Background We retrospectively evaluated in-hospital and overall outcome of patients who received mitral valve replacement (MVR) after failed MitraClip procedure. Methods A total of 26 out of 740 patients received MVR after treatment with MitraClip between June 2010 and December 2020. We analyzed in-hospital mortality and overall mortality during the median follow-up period of 72 days after MVR. Results The median age in the entire cohort was 77.5 years. In-hospital mortality was 15.4% ( n = 4) and the overall mortality during the follow-up period was 27% ( n = 7). The median time between the MitraClip procedure and surgery was 34.5 days. The main reasons for surgery were mitral stenosis (23.1%), persistent prolapse of the mitral valve leaflets (42.3%), and persistent tethering of the mitral valve leaflets (34.6%). At the time of surgery all of the patients presented with New York Heart Association 3 and above. The underlying mitral valve pathology was mainly secondary 61.5% ( n = 16). Median left ventricular end-diastolic diameter was 60 mm. Preoperative ejection fraction was 40% and above in 73% of the cohort. In addition to the mitral valve procedure, 57.7% of patients received either concomitant tricuspid annuloplasty, aortic valve surgery, ascending aortic replacement, or coronary artery bypass grafting. Conclusion The need for MVR for failed MitraClip repair is low and the results are acceptable. However, remaining options for reconstruction are usually limited and MVR is often needed. Anticipating success or failure according to the underlying pathology more than according to concomitant risk factors should form the basis in decision making for the treatment modality of first choice.

BACKGROUND:Residual mitral regurgitation (MR) is thought to be an important predictor of long-term survival following transcatheter edge-to-edge repair (TEER). Intraprocedural MR assessment using transesophageal echocardiography could be limited by image quality, hemodynamics, and patient sedation. The MitraScore is a validated multimodal approach for intraprocedural MR assessment during TEER. OBJECTIVES:This study aimed to assess the impact of residual MR using the MitraScore on 1-year mortality. METHODS:Patients undergoing mitral TEER were eligible for inclusion in the prospective, multicenter MITRA-PRO registry (A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation). Patients with a MitraScore ≤3 were defined as patients with mild residual MR after mitral TEER, whereas a MitraScore ≥4 was considered as relevant residual MR. Mortality, rehospitalization, and major adverse events were assessed 1 year after TEER. RESULTS:A MitraScore ≤3 was found in 1,059 patients (71.0%), whereas 432 patients revealed a MitraScore ≥4 (29.0%). One-year mortality was significantly lower in patients with nonrelevant residual MR (MitraScore ≤3 14.6% vs MitraScore≥4 22.1%). An almost linear relationship between intraprocedural MitraScore after TEER and mortality was observed. The combined clinical endpoint of mortality and rehospitalization within the 1-year follow-up was also significantly lower in the MitraScore ≤3 group (31.5%) than in the MitraScore ≥4 group (40.8%). A subgroup analysis confirmed the predictive value of the MitraScore in patients with primary, secondary, or mixed MR etiologies. CONCLUSIONS:Residual MR assessed by intraprocedural MitraScore after TEER predicts 1-year mortality and rehospitalization. Therefore, the multimodal MitraScore improves MR assessment during mitral TEER and might improve patient survival.(A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation [MITRA-PRO]; DRKS00012288).

Percutaneous coronary intervention (PCI) of unprotected distal left main stenosis (UDLM) is increasingly performed as an alternative to surgical treatment. The optimal strategy for stenting in this setting is still a matter of debate. Therefore, this analysis investigated the long-term clinical outcome of a single- versus a double-stenting strategy for treatment of UDLM.

