Doug Fraser

Cardiovascular manifestations associated with influenza virus infection

Influenza accounts for 3 to 5 million cases of severe illness and up to 300,000 deaths annually. Cardiovascular involvement in acute influenza infection can occur through direct effects of the virus on the myocardium or through exacerbation of existing cardiovascular disease. Epidemiological studies have demonstrated an association between influenza epidemics and cardiovascular mortality and a decrease in cardiovascular mortality in high risk patients has been demonstrated following vaccination with influenza vaccine. Influenza is a recognised cause of myocarditis which can lead to significant impairment of cardiac function and mortality. With recent concerns regarding another potential global pandemic of influenza the huge potential for cardiovascular morbidity and mortality is discussed.

Radial Artery Occlusion After Transradial Interventions: A Systematic Review and Meta‐Analysis

Background Radial artery occlusion (RAO) may occur posttransradial intervention and limits the radial artery as a future access site, thus precluding its use as an arterial conduit. In this study, we investigate the incidence and factors influencing the RAO in the current literature. Methods and Results We searched MEDLINE and EMBASE for studies of RAO in transradial access. Relevant studies were identified and data were extracted. Data were synthesized by meta‐analysis, quantitative pooling, graphical representation, or by narrative synthesis. A total of 66 studies with 31 345 participants were included in the analysis. Incident RAO ranged between <1% and 33% and varied with timing of assessment of radial artery patency (incidence of RAO within 24 hours was 7.7%, which decreased to 5.5% at >1 week follow‐up). The most efficacious measure in reducing RAO was higher dose of heparin, because lower doses of heparin were associated with increased RAO (risk ratio 0.36, 95% CI 0.17–0.76), whereas shorter compression times also reduced RAO (risk ratio 0.28, 95% CI 0.05–1.50). Several factors were found to be associated with RAO including age, sex, sheath size, and diameter of radial artery, but these factors were not consistent across all studies. Conclusions RAO is a common complication of transradial access. Maintenance of radial patency should be an integral part of all procedures undertaken through the radial approach. High‐dose heparin along with shorter compression times and patent hemostasis is recommended in reducing RAO.

Coronary perforation in the drug-eluting stent era: Incidence, risk factors, management and outcome: The UK experience

AIMS Coronary perforation during percutaneous coronary intervention (PCI) is associated with a high risk of mortality and morbidity. However there has been little data on perforation in the current era despite significant changes in PCI practice. We set out to identify incidence, risk factors and management strategies of coronary perforation in the current era. METHODS AND RESULTS We performed a retrospective analysis of the Manchester Heart Centre PCI database from June 2004 to May 2008. Detailed analysis of all cases of suspected perforation was undertaken by case note and angiographic review. Demographic data was collected regarding all patients undergoing intervention. A total of 12,729 coronary lesions were treated in 7,903 patients over four years, during which drug-eluting stent (DES) uptake was 77%. The incidence of perforation was 0.56% (44/12,729). Perforation was associated with an inpatient mortality of 15.9% (7/44). Factors associated with perforation were female sex (p=0.003), increasing age (p<0.01), coronary calcification (p=0.003), use of a cutting balloon (p<0.001) or atheroablation (p<0.001), and treatment of a chronic total occlusion (p<0.01). Factors associated with death after perforation were non-elective procedure (p=0.036) and pericardial drain insertion (p<0.001). CONCLUSIONS Despite treatment of more complex disease, the incidence of coronary perforation has not increased. Major perforations (Ellis class III) are associated with a high rate of emergency coronary artery bypass graft (CABG) and death. Endovascular treatments allow sealing of the perforation in most cases and deaths occur primarily as a result of cardiogenic shock due to occlusion of the culprit artery. Patient risk factors associated with perforation should be considered when planning or performing PCI.

Use of the Heartrail II catheter as a distal stent delivery device; an extended case series.

AIMS The Terumo Heartrail catheter (Terumo Corp., Tokyo, Japan) allows extra deep catheter intubation of coronary vessels and has been shown to be useful in CTO lesions. The aim of this study is to assess the safety and efficacy of using the Heartrail II catheter as a distal stent delivery system in PCI following failure of conventional techniques. METHODS AND RESULTS We prospectively identified cases performed over a 15-month period in which a Heartrail catheter was used to facilitate stent delivery following failure of conventional techniques. Stent delivery using the Heartrail catheter was performed in 35 cases and was successful in 31 cases. Success rates of 100% in grafts, 95% in RCA, 80% in LAD and 60% in circumflex cases were recorded respectively. Successful stent delivery was associated with intubation depth, with 29/29 succeeding when the intubation depth was > 2 cm and failure in 4/5 cases when the intubation depth <or= 2 cm. There were no complications related to deep intubation of the catheter. CONCLUSIONS Use of the Heartrail catheter is safe and highly effective for aiding stent delivery across proximal obstructions in both left and right coronary systems. The small number of unsuccessful cases were related to inability of the catheter to traverse stenotic proximal obstructions within 2 cm of the RCA and LCA origins.

