Extraplaque versus intraplaque tracking in chronic total occlusion percutaneous coronary intervention.

Megaly M, Buda K, Karacsonyi J, Kostantinis S, ... Alaswad K, Brilakis ES
Objective
To compare the clinical outcomes after extraplaque (EP) versus intraplaque (IP) tracking in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).
Background
The impact of modern dissection and reentry (DR) techniques on the long-term outcomes of CTO PCI remains controversial.
Methods
We performed a systematic review and meta-analysis of studies that compared EP versus IP tracking in CTO PCI. Odds ratios (ORs) with 95% confidence intervals (CIs) are calculated using the Der-Simonian and Laird random-effects method.
Results
Our meta-analysis included seven observational studies with 2982 patients. Patients who underwent EP tracking had significantly more complex CTOs with higher J-CTO score, longer lesion length, and more severe calcification and had significantly longer stented segments. During a median follow-up of 12 months (range 9-12 months), EP tracking was associated with a higher risk of major adverse cardiovascular events (MACE) (OR 1.50, 95% CI (1.10-2.06), p = 0.01) and target vessel revascularization (TVR) (OR 1.69, 95% CI (1.15-2.48), p = 0.01) compared with IP tracking. There was no difference in the incidence of all-cause death (OR 1.37, 95% CI (0.67-2.78), p = 0.39), myocardial infarction (MI) (OR 1.48, 95% CI (0.82-2.69), p = 0.20), stent thrombosis (OR 2.09, 95% CI (0.69-6.33), p = 0.19), or cardiac death (OR 1.10, 95% CI (0.39-3.15), p = 0.85) between IP and EP tracking.
Conclusion
EP tracking is utilized in more complex CTOs and requires more stents. EP tracking is associated with a higher risk of MACE, driven by a higher risk of TVR at 1 year, but without an increased risk of death or MI compared with IP tracking. EP tracking is critically important for contemporary CTO PCI.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Sep 2022; epub ahead of print

Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock.

Elkaryoni A, Cohen DJ, Lopez JJ, Huded CP, Kennedy KF, Arnold SV
Background
Before the development of transcatheter aortic valve replacement (TAVR), balloon aortic valvuloplasty (BAV) was the only potential nonsurgical intervention for patients with aortic stenosis complicated by cardiogenic shock. Emergent TAVR is now an option and has shown acceptable outcomes compared with elective TAVR. We explored how treatment patterns for aortic stenosis and cardiogenic shock among patients received invasive intervention have shifted since TAVR was introduced.
Methods
We used the Nationwide In patients Sample to identify nonelective hospitalizations for patient with aortic stenosis complicated by cardiogenic shock who received invasive treatment (TAVR, BAV, or surgical aortic valve replacement [SAVR]). We explored the proportion treated with each treatment modality over time, the patient characteristics and in-hospital mortality associated with each treatment, and used multivariable logistic regression to examine whether changes in in-hospital mortality over time differed by treatment.
Results
Between 2010 and 2019, we identified 9899 hospitalizations for decompensated aortic stenosis with cardiogenic shock during which patients received invasive treatment (TAVR 17.7%, BAV 20.2%, SAVR 62.1%). Use of both TAVR and BAV has increased over time compared with SAVR (TAVR 6.6% ≥ 33.8%, BAV 8.4% ≥ 23.2%, SAVR 91.6% ≥ 43.0%; p < 0.001 for trend). The overall in-hospital mortality rate was 21.0%, which decreased over time for all treatments (TAVR 20.0% ≥ 18.8%, BAV 66.0% ≥ 25.5%, SAVR 17.7% ≥ 11.8%; linear trend p < 0.001 for each), with lower mortality for TAVR versus BAV at all time points. Patients treated with TAVR (vs. BAV) were less likely to require mechanical ventilation (36.8% vs. 46.3%, p < 0.001) or mechanical circulatory support (22.5% vs. 29.9%, p < 0.001). In the multivariable analysis, the interaction between treatment and time was not significant (p = 0.245), indicating the reduction in in-hospital mortality over time did not differ among the treatments.
Conclusions
Since the introduction of TAVR, there has been a shift toward increased use of nonsurgical invasive treatments (both BAV and TAVR) for aortic stenosis and cardiogenic shock. Although in-hospital mortality has declined, it remains high in all groups, but particularly among patients treated with BAV, where the severity of cardiogenic shock appears to be higher than in those treated with other modalities.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Sep 2022; epub ahead of print

Alcohol septal ablation for left ventricular outflow tract obstruction in cardiac amyloidosis: New indication for an established therapy.

Fanta LE, Ewer SM, Gimelli G, Reilly NM
Cardiac amyloidosis can occasionally demonstrate an atypical pattern of infiltration, causing asymmetric septal thickening and a left ventricular outflow tract (LVOT) gradient with systolic anterior motion (SAM) of the mitral valve resembling obstructive hypertrophic cardiomyopathy. We present a case of a 70-year-old man with cardiac light-chain amyloidosis and LVOT obstruction successfully treated with alcohol septal ablation (ASA). Following the procedure, he reported significant improvement in his heart failure symptoms as well as improvement in LVOT gradient and SAM of the mitral valve. This case demonstrates that ASA is a technically feasible and effective procedure for relieving LVOT obstruction in cardiac amyloidosis and can be considered as a treatment option in patients whose symptoms are refractory to medical therapy.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 24 Sep 2022; epub ahead of print

Bespoke valve sizing avoids annular rupture in patients treated with a balloon-expandable transcatheter heart valve.

Chavarria J, Falcao F, Dutra G, Sathananthan J, ... Velianou J, Sheth T
Background
Annular and left ventricular outflow tract (LVOT) calcification increase the risk of annular rupture following transcatheter aortic valve replacement (TAVR). The outcomes of a strategy of routine use of a balloon-expandable valve (BEV) for all patients irrespective of annular or LVOT calcium is unknown.
Objectives
We evaluated the impact of bespoke sizing on annular rupture in patients treated with a BEV.
Methods
All consecutive patients undergoing TAVR at a single centre (February 2020-February 2022) were treated only with a BEV. No other valve design was used. Annular/LVOT calcification was assessed using a standardized grading system. For each annular area, we determined the percentage valve oversizing with nominal deployment. The balloon deployment volume was then adjusted when required (over-/underfilled) to achieve over-sizing of approximately 5% in the presence of annular/LVOT calcium and 5%-10% in the absence of annular/LVOT calcium. Adjusted valve areas were assumed to change proportionately to the change in balloon deployment volume.
Results
Among 533 TAVR treated patients, annular/LVOT calcification was present in 166 (31.1%) and moderate or severe in 90 (16.9%). In patients with annular/LVOT calcification, the adjusted oversizing was 3.5 ± 3.6% and in patients without annular/LVOT calcification, the adjusted oversizing was 6.8 ± 4.7% (p < 0.001). There were no cases of annular rupture and no cases with more than mild paravalvular leak (PVL). Mild PVL was more frequent in patients with annular/LVOT calcium (10.8% vs 4.6%, p = 0.01).
Conclusion
Bespoke BEV sizing by adjustment of balloon deployment volume avoided annular rupture in patients undergoing TAVR.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 24 Sep 2022; epub ahead of print

Usefulness of a novel sizing chart for left atrial appendage occlusion with the Amplatzer Amulet.

Freixa X, Cepas-Guillén P, Korsholm K, Kramer A, ... Jensen JM, Nielsen-Kudsk JE
Purpose
The present article aims to compare a novel sizing chart based on both maximum and minimum diameters (novel MATRIX) with the current sizing recommendation instructions for use (IFU) based on the maximum diameter.
Background
Current IFU with the Amulet device are still based on the maximum left atrial appendage (LAA) diameter, which might lead to inappropriate oversizing, especially in elliptic appendages.
Methods
This was a retrospective analysis of patients undergoing LAA occlusion in two high-volume centers. Two hundred patients were included (100 patients with baseline cardiac computed tomography angiography [CCTA] and 100 with baseline 2D and 3D-transesophageal echocardiography [TEE]). The degree of concordance between the predicted device size recommendation and the actual device selection was the primary outcome.
Results
The novel MATRIX showed a higher level of concordance between the predicted and implanted device size, regardless of imaging modalities. CCTA showed the strongest, and 2D-TEE the weakest concordance between the predicted and implanted device for both MATRIX and IFU charts. The percentage of patients in whom the disagreement among the predicted and implanted device represented >1 size was higher when using the IFU chart. In elliptical LAA anatomies, the differences favoring the use of MATRIX compared to the IFU in terms of predicted/implanted agreement were higher. Finally, no significant differences in clinical or imaging endpoints were observed between the two different sizing charts.
Conclusions
Incorporating both the LAA maximum and minimum diameters, as opposed to just maximum diameter, appears to improve sizing accuracy. The proposed MATRIX sizing chart offered a higher level of concordance between predicted and implanted device compared to the current IFU.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 24 Sep 2022; epub ahead of print

Impact of extracardiac vascular disease on outcomes of 1.4 million patients undergoing percutaneous coronary intervention.

Bashar H, Matetić A, Curzen N, Mamas MA
Objectives
Extracardiac vascular disease (ECVD) is increasingly recognized as a cardiovascular risk factor, but its association with outcomes after percutaneous coronary intervention (PCI) has not been well characterized.
Methods
Using the National Inpatient Sample database, all patients undergoing PCI between October 2015 and December 2018 were stratified by the presence and organ-specific extent of extracardiac vascular comorbidity (cerebrovascular disease (CeVD), renovascular, aortic and peripheral arterial disease (PAD)). Primary outcome was all-cause mortality and secondary outcomes were (a) major adverse cardiovascular and cerebrovascular events (MACCE), (b) acute ischemic stroke and (c) major bleeding. Multivariable logistic regression was used to determine the adjusted odds ratios (aOR) and 95% confidence interval (95% CI).
Results
Of a total of 1,403,505 patients undergoing PCI during the study period, 199,470 (14.2%) had ECVD. Patients with ECVD were older (median of 72 years vs. 70 years, p < 0.001) and had higher comorbidity burden that their counterparts. All cause-mortality was 22% higher in patients with any ECVD compared to those without ECVD. PAD patients had the highest odds of all-cause mortality (aOR 1.48, 95% CI 1.40-1.56), followed by those with CeVD (aOR 1.15, 95% CI 1.10-1.19). Patients with extracardiac disease had increased odds of MACCE, ischemic stroke and bleeding, irrespective of the nature or extent (p < 0.05), compared to patients without ECVD.
Conclusion
ECVD is associated with worse outcomes in patients undergoing PCI including significantly higher rates of death and stroke. These data should inform our shared decision-making process with our patients.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 21 Sep 2022; epub ahead of print

Real-world VASCADE closure device versus manual compression use and outcomes in patients with severe common femoral artery disease.

Nagpal S, Scierka LE, Castro-Dominguez Y, Kansal D, ... Smolderen KG, Mena-Hurtado C
Background
The VASCADE closure device deploys an extravascular collagen plug. Its use in those with access site disease undergoing peripheral vascular intervention (PVI) is unknown. We aimed to evaluate the efficacy and safety of the VASCADE closure device compared to manual compression (MC) in patients with moderate femoral access site disease.
Methods
We performed a single-center, retrospective review of patients undergoing PVI with at least moderate access site disease. Our institutional database was linked to the Vascular Quality Initiative database, and 200 patients were selected from a 1:1 propensity-matched cohort. Data on procedural metrics and outcomes up to 30-days were abstracted.
Results
There were 103 procedures that used VASCADE and 97 used MC. Baseline variables were similar between groups. The mean age was 68.2 ± 11.2 years and 37.6% were women. Closing mean activated clotting time (ACT) was shorter in VASCADE (198 s VASCADE vs. 213 s MC; p = 0.018). There was a nonsignificant decrease in external compression device use with VASCADE (VASCADE 19.0% vs. MC 28.1%; p = 0.15). At 30-days, there was a nonsignificant reduction in hematoma with VASCADE (3.8% vs. 7.8% MC; p = 0.25) and no difference in retroperitoneal bleeding (0.5%). Pseudoaneurysm rate was similar (1.3% VASCADE vs. 1.7% MC; p = 0.79). The 30-day mortality rate was similar between the two groups and not related to the procedure (1.3% VASCADE vs. 0.9% MC; p = 0.79).
Conclusion
In patients undergoing PVI with at least moderate access site disease, safety and efficacy after using VASCADE was comparable with MC.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 21 Sep 2022; epub ahead of print

Outcomes and challenges of the provisional stenting technique: Insights from the PROGRESS-BIFURCATION registry.