OBJECTIVES The aim of this study was to investigate whether percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) improves left ventricular function. BACKGROUND The benefit of PCI in CTOs is still controversial. METHODS Patients with CTOs who were candidates for PCI were eligible for the study and were randomized to PCI or no PCI of CTO. Relevant coexisting non-CTO lesions were treated as indicated. Patients underwent cardiac magnetic resonance imaging at baseline and at 6 months. The primary endpoint was the change in segmental wall thickening (SWT) in the CTO territory. Secondary endpoints were improvement of regional watt motion and changes in Left ventricular volumes and ejection fraction. Furthermore, major adverse coronary events after 12 months were assessed. RESULTS The CTO PCI group comprised 101 patients and the no CTO PCI group 104 patients. The change in SWT did not differ between the CTO PCI (4.1% [interquartile range: 14.6 to 19.3]) and no CTO PCI (6.0% [interquartile range: 8.6 to 6.0]) groups (p = 0.57). Similar results were obtained for other indexes of regional and global left ventricular function. Subgroup analysis revealed that only in patients without major non-CTO lesions (basal SYNTAX [Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery] score <= 13) CTO PCI was associated with larger improvement in SWT than no CTO PCI (p for interaction 0.002). Driven by repeat intervention, major adverse coronary event rates at 12 months were significantly tower in the CTO PCI group (16.3% vs. 5.9%; p = 0.02). CONCLUSIONS No benefit was seen for CTO PCI in terms of the primary endpoint, SWT, or other indexes of left ventricular function. CTO PCI resulted in clinical benefit over no CTO PCI, as evidenced by reduced major adverse coronary event rates at 12 months. (C) 2018 by the American College of Cardiology Foundation.

AIMS:In percutaneous coronary intervention for de-novo coronary bifurcation lesions, the optimal technique for provisional side-branch stenting is still a matter of debate. We tested whether in this setting culotte stenting reduces the incidence of restenosis as compared with T-and-protrusion (TAP) stenting.METHODS AND RESULTS:This trial included 300 patients with a coronary bifurcation lesion requiring a side-branch stent. Patients were randomly assigned to culotte stenting or TAP stenting using drug-eluting stents in a 1:1 fashion. Primary endpoint was maximal per cent diameter stenosis of the bifurcation lesion at 9-month angiographic follow-up. As clinical endpoints we assessed target lesion re-intervention (TLR) and target lesion failure (composite of cardiac death, target vessel myocardial infarction, and TLR).Angiographic follow-up was available in 91% of the patients. After culotte stenting, the maximum per cent diameter stenosis in the treated bifurcation lesion was 21 ± 20% as compared with 27 ± 25% after TAP stenting (P = 0.038). The respective corresponding binary restenosis rates were 6.5 and 17% (P = 0.006). The 1-year incidence of TLR was 6.0% after culotte stenting vs. 12.0% after T-stenting (P = 0.069). Target lesion failure occurred in 6.7% of the culotte group and in 12.0% of the TAP group (P = 0.11). Only one patient of the culotte group incurred a definite stent thrombosis during 1-year follow-up.CONCLUSIONS:Compared with the TAP stenting, culotte stenting was associated with a significantly lower incidence of angiographic restenosis.

There is increasing evidence that various types of drug-eluting stents (DES) may differ regarding the long-term safety and efficacy, particularly in complex lesion subsets.

To investigate the prognostic relevance of elevated Troponin T (cTnT) levels in patients with ST-segment elevation myocardial infarction (STEMI) without significant creatine kinase (CK) elevation on admission.

AIMSPreviously, we reported that the nine-month angiographic result after treatment of coronary bifurcation lesions with provisional T-stenting was not significantly different from that with routine T-stenting. To compare long-term clinical outcomes of the two stenting strategies, we extended the follow-up of our study on bifurcation stenting.METHODS AND RESULTSOne hundred and one patients with coronary bifurcation lesions had been randomly assigned to provisional T-stenting and 101 to routine T-stenting, using sirolimus-eluting stents. We performed complete five-year follow-up. The primary efficacy endpoint was the incidence of target lesion revascularisation (TLR), and the primary safety endpoint was the incidence of definite/probable stent thrombosis (ST). We also monitored death, myocardial infarction (MI) and MACE (composite of death, MI and TLR). The cumulative five-year incidence of TLR in the provisional T-stenting arm was not significantly different from that in the routine T-stenting arm (16.2% vs. 16.3%, p=0.97). The same was true for MACE (22.8% vs. 22.9%, p=0.91), the composite of death and MI (9.9% vs. 13.9%, p=0.40), and ST (2.0% vs. 5.1%; p=0.25).CONCLUSIONSDuring five-year follow-up, routine T-stenting offered no advantage over provisional T-stenting with respect to TLR or MACE. ClinicalTrials.gov Identifier: NCT00288535

