2017 Multimodality Appropriate Use Criteria for Noninvasive Cardiac Imaging: Expert Consensus of the Asian Society of Cardiovascular Imaging.

In 2010, the Asian Society of Cardiovascular Imaging (ASCI) provided recommendations for cardiac CT and MRI, and this document reflects an update of the 2010 ASCI appropriate use criteria (AUC). In 2016, the ASCI formed a new working group for revision of AUC for noninvasive cardiac imaging. A major change that we made in this document is the rating of various noninvasive tests (exercise electrocardiogram, echocardiography, positron emission tomography, single-photon emission computed tomography, radionuclide imaging, cardiac magnetic resonance, and cardiac computed tomography/angiography), compared side by side for their applications in various clinical scenarios. Ninety-five clinical scenarios were developed from eight selected pre-existing guidelines and classified into four sections as follows: 1) detection of coronary artery disease, symptomatic or asymptomatic; 2) cardiac evaluation in various clinical scenarios; 3) use of imaging modality according to prior testing; and 4) evaluation of cardiac structure and function. The clinical scenarios were scored by a separate rating committee on a scale of 1-9 to designate appropriate use, uncertain use, or inappropriate use according to a modified Delphi method. Overall, the AUC ratings for CT were higher than those of previous guidelines. These new AUC provide guidance for clinicians choosing among available testing modalities for various cardiac diseases and are also unique, given that most previous AUC for noninvasive imaging include only one imaging technique. As cardiac imaging is multimodal in nature, we believe that these AUC will be more useful for clinical decision making.

The Asia-Pacific Evaluation of Cardiovascular Therapies (ASPECT) collaboration --improving the quality of cardiovascular care in the Asia Pacific region.

BACKGROUND: Clinicians and other stakeholders recognize the need for clinical registries to monitor data in order to improve the outcome and quality of care in the delivery of medical interventions. The establishment of a collaboration across the Asia Pacific Region to inform on variations in patient and procedural characteristics and associated clinical outcomes would enable regional benchmarking of quality. AIMS & METHODS: The aims of the collaboration are a) to identify the characteristics of patients undergoing PCI across the Asia Pacific region, b) to report on outcomes of patients undergoing PCI, c) to develop an appropriate ethnic and region specific risk adjustment model for patients undergoing PCI and d) to establish a registry framework for research, education and training in the area of cardiovascular interventions across the Asia Pacific Region. Descriptive characteristics of patient undergoing PCI over a 12 month period were collated and reported. RESULTS: Representatives from 27 hospitals attended the inaugural meeting with interested parties from Australia, Singapore, Malaysia and Hong Kong. In every country, males predominated PCI activity. Subjects were older and had higher rates of family history of cardiovascular disease in Australia, while Asian subjects had higher rates of diabetes, dyslipidemia and renal failure. STEMI presentation was higher in Australia than in Asia and drug eluting stent use was higher in Asia. Procedural success rates were similar across the region (>95%). CONCLUSIONS: Procedural success was similar across the region despite differing patient characteristics across countries in terms of pre-procedural risk factors and clinical presentation.

Recommendations for occupational radiation protection in interventional cardiology.

The radiation dose received by cardiologists during percutaneous coronary interventions, electrophysiology procedures and other interventional cardiology procedures can vary by more than an order of magnitude for the same type of procedure and for similar patient doses. There is particular concern regarding occupational dose to the lens of the eye. This document provides recommendations for occupational radiation protection for physicians and other staff in the interventional suite. Simple methods for reducing or minimizing occupational radiation dose include: minimizing fluoroscopy time and the number of acquired images; using available patient dose reduction technologies; using good imaging-chain geometry; collimating; avoiding high-scatter areas; using protective shielding; using imaging equipment whose performance is controlled through a quality assurance programme; and wearing personal dosimeters so that you know your dose. Effective use of these methods requires both appropriate education and training in radiation protection for all interventional cardiology personnel, and the availability of appropriate protective tools and equipment. Regular review and investigation of personnel monitoring results, accompanied as appropriate by changes in how procedures are performed and equipment used, will ensure continual improvement in the practice of radiation protection in the interventional suite. These recommendations for occupational radiation protection in interventional cardiology and electrophysiology have been endorsed by the Asian Pacific Society of Interventional Cardiology, the European Association of Percutaneous Cardiovascular Interventions, the Latin American Society of Interventional Cardiology, and the Society for Cardiovascular Angiography and Interventions.

A summary of recommendations for occupational radiation protection in interventional cardiology.

The radiation dose received by cardiologists during percutaneous coronary interventions, electrophysiology procedures, and other interventional cardiology procedures can vary by more than an order of magnitude for the same type of procedure and for similar patient doses. There is particular concern regarding occupational dose to the lens of the eye. This document provides recommendations for occupational radiation protection for physicians and other staff in the interventional suite. Simple methods for reducing or minimizing occupational radiation dose include minimizing fluoroscopy time and the number of acquired images; using available patient dose reduction technologies; using good imaging-chain geometry; collimating; avoiding high-scatter areas; using protective shielding; using imaging equipment whose performance is controlled through a quality assurance program; and wearing personal dosimeters so that you know your dose. Effective use of these methods requires both appropriate education and training in radiation protection for all interventional cardiology personnel, and the availability of appropriate protective tools and equipment. Regular review and investigation of personnel monitoring results, accompanied as appropriate by changes in how procedures are performed and equipment used, will ensure continual improvement in the practice of radiation protection in the interventional suite. These recommendations for occupational radiation protection in interventional cardiology and electrophysiology have been endorsed by the Asian Pacific Society of Interventional Cardiology, the European Association of Percutaneous Cardiovascular Interventions, the Latin American Society of Interventional Cardiology, and the Society for Cardiovascular Angiography and Interventions.

