Contemporary Use of Laser During Percutaneous Coronary Interventions: Insights from the Laser Veterans Affairs (LAVA) Multicenter Registry.

BACKGROUND: The contemporary use and outcomes of excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) are not well described. METHODS: We examined the baseline clinical and angiographic characteristics and procedural outcomes of 130 target lesions in 121 consecutive PCIs (n = 116 patients) in which ELCA was performed at three United States Department of Veterans Affairs (VA) medical centers between 2008 and 2016. RESULTS: Mean age was 68.5 ± 9 years and 97% of the patients were men. Patients had high prevalence of diabetes mellitus (63%), prior coronary artery bypass graft surgery (41%), and prior myocardial infarction (60%). The most common target vessel was the left anterior descending (32%), followed by the right coronary artery (30%), circumflex artery (20%), and saphenous vein graft (12%). The target lesions were highly complex, with moderate/severe calcification in 62% and in-stent restenosis in 37%. The most common indication for ELCA was balloon-uncrossable lesions (43.8%), followed by balloon-undilatable lesions (40.8%) and thrombotic lesions (12.3%). Use of ELCA was associated with high technical success rate (90.0%) and procedural success rate (88.8%), and low major adverse cardiac event (MACE) rate (3.45%). Mean procedure time was 120 min (interquartile range [IQR], 81-191 min), air kerma radiation dose was 2.76 Gy (IQR, 1.32-5.01 Gy), and contrast volume was 273 mL (IQR, 201-362 mL). CONCLUSION: In a contemporary multicenter United States registry, ELCA was commonly used in highly complex lesions and was associated with high technical and procedural success rates and low incidence of MACE.

Insertion of the Impella via the axillary artery for high-risk percutaneous coronary intervention.

Hemodynamic support with the Impella device is an important tool during high risk percutaneous coronary intervention. This device is usually inserted via the femoral artery. However, some patients have severe peripheral artery disease precluding the use of the femoral artery for this purpose. The axillary artery is a viable alternative in these cases. We reviewed the two access techniques for inserting the Impella via the axillary artery and also described 6 cases of successful implantation.

Beat-to-beat corrected QT analysis detects corrected QT prolongation in 50 consecutive telemetry-monitored patients.

BACKGROUND: The American Heart Association/American College of Cardiology Foundation recommends monitoring for corrected QT (QTc) prolongation. The incidence of QTc prolongation in the general public is unknown. Episodic measurements may miss patients at risk. OBJECTIVE: The purpose of this study was to determine the incidence of QTc prolongation in hospitalized telemetry patients when beat-to-beat monitoring, confirmed by manual calculation, was used for detection. METHODS: After institutional review board approval was obtained, waveforms of telemetry-monitored patients were analyzed consecutively until 50 patients with prolonged QTc were identified (QTc >470 milliseconds in men and >480 milliseconds in women). Prolongation was confirmed by manual calculation. Incidence was calculated. Clinical risk factors and the outcomes of torsades de pointe or sudden death were explored. RESULTS: Telemetry waveforms were evaluated for 192 444 minutes (3207.4 hours) of recordings, yielding 8,076,653 QTc measurements. In 50 consecutive patients (24 [48%] men), 100% had verified episode(s) of QTc prolongation. Home medications that could result in QTc prolongation were identified in 9 patients (18%). Hospital medications with risk of QTc prolongation were administered to 31 patients (62%). Sixteen patients (32%) were not on a QTc-prolonging medication. Corrected QT prolongation risk factors in the history were found in 2 patients (4%) and hypomagnesemia or hypokalemia was seen in 6 patients (12%). Twelve-lead electrocardiogram detected prolonged QTc in 13 of 45 patients (26%). Prolongation of QTc was detected by standard of care manual analysis in 4 patients (8%). No patient experienced torsades de pointe or sudden death. CONCLUSION: With beat-to-beat analysis, QTc prolongation was detected in 100% of 50 consecutive patients where standard of care (nursing manual analysis or 12-lead electrocardiogram) would have detected 28%. Hospital medications were more likely to contribute to QTc prolongation than home medications. IMPLICATIONS FOR PRACTICE: More specific definitions for determining proarrhythmic risk are needed as automated technology improves the capture rate of QTc prolongation events.