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 7, No. 6Near-Fatal Coronary Artery Spasm During Cryoballoon Pulmonary Vein Isolation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBNear-Fatal Coronary Artery Spasm During Cryoballoon Pulmonary Vein IsolationAn Unreported Complication Heiko Lehrmann, MD, Clemens Potocnik, MD, Thomas Comberg, MD, Wolfgang Peck, MD, Alaa Salama, MD, Jens Schneider, Tech, Chan-il Park, MD, Amir S. Jadidi, MD, Reinhold Weber, MD and Thomas Arentz, MD Heiko LehrmannHeiko Lehrmann From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Clemens PotocnikClemens Potocnik From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Thomas CombergThomas Comberg From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Wolfgang PeckWolfgang Peck From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Alaa SalamaAlaa Salama From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Jens SchneiderJens Schneider From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Chan-il ParkChan-il Park From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Amir S. JadidiAmir S. Jadidi From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. , Reinhold WeberReinhold Weber From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. and Thomas ArentzThomas Arentz From the Departments of Cardiology (H.L., C.P., T.C., J.S., C.-i.P., A.S.J., R.W., T.A.), Surgery (W.P.), and Anesthesiology (A.S.), University Heart Center Freiburg/Bad Krozingen, Bad Krozingen, Germany. Originally published1 Dec 2014https://doi.org/10.1161/CIRCEP.114.001788Circulation: Arrhythmia and Electrophysiology. 2014;7:1273–1274Case ReportA 50-year-old nonsmoker with paroxysmal atrial fibrillation was referred to our hospital for pulmonary vein isolation (PVI). He had a known 1-vessel coronary artery disease. Because of stable angina, a drug-eluting stent had been implanted into the midportion of the left anterior descending artery in 2010. Otherwise he was healthy. His medical treatment included warfarin, sotalol, an angiotensin-converting enzyme-inhibitor and a statin. Cryoballoon-PVI (Arctic Front Advance 28 mm; Medtronic) was scheduled under general anesthesia (international normalized ratio, 2–9; minimal activated clotting time, 300 s). After transseptal access, the left PV were targeted first, followed by the right inferior PV and right superior PV, respectively. PVI of all PVs could be visualized in real-time and gained within 40 s. Two freeze–thaw cycles were used for each PV, except for the left superior PV, which had to be treated 3×, because of an initially ineffective freeze (Table I in the Data Supplement). The procedure had been uneventful, until a sudden blood pressure drop occurred (70/40 mm Hg), immediately after the second right superior PV-freeze. Cardiac tamponade was excluded. Twelve-lead ECG revealed global ST-depression and progressive ST-elevation in aVR, consistent with coronary main stem occlusion (Figure 1). Pulseless electric activity developed rapidly, necessitating cardiopulmonary resuscitation. Coronary angiography showed a severe spasm of the left coronary main stem, without evidence for air- or thromboembolism (Figure 2A), which could be completely reverted by balloon dilatation and intracoronary nitroglycerine administration (Figure 2B). The right coronary artery showed a less severe spasm, which was treated by nitroglycerine alone (Figure 3A and 3B). Immediately after coronary reperfusion, ventricular fibrillation occurred, affording several direct current shocks. Because of severe global myocardial stunning, without effective myocardial contractions, an extracorporeal cardiac life support system (veno-arterial extracorporeal cardiac life support system) had to be implanted. Myocardial stunning reverted completely during the following 5 days, and the patient could be weaned from the extracorporeal cardiac life support system. He survived without any major focal neurologic deficit, but impairment of short-term memory was apparent during follow-up. Predischarge echocardiography showed normal biventricular function without wall motion abnormalities. About the used cryoballoon device, the manufacturer excluded a technical malfunction.Download figureDownload PowerPointFigure 1. Progressive ECG changes during cryoballoon-pulmonary vein isolation (PVI). ECG tracings during the procedure are shown in chronological order. Left, The resting ECG at the beginning of the procedure. The following panels depict progressive ECG changes after ablation of the respective PVs (minor changes are marked with an arrow). Right, The ECG directly before cardiac arrest.CPR indicates cardiopulmonary resuscitation; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; and RSPV, right superior pulmonary vein.Download figureDownload PowerPointFigure 2. Left main stem spasm. A, Coronary angiography detects severe left main stem spasm as the cause of cardiac arrest. Of the contrast-filled aorta, a filiformatous left main stem originates (white circle). The left anterior descending and circumflex artery are nearly unvisible. The white arrow shows a stent in the anterior descending artery. B, Coronary angiography after balloon dilatation of the left main stem and intracoronary nitroglycerine injection shows normal left coronary arteries.Download figureDownload PowerPointFigure 3. Less severe spasm in the right coronary artery. A, Coronary angiography of the right coronary artery also shows minor spasm. B, After intracoronary injection of nitroglycerine the spasm resolves completely.DiscussionIn this case report, to date, we describe an unreported serious complication of a near-fatal coronary artery main stem spasm during cryoballoon-PVI. We suspect cryoenergy-induced blood cooling, as the most likely trigger, rather than a direct ablation effect, given the distance between the pulmonary veins and the left main stem (Figure I in the Data Supplement). Further evidence for this theory is provided in Figure 1, which retrospectively showed progressive development of T wave