Yonghe Guo

Relationship between plasma inflammatory markers and platelet aggregation in patients with clopidogrel resistance after angioplasty.

We evaluated the relationship between plasma inflammation markers and clopidogrel resistance in patients after stent implantation. The plasma levels of C-reactive protein (CRP), P-selectin, platelet soluble CD40 ligand (sCD40L), interleukin 6 (IL-6) and platelet aggregation were measured in 352 patients undergoing percutaneous coronary intervention (PCI) at baseline and after 6 months. The plasma levels of CRP, P-selectin, sCD40L, IL-6 was higher in 65 (18.5%) patients with clopidogrel resistance than in those with normal responsiveness at 6 months after PCI. There was a significant positive correlation between soluble CD40L levels and platelet aggregation (r = .28, P < .05). Diabetes (DM) and sCD40L level were independent predictors for unresponsiveness after stent implantation according to stepwise multivariate analyses. The hazard ratio (HR) for sCD40L level was 3.02 (95% CI = 1.28 to 3.25; P = .036) and for DM 2.53 (95% CI = 1.28 to 6.55, P = .03). We conclude that sCD40L and DM may influence clopidogrel resistance.

Efficacy and Safety of Triple Antiplatelet Therapy in Obese Patients Undergoing Stent Implantation

We evaluated the impact of triple antiplatelet therapy on platelet reactivity, reducing cardiovascular events and the safety in obese patients undergoing coronary stenting. Obese patients (n = 428) undergoing coronary stenting were randomly assigned to 2 groups: standard dual group (clopidogrel plus aspirin, n = 215) and triple group (n = 213); adjunctive cilostazol was added to the dual group treatment. Platelet reactivity was assessed at baseline and at 1-year follow-up by conventional aggregometry. Major adverse cardiovascular events, stent thrombosis, target lesion revascularization (TLR), target vessel revascularization, and bleeding events were analyzed after 1-year follow-up. At 1-year follow-up after stenting, major adverse cardiac events including death, myocardial infarction, and ischemic-driven TLR were lower in the triple group than the dual group. Major bleeding was similar in both the groups. In obese patients undergoing percutaneous coronary intervention, triple antiplatelet therapy was superior to dual antiplatelet therapy in decreasing thrombotic events in 12-month cardiac events, mainly driven by a decrease in the incidence of clopidogrel resistance.

Feasibility and Safety of Transcatheter Intervention for Complex Patent Ductus Arteriosus

We evaluated the transcatheter intervention of complex patent ductus arteriosus (PDA) in Chinese adults. Between January 2004 and April 2008, 112 adult patients (43 males, 69 females, mean age 31 ± 19 years) underwent intervention. Coils were used for patients with small PDA, and Amplatzer duct occluders or China-made mushroom-shaped occluders were used for patients with moderate-to-large PDA. The success rate of transcatheter intervention was 93.8%, and 9 patients (8.0%) had small residual shunts. At the end of 12 months follow-up, the rate of residual shunts was 1.8%. Peak systolic pulmonary pressure decreased from 94 ± 21 mm Hg preintervention to 58 ± 20 mm Hg postintervention (P < .001). No severe procedure-related complications (including death, dislocation of occluders, stenosis of aorta or pulmonary artery) occurred. Some patients developed hemolysis or vascular access complications, all resolved by conservative therapy. Transcatheter intervention is an effective and safe treatment for adult PDA patients with complex anatomic or hemodynamic conditions.

Application of Excimer Laser Coronary Atherectomy Guided by Optical Coherence Tomography in the Treatment of a Severe Calcified Coronary Lesion

To the Editor: A 73‐year‐old female was referred to our hospital for evaluation of unstable angina pectoris. She had a greater than 10‐year history of hypertension. Coronary angiography (CAG) was performed in another hospital in March 2017, which showed diffuse calcific stenosis (about 90%) in the proximal and mid‐left anterior descending (LAD) artery, 70% stenosis in the ostial obtuse marginal branch, and no apparent stenosis in the right coronary artery. The lesion in the LAD could not be intervened because the 2.0 mm × 15.0 mm Sprinter balloon (Medtronic, USA) could not be expanded and the 2.5 mm × 15.0 mm NC Sprinter balloon (Medtronic, USA) could not pass through the lesion.

Optimal Revascularization Threshold of Fractional Flow Reserve and its Effect on Outcomes: Perspectives From a High-Volume Center in China

This study aimed to investigate the favorable revascularization threshold for fractional flow reserve (FFR) in daily practice. Between March 2013 and March 2017 in a high-volume center in China, 903 patients with 1210 lesions underwent coronary intervention with adjunctive FFR and were consecutively enrolled. The mean FFR was 0.80 ± 0.11, revascularization was deferred for 68% of lesions, and the median follow-up period was 21 months. For lesions with an FFR > 0.80, deferral of revascularization appeared safe. In contrast, for lesions with an FFR ≤ 0.80, deferral of revascularization was associated with a greater risk of target lesion failure (TLF) than revascularization (hazard ratio [HR] 4.63, 95% confidence interval [CI] 2.02-10.06, P < .001). For lesions with an FFR value in the gray-zone (0.76-0.80), medical treatment alone was less effective than revascularization (P = .020). For deferred lesions, FFR was an independent predictor for the future risk of TLF, when data were categorized (HR [FFR ≤ 0.75 vs FFR ≥ 0.86] 3.35, 95% CI 1.13-9.97, P = .030; HR [FFR 0.76-0.80 vs FFR ≥ 0.86] 4.01, 95% CI 1.73-9.31, P = .001) or continuous (HR 0.004, 95% CI 0.00-0.13, P = .002). Thus, an FFR value of 0.80 appears to be the optimal threshold for decision-making regarding revascularization and risk stratification.

