Femtosecond Laser Percussion Drilling of Silicon Using Repetitive Single Pulse, MHz-, and GHz-Burst Regimes.

In this contribution, we present novel results on top-down drilling in silicon, the most important semiconductor material, focusing specifically on the influence of the laser parameters. We compare the holes obtained with repetitive single pulses, as well as in different MHz- and GHz-burst regimes. The deepest holes were obtained in GHz-burst mode, where we achieved holes of almost 1 mm depth and 35 µm diameter, which corresponds to an aspect ratio of 27, which is higher than the ones reported so far in the literature, to the best of our knowledge. In addition, we study the influence of the energy repartition within the burst in GHz-burst mode.

Abordaje global del paciente con pie diabético: Una revisión / Global approach to the patient with diabetic foot: A review

RESUMEN El artículo de revisión destaca la importancia de la planta del pie en la deambulación y su adaptación a las necesidades humanas. Se enfoca en el pie diabético (PD), definido por signos, síntomas o úlceras en el pie debido a complicaciones crónicas de la diabetes. El PD afecta a alrededor del 25% de los pacientes con diabetes mellitus (DM), con úlceras que pueden derivar en infecciones graves y riesgo de amputación. El manejo del PD es complejo y requiere un enfoque multidisciplinar. Este artículo propone un "Sistema de Evaluación y Tratamiento del Pie Diabético", aplicable en diversos entornos clínicos, que clasifica las úlceras según su profundidad e infección y ofrece guías claras para su tratamiento. Se discuten también la epidemiología de la neuropatía diabética (ND), destacando su alta prevalencia y morbilidad, y la necesidad de un diagnóstico y tratamiento adecuados. Se analiza en detalle la neuropatía de Charcot, una complicación severa del PD, incluyendo sus causas y métodos diagnósticos. Además, se enfatiza la importancia del enfoque multidisciplinar en el tratamiento de las úlceras del PD para reducir amputaciones y mejorar la calidad de vida de los pacientes. También se abordan las infecciones del PD y la antibioticoterapia, recomendando el uso de antibióticos adecuados según la gravedad de la infección y la realización de cultivos microbiológicos precisos. Finalmente, se presenta una visión global del manejo del PD, destacando la importancia de un enfoque multidisciplinar y proponiendo un sistema de evaluación y tratamiento eficaz que puede ser implementado en diversos contextos clínicos.

ABSTRACT The review article highlights the importance of the sole of the foot in ambulation and its adaptation to human needs. It focuses on diabetic foot (DF), defined by signs, symptoms, or ulcers on the foot due to chronic complications of diabetes. DF affects approximately 25 % of patients with diabetes mellitus (DM), with ulcers that can lead to severe infections and risk of amputation. Managing DF is complex and requires a multidisciplinary approach. This article proposes a "Diabetic Foot Evaluation and Treatment System," applicable in various clinical settings, which classifies ulcers according to their depth and infection and provides clear treatment guidelines. The epidemiology of diabetic neuropathy (DN) is also discussed, highlighting its high prevalence and morbidity, and the need for adequate diagnosis and treatment. The article provides a detailed analysis of Charcot neuropathy, a severe complication of DF, including its causes and diagnostic methods. Furthermore, the importance of a multidisciplinary approach in the treatment of DF ulcers is emphasized to reduce amputations and improve patients' quality of life. DF infections and antibiotic therapy are also addressed, recommending the use of appropriate antibiotics according to the severity of the infection and the performance of precise microbiological cultures. Finally, a comprehensive view of DF management is presented, highlighting the importance of a multidisciplinary approach and proposing an effective evaluation and treatment system that can be implemented in various clinical contexts.

Adipocyte-released adipomes in Chagas cardiomyopathy: Impact on cardiac metabolic and immune regulation.

