Erica Resendes

Use of Intravascular Imaging During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry.

Background Intravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention. Methods and Results We examined the frequency of use and outcomes of intravascular imaging among 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers. Mean age was 65.4±10 years and 85% of the patients were men. Intravascular imaging was used in 38%: intravascular ultrasound in 36%, optical coherence tomography in 3%, and both in 1.45%. Intravascular imaging was used for stent sizing (26.3%), stent optimization (38.0%), and CTO crossing (35.7%, antegrade in 27.9%, and retrograde in 7.8%). Intravascular imaging to facilitate crossing was used more frequently in lesions with proximal cap ambiguity (49% versus 26%, P<0.0001) and with retrograde as compared with antegrade‐only cases (67% versus 31%, P<0.0001). Despite higher complexity (Japanese CTO score: 2.86±1.19 versus 2.43±1.19, P=0.001), cases in which imaging was used for crossing had similar technical and procedural success (92.8% versus 89.6%, P=0.302 and 90.1% versus 88.3%, P=0.588, respectively) and similar incidence of major cardiac adverse events (2.7% versus 3.2%, P=0.772). Use of intravascular imaging was associated with longer procedure (192 minutes [interquartile range 130, 255] versus 131 minutes [90, 192], P<0.0001) and fluoroscopy (71 minutes [44, 93] versus 39 minutes [25, 69], P<0.0001) time. Conclusions Intravascular imaging is frequently performed during CTO percutaneous coronary intervention both for crossing and for stent selection/optimization. Despite its use in more complex lesion subsets, intravascular imaging was associated with similar rates of technical and procedural success for CTO percutaneous coronary intervention. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02061436.

Impact of crossing technique on the incidence of periprocedural myocardial infarction during chronic total occlusion percutaneous coronary intervention

We sought to evaluate the impact of crossing strategy on the incidence of periprocedural myocardial infarction (PMI) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The optimal technique for crossing coronary CTOs remains controversial. Methods: We retrospectively examined the incidence of PMI among 184 consecutive patients who underwent CTO PCI at our institution between 2012 and 2015. Creatine kinase‐myocardial band fraction (CK‐MB) and troponin were measured before and after PCI in all patients. PMI was defined as CK‐MB increase ≥3× upper limit of normal (ULN). Results: Mean age was 65 ± 8 years, 98% of patients were men, 57% had diabetes mellitus, 36% were current smokers, 38% had prior heart failure, 31% had prior coronary artery bypass graft surgery (CABG), and 55% had prior PCI. The retrograde approach was used in 38% of cases. As compared with antegrade wire escalation and antegrade dissection/re‐entry, use of the retrograde approach was associated with higher J‐CTO (Multicenter CTO Registry of Japan) scores (P < 0.0001), higher frequency of moderate or severe calcification (P = 0.0061), longer CTO length (P < 0.0001), more frequent proximal cap ambiguity (P < 0.0001), and lower technical (P = 0.0007) and procedural (P = 0.0014) success. The frequency of PMI for the antegrade‐only and retrograde cases was 10% and 33%, respectively (P = 0.0001). On multivariate analysis, use of the retrograde approach and moderate/severe calcification were independently associated with higher incidence of PMI. Conclusions: As compared with antegrade‐only crossing techniques, the retrograde approach is used in patients with more complex anatomy but may carry higher risk for PMI.

Saphenous vein graft near-infrared spectroscopy imaging insights from the lipid core plaque association with clinical events near-infrared spectroscopy (ORACLE-NIRS) registry

We sought to examine near‐infrared spectroscopy (NIRS) imaging findings of aortocoronary saphenous vein grafts (SVGs).

Coronary plaques with near‐infrared spectroscopy

Coronary near‐infrared spectroscopy (NIRS) is an intravascular imaging modality with high sensitivity and specificity for lipid core plaque detection. A combined modality catheter that coregisters NIRS measurements with intravascular ultrasound (IVUS) is available, providing the operator with both structural and compositional data. NIRS/IVUS can identify plaques at risk for periprocedural myocardial infarction during stenting, allowing implementation of preventive strategies. NIRS/IVUS is currently being studied for identification of vulnerable plaques and vulnerable patients at risk of future cardiovascular events.

Procedural outcomes with use of the flash ostial system in aorto‐coronary ostial lesions

The Flash Ostial system (Ostial Corporation, Sunnyvale, CA) was designed to optimize implantation of aorto‐ostial coronary stents by flaring the proximal stent struts against the aortic wall.

