5506], odds ratio [OR] 1.14, 95% confidence interval [CI] 0.71-1.84; p = .58), or a PPM implanted peri- or post-TAVI only (PPM 1.44% [11/763] vs. no PPM 1.47% [81/5506], OR 0.98 [0.51-1.85]; p = .95) did not significantly reduce the primary endpoint. Patients with a PPM at discharge were older, male, had right bundle branch block at baseline, were more likely to have received a first-generation self-expandable prosthesis and had experienced more peri- and post-procedural complications including bailout valve-in-valve rescue, bleeding and acute kidney injury. A Cox proportional hazards model demonstrated significantly reduced long-term survival in all those with a PPM, irrespective of implantation timing (hazard ratio [HR] 1.14 [1.02-1.26]; p = .019) and those receiving a PPM only at the time of TAVI (HR 1.15 [1.02-1.31]; p = .032). The reasons underlying this observation warrant further investigation.

Conclusions: A PPM did not confer a survival advantage in the first 30 days after hospital discharge following TAVI.
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http://dx.doi.org/10.1002/ccd.29498DOI Listing
January 2021

The impact of the COVID-19 pandemic upon patients, staff, and on the future practices of percutaneous coronary intervention.

Eur Heart J Suppl 2020 Dec 23;22(Suppl Pt t):P13-P18. Epub 2020 Dec 23.

Department of Cardiology, Inselspital Universitätsspital, Bern Freiburgstrasse 4, Bern 3010, Switzerland.

The COVID pandemic in 2020 had unpredictable consequences on the presentation and management of patients with ischaemic heart disease. Subsequent to these initial responses the impact of the initial pandemic can be reviewed and responses can be considered. It is clear that there are new opportunities for optimising patient management pathways and in particular enhanced use of information technology. Changes in attitudes towards health and perceived risk are evident within both the catheter lab teams and our patient cohorts. Summating both the intellectual and emotional experiences of the pandemic are essential to prepare for either a second wave of COVID 19 or any new pandemic threat in the future.
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http://dx.doi.org/10.1093/eurheartj/suaa171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757716PMC
December 2020

Outpatient Versus Inpatient Percutaneous Coronary Intervention in Patients With Left Main Disease (from the EXCEL Trial).

Am J Cardiol 2021 Mar 5;143:21-28. Epub 2021 Jan 5.

Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address:

Prior studies in patients with noncomplex coronary artery disease have demonstrated the safety of percutaneous coronary intervention (PCI) in the outpatient setting. We sought to examine the outcomes of outpatient PCI in patients with unprotected left main coronary artery disease (LMCAD). In the EXCEL trial, 1905 patients with LMCAD and site-assessed low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus coronary artery bypass grafting. The primary end point was major adverse cardiovascular events (MACE; the composite of death, stroke, or myocardial infarction). In this sub-analysis, outcomes at 30 days and 5 years were analyzed according to whether PCI was performed in the outpatient versus inpatient setting. Among 948 patients with LMCAD assigned to PCI, 935 patients underwent PCI as their first procedure, including 100 (10.7%) performed in the outpatient setting. Patients who underwent outpatient compared with inpatient PCI were less likely to have experienced recent myocardial infarction. Distal left main bifurcation disease involvement and SYNTAX scores were similar between the groups. Comparing outpatient to inpatient PCI, there were no significant differences in MACE at 30 days (4.0% vs 5.0% respectively, adjusted OR 0.52 95% CI 0.12 to 2.22; p = 0.38) or 5 years (20.6% vs 22.1% respectively, adjusted OR 0.72, 95% CI 0.40 to 1.29; p = 0.27). Similar results were observed in patients with distal left main bifurcation lesions. In conclusion, in the EXCEL trial, outpatient PCI of patients with LMCAD was not associated with an excess early or late hazard of MACE. These data suggest that outpatient PCI may be safely performed in select patients with LMCAD.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.039DOI Listing
March 2021

Outcomes Following Percutaneous Coronary Intervention in Renal Transplant Recipients: A Binational Collaborative Analysis.

Mayo Clin Proc 2021 02 25;96(2):363-376. Epub 2020 Dec 25.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK, and Academic Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK; Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA. Electronic address:

Objective: To investigate the clinical and procedural characteristics in patients with a history of renal transplant (RT) and compare the outcomes with patients without RT in 2 national cohorts of patients undergoing percutaneous coronary intervention (PCI).

Patients And Methods: Data from the National Inpatient Sample (NIS) and British Cardiovascular Intervention Society (BCIS) were used to compare the clinical and procedural characteristics and outcomes of patients undergoing PCI who had RT with those who did not have RT. The primary outcome of interest was in-hospital mortality.

Results: Of the PCI procedures performed in 2004-2014 (NIS) and 2007-2014 (BCIS), 12,529 of 6,601,526 (0.2%) and 1521 of 512,356 (0.3%), respectively, were undertaken in patients with a history of RT. Patients with RT were younger and had a higher prevalence of congestive cardiac failure, hypertension, and diabetes but similar use of drug-eluting stents, intracoronary imaging, and pressure wire studies compared with patients who did not have RT. In the adjusted analysis, patients with RT had increased odds of in-hospital mortality (NIS: odds ratio [OR], 1.90; 95% CI, 1.41-2.57; BCIS: OR, 1.60; 95% CI, 1.05-2.46) compared with patients who did not have RT but no difference in vascular or bleeding events. Meta-analysis of the 2 data sets suggested an increase in in-hospital mortality (OR, 1.79; 95% CI, 1.40-2.29) but no difference in vascular (OR, 1.24; 95% CI, 0.77-2.00) or bleeding (OR, 1.21; 95% CI, 0.86-1.68) events.

