The American Journal of Cardiology

AimsCardiac myosin inhibitors (CMIs) have emerged as an alternative to septal reduction therapy (SRT) for obstructive hypertrophic cardiomyopathy (oHCM). However, comparative data on the time-trajectory of myocardial functional adaptation after septal myectomy (SM), alcohol septal ablation (ASA), and CMI are lacking. We compared temporal changes in echocardiographic parameters including LV global longitudinal strain (LVGLS) and LA reservoir strain (LASr) across these treatment strategies. Methods and ResultsIn this single-center retrospective cohort, symptomatic oHCM patients treated with SM (n=22), ASA (n=11), or CMI (n=47) underwent serial echocardiography with deep-learning-based automated strain analysis. Primary outcomes were temporal changes in LVGLS and LASr. Mixed-effects models adjusted for baseline clinical and echocardiographic variables were used to assess time-trajectories for up to 24 months. Treatment success rates were 86.4% (SM), 72.7% (ASA), and 93.6% (CMI). LVOT gradients were similarly reduced across groups. LVEF showed a subtle early decline after CMI (adjusted P-for-interaction=0.019). LVGLS gradually improved after SM and ASA but remained unchanged with CMI. LASr significantly improved after SM, showed minimal change after ASA, and demonstrated late attenuation beyond 9-12 months in the CMI group (adjusted P=0.029). ConclusionsDespite comparable LVOT gradient reduction, myocardial functional adaptation differed across therapies. Conventional SRT was associated with progressive improvement in LV and LA strain, whereas CMI therapy showed stable LVGLS with subtle early LVEF decline and late attenuation of LASr. These findings underscore the importance of longitudinal deformation imaging during CMI therapy and support reappraisal of SRT in selected patients requiring durable long-term management.

BackgroundIn patients with chronic coronary disease (CCD), it is unclear whether the use of potent P2Y12 inhibitors (ticagrelor or prasugrel) offers advantages to clopidogrel when prescribed in conjunction with aspirin in patients undergoing percutaneous coronary intervention (PCI) with atherectomy. MethodsConsecutive patients undergoing PCI with atherectomy for CCD at a tertiary care center between January 2011 to December 2020 were included. Patients discharged on ticagrelor or prasugrel were compared to patients on clopidogrel. The primary outcome was a composite of death or myocardial infarction (MI), secondary outcomes included individual components of the primary outcome, stroke, major bleeding, and target vessel revascularization at 1 year. Adjusted analyses were performed using propensity score stratification. ResultsOverall, 3,612 patients undergoing atherectomy were included in the analysis (clopidogrel [70.4%, n= 2,543], ticagrelor/prasugrel [29.5%, n=1,069]). Clopidogrel was prescribed more often in older patients with multimorbid risk factors, whereas ticagrelor/prasugrel was used more in patients with greater anatomical and procedural complexity. There was an increase in the use of potent antiplatelet agents over time (p<0.001). At 1-year follow-up, the primary outcome was observed in 5.2% and 4.0% of those taking clopidogrel and ticagrelor/prasugrel, respectively (adjusted hazard ratio (AHR) 0.87, 95% CI 0.58 - 1.3, p = 0.50). There were no significant differences in the rate of bleeding (5.5% vs 3.7%, AHR 0.98, 95% CI 0.66 - 1.46, p = 0.92) or other secondary outcomes between the two groups. ConclusionThe use of clopidogrel was associated with comparable ischemic and bleeding outcomes compared to ticagrelor/prasugrel in patients with CCD undergoing PCI with atherectomy.

BackgroundLeft atrial appendage occlusion (LAAO) is increasingly used as an alternative to oral anticoagulation for stroke prevention in select patients with atrial fibrillation. Data on outcomes in racial and ethnic minority individuals are limited. This analysis assessed differences in the utilization and outcomes of LAAO by race and ethnicity in a large national registry. MethodsThis analysis acquired data on WATCHMAN FLX patients from the National Cardiovascular Data Registry (NCDR) LAAO Registry through September 2022. All patients with an attempted WATCHMAN FLX implantation and known race and ethnicity were included. Baseline characteristics and 1 year event rates were compared. ResultsA total of 97,185 patients were analyzed; 87,339 were White (90%), 3,750 Black (Black/African American 3.9%), and 2,866 Hispanic ([Hispanic/Latinx] 2.9%). Black and Hispanic patients were younger with a higher incidence of prior stroke and significant bleeding compared to White patients. Black and Hispanic patients were treated with LAAO in smaller numbers relative to their proportion of the US population. Rates of procedural success were similar between groups. Though direct oral anticoagulants were prescribed in most patients across the groups, dual and single antiplatelet therapy were prescribed more often in Black patients. Black patients had significantly higher rates of 1-year death and bleeding compared to White and Hispanic patients. ConclusionsPatients from racial and ethnic minority groups comprise a disproportionately small fraction of all patients who undergo LAAO. Black and Hispanic patients were younger but had significantly higher comorbidities compared to White patients. Procedural success was similar amongst the groups but Black patients experienced higher rates of death and bleeding at 1 year. Graphic Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=84 SRC="FIGDIR/small/24306969v1_ufig1.gif" ALT="Figure 1"> View larger version (35K): org.highwire.dtl.DTLVardef@1fa57f9org.highwire.dtl.DTLVardef@a5c781org.highwire.dtl.DTLVardef@1cd139eorg.highwire.dtl.DTLVardef@c3215c_HPS_FORMAT_FIGEXP M_FIG C_FIG What is knownThere is underutilization of LAAO among racial and ethnic minority patients with AF and there are racial and ethnic differences in periprocedural outcomes. What this study addsIn this study from a large US national registry of patients undergoing LAAO, Black patients were younger but had higher baseline comorbidities and experienced higher rates of bleeding at 45 days and 1-year and higher 1-year mortality. Further work is needed to enroll diverse patients into research trials and to provide equitable AF-related access to advanced care and intra- procedural and post-procedural care in US real-world practice.

