Side branch fractional flow reserve after provisional stenting of calcified bifurcation lesions: The ORBID-FFR study.

OBJECTIVES: We examined the incidence of side branch (SB) compromise after provisional stenting of calcified bifurcation lesions treated with rotational atherectomy (RA) or cutting balloon angioplasty (CBA) and the utility of optical coherence tomography (OCT) to detect functionally significant SB stenoses. BACKGROUND: The comparative impact of RA versus CBA on SB compromise and functional significance remains poorly characterized. METHODS: Seventy-one consecutive patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses were randomized to RA (n = 35) or CBA (n = 36). The primary endpoint was SB compromise defined as SB diameter stenosis ≥70%, SB dissection or thrombolysis in myocardial infarction flow grade < 3 after provisional stenting. Secondary endpoints included SB FFR in noncompromised SBs and its correlation with SB ostium area (SBOA) assessed by three-dimensional OCT. RESULTS: SB compromise after provisional stenting was observed in 7 (20.0%) lesions that underwent RA and in 9 (25.0%) lesions treated with CBA (p = .62). Mean SB FFR was 0.83 ± 0.08 and was similar between the study arms. Functionally significant SB stenosis (FFR ≤ 0.80) was detected in 17(30.9%) angiographically noncompromised SBs. SBOA after stenting was an independent predictor of FFR ≤ 0.80 (OR 0.002, 95% CI: 0.00-0.15, p = .002). The optimal cutoff value for SBOA to predict functionally significant SB stenosis was 0.76 mm2 (sensitivity 82%, specificity 89% and area under the curve 0.92, 95% CI: 0.84-0.99). CONCLUSIONS: The rates of SB compromise and functionally significant stenosis after provisional stenting of calcified bifurcation lesions were similar between two lesion preparation strategies. OCT SBOA can detect SB branches with FFR ≤ 0.80 with high sensitivity and specificity.

Predictors of side branch compromise in calcified bifurcation lesions treated with orbital atherectomy.

OBJECTIVES: The aim of the study was to identify the predictors of side branch (SB) compromise in severely calcified bifurcation lesions treated with orbital atherectomy (OA). BACKGROUND: SB compromise remains a major complication of bifurcation lesion percutaneous coronary intervention (PCI). Higher prevalence of lipid-rich plaques and spotty calcification by optical coherence tomography (OCT) and SB ostial stenosis by angiography have been previously suggested as predictors of SB occlusion after main vessel (MV) stenting. METHODS: Patients with chronic stable angina and severely calcified bifurcation lesions, in whom provisional stenting strategy was planned, were enrolled in the study. OA was used for lesion preparation in all cases. OCT imaging of the MV was performed before and after stenting. SB compromise was defined as a composite of SB occlusion (TIMI flow grade ≤ 2) and SB intervention after MV stenting. RESULTS: Thirty stable CAD patients with 30 severely calcified bifurcation lesions were included in the study. Twelve patients (40%) had a compromised SB after MV stenting. Compromised SB was characterized by a greater angiographic diameter stenosis (55.4 ± 8.1% vs. 35.0 ± 14.4%, P < 0.01) and a smaller minimal lumen diameters (0.79 ± 0.17 vs. 1.12 ± 0.30 mm, P = 0.002) before PCI compared to noncompromised SB. The prevalence of OCT lipid-rich plaques was low and did not differ between the groups (18 vs. 19%, P = 0.68). There was no difference in other OCT plaque characteristics including the presence of spotty calcification. CONCLUSION: The severity of SB ostial disease and not MV plaque morphology contributed to SB compromise in severely calcified bifurcation lesions.

Utility of the guideliner catheter for percutaneous coronary interventions in patients with prior transcatheter aortic valve replacement.