Conclusion: This large collaborative analysis of 2 national databases revealed that patients with RT undergoing PCI are younger, have more comorbidities, and have increased mortality risk compared with the general population undergoing PCI.
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http://dx.doi.org/10.1016/j.mayocp.2020.04.045DOI Listing
February 2021

Safety and operational efficiency of restructuring and redeploying a transcatheter aortic valve replacement service during the COVID-19 pandemic: The Oxford experience.

Cardiovasc Revasc Med 2020 Dec 3. Epub 2020 Dec 3.

Oxford Heart Center, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. Electronic address:

Background: The risk of nosocomial COVID-19 infection for vulnerable aortic stenosis patients and intensive care resource utilization has led to cardiac surgery deferral. Untreated severe symptomatic aortic stenosis has a dismal prognosis. TAVR offers an attractive alternative to surgery as it is not reliant on intensive care resources. We set out to explore the safety and operational efficiency of restructuring a TAVR service and redeploying it to a new non-surgical site during the COVID-19 pandemic.

Methods: The institutional prospective service database was retrospectively interrogated for the first 50 consecutive elective TAVR cases prior to and after our institution's operational adaptations for the COVID-19 pandemic. Our endpoints were VARC-2 defined procedural complications, 30-day mortality or re-admission and service efficiency metrics.

Results: The profile of patients undergoing TAVR during the pandemic was similar to patients undergoing TAVR prior to the pandemic with the exception of a lower mean age (79 vs 82 years, p < 0.01) and median EuroScore II (3.1% vs 4.6%, p = 0.01). The service restructuring and redeployment contributed to the pandemic-mandated operational efficiency with a reduction in the distribution of pre-admission hospital visits (3 vs 3 visits, p < 0.001) and the time taken from TAVR clinic to procedure (26 vs 77 days, p < 0.0001) when compared to the pre-COVID-19 service. No statistically significant difference was noted in peri-procedural complications and 30-day outcomes, while post-operative length of stay was significantly reduced (2 vs 3 days, p < 0.0001) when compared to pre-COVID-19 practice.

Conclusions: TAVR service restructuring and redeployment to align with pandemic-mandated healthcare resource rationalization is safe and feasible.
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http://dx.doi.org/10.1016/j.carrev.2020.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836266PMC
December 2020

Percutaneous Coronary Intervention For Bifurcation Coronary Lesions.The 15th Consensus Document from the European Bifurcation Club.

EuroIntervention 2020 Oct 20. Epub 2020 Oct 20.

Insitute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.

The 15th European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019 and it facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that provisional approach with optional side-branch treatment utilising T, T and small protrusion (TAP) or culotte continue to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially when involving the LM, adoption of dedicated 2-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using 2-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardize clinical outcome. The development of novel technical tools and drug regimens deserve attention. In particular, intra-coronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored anti-platelet therapy are identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components have resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimizing the clinical outcomes for every patient undergoing PCI on a CBL.
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http://dx.doi.org/10.4244/EIJ-D-20-00169DOI Listing
October 2020

Consensus statements, guidelines and definition: will they actually improve our treatment of coronary bifurcation lesions?

Authors:
Adrian P Banning

EuroIntervention 2020 Oct 9;16(9):e695-e697. Epub 2020 Oct 9.

Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.

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http://dx.doi.org/10.4244/EIJV16I9A127DOI Listing
October 2020

Reply to the Letter to the Editor Entitled "Intravascular Lithotripsy Facilitated Cardiovascular Interventions".

Angiology 2021 01 6;72(1):98. Epub 2020 Oct 6.

Oxford Heart Centre, 11269John Radcliffe Hospital, Oxford, United Kingdom.

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http://dx.doi.org/10.1177/0003319720963603DOI Listing
January 2021

Implications of Alternative Definitions of Peri-Procedural Myocardial Infarction After Coronary Revascularization.

J Am Coll Cardiol 2020 10;76(14):1609-1621

London School of Hygiene and Tropical Medicine, London, United Kingdom. Electronic address:

Background: Varying definitions of procedural myocardial infarction (PMI) are in widespread use.

Objectives: This study sought to determine the rates and clinical relevance of PMI using different definitions in patients with left main coronary artery disease randomized to percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) surgery in the EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial.

Methods: The pre-specified protocol definition of PMI (PMI) required a large elevation of creatine kinase-MB (CK-MB), with identical threshold for both procedures. The Third Universal Definition of MI (types 4a and 5) (PMI) required lesser biomarker elevations but with supporting evidence of myocardial ischemia, different after PCI and CABG. For the PMI, troponins were used preferentially (available in 49.5% of patients), CK-MB otherwise. The multivariable relationship between each PMI type and 5-year mortality was determined.

Results: PMI occurred in 34 of 935 (3.6%) patients after PCI and 56 of 923 (6.1%) patients after CABG (difference -2.4%; 95% confidence interval [CI]: -4.4% to -0.5%; p = 0.015). The corresponding rates of PMI were 37 (4.0%) and 20 (2.2%), respectively (difference 1.8%; 95% CI: 0.2% to 3.4%; p = 0.025). Both PMI and PMI were associated with 5-year cardiovascular mortality (adjusted hazard ratio [HR]: 2.18 [95% CI: 1.13 to 4.23] and 2.87 [95% CI: 1.44 to 5.73], respectively). PMI was associated with a consistent hazard of cardiovascular mortality after both PCI and CABG (p = 0.86). Conversely, PMI was strongly associated with cardiovascular mortality after CABG (adjusted HR: 11.94; 95% CI: 4.84 to 29.47) but not after PCI (adjusted HR: 1.14; 95% CI: 0.35 to 3.67) (p = 0.004). Results were similar for all-cause mortality and with varying PMI biomarker definitions. Only large biomarker elevations (CK-MB ≥10× upper reference limit and troponin ≥70× upper reference limit) were associated with mortality.

