Publications by authors named "Maarten J Suttorp"

63 Publications

Predictors and outcomes of procedural failure of percutaneous coronary intervention of a chronic total occlusion-A subanalysis of the EXPLORE trial.

Catheter Cardiovasc Interv 2021 05 15;97(6):1176-1183. Epub 2020 Apr 15.

Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Objective: To evaluate predictors of procedural success of percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTOs) in a non-infarct-related artery following ST-segment elevation myocardial infarction (STEMI), and demonstrate the effect on left ventricular functionality (LVF), infarct size (IS), and pro-arrhythmic electrocardiogram (ECG) parameters.

Background: Predictors of unsuccessful revascularization of a CTO are numerous, although following STEMI, these are lacking. Besides, effects of failed CTO PCI (FPCI) on the myocardium are unknown.

Methods: This is a subanalysis of the EXPLORE trial, in which 302 STEMI patients with a concurrent CTO were randomized to CTO PCI (n = 147) or no-CTO PCI (NPCI, n = 154). For the purpose of this subanalysis, we divided patients into successful CTO PCI (SPCI, n = 106), FPCI (n = 41), and NPCI (n = 154) groups. Cardiac magnetic resonance imaging and angiographic data were derived from the EXPLORE database, combined with ECG parameters. To gain more insight, all outcomes were compared with patients that did not undergo CTO PCI.

Results: In multivariate regression, only CTO lesion length >20 mm was an independent predictor of procedural failure (OR 3.31 [1.49-7.39]). No significant differences in median left ventricular ejection fraction, left ventricular end-diastolic volume, IS, and the pro-arrhythmic ECG parameters such as QT-dispersion, QTc-time, and TpTe-intervals were seen between the SPCI and FPCI groups at 4 months follow-up.

Conclusion: This subanalysis of the EXPLORE trial has demonstrated that a CTO lesion length >20 mm is an independent predictor of CTO PCI failure, whereas procedural failure did not lead to any adverse effects on LVF nor pro-arrhythmic ECG parameters.
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http://dx.doi.org/10.1002/ccd.28904DOI Listing
May 2021

A "minimalistic hybrid algorithm" in coronary chronic total occlusion revascularization: Procedural and clinical outcomes.

Catheter Cardiovasc Interv 2020 01 14;95(1):97-104. Epub 2019 Mar 14.

Department of Cardiology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands.

Background: Percutaneous recanalization of coronary chronic total occlusions (CTOs) traditionally relies on the use of dual-access and large bore catheters, with trans-femoral approach adoption in most cases.

Objectives: Aim of this manuscript is to describe the outcomes of an alternative hybrid algorithm, called "Minimalistic Hybrid Algorithm," which has the purpose to minimize the use of double access, large bore catheters, and femoral approach in order to minimize the risk of vascular complications and patient's discomfort, without compromising efficacy.

Methods: In this single-center registry, a "minimalistic" approach was attempted in consecutive patients undergoing CTO PCI between March 2016 and October 2017. Data regarding the applicability of this algorithm and the related procedural success rates were collected, together with common demographic and angiographic characteristics.

Results: Of the 100 CTO PCI performed in the study period, 91(91%) were successfully approached according to the novel algorithm. Mean J-CTO score of all minimalistic procedures was 1.9 ± 1.2, with 31(34%) patients presenting with J-CTO score ≥3. In 52 procedures, the approach consisted of single-catheter access, 49(94.2%) of which were trans-radial. Out of the 39 patients approached with dual-catheters, 26(69.2%) were biradial, and 8(21%) radial-femoral. Procedural success in patients approached with the minimalistic algorithm was 89%, in line with the results of large-multicenter experiences nowadays available.

Conclusions: Our results show that an alternative algorithm limiting the routine use of large bore catheters and trans-femoral approach is feasible in the clinical practice and yields good procedural outcomes.
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http://dx.doi.org/10.1002/ccd.28213DOI Listing
January 2020

Implementing a minimally invasive approach (combining radial approach, small guiding catheters and minimization of double access) for coronary chronic total occlusion intervention according to the hybrid algorithm: The Minimalistic Hybrid Algorithm.

Int J Cardiol 2019 05 9;283:84-87. Epub 2018 Nov 9.

Department of Cardiology, Sint Antonius Ziekenhuis, the Netherlands. Electronic address:

Percutaneous recanalization of coronary chronic total occlusions (CTOs) traditionally relies on the use of dual access and large bore catheters, with trans-femoral approach adoption in most of the cases. Aim of this manuscript is to describe an alternative algorithm, that we called "Minimalistic Hybrid Algorithm", in order to minimize the use of double access, large bore catheters, and femoral approach thus reducing patient's discomfort and possibly procedural complications. This algorithm can be interpreted as an evolution of the classic "Hybrid Algorithm" and requires the operator to be confident with all techniques known in this conventional algorithm. Indeed, all possible techniques and approaches of the conventional hybrid approach to treat CTOs are included in a novel diagram for procedural strategy, which offers an alternative sequence of steps to limit, whenever possible, the invasiveness of the procedure. After dividing the cases in "simple" or "complex" CTO lesions according to the available complexity scores and to the "feeling", knowledge and expertise of the operator, a systematic description of the procedural steps is provided. This includes antegrade and retrograde approaches, as well as sub-intimal and intra-luminal techniques, in order to maintain the simpler single-catheter transradial strategies in the first line for the simple CTO, and the adoption of more complex, double access and transfemoral ones in the further steps. The minimalistic hybrid algorithm herein described is a possible alternative sequence of steps in the setting of CTO recanalization, with the potential of limiting the use of double access, large bore catheters, and femoral approach.
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http://dx.doi.org/10.1016/j.ijcard.2018.11.021DOI Listing
May 2019

Long-term results of carotid stenting and risk factors in patients with severe carotid artery stenosis undergoing subsequent cardiac surgery.

Catheter Cardiovasc Interv 2019 02 9;93(3):E134-E139. Epub 2018 Nov 9.

Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands.

Aims: To identify risk factors for composite outcome of mortality, stroke or myocardial infarction in patients with severe carotid stenosis undergoing staged carotid artery stenting (CAS) with subsequent cardiac surgery.