Chronic Trypanosoma cruzi infection leads to Chagas cardiomyopathy (CCM), with varying manifestations such as inflammatory hypertrophic cardiomyopathy, arrhythmias, and dilated cardiomyopathy. The factors responsible for the increasing risk of progression to CCM are not fully understood. Previous studies link adipocyte loss to CCM progression, but the mechanism triggering CCM pathogenesis remains unexplored. Our study uncovers that T. cruzi infection triggers adipocyte apoptosis, leading to the release of extracellular vesicles named "adipomes". We developed an innovative method to isolate intact adipomes from infected mice's adipose tissue and plasma, showing they carry unique lipid cargoes. Large and Small adipomes, particularly plasma-derived infection-associated L-adipomes (P-ILA), regulate immunometabolic signaling and induce cardiomyopathy. P-ILA treatment induces hypertrophic cardiomyopathy in wild-type mice and worsens cardiomyopathy severity in post-acute-infected mice by regulating adipogenic/lipogenic and mitochondrial functions. These findings highlight adipomes' pivotal role in promoting inflammation and impairing myocardial function during cardiac remodeling in CD.

Diastolic dysfunction and clinical outcomes after transcatheter or surgical aortic valve replacement in patients with atypical aortic valve stenosis.

BACKGROUND: Diastolic dysfunction is a predictor of poor outcomes in many cardiovascular conditions. At present, it is unclear whether diastolic dysfunction predicts adverse outcomes in patients with atypical aortic stenosis who undergo aortic valve replacement (AVR). METHODS: Five hundred and twenty-three patients who underwent transcatheter AVR (TAVR) (n = 303) and surgical AVR (SAVR) (n = 220) at a single institution were included in our analysis. Baseline left and right heart invasive hemodynamics were assessed. Baseline transthoracic echocardiograms were reviewed to determine aortic stenosis subtype and parameters of diastolic dysfunction. Aortic stenosis subtype was categorized as typical (normal flow, high-gradient) aortic stenosis, classical, low-flow, low-gradient (cLFLG) aortic stenosis, and paradoxical, low-flow, low-gradient (pLFLG) aortic stenosis. Cox proportional hazard models were utilized to examine the relation between invasive hemodynamic or echocardiographic variables of diastolic dysfunction, aortic stenosis subtype, and all-cause mortality. Propensity-score analysis was performed to study the relation between aortic stenosis subtype and the composite outcome [death/cerebrovascular accident (CVA)]. RESULTS: The median STS risk was 5.3 and 2.5% for TAVR and SAVR patients, respectively. Relative to patients with typical aortic stenosis, patients with atypical (cLFLG and pLFLG) aortic stenosis displayed a significantly higher prevalence of diastolic dysfunction (LVEDP ≥ 20mmHg, PCWP ≥ 20mmHg, echo grade II or III diastolic dysfunction, and echo-PCWP ≥ 20mmHg) and, independently of AVR treatment modality, had a significantly increased risk of death. In propensity-score analysis, patients with atypical aortic stenosis had higher rates of death/CVA than typical aortic stenosis patients, independently of diastolic dysfunction and AVR treatment modality. CONCLUSION: We demonstrate the novel observation that compared with patients with typical aortic stenosis, patients with atypical aortic stenosis have a higher burden of diastolic dysfunction. We corroborate the worse outcomes previously reported in atypical versus typical aortic stenosis and demonstrate, for the first time, that this observation is independent of AVR treatment modality. Furthermore, the presence of diastolic dysfunction does not independently predict outcome in atypical aortic stenosis regardless of treatment type, suggesting that other factors are responsible for adverse clinical outcomes in this higher risk cohort.

Process Mass Intensity (PMI): A Holistic Analysis of Current Peptide Manufacturing Processes Informs Sustainability in Peptide Synthesis.