Simsek B, Kostantinis S, Karacsonyi J, Allana S, ... Rangan BV, Brilakis ES
Background
Provisional stenting is the most commonly used coronary bifurcation stenting strategy.
Methods
We examined the clinical and angiographic characteristics, challenges encountered, and procedural outcomes with the provisional bifurcation stenting strategy in the Prospective Global Registry of Percutaneous Coronary Intervention (PCI) in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992).
Results
Provisional stenting was used in 334 of 430 bifurcation interventions (78%). Technical success was lower (95% vs. 100%, p = 0.017) in provisional, but procedural success (90% vs. 95%, p = 0.095) and incidence of in-hospital major adverse cardiovascular events were similar (5% vs. 5%, p = 0.945) compared with two-stent strategies. Provisional was less often preferred in left main/left anterior descending involvement (47% vs. 73%, p < 0.001). Provisional stenting cases had smaller side branch (SB) diameter (2.4 ± 0.5 vs. 2.7 ± 0.6 mm, p < 0.001), shorter SB lesion length (5 [3-8] vs. 10 [5-10] mm, p < 0.001), less SB diameter stenosis (46 ± 35 vs. 81 ± 20%, p < 0.001), and were less likely to be Medina 1,1,1 (34% vs. 73%, p < 0.001). PCI challenges were less common (30% vs. 58%, p < 0.001) with provisional stenting: (1) rewiring difficulty (43%) that was overcome with use of a different wire (74%) or microcatheter (46%); (2) inability to deliver a stent (22%) or balloon (9%) that was overcome with use of a smaller balloon (88%), rewiring (25%), or increased support/microcatheter (25%).
Conclusions
Provisional bifurcation stenting was more often performed in distal lesions with less SB involvement and had lower technical success, but similar procedural success and complications compared with two-stent strategies.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 19 Sep 2022; epub ahead of print

Two-year outcomes after transcatheter aortic valve-in-valve implantation in degenerated surgical valves.

Abushouk AI, Abdelfattah O, Gad MM, Saad A, ... Johnston DR, Kapadia SR
Background
Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has emerged in recent years as a safe alternative to redo surgery in high-risk patients. Although early results are encouraging, data beyond short-term outcomes are lacking. Herein, we aimed to assess the 2-year outcomes after ViV-TAVI.
Methods
Patients undergoing ViV-TAVI for degenerated surgical valves between 2013 and 2019 at the Cleveland Clinic were reviewed. The coprimary endpoints were all-cause mortality and congestive heart failure (CHF) hospitalizations. We used time-to-event analyses to assess the primary outcomes. Further, we measured the changes in transvalvular gradients and the incidence of structural valve deterioration (SVD).
Results
One hundred and eighty-eight patients were studied (mean age = 76 years; 65% males). At 2 years of follow-up, all-cause mortality and CHF hospitalizations occurred in 15 (8%) and 28 (14.9%) patients, respectively. On multivariable analysis, the postprocedural length of stay was a significant predictor for both all-cause mortality (hazard ratio [HR] = 1.1; 95% confidence interval [CI]: 1.01, 1.19) and CHF hospitalization (HR = 1.16; 95% CI: 1.07, 1.27). However, the internal diameter of the surgical valve was not associated with significant differences in both primary endpoints. For hemodynamic outcomes, nine patients (4.8%) developed SVD. The mean and peak transvalvular pressure gradients remained stable over the follow-up period.
Conclusion
ViV-TAVI for degenerated surgical valves was associated with favorable 2-year clinical and hemodynamic outcomes. Further studies are needed to better understand the role of ViV-TAVI as a treatment option in the life management of aortic valve disease.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 18 Sep 2022; epub ahead of print

Procedural and long-term outcome among patients undergoing expedited trans-catheter aortic valve replacement.

Berkovitch A, Segev A, Guetta V, Finkelstein A, ... Orvin K, Barbash IM
Objective
Patients with rapidly deteriorating clinical status due to severe aortic stenosis are often referred for expedited transcatheter aortic valve replacement (TAVR). Data regarding the outcome of such interventions is limited. We aimed to evaluate the outcome of patients undergoing expedited TAVR.
Design and setting
Data were derived from the Israeli Multicenter Registry.
Subjects
Subjects were divided into two groups based on procedure urgency: patients who were electively hospitalized for the procedure (N = 3140) and those who had an expedited TAVR (N = 142). Procedural and periprocedural complication rates were significantly higher among patients with an expedited indication for TAVR compared to those having an elective procedure: valve malposition 4.6% versus 0.6% (p < 0.001), procedural cardiopulmonary resuscitation 4.3% versus 1.0% (p = 0.007), postprocedure myocardial infarction 2.0% versus 0.4% (p = 0.002), and stage 3 acute kidney injury 3.0% versus 1.1%, (p < 0.001). Patients with expedited indication for TAVR had significantly higher in hospital mortality (5.6% vs. 1.4%, p = 0.003). Kaplan-Meier\'s survival analysis showed that patients undergoing expedited TAVR had higher 3-year mortality rates compared to patients undergoing an elective TAVR procedure (p < 0.001). Multivariate analysis found that patients with expedited indication had fourfolds increased risk of in-hospital mortality (odds ratio: 4.07, p = 0.001), and nearly twofolds increased risk of mortality at 3-year (hazard ratio: 1.69, p = 0.001) compared to those having an elective procedure.
Conclusion
Patients with expedited indications for TAVR suffer from poor short- and long-term outcomes. It is important to characterize and identify these patients before the deterioration to perform TAVR in a fast-track pathway to minimize their procedural risk.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 18 Sep 2022; epub ahead of print

Predictors of 30-day and 12-month mortality in left main stem percutaneous coronary intervention 2016-2020: A study from two UK centers.

Carande EJ, Protty MB, Verhemel S, Hussein MH, ... Hussain HI, Hailan A
Introduction
Left main stem percutaneous coronary intervention (LMS-PCI) is a complex high-risk procedure which can be performed as an alternative to coronary artery bypass graft (CABG) procedure in surgical turn-down patients or where there is equipoise in percutaneous versus surgical strategies. Current guidelines suggest that PCI is an appropriate alternative to CABG in patients with unprotected LMS disease and low SYNTAX score. However, \"real world\" data on outcomes of LMS-PCI remain limited. This study aims to quantify and determine predictors of mortality following LMS-PCI.
Methods
Using local coronary angioplasty registries from two UK centers, all LMS-PCI cases were identified from 2016 to 2020. Descriptive statistics and multivariate logistic regressions were used to examine the association between baseline and procedural characteristics with 30-day and 12-month mortality.
Results
We identified 484 cases of LMS-PCI between 2016 and 2020. There was a year-on-year increase in the number of LMS-PCI, the highest being in 2020. Covariates associated with higher 30-day mortality were age (OR 1.07, 95% CI: 1.02-1.12) and shock preprocedure (OR 23.88, 95% CI: 7.90-72.20). Covariates associated with higher 12-month mortality were age (OR 1.04, 95% CI: 1.01-1.08), acute coronary syndrome (ACS) (OR 2.50, 95% CI: 1.08-5.80), renal disease (OR 5.24, 95% CI: 1.47-18.68), and shock preprocedure (OR 7.93, 95% CI: 3.30-19.05). Overall, 30-day and 12-month mortality in this contemporary data set were 9.5% and 16.7%, respectively, with significantly lower rates in elective cases (p < 0.01).
Conclusions
Older age and cardiogenic shock preprocedure were associated with increased 30-day mortality after LMS-PCI. Twelve-month mortality was associated with older age, ACS presentation, preexisting renal disease, and cardiogenic shock preprocedure.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 14 Sep 2022; epub ahead of print

False lumen patency status and outcomes after endovascular repair of uncomplicated chronic type B dissection.

Kong M, Ni M, Zhu X, Qian J, ... Feng Z, Dong A
Background
Thoracic endovascular aortic repair (TEVAR) remains a controversial treatment for uncomplicated chronic type B aortic dissection (cTBAD). This study was performed to investigate the postoperative outcomes of TEVAR, such as survival and reintervention, and the risk factors for prognoses.
Methods
In total, 41 patients with uncomplicated cTBAD who underwent TEVAR from 2014 to 2021 were reviewed. The patients were divided into two groups: those with false lumen complete thrombosis (FLCT) and false lumen partial thrombosis (FLPT) based on computed tomography angiography (CTA) images. Kaplan-Meier analysis was performed to estimate survival and freedom from reintervention. Binary logistic analysis was performed to estimate risk factors for partial thrombosis.
Results
During a mean follow-up of 31 (1-78) months, five deaths and six reinterventions had occurred at 5 years. By 1 week, thoracic FLCT had occurred in 23 (56.1%) patients and thoracic FLPT had occurred in 18 (43.9%). The rate of freedom from reintervention was significantly lower in the FLCT than in the FLPT group (p = 0.04). The 5-year survival rate of the two groups was not statistically significant (p = 0.14). Risk factors for thoracic FLPT were the distance between the re-entry site and the graft (p = 0.02) and the proximal oversizing ratio (p = 0.04).
Conclusions
TEVAR is an effective and safe treatment for uncomplicated cTBAD and has a low mortality rate. Thoracic FLCT is associated with less reintervention, but overall survival is not impacted by this difference. Patients treated with TEVAR without certain risk factors can have a good prognosis.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 13 Sep 2022; epub ahead of print

Failure patterns after intravascular brachytherapy for in-stent coronary restenosis.

Wallner K, Kearney KE, Kim M, Tiwana J, ... Phillips ML, Don C
Introduction
One strategy to improve the effectiveness of intravascular brachytherapy (IVBT) is to study its failures. Previous investigations described mostly discrete, focal recurrences, typically at the proximal or distal edges of the irradiated segment after plain angioplasty or bare metal stents. We reviewed failure patterns of 30 unselected drug-eluting stent (DES) patients who had follow-up angiograms for recurrence within their IVBT-treated vessel.
Methods
Records of 53 unselected IVBT patients treated between 2016 and 2021 were reviewed. Thirty of the 53 patients had at least one subsequent percutaneous intervention (PCI) for in-stent restenosis (ISR) after IVBT. Angiographic findings of those 30 patients with ISR within their previously irradiated vessel are reported here.
Results
Of the 30 patients, 21 (70%) developed recurrent ISR within the irradiated segment. Six of the 21 patients who failed within the irradiated segment also experienced ISR proximal or distal to the irradiated segment. Only 15 patients (50%) failed exclusively within the irradiated segment. In nine patients (30%), restenosis occurred proximally and/or distally to the irradiated segment, but not inside of the irradiated segment itself.
Conclusions
We have shown here that 50% of failures after coronary IVBT for DES ISR occur exclusively within the irradiated segment. An additional 20% of patients had failure within and outside of the irradiated segment. These percentages suggest that a higher radiation dose might improve the long-term patency rates, a conclusion that should be tempered by the lack of universal follow-up.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 13 Sep 2022; epub ahead of print

Contemporary diagnosis and management of severe tricuspid regurgitation.

Zahr F, Chadderdon S, Song H, Sako E, ... Bailey SR, Cigarroa J
Many novel percutaneous interventions are being developed for application in the tricuspid valve position. At the present time in the United States, there are no commercially available transcathter devices for this application. This article reviews the growing evidence for diagnosing, imaging, and treating severe tricuspid regurgitation as well as the surgical and transcatheter options that are under current development and in various stages of clinical trials.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 10 Sep 2022; epub ahead of print

Incidence and outcomes of cardiogenic shock among women with spontaneous coronary artery dissection.

Osman M, Syed M, Simpson TF, Bhardwaj B, ... Zahr F, Cigarroa JE
Background
There is a paucity of data on cardiogenic shock (CS) incidence and outcomes among patients with spontaneous coronary artery dissection (SCAD).
Methods
Women admitted to the hospital for acute myocardial infarction (AMI) with and without SCAD were identified from the United States National Readmission Database from October 1, 2015 to December 31, 2018. We calculated the incidence of CS among women with AMI with and without SCAD and odds for developing CS after adjusting for baseline characteristics. In addition, we report the utilization of percutaneous coronary intervention, mechanical circulatory support, severe disability surrogates, and 30-day readmission rates.
Results
A total of 664,292 patients admitted for AMI were eligible for analysis, including 6643 patients with SCAD and 657,649 without SCAD. Patients with SCAD were younger (57 years [interquartile range, IQR 48-68] vs. 71 years [IQR 60-81], p < 0.01) and had fewer comorbidities yet had a higher incidence of CS as compared to patients without SCAD (9% vs. 5%, p < 0.01) and remained at elevated risk after adjusting for baseline comorbidities (adjusted odds ratio 1.5 [95% confidence interval, CI 1.2-1.7]). Among patients who developed CS, those with SCAD had lower in-hospital mortality than non-SCAD (31% vs. 39%, p < 0.01), and were more likely to receive mechanical circulatory support.
Conclusions
In a nationally representative sample of women admitted for AMI, we found that patients with SCAD had a higher risk of developing CS and required more frequent use of mechanical circulatory support but were more likely to survive to discharge than women suffering AMI from causes other than SCAD.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 08 Sep 2022; epub ahead of print

Development and validation of a prediction model for early mortality after transcatheter aortic valve implantation (TAVI) based on the Netherlands Heart Registration (NHR): The TAVI-NHR risk model.