Methods And Results: In this prospective observational study, we enrolled 643 consecutive patients with both symptomatic (i.e., with history of stroke) and asymptomatic severe carotid artery disease, who required cardiac surgery. Generally, cardiac surgery was planned 30 days after the CAS procedure. The composite outcome consisted of death, stroke and myocardial infarction. The composite outcome rate was 26.3% at 5 years and 47% at 8 years after CAS. Age ≥ 80 years (hazard ratio [HR] = 1.89; 95%CI, 1.18-3.03; P = 0.008), history of stroke (HR = 1.66, 1.16-2.37; P = 0.006), chronic obstructive pulmonary disease (HR = 1.86; 1.07-3.24; P = 0.03) and kidney disease (HR = 1.83, 1.11-3.04; P = 0.02) were independent risk factors for the composite outcome during long-term follow-up.

Conclusions: In this study with staged CAS followed by cardiac surgery, we confirm previously reported event-free survival rates and identify several risk factors for the composite outcome. Future studies are needed to confirm the importance of the identified risk factors and to assess their predictive ability.
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http://dx.doi.org/10.1002/ccd.27947DOI Listing
February 2019

Angiographic and clinical outcomes of antegrade versus retrograde techniques for chronic total occlusion revascularizations: Insights from the PRISON IV trial.

Catheter Cardiovasc Interv 2019 02 2;93(2):E81-E89. Epub 2018 Oct 2.

Department of Cardiology, Onze Lieve Vrouw Gasthuis, Amsterdam, The Netherlands.

Objectives: Available data indicate mixed outcomes after using retrograde techniques for chronic total occlusion(CTO) recanalization, with generally higher need for repeat revascularization. Aim of this study is to analyze the angiographic and clinical outcome of patients treated with retrograde techniques in the PRISON-IV trial.

Methods And Results: This is a post-hoc sub-analysis from the randomized PRISON-IV trial. Briefly, 330 patients with a successfully recanalized CTO lesion were randomized 1:1 to receive either hybrid-SES or EES. The hybrid-SES failed to reach the non-inferiority primary endpoint of in-segment late lumen loss at 9-month angiography follow-up. In the present analysis, we divided the population according to the first technical approach, namely antegrade (n = 285) or retrograde approach (n = 45). Demographic characteristics were similar between the two groups, while angiographic features disclosed higher CTO lesion complexity in the group treated with retrograde techniques (J-CTO score: 1.8 ± 1.1 vs 2.6 ± 1.1, respectively, P < 0.001), with longer occlusions (17.6 ± 10 mm vs 28.8 ± 18.7 mm, P < 0.001) and longer stented segment (48.9 ± 24.4 mm vs 73.1 ± 33.2 mm, P < 0.001). Quantitative coronary analysis disclosed similar results at follow-up angiography, with a non-significantly higher in-stent late-lumen loss in the retrograde group (0.08 ± 0.52 mm vs 0.18 ± 0.56 mm, P = 0.32). Clinical follow-up at 12-months showed similar outcome, with a non-significantly higher target-lesions revascularization rate in the retrograde group (6% vs 11.1% respectively, P = 0.2). Significant improvements in angina functional class were observed in both groups.

Conclusions: The present analysis supports the benefits of retrograde techniques in CTO revascularization, with non-significant differences in angiographic and clinical outcomes at late follow-up.
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http://dx.doi.org/10.1002/ccd.27795DOI Listing
February 2019

Impact of collateralisation to a concomitant chronic total occlusion in patients with ST-elevation myocardial infarction: a subanalysis of the EXPLORE randomised controlled trial.

Open Heart 2018;5(2):e000810. Epub 2018 Jul 16.

Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

Objective: The impact on cardiac function of collaterals towards a concomitant chronic total coronary occlusion (CTO) in patients with ST-elevation myocardial infarction (STEMI) has not been investigated yet. Therefore, we have evaluated the impact of well-developed collaterals compared with poorly developed collaterals to a concomitant CTO in STEMI.

Methods And Results: In the EXPLORE trial, patients with STEMI and a concomitant CTO were randomised to either CTO percutaneous coronary intervention (PCI) or no-CTO PCI. Collateral grades were scored angiographically using the Rentrop grade classification. Left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume (LVEDV) at 4 months were measured using cardiac magnetic resonance imaging. Well-developed collaterals (Rentrop grades 2-3) to the CTO were present in 162 (54%) patients; these patients had a significantly higher LVEF at 4 months (46.2±11.4% vs 42.1±12.7%, p=0.004) as well as a trend for a lower LVEDV (208.2±55.7 mL vs 222.6±68.5 mL, p=0.054) when compared with patients with poorly developed collaterals to the CTO. There was no significant difference in the total amount of scar in the two groups. Event rates were statistically comparable between patients with well-developed collaterals and poorly developed collaterals to the CTO at long-term follow-up.

Conclusions: In patients with STEMI and a concomitant CTO, the presence of well-developed collaterals to a concomitant CTO is associated with a better LVEF at 4 months. However, this effect on LVEF did not translate into improvement in clinical outcome. Therefore, the presence of well-developed collaterals is important, but should not solely guide in the clinical decision-making process regarding any additional revascularisation of a concomitant CTO in patients with STEMI.

Clinical Trial Registration: NTR1108.
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http://dx.doi.org/10.1136/openhrt-2018-000810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6059304PMC
February 2021

Impact of ultra-thin struts on restenosis after chronic total occlusion recanalization: Insights from the randomized PRISON IV trial.

J Interv Cardiol 2018 Oct 1;31(5):580-587. Epub 2018 May 1.

Department of Cardiology, Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands.

Objectives: The PRISON-IV trial showed inferior outcome in patients with chronic total occlusions (CTOs) treated with the ultrathin-struts (60 μm for stent diameter ≤3 mm, 81μm >3 mm) hybrid-sirolimus eluting stents (SES) compared with everolimus eluting stents (EES, 81 μm). The aim of this study is to investigate if the use of smaller stents (≤3 mm) was responsible for the inferior outcome reported in the trial.

Methods: In the PRISON-IV trial 330 patients with CTO lesion were randomized 1:1 to receive either hybrid-SES or EES. The hybrid-SES failed to reach the non-inferiority primary endpoint of in-segment late lumen loss (LLL) at 9-month angiographic follow-up. In this sub-analysis, we divided the population according to the different size of stents implanted in those receiving only stents with diameter ≤3 mm (Group-A, 178 patients), only stents >3 mm (Group-B, 59 patients), and those receiving stents of both sizes (Group-C, 93 patients).

