Aims: The purpose of the Multivessel TALENT trial is to compare clinical outcomes of the novel Supraflex Cruz stent with those of the SYNERGY stent in patients with three-vessel disease (3VD)... Show moreAims: The purpose of the Multivessel TALENT trial is to compare clinical outcomes of the novel Supraflex Cruz stent with those of the SYNERGY stent in patients with three-vessel disease (3VD) undergoing state-of-the-art percutaneous coronary intervention (PCI).Methods and results: In this prospective, randomised, 1:1 balanced, multicentre, open-label trial, 1,550 patients with de novo 3VD without left main disease will be assigned to the Supraflex Cruz or SYNERGY arm. The following treatment principles of "best practice" PCI will be applied: Heart Team consensus based on SYNTAX score II treatment recommendation, functional lesion evaluation by quantitative flow ratio (QFR), stent optimisation by intravascular imaging, optimal pharmacological treatment and prasugrel monotherapy. The primary endpoint is a non-inferiority comparison of the patient-oriented composite endpoint (POCE) of all-cause death, any stroke, any myocardial infarction, or any revascularisation, at 12 months post procedure. The powered secondary endpoint is a superiority comparison of the vesseloriented composite endpoint (VOCE), defined as vessel-related cardiovascular death, vessel-related myocardial infarction, or clinically and physiologically indicated target vessel revascularisation, at 24 months.Conclusions: The Multivessel TALENT trial will be evaluating a novel treatment strategy for complex coronary artery disease with state-of-the-art PCI based on angiography-derived QFR with novel ultra-thin Supraflex Cruz stents, compared with SYNERGY stents. Show less
Background and aims: The impact of endothelial shear stress (ESS) on vessel remodeling in vessels implanted with bioresorbable scaffold (BRS) as compared to metallic drug-eluting stent (DES)... Show moreBackground and aims: The impact of endothelial shear stress (ESS) on vessel remodeling in vessels implanted with bioresorbable scaffold (BRS) as compared to metallic drug-eluting stent (DES) remains elusive. The aim of this study was to determine whether the relationship between ESS and remodeling patterns differs in BRS from those seen in metallic DES at 3-year follow-up.Methods: In the ABSORB II randomized trial, lesions were investigated by serial coronary angiography and intravascular ultrasound (IVUS). Three-dimensional reconstructions of coronary arteries post-procedure and at 3 years were performed. ESS was quantified using non-Newtonian steady flow simulation. IVUS cross-sections in device segment were matched using identical landmarks.Results: Paired ESS calculations post-procedure and at 3 years were feasible in 57 lesions in 56 patients. Post-procedure, median ESS at frame level was higher in BRS than in DES, with marginal statistical significance (0.97 +/- 0.48 vs. 0.75 +/- 0.39 Pa, p = 0.063). In the BRS arm, vessel area and lumen area showed larger increases in the highest tercile of median ESS post-procedure as compared to the lowest tercile. In contrast, in DES, no significant relationship between median ESS post-procedure and remodeling was observed. In multivariate analysis, smaller vessel area, larger lumen area, higher plaque burden post-procedure, and higher median ESS post-procedure were independently associated with expansive remodeling in matched frames. Only in BRS, younger age was an additional significant predictor of expansive remodeling.Conclusions: In a subset of lesions with large plaque burden, shear stress could be associated with expansive remodeling and late lumen enlargement in BRS, while ESS had no impact on vessel dimension in metallic DES. Show less
Fractional flow reserve (FFR) and instantaneous wave-free ratio are the present standard diagnostic methods for invasive assessment of the functional significance ofepicardial coronary stenosis.... Show moreFractional flow reserve (FFR) and instantaneous wave-free ratio are the present standard diagnostic methods for invasive assessment of the functional significance ofepicardial coronary stenosis. Despite the overall trend towards more physiology-guided revasculari-zati-on, there remains a gap, between guideline recommendations and the clinical adoption of functional evaItAatiorl of stenosis severity. A number of image-based approaches have been proposed to compute FFR without the use of pressure wire and induced hyperaemia. In order to better understand these emerging technologi'es, we sought to highlight the pri'nci'ples, diagnostic performance, clinical applications, practical aspects, and current challenges of computational physiology in the catheterization Laboratory. Computational FFR has the potential to ex Pand and facilitate the use of physiology for diagnosis, procedural guidance, and evaluation of therapies, with anticipated impact on resource utilization and patient outcomes. Show less
