Publications by authors named "Peter Ludman"

193 Publications

Early Acurate Neo transcatheter heart valve degeneration in a haemodialysis patient successfully managed with Sapien 3 Ultra: a case report.

Eur Heart J Case Rep 2022 Jul 1;6(7):ytac279. Epub 2022 Jul 1.

Department of Cardiology, Queen Elizabeth University Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK.

Background: Aortic valve disease is the most prevalent valvular abnormality in the developed world and carries a high risk of morbidity and mortality. Transcatheter aortic valve replacement (TAVR) is favoured over open-heart surgery in high-risk patient categories and is increasingly used in lower-risk groups. End stage kidney disease (ESKD) is associated with premature calcific degeneration of bioprosthetic heart valves. Redo-TAVR requires meticulous pre-procedural planning to avoid the important risks of sinus sequestration and impaired coronary access. Transcatheter aortic valve replacement with the Acurate Neo transcatheter heart valve (THV) has been clinically available for a short time only and there are limited reports describing redo-TAVR in the Acurate Neo.

Case Summary: We present a case of early, rapid onset, structural valve degeneration in a Acurate Neo, supra-annular, self-expanding THV in a dialysis patient. The patient presented with chest pain and breathlessness 4 years after TAVR with a Acurate Neo for severe stenosis of a bicuspid aortic valve. Echocardiogram now showed severe stenosis of the THV and computed tomography revealed severe THV leaflet calcification but no pannus or leaflet thrombus. After careful pre-procedural planning a S3 Ultra balloon-expandable valve was selected and positioned relatively high to pin the first THV leaflets in a fully open position without compromising coronary artery flow or coronary access.

Discussion: End stage kidney disease may cause rapid, calcific degeneration of TAVR valves leading to presentation with severe aortic stenosis. Redo-TAVR in the Acurate Neo THV with a Sapien 3 Ultra is feasible with careful pre-procedural planning to mitigate the risks of sinus sequestration and impaired coronary access.
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http://dx.doi.org/10.1093/ehjcr/ytac279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9290620PMC
July 2022

Variation in practice for out-of-hospital cardiac arrest treated with percutaneous coronary intervention in England and Wales.

Catheter Cardiovasc Interv 2022 Jun 29. Epub 2022 Jun 29.

Faculty of Medicine, University of Southampton, Southampton, UK.

Objectives: We assessed the association between total center volume, operator volume, and out-of-hospital cardiac arrest (OHCA) percutaneous coronary intervention (PCI) volume.

Background: Variations between OHCA PCI volume, hospital total PCI, and primary PCI volume are not well studied and are unlikely to be clinically justifiable.

Methods: Patients undergoing PCI for the acute coronary syndrome (ACS) between January 1, 2014, and March 31, 2019, in England and Wales were grouped as OHCA PCI and non-OHCA PCI. Spearman's correlation was used to determine the degree of correlation between each hospital PCI volume and OHCA PCI volume.

Results: Out of 250,088 PCI procedures undertaken for ACS, 12,016 (4.8%) were performed for OHCA, and 238,072 (95.2%) were non-OHCA PCI procedures. The OHCA PCI group were younger [mean age (SD) 63.2 (12.3) and 65.6 (12.5, p < 0.001)], less likely to be female (20.2% vs. 26.9%, p < 0.001) or Black, Asian, and Minority Ethnicity (11.5% vs. 14.8%, p < 0.001) compared to the non-OHCA PCI group. Although there was a degree of correlation between total PCI and OHCA PCI, there was wide variation for both ACS cohort (Spearman correlation R  = 0.50) and total PCI volume (Spearman correlation R  = 0.60). Furthermore, the correlation between primary PCI volume and OHCA PCI within centers was weak (R  = 0.10). Similarly, wide variations between operator PCI volume and OHCA PCI volume were observed.

Conclusion: These national data demonstrate wide variation in the practice of OHCA PCI both between centers and individuals. These variations are not expected according to clinical factors and require further investigation.
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http://dx.doi.org/10.1002/ccd.30316DOI Listing
June 2022

Temporal patterns, characteristics, and predictors of clinical outcomes in patients undergoing percutaneous coronary intervention for stent thrombosis.

EuroIntervention 2022 May 23. Epub 2022 May 23.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom.

Background: There are limited data on the outcomes of percutaneous coronary intervention (PCI) following stent thrombosis (ST) and differences exist based on timing.

Aims: Our aim was to study the rates of PCI procedures for an ST indication among all patients admitted for PCI at a national level and to compare their characteristics and procedural outcomes based on ST timing.

Methods: All PCI procedures in England and Wales (2014-2020) were retrospectively analysed and stratified by the presence of ST into four groups: non-ST, early ST (0-30 days), late ST (>30-360 days), very late ST (>360 days). Multivariable logistic regression models were performed to assess the odds ratios (OR) of in-hospital MACCE (major adverse cardiovascular and cerebrovascular events, a composite of mortality, acute stroke and reinfarction) and mortality.

Results: Overall, 7,923 (1.4%) procedures were for ST indication, most commonly for early ST (n=4,171; 52.6%), followed by very late ST (n=2,801; 35.4%) and late ST (n=951; 12.0%). The rate of PCI for ST declined between 2014 and 2020 (1.7 to 1.4%; p<0.001). Early ST was the only subgroup associated with increased odds of MACCE (OR 1.22, 95% CI: 1.05-1.41), all-cause mortality (OR 1.21, 95% CI: 1.07-1.36) and reinfarction (OR 2.48, 95% CI: 1.48-4.14), compared with non-ST indication. The odds of mortality were significantly reduced in ST patients with the use of intravascular imaging (OR 0.66, 95% CI: 0.48-0.92) and newer P2Y inhibitors (ticagrelor: OR 0.69, 95% CI: 0.49-0.95; prasugrel: OR 0.54, 95% CI: 0.30-0.96).

Conclusions: PCI for ST has declined in frequency over a 7-year period, with most procedures performed for early ST. Among the different times of ST onset, only early ST is associated with worse clinical outcomes after PCI. Routine use of intravascular imaging and newer P2Y inhibitors could further improve outcomes in this high-risk procedural group.
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http://dx.doi.org/10.4244/EIJ-D-22-00049DOI Listing
May 2022

Comparison of left ventricular with right ventricular rapid pacing on tamponade during TAVI.

Int J Cardiol 2022 Aug 18;360:46-52. Epub 2022 May 18.

