Trends in Death Rate 2009 to 2018 Following Percutaneous Coronary Intervention Stratified by Acuteness of Presentation.

Percutaneous coronary intervention (PCI) has evolved dramatically, along with patient complexity. We studied trends in in-hospital mortality with changes in patient complexity over the last decade stratified by clinical presentation. The study population included all patients presenting to the cardiac catheterization lab between January 2009 and July 2018. Expected in-hospital mortality was calculated using the National Cardiovascular Data Registry CathPCI risk scoring system. Yearly mean in-hospital mortality rates (%) were plotted and smoothed by weighted least squares regression for each presentation: ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndrome (NSTE-ACS), and stable ischemic coronary artery disease (SI CAD). The overall cohort included 13,732 patients who underwent PCI during the study period, of whom 2,142 were for STEMI, 2,836 for NSTE-ACS, and 8,754 for SI CAD. Indications for PCI have changed over time, with more PCIs being performed for NSTE-ACS and STEMI than for SI CAD. NSTE-ACS and STEMI patients had a steady decrease in in-hospital mortality over time compared with SI CAD patients. Overall observed mortality continues to decrease in NSTE-ACS patients, with reduction in the observed mortality rate within the STEMI population to below expected since 2013. Patient complexity has not changed significantly. These results may be attributed to improved patient selection coupled with optimal pharmacotherapy with more robust therapies during procedure and hospitalization.

Techniques to Optimize the Use of Optical Coherence Tomography: Insights from the Manufacturer and User Facility Device Experience (MAUDE) Database.

BACKGROUND/PURPOSE: Optical coherence tomography (OCT) is a high-resolution intravascular imaging modality used to assess coronary arteries and as an adjunctive tool for optimization of percutaneous coronary interventions. Overall, the rate of complications and adverse events related to intravascular imaging is low. Limited data exist on the most commonly reported complications and modes of failure related to the use of OCT. Therefore, we analyzed the post-marketing surveillance data from the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database to assess the reported complications and failure modes for OCT and reviewed techniques to optimize device use. METHODS/MATERIALS: The MAUDE database was queried for all event reports involving coronary OCT devices. Two independent reviewers identified 49 device reports included in the final analysis. Modes of failure and device-related patient complications were assessed. RESULTS: Of the 49 cases with reported device-related issues, 6.1% involved malfunction prior to insertion of the OCT catheter, and 30.6% of reported events did not result in an associated patient-related adverse event. The most commonly reported adverse events included coronary dissection and difficulty removing the catheter within a previously stented segment. No events of contrast-induced nephropathy were reported. CONCLUSIONS: Findings from the MAUDE database highlight the modes of device-related events associated with OCT. Device issues are uncommon, and as a result, users should be aware of optimal techniques to prevent and minimize adverse events related to device use.

Takotsubo syndrome: State-of-the-art review by an expert panel - Part 1.

Takotsubo syndrome (TTS) is an acute cardiac condition independent of epicardial coronary obstruction that mimics acute coronary syndrome and is characterized by acute heart failure with reversible ventricular motion abnormalities. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Experts in the field provide a thorough and detailed review of this syndrome. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. In part 1 of this two-part manuscript, we discuss how TTS came to be known, several patterns and forms it can take in patients, epidemiology and pathophysiology of the syndrome, and clinical presentation.

Takotsubo syndrome: State-of-the-art review by an expert panel - Part 2.

In part 2 of this two-part manuscript on takotsubo syndrome (TTS), we discuss typical biomarkers (particularly excess catecholamines and what kinds of electrocardiographic information operators should look for) and numerous complications the syndrome can cause. This consensus paper is the result of a multinational effort aiming to summarize the current state of the art on TTS. Several novel and unique sections are emphasized in this document, including the current state of the art on genetics of takotsubo syndrome, microRNAs (miRs), racial differences, role of cardiac spectroscopy and intracoronary imaging, as well as mechanical circulatory support. New structured algorithms are also proposed to aid clinicians in the decision-making process as well as future directions for research given the current lack of evidence-based medical approaches.

Comparison of the Efficacy and Safety of Orbital and Rotational Atherectomy in Calcified Narrowings in Patients Who Underwent Percutaneous Coronary Intervention.

We aimed to compare the safety and efficacy of rotational atherectomy (RA) and orbital atherectomy (OA) during percutaneous coronary intervention in an all-comer population with severely calcified lesions. We included all patients who underwent percutaneous coronary intervention with OA or RA in our institution from October 2013 until October 2016. Comparison of baseline and procedural characteristics, along with acute complication rates and postprocedural cardiac enzyme elevation, was performed. There were 191 RA and 57 OA patients. Other than creatinine clearance, which was lower in patients with OA (p = 0.01), there were no differences in baseline characteristics. OA was more frequent in left anterior descending artery lesions (p = 0.02), whereas RA was more common in right coronary artery lesions (p = 0.01). Intracoronary imaging rates were above 60% in both groups. There was a higher rate of coronary dissections with OA compared with RA (p = 0.003), but there was no difference in periprocedural events. Maximal troponin levels were similar in both groups. Residual stenosis measured by intravascular ultrasound in 29 patients revealed no significant differences between OA and RA (p = 0.58). In conclusion, RA and OA have similar safety and efficacy profiles in treating patients with calcified coronary lesions, and intracoronary imaging is highly beneficial in identifying coronary injury after atherectomy procedures.

