BACKGROUND:Chronic therapy with sodium-glucose cotransporter 2 inhibitors (SGLT2i) is associated with long-term reno-protective benefits. There are limited data on the benefits of these agents against the risk of contrast-associated acute kidney injury (CA-AKI). METHODS:The retrospective study population included all patients with diabetes enrolled in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Percutaneous Coronary Intervention registry, a clinical registry of all percutaneous coronary intervention (PCI) cases at nonfederal hospitals in the state of Michigan. Included patients underwent PCI between January 2022 and September 2023. Patients on dialysis and those without post-PCI serum creatinine measurements were excluded. SGLT2i users were compared with nonusers with respect to CA-AKI outcomes, defined as an increase in serum creatinine of ≥0.5 mg/dL following PCI. Outcomes were evaluated in a risk-adjusted, propensity-matched analysis. RESULTS:Among 13 804 patients with diabetes who underwent PCI, CA-AKI occurred in 3.8% (82/2186) of SGLT2i users versus 5.2% (602/11 618) of nonusers (odds ratio, 0.71; P=0.004). In propensity-matched, risk-adjusted analysis, the pre-PCI use of SGLT2i correlated with a lower incidence of CA-AKI (3.69% versus 4.68%; adjusted odds ratio, 0.72; P=0.027). The protective effect of SGLT2i was preserved among higher-risk subgroups. CONCLUSIONS:Among patients with diabetes who underwent PCI, preprocedural use of SGLT2i correlated with a lower risk of CA-AKI.

BACKGROUND:Frailty before cardiovascular procedures is associated with poorer outcomes. While underutilized, cardiac rehabilitation (CR) is guideline-recommended for patients undergoing cardiovascular procedures and may help mitigate the effects of frailty. This study evaluated the association between preprocedural frailty and CR use, as well as the interaction of frailty and CR use on 1-year mortality. METHODS:Medicare fee-for-service claims were queried for patients undergoing percutaneous or surgical revascularization or aortic valve replacement between July 2016 and December 2018. Patients who experienced mortality during the index admission or within 30 days of discharge were excluded. Patients were stratified into quartiles (Q1-Q4) using the validated claims-based frailty index (CFI). CR use was defined as attending any CR session within 1 year of discharge. Unadjusted comparisons and multivariable analyses were used to evaluate the relationship between frailty and CR use (CFI-Q4 versus CFI-Q1). An inverse probability treatment weighting model was used to determine if there was an interaction between CR, frailty, and 1-year mortality. RESULTS:Overall CR use among the 501 049 beneficiaries was 37.7%; the average age was 75.9 years (SD, 7.3), and 37.0% were female. Increasing frailty was associated with decreased CR use (CFI-Q1: 49.7%, CFI-Q2: 42.2%, CFI-Q3: 35.3%, and CFI-Q4: 23.7%; P<0.001; adjusted odds ratioCFI-Q4 versus CFI-Q1, 0.63 [95% CI, 0.62-0.64]). Unadjusted 1-year mortality was higher with increasing frailty (CFI Q1: 2.5%, CFI-Q2: 5.1%, CFI-Q3: 9.0%, and CFI Q4: 16.9%; P<0.001). After adjustment, the reduction in mortality associated with CR use was greater among frailer patients relative to less frail patients (CFI-Q4: 9.2% and CFI-Q1: 1.7%; P<0.001). CR use was associated with a significantly reduced association between CFI and 1-year mortality (P<0.001). CONCLUSIONS:Preprocedural frailty is associated with lower CR use despite greater absolute benefits on 1-year mortality. Increasing CR use of frail Medicare beneficiaries may reduce 1-year mortality after cardiac interventions.

BACKGROUND:Intracoronary imaging (ICI) to guide percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) carries a Class I recommendation in US guidelines. AIMS:This analysis evaluated the frequency of ICI use among patients with ACS. METHODS:Using data from a large statewide registry, all patients undergoing PCI between January 1, 2019, and December 31, 2024, were studied. The primary measure of interest for this analysis was the use of ICI to guide PCI, defined as the use of ICI after the decision was made to proceed with PCI. The frequency of ICI use among patients with and without ACS was compared, and the trend in ICI use in ACS patients over the study period was examined. RESULTS:During the 6-year study period, 166,238 PCIs were performed at 51 non-federal hospitals in Michigan, of which 90,441 (54.4%) were performed for ACS. ICI was used to guide PCI in 25,234 (27.9%) ACS cases, which was significantly lower than ICI use in 23,999 (31.7%) non-ACS cases (p < 0.001). Over the 6-year study, a progressive and significant increase in ICI use in ACS was observed from 6.5% in the first year to 54.4% in the sixth year of the study (p < 0.001 for trend). CONCLUSIONS:Despite its proven benefits in ACS, ICI was used to guide PCI significantly less often among patients presenting with ACS compared with those without ACS. However, the ICI to guide PCI in ACS has increased significantly over time and at a similar pace compared to those without ACS.

