Faculty Bibliography

BACKGROUND/UNASSIGNED:Studies suggest percutaneous coronary intervention (PCI) guided by intracoronary imaging (ICI) results in larger balloon/stent diameters and longer stents. Whether this occurs in real-world PCI is poorly understood. METHODS/UNASSIGNED:De novo PCIs performed at 48 nonfederal Michigan hospitals between July 2019 and June 2022 were evaluated with regression modeling to evaluate associations between ICI-guided PCI and balloon/stent dimensions. The association between ICI-guided PCI and coronary dissection/perforation was assessed using adjusted odds ratios. RESULTS/UNASSIGNED:=0.33 for trend, respectively). CONCLUSIONS/UNASSIGNED:In real-world practice, ICI-guided PCI was associated with larger stent/balloon diameters and longer stents. While ICI use was associated with dissections and perforations, there was no significant increase in the rate of these complications despite significant increases in ICI use and stent/balloon sizes during the study period. Further research is needed to evaluate the association between ICI use and procedural complications.

BACKGROUND AND AIMS/OBJECTIVE:Radial access site for percutaneous coronary intervention (PCI) is recommended by clinical practice guidelines because of superior outcomes compared with femoral access site. Historically, the adoption of radial access site in the USA has lagged behind much of the rest of the world, but contemporary data on access site selection across the spectrum of clinical presentations and its association with outcomes are lacking. METHODS:A retrospective cohort study from the National Cardiovascular Data Registry's CathPCI Registry was conducted including PCIs performed between 1 January 2013 and 30 June 2022. The comparative safety of radial vs femoral access site for PCI was evaluated with instrumental variable analysis, a technique that can be used to support causal inference, exploiting operator variation in access site preferences as the instrumental variable. RESULTS:Overall, 6 658 479 PCI procedures were performed during the study period, of which 40.4% (n = 2 690 355) were performed via radial access site, increasing from 20.3% in 2013 to 57.5% in 2022. This increase was seen in all geographic regions and across the full spectrum of presentations, with the largest relative increase seen in patients with ST-elevation myocardial infarction. Overall, 2 420 805 PCIs met inclusion criteria for the comparative safety analysis. In instrumental variable analyses, radial access site was associated with lower in-hospital mortality [absolute risk difference (ARD) -.15%, 95% confidence interval (CI) -.20 to -.10], major access site bleeding (ARD -.64%, 95% CI -.68 to -.60), and other major vascular complications (ARD -.21%, 95% CI -.23 to -.18) but a higher risk of ischaemic stroke (ARD .05%, 95% CI .03-.08). There was no association with the falsification endpoint of gastrointestinal or genitourinary bleeding (ARD .00%, 95% CI -.03-.03). CONCLUSIONS:Over the past decade, use of radial access site for PCI has increased 2.8-fold in the USA and now represents the dominant form of access site across all procedural indications. Based on instrumental variable analyses, PCI with radial access site had lower rates of in-hospital mortality, major access site bleeding, and other major vascular complications compared with femoral access site but a slightly higher risk of ischaemic stroke in contemporary practice.

IMPORTANCE/UNASSIGNED:Both myocardial infarction (MI) and anemia have deleterious effects on health-related quality of life (QOL). Red blood cell (RBC) transfusion may improve QOL after MI by relieving symptoms and/or increasing functional capacity. OBJECTIVE/UNASSIGNED:To evaluate whether a liberal transfusion strategy compared with a more restrictive transfusion strategy affects QOL in patients with MI and anemia. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This analysis of QOL as a prespecified secondary outcome of the Myocardial Ischemia and Transfusion (MINT) trial, a randomized clinical trial comparing a liberal vs restrictive RBC transfusion strategy, included participants from 144 sites across 6 countries. Hospitalized adults with acute MI and anemia (hemoglobin [Hb] less than 10 g/dL). The MINT trial randomized 3504 patients, and this analysis included those who had QOL data collected and those who died before the 30-day follow-up period. Data were collected from April 2017 to April 2023, and data were analyzed from February 2024 to January 2025. INTERVENTIONS/UNASSIGNED:The MINT trial randomized patients to a restrictive (Hb of 7 to 8 g/dL) or a liberal (Hb of less than 10 g/dL) RBC transfusion strategy. MAIN OUTCOMES AND MEASURES/UNASSIGNED:QOL was measured using the EQ-5D-5L 30 days after randomization. RESULTS/UNASSIGNED:Of 2844 included patients, 1551 (54.5%) were male, and the mean (SD) age was 71.9 (11.5) years. A total of 2525 (88.8%; 1254 [49.7%] in the restrictive group and 1271 [50.3%] in the liberal group) had QOL data, and 319 (11.2%) died before 30-day follow-up. Overall, there were no differences in mean or median scores for any EQ-5D-5L QOL outcome between assigned transfusion strategies at 30 days postrandomization. Although a higher percentage of patients in the liberal compared with the restrictive transfusion group reported no problems compared with any problem in usual activities (506 of 1268 [39.9%] vs 473 of 1247 [37.9%]), mobility (474 of 1270 [37.3%] vs 460 of 1254 [36.7%]), and self-care (858 of 1271 [67.5%] vs 803 of 1254 [64.0%]) domains, none of these differences were statistically significant. Adjusted mixed-effects linear regressions showed no association between assigned transfusion strategy and mean differences in any QOL outcome. Adjusted regressions in several prespecified subgroups showed an association between a liberal transfusion strategy and better QOL scores in domains related to functional capacity, but the effects were only statistically significant in patients with a history of heart failure (Health Today rating: β, 2.06 [95% CI, -0.23 to 4.35] vs -1.44 [95% CI, -3.81 to 0.92]; P = .04). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This secondary analysis of the MINT trial found that in patients with MI and anemia, a liberal transfusion strategy compared with a restrictive transfusion strategy did not affect QOL outcomes 30 days after randomization. This suggests that higher Hb levels maintained with RBC transfusion may not offer significant benefits to QOL overall in patients with MI and anemia. Additional studies may be useful for further examining and validating transfusion's effect on QOL in patients with MI and heart failure. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT02981407.

