Interventional Cardiology

Based on the abundant published literature, here we expand the understanding of cardiovascular diseases in a framework already presented in previous articles. In this context, some unique distinguishing features of vascular lesions are explained. A rationale for the role of apolipoprotein apoB100 is presented. It is hypothesized that KATP channels and their control by blood pH are behind the development of coronary artery spasm and cardiomyocyte death. Finally, the main cardiovascular risks are explained within the proposed framework.

Use of radial access for percutaneous coronary intervention (PCI) increased 2.8-fold in the United States between 2013 and 2022, according to a study presented at the annual meeting of the Society for Cardiovascular Angiography and Interventions, held from May 2 to 4 in Long Beach, California.

Data on side-branch (SB) ostial effect after drug-coated balloon (DCB) treatment in the context of de novo coronary bifurcation lesions are limited. We aimed to investigate the angiographic outcomes of SB ostium after DCB treatment compared with drug-eluting stents (DESs) implantation in the main vessel (MV) or optimal medical therapy (OMT) for the treatment of de novo coronary bifurcation lesions.

In REC-CAGEFREE II, the strategy of stepwise dual antiplatelet (DAPT) de-escalation − aspirin plus ticagrelor (Brilinta) for 1 month, then 5 months of ticagrelor monotherapy, and finally 6 months of aspirin monotherapy -- showed noninferiority against standard 12-month DAPT in the nearly 2,000-person study, reported Ling Tao, MD, PhD, of Xijing Hospital in Xi'an, China.

In the present study, the performances of the crimping mechanical and degradation behaviors of four structured PLA BVS were comprehensively assessed by utilizing a custom finite element method. The results show that the stent’s design strongly affects its mechanical properties and degradation behaviors. Under the current framework, the DESolve stent performed better with respect to radial stiffness, diameter maintenance, and degradation controllability, even though the degradation and reduction of residual volume were faster compared to the Igaki-Tamai and Fantom stents. The findings provide a theoretical method for studying the mechanical and degradation behaviors of PLA BVS, and could be potentially useful in advancing BVS design and clinical protocols.

DESyne BDS Plus (Elixir Medical) is a thin-strut stent system that uses sirolimus and two anticoagulants (argatroban and rivaroxaban) at the site of implant to deliver site-specific antithrombotic therapy, Alexandre Abizaid (Instituto do Coração, Sao Paulo, Brazil) detailed during a late-breaking trial session at EuroPCR 2024 (14–17 May, Paris, France) where he delivered results from the DESyne BDS Plus trial.

LAAO is a procedure that reduces the risk of stroke in people with atrial fibrillation (AFib). It is an alternative to blood thinner medication. Those with AFib are five times more likely to suffer a stroke. For them, blood does not pump out of the top of the heart normally, and blood clots can form in the left atrial appendage (LAA). The blood clots can then break loose and flow into the bloodstream, where they may travel to the brain causing a stroke.

SAPT following Amplatzer LAAO displayed rates of DRT and stroke comparable to those reported with more intensive antithrombotic regimens. Meanwhile, we observed low rates of major bleeding.

The design of blood-compatible materials requires understanding the physiological mechanisms that give rise to undesirable blood-material interactions. In particular, the materials used in the design of CMDs are determined by the disease for which the CMDs are intended. For example, we review the utility of polymers in developing CMDs when the necessary materials need to be flexible and durable. On the other hand, when there is a need of materials with high mechanical resistance or more remarkable conductors, metals, and metals alloys are the best option. Also, the combination of these two types of materials is used to develop and enhance the ability to perform high workflow rates in CMDs. Even though metals and polymers have tremendous advantages in developing CMDs, there is a predominant recurring challenge, which is biocompatibility.

Stroke is a major driver of increased morbidity and mortality in patients with non-valvular atrial fibrillation (NVAF). While systemic oral anticoagulation (OAC) continues to be the mainstay for stroke reduction therapy in patients with NVAF, several barriers prevent the sustained long-term use of OAC, including increased risk of bleeding, non-compliance, cost, drug-drug interactions, and the need for ongoing laboratory testing. Given the need for continued stroke reduction therapies in patients who are intolerant of or non-compliant with OAC, percutaneous left atrial appendage (LAA) occlusion (LAAO) has emerged as a nonpharmacologic alternative to OAC.

Left atrial appendage occlusion (LAAO) is a reasonable alternative approach that is used in patients with atrial fibrillation who are not candidates for anticoagulation. A number of key trials have shown that Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism. However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Multiple retrospective and prospective studies of Amplatzer device (ACP and Amulet) reported high success rates in device implantation and stroke prevention. Our objective is to consolidate the current literature to better delineate the safety, efficacy and indication of LAAO for stroke prevention.

LAAO is suggested to be of major clinical benefit in AF patients having sustained an ICH. These results have to be confirmed in a randomised clinical trial.

This large real-world prospective registry of catheter-based LAAO using the AMPLATZER Amulet device reports a high implant success rate and a low periprocedural complication rate in a population with a high risk of stroke and bleeding. Transoesophageal echo data confirm good closure rates during follow-up and low rates of device-associated thrombus.

Cardiovascular diseases remain the leading cause of death worldwide, with ischemic heart disease (IHD) as the most common. Ischemia-induced angiogenesis is a process in which vascular endothelial growth factor (VEGF) plays a crucial role. To conduct research in the field of VEGF’s association in cardiovascular diseases, it is vital to understand its role in the physiological and pathological processes in the heart. VEGF-based therapies have demonstrated a promising role in preclinical studies. However, their potential in human therapies is currently under discussion. Furthermore, VEGF is considered a potential biomarker for collateral circulation assessment and heart failure (HF) mortality. Additionally, as VEGF is involved in angiogenesis, there is a need to elucidate the impact of VEGF-targeted therapies in terms of cardiovascular side effects.

