Imaging in Percutaneous Coronary Intervention.

Intracoronary imaging (ICI) use during percutaneous coronary intervention (PCI) has been shown to effectively improve cardiovascular outcomes, particularly for high-risk subgroups. However, data from randomized controlled trials are limited and the overall utilization rate of ICI remains variable between different countries and centers. Potential benefits of ICI include identification of appropriate lesions for PCI, improved characterization of lesions, and optimization of stent placement. Currently available modalities of ICI include intravascular ultrasound, optical coherence tomography and near infrared spectroscopy. Within this review, we summarize the contemporary evidence surrounding ICI and discuss its application in clinical practice.

Calcified coronary lesions: Imaging, prognosis, preparation and treatment state of the art review.

Calcific coronary artery stenosis is a complex disease associated with adverse outcomes and suboptimal percutaneous treatment. Calcium plaque modification has emerged as a key strategy to tackle the issues that accompany calcific stenosis - namely reduced device deliverability, unpredictable lesion characteristics, and difficult dilatation. Atherectomy has traditionally been the treatment modality of choice for heavily calcified coronary stenoses. Contemporary technologies have emerged to aid with planning, preparation, and treatment of calcified coronary stenosis in an attempt to improve procedural success and long-term outcomes. In this State Of The Art Review, we synthesize the body of data surrounding the diagnosis, imaging, and treatment of calcific coronary disease, with a focus on i) intravascular imaging, ii) calcific lesion preparation, iii) treatment modalities including atherectomy, and iv) updated treatment algorithms for the management of calcified coronary stenosis.

Rotational atherectomy combined with cutting balloon to optimise stent expansion in calcified lesions: the ROTA-CUT randomised trial.

BACKGROUND: Percutaneous coronary intervention (PCI) of calcified lesions remains challenging for interventionalists. AIMS: We aimed to investigate whether combining rotational atherectomy (RA) with cutting balloon angioplasty (RA+CBA) results in more optimal stent expansion compared with RA followed by non-compliant balloon angioplasty (RA+NCBA). METHODS: ROTA-CUT is a prospective, multicentre, randomised trial of 60 patients with coronary artery disease undergoing PCI of moderately or severely calcified lesions with drug-eluting stent implantation. Patients were randomised 1:1 to either RA+CBA or RA+NCBA. The primary endpoint was the minimum stent area on intravascular ultrasound (IVUS). Secondary endpoints included minimum lumen area and stent expansion assessed by IVUS and acute lumen gain, final residual diameter stenosis and minimum lumen diameter assessed by angiography. Clinical endpoints were obtained at 30 days. RESULTS: The mean age was 71.1±9.4 years, and 22% were women. The procedural details of RA were similar between groups, as were procedure duration and contrast use. Minimum stent area was similar with RA+CBA versus RA+NCBA (6.7±1.7 mm2 vs 6.9±1.8 mm2; p=0.685). Furthermore, there were no significant differences regarding the other IVUS and angiographic endpoints. Procedural complications were rare, and 30-day clinical events included 2 myocardial infarctions and 1 target vessel revascularisation in the RA+CBA group and 1 myocardial infarction in the RA+NCBA group. CONCLUSIONS: Combining RA with CBA resulted in a similar minimum stent area compared with RA followed by NCBA in patients undergoing PCI of moderately or severely calcified lesions. RA followed by CBA was safe with rare procedural complications and few clinical adverse events at 30 days.

Coronary plaque vulnerability in statin-treated patients with elevated LDL-C and hs-CRP: optical coherence tomography study.

There have been no previous attempts to assess coronary plaque morphology in statin-treated patients with combined residual cholesterol and inflammatory risk. The aim of this study was to characterize the morphology using optical coherence tomography (OCT) and to investigate the underlying molecular mechanisms. Two hundred seventy statin-treated patients with stable coronary artery disease who underwent OCT imaging prior to elective percutaneous coronary intervention were included in this single-center retrospective analysis. Subjects were stratified into four groups based on low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hs-CRP) levels using 70 mg/dl and 2 mg/L as cut-offs, respectively. OCT images of the target lesions were assessed. For a subset of patients, peripheral blood mononuclear cells (PBMC) were isolated, and gene expression was characterized using microarray analysis. Patients with high LDL-C and high hs-CRP demonstrated a higher frequency of lipid-rich plaques (LRP) (91%, P = 0.03) by OCT. LRPs in these patients had a greater maximal lipid arc (186.6 ± 92.5°, P = 0.047). In addition, plaques from patients who did not achieve dual-target were less frequently calcified (P = 0.003). If calcification was present, it was characterized by a lower maximal arc (P = 0.016) and shorter length (P = 0.025). PBMC gene expression analysis demonstrated functional enrichment of toll-like receptors (TLRs) 1-9 to be associated with high LDL-C and hs-CRP. Obstructive coronary lesions in patients on statin therapy with combined residual cholesterol and inflammatory risk demonstrated a higher prevalence of LRP with greater maximal lipid arcs and more frequent spotty calcifications. PBMC from these patients revealed functional enrichment of TLR 1-9.