BackgroundCoronary computed tomography angiography (CCTA) has emerged as a helpful tool in the evaluation of patients with chest pain and suspected coronary artery disease (CAD). The study objective was to evaluate the clinical application of CCTA for assessment of patients presenting with chest pain at a large single urban tertiary health care center located in the US. MethodsA retrospective review of observational data from center was conducted. The study sample included outpatients aged 18 years or older who underwent CCTA during January 2018 through February 2020. ResultsThere were 158 patients in the study, with sixty-two percent having stress testing within 6-months prior to CCTA. Fifty-five percent of these patients had abnormal stress test findings but demonstrated no CAD on CCTA. Among the patients with normal stress tests, 24.4% demonstrated CAD on CCTA. Twenty-five patients underwent invasive coronary angiography (ICA) within the 6-months following CCTA. For these patients, the positive predictive value of CCTA was 91.3% (95% CI: 72.0%, 99.0%) and negative predictive value was 100.0% (95% CI: 15.8%, 100.0%) when compared to ICA results. In addition, CCTA demonstrated myocardial bridging in 10.0% and an anomalous coronary vessel in 8.8% of patients. ConclusionsThis study revealed that CCTA is being used as a diagnostic test in patients presenting with chest pain at the study center. Among patients with prior stress testing, these results were at times potentially inconsistent with the findings from the CCTA. In addition, the CCTA was able to identify variants in anatomical structures.

BackgroundCombination therapy with atherectomy and intravascular lithotripsy (IVL) has emerged as a promising strategy for the treatment of severely calcified occlusive coronary lesions, which potentially enhances procedural efficacy without increasing complication risk. MethodsThe Dual-Prep Registry is a multicenter, prospective registry designed to evaluate the safety and efficacy of IVL after atherectomy in severely calcified lesions. Combined use was selectively applied when the risk of complications was anticipated to be high with a larger atherectomy burr size, or when it was deemed non-beneficial due to unfavorable guidewire bias. All adverse events were adjudicated by a clinical events committee. Kaplan-Meier analysis was performed to evaluate the primary endpoint of major adverse cardiovascular events (MACE; composite endpoint of cardiac death, myocardial infarction, and target vessel revascularization [TVR]) at 1 year. ResultsA total of 118 cases (120 lesions) were enrolled across 20 facilities. Significant comorbidities included diabetes in 56.8% of patients and hemodialysis-dependence in 25.4%. Calcification score after atherectomy was 4.0 in all cases, and calcified nodules were present in 56.4% (core-lab analysis) of cases. One-year follow-up was complete in 99.2% patients. MACE occurred in 7.6% patients at one year (cardiac death 2.5%, myocardial infarction 5.1%, TVR 5.1%) and stent thrombosis was observed in 1 case. ConclusionsAtherectomy followed by IVL resulted in low 1-year rates of MACE, TVR, and stent thrombosis in patients with severely calcified coronary lesions. This approach may be considered for lesions where an "IVL-first" strategy is difficult to apply. Japan Registry of Clinical Trials: jRCT1032230384. URL: https://jrct.mhlw.go.jp A Clinical Perspective1) What Is New? O_LIElective combined use of IVL and atherectomy resulted in low 1 year MACE and TLR. C_LIO_LIThe incidence of MACE was higher in cases with greater residual stenosis after the procedure and a larger baseline reference vessel diameter. C_LI 2) What Are the Clinical Implications? O_LICombining IVL with atherectomy may serve as an effective treatment strategy in cases where IVL-first approaches are difficult to apply. C_LIO_LISevere calcified lesions that are presumed to be unresponsive to RA/OA treatment or carry a high risk of RA/OA complications may be good candidates for this strategy. C_LI

BackgroundPercutaneous coronary intervention (PCI) in patients with bifurcation lesions is associated with higher complexity and adverse outcomes. The goal of this study was to evaluate the inpatient outcomes of patients with PCI of bifurcation lesions. MethodsThe National Inpatient Sample (NIS) database, years 2016-2020, was studied using ICD 10 codes. Patients with bifurcation lesion PCI were compared to other PCIs excluding chronic total occlusions (CTO). We evaluated post-procedural inpatient mortality and complications. ResultsPCI in patients with a bifurcation lesion was associated with higher mortality and post-procedural complications. A weighted total of 9,795,154 patients underwent PCI, with 43,480 having a bifurcation lesion. The bifurcation group had a 3.79% mortality rate vs 2.56%. (OR, 1.50; CI:1.34-1.68; p<0.001). After adjusting for age, sex, race, diabetes mellitus, and chronic kidney disease, bifurcation lesion PCI remained significantly associated with higher mortality (OR, 1.68; 95% CI, 1.49- 1.88; p<0.001). Furthermore, bifurcation PCI was associated with higher rates of myocardial infarction (OR, 2.26; 95% CI, 1.68 - 3.06; p<0.001), coronary perforation (OR, 7.97; 95% CI, 6.25-10.17; p<0.001), tamponade (OR, 3.46; 95% CI, 2.49-4.82, p<0.001), and procedural bleeding (OR, 5.71; 95% CI, 4.85-6.71, p<0.001). All post-procedural complications were more than 4 times more likely in patients with bifurcation than in those without (OR, 4.33; 95% CI, 3.83-4.88; p<0.001). ConclusionUsing a large national inpatient database, PCI performed in patients with a Non-CTO bifurcation lesions were associated with significantly higher mortality and post-procedural complications.