Scaffold thrombosis following implantation of the ABSORB BVS in routine clinical practice: Insight into possible mechanisms from optical coherence tomography.

OBJECTIVES: To identify potential underlying mechanisms of early and (very) late scaffold thrombosis (ScT) by optical coherence tomography (OCT), in a frame-by-frame analysis. BACKGROUND: The absorb scaffold is associated with an increased risk of ScT compared with metallic stents. Several potential causes of bioresorbable ScT have been identified, however the precise etiology still remains unclear. METHODS: Between February 2013 and February 2016, 13 patients presenting with definite ScT underwent OCT imaging. After guidewire passage or balloon inflations, OCT images were acquired. Pullbacks were assessed offline at each 1 mm longitudinal interval within the treated segment and the 5 mm segments adjacent to both edges. Primary cause of ScT was assessed by reviewing medical records, baseline angiographic films, and OCT pullback and angiographic films at time of ScT. RESULTS: 13 patients, with 14 thrombotic lesions presented either with early ScT (i.e., ≤30 days) or very (late) (i.e., >30 days). Analysis demonstrated a significantly smaller in-scaffold maximal lumen diameter in the early cases (2.75 ± 0.85 mm vs. 3.00 ± 0.46 mm; P = 0.033) and a nonsignificant smaller minimal scaffold diameter (2.44 ± 0.62 mm vs. 2.58 ± 0.37 mm P = 0.097). Per-strut analysis demonstrated significantly more malapposed scaffold struts in (very) late cases (6% versus 0.6%, P < 0.001). Assessment of the predominate cause showed underexpansion as the dominant factor in the early cases, while malapposition was predominantly seen in the (very)late cases. CONCLUSIONS: OCT performed in patients presenting with Absorb ScT demonstrated that malapposition of scaffold struts was more prominent in patients presenting with (very) late ScT, while underexpansion was more frequent in the early cases.

Intravascular ultrasound assessment of the effect of laser energy on the arterial wall during the treatment of femoro-popliteal lesions: a CliRpath excimer laser system to enlarge lumen openings (CELLO) registry study.

The CliRpath Excimer Laser System to Enlarge Lumen Openings (CELLO) registry included patients treated with modified excimer laser catheters for the endovascular treatment of peripheral artery disease affecting the superficial femoral artery (SFA) and proximal popliteal artery. The aim of this study was to assess, via intravascular ultrasound (IVUS) the dissections in the vessel wall following treatment with the laser catheters. IVUS grayscale images from the CELLO registry were systematically reviewed for dissections in the treated vessel segments by two investigators. Images from 33 patients; 66 pullbacks (1867 IVUS frames in 2 phases), were successfully matched frame-to-frame to evaluate identical segments of the treated vessels in the two phases; post-2 mm Turbo-Elite laser pilot channel creation and post Turbo-Booster laser atherectomy. Dissections were categorized as; (1) intimal, (2) medial, (3) intramural hematoma, and (4) adventitial according to the ACC Clinical Expert Consensus Document classification of dissections. An average of 57 frames was evaluated per pullback, giving a total of 3734 frames (1867 matched for pre-ablation (post channel creation) and post-ablation phases). Treatments with the modified Excimer laser catheters resulted in a significant increase in lumen area of 5.5 ± 3.2-mm2 (95% CI 4.3-6.8, p < 0.0001) and reduction in plaque plus media volume of -10.6 ± 36.0 mm3 (95% CI -25.8 to 4.6, p = 0.1619) whilst giving rise to mainly intramural hematoma formations post Turbo-Booster laser treatment in 55% of frames assessed and 24% medial dissections with less than 1% adventitial disruption. The Excimer laser based Turbo-Booster treatment of peripheral artery lesions resulted in significant plaque debulking and increased lumen diameter with negligible degree of adventitial layer injury.

Late-breaking Trials from the 2016 American Heart Association's Scientific Sessions.

The late breaking trials released at the American Heart Association scientific sessions conference in November in New Orleans, LA covered a wide range of topics, including new devices within the field of heart failure, new registry data on transcatheter aortic valve replacement (TAVR) in intermediate risk patients, and medical management of peripheral arterial disease, coronary artery disease, and hypercholesterolemia. The following review highlights the late breaking trials presented at the conference that will have significant impact on clinical practice.

Direct communication between the left circumflex and the right coronary arteries: a very rare coronary anomaly circulation.

Coronary artery anomalies (CAA) are congenital changes in their origin, course, and/or structure. Intercoronary communication (ICC) is a very rare subset with uni- or bidirectional blood flow between two or more coronary arteries. We present the case of a 58-year-old man with an acute coronary syndrome whose coronary angiography incidentally showed a surprising and very rare communication between the right coronary and left circumflex arteries.