Chronological vs Biological Age in Interventional Cardiology: A Comprehensive Approach to Care for Older Adults: JACC Family Series.

Aging is the gradual decline in physical and physiological functioning leading to increased susceptibility to stressors and chronic illnesses, including cardiovascular disease. With an aging global population, in which 1 in 6 individuals will be older than 60 years by 2030, interventional cardiologists are increasingly involved in providing complex care for older individuals. Although procedural aspects remain their main clinical focus, interventionalists frequently encounter age-associated risks that influence eligibility for invasive care, decision making during the intervention, procedural adverse events, and long-term management decisions. The unprecedented growth in transcatheter interventions, especially for structural heart diseases at extremes of age, have pushed age-related risks and implications for cardiovascular care to the forefront. In this JACC state-of-the-art review, the authors provide a comprehensive overview of the aging process as it relates to cardiovascular interventions, with special emphasis on the difference between chronological and biological aging. The authors also address key considerations to improve health outcomes for older patients during and after their invasive cardiovascular care. The role of "gerotherapeutics" in interventional cardiology, technological innovation in measuring biological aging, and the integration of patient-centered outcomes in the older adult population are also discussed.

Arrhythmic and Mortality Outcomes Among Ischemic Versus Nonischemic Cardiomyopathy Patients Receiving Primary ICD Therapy.

OBJECTIVES: This study sought to determine the association of cardiomyopathy etiology with the likelihood of ventricular arrhythmias, appropriate implantable cardioverter-defibrillator (ICD) therapy, and mortality. BACKGROUND: There are conflicting data on the benefit of primary prevention ICD therapy in patients with ischemic versus nonischemic cardiomyopathy (ICM/NICM). METHODS: The study population comprised 4803 patients with ICM (n = 3,106) or NICM (n = 1,697) with a primary prevention ICD enrolled in 5 randomized trials conducted between 1997 and 2017. The primary end point was sustained ventricular tachycardia (VT) ≥200 beats/min or ventricular fibrillation (VF). Secondary end points included appropriate ICD therapy and all-cause mortality. Differences in cause-specific mortality, including noncardiac, sudden cardiac, and non-sudden cardiac death, were also examined. RESULTS: Patients with ICM were significantly older and had more comorbid conditions, whereas those with NICM had a more advanced heart failure class at enrollment and were more often prescribed medical or cardiac resynchronization therapy for heart failure. Multivariate analysis showed that ICM versus NICM had a similar risk of VT/VF events (HR: 0.98 [95% CI: 0.79-1.20]) and appropriate ICD therapy (HR: 1.03 [95% CI: 0.87-1.22]), whereas the risk of all-cause mortality was 1.8-fold higher among ICM versus NICM patients (HR: 1.84 [95% CI: 1.42-2.38]), dominated by non-sudden cardiac mortality. CONCLUSIONS: Combined data from 5 landmark ICD clinical trials show that ICM patients experience a similar risk of life-threatening ventricular arrhythmic events but have an increased risk of all-cause mortality, dominated by non-sudden cardiac death, compared with NICM patients.

Variability of Activated Clotting Time by Site of Sample Draw During Percutaneous Coronary Intervention: A Prospective Single-Center Study.

The activated clotting time (ACT) assay is used to monitor and titrate anticoagulation therapy with unfractionated heparin during percutaneous coronary intervention (PCI). Observations at our institution suggested a considerable difference between ACT values drawn from varying arterial sites, prompting the current study. Patients undergoing PCI with unfractionated heparin therapy were prospectively enrolled. Simultaneous arterial blood samples were drawn from the access sheath and the coronary guide catheter. Differences between Hemochron ACT values were determined, and potential interactions with clinical variables were analyzed. Immediately postprocedure, the simultaneous mean guide and sheath ACTs were 327 ± 62 seconds and 257 ± 44 seconds, respectively, with a mean difference of 70 ± 60 seconds (P < .001). Nearly all (90%) ACT values obtained via the guide catheter were higher than the concurrent ACT drawn from the sheath. Logistic regression analysis demonstrated that lower weight-adjusted heparin doses and absence of diabetes were associated with a greater difference between the ACT values. We conclude that the ACT value is substantially greater when assessed via the guide catheter versus the access sheath. Although the biological mechanisms require further study, this difference should be considered when managing anticoagulation during PCI and when reporting ACT as part of research protocols.

Direct right ventricular Impella LD implantation enables postoperative ambulation and may avoid sternal re-entry.