Small molecule therapeutics represent the majority of the FDA-approved drugs. Yet, many attractive targets are poorly tractable by small molecules, generating a need for new therapeutic modalities. Due to their biocompatibility profile and structural versatility, peptide-based therapeutics are a possible solution. Additionally, in the past two decades, advances in peptide design, delivery, formulation, and devices have occurred, making therapeutic peptides an attractive modality. However, peptide manufacturing is often limited to solid-phase peptide synthesis (SPPS), liquid phase peptide synthesis (LPPS), and to a lesser extent hybrid SPPS/LPPS, with SPPS emerging as a predominant platform technology for peptide synthesis. SPPS involves the use of excess solvents and reagents which negatively impact the environment, thus highlighting the need for newer technologies to reduce the environmental footprint. Herein, fourteen American Chemical Society Green Chemistry Institute Pharmaceutical Roundtable (ACS GCIPR) member companies with peptide-based therapeutics in their portfolio have compiled Process Mass Intensity (PMI) metrics to help inform the sustainability efforts in peptide synthesis. This includes PMI assessment on 40 synthetic peptide processes at various development stages in pharma, classified according to the development phase. This is the most comprehensive assessment of synthetic peptide environmental metrics to date. The synthetic peptide manufacturing process was divided into stages (synthesis, purification, isolation) to determine their respective PMI. On average, solid-phase peptide synthesis (SPPS) (PMI ≈ 13,000) does not compare favorably with other modalities such as small molecules (PMI median 168-308) and biopharmaceuticals (PMI ≈ 8300). Thus, the high PMI for peptide synthesis warrants more environmentally friendly processes in peptide manufacturing.

Vitaminas B1, B6, B12 y neuropatías periféricas: Consenso de expertos / Vitamins B1, B6, and B12 and peripheral neuropathies: International expert consensus

RESUMEN A partir de una revisión bibliográfica de la literatura se ha planeado y desarrollado un consenso de expertos internacionales sobre la utilización de las vitaminas B1, B6, B12 en sus déficits y en la neuropatía periférica que puede estar asociada a la misma, como tema que precia de esa aproximación aclaratoria para optimizar su manejo. Se plantearon varias cuestiones de discusión que se consideraron importantes y dignas de ser abordadas y aclaradas, conservando nueve de ellas para su discusión ulterior buscando el consenso en tres rondas consecutivas. Se han propuesto 41 recomendaciones sobre el manejo de estas condiciones, con unanimidad por parte de los participantes en el consenso. Con ellas se ha intentado aclarar puntos oscuros o controvertidos, facilitando la actitud del clínico ante ellos en la práctica médica actual.

ABSTRACT Based on a bibliographic review of the literature, a consensus of international experts has been carried out on the use of vitamins B1, B6, B12, in their deficiencies, and in the peripheral neuropathy that may be associated with them, to optimize the management of these conditions. Several questions considered important and worthy of being addressed and clarified were raised, retaining nine of them for further discussion to achieve consensus. Forty one recommendations on the management of these conditions have been proposed, with unanimity of the participants in the consensus. This has been an attempt to clarify controversial points, assisting the clinician's attitude in current medical practice.

Mitral Valve Transcatheter Edge-to-Edge Repair After TAVR: A Nationwide Analysis.

Patients with persistent severe mitral regurgitation after transcatheter aortic valve replacement (TAVR) may benefit from mitral transcatheter edge-to-edge repair (M-TEER). Using the Nationwide Readmission Database, we identified patients who had M-TEER within 6 months after TAVR and compared their outcomes with patients who had M-TEER without previous recent TAVR during the same calendar year between 2014 and 2020. Because Nationwide Readmission Database data do not cross years, analysis was restricted to the last half of each calendar year. End points included in-hospital mortality and 30-day and 90-day postdischarge rehospitalization rates. In 23,885 M-TEER patients, 396 (1.7%) had a previous recent TAVR. The number of post-TAVR M-TEER procedures increased progressively over time from 16 in 2014 to 92 in 2020. Patients who had M-TEER after a recent TAVR versus those without previous TAVR had similar in-hospital mortality (adjusted odds ratio 0.38, 95% confidence interval [CI] 0.12 to 1.23, p = 0.11), but higher rates of 30-day all-cause hospitalization and heart failure hospitalization (adjusted odds ratios 1.34, 95% CI 1.11 to 1.79, p = 0.04 and 1.63, 95% CI 1.13 to 2.36, p = 0.009, respectively). Nonetheless, in patients who underwent M-TEER post-TAVR, the cumulative 90-day all-cause hospitalization and heart failure hospitalization rates were less after M-TEER compared with before M-TEER (from 45.7% to 31.5%, p = 0.007, and from 29.0% to 16.6%, respectively, both p = 0.005). In conclusion, M-TEER procedures after TAVR in the United States are increasing. Patients with M-TEER after TAVR had similar in-hospital mortality as those who underwent M-TEER without recent TAVR, but higher 30-day hospitalization rates. Nonetheless, 90-day hospitalization rates were decreased after M-TEER in patients with previous TAVR.