Biomarkers of aging are urgently needed to identify individuals at high risk of developing age-associated disease or disability. Growing evidence from population-based studies points to whole-body... Show moreBiomarkers of aging are urgently needed to identify individuals at high risk of developing age-associated disease or disability. Growing evidence from population-based studies points to whole-body magnetic resonance imaging's (MRI) enormous potential for quantifying subclinical disease burden and for assessing changes that occur with aging in all organ systems. The Aging Imageomics Study aims to identify biomarkers of human aging by analyzing imaging, biopsychosocial, cardiovascular, metabolomic, lipidomic, and microbiome variables. This study recruited 1030 participants aged >= 50 years (mean 67, range 50-96 years) that underwent structural and functional MRI to evaluate the brain, large blood vessels, heart, abdominal organs, fat, spine, musculoskeletal system and ultrasonography to assess carotid intima-media thickness and plaques. Patients were notified of incidental findings detected by a certified radiologist when necessary. Extensive data were also collected on anthropometrics, demographics, health history, neuropsychology, employment, income, family status, exposure to air pollution and cardiovascular status. In addition, several types of samples were gathered to allow for microbiome, metabolomic and lipidomic profiling. Using big data techniques to analyze all the data points from biological phenotyping together with health records and lifestyle measures, we aim to cultivate a deeper understanding about various biological factors (and combinations thereof) that underlie healthy and unhealthy aging. Show less
Studies have shown that the quantitative flow ratio (QFR), recently introduced to assess lesion severity from coronary angiography, provides useful prognostic information; however the additive... Show moreStudies have shown that the quantitative flow ratio (QFR), recently introduced to assess lesion severity from coronary angiography, provides useful prognostic information; however the additive value of this technique over intravascular imaging in detecting lesions that are likely to cause events is yet unclear. We analysed data acquired in the PROSPECT and IBIS-4 studies, in particular the baseline virtual histology-intravascular ultrasound (VH-IVUS) and angiographic data from 17 non-culprit lesions with a presumable vulnerable phenotype (i.e., thin or thick cap fibroatheroma) that caused major adverse cardiac events or required revascularization (MACE) at 5-year follow-up and from a group of 78 vulnerable plaques that remained quiescent. The segments studied by VH-IVUS were identified in coronary angiography and the QFR was estimated. The additive value of 3-dimensional quantitative coronary angiography (3D-QCA) and of the QFR in predicting MACE at 5 year follow-up beyond plaque characteristics was examined. It was found that MACE lesions had a greater plaque burden (PB) and smaller minimum lumen area (MLA) on VH-IVUS, a longer length and a smaller minimum lumen diameter (MLD) on 3D-QCA and a lower QFR compared with lesions that remained quiescent. By univariate analysis MLA, PB, MLD, lesion length on 3D-QCA and QFR were predictors of MACE. In multivariate analysis a low but normal QFR (> 0.80 to < 0.97) was the only independent prediction of MACE (HR 3.53, 95% CI 1.16-10.75; P = 0.027). In non-flow limiting lesions with a vulnerable phenotype, QFR may provide additional prognostic information beyond plaque morphology for predicting MACE throughout 5 years. Show less
