Working in interventional cardiology laboratories: The perceived impact of radiation exposure as a health and gender hazard. A NEXT generation ANMCO initiative.

BACKGROUND: Gender-related discrepancies in personal and professional life have been reported among radio-exposed workers. We assessed this topic among cardiac catheterization workers in Italy, with a focus on gender and working position. METHODS: Radio-exposed workers affiliated with the Italian Association of Hospital Cardiologists were invited to answer an online survey, which included 41 questions formatted as multiple choice. RESULTS: Overall, 237 workers responded. The proportion of males was significantly higher than that of females in the population aged >50 years. A greater portion of females than males perceived female-gender discrimination regarding career advancement (77.2% vs 30.9%, p < 0.001) and work compensation (49.1% vs. 17.1%, p < 0.001). There was no difference in perceived gender- discrimination in terms of career advancement opportunities between physician and non-physicians. A larger portion of females than males experienced workplace discrimination (51.8% of females vs. 8.1% of males, p < 0.0001). Non-physician responders made up 38.8% of all respondents and reported a lower yearly radiation exposure than physicians. Non-physicians were more aware of the laws regulating lab access during pregnancy than physicians (93.5% vs. 48.3%, p < 0.0001). A greater percentage of female nurses than physicians communicate without hesitation the pregnancy status to their employers (45.6% vs 20%, p < 0.001). CONCLUSIONS: Gender-based career disparities were perceived among physicians and non-physician staff of cardiology interventional laboratories. Strategies should be implemented to ensure gender equality in career opportunities and to increase knowledge of radioprotection and the laws regulating access to laboratories during pregnancy.

Impact of Different Measures of Body Size on the Radiation Dose During Coronary Angiography and Percutaneous Coronary Intervention: Results from a Large Single Center Cohort.

Efforts to reduce and optimize the radiation exposure during coronary angiography and intervention have pointed at patients' body size as a major determinant of irradiation for the patients and operators. We aimed at comparing body weight and body mass index (BMI) among consecutive patients undergoing angiographic procedures (coronary angiography and/or interventions) in a single center. Patients were divided in normal weight (NW, BMI <25 Kg/m2) and overweight (OW, BMI ≥25 Kg/m2). Patients' dose exposure was evaluated as dose area product (DAP), time of exposure (fluoroscopy duration), and relative DAP (DAP/minutes of exposure). We included 748 patients, 61.6% undergoing percutaneous coronary interventions and 56.8% classified as OW. OW patients were more often men (P < .001), with history of hypertension (P < .001) and diabetes (P = .001). Mean DAP and relative DAP were significantly higher among OW compared with NW patients (P < .001). DAP and relative DAP were directly related with body weight (both r = .22, P < .001); a similar linear association was also described for BMI (r = .18, P < .001 and r = .19, P < .001, respectively). At multivariate analysis, however, body weight, but not BMI, independently predicted the DAP. Therefore, body weight should be considered as the preferred indicator of body size in the setting and optimization of radiation exposure during coronary diagnostic and intervention procedures.

Systematic Fluoroscopic-Echocardiographic Fusion Imaging Protocol for Transcatheter Edge-to-Edge Mitral Valve Repair Intraprocedural Monitoring.