Intra-arterial vasodilators to prevent radial artery spasm: a systematic review and pooled analysis of clinical studies.

OBJECTIVES The aim of this study is to review the available literature on the efficacy and safety of agents used for prevention of RAS. BACKGROUND Different vasodilator agents have been used to prevent radial artery spasm (RAS) in patients undergoing transradial cardiac catheterization. METHODS We included studies that evaluated any intra-arterial drug administered in the setting cardiac catheterization that was undertaken through the transradial access site (TRA). We also compared studies for secondary outcomes of major bleeding, procedure time, and procedure failure rate in setting of RAS prevention, patent hemostasis and radial artery occlusion. RESULTS 22 clinical studies met the inclusion criteria. For placebo, RAS rate was 12% (4 studies, 638 participants), which was similar to 2.5mg of verapamil 12% (3 studies, 768 participants) but greater than 5mg of verapamil (4%, 2 studies, 497 participants). For nicorandil, there was a much higher RAS rate compared to placebo (16%, 3 studies, 447 participants). The lowest rates of RAS was found for nitroglycerin at both 100 μg (4%) and 200 μg (2%) doses, isosorbide mononitrate (4%) and nicardipine (3%). We found no information regarding the procedure failure rates, patent hemostasis, and radial artery occlusion in these studies. CONCLUSIONS In this largest and up-to-date review on intra-arterial vasodilators use to reduce RAS, we have found that the verapamil at a dose of 5mg or verapamil in combination with nitroglycerine are the best combinations to reduce RAS.

Late outcomes of drug eluting and bare metal stents in saphenous vein graft percutaneous coronary intervention.

AIMS PCI with drug eluting stents (DES) has been shown to reduce restenosis and major adverse cardiac event (MACE) rates compared to bare metal stents (BMS) in native coronary vessels, although outcomes in saphenous vein graft (SVG) lesions are less clear. We retrospectively studied 388 consecutive patients admitted to our centre for SVG PCI to assess mortality and MACE outcomes (defined as composite endpoint of all-death, stroke, myocardial infarction, stent thrombosis and target lesion (TLR)/vessel (TVR) revascularisation) associated with BMS and DES use. METHODS AND RESULTS Two hundred and nineteen (219) patients had BMS and 169 had DES (total 388 patients). Mean follow up was 41.9±23.5 months. No significant differences were observed in mortality (14.2% vs. 11.8%) or MACE (37.6% vs. 35.8%) between the BMS and DES groups at four years follow-up or at other intervening time points studied. Similarly, no differences in TVR/TLR rates were observed over a similar time period (19.8% vs. 21.6%). CONCLUSIONS We have observed that DES and BMS use in SVG PCI have comparable mortality and MACE rates, and that in contrast to PCI in native coronary arteries, DES do not reduce revascularisation rates in our study cohort.

Use of the Sideguard (Cappella) stent in bifurcation lesions: a real-world experience.

AIMS The Sideguard® stent (Cappella Medical Devices Ltd, Galway, Ireland), is a novel nitinol self-expanding dedicated bifurcation stent that flares proximally at the ostium of the side branch (SB) into a trumpet shape thereby achieving full ostial coverage. The aim of this study is to report the utility and limitations of this stent in patients undergoing treatment to bifurcation coronary lesions in a real-world setting. METHODS AND RESULTS We prospectively identified 20 successive patients admitted over a 6-month period in whom there was significant SB disease and who were suitable for a bifurcation procedure. The Sideguard® stent was successfully used in all 20 cases including several that would have been technically difficult using conventional bifurcation techniques. We highlight use of this system using five illustrative cases that illustrate its utility and limitations in the treatment of bifurcation lesions. CONCLUSIONS The Sideguard® stent can be used to treat complex bifurcation lesions in a straight forward manner and is not subject to the limitations associated with conventional bifurcation PCI techniques including jailing of the SB ostium and inability to fully cover/scaffold the ostium of the SB.

TAo TAVI + OPCABG: a new hybrid option

Hybrid surgical approaches are gaining popularity. Minimally invasive aortic valve replacement and percutaneous coronary intervention [PCI] is well documented. We wanted to explore the feasibility of trans-catheter aortic valve implantation [TAVI] and off pump coronary artery bypass grafts [OPCAB].