High-Risk "Protected" Percutaneous Coronary Intervention with Mechanical Circulatory Support in a Non-Surgical Center - An Early Asian Experience.

High-risk "protected" percutaneous coronary intervention (PCI) using mechanical circulatory support (MCS) devices, particularly the Impella axial pump, has emerged as a viable treatment option for high-risk patients with satisfactory clinical outcomes. High-risk and complex interventions have mostly remained within the domain of surgical centers. We report on an early "protected" PCI experience using MCS with the Impella flow pump at a high-volume PCI hospital without on-site surgery. A total of 5 patients underwent elective "protected" PCI utilizing MCS with Impella at our institution. The mean left ventricular ejection fraction was 28 ± 10% and all patients had triple vessel coronary artery disease with the majority having a high SYNTAX score. Device implantation and procedural success were achieved in all cases with no intraprocedural or access site complications. All patients were alive at 30 days and clinically well. The Impella unloads the ventricle, improves forward cardiac output and lowers myocardial oxygen demand, thereby improving mean arterial pressure and coronary perfusion. Device insertion is relatively quick and the "learning curve" is short, centering mainly around managing large bore access. Our limited experience suggests that not only is high-risk PCI with Impella support feasible in a non-surgical center, but that it may be crucial to enable success.

Revisiting renovascular imaging for renal sympathetic denervation: current techniques and applications.

UNLABELLED: Renal sympathetic denervation (RDN) is an emerging technique in the treatment of resistant hypertension, most commonly performed using an endovascular approach. Clinical and anatomical criteria for RDN are well established and imaging plays an integral role in selecting patients with suitable anatomy, procedural planning and device selection. Nevertheless, the current body of literature surrounding imaging related to RDN remains limited. The purpose of this article is to illustrate the expectations and limitations of various imaging techniques, including Doppler ultrasound, CT angiography, MR angiography and newer techniques such as non-contrast MR angiography, in the context of RDN. KEY POINTS: • To understand the role of imaging in renal denervation • To understand strengths and weaknesses of current imaging techniques • To understand the relevant imaging findings in the context of renal denervation.

Subacute bioresorbable vascular scaffold thrombosis: a report of 2 cases.

Drug-eluting bioresorbable vascular scaffold (BVS) is a revolutionary treatment option for obstructive coronary artery disease in percutaneous coronary intervention. It restores blood flow to the myocardium but unlike permanent metallic stent, BVS dissolves in the body within 2 years. This allows the coronary vessel to regain its normal function and motion. The clinical efficacy and safety of BVS in the first-in-human trials have been reported with low major adverse cardiac event rates observed at short- and long-term follow-up. The incidence of BVS scaffold thrombosis (ST) in these studies was 0 %. There is limited data on the incidence of BVS ST in the real world. We report 2 cases of subacute ST involving BVS in our real-world practice and discuss on the possible mechanisms of these thrombotic episodes (with insights from intracoronary imaging studies).

Nationwide improvement of door-to-balloon times in patients with acute ST-segment elevation myocardial infarction requiring primary percutaneous coronary intervention with out-of-hospital 12-lead ECG recording and transmission.

STUDY OBJECTIVE: Reducing door-to-balloon times for acute ST-segment elevation myocardial infarction (STEMI) patients has been shown to improve long-term survival. We aim to reduce door-to-balloon time for STEMI patients requiring primary percutaneous coronary intervention by adoption of out-of-hospital 12-lead ECG transmission by Singapore's national ambulance service. METHODS: This was a nationwide, before-after study of STEMI patients who presented to the emergency departments (ED) and required percutaneous coronary intervention. In the before phase, chest pain patients received 12-lead ECGs in the ED. In the after phase, 12-lead ECGs were performed by ambulance crews and transmitted from the field to the ED. Patients whose ECG showed greater than or equal to 2 mm ST-segment elevation in anterior or greater than or equal to 1 mm ST-segment elevation in inferior leads for 2 or more contiguous leads and symptom onset of less than 12 hours' duration were eligible for percutaneous coronary intervention activation before arrival. RESULTS: ECGs (2,653) were transmitted by the ambulance service; 180 (7%) were suspected STEMI. One hundred twenty-seven patients from the before and 156 from the after phase met inclusion criteria for analysis. Median door-to-balloon time was 75 minutes in the before and 51 minutes in the after phase (median difference=23 minutes; 95% confidence interval 18 to 27 minutes). Median door-to-balloon times were significantly reduced regardless of presentation hours. Overall, there was significant reduction in door-to-activation, door-to-ECG, and door-to-cardiovascular laboratory times. No significant difference was found pertaining to adverse events. CONCLUSION: This study describes a nationwide implementation of out-of-hospital ECG transmission resulting in reduced door-to-balloon times, regardless of presentation hours. Out-of-hospital ECG transmission should be adopted as best practice for management of chest pain.

