2018 ESC/EACTS Guidelines on myocardial revascularization

Background The ULISSE registry has demonstrated the real‐world performance of the Ultimaster biodegradable polymer sirolimus‐eluting stent (BP‐SES) in a large cohort of patients undergoing percutaneous coronary intervention, including a large proportion of patients presenting with acute myocardial infarction (AMI). Methods We performed a subgroup analysis of the ULISSE registry in AMI patients and compared the outcomes of this vulnerable cohort with that of patients presenting without AMI (non‐AMI). The primary end point was the incidence of 1‐year target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (TV‐MI), and clinically indicated target lesion revascularization (TLR). Results Of 1,660 patients included in the ULISSE registry, 381(23%) presented with AMI, 207(54.3%) non‐ST elevation myocardial infarction, and 174(45.7%) ST‐elevation myocardial infarction. Compared with non‐AMI patients, those with AMI were more frequently female and smokers, with lower left ventricular ejection fraction (LVEF) and chronic kidney disease requiring dialysis. At 1 year, TLF rate was significantly higher in AMI than non‐AMI patients (7.9 vs. 4.1%; HR 1.98, CI 95% 1.22–3.23; p = .005) driven by higher rate of cardiac death (4.0 vs. 1.1%; HR 3.59, CI 95% 1.64–7.88; p = .01) and TV‐MI (2.8 vs 0.9%; HR 2.99,CI 95% 1.22–7.37; p = .01), without differences in TLR rate (4.3 vs. 2.9%,HR 0.66, CI95% 0.35–1.25; p = .2). At multivariate Cox regression analysis, eGFR <40 mL/min (HR: 2.868) and LVEF <40% (HR: 2.394) were the only independent predictors of TLF. Conclusions In AMI patients, Ultimaster BP‐SES implantation was associated with higher rate of TLF and definite stent thrombosis compared with non‐AMI patients. The high incidence of adverse events was mainly driven by the unfavorable baseline risk profile.

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confidence: 99%

One‐year clinical outcome of biodegradable polymer sirolimus‐eluting stent in patients presenting with acute myocardial infarction: Insight from the ULISSE registry

Moscarella

Ielasi

Beneduce

et al. 2019

“…3 This has led to the widespread adoption of invasive physiological indices, including fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) into routine practice and guidelines. 4,5 These physiological tools are currently recommended for lesions of intermediate angiographic severity. However, this decision is still dependent on subjective visual lesion assessment by the operator, despite the acknowledged shortcomings of this approach.…”

Section: Introductionmentioning

confidence: 99%

Application of the DILEMMA score to improve lesion selection for invasive physiological assessment

Michail

Dehbi

Nerlekar³

et al. 2019

Objectives We sought to assess the validity of the DILEMMA score against instantaneous wave‐free ratio (iFR) and evaluate its utility in rationalizing the number of patients referred for invasive physiological assessment. Background The DILEMMA score is a validated angiographic scoring tool incorporating minimal lumen diameter, lesion length and subtended myocardial area that has been shown to predict the functional significance of lesions as assessed by fractional flow reserve (FFR). Methods Patients in the DEFINE‐FLAIR study who had coronary stenosis of intermediate severity were randomized to either FFR or iFR. DILEMMA score was calculated retrospectively on a subset of this cohort by operators blinded to FFR or iFR values. Results Three hundred and forty‐six lesions (181 assessed by FFR; 165 by iFR) from 259 patients (mean age 66.0 years, 79% male) were included. A DILEMMA score ≤ 2 had a negative predictive value of 96.3% and 95.7% for identifying lesions with FFR >0.80 and iFR >0.89, respectively. A DILEMMA score ≥ 9 had a positive predictive value of 88.9% and 100% for identifying lesions with FFR ≤0.80 and iFR ≤0.89, respectively. The receiver operating characteristic area under the curve values for DILEMMA score to predict FFR ≤0.80 and iFR ≤0.89 were 0.83 (95% CI 0.77–0.90) and 0.82 (0.75–0.89) respectively. A DILEMMA score ≤ 2 or ≥9 occurred in 172 of the 346 lesions (49.7%). Conclusions Using DILEMMA score in patients with coronary stenosis of intermediate severity may reduce the need for pressure wire use, offering potential cost‐savings and minimizing the risks associated with invasive physiological lesion assessment.

“…[1][2][3][4][5][6][7] In the latest European revascularization guideline, radial access was recommended as the standard approach for PCI, unless other considerations override (Class I, level of evidence A). 8 However, there is less consensus on whether this would hold true for left main (LM) lesions. A PCI of the LM lesion poses unique and challenging task as it jeopardizes significant myocardial territory and frequently includes PCI of the bifurcation, another form of a formidable lesion for PCI.…”

Section: Introductionmentioning

confidence: 99%

Transradial versus transfemoral percutaneous coronary intervention of left main disease: A systematic review and meta‐analysis of observational studies

Ando

Aoi

Ashraf

et al. 2018

Objectives To assess the efficacy and safety of transradial (TR) versus transfemoral (TF) percutaneous coronary intervention (PCI) in left main (LM) lesion. Background TR‐PCI is the preferred approach compared with TF approach because of less bleeding risk. LM‐PCI is often challenging because of the anatomical complexity and uniqueness of supplying a large myocardium territory. We performed a systematic review and meta‐analysis to assess the safety and efficacy of TR‐PCI compared with TF‐PCI of the LM lesions. Methods A comprehensive literature search of PUBMED, EMBASE, and Cochrane database was conducted to identify studies that reported the comparable outcomes between both approaches. Odds ratio (OR) and 95% confidence interval (CI) was calculated using the Mantel–Haenszel method. Results A total of eight studies were included in the quantitative meta‐analysis. TR‐PCI resulted in lower bleeding risk (OR 0.31, 95%CI 0.18–0.52, P < 0.01, I2 = 0%) while maintaining similar procedural success rate, target lesion revascularization, myocardial infarction, stent thrombosis, and all‐cause mortality during the study follow‐up period. Conclusions TR‐PCI may achieve similar efficacy with decreased bleeding risk compared to TF‐PCI in LM lesions. When operator experience and anatomical complexity are favorable, TR approach is an attractive alternative access over TF approach in LM‐PCI.