Department of Cardiology, Queen Elizabeth University Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK; Institute for Cardiovascular Sciences, College of Medical & Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.. Electronic address:

Background: Small studies have suggested left ventricular (LV) rapid pacing has similar safety and efficacy to conventional right ventricular (RV) rapid pacing in transcatheter aortic valve implantation (TAVI). However, there are limited data on the comparative rates of tamponade. The study compared the rate of cardiac tamponade between LV and RV-pacing during TAVI.

Methods: Between 2008 and 2021, 1226 consecutive patients undergoing transfemoral or transaxillary TAVI were included. 470(38.3%) patients had TAVI deployment with RV-pacing and 756(61.7%) with LV-pacing. The primary outcome was the frequency and cause of cardiac tamponade. Secondary outcomes included efficacy, procedure duration and crossover rates.

Results: There was a trend to less tamponade with LV-pacing, which did not reach statistical significance [11(2.3%) vs 11(1.5%);P = 0.27]. There was no significant difference in the frequency of tamponade due to annular tear [4(0.9%) vs 9(1.2%);P = 0.59] or LV free-wall perforation [1(0.2%) vs 2(0.3%);P = 0.86]. The frequency of tamponade due to RV perforation was significantly lower in the LV-pacing group [0 vs 6(2.3%);P < 0.005)]. Two patients with tamponade due to RV perforation required emergency sternotomy of whom one died. Deployment success was similar (99% vs 99.6%;P=NS). Procedure duration was shorter with LV-pacing (70 vs 80 mins;P < 0.005). Crossover to RV-pacing was low (0.9%). There were no embolizations caused by loss-of-capture in either group.

Conclusions: LV-pacing appears equally efficacious and is associated with a lower risk of tamponade due to RV perforation caused by the temporary pacing wire. LV-pacing was not associated with an increased risk of tamponade due to LV free-wall perforation.
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http://dx.doi.org/10.1016/j.ijcard.2022.05.035DOI Listing
August 2022

Reperfusion therapy for ST-elevation myocardial infarction complicated by cardiogenic shock: the European Society of Cardiology EurObservational programme acute cardiovascular care-European association of PCI ST-elevation myocardial infarction registry.

Eur Heart J Acute Cardiovasc Care 2022 Jun;11(6):481-490

Hospital Rudolfstiftung, Vienna, Austria.

Aims: To determine the current state of the use of reperfusion and adjunctive therapies and in-hospital outcomes in European Society of Cardiology (ESC) member and affiliated countries for patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).

Methods And Results: ESC EurObservational Research Programme prospective international cohort study of admissions with STEMI within 24 h of symptom onset (196 centres; 26 ESC member and 3 affiliated countries). Of 11 462 patients enrolled, 448 (3.9%) had CS. Patients with compared to patients without CS, less frequently received primary percutaneous coronary intervention (PCI) (65.5% vs. 72.2%) and fibrinolysis (15.9% vs. 19.0), and more often had no reperfusion therapy (19.0% vs. 8.5%). Mechanical support devices (intraaortic ballon pump 11.2%, extracoporeal membrane oxygenation 0.7%, other 1.1%) were used infrequently in CS. Bleeding definition academic research consortium 2-5 bleeding complications (10.1% vs. 3.0%, P < 0.01) and stroke (4.2% vs. 0.9%, P < 0.01) occurred more frequently in patients with CS. In-hospital mortality was 10-fold higher (35.5% vs. 3.1%) in patients with CS. Mortality in patients with CS in the groups with PCI, fibrinolysis, and no reperfusion therapy were 27.4%, 36.6%, and 62.4%, respectively.

Conclusion: In this multi-national registry, patients with STEMI complicated by CS less frequently receive reperfusion therapy than patients with STEMI without CS. Early mortality in patients with CS not treated with primary PCI is very high. Therefore, strategies to improve clinical outcome in STEMI with CS are needed.
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http://dx.doi.org/10.1093/ehjacc/zuac049DOI Listing
June 2022

Ethnicity in Complex High-Risk but Indicated Percutaneous Coronary Intervention Types and Outcomes.

Am J Cardiol 2022 07 14;175:26-37. Epub 2022 May 14.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Primary Care and Health Sciences, Keele University, Keele, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom. Electronic address:

Complex High-risk but indicated Percutaneous coronary interventions (CHiPs) is increasingly common in contemporary practice. However, data on ethnic differences in CHiP types, outcomes, and trends in patients with stable angina are limited; this is pertinent given the population of Black, Asian, and other ethnic minorities (BAME) in Europe is increasing. We conducted a retrospective analysis of CHiP procedures undertaken in patients with stable angina using data obtained from the BCIS (British Cardiovascular Intervention Society) registry (2006 to 2017). CHiP cases were identified and categorized by ethnicity into White and BAME groups. We then performed multivariable regression analysis and propensity score matching to determine adjusted odds ratios (aORs) of in-hospital mortality, major bleeding, and major adverse cardiovascular and cerebral events (MACCEs) in BAME compared with Whites. Of 424,290 procedure records, 105,949 were CHiP (25.0%) (White 89,038 [84%], BAME 16,911 [16%]). BAME patients were younger (median 68.1 vs 70.6 years). Previous coronary artery bypass surgery (33.4% vs 38.3%), followed by chronic total occlusion percutaneous coronary intervention (31.9% vs 32%) were common CHiP variables in both groups. The third common variable was age 80 years and above (23.6%) in White patients and severe vascular calcifications in BAME patients (18.8%). BAME patients had higher rates of diabetes (41.1 vs 23.6%), hypertension (68 vs 66.5%), previous percutaneous coronary intervention (43.7 vs 37.6%), and previous myocardial infarction (44.9 vs 42.5%), (p <0.001 for all). Mortality (aOR 1.1, 95% confidence interval [CI] 0.8 to 1.5) and MACCE (aOR 1.0, 95% CI 0.8 to 1.1) odds were similar among the groups. Bleeding odds (aOR 0.7, 95% CI 0.6 to 0.9) were lower in BAME. In conclusion, CHiP procedures differed among the ethnic groups. BAME patients were younger and had worse cardiometabolic profiles. Similar odds of death and MACCE were seen in BAME compared with their White counterparts. Bleeding odds were 30% lower in the BAME group.
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http://dx.doi.org/10.1016/j.amjcard.2022.03.056DOI Listing
July 2022

Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial.

JAMA 2022 05;327(19):1875-1887

Department of Cardiovascular Medicine, University of Manchester, Manchester, England.

Importance: Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear.

Objective: To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk.

Design, Setting, And Participants: In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019.

Interventions: TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455).

Main Outcomes And Measures: The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation.

Results: Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]).

Conclusions And Relevance: Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year.

Trial Registration: isrctn.com Identifier: ISRCTN57819173.
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http://dx.doi.org/10.1001/jama.2022.5776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9115619PMC
May 2022

Changing trends in the incidence, management and outcomes of coronary artery perforation over an 11-year period: single-centre experience.