BACKGROUND: Whether fluoroscopic-echocardiographic fusion imaging (FI) might offer added value for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair is yet unknown, and few data exist regarding the safety and feasibility of this novel technology. METHODS: The aim of this single-center study was to test and validate a FI protocol for intraprocedural monitoring of transcatheter edge-to-edge mitral valve repair and assess its clinical usefulness. Eighty patients underwent MitraClip implantation using FI guidance (FI+) for either degenerative (35%) or functional (65%) mitral regurgitation and were compared with the last 80 patients before FI introduction, treated using conventional echocardiography and fluoroscopic monitoring (FI-). RESULTS: The number of patients treated for functional and degenerative mitral regurgitation was similar between the FI+ and FI- groups, as well as the number of devices implanted (1.51 ± 0.5 vs 1.58 ± 0.6, P = .46). The prevalence of complex mitral anatomy for percutaneous repair was high (32.5%, up to 39.2% in the hybrid arm). Fluoroscopy time was significantly lower in FI+ patients (37.3 ± 14.6 vs 48.3 ± 28.3 min, P = .003), but not kerma area product (91.5 ± 74.1 vs 108.8 ± 105.0 Gy · cm2, P = .23) or procedural time (92.2 ± 36.1 vs 103.1 ± 42.7 min, P = .086). After adjusting for confounding factors (MitraClip XT device and complex anatomy), FI reduced fluoroscopy time (coefficient = -10.4 min; 95% CI, -18.03 to -2.82; P = .007) and improved procedural success at the end of the procedure (odds ratio, 2.87; 95% CI, 1.00 to 8.24; P = .049) and discharge (odds ratio, 2.24; 95% CI, 1.04 to 4.80; P = .039). Rates of periprocedural complications were similar in both groups (8.9% vs 13.0%, P = .40). CONCLUSIONS: The authors describe the systematic use of an FI protocol for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair, demonstrating a reduction in fluoroscopy time and an improvement in procedural success in a population with a high prevalence of challenging mitral anatomy for percutaneous repair.

Rotational atherectomy-based percutaneous coronary intervention and the risk of contrast-induced nephropathy.

BACKGROUND: Rotational atherectomy (RA)-related complications (e.g., no-reflow and perforation) may be associated with increased risk of contrast-induced nephropathy (CIN), causing hypotension, acute heart failure, and periprocedural myocardial infarction. Our aim was to evaluate the incidence of CIN in patients undergoing RA-based vs. non-RA-based percutaneous coronary intervention (PCI). METHODS: This single-center retrospective registry included all patients who underwent PCI between 2012 and 2016 for whom post-procedural creatinine was determined. Study endpoint was CIN, defined as an increase of serum creatinine ≥0.3 mg/dL or ≥50% from baseline within 72 h post-PCI. Propensity score matching (PSM) was performed to account for selection bias between RA and non-RA patients. RESULTS: Study population included 2580 patients: 70 (3%) had RA PCI and 2510 (97%) had non-RA PCI. Following PSM, there were 70 patients in RA and 280 patients in non-RA group with good overall adjustment between groups, although RA patients received larger contrast volume (263±126 vs. 224±118 mL, P=0.01) and showed higher Mehran risk score at baseline (11.1±6.6 vs. 8.9±4.8, P=0.01). The incidence of CIN was similar between RA and non-RA patients (15.7% vs. 13.2%, P=0.59). New need for dialysis was required in 0% vs. 0.7% patients, respectively (P=0.48). On multivariate analysis, RA PCI was not independently associated with development of CIN. CONCLUSIONS: Despite being performed in patients with a higher burden of comorbidities and with larger volumes of contrast, RA PCI is not associated with higher risk of CIN, compared with PCI in non-RA patients.

Risk of contrast-induced nephropathy in patients undergoing complex percutaneous coronary intervention.

BACKGROUND: Complex percutaneous coronary intervention (PCI) is associated with increased procedural challenges and high contrast load. We aimed to evaluate the association between complex PCI and contrast-induced nephropathy (CIN). METHODS: This single-center retrospective study included all-comers undergoing PCI between January 2012 and December 2016. Complex PCI was defined as a procedure with ≥1 of the following characteristics: 3 vessels treated, ≥3 stents implanted, two-stent bifurcation intervention, total stent length >60 mm, PCI on a chronic total occlusion, saphenous vein graft, or left main, protected PCI, use of rotational/laser atherectomy. CIN was defined as an increase in post-PCI creatinine of ≥0.3 mg/dl or ≥50% from baseline. RESULTS: We included 2660 patients (n = 1128 complex PCI, n = 1532 non-complex PCI). Complex PCI patients tended to be older, and had higher cardiovascular comorbidity and Mehran CIN risk score. They also had a higher prevalence of type B2/C lesions and need for mechanical circulatory support, and received a higher mean contrast volume (284 ±â€¯137 vs. 189 ±â€¯90 ml, p < 0.001). CIN incidence was similar in complex vs. non-complex PCI patients (12.1% vs. 11.5%, p = 0.63), as was the need for in-hospital dialysis (0.5% vs. 0.2%, p = 0.25). Upon multivariable adjustment, age, female sex, diabetes, ejection fraction, periprocedural hypotension, presentation with acute coronary syndrome, and contrast volume were independently associated with CIN, while complex PCI was not. CONCLUSIONS: Complex PCI is not associated with an increased risk of CIN in all-comers. Further studies should confirm our findings and investigate novel effective strategies to decrease the risk of this serious complication.

