BACKGROUND: ST-segment-elevation myocardial infarction (STEMI) is uncommon among inpatients already admitted to the hospital for other indications. Prior studies reported significant differences in clinical characteristi...BACKGROUND: ST-segment-elevation myocardial infarction (STEMI) is uncommon among inpatients already admitted to the hospital for other indications. Prior studies reported significant differences in clinical characteristics and outcomes of patients who develop STEMI while hospitalized versus those who present with out-of-hospital STEMI. However, prior studies were small or not contemporary. METHODS: We compared the characteristics and outcomes of patients presenting with STEMI at the time of hospital admission (preadmission STEMI) versus in-hospital STEMI (occurring during the hospitalization) using data from the National Cardiovascular Data Registry Chest Pain-MI Registry from 2019 to 2022. RESULTS: A total of 112 590 patients (3.8% in-hospital STEMI, 96.2% preadmission STEMI) from 670 hospitals were included. Patients with in-hospital STEMI were significantly older (median age, 67 versus 63 years), more likely to be diabetic (37.6% versus 29.6%) and have congestive heart failure (13.7% versus 6.0%) compared with patients with preadmission STEMI (all <0.001). The median (interquartile range) time from ECG to first device activation (81 minutes [61-110] versus 69 [55-84]; <0.0001) and time from cath laboratory arrival to first device time (28 minutes [21-39] versus 23 [18-30]; <0.001) were significantly longer for patients with in-hospital compared with preadmission STEMI. The incidence of major bleeding (25.5% versus 7.1%), cardiogenic shock (19.7% versus 7.0%), and cardiac arrest (22.3% versus 7.3%) were all significantly higher in the in-hospital STEMI cohort (all <0.001), as was mortality (25.9% versus 5.6%; adjusted odds ratio, 5.7 [95% CI, 5.0-6.4]; <0.001). CONCLUSIONS: Patients who experience in-hospital STEMI represent a high-risk group, with significantly longer times from the diagnostic ECG to primary percutaneous coronary intervention, more complications, and higher mortality.
BACKGROUND: Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (TAVR) field have been obtained from retrospective studies. This prespecified secondary analysis of the LYTEN randomiz...BACKGROUND: Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (TAVR) field have been obtained from retrospective studies. This prespecified secondary analysis of the LYTEN randomized trial (Comparison of the Balloon-Expandable Edwards Valve and Self-Expandable CoreValve Evolut R or Evolut PRO System for the Treatment of Small, Severely Dysfunctional Surgical Aortic Bioprostheses) aims to compare the 3-year hemodynamic performance and clinical outcomes between balloon-expandable valves (BEV) SAPIEN 3/ULTRA (Edwards Lifesciences) and self-expanding valves (SEV) Evolut R/PRO/PRO+ (Medtronic) in valve-in-valve TAVR. METHODS: Patients with a failed small (≤23 mm) surgical valve undergoing valve-in-valve TAVR were randomized to receive a SEV or a BEV. Patients had a clinical and valve hemodynamic (Doppler echocardiography) evaluation at 3-year follow-up. Study outcomes were defined according to VARC (Valve Academic Research Consortium)-2/VARC-3 criteria. Intended performance of the valve was defined as mean gradient <20 mm Hg, peak velocity <3 m/s, Doppler velocity index ≥0.25, and less than moderate aortic regurgitation. RESULTS: Ninety-eight patients underwent TAVR (46 BEV [SAPIEN 3/ULTRA], 52 SEV [Evolut R-PRO-PRO+]). At 3 years, patients receiving a SEV had a higher rate of intended valve performance (BEV: 27.6% versus SEV: 82.4%; <0.001), with lower mean gradients (BEV: 20±9 versus SEV: 13±9 mm Hg; =0.002), and larger indexed effective orifice area (BEV: 0.69±0.27 versus SEV: 0.93±0.32 cm/m; =0.002). The rate of moderate aortic regurgitation was 0% in the BEV group versus 2.9% in the SEV group (=0.582). Functional status and quality of life improved similarly in both groups. No differences were observed in the composite end point of death, stroke, or heart failure-related hospitalization (BEV: 32.6% versus SEV: 25.5%; =0.489). Mortality was also not statistically different between groups (BEV: 23.3% versus SEV: 15.7%; =0.375). No significant differences were observed in other adverse events. CONCLUSIONS: In patients undergoing valve-in-valve TAVR for failed small aortic bioprostheses, SEV demonstrated a superior valve hemodynamic performance at 3-year follow-up, with similar clinical outcomes and functional improvement compared with BEV. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03520101.
