Kambis Mashayekhi

Impact of body mass index on long-term mortality in women and men undergoing percutaneous coronary intervention for chronic total occlusion.

BACKGROUND The obesity paradox has been described in different patient populations. Data on the relation between obesity and outcomes in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) are lacking. Therefore, long-term mortality in patients undergoing CTO PCI was assessed according to different body mass index (BMI) categories. METHODS A total of 1993 patients undergoing CTO PCI at a tertiary care center between January 2005 and December 2013 were divided into five different BMI categories: underweight, <18.5kg/m2; normal BMI, 18.5-24.9kg/m2; overweight, 25.0-29.9kg/m2; obese, 30.0-34.9kg/m2; and very obese, ≥35.0kg/m2. The primary endpoint was all-cause mortality. RESULTS Median follow-up was 2.6 (interquartile range 1.1-3.1) years. Of the 1993 patients, 461 (23.1%) were of normal weight, 985 (49.4%) overweight, 396 (19.9%) obese, and 144 (7.2%) very obese. Compared with normal weight BMI patients (16.3%), overweight patients had a lower all-cause mortality (10.2%, Log Rank p=0.001), while obese (11.1%, Log Rank p=0.08) and severely obese (13.2%, Log Rank p=0.39) patients had similar mortality rates. Being overweight was significantly associated with a lower all-cause mortality (HR 0.69, 95% CI 0.53-0.89, p=0.005), and associations remained significant after multivariable adjustments for confounding factors (HR 0.73, 95% CI 0.56-0.95, p=0.02). While being overweight was linked with a reduced all-cause mortality in men (HR 0.65, 95% CI 0.48-0.88, p=0.005), it was not in women (HR 1.25, 95% CI 0.60-2.52, p=0.58). CONCLUSIONS Overweight is associated with an improved survival in patients undergoing PCI for CTO, particularly in men.

Comparison of the ipsi-lateral versus contra-lateral retrograde approach of percutaneous coronary interventions in chronic total occlusions

Retrograde recanalization of coronary chronic total occlusions (CTO) via contralateral (CL) collateral connections (CCs) is successful in 60–70% of patients in whom conventional antegrade approach fails or is unpromising. This study describes our experience with retrograde CTO‐PCI via ipsi‐lateral (IL) CCs in patients with unfavorable CL CCs.

Novel retrograde approach for percutaneous treatment of chronic total occlusions of the right coronary artery using ipsilateral collateral connections: a European centre experience

AIMS A systematic description of the percutaneous treatment of chronic total occlusions (CTOs) of the right coronary artery (RCA) using ipsilateral collateral connections (CCs) for the retrograde approach has never been carried out. Our aim was to investigate this issue systematically. METHODS AND RESULTS Based on the experiences of a European high-volume CTO centre: 1) a generalised scheme of the varying anatomic courses of ipsilateral CCs bridging CTOs of the RCA was developed; 2) important stepwise technical advice for the ipsilateral retrograde approach was formulated; and 3) a supportive clinical case series was assessed. Of a total of 158 patients with CTOs of the RCA, 30% (n=47) revealed ipsilateral CCs of the RCA. Five different types (A-E) of ipsilateral CCs were assessed. The retrograde ipsilateral approach was attempted in nine patients, and was completed successfully in 89% (8/9 patients). Median left ventricular ejection fraction was 56% (interquartile range [IQR]: 50-60%) and mean J-CTO score was 2.9 (standard error of mean [SEM]: ±0.3). Median procedural duration time was 150 min (IQR 117-160 min), with a median applied amount of contrast of 360 ml (IQR 270-400 ml). No relevant complications, such as acute renal failure or severe bleedings, occurred. CONCLUSIONS The percutaneous treatment of CTOs of the RCA using ipsilateral CCs for the retrograde approach might provide a novel treatment alternative for patients with CTOs of the RCA in specific clinical situations.

Successful Percutaneous Coronary Intervention Improves Cardiopulmonary Exercise Capacity in Patients With Chronic Total Occlusions

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is recommended in patients with an expected reduction of angina pectoris or of ischemia in the corresponding myocardial territory [(1)][1]. However, the prognostic benefit of successful PCIs in CTOs—especially in patients

Effect of Tumor Necrosis Factor Inhibitor Treatment on Proximal Right Coronary Chronic Total Occlusion in a Patient With Rheumatoid Arthritis