BackgroundTarget lesion calcification is known to influence the percutaneous coronary intervention (PCI) outcomes. Calcium cracks as assessed by optical coherence tomography (OCT) after balloon angioplasty were associated with a larger stent area and a larger lumen gain after PCI for the lesions with moderate to severe calcification, although clinical outcomes in those patients remain unclear. This study aimed to assess the impact of calcium cracks after balloon angioplasty on the PCI results as well as the long-term clinical outcomes by multicenter OCT-guided PCI registry. MethodsWe formed a prospective, multicenter registry that include 22 sites from Japan and Korea that enrolled 268 patients who underwent PCI to the lesion with moderate to severe calcification on angiogram. Balloon dilatation and subsequent drug elution stent (DES) implantation were performed with OCT guidance in every case. Lesion modification with rotational atherectomy was performed before balloon dilatation if needed. Serial OCT images just before and after balloon angioplasty, and after stent implantation were analyzed at 1-mm intervals by an independent core laboratory. The incidence of calcium cracks after balloon angioplasty was assessed at the minimal lumen area (MLA) site by OCT. By protocol, follow-up angiography was performed 10 months after PCI (in 85.5% of patients), and both baseline and follow-up angiograms were analyzed by an angiographic core laboratory. The primary endpoint was the relationship between calcium crack after balloon angioplasty and stent expansion. The secondary endpoint was target vessel failure (TVF) at 1 year, defined as a composite of cardiac death, target vessel-related myocardial infarction, and target vessel revascularization. ResultsA total of 242 patients were analyzed. Of these, OCT analysis was performed in 147 patients with a complete OCT data set. Calcium cracks were observed in 28 patients (19%) at the MLA site. The percent stent expansion was greater in lesions with calcium crack than those without (99{+/-}26 % vs. 91{+/-}18 %, p=0.039). In 229 patients who underwent clinical follow-up at 1 year, TVF occurred in 23 patients (10.0%). In 139 patients in whom both OCT analysis and 1-year clinical follow-up was performed, the incidence of TVF was similar between patients with and without crack formation (11 % vs. 13 %, p=1.00). Angiographic sub-analysis with both baseline and 10-months follow-up was performed in 124 patients. Acute lumen gain, as well as late lumens loss, were greater in patients with calcium crack than those without (1.39{+/-}0.55 mm vs. 1.15{+/-}0.48 mm, p=0.037; 0.51{+/-}0.67 mm vs. 0.12{+/-}0.51 mm, p=0.0095, respectively), resulting in similar net lumen gains between the 2 groups. ConclusionThe OCT-guided PCI strategy demonstrated acceptable acute and 1-year clinical outcomes. The presence of calcium cracks after balloon angioplasty may have a potential impact on acute results after DES implantation in calcified lesions. However, its impact may be attenuated by late lumen loss at 10-months follow-up.

BACKGROUNDLipid-rich plaques are strongly associated with adverse cardiac events. However, the vascular response of lipid-rich lesions to drug-coated balloon (DCB) angioplasty has not been fully elucidated. This study aimed to compare vascular responses following DCB angioplasty between lipid-rich and non-lipid-rich coronary lesions. METHODSThis study included patients scheduled for DCB angioplasty for de novo small vessel lesions between February 2021 and April 2024. All patients underwent pre- and post-procedural near-infrared spectroscopy combined with intravascular ultrasound (NIRS-IVUS), along with follow-up coronary angiography and NIRS-IVUS at 8 months. Lesions were categorized as lipid-rich or non-lipid-rich based on the pre-procedural maximum lipid core burden index over 4mm (maxLCBI4mm). Changes in plaque volume and maxLCBI4mm from post-procedure to the 8-month follow-up, as well as the incidence of late lumen enlargement (LLE), were compared between the two groups. RESULTSForty-six patients were included in the final analysis: 15 in the lipid-rich group and 31 in the non-lipid-rich group. LLE occurred in 27% of the lipid-rich group and 39% of the non-lipid-rich group (P = 0.52). Percent plaque volume showed minimal change in the lipid-rich group (+0.3%), while a significant reduction was observed in the non-lipid-rich group (-3.6%; P = 0.045). Conversely, maxLCBI4mm significantly decreased in the lipid-rich group compared with the non-lipid-rich group (-240 vs. -42; P = 0.0030), resulting in comparable values at the 8-month follow-up. CONCLUSIONSDespite limited plaque regression, lipid-rich lesions demonstrated favorable vascular responses, including LLE and plaque stabilization, following DCB angioplasty. This study was registered in the UMIN Clinical Trials Registry (UMIN000043158). https://www.umin.ac.jp/ What is KnownO_LIVascular responses, such as vessel enlargement and plaque regression, are frequently observed following drug-coated balloon (DCB) angioplasty, contributing to late lumen enlargement (LLE). C_LI What the Study AddsO_LIPlaque regression is less likely to occur in lipid-rich lesions. C_LIO_LILLE occurs at a similar rate between lipid-rich and non-lipid-rich lesions. C_LIO_LILipid-rich lesions show a significant reduction in lipid burden. C_LI

