Quality of Life 5 Years Following Transfemoral TAVR or SAVR in Intermediate Risk Patients.

BACKGROUND: Symptomatic patients with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (SAVR) sustain comparable improvements in health status over 5 years after transcatheter aortic valve replacement (TAVR) or SAVR. Whether a similar long-term benefit is observed among intermediate-risk AS patients is unknown. OBJECTIVES: The purpose of this study was to assess health status outcomes through 5 years in intermediate risk patients treated with a self-expanding TAVR prosthesis or SAVR using data from the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial. METHODS: Intermediate-risk patients randomized to transfemoral TAVR or SAVR in the SURTAVI trial had disease-specific health status assessed at baseline, 30 days, and annually to 5 years using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Health status was compared between groups using fixed effects repeated measures modelling. RESULTS: Of the 1,584 patients (TAVR, n = 805; SAVR, n = 779) included in the analysis, health status improved more rapidly after TAVR compared with SAVR. However, by 1 year, both groups experienced large health status benefits (mean change in KCCQ-Overall Summary Score (KCCQ-OS) from baseline: TAVR: 20.5 ± 22.4; SAVR: 20.5 ± 22.2). This benefit was sustained, albeit modestly attenuated, at 5 years (mean change in KCCQ-OS from baseline: TAVR: 15.4 ± 25.1; SAVR: 14.3 ± 24.2). There were no significant differences in health status between the cohorts at 1 year or beyond. Similar findings were observed in the KCCQ subscales, although a substantial attenuation of benefit was noted in the physical limitation subscale over time in both groups. CONCLUSIONS: In intermediate-risk AS patients, both transfemoral TAVR and SAVR resulted in comparable and durable health status benefits to 5 years. Further research is necessary to elucidate the mechanisms for the small decline in health status noted at 5 years compared with 1 year in both groups. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI]; NCT01586910).

Functional Status After Transcatheter and Surgical Aortic Valve Replacement: 2-Year Analysis From the SURTAVI Trial.

OBJECTIVES: This study sought to evaluate patient-centered metrics in intermediate-surgical-risk aortic stenosis patients enrolled in the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial treated with self-expanding transcatheter aortic valve replacement (TAVR) or surgery. BACKGROUND: Studies have shown TAVR to be an alternative to surgery in patients with severe symptomatic aortic stenosis but have focused on "hard endpoints," including all-cause mortality and stroke, rather than on comparative patient-centered metrics, such as functional status and symptom burden. METHODS: The study analyzed functional status (6-minute walk test [6MWT]) and symptom burden (Kansas City Cardiomyopathy Questionnaire) in 1,492 patients from the SURTAVI trial at baseline, 30 days, 1 year, and 2 years. Patients were categorized by baseline functional status into tertiles of slow, medium, and fast walkers. RESULTS: Patients with lowest capacity baseline functional status were commonly women, had higher Society of Thoracic Surgeons scores, and had more New York Heart Association functional class III or IV symptoms; reduced baseline functional status was associated with higher aortic valve- and heart failure-related hospitalization at 2 years. There was greater improvement in 6MWT distance in TAVR compared with surgery patients at 30 days (P < 0.001) and 1 year (P = 0.012), but at 2 years, both groups had similar improvement (P = 0.091). The percentage of patients with large improvement in 6MWT was greatest in patients categorized as slow walkers and lowest in fast walkers. Symptom burden improved after TAVR at 30 days and after both procedures at 1 and 2 years. CONCLUSIONS: In this substudy of patients from the SURTAVI trial, patients receiving TAVR demonstrated a more rapid improvement in functional status and symptom burden compared with patients undergoing surgery; however, both groups had similar improvements in long-term follow-up. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI]; NCT01586910).

Collagenase to facilitate guidewire crossing in chronic total occlusion PCI-The Total Occlusion Study in Coronary Arteries-5 (TOSCA-5) trial.