inversion and ST depression in the 12-lead ECG, already starting after the first cryoenergy application. These changes were not noticed earlier because the procedure was performed using only a limited number of real-time monitored ECG leads (I, III, aVF, V1, V6). Furthermore, the Manufacturer and User Facility Device Experience-database of the US Food and Drug Administration (FDA MAUDE-database), lists 4 additional adverse events related to ST-segment changes with hemodynamic deterioration during cryoballoon-PVI.1 Noteworthy, only 2 of these 4 patients survived. Despite scarce details, a coronary vasospasm (left anterior descending and right coronary artery, respectively) occurred in ≥2 of these cases. Therefore, we suspect cold-induced coronary vasospasm as the unifying mechanism in susceptible patients, analogous to the formerly used cold pressure test to induce coronary vasospasm.2As a consequence, cryoballoon-PVI should not be performed in patients with known or suspected coronary artery vasospasm. In addition, the 12-lead ECG should be continuously monitored throughout the procedure with special attention to ischemic changes. This case report also stresses the need for an onsite surgical support to prevent fatality in such cases. Additional studies will be needed to assess the incidence of this potentially fatal complication and to guide proper patient selection for cryoballoon PVI.DisclosuresNone.FootnotesThe Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.114.001788/-/DC1.Correspondence to Heiko Lehrmann, MD, Arrhythmia Department, University Heart Center Freiburg/Bad Krozingen, Südring 15, 79189 Bad Krozingen, Germany. E-mail [email protected]References1. www.fda.gov/MedicalDevices/Safety.Google Scholar2. Raizner AE, Chahine RA, Ishimori T, Verani MS, Zacca N, Jamal N, Miller RR, Luchi RJ. Provocation of coronary artery spasm by the cold pressor test. Hemodynamic, arteriographic and quantitative angiographic observations.Circulation. 1980; 62:925–932.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByReddy V, Petru J, Funasako M, Kopriva K, Hala P, Chovanec M, Janotka M, Kralovec S and Neuzil P (2022) Coronary Arterial Spasm During Pulsed Field Ablation to Treat Atrial Fibrillation, Circulation, 146:24, (1808-1819), Online publication date: 13-Dec-2022. Hachisuka M, Fujimoto Y, Oka E, Hayashi H, Yamamoto T, Murata H, Yodogawa K, Iwasaki Y, Hayashi M, Miyauchi Y and Shimizu W (2021) Perioperative coronary artery spasms in patients undergoing catheter ablation of atrial fibrillation, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-021-01089-6, 64:1, (77-83), Online publication date: 1-Jun-2022. Miyazaki S (2021) Cryoballoon atrial fibrillation ablation experience in Japan, Current Opinion in Cardiology, 10.1097/HCO.0000000000000910, 37:1, (68-73), Online publication date: 1-Jan-2022. Klaver M, De Potter T, Iliodromitis K, Babkin A, Cabrita D, Fabbricatore D and Boersma L (2021) Ultralow temperature cryoablation using near‐critical nitrogen for cavotricuspid isthmus‐ablation, first‐in‐human results, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15142, 32:8, (2025-2032), Online publication date: 1-Aug-2021. Miyazaki S, Kobori A, Sasaki Y, Miyamoto K, Sato E, Hanazawa K, Morishima I, Kanzaki Y, Yamaji H, Yamao K, Kondo Y, Watanuki M, Kaneshiro T, Uchiyama T, Nakamura K, Hiramatsu S, Nakajima J, Arimoto T, Kaneko S, Osai N, Takagi T, Kaseno K, Takahashi A, Naito S, Kobayashi Y, Hachiya H, Kusano K, Yagi T, Iesaka Y and Tada H (2021) Real-World Safety Profile of Atrial Fibrillation Ablation Using a Second-Generation Cryoballoon in Japan, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2020.11.016, 7:5, (604-613), Online publication date: 1-May-2021. Tsushima T, Osman M, Josephson R and Thal S (2020) First case report: Late‐onset coronary artery spasm after radiofrequency catheter ablation for atrial fibrillation in a Caucasian patient, Clinical Case Reports, 10.1002/ccr3.2977, 8:9, (1786-1790), Online publication date: 1-Sep-2020. Guragai N, Rampal U, Vasudev R, Bhandari P, Prakash A, Virk H, Bikkina M and Fayez S (2020) Coronary vasospasm complicating atrial fibrillation ablation: a case report and review of the literature, Journal of Community Hospital Internal Medicine Perspectives, 10.1080/20009666.2020.1774252, 10:4, (346-349), Online publication date: 3-Jul-2020. Furui K, Morishima I, Kanzaki Y and Tsuboi H (2019) Coronary vasospasm caused by intravenous infusion of dexmedetomidine: Unrecognized pitfall of catheter ablation procedures of atrial fibrillation, Journal of Cardiology Cases, 10.1016/j.jccase.2019.08.010, 20:6, (221-224), Online publication date: 1-Dec-2019. Yajima K, Yamase Y, Oishi H, Ikehara N and Asai Y (2018) Coronary Artery Spasm during Cryoballoon Ablation in a Patient with Atrial Fibrillation, Internal Medicine, 10.2169/internalmedicine.9305-17, 57:6, (819-822), . Kaneshiro T, Matsumoto Y, Nodera M, Kamioka M, Suzuki H and Takeishi Y (2017) Spastic occlusion of coronary artery during cryoballoon pulmonary vein isolation, HeartRhythm Case Reports, 10.1016/j.hrcr.2017.08.001, 3:11, (509-512), Online publication date: 1-Nov-2017. Makimoto H, Kelm M, Shin D and Blockhaus C (2017) Breakage of a Circular Catheter Wedged in a Right Pulmonary Vein during Cryoballoon Pulmonary Vein Isolation, Internal Medicine, 10.2169/internalmedicine.56.7924, 56:9, (1057-1059), . Watanabe T, Hachiya H, Miyazaki S, Nakamura H, Taniguchi H and Iesaka Y (2016) Recurrent and late-onset coronary spasms after cryoballoon ablation procedure in a patient with atrial fibrillation, HeartRhythm Case Reports, 10.1016/j.hrcr.2016.05.008, 2:5, (421-424), Online publication date: 1-Sep-2016. December 2014Vol 7, Issue 6 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.114.001788PMID: 25516586 Manuscript receivedApril 18, 2014Manuscript acceptedMay 23, 2014Originally publishedDecember 1, 2014 Keywordscoronary vasospasmablation techniquesPDF download Advertisement SubjectsCatheter Ablation and Implantable Cardioverter-Defibrillator

