Objectives. Cardiac surgery for coronary artery disease was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with disease ordinarily treated with coronary artery bypass grafting (CABG) instead underwent percutaneous coronary intervention (PCI). We sought to describe 12-month outcomes following PCI in patients who would typically have undergone CABG. Methods. Between March 1, 2020 and July 31, 2020, patients who received revascularization with PCI when CABG would have been the primary choice of revascularization were enrolled in the prospective, multicenter UK-ReVasc Registry. We evaluated the following major adverse cardiovascular events at 12 months: all-cause mortality, myocardial infarction (MI), repeat revascularization, stroke, major bleeding, and stent thrombosis. Results. A total of 215 patients were enrolled across 45 PCI centers in the United Kingdom. Twelve-month follow-up data were obtained for 97% of the cases. There were 9 deaths (4.3%), 5 MIs (2.4%), 12 repeat revascularizations (5.7%), 1 stroke (0.5%), 3 major bleeds (1.4%), and no cases of stent thrombosis. No difference in the primary endpoint was observed between patients who received complete vs incomplete revascularization (residual SYNTAX score <=8 vs > 8) (P = .22). Conclusions. In patients with patterns of coronary disease in whom CABG would have been the primary therapeutic choice outside of the pandemic, PCI was associated with acceptable outcomes at 12 months of follow-up. Contemporary randomized trials that compare PCI to CABG in such patient cohorts may be warranted.

BACKGROUND:The Synergy MegatronTM is an everolimus-drug eluting stent that may offer advantages in the treatment of aorto-ostial disease and large proximal vessels.AIMS:To report the short- to medium-term clinical outcomes from the European Synergy MegatronTM Implanters' Registry.METHODS:This registry was an investigator-initiated study conducted at 14 European centers. The primary outcome was target lesion failure (TLF), defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularisation.RESULTS:Five hundred seventy-five patients underwent PCI with MegatronTM between 2019 and 2021. Patients were 69 ± 12 years old, 26% had diabetes mellitus, 24% had moderate-severe left ventricular impairment and 59% presented with an acute coronary syndrome. 15% were deemed prohibitively high risk for surgical revascularisation. The target vessel involved the left main stem in 55%, the ostium of the RCA in 13% and was a true bifurcation (Medina 1,1,1) in 50%.  At 1 year, TLF was observed in 40 patients, with 26 (65%) occurring within the first 30 days. The cumulative incidence of TLF was 4.5% at 30 days and 8.6% (95% CI 6.3-11.7) at 1 year. The incidence of stent thrombosis was 0.5% with no late stent thromboses. By multivariate analysis, the strongest independent predictors of TLF were severe left ventricular impairment (HR 3.43, 95% CI: 1.67-6.76, p < 0.001) and a target vessel involving the left main (HR 4.00 95% CI 1.81-10.15 p = 0.001).CONCLUSIONS:Use of the Synergy MegatronTM everolimus eluting stent in a 'real-world' setting shows favorable outcomes at 30 days and 1 year.

Objective: Coronary microvascular dysfunction (CMD) is a cause of ischaemia with non-obstructive coronary arteries (INOCA). It is notoriously underdiagnosed due to the need for invasive microvascular function testing. We hypothesized that systemic microvascular dysfunction could be demonstrated non-invasively in the micro -circulation of the bulbar conjunctiva in patients with CMD. Methods: Patients undergoing coronary angiography for the investigation of chest pain or dyspnoea, with physiologically insignificant epicardial disease (fractional flow reserve >= 0.80) were recruited. All patients un-derwent invasive coronary microvascular function testing. We compared a cohort of patients with evidence of CMD (IMR >= 25 or CFR <2.0); to a group of controls (IMR <25 and CFR >= 2.0). Conjunctival imaging was performed using a previously validated combination of a smartphone and slit-lamp biomicroscope. This tech-nique allows measurement of vessel diameter and other indices of microvascular function by tracking erythrocyte motion. Results: A total of 111 patients were included (43 CMD and 68 controls). There were no differences in baseline demographics, co-morbidities or epicardial coronary disease severity. The mean number of vessel segments analysed per patient was 21.0 +/- 12.8 (3.2 +/- 3.5 arterioles and 14.8 +/- 10.8 venules). In the CMD cohort, sig-nificant reductions were observed in axial/cross-sectional velocity, blood flow, wall shear rate and stress. Conclusion: The changes in microvascular function linked to CMD can be observed non-invasively in the bulbar conjunctiva. Conjunctival vascular imaging may have utility as a non-invasive tool to both diagnose CMD and augment conventional cardiovascular risk assessment.

