Operator decision-making in angiography-only guided revascularization for lesions not indicated for FFR: a QFR-based functional assessment in chronic coronary syndrome.

Background: Discordance between coronary angiographic findings and invasive functional significance is well-established. Yet, the prevalence of this mismatch in an era increasingly utilizing invasive functional assessments, such as fractional flow reserve (FFR), remains unclear. This study examines the extent of such discrepancies in current clinical practice. Methods: This single-center prospective registry included consecutive patients with chronic coronary syndrome (CCS) who underwent elective coronary angiography, with or without revascularization. Coronary angiograms deemed not requiring FFR due to clear anatomical distinctions, either anatomically severe indicating a need for revascularization or mild suggesting no need for intervention, were selected for evaluation. These were then subjected to post-hoc analysis by three independent operators who were blinded to the definitive treatment strategies. Importantly, the post-hoc analysis was conducted in two distinct phases: firstly, a re-evaluation of coronary stenosis, and secondly, a separate functional assessment, each carried out independently. Coronary stenosis severity was assessed visually, while functional relevance was determined by quantitative flow ratio (QFR), calculated using a computational fluid dynamics algorithm applied to angiographic images. Analysis focused on discrepancies between QFR-based functional indications and revascularization strategies actually performed. Results: In 191 patients, 488 vessels were analyzed. Average diameter stenosis (DS) was 37 ± 34%, and QFR was 0.87 ± 0.15, demonstrating a moderate correlation (r = -0.84; 95% CI: -0.86 to -0.81, p < 0.01). Agreement with QFR at conventional anatomical cutoffs was 88% for 50% DS and 91% for 70% DS. Mismatches between revascularization decisions and QFR indications occurred in 10% of cases. Discrepancies were more frequent in the left anterior descending artery (14%) compared to the left circumflex (6%) and the right coronary artery (9%; p = 0.07). Conclusion: In a cardiac-center where FFR utilization is high, discordance between coronary angiography and functional significance persists, even when operators are confident in their decisions not to use functional interrogation. This gap, most evident in the left anterior descending artery, highlights the potential need for integrated angiography-based functional assessments to refine revascularization decisions in CCS.

Intentional creation of dissection flaps to treat perforations during chronic total occlusion percutaneous coronary intervention.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) carries a non-negligible risk of coronary perforation. Definitive treatment of a proximal large vessel perforation often requires the use of covered stents; however, the latter carry significant risk of restenosis and thrombosis, and is not feasible if wire control of the distal vessel has not been achieved. We describe two cases of target vessel perforations during CTO PCI which were treated by the intentional creation of dissection flaps using the subintimal tracking and re-entry technique to seal the perforation.

PCI for Flush Occluded Right Coronary Artery: Challenges and Techniques for Success.

A 74-year-old man with prior coronary artery bypass surgery had a failing vein graft to the right coronary artery (RCA). He underwent retrograde chronic total occlusion recanalization of an ostial flush-occluded RCA facilitated by retrograde angioplasty at the aorto-ostial junction after failed retrograde electrocautery. The graft was then sacrificed. (Level of Difficulty: Advanced.).

Electrocautery-assisted re-entry to resolve bilateral aorto-ostial chronic total occlusions due to leaflet obstruction following transcatheter aortic valve replacement.

Coronary artery obstruction is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR). While urgent percutaneous coronary intervention has been described in cases of acute occlusion, little is known about the interventional management of obstruction once it has occurred in the chronic setting. We describe a case in which electrocautery-assisted re-entry was successfully utilized to manage the right coronary artery and left main chronic total occlusion due to leaflet-induced coronary artery obstruction after TAVR.

Role of the retrograde Carlino technique for chronic total occlusion percutaneous coronary intervention.