Long-term follow-up after near-infrared spectroscopy coronary imaging: Insights from the lipid cORe plaque association with CLinical events (ORACLE-NIRS) registry

BACKGROUND Coronary lipid core plaque may be associated with the incidence of subsequent cardiovascular events. METHODS We analyzed outcomes of 239 patients who underwent near-infrared spectroscopy (NIRS) coronary imaging between 2009-2011. Multivariable Cox regression was used to identify variables independently associated with the incidence of major adverse cardiovascular events (MACE; cardiac mortality, acute coronary syndromes (ACS), stroke, and unplanned revascularization) during follow-up. RESULTS Mean patient age was 64±9years, 99% were men, and 50% were diabetic, presenting with stable coronary artery disease (61%) or an acute coronary syndrome (ACS, 39%). Target vessel pre-stenting median lipid core burden index (LCBI) was 88 [interquartile range, IQR 50-130]. Median LCBI in non-target vessels was 57 [IQR 26-94]. Median follow-up was 5.3years. The 5-year MACE rate was 37.5% (cardiac mortality was 15.0%). On multivariable analysis the following variables were associated with MACE: diabetes mellitus, prior percutaneous coronary intervention performed at index angiography, and non-target vessel LCBI. Non-target vessel LCBI of 77 was determined using receiver-operating characteristic curve analysis to be a threshold for prediction of MACE in our cohort. The adjusted hazard ratio (HR) for non-target vessel LCBI ≥77 was 14.05 (95% confidence interval (CI) 2.47-133.51, p=0.002). The 5-year cumulative incidence of events in the above-threshold group was 58.0% vs. 13.1% in the below-threshold group. CONCLUSION During long-term follow-up of patients who underwent NIRS imaging, high LCBI in a non-PCI target vessel was associated with increased incidence of MACE.

CONTEMPORARY USE OF LASER DURING PERCUTANEOUS CORONARY INTERVENTION: RESULTS FROM THE LASER VETERANS AFFAIRS (LAVA) MULTICENTER REGISTRY

BACKGROUND The contemporary use and outcomes of excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) are not well described. METHODS We examined the baseline clinical and angiographic characteristics and procedural outcomes of 130 target lesions in 121 consecutive PCIs (n = 116 patients) in which ELCA was performed at three United States Department of Veterans Affairs (VA) medical centers between 2008 and 2016. RESULTS Mean age was 68.5 ± 9 years and 97% of the patients were men. Patients had high prevalence of diabetes mellitus (63%), prior coronary artery bypass graft surgery (41%), and prior myocardial infarction (60%). The most common target vessel was the left anterior descending (32%), followed by the right coronary artery (30%), circumflex artery (20%), and saphenous vein graft (12%). The target lesions were highly complex, with moderate/severe calcification in 62% and in-stent restenosis in 37%. The most common indication for ELCA was balloon-uncrossable lesions (43.8%), followed by balloon-undilatable lesions (40.8%) and thrombotic lesions (12.3%). Use of ELCA was associated with high technical success rate (90.0%) and procedural success rate (88.8%), and low major adverse cardiac event (MACE) rate (3.45%). Mean procedure time was 120 min (interquartile range [IQR], 81-191 min), air kerma radiation dose was 2.76 Gy (IQR, 1.32-5.01 Gy), and contrast volume was 273 mL (IQR, 201-362 mL). CONCLUSION In a contemporary multicenter United States registry, ELCA was commonly used in highly complex lesions and was associated with high technical and procedural success rates and low incidence of MACE.

Comparison of the American College of Cardiology/American Heart Association and the European Society of Cardiology guidelines for the management of patients with non-ST-segment elevation acute coronary syndromes

Introduction The American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) have been developing guidelines to assist clinicians in making evidence-based decisions. Materials and methods The current ACC/AHA and ESC guidelines for non-ST-segment elevation acute coronary syndromes (NSTE-ACS) that were updated in 2014 and 2015, respectively, were compared to assess the number of recommendations on the basis of class of recommendation and level of evidence (LOE), the sources cited, and the content. Results The total number of recommendations in the ACC/AHA and ESC guidelines was 182 and 147, respectively. The recommendation class distribution of the ACC/AHA guidelines was 61.0% class I (compared with 61.9% in the ESC guidelines, P=0.865), 29.7% class II (compared with 32.0% in the ESC guidelines, P=0.653), and 9.3% class III (compared with 6.1% in the ESC guidelines, P=0.282). The LOE distribution among ACC/AHA guidelines was 15.9% LOE A (compared with 27.9% in the ESC guidelines, P=0.008), 50.0% LOE B (compared with 33.3% in the ESC guidelines, P=0.002), and 34.1% LOE C (compared with 38.8% in the ESC guidelines, P=0.377). The ACC/AHA guidelines cited 827 publications and the ESC guidelines cited 551 publications, 124 of which were shared by both sets of guidelines. The guidelines’ approaches to NSTE-ACS were consistent, with minor differences in diagnostic and medical therapy recommendations. Conclusion Overall, the ACC/AHA and ESC guidelines contain a comparable number of recommendations and provide similar guidance for the management of patients with NSTE-ACS.

PRIOR FAILURE DOES NOT HAVE SIGNIFICANT IMPACT ON PROCEDURAL OUTCOMES OF CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTION: INSIGHTS FROM A CONTEMPORARY MULTICENTER REGISTRY

We sought to examine the impact of prior failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 1,213 consecutive patients who underwent 1,232 CTO PCI between 2012 and

ECHOCARDIOGRAM INTERPRETATION VIA GOOGLE GLASS

We evaluated the use of Google Glass for remote transthoracic echocardiography (TTE) video capture and interpretation. Google Glass was used to record 17 TTE studies with 25 key findings. Ten physicians (3 faculty and 7 fellow cardiologists) interpreted recordings on a) desktop, b) iPhone, c) iPad