Al-Farra H, Ravelli ACJ, Henriques JPS, Houterman S, ... Abu-Hanna A, NHR THI Registration Committee
Background
The currently available mortality prediction models (MPM) have suboptimal performance when predicting early mortality (30-days) following transcatheter aortic valve implantation (TAVI) on various external populations. We developed and validated a new TAVI-MPM based on a large number of predictors with recent data from a national heart registry.
Methods
We included all TAVI-patients treated in the Netherlands between 2013 and 2018, from the Netherlands Heart Registration. We used logistic-regression analysis based on the Akaike Information Criterion for variable selection. We multiply imputed missing values, but excluded variables with >30% missing values. For internal validation, we used ten-fold cross-validation. For temporal (prospective) validation, we used the 2018-data set for testing. We assessed discrimination by the c-statistic, predicted probability accuracy by the Brier score, and calibration by calibration graphs, and calibration-intercept and calibration slope. We compared our new model to the updated ACC-TAVI and IRRMA MPMs on our population.
Results
We included 9144 TAVI-patients. The observed early mortality was 4.0%. The final MPM had 10 variables, including: critical-preoperative state, procedure-acuteness, body surface area, serum creatinine, and diabetes-mellitus status. The median c-statistic was 0.69 (interquartile range [IQR] 0.646-0.75). The median Brier score was 0.038 (IQR 0.038-0.040). No signs of miscalibration were observed. The c-statistic\'s temporal-validation was 0.71 (95% confidence intervals 0.64-0.78). Our model outperformed the updated currently available MPMs ACC-TAVI and IRRMA (p value < 0.05).
Conclusion
The new TAVI-model used additional variables and showed fair discrimination and good calibration. It outperformed the updated currently available TAVI-models on our population. The model\'s good calibration benefits preprocedural risk-assessment and patient counseling.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 07 Sep 2022; epub ahead of print

Radiation reduction in a modern catheterization laboratory: A single-center experience.

Shekhar S, Ajay A, Agrawal A, Kumar A, ... Krishnaswamy A, Kapadia S
Background
Measures were undertaken at the Cleveland Clinic to reduce radiation exposure to patients and personnel working in the catheterization laboratories. We report our experience with these improved systems over a 7-year period in patients undergoing diagnostic catheterization (DC) and percutaneous coronary interventions (PCIs).
Methods
Patients were categorized into preinitiative (2009-2012) and postinitiative (2013-2019) groups in the DC and PCI cohorts. Propensity score matching was done between the pre- and postinitiative groups for both cohorts based on age, sex, body surface area, total fluoroscopy time, and total acquisition time. The effectiveness of radiation reduction measures was assessed by comparing the total air kerma (K_a,r ), and fluoroscopy- and acquisition-mode air kerma in patients in the two groups.
Results
In the DC cohort, there was a significant reduction in K_a,r in the postinitiative group in comparison to the preinitiative group (median, 396 vs. 857 mGy; p < 0.001). In the PCI cohort, K_a,r in the postinitiative group was 1265 mGy, which was significantly lower than the corresponding values in the preinitiative group (1994 mGy; p < 0.001). We also observed a significant reduction in fluoroscopy- and acquisition-based air kerma rates, and air kerma area product in the postinitiative group in comparison to the preinitiative group in both matched and unmatched DC and PCI cohorts after the institution of radiation reduction measures.
Conclusion
There was a significant and sustained reduction in radiation exposure to patients in the catheterization laboratory with the implementation of advanced protocols. Similar algorithms can be applied in other laboratories to achieve a similar reduction in radiation exposure.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 07 Sep 2022; epub ahead of print

Characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock during COVID-19.

Ahlers MJ, Srivastava PK, Basir MB, O\'Neill WW, ... Hollowed J, Nsair A
Objectives
To evaluate characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) during the coronavirus disease 2019 (COVID-19) pandemic.
Background
The COVID-19 pandemic has created challenges in delivering acute cardiovascular care. Quality measures and outcomes of patients presenting with AMICS during COVID-19 in the United States have not been well described.
Methods
We identified 406 patients from the National Cardiogenic Shock Initiative (NCSI) with AMICS and divided them into those presenting before (N = 346, 5/9/2016-2/29/2020) and those presenting during the COVID-19 pandemic (N = 60, 3/1/2020-11/10/2020). We compared baseline clinical data, admission characteristics, and outcomes.
Results
The median age of the cohort was 64 years, and 23.7% of the group was female. There were no significant differences in age, sex, and medical comorbidities between the two groups. Patients presenting during the pandemic were less likely to be Black compared to those presenting prior. Median door to balloon (90 vs. 88 min, p = 0.38), door to support (88 vs. 78 min, p = 0.13), and the onset of shock to support (74 vs. 62 min, p = 0.15) times were not significantly different between the two groups. Patients presented with ST-elevation myocardial infarction more often during the COVID-19 period (95.0% vs. 80.0%, p = 0.005). In adjusted logistic regression models, COVID-19 period did not significantly associate with survival to discharge (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.54-2.19, p = 0.81) or with 1-month survival (OR 0.82, 95% CI 0.42-1.61, p = 0.56).
Conclusions
Care of patients presenting with AMICS has remained robust among hospitals participating in the NCSI during the COVID-19 pandemic.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 07 Sep 2022; epub ahead of print

Validation of reliability and predictivity of membrane septum length measurements for pacemaker need after transcatheter aortic valve replacement.

Hioki H, Watanabe Y, Kozuma K, Ryuzaki T, ... Hayashida K, OCEAN-TAVI Investigators
Objectives
To assess the inter methodological agreement of membrane septum (MS) length measurement and additive value for risk stratification of new pacemaker implantation (PMI) over the established predictors after transcatheter aortic valve replacement (TAVR).
Background
Recent studies have suggested MS length and implantation depth (ID) as predictors for PMI after TAVR. However, the measurement of MS length is neither uniform nor validated in different cohort.
Methods
We retrospectively analyzed patients who underwent TAVR at five centers. The MS length was measured by two previously proposed methods (coronal and annular view method). Predictive ability of risk factors, including MS length and ID, for new PMI within 30 days after TAVR were evaluated.
Results
Among 754 patients of study population, 31 patients (4.1%) required new PMI within 30 days of TAVR. There was a weak correlation (ρ = 0.47) and a poor agreement between the two methods. The ID and the difference between MS length and ID (ΔMSID), were independent predictors for new PMI, whereas MS length alone was not. Further, for predicting new PMI after TAVR, discrimination performance was not significantly improved when MS length was added to the model with ID alone (integrated discrimination improvement = 0, p= 0.99; continuous net-reclassification improvement = 0.10, p= 0.62).
Conclusions
External validity and predictive accuracy of MS length for PMI after TAVR were not sufficient to provide better risk stratification over the established predictors in our cohort. Moreover, the ID and ΔMSID, but not MS length alone, are predictive of future PMI after TAVR.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 07 Sep 2022; epub ahead of print

Retrograde approach for rewiring a jailed side branch during double kissing crush stenting.

Chami T, Mahowald MK, Brilakis E
Double kissing crush (DK crush) is one of the preferred strategies for bifurcation stenting due to the lower risk of target vessel failure but can be difficult to perform. Difficulty in wiring the jailed side branch after stenting the main vessel is not uncommon. The retrograde crossing can provide a solution in selected cases when antegrade rewiring of a jailed side branch fails during DK crush (or other bifurcation stenting techniques).

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 02 Sep 2022; epub ahead of print

Complex, high-risk percutaneous coronary intervention types, trends, and in-hospital outcomes among different age groups: An insight from a national registry.

Shamkhani W, Rashid M, Mamas M
Background
Complex, high-risk percutaneous coronary intervention (PCI) (CHiP) is increasingly being undertaken in octogenarians. However, limited data exist on CHiP types, trends, and outcomes in the octogenarian.
Methods
This is a retrospective cohort study from a national registry dataset on CHiP undertaken in patients with stable angina in England and Wales (January 2006 and December 2017) according to three age groups (group 1 [G1]: < 65 years; group 2 [G2]: 65-79 years; and group 3 [G3]: ≥80 years).
Results
Of 424,290 elective PCI procedures, 138,831 (33.0%) were CHiP [G1: 46,832 (33.7%); G2: 59,544 (42.9%); G3: 32,455 (23.4%)]. Among CHiP types, chronic total occlusion (CTO) (49.2%), prior coronary artery bypass graft (CABG) (30.4%), and severe vascular calcification (21.8%) were common in G1; prior CABG (42.9%), CTO (32.9%), and severe vascular calcifications (27%) were common in G2; prior CABG (15.8%), severe vascular calcification (15.5%), and chronic renal failure (11.1%) were common CHiP among the octogenarians. The older age groups had higher adjusted odds (aOR) for adverse outcomes [G2: mortality, aOR 1.7, 95% confidence interval (CI): (1.3-2.3); major bleeding, aOR 1.3, 95% CI (1.1-1.5); MACCE, aOR 1.2, 95% CI (1.0-1.3); G3: mortality, aOR 2.6, 95%CI (1.9-3.6); major bleeding, aOR 1.4, 95% CI (1.1-1.7); MACCE, aOR 1.3, 95% CI (1.1-1.5)].
Conclusion
There were significant differences in the types of CHiP cases undertaken and clinical outcomes across age groups.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 02 Sep 2022; epub ahead of print

Harnessing the parallax for better spatial awareness.

Targoński R, Gąsecka A, Luis MS, Jagielak D, Jaguszewski M, Piazza N
Despite easy access to imaging diagnostic procedures and an abundance of spatial data, most cardiac interventions are still performed under two-dimensional fluoroscopy. Incorporating anatomical data from scans into procedures plans has the potential to improve the swiftness and outcomes of percutaneous cardiac interventions. Therefore, procedure planning based on the specific anatomy is becoming a new standard of excellence in interventional cardiology. Still, we often tend to disregard specific spatial relations and the actual direction of catheter tip movement inside the body, relying on a try and error approach. The precise spatial orientation of instruments and prosthetic devices is crucial, especially during structural heart interventions. Here, we present how deliberate movements of objects under fluoroscopy can reveal the spatial orientation of catheters and other devices. We also propose a novel \"two-point rule\" for identifying three-dimensional relations between points in space. Understanding and applying this rule might substantially increase the spatial awareness of operators performing cardiovascular interventions. Although the concept is pretty simple, using it \"live\" during interventional cardiology procedures requires thorough understanding and practice. We propose the \"two-point rule\" as a crucial rule to develop expertise in spatial orientation under fluoroscopy and ensure high-quality outcomes.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 02 Sep 2022; epub ahead of print

Sirolimus-coated balloon versus everolimus-eluting stent in de novo coronary artery disease: Rationale and design of the TRANSFORM II randomized clinical trial.

Greco A, Sciahbasi A, Abizaid A, Mehran R, ... Alfonso F, Cortese B
Background
Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation is a widely adopted strategy for the treatment of de novo coronary artery disease. DES implantation conveys an inherent risk for short- and long-term complications, including in-stent restenosis and stent thrombosis. Drug-coated balloons are emerging as an alternative approach to fulfill the \"leaving nothing behind\" principle and avoid long-term DES-related complications.
Design
TRANSFORM II is an investigator-initiated, multicenter, noninferiority, randomized clinical trial, testing a sirolimus-coated balloon (SCB) versus the standard of care for native coronary vessels with a 2-3 mm diameter, in terms of 12-month target lesion failure (TLF; primary endpoint) and net adverse cardiovascular events (coprimary endpoint). Patients undergoing PCI will be randomized to be treated with either SCB or new-generation everolimus-eluting stent and will be followed up clinically for up to 60 months. Assuming a TLF rate of 8% at 12 months with DES, a sample size of 1325 patients was chosen to ensure an 80% power to detect a 1.5% lower incidence in the SCB group with a type I error rate of 0.05. The TRANSFORM II trial is registered on clinicaltrials.gov (identification number NCT04893291). Several substudies, including an optical coherence tomography assessment at 9 months (intracoronary imaging substudy), will investigate the study device in different clinical and lesion settings.
Conclusions
The randomized TRANSFORM II trial will determine whether a novel SCB is noninferior to a current everolimus-eluting stent when adopted for the treatment of de novo lesions in coronary vessels with a diameter between 2 and 3 mm.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 02 Sep 2022; epub ahead of print

Predictive performance of J-Calc-CTO score for guidewire crossing through chronic total occlusion lesions within 30 minutes: J-CTO score modified by computed tomography coronary angiography.

