Abstract Background Coronary microvascular dysfunction (CMD) plays an important role in the pathogenesis of ischemia and non-obstructive coronary arteries (MINOCA) and heart failure with preserved ejection fraction (HFpEF). Left atrial strain (LAS) evaluation by transthoracic echocardiography (TTE) was proposed as a new diagnostic method to assess left ventricular dysfunction and HFpEF. However, its implementation into the diagnostic workup of INOCA has never been evaluated. Purpose The primary objective of the study was to evaluate the frequency of HFpEF in patents with INOCA using LAS as a marker of left ventricular dysfunction. The secondary objective was to assess the association between coronary microcirculatory resistance, LAS and HFpEF. Methods MOSAIC-COR is a single-center, prospective, observational registry of patents with INOCA diagnosed with pressure wire-based comprehensive coronary physiology assessment and provocative test with acetylcholine. In the absence of significant coronary artery stenosis CFR and IMR was calculated in LAD using thermodilution to assess CMD. Serum levels of NT-proBNP and LAS indexes (LA reservoir strain, LA contraction strain, LA conduit strain) were calculated to diagnose HFpEF according to EACVI consensus document published in the year 2022. Results We assessed 63 patients with INOCA, 35% male. Median age was 67 years. Baseline clinical characteristics of the study group is presented in Table. Coronary microvascular dysfunction was diagnosed in 37 patents (59%) and HFpEF was diagnosed in 15 patents (24%) . Worse left atrium reservoir strain was connected with higher value of IMR (P < 0.001) and higher level of NT-proBNP (P < 0.001). Worse left atrium conduit strain was connected with higher value of IMR (P = 0.04). Left atrium contraction strain was connected with higher level of NT-proBNP (P < 0.001) (Figure). Conclusions Confirmation of HFpEF in 24% of INOCA opens new therapeutic option for this group of patents. Association between microvascular resistance and left atrium strain may reflect pathophysiological connection between INOCA and HFpEF. Implementation of SGLT-2 inhibitors in the treatment of CMD with and without INOCA require further evaluation.

Abstract Background Patients with ischemia and non-obstructive coronary arteries (INOCA) account for 30–70% of all patients undergoing elective coronary angiography for angina. In these group of patients various mechanisms may be responsible for myocardial ischemia, including increased microvascular resistance, epicardial spasm or microvascular spasm. There are limited data on the prevalence and coexistence of different mechanisms in patients with INOCA. Purpose The primary objective was to assess the occurrence of coronary microcirculatory disease (CMD), epicardial vasospastic angina (EVSA), microvascular vasospastic angina (MVSA) and their coexistance in patients with INOCA. The secondary objective was the analysis of subgroups' clinical characteristics. Methods This was a single-center, prospective, observational study. In the absence of significant coronary artery stenosis, a complex functional coronary assessment was performed. Values of fractional flow reserve (FFR), RFR, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were determined. Coronary artery and microvascular vasoreactivity was tested using the provocative acetylcholine test. Results We enrolled 90 consecutive patients with INOCA. Overlapping of CMD and CMD/EVSA phenomenon was observed. Accordingly, we distinguished 6 subgroups of INOCA patients in comparison to the CorMicA trial. Mixed pathophysiology (CMD+EVSA and CMD+MVSA) was diagnosed in 33% of patients. In the CMD+EVSA subgroup, 73% of subjects were male, while in the CMD+MVSA only 7.1% were male (p=0.005). Typical cardiovascular risk factors were common in the whole INOCA group. Conclusions The INOCA population is a heterogeneous group with various pathophysiology of myocardial ischemia. Overlapping of different pathomechanisms is a frequent phenomenon, which has to be consider for treatment optimization and future research. Funding Acknowledgement Type of funding sources: None.