The safety and utility of GuideLiner catheters in complex percutaneous coronary interventions (PCI) has been well established. Patients with prior trans-catheter aortic valve replacement especially with CoreValve, who present for PCI, pose a unique set of challenges. Not only does the operator often encounter difficulty with selective engagement of coronary ostia through the struts of the CoreValve, but also the complex nature of the underlying CAD in this high-risk population. We present a case series to illustrate the use of GuideLiner catheter as an adjunctive tool for PCI in this patient population.

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.

Treatment strategies for coronary bifurcation lesions made easy in the current era by introduction of the BIFURCAID app.

Coronary bifurcation lesions account for 15-20% of all percutaneous coronary interventions. Percutaneous revascularization of these lesions is technically challenging and results in lower success rates than nonbifurcation lesions. There are unique procedural considerations and techniques that are employed in the percutaneous revascularization of these lesions. Our objective is to define the procedural complexities of treating coronary bifurcation lesions and describe the leading provisional and dedicated two stent techniques used to optimize procedural and clinical results, as described in the BIFURCAID app.

Procedural and one-year outcomes of patients treated with orbital and rotational atherectomy with mechanistic insights from optical coherence tomography.

AIMS: We sought to evaluate procedural complications and one-year clinical outcomes for patients who underwent percutaneous coronary intervention (PCI) with orbital (OA) and rotational atherectomy (RA). METHODS AND RESULTS: From a total of 13,467 patients who underwent PCI in our hospital between January 2013 and June 2016, 1,149 consecutive patients were treated with atherectomy for moderately-severely calcified lesions (184 with OA, 965 with RA). Procedural complications were similarly observed in the two groups except for higher dissection and perforation rates with OA. Major adverse cardiovascular events (MACE) were defined as the composite of death, myocardial infarction or target lesion revascularisation. Multivariable adjusted analysis showed that OA use was associated with comparable adjusted one-year MACE compared to RA use (hazard ratio 0.79 [95% confidence interval 0.54-1.17], p=0.25). There were no significant differences in individual MACE endpoints. Furthermore, we studied 67 patients with OCT images. OCT analysis showed comparable tissue modification with a trend towards higher stent expansion with OA vs. RA. CONCLUSIONS: OA use was associated with lower unadjusted but similar adjusted one-year MACE outcomes compared to RA with higher rates of dissection and device-induced perforation.

Developing a Mobile Application for Global Cardiovascular Education.

Technological revolution in the field of medical education is here, and it is time to embrace it. Adoption of on-the-go learning style, portability of smartphones, and expression of concepts with interactive illustrations and their global reach have made application (app)-based learning an effective medium. An educational mobile app, BIFURCAID, was developed to simplify and teach complex coronary bifurcation intervention. This app has been downloaded worldwide. The survey results revealed its widespread acceptance and success. The authors believe that educational apps can have a significant impact on shaping the future of cardiovascular education in the 21st century. This experience with developing and testing the app could work as a template for other medical educators.

Intravascular Brachytherapy for the Management of Repeated Multimetal-Layered Drug-Eluting Coronary Stent Restenosis.

BACKGROUND: Because of the widespread acceptance of percutaneous coronary intervention with drug-eluting stents as an effective treatment strategy for in-stent restenosis, it is common to encounter multimetal layer stent restenosis in the recent years. This study aimed to evaluate the clinical outcomes of such patients treated with intravascular brachytherapy (IVBT) in comparison with other percutaneous options. METHODS AND RESULTS: We enrolled patients who underwent percutaneous coronary intervention during the period between 2011 and 2015 for recurrent drug-eluting stents in-stent restenosis with at least 2 layers of stents at the lesion site. This analysis compared patients who underwent treatment with IVBT and those who did not (non-IVBT group). The primary end point measured was major adverse cardiac events defined as a composite of target lesion revascularization, myocardial infarction, and all-cause mortality at 12 months. Adjusted associations were measured using propensity score matching. A total of 328 percutaneous coronary intervention patients met the eligibility criteria, of which 197 patients received IVBT, and 131 patients underwent routine percutaneous intervention. The primary end point was significantly lower in patients undergoing IVBT (13.2% and 28.2%; P=0.01). A propensity score matching for risk factors of in-stent restenosis identified 182 patients. The advantages of IVBT with regard to 1-year major adverse cardiac events were confirmed in this matched cohort (13.2% and 30.8%; adjusted hazard ratio [95% CI]: 0.37 [0.18-0.73]; P<0.01). CONCLUSIONS: In this analysis, IVBT led to significantly lower major adverse cardiac events in patients with multilayered drug-eluting stents restenosis when compared with other percutaneous options at 1-year follow-up.