Ultra-Low Contrast Percutaneous Coronary Intervention to Minimize the Risk for Contrast-Induced Acute Kidney Injury in Patients With Severe Chronic Kidney Disease.

BACKGROUND: The incidence of contrast-induced acute kidney injury (CI-AKI) is particularly high in patients with severe chronic kidney disease (CKD). Novel contrast-sparing strategies are warranted to guarantee the benefit of revascularization in this challenging and growing patient population. We aimed to evaluate the feasibility of an ultra-low contrast volume percutaneous coronary intervention (ULC-PCI) protocol in patients with severe CKD. METHODS: The ULC-PCI protocol is based on the prespecification of the maximum contrast volume to be administered, extensive intravascular ultrasound (IVUS) and/or dextran-based optical coherence tomography (OCT) guidance, and use of diluted contrast media. We created a retrospective registry to compare the outcomes of the ULC-PCI protocol vs conventional angiography-based PCI in patients with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m², applying no angiographic or procedural restriction criteria. RESULTS: We included 111 patients (ULC-PCI group, n = 8; conventional group, n = 103). Baseline clinical and angiographic characteristics were similar between groups. Contrast volume (8.8 mL [interquartile range, 1.3-18.5] vs 90 mL [interquartile range, 58-140 mL]; P<.001) was markedly lower in the ULC-PCI group. Technical success was achieved in all ULC-PCI procedures; in 7 of the 8 cases (88%), the ULC-PCI protocol was also successful (contrast-volume-to-eGFR ratio <1). The incidence of CI-AKI was 0% vs 15.5% in the ULC-PCI and conventional groups, respectively (P=.28). Procedures in the ULC-PCI group included the use of rotational atherectomy, two-stent bifurcation PCI, and mechanically supported chronic total occlusion PCI. CONCLUSIONS: An ULC-PCI protocol in patients with advanced CKD is feasible, appears to be safe, and has the potential to decrease the incidence of CI-AKI, compared with angiographic guidance alone.

Contrast-Induced Nephropathy After Percutaneous Coronary Intervention for Chronic Total Occlusion Versus Non-Occlusive Coronary Artery Disease.

Contrast volume is associated with the incidence of contrast-induced nephropathy (CIN), and CIN risk could be particularly high in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Our aim was to evaluate the incidence of CIN in patients who underwent CTO versus non-CTO PCI. All PCIs performed at our institution from January 2012 to December 2016 were included in this study. CIN was defined as an increase of ≥0.3 mg/dl or ≥50% from baseline within 72 hours. Multivariable logistic regression analysis was performed to identify independent predictors of CIN. A total of 2,580 patients were included (n = 309 CTO PCI and n = 2271 non-CTO PCI). Estimated glomerular filtration rate was lower in the non-CTO group (73.9 ± 27.3 vs 77.1 ± 24.7 ml/min/1.73/m2, p = 0.05). Patients in the non-CTO PCI group presented more often with acute coronary syndrome (47% vs 15%, p < 0.001). Contrast volume (347 ± 159 vs 215 ± 107 ml, p < 0.001) and contrast-volume-to-creatinine-clearance ratio (4.7 ± 2.1 vs 3.2 ± 1.8, p < 0.001) were higher in the CTO group. There was no difference in CIN rates between CTO and non-CTO groups (9.4% vs 12.1%, p = 0.17). This was confirmed in a sensitivity analysis including only patients who underwent PCI in a stable clinical setting (7.7% vs 8.5%, p = 0.66). On multivariate analysis hypotension during/before PCI (odds ratio [OR] 2.86), acute coronary syndrome (OR 1.86), age (OR 1.54), female sex (OR 1.51), left ventricular ejection fraction (OR 0.64), diabetes mellitus (OR 1.49), and contrast volume (OR 1.17) were independent predictors of CIN, while CTO PCI was not. In conclusion, CTO PCI is associated with similar rates of CIN, compared with non-CTO PCI. These findings persisted on sensitivity and multivariable analyses.