A 61-year-old man presented to the emergency department with acute anterior ST-segment myocardial infarction. A 12-lead ECG showed normofrequent sinus rhythm, a right bundle-branch block, significant ST-segment elevations in precordial leads V1 through V4 (Figure 1), and increased troponin I of 5.219 μg/L (normal range, 0–0.045 μg/L). Typical angina pectoris worsened during exercise to Canadian Cardiovascular Society grade II to III for almost 3 days and finally sustained at rest for the last 2 hours (Canadian Cardiovascular Society grade IV). Physical activity was markedly limited over the past weeks to New York Heart Association grade III. The patient´s cardiovascular risk profile consisted of active smoking status and arterial hypertension, whereas comorbidity was characterized by chronic obstructive pulmonary disease, and seropositive rheumatoid arthritis, as well (Figure 2). Daily medication consisted of methotrexate 15 mg (1 time/wk), folic acid (1 time/wk), torsemide (5 mg/d), and tiotropiumbromid and formoterol aerosol sprays. Figure 1. Initial 12-lead ECG demonstrated normofrequent sinus rhythm, a right bundle-branch block, and significant ST-segment elevations in precordial leads V1 through V4. Figure 2. Patient´s hands are affected by rheumatoid arthritis, as indicated by swollen joints, rheumatoid nodules, and palmar erythema. Primary coronary angiography revealed 3-vessel coronary artery disease with concomitant severe ectatic malformation of coronary vessels. The culprit lesion was a subtotal stenosis of the proximal left anterior descending artery with reduced thrombolysis in myocardial infarction flow (Figure 3A). The proximal part of the circumflex artery had a 90% stenosis, and the proximal left obtuse marginal artery did as well (Figure 3A). In addition, a chronic total occlusion (CTO) was verified at the proximal right coronary artery (RCA; thrombolysis in myocardial infarction flow 0; Movie I in the online-only Data Supplement) with retrograde filling from the left posterolateral artery through epimyocardial collaterals to the right posterior interventricular artery (Figure 3B and 3C; Movie …

Survival after Percutaneous Coronary Intervention for Chronic Total Occlusion in Elderly Patients.

AIMS Few data are available on outcomes of percutaneous coronary intervention (PCI) for coronary chronic total occlusions (CTO) in very elderly patients in the drug-eluting stent (DES) era. We aimed to investigate long-term survival in a single-centre cohort of elderly patients following CTO PCI using DES. METHODS AND RESULTS A total of 2,002 consecutive patients who underwent PCI of a CTO at our centre between January 2005 and December 2013 were followed for a median of 2.6 years (interquartile range 1.1-3.1 years). Four hundred and nine (409) patients were older than 75 years. The absolute reduction in all-cause mortality by successful CTO PCI was numerically greater in elderly patients as compared to younger patients (22.1% vs. 7.2% at three years). In multivariate models, successful CTO PCI was significantly associated with improved survival in both elderly (adjusted hazard ratio [HR] 0.58, 95% confidence interval [CI]: 0.39 to 0.87; p=0.009) and younger patients (adjusted HR 0.59, 95% CI: 0.40 to 0.86; p=0.006). CONCLUSIONS In the DES era, elderly patients (≥75 years) derive a similar survival benefit from successful CTO PCI to younger patients. These findings suggest that CTO PCI, when indicated, should not be withheld from the elderly.

Impact of multi-vessel versus single-vessel disease on outcomes after percutaneous coronary interventions for chronic total occlusions

BackgroundSuccessful chronic total occlusion (CTO) revascularization has been associated with prognostic benefits. Whether the extent of coronary artery disease interferes with these benefits has not been investigated yet.AimsWe sought to compare the survival after percutaneous coronary intervention (PCI) for CTO between patients with multi- (MVD) and single-vessel disease (SVD).MethodsA total of 2002 consecutive patients undergoing CTO PCI between 01/2005 and 12/2013 were identified and stratified according to the presence/absence of MVD. The primary endpoint was all-cause mortality. Median follow-up was 2.6 (interquartile range 1.1–3.1) years.ResultsA total of 1634 (81.6%) patients had MVD. Procedural success rates were 81.5 and 89.7% in the MVD and SVD groups (p < 0.001). All-cause mortality during entire follow-up was higher in MVD as compared to SVD patients (13.5 versus 5.7%, p < 0.001), and differences were attenuated after multivariable adjustment for baseline characteristics [adjusted hazard ratio (HR) 1.51, 95% CI 0.98–2.33, p = 0.06]. The effect of successful CTO PCI on all-cause mortality was consistent among patients with MVD [11.0 versus 24.5%; adjusted HR 0.60, 95% CI 0.45–0.80, p < 0.001] and SVD [5.2 versus 10.5%; adjusted HR 0.74, 95% CI 0.24–2.26, p = 0.59, Pint = 0.65]. However, due to the greater baseline risk in the former group, the absolute survival benefit after successful CTO PCI was higher.ConclusionsSuccessful recanalization of a CTO is a strong independent predictor for reduced long-term mortality. Due a higher baseline risk, the absolute benefit in patients with MVD is substantially larger than in patients with SVD.

