Full-Moon Coronary Calcification as Detected With Computed Tomography Angiography in Chronic Total Occlusion Percutaneous Coronary Intervention.

"Full moon" is a central calcification that occludes the entire vessel on coronary computed tomography angiography (CCTA). We examined the association of full moon calcification as identified by CCTA, on clinical and procedural outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We studied patients who underwent elective CTO-PCI in 2 European centers and had preprocedural CCTA. The primary end point was the inability to cross the lesion and/or the need for extensive debulking techniques. Secondary end points were procedural success, in-hospital cardiac mortality, the need for extensive debulking techniques, myocardial infarction, major adverse cardiac events (defined as in-hospital death, myocardial infarction, and clinically driven target vessel revascularization), and stent thrombosis. Secondary procedural end points included procedural time, fluoroscopy time, number of guidewires and balloons, stent length, number and diameter, and contrast volume. Multivariable logistic regression analysis was performed, identifying potential covariates related to the primary outcome according to knowledge and previous studies. Subsequently, a stepwise selection approach was performed to select factors with the greatest predictive value. Of 140 patients included, 28 (20%) had a full moon calcified CTO plaque. Patients in the full moon group were older and had more cardiovascular risk factors. There was not significant difference in the need for retrograde approach and anterograde dissection and reentry techniques between the full moon group and the other groups (32.1% vs 37.5%, p = 0.59 and 0% vs 1.7%, p = 0.47, respectively). Patients in the full moon group had greater incidence of the primary outcome than did those who did not have full moon morphology (53.5% vs 12.5%, p <0.001). On multivariable analysis that included chronic kidney failure and previous coronary artery bypass surgery, full moon calcification was associated with greater incidence of the primary end point (odds ratio 6.5, 95% confidence interval 2.1 to 20.5, p = 0.001). Moreover, less procedural success (71.4% vs 87.5%, p = 0.03), greater incidence of coronary perforations (14.2% vs 3.5%, p <0.02), and greater procedural (172.5 [118.0 to 237.5] vs 144.0 [108.50 to 174.75], p = 0.02) and fluoroscopic time (62.6 [38.1 to 83.0] vs 42.8 [29.5 to 65.7], p = 0.03) were observed in the full moon group. Overall major adverse cardiac events did not differ between the 2 groups (1 patient in the full moon group vs 1 patient in the non-full moon group; 3.5% vs 0.8%, p = 0.29). In conclusion, full moon calcification on CCTA was independently associated with procedural complexity and adverse outcomes in CTO-PCI.

Abbreviated or Standard Antiplatelet Therapy in HBR Patients: Final 15-Month Results of the MASTER-DAPT Trial.

BACKGROUND: Clinical outcomes and treatment selection after completing the randomized phase of modern trials, investigating antiplatelet therapy (APT) after percutaneous coronary intervention (PCI), are unknown. OBJECTIVES: The authors sought to investigate cumulative 15-month and 12-to-15-month outcomes after PCI during routine care in the MASTER DAPT trial. METHODS: The MASTER DAPT trial randomized 4,579 high bleeding risk patients to abbreviated (n = 2,295) or standard (n = 2,284) APT regimens. Coprimary outcomes were net adverse clinical outcomes (NACE) (all-cause death, myocardial infarction, stroke, and BARC 3 or 5 bleeding); major adverse cardiac and cerebral events (MACCE) (all-cause death, myocardial infarction, and stroke); and BARC type 2, 3, or 5 bleeding. RESULTS: At 15 months, prior allocation to a standard APT regimen was associated with greater use of intensified APT; NACE and MACCE did not differ between abbreviated vs standard APT (HR: 0.92 [95% CI: 0.76-1.12]; P = 0.399 and HR: 0.94 [95% CI: 0.76-1.17]; P = 0.579; respectively), as during the routine care period (HR: 0.81 [95% CI: 0.50-1.30]; P = 0.387 and HR: 0.74 [95% CI: 0.43-1.26]; P = 0.268; respectively). BARC 2, 3, or 5 was lower with abbreviated APT at 15 months (HR: 0.68 [95% CI: 0.56-0.83]; P = 0.0001) and did not differ during the routine care period. The treatment effects during routine care were consistent with those observed within 12 months after PCI. CONCLUSIONS: At 15 months, NACE and MACCE did not differ in the 2 study groups, whereas the risk of major or clinically relevant nonmajor bleeding remained lower with abbreviated compared with standard APT. (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen [MASTER DAPT]; NCT03023020).

