Ashkan Eftekhari

Background: The prognostic benefit of revascularization for unprotected left main (LM) disease remains uncertain, as guideline endorsement of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) precludes comparison with deferral, which is unlikely to be assessed in a randomized trial. Objectives: This study aimed to evaluate the prognostic impact of revascularization (PCI/CABG) versus deferred treatment of isolated, unprotected LM disease using real‐world data. Methods: Patients with isolated, unprotected LM disease identified by invasive coronary angiography on the indication chronic coronary syndrome between January 2002 and January 2021, registered in the Western Denmark Heart Registry, were identified and split into four groups: Defer ≤ 50% stenosis, defer > 50% stenosis, PCI, or CABG. Acute coronary syndrome (ACS), revascularization, stroke, and all‐cause mortality risks within 5 years were assessed. Adjusted analyses were conducted. Results: Of 4848 patients identified, 2819 patients underwent PCI, 467 CABG, 992 were in the defer ≤ 50% group, and 570 in defer > 50%. The 5‐year survival probability was 89.5% for PCI, 94.1% for CABG, 91.7% for defer ≤ 50%, and 84.0% for defer > 50% ( p < 0.0005%). Cumulative incidence of ACS was 7.9% for PCI, 3.0% for CABG, 5.3% for defer ≤ 50%, and 8.2% for defer > 50% ( p < 0.0005). For revascularization, numbers were 10.2%, 7.0%, 7.6%, and 15.4% ( p < 0.0005) and stroke 3.6%, 2.1%, 2.5%, and 3.8% ( p < 0.005). In adjusted analyses, the results were unchanged. Conclusions: Using real‐world data, this study demonstrated that either PCI or CABG was associated with improved survival in patients with LM disease, when diameter stenosis exceeded 50%. PCI was associated with higher rates of non‐fatal ACS and repeat revascularization compared to CABG but similar rates as deferred treatment. Clinical Perspectives: The prognostic benefit of revascularization for isolated and unprotected left main disease remains uncertain, as guideline endorsement of PCI or CABG precludes comparison with deferral. Deferred revascularization of unprotected LM disease with >50% diameter stenosis in patients with chronic coronary syndrome was associated with increased all‐cause mortality and non‐fatal acute coronary syndrome. Revascularization remains the treatment of choice in patients with significant unprotected LM disease for prognostic benefit.

BACKGROUND: Optimal treatment of coronary artery disease in patients undergoing transcatheter aortic valve implantation remains debated. Here, our aim was to analyze the impact of the diameter and location of coronary stenosis on outcomes in patients undergoing percutaneous coronary intervention (PCI) with transcatheter aortic valve implantation. METHODS: This study was a prespecified subanalysis of the NOTION-3 trial (Nordic Aortic Valve Intervention), which randomized patients with severe symptomatic aortic stenosis and physiologically significant stable coronary artery disease to receive either PCI or conservative treatment of coronary artery disease with transcatheter aortic valve implantation. In this substudy, patients were stratified according to diameter stenosis (P for interaction=0.051). PCI reduced major adverse cardiovascular events in case of proximal stenosis (26% versus 38%; hazard ratio, 0.61 [95% CI, 0.40–0.93]), although the difference in effect remained nonsignificant when compared with patients with nonproximal stenosis (28% versus 32%; hazard ratio, 0.91 [95% CI, 0.52–1.61]; P for interaction=0.27). CONCLUSIONS: The beneficial effect of PCI in patients undergoing transcatheter aortic valve implantation with physiologically significant stable coronary artery disease was seemingly pronounced in patients with high-grade stenosis, while stenosis location was not found to modify the outcome despite an almost similar beneficial effect with PCI in patients with proximal stenosis.

Background: Prognosis after transcatheter aortic valve implantation (TAVI) keeps improving, yet some high-risk groups persist, with chronic kidney disease being one. Contemporary data on the prognostic importance of pre-TAVI kidney function are sparse, leaving uncertainty regarding which patients derive limited benefit from TAVI. Background and Aims: To assess the association between pre-procedural kidney function and long-term outcomes in TAVI patients. Methods: We used Danish nationwide registries to identify patients with aortic stenosis undergoing TAVI between 2015 and 2022. Patients were categorized by baseline eGFR into ≥60, 30-59, and <30 mL/min/1.73 m2 or recent dialysis. We examined one-year all-cause mortality and hospitalization burden after TAVI and estimated relative risks using multivariable Cox and logistic regression. Results: We included 3888 (60.7%) patients with eGFR ≥60 (58.4% male; median age, 80 years), 2185 (34.1%) with eGFR 30-59 (55.5% male; median age, 83), and 336 (5.2%) with eGFR <30 or recent dialysis (58.0% male; median age, 81). One-year cumulative incidence of all-cause mortality was 5.6% for eGFR ≥60, 9.1% for eGFR 30–59, and 19.6% for eGFR <30 or dialysis. Adjusted hazard ratio was significantly higher for eGFR 30–59 (aHR, 1.45; 95% CI, 1.19–1.78, p =0 .0003) and eGFR <30 or dialysis (aHR, 3.07; 95% CI, 2.32–4.08, p < .0001) than eGFR ≥60. Cumulative rehospitalization exceding14 days after TAVI was most frequent among patients with eGFR <30 or dialysis (18.4%). Conclusions: We observed a stepwise association between pre-TAVI kidney function and post-TAVI one-year mortality as well as hospitalization burden. Kidney impairment potentially has substantial prognostic impact and should be incorporated into lifetime management of patients undergoing TAVI.