Recanalization of Chronic Total Occlusions in Patients With vs Without Chronic Kidney Disease: The Impact of Contrast-Induced Acute Kidney Injury.

BACKGROUND: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with high contrast volumes, which can be particularly deleterious in patients with chronic kidney disease (CKD). We aimed to study the outcomes of CTO PCI in subjects with vs without CKD, and the impact of contrast-induced acute kidney injury (CI-AKI). METHODS: This multicentre registry included patients who underwent CTO PCI at 5 centres. CI-AKI was defined as an increase in serum creatinine ≥0.3 mg/dL or ≥50% from baseline within 72 hours. Study endpoints were CI-AKI, and all-cause death and target-lesion failure (TLF: cardiac death, target-vessel myocardial infarction, or target-lesion revascularization) on follow-up. RESULTS: Study population included 1092 patients (CKD n = 214, no CKD n = 878). Patients with CKD had more comorbidities and adverse angiographic features, compared with subjects without CKD. Patients with CKD experienced lower technical (79% vs 87%, P = 0.001) and procedural (79% vs 86%, P = 0.008) success rates. CI-AKI developed in 9.1% (CKD 15.0% vs no CKD 7.8%, P = 0.001). Rates of in-hospital need for dialysis were 0.5% vs 0%, respectively (P = 0.03). Patients with CKD had higher 24-month rates of all-cause death (11.2% vs 2.7%, P < 0.001) and new need for dialysis (1.1% vs 0.1%, P = 0.03), but similar TLF rates (12.4% vs 10.5%, P = 0.47). CI-AKI was not an independent predictor of all-cause death or TLF. CONCLUSIONS: CTO PCI in patients with CKD is associated with lower success rates and higher incidence of CI-AKI. The need for dialysis both in-hospital and on follow-up is infrequent. Although patients with CKD suffer higher rates of all-cause death, TLF rates are similar regardless of CKD status.

Incidence of contrast-induced acute kidney injury in a large cohort of all-comers undergoing percutaneous coronary intervention: Comparison of five contrast media.

BACKGROUND: There is controversy as to whether iso-osmolar contrast media (IOCM) are associated with lower risk of contrast-induced acute kidney injury (CI-AKI), compared with low-osmolar contrast media (LOCM). We aimed to evaluate if a differential risk of CI-AKI exists after percutaneous coronary intervention (PCI) according to different contrast media (CM) types. METHODS: We performed a single-center retrospective study in a cohort of all-comers undergoing PCI between January 2012 and December 2016. CI-AKI was defined as an increase in serum creatinine ≥0.3 mg/dl or ≥50% within 72 h from PCI. IOCM were represented by iodixanol, whereas four different LOCM were utilized (ioversol, iopromide, iomeprol, iobitridol). Multiple-treatment inverse probability of treatment weighting (IPTW)-adjusted logistic regression analysis was performed to identify whether CM type was an independent predictor of CI-AKI. RESULTS: We included 2648 subjects (ioversol, n = 272; iopromide, n = 818; iomeprol, n = 611; iobitridol, n = 460; iodixanol, n = 487). CI-AKI occurred in 300 patients (11.7%) overall, with no differences across CM groups (ioversol 13.0%, iopromide 11.5%, iomeprol 10.2%, iobitridol 13.9%, iodixanol 11.3%; p = 0.42). CI-AKI requiring dialysis was observed in 8 patients (0.3%) overall (p = 0.50). On IPTW-adjusted analysis, none of the LOCM was associated with a significantly different risk of CI-AKI compared with iodixanol: ioversol OR 0.986 (95% confidence interval [CI] 0.611-1.591), iopromide OR 0.870 (95% CI 0.606-1.250), iomeprol OR 0.904 (95% CI 0.619-1.319), iobitridol OR 1.258 (95% CI 0.850-1.861). CONCLUSIONS: In a large cohort of all-comers undergoing PCI, there were no differences in the adjusted risk of CI-AKI across 4 LOCM, compared with iodixanol.