Successful percutaneous coronary intervention of 2 cases of complex coronary lesions facilitated by use of 0.010-inch guidewire and compatible balloon catheters.

We describe 2 cases of complex coronary lesions in which the conventional 0.014-inch balloon catheters failed to cross a chronic subtotal occlusion and also failed to adequately predilate a calcified coronary lesion. The novel use of a 0.010-inch guidewire and compatible balloon catheters in both cases allowed us to perform the percutaneous coronary intervention (PCI) successfully, and we highlight the usefulness of these new devices as important adjunctive tools in PCI. (J Interven Cardiol 2011;24:315-319).

A case series of ventricular cystic masses.

BACKGROUND: Ventricular cystic masses are uncommon. Elucidating the cause is essential for early directed therapy and prevention of complications. We present two cases of ventricular cystic masses, one in each ventricle, after myocardial infarction (MI) and ventricular septal rupture (VSR), respectively. CASE SUMMARY: Patient 1 is a 58-year-old male with left brachio-facial stroke and evolved anterior MI. A left ventricular (LV) cystic thrombus was seen on transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) imaging. He was started on anticoagulation with reduction in thrombus size 11 days later. Patient 2 is a 67-year-old male with evolved anterior MI, severe LV systolic dysfunction, and normal right ventricular (RV) function. He was readmitted two weeks later with fever, heart failure, Streptococcus agalactiae bacteraemia, and septic pulmonary emboli. Transthoracic echocardiogram showed biventricular systolic dysfunction and a RV cystic mass associated with a partial VSR. He was treated with anticoagulation and antibiotics. Repeat TTE 5 weeks later revealed near resolution of the cystic mass and complete VSR. Cardiac magnetic resonance confirmed these findings and also showed a localized mid-septal transmural infarction at the VSR site. He underwent percutaneous coronary intervention to the left anterior descending and circumflex arteries, and percutaneous VSR closure with a muscular ventricular septal defect device later. DISCUSSION: Our two cases demonstrate that ventricular thrombi can present as cystic masses after MI and VSRs. Infectious, vascular, or oncogenic causes should be considered in the appropriate clinical context. Early diagnosis and treatment is essential to prevent embolic complications, and secondary infection.

12-Month clinical outcomes of amphilimus drug eluting stents in an all-comers South-East Asian registry.

BACKGROUND: Amphilimus-eluting stent (AES) is a novel polymer-free drug eluting stent that combines sirolimus with fatty acid as antiproliferative drug and has shown promising results in percutaneous coronary intervention.We evaluated the clinical safety and efficacy of AES in an all-comers South-East Asian registry. METHODS: Between May 2014 to April 2017, 268 patients (88% male, mean age 60.1 ±â€¯10.8 years) with 291 coronary lesions were treated with AES. The primary endpoint was major adverse cardiac events (MACE) ie a composite of cardiovascular mortality, myocardial infarction (MI) and target lesion revascularization (TLR) at 12-month follow-up. RESULTS: The majority of patients presented with acute coronary syndrome (75%) and 75% had multi-vessel disease on angiography. Diabetes mellitus was present in 123 patients (46%). The most common target vessel for PCI was left anterior descending artery (43%) followed by right coronary artery (36%), left circumflex (10%) and left main (6%).The majority of lesions were type B-C (85%) by ACC/AHA lesion classification. An average of 1.25 ±â€¯0.5 AES were used per patient, with mean AES diameter of 3.1 ±â€¯0.4 mm and average total length of 34.8 ±â€¯19.4 mm.At 12-month follow-up, 4% of patients developed MACE. MACE was mainly driven by cardiovascular mortality (1.5%), MI (2%) and TLR (1.5%). The rate of stent thrombosis was 1.5%. CONCLUSION: In a contemporary all-comers South-East Asian registry with high rate of diabetes mellitus, AES was found to be efficacious with a low incidence of MACE observed at 12-month follow-up.

Sleep apnoea and cardiovascular outcomes after coronary artery bypass grafting.