BACKGROUND:With expansion of transcatheter aortic valve implantation (TAVI) into younger patients, valve durability is critically important.AIMS:We aimed to evaluate long-term valve function and incidence of severe structural valve deterioration (SVD) among patients ≥ 10-years post-TAVI and with echocardiographic follow-up at least 5-years postprocedure.METHODS:Data on patients who underwent TAVI from 2007 to 2011 were obtained from the UK TAVI registry. Patients with paired echocardiograms postprocedure and ≥5-years post-TAVI were included. Severe SVD was determined according to European task force guidelines.RESULTS:221 patients (79.4 ± 7.3 years; 53% male) were included with median echocardiographic follow-up 7.0 years (range 5-13 years). Follow-up exceeded 10 years in 43 patients (19.5%). Valve types were the supra-annular self-expanding CoreValve (SEV; n = 143, 67%), balloon-expandable SAPIEN/XT (BEV; n = 67, 31%), Portico (n = 4, 5%) and unknown (n = 7, 3%). There was no difference between postprocedure and follow-up peak gradient in the overall cohort (19.3 vs. 18.4 mmHg; p = NS) or in those with ≥10-years follow-up (21.1 vs. 21.1 mmHg; p = NS). Severe SVD occurred in 13 patients (5.9%; median 7.8-years post-TAVI). Three cases (23.1%) were due to regurgitation and 10 (76.9%) to stenosis. Valve-related reintervention/death occurred in 5 patients (2.3%). Severe SVD was more frequent with BEV than SEV (11.9% vs. 3.5%; p = 0.02), driven by a difference in patients treated with small valves (BEV 28.6% vs. SEV 3.0%; p < 0.01).CONCLUSIONS:Hemodynamic function of transcatheter heart valves remains stable up to more than 10 years post-TAVI. Severe SVD occurred in 5.9%, and valve-related death/reintervention in 2.3%. Severe SVD was more common with BEV than SEV.

BACKGROUND:Atherosclerotic heart disease often remains asymptomatic until presentation with a major adverse cardiovascular event. Primary preventive therapies improve outcomes, but conventional screening often misattributes risk. Vascular imaging can be utilised to detect atherosclerosis, but often involves ionising radiation. The conjunctiva is a readily accessible vascular network allowing non-invasive hemodynamic evaluation. AIM:To compare conjunctival microcirculatory function in patients with and without obstructive coronary artery disease. METHODS:We compared the conjunctival microcirculation of myocardial infarction patients (MI-cohort) to controls with no obstructive coronary artery disease (NO-CAD cohort). Conjunctival imaging was performed using a smartphone and slit-lamp biomicroscope combination. Microvascular indices of axial (Va) and cross-sectional (Vcs) velocity; blood flow rate (Q); and wall shear rate (WSR) were compared in all conjunctival vessels between 5 and 45 μm in diameter. RESULTS:A total of 127 patients were recruited (66 MI vs 61 NO-CAD) and 3602 conjunctival vessels analysed (2414 MI vs 1188 NO-CAD). Mean Va, Vcs and Q were significantly lower in the MI vs NO-CAD cohort (Va 0.50 ± 0.17 mm/s vs 0.55 ± 0.15 mm/s, p < 0.001; Vcs 0.35 ± 0.12 mm/s vs 0.38 ± 0.10 mm/s, p < 0.001; Q 154 ± 116 pl/s vs 198 ± 130 pl/s, p < 0.001). To correct for differences in mean vessel diameter, WSR was compared in 10-36 μm vessels (3268/3602 vessels) and was lower in the MI-cohort (134 ± 64 s-1 vs 140 ± 63 s-1, p = 0.002). CONCLUSIONS:Conjunctival microcirculatory alterations can be observed in patients with obstructive coronary artery disease. The conjunctival microvasculature merits further evaluation in cardiovascular risk screening.