IntroductionDespite a prevalence of 3-5% among adults, asymptomatic left ventricular systolic dysfunction (LVSD) remains underdiagnosed. There is a critical need for an accurate and widely accessible screening strategy for LVSD, given its association with preventable morbidity and premature mortality. A novel deep learning approach has demonstrated the ability to detect LVSD directly from ECG images, with retrospective validation across multiple institutions. There is a lack of prospective validation. In this pilot study, we evaluate the feasibility of screening and recruiting individuals for prospective echocardiography based on an image-based artificial intelligence (AI)-ECG algorithm applied to the ECG repository at a large academic medical center. Research Methods and AnalysisThis is the protocol for a prospective cohort study in outpatient primary care clinics of the Yale New Haven Hospital (YNHH). Adult patients who have undergone a 12-lead ECG without subsequent echocardiogram as a part of routine clinical care within 90 days of the ECG will be identified in the electronic health record (EHR). The AI-ECG model for LVSD will be deployed to YNHH ECG repository to define the probability of LVSD, identifying 5 patients each with high and low probability of LVSD. After discussion with primary care physicians, and subsequent contact by the study team, screened participants will be invited for and undergo an echocardiogram. The study participants and the cardiologists conducting the echocardiograms will be blinded to the results of the AI-ECG screen. The analysis will focus on feasibility metrics: the proportion (i) of all patients undergoing ECGs who have high probability of LVSD without subsequent echocardiogram, (ii) of patients who agree to participate in the study, and (iii) that undergo an echocardiogram. A descriptive exploration of the comparison of the AI-ECG and echocardiogram results will also be reported. Ethics and DisseminationAll patient EHR data required for assessing eligibility and conducting the AI-ECG screening will be accessed through secure servers approved for protected health information. Potential participants will only be contacted after they have discussed the study information with their primary care physician. All participants will be required to provide written informed consent before participation and data will be deidentified prior to analysis. This study protocol has been approved by the Yale Institutional Review Board (Protocol Number: 2000034006) and has been registered at ClinicalTrials.gov (Identifier: NCT05630170). The results of the future validation study will be published in peer-reviewed journals and summaries will be provided to the study participants.

IntroductionIncreased pulmonary capillary wedge pressure (PCWP) V-wave amplitude has been traditionally associated with significant mitral regurgitation (MR). However, increased PCWP V-waves may also occur in patients with elevated left ventricular end-diastolic pressure (LVEDP) or with dilated left atrium (LA). Interactions between MR, increased LVEDP, and LA dilatation in the genesis of increased PCWP V-waves were not well investigated. Material and MethodsIt was a single-center cohort study of 153 consecutive hemodynamically stable patients referred for invasive hemodynamic evaluation of dyspnea. Patients with significant valvular disease other than MR, acute coronary syndromes (ACS), hemodynamic instability, pericardial disease, and mechanical ventilation or mechanical LV support were excluded. ResultsStudy cohort included 41% males, 68.4+/-11.9 years old, 60% were on beta-adrenergic antagonists and 69.3% were on afterload reduction therapy. PCWP V-wave amplitude was significantly increased in patients with moderate or more severe MR (p<0.001), dilated LA (p=0.002), with a trend towards increased V-wave amplitude in elevated >12 mmHg LVEDP (p=0.117). There were no significant differences in age, gender, prevalence of LV dysfunction, other co-morbidities, and/or E/e ratio according to the MR degree, LA volume, and LVEDP. In patients categorized according to moderate or more severe MR, dilated LA, and increased >12 mmHg LVEDP - the presence of any two of these abnormal parameters was associated with 50-65% prevalence of elevated V-waves and reached 100% when all three were parameters were abnormal (p<0.002). ConclusionsIn euvolemic patients undergoing elective invasive hemodynamic evaluation of dyspnea, elevated PCWP V-waves are determined by three major pathophysiological parameters: moderate or more severe MV regurgitation, LA dilatation, and elevated LVEDP.

BackgroundCatheter ablation for atrial fibrillation (AFCA) is indicated for select patients with atrial fibrillation (AF) and has been shown to reduce AF burden and improve quality of life. Earlier studies demonstrated that women are less likely to undergo AFCA despite having more AF symptoms. We investigated whether an association exists between referral patterns and this sex disparity. Methods and ResultsA retrospective cohort study was conducted of outpatients with newly diagnosed AF using the electronic medical record at Northwestern. Of 5,445 patients analyzed, 2,108 were women, and 3,337 were men. Characteristics including race, insurance status, comorbidities, and prior AF treatment were compared by sex. Logistic regression models adjusted for socioeconomic and clinical factors were constructed to determine associations between sex and binary dependent variables including referrals to and visits with general cardiology and electrophysiology (EP) and utilization of AFCA. There were no significant differences in odds of referral to (aOR, 1.17 [0.92-1.48], P=0.20) or visits with (aOR, 1.03 [0.82-1.30], P=0.79) general cardiologists between women and men. There were no significant differences in odds of referral to (aOR, 0.83 [0.68-1.01], P=0.06) or visits with (aOR, 0.87 [0.72-1.05], P=0.15) electrophysiologists between women and men. Finally, no significant difference was found in likelihood to undergo AFCA between women and men (aOR, 1.08 [0.83-1.40], P=0.56). ConclusionsOur study demonstrates no significant differences in referral patterns to specialists or rates of AFCA between women and men. Encouraging equitable referral to specialists and access to AFCA is essential in ensuring appropriate care for all patients.

