Microcatheters for antegrade recanalization of chronic total coronary occlusions: Feasibility and safety of the corsair - A retrospective registry-based single operator experience.

BACKGROUND: The Corsair collateral channel dilator was designed for retrograde passage in cases of coronary chronic total occlusion (CTO). Its antegrade use is discouraged and the number of published studies regarding such use is limited. Our single-operator experience examines the feasibility and safety of the Corsair in antegrade recanalization of chronic CTOs in a large cohort. METHODS: We queried the European Registry of Chronic Total Occlusion (ERCTO) for all microcatheters used in antegrade recanalizations between 2008 and 2016. We also retrospectively assessed all 722 coronary interventions for CTOs (624 antegrade, 98 retrograde) between January 2008 and December 2016, performed by a single operator who primarily applied the Corsair as antegrade microcatheter. Patient, procedure, and outcome data was analyzed. RESULTS: In 17,787 cases performed by 93 operators contributing to the ERCTO database, there were 3294 with information on microcatheter type. The FineCross MG (73.9 %) was the most commonly used microcatheter. The Corsair was used in only 1.2 % (excluding patients in the single-operator cohort). In the same period 45.7 % (n = 285) of all 624 antegrade cases handled by our single operator were performed using the Corsair, with no exclusions due to anatomical or morphological criteria. The procedural success rate was 93.7 %. There were 2 cases of cardiac tamponade, 5 cases of minor perforation, and one catheter tip fracture. CONCLUSIONS: The Corsair is rarely used for antegrade recanalization. In this single-operator experience, the antegrade use of the Corsair was safe. The success rate was high, although causative conclusions cannot be drawn.

Smartphone-derived multichannel electrocardiogram for exercise stress testing.

INTRODUCTION: The use of mobile devices for electrocardiogram (ECG) recording and the ability to use this technology to immediately review dynamic waveforms is growing tremendously. While over-the-counter ECG devices may display rhythm disorders and ST-segment changes at rest, changes during physical exercise have thus far not been evaluated. We compared a mobile device (smartphone/tablet)-enabled vectorial 4-electrode ECG system (SPE) with the current standard 12­lead (STE) ECG both at rest and during exercise. METHODS AND RESULTS: A total of 428 patients underwent simultaneous ECG testing with both technologies during rest and maximal exercise. The vectorial ECG was displayed as 12­lead ECG, and diagnostic accuracy and ECG quality (independently judged by blinded cardiologists) were compared with the current standard. Signal quality was good with both ECG technologies. At rest, there was excellent agreement between SPE and STE regarding rhythm (98%), AV-conduction (97%), wave duration (90%), and electrical axis (88-97%). During exercise the presence or absence of ST-deviation (>0.1 mm) corresponded in 90% of cases with no statistically significant difference. The positive predictive value was 48.5% and the negative predictive value was 94%. For ST-deviations >0.2 mm the percentage match was 97% during exercise. For rhythm disorders and for intraventricular conduction (left- and right-bundle branch block detection) it was >90%. CONCLUSION: A smart-device-enabled vectorial ECGs system using the CardioSecur system can be used in daily practice to reliably interpret an ECG at rest and during physical exercise, although it is less accurate with respect to the detection of ST-deviation.

Experience with the novel unifemoral parallel sheath technique in percutaneous intervention of chronic total coronary occlusions.

BACKGROUND: Percutaneous interventions to address chronic coronary occlusions (CTO-PCI) often require simultaneous ipsi- and contralateral coronary injections. Although radial access is increasingly popular, bifemoral artery access is still the preferred choice of CTO operators. The aim of this case series is to demonstrate the feasibility and safety of the unifemoral parallel sheath technique, which avoids two puncture sites, increases patient comfort, and improves procedure ergonomics. It offers rapid second access to the femoral artery adjacent to the first sheath as well as closure by unilateral manual compression without or with 1 or 2 vascular closure devices. RESULTS: We retrospectively evaluated the procedure results in 90 consecutive CTO patients where an ipsilateral parallel sheath access was considered. Placement of the second sheath uneventfully failed in two because of severe femoral calcification and narrowing. In 96.6%, the first sheath was 7 F (3.4% 6F), while the second sheath was 4 F in 22.7%, 5 F in 64.7%, and 6 or 7 F in 11.4% each. No major complications nor severe bleeding events occurred, and the mean drop of hemoglobin was low (0.6 g/dL ± 0.86). CONCLUSION: In CTO-PCI requiring contralateral coronary injections or the retrograde technique, the ipsilateral parallel sheath technique might be a feasible alternative to the standard bifemoral or femoral-radial access.