Abstract Background Shortage of endovascular operators able to deliver manual thrombectomy in acute ischemic stroke (AIS) on a 24/7/365 basis is a main challenge in many health care settings around the world. Another fundamental barrier is getting multispecialy teams to work collaboratively with each other in AIS as is already done (albeit on an elective rather than acute basis and in absence of “territorial” issues) in managing stroke mechanistic pathologies such as atrial fibrillation (pharmacology/ablation) or PFO (diagnosis/closure). Purpose To establish a practical path towards a clinically and orranizationally effective cardiology cathlab-based acute ischaemic stroke service, including intracranial manual thrombectomy, in a large multi-specialty hospital with a high-volume stroke unit but absence of neuroradiology service. Methods Withn a symptomatic and increased-stroke-risk asymptomatic carotid stenosis all-comer endovascular revascularization study (NeuroVascular Team decision-making) we have treated, on an emergent basis, 17 patients (13 men, age 58–75 years, median 67 years) with AIS caused by severe thrombotic carotid artery stenoses. All cases were performed as part of our pathway towards a full 24/7 thrombectomy stroke service. Results All lesions (100%) were thrombotic (mobile thrombus - 29%). Proximal neuroprotection (flow reversal using a common carotid artery±external carotid artery occlusive balloon/s) was used in 15/17 patients (88%). In 2 patients (12%) filter protection was applied as proximal system use was unfeasible for anatomic or clinical reasons. All cases were done under activated clotting time control and using a micronet-covered embolic prevention stent system that was routinely optimized -under an effective neuroprotection- with large balloons/high pressures. There were no procedure- or device-related complications. TIMI/TICI-3 was achieved in all cases. Vascular access closure device use was 76%. A 30-day good clinical outcome (mRS of 0–2) rate was 94%. One patient had a haemorrhagic stroke transformation that finally led to death. By 30 days no new stroke, stent thrombosis, myocardial infarction or other SAE occurred Conclusions Cardiologists skilled in carotid interventions are naturally positioned to deliver AIS treatment. 24/7 interventional services and networks for acute myocardial infarction have long been established and, as demonstrated in our centre, the services and skills can be translated -in collaboration with a local stroke unit/neurology- to AIS. Breaking away from traditionally-perceived “territories” towards working as a multispecialy AIS team is a logical concept that provides an effective healthcare solution for large numbers of stroke patients currently needing -and not receving- thrombectomy. Working hand in hand with neurology and radiology in managing acute carotid syndromes is thus part of a natural evolution towards full interventional stroke services including thrombectomy. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University Medical College

Objective: Procedural characteristics, including stent design, may influence the outcome of carotid artery stenting (CAS). A thorough comparison of the effect of stent design on outcome of CAS is thus warranted to allow for optimal evidence-based clinical decision making. This study sought to evaluate the effect of stent design on clinical and radiologic outcomes of CAS. Methods: A systematic search was conducted in MEDLINE, Embase, and Cochrane databases in May 2018. Included were articles reporting on the occurrence of clinical short-and intermediate-term major adverse events (MAEs; any stroke or death) or radiologic adverse events (new ischemic lesions on postprocedural magnetic resonance diffusion-weighted imaging [MR-DWI], restenosis, or stent fracture) in different stent designs used to treat carotid artery stenosis. Random effects models were used to calculate combined overall effect sizes. Metaregression was performed to identify the effect of specific stents on MAE rates. Results: From 2654 unique identified articles, two randomized, controlled trials and 66 cohort studies were eligible for analysis (including 46,728 procedures). Short-term clinical MAE rates were similar for patients treated with open cell vs closed cell or hybrid stents. Use of an Acculink stent was associated with a higher risk of short-term MAE compared with a Wallstent (risk ratio [RR], 1.51; P = .03), as was true for use of Precise stent vs Xact stent (RR, 1.55; P < .001). Intermediate-term clinical MAE rates were similar for open vs closed cell stents. Use of open cell stents predisposed to a 25% higher chance (RR, 1.25; P = .03) of developing postprocedural new ischemic lesions on MR-DWI. No differences were observed in the incidence of restenosis, stent fracture, or intraprocedural hemodynamic depression with respect to different stent design. Conclusions: Stent design is not associated with short- or intermediate-term clinical MAE rates in patients undergoing CAS. Furthermore, the division in open and closed cell stent design might conceal true differences in single stent efficacy. Nevertheless, open cell stenting resulted in a significantly higher number of subclinical postprocedural new ischemic lesions detected on MR-DWI compared with closed cell stenting. An individualized patient data meta-analysis, including future studies with prospective homogenous study design, is required to adequately correct for known risk factors and to provide definite conclusions with respect to carotid stent design for specific subgroups.

