Garrett B. Wong

Utility of three-dimensional reconstruction of coronary angiography to guide percutaneous coronary intervention.

Objective:The goal of this study was to determine whether three‐dimensional (3D) reconstruction of traditional coronary angiography could optimize the choice of drug‐eluting stent (DES) length and number during percutaneous coronary intervention (PCI). Background: Coronary angiography is subject to significant foreshortening artifact that limits the ability of the operator to accurately determine lesion length. Methods: The angiographic images of the target vessels of consecutive PCI procedures were postprocessed using a 3D reconstruction algorithm. The appropriate length and optimal number of DES to span each target lesion were calculated and compared with the number and length of DES actually chosen by the operator. Results: A total of 42 target vessels were analyzed, and 3D reconstruction was successful in 38/42 (90.5%) of cases. The results of 3D analysis would have changed operator decision making in six cases (16%): in four cases, the stent chosen by the operator was too short requiring an additional DES; in two cases, the chosen DES was too long and exchanged for a shorter one. In each of these six cases, 3D analysis would have determined the correct stent length prior to stent selection. The optimal stent number derived by 3D reconstruction was significantly less than the actual number of stents per lesion used by the operator (1.31 ± 0.47 versus 1.54 ± 0.68, P = 0.01), and the optimal stent length trended less than the actual stented length (27.5 ± 12.8 mm versus 28.7 ± 14.7 mm, P = 0.23). Conclusions: 3D reconstruction algorithm of standard coronary angiography is a promising technique to improve DES utilization during PCI.

Transradial and transfemoral coronary angiography and interventions: 1-Year outcomes after initiating the transradial approach in a cardiology training program

BACKGROUND Limited data are available regarding the safety and feasibility of initiating transradial (TR) diagnostic coronary angiography (CA) and percutaneous coronary intervention (PCI) in cardiology fellowship programs. METHODS From July 2010 to June 2011, University of California, Davis Medical Center, adopted the TR approach with supervised cardiology fellows as the primary operators. Procedural variables and clinical outcomes of TR and transfemoral (TF) procedures were compared. To minimize confounding variables, ST-elevation myocardial infarction, bypass graft interventions, chronic total occlusions, and procedures with concomitant right heart catheterizations were excluded. To reflect the learning curve of the TR approach, this experience was assessed in 2 sequential 6-month periods. RESULTS A total of 402 diagnostic CAs and 255 PCIs were included. Transradial access was used in 141 (35%) of the CAs and in 72 (28%) of PCIs. Within the TR-CA and TF-CA (n = 261) groups, there was no difference between fluoroscopy (10.4 ± 6.0 vs 11.0 ± 8.9, P = .63) or procedure (31.8 ± 11.5 vs 33.2 ± 13.8, P = .55) time throughout the academic year with a significant trend toward lower contrast use (128 ± 52 vs 110 vs 50, P = .04) by the second half. In addition, during the second half of the academic year, the TR-CA showed significantly higher fluoroscopy (11.0 ± 8.9 vs 6.7 ± 6.8, P = .001) and procedure (33.2 ± 13.8 vs 27.2 ± 11.6, P = .0015) times when compared with TF-CA. Transfemoral PCI (n = 183) and TR-PCI showed no significant difference between all fluoroscopy and procedure time and contrast use when comparing the 2 halves of the academic year. When comparing TF with TR within each academic half year, there was no difference within the PCI group. Vascular complications were less with the TR approach. Overall procedural success rates were high, and there were low rates of crossover and periprocedural complications in both the TR and the TF groups. CONCLUSION A TR approach is safe for CA and PCI when performed by supervised operators in training. Although the learning curve for trainees appears slower for TR-CA compared with TF-CA, cardiology fellowship training programs should be encouraged to adopt TR procedures as part of their curriculum.