Mizukami T, Ikeda K, Munhoz D
… +39 more, Sakai K, Sonck J, Matsuo H, Shinke T, Ando H, Ko B, Biscaglia S, Rivero F, Engstrøm T, Leone AM, van Nunen LX, Fearon WF, Christiansen EH, Fournier S, Desta L, Yong A, Adjedj J, Escaned J, Nakayama M, Eftekhari A, Zimmermann FM, Storozhenko T, Bouisset F, Galante D, da Costa BR, Campo G, Berry C, Collison D, Amano T, Perera D, Jeremias A, Ali ZA, Korngold E, Wyffels E, Wilgenhof A, Pijls N, De Bruyne B, Johnson NP, Collet C
Circ Cardiovasc Interv
· 2026 Mar · PMID 41623057
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BACKGROUND: The pullback pressure gradient (PPG) is a novel physiological metric that quantifies coronary artery disease patterns as focal or diffuse on a scale from 0 to 1. This study assessed the relationship between P...BACKGROUND: The pullback pressure gradient (PPG) is a novel physiological metric that quantifies coronary artery disease patterns as focal or diffuse on a scale from 0 to 1. This study assessed the relationship between PPG and residual angina at 1 year. METHODS: PPG Global is a prospective, investigator-initiated, single-arm, multicenter study that enrolled patients with at least 1 lesion with a fractional flow reserve ≤0.80 intended to be treated with percutaneous coronary intervention. After the PPG calculation, physicians could revise treatment assignment to medical therapy or coronary artery bypass graft surgery instead of percutaneous coronary intervention. Focal and diffuse disease were defined based on the median PPG value of 0.62. Patient-reported outcomes were assessed using the Seattle Angina Questionnaire at baseline and 1-year follow-up. RESULTS: The study included 947 patients with PPG and the Seattle Angina Questionnaire at 1 year. The mean age was 67.6±10.2 years, 24% were female, and 29% had diabetes. At 1 year, patients with focal coronary artery disease reported less angina than those with diffuse disease (Seattle Angina Questionnaire angina frequency score, 95.3±9.9 versus 92.5±15.0; =0.006). PPG was independently associated with improvement in angina (=0.017). CONCLUSIONS: In patients with flow-limiting coronary artery disease, a focal disease pattern defined by high PPG was associated with greater symptomatic relief at 1 year compared with diffuse disease (low PPG). By capturing the underlying pathophysiologic distribution of epicardial disease and its relation to post-treatment symptom relief, PPG may support a more tailored revascularization decision-making and percutaneous coronary intervention strategy.
