Comparison of Stent Expansion Using a Volumetric Versus the Conventional Method Through Optical Coherence Tomography in an All-Comers Population.

INTRODUCTION: A volumetric approach to measure stent expansion derived from optical coherence tomography (OCT) is superior in regards to clinical outcomes when compared to the conventional method. The current software already performs a semi-automatic assessment and it is available as a clinical tool, however data is still scarce. We evaluated the stent expansion analysis that uses a volumetric vessel model, called minimum expansion index - MEI and compared to the conventional model, which utilizes the minimum stent area expansion (MSAx) indexed to the references, and its potential impact on procedural decision-making strategy in percutaneous coronary intervention. METHODS: This was a prospective, all-comers single center study, from all patients undergoing OCT-guided PCI between September 2018 and May 2019. We utilized the APTIVUE™ OPTIS 5.2 software (Abbott, Santa Clara, CA) to evaluate MEI and MSAx measurements after reference adjustments. RESULTS: We included 100 patients with mean age of 64 ± 12.5 years, 68% were men, and the main arteries analyzed through OCT were LAD (48%), RCA (31%) and LCx (21%). The mean MEI was 77.6% ± 16.7% and the mean MSAx was 71.6% ± 16.9%. MEI location differed from MSAx in 70% of cases, and in those cases the mean distance between MEI and MSAx was 15.3 mm ± 12.4 mm. In 53% of the times, the stent underexpansion based on MEI was located proximally to the MSAx by 18.1 mm ± 11.8 mm. Furthermore, in 42% of the total cases, MEI would change the intervention strategy based on the stent underexpansion being in a different location ≥10 mm in comparison to MSAx (34%) associated with the discrepancy between expansion indexes for MEI and MSAx (22%). CONCLUSION: We concluded that MEI location did not correlate to the conventional MSAx in two thirds of the cases. Moreover, compared to MEI, the MSAx assessment yielded lower expansion values in different stent positions, potentially changing the appropriate post-stent optimization, which thus would impact the decision-making strategy in almost half of the patients.

A Feasibility Study of the DyeVert™ Plus Contrast Reduction System to Reduce Contrast Media Volumes in Percutaneous Coronary Procedures Using Optical Coherence Tomography.

OBJECTIVE: To evaluate the feasibility of using the DyeVert™ Plus EZ Contrast Reduction System in optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) procedures and to assess OCT image quality. BACKGROUND: OCT is employed as a powerful intravascular imaging modality; however, it requires blood displacement via contrast injection during image acquisition, thereby posing risk of nephrotoxicity. The DyeVert System is designed to reduce and facilitate monitoring of contrast media volume (CMV) delivered, without diminishing image quality. METHODS: We conducted a prospective clinical feasibility study to determine whether the DyeVert System is non-inferior to manual contrast injection in reducing CMV without lessening image quality during OCT-guided PCI procedures. Eligible participants were ≥ 18 years of age, indicated for coronary OCT, and able to provide informed consent. The primary endpoint was CMV saved during angiography; the secondary endpoint was image quality as evaluated by operators in real time and by an independent core laboratory that also assessed images from a control group that underwent comparable procedures performed without the DyeVert System. RESULTS: Fourteen participants underwent 15 coronary OCT procedures using the DyeVert System. Mean age among participants was 67 ± 11 years, and 11 (78%) were male. Mean eGFR was 71 ± 20 mL/min/1.73m2. Mean attempted CMV administration was 342.01 ± 129.8 mL; mean CMV delivered was 216.21 ± 88.87 mL, representing CMV savings of 37.5 ± 5.3%. Results from quantified OCT analysis suggest that the clear region of interest (ROI) in the DyeVert group was non-inferior (p < .0001) to the control group. There were no device-related adverse events. CONCLUSIONS: The DyeVert™ Plus EZ Contrast Reduction System reduced CMV and preserved an image quality that was non-inferior to OCT-guided PCI procedures without using the contrast reducing device.

An assessment of the quality of optical coherence tomography image acquisition.

Optical coherence tomography (OCT) provides excellent image resolution, however OCT optimal acquisition is essential but could be challenging owing to several factors. We sought to assess the quality of OCT pullbacks and identify the causes of suboptimal image acquisition. We evaluated 784 (404 pre-PCI; 380 post-PCI) coronary pullbacks from an anonymized OCT database from our Cardiovascular Imaging Core Laboratory. Imaging of the region-of-interest (ROI-lesion or stented segment plus references) was incomplete in 16.1% pullbacks, caused by pullback starting too proximal (63.7%), inappropriate pullback length (17.1%) and pullback starting too distal (11.4%). The quality of image acquisition was excellent in 36.3% pullbacks; whereas 4% pullbacks were unanalyzable. Pullback quality was most commonly affected by poor blood displacement from inadequate contrast volume (27.4%) or flow (25.6%), followed by artifacts (24.1%). Acquisition mode was 'High-Resolution' (54 mm) in 74.4% and 'Survey' (75 mm) in 25.6% of cases. The 54 mm mode was associated with incomplete ROI imaging (p = 0.020) and inadequate contrast volume (p = 0.035). We observed a substantial frequency of suboptimal image acquisition and identified its causes, most of which can be addressed with minor modifications during the procedure, ultimately improving patient outcomes.