Honda Y, Yamawaki M, Mori S, Tsutsumi M, ... Kobayashi N, Ito Y
The original J-CTO score predicts the difficulty of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions, but the grade of calcification has not been fully evaluated. We examined 137 patients (141 CTO lesions) who underwent coronary computed tomography angiography (CTA) pre-PCI between October 2016 and October 2021. They were randomly divided into derivation (n = 94) and validation (n = 47) groups. The degree and distribution of calcification in the occluded segment were assessed using CTA. The calcified index was defined as calcium volume divided by the length of the occluded segment. We created the J-Calc-CTO score consisting of calcification parameters associated with 30-min wire crossing in the derivation group. The validity of the J-Calc-CTO score was compared with that of the original J-CTO score using c-statistics. The procedural success rate was 96%, and 30-min wire crossing during the procedure was achieved in 29%. Dense calcification (calcified-index >12) (odds ratio [OR]: 4.63; 95% confidence interval [CI]: 1.24-22.2; p = 0.04) and calcification in the center of the lumen (OR: 7.25; 95% CI: 1.48-32.1; p = 0.02) were independently associated with 30-min wire crossing as variables evaluated using CTA. The J-Calc-CTO score was created by adding 1 point to the two parameters in place of \"calcification\" in the original J-CTO score. The J-Calc-CTO score showed a higher predictive value of 30-min wire crossing than the J-CTO score in the derivation (c-statistics; 0.836 vs. 0.670; p > 0.01) and validation groups (c-statistics; 0.879 vs. 0.767, p > 0.01). The degree and distribution of calcification evaluated using CTA refined the predictive value of the original J-CTO score for 30-min wire crossing.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 01 Sep 2022; epub ahead of print

Piggyback mounting for stent and valve deployment during percutaneous pulmonary valve implantation.

Zablah JE, Døhlen G, Ystgaard MB, Morgan GJ
Objectives
We report our experience in simultaneously implanting multiple stents and valves mounted on a single balloon before and during transcatheter pulmonary valve placement.
Background
Heterogeneity and complexity of the right ventricular outflow tract (RVOT) may complicate stent deployment when preparing a landing zone for transcatheter pulmonary valve implantation.
Methods
Retrospective analysis of patients from Children\'s Hospital of Colorado, USA; and Oslo University Hospital, Norway, undergoing transcatheter pulmonary valve replacement that had at least two stents mounted on a single balloon, deployed in the RVOT.
Results
Over a 42-month period, a total of 50 subjects from the two centers met inclusion criteria for the study. Subjects were predominantly male (58%), and the median age was 17 years (4-78 years). In six subjects (12%), there was need for prestenting with use of the double or triple stent piggyback technique. Forty subjects (80%) had a Melody ™ TPV implanted. In 45 cases (90%), one or more stents were mounted over the pulmonary valve using its delivery system, either the Ensemble for the Melody™ TPV or the Edwards Commander for the SAPIEN 3 THV. Thirty-seven subjects (74%) had one stent mounted and eight subjects (16%) had two stents mounted over the pulmonary valve for simultaneous deployment. No complications related to this technique were reported.
Conclusions
The piggyback technique aims to simplify and facilitate adequate conduit preparation and valve insertion by minimizing manipulation across the outflow tract and decreasing the risk of stent distortion, misalignment, and embolization.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 01 Sep 2022; epub ahead of print

Variability in healthcare delivery: It is never a good thing.

Butman SM
In medicine, wide variations in healthcare delivery or outcomes are a sign of missing information and beg for more information in a timely resolution. While differences in patient selection for intervention in out-of-hospital-cardiac-arrest in Wales and England might seem regional, there is little reason to assume this is not true across many other geographical areas.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 01 Sep 2022; 100:317-318

When not to treat could be the best option.

Musumeci G, Civera S
Treatment strategy of people who experienced an Out of Hospital Cardiac Arrest without a ST-segment elevation myocardial infarction is still a matter of debate. Recent randomized trials and a meta-analysis comparing early. Against delayed coronary angiography in these patients did not find any improvement in short-term survival with the immediate approach strategy. Further studies are ongoing, whose results will help clarify the correct management of these OHCA-non STEMI patients.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 01 Sep 2022; 100:338-339

Turndown for coronary artery bypass surgery: Never say never to revascularization.

Grines CL, Dupont A
In this issue of Catheterization and Cardiovascular Interventions, Farag et al. reported their experience comparing patients with acute coronary syndrome versus stable angina patients who were turned down for bypass surgery and subsequently treated with coronary stenting (1).

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 01 Sep 2022; 100:367-368

Two-year clinical outcomes after successful transcatheter aortic valve implantation with balloon-expandable versus self-expanding valves: A subanalysis of the GALILEO trial.

Okuno T, Dangas GD, Hengstenberg C, Sartori S, ... Sondergaard L, Windecker S
Background
Midterm data comparing clinical outcomes after successful implantation of self-expanding and balloon-expandable transcatheter heart valves (THV) are limited. We aimed to compare 2-year outcomes after successful transcatheter aortic valve implantation (TAVI) with the Edwards balloon-expandable or the Medtronic self-expanding THV.
Methods
Two-year outcomes were analyzed according to the implanted THV in the GALILEO trial. Major adverse cardiac and cerebrovascular events (MACCE) was a composite of all-cause death or thromboembolic events including stroke, myocardial infarction, symptomatic valve thrombosis, systemic embolism, deep-vein thrombosis, or pulmonary embolism.
Results
Among 1644 patients recruited in 136 centers across 16 countries between 2015 and 2018, 499 received a self-expanding and 757 patients received a balloon-expandable THV. Patients treated with a self-expanding THV were more likely to be female, and had higher surgical risk, lower hemoglobin levels, and more frequent valve-in-valve procedures than those with a balloon-expandable THV. After multivariable adjustment, there were no significant differences in major clinical outcomes between self-expanding versus balloon-expandable THV: MACCE (17.0% vs. 13.4%, adjusted-hazard ratios [HR] 1.18, 95% confidence intervals [CI]: 0.82-1.69); all-cause death (11.4% vs. 9.3%, adjusted-HR 1.26; 95% CI: 0.78-2.05); cardiovascular death (8.5% vs. 4.0%, adjusted-HR 1.53; 95% CI: 0.82-2.86), any stroke (5.1% vs. 3.7%, adjusted-HR 0.86; 95% CI: 0.43-1.73); major or life-threatening bleeding (5.9% vs. 6.8%, adjusted-HR 0.93; 95% CI: 0.53-1.63).
Clinical trial registration
https://www.
Clinicaltrials
gov. NCT02556203.
Conclusions
Two-year follow-up data from the GALILEO trial indicate that successful TAVI either with self-expanding or balloon-expandable THVs according to physician discretion did not show difference in rates of MACCE.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 30 Aug 2022; epub ahead of print

Association of N-terminal pro-B-type natriuretic peptide with mortality in elderly (≥80 years) patients undergoing percutaneous coronary intervention.

Sager R, Keller LS, Stehli J, Jakob P, ... Templin C, Stähli BE
Objectives
The aim of this study was to determine the role of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prognostication of patients ≥80 years of age undergoing percutaneous coronary intervention (PCI).
Background
Elderly patients with coronary artery disease in need of PCI represent a growing patient population. Advanced risk prediction in this frail and comorbid patient population is important.
Methods
A total of 460 consecutive patients ≥80 years of age undergoing PCI for acute (ACS) or chronic coronary syndromes (CCS) at the University Hospital Zurich, Switzerland, between January 2016 and December 2018 and with available baseline NT-proBNP levels were included in the analysis. Patients were stratified according to baseline NT-proBNP levels. The primary endpoint was all-cause mortality at a median follow-up of 33 (interquartile range: 3-392) days.
Results
Median baseline NT-proBNP levels were 1411 (457-3984) ng/L. All-cause mortality was 7.8% in the lowest and 27.8% in the highest NT-proBNP quartile group (p < 0.001). In patients with ACS, all-cause mortality was 4.8% and 30.4% in the lowest and the highest NT-proBNP quartile (p < 0.001), and corresponding rates in patients with CCS were 11.1% and 22.2% (p = 0.38). In multivariable Cox regression analysis, baseline NT-proBNP levels were independently associated with an increased risk of all-cause mortality (adjusted hazard ratio: 1.00, 95% confidence interval: 1.00-1.00, p = 0.04).
Conclusions
Baseline NT-proBNP levels were identified as independent predictor of mortality in elderly (≥80 years) patients undergoing PCI. Hence, baseline NT-proBNP allows for the identification of a high-risk elderly patient subset.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 30 Aug 2022; epub ahead of print

Impact of high-pressure balloon aortic valvuloplasty on the hydrodynamic result after a transcatheter valve-in-valve procedure.

Sadat N, Bruhn D, Scharfschwerdt M, Schaller T, ... Ensminger S, Fujita B
Objectives
The aim of this study was to investigate the degree of functional improvement of a transcatheter heart valve (THV) for valve-in-valve after bioprosthetic valve fracture (BVF) of three small surgical aortic valve bioprostheses (SAVBP) using high-pressure balloon aortic valvuloplasty (HP-BAV) under standardized ex-vivo-conditions.
Methods
A THV 26 mm (Evolut R) and SAVBP 21 mm (Perimount Magna Ease, Trifecta, and Epic supra [n = 4] were used. Mean pressure gradient (MPG), effective orifice area (EOA), geometric orifice area (GOA), minimal internal diameter (MID), and pinwheeling index (PWI) were analyzed before and after HP-BAV of the SAVBP using a noncompliant balloon. Fracturing of the SAVBP was done before implantation of the THV and the balloon pressures at the point of fracture were recorded.
Results
The Magna Ease and Epic fractured at balloon pressures of 18 and 8 atm, respectively. The Trifecta did not fracture up to a balloon pressure of 30 atm but was dilated. HP-BAV led to increased THV expansion as evident by straightened coaptation lines of the Evolut R 26 mm with reduced PWI, increased MID, and increased GOA in all 21 mm SAVBP. Evolut R showed significantly lower MPG and higher EOA as ViV in all prostheses after HP-BAV (p < 0.001). MPG and EOA of Evolut R differed regarding the SAVBP. Evolut R presented the lowest MPG and highest EOA in Magna Ease and the highest MPG and lowest EOA in Epic supra.
Conclusions
The degree of function improvement of the same THV as ViV after HP-BAV depends on the surgical valve model. Functional improvement can also be achieved without valve fracture.

© 2022 Universität zu Lübeck. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 30 Aug 2022; epub ahead of print

Long term follow-up after balloon expandable covered stents implantation for management of transcatheter aortic valve replacement related vascular access complications.

Maurina M, Condello F, Mangieri A, Sanz-Sanchez J, ... Reimers B, Regazzoli D
Objectives
To report the experience of a high-volume center with balloon-expandable (BE) stents implantation to manage vascular complications after transcatheter aortic valve replacement (TAVR).
Background
Despite increased operator experience and better devices, vascular complications after TAVR are still a major issue and covered stent implantation is often required.
Methods
We retrospectively collected baseline and procedural data about 78 consecutive patients who underwent BE stent implantation to manage a vascular complication after transfemoral TAVR. Primary endpoints were technical success, incidence of new-onset claudication and need for vascular interventions during long-term follow-up. Secondary endpoints included length of hospitalization, in-hospital and 30-day mortality, and major postoperative complications.
Results
BE stents implantation to manage vascular complications after TAVR was successfully performed in 96.2% of the cases, with bailout surgery required in two cases. One patient suffered in-hospital death. Predischarge Doppler Ultrasound revealed no cases of in-stent occlusion or fracture. At a median follow-up of 429 days (interquartile range, 89-994 days), no cases of symptomatic leg ischemia were reported and only one patient experienced new-onset claudication.
Conclusions
Our experience showed good periprocedural and long-term results of BE covered stent implantation to manage vascular complication after TAVR. Their great radial outward force may guarantee effective hemostasis without necessarily being associated with stent deformation/fracture resulting in restenosis or further interventions. More research is needed to define the role of BE covered stents in this setting.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 30 Aug 2022; epub ahead of print

Zone 0 thoracic endovascular aortic repair in high risk patients: A retrospective case series.

Yen YT, Chen YY, Kao PH, Lin CH
To report our experience applying endovascular stent graft repair to treat ascending aortic diseases in high-risk patients and to evaluate the safety and feasibility of this approach. Patients with comorbid conditions or older age are not suitable for open procedures but may be considered suitable for ascending endovascular repair. Eleven high-risk patients received zone 0 thoracic endovascular aortic repair from September 2014 to May 2020. All patients were followed up until death or December 2021. Primary outcomes were in-hospital and long-term all-cause mortality as well as in-hospital and long-term aorta-related mortality. The mean follow-up duration of all patients was 35.78 months. The cohort comprised of three pathology subgroups: penetrating atherosclerotic ulcer (PAU) (n =6), acute dissection (AD) (n = 3), and chronic dissecting aneurysm (CDA) (n = 2). The in-hospital all-cause mortality rates were 0%, 33.33% and 0% for PAU, AD, and CDA groups, respectively. Long-term all-cause mortality were 33.33%, 33.33%, and 50% for PAU, AD, and CDA groups, respectively. There was only one in-hospital death related to acute aortic dissection, and no long-term aorta-related deaths occurred during the study period. During the follow-up time, the majority of patients had good remodeling of ascending aorta, slow progression in cases with endoleak, and no aorta-related mortality. Ascending endovascular aortic repair appears to be a safe and feasible procedure for emergent aortic repair in carefully selected patients with prohibitive surgical risk who are not candidates for open procedures.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Aug 2022; epub ahead of print

Orbital atherectomy of calcified coronary ostial lesions.

