Hernán Mejía-Rentería

Background/Objectives: Hypoattenuated leaflet thrombosis (HALT) is a frequent finding after transcatheter aortic valve replacement (TAVR). Although high residual platelet reactivity (HPR) increases thrombotic risk after coronary stent implantation, its role in HALT remains unclear. This study aimed to determine the incidence and predictors of HALT in TAVR patients treated with dual antiplatelet therapy, focusing on the impact of HPR. Methods: This was a prospective, multicenter observational study. Between June 2018 and February 2022 patients with symptomatic severe aortic stenosis undergoing successful TAVR and treated with dual antiplatelet therapy for 3 months were included. Platelet reactivity was assessed 1–3 months post-TAVR using either VerifyNow (72%) or the Multiplate Analyzer (28%). HALT was evaluated using contrast-enhanced multidetector computed tomography. Results: A total of 169 patients were included (mean age 81.5 ± 5 years; 51% female). The incidence of HALT was 22%. Independent predictors of HALT were self-expanding valve (OR 3.05; 95% CI, 1.30–7.14; p = 0.010). Protective factors included larger prosthesis size (OR 0.78; 95% CI, 0.65–0.93; p = 0.007), statin-treated dyslipidemia (OR 0.37; 95% CI, 0.16–0.88; p = 0.024), and higher creatinine clearance (OR 0.98; 95% CI, 0.96–1.00; p = 0.035). HALT incidence was similar in patients with and without HPR (23.7% vs. 33.6%; p = 0.29). No differences in clinical outcomes were observed at 1 year. Conclusions: HALT occurred in nearly one-quarter of TAVR patients treated with dual antiplatelet therapy and was unrelated to platelet reactivity. Valve characteristics, renal function, and statin-treated dyslipidemia were associated with HALT, highlighting the multifactorial nature of its development.

BACKGROUND: Current clinical guidelines recommend considering both obstructive and nonobstructive causes of myocardial ischemia in patients with chronic coronary syndrome. Wire-based physiological assessment constitutes a valid approach for this purpose, but it remains underutilized. We evaluated the diagnostic yield and clinical impact of an alternative wire-free approach for this purpose. METHODS: This is a subanalysis of the multicenter, prospective AID-ANGIO study (Advanced Invasive Diagnosis for Patients with Chronic Coronary Syndromes Undergoing Coronary Angiography), evaluating the impact of a wire-free advanced invasive diagnosis (AID) strategy in the diagnostic workflow of patients with chronic coronary syndrome admitted to the catheterization laboratory. The wire-free AID strategy combined quantitative flow ratio for epicardial evaluation, contrast angiography-derived index of coronary microcirculatory resistance for microvascular assessment, and acetylcholine testing for the endothelial-dependent coronary function. RESULTS: The study included 262 patients. The wire-free AID strategy identified a cause of myocardial ischemia in 84.3% of patients, representing a 2-fold increase in the identification of a cause of myocardial ischemia, compared with coronary angiography alone ( P <0.0001). In addition, the wire-free AID strategy demonstrated substantial agreement compared with the wire-based AID strategy (Cohen κ 0.78). The wire-free AID strategy led to a change in the initial therapeutic plan in 55.3% of patients compared with coronary angiography. Nevertheless, the wire-free AID strategy maintained good concordance with the wire-based AID strategy (16.8% of therapeutic changes). CONCLUSIONS: This study supports the clinical utility of a wire-free AID strategy in patients with chronic coronary syndrome, demonstrating its potential to improve diagnostic yield and guide clinical decision-making compared with coronary angiography alone. In addition, it shows substantial agreement with the wire-based approach.

Background: Bolus thermodilution and intravenous adenosine are established methods for coronary microcirculatory assessment. Yet, its adoption remains low, partly due to procedural time and patient discomfort associated with intravenous adenosine. We investigated differences between intracoronary and intravenous adenosine using bolus thermodilution in terms of microcirculatory indices, procedural time, and side effects associated with adenosine in patients with myocardial ischemia and nonobstructive coronary arteries. Methods and Results: In this prospective, observational study, 102 patients with suspected myocardial ischemia and nonobstructive coronary arteries underwent measurements of mean transit time, coronary flow reserve, index of microcirculatory resistance, procedure time and patient tolerability with low‐dose intracoronary adenosine, high‐dose intracoronary adenosine (HDIC), and intravenous adenosine. HDIC induced greater hyperemia compared with low‐dose intracoronary IC adenosine and intravenous adenosine with a shorter hyperemic mean transit time, P P P =0.031); high index of microcirculatory resistance was downgraded from 23% with intravenous adenosine to 14% with HDIC ( P =0.098). Intracoronary adenosine was associated with lower procedural times ( P P P <0.0001). Conclusions: In patients with suspected myocardial ischemia and nonobstructive coronary arteries undergoing coronary microcirculatory assessment with bolus thermodilution, the use of HDIC compared with intravenous adenosine was associated with enhanced induction of hyperemia. The use of intracoronary adenosine allowed for a shorter procedure time and was better tolerated. Registration+: URL: clinicaltrials.gov ; Unique Identifier: NCT04827498.