Results: Baseline and procedural characteristics were comparable in the three groups. At angiographic follow-up, most of the adverse outcomes occurred in Group A, with higher incidence of binary restenosis in the Hybrid-SES versus EES (10.3% vs 1.3%, P = 0.03) and augmented in-stent diameter stenosis (26.04 ± 18.59% vs 21.24 ± 12.84, P = 0.06). Similarly, optical coherence tomography (OCT), which was performed in 60 patients at follow-up, documented a mild trend toward lower values of minimum in stent area in Hybrid-SES arm of Group A (4.4 ± 1.02mm vs 5.0 ± 1.28mm2, respectively, P = 0.16).

Conclusions: The present analysis suggests that the inferior performance of the ultra-thin hybrid-SES in CTO-PCI is particularly pronounced when smaller stent (≤3 mm diameter) are adopted, if compared with EES.
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http://dx.doi.org/10.1111/joic.12516DOI Listing
October 2018

First report of the use of long-tapered sirolimus-eluting coronary stent for the treatment of chronic total occlusions with the hybrid algorithm.

Catheter Cardiovasc Interv 2018 11 7;92(5):E299-E307. Epub 2018 Feb 7.

Department of Cardiology, St Antonius Ziekenhuis, Nieuwegein, The Netherlands.

Background: Coronary chronic total occlusions (CTO) usually coexist with diffusely diseased coronary segments proximal and/or distal to the CTO segment. During percutaneous treatment of CTO, multiple overlapping stents are often needed to treat these long lesions.

Objectives: Aim of this study is to report the first use of long, tapered coronary sirolimus-eluting stents (SES) in this setting.

Methods And Results: This is a retrospective analysis of 100 consecutive patients undergoing CTO recanalization following the hybrid algorithm. Procedural success rate was 89% (11 failures). Among the successful cases, "conventional" drug-eluting stents(DES) were used in 40(44.9%) patients, while in 49(55%) patients long-tapered SES were attempted with a success rate of 98% (1 cross-over to regular stents). Total stent length in the long-tapered DES group was higher compared to the "conventional" stenting group (76 ± 28 mm vs 46 ± 22 mm, P < .001), with a similar total number of stent (1.6 ± 0.8 vs 1.9 ± 0.8). At quantitative coronary analysis, proximal and distal segment involvement was more extended in patients undergoing long-tapered stenting, with longer overall lesion length. No differences in periprocedural complications and clinical outcomes at a mean follow-up of 303 ± 179 days were observed.

Conclusions: The use of long tapered coronary DES is technically feasible and safe for the percutaneous treatment of CTOs, especially for patients presenting with long lesions.
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http://dx.doi.org/10.1002/ccd.27539DOI Listing
November 2018

Optical coherence tomography findings: insights from the "randomised multicentre trial investigating angiographic outcomes of hybrid sirolimus-eluting stents with biodegradable polymer compared with everolimus-eluting stents with durable polymer in chronic total occlusions" (PRISON IV) trial.

EuroIntervention 2017 Aug 4;13(5):e522-e530. Epub 2017 Aug 4.

Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands.

Aims: The PRISON IV trial investigated the next-generation sirolimus-eluting stent (SES) with ultra-thin struts and biodegradable polymer against the second-generation everolimus-eluting stent (EES) with thin struts and durable polymer in patients with successfully recanalised chronic total occlusions (CTO). In this study, we examined the secondary optical coherence tomography endpoints.

Methods And Results: The main PRISON IV trial randomised 330 patients to either SES or EES. At nine months, 281 (85%) patients underwent repeat angiography. Of these, 60 consecutive patients received optical coherence tomography divided over both stent groups. The mean number of struts analysed was 750±337 and 633±358 in SES and EES patients, respectively (p=0.07). The minimal lumen area, minimal stent area, maximal neointima area and neointimal thickness were comparable between the groups (4.8±2.1 and 4.4±1.5 mm2; 5.3±1.8 and 5.3±1.4 mm2; 2.5±2.0 and 2.2±1.5 mm2; 0.7±1.7 and 0.4±0.2 mm). The percentage of uncovered struts was higher with EES (6.2±7.5% and 11.9±13.4%, p=0.04), whereas the percentage of malapposed struts and mean number of coronary evaginations were significantly higher with SES (2.9±4.0% and 1.2±2.4%, p=0.02; 18.5±17.7 and 5.3±3.1, p=0.004).

Conclusions: The optical coherence tomography findings of this substudy demonstrated improved strut coverage with ultra-thin strut SES with bioresorbable polymer compared to thin-strut EES with durable polymer in CTO. On the other hand, SES showed a higher rate of stent strut malappositon and coronary evaginations. The clinical relevance of these findings remains to be demonstrated.
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http://dx.doi.org/10.4244/EIJ-D-17-00261DOI Listing
August 2017

Randomized Multicenter Trial Investigating Angiographic Outcomes of Hybrid Sirolimus-Eluting Stents With Biodegradable Polymer Compared With Everolimus-Eluting Stents With Durable Polymer in Chronic Total Occlusions: The PRISON IV Trial.

JACC Cardiovasc Interv 2017 01;10(2):133-143

Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands.

Objectives: The aim of this study was to investigate the efficacy and safety of the hybrid ultrathin-strut sirolimus-eluting stent (SES) with biodegradable polymer compared with the thin-strut everolimus-eluting stent (EES) with durable polymer in successfully recanalized chronic total occlusions (CTOs).

Background: The introduction of drug-eluting stents revolutionized the treatment of CTOs. However, limited data are available on new-generation drug-eluting stents with biodegradable polymer in CTOs.

Methods: In this multicenter trial, patients were randomized, after successful CTO recanalization, to either SES or EES. The primary noninferiority endpoint was in-segment late lumen loss (noninferiority margin 0.2 mm). Secondary endpoints included in-stent late lumen loss and clinical endpoints.