Single versus double use of a suture-based closure device for transfemoral aortic valve implantation.

BACKGROUND: The most common method of percutaneous closure in transfemoral transcatheter aortic valve implantation (TAVI) employs two obtusely oriented ProGlide devices. The aim of this study was to assess the feasibility and safety of using a single ProGlide system for primary access site closure in comparison with the double ProGlide approach in an all-comers TAVI population. METHODS: Between March 2016 and December 2018, a total of 1105 patients underwent transfemoral TAVI for severe aortic stenosis at our center. Application of two ProGlide systems was standard until April 2017 (n = 432), whereas thereafter a single ProGlide system was used (n = 663). A 1:1 propensity score matching was performed to adjust for baseline differences between the two groups, resulting in 327 matched cases. Primary outcomes of interest were main access site-related vascular complications. RESULTS: The mean number of ProGlide devices used per patient was 1.03 (SD 0.2) in the single-ProGlide group versus 2.01 (SD 0.14) in the double-ProGlide group. An additional vascular closure device was required to obtain full hemostasis in 23.2% versus 9.5% of patients (p < 0.001) in the two groups, respectively. Technical success of ProGlide usage was similar (94.3% versus 92.1%, p = 0.163). In the matched cohorts, the rates of main access site-related major vascular complications were similar (4.0% vs. 6.4%, p = 0.217). CONCLUSION: The single-ProGlide technique is feasible, with rates of technical success similar to those of the double-ProGlide technique. Use of this method did not lead to more frequent access site-related complications but was more cost effective than the double-ProGlide approach.

Radiation Exposure for Percutaneous Interventions of Chronic Total Coronary Occlusions in a Multicenter Registry: The Influence of Operator Variability and Technical Set-up.

AIMS: Radiation exposure is a limiting factor for percutaneous coronary interventions (PCI) of chronic total coronary occlusion (CTO) lesions. This study was designed to analyze changes in patient radiation dose for CTO-PCI and parameters associated with radiation dose. METHODS AND RESULTS: We analyzed a cohort of 12,136 procedures performed by 23 operators between 2012 and 2017 from the European Registry of CTO-PCI. Radiation exposure was recorded as air kerma (AK) and dose area product (DAP). A dose rate index (DRI) was calculated as AK per fluoroscopy time to normalize for individual differences in fluoroscopy time. The lesion complexity increased from Japanese-CTO (J-CTO) score of 2.19 ± 1.44 to 2.46 ± 1.28, with an increase of retrograde procedures from 31.1% to 40.7%; still, procedural success improved from 87.7% to 92.1%. Fluoroscopy time remained similar, but AK decreased by 14.9%, from 2.35 Gy (interquartile range [IQR], 1.29-4.14 Gy) to 2.00 Gy (IQR, 1.08-3.45 Gy) and DAP decreased by 21.5%, from 130 Gy•cm² (IQR, 70-241 Gy•cm²) to 102 Gy•cm² (IQR, 58-184 Gy•cm²). Radiation exposure was determined by the lesion complexity (J-CTO score) and procedural complexity (antegrade or retrograde). DRI was determined by fluoroscopy frame rate and type of equipment used, but the major influence remained interoperator differences. CONCLUSIONS: Radiation exposure decreased during the observation period despite an increase in lesion and procedural complexity. While many operators already achieved a goal of low radiation exposure, there were considerable interoperator differences in radiation management, indicating further potential for improvement.