BACKGROUND: Chronic total occlusions (CTO) are common and are associated with lower percutaneous coronary intervention (PCI) success rates, often due to failure of antegrade guidewire crossing. Local, intralesional delivery of collagenase (MZ-004) may facilitate guidewire crossing in CTO. AIMS: To evaluate the effect of MZ-004 in facilitating antegrade wire crossing in CTO angioplasty. METHODS: A total of 76 patients undergoing CTO PCI were enrolled at 13 international sites: 38 in the randomized training stage (collagenase [MZ-004] 900 or 1200 µg) and 38 in the placebo-controlled stage (MZ-004 900 or 1200 µg or placebo). Patients received the MZ-004 or identical volume saline (placebo group) in a double-blind design, injected via microcatheter directly into the proximal cap of the CTO. The following day patients underwent CTO PCI using antegrade wire techniques only. RESULTS: Patients were generally similar except for a trend for higher Japanese chronic total occlusion (J-CTO) score in the MZ-004 group (MZ-004 J-CTO score 1.9 vs. 1.4, p = 0.07). There was a numerical increase in the rates of guidewire crossing in the MZ-004 groups compared to placebo (74% vs. 63%, p = 0.52). Guidewire crossing with a soft-tip guidewire (≤1.5 g tip load) was significantly higher in the MZ-004 groups (0% in placebo, 17% in 900 µg, and 29% in 1200 µg MZ-004 group, p = 0.03). Rates of the major adverse cardiovascular event were similar between groups. CONCLUSION: Local delivery of MZ-004 into coronary CTOs appears safe and may facilitate CTO crossing, particularly with softer tipped guidewires. These data support the development of a pivotal trial to further evaluate this agent.

Five-Year Outcomes After Hybrid Coronary Revascularization: A Single Center Experience.

OBJECTIVE: Hybrid coronary revascularization (HCR) combines both surgical and percutaneous coronary revascularization procedures. It offers a minimally invasive strategy for multivessel coronary artery disease and combines the advantages of both. However, quantitative long-term patency and clinical outcomes remain understudied. The objective of this study was to assess clinical outcomes and graft and stent patency at 5-year follow-up. METHODS: From January 2004 to January 2015, 120 patients were enrolled in this study. They underwent robotically assisted minimally invasive coronary artery bypass grafting of left internal thoracic artery (LITA) to the left descending artery (LAD) and percutaneous coronary intervention of non-LAD vessels. Primary outcome was graft (LITA-LAD) patency determined at 5 years of follow-up, assessed by computed tomography angiography and rest and stress myocardial perfusion scintigraphy (MPS-MIBI). Secondary outcomes were stent patency and major adverse major cardiac and cerebrovascular events (MACCE). Also, freedom from recurrence of angina was assessed. RESULTS: At follow-up, 18 of 120 patients (15%) had died (in 5 patients the cause of death was cardiovascular). Among survivors, follow-up was achieved in 83 of 102 (81%). In 76 of 83 patients (92%) there was a patent LITA-LAD graft and in 75 of 83 (90%) a patent stent was demonstrated. MACCE occurred in 36 of 120 patients (30%). Freedom from recurrence of angina occurred in 92 of 120 patients (77%). CONCLUSIONS: HCR is a safe and a promising procedure. It provides a minimally invasive approach and results in complete revascularization with good 5-year patency and clinical outcomes.

Complete 2-Year Results Confirm Bayesian Analysis of the SURTAVI Trial.

OBJECTIVES: The aim of this study was to report the 2-year results of the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial and confirm the interim Bayesian analysis. BACKGROUND: Transcatheter aortic valve replacement (TAVR) with a self-expanding valve was noninferior to surgery in patients with severe aortic stenosis and intermediate operative risk using Bayesian statistical methods. Novel Bayesian designs have been used to shorten the time to primary endpoint analysis in randomized clinical trials, although the predictive value of Bayesian analysis compared with frequentist approaches remains debated. METHODS: The SURTAVI trial randomized 1,660 patients. An interim analysis was performed 1 year after the 1,400th patient was treated to estimate the primary 2-year endpoint of all-cause mortality or disabling strokes for all patients. RESULTS: The Kaplan-Meier rate for the complete 2-year primary endpoint was 12.7% in the TAVR group and 12.6% in the surgery group (0.0% difference; 95% confidence interval: -3.4% to 3.5%), compared with 12.6% with TAVR and 14.0% with surgery (-1.4% difference; Bayesian credible interval: -5.2% to 2.3%) in the interim Bayesian analysis. A comparison of individual clinical, hemodynamic, and quality-of-life endpoints using Bayesian and frequentist methods found no significant differences. CONCLUSIONS: The complete analysis of all patients with aortic stenosis at intermediate risk for surgery in the SURTAVI trial confirmed the noninferiority, with respect to the frequency of all-cause mortality or disabling stroke, of TAVR to surgery, as determined in the interim Bayesian analysis. Follow-up will extend out to 10 years.

Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass Grafting: Comparative Effectiveness Analysis With Long-Term Follow-up.

Background Hybrid coronary revascularization (HCR) involves the integration of coronary artery bypass grafting (CABG) and percutaneous coronary intervention to treat multivessel coronary artery disease. Our objective was to perform a comparative analysis with long-term follow-up between HCR and conventional off-pump CABG. Methods and Results We compared all double off-pump CABG (n=216) and HCR (n=147; robotic-assisted minimally invasive direct CABG of the left internal thoracic artery to the left anterior descending artery and percutaneous coronary intervention to one of the non-left anterior descending vessels) performed at a single institution between March 2004 and November 2015. To adjust for the selection bias of receiving either off-pump CABG or HCR, we performed a propensity score analysis using inverse-probability weighting. Both groups had similar results in terms of re-exploration for bleeding, perioperative myocardial infarction, stroke, blood transfusion, in-hospital mortality, and intensive care unit length of stay. HCR was associated with a higher in-hospital reintervention rate (CABG 0% versus HCR 3.4%; P=0.03), lower prolonged mechanical ventilation (>24 hours) rate (4% versus 0.7%; P=0.02), and shorter hospital length of stay (8.1±5.8  versus 4.5±2.1 days; P<0.001). After a median follow-up of 81 (48-113) months for the off-pump CABG and 96 (53-115) months for HCR, the HCR group of patients had a trend toward improved survival (85% versus 96%; P=0.054). Freedom from any form of revascularization was similar between the 2 groups (92% versus 91%; P=0.80). Freedom from angina was better in the HCR group (73% versus 90%; P<0.001). Conclusions HCR seems to provide, in selected patients, a shorter postoperative recovery, with similar excellent short- and long-term outcomes when compared with standard off-pump CABG.

Emergent Percutaneous Rotational Atherectomy to Bailout Surgical Transapical Aortic Valve Implantation: A Successful Case of Heart Team Turnaround.

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. Percutaneous coronary intervention in patients with TAVI can be challenging. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent rotational atherectomy.

Emergent Percutaneous Rotational Atherectomy to Bailout Surgical Transapical Aortic Valve Implantation: A Successful Case of Heart Team Turnaround / Aterectomia Rotacional Percutânea Emergencial para Dar Suporte ao Implante Cirúrgico Transapical da Válvula Aórtica: Um Caso Bem Sucedido de Reviravolta da Equipe Cardíaca

Abstract Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. Percutaneous coronary intervention in patients with TAVI can be challenging. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent rotational atherectomy.

Resumo O implante valvar aórtico transcateter (TAVI) é um tratamento estabelecido para estenose aórtica grave (EA) em pacientes com risco cirúrgico elevado. Doença arterial coronariana concomitante afeta 55-70% dos pacientes com EA grave. A intervenção coronária percutânea em pacientes com TAVI pode ser um desafio. Relatamos um caso de obstrução coronariana aguda imediatamente após o implante de TAVI transapical, exigindo aterectomia rotacional emergencial.

Cubic-Spline Interpolation for Sparse-View CT Image Reconstruction With Filtered Backprojection in Dynamic Myocardial Perfusion Imaging.