Implementation of a Low Frame-Rate Protocol and Noise-Reduction Technology to Minimize Radiation Dose in Transcatheter Aortic Valve Replacement.

OBJECTIVES: Limiting radiation exposure is necessary in radiological procedures. This study evaluates the impact of a radiological low frame-rate protocol in a standard angiographic system and the implementation of a noise-reduction technology (NRT) on patient radiation exposure during transcatheter aortic valve replacement (TAVR). METHODS: Transfemoral TAVR procedures performed between February 2016 and February 2017 were analyzed according to two angiographic systems, Standard and NRT, and further divided in four subgroups: (1) Standard 15 frames per second (fps) with 15 fps for both fluoroscopy and cine acquisitions; (2) Standard 7.5 fps with 7.5 fps for both fluoroscopy and cine acquisitions; (3) NRT 15 fps with 15 fps for both fluoroscopy and cine acquisitions; and (4) NRT 7.5 fps with 15 fps for fluoroscopy and 7.5 fps for cine acquisitions. Study endpoints were kerma area product (KAP) and cumulative air kerma at interventional reference point (AK at IRP). RESULTS: Significant differences were found in KAP (153 Gy·cm² [IQR, 95-234 Gy·cm²] vs 78.3 Gy·cm² [IQR, 54.4-103.5 Gy·cm²]; P<.001) and AK at IRP (1.454 Gy [IQR, 0.893-2.201 Gy] vs 0.620 Gy [IQR, 0.437-0.854 Gy]; P<.001) between Standard system and NRT. Within the procedures conducted with Standard protocol, a reduction of KAP and AK at IRP was found between Standard 15 fps and Standard 7.5 fps groups (184 Gy·cm² [IQR, 128-262 Gy·cm²] vs 106.8 Gy·cm² [IQR, 76.87-181 Gy·cm²] [P<.01] and 0.973 Gy [IQR, 0.642-1.786 Gy] vs 0.64 Gy [IQR, 0.489-0.933 Gy] [P<.01], respectively). CONCLUSIONS: The present study suggests that the low frame-rate protocol in Standard system and NRT implementation allows a marked reduction of patient radiation exposure in TAVR procedures.

Noise reduction technology reduces radiation dose in chronic total occlusions percutaneous coronary intervention: a propensity score-matched analysis.

Chronic total occlusions (CTO) percutaneous coronary intervention (PCI) is associated with high radiation dose. Our study aim was to evaluate the impact of the implementation of a noise reduction technology (NRT) on patient radiation dose during CTO PCI. A total of 187 CTO PCIs performed between February 2016 and May 2017 were analyzed according to the angiographic systems utilized: Standard (n = 60) versus NRT (n = 127). Propensity score matching (PSM) was performed to control for differences in baseline characteristics. Primary endpoints were Cumulative Air Kerma at Interventional Reference Point (AK at IRP), which correlates with patient's tissue reactions; and Kerma Area Product (KAP), a surrogate measure of patient's risk of stochastic radiation effects. An Efficiency Index (defined as fluoroscopy time/AK at IRP) was calculated for each procedure. Image quality was evaluated using a 5-grade Likert-like scale. After PSM, n = 55 pairs were identified. Baseline and angiographic characteristics were well matched between groups. Compared to the Standard system, NRT was associated with lower AK at IRP [2.38 (1.80-3.66) vs. 3.24 (2.04-5.09) Gy, p = 0.035], a trend towards reduction for KAP [161 (93-244) vs. 203 (136-363) Gycm2, p = 0.069], and a better Efficiency Index [16.75 (12.73-26.27) vs. 13.58 (9.92-17.63) min/Gy, p = 0.003]. Image quality was similar between the two groups (4.39 ± 0.53 Standard vs. 4.34 ± 0.47 NRT, p = 0.571). In conclusion, compared with a Standard system, the use of NRT in CTO PCI is associated with lower patient radiation dose and similar image quality.

