Clinical outcomes among cardiogenic shock patients supported with high-capacity Impella axial flow pumps: A report from the Cardiogenic Shock Working Group.

BACKGROUND: The Impella 5.0 and 5.5 pumps (Abiomed, Danvers, MA) are large-bore transvalvular micro-axial assist devices used in cardiogenic shock (CS) for patients requiring high-capacity flow. Despite their increasing use, real-world data regarding indications, rates of utilization and clinical outcomes with this therapy are limited. The objective of our study was to examine clinical profiles and outcomes of patients in a contemporary, real-world CS registry of patients who received an Impella 5.0/5.5 alone or in combination with other temporary mechanical circulatory support (tMCS) devices. METHODS: The CS Working Group (CSWG) Registry includes patients from 34 US hospitals. For this analysis, data from patients who received an Impella 5.0/5.5 between 2020-2023 were analyzed. Use of Impella 5.0/5.5 with or without additional tMCS therapies, duration of support, adverse events and outcomes at hospital discharge were studied. Adverse events including stroke, limb ischemia, bleeding and hemolysis were not standardized by the registry but reported per individual CSWG Primary Investigator discretion. For those who survived, rates of native heart recovery (NHR) or heart replacement therapy (HRT) including heart transplant (HT), or durable ventricular assist device (VAD) were recorded. We also assessed outcomes based on shock etiology (acute myocardial infarction or MI-CS vs. heart failure-related CS or HF-CS). RESULTS: Among 6,205 patients, 754 received an Impella 5.0/5.5 (12.1%), including 210 MI-CS (27.8%) and 484 HF-CS (64.1%) patients. Impella 5.0/5.5 was used as the sole tMCS device in 32% of patients, while 68% of patients received a combination of tMCS devices. Impella cannulation sites were available for 524/754 (69.4%) of patients, with 93.5% axillary configuration. Survival to hospital discharge for those supported with an Impella 5.0/5.5 was 67%, with 20.4% NHR and 45.5% HRT. Compared to HF-CS, patients with MI-CS supported on Impella 5.0/5.5 had higher in-hospital mortality (45.2% vs 26.2%, p < 0.001) and were less likely to receive HRT (22.4% vs 56.6%, p < 0.001. For patients receiving a combination of tMCS during hospitalization, this was associated with higher rates of limb ischemia (9% vs. 3%, p < 0.01), bleeding (52% vs 33%, p < 0.01), and mortality (38% vs 25%; p < 0.001) compared to Impella 5.0/5.5 alone. Among Impella 5.0/5.5 recipients, the median duration of pump support was 12.9 days (IQR: 6.8-22.9) and longer in patients bridged to HRT (14 days; IQR: 7.7-28.4). CONCLUSIONS: In this multi-center cohort of patients with CS, use of Impella 5.0/5.5 was associated with an overall survival of 67.1% and high rates of HRT. Lower adverse event rates were observed when Impella 5.0/5.5 was the sole support device used. Further study is required to determine whether a strategy of early Impella 5.0/5.5 use for CS improves survival. CONDENSED ABSTRACT: High capacity Impella heart pumps are capable of provide up to 5.5 liter/min of flow while upper body surgical placement allows for ambulation. Patients with advanced cardiogenic shock from acute myocardial infarction or heart failure requiring temporary mechanical circulatory support may benefit from upfront use of Impella 5.5 to improve overall survival, including native heart recovery or successful bridge to durable left ventricular assist device surgery or heart transplantation.

Angiographic Coronary Slow Flow Is Not a Valid Surrogate for Invasively Diagnosed Coronary Microvascular Dysfunction.

