Coronary intravascular lithotripsy in contemporary practice: challenges and opportunities in coronary intervention.

Percutaneous coronary intervention (PCI) of calcified coronary arteries is associated with poor outcomes. Poorly modified calcified lesion hinders the stent delivery, disrupts drug-carrying polymer, impairs drug elution kinetics and results in under-expanded stent (UES). UES is the most common cause of acute stent thrombosis and in-stent restenosis after PCI of calcified lesions. Angiography has poor sensitivity for recognition and quantification of coronary calcium, thereby mandating the use of intravascular imaging. Intravascular imaging, like intravascular ultrasound and optical coherence tomography, has the potential to accurately identify and quantify the coronary calcium and to guide appropriate modification device before stent placement. Available options for the modification of calcified plaque include modified balloons (cutting balloon, scoring balloon and high-pressure balloon), atherectomy devices (rotational atherectomy and orbital atherectomy) and laser atherectomy. Coronary intravascular lithotripsy (IVL) is the newest addition to the tool box for calcified plaque modification. It produces the acoustic shockwaves, which interact with the coronary calcium to cause multiplanar fractures. These calcium fractures increase the vessel compliance and result in desirable minimum stent areas. Coronary IVL has established its safety and efficacy for calcified lesion in series of Disrupt CAD trials. Its advantages over atherectomy devices include ease of use on workhorse wire, ability to modify deep calcium, no debris embolization causing slow flow or no-flow and minimal thermal injury. It is showing promising results in modification of difficult calcified lesion subsets such as calcified nodule, calcified left main bifurcation lesions and chronic total occlusion. In this review, authors will summarize the mechanism of action for IVL, its role in contemporary practice, evidence available for its use, its advantages over atherectomy devices and its imaging insight in different calcified lesion scenarios.

Shock the rock with coronary intravascular lithotripsyPresence of coronary calcium during stenting is associated with the risk of stent under expansion. It's imperative to adequately modify this coronary calcium before placing the stent. Till recent past, the most effective method for calcium modification is debulking it with rotational artherectomy, which is associated with the risk of coronary perforation, slow flow or abrupt vessel closure. Recently, a balloon-based lithotripsy device has established its safety and efficacy for treating such lesions. Coronary intravascular lithotripsy (IVL) is an easy to use calcium modification device and is associated with almost negligible complications, when compared with artherectomy devices. In this review, we will discuss the mechanism of IVL action and its use in different scenarios of calcified coronary artery disease.

Optical Coherence Tomography Predictors of SIde Branch REstenosis after unprotected Left Main bifurcation angioplasty using double kissing crush technique (OP-SIBRE LM Study).

BACKGROUND: Among the two stent strategies, contemporary evidence favors double kissing crush technique (DKC) for complex unprotected distal left main bifurcation (UdLMB) lesions. However one of the major challenges to these lesions is side branch (SB) restenosis. AIMS: Our aim was to identify optical coherence tomographic (OCT) characteristics that may predict SB restenosis (SBR) after UdLMB angioplasty using DKC technique. METHODS: This was a single-center, retrospective study that included 60 patients with complex UdLMB disease, who underwent OCT-guided angioplasty using DKC technique. Angiographic follow-up was performed in all patients at 1 year to identify patients with SBR. Patients with SBR group were compared with patients without SBR (NSBR group) for OCT parameters during index procedure. RESULTS: Twelve (20%) patients developed SBR at 1-year follow-up. The SBR group had longer SB lesion (18.8 ± 3.2 vs. 15.3 ± 3.7 mm, p = 0.004) and neo-metallic carinal length (2.1 vs. 0.1 mm, p < 0.001) when compared to the NSBR group. Longer neo-metallic carinal length was associated with the absence of the dumbbell sign, presence of hanging stent struts across the SB ostium on OCT of final MB pullback. On multivariate regression analysis, SB distal reference diameter (DRD) and SB stent expansion were identified as independent predictors of SBR with SB-DRD of ≤2.8 mm (area under curve-0.73, sensitivity-83.3%, and specificity-62.5%) and SB stent expansion of ≤89% (area under curve-0.88, sensitivity-83.3%, and specificity- 81.2%) as the best cut off values to predict SBR. CONCLUSIONS: SB DRD and SB stent expansion are the OCT predictors of future SBR after UdLMB angioplasty using DKC technique.

Management of a broken guiding catheter tip: Cut and fix technique.