Takotsubo cardiomyopathy associated with opiate withdrawal

### Learning Point for Clinicians Classically, takotsubo cardiomyopathy (TTC) or ‘broken-heart-syndrome’, describes the association of a trigger factor such as ‘death of a loved one’ with induction of a transient cardiomyopathy. However, the trigger factor can be any one of a diverse group of physical or emotional stressors. It has recently been reported that drug withdrawl, particularly from opiates, can also initiate TTC. Thus, prompt recognition of withdrawal-associated TTC is essential for appropriate management and optimal clinical outcome. A 60-year-old woman with hepatitis C, major depression and chronic pain syndrome presented to the emergency department complaining of abdominal discomfort, chills, diaphoresis, nausea and emesis for 72 hr. Several days prior to presentation, she had run out of MS Contin 100 mg (qid), and because of her symptoms she had discontinued all her medications …

Interstitial lung abnormality is prevalent and associated with worse outcome in patients undergoing transcatheter aortic valve replacement

BACKGROUND Interstitial lung abnormality (ILA) is found in 5-10% of the general population and is associated with increased mortality risk. Risk factors for ILA, including advanced age and smoking history also increase the risk for aortic stenosis (AS). Transcatheter aortic valve replacement (TAVR) has become an increasingly utilized intervention for patients with severe AS, and requires a high-resolution computed tomography (HRCT) of the chest to assess aortic valve dimensions. OBJECTIVES To determine the prevalence and clinical significance of ILA on HRCT performed in patients referred for TAVR. METHODS Consecutive pre-TAVR HRCTs performed over a 5-year period were reviewed. ILA was defined as bilateral, nondependent reticular opacities. All-cause mortality among TAVR recipients was compared between ILA cases and non-ILA controls matched 2:1 by age and gender using Cox proportional hazards regression and the Kaplan Meier estimator. RESULTS Of 623 HRCTs screened, ILA was detected in 92 (14.7%), including 62 patients that underwent TAVR. Among ILA cases, 17 (27.4%) had a typical or probable usual interstitial pneumonia pattern, suggesting a diagnosis of idiopathic pulmonary fibrosis. Survival was worse in ILA cases compared to non-ILA controls (p = 0.008) and ILA was an independent predictor of mortality after multivariable adjustment (HR 3.29, 95% CI 1.34-8.08; p = 0.009). CONCLUSIONS ILA is a common finding among patients with severe AS and is associated with increased mortality in those undergoing TAVR. Further research is needed to elucidate the biology underpinning this observation and determine whether ILA evaluation and risk stratification modulates this mortality risk.

PCI after TAVR—What’s the Price of Reentry?

