RESUMEN
Severe calcification is frequent in coronary chronic total occlusions (CTO), and its presence has been associated with increased procedural complexity and poor long-term outcomes following percutaneous coronary intervention (PCI) in an already challenging anatomical setting. The diagnostic characterisation of heavily calcified CTOs using non-invasive and invasive imaging tools can lead to the application of different therapeutic options during CTO PCI, in order to achieve adequate lesion preparation and optimal stent implantation. In this expert review, the European Chronic Total Occlusion Club provides a contemporary, methodological approach, specifically addressing heavily calcified CTOs, suggesting an integration of evidence-based diagnostic methods to tailored, up-to-date percutaneous therapeutic options.
Asunto(s)
Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/métodos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/cirugía , Factores de Riesgo , Resultado del Tratamiento , Enfermedad Crónica , Angiografía CoronariaRESUMEN
Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning. The contemporary procedural success rate is 80-90% with a reduction in complications. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. Despite this evidence, CTO recanalisation is grossly underutilised. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology.
Asunto(s)
Oclusión Coronaria , Intervención Coronaria Percutánea , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/cirugía , Humanos , Calidad de Vida , Sistema de Registros , Resultado del TratamientoRESUMEN
Dual lumen microcatheters (DLMC) have become indispensable tools in the setting of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). Other than allowing preservation and treatment of bifurcated coronary branches within or in the proximity of the CTO body, they enable the use of modified parallel wiring, antegrade dissection and re-entry, collateral selection and retrograde negotiation of the distal CTO cap. This EuroCTO consensus document describes current DLMC and suggests a practical guide to anatomies and techniques in which these devices are applicable.
Asunto(s)
Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/efectos adversosRESUMEN
The proposed 2020 Core Curriculum for Percutaneous Cardiovascular Interventions aims to provide an updated European consensus that defines the level of experience and knowledge in the field of percutaneous cardiovascular intervention (PCI). It promotes homogenous education and training programmes among countries, and is the cornerstone of the new EAPCI certification, designed to support the recognition of competencies at the European level and the free movement of certified specialists in the European Community. It is based on a thorough review of the ESC guidelines and of the EAPCI textbook on percutaneous interventional cardiovascular medicine. The structure of the current core curriculum evolved from previous EAPCI core curricula and from the "2013 core curriculum of the general cardiologist" to follow the current ESC recommendations for core curricula. In most subject areas, there was a wide - if not unanimous - consensus among the task force members on the training required for the interventional cardiologist of the future. The document recommends that acquisition of competence in interventional cardiology requires at least two years of postgraduate training, in addition to four years devoted to cardiology. The first part of the curriculum covers general aspects of training and is followed by a comprehensive description of the specific components in 54 chapters. Each of the chapters includes statements of the objectives, and is further subdivided into the required knowledge, skills, behaviours, and attitudes.
Asunto(s)
Cardiología , Intervención Coronaria Percutánea , Cardiología/educación , Consenso , Curriculum , Europa (Continente) , HumanosRESUMEN
Coronary calcifications remain associated to increased rate of complications and worse clinical outcomes, particularly in the setting of in-stent restenosis. We present the first reported case of combined rotational atherectomy and intravascular lithotripsy for the treatment of heavily calcified neoatherosclerosis.
