Characteristics and Outcomes of Patients With History of CABG Undergoing Cardiac Catheterization Via the Radial Versus Femoral Approach.

OBJECTIVES: The aims of this study were to examine rates of radial artery access in post-coronary artery bypass grafting (CABG) patients undergoing diagnostic catherization and/or percutaneous coronary intervention (PCI), whether operators with higher procedural volumes and higher percentage radial use were more likely to perform diagnostic catherization and/or PCI via the radial approach in post-CABG patients, and clinical and procedural outcomes in post-CABG patients who undergo diagnostic catherization and/or PCI via the radial or femoral approach. BACKGROUND: There are limited data comparing outcomes of patients with prior CABG undergoing transradial or transfemoral diagnostic catheterization and/or PCI. METHODS: Using the National Cardiovascular Data Registry CathPCI Registry, all diagnostic catheterizations and PCIs performed in patients with prior CABG from July 1, 2009, to March 31, 2018 (n = 1,279,058, 1,173 sites) were evaluated. Temporal trends in transradial access were examined, and mortality, bleeding, vascular complications, and procedural metrics were compared between transradial and transfemoral access. RESULTS: The rate of transradial access increased from 1.4% to 18.7% over the study period. Transradial access was associated with decreased mortality (adjusted odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.75 to 0.91), decreased bleeding (OR: 0.57; 95% CI: 0.51 to 0.63), decreased vascular complications (OR: 0.38; 95% CI: 0.30 to 0.47), increased PCI procedural success (OR: 1.11; 95% CI: 1.06 to 1.16; p < 0.0001), and significantly decreased contrast volume across all procedure types. Transradial access was associated with shorter fluoroscopy time for PCI-only procedures but longer fluoroscopy time for diagnostic procedures plus ad hoc PCI and diagnostic procedures only. Operators with a higher rate of transradial access in non-CABG patients were more likely to perform transradial access in patients with prior CABG. CONCLUSIONS: The rate of transradial artery access in patients with prior CABG undergoing diagnostic catheterization and/or PCI has increased over the past decade in the United States, and it was more often performed by operators using a transradial approach in non-CABG patients. Compared with transfemoral access, transradial access was associated with improved clinical outcomes in patients with prior CABG.

Association between distance from the radiation source and radiation exposure: A phantom-based study.

OBJECTIVES: The study evaluated the association between distance from radiation source and radiation exposure. BACKGROUND: Radiation exposure during medical procedures is associated with increased risk of cancer and other adverse effects. METHODS: An American National Standards Institute phantom was used to study the relationship between measured entrance surface exposure (MESE) and distance from the X-ray source in postero-anterior, left anterior oblique, and right anterior oblique projections. Three distance settings for table height were evaluated with "low" defined as 52 cm, "mid" 66 cm, and "high" 80 cm from the focal point of the X-ray source. Air-kerma and dose-area product measurements were recorded. Operator exposure with each of these conditions was measured, in a short operator (150 cm) as well as in a tall operator (190 cm). RESULTS: Aggregate results for the three projections were as follows. MESE (µGy/frame) significantly decreased as table-height increases (median, interquartile range, p-value) (low table-height 192.5 [122.4-201.2], mid table-height 105.8 [82.7-115.8], and high table-height 71.7 [58.4-75], p < .0005). The operator exposure (µGy/frame), significantly increased as the table-height increased (low table-height 0.0943 [0.0598-0.1157], medium table-height 0.1128 [0.0919-0.1397], and high table-height 0.158 [0.1339-0.2165], p < .0005). A shorter operator received higher radiation exposure compared to a taller operator (short operator 0.1405 [0.1155-0.1758] and tall operator 0.0995 [0.0798-0.1212], p < .0005). CONCLUSIONS: Increasing table-height is associated with a significant decrease in MESE. Operator radiation exposure increases with increasing table-height and shorter operators receive greater radiation exposure compared to taller operators.

Angiographic severity does not correlate with fractional flow reserve in heavily calcified coronary arteries.

OBJECTIVES: To determine the relationship between severity of stenosis and hemodynamic significance in calcified coronary arteries. BACKGROUND: Severity of stenosis is widely used to determine the need for revascularization but the effect of lesion calcification on hemodynamic significance is not well understood. METHODS: Two hundred consecutive patients undergoing fractional flow reserve (FFR) testing of an intermediate coronary lesion with a pressure wire and intravenous infusion of adenosine were studied. Coronary calcium was quantified based upon radiopacities at the site of the stenosis on cineangiography using the method of Mintz et al. (0 = none or mild calcium, 1 = moderate calcium, 2 = severe calcium). RESULTS: Mean age was 61 ± 11 years, 66% were males, 87.5% had hypertension, 44.5% had diabetes, and 20.5% were current smokers. The mean coronary stenosis by quantitative coronary angiography was 60 ± 12% and the mean FFR was 0.83 ± 0.08. There were 109, 45, and 46 patients classified as Calcium Score of 0, 1, or 2, respectively. Compared to those with no/mild or moderate calcification, patients with severe coronary calcium were older and more likely to have chronic kidney disease and pulmonary disease. The correlation between angiographic severity and FFR decreased as lesion calcification increased [calcium score = 0 (R2 = 0.25, P < 0.005); calcium score = 1 (R2 = 0.11, P < 0.005); calcium score = 2 (R2 = 0.02, P = 0.35)]. CONCLUSIONS: In patients with heavily calcified coronary lesions, there was no association between angiographic stenosis and hemodynamic significance and FFR is needed to determine hemodynamic significance of intermediate lesions. © 2016 Wiley Periodicals, Inc.

