RESUMEN
Physiologic assessment has become an essential tool to guide revascularization decisions due to the multiple limitations of angiographic and anatomic measures of physiologic significance. However, in certain cases the apparent physiologic measurement may not accurately reflect the severity of coronary disease compared with anatomical measurements. This article will review how anatomy trumps physiology in cases of acute coronary syndromes, left main disease, saphenous vein graft lesions, and myocardial bridging, and how to overcome the limitations of physiologic measurement in these clinical situations.
RESUMEN
PURPOSE OF REVIEW: Multivessel coronary artery disease, defined as significant stenosis in two or more major coronary arteries, is associated with high morbidity and mortality. The diagnosis and treatment of multivessel disease have evolved in the PCI era from solely a visual estimation of ischemic risk to a functional evaluation during angiography. This review summarizes the evidence and discusses the commonly used methods of multivessel coronary artery stenosis physiologic assessment. RECENT FINDINGS: While FFR remains the gold standard in coronary physiologic assessment, several pressure-wire-based non-hyperemic indices of functional stenosis have been developed and validated as well as wire-free angiographically derived quantitative flow ratio. Identifying and treating functionally significant coronary atherosclerotic lesions reduce symptoms and major adverse cardiovascular events. Coronary physiologic assessment in multivessel disease minimizes the observer bias in visual estimates of stenosis, changes clinical management, and improves patient outcomes.
Asunto(s)
Enfermedad de la Arteria Coronaria , Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Intervención Coronaria Percutánea , Constricción Patológica , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Reserva del Flujo Fraccional Miocárdico/fisiología , Humanos , Intervención Coronaria Percutánea/efectos adversos , Valor Predictivo de las PruebasRESUMEN
Outcomes of deferred PCI based on negative FFR are generally good. This study demonstrated deferred target lesion failure with FFR >0.80 in 7% and related it to coexistent risk factors, such as multivessel disease, diabetes, and SVG lesions. A negative FFR is only one variable on the continuum of ischemic risk, but in general provides an excellent prognostic tool.
Asunto(s)
Reserva del Flujo Fraccional Miocárdico , Intervención Coronaria Percutánea , Humanos , Revascularización Miocárdica , Intervención Coronaria Percutánea/efectos adversos , Pronóstico , Resultado del TratamientoRESUMEN
This study compared virtual (residual) post-PCI QFR and actual post-PCI QFR from pre- and post-stent angiograms in predicting post-PCI FFR. While there was no difference in mean values, compared with post-PCI FFR, the post-PCI QFR correlated better than residual QFR. As the CFD algorithms improve, post-PCI QFR can potentially serve as a quality control after PCI to reduce post-PCI angina and adverse outcomes.
Asunto(s)
Reserva del Flujo Fraccional Miocárdico , Intervención Coronaria Percutánea , Angiografía Coronaria , Humanos , Intervención Coronaria Percutánea/efectos adversos , Valor Predictivo de las Pruebas , Stents , Tomografía de Coherencia Óptica , Resultado del TratamientoRESUMEN
The axillary artery is a useful alternative access site for large-bore interventions as it is rarely atherosclerotic. This systematic review of percutaneous large-bore axillary artery access suggests that it is as safe and effective as open surgical access. The Society of Cardiovascular Angiography and Interventions (SCAI) Expert Consensus Statement will soon be convened to provide best practice recommendations on transaxillary access including technique, training, and safety.
Asunto(s)
Arteria Axilar , Axila , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/cirugía , Humanos , Resultado del TratamientoRESUMEN
The present article examines the right heart (RH) pressures of patients with submassive pulmonary embolism before and after catheter-directed thrombolysis (CDT). 40% of patients had a low cardiac output (CI ≤1.8 L/min/m2 ) despite normally preserved blood pressure. After thrombolysis, CI increased and pulmonary artery pressures decreased. Although routine RH pressure measurements may help in CDT management and possibly serve as a surrogate outcome measure, more comprehensive pulmonary embolism trials are needed to solidify the role of hemodynamics in this setting.
Asunto(s)
Embolia Pulmonar , Terapia Trombolítica , Catéteres , Hemodinámica , Humanos , Resultado del TratamientoRESUMEN
Angiographically visible collaterals are seen in a minority of STEMI patients, predominantly to the RCA and in patients with delays to reperfusion. Patients with visible collaterals were less likely to have cardiogenic shock and tended to have a longer survival. Further studies will determine the mechanisms of collateral formation and their protective associations.
Asunto(s)
Infarto del Miocardio con Elevación del ST , Circulación Colateral , Circulación Coronaria , Vasos Coronarios , Humanos , Pronóstico , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Resultado del TratamientoRESUMEN
Compressive pericardial physiology (i.e., cardiac tamponade) reduces ventricular chamber volume/filling and cardiac output, which exacerbates coexisting hemodynamic derangements. In this hemodynamic rounds, we demonstrate the interaction of two hemodynamic conditions in one patient with acute pericardial tamponade in the setting of aortic stenosis (AS). Simultaneous pressures across the aortic valve before and after relief of cardiac tamponade demonstrate an acute and uncommon improvement in the hemodynamics of AS.
