Mony Shuvy

Revascularization of Chronic Total Occlusions: Time to Reconsider?

Up to 20% of all coronary angiograms reveal coronary chronic total occlusions (CTOs). The lack of robust type A evidence with hard clinical outcomes on the benefits of CTO revascularization has hampered attempts to develop recommendations regarding the optimal management of CTOs. This review presents issues surrounding CTO revascularization within the framework of the appropriate use criteria ratings. Appropriate use criteria ratings downgrade CTO percutaneous coronary intervention revascularization relative to non-CTOs and to surgical revascularization. Specific aspects of CTO revascularization include ischemic burden, impact of revascularization on quality of life, risks in CTO revascularization, and the importance of complete revascularization. Contemporary data suggest CTO revascularization may have substantial impact on patient outcomes; thus, revascularization should likely be held to similar criteria as nonocclusive lesions. However, additional large clinical trial data are required to more definitively determine CTO revascularization guidelines.

Long-term clinical outcomes and predictors for survivors of out-of-hospital cardiac arrest ☆

AIMS Improvement in resuscitation efforts has translated to an increasing number of survivors after out-of-hospital cardiac arrest (OHCA). Our objectives were to assess the long-term outcomes and predictors of mortality for patients who survived OHCA. METHODS We conducted a population-based cohort study linking the Toronto RescuNET cardiac arrest database with administrative databases in Ontario, Canada. We included patients with non-traumatic OHCA from December 1, 2005 to December 31, 2014. The primary outcomes were mortality at 1 year and 3 years. Cox proportional hazard models were constructed to evaluate the predictors of mortality. RESULTS Among the 28,611 OHCA patients who received treatment at the scene of arrest, 1591 patients survived to hospital discharge. During hospitalization, 36% received coronary revascularizations and 27% received an implantable cardioverter defibrillator. At one year after discharge, 12.6% of patients had died and 37.3% were readmitted. At 3 years, mortality rate was 20% and all-cause readmission rate was 54.1%. Older age and a history of cancer were associated with higher risk of 3-year mortality. Shockable rhythm at presentation (hazard ratio [HR] 0.62, 95% CI 0.45-0.85), use of coronary revascularization (HR 0.37, 95% CI 0.28-0.51) or implantable cardioverter defibrillator (HR 0.28, 95% CI 0.20-0.41) was associated with substantially lower 3-year mortality. Prior cardiac conditions and other arrest characteristics were not associated with long-term mortality. CONCLUSIONS Survivors of OHCA face significant morbidity and mortality after hospital discharge. Clinical trials are needed to evaluate the potential benefits of invasive cardiac procedures in OHCA survivors.

Management of Chronic Total Coronary Occlusion in Stable Ischemic Heart Disease by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Versus Medical Therapy

Coronary chronic total occlusions (CTOs) are found in approximately 20% of angiograms. We sought to assess the variation in the management of patients with CTOs and to compare the clinical outcomes of CTO lesions with those of non-CTO lesions. We conducted a population-based cohort study and included all patients with stable angina who underwent cardiac catheterization from October 1, 2012, to June 30, 2013, in Ontario, Canada. The primary outcome was a composite of mortality and hospitalization for myocardial infarction. A total of 7,864 patients were included, of whom 2,279 (29%) had a CTO. There were substantial differences in revascularization rates for patients with CTOs across hospitals in Ontario (44.9% to 94.1%). Revascularization was associated with improved outcomes in the overall cohort. Although the advantage of coronary artery bypass grafting over medical therapy was consistent in both patients with CTOs and patients without CTOs, the benefit of percutaneous coronary intervention (PCI) was limited to patients without CTOs (hazard ratio 0.56, 95% confidence interval 0.40- to 0.78), with no difference in patients with CTOs. The CTO lesion, however, was revascularized in few of the PCI cases (41.1%), with PCI limited to the non-CTO lesion in most patients.

Bleeding after percutaneous coronary intervention: can we still ignore the obvious?