Prospective Assessment of the Diagnostic Accuracy of Instantaneous Wave-Free Ratio to Assess Coronary Stenosis Relevance: Results of ADVISE II International, Multicenter Study (ADenosine Vasodilator Independent Stenosis Evaluation II).

OBJECTIVES: The purpose of this study was to assess the diagnostic accuracy of the instantaneous wave-free ratio (iFR) to characterize, outside of a pre-specified range of values, stenosis severity, as defined by fractional flow reserve (FFR) ≤0.80, in a prospective, independent, controlled, core laboratory-based environment. BACKGROUND: Studies with methodological heterogeneity have reported some discrepancies in the classification agreement between iFR and FFR. The ADVISE II (ADenosine Vasodilator Independent Stenosis Evaluation II) study was designed to overcome limitations of previous iFR versus FFR comparisons. METHODS: A total of 919 intermediate coronary stenoses were investigated during baseline and hyperemia. From these, 690 pressure recordings (n = 598 patients) met core laboratory physiology criteria and are included in this report. RESULTS: The pre-specified iFR cut-off of 0.89 was optimal for the study and correctly classified 82.5% of the stenoses, with a sensitivity of 73.0% and specificity of 87.8% (C statistic: 0.90 [95% confidence interval (CI): 0.88 to 0.92, p < 0.001]). The proportion of stenoses properly classified by iFR outside of the pre-specified treatment (≤0.85) and deferral (≥0.94) values was 91.6% (95% CI: 88.8% to 93.9%). When combined with FFR use within these cut-offs, the percent of stenoses properly classified by such a pre-specified hybrid iFR-FFR approach was 94.2% (95% CI: 92.2% to 95.8%). The hybrid iFR-FFR approach obviated vasodilators from 65.1% (95% CI: 61.1% to 68.9%) of patients and 69.1% (95% CI: 65.5% to 72.6%) of stenoses. CONCLUSIONS: The ADVISE II study supports, on the basis rigorous methodology, the diagnostic value of iFR in establishing the functional significance of coronary stenoses, and highlights its complementariness with FFR when used in a hybrid iFR-FFR approach. (ADenosine Vasodilator Independent Stenosis Evaluation II-ADVISE II; NCT01740895).

Conversations in cardiology: bridging antiplatelet therapy before surgery.

Bridging for antiplatelet therapy remains a subject of debate with data favoring GP blockers but at a risk of bleeding. This Conversation in Cardiology addresses a key and often asked question about use of alternatives to P2Y12 agents in patients requiring surgery within 6 months after drug eluting stent implantation.

Successful aspiration of Mynx vascular closure device sealant that embolized to the popliteal artery.

The Mynx (AccessClosure, Inc) is a vascular closure device that uses extravascular deployment of a self-expanding polyethylene glycol (PEG) sealant delivered during removal of the procedural sheath. An intravascular balloon is inflated at the arteriotomy site to prevent leakage of the sealant into the bloodstream. The complication rate with the Mynx vascular closure device is low, but there have been reports of distal embolization of the sealant. Optimal treatment of this complication is unknown, with limited published data relating only to surgical extraction. This is the first reported case of successful percutaneous aspiration of embolized Mynx vascular sealant.

Impact of early surgery on survival of patients with severe mitral regurgitation.

