BACKGROUNDIschemic heart disease is a major cause of out-of-hospital cardiac arrest. The role of immediate coronary angiography and percutaneous coronary intervention (PCI) in the treatment of patients who have been successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) remains uncertain. METHODSIn this multicenter trial, we randomly assigned 552 patients who had cardiac arrest without signs of STEMI to undergo immediate coronary angiography or coronary angiography that was delayed until after neurologic recovery. All patients underwent PCI if indicated. The primary end point was survival at 90 days. Secondary end points included survival at 90 days with good cerebral performance or mild or moderate disability, myocardial injury, duration of catecholamine support, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, major bleeding, occurrence of acute kidney injury, need for renal-replacement therapy, time to target temperature, and neurologic status at discharge from the intensive care unit. RESULTSAt 90 days, 176 of 273 patients (64.5%) in the immediate angiography group and 178 of 265 patients (67.2%) in the delayed angiography group were alive (odds ratio, 0.89; 95% confidence interval [CI], 0.62 to 1.27; P = 0.51). The median time to target temperature was 5.4 hours in the immediate angiography group and 4.7 hours in the delayed angiography group (ratio of geometric means, 1.19; 95% CI, 1.04 to 1.36). No significant differences between the groups were found in the remaining secondary end points. CONCLUSIONSAmong patients who had been successfully resuscitated after out-of-hospital cardiac arrest and had no signs of STEMI, a strategy of immediate angiography was not found to be better than a strategy of delayed angiography with respect to overall survival at 90 days. (Funded by the Netherlands Heart Institute and others; COACT Netherlands Trial Register number, NTR4973.

IMPORTANCE Ischemic heart disease is a common cause of cardiac arrest. However, randomized data on long-term clinical outcomes of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients successfully resuscitated from cardiac arrest in the absence of ST segment elevation myocardial infarction (STEMI) are lacking.OBJECTIVE To determine whether immediate coronary angiography improves clinical outcomes at 1 year in patients after cardiac arrest without signs of STEMI, compared with a delayed coronary angiography strategy. DESIGN, SETTING, AND PARTICIPANTSA prespecified analysis of a multicenter, open-label, randomized clinical trial evaluated 552 patients who were enrolled in 19 Dutch centers between January 8, 2015, and July 17, 2018. The study included patients who experienced out-of-hospital cardiac arrest with a shockable rhythm who were successfully resuscitated without signs of STEMI. Follow-up was performed at 1 year. Data were analyzed, using the intention-to-treat principle, between August 29 and October 10, 2019.INTERVENTIONS Immediate coronary angiography and PCI if indicated or coronary angiography and PCI if indicated, delayed until after neurologic recovery.MAIN OUTCOMES AND MEASURES Survival, myocardial infarction, revascularization, implantable cardiac defibrillator shock, quality of life, hospitalization for heart failure, and the composite of death or myocardial infarction or revascularization after 1 year.RESULTS At 1 year, data on 522 of 552 patients (94.6%) were available for analysis. Of these patients, 413 were men (79.1%); mean (SD) age was 65.4 (12.3) years. A total of 162 of 264 patients (61.4%) in the immediate angiography group and 165 of 258 patients (64.0%) in the delayed angiography group were alive (odds ratio, 0.90; 95% CI, 0.63-1.28). The composite end point of death, myocardial infarction, or repeated revascularization since the index hospitalization was met in 112 patients (42.9%) in the immediate group and 104 patients (40.6%) in the delayed group (odds ratio, 1.10; 95% CI, 0.77-1.56). No significant differences between the groups were observed for the other outcomes at 1-year follow-up. For example, the rate of ICD shocks was 20.4% in the immediate group and 16.2% in the delayed group (odds ratio, 1.32; 95% CI, 0.66-2.64). CONCLUSIONS AND RELEVANCEIn this trial of patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, a strategy of immediate angiography was not found to be superior to a strategy of delayed angiography with respect to clinical outcomes at 1 year. Coronary angiography in this patient group can therefore be delayed until after neurologic recovery without affecting outcomes. TRIAL REGISTRATION trialregister.nl Identifier: NTR4973