OBJECTIVE: Patients with advanced coronary artery disease are referred for coronary artery bypass grafting (CABG) and it remains unknown if sleep apnoea is a risk marker. We evaluated the association between sleep apnoea and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-emergent CABG. METHODS: This was a prospective cohort study conducted between November 2013 and December 2018. Patients from four public hospitals referred to a tertiary cardiac centre for non-emergent CABG were recruited for an overnight sleep study using a wrist-worn Watch-PAT 200 device prior to CABG. RESULTS: Among the 1007 patients who completed the study, sleep apnoea (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Over a mean follow-up period of 2.1 years, 124 patients experienced the four-component MACCE (2-year cumulative incidence estimate, 11.3%). There was a total of 33 cardiac deaths (2.5%), 42 non-fatal myocardial infarctions (3.7%), 50 non-fatal strokes (4.9%) and 36 unplanned revascularisations (3.2%). The crude incidence of MACCE was higher in the sleep apnoea group than the non-sleep apnoea group (2-year estimate, 14.7% vs 7.8%; p=0.002). Sleep apnoea predicted the incidence of MACCE in unadjusted Cox regression analysis (HR 1.69; 95% CI 1.18 to 2.43), and remained statistically significant (adjusted HR 1.57; 95% CI 1.09 to 2.25), after adjustment for age, sex, body mass index, left ventricular ejection fraction, diabetes mellitus, hypertension, chronic kidney disease and excessive daytime sleepiness. CONCLUSION: Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG. TRIAL REGISTRATION NUMBER: NCT02701504.

Causes of delay in door-to-balloon time in south-east Asian patients undergoing primary percutaneous coronary intervention.

OBJECTIVE: To evaluate causes and impact of delay in the door-to-balloon (D2B) time for patients undergoing primary percutaneous coronary intervention (PPCI). SUBJECTS AND METHODS: From January 2009 to December 2012, 1268 patients (86% male, mean age of 58 ± 12 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: Non-delay defined as D2B time ≤ 90 mins and delay group defined as D2B time > 90 mins. Data were collected retrospectively on baseline clinical characteristics, mode of presentation, angiographic findings, therapeutic modality and inhospital outcome. RESULTS: 202 patients had delay in D2B time. There were more female patients in the delay group. They were older and tend to self-present to hospital. They were less likely to be smokers and have a higher prevalence of prior MI. The incidence of posterior MI was higher in the delay group. They also had a higher incidence of triple vessel disease. The 3 most common reasons for D2B delay was delay in the emergency department (39%), atypical clinical presentation (37.6%) and unstable medical condition requiring stabilisation/computed tomographic imaging (26.7%). The inhospital mortality was numerically higher in the delay group (7.4% versus 4.8%, p = 0.12). CONCLUSIONS: Delay in D2B occurred in 16% of our patients undergoing PPCI. Several key factors for delay were identified and warrant further intervention.

Safety and Feasibility of Renal Sympathetic Denervation in Patients With Insufficient Renal Artery Length.

Insufficient renal artery length for renal sympathetic denervation (RDN) is defined as having a main renal artery shorter than 20 mm in length. Such an anatomy is considered a contraindication for most of the currently available endovascular RDN devices. The concern stems from the need to distribute the ablation points to effect circumferential ablation causing sympathetic denervation, without the risk of injuring the renal artery. We postulate that if the requisite ablation points could be distributed between large caliber renal branches and the short main renal artery, RDN is likely feasible and safe. We demonstrate this with 2 cases using 2 different RDN devices and detail the technical feasibility.

Clinical outcomes of elderly South-East Asian patients in primary percutaneous coronary intervention for ST-elevation myocardial infarction.

OBJECTIVE: To evaluate the clinical characteristics and in-hospital outcomes of elderly South-East Asian patients undergoing primary percutaneous coronary intervention (PPCI). METHODS: From January 2009 to December 2012, 1268 patients (86.4% male, mean age of 58.4 ± 12.2 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: elderly group defined as age ≥ 70 years and non-elderly group defined as age < 70 years. Data were collected retrospectively on baseline clinical characteristics, door-to-balloon (D2B) time, angiographic findings, therapeutic modality and hospital course. RESULTS: The elderly group constituted 19% of the study population with mean age 76.6 ± 5.0 years. There was a higher proportion of female gender and ethnic Chinese patients in the elderly group when compared with the non-elderly group. The former was less likely to be smokers and have a significantly higher prevalence of hypertension. The mean D2B time was significantly longer in the elderly group. They also had a significantly higher incidence of triple vessel disease and obstructive left main disease. The use of radial artery access, glycoprotein 2b/3a inhibitors and drug-eluting stents during PPCI were also significantly lower. In-hospital mortality was significantly higher in the elderly group. The rate of cardiogenic shock and inhospital complications were also significantly higher. CONCLUSIONS: Our registry showed that in-hospital mortality rate in elderly South-East Asian patients undergoing PPCI for STEMI was high. Further studies into the optimal STEMI management strategy for these elderly patients are warranted.

Preliminary experience with drug-coated balloon angioplasty in primary percutaneous coronary intervention.