Percutaneous coronary intervention (PCI) is the most common cardiac invasive procedure to treat patients with coronary artery disease. In the USA, it is estimated that more than one million patients undergo PCI each year. Fearsome complications such as coronary dissection or acute vessel closure in the balloon angioplasty era have been largely mitigated with the introduction of coronary artery stents and the routine use of antiplatelet and antithrombotic therapy. In the contemporary practice of interventional cardiology, it is recognised that bleeding has become the most common early complication associated with PCI. While the incidence of bleeding varies across studies, recent data from the USA found major bleeding occurs at a rate of 1.7% after PCI,1 about half from the site of arterial access and half from non-access locations, most commonly the gastrointestinal (GI) tract.1 As a practising clinician, it is easy to remember situations where a patient has undergone successful PCI and then suffered a major bleeding episode. Treating patients who bled after PCI is often complicated because one needs to consider the appropriate intervention to manage the active bleeding, to weigh the potential benefits and risks of withholding or withdrawing antiplatelet or anticoagulation therapy and to evaluate whether red blood cell transfusion outweighs its potential adverse effects. Indeed, many factors directly relating to the bleeding itself and its management have been implicated to be associated with worse outcomes among patients who experienced bleeding after PCI procedures.2 In this issue of Open Heart, Kwok et al 3 make an important contribution to this field, by examining the relationship between bleeding complications in PCI and subsequent death. This comprehensive systematic review is one of the largest to date, with 38 published studies, …

Complex Percutaneous Interventions: What Is the Role for Specialized Bifurcation Stents?

Bifurcation lesions continue to challenge the interventional cardiologist with an estimated prevalence of 15%-20% in patients who undergo percutaneous coronary intervention. However, the preferred technique for tackling these higherrisk lesions continues to be a debated topic. The goal for performing bifurcation intervention is to optimize the longterm patency of the main branch (MB), without compromising side branch (SB) patency. If not properly executed, the patient can suffer a periprocedural myocardial infarction due to loss of the SB. Even with a successful stenting result in the MB, anginal symptoms might continue if SB narrowing occurs as a result of plaque shift, even when SB patency is maintained. The first reports of performing a specialized bifurcation technique appeared in the early 1980s with the description of “kissing balloons.” In 1993, Colombo et al. pioneered the concept of stenting both limbs of the bifurcation, using a variety of techniques such as “V stenting” and its variant, “simultaneous kissing stents,” and “T stenting.” Later, even more complex 2-stent bifurcation techniques were introduced to improve SB ostial stenting and to reduce restenosis. The “culotte” technique uses 2 stents and leads to full coverage of the bifurcation. First, after dilation of the branches, the first stent is deployed across the more angulated branch (commonly the SB). The MB is then rewired through the struts of the stent and a second stent is positioned in the MB. The final step is a “kissing balloon” technique for optimization of the carina. In the “crush” technique, the 2 stents are positioned adjacent to each other in the proximal MB. The stent that extends into the SB is first deployed. The second stent, which extends into the MB, is then expanded, crushing the struts of the first stent that are in the proximal MB. The SB is then rewired through the MB stent, followed by kissing balloons.

Stent Thrombosis Following Drug-Eluting Stents in STEMI: “Much Ado About Nothing?”∗

Coronary stent implantation has become the mainstay of percutaneous revascularization in patients with stable coronary artery disease (CAD) and acute coronary syndromes (ACS). Bare metal stents (BMS) were widely adopted after they were demonstrated to decrease restenosis and acute vessel occlusion

The Mini-STAR Technique in Chronic Total Occlusions: Maximizing the Interventional Toolbox

Coronary chronic total occlusion (CTO) management has become increasingly important in routine practice because CTOs are identified in approximately 15%-20% of all coronary angiograms. Although CTO revascularization has been associated with improved left ventricular function and quality of life, percutaneous coronary intervention (PCI) attempts remain at relatively low levels, in the range of 5%-10% of all CTO cases identified on angiography. The lack of PCI attempts is in part because of the complexity of the procedures, resulting in lower success rates and longer procedure times compared with non-CTO lesions. Historically, PCI procedural success rates for CTOs ranged from 70% to 75%. Advanced techniques and dedicated equipment, along with increasing operator experience, have significantly enhanced PCI success rates to 85% and higher in dedicated, high-volume CTO centres. To achieve these high success rates, angioplasty operators must become adept with antegrade and retrograde approaches. In the latter, guide wire advancement through the CTO is done in the reverse direction (distal to proximal). The guide wire is positioned in the distal CTO vessel through a collateral channel, usually accessed through the contralateral coronary artery. A procedural algorithm, incorporating antegrade and retrograde approaches, known as the “hybrid technique,” has been developed and validated by a group of North American expert CTO operators to more efficiently enable successful CTO revascularization. The choice of approach is dictated by several factors, including the appearance of the proximal cap, lesion length, presence of branches, size of the target vessel at the distal cap, and suitability of collaterals for retrograde techniques. In the antegrade and retrograde approaches, it is exceedingly challenging, and in some cases impossible, to successfully advance the guide wire within the true lumen of the