We investigated a projection interpolation method for reconstructing dynamic contrast-enhanced (DCE) heart images from undersampled x-ray projections with filtered backprojecton (FBP). This method may facilitate the application of sparse-view dynamic acquisition for ultralow-dose quantitative computed tomography (CT) myocardial perfusion (MP) imaging. We conducted CT perfusion studies on 5 pigs with a standard full-view acquisition protocol (984 projections). We reconstructed DCE heart images with FBP from all and a quarter of the measured projections evenly distributed over 360°. We interpolated the sparse-view (quarter) projections to a full-view setting using a cubic-spline interpolation method before applying FBP to reconstruct the DCE heart images (synthesized full-view). To generate MP maps, we used 3 sets of DCE heart images, and compared mean MP values and biases among the 3 protocols. Compared with synthesized full-view DCE images, sparse-view DCE images were more affected by streak artifacts arising from projection undersampling. Relative to the full-view protocol, mean bias in MP measurement associated with the sparse-view protocol was 10.0 mL/min/100 g (95%CI: -8.9 to 28.9), which was >3 times higher than that associated with the synthesized full-view protocol (3.3 mL/min/100 g, 95% CI: -6.7 to 13.2). The cubic-spline-view interpolation method improved MP measurement from DCE heart images reconstructed from only a quarter of the full projection set. This method can be used with the industry-standard FBP algorithm to reconstruct DCE images of the heart, and it can reduce the radiation dose of a whole-heart quantitative CT MP study to <2 mSv (at 8-cm coverage).

Hybrid Coronary Artery Revascularization: A Review and Current Evidence.

OBJECTIVE: The role of hybrid coronary revascularization (HCR), which utilizes the combination of minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery and percutaneous coronary intervention (PCI) of non-left anterior descending vessels to treat multivessel coronary artery disease, is expanding. We set out to provide a review of this technology. METHODS: We conducted a retrospective analysis of all minimally invasive hybrid operations performed at our institution from September 2004 to December 2018. An effective analysis comparing patients undergoing HCR vs off-pump or on-pump surgical coronary artery revascularization was undertaken using an adjusted analysis with inverse-probability weighting based on the propensity score. Outcomes that were assessed include death, myocardial infarction, stroke, atrial fibrillation, renal failure, requirement of blood transfusion, conversion to open procedure (in the hybrid group), length of stay in intensive care unit, and total length of stay in hospital. Intention-to-treat analysis was performed. An up-to-date literature review of HCR complements this study. RESULTS: Since 2004 a total of 191 consecutive patients (61.4±11.1 years; 142 males and 49 females) underwent HCR (robotic-assisted coronary artery bypass graft of the left internal thoracic artery to the left anterior descending coronary artery (LAD) and PCI of a non-LAD vessel) in a single- or double-stage fashion. Successful HCR occurred in 183 of the 191 patients (8 patients required intraoperative conversion to conventional coronary bypass). From our comparative analysis and literature review we found no significant difference between HCR and coronary artery bypass grafting groups with respect to in-hospital and 1-year follow-up. CONCLUSIONS: Current evidences suggest that HCR is a feasible, safe, and effective coronary artery revascularization strategy in selected patients with multivessel coronary artery disease.

Reason and Timing for Conversion to Sternotomy in Robotic-Assisted Coronary Artery Bypass Grafting and Patient Outcomes.

OBJECTIVE: Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients. METHODS: Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart. RESULTS: The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0-20) and the median hospital length of stay was 5 days (range = 3-43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death. CONCLUSIONS: The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.

Is There a Role for Diagonal Coronary Artery Stenting in Patients Undergoing Robotic Coronary Artery Bypass Graft Surgery?