BACKGROUND: Optimal timing of surgery in degenerative mitral regurgitation (MR) remains a controversial topic. The impact of current ACC/AHA guideline recommendations about optimal timing of surgery on outcomes is untested and contemporary data are lacking. OBJECTIVE: To assess the association between the timing of surgery and long-term survival in patients with severe MR. METHODS: A cohort of 481 patients with severe, degenerative mitral regurgitation (1995-2007) from the Duke Cardiovascular Disease Databank who fulfilled at least one ACC/AHA guideline indication for surgery was identified. Exclusion criteria were rheumatic disease, congenital mitral valve (MV) disease, hypertrophic cardiomyopathy, coronary disease in more than one vessel, endocarditis, other severe valve disease, h/o valve repair/replacement. Patients were grouped into early surgery (in ≤ 2 months of presenting with surgical indications) and late surgery (>2 months) groups. An adjusted Cox regression model was constructed for time to death after 2 months with a time-dependent covariate term for late surgery. RESULTS: 168 patients had early surgery (median time to surgery 0.42 months) with 153 followed up after 2 months, 94 had late surgery (median time to surgery 8.75 months) and 219 medically managed. 127/168 in the early surgery group and 84/94 in the late surgery group received MV repair (p=0.02). Over 5.6 years' (median) follow-up there were 35 deaths (21%) in the early surgery group, with two occurring before 2 months and 20 (21%) in the late group. In the multivariable model, those undergoing early surgery had a lower hazard for death than those who underwent late surgery (HR=0.54 (95% CI 0.30 to 0.97), p=0.039). MV repair was independently associated with survival (HR=0.45 (95% CI 0.25 to 0.83), p=0.01). CONCLUSIONS: In patients with severe MR who presented with guideline indications for surgery, those selected for earlier surgery had improved survival. These data support the current guidelines for early referral to surgery in patients with severe MR for enlarged left ventricular dimensions, reduced ejection fraction and symptoms rather than delaying surgery. Larger randomised trials are needed to definitively answer the question of optimal timing of surgery in patients with severe degenerative MR.

Ionizing radiation exposure to patients admitted with acute myocardial infarction in the United States.

BACKGROUND: Invasive and noninvasive cardiovascular imaging is beneficial in the care of patients admitted with acute myocardial infarction. Little is known about patients' cumulative radiation exposure. METHODS AND RESULTS: All patients admitted with an acute myocardial infarction to any of 49 University HealthSystem Consortium member hospitals from 2006 to 2009 were reviewed for inpatient procedures involving ionizing radiation that included chest radiograph, computed tomogram scans, radionuclide imaging, diagnostic cardiac catheterization, and percutaneous coronary intervention. The average cumulative effective radiation dose per patient was estimated on the basis of published typical effective radiation doses for imaging procedures. Patients (n=64 071) admitted for acute myocardial infarction had a median age of 64.9 years. A total of 276 651 procedures involving ionizing radiation were performed during the study period, a median of 4.3 procedures per patient per admission. The majority of patients had invasive catheterization (77%), followed by computed tomogram scans (52%), mostly body examinations. The median cumulative effective radiation dose delivered was 15.02 mSv per patient per acute myocardial infarction admission. Postprocedural bleeding was a significant predictor of radiation exposure (odds ratio, 2.01; 95% confidence interval, 1.85 to 2.18), together with postprocedural mechanical complications resulting from device implantation (odds ratio, 2.86; 95% confidence interval, 2.61 to 3.13). Patients with higher underlying clinical complexity (defined by severity of illness scores) had higher radiation exposure and higher mortality (P<0.0001). There was also significant geographic variation in radiation exposure; patients in New England received the lowest cumulative exposure (odds ratio, 0.78; 95% confidence interval, 0.74 to 0.81). CONCLUSIONS: Acute myocardial infarction inpatients are exposed to an approximate median radiation dose of 15 mSv. This exposure is a result of multiple cardiovascular and noncardiovascular procedures. Efforts should be made to understand the risks and benefits of radiation exposure per episode of care for acute myocardial infarction.

Rho GEF Lsc is required for normal polarization, migration, and adhesion of formyl-peptide-stimulated neutrophils.

Neutrophil migration requires continuous reorganization of the cytoskeleton and cellular adhesion apparatus. Chemoattractants initiate intracellular signals that direct this reorganization. The signaling pathways that link chemoattractant receptors to the cytoskeleton and cellular adhesion apparatus are now being defined. Formyl-peptide chemoattractants released from bacteria stimulate G-protein-linked receptors on the surface of neutrophils and regulate the neutrophil cytoskeleton and adhesion apparatus through RhoA-dependent pathways. Lsc is a RhoA guanine nucleotide exchange factor that binds the heterotrimeric G-protein alpha-subunits, Galpha12 and Galpha13. We have disrupted the Lsc gene and demonstrated that formyl-peptide-stimulated Lsc knock-out (KO) neutrophils are unable to generate and sustain a single-dominant pseudopod and migrate with increased speed and reduced directionality. Unexpectedly, we also found that Lsc is required for normal beta2- and beta1-integrin-dependent neutrophil adhesion. Lsc-deficient mice have a peripheral leukocytosis and extramedullary hematopoiesis, demonstrating that Lsc is required for leukocyte homeostasis. Lsc-deficient neutrophils are recruited normally to sites of bacterial peritonitis and chemical dermatitis, indicating that other signaling pathways compensate for the Lsc deficiency in some forms of inflammation. These results demonstrate that Lsc links formyl-peptide receptors to RhoA signaling pathways that regulate polarization, migration, and adhesion in neutrophils and that Lsc is required for leukocyte homeostasis.