BACKGROUND: Ischemia with no obstructive coronary arteries is frequently caused by coronary microvascular dysfunction (CMD). Consensus diagnostic criteria for CMD include baseline angiographic slow flow by corrected TIMI (Thrombolysis In Myocardial Infarction) frame count (cTFC), but correlations between slow flow and CMD measured by invasive coronary function testing (CFT) are uncertain. OBJECTIVES: The aim of this study was to investigate relationships between cTFC and invasive CFT for CMD. METHODS: Adults with ischemia with no obstructive coronary arteries underwent invasive CFT with thermodilution-derived baseline coronary blood flow, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR). CMD was defined as abnormal CFR (<2.5) and/or abnormal IMR (≥25). cTFC was measured from baseline angiography; slow flow was defined as cTFC >25. Correlations between cTFC and baseline coronary flow and between CFR and IMR and associations between slow flow and invasive measures of CMD were evaluated, adjusted for covariates. All patients provided consent. RESULTS: Among 508 adults, 49% had coronary slow flow. Patients with slow flow were more likely to have abnormal IMR (36% vs 26%; P = 0.019) but less likely to have abnormal CFR (28% vs 42%; P = 0.001), with no difference in CMD (46% vs 51%). cTFC was weakly correlated with baseline coronary blood flow (r = -0.35; 95% CI: -0.42 to -0.27), CFR (r = 0.20; 95% CI: 0.12 to 0.28), and IMR (r = 0.16; 95% CI: 0.07-0.24). In multivariable models, slow flow was associated with lower odds of abnormal CFR (adjusted OR: 0.53; 95% CI: 0.35 to 0.80). CONCLUSIONS: Coronary slow flow was weakly associated with results of invasive CFT and should not be used as a surrogate for the invasive diagnosis of CMD.

The use of PK Papyrus covered coronary stent for carotid reconstruction: an initial institutional experience.

BACKGROUND: The use of covered stent grafts for the treatment of carotid rupture is increasingly being used given their ability to preserve the parent artery while simultaneously occluding the fistula or rupture point. METHODS: This case series describes the technical feasibility of using, and the performance of, the PK Papyrus covered coronary stent (Biotronik, Inc., Lake Oswego, Oregon, USA) in six patients with carotid rupture, including carotid cavernous fistulas, between July 2021 and October 2023 in a single-center institution in the USA. RESULTS: The median decade of life was 5 (IQR 3) with a 1:1 male-to-female ratio. The majority were black patients (n=5/6, 83.3%). The most common disease pathology was carotid cavernous fistula (n=4/6, 66.7%), followed by traumatic carotid rupture (n=2/6, 33.3%). All the stent embolization procedures were successfully treated with the PK Papyrus covered coronary stent. None of the patients had any recurrence or re-treatment. The number of stents required ranged from 1 to 3. A balloon guide catheter was used in 66.7% of cases (n=4/6). In-hospital mortality was 0.0% (n=0/6). No in-stent thrombosis was observed, but there was one case of cangrelor-associated hemorrhagic stroke conversion. Transfemoral access was used in all cases with one access site complication. Median follow-up time was 1.8 months (IQR 3.5). CONCLUSIONS: To our knowledge, this is the largest case series in the USA demonstrating the feasibility and safety of using the PK Papyrus covered coronary stent for the treatment of carotid rupture, including carotid cavernous fistulas.

Sternal-Sparing Surgical Options in Combined Aortic Valve and Coronary Artery Disease: Proof of Concept.