Chambers JW, Martinsen BJ, Sturm RC, Mandair D, ... Guzzetta F, Armstrong EJ
Objectives
To evaluate the feasibility and safety of coronary orbital atherectomy (OA) for the treatment of calcified ostial lesions.
Background
Percutaneous coronary intervention (PCI) is increasingly being completed in complex patients and lesions. OA is effective for severely calcified coronary lesions; however, there is a dearth of evidence on the use of OA in ostial lesions, especially with long-term outcome data.
Methods
Data were obtained from a retrospective analysis of patients who underwent OA of heavily calcified ostial lesions followed by stent implantation from December 2010 to June 2019 at two high-volume PCI centers. Kaplan-Meier analysis was utilized to assess the primary endpoints of 30-day, 1-year, and 2-year freedom-from (FF) major adverse cardiac events (MACE: death, myocardial infarction, or target vessel revascularization), stroke, and stent thrombosis (ST).
Results
A total of 56 patients underwent OA to treat heavily calcified ostial coronary lesions. The mean age was 72 years with a high prevalence of diabetes (55%) and heart failure (36%), requiring hemodynamic support (14%). There was high FF angiographic complications (93%), and at 30-day, 1-year, and 2-year, a high FF-MACE (96%, 91%, and 88%), stroke (98%, 96%, and 96%), and ST (100%), respectively.
Conclusions
This study represents the largest real-world experience of coronary OA use in heavily calcified ostial lesions with long-term outcomes over 2 years. The main finding in this retrospective analysis is that, despite the complex patients and lesions included in this analysis, OA appears to be a feasible and safe treatment option for calcified coronary ostial lesions.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 21 Aug 2022; epub ahead of print

A simplified cardiac damage staging predicts the outcome of patients undergoing TAVR-A multicenter analysis.

Shamekhi J, Hasse C, Veulemans V, Al-Kassou B, ... Nickenig G, Sinning JM
Background
A significant number of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) suffer from extra-aortic cardiac damage. Few studies have investigated strategies to quantify cardiac damage and stratify patients accordingly in different risk groups. The aim of this retrospective multicenter study was to provide a user-friendly simplified staging system based on the proposed classification system of Généreux et al. as a tool to evaluate the prognosis of patients undergoing TAVR more easily. Moreover, we analyzed changes in cardiac damage after TAVR.
Methods
We assessed cardiac damage in patients, who underwent TAVR at the Heart Center Bonn or Düsseldorf, using pre- and postprocedural transthoracic echocardiography. Patients were assigned to the staging system proposed by Généreux et al. according to the severity of their baseline cardiac damage. Based on the established system, we created a simplified staging system to facilitate improved applicability. Finally, we compared clinical outcomes between the groups and evaluated changes in cardiac damage after TAVR.
Results
A total of 933 TAVR patients were included in the study. We found a significant association between cardiac damage and 1-year all-cause mortality (stage 0: 0% vs. stage 1: 3% vs. stage 2: 6.6%; p < 0.009). In multivariate analysis, cardiac damage was an independent predictor of 1-year all-cause mortality (hazard ratio: 2.0, 95% confidence interval: 1.1-3.8; p = 0.03).
Conclusions
In patients undergoing TAVR, cardiac damage is associated with enhanced mortality. A simplified staging system can help identify patients at high risk for an adverse outcome.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 21 Aug 2022; epub ahead of print

Sex differences in time to primary percutaneous coronary intervention and outcomes in patients presenting with ST-segment elevation myocardial infarction.

Savage ML, Hay K, Murdoch DJ, Walters DL, ... Ranasinghe I, Raffel C
Objectives
We assessed sex differences in treatment and outcomes in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI).
Background
Historically, delays to timely reperfusion and poorer outcomes have been described in women who suffer STEMI. However, whether these sex discrepancies still exist with contemporary STEMI treatment remains to be evaluated.
Methods
Consecutive STEMI patients treated with primary PCI patients over a 10-year period (January 1, 2010 to December 31, 2019) from a tertiary referral center were assessed. Comparisons were performed between patient\'s sex. Primary outcomes were 30-day and 1-year mortality. Secondary outcomes were STEMI performance measures.
Results
Most patients (n = 950; 76%) were male. Females were on average older (66.8 vs. 61.4 years males; p < 0.001). Prehospital treatment delays did not differ between sexes (54 min [IQR: 44-65] females vs. 52 min [IQR: 43-62] males; p = 0.061). STEMI performance measures (door-to-balloon, first medical contact-to-balloon [FMCTB]) differed significantly with longer median durations in females and fewer females achieving FMCTB < 90 min (28% females vs. 39% males; p < 0.001). Women also experienced greater rates of initial radial arterial access failure (11.3% vs. 3.1%; p < 0.001). However, there were no significant sex differences in crude or adjusted mortality between sexes at 30-days (3.6% male vs. 5.1% female; p = 0.241, adjusted OR: 1.1, 95% CI: 0.5-2.2, p = 0.82) or at 1-year (4.8% male vs. 6.8% female; p = 0.190, adjusted OR: 1.0, (95% CI: 0.5-1.8; p = 0.96).
Conclusion
Small discrepancies between sexes in measures of timely reperfusion for STEMI still exist. No significant sex differences were observed in either 30-day or 1-year mortality.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 16 Aug 2022; epub ahead of print

Real-world experience with concomitant or staged transcatheter aortic and mitral valve replacements using balloon-expandable valves.

Zajarias A, Kodali S, McCabe JM, Eng MH, Babaliaros V
Objective
To describe outcomes of patients who underwent transcatheter aortic valve replacement (TAVR) in a native valve or failed bioprosthetic valve or transcatheter heart valve (THV) and a transcatheter mitral valve replacement procedure (TMVR; valve-in-valve [mViV], valve-in-ring [mViR], and valve in mitral annulus calcification [ViMAC]) either concomitantly (same procedure) or staged (different procedures).
Background
Patient characteristics, procedural details, and outcomes of concomitant or staged TAVR and TMVR procedures are largely unknown.
Methods
Data were extracted from the STS/ACC TVT Registry™ for patients undergoing concomitant or staged TAVR and TMVR with SAPIEN XT, SAPIEN 3, or SAPIEN 3 Ultra (Edwards Lifesciences) THVs. Descriptive results were reported for procedural, index hospitalization, 30-day, and 1-year outcomes.
Results
A total of 257 patients underwent TAVR and TMVR in concomitant (n = 135) or staged (n = 122) procedures. Device success was 82.9% and 83.9% for concomitant TAVR and TMVR procedures and 83.8% and 82.5% for staged TAVR and TMVR procedures. Significant improvements in aortic and mitral valve function remained stable through 1 year. All-cause mortality for concomitant and staged groups was 14.7% and 10.5% at 30 days, and 32.8% and 24.6% at 1 year, respectively. Stroke rate for concomitant and staged groups was 0.8% and 3.6% at 30 days and 3.9% and 5.6% at 1 year, respectively. Improvements from baseline to 1 year in NYHA class and KCCQ overall summary scores were observed for all patients.
Conclusions
Concomitant or staged transcatheter treatment of patients with aortic and mitral valve disease can be performed in select high-risk patients in experienced centers.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 16 Aug 2022; epub ahead of print

Valve implantation for successful sealing of a balloon predilatation-induced annular rupture during transcatheter aortic valve replacement.

Liu JD, Zhang SY, Wu YQ, Gong R
Annular rupture is a rare and dreaded complication of transcatheter aortic valve replacement (TAVR) and even rarer when caused by predilatation balloon aortic valvuloplasty. This complication often presents as sudden cardiac tamponade with hypotension and requires urgent intervention. The traditional rescue strategy for patients with annular rupture is emergency surgical repair. However, the mortality rate is still high, considering that most patients who undergo TAVR are not candidates for conventional cardiac surgery. Therefore, there is a need for additional emergency treatment strategies to decrease mortality. This report describes a case of predilatation-induced annular rupture during TAVR that was successfully sealed at the rupture site by valve implantation. This case suggests that continuing with valve deployment may be a successful treatment for predilatation-induced annular rupture during TAVR.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 03 Aug 2022; epub ahead of print

Intravascular lithotripsy in chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

Kostantinis S, Simsek B, Karacsonyi J, Davies RE, ... Burke MN, Brilakis ES
Background
The use of intravascular lithotripsy (IVL) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.
Methods
We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 82 CTO PCIs that required IVL at 14 centers between 2020 and 2022.
Results
During the study period, IVL was used in 82 of 3301 (2.5%) CTO PCI procedures (0.4% in 2020 and 7% in 2022; p for trend < 0.001). Mean patient age was 69 ± 11 years and 79% were men. The prevalence of hypertension (95%), diabetes mellitus (62%), and prior PCI (61%) was high. The most common target vessel was the right coronary artery (54%), followed by the left circumflex (23%). The mean J-CTO and PROGRESS-CTO scores were 2.8 ± 1.1 and 1.3 ± 1.0, respectively. Antegrade wiring was the final successful crossing strategy in 65% and the retrograde approach was used in 22%. IVL was used in 10% of all heavily calcified lesions and 11% of all balloon undilatable lesions. The 3.5 mm lithotripsy balloon was the most commonly used balloon (28%). The mean number of pulses per lithotripsy run was 33 ± 32 and the median duration of lithotripsy was 80  (interquartile range: 40-103) seconds. Technical and procedural success was achieved in 77 (94%) and 74 (90%) cases, respectively. Two (2.4%) Ellis Class 2 perforations occurred after IVL use and were managed conservatively.
Conclusion
IVL is increasingly being used in CTO PCI with encouraging outcomes.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 02 Aug 2022; epub ahead of print

Cerebral embolic protection and severity of stroke following transcatheter aortic valve replacement.

Isogai T, Vanguru HR, Krishnaswamy A, Agrawal A, ... Uchino K, Kapadia SR
Background
The cerebral embolic protection (CEP) device captures embolic debris during transcatheter aortic valve replacement (TAVR). However, the impact of CEP on stroke severity following TAVR remains unclear. Therefore, we aimed to examine whether CEP was associated with reduced severity of stroke following TAVR.
Methods
This was a retrospective cohort study of 2839 consecutive patients (mean age: 79.2 ± 9.5 years, females: 41.5%) who underwent transfemoral TAVR at our institution between 2013 and 2020. We categorized patients into Sentinel CEP users and nonusers. Neuroimaging data were reviewed and the final diagnosis of a cerebrovascular event was adjudicated by a neurologist blinded to the CEP use or nonuse. We compared the incidence and severity (assessed by the National Institutes of Health Stroke Scale [NIHSS]) of stroke through 72 h post-TAVR or discharge between the two groups using stabilized inverse probability of treatment weighting (IPTW) of propensity scores.
Results
Of the eligible patients, 1802 (63.5%) received CEP during TAVR and 1037 (36.5%) did not. After adjustment for patient characteristics by stabilized IPTW, the rate of overall stroke was numerically lower in CEP users than in CEP nonusers, but the difference did not reach statistical significance (0.49% vs. 1.18%, p = 0.064). However, CEP users had significantly lower rates of moderate-or-severe stroke (NIHSS ≥ 6: 0.11% vs. 0.69%, p = 0.013) and severe stroke (NIHSS ≥ 15: 0% vs. 0.29%, p = 0.046). Stroke following CEP use (n = 8), compared with stroke following CEP nonuse (n = 15), tended to carry a lower NIHSS (median [IQR], 4.0 [2.0-7.0] vs. 7.0 [4.5-19.0], p = 0.087). Four (26.7%) out of 15 patients with stroke following CEP nonuse died within 30 days, with no death after stroke following CEP use.
Conclusions
CEP use may be associated with attenuated severity of stroke despite no significant difference in overall stroke incidence compared with CEP nonuse. This finding is considered hypothesis-generating and needs to be confirmed in large prospective studies.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 02 Aug 2022; epub ahead of print

Percutaneous transeptal mitral valve endocarditis debulking with AngioVac aspiration system.