Outcomes of a novel thin-strut bioresorbable-polymer sirolimus-eluting stent in patients with chronic total occlusions: A multicenter registry.

BACKGROUND: We aimed to evaluate the mid-term outcomes of a novel thin-strut bioresorbable-polymer sirolimus-eluting stent (BP-SES) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI), as compared with durable-polymer everolimus-eluting stents (EES). METHODS: We compiled a multicenter registry of patients undergoing CTO recanalization followed by BP-SES or EES implantation. The primary endpoint was the incidence of target-lesion failure (TLF, a composite of cardiac death, target-vessel myocardial infarction, and target-lesion revascularization) at one year. Propensity score matching (PSM) was used to adjust for case mix. RESULTS: Overall, 413 patients were included (BP-SES n = 242, EES n = 171). PSM resulted in 131 matched pairs, which represented the subject of the main analysis. Antegrade wire escalation was the most successful crossing technique (66% vs. 63%, p = 0.98) in both the BP-SES and EES groups, respectively. Procedural success rates were similar between groups (BP-SES 96% vs. EES 93%, p = 0.24). At one-year follow-up, there were no differences in the primary endpoint of TLF (5.7% vs. 8.3%, p = 0.44), and in cardiac death (0.9% vs. 2.8%, p = 0.32), target-vessel myocardial infarction (0.9% vs 1.9%, p = 0.57), target-lesion revascularization (3.7% vs 3.7%, p = 0.99), or stent thrombosis (0.9% vs. 1.9%, p = 0.57), in BP-SES vs. EES, respectively. CONCLUSIONS: Patients undergoing CTO PCI with BP-SES suffer a low rate of TLF at one-year follow-up, which is similar to that of subjects treated with durable-polymer EES.

Analysis of a Low Dose Protocol to Reduce Patient Radiation Exposure During Percutaneous Coronary Interventions.

The cardiac catheterization laboratory is an important source of radiation for patients and operators and it is good practice to limit exposure as much as possible. The purpose of this study was to evaluate the effectiveness and impact of a radiological low dose protocol (LDP) in terms of reduction in patient radiation exposure during percutaneous coronary interventions (PCIs). From November 2014 to October 2015, 906 consecutive patients who underwent PCI were evaluated. Of these, 571 patients (63%) were treated with the standard dose protocol (SDP) of 15 frames per second for cine acquisition and standard settings for fluoroscopy, and 335 patients (37%) with the LDP of 7.5 frames per second for cine acquisition and low-dose settings for fluoroscopy. In the LDP group, we observed a significant reduction of kerma area product (53.3 LDP vs 115 SDP Gycm2, p <0.0001) and air kerma at interventional reference point (0.79 LDP vs 1.976 SDP Gy, p <0.0001). Marked differences were observed regarding the exceeding of International Commission on Radiological Protection and National Council on Radiation Protection and Measurements' air kerma at interventional reference point trigger level (cutoff for potential skin injuries), which were significantly lower in the LDP group (1.8% vs 7.2%, p <0.0001). Such difference was more relevant in complex PCI. In conclusion, the implementation of LDP allowed a marked reduction in patient dosimetric parameters for PCI and significantly reduced the risk of exceeding the International Commission on Radiological Protection/National Council on Radiation Protection and Measurements trigger levels for potential skin injuries.

Radiation Exposure and Contrast Agent Reduction During Transcatheter Aortic Valve Implantation: An Ongoing Experience.