OBJECTIVE: The standard management of concomitant aortic valve (AV) and coronary artery disease has been coronary artery bypass and AV replacement (AVR). With the advent of minimally invasive options, many isolated lesions have been successfully managed using a sternal-sparing approach. In our institution, patients with isolated AV disease are offered minimally invasive surgical or transcatheter AVR, and those with isolated coronary artery disease are routinely managed with robotic totally endoscopic coronary artery bypass or percutaneous coronary intervention. Various combinations of these techniques can be used when a sternal-sparing posture is desired because of patient risk or preference. The aim of this study was to review the outcomes in patients with combined AV and coronary disease who were managed using sternal-sparing approaches. METHODS: We reviewed the records of 10 patients in our minimally invasive surgical database who presented with concomitant AV and coronary artery disease and underwent combined sternal-sparing management of these 2 lesions using various combinations of minimally invasive approaches. RESULTS: Four patients had totally endoscopic coronary artery bypass and minimally invasive AVR at the same time, 2 patients underwent transcatheter AVR followed by totally endoscopic coronary artery bypass, and 4 patients underwent minimally invasive AVR with percutaneous coronary intervention. There was no 30-day mortality. The duration of postoperative surgical hospital stay was 3.1 ± 0.9 days. CONCLUSIONS: Sternal-sparing approaches in combined AV and coronary artery disease are feasible with patient-specific treatment selection of minimally invasive techniques.

Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts.

INTRODUCTION: The left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts. METHODS: We retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group. RESULTS: Society of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent. CONCLUSIONS: Grafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.

Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI.

OBJECTIVE: Hybrid coronary revascularization (HCR) is the integration of sternal-sparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD). It is traditionally performed with single-vessel bypass (left internal mammary artery [LIMA] to left anterior descending artery [LAD]) and PCI but can also be accomplished with multiple arterial grafts using bilateral IMA conduits. We sought to review our HCR experience over an 8-year period with robotic totally endoscopic coronary artery bypass (TECAB) and PCI. METHODS: Of 694 patients undergoing beating-heart TECAB from August 2013 to June 2022, 306 patients were designated as intention-to-treat HCR candidates. Patients underwent PCI prior to, the same day as, or following TECAB, performed using single or bilateral IMA grafts. We retrospectively reviewed early and midterm outcomes up to 8 years in this cohort of patients. RESULTS: The mean Society of Thoracic Surgeons predicted risk of mortality was 1.5% ± 2.5%. There were 44 patients (14%) who had ≥70% left main disease and 218 patients (71%) who had triple-vessel disease. A total of 193 patients (63%) underwent multivessel grafting (advanced HCR), with 83% bilateral IMA use. Mean operative time was 263 ± 80 min, and mean length of stay was 2.6 days. The mean number of vessels bypassed per patient was 1.7 ± 0.6. The mean number of vessels stented was 1.2 ± 0.5. Of the patients, 84% underwent TECAB first, 14% PCI first, and 2% same-day TECAB/PCI. Mortality was 0.6% (observed to expected ratio: 0.42). Early graft patency was 97% (328 of 339 grafts); LIMA-LAD patency was 98%. At 8-year follow-up (mean 37 ± 26 months), all-cause and cardiac-related mortality were 13% and 2.6%, respectively. Freedom from major adverse cardiac and cerebrovascular events was 92%. CONCLUSIONS: In patients with multivessel CAD, integrating robotic single and multivessel TECAB with PCI resulted in excellent early and midterm outcomes. In experienced hands, the robotic endoscopic approach allows the routine use of multiple arterial grafting during HCR.

Creating patient-specific vein models to characterize wall shear stress in hemodialysis population.

End-Stage Renal Disease (ESRD) patients require arteriovenous fistulas (AVF) that allow a mature vein to withstand hemodialysis. Unfortunately, venous thrombosis and stenosis in the cephalic vein arch after AVF placement is common and heavily influenced by hemodynamics. To better assess forces and flow behavior in the cephalic arch, we have built patient-specific millifluidic models that allow us to explore the complex interplay between patient-specific vein geometry and fluctuating hemodynamics. These 3D models were created from patient-specific intravascular ultrasound and venogram images obtained three- and twelve-months post AVF creation and fabricated into soft elastomer-based millifluidic devices. Geometric validation of fabricated phantom millifluidic device shows successful replication of original computational 3D model. Millifluidic devices were perfused with a blood-mimicking fluid containing fluorescent tracer beads under steady-state physiologic cephalic vein flow conditions (20 mL/min). Particle image velocimetry was employed to calculate wall shear stress (WSS) across the cephalic arches. Experimental WSS profile evaluation reveals that the physiologic cephalic arch model yields WSS values within physiologic range [76-760 mPa]. Moreover, upon comparing WSS profiles across all models, it is noticeable that WSS values increase as vein diameter decreases, which further supports employed experimental and analysis strategy. The presented millifluidic devices show promise for experimental WSS characterization under pathologic flow conditions to contrast from calculated physiologic hemodynamics and better understand WSS influence on thrombosis and stenosis in hemodialysis patients.

