Predictors of periprocedural myocardial infarction after rotational atherectomy.

Introduction: Rotational atherectomy (RA) presents superior efficacy over traditional balloon angioplasty in managing calcified plaques, albeit being associated with a perceived heightened aggressiveness and increased risk of periprocedural complications. Aim: To assess the frequency and predictive factors of periprocedural myocardial infarction (MI) following RA. Material and methods: This was a retrospective observational study, encompassing 534 patients. The definition of periprocedural MI was consistent with the 4th universal definition of MI. Results: Periprocedural MI occurred in 45 (8%) patients. This subset tended to be older (74.6 ±8.2 vs. 72 ±9.3%; p = 0.04) with SYNTAX Score (SS) > 33 points (p = 0.01), alongside elevated rates of no/slow flow (p = 0.0003). These patients less often fulfilled the indication for RA, which is a non-dilatable lesion. The incidence of traditional risk factors was similar in both groups. Univariable logistic regression models revealed: male gender (OR = 0.54; p = 0.04), non-dilatable lesion (OR = 0.41; p = 0.01), prior coronary artery bypass grafting (CABG) (OR = 0.07; p = 0.01) as negative and SS > 33 (OR = 2.8; p = 0.02), older age (OR = 1.04; p = 0.04), no/slow flow (OR = 7.85; p = 0.002) as positive predictors. The multivariable model showed that occurrence of no/slow flow (OR = 6.7; p = 0.02), SS > 33 (OR = 2.95; p = 0.02), non-dilatable lesion (OR = 0.42; p = 0.02), and prior CABG (OR = 0.08; p = 0.02) were independent predictors of periprocedural MI. Conclusions: Periprocedural MI after RA was not an uncommon complication, occurring in nearly one-twelfth of patients. Our analysis implicated female gender, older age, and more severe coronary disease in its occurrence. As expected, the presence of no/slow flow amplified the risk of periprocedural MI, whereas prior CABG and non-dilatable lesions mitigated this risk.

Current role of intravascular imaging in percutaneous treatment of calcified coronary lesions.

Percutaneous treatment of calcified coronary lesions is still a challenge in modern interventional cardiology practice. Coronary angiography is limited to the precise and quantitative assessment of calcium in coronary arteries. Intracoronary imaging (ICI) modalities, including optical coherence tomography (OCT) and intravascular ultrasound (IVUS), produce a very detailed image of calcifications and could help in proper percutaneous treatment. Intracoronary imaging indicates the need to use additional tools and improves the final effect of an intervention. Drawing on the already published literature, the authors focused on the qualification of patients to the procedure, conduct and result of interventional procedures involving calcified lesions supported by ICI. The article shows the advantages and disadvantages of both ICI methods in general and especially in calcified lesions. Currently available tools dedicated to dealing with coronary calcium and helping to meet optimal stent implantation criteria are also described. This article reviews the data on ICI implementation in daily clinical practice to improve the results of percutaneous interventions, and indicates further directions.

Acute Angulation and Sequential Lesion Increase the Risk of Rotational Atherectomy Failure.

BACKGROUND: The aim of the study was to assess anatomical and procedural predictors of clinical and procedural failure of rotational atherectomy (RA) in an all-comers population.Methods and Results:A total of 534 consecutive patients who underwent RA were included in a double-center observational study. The primary composite endpoint consisted of: rota-wire introduction failure, burr-passage failure, periprocedural complications and procedure-related major adverse events. The second primary endpoint included rota-wire introduction failure and burr-passage failure. The primary endpoint occurred in 76 (14.2%) patients and the second primary endpoint occurred in 64 (12%) Periprocedural complications occurred in 23 (4.3%) and procedure-related adverse events in 23 (4.3%) patients. Multivariable analysis revealed angulation on lesion ≤90° (HR=2.18, 95% CI: 1.21-3.94, P=0.0096) and sequential lesion (HR=1.89, 95% CI: 1.01-3.54, P=0.046) as independent predictors of no clinical success of RA. Multivariable analysis revealed again that angulation on lesion ≤90° (HR=2.26, 95% CI: 1.16-4.40, P=0.02) and sequential lesion (HR=3.77, 95% CI: 1.64-8.69, P<0.01) as independent predictors of no procedural success of RA. CONCLUSIONS: The presence of an acute angulation on lesion and sequential lesion are independent determinants of clinical and procedural failure of RA. Further research is necessary to establish a score predicting RA failure, which can help in preproceduralrisk stratification of patients undergoing complex percutaneous coronary intervention with RA.

Utility of the SYNTAX Score in the risk stratification of patients undergoing rotational atherectomy.

INTRODUCTION: The SYNTAX Score (SS) evaluates the angiographic complexity of coronary artery disease to assess the cardiovascular risk after coronary revascularization. The aim of the study was to evaluate whether SS results are associated with in-hospital and 1-year outcomes of patients undergoing percutaneous coronary intervention (PCI) requiring rotational atherectomy (RA). MATERIAL AND METHODS: We analyzed data of 207 consecutive patients who underwent PCI with RA. Patients were divided into two groups: those with high SS (> 33 points) and those with low/intermediate SS (0-33 points). RESULTS: In 21 (10%) patients SS was high and 186 (90%) patients had low/intermediate SS. Patients with high SS were older (76 vs. 71 years, p = 0.008) and more frequently diagnosed with chronic kidney disease (38% vs. 18%, p = 0.03) and heart failure (71% vs. 30%, p = 0.0001). In patients with high SS the RA procedure was longer (p = 0.004), required more contrast (p = 0.005) and higher radiation doses (p = 0.04), and contrast-induced nephropathy was more frequent (14% vs. 2%, p = 0.001). CONCLUSIONS: In our RA patients there was no significant difference between the frequency of in-hospital and 1-year adverse cardiovascular events depending on the SS result. High SS correlates only with parameters describing the extensity and technical complexity of the procedure. However, the unavailability of other risk assessment tools in this population raises the need to create a new more specific risk score for patients requiring RA.