Conclusions: The rates of PMI after PCI and CABG vary greatly with different definitions. In the EXCEL trial, the pre-specified PMI was associated with similar hazard after PCI and CABG, whereas PMI was strongly associated with mortality after CABG but not after PCI. (EXCEL Clinical Trial [EXCEL]; NCT01205776).
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http://dx.doi.org/10.1016/j.jacc.2020.08.016DOI Listing
October 2020

Drug coated balloons and their role in bifurcation coronary angioplasty: appraisal of the current evidence and future directions.

Expert Rev Med Devices 2020 Oct 14;17(10):1021-1033. Epub 2020 Oct 14.

Department of Cardiology, Clinical Center of Serbia, and Medical Faculty, University of Belgrade , Belgrade, Serbia.

Introduction: Coronary Bifurcation lesions are technically more challenging and Bifurcation percutaneous coronary intervention (PCI) remains a challenge with unpredictable and sub-optimal clinical and angiographic results. Drug-Coated Balloons (DCB) are emerging devices in the field of coronary intervention with promising results that may overcome some of drug eluting stents limitations and may have potential advantages in complex bifurcation PCI.

Areas Covered: We have performed a re-appraisal about the issues with current bifurcation PCI techniques and the use of DCB in the treatment of Bifurcation lesions. Several studies performed utilizing DCB are described and critically appraised. Over the recent years, there have been tremendous developments in the DCB technology, lesion preparation, clinical experience, and clinical data during bifurcation PCI. The current review describes the advances in the DCB technology, pharmacokinetics, role of excipients, and optimization of the technique. Special emphasis in lesion preparation and potential pathway of using DCB in bifurcation PCI is proposed.

Expert Opinion: Although different proof of concept and pilot studies have shown promising results in treatment of bifurcation lesions with DCB, larger randomized trials and/or international consensus papers are required to enable worldwide translation of this idea to clinical practice.
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http://dx.doi.org/10.1080/17434440.2020.1831385DOI Listing
October 2020

Safety and effectiveness of coronary intravascular lithotripsy in eccentric calcified coronary lesions: a patient-level pooled analysis from the Disrupt CAD I and CAD II Studies.

Clin Res Cardiol 2021 Feb 18;110(2):228-236. Epub 2020 Sep 18.

Department of Cardiology, Medical Clinic I, University Hospital Giessen, Justus Liebig University Giessen, Klinikstrasse 33, 35392, Giessen, Germany.

Background: The aim of this study was to assess the safety and effectiveness of intravascular lithotripsy (IVL) in treating eccentric calcified coronary lesions.

Methods: Between December 2015 and March 2019, 180 patients were enrolled in the Disrupt CAD I and CAD II studies across 19 sites in 10 countries. Patient-level data were pooled from these two studies (n = 180), within which 47 eccentric lesions (26%) and 133 concentric lesions were identified.

Results: Clinical success, defined as residual stenosis < 50% after stenting and no in-hospital MACE, was similar between the eccentric and concentric cohorts (93.6% vs. 93.2%, p = 1.0). There were no perforations, abrupt closure, slow flow or no reflow events observed in either group, and there were low rates of flow-limiting dissections (Grade D-F: 0% eccentric, 1.7% concentric; p = 0.54). Final acute gain and percent residual stenosis were similar between the two groups. Final residual stenosis of 8.6 ± 9.8% in eccentric and 10.0 ± 9.0% (p = 0.56) in concentric stenosis confirms the significant effect of IVL in calcified coronary lesions.

Conclusion: In this first report from a pooled patient-level analysis of coronary IVL from the Disrupt CAD I and CAD II studies, IVL use was associated with consistent improvement in procedural and clinical outcomes in both eccentric and concentric calcified lesions.
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http://dx.doi.org/10.1007/s00392-020-01737-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862504PMC
February 2021

No-reflow phenomenon in ST-segment elevation myocardial infarction: still the Achilles' heel of the interventionalist.

Future Cardiol 2021 Mar 11;17(2):383-397. Epub 2020 Sep 11.

Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.

Improvements in systems, technology and pharmacotherapy have significantly changed the prognosis over recent decades in patients presenting with ST-segment elevation myocardial infarction. These clinical achievements have, however, begun to plateau and it is becoming increasingly necessary to consider novel strategies to further improve outcomes. Approximately a third of patients treated by primary percutaneous coronary intervention for ST-segment elevation myocardial infarction will suffer from coronary no-reflow (NR), a condition characterized by poor myocardial perfusion despite patent epicardial arteries. The presence of NR impacts significantly on clinical outcomes including left ventricular dysfunction, heart failure and death, yet conventional management algorithms neither assess the risk of NR nor treat NR. This review will provide a contemporary overview on the pathogenesis, diagnosis and treatment of NR.
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http://dx.doi.org/10.2217/fca-2020-0077DOI Listing
March 2021

In-hospital stroke after transcatheter aortic valve implantation: A UK observational cohort analysis.

Catheter Cardiovasc Interv 2020 Aug 11. Epub 2020 Aug 11.

Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.

Objectives: We sought to identify baseline demographics and procedural factors that might independently predict in-hospital stroke following transcatheter aortic valve implantation (TAVI).

Background: Stroke is a recognized, albeit infrequent, complication of TAVI. Established predictors of procedure-related in-hospital stroke; however, remain poorly defined.

Methods: We conducted an observational cohort analysis of the multicenter UK TAVI registry. The primary outcome measure was the incidence of in-hospital stroke.