BACKGROUND: Current clinical guidelines recommend considering both obstructive and nonobstructive causes of myocardial ischemia in patients with chronic coronary syndrome. Wire-based physiological assessment constitutes...BACKGROUND: Current clinical guidelines recommend considering both obstructive and nonobstructive causes of myocardial ischemia in patients with chronic coronary syndrome. Wire-based physiological assessment constitutes a valid approach for this purpose, but it remains underutilized. We evaluated the diagnostic yield and clinical impact of an alternative wire-free approach for this purpose. METHODS: This is a subanalysis of the multicenter, prospective AID-ANGIO study (Advanced Invasive Diagnosis for Patients with Chronic Coronary Syndromes Undergoing Coronary Angiography), evaluating the impact of a wire-free advanced invasive diagnosis (AID) strategy in the diagnostic workflow of patients with chronic coronary syndrome admitted to the catheterization laboratory. The wire-free AID strategy combined quantitative flow ratio for epicardial evaluation, contrast angiography-derived index of coronary microcirculatory resistance for microvascular assessment, and acetylcholine testing for the endothelial-dependent coronary function. RESULTS: The study included 262 patients. The wire-free AID strategy identified a cause of myocardial ischemia in 84.3% of patients, representing a 2-fold increase in the identification of a cause of myocardial ischemia, compared with coronary angiography alone (<0.0001). In addition, the wire-free AID strategy demonstrated substantial agreement compared with the wire-based AID strategy (Cohen κ 0.78). The wire-free AID strategy led to a change in the initial therapeutic plan in 55.3% of patients compared with coronary angiography. Nevertheless, the wire-free AID strategy maintained good concordance with the wire-based AID strategy (16.8% of therapeutic changes). CONCLUSIONS: This study supports the clinical utility of a wire-free AID strategy in patients with chronic coronary syndrome, demonstrating its potential to improve diagnostic yield and guide clinical decision-making compared with coronary angiography alone. In addition, it shows substantial agreement with the wire-based approach.
BACKGROUND: The DynamX bioadaptor, a novel coronary implant, is designed to restore vessel function when the thin polymer coating covering the helical strands resorbs 6 months post-percutaneous coronary intervention. We...BACKGROUND: The DynamX bioadaptor, a novel coronary implant, is designed to restore vessel function when the thin polymer coating covering the helical strands resorbs 6 months post-percutaneous coronary intervention. We aimed to evaluate vessel conformability 1 year after percutaneous coronary intervention with the bioadaptor, compared with conventional drug-eluting stents (DESs). METHODS: Vessel segments were 1:1 randomized to a novolimus-eluting bioadaptor or a durable polymer novolimus-eluting second-generation DES. Coronary computed tomography angiography was performed at 1 and 12 months post-implantation, and the 3-dimensional geometry of the treated segments in coronary computed tomography angiography was analyzed. The primary outcome was the change in dynamic vessel geometry, including curvature flexibility (bending motion), torsion flexibility (twisting motion), and path flexibility (3-dimensional motion) of the treated segment during the cardiac cycle. RESULTS: A total of 48 vessel segments in 48 patients were randomized, with 24 receiving bioadaptor and 24 receiving DES. In within-group paired analyses, the bioadaptor group showed a significant improvement in torsion flexibility from 1 to 12 months, whereas no significant change was observed in the DES group. Although curvature and path flexibility increased numerically in the bioadaptor group, these within-group differences were not statistically significant. However, when comparing the magnitude of change between groups, the increase in path flexibility was significantly greater with the bioadaptor than with DES, indicating a superior restoration of 3-dimensional vessel motion. CONCLUSIONS: The novel bioadaptor technology demonstrated favorable restoration of 3-dimensional dynamic geometry of the treated vessel segment 12 months after implantation, in comparison with traditional DES. These initial mechanistic findings suggest a potential explanation for the favorable clinical outcomes observed in prior trials, and our analytical approach may offer new insights to guide future vascular implant designs and evaluations. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04936191.
