Mohan Edupuganti

12-month primary patency rates of contemporary endovascular device therapy for femoro-popliteal occlusive disease in 6,024 patients: beyond balloon angioplasty.

Endovascular approach to superficial femoral artery (SFA) disease, the most common cause of symptomatic peripheral arterial disease, remains fraught with high failure rates. Newer devices including second‐generation nitinol stents, drug‐coated stents, drug‐coated balloons, covered stents, cryo‐therapy, LASER, and directional atherectomy have shown promising results. Clinical equipoise still persists regarding the optimal selection of devices, largely attributable to the different inclusion criteria, study population, length of lesions treated, definition of “patency” and “restenosis,” and follow‐up methods in the pivotal trials.

Evaluation of Myocardial Strain in Patients With Amyloidosis Using Cardiac Magnetic Resonance Feature Tracking

PURPOSE To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis. MATERIALS AND METHODS CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed. RESULTS There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P < 0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal. CONCLUSION Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.

Optimizing selection of antithrombotic therapy in patients requiring PCI and long term anticoagulation.

There remains clinical equipoise in the appropriate selection of antiplatelet therapy for the patient on long-term anticoagulation requiring percutaneous coronary intervention. Since most of these patients represent an increasingly aging population, the significant risk of thromboembolism and stent thrombosis must be weighed against the risk of major bleeding. This article reviews the current state of evidence to provide a framework for the practicing clinician.

PREDICTIVE ACCURACY OF RESTING GRADIENT (PD/PA) FOR IDENTIFYING ISCHEMIC CORONARY LESIONS

Adenosine is used to induce maximal hyperemia during fractional flow reserve (FFR) measurement. Adenosine administration can be time consuming, with added cost and sometimes may have undesirable side effects. We evaluated the predictive accuracy of resting trans-lesional gradient (distal coronary

Comparison of regional and global cardiac MRI diastolic strain rates with echo grading of diastolic dysfunction

Background Echocardiographic examination is currently the gold standard for the non invasive assessment of diastolic dysfunction. Although strain is not load independent, studies have shown that systolic strain rates can assess myocardial contractility and are relatively load independent. It remains to be established if diastolic strain parameters correlate with the degree of diastolic dysfunction and if so which parameter correlates best with echo derived grade of diastology.

Outcomes of Fractional Flow Reserve-Based Deferral in Saphenous Vein Graft Narrowing

Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries of patients with stable coronary disease. However, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the prognostic value of deferring intervention in lesions with FFR >0.8 in SVG lesions. Clinical, angiographic, and hemodynamic variables and long-term outcomes were recorded in consecutive patients in whom percutaneous coronary intervention was deferred based on an FFR >0.8 for intermediate native coronary artery or SVG stenosis. Thirty-three patients underwent FFR of SVG lesions and were compared with 532 patients who underwent native vessel FFR during the same period. There were no differences in age (66.6 [interquartile range, IQR 63 to 76] vs 65 years [IQR 61 to 70]; p = 0.12), diabetes (41% vs 50%; p = 0.35), or hypertension (94% vs 97%; p = 0.71). During a median follow-up of 3.2 years (IQR 1.7 to 4.6 years) major adverse cardiac event was significantly higher in SVG group (36% vs 21%; log rank p = 0.01). Similarly, the rate of target vessel failure was significantly higher in the SVG group (27% vs 14%; p = 0.01). Deferred SVG lesions had the worst survival free of target vessel failure compared with deferred native lesions in both patients with and without previous CABG. An SVG lesion was an independent predictor of major adverse cardiac events on Cox proportional hazards analysis (hazard ratio 2.26; confidence interval 1.19, 4.28; p = 0.01). In conclusion, nonischemic FFR carries a significantly worse prognosis in SVG compared with non-SVG lesions. Caution is warranted in utilizing FFR for clinical decision-making in SVG lesions.

DOES POST PCI FFR CARRY THE SAME PROGNOSTIC WEIGHT AS NON-ISCHEMIC FFR IN DEFERRED LESIONS?

Background: Deferring PCI based on a non-ischemic FFR has been well established. Growing evidence suggests an increasingly important role of post-PCI FFR in outcome prediction. Whether the FFR value post-PCI contains the same prognostic weight as FFR in deferred lesions is not known. Methods: Major

TEMPORAL CHANGES IN FRACTIONAL FLOW RESERVE IN INITIALLY DEFERRED VESSELS IN SYMPTOMATIC PATIENTS

A sizeable proportion of PCI-deferred patients based on non-ischemic FFR, continue to experience symptoms. Consecutive patients undergoing FFR evaluation in whom PCI was deferred were followed. Patients who had FFR re-measured across the same lesion during follow-up for recurrent symptoms were

CLINICAL DECISION MAKING FOR THE HEMODYNAMIC GRAY ZONE (FFR 0.75-0.80) AND IMPACT ON LONG TERM OUTCOMES

A fractional flow reserve (FFR) value between 0.75 and 0.80 is considered the “gray zone” and outcomes data are limited in this group. We sought to evaluate the impact of revascularization vs. medical therapy alone (deferral) on long term outcomes for patients in the gray zone. Consecutive

Extrapolating echocardiographic determinants of elevated Left Atrial Pressure (LAP) to Cardiac Magnetic Resonance Imaging (CMR) to determine the best CMR correlate of elevated LAP

Background The ratio of the transmitral early inflow wave velocity (E wave velocity) and the velocity of the septal (or lateral) mitral annulus as measured by tissue Doppler (the e’ wave velocity) can be used to estimate left atrial pressure on echocardiographic examination. An elevated E/e’ (more than 15 when using the septal mitral annular velocity) is an established measure of elevated LAP. Furthermore when the left atrial pressure rises, simultaneous changes take place in the pulmonary venous flow. The normal flow pattern in the pulmonary veins consist of a prominent systolic and a smaller diastolic component with the ratio of the peak systolic to diastolic velocities more than 1. With elevated left atrial pressure the ratio drops to below 1.