Right ventricular assist devices (RVADs) typically require groin cannulation or sternal re-entry which can be avoided by direct pulmonary artery implantation with an Impella. We report the first use of the Impella LD as a directly implanted RVAD.

Patient and Physician Perspectives on Public Reporting of Mortality Ratings for Percutaneous Coronary Intervention in New York State.

BACKGROUND: Public reporting of physician-specific outcome data for procedures, such as percutaneous coronary intervention (PCI), can influence physicians to avoid high-risk patients who may benefit from treatment. Prior physician attitudes toward public scorecards in New York State (NYS) have been studied, but the exclusion criteria have evolved. Additionally, patient perceptions toward such reports remain poorly understood. This study evaluates (1) whether exclusion of certain high-risk patients from public reporting of PCI outcomes in NYS has influenced physician attitudes, (2) current patient awareness and use of publicly reported outcome data, and (3) differences in physician and patient attitudes toward public reporting. METHODS AND RESULTS: A questionnaire was administered to interventional cardiologists in NYS with specific emphasis on how modifications in publicly reported outcome data have influenced their practice. The results were compared with a 2003 survey administered by our group. A separate questionnaire regarding the publicly available NYS PCI Report was administered to patients referred to our center for possible PCI. The majority of interventional cardiologists indicated that the exclusion of patients with anoxic brain injury and refractory cardiogenic shock from public reporting has made them more likely to perform PCI for these subgroups. While patient awareness of the NYS PCI Report was low, patients were significantly more likely than physicians to think that publication of physician-specific mortality data can provide an accurate measure of physician quality, serve to improve patient care, and provide useful information in terms of physician selection. CONCLUSIONS: The study provides further evidence that public reporting of physician-specific outcome data influences physician behavior and indicates that significant discrepancies exist in how scorecards are perceived by physicians versus patients.

Distal Embolization During Percutaneous Subclavian Artery Intervention.

Distal embolization due to atherothrombotic debris during subclavian artery interventions is extremely rare and can usually be managed conservatively. Herein, we describe a case of acute hand ischemia due to massive distal embolization during balloon angioplasty and stenting of a left subclavian artery chronic total occlusion. This limb-threatening complication was effectively treated with rescue surgical thrombectomy.

Inferior Vena Cava Thrombosis.

Thrombosis of the inferior vena cava (IVC) is an under-recognized entity that is associated with significant short- and long-term morbidity and mortality. In absence of a congenital anomaly, the most common cause of IVC thrombosis is the presence of an unretrieved IVC filter. Due to the substantial increase in the number of IVC filters placed in the United States and the very low filter retrieval rates, clinicians are faced with a very large population of patients at risk for developing IVC thrombosis. Nevertheless, there is a paucity of data and societal guidelines with regards to the diagnosis and management of IVC thrombosis. This paper aims to enhance the awareness of this uncommon, but morbid, condition by providing a concise, yet comprehensive, review of the etiology, diagnostic approaches, and treatment strategies in patients with IVC thrombosis.

Percutaneous Decompression of the Left Ventricle in Cardiogenic Shock Patients on Venoarterial Extracorporeal Membrane Oxygenation.

OBJECTIVE: Extracorporeal membrane oxygenation is an important therapeutic option for patients with refractory cardiogenic shock. Adequate decompression of the left ventricular in these patients is a key predictor of successful recovery. The currently available percutaneous decompression techniques are limited by their partial unloading capability. METHOD: We describe a series of four consecutive patients with refractory cardiogenic shock in whom adequate left ventricular decompression was achieved by integrating a transseptally placed left ventricular cannula into the existing extracorporeal membrane oxygenation circuit. RESULTS: From May to June 2015, four consecutive patients underwent transvenous transseptal left ventricular decompression with a 22 French cannula that was integrated into the extracorporeal membrane oxygenation circuit in a Y fashion. The mean age was 47.5 ± 20 years. All patients had refractory shock, and three patients failed prior decompression with an intra-aortic balloon pump. Fluoroscopy time was 12.15 ± 2.6 minutes. No procedural complications were noted. All patients had significant reduction in their pulmonary capillary wedge pressure and resolution of their pulmonary edema. Two patients died during the hospitalization due to sepsis and/or multiorgan failure. CONCLUSION: Antegrade transseptal left ventricular decompression is feasible in patients on extracorporeal membrane oxygenation and persistent pulmonary edema.

Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial.