Actitudes de los médicos hacia el abordaje de la neuropatía diabética en establecimientos de salud públicos y privados, 2023 / Physicians' attitudes towards the approach to diabetic neuropathy in public and private health facilities, 2023

RESUMEN Objetivo: Describir las actitudes de los médicos hacia el abordaje de la neuropatía diabética. Métodos: Estudio descriptivo, observacional, transversal y prospectivo, muestra 143 médicos, muestreo no probabilístico por conveniencia. Las variables: años de ejercicio profesional, especialidad, proporción de pacientes en la consulta médica con diagnóstico de diabetes mellitus (tipo 1 o 2), proporción de pacientes con diabetes mellitus con diagnóstico de neuropatía diabética, actitudes hacia el abordaje de la neuropatía diabética. Se empleó escala Likert de 5 categorías para evaluar actitudes en 3 dimensiones: priorización, diagnóstico y tratamiento. Se emplearon estadísticos descriptivos. Resultados: En la dimensión priorización el 57.4% prioriza el control metabólico sobre la evaluación de complicaciones. Dimensión diagnostico el 80.5% de médicos encuestados se basan en síntomas y signos referidos por el paciente para hacer el diagnóstico de dicha complicación, el 66,5% reconocen que no usan instrumento para la evaluación de la neuropatía y el 39.9% tampoco lo usarían así lo tuviera. En la dimensión tratamiento el 73,5% reconocen que el tratamiento analgésico de la neuropatía diabética es frustrante y el 50,4% siente "temor" para titular la dosis de la medicación analgésica anti-neuropática por los efectos adversos. Conclusiones: Las actitudes de los médicos comprometen diferentes áreas del abordaje de la neuropatía diabética como la priorización, el diagnóstico y el tratamiento con una tendencia a la priorización del control metabólico y de otras complicaciones microvasculares, al sub-diagnóstico, al "sub-tratamiento" y a la necesidad de referir a los pacientes para manejo especializado.

ABSTRACT Objective: To describe the attitudes of doctors towards the approach to diabetic neuropathy. Methods: Descriptive, observational, cross-sectional and prospective study, sample of 143 doctors, non-probabilistic convenience sampling. The variables: years of professional practice, specialty, proportion of patients in the medical consultation with a diagnosis of diabetes mellitus (type 1 or 2), proportion of patients with diabetes mellitus with a diagnosis of diabetic neuropathy, attitudes towards the approach to diabetic neuropathy. A 5-category Likert scale was used to evaluate attitudes in 3 dimensions: prioritization, diagnosis and treatment. Descriptive statistics were used. Results: In the prioritization dimension, 57.4% prioritize metabolic control over the evaluation of complications. Diagnostic dimension: 80.5% of doctors surveyed rely on symptoms and signs reported by the patient to make the diagnosis of said complication, 66.5% recognize that they do not use an instrument for the evaluation of neuropathy and 39.9% would not use it either. had it. In the treatment dimension, 73.5% recognize that analgesic treatment for diabetic neuropathy is frustrating and 50.4% feel "afraid" to titrate the dose of anti-neuropathic analgesic medication due to adverse effects. Conclusions: The attitudes of doctors compromise different areas of the approach to diabetic neuropathy such as prioritization, diagnosis and treatment with a tendency to prioritize metabolic control and other microvascular complications, to under-diagnosis, to "under-treatment". " and the need to refer patients for specialized management.