Open Heart 2022 04;9(1)

Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK.

Introduction: Coronary artery perforation (CP) is a rare but life-threatening complication of percutaneous coronary intervention (PCI). This study aimed to assess the incidence, management and outcomes of CP over time.

Methods: A single-centre retrospective cohort study of all PCIs performed between January 2010 and December 2020. Patients with CP were divided into two cohorts (A+B), representing the two halves of the 11-year study.

Results: The incidence of CP was 68 of 9701 (0.7%), with an increasing trend over the two 5.5-year periods studied (24 of 4661 (0.5%) vs 44 of 5040 (0.9%); p=0.035). Factors associated with CP included chronic total occlusions (CTOs) (16 of 68 (24%) vs 993 of 9633 (10%); p<0.001), type C lesions (44 of 68 (65%) vs 4280 of 9633 (44%); p<0.001), use of intravascular ultrasound (IVUS) (12 of 68 (18%) vs 541 of 9633 (6%); p<0.001), cutting balloon angioplasty (3 of 68 (4%) vs 98 of 9633 (1%); p<0.001) and hydrophilic wires (24 of 68 (35%) vs 1454 of 9633 (15%); p<0.001). Cohorts A and B were well matched with respect to age (69±11 vs 70±12 years; p=0.843), sex (males: 13 of 24 (54%) vs 31 of 44 (70%); p=0.179) and renal function (chronic kidney disease: 1 of 24 (4%) vs 4 of 44 (9%); p=0.457). In cohort A, CP was most frequently caused by post-dilatation with non-compliant balloons (10 of 24 (42%); p=0.009); whereas in cohort B, common causes included guidewire exits (23 of 44 (52%)), followed by stent implantation (10 of 44 (23%)). The most common treatment modality in cohorts A and B was balloon inflation, which accounted for 16 of 24 (67%) and 13 of 44 (30%), respectively. The use of covered stents (16%) and coronary coils (18%) during cohort B study period did not impact all-cause mortality, which occurred in 2 of 24 (8%) and 7 of 44 (16%) (p=0.378) in cohorts A and B, respectively.

Conclusion: The incidence of CP is increasing as more complex PCI is performed. Factors associated with perforation include CTO or type C lesions and use of IVUS, cutting balloon angioplasty or hydrophilic wires.
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http://dx.doi.org/10.1136/openhrt-2021-001916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9052042PMC
April 2022

Data standards for acute coronary syndrome and percutaneous coronary intervention: the European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart).

Eur Heart J 2022 06;43(24):2269-2285

Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.

Standardized data definitions are essential for monitoring and benchmarking the quality of care and patient outcomes in observational studies and randomized controlled trials. There are no contemporary pan-European data standards for the acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) project of the European Society of Cardiology (ESC) aimed to develop such data standards for ACS and PCI. Following a systematic review of the literature on ACS and PCI data standards and evaluation of contemporary ACS and PCI registries, we undertook a modified Delphi process involving clinical and registry experts from 11 European countries, as well as representatives from relevant ESC Associations, including the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Acute CardioVascular Care (ACVC). This resulted in final sets of 68 and 84 'mandatory' variables and several catalogues of optional variables for ACS and PCI, respectively. Data definitions were provided for these variables, which have been programmed as the basis for continuous registration of individual patient data in the online EuroHeart IT platform. By means of a structured process and the interaction with major stakeholders, internationally harmonized data standards for ACS and PCI have been developed. In the context of the EuroHeart project, this will facilitate country-level quality of care improvement, international observational research, registry-based randomized trials, and post-marketing surveillance of devices and pharmacotherapies.
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http://dx.doi.org/10.1093/eurheartj/ehac133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9209007PMC
June 2022

The Impact of Intracoronary Imaging on PCI Outcomes in Cases Utilising Rotational Atherectomy: An Analysis of 8,417 Rotational Atherectomy Cases from the British Cardiovascular Intervention Society Database.

J Interv Cardiol 2022 15;2022:5879187. Epub 2022 Mar 15.

Department of Cardiology, University Hospital of Wales, Cardiff, UK.

Introduction: There is increasing evidence supporting the use of intracoronary imaging to optimize the outcomes of percutaneous coronary intervention (PCI). However, there are no studies examining the impact of imaging on PCI outcomes in cases utilising rotational atherectomy (RA-PCI). Our study examines the determinants and outcomes of using intracoronary imaging in RA-PCI cases including 12-month mortality.

Methods: Using the British Cardiac Intervention Society database, data were analysed on all RA-PCI procedures in the UK between 2007 and 2014. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural, and outcome associations with intravascular imaging.

Results: Intracoronary imaging was used in 1,279 out of 8,417 RA-PCI cases (15.2%). Baseline covariates associated with significantly more imaging use were number of stents used, smoking history, previous CABG, pressure wire use, proximal LAD disease, laser use, glycoprotein inhibitor use, cutting balloons, number of restenosis attempted, off-site surgery, and unprotected left main stem (uLMS) PCI. Adjusted rates of in-hospital major adverse cardiac/cerebrovascular events (IH-MACCE), its individual components (death, peri-procedural MI, stroke, and major bleed), or 12-month mortality were not significantly altered by the use of imaging in RA-PCI. However, subgroup analysis demonstrated a signal towards reduction in 12-month mortality in uLMS RA-PCI cases utilising intracoronary imaging (OR 0.67, 95% CI 0.44-1.03).

Conclusions: Intracoronary imaging use during RA-PCI is associated with higher risk of baseline and procedural characteristics. There were no differences observed in IH-MACCE or 12-month mortality with intracoronary imaging in RA-PCI.
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http://dx.doi.org/10.1155/2022/5879187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8941577PMC
April 2022

A Longitudinal Study of Mitral Regurgitation Detected after Acute Myocardial Infarction.

J Clin Med 2022 Feb 13;11(4). Epub 2022 Feb 13.

Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.

Background: Mitral regurgitation (MR) is common following myocardial infarction (MI). However, the subsequent trajectory of MR, and its impact on long-term outcomes are not well understood. This study aimed to examine the change in MR severity and associated clinical outcomes following MI.

Methods: Records of patients admitted to a single centre between 2016 and 2017 with acute MI treated by percutaneous coronary intervention (PCI) were retrospectively examined.