Trimaille A, Garot P, Toupin S
… +24 more, Sanguineti F, Hovasse T, Duhamel S, Champagne S, Unterseeh T, Akodad M, Neylon A, Hamzi L, Gonçalves T, Afana AS, Unger A, Florence J, Gall E, Martial PJ, Pfeffer A, Canuti ES, Kante A, Singh M, Dillinger JG, Henry P, Morel O, Bousson V, Garot J, Pezel T
BACKGROUND: Identifying patients with chronic coronary syndrome who will benefit most from a coronary revascularization strategy is essential. Data on the performance of stress cardiac magnetic resonance (CMR) to guide r...BACKGROUND: Identifying patients with chronic coronary syndrome who will benefit most from a coronary revascularization strategy is essential. Data on the performance of stress cardiac magnetic resonance (CMR) to guide revascularization are limited. To assess the long-term prognostic impact of stress CMR-guided revascularization strategy to predict all-cause death. METHODS: We conducted an observational study including all consecutive patients who underwent stress CMR for suspected or known chronic coronary syndrome in 3 centers in France. CMR-guided coronary revascularization was defined as any revascularization performed within 90 days following stress CMR. The primary outcome was all-cause death. RESULTS: A total of 50 701 patients were included (mean age, 64±12 years; 68.5% men). After a median follow-up of 7.2 years (interquartile range, 3.0-11.0), 3665 (7.2%) patients died. Among the 7396 patients with ischemia, 6523 (88%) underwent revascularization. Ischemia and late gadolinium enhancement (LGE) without viability were independent predictors of death (adjusted hazard ratio, 3.67 [99.5% CI, 3.15-4.27] and adjusted hazard ratio, 1.26 [99.5% CI, 1.10-1.44], respectively; <0.001 for both). CMR-guided revascularization was an independent predictor of improved survival in the overall population (adjusted hazard ratio, 0.30 [99.5% CI, 0.25-0.36]). In a 1:1 propensity-matched cohort of 1700 patients, CMR-guided revascularization remained independently associated with a lower incidence of death (adjusted hazard ratio, 0.37 [99.5% CI, 0.28-0.50]; <0.001). This beneficial effect was observed in patients without LGE or with LGE and viability (<0.001 for both), but not in those with LGE without viability (=0.23). CONCLUSIONS: In this registry of consecutive patients with chronic coronary syndrome from 3 centers, stress CMR-guided revascularization was associated with a lower rate of death. The combined assessment of inducible myocardial ischemia and LGE may help to select patients most suitable for revascularization.
Ricciardi MJ, Singh G, Rogers JH
… +17 more, Ruf T, Rottbauer W, Horn P, Mahoney P, Chehab B, Asch FM, Zamorano J, Price MJ, Morse MAM, Rinaldi MJ, Denti P, Dong M, Huang R, Maisano F, von Bardeleben RS, Rodriguez E, Kar S
Circ Cardiovasc Interv
· 2026 Feb · PMID 41562136
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BACKGROUND: Atrial secondary mitral regurgitation (aSMR) is a distinct subtype of SMR characterized by normal leaflets, annular dilatation, left atrial (LA) enlargement, and preserved left ventricular function. Treatment...BACKGROUND: Atrial secondary mitral regurgitation (aSMR) is a distinct subtype of SMR characterized by normal leaflets, annular dilatation, left atrial (LA) enlargement, and preserved left ventricular function. Treatment pathways for aSMR are undefined, and limited data exist regarding outcomes following mitral transcatheter edge-to-edge repair (MTEER). The analysis aimed to evaluate outcomes in patients with aSMR treated with MTEER from the EXPANDed (Evaluation of the MitraClip X System Post-MArket Real-World CliNical Outcomes Database ) studies. METHODS: One-year outcomes were assessed in patients from the EXPANDed studies (EXPAND and EXPAND G4 [Evaluation of the MitraClip X System Post-MArket Real-World CliNical Outcomes Database Generation 4 ]) who met criteria for aSMR. aSMR was defined by the presence of atrial fibrillation, left ventricular ejection fraction ≥45%, and at least 1 dilated LA parameter per echocardiographic core laboratory assessment: LA volume index, LA diameter, or LA diameter index. RESULTS: Of the 967 patients with SMR treated with MTEER in the EXPANDed data set, 160 (17%) met criteria for aSMR. Patients with aSMR were elderly (78±8 years), symptomatic (Kansas City Cardiomyopathy Questionnaire Overall Summary score, 48±27 pts), and had small left ventricular and large LA dimensions at baseline. Acute procedural success was achieved in 97.5% of patients with aSMR, with MR reduction to ≤1+ in 95.2% at 1 year. There were significant 1-year improvements in quality of life (+19 pt Kansas City Cardiomyopathy Questionnaire Overall Summary) and functional capacity (New York Heart Association I/II 80%). The 1-year all-cause mortality rate was 9%, with patients experiencing a 56% reduction in 1-year heart failure hospitalization rates from pre- to post-MTEER. CONCLUSIONS: In the largest population of patients with aSMR assessed by an echocardiographic core laboratory, MTEER safely and significantly reduced MR with improvements in quality of life and reduction in heart failure hospitalization through 1 year.