Bessel Beam Dielectrics Cutting with Femtosecond Laser in GHz-Burst Mode.

We report, for the first time to the best of our knowledge, Bessel beam dielectrics cutting with a femtosecond laser in GHz-burst mode. The non-diffractive beam shaping is based on the use of an axicon and allows for cutting glasses up to 1 mm thickness with an excellent cutting quality. Moreover, we present a comparison of the cutting results with the state-of-the-art method, consisting of short MHz-bursts of femtosecond pulses. We further illustrate the influence of the laser beam parameters such as the burst energy and the pitch between consecutive Bessel beams on the machining quality of the cutting plane and provide process windows for both regimes.

Comparative Study of Percussion Drilling in Glasses with a Femtosecond Laser in Single Pulse, MHz-Burst, and GHz-Burst Regimes and Optimization of the Hole Aspect Ratio.

In this contribution, we present a comparative study on top-down drilling in sodalime glass, with a femtosecond laser operating in single-pulse, MHz-burst and GHz-burst modes, respectively. We investigate the hole depth, drilling rate, and hole morphology for these three regimes while keeping the same experimental conditions. We demonstrate that, for both burst regimes, the burst length has to be adapted for optimizing the hole depth. In the GHz-burst regime, the lower the ablation rate the longer the holes. The three drilling regimes lead to different hole morphologies, where the GHz-burst mode results in the best hole quality featuring glossy inner walls and an almost cylindrical morphology. Furthermore, we obtain crack-free holes, the deepest measuring 3.7 mm in length and 25 µm in entrance diameter corresponding to an aspect ratio of 150, which is the highest aspect ratio reported thus far with femtosecond GHz-burst drilling to the best of our knowledge.

A goal-oriented hemodynamic approach to acute myocardial infarction complicated by cardiogenic shock-A single center experience.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is the most common cause of mortality following AMI, and treatment algorithms vary widely. We report the results of an analysis using time-sensitive, hemodynamic goals in the treatment of AMI-CS in a single center study. METHODS: Consecutive patients with AMI-CS from November 2016 through December 2021 were included in our retrospective analysis. Clinical characteristics and outcomes were analyzed using the electronic medical records. We identified 63 total patients who were admitted to our center with AMI-CS, and we excluded patients who did not have clear timing of AMI onset or CS onset. We evaluated the rate of survival to hospital discharge based on the quantity of certain time-sensitive hemodynamic goals were met. RESULTS: We identified 63 patients who met criteria for AMI-CS, 39 (62%) of whom survived to hospital discharge. Odds of survival were closely related to the achievement of four time-dependent goals: cardiac power output (CPO) >0.6 Watts (W), pulmonary artery pulsatility index (PAPi) >1, lactate <4 mmol/L, and <2 vasopressors required. Of the 63 total patients, 36 (57%) received intra-aortic balloon pump (IABP) and 18 (29%) received an Impella CP (Abiomed) as an initial mechanical circulatory support strategy. Six patients were escalated from IABP to Impella CP for additional hemodynamic support. Nine patients were treated with vasopressors/inotropes alone. Regarding the 39 patients who survived to hospital discharge, 75% of patients met 3 or 4 goals at 24 h, whereas only 16% of deceased patients met 3 or 4 goals at 24 h. Of the 24 patients who did not survive to hospital discharge, 18 (75%) met either 0-1 goal at 24 h. There was no effect of the initial treatment strategy on achieving 3-4 goals at 24 h. CONCLUSION: Our study evaluated the association of meeting 4 time-sensitive goals (CPO >0.6 W, PAPi >1, <2 vasopressors, and lactate <4 mmol/L) at 24 h after treatment for AMI-CS with in-hospital mortality. Our data show, in line with previous data, that the higher number of goals met at 24 h was associated with improved in-hospital mortality regardless of treatment strategy.

Advances in Femtosecond Laser GHz-Burst Drilling of Glasses: Influence of Burst Shape and Duration.