OBJECTIVES:This study sought to assess aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) with the self-expandable Medtronic CoreValve (MCV) (Medtronic Inc., Minneapolis, Minnesota) versus balloon-expandable Edwards Sapien XT valve (ESV) (Edwards Lifesciences, Irvine, California). BACKGROUND:AR after TAVI has been associated with poor survival, but limited data exist comparing MCV with ESV. METHODS:We pooled the prospective TAVI databases of 2 German centers. The primary endpoint was more-than-mild post-TAVI AR assessed by echocardiography. We also assessed device success and survival within 1 year. Endpoints were adjudicated according to the Valve Academic Research Consortium criteria and analyzed by unadjusted and propensity-score-adjusted models. RESULTS:A total of 394 patients were included, 276 treated with MCV and 118 with ESV. More-than-mild AR was significantly higher with MCV than with ESV (12.7% vs. 2.6%, p = 0.002). This difference remained significant after propensity adjustment (adjusted odds ratio [OR]: 4.59, 95% confidence interval [CI]: 1.03 to 20.44). The occurrence of any degree of AR was also higher with MCV (71.6% vs. 56.9%, p = 0.004). Device success was mainly influenced by the occurrence of AR and was consequently higher with ESV (95.8% vs. 86.6%, p = 0.007), but this was not significant after propensity adjustment (adjusted OR: 0.34, 95% CI: 0.11 to 1.03, p = 0.06). At 1 year, survival was comparable between both valve types (83.8% MCV vs. 88.2% ESV, p = 0.42), but was significantly worse in patients with more-than-mild AR (69.8% vs. 87.4%, p = 0.004) and in those with device failure (65.6% vs. 87.4%, p < 0.001). CONCLUSIONS:More-than-mild AR after TAVI was more frequent with MCV than with ESV. This finding deserves consideration, as more-than-mild AR was associated with higher mortality at 1 year.

