Clinical use of optical coherence tomography during percutaneous coronary intervention and coronary procedures in Southeast Asia: a survey-based expert consensus summary.

Optical coherence tomography (OCT), an established intravascular imaging technique, enables rapid acquisition of high-resolution images during invasive coronary procedures to assist physician decision-making. OCT has utility in identifying plaque/lesion morphology (e.g., thrombus, degree of calcification, and presence of lipid) and vessel geometry (lesion length and vessel diameter) and in guiding stent optimisation through identification of malapposition and underexpansion. The use of OCT guidance during percutaneous coronary interventions (PCI) has demonstrated improved procedural and clinical outcomes in longitudinal registries, although randomised controlled trial data remain pending. Despite growing data and guideline endorsement to support OCT guidance during PCI, its use in different countries is not well established. This article is based on an advisory panel meeting that included experts from Southeast Asia (SEA) and is aimed at understanding the current clinical utility of intracoronary imaging and OCT, assessing the barriers and enablers of imaging and OCT adoption, and mapping a path for the future of intravascular imaging in SEA. This is the first Southeast Asian consensus that provides insights into the use of OCT from a clinician's point of view.

Clinical Outcomes of Rotational Atherectomy in Heavily Calcified Lesions: Evidence From the Largest Cardiac Center in Thailand.

Background: Evidence regarding the clinical outcomes of rotational atherectomy (RA) in middle-income countries is limited. We analyzed the clinical outcomes of patients with heavily calcified coronary lesions who underwent RA-assisted percutaneous coronary intervention (PCI) and explored the risks for developing major adverse cardiovascular and cerebrovascular events (MACCE). Methods: This is a single-center, retrospective cohort analysis that enrolled consecutive patients who underwent RA-assisted PCI at the largest tertiary hospital in Thailand. The primary endpoint is the incidence of MACCE during the first-year follow-up. MACCE consists of cardiac death, ischemic stroke, definite stent thrombosis, target lesion revascularization, and target vessel revascularization. Results: From January 2015 to December 2018, 616 patients (663 lesions) were enrolled. The mean age was 72.8 ± 9.7 years, 292 (47.4%) patients were female and 523 (84.9%) completed one-year follow-up. Drug-eluting stents were deployed in 606 (91.4%) lesions. The RA success rate - defined as when the operator successfully passed the burr across the target lesion - was 99.4% and the angiographic success rate was 94.8%. 130 (21.4%) procedures developed periprocedural complications. The cumulative MACCE rate at 30-days was 1.5% and at 1-year was 6.3%. The in-hospital mortality rate was 1.1% and the cardiac death rate was 1.6%. Independent risk factors for developing MACCE included the use of an intra-aortic balloon pump (hazard ratio [HR] 3.96, 95% confidence interval [CI] 1.54-10.21; P = 0.004), a history coronary artery bypass graft (HR 2.30, 95% CI 1.01-5.25; P = 0.048), and increased serum creatinine (HR 1.16, 95% CI 1.04-1.30; P = 0.008). Conclusions: RA is an effective revascularization technique for heavily calcified lesions. This study demonstrates a high success rate and good short- to intermediate-term results of RA-assisted PCI in middle-income countries which are similar to high-income countries. Nevertheless, the rate of periprocedural complications remains high.

Preprocedural and procedural variables that predict new-onset conduction disturbances after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances are a common complication after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the preprocedural and procedural variables that predict new-onset conduction disturbances post-TAVR (hereafter CD/CDs). METHODS: Consecutive patients who underwent TAVR during December 2009-March 2021 at the Faculty of Medicine Siriraj Hospital, Mahidol University-Thailand's largest national tertiary referral center-were enrolled. Patients with prior implantation of a cardiac device, periprocedural death, or unsuccessful procedure were excluded. Clinical and electrocardiographic data, preprocedural imaging, including membranous septum (MS) length, and procedural variables, including implantation depth (ID), were analyzed. CD was defined as new left or right bundle branch block, significant intraventricular conduction disturbance with QRS interval ≥ 120 ms, new high-grade atrioventricular block, or complete heart block. Multivariate binary logistic analysis and receiver operating characteristic (ROC) curve analysis were used to identify independent predictors and the optimal ∆MSID (difference between the MS length and ID) cutoff value, respectively. RESULTS: A total of 124 TAVR patients (mean age: 84.3 ± 6.3 years, 62.1% female) were included. The mean Society of Thoracic Surgeons score was 7.3%, and 85% of patients received a balloon expandable transcatheter heart valve. Thirty-five patients (28.2%) experienced a CD, and one-third of those required pacemaker implantation. The significant preprocedural and procedural factors identified from univariate analysis included intraventricular conduction delay, mitral annular calcification, MS length ≤ 6.43 mm, self-expanding device, small left ventricular cavity, and ID ≥ 6 mm. Multivariate analysis revealed MS length ≤ 6.43 mm (adjusted odds ratio [aOR] 9.54; 95% CI 2.56-35.47; p = 0.001) and ∆MSID < 0 mm (adjusted odds ratio [aOR] 10.77; 95% CI 2.86-40.62; p = < 0.001) to be independent predictors of CD. The optimal ∆MSID cutoff value for predicting conduction disturbances was less than 0 mm (area under the receiver operating characteristic curve [AuROC]: 0.896). CONCLUSION: This study identified MS length ≤ 6.43 mm and ∆MSID < 0 mm as independent predictors of CDs. ∆MSID < 0 was the strongest and only modifiable predictor. Importantly, we expanded the CD criteria to cover all spectrum of TAVR-related conduction injury to lower the threshold of this sole modifiable risk. The optimal ∆MSID cutoff value was < 0 mm. TRIAL REGISTRATION: TCTR, TCTR20210818002. Registered 17 August 2021-Retrospectively registered, http://www.thaiclinicaltrials.org/show/TCTR 20210818002.