Results: Overall, 330 patients were included. At 9 months, angiography was available in 281 patients (85%). Duration of occlusion ≥3 months was 92.5%, with mean stent length of 52.4 ± 28.1 mm versus 52.3 ± 26.5 mm in the SES and EES groups. The primary noninferiority endpoint, in-segment late lumen loss, was not met for SES versus EES (0.13 ± 0.63 mm vs. 0.02 ± 0.47 mm; p = 0.08, 2-sided; difference 0.11 mm; 95% confidence interval: -0.01 to 0.25 mm; p = 0.11, 1-sided). In-stent late lumen loss was comparable between SES and EES (0.12 ± 0.59 mm vs. 0.07 ± 0.46 mm; p = 0.52). The incidence of in-stent and in-segment binary restenosis was significantly higher with SES compared with EES (8.0% vs. 2.1%; p = 0.028), with comparable rates of reocclusions (2.2% vs. 1.4%; p = 0.68). Clinically indicated target lesion and target vessel revascularization (9.2% vs. 4.0% [p = 0.08] and 9.2% vs. 6.0% [p = 0.33]), target vessel failure (9.9% vs. 6.6%; p = 0.35), and definite or probable stent thrombosis (0.7% vs. 0.7%; p = 1.00) were comparable between the SES and EES groups.

Conclusions: This randomized trial failed to show noninferiority of hybrid SES relative to EES in terms of in-segment late lumen loss in successfully recanalized CTOs. Furthermore, a statistically significantly higher rate of binary restenosis was found with SES.
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http://dx.doi.org/10.1016/j.jcin.2016.10.017DOI Listing
January 2017

Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI: The EXPLORE Trial.

J Am Coll Cardiol 2016 10;68(15):1622-1632

Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.

Background: In 10% to 15% of patients with ST-segment elevation myocardial infarction (STEMI), concurrent coronary chronic total occlusion (CTO) in a non-infarct-related artery is present and is associated with increased morbidity and mortality.

Objectives: The EXPLORE (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Elevation Myocardial Infarction) trial evaluated whether patients with STEMI and concurrent CTO in a non-infarct-related artery benefit from additional percutaneous coronary intervention (PCI) of CTO shortly after primary PCI.

Methods: From November 2007 through April 2015, we enrolled 304 patients with acute STEMI who underwent primary PCI and had concurrent CTO in 14 centers in Europe and Canada. A total of 150 patients were randomly assigned to early PCI of the CTO (CTO PCI), and 154 patients were assigned to conservative treatment without PCI of the CTO (no CTO PCI). Primary outcomes were left ventricular ejection fraction (LVEF) and left ventricular end diastolic volume (LVEDV) on cardiac magnetic resonance imaging after 4 months.

Results: The investigator-reported procedural success rate in the CTO PCI arm of the trial was 77%, and the adjudicated success rate was 73%. At 4 months, mean LVEF did not differ between the 2 groups (44.1 ± 12.2% vs. 44.8 ± 11.9%, respectively; p = 0.60). Mean LVEDV at 4 months was 215.6 ± 62.5 ml in the CTO PCI arm versus 212.8 ± 60.3 ml in the no-CTO PCI arm (p = 0.70). Subgroup analysis revealed that patients with CTO located in the left anterior descending coronary artery who were randomized to the CTO PCI strategy had significantly higher LVEF compared with patients randomized to the no-CTO PCI strategy (47.2 ± 12.3% vs. 40.4 ± 11.9%; p = 0.02). There were no differences in terms of 4-month major adverse coronary events (5.4% vs. 2.6%; p = 0.25).

Conclusions: Additional CTO PCI within 1 week after primary PCI for STEMI was feasible and safe. In patients with STEMI and concurrent CTO, we did not find an overall benefit for CTO PCI in terms of LVEF or LVEDV. The finding that early CTO PCI in the left anterior descending coronary artery subgroup was beneficial warrants further investigation. (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary Intervention on Occlusions After ST-Segment Elevation Myocardial Infarction; NTR1108).
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http://dx.doi.org/10.1016/j.jacc.2016.07.744DOI Listing
October 2016

Recurrent Myocardial Infarction After Primary Percutaneous Coronary Intervention in Multivessel Coronary Disease Is Primarily Related to Stent Failure: Post-Hoc Analysis of the PASSION Trial.

J Interv Cardiol 2015 Dec;28(6):523-30

Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands.

Objectives: Our aim was to investigate the risk of events related to non-culprit lesions after primary percutaneous coronary intervention (PCI) in patients with multivessel coronary disease (MVD).

Background: In patients undergoing primary PCI for ST-elevation myocardial infarction (STEMI) who are diagnosed with MVD, the optimal treatment strategy is currently under debate. Although observational data exposed an increased risk of multivessel PCI in the acute phase of STEMI, 2 recently published randomized controlled trials showed a reduction of death or recurrent myocardial infarction (MI) after preventive PCI of non-culprit lesions when compared with culprit-lesion PCI only.

Methods: We performed a post-hoc analysis of 279 patients with MVD included in the Paclitaxel-Eluting Stent versus Conventional Stent in Myocardial Infarction with ST-Segment Elevation (PASSION) trial. We analyzed the incidence and cause of recurrent MI. Recurrent MI due to stent failure was assumed in the event of definite or probable stent thrombosis.

Results: After 5 years, 14 patients (5.7%) with MVD had a recurrent MI versus 17 (5.4%) patients with 1-vessel disease (HR 1.06, 95%CI 0.52-2.15, P = 0.87). The majority of events was attributable to stent failure, while of the remaining 6 events, only 1 was proven to originate from a lesion that was judged significant at enrolment.

Conclusions: In this post-hoc analysis of the PASSION trial, recurrent MI in patients with MVD was mainly related to stent failure rather than a new event originating from a significant stenosis in a non-culprit coronary artery.
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http://dx.doi.org/10.1111/joic.12246DOI Listing
December 2015

Initial experience with therapeutic geometric modification of the carotid bulb for true resistant hypertension.

EuroIntervention 2015 May;11(1):117-20

Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

The contribution of carotid baroreceptor feedback in preventing or potentially contributing to the essential hypertensive cascade is poorly understood. It is clear the carotid sinus nerve action potentials are triggered by carotid bulb stretch rather than pressure and are only sustained during pulsatile increases in pressure. In addition, the carotid baroreceptor negative feedback is gradually extinguished in hypertension patients (a phenomenon known as "resetting"). We report a case of significant reduction in blood pressure in a patient with true resistant hypertension after change in the carotid bulb pulsatile strain patterns following the implant of an intravascular prosthesis.
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http://dx.doi.org/10.4244/EIJV11I1A20DOI Listing
May 2015

Percutaneous closure of secundum type atrial septal defects: More than 5-year follow-up.