BACKGROUND: Intravascular imaging (IVI) during percutaneous coronary intervention (PCI) improves outcomes. Pullback pressure gradient characterizes coronary artery disease patterns as focal or diffuse; however, the benefit of IVI across this spectrum remains incompletely understood. We aimed to evaluate clinical outcomes after PCI with or without IVI guidance in patients with focal and diffuse disease defined by pullback pressure gradient. METHODS: Prospective, multicenter, single-arm study of 811 patients (840 vessels) undergoing PCI. Pullback pressure gradient was calculated from manual fractional flow reserve pullbacks to define focal (pullback pressure gradient ≥0.62) or diffuse coronary artery disease. IVI use was at the operator’s discretion. The primary outcome was target vessel failure at 1-year follow-up. RESULTS: IVI-guided PCI was performed in 41% of patients. In the overall cohort, target vessel failure was lower with IVI guidance (adjusted hazard ratio, 0.60 [95% CI, 0.36–0.99]; P =0.044), with a lower incidence of cardiac death ( P =0.042). The results were consistent irrespective of the baseline coronary artery disease pattern ( P _interaction =0.128). Among patients with focal disease, IVI-guided PCI was associated with a significantly lower incidence of target vessel failure compared with non-IVI-guided PCI (hazard ratio, 0.41 [95% CI, 0.18–0.91]; P =0.029). There was no statistical difference in target vessel failure with the use of IVI among patients with diffuse disease (hazard ratio, 0.91 [95% CI, 0.48–1.73]; P =0.771). CONCLUSIONS: In patients undergoing physiology-guided PCI, the use of IVI reduced clinical events at 1 year. These findings suggest that the benefit of IVI extends across the full spectrum of coronary artery disease.

Aims: We aimed to compare procedural, echocardiographic, and clinical outcomes within the first year after transcatheter aortic valve implantation (TAVI) among inhospital and subacute patients to elective patients in the COMPARE-TAVI 1 cohort. Methods and results: Among 1030 patients treated with TAVI, 927 (90%) had an elective procedure, 63 (6.1%) had a subacute procedure, and 40 (3.9%) had an inhospital procedure. Procedural characteristics and outcomes were comparable. Among elective, subacute, and inhospital patients, mortality at 30 days was 15 (1.6%), 0 (0%), and 0 (0%) and at 1 year 54 (5.8%), 4 (6.3%), and 2 (5.0%). Stroke at 30 days was 28 (3.0%), 0 (0%), and 3 (7.5%) and at 1 year 42 (4.5%), 5 (7.9%), and 3 (7.5%). New pacemaker at 30 days was 119 (14%), 12 (21%), and 6 (17%) and at 1 year 130 (16%), 14 (25%), and 7 (19%). Elective, subacute, and inhospital patients with LVEF ≤40%, improved their LVEF from 33% (28–37), 33% (27–37), and 28% (22–33) before TAVI to 46% (35–60), 43% (33–52), and 42% (33–55) at 30-days, and 54% (45–62), 53% (43–61), and 49% (39–63) at 1-year. Differences between the groups were not statistically significant. Conclusion: After transfemoral TAVI with balloon-expandable valves in COMPARE-TAVI 1, procedural, echocardiographic, and clinical outcomes were comparable among elective, subacute, and inhospital patients within the first year.

Background: The polymer‐free biolimus A9‐coated BioFreedom stent (BF‐BCS) releases a lipophilic drug that may provide a potent anti‐inflammatory effect in patients with acute coronary syndromes (ACS). Five‐year efficacy and safety of BF‐BCS were compared to the ultrathin strut biodegradable polymer sirolimus‐eluting Orsiro stent (O‐SES) in ACS patients. Methods: From SORT OUT IX, 1672 ACS patients were analyzed (821 treated with BF‐BCS and 851 with O‐SES); 764 (46%) presented with ST‐segment‐elevation myocardial infarction (STEMI) and 907 (54%) with non‐STEMI. Endpoints were target lesion failure (TLF) (a composite of cardiac death, target lesion myocardial infarction [MI], target lesion revascularization [TLR]) and definite stent thrombosis (ST) at 5‐years. Results: At 5‐years, TLF in ACS patients did not differ significantly between BF‐BCS and O‐SES (12.5% vs. 10.8%; rate ratio (RR) 1.12; 95% confidence interval (CI): 0.84–1.49). Cardiac death, target lesion MI, and definite ST rates were similar. TLR was higher with BF‐BCS compared to O‐SES within the first year (2.9% vs. 1.2%, RR 2.37; 95% CI: 1.13–4.99), but this difference was not maintained at 5‐year follow‐up (6.2% vs. 4.3%; RR 1.42; 95% CI: 0.92–2.18). The increased risk of TLR within the first year was driven by increased risk of TLR in STEMI patients treated with BF‐BCS compared to O‐SES (2.5% vs. 0.3%, RR 9.96; 95% CI: 1.26–79.0), while there were no differences in TLR rates in NSTEMI patients. Conclusion: At 5‐year follow‐up, TLF did not differ significantly in BF‐BCS or O‐SES treated ACS patients. The increased risk of early TLR in STEMI patients treated with BF‐BCS was not maintained at 5‐year follow‐up.