Carlos E. Sanchez

Practical Implementation of the Coronary Revascularization Heart Team

Multidisciplinary decision making has been shown to be highly effective in various aspects of medicine, most notably with the concept of tumor boards and transplant committees.1 ,2 The most updated guidelines for percutaneous coronary intervention (PCI), published jointly by the American College of Cardiology Foundation, American Heart Association, and the Society for Cardiovascular Angiography and Interventions, assign a class IC recommendation for the use of a collaborative Heart Team approach in the treatment of patients with complex coronary artery disease (CAD).3 The guidelines assert that this recommendation is based on retrospective analyses showing that patients with complex CAD referred for revascularization based on a Heart Team consensus have improved mortality compared with patients merely assigned to a particular strategy in the context of their trial enrollment. Despite the suggestion of improved mortality in this retrospective comparison, the Heart Team approach has not been adopted widely in the current clinical practice of cardiovascular medicine. This multidisciplinary innovation remains in its infancy, and numerous questions remain about its practicality, feasibility, and efficacy.nnFor several reasons, there remains significant variability in the care delivered to patients with complex CAD.4 Numerous reports show that although differences in patient characteristics may explain some of the variability in revascularization decisions, much of this variance is physician driven, such as practicing in a fee-for-service model or high-risk anatomy for low-volume operators.4,5 As emphasis grows on informed decision making and patient-centered care, a critical evaluation of these difficult questions will be essential to discovering whether there is a clinically meaningful effect of the Heart Team approach on patients with complex CAD.nnAlthough the longstanding use of tumor boards in the field of oncology represents a functioning model of interdisciplinary care on which the Heart Team may be based, it is critical …

Safety and Efficacy of Implementing a Multidisciplinary Heart Team Approach for Revascularization in Patients With Complex Coronary Artery Disease: An Observational Cohort Pilot Study

IMPORTANCEnSince the advent of transcatheter aortic valve replacement, the multidisciplinary heart team (MHT) approach has rapidly become the standard of care for patients undergoing the procedure. However, little is known about the potential effect of MHT on patients with coronary artery disease (CAD).nnnOBJECTIVEnTo determine the safety and efficacy of implementing the MHT approach for patients with complex CAD.nnnDESIGN, SETTING, AND PARTICIPANTSnObservational cohort pilot study of 180 patients with CAD involving more than 1 vessel in a single major academic tertiary/quaternary medical center. From May 1, 2012, through May 31, 2013, MHT meetings were convened to discuss evidence-based management of CAD. All cases were reviewed by a team of interventional cardiologists and cardiac surgeons within 72 hours of angiography. All clinical data were reviewed by the team to adjudicate optimal treatment strategies. Final recommendations were based on a consensus decision. Outcome measures were tracked for all patients to determine the safety and efficacy profile of this pilot program.nnnEXPOSURESnMultidisciplinary heart team meeting.nnnMAIN OUTCOMES AND MEASURESnThirty-day periprocedural mortality and rate of major adverse cardiac events.nnnRESULTSnMost of the patients underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); a small percentage of patients underwent a hybrid procedure or medical management. Incidence of 30-day periprocedural mortality was low across all groups of patients (PCI group, 5 of 64 [8%]; CABG group, 1 of 87 [1%]). The rate of major adverse cardiac events during a median follow-up of 12.1 months ranged from 12 of 87 patients (14%) in the CABG group to 15 of 64 (23%) in the PCI group.nnnCONCLUSIONS AND RELEVANCEnOutcomes of patients with complex CAD undergoing the optimal treatment strategy recommended by the MHT were similar to those of published national standards. Implementation of the MHT approach for patients with complex CAD is safe and efficacious.

Coronary and peripheral stenting in aorto-ostial protruding stents: The balloon assisted access to protruding stent technique.

Treatment of aorto‐ostial in‐stent restenosis lesions represents a challenge for interventional cardiologists. Excessive protrusion of the stent into the aorta may lead to multiple technical problems, such as difficult catheter reengagement of the vessel ostium or inability to re‐wire through the stent lumen in repeat interventions. We describe a balloon assisted access to protruding stent technique in cases where conventional coaxial engagement of an aorto‐ostial protruding stent with the guide catheter or passage of the guide wire through the true lumen is not feasible. This technique is applicable both in coronary and peripheral arteries.

Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease

To evaluate how a comprehensive evidence‐based clinical review by a multidisciplinary revascularization heart team on treatment decisions for revascularization in patients with complex coronary artery disease using SYNTAX scores combined with Society of Thoracic Surgeons‐derived clinical variables can be additive to the utilization of Appropriate Use Criteria for coronary revascularization.

TAVR and DAPT: Are We Any Closer to the Answer?