Results: 294/1000 consecutive patients had MR on baseline (pre-discharge) transthoracic echocardiography (TTE), of whom 126 (mean age: 70.9 ± 11.4 years) had at least one follow-up TTE. At baseline, most patients had mild MR ( = 94; 75%), with = 30 (24%) moderate and = 2 (2%) severe MR. Significant improvement in MR was observed at the first follow-up TTE (median 9 months from baseline; interquartile range: 3-23), with 36% having reduced severity, compared to 10% having increased MR severity ( < 0.001). Predictors of worsening MR included older age (mean: 75.2 vs. 66.7 years; = 0.003) and lower creatinine clearance (mean: 60 vs. 81 mL/min, = 0.015). Change in MR severity was significantly associated with prognosis: 16% with improving MR reached the composite endpoint of death or heart failure hospitalisation at 5 years, versus 44% ( = 0.004) with no change, and 59% ( < 0.001) with worsening MR.

Conclusions: Of patients with follow-up TTE after MI, MR severity improved from baseline in approximately one-third, was stable in around half, with the remainder having worsening MR. Patients with persistent or worsening MR had worse clinical outcomes than those with improving MR.
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http://dx.doi.org/10.3390/jcm11040965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8880345PMC
February 2022

Same-Day Discharge After Elective Percutaneous Coronary Intervention for Chronic Total Occlusion in the UK.

J Invasive Cardiol 2022 03 28;34(3):E179-E189. Epub 2022 Jan 28.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom.

Objectives: This study examines the safety and feasibility of same-day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) to coronary chronic total occlusions (CTOs) and explores independent associations of clinical and procedural characteristics with SDD.

Background: While the recently published consensus statements recommend SDD following uncomplicated CTO-PCI, there are limited studies to support this approach.

Methods: Data were obtained from the British Cardiovascular Intervention Society (BCIS) registry dataset including 21,330 patients who underwent CTO-PCI electively from 2007 to 2014 in England and Wales. We used multiple logistic regression to evaluate associations with SDD and the BCIS national risk model to examine for safety of SDD.

Results: Although overnight stay remained the standard of care following elective CTO-PCI, SDD practice increased from 21.7% to 44.7%. Women were less likely to have SDD than males. SDD was more common in higher CTO volume centers (36.3%) than low CTO volume centers (31.6%), and SDD patient profiles grew riskier over time, with the average age of SDD patients increasing from 61.4 years to 63.2 years. Transradial PCI was most strongly independently associated with SDD (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.80-2.09). Finally, the SDD observed 30-day mortality rates were not different vs those predicted by the BCIS risk model, and SDD was not independently associated with 30-day mortality (OR, 0.54; 95% CI, 0.25-1.15).

Conclusion: This study illustrates that SDD is safe in selected patients undergoing CTO-PCI.
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March 2022

Risk of infective endocarditis after surgical and transcatheter aortic valve replacement.

Heart 2022 04 20;108(8):639-647. Epub 2022 Jan 20.

Department of Cardiology, St Thomas' Hospital, London, UK

Objective: To define the incidence and risk factors for infective endocarditis (IE) following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).

Methods: All patients who underwent first SAVR or TAVI in England between 2007 and 2016 were identified from the NICOR databases. Hospital admissions with a primary diagnosis of IE were identified by linkage with the NHS Hospital Episode Statistics database. Approval was obtained from the NHS Research Ethics Committee.

Results: 2057 of 91 962 patients undergoing SAVR developed IE over a median follow-up of 53.9 months-an overall incidence of 4.81 [95% CI 4.61 to 5.03] per 1000 person-years. Correspondingly, 140 of 14 195 patients undergoing TAVI developed IE over a median follow-up of 24.5 months-an overall incidence of 3.57 [95% CI 3.00 to 4.21] per 1000 person-years. The cumulative incidence of IE at 60 months was higher after SAVR than after TAVI (2.4% [95% CI 2.3 to 2.5] vs 1.5% [95% CI 1.3 to 1.8], HR 1.60, p<0.001). Across the entire cohort, SAVR remained an independent predictor of IE after multivariable adjustment. Risk factors for IE included younger age, male sex, atrial fibrillation, and dialysis.

Conclusions: IE is a rare complication of SAVR and TAVI. In our population, the incidence of IE was higher after SAVR than after TAVI.
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http://dx.doi.org/10.1136/heartjnl-2021-320080DOI Listing
April 2022

Sex differences in high-risk but indicated coronary interventions (CHiP): National report from British Cardiovascular Intervention Society Registry.

Catheter Cardiovasc Interv 2022 02 18;99(2):447-456. Epub 2022 Jan 18.

Research Department, Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, North Midlands, UK.

Objective: To assess sex-based differences in clinical outcomes following complex and high-risk but indicated percutaneous coronary intervention (CHiP).

Background: CHiP is increasingly common in contemporary percutaneous coronary intervention (PCI) practice. Data on sex differences in the type of CHiP procedures undertaken or their associated clinical outcomes are limited.

Methods: Patients with stable coronary artery disease who underwent CHiP between January 1, 2006, and December 31, 2017, were included. All procedures were stratified by sex. Multivariate logistic regression analyses were performed to investigate the sex-specific adjusted odds ratios (aOR) of in-hospital outcomes.

Results: Out of 424,290 PCI procedures, 141,610 (33.37%) were CHiP procedures. Overall, 32,129 (23%) of CHiP were undertaken in females. Females were older than males (median: 74.8 vs. 69.1 years). Males had a higher prevalence of previous myocardial infarction (MI) (44.6% vs. 35.6%) and previous PCI (40% vs. 32.5%). The most common variable observed in female patients undergoing CHiP was age >80 (35.4%), followed by prior coronary artery bypass graft (CABG) (24.3%) and severe coronary calcification (22.6%). In contrast, the most common variable in male patients was prior CABG (36%), followed by chronic thrombus occlusion (CTO) PCI (34.4%) and severe coronary calcification (22%). Females had higher odds (aOR) for mortality (aOR: 1.78, 95% CI: [1.4, 2.2]), bleeding (aOR: 1.99, 95% CI: [1.72, 3.2]), and major adverse cardiovascular and cerebral events (aOR: 1.23, 95% CI: [1.09, 1.38]) compared to males.

Conclusion: In this national analysis of CHiP procedures over 12 years, there were significant sex differences in the type of CHiP procedures undertaken, with females at increased odds for mortality and in-hospital adverse outcomes.
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http://dx.doi.org/10.1002/ccd.30081DOI Listing
February 2022

Defining Percutaneous Coronary Intervention Complexity and Risk: An Analysis of the United Kingdom BCIS Database 2006-2016.

JACC Cardiovasc Interv 2022 01;15(1):39-49

Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom; Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, United Kingdom. Electronic address:

Objectives: The authors used the BCIS (British Cardiovascular Intervention Society) database to define the factors associated with percutaneous coronary intervention (PCI) procedural complexity.