Radiation exposure and contrast agent use related to radial versus femoral arterial access during percutaneous coronary intervention (PCI)-Results of the FERARI study.

BACKGROUND Data regarding radiation exposure related to radial versus femoral arterial access in patients undergoing percutaneous coronary intervention (PCI) remain controversial. This study aims to evaluate patients enrolled in the FERARI study regarding radiation exposure, fluoroscopy time and contrast agent use. METHODS The Femoral Closure versus Radial Compression Devices Related to Percutaneous Coronary Interventions (FERARI) study evaluated prospectively 400 patients between February 2014 and May 2015 undergoing PCI either using the radial or femoral access. In these 400 patients, baseline characteristics, procedural data such as procedural duration, fluoroscopy time, dose-area product (DAP) as well as the amount of contrast agent used were documented and analyzed. RESULTS Median fluoroscopy time was not significantly different in patients undergoing radial versus femoral access (12.2 vs. 9.8min, p=0.507). Furthermore, median DAP (54.5 vs. 52.0 Gycm2, p=0.826), procedural duration (46.0 vs. 45.0min, p=0.363) and contrast agent use (185.5 vs. 199.5ml, p=0.742) were also similar in radial and femoral PCI. CONCLUSION There was no difference regarding median fluoroscopy time, procedural duration, radiation dose or contrast agent use between radial versus femoral arterial access in PCI.

Comparison of Benefit of Successful Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients With Versus Without Reduced (≤40%) Left Ventricular Ejection Fraction

Successful recanalization of chronic total occlusions (CTO) has been associated with improved survival. Data on outcomes in patients with left ventricular (LV) systolic dysfunction undergoing percutaneous coronary intervention for CTO, however, are scarce. Between January 2005 and December 2013, a total of 2,002 consecutive patients undergoing elective CTO percutaneous coronary intervention at a tertiary care center were divided into patients with (LV ejection fraction ≤ 40%) and without (LV ejection fraction > 40%) LV systolic dysfunction as defined by transthoracic echocardiography. The primary end point was all-cause mortality. Median follow-up was 2.6 (1.1 to 3.1) years. A total of 348 (17.4%) patients had LV dysfunction. All-cause mortality was higher in patients with LV dysfunction (30.2%) than in those with normal LV function (8.2%, p <0.001), and associations remained significant after adjustment for baseline differences (adjusted hazard ratio [HR] 3.39, 95% confidence interval [CI] 2.57 to 4.47, p <0.001). Successful CTO recanalization was independently associated with reduced all-cause mortality, with similar relative risk reductions in both the preserved (6.6% vs 16.9%, adjusted HR 0.48, 95% CI 0.34 to 0.70, p <0.001) and the reduced LV function groups (26.2% vs 45.2%, adjusted HR 0.63, 95% CI 0.41 to 0.98, p = 0.04, interaction p = 0.28). In conclusion, irrespective of LV function, successful CTO recanalization is associated with a clear survival benefit.

Interventional Left Atrial Appendage Closure Affects the Metabolism of Acylcarnitines

Background: Left atrial appendage closure (LAAC) represents the interventional alternative to oral anticoagulation for stroke prevention in atrial fibrillation (AF). The metabolism of acylcarnitines was shown to affect cardiovascular diseases. This study evaluates the influence of successful LAAC on the metabolism of acylcarnitines. Methods: Patients undergoing successful LAAC were enrolled prospectively. Peripheral blood samples for metabolomics measurements were collected immediately before (i.e., index) and six months after LAAC (i.e., mid-term). A targeted metabolomics analysis based on electrospray ionization–liquid chromatography–mass spectrometry (ESI–LC–MS/MS) and MS/MS measurements was performed. Results: 44 patients with non-valvular AF (median CHA2DS2-VASc score 4, median HAS-BLED score 4) and successful LAAC were included. Significant changes in acylcarnitine levels were found in the total cohort, which were mainly attributed to patients with impaired left ventricular and renal function, elevated amino-terminal pro-brain natriuretic peptide (NT-proBNP) and diabetes mellitus. Adjusted multivariable regression models revealed significant changes of five metabolites over mid-term follow-up: C2, C14:1, C16, and C18:1 decreased significantly (each p < 0.05); short-chain C5 acylcarnitine plasma levels increased significantly (p < 0.05). Conclusion: This study demonstrates that successful LAAC affects the metabolism of acylcarnitines at mid-term follow-up. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02985463.