We evaluated the clinical feasibility of using drug-coated balloon (DCB) angioplasty in patients undergoing primary percutaneous coronary intervention (PPCI). Between January 2010 to September 2014, 89 ST-elevation myocardial infarction patients (83% male, mean age 59 ± 14 years) with a total of 89 coronary lesions were treated with DCB during PPCI. Clinical outcomes are reported at 30 d follow-up. Left anterior descending artery was the most common target vessel for PCI (37%). Twenty-eight percent of the patients had underlying diabetes mellitus. Mean left ventricular ejection fraction was 44% ± 11%. DCB-only PCI was the predominant approach (96%) with the remaining 4% of patients receiving bail-out stenting. Thrombolysis in Myocardial Infarction (TIMI) 3 flow was successfully restored in 98% of patients. An average of 1.2 ± 0.5 DCB were used per patient, with mean DCB diameter of 2.6 ± 0.5 mm and average length of 23.2 ± 10.2 mm. At 30-d follow-up, there were 4 deaths (4.5%). No patients experienced abrupt closure of the infarct-related artery and there was no reported target-lesion failure. Our preliminary experience showed that DCB angioplasty in PPCI was feasible and associated with a high rate of TIMI 3 flow and low 30-d ischaemic event.

Clinical Efficacy and Safety of SeQuent Please Paclitaxel-Eluting Balloon in a Real-World Single-Center Registry of South-East Asian Patients.

BACKGROUND: Drug eluting balloon (DEB) is a new therapeutic option for treatment of obstructive coronary lesions in percutaneous coronary intervention (PCI). There is limited data on the safety and efficacy of DEB in Asian patients in contemporary clinical registries. We evaluated the clinical efficacy and safety of SeQuent Please paclitaxel-eluting balloon in our cohort of South-East Asian patients in real world clinical practice. METHODS: Between January 2010 to November 2012, 320 patients (76% male, mean age 61.3 ± 11.2 years) with a total of 337 coronary lesions were treated with SeQuent Please drug-eluting balloon (DEB). The primary endpoint was major adverse cardiac events (MACE) ie a composite of cardiovascular death, target vessel related myocardial infarction (MI) and target lesion revascularization (TLR) at 9 months follow-up. RESULTS: The majority of patients presented with acute coronary syndrome (76%).The most common indication for the use of DEB was small vessel disease (54%) followed by instent restenosis (21%), bifurcation lesions (6%) and others (19%). An average of 1.23 ± 0.5 DEB were used per patient, with mean DEB diameter of 2.6 ± 0.6 mm and average total length of 24.0 ± 11.1 mm.At 9 months follow-up, 5.3% of patients developed MACE. MACE was mainly driven by TLR(4%) followed by target vessel related myocardial infarction (2.6%) and cardiovascular death (1%). CONCLUSION: SeQuent Please DEB was a safe and effective treatment modality in our cohort of South-East Asian patients with a low incidence of MACE observed at 9 months follow-up.

Radial artery spasm during transradial cardiac catheterization and percutaneous coronary intervention: incidence, predisposing factors, prevention, and management.

Transradial cardiac catheterization and percutaneous coronary intervention are increasingly being performed worldwide in elective and emergency procedures, with many centers adopting the transradial route as their first choice of arterial access. One of the most common complications encountered during transradial procedures is radial artery spasm. This article reviews the current literature on the incidence, predisposing factors, preventive, and treatment measures for radial artery spasm.

Deliverability of integrity coronary stents in severely tortuous coronary arteries: a preliminary experience.

BACKGROUND: Stent delivery failure occurs in 4% of all percutaneous coronary interventions (PCIs) and >90% of these failures are due to vessel tortuosity and/or calcification. Stent performance of the newly launched Integrity coronary stent has markedly improved due to its novel manufacturing process utilizing continuous sinusoid technology. We sought to evaluate the deliverability of Integrity coronary stents in severely tortuous coronary lesions in real-world clinical practice. METHODS: From January to August 2011, a total of 35 patients (25 males; mean age, 60.7 ± 11.4 years) with obstructive coronary artery disease involving severely tortuous coronary vessels underwent PCI with Integrity coronary stents. RESULTS: The most common target vessel for PCI was left circumflex artery (54.3%) followed by right coronary artery (42.8%) and left anterior descending (2.9%), with 37.1% of lesions located distally. Mean stent diameter was 3.04 ± 0.51 mm and mean stent length was 20.5 ± 6.6 mm. Acute procedural success was achieved in 33 patients (94%) using conventional PCI techniques. Predilatation was performed in 31 patients (89%) and buddy wires were used in 12 patients (34.3%). For the 2 cases (6%) in which stent delivery failed, Heartrail catheters were used as a bailout to facilitate stent delivery. There were no peri- or postprocedural adverse events. CONCLUSION: This early experience with Integrity coronary stent in severely tortuous coronary arteries yielded a promising result in terms of stent deliverability. It could potentially shorten PCI procedural time in this technically challenging subgroup of patients.