The journey of Malaysian NCVD-PCI (National Cardiovascular Disease Database-Percutaneous Coronary Intervention) Registry: a summary of three years report.

INTRODUCTION: The Malaysian National Cardiovascular Disease Database (NCVD) team presents Percutaneous Coronary Intervention (PCI) Registry report for the year 2007 to 2009. It provides comprehensive information regarding practice and outcome of PCI in Malaysia. METHODOLOGY: It was a voluntary, multi-centered, observational, cohort study and included patients of 18 years or above who underwent PCI at eleven participating centers in Malaysia from the year 2007 to 2009. RESULT: Ten thousand six hundred and two patients underwent 11,498 PCI procedures with 18,116 stents for 15,538 lesions. Mean age of the patients was 57 years and more than 98% of patients had at least one cardiovascular risk factor. A significant number of our patients were diabetic (50%) and had renal impairment (44.7% had ≤ stage 3 chronic kidney disease) at the time of procedure. Fifty eight percent of the lesions were type B2 or type C lesion. Twenty eight percent of the lesions had high risk characteristics. Procedural success rate was about 97% and post-procedural complications were low. Overall in-hospital, all cause mortality was 1%, of which 85% were cardiac related deaths. The poor prognostic factors for in-hospital mortality were acute coronary syndrome cases, higher Killip class and increasing age. CONCLUSION: Compared to other registries, Malaysian patients undergoing PCI were much younger with high prevalence of risk factors. In spite of complex and high risk lesions, procedural success was high, with overall low mortality rate. NCVD-PCI Registry aims to improve over-all cardiac services in Malaysia through its ongoing journey.

Clinical results after coronary stenting with the Genous™ Bio-engineered R stent™: 12-month outcomes of the e-HEALING (Healthy Endothelial Accelerated Lining Inhibits Neointimal Growth) worldwide registry.

AIMS: e-HEALING is a worldwide, internet-based registry designed to capture post marketing clinical data on the use of the Genous™ EPC capturing R stent™. Rapid restoration of a healthy endothelial layer after stent placement by capturing circulating endothelial progenitor cells may reduce both stent thrombosis (ST) and in-stent-restenosis. METHODS AND RESULTS: We planned a 5,000 patient registry with ≥1 lesion suitable for stenting. The 12-month primary outcome was target vessel failure (TVF), defined as target vessel-related cardiac death or myocardial infarction (MI) and target vessel revascularisation. Secondary outcomes were the composite of cardiac death, MI or target lesion revascularisation (TLR), and individual outcomes including ST. A total of 4,939 patients received ≥1 Genous stent between 2005 and 2007. Baseline characteristics showed a median age of 63 years, 79% males, 25% diabetics, and 37% with prior MI. A total of 49% of lesions treated were ACC/AHA type B2 or C; 1.1 stents per lesion were used. At 12 months, TVF occurred in 8.4% and the composite of cardiac death, MI or TLR in 7.9%. Twelve-month TLR and ST were 5.7% and 1.1%, respectively. CONCLUSIONS: Coronary stenting with the Genous results in good clinical outcomes, and low incidences of repeat revascularisation and ST.

Use of non-invasive phase contrast magnetic resonance imaging for estimation of atrial septal defect size and morphology: a comparison with transesophageal echo.

BACKGROUND: Transesophageal echocardiography (TEE) is a trusted method of sizing atrial septal defect (ASD) prior to percutaneous closure but is invasive, uncomfortable, and may carry a small risk of morbidity and mortality. Magnetic resonance imaging (MRI) may be useful non-invasive alternative in such patients who refuse or are unable to tolerate TEE and may provide additional information on the shape of the A0SD. PURPOSE: To validate the accuracy of ASD sizing by MRI compared with TEE. METHOD: Twelve patients (mean age 30 years; range 11-60 years) scheduled for ASD closure underwent TEE, cine balanced fast field echo MRI (bFFE-MRI) in four-chamber and sagittal views and phase-contrast MRI (PC-MRI) with reconstruction using the two orthogonal planes of T2-weighted images as planning. The average of the three longest measurements for all imaging modalities was calculated for each patient. RESULTS: Mean maximum ASD length on TEE was 18.8 +/- 4.6 mm, mean length by bFFE-MRI was 20.0 +/- 5.0 mm, and mean length by PC-MRI was 18.3 +/- 3.6 mm. The TEE measurement was significantly correlated with the bFFE-MRI and PC-MRI measurements (Pearson r = 0.69, p = 0.02 and r = 0.59, p = 0.04, respectively). The mean difference between TEE and bFFE-MRI measurements was -1.2mm (95% CI: -3.7, 1.3) and between TEE and PC-MRI was 0.5 mm (95% CI: -1.9, 2.9). Bland-Altman analysis also determined general agreement between both MRI methods and TEE. The ASDs were egg-shaped in two cases, circular in 1 patient and oval in the remaining patients. CONCLUSION: ASD sizing by MRI using bFFE and phase-contrast protocols correlated well with TEE estimations. PC-MRI provided additional information on ASD shapes and proximity to adjacent structures.