Asunto(s)
Aterectomía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/terapia , Stents Liberadores de Fármacos , Litotricia , Intervención Coronaria Percutánea/instrumentación , Placa Aterosclerótica , Calcificación Vascular/terapia , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/etiologíaAsunto(s)
Disección Aórtica/diagnóstico por imagen , Aneurisma Coronario/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Tomografía de Coherencia Óptica , Disección Aórtica/tratamiento farmacológico , Tratamiento Conservador , Aneurisma Coronario/tratamiento farmacológico , Angiografía Coronaria , Vasos Coronarios/efectos de los fármacos , Humanos , Masculino , Persona de Mediana EdadAsunto(s)
Implantes Absorbibles , Enfermedad de la Arteria Coronaria/cirugía , Intervención Coronaria Percutánea/instrumentación , Polímeros , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Trombosis Coronaria/etiología , Difusión de Innovaciones , Humanos , Intervención Coronaria Percutánea/efectos adversos , Diseño de Prótesis , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
Coronary artery disease is associated to high mortality and morbidity rates and an accurate diagnostic assessment during heart catheterization has a fundamental role in prognostic stratification and treatment choices. Coronary angiography has been integrated by intravascular imaging modalities, namely intravascular ultrasound and optical coherence tomography, which allow the precise quantification of the atherosclerotic burden of coronary arteries. The hemodynamic relevance of a given coronary stenosis can be assessed using stress or resting indexes: fractional flow reserve and instantaneous wave-free ratio are both coronary flow surrogates, used to guide percutaneous coronary interventions. This review summarizes the current state-of-the-art of invasive diagnostic methods during heart catheterization and highlights the potential role that an integration of anatomical and functional information enables.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/fisiopatología , Cateterismo Cardíaco , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Reserva del Flujo Fraccional Miocárdico , Humanos , Tomografía de Coherencia Óptica , Ultrasonografía IntervencionalRESUMEN
We sought to assess in-stent variations in fractional flow reserve (FFR) in patients with previous percutaneous coronary intervention (PCI) and to associate any drop in FFR with findings by optical coherence tomography (OCT) imaging. Suboptimal post-PCI FFR values were previously associated with poor outcomes. It is not known to which extent in-stent pressure loss contributes to reduced FFR. In this single-arm observational study, 26 patients who previously underwent PCI with drug-eluting stent or scaffold implantation were enrolled. Motorized FFR pullback during continuous intravenous adenosine infusion and OCT assessments was performed. Post-PCI FFR < 0.94 was defined as suboptimal. At a median of 63 days after PCI (interquartile range: 59-64 days), 18 out of 26 patients (72%) had suboptimal FFR. The in-stent drop in FFR was significantly higher in patients with suboptimal FFR vs. patients with optimal FFR (0.08 ± 0.07 vs. 0.01 ± 0.02, p < 0.001). Receiver operating characteristic curve analysis showed that an in-stent FFR variation of > 0.03 was associated with suboptimal FFR. In patients with suboptimal FFR, the OCT analyses revealed higher mean neointimal area (respectively: 1.06 ± 0.80 vs. 0.51 ± 0.23 mm2; p = 0.018) and higher neointimal thickness of covered struts (respectively 0.11 ± 0.07 vs. 0.06 ± 0.01 mm; p = 0.021). Suboptimal FFR values following stent-implantation are mainly caused by significant in-stent pressure loss during hyperemia. This finding is associated to a larger neointimal proliferation.
Asunto(s)
Implantes Absorbibles , Cateterismo Cardíaco , Enfermedad de la Arteria Coronaria/terapia , Vasos Coronarios/diagnóstico por imagen , Stents Liberadores de Fármacos , Reserva del Flujo Fraccional Miocárdico , Intervención Coronaria Percutánea/instrumentación , Tomografía de Coherencia Óptica , Adenosina/administración & dosificación , Adulto , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Vasos Coronarios/fisiopatología , Femenino , Hemodinámica , Humanos , Hiperemia/diagnóstico por imagen , Hiperemia/fisiopatología , Hiperplasia , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Neointima , Intervención Coronaria Percutánea/efectos adversos , Valor Predictivo de las Pruebas , Factores de Tiempo , Resultado del Tratamiento , Vasodilatadores/administración & dosificaciónRESUMEN