A prospective, multicentre first-in-man study of the polymer-free ultrathin-strut BIOrapid stent (BIOVITESSE).

BACKGROUND: Polymer-free drug-coated stents aim to avoid the inflammatory potential of durable polymers, thereby improving the long-term safety profile, and allowing a shorter duration of dual antiplatelet therapy. AIMS: The BIOVITESSE study was conducted to assess the safety and clinical performance of the BIOrapid polymer-free coronary stent system coated with a novel highly lipophilic sirolimus derivate. METHODS: BIOVITESSE was a prospective, multicentre, first-in-man study that enrolled subjects with de novo coronary lesions in two cohorts of 33 patients each. The primary endpoint of the first cohort was strut coverage at one month as assessed by optical coherence tomography. The primary endpoint of the second cohort was late lumen loss at nine-month follow-up. RESULTS: Patients were on average 63 years old (range: 42-87) and 12% had diabetes. The 66 patients had 70 lesions with an average lesion length of 12.5±5.4 mm. Predilatation was performed in 91.4% and post-dilatation in 87.1% lesions; device success was obtained in 97.4%. At one month, 95.2±5.6% (95% CI: 93.2-97.2) of struts were covered and at nine months, in-stent late lumen loss was 0.31±0.30 mm (95% CI: 0.20-0.42) and in-segment late lumen loss was 0.20±0.29 mm. Two target lesion failures occurred (3.1%): one at day 1 (to cover an asymptomatic stent edge dissection), and one at day 288 post-procedure for restenosis. No stent thrombosis was reported during the 12-month study duration. CONCLUSIONS: The BIOrapid stent system exhibited an excellent safety profile, high strut coverage at one-month, and moderate angiographic efficacy according to the late lumen loss at nine-month angiographic follow-up.

[The Role of Percutaneous Coronary Revascularization in Chronic Coronary Syndromes]. / Perkutane koronare Revaskularisation beim chronischen Koronarsyndrom: wann sinnvoll, wann nicht?

The Role of Percutaneous Coronary Revascularization in Chronic Coronary Syndromes Abstract. Coronary heart disease represents the leading cause of morbidity and mortality worldwide. Optimal management of these patients is therefore crucial and includes lifestyle changes, optimal medical therapy, and coronary revascularization. This review summarizes diagnostic and therapeutic strategies of patients with chronic coronary syndromes, focusing on the 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of chronic coronary syndromes. In particular, the role of invasive assessment and coronary revascularization in chronic coronary syndromes is discussed.

Diagnostic performance of angiography-based quantitative flow ratio for the identification of myocardial ischemia as assessed by 13N-ammonia myocardial perfusion imaging positron emission tomography.

BACKGROUND: Quantitative flow ratio (QFR) is a novel, adenosine-free method for functional lesion interrogation based on 3-dimensional quantitative coronary angiography and computational algorithms. We sought to investigate the diagnostic performance of QFR versus myocardial perfusion imaging positron emission tomography (MPI-PET), which yields the highest accuracy for detection of myocardial ischemia. METHODS: Diagnostic performance of QFR versus MPI-PET was assessed in consecutive patients undergoing both clinically indicated coronary angiography and 13N-ammonia MPI-PET within a six-month period. RESULTS: Out of 176 patients (439 coronary arteries), 19.3% were women. Percent area stenosis was 45 [32-58] %. Myocardial ischemia on 13N-ammonia MPI-PET was detected in 106 (24.1%) vessel territories and hemodynamic significance defined as contrast-flow vessel QFR ≤ 0.80 was observed in 83 (18.9%) vessels. Diagnostic accuracy, sensitivity, and specificity of contrast-flow vessel QFR for the prediction of myocardial ischemia on 13N-ammonia MPI-PET were 92.5 (95% CI 89.6-94.7) %, 73.6 (95% CI 64.1-81.7) %, and 98.5 (95% CI 96.5-99.5) %, respectively. The AUCs for contrast-flow vessel QFR, percent diameter stenosis, and percent area stenosis were 0.85 (95% CI 0.81-0.88, p < 0.001), 0.76 (95% CI 0.71-0.79, p < 0.001) and 0.75 (95% CI 0.70-0.79, p < 0.001), respectively. CONCLUSIONS: QFR, a novel diagnostic tool for functional coronary lesion assessment, provides good diagnostic agreement with MPI-PET and superior diagnostic accuracy for the detection of myocardial ischemia as compared to anatomic indices. Future studies will have to determine the non-inferiority of QFR to fractional flow reserve with respect to clinical outcomes.