Purpose: Despite advancements in recanalization technique there is limited data on prognosis after percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTOs) in the era of drug-eluting stents (DES). Methods: We evaluated long-term mortality in 1642 consecutive patients who underwent elective PCI of a CTO in our center between 01/2005 and 12/2011. Median follow-up was 3.0 years (interquartile range 1.1–3.8 years). Procedural success was defined as <30% residual diameter stenosis of the CTO lesion after DES implantation. Survival was assessed with unadjusted and adjusted Cox proportional hazard models. Results: Mean age was 65.8±11 years, 18% were female, 28% diabetics, 17% had a serum creatinin >1.3mg/dl, 11% a prior coronary bypass operation, 24% a previous myocardial infarction and 17% a left ventricular ejection fraction <40%. Procedural success was obtained in 1216 (74.1%) patients with a stent rate of 96.2%. Of the stents implanted 92% were DES. Patients with procedural success compared to failure were younger and had less often a previous coronary bypass operation. After multivariable adjustment procedural success was independently predictive for reduced long-term mortality (adjusted HR 0.56; 95% CI 0.38–0.81; p=0.003). Figure shows adjusted 3-years mortality from any cause. Conclusion: Successful recanalization of a CTO is an independent predictor for reduced long-term mortality.

Purpose: There is limited data on prognosis after percutaneous coronary intervention (PCI) for chronic total coronary occlusions (CTOs) in multi-vessel disease. Methods: Between 01/2005 and 12/2011 we performed elective PCI of a CTO in 1642 consecutive patients. Median follow-up was 3.0 (1.1,3.8) years. CTO patients were assigned to coronary one/two vessel disease (1+2VD) or three vessel disease (3VD). Procedural success was defined as <30% residual diameter stenosis of the CTO lesion after drug eluting stent implantation. All-cause mortality was assessed with adjusted Cox proportional hazard models. Results: Of the CTO patients 757 (46%) had 1+2VD and 885 (54%) had 3VD. Patients with 3VD compared to 1+2VD were older (67.3±11 vs. 64.0±11; p<0.001), had higher serum creatinine (1.10±0.6 vs. 1.03±0.6; p=0.033), more often diabetes (33.5% vs. 25.8%; p<0.001), left ventricular ejection fraction (LVEF) <40% (25.2% vs. 16.7%; p<0.001), previous myocardial infarction (25.9% vs. 17.8%; p<0.001) or coronary bypass operation (19.1% vs. 2.6%; p<0.001). Procedural success was lower in 3VD compared to 1+2VD (70.9% vs. 78.5%; p<0.001). Total long-term mortality for 3VD and 1+2VD was (21.4% and 15.6%; p=0.003). After multivariable adjustment for relevant covariates (age, serum creatinine, LVEF <40%) procedural success remained an independent predictor for reduced long-term mortality in patients in 3VD (adjusted HR 0.50; 95% CI 0.31-0.81; p=0.004) but not in patients in 1+2VD (adjusted HR 0.71; 95% CI 0.37-1.35; p=0.3) [Figure]. Figure 1 Conclusion: Successful recanalisation of a CTO is a strong independent predictor for reduced long-term mortality in patients with 3VD but not with 1+2VD. So there is an enhanced prognostic effect of recanalisation success for CTO patients with more extensive coronary artery disease.

