Zubair Ahmed

Effectiveness of Percutaneous Coronary Intervention With Drug-Eluting Stents Compared With Bypass Surgery in Diabetics With Multivessel Coronary Disease: Comprehensive Systematic Review and Meta-analysis of Randomized Clinical Data

Background Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD). Coronary artery bypass grafting (CABG) has been compared with percutaneous coronary intervention (PCI) using drug‐eluting stents (DES) in recent randomized controlled trials (RCTs). Methods and Results RCTs comparing PCI with DES versus CABG in diabetic patients with MVD who met inclusion criteria were analyzed (protocol registration No. CRD42013003693). Primary end point (major adverse cardiac events) was a composite of death, myocardial infarction, and stroke at a mean follow‐up of 4 years. Analyses were performed for each outcome by using risk ratio (RR) by fixed‐ and random‐effects models. Four RCTS with 3052 patients met inclusion criteria (1539 PCI versus 1513 CABG). Incidence of major adverse cardiac events was 22.5% for PCI and 16.8% for CABG (RR 1.34, 95% CI 1.16 to 1.54, P<0.0001). Similar results were obtained for death (14% versus 9.7%, RR 1.51, 95% CI 1.09 to 2.10, P=0.01), and MI (10.3% versus 5.9%, RR 1.44, 95% CI 0.79 to 2.6, P=0.23). Stroke risk was significantly lower with DES (2.3% versus 3.8%, RR 0.59, 95% CI 0.39 to 0.90, P=0.01) and subsequent revascularization was several‐fold higher (17.4% versus 8.0%, RR 1.85, 95% CI 1.0 to 3.40, P=0.05). Conclusions These data demonstrate that CABG in diabetic patients with MVD at low to intermediate surgical risk (defined as EUROSCORE <5) is superior to MVD PCI with DES. CABG decreased overall death, nonfatal myocardial infarction, and repeat revascularization at the expense of an increase in stroke risk.

Optimization of stent implantation using a high pressure inflation protocol

High‐pressure inflation is the universal standard for stent deployment but a specific protocol for its use is lacking. We developed a standardized “pressure optimization protocol” (POP) using time to inflation pressure stability as an endpoint for determining the required duration of stent inflation. Objectives: The primary study purpose was to determine the stent inflation time (IT) in a large patient cohort using the standardized inflation protocol, to correlate various patient and lesion characteristics with IT, and ascertain in an in vitro study the time for pressure accommodation within an inflation system.

Clinical and prognostic value of poststenting fractional flow reserve in acute coronary syndromes

Objectives Fractional flow reserve (FFR) has been suggested to have value in acute coronary syndromes (ACSs). The clinical and prognostic value of ischaemia reduction assessed by post-percutaneous coronary intervention (PCI) FFR has not been studied in this population. Methods Consecutive stable ischaemic heart disease (SIHD) (N=390) and patients with ACS (N=189) who had pre-PCI FFR and post-PCI FFR were followed for 2.4±1.5 years. Primary endpoint was major adverse cardiac events (MACE) (composite of myocardial infarction, target vessel revascularisation and death). Results In patients with ACS, PCI led to significant improvement in FFR from 0.62±0.15 to post-PCI FFR 0.88±0.08 (p<0.0001). Post-PCI FFR identified 29 patients (15%) who had persistently low FFR<0.80 (0.75±0.06) despite angiographically optimal results prompting subsequent interventions improving repeat FFR (0.85±0.06; p<0.0001). The difference in MACE events between patients with ACS and patients with SIHD varied according to the post-PCI FFR value (interaction p=0.044). Receiver operator curve analysis identified a final FFR cut-off of ≤0.91 as having the best predictive accuracy for MACE in the ACS study population (30% vs 19%; p=0.03). Patients with ACS achieving final FFR of >0.91 had similar outcomes compared with patients who had SIHD (19% vs 16%; p=0.51). However, in patients with final FFR of ≤0.91 there was increased MACE versus patients with SIHD (30% vs 16%; p<0.01). Conclusions Post-PCI FFR is valuable in assessing the functional outcome of PCI in patients with ACS. Use of post-PCI FFR in patients with ACS allows for functional optimisation of PCI results and is predictive of long-term outcomes in patients with ACS.

Classification of mechanisms of strut malapposition after angiographically optimized stent implantation: An optical coherence tomography study

To elucidate causes and extent of strut malapposition in angiographically optimized stenting.

A novel stent inflation protocol improves long‐term outcomes compared with rapid inflation/deflation deployment method

High‐pressure inflation for coronary stent deployment is universally performed. However, the duration of inflation is variable and does not take into account differences in lesion compliance. We developed a standardized “pressure optimization protocol” (POP) using inflation pressure stability rather than an arbitrary inflation time or angiographic balloon appearance for stent deployment. Whether this approach improves long‐term outcomes is unknown.