Aims: The aim of this study was to assess the acute performance of the 95 mu m ArterioSorb oriented poly L-lactic acid (PLLA) scaffold in comparison with the XIENCE metallic drug-eluting stent (DES... Show moreAims: The aim of this study was to assess the acute performance of the 95 mu m ArterioSorb oriented poly L-lactic acid (PLLA) scaffold in comparison with the XIENCE metallic drug-eluting stent (DES) in porcine coronary arteries.Methods and results: In 15 non-atherosclerotic Yucatan mini pigs, the ArterioSorb (3.0/14 mm) and XIENCE (3.0/15 mm) were implanted in 25 and 15 vessels, respectively. Acute performance was evaluated by using quantitative coronary angiography (QCA) and optical coherence tomography (OCT). Following three-dimensional reconstruction of the coronary arteries, endothelial shear stress (ESS) was quantified using non-Newtonian steady-flow simulation. Acute recoil measured by QCA was comparable in the two aims. Post-procedural flow and scaffold/stent area by OCT did not differ between the two devices. ESS post procedure was comparable between ArterioSorb and XIENCE (2.21 +/- 1.97 vs 2.25 +/- 1.71 Pa, p=0.314).Conclusions: Acute recoil, luminal dimensions and ESS in the ArterioSorb oriented PLLA scaffold with thin struts of 95 mu m were comparable to those in the XIENCE metallic DES. Show less
Kishi, S.; Magalhaes, T.A.; Cerci, R.J.; Zimmermann, E.; Matheson, M.B.; Vavere, A.; ... ; Arbab-Zadeh, A. 2020
Purpose To provide comparative prognostic information of coronary atherosclerotic plaque volume and stenosis assessment in patients with suspected coronary artery disease (CAD). Methods We followed... Show morePurpose To provide comparative prognostic information of coronary atherosclerotic plaque volume and stenosis assessment in patients with suspected coronary artery disease (CAD). Methods We followed 372 patients with suspected or known CAD enrolled in the CORE320 study for 2 years after baseline 320-detector row cardiac CT scanning and invasive quantitative coronary angiography (QCA). CT images were analyzed for coronary calcium scanning (CACS), semi-automatically derived total percent atheroma volume (PAV), segment stenosis score (SSS), in addition to traditional stenosis assessment (>= 50%) by CT and QCA for (1) 30-day revascularization and (2) major adverse cardiac events (MACE). Area under the receiver operating characteristic curve (AUC) was used to compare accuracy of risk prediction. Results Sixty percent of patients had obstructive CAD by QCA with 23% undergoing 30-day revascularization and 9% experiencing MACE at 2 years. Most late events (20/32) were revascularization procedures. Prediction of 30-day revascularization was modest (AUC range 0.67-0.78) but improved after excluding patients with known CAD (AUC range 0.73-0.86, p < 0.05 for all). Similarly, prediction of MACE improved after excluding patients with known CAD (AUC range 0.58-0.73 vs. 0.63-0.77). CT metrics of atherosclerosis burden performed overall similarly but stenosis assessment was superior for predicting 30-day revascularization. Conclusions Angiographic and coronary atherosclerotic plaque metrics perform only modestly well for predicting 30-day revascularization and 2-year MACE in high risk patients but improve after excluding patients with known CAD. Atherosclerotic plaque metrics did not yield incremental value over stenosis assessment for predicting events that predominantly consisted of revascularization procedures. Show less
BackgroundLeft ventricular (LV) systolic function is a prognostic factorin patients with severe aortic stenosis (AS). Multi-detector row computed tomography (MDCT) data are key in the evaluation... Show moreBackgroundLeft ventricular (LV) systolic function is a prognostic factorin patients with severe aortic stenosis (AS). Multi-detector row computed tomography (MDCT) data are key in the evaluation of patients undergoing transcatheter aortic valve implantation (TAVI) and when acquired retrospectively, LV systolic function can be assessed. Novel software permits assessment of LV global longitudinal strain (GLS) from MDCT data.ObjectivesThe present study investigated the feasibility of feature tracking MDCT-derived LV GLS and its agreement with echocardiographic LV GLS in patients treated with TAVI.MethodsLV GLS was measured on transthoracic echocardiography using speckle tracking analysis and on dynamic MDCT using feature tracking technology. Agreement between the measurements of two different modalities was assessed using Bland-Altman analysis.ResultsA total of 214 patients (51% male, mean age: 80 ± 7 years) were analysed. Mean LV GLS on echocardiography was −13.91 ± 4.32%, whereas mean feature tracking MDCT-derived GLS was −12.46 ± 3.97%. Correlation of measurements between feature tracking MDCT-derived LV GLS and echocardiographic LV GLS demonstrated a large effect size (r = 0.791, p < 0.001). On Bland-Altman analysis, feature tracking MDCT-derived strain analysis underestimated LV GLS compared to echocardiography with a mean difference of 1.44% (95% limits of agreement −3.85% - 6.73%).ConclusionsAssessment of LV GLS on dynamic feature tracking MDCT data is feasible in TAVI patients. Compared to speckle tracking echocardiography, feature tracking MDCT underestimates the value of LV GLS. Show less