Background: Complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly defined.

Methods: The BCIS (British Cardiovascular Intervention Society) database was used to study all PCI procedures in the United Kingdom 2006-2016. A multiple logistic regression model was developed to identify variables associated with in-hospital major adverse cardiac or cerebrovascular events (MACCE) and to construct a CHIP score. The cumulative effect of this score on patient outcomes was examined.

Results: A total of 313,054 patients were included. Seven patient factors (age ≥80 years, female sex, previous stroke, previous myocardial infarction, peripheral vascular disease, ejection fraction <30%, and chronic renal disease) and 6 procedural factors (rotational atherectomy, left main PCI, 3-vessel PCI, dual arterial access, left ventricular mechanical support, and total lesion length >60 mm) were associated with increased in-hospital MACCE and defined as CHIP factors. The mean CHIP score/case for all PCIs increased significantly from 1.06 ± 1.32 in 2006 to 1.49 ± 1.58 in 2016 (P < 0.001 for trend). A CHIP score of 5 or more was present in 2.5% of procedures in 2006 increasing to 5.3% in 2016 (P < 0.001 for trend). Overall in-hospital MACCE was 0.6% when the CHIP score was 0 compared with 1.2% with any CHIP factor present (P < 0.001). As the CHIP score increased, an exponential increase in-hospital MACCE was observed. The cumulative MACCE for procedures associated with a CHIP score 4+ or above was 3.2%, and for a CHIP score 5+ was 4.4%. All other adverse clinical outcomes were more likely as the CHIP score increased.

Conclusions: Seven patient factors and 6 procedural factors were associated with adverse in-hospital MACCE and defined as CHIP factors. Use of a CHIP score might be a future target for risk modification.
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http://dx.doi.org/10.1016/j.jcin.2021.09.039DOI Listing
January 2022

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion by treated segment length.

Catheter Cardiovasc Interv 2022 02 19;99(2):234-244. Epub 2021 Nov 19.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK.

Background: Long lesions are known to have worse outcomes following percutaneous coronary intervention (PCI), but there are limited data assessing the association between lesion length and clinical outcomes in PCI procedures undertaken in chronic total occlusions (CTO).

Methods And Results: We formed a longitudinal cohort (2006-2018, n = 27,205) of stable angina patients who underwent PCI to CTO in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographical, procedural, and outcome data were analyzed in three groups by treated segment length, < 30 mm (n = 11,782), 30-59 mm (n = 10,415), ≥ 60 mm (n = 5008). Prevalence of previous myocardial infarction and PCI were higher in patients in 30-59 mm group or ≥ 60 mm group compared with < 30 mm group. Following multivariable analysis, no significant difference was observed in in-patient death (OR = 30-59 mm group = 1.10, CI:0.55-2.19, p = 0.78) (OR ≥ 60 mm group = 0.82, CI: 0.33-2.05, p = 0.67), and 1-year death (OR = 30-59 mm group = 1.06, CI: 0.81-1.37, p = 0.69) (OR ≥ 60 mm group =1.01, CI: 0.70-1.43, p = 0.99) (< 30 mm group = reference) but in-patient MACE was higher in > = 60 mm group (OR: 1.52, CI: 1.15-2.01, p = 0.06) but similar in 30-59 mm group (OR: 1.16, CI: 0.91-1.48, p = 0.22) compared with < 30 mm group. The adjusted rates of procedural complications were higher in ≥ 60 mm group (OR: 1.61, CI: 1.40-1.85, p < 0.001) but were similar in 30-59 mm group (OR: 1.06, CI: 0.94-1.20, p < 0.31) compared with < 30 mm group. For every 10 mm increase, there was an increased adjusted risk of in-patient procedural complications and coronary perforation but not in-patient MACE or death.

Conclusion: Patients with very long CTO lesions have higher risk of procedural complications and in-patient MACE but similar risk of short or long-term mortality compared with short CTO lesions.
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http://dx.doi.org/10.1002/ccd.30015DOI Listing
February 2022

The characteristics of mitral regurgitation: Data from patients admitted following acute myocardial infarction.

Data Brief 2021 Dec 12;39:107451. Epub 2021 Oct 12.

Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.

Data were collected on patients admitted to the Queen Elizabeth Hospital Birmingham with type-1 myocardial infarction during 2016 and 2017 inclusively, who were treated by percutaneous intervention and had pre-discharge transthoracic echocardiography. The data were obtained from prospectively maintained hospital databases and records. Echocardiography was performed and reported contemporaneously by accredited echocardiographers. The purpose was to understand the prevalence and characteristics of mitral regurgitation (MR) after acute MI, including patients with ST-elevation (STEMI) and non-ST elevation MI (NSTEMI). MR was observed in 294/1000 patients with the following relative severities: mild = 76%, moderate = 21%, severe = 3% [1]. MR was graded by multiparametric quantification including proximal isolvelocity surface area (PISA), vena contracta (VC), effective regurgitant orifice area (EROA) and regurgitant volume (RVol). Amongst all patients with MR (n=294), PISA was performed in 89/294 (30%), VC 75/294 (26%), EROA in 53/294 (18%) and RVol in 26/294 (9%). Amongst patients with moderate or severe MR (n=70), PISA was performed in 57/70 (81%), VC in 55/70 (79%), EROA in 46/70 (66%) and RVol in 25/70 (36%). Characteristics of MR following acute MI were also assessed including frequency of reported leaflet thickness (259/294 = 88%) and mitral annular calcification (102/294 = 35%). Furthermore, the effect of MI on pre-existing MR was investigated and patients with pre-existing MR who continue to have MR after acute MI were found to have progression of MR by one grade in approximately 25% of cases. Finally, using Cox proportional hazards univariate analysis, significant factors associated with mortality in patients with MR post-MI include age (HR 1.065; 95% CI 1.035-1.096; p<0.001), creatinine clearance, (HR 0.981; 95% CI 0.971-0.991; p<0.001), left ventricular ejection fraction (LVEF) (HR 0.966; 95% CI 0.948-0.984; p<0.001), indexed left ventricular end-diastolic volume (LVEDVi) (HR 1.016; 95% CI 1.003-1.029; p=0.018), indexed left ventricular end-systolic volume (LVESVi) (HR 1.021; 95% CI 1.008-1.034; p=0.001), indexed left atrial volume (HR 1.026; 95% CI 1.012-1.039; p<0.001), and those with intermediate likelihood of pulmonary hypertension (pHTN) (HR 2.223; 95% CI 1.126-4.390; p=0.021); or high likelihood of pHTN (HR 5.626; 95% CI 2.189-14.461; p<0.001). Age and LVEF were found to be independent predictors of mortality on multivariate analysis [1].
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http://dx.doi.org/10.1016/j.dib.2021.107451DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8526959PMC
December 2021

Retrieval of Entrapped Catheter-Mounted Axial Flow Pump From Mitral Subvalvular Apparatus Using a Snare Catheter.