Eosinopenia is considered a surrogate of inflammation in several disease settings. Following ST-segment elevation myocardial infarction, eosinopenia is presumed to be a marker of infarct severity. We sought to study the relationship between eosinopenia and infarct severity and how this relationship determined the long-term outcomes following ST-segment elevation myocardial infarction.Six hundred and six consecutive patients undergoing primary percutaneous coronary interventions from a large volume single center were enrolled. Low eosinophil count was defined as < 40 cells/mL from samples within 2 hours after reperfusion. Primary endpoint was defined as composite of death, myocardial infarction, stroke, unplanned revascularization, and readmission for heart failure over 3.5 years’ follow-up.Sixty-five percent of the patients had eosinopenia. Patients in the low eosinophil group had larger infarct size as measured by troponin value (2934 vs 1177 ng/L, P < .001) and left ventricle systolic function on echocardiography (48% vs 50%, P = 0.029). There was a weak correlation between eosinophil count and both troponin (r = -0.25, P < 0.001) and ejection fraction (r = 0.10, P = .017). The primary endpoint was higher in eosinopenic patients (28.8% vs. 20.4%; hazard ratio [HR] 1.49, 95% confidence interval [CI] 1.05 to 2.13, P = .023). A discordance between eosinopenia and severe left ventricle systolic dysfunction was observed in 55.6% of cases. Compared with normal count, eosinopenia was associated with worse clinical outcomes in patients with non-severe left ventricle dysfunction (24.1% vs 16.2%; HR 1.58, 95% CI 1.01 to 2.45, P = .044) but not in those with severe left ventricle dysfunction (42.3% vs. 38.9%; HR 1.10, 95% CI 0.59 to 2.03, P = .77) (P < .01 for interaction).Eosinopenia is an easily determined marker that reflects worse clinical outcomes over long-term follow-up.

The 'gold standard' in the management of left main coronary artery disease has historically been coronary artery bypass surgery. Recent innovations in drug-eluting stent technology coupled with the increasing utility of physiology and imaging guidance for procedures have led to an evolving role of percutaneous coronary intervention in left main disease of low and intermediate anatomical complexity. This revascularization modality carries the clear advantage of being less invasive and significantly reduced recovery times. This practice is currently supported by international guidelines, however, it remains a controversial topic in the field of interventional cardiology, and the long-term outcomes of a percutaneous strategy have been questioned. This review describes the current evidence base for the assessment and choice of intervention in left main coronary artery disease. The percutaneous revascularization techniques and use of imaging to optimize procedures and improve clinical outcomes have been discussed.

OBJECTIVES:The aim of this study was to determine the safety and efficacy of same-day discharge (SDD) after transcatheter aortic valve replacement (TAVR) during the COVID-19 pandemic.BACKGROUND:The COVID-19 pandemic has placed significant stress on health care systems worldwide. SDD in highly selected TAVR patients can facilitate the provision of essential cardiovascular care while managing competing COVID-19 resource demands.METHODS:Patient selection for SDD was at the discretion of the local multidisciplinary heart team, across 7 international sites. The primary outcome was a composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new permanent pacemaker (PPM) implantation.RESULTS:From March 2020 to August 2021, 124 of 2,100 patients who underwent elective transfemoral TAVR were selected for SDD. The average age was 78.9 ± 7.8 years, the median Society of Thoracic Surgeons score was 2.4 (IQR: 1.4-4.2), and 32.3% (n = 40) had preexisting PPMs. There were no major vascular complications, strokes, or deaths during the index admission. One patient (0.8%) required PPM implantation for complete heart block and was discharged the same day. No patient required a PPM between discharge home and 30-day follow-up. The composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new PPM at 30 days occurred in 5.7% patients (n = 6 of 106).CONCLUSIONS:SDD post-TAVR is safe and feasible in selected patients at low risk for adverse clinical events postdischarge. This strategy may have a potential role in highly selected patients even when the COVID-19 pandemic abates.

