Andrew J. Klein

Percutaneous Transcatheter Closure of Prosthetic Mitral Paravalvular Leaks : Are We There Yet?

A potential complication of mitral valve replacement surgery is the development of a paravalvular leak (PVL). Percutaneous transcatheter closures of PVLs using a wide array of devices have been reported in the literature, although the procedural success rate of this approach remains variable. One major challenge of transcatheter mitral PVL closure lies in the ability to adequately visualize the area of interest to facilitate defect crossing and equipment selection. Furthermore, the current spectrum of devices available for off-label use in the closure of these unique defects remains limited. This review examines the current state of transcatheter prosthetic mitral PVL closure, describes our institutions experience using advanced imaging modalities for procedural guidance, and illustrates some of the limitations associated with using existing devices in transcatheter PVL closure.

Quantitative assessment of the conformational change in the femoropopliteal artery with leg movement

The unique physical forces exerted on the femoropopliteal (FP) artery during movement have been implicated in the high rates of restenosis and stent fracture in this artery. Conformational changes in the FP artery during movement are important surrogates of these forces. This study sought to quantify the conformational change in the FP artery between the straight‐leg (SL) and crossed‐leg (CL) positions.

Temporal Trends and Outcomes of Patients Undergoing Percutaneous Coronary Interventions for Cardiogenic Shock in the Setting of Acute Myocardial Infarction: A Report From the CathPCI Registry

OBJECTIVES The purpose of this study was to examine the temporal trends in demographics, clinical characteristics, management strategies, and in-hospital outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS-AMI) who underwent percutaneous coronary intervention (PCI) from the Cath-PCI Registry (2005 to 2013). BACKGROUND The authors examined contemporary use and outcomes of PCI in patients with CS-AMI. METHODS The authors used the Cath-PCI Registry to evaluate 56,497 patients (January 2005 to December 2013) undergoing PCI for CS-AMI. Temporal trends in clinical variables and outcomes were assessed. RESULTS Compared with cases performed from 2005 to 2006, CS-AMI patients receiving PCI from 2011 to 2013 were more likely to have diabetes, hypertension, dyslipidemia, previous PCI, dialysis, but less likely to have chronic lung disease, peripheral vascular disease, or heart failure within 2 weeks (p < 0.01). Between 2005 and 2006 to 2011 and 2013, intra-aortic balloon pump use decreased (49.5% to 44.9%; p < 0.01), drug-eluting stent use declined (65% to 46%; p < 0.01), and the use of bivalirudin increased (12.6% to 45.6%). Adjusted in-hospital mortality; increased (27.6% in 2005 to 2006 vs. 30.6% in 2011 to 2013, adjusted odds ratio: 1.09, 95% confidence interval: 1.005 to .173; p = 0.04) for patients who were managed with an early invasive strategy (<24 h from symptoms). CONCLUSIONS Our study shows that despite the evolution of medical technology and use of contemporary therapeutic measures, in-hospital mortality in CS-AMI patients who are managed invasively continues to rise. Additional research and targeted efforts are indicated to improve outcomes in this high-risk cohort.

Initial clinical experience of selective coronary angiography using one prolonged injection and a 180° rotational trajectory

Evaluate the safety of prolonged coronary injections during a rotational acquisition covering 180°.

Safety and efficacy of dual-axis rotational coronary angiography vs. standard coronary angiography.

Objective: To determine the safety and efficacy of dual‐axis rotational coronary angiography (DARCA) by directly comparing it to standard coronary angiography (SA). Background: Standard coronary angiography (SA) requires numerous fixed static images of the coronary tree and has multiple well‐documented limitations. Dual‐axis rotational coronary angiography (DARCA) is a new rotational acquisition technique that entails simultaneous LAO/RAO and cranial/caudal gantry movement. This technological advancement obtains numerous unique images of the left or right coronary tree with a single coronary injection. We sought to assess the safety and efficacy of DARCA as well as determine DARCAs adequacy for CAD screening and assessment. Methods: Thirty patients underwent SA following by DARCA. Contrast volume, radiation dose (DAP) and procedural time were recorded for each method to assess safety. For DARCA acquisitions, blood pressure (BP), heart rate (HR), symptoms and any arrhythmias were recorded. All angiograms were reviewed for CAD screening adequacy by two independent invasive cardiologists. Results: Compared to SA, use of DARCA was associated with a 51% reduction in contrast, 35% less radiation exposure, and 18% shorter procedural time. Both independent reviewers noted DARCA to be at least equivalent to SA with respect to the ability to screen for CAD. Conclusion: DARCA represents a new angiographic technique which is equivalent in terms of image quality and is associated with less contrast use, radiation exposure, and procedural time than SA.