[This corrects the article DOI: 10.1016/j.jscai.2024.102397.].

BACKGROUND/UNASSIGNED:Injection of contrast media for rapid measurement of contrast fractional flow reserve (cFFR) obviates the side effects and time requirements of adenosine fractional flow reserve (aFFR) and improves diagnostic performance relative to nonhyperemic pressure ratios. However, studies of cFFR have had variable delivery of contrast. We evaluated the diagnostic performance of cFFR using an automated contrast injector with a standardized volume and rate of delivery of contrast to the reference standard aFFR. METHODS/UNASSIGNED:) and RXi/Navvus FFR microcatheter. The diagnostic performance of cFFR was assessed using a 0.83 cutoff value based on published literature. Optimal cFFR cutoffs were also determined and illustrated using Bland-Altman analysis. RESULTS/UNASSIGNED:A total of 192 lesions from 178 patients were included in the per-protocol analysis (69 with an aFFR ≤0.80 and 109 with an aFFR >0.80). Using a cFFR cutoff value of ≤0.83, the accuracy, sensitivity, and specificity of cFFR were 0.89 (95% CI, 0.83-0.93), 0.70 (95% CI, 0.58-0.81), and 0.99 (95% CI, 0.95-1.00), respectively. The mean difference between cFFR and aFFR was 0.05 (-0.04 to 0.13). A cFFR threshold of ≤0.85 had the highest accuracy in predicting aFFR ≤0.80 with accuracy, sensitivity, and specificity equaling 0.90 (95% CI, 0.84-0.94), 0.87 (95% CI, 0.77-0.94), and 0.91 (95% CI, 0.84-0.95), respectively. CONCLUSIONS/UNASSIGNED:cFFR utilizing standardized parameters for contrast delivery leads to clinically acceptable levels of diagnostic performance compared with traditional aFFR to identify physiologically significant intermediate lesions. Future data evaluating the impact on clinical outcomes of cFFR-guided percutaneous coronary intervention are warranted. REGISTRATION/UNASSIGNED:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03557385.

BACKGROUND:Patients undergoing atrial fibrillation (AF) ablation have historically been hospitalized overnight or longer postprocedure. National rates of same-day discharge (SDD) following AF ablation remain unknown. METHODS AND RESULTS/RESULTS:<0.0001), surpassing overnight hospitalization in Q1 of 2021. The likelihood of SDD increased significantly over time (odds ratio [OR], 1.26 per quarter-year [95% CI, 1.26-1.26]) with substantial variation across hospitals (median OR, 4.12 [95% CI, 3.48-4.79]). Those discharged the same day were less likely of Black race (OR, 0.71 [95% CI, 0.65-0.78]) and to have persistent AF (OR, 0.85 [95% CI, 0.82-0.88]) and cardiomyopathy (OR, 0.87 [95% CI, 0.84-0.91]). In total, major and overall complication rates were 0.70% and 2.13%, respectively. Major and overall complication rates were 0.03% and 0.19% for SDD and 0.24% and 0.98%, respectively, for overnight hospitalization. CONCLUSIONS:Rates of SDD following AF ablation markedly increased over time, corresponding with onset of the COVID-19 pandemic, with substantial hospital variation. SDD patients had fewer comorbid conditions and were less likely to have persistent AF. Postprocedural complication rates with SDD were low and comparable with patients hospitalized overnight.

BACKGROUND:Cardiogenic shock (CS) is a common complication of acute coronary syndrome (ACS) and is associated with significant morbidity and mortality. Revascularization has been shown to reduce mortality in ACS-CS. Patients with cancer are at high risk of ACS and CS. However, patients with cancer are often undertreated with invasive procedures and outcomes of patients with cancer and ACS-CS have not been thoroughly characterized. METHODS:Patients with ACS-CS from 2014 to 2020 with and without cancer were identified using the National Readmission Database (NRD). Primary outcome was death at 90-days. Secondary outcomes were 90-day cardiovascular (CV) and bleeding readmissions, and index hospitalization major bleeding and thrombotic complications. Patients with cancer were compared to patients without cancer using multivariable logistic and Cox proportional hazards regression. Temporal trends in revascularization among patients with and without cancer were examined. Effect of revascularization among patients with cancer and ACS-CS was assessed using propensity score weighting (PSW). RESULTS:A total of 140,205 patients were identified, of whom 6118 (4.4 %) with cancer were identified. Patients with cancer were less likely to undergo percutaneous coronary intervention (45.5 % vs 53.5 %) or be managed with mechanical circulatory support (36.6 % vs 46.0 %). After multivariable logistic regression, there was no difference in primary outcome (adjusted OR 0.98, 95 % CI 0.92-1.06) but patients with cancer had higher risk of 90-day CV (HR 1.11, 95 % CI 1.01-1.22) and bleeding readmissions (HR 1.39, 95 % CI 1.10-1.76). Among patients with cancer and ACS-CS, revascularization was associated with lower primary outcome (OR 0.54, 95 % CI 0.50-0.58) and 90-day CV readmission (HR 0.68, 95 % CI 0.59-0.77) after PSW. CONCLUSIONS:Among patients with ACS-CS, patients with cancer have similar 90-day death but higher risk of 90-day CV and bleeding readmissions. Additionally, revascularization was associated with improved outcomes among patients with cancer and ACS-CS. Further studies are needed to optimize patient selection for invasive management among patients with cancer.