Memon S, Goldman S, Hawthorne KM, Gnall EM
Vacuum assisted aspiration with the AngioVac system has been well described for; right sided endocarditis, venous thrombus, lead related infection/thrombus aspiration and right sided cardiac mass evacuation. Percutaneous transeptal debulking with AngioVac for mitral valve endocarditis (MVE) in the inoperable or high surgical risk patient has not been well defined. A significant proportion of high/prohibitive surgical risk patients with left sided infective endocarditis (IE) are not offered valve surgery as patients in the acute active phase of IE have a high surgical mortality. Nonetheless, sequala of acute IE ie stroke, sepsis or hemodynamic instability in itself is associated with high morbidity and mortality without surgical treatment. A case report of an inoperable patient with methicillin sensitive staphylococcus aureus MVE who was offered MV vegetation debulking with the AngioVac Gen3 C 180 MV system is described. Preprocedural planning with attention to; optimal transeptal height puncture, use of sentinel cerebral protection device to decrease risk of procedure related cerebral embolism and venous extracorporeal membrane cannula, rather than arterial cannula for reinfusion, is described to avoid large bore arterial access related vascular complications. Further studies in a randomized manner are warranted to test these procedural techniques and determine outcomes of percutaneous aspiration of left sided IE with the AngioVac system in this highrisk inoperable cohort of patients.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 30 Jul 2022; epub ahead of print

Short- and medium-term outcomes for patent ductus arteriosus stenting in neonates ≤2.5 kg with duct-dependent pulmonary circulation.

Nasef MA, Shahbah DA, Batlivala SP, Darwish R, ... Goldestein BH, Kenny D
Background
Morbidity with surgical systemic-to-pulmonary artery shunting (SPS) in infants ≤2.5 kg has remained high. Patent ductus arteriosus (PDA) stenting may be a valid alternative. The objective of this study is to evaluate outcomes following PDA stenting in patients ≤2.5 kg from four large tertiary centers.
Methods
Retrospective review of all neonates ≤2.5 kg with duct-dependent pulmonary circulation who underwent PDA stenting. Procedural details, pulmonary arterial growth, reinterventions, surgery type, and outcomes were assessed.
Results
PDA stents were implanted in 37 of 38 patients attempted (18 female) at a median procedural weight of 2.2 kg (interquartile range [IQR], 2-2.4 kg). Seven patients (18%) had a genetic abnormality and 16 (42%) had associated comorbidities. The median intensive care unit stay was 4 days (IQR, 2-6.75 days), and the median hospital stay was 20 days (IQR, 16-57.25). One patient required a rescue shunt procedure, with three others requiring early SPS (<30 days postprocedure). Twenty patients (54%) required reintervention with either balloon angioplasty, restenting, or both. At 6-month follow-up, right pulmonary artery growth (median z-score -1.16 to 0.01, p = 0.05) was greater than the left pulmonary artery (median z-score -0.9 to -0.64, p = 0.35). Serious adverse effects (SAEs) were seen in 18% (N = 7) of our cohort. One patient developed an SAE during planned reintervention There were no intraprocedural deaths, with one early procedure-related mortality, and three interstage mortalities not directly related to PDA stenting.
Conclusions
PDA stenting in infants ≤2.5 kg is feasible and effective, promoting pulmonary artery growth. Reintervention rates are relatively high, though many are planned to allow for optimal growth before a definitive operation.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 29 Jul 2022; epub ahead of print

Iliac \"paving & cracking\" technique for transcatheter aortic valve implantation.

Gallitto E, Palmerini T, Saia F, Gargiulo M
Challenging femoral/iliac access (CA) can lead to vascular complications which can hamper the clinical benefit of transfemoral (TF) transcatheter aortic valve implantation (TAVI). In this sense, iliac artery rupture is a severe complication associated with significant morbidity and mortality. We report a case of TF-TAVI managed with the \"paving and cracking technique\" to overcome CA.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Jul 2022; epub ahead of print

An unexpected circular shunt: Novel method to treat semilunar valve insufficiency in a single ventricle patient on mechanical circulatory support.

Hagel JA, Batlivala SP, Morales DLS, Shahanavaz S
Severe semilunar valve insufficiency in single ventricle patients supported with mechanical circulatory support while awaiting transplant remains a complex clinical scenario with few favorable options for management. We present the first case, to our knowledge, of transcatheter closure of the pulmonic valve in a patient palliated with a hybrid stage 1 procedure for hypoplastic left heart syndrome.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Jul 2022; epub ahead of print

Minimalistic hybrid approach for the percutaneous treatment of chronic coronary total occlusions: An in-depth analysis of the whole algorithm.

Wilgenhof A, Vescovo GM, Bezzeccheri A, Scott B, ... Zivelonghi C, Agostoni P
Introduction
The minimalistic hybrid approach (MHA) is an algorithm to perform chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The current study aims to evaluate the distribution of patients among the five different treatment strategies, the different techniques used in each strategy, the overall procedural success, and the safety of the MHA algorithm.
Methods
Data from a consecutive series of patients with a CTO who underwent elective PCI between February 2019 and July 2021 were prospectively collected and retrospectively analyzed.
Results
One hundred and forty-three CTOPCI in 135 patients were approached according to the MHA algorithm: 134 CTO (93.7%) were successfully recanalized and 9 procedures failed. About half of the procedures (48.3%) were approached using strategy A: antegrade \"blind wiring\" with contralateral retrograde options, making this the most popular strategy. A total of 89 procedures (62.2%) were completed with a single guiding catheter; in 86 (96.6%) a forearm approach was used. The remaining 54 cases were performed with dual access; in the majority of these patients (90.7%), a bilateral forearm approach was used. The only reason to use the femoral access was inadequate forearm access. One hundred and fifty-four out of 197 (78.2%) access sites were 6 French sheaths.
Conclusion
MHA is a stepwise approach focused on the forearm approach to reduce the number of access sites and catheter size used in CTOPCI while maintaining proficiency and safety. Operators should be warned that this approach should be adopted only by experienced CTO operators who master all the strategies of the classic hybrid algorithm and the forearm approach.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Jul 2022; epub ahead of print

Transcatheter vacuum-assisted left-sided mass extraction with the AngioVac system.

Qintar M, Wang DD, Lee J, Villablanca P, ... O\'Neill BP, O\'Neill WW
Objectives
To study the safety and efficacy of AngioVac for left-sided transcatheter vacuum-assisted mass extraction (TVME).
Background
The AngioVac system is approved for right-sided TVME and has emerged as an effective and safe alternative for open surgical treatment. The use of the AngioVac device for aspiration of left-sided TVME has been limited.
Methods
Consecutive patients from two Michigan centers who underwent left-sided TVME were included. Data on patient demographics, procedural information, in-hospital and follow-up events were collected through electronic medical records review. Technical success was defined as aspirating of 70%-100% of the material.
Results
Ten patients (mean age 58.3 [±17.3] years, 50% male) were included. Indications for TMVE were in large for recurrent embolic events. All patients underwent bilateral cerebro-embolic protection using the Sentinel device. The total mean procedure time was 192.5 (±47.5) min of which the meantime for active aspiration (bypass time) was 9.3 (±4.2) min. The circuit configuration was: arteriovenous (AV) in four cases and arterioarterial (AA) in six cases. Successful aspiration was achieved in 80% of cases. No complications were reported (range follow-up 1-16 months).
Conclusions
Our small case series demonstrates the feasibility and safety of the AngioVac system in left-sided mass extraction. Larger trials are needed to further demonstrate its effectiveness and safety and potentially apply for on-label use.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Jul 2022; epub ahead of print

Early coronary angiography in patients after out-of-hospital cardiac arrest without ST-segment elevation: Meta-analysis of randomized controlled trials.

Freund A, van Royen N, Kern KB, Jobs A, ... PEARL, and COACT investigators
Objectives
To compare early coronary angiography to a delayed or selective approach in out-of-hospital cardiac arrest (OHCA) without ST-segment elevation of possible cardiac cause by means of meta-analysis of available randomized controlled trials (RCTs).
Methods
We searched MEDLINE and the Cochrane Central Register of Controlled Trials for RCTs comparing early with delayed or selective coronary angiography in OHCA patients of possible cardiac origin without ST-segment elevation. The primary endpoint was all-cause short-term mortality (PROSPERO CRD42021271484).
Results
The search strategy identified three RCTs enrolling a total of 1167 patients. An early invasive approach was not associated with improved short-term mortality (odds ratio 1.19, 95% confidence interval 0.94-1.52; p = 0.15). Further, no significant differences were shown with respect to the risk of severe neurological deficit, the composite of all-cause mortality or severe neurological deficit, need for renal replacement therapy due to acute renal failure, and significant bleeding at short-term follow-up.
Conclusion
Early coronary angiography in OHCA without ST-segment elevation is not superior compared to a delayed/selective approach.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Jul 2022; epub ahead of print

Antegrade dissection and re-entry versus parallel wiring in chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

Simsek B, Kostantinis S, Karacsonyi J, Alaswad K, ... Brilakis ES, PROGRESS-CTO Investigators
Background
The comparative efficacy and safety of parallel wiring versus antegrade dissection and re-entry (ADR) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is controversial.
Methods
We compared the clinical and angiographic characteristics and outcomes of parallel wiring versus ADR after failed antegrade wiring in a large, multicenter CTO PCI registry.
Results
A total of 1725 CTO PCI procedures with failed antegrade wiring with a single wire were approached with parallel wiring (692) or ADR (1033) at the discretion of the operator. ADR patients were older (65 ± 10 vs. 62 ± 10, years, p < 0.001) and had higher prevalence of comorbidities, such as diabetes mellitus (43% vs. 32%, p < 0.001), prior coronary artery bypass graft surgery (31% vs. 19%, p < 0.001), and lower left ventricular ejection fraction (50 ± 14 vs. 53 ± 11%, p < 0.001). The ADR group had higher J-CTO (2.8 ± 1.1 vs. 2.1 ± 1.3, p < 0.001) and PROGRESS-CTO (1.6 ± 1.1 vs. 1.2 ± 1.0, p < 0.001) scores. Equipment use including guidewires, balloons, and microcatheters was higher, and the procedures lasted longer in the ADR group. Technical success (78% vs. 75%, p = 0.046) and major adverse cardiovascular events (composite of all-cause mortality, stroke, acute myocardial infarction, emergency surgery or re-PCI, and pericardiocentesis) (3.7% vs. 1.9%, p = 0.029) were higher in the ADR group, with similar procedural success (75% vs. 73%, p = 0.166).
Conclusion
In lesions that could not be crossed with antegrade wiring, ADR was associated with higher technical but not procedural success, and also higher MACE compared with parallel wiring.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 28 Jul 2022; epub ahead of print

Treatment of cardiac device-related infective endocarditis utilizing the new T20 curve catheter and flow saver with the Inari mechanical aspiration system.

Whitbeck MG, Chambers JW
Emerging innovations have led to the development of tools and techniques to perform mechanical aspiration of right-sided endocarditis vegetations. However, blood loss during aspiration, the need for veno-veno bypass, and nonsteerable catheters have limited expansion of these treatment options to more patients. We present a case of pacemaker lead endocarditis treated with the Inari mechanical aspiration system utilizing the new T20 curved catheter (Inari Medical).

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 26 Jul 2022; epub ahead of print

Facilitation techniques to cross the interatrial septum with intracardiac echocardiography during left atrial appendage closure.

Vanhaverbeke M, Nuyens P, Bieliauskas G, Sondergaard L, Vejlstrup N, De Backer O
Objectives
This study aimed to assess the rate of difficult interatrial septum (IAS) crossing with the intracardiac echocardiography (ICE) probe during percutaneous left atrial appendage (LAA) closure and to identify techniques that facilitate IAS crossing with the ICE probe.
Background
Percutaneous LAA closure is increasingly performed by ICE guidance. Although such an approach omits the need for general anesthesia, crossing of the IAS with the ICE probe may sometimes be challenging.
Methods
All consecutive patients that underwent ICE-guided percutaneous LAA closure with an Amplatzer Amulet (Abbott) or WatchmanFLX (Boston Scientific) at our center in the period 2018-2021 were included. Cases in which IAS crossing with ICE was difficult were identified and techniques used to facilitate IAS crossing were identified and listed.
Results
In 17 (5%) out of 354 cases, IAS crossing with the ICE probe was difficult and required use of additional techniques. Ultimately, IAS crossing was also successful in these 17 cases by using one of three possible facilitation techniques: the probing technique (12 cases), the double-wire technique (3 cases), and the snaring technique (2 cases). In one case, the double-wire technique was converted to the snaring technique, as crossing of the ICE probe remained challenging despite the use of two stiff guidewires.
Conclusion
Crossing of the IAS with the ICE probe can be challenging in 5% of ICE-guided percutaneous LAA closure procedures. Operators should be aware of possible facilitation techniques in challenging cases, as these show to be safe and effective.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 26 Jul 2022; epub ahead of print

Instantaneous wave-free ratio-guided revascularization of nonculprit lesions in STEMI patients with multivessel coronary disease: The WAVE registry.