Results: A total of 8,652 TAVI procedures were performed from 2007 to 2015. There were 205 in-hospital strokes reported by participating centers equivalent to an overall stroke incidence of 2.4%. Univariate analysis showed that the implantation of balloon-expandable valves caused significantly fewer strokes (balloon-expandable 96/4,613 [2.08%] vs. self-expandable 95/3,272 [2.90%]; p = .020). After multivariable analysis, prior cerebrovascular disease (CVD) (odds ratio [OR] 1.51, 95% confidence interval [CI 1.05-2.17]; p = .03), advanced age at time of operation (OR 1.02 [0.10-1.04]; p = .05), bailout coronary stenting (OR 5.94 [2.03-17.39]; p = .008), and earlier year of procedure (OR 0.93 [0.87-1.00]; p = .04) were associated with an increased in-hospital stroke risk. There was a reduced stroke risk in those who had prior cardiac surgery (OR 0.62 [0.41-0.93]; p = .01) and a first-generation balloon-expandable valve implanted (OR 0.72 [0.53-0.97]; p = .03). In-hospital stroke significantly increased 30-day (OR 5.22 [3.49-7.81]; p < .001) and 1-year mortality (OR 3.21 [2.15-4.78]; p < .001).

Conclusions: In-hospital stroke after TAVI is associated with substantially increased early and late mortality. Factors independently associated with in-hospital stroke were previous CVD, advanced age, no prior cardiac surgery, and deployment of a predominantly first-generation self-expandable transcatheter heart valve.
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http://dx.doi.org/10.1002/ccd.29157DOI Listing
August 2020

Transcatheter aortic valve replacement and percutaneous coronary intervention versus surgical aortic valve replacement and coronary artery bypass grafting in patients with severe aortic stenosis and concomitant coronary artery disease: A systematic review and meta-analysis.

Catheter Cardiovasc Interv 2020 Nov 14;96(5):1113-1125. Epub 2020 Jul 14.

Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.

Objectives: We performed a systematic review and meta-analysis to evaluate the early and midterm outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI).

Background: Contemporary guidelines suggest that surgical or percutaneous revascularization of significant coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is a reasonable strategy.

Methods: We conducted a comprehensive search of Medline and Embase to identify studies comparing a percutaneous transcatheter versus a surgical approach. Random effects meta-analyses using the Mantel-Haenszel method were performed to estimate the effect of percutaneous compared surgical strategies using aggregate data.

Results: Six studies reporting on 1770 participants were included in the meta-analysis. There were no significant differences in effect estimates for early and midterm mortality (OR: 0.78; 95% CI, 0.50-1.20 and OR: 1.09; 95% CI, 0.80-1.49, respectively) or myocardial infarction (OR: 0.52; 95% CI, 0.20-1.33 and OR: 1.34; 95% CI, 0.67-2.65, respectively). No significant difference was shown for peri-procedural stroke (OR: 0.80; 95% CI, 0.35-1.87). A transcatheter approach had a higher rate of major vascular complications (OR: 14.44; 95% CI, 4.42-47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19-0.91).

Conclusion: Our analysis suggests that a percutaneous transcatheter approach confers similar outcomes compared to a surgical approach in patients with severe AS and CAD. However, our findings are based on low quality studies and should serve as hypothesis generating. In the absence of adequately powered studies yielding high level evidence, individualized decision making should be based on surgical risk assessment.
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http://dx.doi.org/10.1002/ccd.29110DOI Listing
November 2020

Impact of lesion preparation strategies on outcomes of left main PCI: The EXCEL trial.

Catheter Cardiovasc Interv 2020 Jun 27. Epub 2020 Jun 27.

Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.

Objectives: We examined outcomes according to lesion preparation strategy (LPS) in patients with left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the EXCEL trial.

Background: The optimal LPS for LMCA PCI is unclear.

Methods: We categorized LPS hierarchically (high to low) as: (a) rotational atherectomy (RA); (b) cutting or scoring balloon (CSB); (c) balloon angioplasty (BAL); and d) direct stenting (DIR). The primary endpoint was 3-year MACE; all-cause death, stroke, or myocardial infarction.

Results: Among 938 patients undergoing LMCA PCI, RA was performed in 6.0%, CSB 9.5%, BAL 71.3%, and DIR 13.2%. In patients treated with DIR, BAL, CSB, and RA, respectively, there was a progressive increase in SYNTAX score, LMCA complex bifurcation, trifurcation or calcification, number of stents, and total stent length. Any procedural complication occurred in 10.4% of cases overall, with the lowest rate in the DIR (7.4%) and highest in the RA group (16.1%) (p = .22). There were no significant differences in the 3-year rates of MACE (from RA to DIR: 17.9%, 20.2%, 14.5%, 14.7%; p = .50) or ischemia-driven revascularization (from RA to DIR: 16.8%, 10.8%, 12.3%, 14.2%; p = .65). The adjusted 3-year rates of MACE did not differ according to LPS.

Conclusions: The comparable 3-year outcomes suggest that appropriate lesion preparation may be able to overcome the increased risks of complex LMCA lesion morphology.
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http://dx.doi.org/10.1002/ccd.29116DOI Listing
June 2020

European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions.

Catheter Cardiovasc Interv 2020 Nov 24;96(5):1067-1079. Epub 2020 Jun 24.

Medical Faculty, Department of Cardiology, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia.

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.
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http://dx.doi.org/10.1002/ccd.29071DOI Listing
November 2020

Shockwave Intravascular Lithotripsy for the Treatment of Severe Vascular Calcification.

Angiology 2020 09 22;71(8):677-688. Epub 2020 Jun 22.

Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom.