Surgical Correction of Spontaneous Outflow Graft Twisting of HeartMate 3 LVAD via a Subcostal Approach.

We present two cases of successful surgical correction of a HeartMate 3 left ventricular assist device (LVAD) outflow graft twisting through a subcostal approach. These twistings were diagnosed with computed tomography or pull-back pressure measurement. Technically, a subcostal approach allowed us to access directly the twisted outflow graft and the device connector in a less invasive fashion as compared with a re-sternotomy. Diagnostic modality and surgical tips that address graft twisting are presented within the discussion of these two case studies. The institutional review board of our institution approved this study and waived the requirement for informed consent.

Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors.

OBJECTIVES: Robotic totally endoscopic coronary artery bypass (TECAB) on the beating heart has been facilitated in our experience using distal coronary anastomotic connectors. In this study, we retrospectively reviewed graft patency in all robotic TECAB patients who underwent formal angiography at our current institution over a 5-year period. METHODS: Between July 2013 and June 2018, 361 consecutive patients underwent robotic beating-heart TECAB. Of these patients, 121 had a follow-up angiogram, which assessed graft patency. Eighty-four patients had an angiogram as part of planned hybrid procedures and 37 patients underwent an unplanned angiogram for clinical indications. Retrospective analysis of angiographic patency and clinical outcomes was performed. RESULTS: The mean Society of Thoracic Surgeons predicted risk of mortality was 1.8%. Single-vessel bypass was performed in 40 (33%) patients and multivessel grafting in 81 (67%). Average flow (ml/min) and pulsatility index in the grafts was 74.7 ± 39.1 and 1.42 ± 0.52, respectively. The number of grafts evaluated was 204 (130 left internal mammary artery and 74 right internal mammary artery grafts). The median time to angiography was 1.0 and 16.0 months and graft patency was 98% and 91% in the hybrid and non-hybrid groups, respectively. Overall graft patency was 95.6% (left internal mammary artery = 96%; right internal mammary artery = 93%). Left internal mammary artery to left anterior descending artery graft patency was 97%. Clinical follow-up was available for 316 (88%) patients at mean 22.5 ± 15.1 months. Freedom from major adverse cardiac events at 2 years was 92%. CONCLUSIONS: In this consecutive series of patients undergoing formal angiography after robotic single and multivessel TECAB, we found satisfactory graft patency and 2-year clinical outcomes. Longer-term follow-up is warranted.

An Unusual Case of Resistant Hypertension Secondary to Fibromuscular Dysplasia.

A 28-year-old woman with resistant hypertension was given a diagnosis of fibromuscular dysplasia with 100% occlusion of a right renal artery branch supplying an atrophied lower pole, collateralized by the right adrenal artery. Successful adrenal collateral coil embolization restored normotension, but hypertension recurred, necessitating right partial heminephrectomy with blood pressure normalization off medications. (Level of Difficulty: Intermediate.).

Residual SYNTAX Score After Advanced Hybrid Robotic Totally Endoscopic Coronary Revascularization.

