Safety, effectiveness and mid-term follow-up in 136 consecutive patients with moderate to severely calcified lesions undergoing phoenix atherectomy.

To investigate the safety and effectiveness of the Phoenix atherectomy device for the treatment of complex and calcified lesions in patients with peripheral artery disease (PAD). 136 consecutive all-comer patients with chronic PAD underwent Phoenix atherectomy. Safety in terms of vessel injury and embolism, efficacy and clinical success in terms of ≥ 1Rutherford class (RF) improvement during follow-up were systematically analyzed. Lesion calcification was categorized by the Peripheral Arterial Calcium Scoring System (PACSS), whereas lesion complexity was classified by the Transatlantic Inter-Society Consensus (TASC). 151 lesions were treated in 136 consecutive patients. Clinical follow-up was available at 10.3 ± 4.2 months in 132 (97%) patients. 55 patients (40%) had intermittent claudication, 16 (12%) rest pain and 65 (48%) had ischemic ulcerations (mean RF class = 4.2 ± 1.1). 15 (11%) patients had TASC B lesions, whereas the majority 72 (53%) and 49 (36%) exhibited TASC C and D lesions, respectively. Mean PACSS score was 3.3 ± 0.9. Mean lesion length was 106 ± 92 mm. Atherectomy was combined with drug-coated balloon (DCB) in 129 (95%) patients. Nine (6.6%) patients with infra-inguinal lesions received stents. Technical and procedural success were recorded in 102 (75%) and 135 (99%), respectively. Perforation was noticed in 2 (1%), whereas asymptomatic embolism occurred in 6 (4%) patients. Clinical success was present in 54 (100%) patients with claudication and in 65 of 78 (83%) patients with critical limb ischemia (CLI). Atherectomy in combination with DCB angioplasty can be safely performed in patients with complex, calcified peripheral lesions with a relatively low rate of bail-out stenting and promising clinical mid-term results.German Clinical Trials Register: DRKS00016708.

Splenic Switch-Off for Determining the Optimal Dosage for Adenosine Stress Cardiac MR in Terms of Stress Effectiveness and Patient Safety.

BACKGROUND: Adenosine stress MRI is well established for the evaluation of known and suspected coronary artery disease. However, a proportion of patients might be "under-stressed" using the standard adenosine dose. PURPOSE: To compare three different adenosine dosages for stress MRI in terms of stress adequacy based on splenic switch-off (SSO) and limiting side effects. STUDY TYPE: Prospective. POPULATION: In all, 100 patients were randomized in group 1 (33 pts), group 2 (34 pts), and group 3 (33 pts), receiving dosages of 140 µg/kg/min, 175 µg/kg/min, or 210 µg/kg/min, respectively. SSO was evaluated visually and quantitatively. SEQUENCE: Stress perfusion was performed using a 1.5T scanner in three short axes using a standard single-shot, saturation recovery gradient-echo sequence. ASSESSMENT: Three blinded experienced operators evaluated SSO on stress and rest perfusion acquisitions in the three groups. The signal intensity of the spleen and myocardium and the presence of inducible ischemia and late gadolinium enhancement were assessed. STATISTICAL ANALYSIS: T-test, analysis of variance (ANOVA), chi-squared test, and Pearson's correlation coefficient. RESULTS: SSO was present more frequently in patients receiving 175 µg/kg/min and 210 µg/kg/min (31/33 [94%] and 27/29 [93%], respectively) compared to those receiving the standard dose (19/33 [58%], P < 0.05). A positive stress result was noted in 3/33 (9%) patients receiving 140 µg/kg/min vs. 9/33 (27%) patients receiving 175 µg/kg/min and 10/31 (33%) patients receiving 210 µg/kg/min (P < 0.05 for all, P < 0.05 for group 1 vs. groups 2, 3). The relative decrease of splenic signal intensity at hyperemia vs. baseline was significantly lower in group 1 compared to groups 2 and 3 (-33% vs. -54%, -56%, respectively; P < 0.05). No adverse events during scanning were noted in groups 1 and 2, whereas in group 3 four examinations were stopped due to severe dyspnea (n = 2) and AV-blockage (n = 2). DATA CONCLUSION: A dosage of 175 µg/kg/min adenosine results in a higher proportion of SSO, which may be an indirect marker of adequate coronary vasodilatation and simultaneously offers similar safety compared to the standard 140 µg/kg/min dosage. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 2 J. MAGN. RESON. IMAGING 2020;52:1732-1742.