Vascular calcification is a highly prevalent pathophenotype that is associated with aging, atherosclerotic cardiovascular disease, diabetes mellitus, and chronic kidney disease. When present, it portends a worse clinical outcome and predicts major adverse cardiovascular events. Heavily calcified coronary and peripheral artery lesions are difficult to dilate appropriately with conventional balloons during percutaneous intervention, and the use of several adjunctive strategies of plaque modification has been suggested. Intravascular lithotripsy (IVL) offers a novel option for lesion preparation of severely calcified plaques in coronary and peripheral vessels. It is unique among all technologies in its ability to modify calcium circumferentially and transmurally, thus modifying transmural conduit compliance. In this article, we summarize the currently available evidence on this technology, and we highlight its best clinical application through appropriate patient and lesion selection, with the main objective of optimizing stent delivery and implantation, and subsequent improved short- and long-term outcomes. We believe that the IVL balloon will transform the market, as it is easy to use, with predictable results. However, cost-effectiveness of such advanced technology will need to be considered.
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http://dx.doi.org/10.1177/0003319720932455DOI Listing
September 2020

Angiography-derived index of microcirculatory resistance as a novel, pressure-wire-free tool to assess coronary microcirculation in ST elevation myocardial infarction.

Int J Cardiovasc Imaging 2020 Aug 14;36(8):1395-1406. Epub 2020 May 14.

Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Headley Way, Oxford, OX39DU, UK.

Immediate assessment of coronary microcirculation during treatment of ST elevation myocardial infarction (STEMI) may facilitate patient stratification for targeted treatment algorithms. Use of pressure-wire to measure the index of microcirculatory resistance (IMR) is possible but has inevitable practical restrictions. We aimed to develop and validate angiography-derived index of microcirculatory resistance (IMR) as a novel and pressure-wire-free index to facilitate assessment of the coronary microcirculation. 45 STEMI patients treated with primary percutaneous coronary intervention (pPCI) were enrolled. Immediately before stenting and at completion of pPCI, IMR was measured within the infarct related artery (IRA). At the same time points, 2 angiographic views were acquired during hyperaemia to measure quantitative flow ratio (QFR) from which IMR was derived. In a subset of 15 patients both IMR and IMR were also measured in the non-IRA. Patients underwent cardiovascular magnetic resonance imaging (CMR) at 48 h for assessment of microvascular obstruction (MVO). IMR and IMR were significantly correlated (ρ: 0.85, p < 0.001). Both IMR and IMR were higher in the IRA rather than in the non-IRA (p = 0.01 and p = 0.006, respectively) and were higher in patients with evidence of clinically significant MVO (> 1.55% of left ventricular mass) (p = 0.03 and p = 0.005, respectively). Post-pPCI IMR presented and area under the curve (AUC) of 0.96 (CI95% 0.92-1.00, p < 0.001) for prediction of post-pPCI IMR > 40U and of 0.81 (CI95% 0.65-0.97, p < 0.001) for MVO > 1.55%. IMR is a promising tool for the assessment of coronary microcirculation. Assessment of IMR without the use of a pressure-wire may enable more rapid, convenient and cost-effective assessment of coronary microvascular function.
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http://dx.doi.org/10.1007/s10554-020-01831-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381481PMC
August 2020

Rescue aortic balloon valvuloplasty during procedural cardiac arrest while treating critical left main stem stenosis: a case report.

Eur Heart J Case Rep 2020 Apr 21;4(2):1-5. Epub 2020 Feb 21.

Oxford Heart Centre, Oxford University Hospitals, Headley Way, Oxford OX39DU, UK.

Background: Best timing for coronary revascularization in patients with severe aortic stenosis (AS) who was a candidate for transcatheter aortic valve implantation (TAVI) is still matter of debate.

Case Summary: We here report the case of an 87-year-old man with severe AS presenting with non-ST-segment elevation myocardial infarction. Coronary angiography revealed a highly complex and calcific left main stem (LMS) lesion. Rotablation-assisted percutaneous coronary intervention (PCI) was attempted but was complicated by post-stenting rapidly evolving haemodynamic impairment. A rescue 'pacing-free' balloon aortic valvuloplasty (BAV) was performed to rescue the patients, allowing prompt restoration of cardiac output and coronary perfusion.

Discussion: According to guidelines and preliminary evidence, decision should be performed case by case and based on the degree of severity and complexity of either AS or coronary disease. The strategy of treating coronary lesions first may limit the risk of potential ischaemic complications during TAVI. However, the downside of it is the risk of hemodynamic crash with potential catastrophic evolution in case of PCI complications in presence of severe AS. A 'bailout BAV' can be considered as a salvage-strategy in case of complex and complicated LMS-PCI in the context of severe AS and advanced status of haemodynamic impairment. This approach must be seen as very last resort, while appropriate pre-procedural planning is still highly recommended in order to prevent potentially fatal procedural complications in this fragile clinical setting.
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http://dx.doi.org/10.1093/ehjcr/ytaa030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180547PMC
April 2020

Long-term outcomes in the management of left main disease: An updated meta-analysis of randomized controlled trials.

Hellenic J Cardiol 2020 Apr 15. Epub 2020 Apr 15.

Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK. Electronic address:

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http://dx.doi.org/10.1016/j.hjc.2020.04.006DOI Listing
April 2020

Novel Indices of Coronary Physiology: Do We Need Alternatives to Fractional Flow Reserve?

Circ Cardiovasc Interv 2020 04 16;13(4):e008487. Epub 2020 Apr 16.

MedStar Washington Hospital Centre, Interventional Cardiology Department, Washington, DC (Y.O., H.M.G.-G., A.H.-K., E.S., K.D., R.W.).