Prognostic Relation Between Severity of Diabetes Mellitus (On or Off Insulin) ± Chronic Kidney Disease with Cardiovascular Risk After Percutaneous Coronary Intervention.

The presence of either diabetes mellitus (DM) or chronic kidney disease (CKD) is associated with a worse prognosis after percutaneous coronary intervention (PCI). It is also known that outcomes in patients treated with insulin (insulin requiring type 2 diabetes mellitus [ITDM]) are worse than those who are not on insulin (non-insulin type 2 diabetes mellitus [NITDM]). We sought to compare long-term outcomes in patients who underwent PCI with varying severity of DM with and without CKD. We retrospectively studied 17,898 patients who underwent PCI from January 2009 to December 2014 in the Mount Sinai Cath Lab. Patients were categorized into groups by the presence or the absence of CKD and by the DM status (none, NITDM, or ITDM). In the absence of CKD, adjusted hazard ratios (95% confidence interval [CI]) for death or myocardial infarction associated with NITDM and ITDM were 1.65 (95% CI 1.02 to 2.67) and 3.78 (95% CI 2.23 to 6.40), respectively. Analogous risks in the presence of CKD were 3.34 (95% CI 1.99 to 5.61) and 6.26 (95% CI 3.84 to 10.2). This study shows that irrespective of renal status, the need for insulin in the setting of DM identifies a group with substantial risk of death or myocardial infarction at 1 year.

Real-World Bioresorbable Vascular Scaffold Experience Compared With Second-Generation Metallic Drug-Eluting Stents in Complex Coronary Lesions.

OBJECTIVES: The aim of the study was to compare the acute outcomes of Absorb bioresorbable vascular scaffolds (BVS) and second-generation drug-eluting stent (DES) implantation in routine clinical practice. There is a paucity of data regarding BVS use in a real-world patient population. METHODS: The study population comprised 40 consecutive patients who underwent percutaneous coronary intervention (PCI) with BVS implantation at a tertiary-care center in New York, New York between July and December of 2016. An optimal implantation technique including adequate lesion preparation, mandatory postdilation, and optical coherence tomography (OCT) imaging was used in all cases. De novo lesions treated with BVS were compared to lesions treated with DES matched by OCT calcium arc, scaffold/stent size, use of atherectomy device, and lesion postdilation. Acute lumen gain, minimal device area, malapposition, eccentricity, and symmetry index were assessed using OCT. RESULTS: We analyzed OCT images of 40 BVS cases and 40 matching DES cases from 35 and 40 patients, respectively. Compared to the DES group, the BVS group demonstrated similar acute lumen gain, minimal scaffold/stent area, eccentricity index, and symmetry index after PCI. There were fewer malapposed struts detected after BVS implantation; however, malapposition distance and length were not different between the groups. CONCLUSION: BVS implantation in a real-world patient population with optimal implantation technique resulted in similar stent expansion and better strut apposition compared to DES implantation.

Outcomes of Saphenous Vein Graft Intervention With and Without Embolic Protection Device: A Comprehensive Review and Meta-Analysis.