IntroductionMeasurement of the interventricular septum (IVS) is a key diagnostic and prognostic parameter in the evaluation of hypertrophic cardiomyopathy (HCM). Right ventricular muscle bundles (RVMB) that parallel the IVS complicate septal measurement on both echocardiography and magnetic resonance imaging. Current guideline statements reference left ventricular wall thickness measurements more than 15 mm as part of the diagnostic criteria for HCM. The medical literature lacks published data on the impact of including RVMB as part of the IVS measurement and its influence on diagnostic accuracy for HCM. MethodsWe measured the IVS and RVMB separately on echocardiography in 97 consecutive subjects referred for both echocardiography and magnetic resonance imaging (MRI) as part of the initial evaluation for HCM. Subjects were categorized as having or not having HCM based on current practice guidelines. Patients with HCM were sub-categorized as having septal involvement (HCM-Sep) or primarily apical hypertrophy (HCM-Ap). This was done because subjects with obvious HCM-Ap could be diagnosed with HCM irrespective of IVS thickness. ResultsCompared to subjects who did not have HCM, those with HCM-Sep had both increased IVS (15.4 {+/-} 2.7 vs 9.8 {+/-} 1.9 mm, p<0.001) and RVMB thickness (5.2 {+/-} 3.1 vs 1.9 {+/-} 1.9 mm, p<0.001). Within the group of subjects that either had HCM-Sep or did not have HCM, inclusion of the RVMB in the septal measurement increased the sensitivity for HCM from 63% to 100%, whereas specificity decreased from 100% to 87%. RVMB thickness more than 5 mm was seen in 46% of subjects with HCM-Sep but was absent in all subjects with HCM-Ap and those without HCM. The RVMB was visible on long axis imaging in 55% of subjects without HCM, 75% of subjects with HCM-Ap and 85% of subjects with HCM-Sep. ConclusionsInclusion of the RVMB in the measurement of IVS thickness on echocardiography may improve overall diagnostic accuracy for HCM. In addition, RVMB thickness is increased and is more often visible on parasternal long axis imaging in subjects with HCM, consistent with being part of the HCM pathology. This is particularly true in those with HCM-Sep. These data have implications for standardization of echocardiographic and MRI reporting in HCM.

BackgroundPercutaneous coronary intervention (PCI) for lesions with calcified nodules (CNs) is associated with worse outcomes than PCI for other calcified lesions. We aimed to clarify the relationship between CNs at index PCI, optical coherence tomography (OCT) findings at 8-month follow-up, and clinical outcomes using serial OCT. MethodsThis retrospective observational study utilized data from a prospective, single-center registry. We conducted consecutive PCI for calcified lesions requiring rotational atherectomy (RA) with OCT guidance. We categorized 51 patients (54 lesions) into those with (16 patients [16 lesions]) and without CNs (35 patients [38 lesions]). ResultsPost-PCI, stent expansion was comparable between the two groups, and CN-like protrusion was observed in 75% of patients in the CN group. Follow-up OCT at 8 months revealed in-stent CNs in 54% of treated CN lesions with CN-like protrusion, whereas non-CN lesions lacked in-stent CNs. The CN group exhibited greater maximum neointimal tissue (NIT) thickness than the non-CN group (p<0.001). Multivariate linear regression analysis demonstrated that CN was associated with maximum NIT (p=0.02). Consequently, the CN group exhibited a higher clinically-driven target lesion revascularization (TLR) rate than the non-CN group at 1 (p=0.009) and 5 years (p=0.02). TLR primarily occurred in lesions with maximum CN angles >180{degrees}. ConclusionsFollowing RA treatment with acceptable stent expansion, the presence of CNs before PCI correlated with greater neointimal tissue formation with in-stent CNs, resulting in a higher TLR rate, especially in lesions with maximum CN angles exceeding 180{degrees}. What is KnownO_LICalcified lesions with calcified nodules (CNs) are associated with a higher target lesion revascularization (TLR) rate in percutaneous coronary intervention (PCI) than other types of calcified lesions. C_LIO_LIIn-stent CNs may appear after PCI for CNs and is a major cause of increased TLR rates after PCI for CNs. C_LIO_LIThe relationship between calcified plaque morphology at the index PCI, neointimal tissue characteristics concerning in-stent CN location and frequency during follow-up, and subsequent clinical outcomes has not been explored with serial optical coherence tomography. C_LI What the Study AddsO_LIFollow-up OCT at 8 months revealed in-stent CNs in 54% of treated CN lesions with CN-like protrusion, whereas non-CN lesions lacked in-stent CNs. C_LIO_LIPCI for CNs exhibited a higher clinically-driven target lesion revascularization rate than PCI for lesions without CNs, primarily in lesions with maximum CN angles >180{degrees}. C_LI