Reiber, J.H.C.; Pereira, G.T.R.; Dallan, L.A.P.; Bezerra, H.G.; Sutter, J. de; Stillman, A.E.; ... ; Lotz, J. 2020
Computed tomography plays a central role in the evaluation of patients with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI). Advances in left ventricular (LV)... Show moreComputed tomography plays a central role in the evaluation of patients with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI). Advances in left ventricular (LV) analysis with multidetector row computed tomography (MDCT) permit measurement of LV global longitudinal strain (GLS). The present study aimed at evaluating the association between feature tracking (FT) MDCT derived LV GLS and all-cause mortality in patients treated with TAVI. A total of 214 patients with severe aortic stenosis (51% male, 80 +/- 7 years) who underwent TAVI and with dynamic MDCT data allowing LV GLS measurement with novel FT algorithm were included. LV GLS was measured at baseline and were divided according to a previously published cut-off value of LV GLS associated with all-cause mortality (<=-14% [more preserved LV systolic function] vs >-14% [more impaired LV systolic function]). Patients were followed for the occurrence of all-cause mortality. Mean FT MDCT-derived LV GLS was -12.5 +/- 4%. During a median follow-up of 45 months (interquartile range: 29 to 62 months), 67 (31%) patients died. The cumulative rate of all-cause mortality for the patients with FT MDCT-derived LV GLS <=-14% was 15% versus28% for the patients with FT MDCT-derived LV GLS >-14%, Log rank p = 0.001). FT MDCT-derived LV GLS was independently associated with all-cause mortality (hazard ratio: 0.851; 95% confidence interval: 0.772 to 0.937; p = 0.001). In conclusion, impaired FT MDCT-derived LV GLS is independently associated with all-cause mortality in patients treated with TAVI. Besides aortic valve area and calcification, FT MDCT-derived LV GLS is an important prognostic marker. (C) 2019 Elsevier Inc. All rights reserved. Show less
Introduction Chest pain or discomfort affects 20%-40% of the general population over the course of their life and may be a symptom of myocardial ischaemia. For the diagnosis of obstructive... Show moreIntroduction Chest pain or discomfort affects 20%-40% of the general population over the course of their life and may be a symptom of myocardial ischaemia. For the diagnosis of obstructive macrovascular coronary artery disease (CAD), algorithms have been developed; however, these do not exclude microvascular angina. This may lead to false reassurance of symptomatic patients, mainly women, with functionally significant, yet non-obstructive coronary vascular disease. Therefore, this study aims to estimate the prevalence of both macrovascular and microvascular coronary vascular disease in women and men presenting with chest pain or discomfort, and to subsequently develop a decision-support tool to aid cardiologists in referral to cardiovascular imaging for both macrovascular and microvascular CAD evaluation. Methods and analysis Women and men with chest pain or discomfort, aged 45 years and older, without a history of cardiovascular disease, who are referred to an outpatient cardiology clinic by their general practitioner are eligible for inclusion. Coronary CT angiography is used for anatomical imaging. Additionally, myocardial perfusion imaging by adenosine stress cardiac MRI is performed to detect functionally significant coronary vascular disease. Electronic health record data, collected during regular cardiac work-up, including medical history, cardiovascular risk factors, physical examination, echocardiography, (exercise) ECG and blood samples for standard cardiovascular biomarkers and research purposes, are obtained. Participants will be classified as positive or negative for coronary vascular disease based on all available data by expert panel consensus (a cardiovascular radiologist and two cardiologists). After completion of the clinical study, all collected data will be used to develop a decision support tool using predictive modelling and machine-learning techniques. Ethics and dissemination The study protocol was approved by the Institutional Review Board of the University Medical Center Utrecht. Results will be disseminated through national and international conferences and in peer-reviewed journals in cardiovascular disease. Show less
