Radiation protection for healthcare professionals working in catheterisation laboratories during pregnancy: a statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Heart Rhythm Association (EHRA), the European Association of Cardiovascular Imaging (EACVI), the ESC Regulatory Affairs Committee and Women as One.

The European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Heart Rhythm Association (EHRA), the European Association of Cardiovascular Imaging (EACVI), the European Society of Cardiology (ESC) Regulatory Affairs Committee and Women as One support continuous review and improvement, not only in the practice of assuring patients a high quality of care but also in providing health professionals with support documents to help them in their career and enhance gender equity. Recent surveys have revealed that radiation exposure is commonly reported as the primary barrier for women pursuing a career in interventional cardiology or cardiac electrophysiology (EP). The fear of foetal exposure to radiation during pregnancy may lead to a prolonged interruption in their career. Accordingly, this joint statement aims to provide a clear statement on radiation risk and the existing data on the experience of radiation-exposed cardiologists who continue to work in catheterisation laboratories (cath labs) throughout their pregnancies. In order to reduce the barrier preventing women from accessing these careers, increased knowledge in the community is warranted. Finally, by going beyond simple observations and review of the literature, our document suggests proposals for improving workplace safety and for encouraging equity.

Outcomes After Orbital Atherectomy of Severely Calcified Left Main Lesions: Analysis of the ORBIT II Study.

OBJECTIVES: The ORBIT II trial reported excellent outcomes in patients with severely calcified coronary lesions treated with orbital atherectomy. Severe calcification of the left main (LM) artery represents a complex coronary lesion subset. This study evaluated the safety and efficacy of coronary orbital atherectomy to prepare severely calcified protected LM artery lesions for stent placement. METHODS: The ORBIT II trial was a prospective, multicenter clinical trial that enrolled 443 patients with severely calcified coronary lesions in the United States. The major adverse cardiac event (MACE) rate through 2 years post procedure, defined by cardiac death, myocardial infarction (CK-MB >3x upper limit of normal with or without a new pathologic Q-wave) and target-vessel revascularization, was compared in the LM and non-left main (NLM) groups. RESULTS: Among the 443 patients, a total of 10 underwent orbital atherectomy of protected LM artery lesions. At 2 years, there was no significant difference in the 2-year MACE rate in the LM and NLM groups (30.0% vs 19.1%, respectively; P=.36). Cardiac death was low in both groups (0% vs 4.4%, respectively; P=.99). Myocardial infarction occurred within 30 days in both groups (10.0% vs 9.7%, respectively; P=.99). Severe dissection, perforation, persistent slow flow, and persistent no reflow did not occur in the LM group. Abrupt closure occurred in 1 patient in the LM group. CONCLUSIONS: Orbital atherectomy for patients with heavily calcified LM coronary artery lesions is safe and feasible. Further studies are needed to assess the safety and efficacy of orbital atherectomy in patients with severely calcified LM artery lesions.

A case of late presenting unicuspid aortic valve in a 62-year-old female.

We describe the case of a 62-year-old female presenting with new onset progressive dyspnea on exertion and a new diagnosis of aortic stenosis. Transesophageal echocardiography showed fusion of the aortic valve leaflets suspicious for bicuspid aortic valve with dilated ascending aorta. Surgical replacement of the valve revealed a unicuspid aortic valve with one true commissure at the level of the left and noncoronary cusps. The case is supported by clinical, echocardiographic and angiographic imaging and discussion of current imaging modalities used in diagnosis of aortic valve pathology.

A simple scoring tool for the evaluation of patients in an emergency department chest pain unit.

BACKGROUND: There are multiple risk scores to determine the prognosis of high-risk patients presenting with acute coronary syndromes (ACS) to emergency departments (ED) and chest pain units (CPU), however, there are few options for patients without ACS (no diagnostic ST-segment deviation or positive biomarkers). OBJECTIVES: To derive a clinical risk score for the management of lower-risk patients seen in ED CPUs. METHODS: We evaluated all patients triaged through the Mount Sinai ED CPU over a 76-month period who underwent stress testing after negative serial biomarkers and ECGs. Primary and secondary endpoints of hospital admission and coronary revascularization were retrospectively obtained. Variables associated with admission at P < 0.1 level were entered into a multivariable model. Each variable was assigned an integer score based on the beta coefficients in the final model. RESULTS: A total of 4,666 patients were evaluated and 738 (15.8%) had an abnormal stress test, 575 (12.3%) were admitted to the hospital, and 133 (2.9%) underwent coronary revascularization. A score consisting of age > 55 years, gender, chest pain quality (typical vs atypical), known coronary artery disease, shortness of breath, diabetes, smoking, and abnormal ECG demonstrated strong correlation between observed vs predicted hospital admission. The clinical score showed good ability to predict admission with a receiver operating characteristic (ROC) area of 0.72, which improved to 0.81 when the results of stress testing were added. CONCLUSIONS: This new clinical risk score is simple to use, predicts a clinically relevant outcome to ED physicians, and the results of noninvasive testing are additive.

RV dysfunction in pulmonary hypertension is independently related to pulmonary artery stiffness.

OBJECTIVES: This study investigated whether right ventricular (RV) adaptation to chronic pressure overload is associated with pulmonary artery (PA) stiffness beyond the degree of severity of pulmonary hypertension (PH). BACKGROUND: Increased PA stiffness has been associated with reduced survival in PH. The mechanisms for this association remain unclear. METHODS: Right heart catheterization and cardiac magnetic resonance were performed within 1 week in 124 patients with known or suspected chronic PH. Pulmonary vascular resistance index (PVRI) and PA pressures were quantified from right heart catheterization. Cardiac magnetic resonance included standard biventricular cine sequences and main PA flow quantification with phase-contrast imaging. Indexes of PA stiffness (elasticity, distensibility, capacitance, stiffness index beta, and pulse pressure) were quantified combining right heart catheterization and cardiac magnetic resonance data. RV performance and adaptation were measured by RV ejection fraction, right ventricular mass index (RVMI), RV end-systolic volume index, and right ventricular stroke work index (RVSWI). RESULTS: All indexes of PA stiffness were significantly correlated with measures of RV performance (Spearman rho coefficients ranging from -0.20 to 0.61, p < 0.05). Using multivariate regression analysis, PA elasticity, distensibility, and index beta were independently associated with all measures of RV performance after adjusting PVRI (p ≤ 0.024). PA capacitance was independently associated with RV ejection fraction, RVMI, and RVSWI (p < 0.05), whereas PA pulse pressure was associated with RVMI and RVSWI (p ≤ 0.027). Compared with PVRI, PA elasticity, distensibility, capacitance, and index beta explained 15% to 68% of the variability in RV ejection fraction, RVMI, and RV end-systolic volume index. Relative contributions of PA stiffness for RVSWI were 1.2× to 18.0× higher than those of PVRI. CONCLUSIONS: PA stiffness is independently associated with the degree of RV dysfunction, dilation, and hypertrophy in PH. RV adaptation to chronic pressure overload is related not only to the levels of vascular resistance (steady afterload), but also to PA stiffness (pulsatile load).

Coronary heart disease in the elderly: identifying established and subclinical disease with stress testing.

Although cardiovascular disease is a major cause of mortality, morbidity, and healthcare expense in the United States, diagnosis in elderly patients, especially those who are asymptomatic, can be challenging. Noninvasive testing offers an opportunity to identify these patients, but guidelines reflect uncertainty of the impact of diagnosis on long-term outcomes. We review the role of different forms of noninvasive testing in both symptomatic and asymptomatic patients, as well as patients under consideration for elective surgery.