BackgroundAnomalous aortic origin of a coronary artery (AAOCA) can cause myocardial ischemia and sudden cardiac death. The optimal stress-testing strategy and impact of coronary morphology on ischemia remain unclear. We assessed the effect of coronary morphology on stress-test completion and results across multiple test modalities. MethodsThis retrospective cohort study included 531 adults with AAOCA at our institution (7/2015 - 3/2023). Coronary morphology was characterized by the anomalous coronary (right [RCA], left main [LMCA], left anterior descending [LAD], left circumflex) and the course type (intramural, interarterial-only, transseptal, and other [prepulmonic and retroaortic]). Exercise and pharmacologic stress tests were positive if ischemia included the territory of the anomalous coronary. A mixed-effect logistic regression modeled the odds of a positive test based on morphology, comorbidities, and modality. A random forest regression analyzed the stress iFR as a continuous outcome. ResultsStress test results were available for 396 (75%) of patients (age 50 {+/-} 17 years; 42% female). Stress testing included 699 ECGs, 198 echocardiograms, 288 SPECTs, 133 PETs, and 103 dobutamine iFR studies. Completion of invasive dobutamine iFR (versus noninvasive-only) stress testing was associated with high-risk coronary morphology, p<0.001. Coronary morphology that trended toward higher adjusted odds of ischemia included the anomalous LMCA (OR: 2.1, p=0.054) and intramural course (OR: 1.9, p=0.14). Compared to ECG, iFR had higher adjusted odds of a positive result (OR: 27, p<0.001), followed by PET (OR: 9.0, p<0.001). In the random forest regression, stress iFR value was lowest for LAD (0.75) compared to LMCA (0.83) and RCA (0.84). For course type, transseptal (strongly correlated with the anomalous LAD) had the lowest stress iFR (0.77), followed by intramural (0.83), and interarterial (0.88). ConclusionsIn our adult AAOCA cohort, high-risk coronary morphology demonstrated a borderline association with ischemia on stress testing, whereas stress test modality was the strongest determinant of ischemia detection. Invasive stress testing was reserved for higher-risk coronary morphology. These findings underscore that effective risk stratification in AAOCA integrates clinical symptoms, coronary morphology, and stress test modality. Long-term follow-up is needed to determine the optimal strategy for ischemia evaluation. Clinical PerspectivesO_ST_ABSWhat is new?C_ST_ABSO_LIIn this single-center registry of adults with anomalous aortic origin of a coronary artery (AAOCA), 75% of patients had stress testing, enabling the largest analysis of how anomalous coronary morphology impacts stress testing practices and the presence of ischemia. C_LIO_LIConsistent with published data in younger AAOCA cohorts, our adult population (mean age >50 years) trended toward increased risk of ischemia with an anomalous left coronary and intramural course. C_LIO_LIComparing various stress test modalities for AAOCA, instantaneous wave-free, followed by positron emission tomography and single-photon emission computed tomography, have higher odds of being positive for ischemia than electrocardiogram and echocardiograms. C_LI What are the clinical implications?O_LIAdults with AAOCA remain at risk for ischemia and require careful risk stratification, with coronary morphology and clinical symptoms informing stress test selection and result interpretation. C_LIO_LIFor higher risk morphologic variants of AAOCA, consider further risk stratification with invasive coronary provocative studies to detect inducible ischemia. C_LI

ObjectiveTo evaluate utilization of sodium-glucose cotransporter-2 inhibitors (SGLT2i) and angiotensin receptor neprilysin inhibitors (ARNi) in patients with atrial fibrillation (AF) and heart failure (HF). MethodsWe analyzed the MarketScan databases for the period 1/1/2021 to 6/30/2022. Validated algorithms were used to identify patients with AF and HF, and to classify patients into HF with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). We assessed the prevalence of SGLT2i and ARNi use overall and by HF type. Additionally, we explored correlates of lower utilization, including demographics and comorbidities. ResultsThe study population included 60,927 patients (mean age 75, 43% female) diagnosed with AF and HF (85% with HFpEF, 15% with HFrEF). Prevalence of ARNi use was 11% overall (30% in HFrEF, 8% in HFpEF), while the corresponding figure was 6% for SGLT2i (13% in HFrEF, 5% in HFpEF). Use of both medications increased over the study period: ARNi from 9% to 12% (from 22% to 29% in HFrEF, from 6% to 8% in HFpEF), and SGLT2i from 3% to 9% (from 6% to 16% in HFrEF, from 2% to 7% in HFpEF). Female sex, older age, and specific comorbidities were associated with lower utilization of these two medication types overall and by HF type. ConclusionUse of ARNi and SGLT2i in patients with AF and HF is suboptimal, particularly among females and older individuals, though utilization is increasing. These results underscore the need for understanding reasons for these disparities and developing interventions to improve adoption of evidence-based therapies among patients with comorbid AF and HF.