Background: Conduction disturbances represent one of the most common complications following transcatheter aortic valve replacement (TAVR). We sought to investigate the role of left ventricular outflow tract (LVOT) morphology in the development of conduction disturbances following TAVR. Methods and Results: Consecutive patients who underwent TAVR in our center were included. The ratio between the LVOT area and the aortic annulus area was calculated. Patients were then divided into 2 groups on the basis of this ratio: group 1, which included patients with an LVOT area/aortic annulus area ratio P =0.014; and HR: 4.3 [95% CI 2.4–7.6], P <0.001); at a median follow‐up time of 15.5 (interquartile range, 15) months. Conclusions: A tapered‐LVOT morphology was associated with increased risk for permanent pacemaker implantation. LVOT morphology may be an additional factor to consider when choosing prosthesis size.

Background: While it is broadly accepted that ageing is associated with impairment of coronary microvascular function, little is known about the underlying mechanisms.Aims: We investigated age‐related changes in coronary microvascular structure in patients with stable angina without epicardial coronary stenoses.Methods: In an analysis of the IDEAL registry, a total of 165 vessels without coronary stenosis were interrogated with combined pressure/Doppler guidewires. We calculated diastolic microvascular conductance (DMVC) and backward expansion wave (BEW), and compared them between age tertiles. We calculated the prevalence of CMD, defined by reduced coronary flow reserve (CFR), and the prevalence of low BEW and low DMVC in each group.Results: The three study groups were defined as having 37–53, 54–66, and 67–77 years of age, respectively. Oldest (3rd tertile) patients showed lower hyperemic flow velocity (46.7 ± 14.4 vs. 45.1 ± 12.4 vs. 38.4 ± 11.5 cm s⁻¹, p = 0.019), lower DMVC (1.90 ± 0.71 vs. 1.44 ± 0.56 vs. 1.37 ± 0.67 cm s⁻¹ mmHg⁻¹, p < 0.001) and lower BEW intensity (5.9 [2.9–8.4] vs. 4.8 [2.9–6.8] vs. 4.4 [3.4–6.3] × 10⁶ W m⁻² s⁻¹, p = 0.094). Older age was independently associated with lower BEW intensity (B: −0.10, 95% confidence interval [CI]: −0.17 to −0.09, p = 0.021) and DMVC (B: −0.25 95% CI: −0.45 to −0.09, p = 0.027). In patients with CFR < 2.5, the prevalence of BEW intensity and DMVC below the 25th percentile increased with age (25.0% vs. 52.0% vs. 72.7%, p = 0.010).Conclusions: Ageing is independently associated with structural microcirculatory remodeling that is reflected in BEW intensity and DMVC measurements, and with an increased prevalence of structural CMD. These results are important to understand non‐obstructive mechanisms of myocardial ischemia in the elderly.