Musto C, Scappaticci M, Biondi-Zoccai G, De Felice F, ... Versaci F, Gabrielli D
Background
Complete revascularization (CR) of nonculprit lesions (NCL) is strongly recommended in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD), but no definitive evidence is available regarding which diagnostic strategy should be preferred. Instantaneous wave-free ratio (iFR) has never been investigated in this setting. We aimed to describe clinical outcomes of a cohort of patients undergoing iFR-guided CR.
Methods
Following primary percutaneous coronary intervention (PCI), consecutive patients with STEMI and intermediate NCL were enrolled and destinated to an iFR-guided CR. NCL with iFR ≤ 0.89 underwent PCI while NCL with iFR > 0.89 were deferred. The primary endpoint was NC target lesion failure (NC-TLF) and the secondary endpoint was major adverse cardiovascular events (MACE), at 1-year follow-up.
Results
Overall, 209 patients were enrolled (ischemic iFR = 83; nonischemic iFR = 126). Patients with ischemic iFR showed a higher prevalence of traditional cardiovascular risk factors and angiographically determined three-vessel disease. In the entire cohort, NC-TLF and MACE occurred in 6.7% and 10.5% of patients, respectively. Compared to the deferred group, patients with ischemic iFR experienced significantly higher rates of both NC-TLF (3.2% vs. 12.1%; p = 0.021) and MACE (7.1% vs. 16.9%; p = 0.041). These results were mostly driven by increased rates of NC-TLF PCI and further revascularizations in this latter group, while no differences were evident in terms of nonfatal myocardial infarction or death. At multivariable analysis, the strongest predictor of MACE was symptom onset to balloon time (HR = 1.17 [95% CI: 1.04-1.31], p = 0.008).
Conclusions
In our study enrolling STEMI patients with MVD, iFR assessment was feasible and safe. PCI-deferring according to iFR evaluation of NCL was associated with low rates of adverse events. Further randomized studies are needed to investigate the effectiveness of iFR-guided revascularization compared to current practice in this setting.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 23 Jul 2022; epub ahead of print

Radial access for chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry.

Simsek B, Gorgulu S, Kostantinis S, Karacsonyi J, ... Brilakis ES, PROGRESS-CTO investigators
Use of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been increasing. We examined the clinical characteristics and procedural outcomes of patients who underwent CTO PCI with radial versus femoral access in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). Of 10,954 patients who underwent CTO PCI at 55 centers in 7 countries between 2012 and 2022, 2578 (24%) had a radial only approach. Patients who underwent radial only access were younger (63 ± 10 vs. 65 ± 10, years, p < 0.001), more likely to be men (84% vs. 81%, p = 0.001), and had significantly lower prevalence of comorbidities compared with the femoral access group including diabetes mellitus (39% vs. 45%, p < 0.001) and coronary artery bypass graft surgery (57% vs. 64%, p < 0.001). In addition, radial only cases had lower angiographic complexity with lower J-CTO and PROGRESS-CTO scores. After adjusting for potential confounders, radial only access was associated with lower risk of access site complications (odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.22-0.91), similar technical success (OR: 0.87, 95% CI: 0.74-1.04) and major adverse cardiovascular events (MACE) (OR: 0.65, 95% CI: 0.40-1.07), compared with the femoral access group. Radial only access was used in 24% of CTO PCIs and was associated with lower access site complications, and similar technical success and MACE as compared with the femoral access group.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 23 Jul 2022; epub ahead of print

Left atrial appendage closure with the II generation Ultraseal device: An international registry. The LIGATE study.

Pivato CA, Liccardo G, Sanz-Sanchez J, Pelloni E, ... Stefanini GG, Pagnotta P
Objectives
To assess feasibility and safety of second-generation left atrial appendage closure (LAAC) Ultraseal device in patients with nonvalvular atrial fibrillation (NVAF).
Background
LAAC with first-generation Ultraseal device (Cardia, Eagan, Minnesota) has been shown to be a feasible therapeutic option in patients with NVAF. However, there is a paucity of data regarding the novel second-generation Ultraseal device.
Methods
All patients with NVAF undergoing second-generation Ultraseal device implantation between February 2018 and September 2020 were included in a multicenter international registry. Periprocedural and post-discharge events were collected through 6-month follow-up. Co-primary efficacy endpoints were device success and technical success while primary safety endpoint was in-hospital major adverse event (MAE) occurrence.
Results
A total of 52 patients were included: mean age 75 ± 8, 30.8% women, mean HAS-BLED 3 ± 1. The device was successfully implanted in all patients. Technical success was achieved in 50 patients (96.1%). In-hospital MAEs occurred in three patients (5.8%). The incidence of 6-month all-cause death and major bleeding was 11.6% and 2.1%, respectively. No strokes, transient ischemic attacks, systemic embolisms, or device embolization were reported after discharge.
Conclusions
Second-generation Ultraseal device implantation was associated with high success rates and a low incidence of peri-procedural complications. Larger studies with longer follow-up are warranted to further evaluate the safety and the efficacy of this device, especially at long-term follow-up.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 16 Jul 2022; epub ahead of print

Directional versus orbital atherectomy of femoropopliteal artery lesions: Angiographic and intravascular ultrasound outcomes.

Babaev A, Halista M, Bakirova Z, Avtushka V, Matsumura M, Maehara A
Objectives
The aim of this study was to compare the ability of two different atherectomy modalities, the directional atherectomy system (DAS) and the orbital atherectomy system (OAS), to modify plaque and augment luminal gain as evaluated by angiography and intravascular ultrasound (IVUS) in patients with symptomatic femoro-popliteal peripheral arterial disease (PAD).
Background
Atherectomy is frequently utilized in the treatment of complex PAD. To date, there are no head-to-head comparisons of existing devices and their selection is based mostly on operator preference rather than on supportive data.
Methods
This was a single-center, prospective, randomized trial designed to assess the impact of DAS in comparison to OAS on atherosclerotic plaque. Pre- and postatherectomy lesion characterization was performed by angiography and IVUS. Drug-coated balloon (DCB) angioplasty was performed after atherectomy with similar analysis repeated.
Results
Sixty patients were randomized to undergo either DAS or OAS. Pretreatment angiographic and IVUS characteristics were similar in the DAS and OAS groups. DAS led to a greater reduction in plaque volume throughout the entire lesion (5.9% vs. 1.1%, p = 0.003). This corresponded to a greater increase in total vessel and lumen volume by IVUS (161.5 mm³ vs. 50.2 mm³ , p = 0.001; 178.6 mm³ vs. 47.0 mm³ , p = 0.004, respectively), as well as a reduction in angiographic stenosis (40% vs. 70%, p < 0.001). After DCB, 10 patients required stenting for suboptimal results in the OAS group compared with two in the DAS group (p = 0.021).
Conclusions
Compared to OAS, DAS demonstrated a greater plaque volume reduction and luminal gain with significantly fewer stents needed post-DCB.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 16 Jul 2022; epub ahead of print

Evaluation of the incidence of radial artery occlusion using different introducer sheaths and hemostasis techniques.

Patel P, Sethi N, Patel GA, Kalisetti D, Patel TM
Background
Radial artery occlusion (RAO) remains one of the most important complications of transradial access (TRA). Despite the identification of multiple predictors, the interaction between these predictors on the occurrence of RAO has not been evaluated.
Methods
Consecutive patients undergoing TRA coronary angiography (CA) or percutaneous coronary intervention (PCI), were retrospectively analyzed to compare the effect of standard patent hemostasis using a one-bladder band versus two-bladder band with simultaneous ipsilateral ulnar artery compression and two introducer sizes on the primary endpoint of RAO. Access was obtained using 6-Fr slender introducer sheath or 7-Fr slender introducer sheath and hemostasis with either a one-bladder band or a two-bladder band. The radial artery was evaluated using ultrasound.
Results
Total of 2019 patients undergoing CA or PCI were included in the analysis. In the one-bladder band group, the incidence of RAO with a 6-Fr slender introducer sheath was 4.2%. In those receiving hemostasis with a two-bladder band, RAO occurred in 1% of patients receiving a 6-Fr slender introducer sheath versus 0.9% in those receiving a 7-Fr slender introducer sheath (p = 0.68). Larger radial artery diameter, larger body weight, and a two-bladder hemostasis band with ipsilateral ulnar compression were independently associated with a lower incidence of RAO.
Conclusion
A two-bladder band with simultaneous ipsilateral ulnar artery compression when used for radial artery hemostasis, is associated with a lower incidence of RAO, and can mitigate the penalty for a larger catheter with reassuring implications for use of a 7-Fr capable system for complex transradial PCI.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 16 Jul 2022; epub ahead of print

In-hospital outcomes of TAVR patients with a bundle branch block: Insights from the National Inpatient Sample 2011-2018.

Zahid S, Khan MZ, Ullah W, Tanveer Ud Din M, ... Depta JP, Balla S
Introduction
Data on the outcomes following transcatheter aortic valve replacement (TAVR) in patients with a bundle branch block (BBB) remains limited.
Methods
We studied the outcomes of TAVR patients with a BBB from the National Inpatient Sample (NIS) database between 2011 and 2018 using ICD-9-CM and ICD-10-CM codes.
Results
Between 2011 and 2018, 194,237 patients underwent TAVR, where 1.7% (n = 3,232) had a right BBB (RBBB) and 13.7% (n = 26,689) had a left BBB (LBBB). Patients with a RBBB and LBBB had a higher rate of new permanent pacemaker (PPM) implantation (31.5% - RBBB, 15.7% LBBB vs. 10.2% - no BBB). RBBB was associated with a significantly longer median length of stay (5 days) and total hospitalization cost ($53,669) compared with LBBB (3 days and $47,552) and no BBB (3 days and $47,171). Trend analysis revealed lower rates of PPM implantation and reduced lengths of stay and costs across all comparison groups.
Conclusion
In conclusion, patients undergoing TAVR with a BBB are associated with higher new rates of PPM implantation. RBBB is the strongest independent predictor for new PPM implantation following TAVR. Rates of new PPM implantation in TAVR patients with and without a BBB have improved over time including reductions in length of stay and hospital costs. Further study is needed to reduce the risks of PPM implantation in TAVR patients.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 16 Jul 2022; epub ahead of print

The impact of frailty on adverse outcomes after transcatheter aortic valve replacement in older adults: A retrospective cohort study.

Dautzenberg L, van Aarle TTM, Stella PR, Emmelot-Vonk M, Weterman MA, Koek HL
Background
Transcatheter aortic valve replacement (TAVR) is an effective alternative to surgical aortic valve replacement for patients who are at increased surgical risk. Consequently, frailty is common in patients undergoing TAVR.
Objectives
This study aims to investigate the impact of frailty on outcomes following TAVR.
Methods
A retrospective cohort study was conducted, including all TAVR candidates who visited the geriatric outpatient clinic for preoperative screening. Frailty status was assessed according to the Groningen Frailty Indicator. The primary outcome of the study was defined as the occurrence of postoperative complications, and this was evaluated according to the Clavien-Dindo classification. An additional analysis was performed to assess the impact of frailty on 1-year all-cause mortality and complications within 30 days of TAVR according to the Valve Academic Research Consortium (VARC-2) criteria. The VARC-2 criteria provide harmonized endpoint definitions for TAVR studies.
Results
In total, 431 patients with a mean age of 80.8 ± 6.2 years were included, of whom 56% were female. Frailty was present in 36% of the participants. Frailty was associated with a higher risk of the composite outcome of complications [adjusted odds ratio (OR): 1.55 (95% confidence interval, CI: 1.03-2.34)], 30-day mortality [adjusted OR: 4.84 (95% CI: 1.62-14.49)], 3-month mortality [adjusted OR: 2.52 (95% CI: 1.00-6.28)] and 1-year mortality [adjusted OR: 2.96 (95% CI: 1.46-6.00)].
Conclusions
Frailty is common in TAVR patients and is associated with an increased overall risk of postoperative complications, particularly mortality. Increased optimization of screening and treatment of frailty in the guidelines for valvular heart diseases is recommended.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 13 Jul 2022; epub ahead of print

PRospective REgistry of PAtients in REfractory cardiogenic shock-The PREPARE CardShock registry.

von Lewinski D, Herold L, Stoffel C, Pätzold S, ... Zirlik A, Toth GG
Aim
Cardiogenic shock (CS) is a hemodynamically complex multisystem syndrome associated with persistently high morbidity and mortality. As CS is characterized by progressive failure to provide adequate systemic perfusion, supporting end-organ perfusion using mechanical circulatory support (MCS) seems intriguing. Since most patients with CS present in the catheterization laboratory, percutaneously implantable systems have the widest adoption in the field. We evaluated feasibility, outcomes, and complications after the introduction of a full-percutaneous program for both the Impella CP device and venoarterial extracorporeal membrane oxygenator (VA-ECMO).
Methods
PREPARE CardShock (PRospective REgistry of PAtients in REfractory cardiogenic shock) is a prospective single-center registry, including 248 consecutive patients between May 2019 and April 2021, who underwent cardiac catheterization and displayed advanced cardiogenic shock. The median age was 70 (58-77) years and 28% were female. Sixty-five percent of the cases had cardiac arrest, of which 66% were out-of-hospital cardiac arrest. A local standard operating procedure (SOP) indicating indications as well as relative and absolute contraindications for different means of MCS (Impella CP or VA-ECMO) was used to guide MCS use. The primary endpoint was in-hospital death and secondary endpoints were spontaneous myocardial infarction and major bleedings during the hospital stay.
Results
Overall mortality was 50.4% with a median survival of 2 (0-6) days. Significant independent predictors of mortality were cardiac arrest during the index event (odds ratio [OR] with 95% confidence interval [CI]: 2.53 [1.43-4.51]; p = 0.001), age > 65 years (OR: 2.05 [1.03-4.09]; p = 0.036]), pH < 7.30 (OR: 2.69 [1.56-4.66]; p < 0.001), and lactate levels > 2 mmol/L (OR: 4.51 [2.37-8.65]; p < 0.001).
Conclusions
Conclusive SOPs assist target-orientated MCS use in CS. This study provides guidance on the implementation, validation, and modification of newly established MCS programs to aid centers that are establishing such programs.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 13 Jul 2022; epub ahead of print

Suture connection of overlapping covered CP stents for transcatheter treatment of sinus venosus atrial septal defect with anomalous pulmonary venous connection.