BACKGROUND: Current guidelines give a class I recommendation to use of embolic protection devices (EPD) for saphenous vein graft (SVG) intervention; however, studies have shown conflicting results. The objective of this meta-analysis is to compare all-cause mortality, major adverse cardiovascular events, myocardial infarction (MI), or target vessel revascularization in SVG intervention with and without EPD. METHODS AND RESULTS: Literature was searched through October 2016. Eight studies (n=52 893) comparing SVG intervention performed with EPD (n=11 506) and without EPD (n=41 387) were included. There was no significant difference in all-cause mortality (odds ratio [OR], 0.79; confidence interval [CI], 0.55-1.12; P=0.19), major adverse cardiovascular events (OR, 0.73, CI, 0.51-1.05; P=0.09), target vessel revascularization (OR, 1.0; CI, 0.95-1.05; P=0.94), periprocedural MI (OR, 1.12; CI, 0.65-1.90, P=0.69), and late MI (OR, 0.80; CI, 0.52-1.23; P=0.30) between the 2 groups. Sensitivity analysis excluding CathPCI Registry study showed no difference in periprocedural MI, late MI, and target vessel revascularization; however, it favored EPD use in all-cause mortality and major adverse cardiovascular events. Further sensitivity analysis including only observational studies revealed no difference in all-cause mortality, major adverse cardiovascular events, target vessel revascularization, and late MI. Additional analysis after excluding CathPCI Registry study revealed no difference in outcomes. CONCLUSIONS: This study including 52 893 patients suggests no apparent benefit in routine use of EPD during SVG intervention in the contemporary real-world practice. Further randomized clinical trials are needed in current era to evaluate long-term outcomes in routine use of EPD, and meanwhile, current guideline recommendations on EPD use should be revisited.

Intracoronary Imaging, Cholesterol Efflux, and Transcriptomics after Intensive Statin Treatment in Diabetes.

Residual atherothrombotic risk remains higher in patients with versus without diabetes mellitus (DM) despite statin therapy. The underlying mechanisms are unclear. This is a retrospective post-hoc analysis of the YELLOW II trial, comparing patients with and without DM (non-DM) who received rosuvastatin 40 mg for 8-12 weeks and underwent intracoronary multimodality imaging of an obstructive nonculprit lesion, before and after therapy. In addition, blood samples were drawn to assess cholesterol efflux capacity (CEC) and changes in gene expression in peripheral blood mononuclear cells (PBMC). There was a significant reduction in low density lipoprotein-cholesterol (LDL-C), an increase in CEC and beneficial changes in plaque morphology including increase in fibrous cap thickness and decrease in the prevalence of thin cap fibro-atheroma by optical coherence tomography in DM and non-DM patients. While differential gene expression analysis did not demonstrate differences in PBMC transcriptome between the two groups on the single-gene level, weighted gene coexpression network analysis revealed two modules of coexpressed genes associated with DM, Collagen Module and Platelet Module, related to collagen catabolism and platelet function respectively. Bayesian network analysis revealed key driver genes within these modules. These transcriptomic findings might provide potential mechanisms responsible for the higher cardiovascular risk in DM patients.

Obesity Cardiomyopathy: Pathophysiologic Factors and Nosologic Reevaluation.

Cardiovascular disease in populations with obesity is a major concern because of its epidemic proportion. Obesity leads to the development of cardiomyopathy directly via inflammatory mediators and indirectly by obesity-induced hypertension, diabetes and coronary artery diseases. The aim of this review article is to re-visit the available knowledge and the evidence on pathophysiologic mechanisms of obesity-related cardiomyopathy and to propose its placement into a specific category of myocardial disease.

Valvular performance and aortic regurgitation following transcatheter aortic valve replacement using Edwards valve versus CoreValve for severe aortic stenosis: A Meta-analysis.