BACKGROUND: Transcatheter edge-to-edge repair is an established treatment for tricuspid regurgitation (TR) in nonoptimal surgical candidates. Two techniques have been described: zipping (or bicuspidization) and clover (o...BACKGROUND: Transcatheter edge-to-edge repair is an established treatment for tricuspid regurgitation (TR) in nonoptimal surgical candidates. Two techniques have been described: zipping (or bicuspidization) and clover (or triple-orifice). This study aimed to compare the echocardiographic and clinical outcomes of these 2 techniques. METHODS: This multicenter registry included 288 patients undergoing tricuspid transcatheter edge-to-edge repair from June 2020 to December 2024. Patients were categorized into 2 groups (zipping and clover repairs). The primary study end point was the TR reduction at follow-up. The secondary end point was the composite of all-cause mortality and heart failure hospitalization at follow-up. RESULTS: The median age was 77 years (interquartile range, 73-82), with 203 females (70.5%) and a median TRISCORE of 4.1±1.8. Of these, 197 patients (68.4%) underwent zipping repair, while 91 (31.6%) received the clover repair technique. The median follow-up duration was 11.6 months (interquartile range, 4.5-21.2). Patients treated with the clover technique experienced lower rates of residual TR ≤2+ (76% versus 89%, =0.006) and higher single-leaflet device attachment in the follow-up, attributed to a higher prevalence of complex tricuspid valve anatomy. Similar rates of the composite end point were observed among the groups without differences in New York Heart Association functional class (=0.835) and TR reintervention at 1-year (=0.196). CONCLUSIONS: Residual TR was more common in patients treated with the clover technique, owing to the higher prevalence of complex tricuspid valve anatomy. Clinical outcomes were similar between the zipping and clover techniques. Both approaches represent viable and effective treatment options for managing TR.
BACKGROUND: The prognostic implications of bolus thermodilution-derived resting coronary blood flow in all-comer patients with chronic coronary syndrome are not known. We investigated the association of thermodilution-de...BACKGROUND: The prognostic implications of bolus thermodilution-derived resting coronary blood flow in all-comer patients with chronic coronary syndrome are not known. We investigated the association of thermodilution-derived indices characterizing coronary flow with outcomes. METHODS: Patients with chronic coronary syndrome with and without obstructive coronary artery disease were included before undergoing coronary angiography in this prospective observational study. Measurements of the index of microcirculatory resistance, baseline resistance index, resting coronary blood flow (CBF), and hyperemic CBF were obtained with thermodilution in the left anterior descending coronary artery. Cox-regression analyses adjusted for age, sex, number of diseased vessels, and estimated creatinine clearance, as well as Kaplan-Meier plots, were used to evaluate the relation between flow indices and the primary composite outcome of all-cause mortality, nonfatal myocardial infarction, or heart failure hospitalization. RESULTS: Analyses included 410 patients with 55 events. Median follow-up was 5.4 years. Resting CBF was independently associated with the primary outcome (hazard ratio, 1.23 [95% CI 1.02-1.48]). Resting CBF was associated with the primary outcome in patients undergoing revascularization (hazard ratio, 1.30 [95% CI 1.04-1.64]) but not in patients not undergoing revascularization (hazard ratio, 1.15 [95% 0.82-1.60]; interaction=0.771). Neither the index of microcirculatory resistance nor hyperemic CBF were associated with outcomes. Functional coronary microvascular dysfunction was associated with a higher incidence of death and nonfatal myocardial infarction versus no coronary microvascular dysfunction (log-rank =0.041), whereas structural coronary microvascular dysfunction was not. CONCLUSIONS: Elevated resting CBF in the left anterior descending coronary artery was associated with major adverse cardiovascular events in chronic coronary syndrome, whereas hyperemic microcirculatory resistance and flow were not. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT06306066.