BACKGROUND: There is scarce data on the outcomes of the Carlino technique for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We aimed to investigate the indications and outcomes of the Carlino technique as performed in the context of the retrograde approach. METHODS: We pooled CTO PCI cases where a retrograde Carlino technique was performed from high-volume operators at four centers. The Carlino technique was characterized according to its indication (achieving plaque/cap modification, clarifying microcatheter location within the vessel, resolving distal cap ambiguity) and was considered successful when it led to the desired outcome. RESULTS: A total of 43 patients were included. Occlusion complexity was very high (mean J-CTO score 3.3 ± 0.8). The two most common indications were understanding the anatomy of the occlusion and clarifying gear location (37.2%) and impenetrable distal cap (34.9%). The Carlino technique was successful in 88.4% of cases. Overall technical and procedural success was 86.0%. The most common successful crossing technique was reverse controlled antegrade and retrograde subintimal tracking (70.3%). No complications were attributed to the Carlino technique. CONCLUSIONS: We observed a high success rate of the retrograde Carlino technique, as well as overall technical and procedural success rates. No Carlino technique-related complications were observed. Additional data from larger registries are warranted to further confirm the safety and efficacy of this technique.

A Stepwise Approach Utilizing a Double-Helix Wire Technique, Snare Capture and a Switch From a Transfemoral to Transradial Approach to Remove an Entrapped Balloon.

During an attempted PCI utilizing a femoral approach, a balloon became entrapped in the Left Circumflex Artery. Initial retrieval efforts including pulling the balloon and inflating a second balloon over the entrapment failed, the balloon fractured, and the distal end of the balloon apparatus migrated out of the guide catheter. We utilized a stepwise approach with a double helix wiring technique, snares and a change from a transfemoral to transradial approach to successfully retrieve the foreign bodies. This case highlights the importance of utilizing multiple techniques in series and understanding anatomical influences on equipment retrieval when single techniques and approaches fail.

Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia).

Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.

Balloon Aortic Valvuloplasty With Same-Setting Complex Percutaneous Coronary Intervention in the TAVR Era: A Case Series.

BACKGROUND: The use of balloon aortic valvuloplasty (BAV) prior to same-setting complex percutaneous coronary intervention (PCI) in patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD) has not been well studied in the era of transcatheter aortic valve replacement (TAVR). METHODS: We reviewed 379 BAVs performed between January 2016 and April 2020 at an academic tertiary-care medical center. Overall, 327 BAVs were performed in the setting of TAVR. Of the remaining 52 BAVs, 20 were performed immediately prior to same-setting complex PCI. We examined the baseline and procedural data, and clinical outcomes of these cases. RESULTS: Mean patient age was 81 ± 9 years and 70% were men. Chronic kidney disease (40%), diabetes mellitus (35%), and atrial fibrillation (35%) were the most prevalent comorbidities. Rotational atherectomy was performed in 75% of cases and Impella device was utilized in 15%. PCI of distal left main coronary artery and proximal left anterior descending coronary artery was performed in 30% and 80% of cases, respectively. Mean contrast volume was 149 ± 61 mL, fluoroscopy time was 37 ± 20 minutes, total skin dose was 2821 ± 1931 mGy, and total area dose was 18651 ± 12090 µGy/m². Rate of in-hospital complications was low, with a 0% mortality and stroke rate. Eighty percent of patients were referred for TAVR; 70% went on to undergo successful TAVR and 10% deferred TAVR due to improvement in symptoms. CONCLUSIONS: BAV with same-setting complex PCI is safe and feasible in patients with severe AS and severe CAD awaiting TAVR.

Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction.

OBJECTIVE: In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI. METHODS: We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL. RESULTS: 808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography. CONCLUSIONS: Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.

Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI.

BACKGROUND: The current ST-elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) paradigm prevents some NSTEMI patients with acute coronary occlusion from receiving emergent reperfusion, in spite of their known increased mortality compared with NSTEMI without occlusion. We have proposed a new paradigm known as occlusion MI vs. nonocclusion MI (OMI vs. NOMI). OBJECTIVE: We aimed to compare the two paradigms within a single population. We hypothesized that STEMI(-) OMI would have characteristics similar to STEMI(+) OMI but longer time to catheterization. METHODS: We performed a retrospective review of a prospectively collected acute coronary syndrome population. OMI was defined as an acute culprit and either TIMI 0-2 flow or TIMI 3 flow plus peak troponin T > 1.0 ng/mL. We collected electrocardiograms, demographic characteristics, laboratory results, angiographic data, and outcomes. RESULTS: Among 467 patients, there were 108 OMIs, with only 60% (67 of 108) meeting STEMI criteria. Median peak troponin T for the STEMI(+) OMI, STEMI(-) OMI, and no occlusion groups were 3.78 (interquartile range [IQR] 2.18-7.63), 1.87 (IQR 1.12-5.48), and 0.00 (IQR 0.00-0.08). Median time from arrival to catheterization was 41 min (IQR 23-86 min) for STEMI(+) OMI compared with 437 min (IQR 85-1590 min) for STEMI(-) OMI (p < 0.001). STEMI(+) OMI was more likely than STEMI(-) OMI to undergo catheterization within 90 min (76% vs. 28%; p < 0.001). CONCLUSIONS: STEMI(-) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(-) OMI.