OBJECTIVES: To compare incidence of aortic regurgitation (AR), paravalvular AR and valvular performance with Doppler hemodynamic parameters following transcatheter aortic valve replacement (TAVR) with Edwards valve (EV) versus CoreValve (CV). Currently, there are scarce data on post-TAVR echocardiographic outcomes comparing EV and CV. METHODS: PubMed and the Cochrane Center Register of Controlled Trials were searched through May 2015. Twenty studies (n=11,244) comparing TAVR procedure that used EV (n=6445) and CV (n=4799) were included. End points were post-TAVR moderate to severe AR and paravalvular AR, effective orifice area (EOA), mean trans-aortic pressure gradient (MPG), peak trans-aortic pressure gradient (PPG) and left ventricular ejection fraction (LVEF). The mean difference (MD) or relative risk (RR) with 95% confidence interval (CI) was computed and p<0.05 was considered as a level of significance. RESULTS: Moderate to severe AR and paravalvular AR were significantly lower in EV group (RR: 0.57, CI: 0.52-0.63, p<0.00001 and RR: 0.40, CI: 0.25-0.63, p<0.0001 respectively) compared to CV group. EOA and PPG were not significantly different between EV and CV groups. MPG was significantly lower among patients in CV group (MD: 1.08, CI: 0.05-2.10, p=0.04). LVEF was significantly higher in patients in EV group (MD: 2.26, CI: 0.77-3.74, p=0.03). CONCLUSIONS: This study showed CV is associated with higher incidence of post-TAVR moderate to severe paravalvular AR. Echocardiographic valvular performance measures (MPG, LVEF) showed minimal but significant difference, which may not be clinically significant.

Mortality and major adverse cardiovascular events after transcatheter aortic valve replacement using Edwards valve versus CoreValve: A meta-analysis.

OBJECTIVES: In patients with severe aortic stenosis who are at high risk for surgery, transcatheter aortic valve replacement (TAVR) has emerged as an alternative procedure using EV or CV. The objective of this meta-analysis is to compare 1-year mortality and major adverse cardiovascular and cerebrovascular events (MACCE) between Edwards valve (EV) and Medtronic CoreValve (CV). METHODS: PubMed and the Cochrane Center Register of Controlled Trials were searched through December 2014. Twenty seven studies (n=12,249) comparing TAVR procedure that used EV (n=5745) and CV (n=6504) were included. End points were procedural success rates, post-procedural mortality, myocardial infarction (MI), stroke, major bleeding, major vascular complications, incidence of new permanent pacemaker (PPM) placement and new left bundle branch block (LBBB). The odds ratio (OR) with 95% confidence interval (CI) was computed and p<0.05 was considered for significance. RESULTS: There were no significant differences between EV and CV for post-procedural in-hospital, 30-day and 1-year all-cause mortality rates (p=0.53, 0.33 and 0.94 respectively), cardiovascular mortality (p=0.61), stroke (p=0.54), major bleeding (p=0.25) and major vascular complications (p=0.27). MI was significantly lower with EV compared to CV (OR: 0.56, CI: 0.35-0.89, p=0.01). Placement of new PPM and new onset LBBB were significantly higher in CV compared to EV (OR: 3.35, CI: 2.96-3.79, p<0.00001 and OR: 6.55, CI: 4.76-9.03, p<0.00001 respectively). CONCLUSIONS: The results of our meta-analysis suggest that TAVR procedure using CV may be associated with a higher incidence of MI, new PPM placement, and new onset LBBB compared to EV. However, the type of valve placed does not affect mortality.

Aortic Dissection in a Healthy Male Athlete: A Unique Case with Comprehensive Literature Review.

A young otherwise healthy 27-year-old male who has been using anabolic steroids for a long time developed Type I aortic dissection associated with heavy weightlifting. The patient did not have a recent history of trauma to the chest, no history of hypertension, and no illicit drug use. He presented with severe chest pain radiating to back and syncopal event with exertion. Initial vitals were significant for blood pressure of 80/50 mmHg, pulse of 80 beats per minute, respirations of 24 per minute, and oxygen saturation of 92% on room air. Physical exam was significant for elevated jugular venous pressure, muffled heart sounds, and cold extremities with diminished pulses in upper and absent pulses in lower extremities. Bedside echocardiogram showed aortic root dilatation and cardiac tamponade. STAT computed tomography (CT) scan of chest revealed dissection of ascending aorta. Cardiothoracic surgery was consulted and patient underwent successful repair of ascending aorta. Hemodynamic stress of weightlifting can predispose to aortic dissection. Aortic dissection is a rare but often catastrophic condition if not diagnosed and managed acutely. Although rare, aortic dissection needs to be in the differential when a young weightlifter presents with chest pain as a delay in diagnosis may be fatal.