Objective: To assess the frequency of cervical and intracranial arteries involvement and associated clinical symptoms in consecutive patients with renal fibromuscular dysplasia (FMD) enrolled into ARCADIA-POL study. Design and method: From 183 patients with FMD enrolled into ARCADIA-POL study since 2015 (Polish-French collaboration) all consecutive 157 patients (132F, 25 M, mean age:45.1 ± 15.1 years) with renal FMD were analyzed. All patients underwent clinical evaluation: ABPM, biochemical evaluation, biobanking, duplex Doppler of cervical and abdominal arteries and whole body angio-CT including cervical and intracranial arteries. Results: Among 157 patients with renal FMD, 38 (24.2%) had coexisting FMD lesions in cervical and/or intracranial arteries and/or intracranial aneurysms: 17 (10.8%) patients in carotid, 7 (4.5%) patients in vertebral and 24 (15.3%) patients had lesions in intracranial arteries. Dissections of carotid arteries were present in 3 (1.9%) patients and vertebral artery dissections in 3 (1.9%) patients. In 10 (6.4%) pts internal carotid artery aneurysm and in 2 (1.3%) patients vertebral artery aneurysm were found. 18 (11.5%) patients had intracranial aneurysms: 15 (9.6%) patients had one aneurysm, 2 (1.3%) pts 2 aneurysms and 1 (0.6%) patient had 3 aneurysms. Patients with and without cervical and/or intracranial FMD lesions didn’t differ in terms of age, gender, clinical and ambulatory blood pressure levels, hypertension prevalence and number of antihypertensive medications. There were no significant differences in the prevalence of symptoms such as headaches, tinnitus, dizziness and cervical bruits between the patients with and without cervical and/or intracranial FMD. There was only a significant difference in the presence of Horner's syndrome between patients with and without cervical and/or intracranial FMD (16.7% vs.1.9%; p = 0.001, respectively). There was no difference in the prevalence of stroke, transient ischemic attack or intracranial bleeding between the groups. Conclusions: There were no specific clinical features suggesting the presence of FMD lesions and vascular complications in cervical and/or intracranial arteries in patients with confirmed renal FMD included into ARCADIA-POL STUDY. Our study showed that systematic evaluation of cervical and intracranial arteries in patients with renal FMD results in revealing relatively high prevalence of FMD lesions and vascular complications in cervical and/or intracranial arteries.

Objective: To compare clinical presentation of two angiographic subtypes of renal fibromuscular dysplasia (FMD) in patients with renal FMD enrolled to ARCADIA-POL registry. Design and method: From 84 patients with confirmed FMD in any vascular bed enrolled in the ARCADIA-POL registry in 2015 (instituted on the basis of as Polish-French collaboration), we analyzed 74 patients (54F, 20 M, mean age:41.7 ± 15.2 years, range:18–72) with renal FMD. All patients underwent evaluation including ambulatory blood pressure monitoring, biochemical evaluation, biobanking, duplex Doppler of carotid and abdominal arteries and whole body angio-CT. In this analysis we divided patients into two groups according to angiographic subtypes of renal FMD lesions (Savard et al. Circulation 2012). FMD lesions were classified according to angio-CT as multifocal if there were at least 2 stenoses in the same arterial segment (Group 1); otherwise as unifocal (Group2). Results: Of 74 patients with renal FMD, 48 pts (64.9%) were classified as multifocal (Group 1) and 26 pts (35.1%) as unifocal (Group 2). Patients in Group 1 as compared to Group 2 were characterized by non-significantly higher rate of females (79.2vs.61.5%; p = 0.103). At evaluation there were no differences in age, frequency of smokers, hypertension rate, median number of antihypertensive medications, nor in office and 24-hour blood pressure values. Group 1 differed significantly from Group 2 in mean age at diagnosis of FMD (29.2 ± 14.2vs.41.0 ± 15.5 years, p = 0.003) and hypertension (23.4 ± 12.6vs.34.8 ± 14.0 years, p = 0.002). Among 27 patients in whom FMD was diagnosed at age over 40 years only 4 (14.8%) had unifocal and 20 (85.2%) had multifocal type. Group 1 were characterized by non-significantly higher proportion of patients with more than one vascular bed involved (36% vs. 54.2 %,p = 0.14). Aneurysm of renal artery was found in 10 pts with multifocal and in 3 patients with unifocal lesions (20.8% vs.11.5 %,p = 0.316). In two patients with multifocal and none of patients with unifocal FMD renal artery dissection was observed. Conclusions: A binary angiographic classification in unifocal and multifocal FMD discriminated two groups of patients with different age at diagnosis of FMD and hypertension, as well as tendency towards different proportion of multiple beds involvement and vascular complications.