World J Cardiol 2015 Mar;7(3):150-6

Roel JR Snijder, Maarten J Suttorp, Jurriën M Ten Berg, Martijn C Post, Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands.

Aim: To investigate long-term efficacy of two different devices more than five years after percutaneous atrial septal defect (ASD) closure in adults.

Methods: All patients who underwent percutaneous closure of an ASD in the St. Antonius Hospital, Nieuwegein, The Netherlands, between February 1998 and December 2006 were included. Percutaneous closure took place under general anaesthesia and transesophageal echocardiographic monitoring. Transthoracic echocardiography (TTE) was performed 24 h post-procedure to visualize the device position and to look for residual shunting using color Doppler. All complications were registered. All patients were invited for an outpatient visit and contrast TTE more than 5-years after closure. Efficacy was based on the presence of a residual right-to-left shunt (RLS), graded as minimal, moderate or severe. The presence of a residual left-to-right shunt (LRS) was diagnosed using color Doppler, and was not graded. Descriptive statistics were used for patients' characteristics. Univariate analysis was used to identify predictors for residual shunting.

Results: In total, 104 patients (mean age 45.5 ± 17.1 years) underwent percutaneous ASD closure using an Amplatzer device (ASO) in 76 patients and a Cardioseal/Starflex device (CS/SF) in 28 patients. The mean follow-up was 6.4 ± 3.4 years. Device migration occurred in 4 patients of whom two cases occurred during the index hospitalization (1 ASO, 1 CS/SF). The other 2 cases of device migration occurred during the first 6 mo of follow-up (2 CS/SF). The recurrent thrombo-embolic event rate was similar in both groups: 0.4% per follow-up year. More than 12 mo post-ASD closure and latest follow-up, new-onset supraventricular tachyarrhythmia's occurred in 3.9% and 0% for the ASO and CS/SF group, respectively. The RLS rate at latest follow-up was 17.4% (minimal 10.9%, moderate 2.2%, severe 4.3%) and 45.5% (minimal 27.3%, moderate 18.2%, severe 0%) for the ASO- and CS/SF groups, respectively. There was no residual LRS in both groups.

Conclusion: Percutaneous ASD closure has good long-term safety and efficacy profiles. The residual RLS rate seems to be high more than 5 years after closure, especially in the CS/SF. Residual LRS was not observed.
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http://dx.doi.org/10.4330/wjc.v7.i3.150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4365306PMC
March 2015

Three-year clinical outcome in the Primary Stenting of Totally Occluded Native Coronary Arteries III (PRISON III) trial: a randomised comparison between sirolimus-eluting stent implantation and zotarolimus-eluting stent implantation for the treatment of total coronary occlusions.

EuroIntervention 2015 Mar;10(11):1272-5

Department of Interventional Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

Aims: Sirolimus-eluting stents (SES) have been shown to be superior to Endeavor zotarolimus-eluting stents (ZES) and comparable to Resolute ZES at eight-month angiography in patients treated for total coronary occlusions (TCO). This study investigated clinical outcome at three-year follow-up.

Methods And Results: The PRISON III trial investigated the efficacy and safety of SES against ZES (Endeavor and Resolute) in two study phases. In the first phase, 51 patients were randomised to receive SES and 46 to Endeavor ZES. In the second phase, 103 and 104 patients were randomised to SES or Resolute ZES, respectively. Between one and three years there were only a few additional clinical events in all groups. As a result, the rates of target lesion revascularisation 12.2% vs. 19.6%, p=0.49, target vessel failure 14.3% vs. 19.6%, p=0.68, and definite or probable stent thrombosis 4.1% vs. 2.2% were comparable between SES and Endeavor ZES at three years. In the second study phase, the rates of target lesion revascularisation 10% vs. 5.9%, p=0.42, target vessel failure 10% vs. 7.9%, p=0.79 and definite or probable stent thrombosis 1.0% vs. 0% were similar between SES and Resolute ZES.

Conclusions: The present study demonstrated a low incidence of clinical events between one- and three-year follow-up with either SES compared to Endeavor ZES or SES versus Resolute ZES in patients treated for total coronary occlusions.
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http://dx.doi.org/10.4244/EIJY14M08_07DOI Listing
March 2015

Modifying effect of dual antiplatelet therapy on incidence of stent thrombosis according to implanted drug-eluting stent type.

Eur Heart J 2014 Aug 13;35(29):1932-48. Epub 2014 Mar 13.

Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France INSERM U-698, Paris, France Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris, Paris, France NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK.

Aim: To investigate the putative modifying effect of dual antiplatelet therapy (DAPT) use on the incidence of stent thrombosis at 3 years in patients randomized to Endeavor zotarolimus-eluting stent (E-ZES) or Cypher sirolimus-eluting stent (C-SES).

Methods And Results: Of 8709 patients in PROTECT, 4357 were randomized to E-ZES and 4352 to C-SES. Aspirin was to be given indefinitely, and clopidogrel/ticlopidine for ≥ 3 months or up to 12 months after implantation. Main outcome measures were definite or probable stent thrombosis at 3 years. Multivariable Cox regression analysis was applied, with stent type, DAPT, and their interaction as the main outcome determinants. Dual antiplatelet therapy adherence remained the same in the E-ZES and C-SES groups (79.6% at 1 year, 32.8% at 2 years, and 21.6% at 3 years). We observed a statistically significant (P = 0.0052) heterogeneity in treatment effect of stent type in relation to DAPT. In the absence of DAPT, stent thrombosis was lower with E-ZES vs. C-SES (adjusted hazard ratio 0.38, 95% confidence interval 0.19, 0.75; P = 0.0056). In the presence of DAPT, no difference was found (1.18; 0.79, 1.77; P = 0.43).

Conclusion: A strong interaction was observed between drug-eluting stent type and DAPT use, most likely prompted by the vascular healing response induced by the implanted DES system. These results suggest that the incidence of stent thrombosis in DES trials should not be evaluated independently of DAPT use, and the optimal duration of DAPT will likely depend upon stent type (Clinicaltrials.gov number NCT00476957).
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http://dx.doi.org/10.1093/eurheartj/ehu084DOI Listing
August 2014

Percutaneous reclosure of a patent foramen ovale after bioabsorbable device implantation.