SCAI expert consensus statement for femoral-popliteal arterial intervention appropriate use

Successful endovascular intervention for femoral‐popliteal (FP) arterial disease provides relief of claudication and offers limb‐salvage in cases of critical limb ischemia. Technologies and operator technique have evolved to the point where we may now provide effective endovascular therapy for a spectrum of lesions, patients, and clinical scenarios. Endovascular treatment of this segment offers a significant alternative to surgical revascularization, and may confer improved safety for a wide range of patients, not solely those deemed high surgical risk. Although endovascular therapy of the FP segment has historically been hampered by high rates of restenosis, emerging technologies including drug‐eluting stents, drug‐coated balloons, and perhaps bio‐absorbable stent platforms, provide future hope for more durable patency in complex disease. By combining lessons learned from clinical trials, international trends in clinical practice, and insights regarding emerging technologies, we may appropriately tailor our application of endovascular therapy to provide optimal care to our patients. This document was developed to guide physicians in the clinical decision‐making related to the contemporary application of endovascular intervention among patients with FP arterial disease.

The Current State of Medical Simulation in Interventional Cardiology: A Clinical Document from the Society for Cardiovascular Angiography and Intervention's (SCAI) Simulation Committee

To assess the current use and application of simulators in interventional cardiology.

SCAI expert consensus statement for aorto-iliac arterial intervention appropriate use.

Aorto‐iliac arterial occlusive disease is common and may cause a spectrum of chronic symptoms from intermittent claudication to critical limb ischemia. Treatment is indicated for symptoms that have failed lifestyle and medical therapies or occasionally to facilitate other interventional procedures such as TAVR and/or placement of hemodynamic assist devices. It is widely accepted that TASC A, B, and C lesions are best managed with endovascular intervention. In experienced hands, most TASC D lesions may be treated by endovascular methods, and with the development of chronic total occlusion devices, many aorto‐iliac occlusions may be recanalized safely by endovascular means. Interventional cardiologists should be well versed in the anatomy, as well as the treatment of aorto‐iliac disease, given their need to traverse these vessels during transfemoral procedures. Overall, aorto‐iliac occlusive disease is more commonly being treated with an endovascular‐first approach, using open surgery as a secondary option. This document was developed to guide physicians in the clinical decision‐making related to the contemporary application of endovascular intervention among patients with aorto‐iliac arterial disease.

Clinical outcomes using aggressive approach to anatomic screening and endovascular revascularization in a veterans affairs population with critical limb ischemia

Background: This study sought to examine the impact of an aggressive approach to anatomic screening and endovascular revascularization in a veterans administration population with critical limb ischemia (CLI) on the primary treatments received and overall clinical outcomes. Methods: The baseline clinical and angiographic characteristics and clinical outcomes of the first consecutive fifty veterans who were referred for the evaluation and treatment of CLI using the strategy outlined were assessed by retrospective review of the computerized medical record and angiographic data. Results: Among the entire cohort, the primary treatments received were as follows – revascularization n = 44 (88%), primary amputation n = 1 (2%), medical treatment n = 3 (6%), and primary minor amputation n = 2 (4%). Endovascular revascularization was the dominant mode of revascularization (94%), with a procedural success rate of 91%. Repeat revascularization was required in 19% of patients who had an initially successful endovascular procedure. A total of eight deaths and four major amputations occurred in the entire cohort over a mean follow‐up of 397 ± 190 days. The 1‐year Kaplan‐Meier estimates for survival and amputation‐free survival for the entire cohort were 90 and 81%, respectively. Resolution of rest pain or complete wound healing was achieved in 85% of patients at a mean of 157 ±126 days. Conclusions: An aggressive approach to anatomic screening and contemporary endovascular treatment of CLI resulted in a higher rate of revascularization as the primary treatment for CLI than previously reported, and was associated with high rates of overall and amputation‐free survival.

Association of prior coronary artery bypass graft surgery with quality of care of patients with non-ST-segment elevation myocardial infarction: a report from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines.

BACKGROUND The American College of Cardiology/American Health Association guidelines recommend both an early invasive strategy and administration of antiplatelet/anticoagulant therapy for high-risk patients in the absence of contraindications. Little is known about adherence to guideline recommendations in patients with prior coronary artery bypass graft (CABG) surgery presenting with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS We analyzed 47,557 patients with NSTEMI in the 2007-2008 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines. Treatment patterns were compared between patients with and without prior CABG surgery. Multivariable regression with generalized estimating equations evaluated the association between prior CABG and in-hospital outcomes. RESULTS In this study, 8,790 NSTEMI patients (18.5%) had a history of CABG surgery. Prior CABG surgery was associated with a significantly lower adjusted likelihood of early cardiac catheterization (adjusted odds ratio [OR] 0.88, 95% CI 0.83-0.92), higher rates of short-term clopidogrel use (adjusted OR 1.08, 95% CI 1.02-1.14), and comparable use of anticoagulant therapy (adjusted OR 0.96, 95% CI 0.88-1.04). Adjusted risks of bleeding and in-hospital mortality did not differ significantly between the 2 groups (adjusted ORs 1.00, 95% CI 0.92-1.11 and 0.99, 95% CI 0.87-1.11, respectively). CONCLUSIONS Patients with prior CABG surgery presenting with NSTEMI are often felt to be at high risk for adverse outcomes and therefore require aggressive treatment. Our study indicates that they are less likely to undergo guideline-recommended early cardiac catheterization but equally or more likely to receive guideline-recommended antiplatelet and anticoagulant therapy. This risk-treatment paradox, however, does not appear to negatively influence short-term clinical outcomes.