Background: While it is broadly accepted that ageing is associated with impairment of coronary microvascular function, little is known on the underlying mechanisms. Diastolic microcirculatory conductance (DMVC) and the backward expansion wave (BEW) derived from wave intensity analysis (WIA) are two physiological indices derived from post-analysis of coronary pressure and flow that have been previously validated against endomyocardial biopsy micromorphometry, thus serving as metrics of structural microcirculatory remodelling applicable to in vivo assessment of the human coronary microcirculation. We investigated age-related changes in coronary microvascular structure in patients with stable angina without epicardial coronary stenoses. Methods: This is an analysis of the IDEAL registry, including a total of 165 vessels without coronary stenosis interrogated with combined pressure/Doppler guidewires in non-diabetic patients. We calculated DMVCs and BEWs using dedicated software, and we compared them between patient groups according to age tertiles. We also calculated the prevalence of CMD, defined by reduced Coronary Flow Reserve (CFR th percentile) in each group. Results: The three study groups were defined as having 37-53; 54-66 and 67-77 years of age, respectively. Oldest (3 ^rd tertile) patients show lower hyperemic flow velocity (46.7±14.4 vs 45.1±12.4 vs 38.4±11.5 cm.s-1, p=0.019), lower DMVC (1.90±0.71 vs 1.44±0.56 vs 1.37±0.67 cm.s ^-1 .mmHg ^-1 , p6 W.m ^-2 .s ^-1 , p=0.094). Older age was also found to be an independent predictor of lower cumulative BEW intensity (B −0.10, 95% CI: −0.17 to −0.09, p=0.021) and lower DMVC (B −0.25 95% CI: −0.45 to −0.09, p=0.027). In patients with CMD as determined by CFR th percentile increased with age (25.0%, vs 52.0% vs 72.7%, for the 1 ^st , 2 ^nd and 3 ^rd age tertiles, respectively, p=0.010). Conclusions: Ageing is independently associated with structural microcirculatory remodelling that is reflected in BEW intensity and DMVC measurements and increased prevalence of structural CMD. These results are important in understanding non-obstructive mechanisms of myocardial ischemia in the elderly. CLINICAL PERSPECTIVE: What is new? Ageing is independently associated with structural remodelling of the coronary microcirculation. Coronary structural microcirculatory remodelling is reflected by reductions in the Backward Expansion Wave intensity and in Diastolic Microvascular Conductance. What are the clinical implications? lder patients exhibit lower hyperemic flow response to pharmacological hyperemia. can explain the observed age-related differences between hyperemic and non-hyperemic indices of functional stenosis classification.

In current clinical practice, commissural alignment of the transcatheter heart valve (THV) during transcatheter aortic valve implantation (TAVI) is seldom achieved. Orientation of the THV within the aortic root and the subsequent influence upon leaflet haemodynamic function, coronary blood flow, and ease of access to the coronary ostia are gaining significant interest. Herein, we review the incidence and clinical implications of commissural misalignment in TAVI and offer thorough descriptions of how optimal alignment can be achieved with several different contemporary THV devices.

A 58-year-old male with hypertension was admitted following an out-of-hospital cardiac arrest after an episode of chest pain. He received bystander cardiopulmonary resuscitation and subsequently underwent defibrillation for ventricular fibrillation (VF).

Objectives: We aimed to evaluate the diagnostic accuracy of quantitative flow ratio (QFR) in left main (LM) coronary stenoses, using Fractional Flow Reserve (FFR) as reference.Background: QFR has demonstrated a high accuracy in determining the functional relevance of coronary stenoses in non‐LM. However, there is an important paucity of data regarding its diagnostic value in the specific anatomical subset of LM disease.Methods: This is a retrospective, observational, multicenter, international, and blinded study including patients with LM stenoses. Cases with significant ostial LM disease were excluded. QFR was calculated from conventional angiograms at blinded fashion with respect to FFR.Results: Sixty‐seven patients with LM stenoses were analyzed. Overall, LM had intermediate severity, both from angiographic (diameter stenosis [%DS] 43.8 ± 11.1%) and functional perspective (FFR 0.756 ± 0.105). Mean QFR was 0.733 ± 0.159. Correlation between QFR and FFR was moderate (r = 0.590). Positive and negative predictive value, sensitivity and specificity were 85.4%, 64%, 85.4%, and 69.6% respectively. Classification agreement of QFR and FFR in terms of functional stenosis severity was 78.1%. Area under the receiver operating characteristics of QFR using FFR as reference was 0.82 [95% confidence interval [CI], 0.71−0.93], and significantly better than angiographic evaluation including %DS (area under the receiver‐operating characteristic curve [AUC] 0.45 [95% CI, 0.32−0.58], p < 0.001) and minimum lumen diameter (AUC 0.60 [95% CI, 0.47−0.74], p < 0.001).Conclusions: Compared with FFR, QFR has acceptable diagnostic performance in determining the functional relevance of LM stenosis, being better than conventional angiographic assessment. Nonetheless, caution should be taken when applying functional angiography techniques for the assessment of LM stenosis given its particular anatomical characteristics.

A 74-year-old man who previously underwent percutaneous coronary intervention (PCI) for a right coronary non-ST-segment elevation myocardial infarction was scheduled for physiology-guided PCI to a left main stem (LMS)/left anterior descending (LAD) lesion. Clinical Images from Journal of Invasive Cardiology. percutaneous coronary intervention non-ST-segment elevation myocardial infarction