Asunto(s)
Estenosis de la Válvula Aórtica/fisiopatología , Válvula Aórtica/fisiopatología , Taponamiento Cardíaco/fisiopatología , Hemodinámica , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Taponamiento Cardíaco/complicaciones , Taponamiento Cardíaco/diagnóstico por imagen , Taponamiento Cardíaco/terapia , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/fisiopatología , Masculino , Persona de Mediana Edad , Pericardiocentesis , Recuperación de la Función , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
The intraaortic balloon pump (IABP) provides counterpulsation by displacing a 40-50 cc blood volume during diastole augmenting diastolic pressure. The rapid deflation of the balloon timed to the initiation of systole reduces the afterload of ventricular ejection and thus peak systolic pressure. As a direct result, IABP increases mean arterial pressure (MAP) and peak diastolic pressure while reducing systolic pressure and myocardial work. IABP increases coronary flow velocity in non-obstructed vessels, but does not increase flow across a severe obstruction as shown by intracoronary Doppler flow studies (Kern et al., Circulation, 1993;87:500-511 and Kern et al., Circulation 1991;84:II-485). There are few studies using pressure sensor guidewires to confirm these responses. We present a case illustrating the translesional hemodynamics using an angioplasty sensor pressure wire across a severe stenosis and the unique influence of the IABP.
Asunto(s)
Angioplastia Coronaria con Balón , Estenosis Coronaria/terapia , Reserva del Flujo Fraccional Miocárdico , Insuficiencia Cardíaca/terapia , Hemodinámica , Contrapulsador Intraaórtico , Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Estenosis Coronaria/diagnóstico , Estenosis Coronaria/fisiopatología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Transductores de Presión , Resultado del TratamientoRESUMEN
Transradial angiography and intervention continues to become increasingly common as an access site for coronary procedures. Since the first "Best Practices" paper in 2013, ongoing trials have shed further light onto the safest and most efficient methods to perform these procedures. Specifically, this document comments on the use of ultrasound to facilitate radial access, the role of ulnar artery access, the utility of non-invasive testing of collateral flow, strategies to prevent radial artery occlusion, radial access for primary PCI and topics that require further study.
Asunto(s)
Cateterismo Cardíaco/normas , Cateterismo Periférico/normas , Angiografía Coronaria/normas , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/normas , Arteria Radial/diagnóstico por imagen , Ultrasonografía Intervencional/normas , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/fisiopatología , Arteriopatías Oclusivas/prevención & control , Benchmarking , Cateterismo Cardíaco/efectos adversos , Cateterismo Periférico/efectos adversos , Consenso , Angiografía Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/fisiopatología , Humanos , Intervención Coronaria Percutánea/efectos adversos , Valor Predictivo de las Pruebas , Arteria Radial/fisiopatología , Factores de Riesgo , Resultado del Tratamiento , Arteria Cubital/diagnóstico por imagen , Ultrasonografía Intervencional/efectos adversos , Grado de Desobstrucción Vascular , VasoconstricciónRESUMEN
The society for cardiovascular angiography and interventions (SCAI) think tank is a collaborative venture that brings together interventional cardiologists, administrative partners, and select members of the cardiovascular industry community for high-level field-wide discussions. The 2020 think tank was organized into four parallel sessions reflective of the field of interventional cardiology: (a) coronary intervention, (b) endovascular medicine, (c) structural heart disease, and (d) congenital heart disease (CHD). Each session was moderated by a senior content expert and co-moderated by a member of SCAI's emerging leader mentorship program. This document presents the proceedings to the wider cardiovascular community in order to enhance participation in this discussion, create additional dialogue from a broader base, and thereby aid SCAI and the industry community in developing specific action items to move these areas forward.