JACC Case Rep 2021 Oct 6;3(13):1494-1498. Epub 2021 Oct 6.

Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.

Axial-flow ventricular assist devices are being increasingly used to support hemodynamically compromised patients undergoing percutaneous coronary intervention. Periprocedural valvular complications have been recognized in a few case reports. We present a unique case of entanglement of the Impella within he mitral subvalvular apparatus, retrieved successfully using a snare under fluoroscopic guidance. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.06.041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511436PMC
October 2021

Procedural Mortality With Transcatheter Aortic Valve Replacement - Balloon Inflation is Associated With Increased Risk.

J Invasive Cardiol 2021 Oct 8;33(10):E761-E768. Epub 2021 Sep 8.

Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, BN2 5BE Brighton, United Kingdom.

Objectives: To assess the impact of balloon use for predilation, valve implantation, or postdilation on in-hospital mortality among patients undergoing transcatheter aortic valve replacement (TAVR).

Background: TAVR utilizes self-expanding, mechanically expanding, or balloon-expandable valves. Balloon inflation is inherent to deployment of balloon-expandable valves. Balloons may additionally be used with all valve types for pre- and postdilation. The relationships between valve mechanism, balloon use, and in-hospital mortality are not fully characterized.

Methods: Prospective data were collected on 4063 patients undergoing TAVR for aortic stenosis at 4 high-volume centers in the United Kingdom. In-hospital mortality was analyzed according to valve expansion mechanism, use of balloons for pre- and postdilation, and specific cause of death.

Results: Mean patient age was 83 ± 8 years. Implanted valves were self expanding (n = 2241; 55%), mechanically expanding (n = 1092; 27%), or balloon expandable (n = 727; 18%). In-hospital death occurred in 66 cases (1.6%). Thirty-six deaths (54.5%) were classified as implantation-related mortalities, with rates of 0.8%, 0.5%, and 1.7% (P=.04) among self-expanding, mechanically expanding, and balloon-expandable technologies, respectively. Patients who underwent balloon inflation at any stage of their procedure (n = 2556; 63%) had significantly higher implantation-related mortality than those who did not (1.3% vs 0.3%, respectively; P<.01). Balloon-expandable valve procedures were associated with significantly higher all-cause mortality (2.6% vs 1.4%; P=.02) and implantation-related mortality (1.7% vs 0.7%; P=.02) than non-balloon-expandable valve procedures. Balloon-related complications accounted for 18 cases (26%) of total in-hospital mortality, including all 12 cases (17.4%) of annular rupture and 5 cases (7.2%) of coronary occlusion.

Conclusions: Balloon use for predilation, valve implantation, or postdilation was associated with an increased mortality risk. Balloon-related complications were the largest contributor to in-hospital mortality, comprising all cases of annular rupture and the majority of coronary occlusion cases.
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October 2021

Mitral Regurgitation Following Acute Myocardial Infarction Treated by Percutaneous Coronary Intervention-Prevalence, Risk factors, and Predictors of Outcome.

Am J Cardiol 2021 10 18;157:22-32. Epub 2021 Aug 18.

Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, University Hospitals Birmingham, Birmingham, United Kingdom. Electronic address:

Mitral regurgitation (MR) following acute myocardial infarction (AMI) worsens prognosis and reports of prevalence vary significantly. The objective was to determine prevalence, risk factors, and outcomes related to MR following AMI. We identified 1000 consecutive patients admitted with AMI in 2016/17 treated by percutaneous coronary intervention with pre-discharge transthoracic echocardiography. MR was observed in 294 of 1000 (29%), graded as mild (n = 224 [76%]), moderate (n = 61 [21%]) and severe (n = 9 [3%]). Compared with patients without MR, patients with MR were older (70 ± 12 vs 63 ± 13 years; p <0.001), with worse left ventricular ejection fraction (LVEF) (52 ± 15% vs 55 ± 11%; p <0.001) and creatinine clearance (69 ± 33 ml/min vs 90 ± 39 ml/min; p <0.001). They also had higher rates of hypertension (64% vs 55%; p = 0.012), heart failure (3.4% vs 1.1%; p = 0.014), previous MI (28% vs 20%; p = 0.005) and severe flow-limitation in the circumflex (50% vs 33%; p <0.001) or right coronary artery (51% vs 42%; p = 0.014). Prevalence and severity of MR were unaffected by AMI subtype. Revascularization later than 72 hours from symptom-onset was associated with increased likelihood of MR (33% vs 25%; p = 0.036) in patients with non-ST elevation myocardial infarction (NSTEMI). After a mean of 3.2 years, 56 of 288 (19%) patients with untreated MR died. Age and LVEF independently predicted mortality. The presence of even mild MR was associated with increased mortality (p = 0.029), despite accounting for confounders. In conclusion, MR is observed in over one-quarter of patients after AMI and associated with lower survival, even when mild. Prevalence and severity are independent of MI subtype, but MR was more common with delayed revascularization following NSTEMI.
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http://dx.doi.org/10.1016/j.amjcard.2021.07.029DOI Listing
October 2021

Impact of SARS-CoV-2 positivity on clinical outcome among STEMI patients undergoing mechanical reperfusion: Insights from the ISACS STEMI COVID 19 registry.

Atherosclerosis 2021 09 21;332:48-54. Epub 2021 Jul 21.

Division of Cardiology, Ospedale "Sant'Anna", Ferrara, Italy.

Background And Aims: SARS-Cov-2 predisposes patients to thrombotic complications, due to excessive inflammation, endothelial dysfunction, platelet activation, and coagulation/fibrinolysis disturbances. The aim of the present study was to evaluate clinical characteristics and prognostic impact of SARS-CoV-2 positivity among STEMI patients undergoing primary percutaneous coronary intervention (PPCI).

Methods: We selected SARS-CoV-2 positive patients included in the ISACS-STEMI COVID-19, a retrospective multicenter European registry including 6609 STEMI patients treated with PPCI from March 1st until April 30th, in 2019 and 2020. As a reference group, we randomly sampled 5 SARS-Cov-2 negative patients per each SARS-CoV-2 positive patient, individually matched for age, sex, and hospital/geographic area. Study endpoints were in-hospital mortality, definite stent thrombosis, heart failure.