BACKGROUND: In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), the composite primary endpoint of stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke thereafter did not differ between carotid artery stenting and carotid endarterectomy for symptomatic or asymptomatic carotid stenosis. A secondary aim of this randomised trial was to compare the composite endpoint of restenosis or occlusion. METHODS: Patients with stenosis of the carotid artery who were asymptomatic or had had a transient ischaemic attack, amaurosis fugax, or a minor stroke were eligible for CREST and were enrolled at 117 clinical centres in the USA and Canada between Dec 21, 2000, and July 18, 2008. In this secondary analysis, the main endpoint was a composite of restenosis or occlusion at 2 years. Restenosis and occlusion were assessed by duplex ultrasonography at 1, 6, 12, 24, and 48 months and were defined as a reduction in diameter of the target artery of at least 70%, diagnosed by a peak systolic velocity of at least 3·0 m/s. Studies were done in CREST-certified laboratories and interpreted at the Ultrasound Core Laboratory (University of Washington). The frequency of restenosis was calculated by Kaplan-Meier survival estimates and was compared during a 2-year follow-up period. We used proportional hazards models to assess the association between baseline characteristics and risk of restenosis. Analyses were per protocol. CREST is registered with ClinicalTrials.gov, number NCT00004732. FINDINGS: 2191 patients received their assigned treatment within 30 days of randomisation and had eligible ultrasonography (1086 who had carotid artery stenting, 1105 who had carotid endarterectomy). In 2 years, 58 patients who underwent carotid artery stenting (Kaplan-Meier rate 6·0%) and 62 who had carotid endarterectomy (6·3%) had restenosis or occlusion (hazard ratio [HR] 0·90, 95% CI 0·63-1·29; p=0·58). Female sex (1·79, 1·25-2·56), diabetes (2·31, 1·61-3·31), and dyslipidaemia (2·07, 1·01-4·26) were independent predictors of restenosis or occlusion after the two procedures. Smoking predicted an increased rate of restenosis after carotid endarterectomy (2·26, 1·34-3·77) but not after carotid artery stenting (0·77, 0·41-1·42). INTERPRETATION: Restenosis and occlusion were infrequent and rates were similar up to 2 years after carotid endarterectomy and carotid artery stenting. Subsets of patients could benefit from early and frequent monitoring after revascularisation. FUNDING: National Institute of Neurological Disorders and Stroke and Abbott Vascular Solutions.

Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial.

BACKGROUND: The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) found a higher risk of stroke after carotid artery stenting and a higher risk of myocardial infarction (MI) after carotid endarterectomy. METHODS AND RESULTS: Cardiac biomarkers and ECGs were performed before and 6 to 8 hours after either procedure and if there was clinical evidence of ischemia. In CREST, MI was defined as biomarker elevation plus either chest pain or ECG evidence of ischemia. An additional category of biomarker elevation with neither chest pain nor ECG abnormality was prespecified (biomarker+ only). Crude mortality and risk-adjusted mortality for MI and biomarker+ only were assessed during follow-up. Among 2502 patients, 14 MIs occurred in carotid artery stenting and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence interval, 0.26 to 0.94; P=0.032) with a median biomarker ratio of 40 times the upper limit of normal. An additional 8 carotid artery stenting and 12 carotid endarterectomy patients had biomarker+ only (hazard ratio, 0.66; 95% confidence interval, 0.27 to 1.61; P=0.36), and their median biomarker ratio was 14 times the upper limit of normal. Compared with patients without biomarker elevation, mortality was higher over 4 years for those with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or biomarker+ only (hazard ratio, 3.57; 95% confidence interval, 1.46 to 8.68). After adjustment for baseline risk factors, both MI and biomarker+ only remained independently associated with increased mortality. CONCLUSIONS: In patients randomized to carotid endarterectomy versus carotid artery stenting, both MI and biomarker+ only were more common with carotid endarterectomy. Although the levels of biomarker elevation were modest, both events were independently associated with increased future mortality and remain an important consideration in choosing the mode of carotid revascularization or medical therapy. CLINICAL TRIAL REGISTRATION: URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00004732.

Time dependence of life-threatening ventricular tachyarrhythmias after coronary revascularization in MADIT-CRT.