BackgroundPatients with repaired tetralogy of Fallot (rTOF) remain at risk of sustained monomorphic ventricular tachycardia (SMVT) related to slow-conducting anatomical isthmuses (SCAI). Invasive electroanatomical mapping (EAM) is the only available method to identify SCAI (SCAIEAM). We aimed to determine rTOF-specific high signal intensity threshold values (HSIt) to identify abnormal myocardium by 3D late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) and assess the performance of LGE-CMR to non-invasively identify SCAIEAM. MethodsConsecutive rTOF patients who underwent right ventricular EAM (RV-EAM) and 3D LGE-CMR were included (2012-2021). A SCAIEAM was defined as an anatomical isthmus (AI) with conduction velocity (CV) <0.5 m/s. LGE-CMR-derived 3D RV reconstructions were merged with 3D RV-EAM data. The HSIt was determined based on the comparison of local bipolar voltages (BV) and the corresponding local SI using ROC analysis. An abnormal AI on LGE-CMR (Abnormal AICMR) was defined as AI showing continuous high SI (>HSIt) between anatomical boundaries. ResultsForty-eight rTOF patients (34{+/-}16 years, 58% male) were included. Of 107 AIs on EAM (AI1 and 3 in all, AI2 in 11), 78 were normal-conducting AIEAM (NCAIEAM), 22 were SCAIEAM (SCAIEAM2 in 2 and SCAIEAM3 in 20), and 7 were blocked AIEAM3. All 14 induced SMVTs were related to SCAIEAM3. A total of 9240 EAM points were analyzed. HSIt was 42% of the maximal SI (AUC 0.80; sensitivity, 74%; specificity, 78%). On 3D-CMR RV construction, all 29 SCAIEAM or Blocked AIEAM were identified as abnormal AICMR. Among the 78 NCAIEAM, 70 were normal AICMR and 8 were abnormal AICMR. The sensitivity and specificity of 3D LGE-CMR for identifying SCAIEAM or blocked AIEAM were 100% and 90% (29/29 and 70/78), respectively. Among patients with NCAIEAM3 (n=28), those with abnormal AICMR3 (n=6) had significantly lower BV and slower CV compared with those with normal AICMR3 (n=22) (BV, 1.91 [1.62-2.60] vs. 3.45 mV [2.22-5.67]; CV, 0.69 [0.62-0.81] vs, 0.95 m/s [0.82-1.09]; both P<0.01). Conclusion3D LGE-CMR can identify SCAI with excellent sensitivity and specificity and may identify diseased AI3 even before critical conduction delay occurs, which may enable non-invasive risk stratification of VT and may refine patient selection for invasive EAM. What is new?O_LIrTOF-specific high signal intensity threshold (HSIt) value on 3D LGE-CMR to identify abnormal myocardium was determined by direct comparison between 9240 superimposed 3D EAM points and corresponding local signal intensity on the 3D CMR-derived reconstruction. C_LIO_LIThe newly proposed method of CMR image analysis using the obtained HSIt showed an excellent interobserver agreement and could identify SCAI or blocked AI with 100% sensitivity and 90% specificity. C_LIO_LICompared to patients with NCAIEAM and normal AICMR (true negative CMR), those with NCAIEAM but abnormal AICMR (false positive CMR) had already significantly lower BV and CV on EAM. C_LI What are the clinical implications?O_LIThe newly proposed technique of 3D LGE-CMR image analysis may allow for non-invasive and serial risk stratification of VT in patients with rTOF and can refine patient selection for invasive EAM and concomitant ablation. C_LI

BackgroundComputed tomography (CT) is routinely performed for planning transcatheter aortic valve implantation (TAVI) procedures. Aortic valve calcium score (AVCS) is recommended to ascertain the severity of degenerative aortic stenosis (AS) in low-flow states, with the role of CT-AVA (aortic valve area) being uncertain. In this study, we determined the best AVCS and CT-AVA thresholds in patients referred for TAVI. MethodsA retrospective multicentre study evaluated 1162 patients undergoing TAVI CT for severe AS. Two inclusion criteria for normal cardiac output by transthoracic echocardiography (TTE) were considered: Group A: left ventricular ejection fraction [&ge;]50% and indexed stroke volume 28-48 ml/m2, Group B: cardiac index 1.9-4.3 L/min/m2. The predictive ability of CT parameters for severe AS (mean gradient [&ge;]40 mmHg) was assessed using ROC curves and optimal thresholds were determined. Results428 patients in Group A and 685 patients in Group B fulfilled the inclusion criteria. Best thresholds for AVCS and CT-AVA in group A (mean age 81{+/-}7.5 years; 54% women) were [&ge;]2034 AU (AUC 0.79) and [&le;]0.90 cm2 (AUC 0.71) for women and [&ge;]3046 AU (AUC 0.78) and [&le;]0.97 cm2 (AUC 0.69) for men; while in Group B (mean age 81{+/-}7.5 years; 45% women), they were [&ge;]1962 AU (AUC 0.80) and [&le;]0.99 cm2 (AUC 0.73) in women, and [&ge;]2983 AU (AUC 0.78) and [&le;]1.04 cm2 in men. ConclusionsThis study defines optimal AVCS thresholds for severe AS in a TAVI patient cohort, which are much higher than previously reported. CT-AVA could also be an additional parameter to establish AS severity.