The femtosecond GHz-burst mode laser processing has attracted much attention in the last few years. Very recently, the first percussion drilling results obtained in glasses using this new regime were reported. In this study, we present our latest results on top-down drilling in glasses, focusing specifically on the influence of burst duration and shape on the hole drilling rate and the quality of the drilled holes, wherein holes of very high quality with a smooth and glossy inner surface can be obtained. We show that a decreasing energy repartition of the pulses within the burst can increase the drilling rate, but the holes saturate at lower depths and present lower quality than holes drilled with an increasing or flat energy distribution. Moreover, we give an insight into the phenomena that may occur during drilling as a function of the burst shape.

Fibrinolytic Status and Risk of Death After Acute Pulmonary Embolism.

BACKGROUND: Acute pulmonary embolism (PE) is a heterogeneous disease process with variable presentation and outcomes. The endogenous fibrinolytic system is a complex framework of regulatory pathways that maintains homeostasis by dissolving overabundant thrombi. We sought to investigate phenotypic profiles of the endogenous fibrinolytic system among patients presenting with acute PE and their impact on mortality. METHODS: We enrolled all consecutive patients with acute PE in our institutional Pulmonary Embolism Response Team registry. We collected blood samples at the time of PE diagnosis and analyzed concentrations of plasminogen activator inhibitor 1 (PAI-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and alpha-2-antiplasmin (A2A). We assessed the association of concentration of fibrinolytic inhibitors and 1-year all-cause mortality and various echocardiographic markers of right ventricular (RV) dysfunction. RESULTS: There is significant variability of PAI-1, A2A, and TAFI concentrations across the spectrum of PE risk profiles with high PAI-1, low TAFI, and low A2A (herein referred to as a high-risk biomarker profile) correlating with worse PE severity. High-risk biomarker profile correlated with high-risk echocardiographic features of RV dysfunction, including increased RV/left ventricular (LV) ratio, low tricuspid annular plane systolic excursion, and low right ventricular outflow tract velocity time integral. Higher-risk biomarker profile was able to discriminate and independently identify patients at high risk of all-cause mortality (Group 2 HR 6 95% CI 1.3-27.8, Group 3 HR 12, 95% CI 1.7-86). CONCLUSIONS: Further studies are needed to assess the exact pathophysiological link between fibrinolytic status and poor outcome after acute PE and to ascertain the impact of anti-inhibitors of the fibrinolytic system on response to therapy and outcomes after acute PE.

ISR vs De Novo Lesion Treatment During OCT-Guided PCI: Insights From the LightLab Initiative.

Background: Long-term outcomes after percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) are poor, yet limited granular procedural data exist evaluating lesion assessment, vessel treatment, and acute procedural outcomes. Methods: The LightLab Initiative was a multicenter, prospective, observational study with contemporaneous procedural data collection during PCI procedures. Data were collected during PCIs performed by 48 interventional cardiologists at 17 US hospitals (2019-2021). Optical coherence tomography (OCT) was performed pre-PCI for lesion assessment and post-PCI for stent optimization, and results were compared between ISR and de novo lesion PCI. Results: In total, 2592 OCT-guided PCIs involving 2944 lesions were included, of which 458 procedures (17.7%) were ISR PCI. Compared with de novo lesion PCI, ISR lesions were more commonly type C (64.8% vs 52.9%) and performed via femoral artery access (46.4% vs 37.7%). Use of OCT changed operator assessment and treatment decisions more frequently in ISR PCI (94.2% vs 85.2%; P = .002). Scoring balloons (21.8% vs 2.5%), cutting balloons (16.4% vs 3.4%), and atherectomy (26.3% vs 9.9%) were used more commonly in ISR PCI (all P < .0001), and ISR PCI procedures were longer (62 vs 51 min). Moreover, the final achieved minimum stent area and percent expansion (4.4 vs 5.1 mm2 and 80% vs 83%, respectively; both P < .0001) were lower in ISR PCI. Conclusions: In this real-world cohort of patients who underwent OCT-guided PCI, ISR procedures were longer and final minimum stent area and percent expansion were lower despite greater use of advanced lesion modification. OCT frequently altered physician decision making, emphasizing its utility in potentially reducing recurrent stent failure in this high-risk population.