Influence of novel X-ray imaging technology on radiation exposure during chronic total occlusion procedures.

OBJECTIVES: We assessed whether use of the novel X-ray imaging technology AlluraClarity (Philips Healthcare, Best, The Netherlands) results in a meaningful reduction of radiation exposure for patients during coronary intervention on chronic total occlusions (CTO-PCI) compared to its predecessor Allura Xper (Philips Healthcare, Best, The Netherlands). BACKGROUND: Percutaneous coronary intervention on chronic total occlusion causes 2- to 10-fold higher radiation burden on patients and operators compared to standard PCI. To avoid iatrogenic damage to our patients and personnel, all efficient ways to reduce radiation should be identified and implemented. METHODS: Radiation exposure of 196 consecutive CTO patients treated in the same laboratory by a single experienced operator (total experience: > 2,500 CTOs, annual experience: > 100 CTOs/year) was analyzed. Ninety-eight CTO-PCIs (n1 ) were performed with the Allura Xper system and 98 patients (n2 ) were treated using AlluraClarity. RESULTS: The two groups had similar BMI (n1 : mean 28.43 kg/m2 ; n2 : mean 28.41 kg/m2 ), procedure duration (n1 : mean 75.9 min; n2 : mean 70.7 min), and J-CTO scores (n1 : mean 2.99; n2 : mean 2.82). The success rates did not differ (n1 : 86/98 successful). n2 : 87/98 successful). The radiation doses, however, revealed significant differences in kerma area product (KAP; absolute reduction of 34%; n1 : mean 61.5 Gycm2 ; n2 : mean 40.8 Gycm2 ; P < 0.002) and cumulative air kerma (AK; absolute reduction of 30%; n1 : mean 966.8 mGy; n2 : mean 675.9 mGy; P < 0.002). CONCLUSION: Use of the novel X-ray imaging technology resulted in a meaningful and significant reduction in patient radiation exposure during complex coronary interventions (CTO-PCI) compared to use of its predecessor. Similar success rates support the operator's subjective impression of similar, and in some cases superior, image quality.

Augmenter of liver regeneration attenuates inflammatory response in the postischemic mouse liver in vivo.

BACKGROUND: Augmenter of Liver Regeneration (ALR), a protein synthesized in the liver is suggested to be protective against oxidative stress-induced cell death. Hepatic ischemia-reperfusion (I/R) injury is triggered by reactive oxygen species. Here, we tested the hypothesis that ALR attenuates hepatic I/R injury in vivo. METHODS: C57BL6 mice were subjected to warm hepatic ischemia for 90 min. Either recombinant ALR (100 µg/kg) or vehicle were administered to mice prior ischemia. During reperfusion, neutrophil and CD4+ T cell migration and sinusoidal perfusion were analyzed using intravital microscopy. Alanine aminotransferase-aspartate aminotransferase (plasma) and caspase-3 (tissue) activities were determined as markers of hepatocellular necrotic and apoptotic injury. RESULTS: Hepatic I/R led to dramatic enhancement of neutrophil and CD4+ T cell recruitment in hepatic microvessels, sinusoidal perfusion failure, and strong elevation of aspartate aminotransferase-alanine aminotransferase and caspase-3 activities. During early reperfusion (60 min), the pretreatment with ALR improved postischemic perfusion failure (P < 0.05) and attenuated liver enzyme activities. Recruitment of CD4+ T cells, but not of neutrophils was attenuated. After 240 min of reperfusion, the protective effect of ALR was stronger, since the liver enzyme activity, perfusion failure, and leukocyte influx were significantly attenuated. As shown by the measurement of caspase-3 activity, postischemic apoptosis was reduced in the ALR-treated group. CONCLUSIONS: Our in vivo data show that ALR has a therapeutic potential against postischemic liver injury. As a mechanism, we suggest a direct protective effect of ALR on apoptotic and necrotic death of hepatocytes and an attenuation of inflammatory cell influx into the postischemic tissue.