Fractional flow reserve is the current invasive gold standard for assessing the ischemic potential of an angiographically intermediate coronary stenosis. Procedural cost and time, the need for coronary vessel instrumentation, and the need to administer adenosine to achieve maximal hyperemia remain integral components of invasive fractional flow reserve. The number of new alternatives to fractional flow reserve has proliferated over the last ten years using techniques ranging from alternative pressure wire metrics to anatomic simulation via angiography or intravascular imaging. This review article provides a critical description of the currently available or under-development alternatives to fractional flow reserve with a special focus on the available evidence, pros, and cons for each with a view towards their clinical application in the near future for the functional assessment of coronary artery disease.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008487DOI Listing
April 2020

Transcatheter aortic valve implantation via surgical subclavian versus direct aortic access: A United Kingdom analysis.

Int J Cardiol 2020 06 21;308:67-72. Epub 2020 Mar 21.

Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK. Electronic address:

Background: Surgical subclavian (SC) and direct aortic (DA) access are established alternatives to the default transfemoral route for transcatheter aortic valve implantation (TAVI). We sought to find differences in survival and procedure-related outcomes after SC- versus DA-TAVI.

Methods: We performed an observational cohort analysis of cases prospectively uploaded to the UK TAVI registry. To ensure the most contemporaneous comparison, the analysis focused on SC and DA procedures performed from 2013 to 2015.

Results: Between January 2013 and July 2015, 82 (37%) SC and 142 (63%) DA cases were performed that had validated 1-year life status. Multivariable regression analysis showed procedure duration was longer for SC cases (SC 193.5 ± 65.8 vs. DA 138.4 ± 57.7 min; p < .01) but length of hospital stay was shorter (SC 8.6 ± 9.5 vs. DA 11.9 ± 10.8 days; p = .03). Acute kidney injury was observed less frequently after SC cases (odds ratio [OR] 0.35, 95% confidence interval [CI 0.12-0.96]; p = .042) but vascular access site-related complications were more common (OR 9.75 [3.07-30.93]; p < .01). Procedure-related bleeding (OR 0.54 [0.24-1.25]; p = .15) and in-hospital stroke rate (SC 3.7% vs. DA 2.1%; p = .67) were similar. There were no significant differences in in-hospital (SC 2.4% vs. DA 4.9%; p = .49), 30-day (SC 2.4% vs. DA 4.2%; p = .71) or 1-year (SC 14.5% vs. DA 21.9%; p = .344) mortality.

Conclusions: Surgical subclavian and direct aortic approaches can offer favourable outcomes in appropriate patients. Neither access modality conferred a survival advantage but there were significant differences in procedural metrics that might influence which approach is selected.
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http://dx.doi.org/10.1016/j.ijcard.2020.03.059DOI Listing
June 2020

Reflectance spectral analysis for novel characterization and clinical assessment of aspirated coronary thrombi in patients with ST elevation myocardial infarction.

Physiol Meas 2020 05 7;41(4):045001. Epub 2020 May 7.

Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, John Radcliffe Hospital, Oxford, United Kingdom.

Objective: The visual appearance of coronary thrombi may be clinically informative in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). However, subjective assessment is poorly reproducible and cannot provide an objective basis for treatment decisions or patient stratification. We have assessed the feasibility of a novel reflectance spectroscopy technique to systematically characterize coronary artery thrombi retrieved by aspiration during pPCI in patients with STEMI, and the clinical utility for predicting distal microvascular obstruction.

Approach: Patients with STEMI treated with pPCI and thrombus aspiration (n = 288) were recruited from the Oxford Acute Myocardial Infarction (OxAMI) Study. Of these, 158 patients underwent cardiac magnetic resonance imaging within 48 h for assessment of microvascular obstruction (MVO). Coronary thrombi were imaged by reflectance spectroscopy across wavelengths 500-800 nm.

Main Results: Spectral data were analysed using function fitting and multivariate models. The coefficient 'c ' determined from the fitting procedure correlated with the visually-assessed colour of thrombi ('red' or 'white') and with MVO. When applied to a reduced data set, consisting of spectra from 20 patients with the largest MVO and from 20 propensity-score-matched patients with no MVO, three multivariate analysis methods were able to discriminate spectra of thrombi from patients without MVO and with the largest MVO.

Significance: Reflectance spectral analysis of coronary thrombus provides new insights into the pathology of STEMI, with potential clinical implications for emergency patient care. Further studies are warranted for validation as a point-of-care stratification tool in predicting the degree of microvascular injury and clinical outcomes in STEMI.
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http://dx.doi.org/10.1088/1361-6579/ab81deDOI Listing
May 2020

Antithrombotic regimens for percutaneous coronary intervention of the left main coronary artery: The EXCEL trial.

Catheter Cardiovasc Interv 2020 Mar 17. Epub 2020 Mar 17.

Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA.

Objectives: We compared the effect of bivalirudin or heparin and use or nonuse of glycoprotein IIb/IIIa inhibitors (GPI) on the outcome of left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the randomized EXCEL trial.

Background: The optimal antithrombotic regimen to support PCI of the LMCA remains controversial because of low representation of this subset in clinical trials.

Methods: The PCI cohort (n = 928) in EXCEL was divided according to bivalirudin versus heparin antithrombin treatment and compared for the primary composite endpoint of death, myocardial infarction (MI), or stroke at 30 days and 5 years.

Results: Bivalirudin was used in 319 patients (34.4%). The composite endpoint at 30 days occurred in 7.2% versus 3.8% bivalirudin and heparin patients, respectively, p = .02; at 5 years, the composite endpoint occurred in 26.3% versus 19.9% bivalirudin and heparin patients, respectively, p = .02. Major bleeding was more frequent in bivalirudin patients (4.1% versus 1.3%, p = .008). There were no differences in stent thrombosis between the groups. Bivalirudin use was an independent predictor of the 30-day composite endpoint (OR 2.88, 95% CI 1.28-6.48, p = .01) but not of the 5-year composite endpoint (OR 1.30, 95% CI 0.84-2.02, p = .23). GPI use was infrequent (n = 67, 7.2%) and was not associated with adverse outcomes.