Objective: To present and compare clinical characteristics of patients with fibromuscular dysplasia (FMD) in one and two or more vascular beds Design and method: 84 patients (59F, 25 M, mean age:42.5 ± 14.8 years, range:18–72) with confirmed FMD in any vascular bed were enrolled in 2015 in ARCADIA-POL registry (instituted as Polish-French collaboration). All patients underwent evaluation including ambulatory blood pressure monitoring, biochemical evaluation, biobanking, duplex Doppler of carotid and abdominal arteries and whole body angio-CT. In this analysis we divided patients into two groups according to the number of vascular beds affected – Group 1 (patients with FMD in one vascular bed) and Group 2 (patients with FMD in two or more vascular beds) Results: Of 84 patients with established FMD, 45 pts(53.6%) had one vascular bed affected (Group 1) and 39pts(46.4%) had two or more vascular bed affected (Group 2). Patients in group 2 as compared with group 1 were significantly older (46.1 ± 14.5vs.39.4 ± 14.4, p = 0.037) and were characterized by non-significantly higher rate of females (79.5vs.62.2%; p = 0.084). At evaluation there were no difference in frequency of smokers, hypertension rate, median number of antihypertensive medications, nor in office and 24-hour blood pressure values. Patients in group 2 differed significantly in median age at diagnosis of FMD (41.9 ± 14.8 vs.34.4 ± 15.9 ys, p = 0.038) and hypertension (35.9 ± 14.8 vs.27.9 ± 13.9 ys, p = 0.024) as compared to group 1. Bilateral renal artery FMD lesions were non-significantly higher in patients in group 2 (43.6% vs. 26.7%, p = 0.104). Patients in group 2 were characterized by significantly higher frequency of aneurysms in any artery (43.6vs.11.4%, p = 0.001) and non- significantly higher incidence of artery dissection (21.1%vs.9.1%, p = 0.126) as compared to group 1. There was no difference in the incidence of dissection of any artery between the groups. In multiple logistic regression analysis the only predictor of an involvement of two and more vascular beds was the presence of aneurysm Conclusions: Patients with FMD confirmed in two or more vascular bed were older and were characterized by older age at diagnosis of FMD and hypertension as well as higher incidence of aneurysm as compared to patients with FMD affecting only one vascular bed

Purpose: Recent evidence shows that blood biomarkers, in isolation, are largely ineffective in risk stratification of carotid atherosclerotic plaque (CS) symptomatic transformation. Stenosis degree is a poor marker of symptom risk while plaque morphology may play a role. Intravascular ultrasound (IVUS) provides high-resolution (axial ≤0.12mm for 20MHz transducer) imaging, but conventional phenotypic virtual histology (VH-IVUS) plaque classification poor between-center/-observer reproducibility limits any wider applicability. Moreover, conventional VH-IVUS, addressing total content of eg necrotic core (NC), does not discriminate focal vs. dissociated NC that is relevant to rupture risk. We investigated whether quantitative measures of key plaque components implicated in rupture risk are related to levels of several circulating biomarkers. Methods: We developed a novel software-based algorithm for detailed, fully-quantitative VH-IVUS analysis of key plaque components known for their role in plaque rupture/thrombosis. In 21 plaques we validated inter-transducer (2 transducers) and inter-observer (3 observers) reproducibility of qVH-IVUS analysis including minimal fibrous cap (FC) thickness, and peak confluent NC area, thickness and arc. Next we employed our qVH-IVUS algorithm to evaluate CS lesions in 252 consecutive patients (age 47–83, 63.4% men, h/o CS-attributable symptoms in 50.3%) presenting for potential CS revascularization. Finally, in the first 200 subjects we determined the levels of a panel of biomarkers and preformed regression analysis in search for quantitative CS morphology/biomarker associations. Results: qVH-IVUS revealed significant differences in minimal FC thickness (0.41±0.04 v 0.34±0.05 v 0.16±0.02 v 0.19±0.03mm), peak confl NC area (3.0±0.2 v 2.5±0.3 v 4.4±0.4 v 3.4±0.5mm2), arc (87.1±6 v 67.2±6 v 121.6±9 v 94.0±9deg) and thickness (0.88±0.04 v 1.07±0.07 v 1.34±0.06 v 1.16±0.11 mm); data for asympt CS in absence of contralat symptoms, asympt CS in presence of contralat symptoms, recently symptomatic and remotely symptomatic CS, p<0.001 for all. While hsCRP was not correlated with min FC (r=-0.24, p=0.74) or NC area (r=0.05, p=0.48), TIMP correlated with min FC (r=0.34, p=0.001). Modest though highly significant correlations were identified between Lp-PLA2 and confl NC area (r=0.3, p=0.0001), HDL and confl NC thckn (r=-0.21, p=0.002). Fibrinogen level correlated with % plaque fibrotic content (r=0.19, p=0.008). Conclusion: These findings provide novel insights into circulating biomarker/quantitative plaque morphology associations that may be relevant to plaque biology and risk.