Transcatheter aortic valve replacement (TAVR) has dramatically transformed the treatment of symptomatic severe aortic stenosis. This therapy was initially used to treat inoperable and high-risk patients and now includes intermediate-risk and in many countries, low-risk patients. Advances in pre-procedural evaluation of the patient, valve design, and improved procedural techniques have allowed the heart team to deliver consistent excellent results with low morbidity and mortality. The majority of patients undergoing TAVR are now treated with minimal sedation and are frequently discharged home in 1–2 days. Moreover, in patients undergoing TAVR, 40–75% have underlying coronary artery disease (CAD) and the optimal management and timing of coronary revascularization is now being defined. For CAD patients undergoing surgical aortic valve replacement, concomitant coronary artery bypass graft surgery is performed at the time of operation. Presently, in patients with CAD who are treated with TAVR, the heart team reviews the angiogram, clinical symptoms, and develops a strategy regarding the need for percutaneous revascularization before TAVR. Worldwide, transcatheter aortic heart valves (THV) include balloon expandable intra-annular (Sapien series, Edwards Lifesciences Irvine, CA, USA), self-expanding supraannular (CoreValve series, Medtronic Inc, Minneapolis, MN, USA; Acurate series, Boston Scientific, Boston, MA, USA), and self-expanding annular (Portico series, Abbott, Lake Bluff, IL, USA). There is a large experience base and body of evidence for the two approved transcatheter valves, Sapien and CoreValve. Both valves feature a stent frame with three biologic leaflets. Functionally, the valves are similar but there are significant differences in stent frame design and height. By design, the self-expanding supra-annular valve has a stent frame that extends above the coronary ostia, which may impede catheter cannulation after TAVR. In order to avoid catastrophic coronary obstruction at the time of valve deployment, pre-procedural planning is critical and must take into account the height of the coronary origins relative to the annular plane, dimensions of the annulus, sinus, and sinotubular junction, native leaflet length and THV measurements. With the high prevalence of CAD and risk of disease progression and acute coronary events, the ability to reaccess the coronary ostia for angiography and potentially to perform PCI is extremely important. Case reports and small studies have suggested that angiography and coronary interventions are more difficult in patients with self-expanding valves. In this issue of Structural Heart, Jeroudi and colleagues report on a single center retrospective analysis of patients undergoing cardiac catheterization following TAVR with the self-expanding Medtronic CoreValve device. Based on their experience of 573 CoreValve cases from October 2011 to November 2016, 20 patients underwent a total of 24 cardiac catheterization procedures after TAVR at their institution. The left main (LM) coronary artery was successfully selectively cannulated in 18 of 23 cases (79%) while the right coronary artery (RCA) was selectively cannulated in three of 12 cases (25%), a marked difference compared to 11 of 13 (85%) prior to TAVR. The remainder of the engagements were considered subselective, but adequate for coronary imaging in all but one of 23 (5%) LM attempts and one of 12 (11%) RCA attempts. Of the seven patients that required PCI after TAVR, six were successful. The only failure was an anterograde chronic total occlusion attempt. Although selective coronary engagement was less common in the RCA post-TAVR, the authors conclude that coronary angiography and PCI are in large part feasible and successful after TAVR. Jeroudi and colleagues are to be commended on their important contribution to the evidence regarding the ability to access the coronary ostia through the CoreValve stent frame and perform angiography or PCI. The 2017 appropriate use criteria for coronary revascularization in stable ischemic heart disease prior to TAVR, has deemed such revascularization as “may be appropriate,” even if the physiologic assessment findings are considered low-risk. Even if PCI were to be performed pre-TAVR, the prescient interventionalist would do well to mind the need for future re-entry through the cells of the stent of the THV to access the coronary ostia. Knowledge of the CoreValve design, stent frame architecture and leaflet attachment location is essential. The frame is a laser-cut nitinol tube with the lower portion having a high radial force to expand and exclude the native leaflets, while the middle portion is concave with narrowing “waist” to permit clearance for the coronary arteries and serve as an attachment point for the leaflets, and the upper portion is flared to assist in valve anchoring and stabilization. The spatial relationship between the THV including its orientation with respect to the commissural post, annulus, sinus of Valsalva diameter, sinus height and coronary height, must be appreciated to optimize successful access to the coronary ostia. At the time of valve replacement, implantation depth must be considered, especially with

Specials: Rotablation Through Stent Accordion

A 52-year-old man presented with NSTEMI. He had diabetes mellitus, hypertension, dyslipidemia, prior tobacco, and heavy alcohol use. He had a past history of CAD with CABG 3 years ago with LIMA to LAD, SVG to first diagonal, SVG to OM1, SVG to circumflex, and SVG to RCA. His LVEF was 35%. Coronary angiography showed severe native three-vessel disease, patent LIMA graft to the LAD, occluded SVGs to the OM1, RCA, and circumflex and severe stenosis in the SVG to the diagonal (Fig. 25.1, Videos 25.1 and 25.2) We proceed to intervene on the SVG-diagonal lesion.

Cerebral Embolization After Implantation of a Balloon-Expandable Aortic Valve Without Prior Balloon Valvuloplasty: When Is Doing Less More?

Transcatheter aortic valve replacement (TAVR) is an established therapeutic option for patients with severe symptomatic aortic stenosis. However, the periprocedural stroke rate continues to be relatively high, ranging between 3% and 5% in randomized clinical trials and large registries [(1,2)][1].