Association of left ventricular end-diastolic pressure with mortality in patients undergoing percutaneous coronary intervention for acute coronary syndromes.

OBJECTIVES: This study sought to investigate the relation between left ventricular end-diastolic pressure (LVEDP) and outcomes in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). BACKGROUND: Risk stratification in ACS patients is important. Data on the role of LVEDP in the prognostication of ACS patients are scarce. METHODS: A total of 1,410 patients undergoing PCI for ACS and with available data on LVEDP were divided according to LVEDP tertiles (lowest tertile: ≤13 mmHg, intermediate tertile: 14-20 mmHg, and highest tertile: >20 mmHg). The primary endpoint was all-cause mortality at a median follow-up of 246 [28-848] days. RESULTS: Median LVEDP was 16 (11-22) mmHg. All-cause mortality was 2.8%, 4.5%, and 15.0% in the lowest, the intermediate, and the highest LVEDP tertile groups (p < .001), respectively. Belonging to the highest LVEDP tertile was associated with an increased risk of all-cause mortality (adjusted hazard ratio [HR] = 2.66, 95% confidence interval [CI] [1.30, 5.47], p = .008). By receiver operating characteristic curve analysis, the optimal cut-off value for predicting all-cause mortality was 20 mmHg (sensitivity 68.3%, specificity 72.5%). There was no differential effect of LVEDP on mortality in patients with and without LV dysfunction (interaction p = .23) or ST-elevation myocardial infarction as index ACS event (interaction p = .86). CONCLUSIONS: In patients undergoing PCI for ACS, LVEDP was independently related with mortality. Hence, LVEDP should be incorporated into early risk stratification and clinical decision making of ACS patients.

Association of the body mass index with outcomes in elderly patients (≥80 years) undergoing percutaneous coronary intervention.

BACKGROUND: The obesity paradox has been recognized in patients with cardiovascular disease. The association between obesity and outcomes in elderly patients undergoing percutaneous coronary intervention (PCI) has not been investigated, yet. METHODS: A total of 990 elderly (≥80 years) patients undergoing PCI at our institution between January 2009 and December 2017 and with available data on body mass index (BMI) were divided according to BMI tertiles (lowest BMI tertile: ≪24.1 kg/m2, middle BMI tertile: 24.1-27.2 kg/m2, and highest BMI tertile: ≫27.2 kg/m2). The primary endpoint was all-cause mortality at a median follow-up of 233 [34-862] days. RESULTS: All-cause mortality was 11.2%, 7.6%, and 5.8% in the lowest, the middle, and the highest BMI tertiles (Log Rank p = 0.008). Belonging to the lowest BMI tertile was associated with an increased risk of all-cause mortality (HR 2.14, 95% CI 1.23-3.73, p = 0.007), and associations remained significant after multivariable adjustments (adjusted HR 1.92, 95% CI 1.05-3.52, p = 0.03). While belonging to the lowest BMI tertile was independently associated with an increased all-cause mortality in patients with acute coronary syndromes (HR 2.32, 95% CI 1.24-4.35, p = 0.009; adjusted HR 2.40, 95% CI 1.19-4.84, p = 0.01), relations were not significant in patients with stable coronary artery disease (HR 1.32, 95% CI 0.38-4.56, p = 0.67; adjusted HR 0.80, 95% CI 0.21-3.05, p = 0.75). CONCLUSIONS: In elderly (≥80 years) patients undergoing PCI, belonging to the lowest BMI tertile was associated with an increased mortality, mainly in acute coronary syndromes. Hence, the BMI should be incorporated into the risk stratification of elderly patients with coronary artery disease.

Right coronary artery motion analysis: a novel method to measure right ventricular systolic function by selective coronary angiography.