BACKGROUND: Advanced hybrid coronary revascularization (AHCR) combines multivessel robotic beating-heart totally endoscopic coronary artery bypass with percutaneous coronary intervention. The aim of this study was to quantify the remaining coronary artery disease after AHCR using the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) study score. METHODS: From July 2013 to September 2017, patients who had postoperative angiography after AHCR were reviewed. The cohort was divided into two groups: group 1, complete or near-complete revascularization (residual SYNTAX score of 8 or less); and group 2, incomplete revascularization (residual SYNTAX score more than 8). RESULTS: Among 308 patients who underwent totally endoscopic coronary artery bypass, 57 patients received AHCR and 51 patients had postoperative angiograms that allowed calculations of residual SYNTAX score. Mean baseline and residual SYNTAX scores were 33.1 ± 11.0 and 4.6 ± 6.5 respectively. There were 44 patients (86%) in the complete or near-complete revascularization group, and of these, 16 patients (31%) achieved true complete revascularization (residual SYNTAX score = 0). Overall graft patency was 96.2%. There were no differences in preoperative characteristics or postoperative outcomes between the two groups. Two-year survival rate and freedom from major adverse cardiac events (death, myocardial infarction, and repeat revascularization) were significantly higher in the complete or near-complete revascularization group compared with the incomplete revascularization group. CONCLUSIONS: Advanced hybrid coronary revascularization at our institution was safely performed with excellent early outcomes, graft patency, and high achievement of complete or near-complete revascularization. Residual SYNTAX score might predict long-term ischemic events after hybrid coronary revascularization.

Monocyte and macrophage subtypes as paired cell biomarkers for coronary artery disease.

NEW FINDINGS: What is the central question of this study? Are circulating monocyte markers correlated with their derived macrophage polarization patterns and coronary artery disease severity? What is the main finding and its importance? There was an inverse relationship between circulating CD16+ monocytes (high) and M2 macrophages (low) that marked coronary disease severity, and the differences in polarization of macrophages were seen despite a week of cell culture ex vivo. This study highlights the importance, and potential prognostic implications, of circulating monocyte and descendant macrophage phenotypes in coronary artery disease. ABSTRACT: Monocytes and macrophages are central to atherosclerosis, but how they combine to mark progression of human coronary artery disease (CAD) is unclear. We tested whether patients' monocyte subtypes paired with their derived macrophage profiles were correlated with extent of CAD. Peripheral blood was collected from 40 patients undergoing cardiac catheterization, and patients were categorized as having no significant CAD, single vessel disease or multivessel disease according to the number of affected coronary arteries. Mononuclear cells were measured for the monocyte markers CD14 and CD16 by flow cytometry, and separate monocytes were cultured into macrophages over 7 days and measured for the polarization markers CD86 and CD206. At baseline, patients with a greater CAD burden were older, with higher rates of statin, ß-blocker and antiplatelet drug use, whereas other characteristics were similar across the spectrum of coronary disease. CD16+ (both intermediate and non-classical) monocytes were elevated in patients with single vessel and multivessel disease compared with those without significant CAD (P < 0.05), whereas regulatory M2 macrophages (CD206+ ) were decreased in patients with single vessel and multivessel disease (P < 0.001). An inverse relationship between paired CD16+ monocytes and M2 macrophages marked CAD severity. On multivariable linear regression, CAD severity was associated, along with age and traditional cardiovascular risk factors, with CD16+ monocytes (directly) and M2 macrophages (inversely). Circulating monocytes may influence downstream polarization of lesional macrophages, and these measures of monocyte and macrophage subtypes hold potential as biomarkers in CAD.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis.

PURPOSE OF REVIEW: This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials. RECENT FINDINGS: In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13-2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups. A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.

Percutaneous Coronary Intervention following Placement of Sutureless Aortic Bioprostheses.

Coronary artery disease is often present with aortic stenosis. Although transcatheter aortic valve replacement and minimally invasive surgery provide alternative sternal-sparing options for isolated aortic valve replacement, non-sternotomy treatment of combined coronary artery disease and aortic stenosis has not been well-defined. We report 3 patients who presented with severe aortic stenosis and obstructive coronary artery disease in whom minimally invasive aortic valve replacement using sutureless valve was performed, followed by transradial percutaneous coronary intervention of obstructive coronary lesion. This case series demonstrates a hybrid technique for the treatment of combined severe aortic stenosis and coronary artery disease, which has potential for adequately treating both conditions with minimal risk.