Angiograms of cardiac transplant (HTx) recipients were to be evaluated in a ring experiment and a joint consensus on criteria of angiographic evaluation of coronary arteries of HTx patients was to be reached. Twenty-four coronary angiograms from 11 hospitals were circulated. One hundred eighty-eight blinded evaluations were returned. A joint evaluation by six experienced cardiologists was used as reference standard and a consensus evaluation form was developed. Significant lesions (stenosis 75%, 50% in the left main coronary artery) were diagnosed in 10/23 abnormal coronary angiograms (41.7%). Interventional revascularization was recommended in 8/10 (80%). In 21 coronary angiograms distal pruning was found and in 11/21 (52.4%) cases with distal pruning occlusion of at least one peripheral vessel was detected. The best kappa value (0.7) was found for the presence of at least one clinically significant stenosis. Agreement on the site and grade of local stenosis was much less. Some agreement on remodeling was found in assessing diffuse narrowing in the LCA (kappa=0.371, P<0.001). The kappa value for peripheral obliteration was 0.331 (P=0.001). Angiographic evaluation of cardiac allograft vasculopathy, particularly of diffuse and peripheral disease and remodeling, needs standardization. This should be performed in a downward compatible improvement process.

Background The purpose of this study was to assess the long-term risks and benefits of drug-eluting stents (DESs) compared with bare-metal stents (BMSs) for treatment of coronary bifurcation lesions.Methods Our registry comprised 1,038 patients treated for coronary bifurcation lesion according to the provisional T-stenting strategy who were followed up for 3 years.Results Target lesion revascularization rates were 24.3% for BMSs (n = 337), 15.6% for sirolimus-eluting stents (SESs, n = 422), and 17.3% for paclitaxel-eluting stents (PESs, n = 279) (P = .003 BMSs vs DESs, P = .54 SESs vs PESs). The respective incidences were 11.4%, 9.5%, and 14.8% (P = .65, P = .13) for death and myocardial infarction and 9.9%, 6.5%, and 10.6% (P = .72, P = .19) for death. Propensity score adjusted hazard ratios (95% CI) for DESs versus BMSs were 0.49 (0.35-0.68, P < .001) for target lesion revascularization, 0.94 (0.64-1.40, P = .078) for death and myocardial infarction, and 0.85 (0.55-1.32, P = .47) for death. We did not find any significant differences between SESs and PESs, except for an increased risk of death after PESs compared with SESs (but not BMSs) in the subgroup receiving a side-branch stent (adjusted hazard ratio 2.45, 95% CI 1.05-5.73, P = .035).Conclusions Compared with BMSs, both PESs and SESs substantially reduced the long-term need for repeated revascularization but did not increase the risk of death and myocardial infarction. (Am Heart J 2010; 159:454-61.)

We investigated whether routine T-stenting reduces restenosis of the side branch as compared with provisional T-stenting in patients with de novo coronary bifurcation lesions.Our randomized study assigned 101 patients with a coronary bifurcation lesion to routine T-stenting with sirolimus-eluting stents (SES) in both branches and 101 patients to provisional T-stenting with SES placement in the main branch followed by kissing-balloon angioplasty and provisional SES placement in the side branch only for inadequate results. Primary endpoint was per cent diameter stenosis of the side branch at 9 month angiographic follow-up. Angiographic follow-up in 192 (95%) patients revealed a per cent stenosis of the side branch of 23.0 +/- 20.2% after provisional T-stenting (19% with side-branch stent) and of 27.7 +/- 24.8% (P = 0.15) after routine T-stenting (98.2% with side-branch stent). The corresponding binary restenosis rates were 9.4 and 12.5% (P = 0.32), prompting re-intervention in 5.0 and 7.9% (P = 0.39), respectively. In the main branch, binary restenosis rates were 7.3% after provisional and 3.1% after routine T-stenting (P = 0.17). The overall 1 year incidence of target lesion re-intervention was 10.9% after provisional and 8.9% after routine T-stenting (P = 0.64).Routine T-stenting with SES did not improve the angiographic outcome of percutaneous coronary intervention of coronary bifurcation lesions as compared with stenting of the main branch followed by kissing-balloon angioplasty and provisional side-branch stenting.