It is an honor to contribute to a tribute to my friend Richard Conti, a true pioneer in Cardiology, and in his earlier years a denizen of the Cath Lab. Dick coached me on transeptal puncture and years later I had the chance to return the favor by helping him get started with stenting. For many years at far flung venues I looked forward to getting together with him in the ACCEL office to talk about late breaking trials and new breakthroughs. From Sylvan Weinberg to Dick to Fred Bove and my brief stint chairing ACCEL, the interactions with Dick were a highlight of the meetings as well as the post meeting activities, and golf. It was all fun and I miss it. It seems appropriate in honoring Dick to pick a Cath Lab topic that is both old and new.
Background and objectives:
This study sought to compare clinical outcomes between bioresorbable scaffolds (BRS) and durable polymer everolimus-eluting metallic stents (DP-EES) in patients with acute myocardial infarction (AMI) undergoing successful percutaneous coronary intervention (PCI).
Methods:
From March 2016 to October 2017, 952 patients with AMI without cardiogenic shock undergoing successful PCI with BRS (n = 136) or DP-EES (n = 816) were enrolled from a multicenter, observational Korea Acute Myocardial Infarction Registry.
Results:
In the crude population, there was no significant difference in the 1-year rate of device-oriented composite endpoint (DOCE) and device thrombosis between the BRS and DP-EES groups (2.2% vs. 4.8%, hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.13-1.41, p = 0.163; 0.7% vs. 0.5%, HR 1.49, 95% CI 0.16-13.4, p = 0.719, respectively). BRS implantation was opted in younger patients (53.7 vs. 62.6 years, p < 0.001) with low-risk profiles, and intravascular image-guided PCI was more preferred in the BRS group (60.3% vs. 27.2%, p < 0.001).
Conclusions:
At 1-year follow-up, no differences in the rate of DOCE and device thrombosis were observed between patients with AMI treated with BRS and those treated with DP-EES. Our data suggest that imaging-guided BRS implantation in young patients with low risk profiles could be a reasonable strategy in the setting of AMI.
Background: Three-dimensional design simulations of coronary metallic stents utilizing mathematical
and computational algorithms have emerged as important tools for understanding biomechanical
stent properties, predicting the interaction of the implanted platform with the adjacent tissue, and
informing stent design enhancements. Herein, we demonstrate the hemodynamic implications
following virtual implantation of bioresorbable scaffolds using finite element methods and advanced
computational fluid dynamics (CFD) simulations to visualize the device-flow interaction immediately
after implantation and following scaffold resorption over time.
Methods and Results: CFD simulations with time averaged wall shear stress (WSS) quantification
following virtual bioresorbable scaffold deployment in idealized straight and curved geometries were
performed. WSS was calculated at the inflow, endoluminal surface (top surface of the strut), and
outflow of each strut surface post-procedure (stage I) and at a time point when 33% of scaffold
resorption has occurred (stage II). The average WSS at stage I over the inflow and outflow surfaces was
3.2 and 3.1 dynes/cm2 respectively and 87.5 dynes/cm2 over endoluminal strut surface in the straight
vessel. From stage I to stage II, WSS increased by 100% and 142% over the inflow and outflow surfaces,
respectively, and decreased by 27% over the endoluminal strut surface. In a curved vessel, WSS change
became more evident in the inner curvature with an increase of 63% over the inflow and 66% over the
outflow strut surfaces. Similar analysis at the proximal and distal edges demonstrated a large increase
of 486% at the lateral outflow surface of the proximal scaffold edge.
Conclusions: The implementation of CFD simulations over virtually deployed bioresorbable
scaffolds demonstrates the transient nature of device/flow interactions as the bioresorption process
progresses over time. Such hemodynamic device modeling is expected to guide future bioresorbable
scaffold design.
BACKGROUND: The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial failed to show a reduction in hard clinical end points with an early invasive strategy in stable ischemic heart disease (SIHD). However, the influence of left main disease and high-risk coronary anatomy was left unaddressed. In a large angiographic disease-based registry, we examined the modulating effect of revascularization on long-term outcomes in anatomically highrisk SIHD. METHODS AND RESULTS: 9016 patients with SIHD with high-risk coronary anatomy (3 vessel disease with ≥70% stenosis in all 3 epicardial vessels or left main disease ≥50% stenosis [isolated or in combination with other disease]) were selected for study from April 1, 2002 to March 31, 2016. The primary composite of all-cause death or myocardial infarction (MI) was compared between revascularization versus conservative management. A total of 5487 (61.0%) patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175), while 3529 (39.0%) patients were managed conservatively. Selection for coronary revascularization was associated with improved all-cause death/ MI as well as longer survival compared with selection for conservative management (Inverse Probability Weighted hazard ratio [IPW-HR] 0.62; 95% CI 0.58 to 0.66; P<0.001; IPW-HR 0.57; 95% CI 0.53-0.61; P<0.001, respectively). Similar risk reduction was noted with percutaneous coronary intervention (IPW-HR 0.64, 95% CI 0.59-0.70, P<0.001) and coronary artery bypass graft surgery (IPW-HR 0.61; 95% CI 0.57-0.66; P<0.001). CONCLUSIONS: Revascularization in patients with SIHD with high-risk coronary anatomy was associated with improved longterm outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.