BACKGROUND: Coronary revascularization (CR) may confer electrical stability in patients with ischemic cardiomyopathy. However, data regarding the effect of CR on the development of ventricular tachyarrhythmias in this population are limited. OBJECTIVE: The purpose of this study was to evaluate the association between CR and arrhythmic risk in postmyocardial infarction (post-MI) patients with left ventricular dysfunction. METHODS: The risk for life-threatening ventricular tachyarrhythmias (defined as a first appropriate defibrillator therapy for ventricular tachycardia [VT]/ventricular fibrillation [VF] or death) was compared between post-MI patients with and those without prior CR (n = 612 and 147, respectively) enrolled in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT). RESULTS: The 3-year cumulative rate of VT/VF or death was significantly higher among patients without prior CR (42%) than in patients who underwent prior CR (32%, P = .02). Multivariate analysis demonstrated that patients without prior CR had 48% increased risk (P = .01) for VT/VF or death. Risk reduction associated with CR was related to elapsed time from CR, assessed both as a categorical variable (tertiles for time from CR: ≥7 years, hazard ratio [HR] = 1.93, P = .001; 1.5-7 years, HR = 1.70, P = .01 vs <1.5 years) and as a continuous measure (4%, P = .002, increased risk for VT/VF or death per 1-year increment of elapsed time from CR). The effect of CR on arrhythmic risk was similar in patients treated with a defibrillator alone or when combined with cardiac resynchronization therapy. CONCLUSION: Post-MI patients with left ventricular dysfunction who undergo CR experience a time-dependent reduction in the risk for subsequent life-threatening ventricular tachyarrhythmias.

Access strategies for peripheral arterial intervention.

An operator's ability to determine the optimal vascular access strategy for patients undergoing peripheral endovascular intervention is critical to maximizing procedural safety and success. Individualizing an approach to access requires careful planning, and is contingent upon a solid general knowledge of normal and abnormal vascular anatomy, as well as the particulars of each patient's history, physical examination, and non-invasive test results. An awareness of the technical nuances, relative safety, and indications for obtaining percutaneous arterial access at all potential sites is essential. Available means for approaching lower extremity arterial disease include the retrograde and antegrade common femoral approaches, the contralateral crossover technique, upper extremity approaches from the radial, brachial, or axillary arteries, or occasionally retrograde access via the popliteal, dorsalis pedis, or tibial arteries. These techniques, as well as important considerations for approaching disease of the renal, subclavian, and carotid arteries are reviewed.

A prospective, randomized trial of topical hemostasis patch use following percutaneous coronary and peripheral intervention.

The use of topical hemostasis patches has grown rapidly despite a paucity of evidence supporting their clinical utility. We performed a randomized, controlled trial to assess the efficacy of a topical hemostasis patch as a means to accelerate vascular hemostasis following percutaneous intervention. One hundred fifty (150) patients undergoing coronary or peripheral intervention through a 6 Fr femoral arterial sheath were randomized to sheath removal with either: (1) manual pressure and adjunctive use of a patch incorporating a polysaccharide based procoagulant material (SafeSeal Patch, Possis Medical Inc.); or (2) conventional manual pressure alone. Sheaths were removed when the activated clotting time (ACT) fell to < or = 250 seconds. Patients ambulated 2 hours after hemostasis was achieved. Time to hemostasis (duration of compression required until cessation of bleeding following sheath removal) was significantly lower in the hemostasis patch arm (11.8 +/- 3.6 vs. 13.8 +/- 5.8 minutes; p = 0.02). Attainment of hemostasis in < 15 minutes was also more likely among patients randomized to the hemostasis patch rather than manual compression alone (odds ratio = 2.5; 95% confidence intervals 1.2, 5.1; p = 0.014). The median time to ambulation (total duration from the end of the interventional procedure to ambulation) was significantly reduced among patients in the hemostasis patch arm (2.8 vs. 3.8 hours; p = 0.03). Bleeding complications were uncommon and did not differ between the study arms. In conclusion, this trial supports the concept that the polysaccharide-based SafeSeal Patch enhances access site hemostasis following endovascular intervention.

Potential pitfalls of renal angiography: a case of atypical fibromuscular dysplasia.

Although angiography remains the gold standard for the diagnosis of renal artery stenosis, renovascular disease can at times present with unusual patterns that may be difficult to detect. The authors present a case in which an initial renal angiogram failed to identify the presence of severe disease involving both a main and accessory renal artery. Repeat angiography coupled with the use of adjunctive catheter-based techniques including translesional pressure gradient determination and intravascular ultrasound with virtual histology imaging revealed the presence of atypical fibromuscular dysplasia that was treated with good clinical results. The case highlights the importance of performing careful and complete renal angiography, including imaging of smaller accessory renal arteries, and describes several readily available catheter-based techniques that can be useful in elucidating the physiological significance and etiology of renal artery stenosis.