The impact of acute coronary syndrome on late drug-eluting stents restenosis: Insights from optical coherence tomography

Abstract The aim of the study was to investigate the optical coherence tomography (OCT)-identified difference of in-stent restenosis (ISR) tissue characteristics between patients with and without acute coronary syndrome (ACS) at index intervention. The retrospective study included 80 patients with 85 drug-eluting stent (DES) restenosis lesions. Subjects were classified according to clinical presentation at the time of de-novo lesion intervention, namely ACS and non-ACS. OCT was performed at 5 years follow-up. The frequency of malapposition, neointimal characteristics, thrombus, and minimal stent area (MSA) were evaluated. ACS group consisted of 48 (60%) patients. The mean duration from initial intervention to OCT study was 66.15 months. Malapposition was more frequent in the ACS group (25.5% vs 2.9%, P = .006), as well as a higher prevalence of thrombus in the ACS group (21.6% vs 0%, P = .015). MSA of ACS group was significantly less than that of non-ACS group (4.99 ± 1.80 vs 5.62 ± 2.08 mm2, P = .018). Compared with non-ACS group, only MI group was related to smaller MSA (4.37 ± 1.39 vs 5.62 ± 2.08 mm2, P = .048); The unstable angina (UA) group was not associated with a decreased MSA. The occurrence of neoatherosclerosis tended to be higher in ACS group (60.8% vs 41.2%, P = .076). In DES restenosis, an ACS presentation at initial intervention is associated with a higher incidence of malapposition, thrombus, and smaller MSA.

Transient ulnar artery compression facilitates transradial access

Background:Unsuccessful radial artery puncture is one of the important causes of transradial procedure failure. Ulnar artery compression made the radial artery pulse stronger. Whether it would make transradial access easier, however, is uncertain. Methods:A prospective randomized controlled trial was conducted among 446 patients who planned for transradial cardiac catheterization. Patients were randomized to receiving either transient ulnar artery compression (UC) or standard treatment (standard) for half an hour prior to needle insertion (217 UC, 229 standard). The diameters of right radial artery and ulnar artery were measured by ultrasound on admission and before artery puncture. Primary endpoints included the number of attempts to access, the rate of first-pass success, and time for a successful access. Secondary endpoints were the number of difficult procedures, and the incidence of puncture failure. Results:The diameters of radial artery were larger after half an hours ulnar artery compression, but there were no obvious changes in that of ulnar artery. As compared with standard group, the number of attempts was significantly decreased (1.42 ± 1.10 vs 2.97 ± 2.38, P <0.001), and the rate of first-pass success was greatly enhanced (73.27% vs 57.64%, P <0.001) in UC group. Meanwhile, the time for access was decreased (59 ± 15 seconds vs 71 ± 18 seconds, P <0.001) with UC. In addition, the proportion of difficult procedures of UC group was less than that of standard group (4.61% vs 10.92%, P = 0.013). No significant differences were found in failure rates of sheath insertion and puncture between the 2 groups. Conclusion:Transient ulnar artery compression enhances the efficacy and feasibility of radial artery intubatton in transradial catheterization.

Supplement for Triple Antiplatelet Therapy in Obese Patients Undergoing Stent Implantation

We thank Balta et al 1 for their interest in our article and their attention to the topic of triple antiplatelet therapy in patients undergoing stent implantation. Dual antiplatelet therapy has become a part of standard antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) with the aim of preventing stent restenosis. However, thrombotic events related to clopidogrel resistance were not completely avoided and could cause severe cardiac events in patients post-PCI. Triple antiplatelet therapy seems to be an effective and prospective treatment to resolve this problem. Triple antiplatelet therapy may be superior to dual antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary PCI with stents. Nevertheless, the efficiency of triple antiplatelet therapy and status of clopidogrel resistance is unclear in obese patients undergoing stent implantation. In our study, thrombotic events and the subsequent target lesion revascularization may have been associated with resistance to clopidogrel in obese patients undergoing stent implantation, and previous studies showed that obese patients have a higher risk of long-term thrombotic events following PCI with drug-eluting stent than in patients with normal weight. These results may provide the rationale for the use of triple antiplatelet therapy in obese patients. In the followed study, we found that triple antiplatelet therapy results in an adequate inhibition of adenosine diphosphate-induced platelet aggregation and decreases the incidence of clopidogrel resistance compared with dual antiplatelet therapy. Additionally, it is important that this benefit was not associated with increased bleeding. Our results showed that triple antiplatelet therapy was superior to dual antiplatelet therapy in decreasing thrombotic events, a finding possibly driven by a decrease in clopidogrel resistance. Risk factors for thrombotic events and in-stent restenosis in patients undergoing stent implantation are complex. These include periprocedural and cardiovascular risk factors. So, there is no doubt that further large-scale prospective randomized clinical trials are needed to indicate the long-term outcomes of triple antiplatelet therapy.