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Optical Coherence Tomography to Optimize Results of Percutaneous Coronary Intervention in Patients with Non-ST-Elevation Acute Coronary Syndrome: Results of the Multicenter, Randomized DOCTORS Study (Does Optical Coherence Tomography Optimize Results of Stenting).

Background: No randomized study has investigated the value of optical coherence tomography (OCT) in optimizing the results of percutaneous coronary intervention (PCI) for non–ST-segment elevation acute coronary syndromes. Methods: We conducted a multicenter, randomized study involving 240 patients with non–ST-segment elevation acute coronary syndromes to compare OCT-guided PCI (use of OCT pre- and post-PCI; OCT-guided group) to fluoroscopy-guided PCI (angiography-guided group). The primary end point was the functional result of PCI assessed by the measure of post PCI fractional flow reserve. Secondary end points included procedural complications and type 4a periprocedural myocardial infarction. Safety was assessed by the rate of acute kidney injury. Results: OCT use led to a change in procedural strategy in 50% of the patients in the OCT-guided group. The primary end point was improved in the OCT-guided group, with a significantly higher fractional flow reserve value (0.94±0.04 versus 0.92±0.05, P=0.005) compared with the angiography-guided group. There was no significant difference in the rate of type 4a myocardial infarction (33% in the OCT-group versus 40% in the angiography-guided group, P=0.28). The rates of procedural complications (5.8%) and acute kidney injury (1.6%) were identical in each group despite longer procedure time and use of more contrast medium in the OCT-guided group. Post-PCI OCT revealed stent underexpansion in 42% of patients, stent malapposition in 32%, incomplete lesion coverage in 20%, and edge dissection in 37.5%. This led to the more frequent use of poststent overdilation in the OCT-guided group versus the angiography-guided group (43% versus 12.5%, P<0.0001) with lower residual stenosis (7.0±4.3% versus 8.7±6.3%, P=0.01). Conclusions: In patients with non–ST-segment elevation acute coronary syndromes, OCT-guided PCI is associated with higher postprocedure fractional flow reserve than PCI guided by angiography alone. OCT did not increase periprocedural complications, type 4a myocardial infarction, or acute kidney injury. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01743274.

Clinical significance of optical coherence tomography‑guided angioplasty on treatment selection

The present study aimed to observe whether optical coherence tomography (OCT)-guided angioplasty is able to provide useful clinical information beyond that obtained by angiography as well as provide recommendations for physicians that may improve treatment selection. This prospective study included 83 patients with coronary artery disease (>18 years) undergoing coronary angiography (CAG) for ST-elevation myocardial infarction (n=13), non-ST-elevation myocardial infarction (n=19), stable angina (n=22), unstable angina (n=10), silent ischemia (n=11), or elective percutaneous coronary intervention (n=8). Following the initial CAG (CAG-pre), the patients underwent OCT before angioplasty (OCT-pre, 24 patients), after angioplasty (OCT-post, 22 patients), or both (37 patients). The thrombus burden, calcification and plaque dissection or rupture were compared between the OCT-pre and CAG-pre recordings. Following angioplasty, stent malapposition, suboptimal stent deployment, suboptimal stent lesion coverage, and edge dissection were compared between OCT-post and CAG-post alone. Among the 83 patients, 45.7% had single-vessel and 54.3% had multiple-vessel disease. OCT pre- and post-angioplasty revealed significantly more information on the procedure than CAG alone. This clinical information changed the clinical strategies in 41/83 (49.4%) patients, including 58 modifications of therapeutic strategy (69.9%, 58/83): Thrombus aspiration in 2 cases (2.4%), administration of glycoprotein IIb/IIIa inhibitors in 8 cases (9.6%), additional balloon inflation in 23 cases (27.7%), additional stent implantation in 17 cases (20.5%), avoiding stent implantation in 4 cases (4.8%), collateral intervention in 2 cases (2.4%), and guidewire reposition in 2 cases (2.4%). In conclusion, OCT-pre and OCT-post provided additional clinical information beyond that obtained by angiography alone, which resulted in modification of the treatment strategies in half of the included patients.

Incidence, Predictors, and Impact on Six-Month Mortality of Three Different Definitions of Contrast-Induced Acute Kidney Injury After Coronary Angiography

We assessed incidence, predictors, and impact on 6-month mortality of contrast-induced acute kidney injury (CI-AKI) after coronary angiography with or without percutaneous coronary intervention in patients with acute coronary syndrome (ACS), according to 3 different CI-AKI definitions. Serum creatinine (sCr) was assessed at baseline and 48 to 72 hours after procedure to classify patients into 3 CI-AKI groups: Group 1: increase in sCR ≥25% over baseline but absolute increase <0.5 mg/dl; Group 2: absolute increase ≥0.5 mg/dl; Group 3: absolute increase ≥0.3 mg/dl or ≥50% over baseline. The association between CI-AKI and all-cause 6-month mortality was assessed using multivariate Cox regression. Among 1,002 patients included, median age was 68 [57 to 79] years. The sample had the following characteristics: 70% men, 25% diabetics, 22% had a history of myocardial infarction, 21% had baseline estimated glomerular filtration rate (as calculated by the Modification of Diet in Renal Disease)  <60 ml/min/1.72 m2, 34% had ST-segment elevation myocardial infarction, 61% underwent percutaneous coronary intervention, and 43% had multivessel disease. Based on changes in sCr, 89 patients (8.9%) were classified in Group 1; 69 (6.9%) in Group 2; and 157 (15.7%) in Group 3, whereas sCr did not increase >25% in the remaining 844 (84.2%). CI-AKI was significantly associated with 6-month all-cause mortality using the definitions for Group 2 (hazard ratio 3.1, 95% confidence interval [CI] 1.5 to 6.6, p = 0.002) and Group 3 (hazard ratio 2.03, 95% CI 1.03 to 4.0, p = 0.04), but not Group 1. In conclusion, based on the definition used for CI-AKI, CI-AKI is observed in 6% to 15.7% of patients. An increase of 25% over baseline sCr does not identify high-risk patients. CI-AKI defined as an increase in sCr >0.3 mg/dl identifies 15.7% of the population at 2-fold higher risk of mortality.

IMPACT OF LEFT ATRIAL PRESSURE ON RECURRENCE OF ATRIAL FIBRILLATION 3 MONTHS AFTER CATHETER ABLATION

Background: Catheter ablation is the treatment of choice for the management of atrial fibrillation (AF). The main limitation of this technique is the success rate, which is in the range of 70 to 80%. It is therefore critical to identify patients likely to benefit from this procedure, and who will

Prognostic impact of thrombus burden as evaluated by OCT in patients with non-ST elevation acute coronary syndromes undergoing PCI

Introduction: We aimed to evaluate the impact of thrombus burden quantified by optical coherence tomography (OCT) on the risk of peri-procedural myocardial infarction (MI) (type IVa) in patients un...