Conclusion: Among patients undergoing LMCA PCI in the EXCEL trial, procedural use of bivalirudin was associated with greater rates of periprocedural MI and the 30-day composite endpoint without reducing bleeding complications. Five-year outcomes were similar. GPIs were used infrequently and were not associated with clinical outcomes.
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http://dx.doi.org/10.1002/ccd.28858DOI Listing
March 2020

Hyper-acute cardiovascular magnetic resonance T1 mapping predicts infarct characteristics in patients with ST elevation myocardial infarction.

J Cardiovasc Magn Reson 2020 01 9;22(1). Epub 2020 Jan 9.

Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.

Background: Myocardial recovery after primary percutaneous coronary intervention in acute myocardial infarction is variable and the extent and severity of injury are difficult to predict. We sought to investigate the role of cardiovascular magnetic resonance T1 mapping in the determination of myocardial injury very early after treatment of ST-segment elevation myocardial infarction (STEMI).

Methods: STEMI patients underwent 3 T cardiovascular magnetic resonance (CMR), within 3 h of primary percutaneous intervention (PPCI). T1 mapping determined the extent (area-at-risk as %left ventricle, AAR) and severity (average T1 values of AAR) of acute myocardial injury, and related these to late gadolinium enhancement (LGE), and microvascular obstruction (MVO). The characteristics of myocardial injury within 3 h was compared with changes at 24-h to predict final infarct size.

Results: Forty patients were included in this study. Patients with average T1 values of AAR ≥1400 ms within 3 h of PPCI had larger LGE at 24-h (33% ±14 vs. 18% ±10, P = 0.003) and at 6-months (27% ±9 vs. 12% ±9; P < 0.001), higher incidence and larger extent of MVO (85% vs. 40%, P = 0.016) & [4.0 (0.5-9.5)% vs. 0 (0-3.0)%, P = 0.025]. The average T1 value was an independent predictor of acute LGE (β 0.61, 95%CI 0.13 to 1.09; P = 0.015), extent of MVO (β 0.22, 95%CI 0.03 to 0.41, P = 0.028) and final infarct size (β 0.63, 95%CI 0.21 to 1.05; P = 0.005). Receiver-operating-characteristic analysis showed that T1 value of AAR obtained within 3-h, but not at 24-h, predicted large infarct size (LGE > 9.5%) with 100% positive predictive value at the optimal cut-off of 1400 ms (area-under-the-curve, AUC 0.88, P = 0.006).

Conclusion: Hyper-acute T1 values of the AAR (within 3 h post PPCI, but not 24 h) predict a larger extent of MVO and infarct size at both 24 h and 6 months follow-up. Delayed CMR scanning for 24 h could not substitute the significant value of hyper-acute average T1 in determining infarct characteristics.
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http://dx.doi.org/10.1186/s12968-019-0593-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951001PMC
January 2020

The year in cardiology: acute coronary syndromes.

Eur Heart J 2020 02;41(7):821-832

Royal Brompton & Harefield Hospital, Imperial College, London, UK.

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http://dx.doi.org/10.1093/eurheartj/ehz942DOI Listing
February 2020

Pressure-bounded coronary flow reserve to assess the extent of microvascular dysfunction in patients with ST-elevation acute myocardial infarction.

EuroIntervention 2019 12 24. Epub 2019 Dec 24.

Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom.

Aims: Assessment of microvascular function in patients with ST-elevation acute myocardial infarction (STEMI) may be useful to determine treatment strategy. The possible role of pressure-bounded coronary flow reserve (pb-CFR) in this setting has not been determined.

Methods And Results: Thermodilution-pressure-wire assessment of the infarct-related artery was performed in 148 STEMI patients before stenting and/or at completion of primary percutaneous coronary intervention (PPCI). The extent of the myocardial injury was assessed with cardiovascular magnetic resonance imaging at 48-hours and 6-months after STEMI. Post-PPCI pb-CFR was impaired (<2) and normal (>2) in 69.9% and 9.0% of the cases respectively. In the remaining 21.1% of the patients, pb-CFR was "indeterminate". In this cohort, pb-CFR correlated poorly with thermodilution-derived coronary flow reserve (k=0.03, p=0.39). The index of microcirculatory resistance (IMR) was significantly different across the pb-CFR subgroups. Similarly, significant differences were observed in microvascular obstruction (MVO), myocardium area-at-risk and 48-hours infarct-size (IS). A trend towards lower 6-month IS was observed in patients with high (>2) post-PPCI pb-CFR. Nevertheless, pb-CFR was inferior to IMR in predicting MVO and the extent of IS.

Conclusions: Pb-CFR can identify microvascular dysfunction in patients after STEMI and provided superior diagnostic performance compared to thermodilution-derived CFR in predicting MVO. However, IMR was superior to both pb-CFR and thermodilution-derived CFR and consequently, IMR was the most accurate in predicting all of the studied CMR endpoints of myocardial injury after PPCI.
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http://dx.doi.org/10.4244/EIJ-D-19-00674DOI Listing
December 2019

The cardiac sympathetic co-transmitter neuropeptide Y is pro-arrhythmic following ST-elevation myocardial infarction despite beta-blockade.

Eur Heart J 2020 06;41(23):2168-2179

Department of Physiology, Anatomy and Genetics, Burdon Sanderson Cardiac Science Centre, University of Oxford, Parks Road, Oxford OX13PT, UK.

Aims: ST-elevation myocardial infarction is associated with high levels of cardiac sympathetic drive and release of the co-transmitter neuropeptide Y (NPY). We hypothesized that despite beta-blockade, NPY promotes arrhythmogenesis via ventricular myocyte receptors.