Results: Our population is represented by 62 positive SARS-CoV-2 positive patients who were compared with a matched population of 310 STEMI patients. No significant difference was observed in baseline characteristics or the modality of access to the PCI center. In the SARS-CoV-2 positive patients, the culprit lesion was more often located in the RCA (p < 0.001). Despite similar pre and postprocedural TIMI flow, we observed a trend in higher use of GP IIb-IIIa inhibitors and a significantly higher use of thrombectomy in the SARS-CoV-2 positive patients. SARS-CoV-2 positivity was associated with a remarkably higher in hospital mortality (29% vs 5.5%, p < 0.001), definite in-stent thrombosis (8.1% vs 1.6%, p = 0.004) and heart failure (22.6% vs 10.6%, p = 0.001) that was confirmed after adjustment for confounding factors.

Conclusions: Our study showed that among STEMI patients, SARS-CoV-2 positivity is associated with larger thrombus burden, a remarkably higher mortality but also higher rates of in-stent thrombosis and heart failure.
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http://dx.doi.org/10.1016/j.atherosclerosis.2021.06.926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294603PMC
September 2021

Reperfusion therapies and in-hospital outcomes for ST-elevation myocardial infarction in Europe: the ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology.

Eur Heart J 2021 11;42(44):4536-4549

Spitalul Clinic de Urgenta "Floreasca", Calea Floreasca 8, București 014461, Romania.

Aims: The aim of this study was to determine the contemporary use of reperfusion therapy in the European Society of Cardiology (ESC) member and affiliated countries and adherence to ESC clinical practice guidelines in patients with ST-elevation myocardial infarction (STEMI).

Methods And Results: Prospective cohort (EURObservational Research Programme STEMI Registry) of hospitalized STEMI patients with symptom onset <24 h in 196 centres across 29 countries. A total of 11 462 patients were enrolled, for whom primary percutaneous coronary intervention (PCI) (total cohort frequency: 72.2%, country frequency range 0-100%), fibrinolysis (18.8%; 0-100%), and no reperfusion therapy (9.0%; 0-75%) were performed. Corresponding in-hospital mortality rates from any cause were 3.1%, 4.4%, and 14.1% and overall mortality was 4.4% (country range 2.5-5.9%). Achievement of quality indicators for reperfusion was reported for 92.7% (region range 84.8-97.5%) for the performance of reperfusion therapy of all patients with STEMI <12 h and 54.4% (region range 37.1-70.1%) for timely reperfusion.

Conclusions: The use of reperfusion therapy for STEMI in the ESC member and affiliated countries was high. Primary PCI was the most frequently used treatment and associated total in-hospital mortality was below 5%. However, there was geographic variation in the use of primary PCI, which was associated with differences in in-hospital mortality.
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http://dx.doi.org/10.1093/eurheartj/ehab342DOI Listing
November 2021

Operator Volumes and In-Hospital Outcomes: An Analysis of 7,740 Rotational Atherectomy Procedures From the BCIS National Database.

JACC Cardiovasc Interv 2021 07 16;14(13):1423-1430. Epub 2021 Jun 16.

Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, United Kingdom; Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom.

Objectives: The aims of this study were to use a national percutaneous coronary intervention (PCI) registry to study temporal changes in procedure volumes of PCI using rotational atherectomy (ROTA-PCI), the patient and procedural factors associated with differing quartiles of operator ROTA-PCI volume, and the relationship between operator ROTA-PCI volumes and in-hospital patient outcomes.

Background: Whether higher operator volume is associated with improved outcomes after ROTA-PCI is poorly defined.

Methods: Data from the British Cardiovascular Intervention Society national PCI database were analyzed for all ROTA-PCI procedures performed in the United Kingdom between 2013 and 2016. Individual logistic regressions were performed to quantify the independent association between annual operator ROTA-PCI volume and in-hospital outcomes.

Results: In total, 7,740 ROTA-PCI procedures were performed, with a negatively skewed distribution and an annualized operator volume median of 2.5 procedures/year (range 0.25 to 55.25). Higher volume operators undertook more complex procedures in patients with greater comorbid burdens than lower volume operators. A significant inverse association was observed between operator ROTA-PCI volume and in-hospital mortality (odds ratio [OR]: 0.986/case; 95% confidence interval [CI]: 0.975 to 0.996; p = 0.007) and major adverse cardiac and cerebral events (OR: 0.983/case; 95% CI: 0.975 to 0.993; p < 0.001). Additionally, lower rates of emergency cardiac surgery (OR: 0.964/case; 95% CI: 0.939 to 0.991; p = 0.008), arterial complications (OR: 0.975/case; 95% CI: 0.975 to 0.982; p < 0.001) and in-hospital major bleeding (OR: 0.985/case; 95% CI: 0.977 to 0.993; p < 0.001) were associated with higher ROTA-PCI operator volume. Sensitivity analyses in several subgroups demonstrated a consistency of improved outcomes as annual ROTA-PCI volume increased. An annual volume of <4 ROTA-PCI procedures/year was observed to be associated with increased major adverse cardiac and cerebral events, with 239 of 432 operators (55%) not exceeding this threshold.

Conclusions: In-hospital adverse outcomes occurred less frequently as ROTA-PCI operator volume increased. These data suggest that operator volume is an important factor determining outcome after ROTA-PCI.
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http://dx.doi.org/10.1016/j.jcin.2021.04.034DOI Listing
July 2021

International Prospective Registry of Acute Coronary Syndromes in Patients With COVID-19.

J Am Coll Cardiol 2021 05;77(20):2466-2476

Cardiovascular Department, Manzoni Hospital, Lecco, Italy.

Background: Published data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear.

Objectives: The purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre-COVID-19 cohorts.

Methods: From March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re-myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre-COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019).

Results: In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p < 0.001; COVID NSTE-ACS vs. MINAP: 417.0 min vs. 295.0 min; p = 0.012). Mortality in COVID-ACS patients was significantly higher than BCIS/MINAP control subjects in both subgroups (COVID-STEMI: 22.9% vs. 5.7%; p < 0.001; COVID NSTE-ACS: 6.6% vs. 1.2%; p < 0.001), which remained following multivariate propensity analysis adjusting for comorbidities (STEMI subgroup odds ratio: 3.33 [95% confidence interval: 2.04 to 5.42]). Cardiogenic shock occurred in 20.1% of COVID-STEMI patients versus 8.7% of BCIS patients (p < 0.001).

Conclusions: In this multicenter international registry, COVID-19-positive ACS patients presented later and had increased in-hospital mortality compared with a pre-COVID-19 ACS population. Excessive rates of and mortality from cardiogenic shock were major contributors to the worse outcomes in COVID-19 positive STEMI patients.
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http://dx.doi.org/10.1016/j.jacc.2021.03.309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128002PMC
May 2021

Risks and benefits of percutaneous coronary intervention in spontaneous coronary artery dissection.

