STEMI in the cancer patient: Do not withhold primary PCI!

Poor outcomes observed in cancer patients who sustain STEMI are due, in part, to advanced age, comorbidities, and underutilization of guidelines-based therapies. Coronary angiography in the cancer patient is more likely to demonstrate MINOCA, but the majority have critical disease and PCI success is similar to noncancer patients. We recommend primary PCI with stenting as the default strategy in STEMI patients with cancer.

Does the method of administering fluids matter for contrast-induced nephropathy? REMEDIAL III compares LVEDP versus urine flow-guided hydration.

Contrast-induced nephropathy (CIN) is a major cause of morbidity and mortality among patients undergoing angiographic procedures. Limiting contrast dose and administration of intravenous normal saline appear to be the best approaches to reducing CIN, but the timing, dose, and duration of optimal hydration is poorly understood. The REMEDIAL III trial protocol outlines two different targeted hydration regimens (guided either by continuous measurement of urine output or by initial left ventricular end diastolic pressure (LVEDP), and 700 patients at high risk of CIN will be randomized.

Feasibility and Safety of Low-Dose Intra-Coronary Tenecteplase During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction (ICE T-TIMI 49).

Following primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction, microvascular perfusion is often impaired secondary to thrombotic embolization. Intracoronary (IC) fibrinolytic administration may reduce thrombotic burden and distal embolization. The ICE-T-TIMI-49 study evaluated the feasibility and safety of low-dose IC tenecteplase (TNK) during PPCI. The study randomized 40 PPCI patients to a volume matched bolus of IC TNK (4 mg) (n = 20) or IC saline placebo (n = 20) before and following PPCI. The primary end point was percent diameter stenosis of the culprit lesion following first bolus. The primary end point did not differ between IC placebo (median 100%, interquartile range [IQR] 83.0,100.0) and IC TNK (median 100% stenosis, IQR 91.0,100.0; p = 0.522). However, the proportion of patients with reduction in thrombus following first bolus tended to be greater with IC TNK (placebo: 12.5% vs IC TNK: 40.0%, p = 0.133). Following PPCI, the corrected Thrombolysis In Myocardial Infarction (TIMI) frame count (cTFC) was lower (faster) with placebo (16.0 frames [IQR 12.0,24.0] vs 24.0 frames [22.0,32.0], p = 0.045) due to a trend towards greater frequency of hyperemia (cTFC <14), a marker of distal embolization (50.0% vs 8.3%, p = 0.056). There was no difference in TIMI major bleeds and no intracranial hemorrhage. In conclusion, treatment with low-dose IC TNK appears safe and well tolerated during PPCI. Although IC TNK administration did not improve percent stenosis, a trend towards reduced thrombus burden was demonstrated with less hyperemia (a marker of distal embolization). Our findings provide support for a large randomized study.

Clinical Conference Proceedings: 15th Biennial International Andreas Gruentzig Society Meeting.

The International Andreas Gruentzig Society is an educational society of physicians and scientists interested in cardiovascular and related fields. Members cooperate in the advancement of knowledge and education through research, publication, study, and teaching in the fields of cardiovascular disease. This summary reflects the proceedings from the recent scientific meeting to assess current clinical problems and propose future directions and possible solutions.

Interoperator and intraoperator (in)accuracy of stent selection based on visual estimation.

OBJECTIVES: The objectives of this study were to evaluate the ability of interventional cardiologists to accurately measure lesion length and select appropriate stents. BACKGROUND: Inaccurate measurement of lesion length during percutaneous coronary intervention (PCI) increases the risk of restenosis. METHODS: Interventional cardiologists (n = 40) evaluated 25 matched orthogonal angiographic images that were prescored using quantitative coronary angiography (QCA) by a core laboratory. Visual estimates of lesion length and stent length selection were compared to the maximum QCA value. A 2-4 mm stent overlap of both the proximal and distal lesion edges was considered to be optimal. Based on optimal stent overlap, accurate lesion lengths were those measured from -1 to +4 mm from the QCA. Likewise, appropriate stent lengths were those that measured between +4 mm to +8 mm from the QCA value. Five images were repeated to assess intrarater variability. RESULTS: Lesion length measurements were short and long for 51.1% (95% CI 47.6-54.6%) and 19.0% (95% CI 16.3-21.9%) of the images, respectively. Stent length selections that were short and long were recorded for 55.0% (95% CI 51.5-58.5%) and 22.8% (95% CI 19.9-25.8%) of the images, respectively. Intrarater variability evaluation indicated that 38.5% (95% CI 31.7-45.6%) of lesion length measurements and 37.5% (95% CI 30.8-44.6%) of stent length selections were >3 mm different between the first and second evaluation of repeated images. CONCLUSIONS: Visual estimation of coronary lesion length has a high degree of variability, which may lead to inappropriate stent selection. Improving the accuracy of lesion length measurement may improve patient outcomes.