Background: Aortic stenosis (AS) is associated with pathophysiological changes in both left ventricular and coronary microvascular structure and function. The treatment of AS with transcatheter aortic valve replacement (TAVR) has been associated with improvements in invasive indices of coronary microvascular function. This study sought to address whether systemic microvascular dysfunction was present in patients with AS and if microvascular function was altered by treatment of aortic stenosis with TAVR. The conjunctival microcirculation was used as the site for the non-invasive assessment of systemic microvascular function. Methods: Patients undergoing TAVR for the treatment of severe AS were compared to a cohort of age- and sex-matched controls without valvular heart disease. Conjunctival vascular imaging was performed in all subjects using a previously validated combination of a smartphone and slit-lamp biomicroscope. This technique allowed measurement of vessel diameter and other indices of microvascular function by tracking erythrocyte motion. Conjunctival hemodynamics were compared pre- and post-TAVR, in addition to between the severe AS and control cohorts. Results: A total of 165 patients were included (90 severe AS and 75 controls). Baseline characteristics were well matched between groups. In comparison to the control cohort, arteriole axial (Va) and cross-sectional velocity (Vcs) were significantly lower in females with AS (Va severe AS 0.53 ± 0.11mm/s vs control 0.59 ± 0.12mm/s, p=0.047; Vcs severe AS 0.38 ± 0.07mm/s vs control 0.41 ± 0.08mm/s, p=0.043), but not in males (Va severe AS 0.61 ± 0.11mm/s vs control 0.58 ± 0.10mm/s, p=0.19; Vcs severe AS 0.43 ± 0.08mm/s vs control 0.41 ± 0.07mm/s, p=0.20). Arteriole Va and Vcs significantly increased following TAVR in females (Va Pre-TAVR 0.52 ± 0.16mm/s vs post-TAVR 0.59 ± 0.15mm/s, p<0.001; Vcs Pre-TAVR 0.37 ± 0.11mm/s vs post-TAVR 0.42 ± 0.11mm/s, p<0.001). Conclusion: This study highlights sex-specific differences in conjunctival microvascular function in patients with severe AS. In this study TAVR resulted in significant improvements in conjunctival arteriolar V a and V cs . These findings are consistent with severe AS being a reversible cause of systemic microvascular dysfunction.

OBJECTIVES:To define the optimal implantation of the Sapien 3 (Edwards Lifesciences) transcatheter heart valve (THV), this study systematically analyzed the predeployment fluoroscopic THV position and correlated this to clinical outcomes. METHODS:This was an observational study of 279 patients treated with the Sapien 3 THV. Fluoroscopic imaging was used to categorize patients into low (n = 147), intermediate (n = 86), and high (n = 46) implantation zones. These zones were based on the relationship of the balloon marker and radiolucent line of the valve frame (line of lucency) to the annular plane at deployment. The primary outcome was the rate of permanent pacemaker implantation (PPI) at 30 days. The secondary outcomes were the rates of new left bundle-branch block (LBBB) in-hospital and all-cause mortality at 1 year. RESULTS:In the high, intermediate, and low groups, 30-day PPI rates were 4.3%, 8.1%, and 8.8% (P=.62); in-hospital LBBB rates were 10.9%, 26.7%, and 32.0% (P=.02); and all-cause mortality rates at 1 year were 3.1%, 7.3%, and 12.5% (P=.14), respectively. No differences were observed with respect to procedural success/complications or THV performance between the groups. CONCLUSION:This study demonstrates fewer conduction abnormalities for Sapien 3 valves positioned within a higher zone defined fluoroscopically by the line of lucency and balloon marker.

