Daniel H. Steinberg

Detection of Lipid-Core Plaques by Intracoronary Near-Infrared Spectroscopy Identifies High Risk of Periprocedural Myocardial Infarction

Background— Percutaneous coronary intervention (PCI) is associated with periprocedural myocardial infarction (MI) in 3% to 15% of cases (depending on the definition used). In many cases, these MIs result from distal embolization of lipid-core plaque (LCP) constituents. Prospective identification of LCP with catheter-based near-infrared spectroscopy (NIRS) may predict an increased risk of periprocedural MI and facilitate development of preventive measures. Methods and Results— The present study analyzed the relationship between the presence of a large LCP (detected by NIRS) and periprocedural MI. Patients with stable preprocedural cardiac biomarkers undergoing stenting were identified from the COLOR Registry, an ongoing prospective observational study of patients undergoing NIRS before PCI. The extent of LCP in the treatment zone was calculated as the maximal lipid-core burden index (LCBI) measured by NIRS for each of the 4-mm longitudinal segments in the treatment zone. A periprocedural MI was defined as new cardiac biomarker elevation above 3× upper limit of normal. A total of 62 patients undergoing stenting met eligibility criteria. A large LCP (defined as a maxLCBI4 mm ≥500) was present in 14 of 62 lesions (22.6%), and periprocedural MI was documented in 9 of 62 (14.5%) of cases. Periprocedural MI occurred in 7 of 14 patients (50%) with a maxLCBI4 mm ≥500, compared with 2 of 48 patients (4.2%) patients with a lower maxLCBI4 mm (P=0.0002). Conclusions— NIRS provides rapid, automated detection of extensive LCPs that are associated with a high risk of periprocedural MI, presumably due to embolization of plaque contents during coronary intervention.

New onset atrial fibrillation after patent foramen ovale closure.

Objectives: In this study, we evaluated the incidence of new onset atrial fibrillation (symptomatic or detected by routine ECG) after patent foramen ovale (PFO‐) closure. Background: Although atrial fibrillation is known to occur in some patients following patent foramen ovale closure, the incidence and the risk associated with each device is not well known. Methods: We evaluated 1,349 consecutive patients who underwent PFO closure with an approved device and examined the incidence and risk factors associated with the development of atrial fibrillation. The patients had a mean age of 50 years and underwent PFO closure for cerebrovascular accident in 696 (51.6%), transient ischemic attack in 610 (45.2%), paradoxical embolism in 22 (1.6%), decompression sickness in 13 (0.9%), and other reasons including migraine headaches in 6 (0.4%) of cases. Results: Over a mean follow‐up period of 38.1 ± 28 months, 53 (3.9%) patients developed new onset atrial fibrillation, which is higher compared with an age‐matched population. Of these, 33 (62.3%) patients developed atrial fibrillation within 4 weeks and 8 (15%) within 6 months following PFO closure (totally 77% from 0 to 6 months). The event consisted of a single paroxysm lasting less than 48 hr in 23 patients, resolving either spontaneously or with cardioversion. 40 (75.5%) patients were symptomatic at the time of diagnosis. Thirty (56.6%) patients developed chronic atrial fibrillation. On multivariate analysis, advanced age and use of the STARFlex device predicted atrial fibrillation. Conclusions: The number of patients in whom atrial fibrillation was detected was relatively low. It is often a self‐limited complication of PFO closure that may occur more frequently in elderly patients and those treated with the STARFlex device.

Long-Term Impact of Routinely Detected Early and Late Incomplete Stent Apposition: An Integrated Intravascular Ultrasound Analysis of the TAXUS IV, V, and VI and TAXUS ATLAS Workhorse, Long Lesion, and Direct Stent Studies

OBJECTIVES We sought to determine the 2-year impact of early and late-acquired incomplete stent apposition (ISA) on clinical events. BACKGROUND The late clinical impact of early or late-acquired ISA in bare-metal stents (BMS) and TAXUS stents (Boston Scientific, Natick, Massachusetts) is debatable. METHODS We evaluated 1,580 patients enrolled in the intravascular ultrasound (IVUS) substudies of TAXUS IV, V, VI and TAXUS-ATLAS WH, LL, and DS trials. RESULTS There were 96 cases of early ISA in 26 (7.2%) BMS patients, 35 (9.7%) TAXUS Express patients (p = 0.28 vs. BMS), and 35 (7.3%) TAXUS Liberté patients (p = 0.21 vs. TAXUS Express, and p = 1.00 vs. BMS). Major adverse cardiovascular events were similar at 9 months in patients with early ISA versus control subjects with no ISA for BMS (3.8% vs. 15.2%, p = 0.13) and for TAXUS (11.6% vs. 8.8%, p = 0.45). There was no impact of early ISA on stent thrombosis. At 9-month follow-up, there were 36 cases of late-acquired ISA in 7 (2.7%) BMS patients, 17 (3.1%) patients with TAXUS slow-release (TAXUS Express or TAXUS Liberté), and 12 (15.4%) patients receiving TAXUS moderate-release. Over 2 ensuing years, major adverse cardiovascular events were similar in patients with late-acquired ISA versus control subjects with no ISA for BMS (14.3% vs. 7.9%, p = 0.54), TAXUS (overall, 8.3% vs. 8.1% p = 0.87), or TAXUS slow-release formulation (0% vs. 7.9%, p = 0.28). There was no impact of late-acquired ISA on stent thrombosis. CONCLUSIONS Neither routinely detected acute ISA nor routinely detected late-acquired ISA in BMS or TAXUS patients was associated with adverse clinical events over long-term follow-up.

