David M. Leistner

Coronary Atherosclerotic Plaque Characteristics and Cardiovascular Risk Factors ― Insights From an Optical Coherence Tomography Study ―

BACKGROUND The association between cardiovascular risk factors (CVRF) and the risk of coronary events is widely acknowledged. Whether individual risk factors may be associated with distinct plaque characteristics is currently unclear. We investigated the relationship between CVRF and coronary plaque burden and phenotype.Methods and Results:We assessed coronary atherosclerotic plaque characteristics by optical coherence tomography in 67 patients with stable coronary artery disease undergoing coronary angiography. The plaque burden and the distinct plaque phenotypes were compared with regard to different CVRF. Overall plaque burden was significantly greater in patients with diabetes mellitus (P=0.010), prediabetes (P=0.035) and obesity (P=0.024), and correlated with the number of CVRF (R=0.358, P=0.003). Patients with diabetes had a greater extent of fibroatheroma (P=0.015), calcific fibroatheroma (P=0.031), thin-cap fibroatheroma (TCFA-P=0.011) and plaque erosion (P=0.002). Obese patients showed a greater extent of fibroatheroma (P=0.007), TCFA (P=0.015) and macrophage load (P=0.043). The number of CVRF correlated with fibroatheroma (R=0.425, P<0.001), calcific fibroatheroma (R=0.321, P=0.008), TCFA (R=0.347, P=0.004), macrophage load (R=0.314, P=0.010) and erosion (R=0.271, P=0.029). In the multivariate analysis, altered glycemic status and obesity were the only independent predictors of TCFA (P=0.026 and P=0.046, respectively), whereas altered glycemic status was the only independent predictor of plaque erosion (P=0.001). CONCLUSIONS Patients with diabetes, prediabetes and obesity show more extensive coronary atherosclerosis and more vulnerable plaque phenotypes.

Real‐time optical coherence tomography coregistration with angiography in percutaneous coronary intervention–impact on physician decision‐making: The OPTICO‐integration study

Intracoronary optical coherence tomography (OCT) imaging allows for high‐resolution characterization of coronary lesions. Difficulties in matching cross‐sectional OCT‐images with angiographic lesion localization may limit optimal clinical utilization. We sought to prospectively assess the impact of a novel system of real‐time OCT coregistration with angiography (ACR) on physician decision‐making during percutaneous coronary interventions (PCI).

Interventional Treatment of Severe Tricuspid Regurgitation: Early Clinical Experience in a Multicenter, Observational, First-in-Man Study

Background— Transcatheter caval valve implantation is under evaluation as a treatment option for inoperable patients with severe tricuspid regurgitation (TR). The procedure involves the catheter-based implantation of bioprosthetic valves in the inferior vena cava and superior vena cava to treat symptoms associated with TR. This study is the first to evaluate the feasibility, safety, and efficacy of this interventional concept. Methods and Results— Twenty-five patients (mean age, 73.9±7.6 years; women, 52.0%) with severe symptomatic TR despite optimal medical treatment deemed unsuitable for surgery were treated with caval valve implantation under a compassionate clinical use program. Technical feasibility defined as procedural success, hemodynamic effect defined as venous pressure reduction, and safety defined as periprocedural adverse events were evaluated, with clinical follow-up at discharge and up to 12 months. The functional impact was evaluated by assessment of New York Heart Association class at the time of hospital discharge. The total number of valves implanted in the caval position was 31. Patients were treated with single (inferior vena cava-only; n=19; 76.0%) or bicaval valve implantation (inferior vena cava+superior vena cava; n=6; 24.0%). Either balloon-expandable valves (Sapien XT/3: n=18; 72.0%) or self-expandable valves (TricValve: n=6; 24.0%; Directflow: n=1; 4.0%) were used. Procedural success was achieved in 96% (n=24). Early and late valve migration requiring surgical intervention occurred in 1 patient each. Thirty-day and in-hospital mortality were 8% (2 of 25) and 16% (4 of 25). Causes of in-hospital mortality included respiratory (n=1) or multiple organ failure (n=3) and were not linked to the procedure. Mean overall survival in the study cohort was 316±453 days (14–1540 days). Conclusions— Caval valve implantation for the treatment of severe TR and advanced right ventricular failure is associated with a high procedural success rate and seems safe and feasible in an excessive-risk cohort. The study demonstrates hemodynamic efficacy with consistent elimination of TR-associated venous backflow and initial clinical improvement. These results encourage further trials to determine which patients benefit most from this interventional approach.