Predicted Coronary Occlusion and Impella Salvage During Valve-in-Valve Transcatheter Aortic Valve Replacement.

We describe an interesting case of a 71 years old fragile female, with progressive shortness of breath on exertion and ankle swelling, cardiac failure NYHA class III. She also had chest irradiation due to Hodgkin's disease many years before, previous surgical aortic valve replacement using bioprosthetic stent-less Freestyle #25 mm valve (Medtronic, Inc) in 2000 for severe aortic stenosis, history of cardiac arrest in 2012 and angioplasty to ostial RCA, PCI to ostial RCA in 2014, CABG (RA graft to RCA) in 2014 (RCA intra-stent restenosis with refractory ischemia), anemia requiring regular transfusions, bronchiectasis and chronic kidney disease. Because of the great comorbidities, STS 4.9% and worsening of the symptoms due to severe aortic valve regurgitation, heart team decided to perform "valve-in-valve" Transcatheter Aortic Valve Replacement (VIV-TAVR), but we already predicted coronary occlusion while performing this procedure because of the low left main coronary ostium and short aortic valve sinus. So regarding the probable left main coronary occlusion during the valve implantation, we decided to perform the placement of a not deployed stent inside the left main prior to the valve procedure, and to deploy it in case the predicted left main occlusion occurred. So just after the VIV-TAVR procedure, we observed left main coronary occlusion and the patient got ischemic cardiogenic shock and cardiac arrest, so we performed immediate PCI and deployed the bailout stent. After some minutes of chest compressions, an Impella mechanical circulatory support system (Abiomed, Danvers, MA) had to be installed. Patient recovered spontaneous circulation, and after hemodynamic stabilization, she was sent to the Intensive Coronary Unit, without further complications. She was discharged successfully without neurological or cardiac sequelae after 1 week.

Feasibility of coronary angiogram-derived vessel fractional flow reserve in the setting of standard of care percutaneous coronary intervention and its correlation with invasive FFR.

BACKGROUND: Vessel Fractional Flow Reserve (vFFR), a new angiography-derived method for the functional assessment of coronaries, was recently shown to have good correlation with invasive wire-derived FFR, when vFFR-specific image acquisition requirements were followed. We sought to investigate the feasibility of vFFR analysis and its correlation with FFR in the situation where angiography is completed in routine fashion, without intention for virtual analysis. METHODS: Utilizing an anonymized database maintained at our Cardiovascular Imaging Core Laboratory, we included angiographic images from patients that underwent pre- and post-PCI FFR. CAAS Workstation 8.1 software (Pie Medical Imaging) was used for vFFR evaluation. RESULTS: Out of 624 angiograms (312 pre-PCI and 312 post-PCI), vFFR was successfully analyzed in 219 (35.1%) (115 pre-PCI and 104 post-PCI). Reasons for vFFR analysis failure were: <2 angiographic projections (42.5%), table movement while acquisition (25.7%) and resolution incompatibility (15%). From 115 patients with analyzable pre-PCI vFFR, 74 (64.3%) showed agreement with the respective FFR results in terms of positive (≤0.80) vs negative (>0.80) FFR. Pearson's correlation coefficient between them was 0.449 (p < 0.0001). From 104 lesions with analyzable post-PCI vFFR, 94 had availability of FFR, 74 (78.7%) of which showed agreement between the vFFR and FFR. Pearson's correlation between the values was 0.115 (p = 0.2703). CONCLUSION: vFFR could be analyzed in about one-third of previously completed angiographies and a weak correlation was seen between vFFR and FFR. Our results show the importance of following the pre-specified requirements for vFFR analysis. Further studies are needed to validate the software in different settings.

Rotational Atherectomy and Mechanical Support to Treat Left Main.

We describe a complex percutaneous coronary intervention using rotational atherectomy (Rotablator, Boston Scientific, Marlborough, Massachusetts) and mechanical circulatory support (Impella, Abiomed, Danvers, Massachusetts) in a patient with multiple comorbidities scheduled to undergo a left main coronary percutaneous coronary intervention using a 2-stent technique based on angiography. However, intracoronary optical coherence tomography changed our strategy to a successful single-stent procedure. (Level of Difficulty: Advanced.).