Asunto(s)
Cateterismo Cardíaco/tendencias , Cardiología/tendencias , Angiografía Coronaria/tendencias , Cardiopatías/diagnóstico por imagen , Cardiopatías/terapia , Intervención Coronaria Percutánea/tendencias , Difusión de Innovaciones , Cardiopatías/fisiopatología , HumanosRESUMEN
BACKGROUND: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System. METHODS: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay. We examined trends of SDD, and using 2:1 propensity matching, we assessed 30-day rates of readmission, mortality, and total costs at 30â¯days. RESULTS: Of 21,261 PCIs from 67 sites, 728 were SDDs (3.9% of overall cohort). The rate of SDD increased from 1.6% in 2008 to 9.7% in 2016 (Pâ¯<â¯.001). SDD patients had lower rates of atrial fibrillation, peripheral arterial disease, and prior coronary artery bypass grafting and were treated at higher-volume centers. Thirty-day readmission and mortality did not differ significantly between the groups (readmission: 6.7% SDD vs 5.6% for overnight stay, Pâ¯=â¯.24; mortality: 0% vs. 0.07%, Pâ¯=â¯.99). The mean (SD) 30-day cost accrued by patients undergoing SDD was $23,656 ($15,480) versus $25,878 ($17,480) for an overnight stay. The accumulated median cost savings for SDD was $1503 (95% CI $738-$2,250). CONCLUSIONS: Veterans Affairs Health System has increasingly adopted SDD for elective PCI procedures, and this is associated with cost savings without an increase in readmission or mortality. Greater adoption has the potential to reduce costs without increasing adverse outcomes.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , Angina Estable/cirugía , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Intervención Coronaria Percutánea/estadística & datos numéricos , Anciano , Procedimientos Quirúrgicos Ambulatorios/economía , Procedimientos Quirúrgicos Ambulatorios/mortalidad , Ahorro de Costo , Procedimientos Quirúrgicos Electivos/economía , Procedimientos Quirúrgicos Electivos/mortalidad , Femenino , Hospitales de Alto Volumen/estadística & datos numéricos , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Alta del Paciente/economía , Alta del Paciente/tendencias , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Readmisión del Paciente/tendencias , Intervención Coronaria Percutánea/economía , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/mortalidad , Puntaje de Propensión , Factores de Tiempo , Estados Unidos , United States Department of Veterans AffairsRESUMEN
TAVR patients given pacemakers operating in mandatory DDD mode had more ventricular pacing, heart failure hospitalization, and mortality compared with AAI-DDD or VVI modes. AV conduction disturbances are often transient after TAVR. Minimizing ventricular pacing where possible avoids the risk of pacemaker-induced cardiomyopathy. Pacemaker specialists should be consulted for any TAVR patient with mild rhythm abnormalities given the high incidence of AV block.
Asunto(s)
Marcapaso Artificial , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica , Estimulación Cardíaca Artificial , Catéteres , Electrónica , Humanos , Pacientes , EspecializaciónRESUMEN
IVUS measurements of luminal area have only modest correlations to FFR. This study used IVUS 3D anatomical data in a computational fluid dynamic model to estimate FFR with a reasonable degree of accuracy. Further studies are needed to refine the models to make them more accurate and practical for routine use.
Asunto(s)
Reserva del Flujo Fraccional Miocárdico , Hemodinámica , Hidrodinámica , Ultrasonografía , Ultrasonografía IntervencionalRESUMEN
There is limited evidence supporting the preloading of potent oral P2Y12 inhibitors in ST-elevation myocardial infarction (STEMI). This study demonstrates that longer pretreatment times were associated with improved angiographic coronary flow grades and ST-segment resolution. Although larger studies would be needed to prove a clinical benefit, in the absence of harm preloading in STEMI would be the most reasonable strategy.
Asunto(s)
Infarto de la Pared Anterior del Miocardio , Cálculos , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Inhibidores de Agregación PlaquetariaRESUMEN
Patients may have preferences and priorities for their catheterization procedure that may differ from the operator's expectations. This online survey of normal volunteers suggested that patients place the highest value on same-day discharge and lesser values for radiation exposure, bleeding risk, and access site. Patient-centered care needs to increasingly emphasize same-day discharge after PCI for highest patient satisfaction.
Asunto(s)
Colaboración de las Masas , Intervención Coronaria Percutánea , Voluntarios Sanos , Humanos , Alta del Paciente , Resultado del TratamientoRESUMEN
FFR/iFR is discordant in 15-20% of cases, at times causing confusion about revascularization decisions. The CONTRAST substudy identifies lesion location, lesion severity, and bradycardia as major predictors for FFR/iFR discordance, with age a minor predictor. Each of these predictors can be explained physiologically through the mechanisms related to resting and hyperemic pressure loss across different patterns of atherosclerotic stenoses. A logical approach to using both resting and hyperemic pressure ratios is proposed.
Asunto(s)
Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Angiografía Coronaria , Vasos Coronarios , Humanos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Dyspnea due to mitral stenosis (MS) and/or pulmonary hypertension (PHT) in patients who may have both conditions presents a challenging diagnostic dilemma. The hemodynamic response to exercise is probably the most helpful method to arrive at the correct diagnosis and treatment algorithm. In this hemodynamic rounds discussion, we evaluated a patient with MS and PHT prior to the decision for mitral valvuloplasty. KEY POINTS: Symptoms in patients with mitral stenosis and pulmonary hypertension cannot always be attributed to one pathology. Catheter-based hemodynamics are often needed to differentiate valve from lung disease. Exercise hemodynamics can clarify the predominant pathology in complex clinical scenarios.