Background-Long coronary lesions treated with stents have a poor outcome. This study compared the 6-month outcome of stent implantation for long lesions in patients randomized to intravascular ultrasound (IVUS; nϭ73) or angiographic guidance (nϭ71). Methods and Results-Stenoses Ͼ20 mm in length and a reference diameter that permitted a stent diameter Ն3 mm were eligible. Primary end points were 6-month minimal lumen diameter (MLD) and the combined end point of death, myocardial infarction, and target-lesion revascularization (TLR). Baseline clinical and angiographic data were comparable in both groups. At 6 months, MLD in the IVUS group (1.82Ϯ0.53 mm) was larger than in the angiography group (1.51Ϯ0.71 mm; Pϭ0.042). TLR and combined end-point rates at 6 months were 4% (nϭ3) and 6% (nϭ4) in the IVUS group and 14% (nϭ10) and 20% (nϭ14) in the angiography group, respectively (Pϭ0.037 for TLR and Pϭ0.01 for combined events). Restenosis (Ͼ50% diameter stenosis) was found in 23% of the IVUS group and 45% of the angiography group (Pϭ0.008). At 12 months, TLR and the combined end point occurred in 10% (nϭ7) and 12% (nϭ9) of the IVUS group and 23% (nϭ17) and 27% (nϭ19)

Background-Acute hemodynamic effects of cardiac resynchronization therapy (CRT) were reported previously, but detailed invasive studies showing hemodynamic consequences of long-term CRT are not available. Methods and Results-We studied 22 patients scheduled for implantation of a CRT device based on conventional criteria (New York Heart Association class III or IV, left ventricular [LV] ejection fraction Ͻ35%, left bundle-branch block, and QRS duration Ͼ120 ms). During diagnostic catheterization before CRT, we acquired pressure-volume loops using conductance catheters during atrial pacing at 80, 100, 120, and 140 bpm. Studies were repeated during biventricular pacing at the same heart rates after 6 months of CRT. Our data show a significant clinical benefit of CRT (New York Heart Association class change from 3.1Ϯ0.5 to 2.1Ϯ0.8; quality-of-life score change from 44Ϯ12 to 31Ϯ16; and 6-minute hall-walk distance increased from 260Ϯ149 to 396Ϯ129 m; all PϽ0.001), improved LV ejection fraction (from 29Ϯ10% to 40Ϯ13%, PϽ0.01), decreased end-diastolic pressure (from 18Ϯ8 to 13Ϯ6 mm Hg, PϽ0.05), and reverse remodeling (end-diastolic volume decreased from 257Ϯ67 to 205Ϯ54 mL, PϽ0.01). Previously reported acute improvements in LV function remained present at 6 months: dP/dt max increased 18%, ϪdP/dt min increased 13%, and stroke work increased 34% (all PϽ0.01). Effects of increased heart rate were improved toward more physiological responses for LV ejection fraction, cardiac output, and dP/dt max . Moreover, our study showed improved ventricular-arterial coupling (69% increase, PϽ0.01) and improved mechanical efficiency (44% increase, PϽ0.01). Conclusions-Hemodynamic

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Sirolimus-eluting stent implantation in STEMI patients is associated with a favorable midterm clinical and angiographic outcome compared with treatment with BMS. However, LSM raises concern about the long-term safety of SES in STEMI patients.

This paper describes a new approach to the automated segmentation of X-ray left ventricular (LV) angiograms, based on active appearance models (AAMs) and dynamic programming. A coupling of shape and texture information between the end-diastolic (ED) and end-systolic (ES) frame was achieved by constructing a multiview AAM. Over-constraining of the model was compensated for by employing dynamic programming, integrating both intensity and motion features in the cost function. Two applications are compared: a semi-automatic method with manual model initialization, and a fully automatic algorithm. The first proved to be highly robust and accurate, demonstrating high clinical relevance. Based on experiments involving 70 patient data sets, the algorithm's success rate was 100% for ED and 99% for ES, with average unsigned border positioning errors of 0.68 mm for ED and 1.45 mm for ES. Calculated volumes were accurate and unbiased. The fully automatic algorithm, with intrinsically less user interaction was less robust, but showed a high potential, mostly due to a controlled gradient descent in updating the model parameters. The success rate of the fully automatic method was 91% for ED and 83% for ES, with average unsigned border positioning errors of 0.79 mm for ED and 1.55 mm for ES.