Left atrial appendage closure in a patient with left atrial appendage thrombus using a novel fish ball technique

We report about a male patient with permanent atrial fibrillation and CHADs2-Vasc-score 3 / Hasbled-score 4. Intracranial hemorrhage occured during oral anticoagulation (OAC) with Warfarin. OAC was changed to Apixaban. Transesophageal echocardiography revealed a thrombus in the left atrial appendage (LAA) which was persistent even after changing the OAC to Dabigatran. A 28mm Amulet endocardial LAA occluder was performed using the so called fish-ball technique. No clinical significant stroke occurred during or after the procedure. LAA occlusion with the Amulet TM device may present an option in selected patients with LAA thrombus and high risk for bleeding complications under OAC.history.

FD-OCT and IVUS for detection of incomplete stent apposition in heavily calcified vessels: novel insights

In the present issue of Open Heart , Gudmundsdottir and colleagues compare two intracoronary imaging modalities, intravascular ultrasound (IVUS) and FD-optical coherence tomography (FD-OCT), in patients undergoing complex percutaneous coronary intervention (PCI) with rotablation for calcific coronary lesions. In particular, this study sought to detect incomplete stent apposition (ISA) using these different imaging modalities. ISA may play a role in the risk of target vessel failure, for example, stent thrombosis.1 Intracoronary imaging has become widely available with the advent of IVUS in the early 1990s.2 IVUS-derived images with an axial resolution down to 150 µm have given novel insights into the clinical evolution of coronary artery disease and plaque composition.3 This technology was rapidly embraced by the interventional cardiology community, mainly to assess coronary lesions of intermediate significance in larger coronary arteries, to size the stent diameter or to monitor optimal stent deployment and exclude coronary dissections post-stenting.2 While this new intracoronary imaging fuelled enthusiasm, to date, limited data exist to demonstrate that IVUS-guided PCI translates into a superior clinical outcome with respect to incomplete stent apposition (table 1). However, a large observational analysis comparing IVUS-guided against angiography-guided PCI suggested that IVUS guidance was associated with a reduction in stent thrombosis, myocardial infarction and major adverse cardiac events within …

Long-term follow up of 3 T MRI-detected brain lesions after percutaneous catheter-based left atrial appendage closure

Left atrial appendage closure (LAAC) for stroke prevention is an increasingly performed intervention.

Impact of acute kidney injury in elderly (≥80 years) patients undergoing percutaneous coronary intervention

OBJECTIVES This study sought to investigate the prevalence and impact of acute kidney injury (AKI) in elderly patients undergoing percutaneous coronary intervention (PCI). BACKGROUND AKI may complicate PCI and has been associated with worse outcomes. Data on AKI following PCI in elderly patients are scarce. METHODS A total of 458 elderly (≥80 years) patients undergoing PCI at Charité-University Medicine Berlin between January 2009 and December 2014 were stratified according to the presence/absence of AKI. The primary endpoint was all-cause mortality. The secondary endpoint was rate of major adverse cardiovascular events (MACE), a composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, and rehospitalization for heart failure. Median follow-up was 280 (interquartile range 22-1190) days. RESULTS Of the 458 patients, 125 (27.3%) developed AKI following PCI. Age >90 years, congestive heart failure, and C-reactive protein at presentation emerged as independent predictors of AKI. All-cause mortality was 20.0% and 8.4% in patients with and without AKI (P = 0.001), and corresponding rates of MACE were 39.2% and 26.4% (P = 0.01), respectively. The occurrence of AKI was associated with an increased risk of all-cause mortality (adjusted HR 2.41, 95%CI 1.12-5.17, P = 0.02) and MACE (adjusted HR 1.75, 95%CI 1.15-2.67, P = 0.01). CONCLUSIONS AKI occurs in a third of elderly (≥80 years) patients undergoing PCI and is associated with increased mortality. These findings underline the unmet clinical need to identify novel strategies for the prevention of AKI in this high-risk patient subset.