Fibrous Cap Thickness Predicts Stable Coronary Plaque Progression: Early Clinical Validation of a Semiautomated OCT Technology.

Background: Imaging-based characteristics associated with the progression of stable coronary atherosclerotic lesions are poorly defined. Utilizing a combination of optical coherence tomography (OCT) and intravascular ultrasound (IVUS) imaging, we aimed to characterize the lesions prone to progression through clinical validation of a semiautomated OCT computational program. Methods: Patients with stable coronary artery disease underwent nonculprit vessel imaging with IVUS and OCT at baseline and IVUS at the 12-month follow-up. After coregistration of baseline and follow-up IVUS images, paired 5-mm segments from each patient were identified, demonstrating the greatest plaque progression and regression as measured by the change in plaque burden. Experienced readers identified plaque features on corresponding baseline OCT segments, and predictors of plaque progression were assessed by multivariable analysis. Each segment then underwent volumetric assessment of the fibrous cap (FC) using proprietary software. Results: Among 23 patients (70% men; median age, 67 years), experienced-reader analysis demonstrated that for every 100 µm increase in mean FC thickness, plaques were 87% less likely to progress (P = .01), which persisted on multivariable analysis controlling for baseline plaque burden (P = .05). Automated FC analysis (n = 17 paired segments) confirmed this finding (P = .01) and found thinner minimal FC thickness (P = .01) and larger FC surface area of <65 µm (P = .02) and <100 µm (P = .04) in progressing segments than in regressing segments. No additional imaging features predicted plaque progression. Conclusions: A semiautomated FC analysis tool confirmed the significant association between thinner FC and stable coronary plaque progression along entire vessel segments, illustrating the diffuse nature of FC thinning and suggesting a future clinical role in predicting the progression of stable coronary artery disease.

Decision-Making During Percutaneous Coronary Intervention Guided by Optical Coherence Tomography: Insights From the LightLab Initiative.

BACKGROUND: Use of intracoronary imaging is associated with improved outcomes in patients undergoing percutaneous coronary intervention (PCI). Yet, the impact of intracoronary imaging on real-time physician decision-making during PCI is not fully known. METHODS: The LightLab Initiative is a multicenter, prospective, observational study designed to characterize the use of a standardized optical coherence tomography (OCT) workflow during PCI. Participating physicians performed pre-PCI and post-PCI OCT in accordance with this workflow and operator assessments of lesion characteristics and treatment plan were recorded for each lesion based on angiography alone and following OCT. Physicians were categorized as having low (n=15), intermediate (n=13), or high (n=14) OCT use in the year preceding participation. RESULTS: Among 925 patients with 1328 lesions undergoing PCI, the prescribed OCT workflow was followed in 773 (84%) of patients with 836 lesions. Operator lesion assessment and decision-making during PCI changed with OCT use in 86% (721/836) of lesions. Pre-PCI OCT use changed operator decision-making in 80% of lesions, including lesion assessment (45%), vessel preparation strategy (27%), stent diameter (37%), and stent length (36%). Post-PCI OCT changed stent optimization decision-making in 31% of lesions. These findings were consistent across strata of physician prior OCT experience. CONCLUSIONS: A standardized OCT workflow impacted PCI decision-making in 86% of lesions, with a predominant effect on pre-PCI lesion assessment and planning of treatment strategy. This finding was consistent regardless of operator experience level and provides insight into mechanisms by which intravascular imaging might improve PCI outcomes.

Immersive educational curriculum on intracoronary optical coherence tomography image analysis among naïve readers.