Intravascular Imaging Guidance Reduce 1-Year MACE in Patients Undergoing Rotablator Atherectomy-Assisted Drug-Eluting Stent Implantation.

Objectives: This study aimed to investigate the incidence of 1-year major adverse cardiac events (MACE) compared between intravascular imaging guidance and angiographic guidance in patients undergoing rotablator atherectomy (RA)-assisted percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Methods: This retrospective analysis included 265 consecutive patients with heavy calcified lesion who underwent RA-assisted PCI with DES implantation at our institution during the January 2016-December 2018 study period. This study was approved by the Siriraj Institutional Review Board. Patients were divided into either the angiographic guidance PCI group or the imaging guidance PCI group, which was defined as intravascular ultrasound or optical coherence tomography. The primary endpoint was 1-year MACE. Results: Two hundred and sixty-five patients were enrolled, including 188 patients in the intravascular imaging guidance group, and 77 patients in the angiographic guidance group. One-year MACE was significantly lower in the imaging guidance group compared to the angiographic guidance group (4.3 vs. 28.9%, respectively; odds ratio (OR): 9.06, 95% CI: 3.82-21.52; p < 0.001). The 1-year rates of all-cause death (OR: 8.19, 95% CI: 2.15-31.18; p = 0.002), myocardial infarction (MI) (OR: 6.13, 95% CI: 2.05-18.3; p = 0.001), and target vessel revascularization (TVR) (OR: 3.67, 95% CI: 1.13-11.96; p = 0.031) were also significantly lower in the imaging guidance group compared with the angiographic guidance group. The rate of stroke was non-significantly different between groups. Conclusion: In patients with heavy calcified lesion undergoing RA-assisted DES implantation, the intravascular imaging guidance significantly reduced the incidence of 1-year MACE, all-cause death, MI, and TVR compared to the angiographic guidance.

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature.

-Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67-year-old man with symptomatic severe aortic stenosis after TAVR. -Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.

2020 Asian Pacific Society of Cardiology Consensus Recommendations on Antithrombotic Management for High-risk Chronic Coronary Syndrome.

The unique characteristics of patients with chronic coronary syndrome (CCS) in the Asia-Pacific region, heterogeneous approaches because of differences in accesses and resources and low number of patients from the Asia-Pacific region in pivotal studies, mean that international guidelines cannot be routinely applied to these populations. The Asian Pacific Society of Cardiology developed these consensus recommendations to summarise current evidence on the management of CCS and provide recommendations to assist clinicians treat patients from the region. The consensus recommendations were developed by an expert consensus panel who reviewed and appraised the available literature, with focus on data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting recommendations provide guidance on the assessment and management of bleeding and ischaemic risks in Asian CCS patients. Furthermore, the selection of long-term antithrombotic therapy is discussed, including the role of single antiplatelet therapy, dual antiplatelet therapy and dual pathway inhibition therapy.

Asian Pacific Society of Cardiology Consensus Recommendations on Dyslipidaemia.

The prevalence of dyslipidaemia has been increasing in the Asia-Pacific region and this is attributed to dietary changes and decreasing physical activity. While there has been substantial progress in dyslipidaemia therapy, its management in the region is hindered by limitations in awareness, adherence and healthcare costs. The Asian Pacific Society of Cardiology (APSC) developed these consensus recommendations to address the need for a unified approach to managing dyslipidaemia. These recommendations are intended to guide general cardiologists and internists in the assessment and treatment of dyslipidaemia and are hoped to pave the way for improving screening, early diagnosis and treatment. The APSC expert panel reviewed and appraised the evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed, which were then put to an online vote. The resulting consensus recommendations tackle contemporary issues in the management of dyslipidaemia, familial hypercholesterolaemia and lipoprotein(a) in the Asia-Pacific region.