EuroIntervention 2014 Nov;10(7):860

Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

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http://dx.doi.org/10.4244/EIJV10I7A146DOI Listing
November 2014

Primary Stenting of Totally Occluded Native Coronary Arteries III (PRISON III): a randomised comparison of sirolimus-eluting stent implantation with zotarolimus-eluting stent implantation for the treatment of total coronary occlusions.

EuroIntervention 2013 Nov;9(7):841-53

Department of Interventional Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

Aims: We investigated whether sirolimus-eluting stents (SES) are superior to next-generation zotarolimus-eluting stents (ZES) in treating patients with total coronary occlusions (TCO).

Methods And Results: In a prospective, randomised trial we compared the SES with the zotarolimus-eluting stent (ZES; Endeavor or Resolute) after successful recanalisation of TCO. During the first phase of the trial, 51 patients were assigned to receive the SES and 46 patients to receive the Endeavor ZES. In the second phase we randomised 103 patients to the SES group and 104 patients to the Resolute ZES group. The primary endpoint was in-segment late lumen loss at eight-month follow-up. At eight months, patients in the SES group had less in-segment and in-stent late loss as compared to the Endeavor group: -0.13±0.3 mm vs. 0.27±0.6 mm (p=0.0002) and -0.13±0.5 mm vs. 0.54±0.5 mm (p<0.0001), respectively. In contrast, the SES and the Resolute ZES showed comparable amounts of in-segment (-0.03±0.7 mm vs. -0.10±0.7 mm, p=0.6) and in-stent (0.03±0.8 mm vs. 0.05±0.8 mm, p=0.9) late loss.

Conclusions: In the treatment of TCOs, the SES was associated with superior angiographic outcomes compared to the Endeavor ZES. On the other hand, the SES and the Resolute ZES showed comparable angiographic outcomes.
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http://dx.doi.org/10.4244/EIJV9I7A138DOI Listing
November 2013

Late catch-up in lumen diameter at five-year angiography in MACE-free patients treated with sirolimus-eluting stents in the Primary Stenting of Totally Occluded Native Coronary Arteries: a randomised comparison of bare metal stent implantation with sirolimus-eluting stent implantation for the treatment of total coronary occlusions (PRISON II).

EuroIntervention 2013 Jun;9(2):212-9

Department of Interventional Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

Aims: The present study was designed to examine the five-year angiographic follow-up of MACE-free patients enrolled in the PRISON II study.

Methods And Results: In the PRISON II study a total of 200 patients were randomised to either bare metal stents (BMS) or sirolimus-eluting stents (SES) after successful recanalisation of total coronary occlusions (TCO). Patients free of MACE with available angiography at six months were approached for repeated angiography at five years. The primary endpoint was in-stent very late luminal loss (VLLL) at five years. The secondary endpoint was additional late luminal loss (ALLL) between six months and five years. At five years, repeated angiography was performed in 72 patients, 50/82 (61%) in the SES group and 22/58 (38%) in the BMS group. In-stent VLLL was lower in the SES group (0.19 mm ± 0.72 vs. 0.51 mm ± 0.71, p=0.09) compared to the BMS group and in-segment VLLL was comparable in both groups (0.01 mm±0.58 vs. 0.03 mm ± 0.73, p=0.89). Late catch-up in lumen diameter was observed in the SES group with a trend towards increased ALLL compared to the BMS group (in-stent, 0.35 mm ± 0.88 vs. 0.04 mm ± 0.81, p=0.16; in-segment, 0.20 mm ± 0.74 vs. -0.05 mm ± 0.73, p=0.19).

Conclusions: At five-year angiographic follow-up, late catch-up was observed after successful recanalisation of TCOs treated with SES. Despite a late catch-up, the angiographic results of SES were superior in-stent and similar in-segment compared to BMS.
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http://dx.doi.org/10.4244/EIJV9I2A36DOI Listing
June 2013

A randomized multicenter comparison of hybrid sirolimus-eluting stents with bioresorbable polymer versus everolimus-eluting stents with durable polymer in total coronary occlusion: rationale and design of the Primary Stenting of Occluded Native Coronary Arteries IV study.

Trials 2012 Dec 15;13:240. Epub 2012 Dec 15.

Department of Cardiology, St. Antonius Hospital, Koekoekslaan1, 3435 CM, Nieuwegein, the Netherlands.

Background: Percutaneous recanalization of total coronary occlusion (TCO) was historically hampered by high rates of restenosis and reocclusions. The PRISON II trial demonstrated a significant restenosis reduction in patients treated with sirolimus-eluting stents compared with bare metal stents for TCO. Similar reductions in restenosis were observed with the second-generation zotarolimus-eluting stent and everolimus-eluting stent. Despite favorable anti-restenotic efficacy, safety concerns evolved after identifying an increased rate of very late stent thrombosis (VLST) with drug-eluting stents (DES) for the treatment of TCO. Late malapposition caused by hypersensitivity reactions and chronic inflammation was suggested as a probable cause of these VLST. New DES with bioresorbable polymer coatings were developed to address these safety concerns. No randomized trials have evaluated the efficacy and safety of the new-generation DES with bioresorbable polymers in patients treated for TCO.

Methods/design: The prospective, randomized, single-blinded, multicenter, non-inferiority PRISON IV trial was designed to evaluate the safety, efficacy, and angiographic outcome of hybrid sirolimus-eluting stents with bioresorbable polymers (Orsiro; Biotronik, Berlin, Germany) compared with everolimus-eluting stents with durable polymers (Xience Prime/Xpedition; Abbott Vascular, Santa Clara, CA, USA) in patients with successfully recanalized TCOs. In total, 330 patients have been randomly allocated to each treatment arm. Patients are eligible with estimated duration of TCO ≥4 weeks with evidence of ischemia in the supply area of the TCO. The primary endpoint is in-segment late luminal loss at 9-month follow-up angiography. Secondary angiographic endpoints include in-stent late luminal loss, minimal luminal diameter, percentage of diameter stenosis, in-stent and in-segment binary restenosis and reocclusions at 9-month follow-up. Additionally, optical coherence tomography is performed in the first 60 randomized patients at 9 months to assess neointima thickness, percentage of neointima coverage, and stent strut malapposition and coverage. Personnel blinded to the allocated treatment will review all angiographic and optical coherence assessments. Secondary clinical endpoints include major adverse cardiac events, clinically driven target vessel revascularization, target vessel failure and stent thrombosis to 5-year clinical follow-up. An independent clinical event committee blinded to the allocated treatment will review all clinical events.