Performance of One- Compared With Two-Catheter Concepts in Transradial Coronary Angiography (from the Randomized Use of Different Diagnostic Catheters-Radial-Trial)

The Use of Different Diagnostic Catheters-Radial-Trial sought to compare the safety and efficacy of one-catheter concepts (OCC) using Tiger II or BLK catheters with two-catheter concepts (TCC) using standard Judkins catheters for transradial coronary angiography. A total of 300 patients planed for coronary angiography were enrolled into this single-center, single-blinded trial. Patients were randomized in a 2:1 ratio to either OCC by Tiger II (n = 100) and BLK (n = 100) or TCC by Judkins (n = 100) catheters. Primary end point was time required to perform a complete coronary angiography. Coronary angiography duration was 603 ± 29 seconds and 552 ± 26 sec in the OCC and the TCC groups (p = 0.052). Fluoroscopy time was longer in the OCC (408 ± 28 sec) as compared with the TCC group (258 ± 28 sec, p = 0.009) and the amount of contrast volume used significantly higher (98 ± 5 ml vs 67 ± 4 ml, p < 0.001). Crossover rates were increased in the OCC as compared with the TCC group (37% vs 4%, p < 0.001). These effects were observed irrespective of OCC catheter type. In conclusion, this study demonstrates that OCC do not reduce angiography time, but are associated with an increased amount of contrast volume and longer fluoroscopy time as compared with TCC.

Effect of Physical Disability on Mortality in Elderly Patients of ≥80 Years of Age Undergoing Percutaneous Coronary Intervention

Functional decrease has been linked with adverse events in different clinical contexts. The predictive role of activity of daily living status as assessed by the Barthel index (BI) in elderly patients who underwent percutaneous coronary intervention (PCI) has not been investigated, yet. In this study, a total of 616 patients (≥80 years) who underwent PCI between January 2009 and December 2014 and with available activity of daily living data on admission were stratified according to BI (low BI <85, intermediate BI 85 to 95, high BI 100). The primary end point was all-cause mortality at a total follow-up of 442 days (interquartile range 47 to 1243). Of the 616 patients, 178 (29%), 128 (21%), and 310 (50%) were in the low, the intermediate, and the high BI groups, respectively. All-cause mortality was 10%, 13%, and 5% in the low, the intermediate, and the high BI groups, respectively (log-rank p <0.001). Belonging to the high BI group was associated with a reduced risk of all-cause mortality (hazard ratio 0.35, 95% confidence interval 0.18 to 0.69, p = 0.002), and associations remained significant after multivariable adjustments (adjusted hazard ratio 0.34, 95% confidence interval 0.13 to 0.93, p = 0.04). Functional capacity was identified as independent predictor of survival in a large cohort of patients who underwent PCI. In conclusion, activities of daily living should be incorporated into the risk stratification of elderly patients with coronary artery disease.

Intravaskulärer Ultraschall in der Behandlung der koronaren Herzkrankheit

ZusammenfassungDer intravaskuläre Ultraschall (IVUS) stellt ein zur konventionellen Koronarangiographie komplementäres bildgebendes Verfahren dar, das ultraschallbasierte hochauflösende Schnittbilder der Gefäßwand erzeugt. Dadurch können atherosklerotische Plaques und adaptive Remodelling-Prozesse der Gefäßwand direkt visualisiert werden. Die IVUS-Bildgebung findet sowohl in der klinischen Praxis als auch im Rahmen von Studien Verwendung. Insbesondere unterstützt sie die Beurteilung komplexer Koronarläsionen, ermöglicht eine genaue prozedurale Planung und hat im Rahmen von Studien einen wichtigen Beitrag zum Verständnis der Atherosklerose geleistet.AbstractIntravascular ultrasound (IVUS) imaging was developed to overcome the limitations of conventional coronary angiography, which only delineates the vessel lumen. This complementary imaging modality provides high-resolution cross-sectional images of the arterial lumen and wall and thereby enables direct visualization of atherosclerotic plaques and remodelling responses of the corresponding vessel segments. The IVUS is widely used in the clinical practice and for research purposes. In particular, IVUS imaging assists in the assessment of complex coronary lesions, provides guidance for percutaneous coronary interventions and from the results of studies has made a substantial contribution to our understanding of atherosclerosis.