Renal sympathetic denervation as second-line therapy in mild resistant hypertension: A pilot study

Catheter‐based renal sympathetic denervation (CRD) is associated with significant blood pressure (BP) reductions in patients with severe therapy‐resistant hypertension (office systolic BP ≥ 160 mm Hg or ≥ 150 mm Hg in diabetic patients). Effects of renal denervation on BP in patients with milder forms of therapy‐resistant hypertension have not been examined. We sought to investigate the feasibility, safety, and effectiveness of CRD in patients with longstanding mild hypertension despite treatment with ≥ 3 antihypertensive drugs.

Diagnostic value of quantitative stenosis predictors with coronary CT angiography compared to invasive fractional flow reserve

OBJECTIVE To evaluate the diagnostic performance of CCTA-derived stenosis predictors including CT-FFR for the detection of ischemia-inducing stenosis compared to invasive FFR. MATERIALS AND METHODS Stenosis parameters were assessed using dual-source CT (DSCT). All patients underwent both CCTA and invasive FFR within 3 months and were retrospectively analyzed. Observers visually assessed all CCTA studies and performed multiple lesion measurements. Lesion length/minimal luminal diameter(4) (LL/MLD(4)), transluminal attenuation gradient (TAG), corrected coronary attenuation (CCO) and CT-FFR were calculated. RESULTS The cohort included 32 patients (58±12 years, 66%male). Among 32 coronary lesions, 8 (25%) were considered hemodynamically significant with an FFR <0.80. Compared to invasive FFR, the per-vessel sensitivity and specificity of CCTA, CT-FFR, LL/MLD(4), CCO and TAG for detecting hemodynamically significant lesions were 100% and 54%, 100% and 91%, 85% and 92%, 66% and 88%, 37% and 58%, respectively. Receiver operating characteristics analysis resulted in an area under the curve of 0.91 for CT-FFR (p=0.0005), 0.88 for LL/MLD(4) (p<0.0001), 0.85 for CCO (p<0.0001). TAG with an AUC of 0.67 (p=0.152) was unable to discriminate between vessels with or without hemodynamically significant lesions. CONCLUSION CT-FFR, LL/MLD(4) and CCO provide enhanced diagnostic performance over CCTA analysis alone for discrimination of hemodynamically significant coronary stenosis.

Coronary CT Angiography versus Conventional Cardiac Angiography for Therapeutic Decision Making in Patients with High Likelihood of Coronary Artery Disease

PURPOSE To assess the efficacy of coronary computed tomographic (CT) angiography for therapeutic decision making in patients with high likelihood of coronary artery disease (CAD)-specifically the ability of coronary CT angiography to help differentiate patients without and patients with a need for revascularization and determine the appropriate revascularization procedure. MATERIALS AND METHODS The study protocol was approved by institutional review board, with written informed consent from all patients. The study was conducted in compliance with HIPAA. One hundred eighty-five consecutive symptomatic patients (121 men; mean age, 59.4 years±9.7) with a positive single photon emission computed tomography (SPECT) myocardial perfusion study underwent coronary CT angiography and conventional cardiac angiography (hereafter, cardiac catheterization). The management strategy (conservative treatment vs revascularization) and revascularization procedure (percutaneous coronary intervention [PCI] vs coronary artery bypass graft surgery [CABG]) were prospectively selected on the basis of a combination of coronary CT angiography and SPECT. In addition, the authors calculated the accuracy, sensitivity, specificity, and negative and positive predictive values of coronary CT angiography in the detection of obstructive CAD and the selection of a revascularization strategy. Cardiac catheterization was used as the standard of reference. RESULTS Of the 185 patients, 113 (61%) did not undergo revascularization and 42 (23%) were free of CAD. In 178 patients (96%), the same therapeutic strategy (conservative treatment vs revascularization) was chosen on the basis of coronary CT angiography and catheterization. All patients in need of revascularization were identified with coronary CT angiography. When revascularization was indicated, the same procedure (PCI vs CABG) was chosen in 66 of 72 patients (92%). CONCLUSION In patients with high likelihood of CAD, the performance of coronary CT angiography in the differentiation of patients without and patients with a need for revascularization and the selection of a revascularization strategy was similar to that of cardiac catheterization; accordingly, coronary CT angiography has the potential to limit the number of patients without obstructive CAD who undergo cardiac catheterization and to inform decision making regarding revascularization.