Clinical and angiographic predictors of persistently ischemic fractional flow reserve after percutaneous revascularization

Aims Despite optimal angiographic results after percutaneous coronary intervention (PCI), some lesions may continue to produce ischemia under maximal hyperemia. We evaluated the factors associated with persistently ischemic fractional flow reserve (FFR) after angiographically successful PCI. Methods and results A total of 574 consecutive patients with 664 lesions undergoing PCI who had FFR pre‐ and post‐PCI were analyzed. Percutaneous coronary intervention led to effective ischemia reduction from pre‐FFR (0.65 ± 0.14) to post‐FFR (0.87 ± 0.08; &Dgr;FFR 0.22 ± 0.16, P < .001). There were 63 (9.5%) lesions with a persistently ischemic FFR of ≤0.80 despite optimal angiographic PCI results. Multivariate analysis revealed the presence of diffuse disease (odds ratio [OR] 3.54, 95% CI 1.80‐6.94, P < .01), left anterior descending artery PCI (OR 8.35, 95% CI 3.82‐18.27, P < .01), use of intravenous adenosine for inducing hyperemia (OR 3.95, 95% CI 2.0‐7.84, P < .01), and pre‐PCI FFR (OR 0.03, 95% CI 0.004‐0.23, P < .01) as independent predictors of persistently ischemic FFR (≤0.80) after PCI. The predictive accuracy of this model was robust, with an area under the curve of 0.85 (95% CI 0.82‐0.88). Conclusion Multiple factors are associated with persistently ischemic FFR after angiographically optimal PCI. It is recommended that in lesions with the above‐identified factors, FFR should be remeasured after PCI, and if abnormal, further measures should be undertaken for functional optimization.

PREDICTIVE ACCURACY OF RESTING GRADIENT (PD/PA) FOR IDENTIFYING ISCHEMIC CORONARY LESIONS

Adenosine is used to induce maximal hyperemia during fractional flow reserve (FFR) measurement. Adenosine administration can be time consuming, with added cost and sometimes may have undesirable side effects. We evaluated the predictive accuracy of resting trans-lesional gradient (distal coronary

DVT of the Heart: A "Novel" Treatment for an Old Problem.

Thrombotic lesions of saphenous venous grafts (SVGs) are frequently encountered, and interventions may be technically fraught with embolic complications. The following 2 cases suggest the potential role in selected cases of novel oral anticoagulants (NOACs) in the treatment of SVG thrombosis to

Association of acute stent strut malapposition on long‐term outcomes

To the Editor, We read with great interest the CLI-OPCI substudy by Romagnoli et al. on the relationship between acute stent malapposition (ASM) by optical coherence tomography (OCT) and clinical outcomes [1]. The authors found that the severity of ASM, either measured as distance between strut and vessel wall or length of strut malapposition, was not related to long-term adverse events [major adverse cardiac events (MACE)] which included the combination of death, target vessel-MI (either periprocedural or long-term), and target lesion revascularization. These data add to other studies which have not shown a relationship between ASM and long-term outcomes. We have recently presented an OCT-based classification system of ASM (Table 1) based on adequacy of stent implantation and vessel anatomy [2]. We found, as in the study by Romagnoli et al, that ASM is frequent, occurring in 74.5% of all angiographically optimized stents, very similar to the current study wherein 72.3% of stents showed ASM. Of the five classes of ASM in our study, the most frequent cause of ASM was localized vessel enlargement, i.e. the stent deployment was adequate but the vessel had some degree of positive remodeling. With this ASM cause there was relatively small strut-to-wall malapposition distance and ASM vessel length. On the other hand, stent undersizing, defined as the nominal stent diameter being smaller than the proximal reference diameter and the proximal stent segment being malapposed, showed the greatest strut distance from the wall and length of strut malapposition. We have hypothesized that differences in outcome studies evaluating the relationship of ASM on long-term outcomes may be explained by different causes of ASM as reflected in our classification system. Our question to the authors is that if they limited their analysis of ASM to stent undersizing only, would there be a relationship between ASM and MACE? We understand that this analysis was not part of their original study but do believe that such an analysis would be edifying and might help to explain the heterogeneity in long-term outcomes previously reported. We thank the authors for an important contribution in understanding the significance of ASM to long-term outcomes and appreciate their consideration of our request.

Percutaneous management of patients with acute coronary syndromes from unprotected left main disease: A comprehensive review and presentation of a treatment algorithm

The patient with acute coronary syndrome, particularly with myocardial infarction, from an unprotected left main coronary stenosis represents one of the highest risk subgroups with mortality exceeding 25–50%. Once a patient develops cardiogenic shock, the risk of death during index hospitalization is exceedingly high. Percutaneous coronary intervention may improve short‐ and long‐term outcome, particularly if performed prior to shock development. Should the patient survive index hospitalization, survival tends to be rather good. This review summarizes current knowledge and proposes a clinical algorithm for evaluation and treatment.