The use of rotational atherectomy in high-risk patients: results from a high-volume centre.

BACKGROUND: Rotational atherectomy (RA) is indicated for fibrocalcified lesions when traditional percutaneous coronary intervention (PCI) could not be successfully performed. In some of the high-risk patients the RA procedure is the last resort for successful revascularisation. Such patients are, among others, those in whom coronary artery bypass grafting (CABG) is not feasible. AIM: The aim of the study was to assess in-hospital and one-year outcomes of PCI with RA in high-risk patients without other revascularisation options (RA-only group), in comparison to lower-risk patients undergoing RA. METHODS: We evaluated data of 207 consecutive patients who underwent PCI with RA. Primary endpoints were one-year all-cause mortality and one-year major adverse cardiac events (MACEs). Secondary endpoints were in-hospital outcomes. RESULTS: During the study 35% of patients fulfilled the inclusion criteria to the high-risk group. Those patients had significantly lower left ventricular ejection fraction, more often prior CABG, higher admission glucose level, and higher EuroSCORE II and Syntax Score. Procedural success was similar in both groups (85% in RA-only group vs. 91% in remaining patients, p = 0.18). In-hospital outcomes were similar, except more frequent no/slow-flow phenomenon in the RA-only group. The MACE and mortality rates in one-year follow-up were not statistically different in both groups (19% vs. 18%, p = 0.82 and 11% vs. 9%, p = 0.64, respectively). CONCLUSIONS: Despite the high-risk characteristics of the study subgroup, no significant differences between in-hospital and one-year outcomes were found in comparison to lower-risk RA patients. Complex PCI with RA in patients without other revascularisation options should be taken into consideration.

Novel predictors of outcome after coronary angioplasty with rotational atherectomy. Not only low ejection fraction and clinical parameters matter.

INTRODUCTION: Most established risk factors after rotational atherectomy (RA) of heavily fibro-calcified lesions are associated with patients' general risk and clinical related factors and are not specific for either coronary and culprit lesion anatomy or the RA procedure. AIM: To assess novel predictors of poor outcome after percutaneous coronary intervention using RA in an all-comers population. MATERIAL AND METHODS: A total of 207 consecutive patients after RA were included in a single-center observational study. Primary endpoints were 1-year mortality and 1-year major adverse cardiac events (MACE). Secondary endpoints were angiographic and procedural success and in-hospital complications. RESULTS: Procedural complications occurred in 19 (8%) patients. In-hospital mortality was 1%, peri-procedural myocardial infarction (MI) was 9%, and acute stroke occurred in one patient. The 1-year MACE rate was 20% with all-cause mortality 10%, MI 10% and stroke 1%. Multivariable analysis revealed heart failure with left ventricle ejection fraction (LVEF) ≤ 35% (p = 0.02) and uncrossable lesion, as compared to undilatable lesion (p = 0.01), as independent predictors of 1-year mortality and residual SYNTAX score ≤ 8 as an independent predictor of favorable outcome (p = 0.04). Heart failure with LVEF ≤ 35% (p < 0.01) and uncrossable lesion (p = 0.04) were independent predictors of 1-year MACE. CONCLUSIONS: The presence of a novel factor, uncrossable lesion, as compared to undilatable lesion, is associated with poor outcome, and low residual SYNTAX score ≤ 8 is associated with favorable outcome in 1-year follow-up after the RA procedure and can help in risk stratification of patients undergoing complex coronary intervention with RA.

In patients undergoing percutaneous coronary intervention with rotational atherectomy radial access is safer and as efficient as femoral access.

INTRODUCTION: Transfemoral approach (TFA) may be preferred access site in order to facilitate complex percutaneous procedures such as rotational atherectomy (RA). Notwithstanding, there is a growing evidence that transradial approach (TRA) is associated with lower access site complication rates and even lower mortality. The aim was to assess in-hospital and 1-year outcomes in patients undergoing RA using TRA, in comparison to TFA. METHODS: A single center observational study included all consecutive patients, who underwent RA from 2010 to 2015. Primary endpoints were procedural success, in-hospital mortality and major adverse cardiovascular events (MACE). Secondary endpoints were 1-year all-cause mortality and MACE. RESULTS: The study included 177 patients, 69% in TRA group and 31% in TFA group. Except for male sex and logistic Euroscore II there were no differences in common risk factors. There was no difference in procedural success (95% vs 87%, P = 0.07) with even a trend in favor of TRA. Performing RA via TRA lower amount of contrast volume (P = 0.009) was used and hospital stay after the procedure was shorter (P = 0.004). Periprocedural complication rates were similar, however patients with TFA had significantly higher rate of major access site bleedings (13% vs 1%, P = 0.001), with no differences in mortality and other adverse events both in-hospital and during 1-year observation. CONCLUSIONS: Even though RA is a demanding technique, when performed via TRA allows to maintain the same procedural success and long-term results in comparison to TFA, reduces in-hospital major access site bleedings, lowers the amount of contrast media and shortens hospital stay.