Spontaneous coronary artery dissection (SCAD) is a less common cause of acute coronary syndrome. Pregnancy-related SCAD is uncommon, but often presents with a more severe phenotype. This report describes a 30-year-old woman with an anterior ST elevation MI, presenting 1 day postpartum. Left main stem (LMS) SCAD with extensive intramural haematoma (IMH) and resultant LMS occlusion was confirmed by angiography and intravascular imaging. Given the extent of disease, the patient underwent emergency cardiac surgery. Coronary flow was initially improved by decompressing the IMH using cutting balloons. The coronary wires were successfully left in situ during transfer in an effort to both maintain flow and allow the surgeon to identify true LMS. Ideally, SCAD can be managed conservatively given the risk of intervention worsening IMH, and hence myocardial ischaemia/MI. However, emergency revascularisation is indicated in cases of persistent ischaemia. This case demonstrates percutaneous therapies to bridge towards and help with subsequent surgical revascularisation.

Microvascular haemodynamic alterations are associated with coronary artery disease (CAD). The conjunctival microcirculation can easily be assessed non-invasively. However, the microcirculation of the conjunctiva has not been previously explored in clinical algorithms aimed at identifying patients with CAD. This case-control study involved 66 patients with post-myocardial infarction and 66 gender-matched healthy controls. Haemodynamic properties of the conjunctival microcirculation were assessed with a validated iPhone and slit lamp-based imaging tool. Haemodynamic properties were extracted with semi-automated software and compared between groups. Biomarkers implicated in the development of CAD were assessed in combination with conjunctival microcirculatory parameters. The conjunctival blood vessel parameters and biomarkers were used to derive an algorithm to aid in the screening of patients for CAD. Conjunctival blood velocity measured in combination with the blood biomarkers (N-terminal pro-brain natriuretic peptide and adiponectin) had an area under receiver operator characteristic curve (AUROC) of 0.967, sensitivity 93.0%, specificity 91.5% for CAD. This study demonstrated that the novel algorithm which included a combination of conjunctival blood vessel haemodynamic properties, and blood-based biomarkers could be used as a potential screening tool for CAD and should be validated for potential utility in asymptomatic individuals.

Microcirculatory dysfunction occurs early in cardiovascular disease (CVD) development. Acute myocardial infarction (MI) is a late consequence of CVD. The conjunctival microcirculation is readily-accessible for quantitative assessment and has not previously been studied in MI patients. We compared the conjunctival microcirculation of acute MI patients and age/sex-matched healthy controls to determine if there were differences in microcirculatory parameters. We acquired images using an iPhone 6s and slit-lamp biomicroscope. Parameters measured included diameter, axial velocity, wall shear rate and blood volume flow. Results are for all vessels as they were not sub-classified into arterioles or venules. The conjunctival microcirculation was assessed in 56 controls and 59 inpatients with a presenting diagnosis of MI. Mean vessel diameter for the controls was 21.41 ± 7.57 μm compared to 22.32 ± 7.66 μm for the MI patients (p < 0.001). Axial velocity for the controls was 0.53 ± 0.15 mm/s compared to 0.49 ± 0.17 mm/s for the MI patients (p < 0.001). Wall shear rate was higher for controls than MI patients (162 ± 93 s −1 vs 145 ± 88 s −1 , p < 0.001). Blood volume flow did not differ significantly for the controls and MI patients (153 ± 124 pl/s vs 154 ± 125 pl/s, p = 0.84). This pilot iPhone and slit-lamp assessment of the conjunctival microcirculation found lower axial velocity and wall shear rate in patients with acute MI. Further study is required to correlate these findings further and assess long-term outcomes in this patient group with a severe CVD phenotype.

To describe the utility and safety of intravascular lithotripsy (IVL) in the setting of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI).