BACKGROUND: The efficacy of diagonal coronary artery stenting in patients undergoing robotic left internal thoracic artery-to-left anterior descending (LITA-to-LAD) anastomosis is not well defined. The objective of this study was to assess graft and stent patency in a single-stage hybrid revascularization with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery. METHODS: From 2004 to 2014, a total of 25 patients consented to robotic-assisted LITA harvesting and a small left anterior thoracotomy for off-pump coronary artery bypass anastomosis onto the LAD along with concomitant PCI to the diagonal coronary artery. PCI to the diagonal coronary artery was performed in the same fluoroscopy-equipped hybrid operating room. RESULTS: Patients were on average 66 ± 11 years with 32% female. Pre-operative characteristics of these patients included 8% with a grade 3 or 4 left ventricle, 16% with a recent MI, and 92% with CCS III/IV symptoms. There were no death, one patient required an intra-aortic balloon pump, and one patient required re-operation for bleeding. The average ICU stay was 1.1 ± 0.53 days, and the average hospital stay was 4.6 ± 2.4 days. Fitzgibbon Grade A LITA-to-LAD patency at 6-month follow-up was 100%. As well, at 6-month follow-up the DES to the diagonal coronary artery had a patency rate of 96%. CONCLUSIONS: Single-stage hybrid revascularization strategy for bifurcating lesions of the LAD and diagonal coronary arteries with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery appears to have acceptable clinical results with excellent 6-month angiographic patency results.

Impact of Obesity on Noninvasive Cardiac Hemodynamic Measurement by Electrical Cardiometry in Adults With Aortic Stenosis.

OBJECTIVES: There are substantial potential benefits to noninvasive cardiac monitoring methods, such as electrical cardiometry (EC), over more invasive methods, including significantly reduced risk of complications, lower up-front and operational costs, ease of use, and continuous monitoring. To take advantage of these technologies, clinical equivalence to currently established methods must be determined. The authors sought to determine if the noninvasive measurement of cardiac index (CI) by EC was clinically equivalent to thermodilution (TD) in adult patients with aortic stenosis (AS). DESIGN: This is a cross-sectional study comparing measurement devices in a single patient group. SETTING: Single-center, university teaching hospital. PARTICIPANTS: The study included 52 adult patients with aortic stenosis undergoing right heart catheterization. INTERVENTIONS: Cardiac output (CO) was measured concurrently using EC with an ICON device and TD in 52 participants with AS. CI values were to determine the accuracy and precision of EC in reference to TD. Percentage error (PE) was used to assess their clinical equivalence. The participants were divided further into groups (normal and overweight/obese) based on body mass index and the analysis was repeated. MEASUREMENTS AND MAIN RESULTS: CO measurement made by EC in adult patients with obesity or overweight was reduced significantly relative to TD. This was not observed in normal-weight adult AS patients. EC provided clinically equivalent measurements to TD for measuring CI in normal-weight adult AS patients (PE = 25.0%), but not for those adult AS patients with overweight or obesity (PE = 42.3%). CONCLUSION: Overall, the ICON device produced lower CO and index measurements relative to TD in adult patients with AS. Overweight and obesity also significantly affected the relative precision and accuracy of the ICON electrical cardiometric device to measure CI in these patients.

Functional CT assessment of extravascular contrast distribution volume and myocardial perfusion in acute myocardial infarction.

PURPOSE: In a pig model of acute myocardial infarction (AMI), we validated a functional computed tomography (CT) technique for concomitant assessment of myocardial edema and ischemia through extravscualar contrast distribution volume (ECDV) and myocardial perfusion (MP) measurements from a single dynamic imaging session using a single contrast bolus injection. METHODS: In seven pigs, balloon catheter was used to occlude the distal left anterior descending artery for one hour followed by reperfusion. CT and cardiac magnetic resonance (CMR) imaging studies were acquired on 3 days and 12 ±â€¯3 day post ischemic insult. In each CT study, 0.7 ml/kg of iodinated contrast was intravenously injected at 3-4 ml/s before dynamic contrast-enhanced (DCE) cardiac images were acquired with breath-hold using a 64-row CT scanner. DCE cardiac images were analyzed with a model-based deconvolution to generate ECDV and MP maps. ECDV as an imaging marker of edema was validated against CMR T2 weighted imaging in normal and infarcted myocardium delineated from ex-vivo histological staining. RESULTS: ECDV in infarcted myocardium was significantly higher (p < 0.05) than that in normal myocardium on both days post AMI and was in agreement with the findings of CMR T2 weighted imaging. MP was significantly lower (p < 0.05) in the infarcted region compared to normal on both days post AMI. CONCLUSION: This imaging technique can rapidly and simultaneously assess myocardial edema and ischemia through ECDV and MP measurements, and may be useful for delineation of salvageable tissue within at-risk myocardium to guide reperfusion therapy.