OBJECTIVES: To assess the anatomical and functional impact of final kissing balloon inflation (FKBI) after implantation of a dedicated bifurcation stent system. BACKGROUND: Current evidence suggests clinical benefit of FKBI in patients undergoing bifurcation dilatation using the Tryton side branch stent (Tryton-SBS). We hypothesized that FKBI improves anatomical reconstruction and functional results of bifurcation treated by Tryton-SBS. METHODS: An unselected group of patients with complex bifurcation coronary lesions undergoing percutaneous coronary intervention (PCI) with Tryton-SBS underwent paired anatomical assessment with two- and three-dimensional quantitative coronary analysis (2D- and 3D-QCA), and optical coherence tomography (OCT), including 3D reconstruction before and after FKBI. Functional assessment by fractional flow reserve (FFR) was performed in the main branch (MB) and side branch (SB) before and after FKBI. RESULTS: Paired pre- and post-FKBI data were obtained in 10 patients. By OCT imaging, FKBI increased both the SB ostial area (4.93 ± 2.81 vs. 7.43 ± 2.87 mm2 , P < 0.001) and the SB maximum diameter (3.12 ± 0.98 vs. 3.82 ± 1.10 mm, P = 0.003). These findings were associated with a significant increase in FFR in the SB (0.90 ± 0.05 vs. 0.94 ± 0.03; P = 0.011), with no significant change in the MB (0.91 ± 0.05 vs. 0.92 ± 0.04; P = 0.470). CONCLUSIONS: In patients with complex bifurcation stenosis undergoing PCI with a dedicated bifurcation system, FKBI is associated with improved anatomical and functional results at the SB level, without compromising the result at the MB. © 2016 Wiley Periodicals, Inc.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Cateterismo Cardíaco , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Vasos Coronarios/diagnóstico por imagen , Reserva del Flujo Fraccional Miocárdico , Imagenología Tridimensional , Interpretación de Imagen Radiográfica Asistida por Computador , Stents , Tomografía de Coherencia Óptica , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/efectos adversos , Enfermedad de la Arteria Coronaria/fisiopatología , Estenosis Coronaria/fisiopatología , Vasos Coronarios/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Diseño de Prótesis , Resultado del TratamientoRESUMEN
AIMS: Our aim was to assess the clinical outcomes of the Direct Flow Medical Transcatheter Aortic Valve System (DFM-TAVS), when used in routine clinical practice. METHODS AND RESULTS: This is a prospective, open-label, multicentre, post-market registry of patients treated with DFM-TAVS according to approved commercial indications. Echocardiographic and angiographic data were evaluated by an independent core laboratory and adverse events were adjudicated and classified according to VARC-2 criteria by an independent clinical events committee. The primary endpoint was freedom from all-cause mortality at 30 days post procedure. Secondary endpoints included procedural, early safety and efficacy endpoints at 30 days. Two hundred and fifty patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) with the DFM-TAVS were enrolled in 21 European centres. The primary endpoint, freedom from all-cause mortality at 30 days, was met in 98% (245/250) of patients. Device success was 83.8%. Moderate or severe aortic regurgitation was reported in 3% of patients, and none/trace regurgitation in 73% of patients. Post-procedural permanent pacemaker implantation was performed in 30 patients (12.0%). CONCLUSIONS: The DFM-TAVS was associated with good short-term outcomes in this real-world registry. The low pacemaker and aortic regurgitation rates confirm the advantages of this next-generation transcatheter heart valve (THV).
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Insuficiencia de la Válvula Aórtica/etiología , Cateterismo Cardíaco , Femenino , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Resultado del TratamientoRESUMEN
AIMS: Our aim was to compare, in a large unprotected left main coronary artery (ULMCA) all-comer registry, the long-term clinical outcome after percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS). METHODS AND RESULTS: Of a total of 2,775 patients enrolled in the Drug Eluting Stents for Left Main Coronary Artery Disease (DELTA) multicentre registry, 379 (13.7%) patients with ACS treated with PCI (n=272) or CABG (n=107) were analysed. Baseline demographics were considerably different in the two groups before propensity matching. No significant differences emerged for the composite endpoint of all-cause death, myocardial infarction (MI), and cerebrovascular accident (HR 1.11, 95% CI: 0.63-1.94; p=0.727), all-cause death (HR 1.26, 95% CI: 0.68-2.32; p=0.462), the composite endpoint of all-cause death and MI (HR 1.02, 95% CI: 0.56-1.84; p=0.956), and major adverse cardiac and cerebrovascular events (HR 0.82, 95% CI: 0.50-1.36; p=0.821). However, a higher incidence of target vessel revascularisation (HR 4.67, 95% CI: 1.33-16.47; p=0.008) was observed in the PCI compared with the CABG group, which was confirmed in the propensity score-matched analysis. CONCLUSIONS: In the DELTA all-comer, multinational registry, PCI for ACS in ULMCA is associated with comparable clinical outcomes to those observed with CABG at long-term follow-up, despite the use of first-generation DES.