Trial Registration: Clinical Trials.gov: NCT01516723. Patient recruitment started in February 2012.
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http://dx.doi.org/10.1186/1745-6215-13-240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543352PMC
December 2012

Safety and efficacy of the cobalt chromium PRO-Kinetik coronary stent system: results of the MULTIBENE study.

Cardiovasc Revasc Med 2012 Nov-Dec;13(6):316-20

ZNA Middelheim, Department Interventional Cardiology, Antwerpen 2020, Belgium.

Background: The aim of this MULTIBENE study was to evaluate the safety and efficacy of the silicon carbide coated cobalt chromium PRO-Kinetik coronary stent system in patients with single de novo coronary lesions.

Methods And Materials: This prospective international multicenter study included 202 patients at 10 European sites. Analysis was performed on the per protocol population of 197 patients. Patients were followed until 12 months, a subset of patients (n=72) underwent additional coronary angiography at 6 months. Primary endpoint was 6-months rate of target vessel failure (TVF), defined as a composite of cardiac death, myocardial infarction and target vessel revascularization (TVR).

Results: At 6 months, rate of TVF was 10.9% and rate of major adverse cardiac events, a composite of cardiac death, MI, target lesion revascularization (TLR) and coronary artery bypass graft, was 11.4%, both being mainly attributed to TVR respective TLR. No cardiac death or stent thrombosis occurred. In-segment late lumen loss was 0.66±0.61mm and binary restenosis was 20.8%, as determined by core laboratory in the angiographic subgroup.

Conclusion: Based on these data, the PRO-Kinetik coronary stent system was found to be safe and effective.
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http://dx.doi.org/10.1016/j.carrev.2012.09.006DOI Listing
May 2013

Carotid artery stenting and cardiac surgery in symptomatic patients.

JACC Cardiovasc Interv 2011 Nov;4(11):1190-6

Department of Interventional Cardiology, St-Antonius Hospital, Nieuwegein, the Netherlands.

Objectives: The purpose of this study was to evaluate the feasibility and safety of the combined outcome of carotid artery stenting (CAS) and coronary artery bypass graft (CABG) surgery in neurologically symptomatic patients.

Background: The risk of perioperative stroke in patients undergoing CABG who report a prior history of transient ischemic attack or stroke has been associated with a 4-fold increased risk as compared to the risk for neurologically asymptomatic patients. It seems appropriate to offer prophylactic carotid endarterectomy to neurologically symptomatic patients who have significant carotid artery disease and are scheduled for CABG. The CAS-CABG outcome for symptomatic patients remains underreported, notwithstanding randomized data supporting CAS for high-risk patients.

Methods: In a prospective, single-center study, the periprocedural and long-term outcomes of 57 consecutive patients who underwent CAS before cardiac surgery were analyzed.

Results: The procedural success rate of CAS was 98%. The combined death, stroke, and myocardial infarction rate was 12.3%. The death and major stroke rate from time of CAS to 30 days after cardiac surgery was 3.5%. The myocardial infarction rate from time of CAS to 30 days after cardiac surgery was 1.5%.

Conclusions: This is the first single-center study reporting the combined outcome of CAS-CABG in symptomatic patients. The periprocedural complication rate and long-term results of the CAS-CABG strategy in this high-risk population support the reliability of this approach. In such a high-risk population, this strategy might offer a valuable alternative to the combined surgical approach; however, a large randomized trial is clearly warranted.
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http://dx.doi.org/10.1016/j.jcin.2011.07.012DOI Listing
November 2011

Five-year clinical outcome after primary stenting of totally occluded native coronary arteries: a randomised comparison of bare metal stent implantation with sirolimus-eluting stent implantation for the treatment of total coronary occlusions (PRISON II study).

EuroIntervention 2012 Feb;7(10):1189-96

St. Antonius Hospital, Nieuwegein, The Netherlands.

Aims: The aim of this study was to examine the five-year clinical outcome in patients enrolled in the Primary Stenting of Totally Occluded Native Coronary Arteries II (PRISON II) study.

Methods And Results: Patients with totally occluded coronary arteries were randomised to either sirolimus-eluting stent (SES, n=100) or bare metal stent (BMS, n=100) implantation. At five years, patients in the SES group had significantly lower rates of target lesion revascularisation (12% vs. 30%, p=0.001), target vessel revascularisation (17% vs. 34%, p=0.009) and major adverse cardiac events (12% vs. 36%, p<0.001). There were no significant differences in death and myocardial infarction. Eight (8%) cases of stent thrombosis (seven definite and one probable; one early, one late, and six very late) were noticed in the SES group versus three cases (3%, one definite and two possible; all very late) in the BMS group (p=0.21).

Conclusions: The results of the present study show that the documented superior short-term angiographic and clinical results of SES in patients with total coronary occlusions are maintained during long-term 5-year follow-up as compared with BMS. On the other hand, there is a trend to a higher stent thrombosis rate in the SES group.
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http://dx.doi.org/10.4244/EIJV7I10A190DOI Listing
February 2012

Patency of paclitaxel-eluting versus bare metal stents long term after implantation in acute ST-segment elevation myocardial infarction.

Am J Cardiol 2011 Nov 23;108(9):1214-9. Epub 2011 Aug 23.

Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

Drug-eluting stents effectively inhibit neointimal hyperplasia within the first year, thereby reducing the need for repeat revascularization. However, a delayed pattern of restenosis might be more prominent in drug-eluting stents compared to bare metal stents (BMSs). The extent of restenosis of paclitaxel-eluting stents (PESs) long term after implantation in acute ST-segment elevation myocardial infarction is currently unknown. The present study was designed to evaluate very late luminal loss (VLLL) of PESs used in ST-segment elevation myocardial infarction compared to BMSs. A total of 116 patients (61 with PESs and 55 with BMSs) initially included in the Paclitaxel Eluting Stent Versus Conventional Stent in ST-segment Elevation Myocardial Infarction (PASSION) trial and who were free from previous lesion failure underwent angiographic follow-up. Off-line quantitative coronary analysis of the angiogram immediately after stent implantation and at follow-up was performed. The primary end point was VLLL within the stent. The presence of binary restenosis was defined as diameter stenosis >50% as a secondary end point. The mean interval between stent implantation and follow-up was 4.1 ± 0.5 years in both stent groups. In-stent VLLL was 0.12 mm (interquartile range -0.03 to 0.42) in the PES group versus 0.30 mm (interquartile range 0.08 to 0.69) in the BMS group (p = 0.011). In-segment binary restenosis was found in 4 patients (6.6%) with a PES and 6 patients (10.9%) with a BMS (p = 0.40). In conclusion, angiographic follow-up 4 years after implantation in ST-segment elevation myocardial infarction showed that in patients prospectively randomized to PESs or BMSs, VLLL was low in both stent groups. PESs were associated with lower VLLL than BMSs, and the observed rate of binary restenosis was not significantly different between the 2 stent groups.
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http://dx.doi.org/10.1016/j.amjcard.2011.06.034DOI Listing
November 2011

Lack of long-term clinical benefit of thrombus aspiration during primary percutaneous coronary intervention with paclitaxel-eluting stents or bare-metal stents: post-hoc analysis of the PASSION-trial.

Catheter Cardiovasc Interv 2012 May 12;79(6):870-7. Epub 2011 Dec 12.

Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.

Background: Although current clinical guidelines recommend the use of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI), previous studies evaluating TA demonstrated contradictory results. The aim of this study was to evaluate long-term clinical outcome after TA in adjunct to PPCI for acute ST-segment myocardial infarction (STEMI), as compared with conventional treatment, with the use of paclitaxel-eluting stents or bare-metal stents.

Methods: We analyzed data of the PASSION trial, in which 619 patients with STEMI were randomly assigned to a paclitaxel-eluting stent or a bare-metal stent. TA was performed in 311 patients (50.2%). Clinical endpoints at 2 years were compared between patients who received TA during PPCI with patients who underwent conventional PPCI. The primary outcome of interest was a composite of cardiac death, recurrent myocardial infarction (MI), or target-lesion revascularization (TLR). A propensity score model was made to account for baseline differences that could have affected the probability of performing TA.

Results: Complete follow-up was available for 598 patients (96.6%). The cumulative incidence of the combined outcome measure of cardiac death, recurrent MI, or TLR was 40 (13.0%) in the TA group and 41 (13.5%) in the conventional PPCI group (HR 0.96; 95% CI 0.62-1.47; P = 0.84). Also after adjusting for propensity score, no significant difference in event rate was observed between both treatment groups.

Conclusions: In this post-hoc analysis of the PASSION trial, TA in adjunct to PPCI did not affect rates of major adverse cardiac events at 2 years follow-up, as compared with conventional PPCI.
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http://dx.doi.org/10.1002/ccd.23226DOI Listing
May 2012

Comparison of outcome after patent foramen ovale closure in older versus younger patients.

EuroIntervention 2011 Jun;7(2):209-15

Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

Aims: Percutaneous patent foramen ovale (PFO) closure seems to be effective for secondary prevention of cryptogenic stroke in patients younger than 55 years of age. The efficacy in older patients remains uncertain. We compared the efficacy of PFO closure between patients younger and older than 55 years.

Methods And Results: All 335 patients (mean age 50.2 ± 12.6 years; 205 men) with cryptogenic thromboembolism who underwent PFO closure in our centres between 1998 and 2008 were included. Mean follow-up period was 4.2 ± 1.9 years in the elderly (n=120) and 3.8 ± 2.4 years in the younger patients (n=215) (p=0.15). Prevalence of hypertension, diabetes, hyperlipidaemia and coronary and peripheral artery disease was higher in the elderly (p<0.05 for all). Re-occurrence of stroke or TIA was higher in the elderly compared to the younger (annual event rate 2.4% versus 0.6%; log rank, p=0.005). Re-occurrence of stroke alone was higher in the elderly (annual event rate 1.2% versus 0.1%; log rank, p=0.01). Multivariate analysis showed that an age of >55 years was an independent predictor of recurrent stroke or TIA (HR 3.2, p=0.03).

Conclusions: Percutaneous PFO closure appears to be effective for secondary prevention of cryptogenic stroke in younger patients but seems to be related with less beneficial outcome in elderly. Randomised controlled trials are needed to confirm our findings.
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http://dx.doi.org/10.4244/EIJV7I2A35DOI Listing
June 2011

CT measurement of changes in cerebral perfusion in patients with asymptomatic carotid artery stenosis undergoing carotid stenting prior to cardiac surgery: "proof of principle".

EuroIntervention 2011 Apr;6(9):1091-7

Department of Interventional Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.

Aims: To identify asymptomatic patients with impaired cerebral perfusion using CT perfusion (CTP) technique during staged carotid stenting (CAS) and cardiac surgery.

Methods And Results: This is a prospective, non-randomised study in 16 neurologically asymptomatic patients designed to analyse cerebral perfusion using CTP before and after CAS. Mean transit time (MTT) was significant lower and cerebral blood flow (CBF) was significantly higher in the non-target hemisphere compared to the target hemisphere before treatment (4.64 ± 1.08 s vs. 5.67 ± 1.29 and 57.37 ± 24.90 s vs. 48.19 ± 13.02, respectively). Mean dMTT (absolute difference in MTT values between treated and untreated hemisphere) decreased from 0.92 ± 1.08 s before to 0.04 ± 0.30 s after carotid revascularisation (p<0.05) and mean relative CBF (ratios of the treated to the untreated hemisphere) increased from 0.92 ± 0.12 to 1.04 ± 0.12 after revascularisation (p<0.05). Subgroup analysis based on pre-treatment dMTT showed significant changes in 50% of the patients with larger dMTT. There was one transient ischaemic attack reported 30 days after combined procedure.

Conclusions: A significant improvement of cerebral perfusion after carotid stenting is shown in about 50% of the asymptomatic patients in this study. This suggests the potential presence of a compromised cerebral circulation in asymptomatic patients with severe carotid artery disease scheduled for cardiac surgery.
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http://dx.doi.org/10.4244/EIJV6I9A190DOI Listing
April 2011
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