OBJECTIVES: To determine the patient radiation exposure and contrast agent variation during transcatheter aortic valve implantation (TAVI) procedures resulting from technological improvements. METHODS: TAVI procedures from January 2008 to July 2015 were analyzed in three different time periods: 1st period, when the angiography was equipped with an image intensifier technology; 2nd period, starting with the installation of a new angiography system with flat-panel detector (FPD) technology; and 3rd period, starting with the systematic use of preprocedural multidetector computed tomography (MDCT) to individualize optimal fluoroscopic projections for the aortic prosthesis implantation. RESULTS: Significant differences were found in contrast volume (198 ± 99 mL vs 139 ± 74 mL; P<.001), kerma area product (211 ± 135 Gy•cm² vs 147 ± 120 Gy•cm²; P<.001) and effective dose (42 ± 27 mSv vs 29 ± 24 mSv; P<.001) between the 1st and 2nd periods, respectively. The reduction continued between the 2nd and 3rd periods for contrast volume (139 ± 74 mL vs 110 ± 61 mL; P<.001), kerma area product (147 ± 120 Gy•cm² vs 111 ± 69 Gy•cm²; P<.001), and effective dose (29 ± 24 mSv vs 22 ± 11 mSv; P<.001), respectively. CONCLUSIONS: The present study suggests that the appropriate use of FPD technology and preprocedural MDCT to individualize fluoroscopic implant projections for TAVI temporally reduced the amount of radiation and contrast agent administered over time.

A comparison of the femoral and radial crossover techniques for vascular access management in transcatheter aortic valve implantation: the Milan experience.

OBJECTIVE: To compare radial and femoral crossover techniques (CT) for vascular access management in transcatheter aortic valve implantation (TAVI). BACKGROUND: Femoral crossover for controlled angiography and balloon inflation of the therapeutic access site to facilitate safe vascular closure is beneficial but technically challenging in patients with complex femoral anatomy. An alternative approach should be available. METHODS: Between June 2011 and March 2012, 41 transfemoral TAVI patients receiving the femoral CT were compared to 46 transfemoral TAVI patients receiving the radial CT. Outcomes were 30-day valve academic research consortium (VARC) endpoints. RESULTS: Patients undergoing the radial CT received higher median contrast volumes (150 interquartile range [IQR]: 105-180 vs. 111 IQR: 90-139 ml; P = 0.025) but procedural radiation dose and fluoroscopy times were comparable. Thirty day all cause and cardiovascular death were similar between radial and femoral CT groups (respectively 2.4% vs. 7.9%, P = 0.258 and 0% vs. 7.9%, P = 0.063). There were no differences in major vascular complications (4.3% vs. 7.3%, P = 0.553), life threatening or major bleeding events (respectively 9.1% vs. 19.5%, P = 0.168 and 13.6% vs. 22%, P = 0.315). CONCLUSION: In TAVI cases with unfavorable contralateral femoral anatomy, radial CT for vascular access management is a reasonable alternative to the femoral CT.

Estimating incidence of organ cancer related to PCI radiation exposure in patients treated for acute and chronic total occlusions.

BACKGROUND: Minimal data exist on the number of additional cancer cases related to radiation exposure following percutaneous coronary intervention (PCI). The aim of this study is to estimate the lifetime attributable risk (LAR) of cancer incidence for individual organs following radiation exposure during PCI in the context of two opposite sides of the angiographic spectrum of coronary occlusive disease: ST-elevation myocardial infarction (STEMI) and chronic coronary total occlusion (CTO). METHODS AND RESULTS: We identified all consecutive patients treated with PCI for STEMI (n = 555) and for CTO (n = 543) in a tertiary care center in 6 years. The LARs of cancer incidence for 6 organs were estimated using the Biological Effects of Ionizing Radiation (BEIR) VII model. The estimated LAR of cancer incidence for individual organs was found to markedly increase as the age of the patient decreased and was significantly higher for the lung (additional risk up to 18/100,000 persons exposed in CTO and 9/100,000 persons exposed in STEMI patients, respectively; P<.0001) and for the red bone marrow (up to 3.5/100,000 persons exposed and 1.5/100,000 persons exposed, respectively; P<.0001). CONCLUSION: In PCI procedures, the lung was the organ with the highest radiation absorbed. The number of additional estimated cancer cases for individual organs was on average two times higher in patients treated with PCI for CTO and the highest estimated LARs were for lung and red bone marrow cancers.