Aims Quantitative flow ratio (QFR) is a recently developed technique to calculate fractional flow reserve (FFR) based on 3D quantitative coronary angiography and computational fluid dynamics,... Show moreAims Quantitative flow ratio (QFR) is a recently developed technique to calculate fractional flow reserve (FFR) based on 3D quantitative coronary angiography and computational fluid dynamics, obviating the need for a pressure-wire and hyperaemia induction. QFR might be used to guide patient selection for FFR and subsequent percutaneous coronary intervention (PCI) referral in hospitals not capable to perform FFR and PCI. We aimed to investigate the feasibility to use QFR to appropriately select patients for FFR referral.Methods and results Patients who underwent invasive coronary angiography in a hospital where FFR and PCI could not be performed and were referred to our hospital for invasive FFR measurement, were included. Angiogram images from the referring hospitals were retrospectively collected for QFR analysis. Based on QFR cut-off values of 0.77 and 0.86, our patient cohort was reclassified to 'no referral' (QFR >= 0.86), referral for 'FFR' (QFR 0.78-0.85), or 'direct PCI' (QFR <= 0.77). In total, 290 patients were included. Overall accuracy of QFR to detect an invasive FFR of <= 0.80 was 86%. Based on a QFR cut-off value of 0.86, a 50% reduction in patient referral for FFR could be obtained, while only 5% of these patients had an invasive FFR of <= 0.80 (thus, these patients were incorrectly reclassified to the 'no referral' group). Furthermore, 22% of the patients that still need to be referred could undergo direct PCI, based on a QFR cut-off value of 0.77.Conclusion QFR is feasible to use for the selection of patients for FFR referral. Show less
Kogame, N.; Takahashi, K.; Tomaniak, M.; Chichareon, P.; Modolo, R.; Chang, C.C.; ... ; Onuma, Y. 2019
OBJECTIVES The aim of this study was to investigate the impact of post-percutaneous coronary intervention (PCI) quantitative flow ratio (QFR) on clinical outcomes in patients with de novo 3-vessel... Show moreOBJECTIVES The aim of this study was to investigate the impact of post-percutaneous coronary intervention (PCI) quantitative flow ratio (QFR) on clinical outcomes in patients with de novo 3-vessel disease (3VD) treated with contemporary PCI.BACKGROUND The clinical impact of post-PCI QFR in patients treated with state-of-the-art PCI for de novo 3VD is undetermined.METHODS All vessels treated in the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) II trial were retrospectively screened and analyzed for post-PCI QFR. The primary endpoint of this substudy was vessel-oriented composite endpoint (VOCE) at 2 years, defined as the composite of vessel-related cardiac death, vessel-related myocardial infarction, and target vessel revascularization. The receiver-operating characteristic curve was used to calculate the optimal cutoff value of post-PCI QFR for predicting 2-year VOCE. All the analyzable vessels were stratified on the basis of the optimal cutoff value.RESULTS A total of 968 vessels treated with PCI were screened. Post-PCIQFR was analyzable in 771 (79.6%) vessels. A total of 52 (6.7%) VOCEs occurredat 2 years. The mean value of post-PCIQFR was 0.91 +/- 0.07. The diagnostic performance of post-PCI QFR to predict 2-year VOCE was moderate (area under the curve: 0.702; 95% confidence interval: 0.633 to 0.772), with the optimal cutoff value of post-PCI QFR for predicting 2-year VOCE 0.91 (sensitivity 0.652, specificity 0.635). The incidence of 2-year VOCE in the vessels with post-PCIQFR<0.91 (n = 284) was significantly higher compared with vessels with post-PCI QFR >= 0.91 (n = 487) (12.0% vs. 3.7%; hazard ratio: 3.37; 95% confidence interval: 1.91 to 5.97; p < 0.001).CONCLUSIONS A higher post-PCI QFR value is associated with improved vessel-related clinical outcomes in state-of the art PCI practice for de novo 3VD. Achieving a post-PCI QFR value >= 0.91 in all treated vessels should be a target when treating de novo 3VD. These findings require confirmation in future prospective trials. (C) 2019 by the American College of Cardiology Foundation. Show less