First report of a hybrid robotic beating-heart quadruple totally endoscopic coronary artery bypass: toward complete revascularization.

To the best of our knowledge, this is the first report describing robotic beating-heart quadruple all-arterial totally endoscopic coronary artery bypass combined with percutaneous coronary intervention attempting complete revascularization (residual SYNTAX score 0). A 66-year-old male with severe triple-vessel coronary artery disease underwent percutaneous coronary intervention for a sub-total occlusion of the right coronary artery as the initial component of a hybrid revascularization strategy. Subsequently, the left coronary system was revascularized via robotic beating-heart totally endoscopic coronary artery bypass with bilateral internal mammary artery grafts.

Hybrid coronary revascularization: Midterm outcomes of robotic multivessel bypass and percutaneous interventions.

OBJECTIVE: The purpose of this study was to investigate the outcomes of patients undergoing advanced hybrid coronary revascularization, defined as robotic beating-heart multivessel totally endoscopic coronary artery bypass combined with percutaneous coronary intervention. METHODS: This is a retrospective study. Among 308 consecutive patients who underwent totally endoscopic coronary artery bypass, 57 who underwent advanced hybrid coronary revascularization (mean age, 65.6 years) from July 2013 to September 2017 were included. Midterm survival and freedom from major adverse cardiac events, including death, myocardial infarction, and repeat revascularization, were analyzed. RESULTS: Multivessel totally endoscopic coronary artery bypass was successfully performed without conversion to thoracotomy. Bilateral internal thoracic artery grafting was used in 50 patients (87.7%). The mean operative time was 318.4 ± 51.0 minutes. The mean length of hospital stay was 3.0 ± 1.3 days. There was no 30-day mortality. Percutaneous coronary intervention was planned after totally endoscopic coronary artery bypass in 51 patients (89.4%). The target lesions were the right coronary artery only in 38 patients, the left circumflex artery only in 4 patients, and multiple lesions in 13 patients. Eventually, 2 patients did not receive percutaneous coronary intervention. Percutaneous coronary intervention attempt was unsuccessful in 8 lesions. Patency of the left/right internal thoracic artery was 95.2% (60/63) and 95.7% (45/47), respectively. Graft patency was 95.2% (40/42) in the left circumflex artery and 93.3% (14/15) in the diagonal branch. Three-year survival was 92.8%, and 3-year freedom from major adverse cardiac events was 80.2%. CONCLUSIONS: Advanced hybrid coronary revascularization is a safe and less-invasive approach with short hospital stay and good midterm outcomes.

Broken arrow: Successful retrieval of a dislodged coronary orbital atherectomy microtip.

A 68-year-old female with a history of coronary artery disease and prior bypass surgery presented for staged percutaneous coronary intervention (PCI) to a calcified and angulated ostial left circumflex (LCX) artery lesion after PCI of the anastomosis of the left internal mammary artery - to left anterior descending artery. Orbital atherectomy of the LCX was performed at a speed of 80,000 RPM with multiple passes, and was complicated by device microtip dislodgement and entrapment within the vessel. After advancing a "buddy" wire beyond the microtip, a tapered microcatheter was advanced over the ViperWire and into the edge of the broken microtip and torqued into the microtip with forward pressure using the 0.014 in ViperWire tip as a "backstop." The guidewire, microcatheter, and microtip were then successfully removed as a unit and the intervention with stent placement was completed over the "buddy" wire. Scanning electron microscopy of the shaft revealed evidence of cyclic fatigue, indicating that the fracture occurred while spinning. The fracture when performing atherectomy in a model coronary artery with a radius of approximately 6 mm. This represents a first case of microtip dislodgement and entrapment during the use of a coronary orbital atherctomy device.short.