Introduction: A large proportion of patients with cardiovascular disease (CVD) remain asymptomatic until presentation with myocardial infarction. Conventional CV risk assessment can be augmented by investigations such as CT coronary artery calcium scoring; but are limited by cost, availability and exposure to ionizing radiation. This study utilizes the conjunctiva as a network of blood vessels that can be assessed non-invasively in order to compare hemodynamic parameters in patients with and without established coronary microvascular disease (MVD). Methods: We assessed the conjunctival microcirculation of patients diagnosed with angina undergoing invasive coronary angiography and physiological evaluation of epicardial stenoses and MVD. All patients had haemodynamically insignificant epicardial disease (FFR ≥0.80). Conjunctival imaging was performed using an adapted iPhone 11pro and slit-lamp biomicroscope. We compared a cohort of patients with MVD (IMR ≥25); to a group of controls without MVD (IMR <25). Results: A total of 54 patients were included (19 MVD and 35 controls). Table 1 demonstrates a comparison of baseline demographics and hemodynamics between the groups. A total of 866 conjunctival vessels were analysed (366 MVD and 500 controls) and the differences in microvascular parameters between groups determined ( Table 2) . Statistically significant differences were observed in axial velocity, cross sectional velocity and blood flow rate. Conclusion: This study demonstrates the ability to non-invasively detect abnormal microvascular function. The conjunctival microcirculation therefore has potential merit to complement conventional CV risk screening.

BACKGROUND Outcomes from the new Synergy Megatron drug-eluting stent (DES) platform (Boston Scientific) are not yet reported. This study sought to evaluate periprocedural outcomes in patients undergoing percutaneous coronary intervention (PCI) using this technology. METHODS This was a retrospective study across two United Kingdom centers of 139 patients undergoing PCI of 146 coronary lesions using the Synergy Megatron DES. The primary endpoint was the rate of cardiovascular death. The secondary endpoint was the rate of a composite of non-fatal myocardial infarction, target-vessel revascularization, in-stent restenosis, and probable/definite stent thrombosis. Available intravascular ultrasound (IVUS) imaging was reviewed post hoc and evaluated according to predefined IVUS optimization criteria. RESULTS Mean follow-up duration was 137.3 ± 38.3 days. The primary endpoint occurred in 0.7% of patients and the secondary endpoint occurred in 0.0% of patients. There were no cases of longitudinal stent deformation (LSD); in patients undergoing an IVUS-guided procedure, our criteria for successful IVUS optimization was achieved in 74.1% of left main stem (LMS) and 83.3% of right coronary artery (RCA) lesions. Mean minimal stent area (MSA) was 14.5 ± 3.4 mm² in the LMS, 10.0 ± 2.5 mm² in the left anterior descending coronary artery, 9.8 ± 3.0 mm² in the left circumflex, and 12.2 ± 4.0 mm² in the RCA. CONCLUSION This study demonstrated very low rates of short-term major adverse cardiovascular events with no cases of LSD or acute/subacute stent thrombosis. It highlights the overexpansion capabilities of the Synergy Megatron DES platform. The technology safely and effectively facilitates IVUS-optimized stent parameters for the treatment of large proximal vessels and bifurcations.