Methods And Results: In 78 patients treated with primary percutaneous coronary intervention, sustained ventricular tachycardia (VT) or fibrillation (VF) occurred in 6 (7.7%) within 48 h. These patients had significantly (P < 0.05) higher venous NPY levels despite the absence of classical risk factors including late presentation, larger infarct size, and beta-blocker usage. Receiver operating curve identified an NPY threshold of 27.3 pg/mL with a sensitivity of 0.83 and a specificity of 0.71. RT-qPCR demonstrated the presence of NPY mRNA in both human and rat stellate ganglia. In the isolated Langendorff perfused rat heart, prolonged (10 Hz, 2 min) stimulation of the stellate ganglia caused significant NPY release. Despite maximal beta-blockade with metoprolol (10 μmol/L), optical mapping of ventricular voltage and calcium (using RH237 and Rhod2) demonstrated an increase in magnitude and shortening in duration of the calcium transient and a significant lowering of ventricular fibrillation threshold. These effects were prevented by the Y1 receptor antagonist BIBO3304 (1 μmol/L). Neuropeptide Y (250 nmol/L) significantly increased the incidence of VT/VF (60% vs. 10%) during experimental ST-elevation ischaemia and reperfusion compared to control, and this could also be prevented by BIBO3304.

Conclusions: The co-transmitter NPY is released during sympathetic stimulation and acts as a novel arrhythmic trigger. Drugs inhibiting the Y1 receptor work synergistically with beta-blockade as a new anti-arrhythmic therapy.
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http://dx.doi.org/10.1093/eurheartj/ehz852DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299634PMC
June 2020

Ultrasound guided vascular access site management and left ventricular pacing are associated with improved outcomes in contemporary transcatheter aortic valve replacement: Insights from the OxTAVI registry.

Catheter Cardiovasc Interv 2020 08 19;96(2):432-439. Epub 2019 Nov 19.

Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK.

Objectives: To identify clinical and procedural practice predictors of avoidable complications during transcatheter aortic valve replacement (TAVR).

Background: TAVR is evolving as a viable strategy for treatment of aortic stenosis (AS). Vascular complications, major bleeding, or pericardial tamponade may be influenced by procedural practice.

Methods: The Oxford TAVR (OxTAVI) prospective registry was retrospectively analyzed to identify predictors of avoidable procedural complications in a contemporary cohort of transfemoral TAVR between January 2015 and September 2018. The primary endpoint was defined as a hierarchic composite of in-hospital mortality, pericardial effusion/cardiac tamponade, major bleeding, and vascular access complications. Individual components of the primary endpoint have been analyzed separately.

Results: Five-hundred-twenty-nine patients underwent transfemoral TAVR using contemporary techniques during the study period and were enrolled in the OxTAVI registry. Female sex and high frailty were associated with a higher risk of death, major bleeding, vascular complication or pericardial tamponade. The use of ultrasound (US) guidance for vascular access management was independently associated with a reduced composite primary endpoint (OR = 0.35, CI:0.14-0.86, p = .02) after adjustment for clinical confounders, largely driven by a threefold reduction in vascular access complication (OR = 0.29, CI:0.15-0.55, p < .001). Performing rapid pacing via the left ventricle guidewire (LV-GW) was associated with a significant decrease in the risk of cardiac tamponade/pericardial effusion (OR = 0.19, CI:0.05-0.66, p = .009).

Conclusion: US-guided vascular access management and rapid pacing via the LV-GW are important determinants of reduced procedural complications during TAVR.
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http://dx.doi.org/10.1002/ccd.28578DOI Listing
August 2020

Transcatheter Aortic Valve Replacement Influence on Coronary Hemodynamics: A Quantitative Meta-Analysis and Proposed Decision-Making Algorithm.

J Invasive Cardiol 2020 Jan 15;32(1):37-40. Epub 2019 Nov 15.

Oxford Heart Centre, John Radcliffe Hospital, Headley Way, OX3 7BA, Oxford, United Kingdom.

Background: As transcatheter aortic valve replacement (TAVR) expands to younger and lower-risk severe aortic stenosis patients, appropriate coronary artery disease treatment is key to reducing long-term adverse cardiovascular outcomes. Recently, studies have been exploring the role of coronary-physiology guided revascularization strategies. Our aim was to investigate whether TAVR influences coronary physiology measurements using quantitative meta-analytic methods.

Methods: We performed a Medline and Embase search for studies evaluating coronary physiology indices before and after TAVR. Double independent screening and extractions of baseline, procedural, angiographic, and echocardiographic data were performed. Risk of bias was assessed using the ACROBAT-NRSI tool. Pooled mean difference estimates of coronary hemodynamic indices before and after TAVR were derived using random-effects models with the inverse variance method (RevMan, Review Manager, version 5.3.5; Nordic Cochrane Centre).

Results: Five studies evaluating 250 coronary vessels in 169 severe aortic stenosis patients were quantitatively synthesized. Coronary flow reserve did not change immediately after TAVR in non-diseased vessels (n = 3; mean difference, 0.11; 95% confidence interval [CI], -0.10-0.32; P=.29; I²=0%; P=.68). Importantly, fractional flow reserve also did not vary significantly following TAVR in both non-diseased (n = 3; mean difference, -0.01; 95% CI, -0.04-0.03; P=.75; I²=41; P=.19) and diseased coronaries (n = 3; mean difference, -0.01; 95% CI, -0.03-0.01; P=.49; I²=0%; P=.46). Similarly, instantaneous wave-free ratio remained stable following TAVR (n = 2; mean difference, 0.00; 95% CI, -0.02-0.02; P>.99; I²=0; P>.99.

Conclusions: Pooled coronary physiology measurements before and after TAVR are similar, but data on variation within individual lesions are limited.
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January 2020