Asunto(s)
Síndrome Coronario Agudo/terapia , Puente de Arteria Coronaria , Estenosis Coronaria/terapia , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Adulto , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/métodos , Sistema de Registros , Accidente Cerebrovascular , Resultado del TratamientoRESUMEN
BACKGROUND: Periprocedural myocardial injury (PMI) after percutaneous coronary intervention (PCI) might occur more frequently during challenging procedures such as PCI of chronic coronary total occlusion (CTO). The prognostic implication of PMI in CTO-PCI remains unclear. METHODS: From January 2006 to September 2012, a total of 715 consecutive patients undergoing CTO-PCI were screened at three centers. Only patients with available pre-PCI and post-PCI troponin (cTn) were included (n = 442). PMI was defined as an elevation of cTn >5x the upper reference limit (URL), or a rise of cTn >20% if baseline values were elevated. RESULTS: Patients were grouped into: (1) successful CTO-PCI and no-PMI (Group A; n = 195); (2) successful CTO-PCI with PMI (Group B; n = 133); failed CTO-PCI (Group C; n = 114). Occurrence of major adverse cardiovascular event (MACE) was assessed in 431 patients (97%), at a median follow-up of 25 months, and were significantly lower in patients successfully treated without PMI occurrence, while increased in cases of PMI or failed CTO-PCI (Group A, 9%; Group B, 15%; Group C, 28%; hazard ratio, 1.57 (95% confidence interval, 1.12-2.18); P<.01). At Kaplan-Meier analysis, MACE-free survival was significantly higher in Group A (log-rank, 21.46; P<.001). CONCLUSION: Successful CTO revascularization is still associated with a better long-term clinical outcome vs patients in whom it failed, regardless of the occurrence of PMI.
Asunto(s)
Angiografía Coronaria , Oclusión Coronaria , Efectos Adversos a Largo Plazo , Intervención Coronaria Percutánea , Complicaciones Posoperatorias , Anciano , Bélgica/epidemiología , Enfermedad Crónica , Angiografía Coronaria/efectos adversos , Angiografía Coronaria/métodos , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/epidemiología , Oclusión Coronaria/cirugía , Femenino , Humanos , Efectos Adversos a Largo Plazo/diagnóstico , Efectos Adversos a Largo Plazo/epidemiología , Efectos Adversos a Largo Plazo/etiología , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Pronóstico , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo/métodos , Factores de RiesgoRESUMEN
AIMS: Our aim was to assess the performance of the Direct Flow Medical (DFM) repositionable and retrievable transcatheter aortic valve implantation (TAVI) system in high-risk patients with severe aortic stenosis. METHODS AND RESULTS: One hundred and five consecutive high-risk patients with severe aortic stenosis undergoing TAVI with the DFM prosthesis were enrolled in six high-volume TAVI centres in Germany, Italy, The Netherlands, Belgium, and Luxembourg. The "inner curve" technique was systematically used in all patients. The primary endpoint was all-cause mortality at 30 days of clinical follow-up. Secondary endpoints for the same time frame were: (i) VARC-2-defined patient safety; and (ii) VARC-2-defined device success. The primary endpoint of all-cause mortality at 30 days was met in 1.9% (two patients). The VARC-2-defined device success rate was 98.1%. The combined patient safety endpoint was met in 88.6%. Residual moderate aortic regurgitation was observed in 1.9% (two patients). Permanent pacemaker implantation due to post-procedural persistent advanced atrioventricular block was performed in 9.5% (10 patients). CONCLUSIONS: In a multicentre, real-world clinical setting of high-risk patients with severe aortic stenosis, a repositionable and retrievable TAVI system was effective and safe in the short-term follow-up.