BACKGROUND: Optical coherence tomography (OCT) is an intravascular imaging modality for analysing coronary vessels. Image interpretation remains an obstacle for novice readers due to technical artefacts and uncertainty in tissue characterization. Despite an expanding clinical and research role for OCT, few training efforts exist, and there is an absence of a national standardized educational curriculum. We sought to determine whether an interactive, feedback-based OCT curriculum improved image interpretation among naive readers. METHODS: Naive OCT readers completed both a Standard curriculum, comprised of self-directed didactics and consensus statements, and an Augmented curriculum, which provided real-time digital feedback of feature identification and measurements. Modules were separated by a minimum one-week washout period. After each module, and blinded to the exam answers, subjects completed an identical expert-designed 413-item exam to assess technical knowledge and ability to identify and measure vessel features. Performances were compared using Exact Wilcoxon signed-rank tests. RESULTS: Among the 7 included subjects were 3 medical students, 3 internal medicine residents, and 1 cardiovascular medicine fellow with no prior OCT experience. The technical knowledge score (maximum 13) was significantly higher with the Augmented compared with the Standard curriculum (median 11 vs. 7, p = 0.03). After undergoing the Augmented curriculum, all 7 subjects were able to identify features of plaque rupture (Standard curriculum: 5/7 subjects, p = 0.5) and macrophages (Standard curriculum: 6/7 subjects, p = 0.99), differentiate the components between red and white thrombus (Standard curriculum: 6/7 subjects, p = 0.99), and characterize lipid plaque by attenuation, signal, homogeneity, and borders (Standard curriculum: 5/7 subjects, p = 0.5). Performances on the remaining exam portions did not differ between curricula. CONCLUSIONS: The need for standardized, effective training in OCT image interpretation is increasingly essential as the intravascular imaging modality becomes widely utilized among interventional cardiologists and trainees. A novel interactive OCT curriculum enhanced naive readers' technical knowledge and may supplement traditional self-learning in refining analytic skills.

Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock.

BACKGROUND: Before the development of transcatheter aortic valve replacement (TAVR), balloon aortic valvuloplasty (BAV) was the only potential nonsurgical intervention for patients with aortic stenosis complicated by cardiogenic shock. Emergent TAVR is now an option and has shown acceptable outcomes compared with elective TAVR. We explored how treatment patterns for aortic stenosis and cardiogenic shock among patients received invasive intervention have shifted since TAVR was introduced. METHODS: We used the Nationwide In patients Sample to identify nonelective hospitalizations for patient with aortic stenosis complicated by cardiogenic shock who received invasive treatment (TAVR, BAV, or surgical aortic valve replacement [SAVR]). We explored the proportion treated with each treatment modality over time, the patient characteristics and in-hospital mortality associated with each treatment, and used multivariable logistic regression to examine whether changes in in-hospital mortality over time differed by treatment. RESULTS: Between 2010 and 2019, we identified 9899 hospitalizations for decompensated aortic stenosis with cardiogenic shock during which patients received invasive treatment (TAVR 17.7%, BAV 20.2%, SAVR 62.1%). Use of both TAVR and BAV has increased over time compared with SAVR (TAVR 6.6% ≥ 33.8%, BAV 8.4% ≥ 23.2%, SAVR 91.6% ≥ 43.0%; p < 0.001 for trend). The overall in-hospital mortality rate was 21.0%, which decreased over time for all treatments (TAVR 20.0% ≥ 18.8%, BAV 66.0% ≥ 25.5%, SAVR 17.7% ≥ 11.8%; linear trend p < 0.001 for each), with lower mortality for TAVR versus BAV at all time points. Patients treated with TAVR (vs. BAV) were less likely to require mechanical ventilation (36.8% vs. 46.3%, p < 0.001) or mechanical circulatory support (22.5% vs. 29.9%, p < 0.001). In the multivariable analysis, the interaction between treatment and time was not significant (p = 0.245), indicating the reduction in in-hospital mortality over time did not differ among the treatments. CONCLUSIONS: Since the introduction of TAVR, there has been a shift toward increased use of nonsurgical invasive treatments (both BAV and TAVR) for aortic stenosis and cardiogenic shock. Although in-hospital mortality has declined, it remains high in all groups, but particularly among patients treated with BAV, where the severity of cardiogenic shock appears to be higher than in those treated with other modalities.