OBJECTIVES:Contrast volume minimization can mitigate acute kidney injury (AKI) risk following percutaneous coronary intervention (PCI), but national data regarding contemporary contrast volume dosing patterns are lacking. The authors analyzed data from the National Cardiovascular Data Registry (NCDR) CathPCI registry to assess the prevalence and outcomes of renal function-based contrast dosing during PCI in patients with pre-existing renal impairment. METHODS:The authors analyzed data from 463 753 patients with an eGFR ≤ 60 mL/min/1.73 m2, and categorized patients based on contrast volume/eGFR: high (> 3), low (1-3), and ultra-low (less than 1). eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. The primary outcome was occurrence of AKI. Outcomes were adjusted based on covariates derived from a validated AKI prediction model. RESULTS:The majority (51.4%) of patients received high contrast volume. Compared with patients who received low contrast volume, patients with high contrast volume use had a significantly higher incidence of AKI (adjusted OR 1.36 [1.28 to 1.45]) and a higher stage of AKI (adjusted OR 1.90 [1.80 to 2.00]). The incidence of AKI was similar between low and ultra-low contrast volume use. The development of new need for dialysis was higher in patients who received high contrast volume (2.8%) compared with those who received low contrast volume (0.8%) and ultra-low contrast volume (0.8%) (P less than .001). CONCLUSIONS:High contrast volume during PCI is associated with worse outcomes including AKI and new need for dialysis. Our study provides further support for the use of contrast volume less than 3 times the eGFR as a target to guide contrast dosing during PCI.

BACKGROUND:The volume of percutaneous coronary intervention (PCI) at ambulatory surgical centers (ASC) is expected to increase. METHODS:We surveyed US interventional cardiologists with a 58-question, anonymous online survey to evaluate their knowledge of and perspectives on ASC PCI. RESULTS:A total of 114 interventional cardiologists (9 fellows) responded. Participants were most commonly between 45 and 54 years old (33%). Most participants identified as male (95%), white (58%), non-Hispanic (95%), and with an academic affiliation (61%); 13 participants (11%) were PCI operators at an ASC. Most participants (59%) were in support of ASC PCI, 63% were very confident in their ability to decide if a patient is well-suited for ASC PCI, and 43% were not familiar with national and state-level laws/regulations of ASC PCI. Perceived benefits of ASC PCI included positive patient experience (69%), greater efficiency (79%), and lower costs for patients (50%) and institutions (53%). Participants reported a high level of concern about private equity involvement in ASC PCI (58%), occurrence of adverse events away from the hospital (47%), lower quality of care (39%), inappropriate patient selection (40%), inadequate regulatory standards (35%), and institutional pressures (47%). Supporters of ASC PCI reported a better self-assessed knowledge of it and perceived more benefits with fewer concerns. CONCLUSIONS:Most survey participants expressed support for ASC PCI, citing benefits such as improved patient experience, greater efficiency, and reduced costs. However, participants expressed concern for private equity involvement and the risk of adverse events occurring away from the hospital setting.

Background Despite the robust clinical evidence base supporting their role for high-risk patients with type 2 diabetes (T2DM) and concomitant cardiovascular disease, prescription of sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) remains suboptimal. Clinical encounters occurring in the period post angiography may present a key opportunity to improve implementation in high-risk patients with T2DM. Methods Reminders EMbedded IN PCI Reports to Optimize Discharge Diabetes Mellitus Care (REMIND-DM) is a pragmatic, prospective, cluster randomized quality improvement study in patients with type 2 diabetes undergoing angiography and was run as a quality improvement initiative. Following a 6 month "baseline period", REMIND-DM randomized 23 participating percutaneous coronary intervention (PCI) sites (caring for 7,045 patients over the study period) within the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) quality improvement collaborative to either usual care or a quality improvement intervention consisting of a templated PCI report "reminder" of medication eligibility linked to a decision support tool. Sites were followed for a 6 month "evaluation period." The primary outcome is the new prescription of SGLT2 inhibitor or GLP-1RA among eligible patients at discharge after PCI. To examine the effectiveness of the intervention, primary analyses will be conducted using a difference-in-difference design examining changes in new cardioprotective therapy prescription from baseline to the evaluation periods in both arms. Conclusions The REMIND-DM implementation trial has enrolled a large, high-risk population of patients with T2DM and will determine the effectiveness of a low touch QI intervention within BMC2 implemented in the post-PCI period to improve timely prescription of risk lowering therapies in high-risk patients with T2DM.