Right ventricular systolic dysfunction is prognostic in various cardiovascular diseases. Right ventricular systolic function is not commonly assessed in the catheterization laboratory. Therefore, we developed a novel, reproducible method to measure right ventricular systolic function during selective coronary angiography. We analyzed the angiographic systolic translational motion and maximum speed of the right coronary artery (RCA) in 97 consecutive patients and compared it to the tricuspid annular plane systolic excursion (TAPSE) as measured by echocardiography. All measurements were performed by two independent operators on two occasions. Inter-observer variability and intra-observer variability were excellent for RCA motion distance and for RCA maximum speed. There was a significant correlation of the RCA motion distance and RCA maximum speed with the TAPSE measured by echocardiography (Pearson's correlation for RCA distance: r = 0.59, p < 0.001, r2 = 0.35; for RCA speed: r = 0.40, p < 0.001, r2 = 0.16). The area under the receiver operating curve for the RCA motion distance was 0.88 (95% CI 0.80-0.96) for discrimination of normal and abnormal right ventricular systolic function. A cut-off value less than 22.3 mm systolic RCA motion had a specificity of 93.3% and a sensitivity of 75.6% for identifying an abnormal right ventricular systolic function. Analysis of the RCA motion is a reproducible and reliable method to measure right ventricular systolic function during selective coronary angiography. It is a simple and useful tool to assess right ventricular function in the catheterization laboratory and may serve for risk assessment for right ventricular failure. CLINICAL TRIAL REGISTRATION: Data for this study was collected retrospectively from Swiss Transcatheter Aortic Valve Implantation Registry (NCT01368250). https://clinicaltrials.gov/show/NCT01368250 .

Rotational Atherectomy in Acute STEMI with Heavily Calcified Culprit Lesion is a Rule Breaking Solution.

BACKGROUND: Calcified coronary lesions represent technical challenges during percutaneous coronary intervention and are associated with a high frequency of restenosis and target lesion revascularization. Rotational atherectomy has been shown to increase procedural success in severely calcified lesions, facilitate stent delivery in undilatable lesions and ensure complete stent expansion. However, rotational atherectomy in ST-elevation Myocardial Infarction (STEMI) is traditionally avoided given the concern for slow or no reflow and considered a contraindication in lesions with a visible thrombus by its manufacturer (Rotablator, Boston Scientific). CONCLUSION: This case demonstrates the successful use of rotational atherectomy to facilitate dilation and revascularization of a heavily calcified culprit lesions in a patient with acute anterior STEMI with ongoing chest pain.

STEMI Due to Big Ostial Left Main Thrombus Extending Into Aorta: Challenging Situation With No Clear Guidelines.

Extensive left main (LM) coronary artery thrombus is a rare and life-threatening angiographic finding with usual dramatic clinical presentation including hemodynamic instability and sudden cardiac death. The proper management of a big LM thrombus extending into aorta remains a challenging issue with no clear guidelines. In the following case report we present a 45-year-old patient with no apparent risk factors for coronary artery disease who presented with acute infero-lateral ST-elevation myocardial infarction (STEMI). The examination was performed using a right transfemoral approach and it revealed the presence of a large mobile, hazy mass within the left main coronary artery (LMCA) extending into the aorta. To confirm the extension of that structure we performed intravascular ultrasound (IVUS) which revealed a circumferential mass in the LMCA extending with its two-thirds into the aorta with no evidence of atherosclerotic plaques. After a long discussion within our Heart team we decided to transfer the patient for urgent surgical removal. Such decision was made with regard to the large size of the mass and in order to avoid systemic or distal embolization into coronary arteries. Perioperative transesophageal echocardiography (TEE) confirmed diagnosis and excluded presence of patent foramen ovale (PFO). Surgical removal was done successfully with complete resolution of ST-segment elevation and rapid fall of cardiac enzymes to normal levels. Postoperative course was uneventful. The mass was defined as a thrombus by pathophysiology examination. Patient was discharged well from our hospital after 1 week.

Contrast-free diagnosis and treatment of coronary artery disease guided by integrated cardiac imaging: concept and first clinical experience.

The use of iodinated contrast media (ICM) remains a potential hazard for patients undergoing diagnostic cardiac imaging and percutaneous coronary intervention. In particular patients with history of prior adverse reaction to a contrast agent are at a high risk in case of re-exposure, even if designated premedication is administered. Based on a patient with recurrent angina pectoris and history of systemic anaphylactic reaction to ICM, we describe the logical stepwise approach from diagnostic imaging to safe and successful imaging guided percutaneous coronary intervention without the use of contrast agent.

Reproducibility and clinical potential of myocardial mass at risk calculated by a novel software utilizing cardiac computed tomography information.