This meta-analysis suggests that the use of stent-less DEB strategies offers a safety and efficacy profile comparable to DES implantation in the treatment of calcified coronary lesions, especially when followed by adequate plaque preparation. Although the DEB strategy was associated with inferior acute angiographic outcomes, it appears to be associated with better angiographic results at 12 months, with a greater reduction in late lumen loss. While prospective studies with larger sample sizes and a longer follow-up are needed, these findings may support the potential of the DEB technique as a viable alternative in the treatment of CCLs.

Coronary artery bypass grafting is associated with a higher risk for all-cause and in-hospital mortality compared with percutaneous coronary intervention in patients on dialysis.

Despite the progress, challenges remain within the ureteral stents market:

• Stent-related Complications: Common issues include discomfort, urinary symptoms, and encrustation leading to the need for replacement.
• Cost Considerations: High cost of innovative stents can limit accessibility, especially in developing regions.
• Infection Risks: Stents can increase the risk of urinary tract infections.

Intravascular ultrasound-guided percutaneous coronary intervention has been shown to result in superior clinical outcomes compared with angiography-guided percutaneous coronary intervention. However, insufficient data are available concerning the advantages of intravascular ultrasound guidance for patients with an acute coronary syndrome. This trial aimed to investigate whether the use of intravascular ultrasound guidance, as compared with angiography guidance, improves the outcomes of percutaneous coronary intervention with contemporary drug-eluting stents in patients presenting with an acute coronary syndrome.

This Perspective article is a form of ‘pastiche’, inspired by the 1993 review by Lincoff and Topol entitled ‘Illusion of reperfusion’, and explores how their concept continues to apply to percutaneous revascularization in patients with coronary artery disease and ischaemia. Just as Lincoff and Topol argued that reperfusion of acute myocardial infarction was facing unresolved obstacles that hampered clinical success in 1993, we propose that challenging issues are similarly jeopardizing the potential benefits of stent-based angioplasty today. By analysing the appropriateness and efficacy of percutaneous coronary intervention (PCI), we emphasize the limitations of relying solely on visual angiographic guidance, which frequently leads to inappropriate stenting and overtreatment in up to one-third of patients and the associated increased risk of periprocedural myocardial infarction. The lack of optimal revascularization observed in half of patients undergoing PCI confers risks such as suboptimal physiology after PCI, residual angina and long-term stent-related events, leaving an estimated 76% of patients with an ‘illusion of revascularization’.

The presence of microvascular disease anywhere in the body significantly increases the risk for leg amputation in ensuing decade, results of a large study of US veterans shows. Additionally, in patients with PAD, having microvascular diseases such as retinopathy and neuropathy dramatically compounds lower-limb risk.

Until today, there were no stents or drug-coated balloons approved for use below the knee in the U.S. The standard of care has been balloon angioplasty, which relies on a small balloon delivered via a catheter to the blockage to compress it against the arterial wall, opening the vessel and restoring blood flow. However, blockages treated only with balloon angioplasty have poor short- and long-term results, and in many instances the vessels become blocked again, requiring additional treatment. The Esprit BTK System is a first-of-its-kind dissolvable stent and is comprised of material similar to dissolving sutures. The device is implanted during a catheter-based minimally invasive procedure via a small incision in the leg. Once the blockage is open, the Esprit BTK scaffold helps heal the vessel and provides support for approximately three years until the vessel is strong enough to remain open on its own.

Patients who received the scaffold also saw significantly fewer clinical events—such as amputations starting above the ankle, total blockage of the targeted vessel or the need for a repeat procedure within one year. The study also tracked major limb interventions, including surgical bypass grafting or mechanical blood clot removals. After 12 months, 74% of patients treated with Esprit BTK had zero of these clinical events, compared to only 44% of those in the angioplasty arm, while safety measures between the two groups were similar. The pivotal results were simultaneously published in the New England Journal of Medicine.

Overall, antithrombogenicity was better in the order FP-EES, BL-ZES, EP-RES and BMS. Although three durable polymer DES showed greater albumin coverage as compared to BMS, albumin intensity indicating concentration of albumin was not equivalent in three durable polymer DES. The results of albumin adsorption might be the cause of differences in platelet adhesion seen in the three different types of durable polymer DES and BMS, although other factors such as the adhesion of leukocytes also probably play a role. Because we also showed that the antiproliferative agents loaded onto DES have some thromboresistant properties, it is important to acknowledge the potential contribution of the antiproliferative agents as contributing to the thromboresistant effects seen in the different DES studied. These experiments may provide insight into the suitability of different durable polymer DES for shortening DAPT duration.

The launch of Esprit BTK also compensates for the withdrawal of Absorb BVS, although the Esprit BTK market is currently not comparable to the coronary stent market at all. However, with a market volume of more than 200,000, it will be able to recoup the development costs of absorbable stents and support the development of a new generation of absorbable coronary stents.

In February, CE approved Biotronik's next-generation resorbable coronary stent, Freesolve, and overseas response to Freesolve has been very favorable. This will also provide impetus for Abbott's absorbable coronary stent development. We are looking forward to the resurgence of absorbable stents in the future.

Carmat aims to meet a major public health challenge related to cardiovascular diseases, namely heart failure, the leading cause of death in the western world. More specifically, Carmat aims to provide a lasting solution for the treatment of terminal heart failure, a disease for which there are very few effective options today, the main one being heart transplants.