The antiplatelet medication of choice for patients undergoing transcatheter aortic valve replacement (TAVR) has been derived empirically. Periprocedural stroke and adverse cardiac events have been associated with worse outcomes at 30 days and 1 year after TAVR, with half of these events occurring after 24 hours. Dual antiplatelet therapy (DAPT), consisting of a thienopyridine and aspirin, improves clinical outcomes following coronary artery stenting through reductions in stent thrombosis and myocardial infarction. The mechanism of cardiac event rate reduction in coronary artery disease may be significantly different to that of TAVR. Platelet-mediated stent thrombosis, the antiproliferative effects of drug-eluting stents, and small caliber arteries are clearly a different milieu compared to TAVR procedures. The TAVR prosthesis has a greater metallic burden and greater flow turbulence across the valve, in coronary sinuses and paravalvular spaces, compared to drug-eluting coronary stents. The TAVR patient tends to be older and more likely to have peripheral vascular disease, and due to a higher rate of comorbidities, may have a higher risk of bleeding. The benefit of DAPT in coronary artery disease, weighed against the risk of bleeding, has been extrapolated to TAVR, without clear prior evidence to support this. The ACCF/AATS/SCAI/STS panel recommends DAPT with aspirin and clopidogrel after TAVR. The Canadian Cardiovascular Society recommends aspirin indefinitely and clopidogrel for 3 months in patients undergoing TAVR. Similarly to the duration of DAPT after coronary stenting, the necessary duration of clopidogrel remains unclear. In the meta-analysis by Abuzaid and colleagues (this issue), single antiplatelet therapy (SAPT) was compared to DAPT following TAVR. Previous meta-analyses on this subject have had variable conclusions, especially with regard to major bleeding complications. This analysis is the most current, comprehensive evaluation of this topic, comparing aspirin as SAPT versus dual antiplatelet therapy. The STS data registry is not included in this analysis due to a lack of clarity of SAPT as aspirin alone. Clinical trials that included anticoagulant therapy were also not included. There were 10 studies thatmet selection criteria with 2412 patients included. There were no differences in all-cause mortality, myocardial infarction or stroke, but the risk of major bleeding was greater with DAPT. The length of follow-up was approximately 6 months, which limits long-term conclusions. The increase in bleeding was driven largely by the observational studies rather than the randomized trials included in the meta-analysis. Major bleeding has been associated with an increase in overall mortality in randomized TAVR clinical trials. This publication contributes to a better understanding of necessary antiplatelet therapy, with more focus on safety. Several clinical scenarios require further clarification regarding DAPT strategies in TAVR patients, such as concomitant atrial fibrillation. As many as a third of extreme and high-risk TAVR patients have atrial fibrillation. Although many of these patients are already on anticoagulant therapy, there is an increased risk of cerebrovascular events in follow-up for 1 year after TAVR. As in PCI, adding antiplatelet therapy to existing anticoagulation increases bleeding risk. Anticoagulation with warfarin has been recommended (Class I, LOE B-NR) for stroke prevention in TAVR patients with atrial fibrillation, since the direct oral anticoagulants (apixaban, rivaroxaban, edoxaban or dabigatran) are not approved specifically for these patients. One such trial, Global Study Comparing a Rivaroxaban-based Antithrombotic Strategy to an Antiplatelet-based Strategy After Transcatheter Aortic Valve Replacement to Optimize Clinical Outcomes (GALILEO), should shed light on the efficacy and safety of rivaroxaban in TAVR patients who develop atrial fibrillation after the procedure. Determining the most appropriate anticoagulant and antiplatelet strategies is essential due to high clinical event rate and bleeding complication rate following development of atrial fibrillation on dual or triple therapy. Another clinical situation following TAVR is the development of leaflet thrombosis following TAVR. Thrombosis of valve leaflets may result in reduced leaflet motion, elevated valvular gradient and potentially decreased valve durability. Often computed tomography (CT) is necessary for confirmation of the diagnosis. The occurrence of leaflet thrombosis occurs more commonly in TAVR patients who received antiplatelet therapy compared to those on anticoagulation, although routine oral anticoagulation is not certain to prevent leaflet thrombosis. There may not be a difference in those taking warfarin compared to those on a direct oral anticoagulant. The treatment of leaflet thrombosis is anticoagulation, with no clear difference in efficacy between warfarin or direct oral anticoagulants. Leaflet thrombosis may also occur in patients who have received surgical bioprosthetic aortic valves. Guideline recommendations for anticoagulation following surgical bioprosthetic aortic valve replacement have been modified, with greater short-term use of anticoagulation with warfarin for 3–6 months after surgery. Moreover, a vitamin K antagonist for at least 3-months is also recommended (class IIa) after TAVR in patients at low risk for bleeding The incidence of leaflet thrombosis is being studied

Innovations in Transcatheter Valve Technology: What the Next Five Years Hold

Transcatheter aortic valve replacement is indicated for the treatment of symptomatic severe aortic stenosis in patients at intermediate or greater risk for surgery. Future indications may include low-risk patients, asymptomatic patients, bicuspid valves, moderate aortic stenosis, and pure native aortic valve regurgitation. Key hurdles to overcome include pacemaker risk, vascular injury, paravalvular regurgitation, coronary artery reaccess, durability, and embolic risk. New valve designs include synthetic polymeric valves that may allow for greater durability, in addition to advances in terms of precise positioning and repositioning to reduce the complication rate.