Obstructive Sleep Apnea as a Risk Factor for Atrial Fibrillation: A Meta-Analysis.

OBJECTIVES: To conducted a meta-analysis assessing the relationship between Obstructive Sleep Apnea (OSA) and the risk of Atrial Fibrillation (AF). METHODS: We searched PUBMED, Medline, and Cochrane Library using the keywords "atrial fibrillation", "obstructive sleep apnea" and "sleep disordered breathing (SDB)". All subjects included had established diagnosis of OSA/SDB. We then compared the occurrence of AF versus no AF. Analysis done with Comprehensive Meta-Analysis package V3 (Biostat, USA). RESULTS: A total of 579 results were generated. Duplicates were removed and 372 records were excluded based on irrelevant abstracts, titles, study design not consistent with the stated outcome, or full-text unavailable. Twelve studies meeting the inclusion criteria were reviewed in full-text; 2 of these articles were eventually removed due to unconfirmed OSA diagnostic modality, and one was also removed based on a control group inconsistent with the other studies. Therefore, a total of 9 studies were included (n=19,837). Sample sizes ranged from n=160 patients to n=6841 patients. The risk of AF was found to be higher among OSA/SDB versus control group (OR; 2.120, C.I: 1.845-2.436, Z; 10.598 p: <0.001). The heterogeneity observed for the pooled analysis was Q-value; 22.487 df (Q); 8 P-value; 0.004, I-squared; 64.424 Tau2; 0.098, suggesting appropriate study selection and moderate heterogeneity. CONCLUSION: OSA/SDB is strongly associated with AFib confirming the notion that OSA/SDB populations are high risk for development of AF. Prospective studies are needed to ascertain the effect of the treatment of OSA/SDB for the prevention of AF, a growing health burden with serious consequences.

Discontinuation/Dose Reduction of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers during Acute Decompensated Heart Failure in African-American Patients with Reduced Left-Ventricular Ejection Fraction.

OBJECTIVES: Patients with heart failure (HF) and reduced left-ventricular ejection fraction (LVEF) benefit from angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blocker (ARB) therapy. While dose reduction/discontinuation (r/d) of ß-blockers (BB) and furosemide in acute decompensated HF (ADHF) worsen outcomes, data on ACEI/ARB are lacking. METHODS: To determine the frequency and reasons for ACEI/ARB therapy r/d in ADHF patients, we studied 174 patients with LVEF <40% on ACEI/ARB and BB therapy upon admission over 1 year. RESULTS: ACEI/ARB doses were r/d in 17.2% because of acute kidney injury (56.7%), hypotension (23.3%), and hyperkalemia (10%). Clinical characteristics were similar between patients with r/d and continued therapy. Admission and discharge creatinine (Cr) levels were higher in the r/d group. On multivariate analysis, admission Cr and admission systolic blood pressures were independent predictors of r/d. Among patients with renal dysfunction cited as the r/d reason, Cr did not significantly rise in 23.5%. The r/d group had a longer length of stay (LOS). CONCLUSIONS: ACEI/ARB dose is reduced and/or discontinued in nearly one-fifth of all ADHF admissions, and LOS is longer in the ACEI/ARB r/d group. While impaired renal function is the most frequently cited reason, nearly one-fourth of the patients had stable renal function. ACEI/ARB r/d therapy in the setting of ADHF merits further study.