Coronary artery disease management and cost implications with fractional flow reserve guided coronary intervention in Indian patients with stable ischemic coronary artery disease.

OBJECTIVES: To study the safety of stent avoidance, frequency of change in management decisions, and its cost implications while using a fractional flow reserve (FFR)-guided treatment strategy for intermediate-grade coronary artery stenosis. BACKGROUND: The impact of FFR in guiding management decisions and its cost implications has not been studied after imposition of a ceiling on stent prices by the Government of India. METHODS: In 400 patients with 477 intermediate-grade coronary lesions for whom coronary intervention was planned, functional assessment using FFR was done. Incidence of the primary composite endpoint (major adverse cardiac event [MACE], cardiac death, myocardial infarction, objective evidence of ischemia, and target vessel revascularization) in the stent avoided subset was compared with the stented group at follow-up. Micro-costing analysis was done using a computed model with current stent and FFR wire prices. RESULTS: The overall incidence of MACE was 4.9%, 0.9% in the stent-avoided subset and 6.9% in stented group (p = 0.04, comparing the latter two) at a median follow-up of 21 months (interquartile range 12-31 months). Serious adverse events occurred only in 1% of patients receiving adenosine. The average cost saving was Indian rupees (INR) 51,847 [United States Dollar (USD) 746] per patient, resulting in total savings of INR 15,813,379 (USD 227,530). Cost savings persisted but were lower by 36% (INR 18,613/USD 268 per patient) after the ceiling of stent prices. CONCLUSION: FFR-guided percutaneous coronary intervention (PCI) strategy is safe and cost-effective in countries where majority of patients self-finance their health care, resulting in stent and PCI avoidance in approximately one in three patients referred for coronary angioplasty.

Cardiac tumors in both twins - A case report of a rare occurrence.

Cardiac tumors in neonates and infancy are one among the many known congenital cardiac diseases. Although fetal cardiac tumors are rare, there is increased detection because of expertise in echocadiographic examination. Rhabdomyomas are the most common cardiac tumors among infants and children. Here, we describe twin neonates who had multiple cardiac tumors. This kind of presentation appears to be a very rare situation.

Type 3 Coronary Perforation on Optical Coherence Imaging.

OCT imaging revealed a 1.5 mm-long transmural breach in a segment of the artery devoid of calcium or eccentric plaque burden. Focal negative remodeling identified on OCT was deemed the reason for this otherwise unexplained cause of coronary rupture.

Radiation dose from percutaneous transluminal coronary angioplasty procedure performed using a flat detector for different clinical angiographic projections.

The radiation dose from complex cardiac procedures is of concern due to the lengthy fluoroscopic screening time and vessel complexities. This study intends to assess radiation dose based on angiographic projection and vessel complexities for clinical protocols used in the performance of percutaneous transluminal coronary angioplasty (PTCA). Dose-area product (DAP), reference air kerma (K a,r) and real-time monitoring of tube potentials and tube current for each angiographic projection and dose setting were evaluated for 66 patients who underwent PTCA using a flat detector system. The mean DAP and cumulative K a,r were 32.71 Gy cm2 (0.57 Gy), 51.24 Gy cm2 (0.9 Gy) and 102.03 Gy cm2 (1.77 Gy) for single-, double- and triple-vessel PTCA, respectively. Among commonly used angiographic projections, left anterior oblique 45°-caudal 35° reached 2 Gy in 55 min using a low-dose fluoroscopy setting and 21 min for a medium-dose setting. Use of a low-dose setting for fluoroscopic screening showed a radiation dose reduction of 39% compared with a medium-dose setting.

Radiation doses and estimated risk from angiographic projections during coronary angiography performed using novel flat detector.

Coronary angiography (CA) procedure uses various angiographic projections to elicit detailed information of the coronary arteries with some steep projections involving high radiation dose to patients. This study intends to evaluate radiation doses and estimated risk from angiographic projections during CA procedure performed using novel flat detector (FD) system with improved image processing and noise reduction techniques. Real-time monitoring of radiation doses using kerma-area product (KAP) meter was performed for 140 patients using Philips Clarity FD system. The CA procedure involved seven standard projections, of which five were extensively selected by interventionalists. Mean fluoroscopic time (FT), KAP, and reference air kerma (Ka,r) for CA procedure were 3.24 min (0.5-10.51), 13.99Gycm2 (4.02-37.6), and 231.43 mGy (73.8-622.15), respectively. Effective dose calculated using Monte Carlo-based PCXMC software was found to be 4.9mSv. Left anterior oblique (LAO) 45° projection contributed the highest radiation dose (28%) of the overall KAP. Radiation-induced risk was found to be higher in females compared to males with increased risk of lung cancer. An increase of 10%-15% in radiation dose was observed when one or more additional projections were adopted along with the seven standard projections. A 14% reduction of radiation dose was achieved from novel FD system when low-dose protocol during fluoroscopy and medium-dose protocol during cine acquisitions were adopted, compared to medium-dose protocol.