Heart 2021 09 18;107(17):1398-1406. Epub 2021 May 18.

Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, Leicestershire, UK

Objective: To investigate percutaneous coronary intervention (PCI) practice in an international cohort of patients with spontaneous coronary artery dissection (SCAD). To explore factors associated with complications and study angiographic and longer term outcomes.

Methods: SCAD patients (n=215, 94% female) who underwent PCI from three national cohort studies were investigated and compared with a matched cohort of conservatively managed SCAD patients (n=221).

Results: SCAD-PCI patients were high risk at presentation with only 8.8% undergoing PCI outside the context of ST-elevation myocardial infarction/cardiac arrest, thrombolysis in myocardial infarction (TIMI) 0/1 flow or proximal dissections. PCI complications occurred in 38.6% (83/215), with 13.0% (28/215) serious complications. PCI-related complications were associated with more extensive dissections (multiple vs single American Heart Association coronary segments, OR 1.9 (95% CI: 1.06-3.39),p=0.030), more proximal dissections (proximal diameter per mm, OR 2.25 (1.38-3.67), p=0.001) and dissections with no contrast penetration of the false lumen (Yip-Saw 2 versus 1, OR 2.89 (1.12-7.43), p=0.028). SCAD-PCI involved long lengths of stent (median 46mm, IQR: 29-61mm). Despite these risks, SCAD-PCI led to angiographic improvements in those with reduced TIMI flow in 84.3% (118/140). Worsening TIMI flow was only seen in 7.0% (15/215) of SCAD-PCI patients. Post-PCI major adverse cardiovascular and cerebrovascular events (MACCE) and left ventricular function outcomes were favourable.

Conclusion: While a conservative approach to revascularisation is favoured, SCAD cases with higher risk presentations may require PCI. SCAD-PCI is associated with longer stent lengths and a higher risk of complications but leads to overall improvements in coronary flow and good medium-term outcomes in patients.
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http://dx.doi.org/10.1136/heartjnl-2020-318914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8372386PMC
September 2021

Indirect Impact of the COVID-19 Pandemic on Activity and Outcomes of Transcatheter and Surgical Treatment of Aortic Stenosis in England.

Circ Cardiovasc Interv 2021 05 18;14(5):e010413. Epub 2021 May 18.

Royal Stoke Hospital, Stoke on Trent and Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, United Kingdom (J.N., L.B., M.A.M.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.010413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126473PMC
May 2021

Outcomes following PCI in CABG candidates during the COVID-19 pandemic: The prospective multicentre UK-ReVasc registry.

Catheter Cardiovasc Interv 2022 02 4;99(2):305-313. Epub 2021 May 4.

Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester, Leicester, UK.

Objectives: To describe outcomes following percutaneous coronary intervention (PCI) in patients who would usually have undergone coronary artery bypass grafting (CABG).

Background: In the United Kingdom, cardiac surgery for coronary artery disease (CAD) was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with "surgical disease" instead underwent PCI.

Methods: Between 1 March 2020 and 31 July 2020, 215 patients with recognized "surgical" CAD who underwent PCI were enrolled in the prospective UK-ReVasc Registry (ReVR). 30-day major cardiovascular event outcomes were collected. Findings in ReVR patients were directly compared to reference PCI and isolated CABG pre-COVID-19 data from British Cardiovascular Intervention Society (BCIS) and National Cardiac Audit Programme (NCAP) databases.

Results: ReVR patients had higher incidence of diabetes (34.4% vs 26.4%, P = .008), multi-vessel disease with left main stem disease (51.4% vs 3.0%, P < .001) and left anterior descending artery involvement (94.8% vs 67.2%, P < .001) compared to BCIS data. SYNTAX Score in ReVR was high (mean 28.0). Increased use of transradial access (93.3% vs 88.6%, P = .03), intracoronary imaging (43.6% vs 14.4%, P < .001) and calcium modification (23.6% vs 3.5%, P < .001) was observed. No difference in in-hospital mortality was demonstrated compared to PCI and CABG data (ReVR 1.4% vs BCIS 0.7%, P = .19; vs NCAP 1.0%, P = .48). Inpatient stay was half compared to CABG (3.0 vs 6.0 days). Low-event rates in ReVR were maintained to 30-day follow-up.

Conclusions: PCI undertaken using contemporary techniques produces excellent short-term results in patients who would be otherwise CABG candidates. Longer-term follow-up is essential to determine whether these outcomes are maintained over time.
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http://dx.doi.org/10.1002/ccd.29702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8239910PMC
February 2022

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion in prior coronary artery bypass grafting patients.

Catheter Cardiovasc Interv 2022 01 4;99(1):74-84. Epub 2021 May 4.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK.

Objective: To compare the clinical characteristics and outcomes in patients with stable angina who have undergone chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in native arteries with or without prior coronary artery bypass grafting (CABG) surgery in a national cohort.

Background: There are limited data on outcomes of patients presenting with stable angina undergoing CTO PCI with previous CABG.

Methods: We identified 20,081 patients with stable angina who underwent CTO PCI between 2007-2014 in the British Cardiovascular Intervention Society database. Clinical, demographical, procedural and outcome data were analyzed in two groups; group 1-CTO PCI in native arteries without prior CABG (n = 16,848), group 2-CTO PCI in native arteries with prior CABG (n = 3,233).

Results: Patients in group 2 were older, had more comorbidities and higher prevalence of severe left ventricular systolic dysfunction. Following multivariable analysis, no significant difference in mortality was observed during index hospital admission (OR:1.33, CI 0.64-2.78, p = .44), at 30-days (OR: 1.28, CI 0.79-2.06, p = .31) and 1 year (OR:1.02, CI 0.87-1.29, p = .87). Odds of in-hospital major adverse cardiovascular events (MACE) (OR:1.01, CI 0.69-1.49, p = .95) and procedural complications (OR:1.02, CI 0.88-1.18, p = .81) were similar between two groups but procedural success rate was lower in group 2 (OR: 0.34, CI 0.31-0.39, p < .001). The adjusted risk of target vessel revascularization (TVR) remained similar between the two groups at 30-days (OR:0.68, CI 0.40-1.16, P-0.16) and at 1 year (OR:1.01, CI 0.83-1.22, P-0.95).

Conclusion: Patients with prior CABG presenting with stable angina and treated with CTO PCI in native arteries had more co-morbid illnesses but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality, MACE or TVR.
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http://dx.doi.org/10.1002/ccd.29691DOI Listing
January 2022
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