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.

Dual-Source CT Imaging to Plan Transcatheter Aortic Valve Replacement: Accuracy for Diagnosis of Obstructive Coronary Artery Disease

PURPOSE To assess the accuracy of computed tomographic (CT) examinations performed for the purpose of transcatheter aortic valve replacement (TAVR) planning to diagnose obstructive coronary artery disease (CAD). MATERIALS AND METHODS With institutional review board approval, waivers of informed consent, and in compliance with HIPAA, 100 consecutive TAVR candidates (61 men, mean age 79.6 years ± 9.9) who underwent both TAVR planning CT (with a dual-source CT system) and coronary catheter (CC) angiographic imaging were retrospectively analyzed. At both modalities, the presence of stenosis in the native coronary arteries was assessed. Additionally, all coronary bypass grafts were rated as patent or occluded. With CC angiographic imaging as the reference standard, the accuracy of CT for lesion detection on a per-vessel and per-patient basis was calculated. The accuracy of CT for the assessment of graft patency was also analyzed. RESULTS For per-vessel and per-patient analysis for the detection of stenosis that was 50% or more in the native coronary arteries, CT imaging had, respectively, 94.4% and 98.6% sensitivity, 68.4% and 55.6% specificity, 94.7% and 93.8% negative predictive value (NPV), and 67.0% and 85.7% positive predictive value. Per-patient sensitivity of stenosis 50% or greater with CT for greater than 70% stenosis at CC angiographic imaging was 100%. All 12 vessels in which percutaneous coronary intervention was performed were correctly identified as demonstrating stenosis 50% or greater with CT. There was agreement between CT and CC angiographic imaging regarding graft patency in 114 of 115 grafts identified with CC angiographic imaging. CONCLUSION TAVR planning CT has high sensitivity and NPV in excluding obstructive CAD. An additional preprocedural CC angiographic examination may not be required in TAVR candidates with a CT examination that does not show obstructive CAD.

Multimodality direct coronary imaging with combined near-infrared spectroscopy and intravascular ultrasound: Initial US experience

Recent studies emphasize the importance of direct intracoronary imaging techniques that provide insights regarding not only lesion architecture but also plaque composition, particularly the presence or absence of lipid‐core plaque (LCP). Intracoronary near‐infrared spectroscopy (NIRS) is the only validated FDA approved device for in vivo detection of LCP. A recently introduced catheter provides simultaneous NIRS spectral data coregistered with standard intravascular ultrasound (IVUS) images in a single intracoronary pullback. The present series of cases illustrates the unique data obtained by this combined NIRS‐IVUS device and highlights its potential clinical applications.

Left ventricular end-diastolic pressure affects measurement of fractional flow reserve

BACKGROUND Fractional flow reserve (FFR), the hyperemic ratio of distal (Pd) to proximal (Pa) coronary pressure, is used to identify the need for coronary revascularization. Changes in left ventricular end-diastolic pressure (LVEDP) might affect measurements of FFR. METHODS AND MATERIALS LVEDP was recorded simultaneously with Pd and Pa during conventional FFR measurement as well as during additional infusion of nitroprusside. The relationship between LVEDP, Pa, and FFR was assessed using linear mixed models. RESULTS Prospectively collected data for 528 cardiac cycles from 20 coronary arteries in 17 patients were analyzed. Baseline median Pa, Pd, FFR, and LVEDP were 73 mmHg, 49 mmHg, 0.69, and 18 mmHg, respectively. FFR<0.80 was present in 14 arteries (70%). With nitroprusside median Pa, Pd, FFR, and LVEDP were 61 mmHg, 42 mmHg, 0.68, and 12 mmHg, respectively. In a multivariable model for the entire population LVEDP was positively associated with FFR such that FFR increased by 0.008 for every 1-mmHg increase in LVEDP (beta=0.008; P<0.001), an association that was greater in obstructed arteries with FFR<0.80 (beta=0.01; P<0.001). Pa did not directly affect FFR in the multivariable model, but an interaction between LVEDP and Pa determined that LVEDPs effect on FFR is greater at lower Pa. CONCLUSIONS LVEDP was positively associated with FFR. The association was greater in obstructive disease (FFR<0.80) and at lower Pa. These findings have implications for the use of FFR to guide revascularization in patients with heart failure. SUMMARY FOR ANNOTATED TABLE OF CONTENTS The impact of left ventricular diastolic pressure on measurement of fractional flow reserve (FFR) is not well described. We present a hemodynamic study of the issue, concluding that increasing left ventricular diastolic pressure can increase measurements of FFR, particularly in patients with FFR<0.80 and lower blood pressure.