To select the best revascularization strategy a correct understanding of the ischemic territory and the coronary anatomy is crucial. Stress myocardial perfusion single photon emission computed tomography (SPECT) is the gold standard to assess ischemia, however, SPECT has important limitations such as lack of coronary anatomical information or false negative results due to balanced ischemia in multi-vessel disease. Angiographic scores are based on anatomical characteristics of coronary arteries but they lack information on the extent of jeopardized myocardium. Cardiac computed tomography (CCT) has the ability to evaluate the coronary anatomy and myocardium in one sequence, which is theoretically the ideal method to assess the myocardial mass at risk (MMAR) for any target lesion located at any point in the coronary tree. In this study we analyzed MMAR of the three main coronary arteries and three major side branches; diagonal (Dx), obtuse marginal (OM), and posterior descending artery (PDA) in 42 patients with normal coronary arteries using an algorithm based on the Voronoi method. The distribution of MMAR among the three main coronary arteries was 44.3 ± 5.6 % for the left anterior descending artery, 28.2 ± 7.3 % for the left circumflex artery, and 26.8 ± 8.6 % for the right coronary artery. MMAR of the three major side branches was 11.3 ± 3.9 % for the Dx, 12.6 ± 5.2 % for the OM and 10.2 ± 3.4 % for the PDA. Intra- and inter-observer analysis showed excellent correlation (r = 0.97; p < 0.0001 and r = 0.95; p < 0.0001, respectively). In conclusion, CCT-based MMAR assessment is reliable and may offer important information for selection of the optimal revascularization procedure.

A novel homemade snare, safe, economical and size-adjustable.

AIMS: Snaring has recently been reported as being effective in catching the retrograde guidewire (GW) in retrograde percutaneous coronary intervention (PCI) for chronic total occlusion. However, commercially available snares and previously reported homemade snares have a number of drawbacks, such as additional cost, limited size adjustability, risk of vessel injury and difficult handling. We report here a novel method to create easily an inexpensive, safe and size-adjustable snare. METHODS AND RESULTS: Our newly developed homemade snare consists of a conventional 0.014" GW, a PCI balloon, and a guiding catheter (GC). In most cases, no extra cost is needed. As the snare is created by the soft wire tip, vascular injury is negligible. To adjust the size of the snare loop, the snare wire is simply pulled backwards and pushed forwards. Using this snare technique, we succeeded in the total revascularisation of a CTO in the left main trunk with a retrograde approach. CONCLUSIONS: We report a novel method to create easily an inexpensive, safe and size-adjustable snare, and demonstrate its use in a retrograde CTO intervention. In some cases where a conventional snare is indicated, such as removal of intravascular iatrogenic foreign bodies, this novel homemade snare would be preferable because of its advantages.

Recovery mismatch between myocardial blood flow and cardiac workload after physical exercise: a positron emission tomography study.

AIMS: We studied the interrelation between oxygen consumption and myocardial blood flow (MBF) during recovery. MBF is directly dependent on oxygen consumption. The latter is linearly related to the heart rate-blood pressure product (RPP, bpm × mmHg), an index reflecting external cardiac work. In the immediate post-exercise period, cardiac output decreases considerably. This is expected to be paralleled by a rapid fall in oxygen demand, rendering ischaemia unlikely. Thus, the phenomenon of ST-segment depression during recovery remains unexplained. METHODS AND RESULTS: (15)O-labelled water and positron emission tomography were used to measure MBF in 14 young healthy volunteers (mean age 27 ± 3 years) during the following study conditions: (i) at rest, (ii) during a steady submaximal supine bicycle exercise stress within the scanner, and (iii) during recovery immediately after cessation of exercise. During recovery, RPP decreased by 43% (18 768 ± 1337 vs. 11 652 ± 3224, P < 0.001). In contrast, the associated decrease in MBF (2.52 ± 0.52 vs. 1.93 ± 0.50 mL/min/g, P < 0.001) and perfusion reserve (2.68 ± 0.51 vs. 2.03 ± 0.42, P < 0.001) was significantly less pronounced (-24%, P < 0.01), indicating a relative delay in MBF recovery compared with cardiac work load. CONCLUSION: The mismatch between a rapid decrease in cardiac workload but preserved hyperaemic response early after cessation of physical exercise suggests an uncoupling of cardiac work and MBF during recovery.

Reversed C-arm projection for reduction of focal skin radiation exposure: experimental analysis and first clinical experience.

Radiodermatitis, predominantly over the right scapula, is a well-known complication of complex percutaneous coronary interventions (PCI). To reduce focal radiation exposure, we analyzed an inversed X-ray beam direction using a reversed C-arm position. On phantom experiment, we found that 130° right anterior oblique projection reduced skin dose over the right scapula by 98.2 % (P < 0.001) compared with conventional 50° left anterior oblique projection. A 73-year-old man with history of bypass surgery, multiple PCI and chronic radiodermatitis over the right scapula presented with recurrent chest pain. After successful PCI using the reversed C-arm projection, no aggravation of radiodermatitis was found.