Hybrid Coronary Revascularization Versus On-Pump Coronary Artery Bypass Grafting.

BACKGROUND: Hybrid coronary revascularization (HCR) is an evolving coronary revascularization strategy for the treatment of multivessel coronary artery disease. We provide a comparative analysis to conventional on-pump coronary artery bypass graft surgery (CABG) with long-term follow-up. METHODS: We included all double on-pump CABG (n = 682) and HCR (147 robotic-assisted minimally invasive bypass grafts of the left internal thoracic artery to the left anterior descending coronary artery and percutaneous coronary intervention to one of the non-left anterior descending coronary artery vessels) performed in our institution between March 2004 and November 2015. We performed an adjusted analysis using inverse-probability weighting based on the propensity score of receiving either on-pump CABG or HCR. RESULTS: In the adjusted analysis, there was no statistically significant difference in the incidence of reexploration for bleeding, perioperative myocardial infarction, stroke, need for hemodialysis, blood transfusion rate, prolonged mechanical ventilation, and intensive care unit length of stay. Hybrid coronary revascularization was associated with lower inhospital mortality (CABG 1.3%, HCR 0%, p = 0.008), and shorter mean (± SD) hospital length of stay (CABG 6.7 ± 4.7 days, HCR 4.5 ± 2.1 days, p < 0.001). After a median follow-up period of 70 months (range, 37 to 106) for the CABG group and 96 months (range, 53 to 114) for the HCR group, there was no significant difference in survival (CABG 92%, HCR 97%, p = 0.13) or freedom from any form of revascularization (CABG 93%, HCR 91%, p = 0.27). Hybrid coronary revascularization was superior in freedom from angina (CABG 70%, HCR 91%, p < 0.001). CONCLUSIONS: For selected patients, HCR is associated with a faster postoperative recovery as well as similar short-term and long-term outcomes when compared with standard on-pump CABG.

Ultra-low dose quantitative CT myocardial perfusion imaging with sparse-view dynamic acquisition and image reconstruction: A feasibility study.

PURPOSE: We implemented and validated a compressed sensing (CS) based algorithm for reconstructing dynamic contrast-enhanced (DCE) CT images of the heart from sparsely sampled X-ray projections. METHODS: DCE CT imaging of the heart was performed on five normal and ischemic pigs after contrast injection. DCE images were reconstructed with filtered backprojection (FBP) and CS from all projections (984-view) and 1/3 of all projections (328-view), and with CS from 1/4 of all projections (246-view). Myocardial perfusion (MP) measurements with each protocol were compared to those with the reference 984-view FBP protocol. RESULTS: Both the 984-view CS and 328-view CS protocols were in good agreements with the reference protocol. The Pearson correlation coefficients of 984-view CS and 328-view CS determined from linear regression analyses were 0.98 and 0.99 respectively. The corresponding mean biases of MP measurement determined from Bland-Altman analyses were 2.7 and 1.2ml/min/100g. When only 328 projections were used for image reconstruction, CS was more accurate than FBP for MP measurement with respect to 984-view FBP. However, CS failed to generate MP maps comparable to those with 984-view FBP when only 246 projections were used for image reconstruction. CONCLUSION: DCE heart images reconstructed from one-third of a full projection set with CS were minimally affected by aliasing artifacts, leading to accurate MP measurements with the effective dose reduced to just 33% of conventional full-view FBP method. The proposed CS sparse-view image reconstruction method could facilitate the implementation of sparse-view dynamic acquisition for ultra-low dose CT MP imaging.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization.

OBJECTIVE: Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. METHODS: In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. RESULTS: Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. CONCLUSIONS: In patients undergoing robotic-assisted CABG, ultrafast-track cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

OBJECTIVE: Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. METHODS: From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ± 41.4 months. RESULTS: Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. CONCLUSIONS: Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.