Salman A. Arain

Endovascular therapy for critical limb ischemia

Abstract Chronic critical limb ischemia (CLI) occurs when arterial perfusion is reduced below a threshold level that results in rest pain and/or tissue breakdown in the lower extremities. Importantly, it is associated with high cardiovascular morbidity and mortality. Without prompt revascularization, CLI may result in loss of a limb (i.e. amputation) and/or life. The goal of endovascular therapy is the re-establishment of pulsatile, straight-line flow to the distal extremity. Percutaneous transluminal angioplasty (PTA) has been shown to be effective and safe in the setting of CLI, with limb salvage rates that compare favorably with surgical procedures. Stents are indicated for failed PTA, while adjunctive therapies such as lasers, thermal angioplasty and atherectomy devices lack data demonstrating improved efficacy compared with conventional lower extremity interventions. In addition to successful revascularization, the institution of lifestyle changes, atherosclerotic risk factor modification, and pharmacologic therapies are indicated to reduce cardiovascular morbidity and mortality.

Mediators of anemia in chronic heart failure.

Anemia is highly prevalent in patients with chronic heart failure (CHF) and is associated with poor clinical outcome. Increased prevalence of anemia in CHF has been linked to advanced age, female gender, renal function impairment, severity of symptoms, and clinical settings. Overall, the anemia of CHF shares many common features with the anemia of chronic disease. Both impaired iron metabolism and inflammatory stress appear to be the key mediators of the anemia of CHF.

Ischemic time is a better predictor than door‐to‐balloon time for mortality and infarct size in ST‐elevation myocardial infarction

Current guidelines for ST‐elevation myocardial infarction (STEMI) recommend early revascularization with optimal ischemic time (IT) < 120 min and door‐to‐balloon (D2B) time < 90 min. The focus of most studies has been D2B time, while IT is not frequently reported. We tested the hypothesis that total IT is a better predictor than D2B time for mortality and infarct size.

Percutaneous Left Axillary Artery Approach for Impella 2.5 Liter Circulatory Support for Patients with Severe Aortoiliac Arterial Disease Undergoing High-Risk Percutaneous Coronary Intervention

The use of the Impella 2.5 liter (L) device for hemodynamic support has been well described. The typical access site for the Impella 2.5 L device is the femoral artery. The use of the axillary and subclavian artery has been described via surgical cut down for the Impella 5 L device when femoral artery access is not possible. In patients with severe aortoiliac disease and difficult anatomy the femoral artery access for the Impella 2.5 L device is not feasible. We describe the successful percutaneous use of the Impella 2.5 L device for hemodynamic support via the left axillary artery in 2 patients undergoing high-risk PCI with concomitant severe aortoiliac disease.

Successful endovascular extraction of newer generation Angio-Seal collagen plug and anchor after acute embolization

A 75-year-old woman with past medical history of coronary bypass, atrial fibrillation, mitral valve repair undergoes percutaneous coronary intervention of left circumflex artery with a drug eluting stent. An Angio-Seal vascular closure device was used post procedure to obtain hemostasis. Shortly after deployment, frank bleeding was observed necessitating manual compression at the arteriotomy site. After hemostasis was achieved, the right lower extremity was found to be pale, bluish with feeble pulses. Doppler ultrasound was emergently performed revealing decreased blood flow after mid superficial femoral artery (SFA) and an echo lucent object lodged luminally in the SFA. Patient was urgently taken to the vascular laboratory where an Angio-Seal device, including the collagen plug and anchor, was successfully removed endovascularly patient made full recovery and was discharged home the following day.

Techniques and best practices for Optical coherence tomography: A practical manual for interventional cardiologists

Optical coherence tomography (OCT) is a novel intracoronary imaging modality that utilizes near‐infrared light to provide information regarding lesion length and severity, vessel lumen diameter, plaque morphology, as well as the opportunity for stent procedure guidance and follow‐up. While analogous to intravascular ultrasound (IVUS), the specific imaging properties, including significantly higher resolution, and technical specifications of OCT offer the ability for intracoronary diagnostic and interventional procedure guidance roles that require a thorough understanding of the technology. We provide coronary interventionalists a users guide to OCT, focusing on techniques and approaches to optimize imaging, with a focus on efficiency, safety and strategies for effective imaging.

Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction

We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST‐PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST‐elevation myocardial infarction (STEMI).

Safety and efficacy of coil embolization of the septal perforator for septal ablation in patients with hypertrophic obstructive cardiomyopathy

The objective of this study was to evaluate safety, efficacy, and durability of coil embolization of the major septal perforator of the left anterior descending coronary artery in patients with hypertrophic obstructive cardiomyopathy (HOCM).

Regional Artery Specific Thresholds Of Quantitative Myocardial Perfusion By PET Associated With Reduced MI and Death After Revascularization In Stable CAD

Because randomized coronary revascularization trials in stable coronary artery disease (CAD) have shown no reduced myocardial infarction (MI) or mortality, the threshold of quantitative myocardial perfusion severity was analyzed for association with reduced death, MI, or stroke after revascularization within 90 d after PET. Methods: In a prospective long-term cohort of stable CAD, regional, artery-specific, quantitative myocardial perfusion by PET, coronary revascularization within 90 d after PET, and all-cause death, MI, and stroke (DMS) at 9-y follow-up (mean ± SD, 3.0 ± 2.3 y) were analyzed by multivariate Cox regression models and propensity analysis. Results: For 3,774 sequential rest–stress PET scans, regional, artery-specific, severely reduced coronary flow capacity (CFC) (coronary flow reserve ≤ 1.27 and stress perfusion ≤ 0.83 cc/min/g) associated with 60% increased hazard ratio for major adverse cardiovascular events and 30% increased hazard of DMS that was significantly reduced by 54% associated with revascularization within 90 d after PET (P = 0.0369), compared with moderate or mild CFC, coronary flow reserve, other PET metrics or medical treatment alone. Depending on severity threshold for statistical certainty, up to 19% of this clinical cohort had CFC severity associated with reduced DMS after revascularization. Conclusion: CFC by PET provides objective, regional, artery-specific, size–severity physiologic quantification of CAD severity associated with high risk of DMS that is significantly reduced after revascularization within 90 d after PET, an association not seen for moderate to mild perfusion abnormalities or medical treatment alone.

TCT-668 Comparison of Early Readmissions after Transcatheter and Surgical Aortic Valve Replacement

RESULTS Over the recommended annulus diameter ranges of the respective THVs, the SAPIEN XT exerted the largest RF (maximum of 147 N) whereas the self-expanding valves presented with a significantly lower RF (maximum of 66 N). As expected, the RF increased with decreasing valve diameter. Self-expanding valves showed a particular behavior known as ‘biased stiffness’. This indicates that the RF depends on the compression-state in which the stent was before deployment and such a phenomenon was not seen with the balloonexpandable valves. In contrast, the SAPIEN XT valve was characterized by a so called ‘stent recoil’, which is a decrease of the valvediameter right after full deployment indicating that the SAPIEN XT displays elastic properties around its maximal diameter. Finally, we observed that a diameter variation of 2mm was associated with significant changes in radial forces, which is of utmost importance in clinical practice avoiding fatal complications such as an annulus perforation.