BackgroundThe association between transthyretin cardiac amyloidosis (TTR-CA) and aortic stenosis (AS) has been described, although the mechanism by which they interact remains unclear. It has previously been proposed that this may be secondary to excess valvular calcification. ObjectivesWe propose that patients with suspected cardiac amyloidosis will have increased aortic valve calcification, as evidenced by elevated aortic valve calcium score on CT imaging. MethodsWe retrospectively identified patients with severe AS referred for transcatheter aortic valve implantation (TAVI) from January 2017 to November 2022. This population was divided into two cohorts; the Likely CA cohort had suspected TTR-CA by echocardiogram while the Unlikely CA cohort did not. Baseline characteristics, echocardiographic data, CT aortic valve calcium scores, and post-procedural complications were compared. ResultsOf the 496 patients analyzed, 145 (29.2%) patients met echocardiographic criteria (interventricular septal thickness (IVS) [&ge;]1.2 cm and average mitral annular systolic s [&le;] 6 cm/s) for the Likely CA cohort. The Likely CA cohort was more likely to be older, be male, have atrial fibrillation, and have worse renal function. On echocardiogram, the Likely CA cohort had increased hypertrophy, worsened diastolic function, and decreased systolic function. Aortic valve calcium score by CT was not significantly different between the Likely CA and Unlikely CA cohort (2834.95 AU compared to 2852.27 AU, p=0.914). There was no statistically significant difference in post-TAVI complications. ConclusionsPatients with an echocardiographic profile consistent with TTR-CA had no difference in aortic valve calcification in comparison to a population unlikely to have TTR-CA.

2.BackgroundOstial stenosis, a narrowing at the origin of coronary side branches, is commonly observed in branches diverging from stenotic coronary segments. However, it may also occur in branches diverging from non-stenotic segments, and the factors contributing to this phenomenon remain unclear. ObjectivesThis study aimed to assess the incidence of ostial stenosis in coronary side branches diverging from non-stenotic segments and to identify associated risk factors. MethodsWe conducted a retrospective analysis of first-time, elective coronary angiograms (CAGs) from 884 patients. Side branches with a diameter larger than 2mm were included. Ostial stenosis was defined by two criteria: 1) the side branch diverged from a coronary segment with less than 25% diameter stenosis, and 2) the side branch exhibited ostial narrowing with more than 50% diameter stenosis. Clinical factors, including diabetes mellitus and lipid profiles, were assessed. Multivariate logistic regression was used to identify independent predictors of ostial stenosis. ResultsOf the 4,739 side branches analyzed, 508 (10.7%) exhibited ostial stenosis. Ostial stenosis was present in 285 (32.2%) patients. Patients with ostial stenosis had a significantly higher prevalence of diabetes mellitus (60.0% vs. 33.0%, p<0.00001) and lower high-density lipoprotein (HDL) cholesterol levels (48.5 {+/-} 14.6 mg/dL vs. 52.0 {+/-} 14.9 mg/dL, p<0.01) compared to those without stenosis. No significant differences were found in other clinical factors. Multivariate analysis identified diabetes mellitus as an independent predictor of ostial stenosis (odds ratio: 0.29, 95% CI: 0.20-0.43, p<0.0001). ConclusionsOstial stenosis in side branches diverging from non-stenotic coronary segments is significantly associated with diabetes mellitus. In diabetic patients, factors such as negative arterial remodeling, insulin resistance, and endothelial dysfunction likely play key roles in the development of this condition. These findings suggest that ostial stenosis could be an additional marker of advanced coronary artery disease in diabetes.

BACKGROUNDExcimer laser coronary atherectomy (ELCA) is used for thrombotic culprit lesions in ST-segment elevation myocardial infarction (STEMI), but its efficacy is still unclear. The study objective was to investigate the clinical outcomes of STEMI patients after ELCA. METHODSData of consecutive patients undergoing primary percutaneous coronary intervention (PCI) within 24 hours of onset, in 12 healthcare facilities in Japan, were retrospectively analyzed. Patients were divided into ELCA and non-ELCA groups. The primary endpoint was target vessel-related major adverse cardiac events (TV-MACE). Cox regression analysis and propensity score matching were performed to adjust for selection bias in the cohort. RESULTSA total of 2593 patients, which included 427 patients treated with ELCA, were analyzed with a median follow-up of 815 (390-1385) days. There was no significant difference between the two groups in terms of TV-MACE-free survival rate. ELCA use was not a significant determinant of TV-MACE (hazard ratio [HR] 1.265, 95% confidence interval [CI], 0.910-1.757; p=0.161). Nevertheless, when the ELCA group was stratified by the ELCA catheter size, the large catheter (1.4 mm-1.7 mm) group showed better clinical outcomes than the others in univariate Cox regression analysis (HR 0.30, 95% CI 0.10-0.95, p=0.040). In the propensity score-matched cohort of 736 patients (368 pairs), the TV-MACE-free survival did not differ between the two groups. CONCLUSIONSELCA did not show clinical benefit in terms of the rate of adverse cardiac events in patients with STEMI. There was evidence of efficacy when a large ELCA catheter was used, warranting further prospective studies. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIIn a relatively large-scale registry of STEMI patients undergoing primary PCI, which included 427 patients treated with ELCA, the use of ELCA did not show clinical benefits in reducing target-vessel related adverse events. C_LIO_LIThe use of ELCA was not associated with improved coronary flow or myocardial perfusion, but rather with higher peak values of cardiac markers. C_LIO_LILarger ELCA catheters ([&ge;]1.4mm diameter) may be associated with better clinical outcomes compared to smaller (0.9mm) ELCA catheters, suggesting potential areas for future research. C_LI What are the clinical implications?O_LIThe routine use of ELCA may not reduce adverse cardiac events in primary PCI for patients with STEMI. C_LIO_LIThe use of ELCA should be limited to lesions where large-sized ELCA catheters can be safely applied. C_LI