The Cone Flare Crush Modified-T (CFCT) stenting technique for coronary artery bifurcation lesions.

BACKGROUND: The present study is a prospective observational single arm clinical investigation, with parallel bench test interrogation, aimed at investigating the technical feasibility, safety and clinical outcomes with the cone flare crush modified-T (CFCT) bifurcation stenting technique. Bifurcation percutaneous coronary intervention (PCI) remains an area of ongoing procedural evolution. More widely applicable and reproducible techniques are required. METHODS: From April 2018 until March 2019, 20 consecutive patients underwent bifurcation PCI using the CFCT technique with a Pt-Cr everolimus drug-eluting stent with a bioresorbable polymer. Exercise stress echocardiography was performed at 12-month follow-up. The primary outcome was a composite of cardiac related mortality, myocardial infarction, target lesion/vessel revascularization and stroke. Safety secondary endpoints included bleeding, all-cause mortality and stent thrombosis. RESULTS: All patients underwent a successful CFCT bifurcation procedure with no complications to 30-day follow-up. One patient met the primary endpoint requiring target lesion revascularization at 9 months for stable angina. There were no other primary or secondary outcome events in the cohort. There were no strokes, deaths, stent thrombosis or myocardial infarction during the follow-up period. The mean CCS score improved from 2.25 to 0.25 (p < 0.0001). Optical coherence tomography (OCT) and bench test findings indicated optimal side branch ostial coverage and minimal redundant strut material crowding the neo-carina. CONCLUSIONS: The CFCT technique appears to be a safe, efficacious and feasible strategy for managing coronary artery bifurcation disease. Expanded and randomized datasets with longer term follow-up are required to further explore confirm this feasibility data. (ANZCTR ID: ACTRN12618001145291).

The Prophylactic Chimney Snorkel Technique for the Prevention of Acute Coronary Occlusion in High Risk for Coronary Obstruction Transcatheter Aortic Valve Replacement/Implantation Cases.

Coronary occlusion (immediate or delayed) is an uncommon but potentially devastating complication of transcatheter aortic valve replacement/implantation (TAVR/TAVI). Several patient-related, anatomical, device and procedural risk factors can be assessed to risk-stratify patients and assist in procedural planning. In patients at high risk for coronary occlusion, coronary protection measures should be employed. In the highest risk patients, consideration should be given to prophylactic techniques to prevent coronary occlusion. This how-to-do-it report provides a framework for risk assessment for coronary occlusion followed by a step-wise description of the emerging chimney snorkel coronary stenting technique as a predictable procedural approach for the management of this potentially challenging clinical scenario.

Novel Oral Anticoagulants in Direct Current Cardioversion for Atrial Fibrillation.

BACKGROUND: For some patients with atrial fibrillation, direct current cardioversion (DCCV) is one strategy that can be used to establish sinus rhythm but appropriate anticoagulation is mandatory to prevent thromboembolic events. Historically, patients were anticoagulated with warfarin with bridging with unfractionated or low molecular weight heparin, however, recently novel oral anticoagulants (NOACs), apixaban, dabigatran and rivaroxaban have become more popular. Despite the increase in use, real world data on safety and efficacy is limited. METHODS: We retrospectively analysed patients that underwent DCCV at Wollongong Hospital from 1 January 2014 to 30 June 2016 and compared peri-procedural anticoagulation with warfarin and the three NOACs. Patients were treated with at least 24hours of anticoagulation before and at least four weeks after the procedure unless contraindication developed. All patients underwent transoesophageal echocardiography prior to cardioversion regardless of anticoagulation type or duration. Patients with left atrial or left atrial appendage thrombus did not undergo cardioversion. We analysed the utilisation rates of NOACs and compared the incidence of post procedural ischaemic strokes and major bleeding events at eight weeks follow-up. RESULTS: Over the study period, 284 patients underwent DCCV; 109 (38.4%) patients were anticoagulated with warfarin and 175 (61.6%) with one of the three NOACs; 77 (27.1%) with apixaban, 60 (21.1%) with rivaroxaban and 38 (13.4%) with dabigatran. Patients treated with warfarin were on average older (71.3±9.7 vs. 65.2±12.9; p value, 0.0005) with more cardiac risk factors including documented heart failure with reduced ejection fraction (39.4% vs. 22.9%; p value, 0.0032), medically treated hypertension (76.1% vs. 48.6%; p value, 0.0001) and peripheral vascular disease (31.2% vs. 12.1%; p value, 0.0004). The NOACs were more frequently used in patients with lower CHA2DS2-VASc scores; 179 patients had a score≤3 with 52 (29.1%) patients treated with warfarin and 127 (70.9%) treated with a NOAC (p value, 0.0001). In our cohort, the use of NOACs increased over the study period from 45.6% in 2014 to 82.8% in 2016. There was a low incidence of ischaemic stroke and bleeding events in both groups, 1.8% versus 0.6% (p value, 0.5607) and 3.6% versus 1.7% (p value, 0.4343) respectively. In the NOAC group, 95 of the 174 patients were anticoagulation-naïve and anticoagulated for less than five days; in comparison to longer duration therapy there was no difference in ischaemic stroke and bleeding events. CONCLUSION: In our institution, the use of NOACs in electrical cardioversion increased significantly over the study period and in our experience, they appear to be as safe as warfarin with low rates of ischaemic stroke and major bleeding. In addition, a short duration NOAC strategy was comparable to longer duration therapy.