Coronary microvascular dysfunction in patients with heart failure with preserved ejection fraction.

There are multiple proposed mechanisms for the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). We hypothesized that coronary microvascular dysfunction is common in these patients. In a prospective, observational study, patients undergoing cardiac catheterization with HFpEF [left ventricular (LV) ejection fraction ≥ 50% and with clinical HF] were compared with similar patients without HFpEF. Patients with ≥50% stenosis were excluded, and coronary flow reserve (CFR) and the index of microvascular resistance (IMR) were measured after adenosine administration using a guidewire, with CFR ≤ 2 and IMR ≥ 23 being abnormal. Baseline characteristics and CFR and IMR were compared in 30 HFpEF patients and 14 control subjects. Compared with control subjects, HFpEF patients were older (65.4 ± 9.6 vs. 55.1 ± 3.1 yr, P < 0.01), had higher numbers of comorbidities (4.4 ± 1.5 vs. 2.6 ± 1.9, P = 0.002), had higher median B-type natriuretic peptide [161 (interquartile range: 75-511) pg/dl vs. 37 (interquartile range: 18.5-111) pg/dl, P < 0.01], and had higher LV end-diastolic pressure (17.8 ± 4.2 vs. 8.4 ± 4.2, P < 0.01). HFpEF patients had lower CFR (2.55 ± 1.60 vs. 3.84 ± 1.89, P = 0.024) and higher IMR (26.7 ± 10.3 vs. 19.7 ± 9.7 units, P = 0.037) than control subjects. Most (71.4%) control subjects had normal coronary physiology, whereas 36.7% of HFpEF patients had both abnormal CFR and IMR and another 36.7% had either abnormal CFR or IMR. In conclusion, this is the first study that has reported invasively determined CFR and IMR in HFpEF patients. We demonstrated the presence of four distinct coronary physiology groups in HFpEF patients. Investigation into the potential mechanisms for these findings is needed. NEW & NOTEWORTHY In this prospective observational study of patients with heart failure with preserved ejection fraction (HFpEF), we found that patients with HFpEF had more abnormalities of coronary flow and resistance than asymptomatic control patients, indicating that coronary microvascular dysfunction may play a role in the HFpEF disease process.

Right Internal Mammary Artery Use in 140 Robotic Totally Endoscopic Coronary Bypass Cases: Toward Multiarterial Grafting.

OBJECTIVE: Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic totally endoscopic coronary bypass (TECAB) has allowed for routine harvesting and use of the right internal mammary artery (RIMA). We retrospectively reviewed the technical considerations and target choice in 140 cases of beating heart TECAB where a RIMA graft was used. METHODS: In 2008, we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with bilateral internal mammary artery. A robotic stabilizer was used not only to facilitate exposure of the coronary targets but also to aid the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice, and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts. RESULTS: From February 2008 to January 2015, a total of 404 patients underwent beating heart TECAB with anastomotic connectors, of which 194 (48%) were mulitvessel procedures. One hundred forty patients (35%) had a RIMA graft and constitute the patient population for this review. One hundred thirty-one RIMA grafts were harvested via left-sided ports and grafted to left coronary targets, and nine RIMA grafts were harvested via right-sided ports and grafted to the right coronary artery. Flow was greater than 25 mL/min (pulsatility index < 2) in 95% of grafts. Perioperative mortality was 0.7% and mean ± standard deviation length of hospital stay was 3.1 (1.5) days. The RIMA was used as an in situ graft in 124 cases (84%) and as a free T-graft in 24 cases (16%) cases. Right internal mammary artery graft use in all TECABS increased from 23% in the first 5 years to 53% in the last 2 years. CONCLUSIONS: Robotic TECAB allows the routine harvesting and use of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multiarterial grafting.