BACKGROUND:Studies suggest percutaneous coronary intervention (PCI) guided by intracoronary imaging (ICI) results in larger balloon/stent diameters and longer stents. Whether this occurs in real-world PCI is poorly understood. METHODS:De novo PCIs performed at 48 nonfederal Michigan hospitals between July 2019 and June 2022 were evaluated with regression modeling to evaluate associations between ICI-guided PCI and balloon/stent dimensions. The association between ICI-guided PCI and coronary dissection/perforation was assessed using adjusted odds ratios. RESULTS:ICI was used in 16 777 (22.5%) PCI-treated lesions and increased from 11.2% of cases in July 2019 to 32.1% in June 2022. Compared with angiography alone, the average patient/procedural-adjusted treatment effect of ICI use included: +0.19 mm stent diameter (95% CI +0.16 to +0.22), +0.45 mm maximum balloon diameter (95% CI +0.40 to +0.51), and +3.51 mm stent length (95% CI +2.54 to +4.48). These findings persisted when controlling for the operator. ICI use was associated with a higher risk of dissections (adjusted odds ratio, 2.55 [95% CI, 2.05-3.16]) and perforations (adjusted odds ratio, 2.25 [95% CI, 1.74-2.91]); however, increased use of ICI and larger stent/balloon sizes over the study period (P<0.001 for trend for both) was not associated with a concomitant increase in rates of dissection or perforation (P=0.78 and P=0.33 for trend, respectively). CONCLUSIONS:In real-world practice, ICI-guided PCI was associated with larger stent/balloon diameters and longer stents. While ICI use was associated with dissections and perforations, there was no significant increase in the rate of these complications despite significant increases in ICI use and stent/balloon sizes during the study period. Further research is needed to evaluate the association between ICI use and procedural complications.

Transthoracic echocardiography (TTE) plays the primary role in the assessment of patients with aortic stenosis (AS). Alternative imaging modalities are important for the confirmation of AS severity in patients with discordant AS or inadequate assessment by TTE. Multimodality imaging can inform prognosis in patients with AS. In this article, we discuss the role of multimodality imaging for accurate diagnosis of AS severity and assessment of prognosis to inform patient management. We provide an overview of the use of computed tomography for procedural planning for transcatheter aortic valve replacement.

BACKGROUND:The cause of increased risk for reoperation after transcatheter aortic valve replacement (TAVR) vs prior surgical aortic valve replacement (SAVR) is poorly understood. This study evaluated the impact of concomitant mitral and tricuspid valve disease on associated risk of TAVR explantation. METHODS:Patients undergoing aortic valve replacement after prior SAVR or TAVR were extracted from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). Patients were stratified by TAVR explantation status and presence of severe concomitant valve disease for analyses. Risk adjustment was performed by multivariable logistic regression. Interaction terms were used to evaluate differential risk of concomitant valve disease for TAVR explantation vs redo-SAVR. RESULTS:Of 24,097 redo aortic valve replacement patients, 877 (3.6%) underwent TAVR explantation. TAVR explantation patients had higher rates of concomitant severe valve disease (17% vs 14%; P < .001). Patients with severe concomitant valve disease had worse operative mortality after TAVR explantation (26.2% vs 14.6%; P < .001) and redo-SAVR (12.3% vs 6.9%; p < .001). TAVR explantation was independently associated with higher mortality (adjusted odds ratio [ORadj], 1.3 [1.0-1.6]; P = .030). Severe mitral regurgitation (ORadj, 1.2 [1.0-1.6]; P = .017), mitral stenosis (ORadj, 2.0 [1.5-2.7; P < .001), and tricuspid regurgitation (ORadj, 1.6 [1.3-1.9]; P < .001) were all associated with mortality, although these factors were not associated with disproportionately higher risk during TAVR explantation (P > .05). CONCLUSIONS:TAVR explantation cases have a higher burden of severe concomitant valve disease than redo-SAVR cases. Heart teams should consider these findings when discussing initial procedure choices for patients with multivalve disease, given their extreme risk at time of TAVR explantation.

Background: There is a high prevalence of significant tricuspid regurgitation (TR) in patients undergoing mitral transcatheter edge-to-edge repair (M-TEER). Significant TR is associated with poor prognosis and affects decision-making between M-TEER and concomitant mitral and tricuspid valve surgery. Improved quality of life (QoL) is an important metric for patients. Methods: We analyzed data from 1838 patients undergoing M-TEER included in a multicenter statewide registry from 2015 to 2023. QoL was assessed using baseline and 30-day Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. Patients were classified as no/mild TR or moderate/severe TR, and changes in KCCQ scores were compared. The primary outcome was an adjusted analysis consisting of survival to 30 days with a >15-point improvement in KCCQ score. Results: Complete endpoint data were available for 1421 patients (77.3%). On average, patients undergoing M-TEER experienced large improvements in QoL, regardless of baseline TR group. Thirty-day mortality for patients with moderate/severe TR was higher than for those with no/mild TR (42 [4.1%] vs. 16 [2.0%], respectively, p = 0.018). The majority of patients survived to 30 days with Delta KCCQ >15 (63.8% for no/mild TR vs. 59.6% for moderate/severe TR, p = 0.120). Patients with moderate/severe TR exhibited no difference in the primary adjusted outcome (adjusted odds ratio: 0.851, p = 0.177). Conclusions: The majority of patients experience a large improvement in QoL after M-TEER, regardless of baseline TR severity. Further research should explore a staged approach of M-TEER followed by tricuspid valve intervention as needed compared to concomitant mitral/tricuspid valve surgery. MR, mitral regurgitation; TR, tricuspid regurgitation; M-TEER, mitral transcatheter edge-to-edge repair; T-TEER, tricuspid transcatheter edge-to-edge repair; QoL, quality of life; KCCQ, Kansas City Cardiomyopathy Questionnaire; MISHC, Michigan Structural Heart Consortium; TVT, transcatheter valve therapy.