A 49-year-old male presented with class III exertional angina, 1 year after angioplasty of the left anterior descending artery (LAD) and right coronary artery. Coronary angiogram revealed 90% in-stent restenosis (ISR) in mid-LAD with angiographic impression of stent fracture. Optical coherence tomographic evaluation of mid-LAD ISR showed a distinct 3 mm long "eclipse sign" indicating embolized, broken guiding catheter tip as a cause of ISR, which was confirmed on reviewing 1-year-old angiographic images. This was managed with "cut and fix technique" using cutting balloon and another drug-eluting stent. Optical coherence tomographic at 9 months showed well endothelialized stent with a thin layer of neo-intimal hyperplasia over the sandwiched broken guiding tip.

Femoral artery access site closure with perclose suture mediated device in coronary interventions.

OBJECTIVE: To compare the outcome of suture mediated vascular closure device Perclose Proglide (PP) with manual compression (MC) following transfemoral access for coronary interventions (CI). METHODS: It is a retrospective, observational, single centre study from January 2018 to September 2019. Consecutive patients undergoing interventions through transfemoral access were divided into PP and MC groups. Those with less than 3 months follow up were excluded. Two groups were compared for baseline characteristics and various complications at 24 h and at 30 days. RESULTS: Out of 1743 patients studied, PP group included 1343 and MC group, 400 patients. Both groups were comparable in baseline characteristics, sheath size and use of antiplatelets and anticoagulation. PP group had significantly less minor bleeding (P = .01, CI 0.34-4.03) and hematoma (P = .0007, CI 0.95-5.10) at 24 h. At 30 days, minor bleeding (P < .0001, CI 0.97-4.25), hematoma (P = .0002, CI 1.05-4.93) and pseudo-aneurysm (P = .0095, CI 0.03-1.18) were also significantly less in PP group. Obesity (OR 3.5, CI 1.29-9.49) and hypertension (OR 2.41, CI 1.12-5.19) were associated with increased minor bleeding at 24 h. Device failure rate was 2.38%. CONCLUSIONS: PP device is safe, effective and is associated with fewer complications than MC in CI. Device failure rate is low. Obesity and hypertension are associated with increased minor bleeding in both groups.

Appropriate use of PCSK9 Inhibitors in India.

The burden of atherosclerotic cardiovascular (CV) disease is alarmingly high and increasing in our country. Dyslipidemia is one of the major modifiable risk factors, and INTERHEART study showed that dyslipidemia had the highest population attributable risk for myocardial infarction. In the management of dyslipidemia, low-density lipoprotein cholesterol (LDL-C) is the primary therapeutic target. In addition to therapeutic lifestyle changes, statins and ezetimibe effectively lower LDL-C and consequently improve CV outcomes. However, there are situations where these drugs fall short of achieving the target or they may not be well tolerated.

"Transcollateral" renal angioplasty for a completely occluded renal artery.

Percutaneous transluminal renal angioplasty with stenting has been effective in the control of hypertension, renal function, and pulmonary edema caused by atherosclerotic renal artery stenosis. However, the role of the procedure has not been fully established in the context of chronic total occlusion of renal artery. We report the successful use of this procedure in 57-year-old male patient who reported for evaluation of a recent episode of accelerated hypertension. A renal angiogram in this patient showed ostial stenosis of the right renal artery, which was filling by way of the collateral artery. Renal angioplasty for chronic total occlusion of right renal artery was successfully performed in a retrograde fashion through a collateral artery, thereby leading to improvement of renal function and blood pressure control.

ECG changes of hyperkalemia during paced rhythm.

Paced rhythms can mask ECG changes of several conditions. ECG changes due to hyperkalemia during paced rhythm have not been well described. We report a patient with isolated noncompaction of left ventricle with left ventricular dysfunction and complete heart block on a permanent pacemaker who developed hyperkalemia. Typical ECG changes of hyperkalemia including widening of QRS complex and sine waves were seen even during paced rhythm that reverted with correction of hyperkalemia.

Buddy wire technique: a simple technique for treating calcified lesion during percutaneous coronary intervention: a case report.

The buddy wire technique, i.e., using an additional 0.014 inch coronary guidewire along with the one being used to advance balloons, stents or other devices help to accomplish otherwise challenging procedures during percutaneous coronary intervention (PCI). It improves the balloon or stent support and also provides the guiding catheter stability. It is a simple, quick, easily available and deliverable method for complex lesions during PCI. We report technical aspects of a case of a mid-left anterior descending (LAD) calcified lesion in which a buddy wire facilitated the procedural success of PCI.

Isolated noncompaction of left ventricle presenting as peripartum cardiomyopathy.

Long term follow-up of the first reported case of isolated noncompaction of left ventricle presenting as peripartum cardiomyopathy is presented.