Atrioventricular delay programming in cardiac resynchronization therapy devices: fixed or adaptive? A randomized monocenter trial.

INTRODUCTION: Cardiac resynchronization therapy devices are routinely programmed on fixed atrioventricular delays (AVD) under resting conditions based on echocardiographic techniques. Whether this AVD also ensures optimal exercise hemodynamics, is unclear. METHODS: In order to compare fixed-AVD with rate-adaptive AVD, 100 patients with cardiac resynchronization therapy systems and sinus rhythm were randomized to fixed-AVD or adaptive-AVD. The patients then underwent bicycle ergometry with noninvasive hemodynamic monitoring. At rest and at peak exercise, stroke volume, cardiac output, and cardiac index were determined using "electrical velocimetry." RESULTS: There were no significant differences in clinical characteristics and baseline hemodynamic parameters between fixed or adaptive AVD. In patients randomized to adaptive AVD, a trend towards higher stroke volume, cardiac output, and cardiac index at peak exercise was encountered. CONCLUSIONS: Based on the trend towards better exercise hemodynamics demonstrated by this pilot study, a randomized follow-up study with clinical end points appears to be justified to clarify this issue.

Successful Endovascular Treatment of Acute Thromboembolic Upper Limb Ischemia in a Patient with Atrial Fibrillation.

Acute limb ischemia represents a medical emergency that requires prompt diagnosis and treatment to preserve the viability of the affected tissue. The majority of the ischemic events are thrombotic in nature, especially in patients with atrial fibrillation. To date, surgical thrombectomy is usually used for the treatment of acute thromboembolic upper limb ischemia. Herein, we present a case of an 88-year-old patient who presented with right upper limb pain, pulselessness, and paresthesia. Duplex sonography revealed thrombotic occlusion and the absence of flow in both the ulnar and radial arteries. Electrocardiogram exhibited atrial fibrillation with a heart rate of 88 bpm. Antegrade puncture of the brachial artery was performed, and digital subtraction angiography confirmed fresh occlusion of the ulnar and radial arteries with some residual flow in the accessory brachial artery. Thrombus aspiration using a 6-Fr Eliminate aspiration catheter (Terumo Interventional Systems, Eschborn, Germany) was repeatedly performed, resulting in thrombolysis in myocardial infarction (TIMI) III antegrade flow to the right hand, promptly filling of the palmar arch and retrograde filling of the ulnar artery. Pain and paresthesia immediately resolved without need for further pharmacological interventions. The patient was discharged without functional deficits of his right hand, and duplex sonography after 4 weeks and 6 months revealed triphasic flow of the brachial and radial arteries and retrograde flow of the ulnar artery.

Safety of symptom-limited exercise testing in a big cohort of a modern ICD population.

BACKGROUND: Exercise may predispose to ventricular arrhythmias especially in patients with congestive heart failure. As therapy with implanted cardioverter-defibrillators (ICDs) has become standard medical care, there is an emerging number of exercise tests that need to be performed in patients with ICDs. In contrast, little is known about the safety of symptom-limited exercise testing in these patients. METHODS AND RESULTS: 400 ICD patients performed symptom-limited exercise treadmill testing. 200 patients performed a ramp protocol with an initial workload of 0 W increased by 15 W every minute. Another 200 ICD patients did a slightly modified ramp protocol with again an initial workload of 0 W but with an increased capacity of 15 W every 2 min. The study population consists mainly of patients with ischemic (63%) and non-ischemic (34%) heart disease. Atrial fibrillation was present in 16% of the subjects. The mean ejection fraction was 28 ± 8, and 78% of the patients had an ejection fraction below 30%. In this cohort of patients, no sustained ventricular arrhythmias and no deaths occurred during or after exercise testing. No inappropriate shock delivery was observed. The modified ramp protocol resulted in a prolonged exercise time with equal exercise capacity but does not result in an enhanced susceptibility for ventricular arrhythmias. CONCLUSIONS: Symptom-limited exercise treadmill testing in heart failure patients with ICDs is a safe procedure. The use of a ramp protocol is sufficient in terms of safety and is easy to perform in general practice. The exercise duration in heart failure patients with ICDs does not predict serious adverse events.