How should I treat a left main spontaneous dissection involving left anterior descending artery, intermediate branch artery and left circumflex artery?

BACKGROUND: A 45-year-old woman presented to the emergency department with ST-segment elevation myocardial infarction (STEMI). INVESTIGATION: Physical examination, electrocardiography, coronary angiography, echocardiography, cardiac computed tomography. DIAGNOSIS: STEMI due to spontaneous left main coronary artery dissection involving left anterior descending, intermediate and left circumflex arteries. TREATMENT: Percutaneous coronary intervention (PCI).

New-generation drug-eluting stent experience in the percutaneous treatment of unprotected left main coronary artery disease: the NEST registry.

OBJECTIVES: To explore the 2-year clinical outcomes in patients with unprotected left main coronary artery (ULMCA) disease treated with overall new drug-eluting stent (DES) options. BACKGROUND: Recent available data have shown the feasibility and the safety of new DESs, mainly evaluating the everolimus-eluting stents in the setting of ULMCA disease. METHODS: Patients with ULMCA disease undergoing percutaneous coronary intervention (PCI) with everolimus-, zotarolimus-, and biolimus A9-eluting stents were prospectively evaluated. The study objective was the composite of major adverse cardiac events (MACEs), consisting of all-cause mortality, myocardial infarction (MI), and target vessel revascularization (TVR) at 2-year clinical follow-up. RESULTS: A total of 154 patients were analyzed. The mean EuroSCORE and SYNTAX scores were 4.7 ± 2.6 and 27.5 ± 8.3, respectively. Distal location was present in 126 patients (81.8%) and 96 lesions (76.3%) were true Medina bifurcations. The 2-stent technique was used in 73 cases (57.9%). Everolimus-, zotarolimus-, and biolimus A9-eluting stents were implanted in 68 patients (44.2%), 46 patients (29.9%), and 40 patients (25.9%), respectively. At a median clinical follow-up of 551.5 days (interquartile range, 360.8-1045.5 days), MACEs occurred in 29 patients (18.8%). Ten patients (6.5%) died, and 2 deaths (1.3%) were adjudicated as cardiac. No patient had myocardial infarction or definite stent thrombosis (ST). One probable and 1 possible ST were adjudicated. TVR was required in 19 patients (12.3%) and target lesion revascularization was required in only 7 patients (4.5%). CONCLUSIONS: In our experience, despite the presence of complex distal left main lesions, new DESs in ULMCA disease appear to be promising in terms of safety and efficacy at 2-year clinical follow-up.

A "modified crossover technique" for vascular access management in high-risk patients undergoing transfemoral transcatheter aortic valve implantation.

OBJECTIVES: To describe results from our "modified crossover technique" for vascular access management during transcatheter aortic valve implantation (TAVI). BACKGROUND: Vascular access management remains a major cause of complications following TAVI due to the large bore sheaths required. METHODS: All suitable patients undergoing TAVI in our center, between June and August 2011, underwent our "modified crossover technique," which enables the passage of a balloon through left radial access and inflation in the proximal iliac to allow percutaneous closure in a clean field. RESULTS: In total, 15 patients were included: the logistic EuroSCORE was 19.7 ± 12.1% and STS score 5.7 ± 5.6%. The mean therapeutic femoral access site diameter was 8.1 ± 1.0 mm. Ten (66.7%) patients received Edwards SAPIEN™ XT (two using the new E-sheath) and five (33.3%) patients a Medtronic CoreValve ReValving System® device. The "modified crossover technique" was used successfully in all patients. There were three vascular complications occurring at the therapeutic access site: one rupture of the external iliac artery, one Prostar failure, and one pseudoaneurysm of the right common femoral artery. All complications were successfully treated percutaneously with covered stent implantation via access from the contralateral femoral artery. In view of the balloon inflation from the left radial artery, the complications could be treated in a clean field with minimal blood loss. CONCLUSIONS: Our "modified crossover technique" using the left radial artery as the diagnostic site for balloon inflation appears a helpful adjunct in managing TAVI vascular access sites.