BACKGROUND: Microaxial flow pump (mAFP) use in selected patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock improves survival. The present study aimed to assess the influence of dela...BACKGROUND: Microaxial flow pump (mAFP) use in selected patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock improves survival. The present study aimed to assess the influence of delay from first symptoms to randomization on the benefit of an mAFP in patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock. METHODS: This was a secondary analysis of the international, multicenter, randomized, open-labeled DanGer Shock trial (Danish-German Cardiogenic Shock). A total of 345 of 355 patients with ST-segment-elevation myocardial infarction and cardiogenic shock were enrolled in this substudy. Patients were stratified into quartiles according to delay from first symptoms to randomization to either an mAFP or standard care alone. The end point was death from any cause at 180 days for treatment with an mAFP versus standard of care, according to time from onset of symptoms to randomization obtained by logistic regression analysis. RESULTS: Mortality at 180 days increased across quartiles of time from onset of symptoms to randomization: Q1 (0-140 minutes), 36%; Q2 (141-248 minutes), 53%; Q3 (249-650 minutes), 59%; and Q4 (> 651 minutes), 62%, respectively (log-rank =0.002). However, those with longer delays were also older and more often women. Median age rose from 66 years (interquartile range, 57-73) in the earliest quartile to 71 years (interquartile range, 62-79) in the latest quartile (=0.005), and the proportion of women increased from 15% to 34%, respectively. Combining the 3 lowest quartiles for the time from onset of symptoms to randomization, the mAFP treatment was associated with an odds ratio of 0.51 (95% CI, 0.31-0.84), whereas the odds ratio for the highest quartile was 0.92 (95% CI, 0.38-2.22; for interaction = 0.26). CONCLUSIONS: In patients with ST-segment-elevation myocardial infarction complicated with cardiogenic shock, treatment with an mAFP was associated with reduced all-cause mortality, but the treatment benefit appeared to weaken with prolonged time from the onset of symptoms to randomization. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT01633502.
BACKGROUND: Racial and ethnic disparities exist in postacute myocardial infarction (AMI) care. High-potency P2Y12 inhibitors use among patients with AMI who undergo percutaneous coronary intervention (PCI) carries a clas...BACKGROUND: Racial and ethnic disparities exist in postacute myocardial infarction (AMI) care. High-potency P2Y12 inhibitors use among patients with AMI who undergo percutaneous coronary intervention (PCI) carries a class I indication in the guidelines. This study aims to examine racial and ethnic differences in high-potency P2Y12 inhibitor prescription on discharge among patients with AMI undergoing PCI. METHODS: Using data from the NCDR Cath PCI registry, we identified consecutive patients with AMI who underwent PCI from April 2018 to June 2023. Likelihood of high-potency P2Y12 inhibitor prescription on discharge was assessed using logistic regression models adjusted for social deprivation index and other patient- and procedure-related variables. RESULTS: Among 1 662 387 patients hospitalized with AMI and who underwent PCI, 165 579 (9.9%) were Black, 58 595 (3.5%) were Asian, and 1 302 576 (78.3%) were of White race, while 135 637 (8.1%) were of Hispanic ethnicity. At discharge 876 078 (52.7%) were prescribed a high-potency P2Y12 inhibitor. Compared with White patients, Black patients were less likely (adjusted odds ratio, 0.93 [95% CI, 0.92-0.94]), while Asians were more likely (adjusted odds ratio, 1.08 [1.07-1.10]) to have a high-potency P2Y12 inhibitor discharge prescription. Compared with non-Hispanics, Hispanic patients were less likely to have a high-potency P2Y12 inhibitor discharge prescription (adjusted odds ratio, 0.95 [95% CI, 0.93-0.96). CONCLUSIONS: In a contemporary national registry of hospitalized patients with AMI who underwent PCI, Black and Hispanic patients were less likely to be discharged on a high-potency P2Y12 inhibitor irrespective of socioeconomic status. These findings highlight an opportunity to achieve equity in guideline-directed AMI pharmacotherapies to improve outcomes.