Introduction Current guidelines advocate a Heart Team (HT) approach to decision making in complex coronary artery disease (CAD). Available evidence suggests that PCI is non-inferior to surgery in patients with three vessel or left main stem disease in the setting of a low-intermediate anatomical syntax score. The majority of HT discussions result in a recommendation of percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG), however a decision is deemed to be equipoised when one revascularisation strategy is not felt to carry significant prognostic benefit. In this study we sought to evaluate clinical outcomes following an equipoise decision in a Heart Team meeting. Methods This was a single centre retrospective study. All patients requiring intervention for structural heart disease in addition to CAD were excluded. Between January 2015 and December 2018 a total of 134 patients were deemed to be equipoise following discussion at a Heart Team meeting (7.1% of all discussions). Demographics, procedural details and clinical outcomes were obtained from our national electronic health care record. The primary outcome was the 3-year rate of major adverse cardiovascular and cerebrovascular events (MACCE). This was a composite of cardiovascular death, non-procedural myocardial infarction (MI), stroke and unplanned revascularisation. Results A total of 108 patients underwent PCI and 26 CABG. Mean follow-up was 1177±384 days in the PCI cohort and 1201±349 days in the CABG cohort (p=0.77). Baseline demographics did not differ significantly with the exception of chronic kidney disease and CAD involving 3 vessels (tables 1 & 2). In the PCI cohort advanced calcium modification (intravascular lithotripsy or rotablation) was performed in 11.1% of procedures and intravascular imaging in 58.3%. The mean number of stents used was 3.3±1.5 and total stent length was 97.0±47.5mm. The 3-year MACCE rate was 14.3% in the PCI cohort and 11.5% in the CABG cohort (p=0.76) (figure 1). 3-year cardiovascular death (PCI 2.8% vs CABG 0.0%, p=0.39) and unplanned revascularisation (PCI 11.5% vs CABG 7.9%, p=0.62) rates were numerically higher with PCI, whereas non-procedural MI (PCI 6.6% vs CABG 7.7%, p=0.85) and stroke (PCI 0.9% vs CABG 3.8%, P=0.27) rates were numerically higher with CABG. None of these differences met statistical significance. The incidence of stent thrombosis at 1-year was 1.9% in the PCI cohort. PCI resulted in a reduction in total length of stay (10.9±4.9 days in the inpatient PCI vs 34.3±15.5 days in the inpatient CABG cohorts, p<0.001). Conclusions This study demonstrated no difference in MACCE between revascularisation modalities in patients with complex CAD deemed to be clinically equipoised following HT discussion. These results suggest that PCI is non-inferior to CABG in this population and provide validation to the decision making process of the HT in real life. Conflict of Interest nil

Purpose: Congenital heart disease (CHD) is the most common live birth defect and a proportion of these patients have chronic hypoxia. Chronic hypoxia leads to secondary erythrocytosis resulting in microvascular dysfunction and increased thrombosis risk. The conjunctival microcirculation is easily accessible for imaging and quantitative assessment. It has not previously been studied in adult CHD patients with cyanosis (CCHD). Methods: We assessed the conjunctival microcirculation and compared CCHD patients and matched healthy controls to determine if there were differences in measured microcirculatory parameters. We acquired images using an iPhone 6s and slit-lamp biomicroscope. Parameters measured included diameter, axial velocity, wall shear rate and blood volume flow. The axial velocity was estimated by applying the 1D + T continuous wavelet transform (CWT). Results are for all vessels as they were not sub-classified into arterioles or venules. Results: 11 CCHD patients and 14 healthy controls were recruited to the study. CCHD patients were markedly more hypoxic compared to the healthy controls (84% vs 98%, p = 0.001). A total of 736 vessels (292 vs 444) were suitable for analysis. Mean microvessel diameter (D) did not significantly differ between the CCHD patients and controls (20.4 +/- 2.7 mu m vs 20.2 +/- 2.6 mu m, p = 0.86). Axial velocity (Va) was lower in the CCHD patients (0.47 +/- 0.06 mm/s vs 0.53 +/- 0.05 mm/s, p = 0.03). Blood volume flow (Q) was lower for CCHD patients (121 +/- 30pl/s vs 145 +/- 50pl/s, p = 0.65) with the greatest differences observed in vessels >22 mu m diameter (216 +/- 121pl/s vs 258 +/- 154pl/s, p = 0.001). Wall shear rate (WSR) was significantly lower for the CCHD group (153 +/- 27 s(-1)vs 174 +/- 22s(-1), p = 0.04). Conclusions: This iPhone and slit-lamp combination assessment of conjunctival vessels found lower axial velocity, wall shear rate and in the largest vessel group, lower blood volume flow in chronically hypoxic patients with congenital heart disease. With further study this assessment method may have utility in the evaluation of patients with chronic hypoxia.