The association between experience and proficiency with robotic-enhanced coronary intervention-insights from the PRECISE multi-center study.

OBJECTIVES: The PRECISE multi-center study demonstrated the safety and feasibility of robotic-enhanced coronary intervention (PCI). We studied the learning curve associated with the robotic PCI approach. METHODS: The CorPath 200 robotic system was used to perform clinically indicated PCI. The first 3 cases performed by each interventional cardiologist were considered early-experience cases and subsequent procedures were regarded as advanced-experience cases. We compared procedure efficiency, patient radiation exposure, and clinical outcomes in early and advanced-experience cases. RESULTS: A total of 164 robotic-enhanced PCI procedures were performed, with 60 early-experience cases. Advanced-experience cases were associated with shorter procedure duration (51.3 ± 25.5 min vs. 42.2 ± 16.4 min, P = 0.008) and fluoroscopy time (12.9 ± 7.8 min vs. 10.1 ± 4.8 min, 0.009) as compared to early-experience cases. CONCLUSIONS: After performing 3 cases, interventionalists were able to complete robotic-enhanced PCI faster, with reduced radiation, and without compromising safety. The steep learning curve highlights the easy adoption of remote-control robotic technology for PCI.

Safety and feasibility of robotic percutaneous coronary intervention: PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) Study.

OBJECTIVES: The aim of this study was to evaluate the safety as well as the clinical and technical effectiveness of robotic-assisted percutaneous coronary intervention. BACKGROUND: Robotic systems have been suggested to enhance the performance of cardiovascular procedures, as well as to provide protection from the occupational hazards that are associated with interventional practice. METHODS: Patients with coronary artery disease and clinical indications for percutaneous intervention were enrolled. The coronary intervention was performed with the CorPath 200 robotic system, which consists of a remote interventional cockpit and a bedside disposable cassette that enables the operator to advance, retract, and rotate guidewires and catheters. The primary endpoints were clinical procedural success, defined as <30% residual stenosis at the completion of the robotic-assisted procedure without major adverse cardiovascular events within 30 days, and device technical success, defined as the successful manipulation of the intracoronary devices using the robotic system only. RESULTS: A total of 164 patients were enrolled at 9 sites. Percutaneous coronary intervention was completed successfully without conversion to manual operation, and device technical success was achieved in 162 of 164 patients (98.8%). There were no device-related complications. Clinical procedural success was achieved in 160 of 164 patients (97.6%), whereas 4 (2.4%) had periprocedural non-Q-wave myocardial infarctions. No deaths, strokes, Q-wave myocardial infarctions, or revascularization occurred in the 30 days after the procedures. Radiation exposure for the primary operator was 95.2% lower than the levels found at the traditional table position. CONCLUSIONS: This pivotal multicenter study with a robotic-enhanced coronary intervention system demonstrated the safety and feasibility of the system. The robotic remote-control procedure met the expected technical and clinical performance, with significantly lower radiation exposure to the operator. (Evaluation of the Safety and Effectiveness of the CorPath 200 System in Percutaneous Coronary Interventions [PCI] [PRECISE]; NCT01275092).

Effect of percutaneous coronary intervention on quality of life: a consensus statement from the Society for Cardiovascular Angiography and Interventions.

Percutaneous coronary intervention (PCI) decreases ischemic complications of acute coronary syndromes. The benefits of PCI in stable ischemic heart disease (SIHD) depend on its effect on quality of life (QoL), including angina, physical activity, and emotional well-being. PCI decreases angina and the need for anti-anginal medications, and increases exercise capacity and QoL, compared with baseline status and compared with medical therapy without PCI. These benefits are greater when QOL is markedly impaired by severe angina before the procedure. When considering treatment options for symptomatic SIHD, physicians should consider and provide objective data regarding QoL effects for each treatment strategy. QoL outcomes should be considered in clinical trials, appropriate use criteria, practice guidelines, and reimbursement policies for PCI.