Fractional flow reserve using computed tomography for assessing coronary artery disease: a meta-analysis.

AIMS: Noninvasive fractional flow reserve (FFR) measurement with computed tomography (FFRCT) is a newly described method for assessing functional significance of coronary disease. The objective of this meta-analysis is to determine the diagnostic performance of FFRCT in the assessment of hemodynamically significant coronary artery stenosis. METHODS: PubMed and the Cochrane Center Register of Controlled Trials were searched from January 2000 through February 2015. Six original studies were found comparing FFRCT to invasive FFR in evaluating hemodynamic significance of coronary lesions (1354 vessels; 812 patients). Lesions were considered hemodynamically significant if invasive FFR was 0.80 or less. FFRCT used the same cutoff as invasive FFR to be considered as a positive test. Sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were calculated. RESULTS: One-third of the lesions (n = 443) were hemodynamically significant. The pooled per-vessel analysis showed that the sensitivity, specificity, negative and positive likelihood ratios, and diagnostic odds ratio of FFRCT to diagnose hemodynamically significant coronary disease were 0.84 [95% confidence interval (CI): 0.80-0.87], 0.76 (95% CI: 0.73-0.79), 0.22 (95% CI: 0.17-0.29), 3.48 (95% CI: 2.21-5.47), and 16.82 (95% CI: 8.20-34.49), respectively. CONCLUSION: The results of this meta-analysis demonstrate that FFRCT results correlate closely with invasive coronary angiography and FFR measurement. It is a feasible noninvasive method to assess hemodynamic significance of coronary lesions in patients with stable coronary artery disease.

Incidence of Renal Failure Requiring Hemodialysis Following Transcatheter Aortic Valve Replacement.

OBJECTIVE: Studies have shown that iodinated radiocontrast use is associated with acute renal failure especially in the presence of chronic kidney disease and multiple factors modulate this risk. The purpose of this meta-analysis is to compare the incidence of renal failure requiring hemodialysis between transfemoral (TF) and transapical (TA) transcatheter aortic valve replacement using the Edwards valve. METHODS: The PubMed database was searched from January 2000 through December 2014. A total of 10 studies (n = 2,459) comparing TF (n = 1,268) and TA (n = 1,191) TAVR procedures using the Edwards valve were included. Variables of interest were baseline logistic EuroSCORE, prevalence of diabetes mellitus, hypertension, peripheral arterial disease, chronic kidney disease and amount of contrast used. The primary endpoint was incidence of renal failure requiring hemodialysis. The odds ratio and 95% CI were computed and P < 0.05 was considered as the level of significance. RESULTS: The logistic EuroSCORE was significantly higher in TA compared to TF (P = 0.001) TAVR. The amount of contrast (mL) used was significantly higher in the TF group compared to the TA group (mean difference: 36.9, CI: 25.7-48.1, P < 0.001). The incidence of hemodialysis following the procedure was significantly higher in the TA group compared to TF group (odds ratio = 4.3, CI: 2.4-7.8, P < 0.00001). CONCLUSIONS: This meta-analysis suggests that despite the lower amount of contrast used in TA-TAVR, the incidence of renal failure requiring hemodialysis was higher with the Edwards valve. This suggests that the incidence of renal failure requiring hemodialysis after TAVR is associated with baseline comorbidities in the TA-TAVR group rather than the volume of contrast used.