Tan W, Levi D, Perens G, Aboulhosn J
Transcatheter correction of a superior sinus venosus defect and partial anomalous pulmonary venous connection with covered stents is a feasible alternative to surgical repair in select patients. Commercially available balloon-expandable covered stents may be of inadequate length to treat some patients. This may require multiple stents to be placed, which increases the risk of stent migration or embolization. A modification of this technique utilizing two interdigitating covered stents secured together with sutures is described, allowing for increased stability of a long stent complex. One failed case and a second successful case are presented.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 12 Jul 2022; epub ahead of print

Angiographic predictors of aberrant circumflex artery during cardiac catheterization.

Triantafyllis AS, van Nunen LX, Lesizza P, Pagourelias ED, ... Tonino PAL, McCutcheon K
Objectives
To identify angiographic predictors of aberrant left circumflex artery (LCx) by comparing left main (LM) length and bifurcation angle between patients with aberrant LCx and normal anatomy.
Background
Failure to recognize aberrant LCx during a cardiac catheterization may hamper correct diagnosis, delay intervention in acute coronary syndromes, and result in increased contrast volume, radiation exposure, and infarct size.
Methods
We retrospectively analyzed angiograms of aberrant LCx patients and normal anatomy matched controls, in three-participating centers. LM-length, bifurcation angle between the left anterior descending (LAD) and the first non-LAD branch of the LM, and procedural data were compared.
Results
Between 2003 and 2020, 136 patients with aberrant LCx and 135 controls were identified. More catheters (2.4 ± 0.6 vs. 2.2 ± 0.9, p = 0.009), larger contrast volumes (169 ± 94 ml vs. 129 ± 68 ml, p < 0.0005), and prolonged fluoroscopy time (652.9 ± 623.7 s vs. 393.1 ± 332.1 s, p < 0.0005), were required in the aberrant LCx-group compared with controls. Patients with aberrant LCx had a longer LM-length and a more acute bifurcation angle, both in caudal and cranial views, compared with controls (24.7 ± 8.1 vs. 10.8 ± 4.5 mm, p < 0.0005 and 26.7 ± 7.4 vs. 12 ± 5.5 mm, p < 0.0005, respectively, and 45.2° ± 12° vs. 88.8° ± 23°, p < 0.0005 and 51.9° ± 21° vs. 68.2° ± 28.3°, p < 0.0005, respectively). In ROC analysis, LM-length showed the best diagnostic accuracy for detecting aberrant LCx. In multiple logistic regression analysis, a cranially measured LM-length > 17.7 mm was associated with a 5.3 times greater probability of predicting aberrant LCx [95% CI (3.4-8.1), p < 0.0001].
Conclusions
Our study suggests that a long LM-length and an acute bifurcation angle can indicate the presence of aberrant LCx. We present a practical algorithm for its rapid identification.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 12 Jul 2022; epub ahead of print

Dual guidewire balloon antegrade fenestration and re-entry technique for coronary chronic total occlusions percutaneous coronary interventions.

Galassi AR, Vadalà G, Testa G, Puglisi S, ... Giunta R, Novo G
Objectives
To describe the experience of coronary chronic total occlusions (CTOs) percutaneous coronary interventions (PCI) using antegrade fenestration and re-entry (AFR) technique with a dedicated dual guidewire balloon (DGB).
Background
Antegrade dissection and re-entry (ADR) techniques has been emphasized in recent worldwide CTO consensus documents. We investigated the feasibility and safety of DGB as a dedicated device to perform guidewire-based AFR.
Methods and results
Fourteen consecutive patients with complex CTO (J-CTO score: 3.1 ± 0.9) underwent DGB-AFR in the years 2020-2021. DGB-AFR consists in advancing the DGB over a guidewire that reached the vessel distal to the CTO in an extra plaque fashion, inflating/deflating the DGB to create fenestration between subintimal space and the true lumen and advancing a proximal re-entry guidewire through fenestration in the true lumen. DGB-AFR alone was successful in 10 of 14 (71%) cases, a rescue wire-based ADR was needed in two cases for re-entry into the true lumen with a total success rate in 12 of 14 (86%) cases. Among all DGB-AFR cases, four (28%) were performed as a first-line strategy while the remaining 10 (71%) cases were performed as a bail-out strategy after failure of other antegrade crossings for 30 min of procedural time. No DGB-related complications were observed.
Conclusions
DGB-AFR is a user-friendly reliable strategy for the treatment of many CTO lesions. It can be used as bail-out after failure of conventional antegrade wiring techniques, achieving high procedural success rate and low occurrence of procedural adverse events.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 12 Jul 2022; epub ahead of print

Validation of a simplified intravascular ultrasound core lab analysis method in stented coronary arteries.

Neleman T, Khachabi J, Jonker H, Rademaker-Havinga T, Spitzer E, Daemen J
Objectives
To validate a simplified core laboratory intravascular ultrasound (IVUS) analysis method based on frames with visually determined minimal lumen areas (MLAs) as compared with a comprehensive (per frame) analysis method.
Background
IVUS-guided percutaneous coronary intervention has proven to be superior to angiography-guided stenting. In clinical practice, cross-sections with visually determined MLA are measured to determine lesion severity or minimal stent area (MSA), however, its accuracy has not been compared with a comprehensive per frame analysis method.
Methods
A total of 50 stented coronary segments of anonymized core lab datasets were analyzed using a comprehensive analysis method and reanalyzed by two core lab analysts using the simplified method including a maximum of seven frames to be analyzed (the visually determined MSA, the first and last frame, and the MLA of each reference segment). The main parameters of interest were MSA, MLA in the reference segments, and plaque burden.
Results
The simplified method showed moderate agreement for measurement of the proximal MLA (7.51 ± 2.52 vs. 6.32 ± 1.88 mm² , intraclass correlation coefficient [ICC] = 0.73), good agreement for the distal MLA (5.41 ± 1.85 vs. 5.11 ± 1.38 mm² , ICC = 0.84) and plaque burden proximal (0.49 ± 0.12 vs. 0.50 ± 0.11, ICC = 0.88), and excellent agreement for the MSA (5.35 ± 1.05 vs. 5.32 ± 0.99 mm² , ICC = 0.94) and plaque burden distal (0.47 ± 0.14 vs. 0.47 ± 0.12, ICC = 0.92), when compared with the comprehensive analysis method. Inter- and intraobserver analysis revealed good-to-excellent agreement for all parameters.
Conclusions
Measuring poststenting IVUS cross-sections with visually determined MLAs by experienced core lab analysts is an accurate and reproducible method to identify MLAs.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 10 Jul 2022; epub ahead of print

VA-ECMO-assisted aspiration thrombectomy in a patient presenting with acute massive PE with absolute contraindications to thrombolytics.

Patel M, Mujer M, John A, Darki A
Massive pulmonary embolism (PE) is a life-threatening complication of major surgery with a mortality rate up to 50%. First-line therapy for massive PE is systemic thrombolytics, but surgical patients are at high bleeding risk with absolute contraindications. As surgical thrombectomy carries a high burden of morbidity and mortality, endovascular interventions are becoming more common in these clinical scenarios. We report a case of a neurosurgical patient whose postoperative course was complicated by massive PE and subsequent cardiac arrest that required emergent venoarterial extracorporeal membrane oxygenation, followed by aspiration thrombectomy with the Inari FlowTriever Device (Inari Medical). The patient had immediate hemodynamic improvement with eventual recovery to baseline functional status.

© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 08 Jul 2022; epub ahead of print

Sex differences on outcomes following left atrial appendage occlusion in atrial fibrillation: A systematic review and meta-analysis.

Zhu Y, Sasmita BR, Xue Y, Jiang Y, Huang B, Luo S
There is a lack of sufficient data on sex-related differences in outcomes of nonvalvular atrial fibrillation (AF) patients following left atrial appendage occlusion (LAAO). We conducted a meta-analysis to investigate the procedural complications and long-term outcomes after LAAO in women versus men. We screened Medline, EMBASE, Cochrane Center Register of Controlled Trials, and Clinical Trials.gov. The inclusion criteria were studies targeting the sex-related differences in outcomes in nonvalvular AF patients treated by LAAO. Procedural endpoints of interest included success rate, pericardial complications, major bleeding, and vascular complications during hospitalization. Long-term outcomes included all-cause mortality and ischemic stroke during follow-up. Studies that merely considered sex in the subgroup analysis were not included. Six observational studies with a total of 64,035 patients were identified. The procedural success rates did not differ between sexes (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.89-1.09, p = 0.77), while women experienced more pericardial complications (OR: 1.78, 95% CI: 1.58-2.01, p < 0.00001), major bleedings (OR: 2.04, 95% CI: 1.75-2.39, p < 0.00001), and vascular complications (OR: 1.75, 95% CI: 1.41-2.17, p < 0.00001) than men. The sensitivity analysis performed by removing the largest study showed good stability. The long-term mortality and stroke rates did not differ between women and men in either the 1-year subgroup or the 2-year subgroup. In conclusion, despite comparable procedural success rates, women have a significantly higher incidence of pericardial complications, major bleeding, and vascular complications following LAAO. The long-term mortality and stroke rates do not differ between the sexes.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 08 Jul 2022; epub ahead of print

Local versus general anesthesia for endovascular aneurysm repair in ruptured abdominal aortic aneurysm: A systematic review and meta-analysis.

Lei J, Pu H, Wu Z, Huang Q, ... Liu G, Lu X
Objectives/background
In the endovascular treatment of ruptured abdominal aortic aneurysm (RAAA), there is no effective evidence to show preference for a specific anesthetic option. A meta-analysis was conducted to assess the result of different anesthesia in endovascular aneurysm repair (EVAR) of RAAA.
Methods
Randomized controlled trials (RCTs) and cohort studies were searched in PubMed, Embase, Ovid, and the Cochrane Library. Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool were applied to evaluate the quality of cohort studies and RCTs, respectively. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to express differences for primary and secondary outcomes. Subgroup analyses and sensitivity analyses were applied in the primary outcome to illustrate the results further. Significance was set at p < 0.05. Random-effects models were used considering limited research regardless of I²  < 50%.
Results
Ten cohort studies were included in this meta-analysis. Perioperative mortality was presented as the primary outcome by analyzing eight of these research. Among the included patients, local anesthesia (LA) was considered as a better choice considering perioperative mortality (n = 156/902) rather than general anesthesia (n = 907/3434) with significant difference (OR: 0.49; 95% CI: 0.35-0.67; p < 0.00001; I²  = 42%). However, no significant difference was found in the secondary outcome: the complication rate, ICU admission rate, postoperative morbidity of pneumonia, myocardial infarction, leg ischemia, and wound complication.
Conclusions
There exists some evidence in this review that LA appears to improve perioperative mortality, especially in hemodynamically stable patients and should be recommended for patients undergoing EVAR with RAAA when appropriate.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 08 Jul 2022; epub ahead of print

TAVR in an XXXL annulus (1057 mm ) with type I bicuspid aortic valve.

Russo M, Chen C, Sethi A, Hakeem A
We report the largest annulus (>1000 m² ) treated with transcatheter aortic valve replacement to date. It highlights the unique challenges in planning, sizing, and deployment considerations in the setting of a very large and altered geometry of a bicuspid aortic valve.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 06 Jul 2022; epub ahead of print

Angiography versus FFR guided complete revascularization versus culprit-only revascularization for patients presenting with STEMI: Network meta-analysis.

Okuya Y, Gohil K, Moussa ID
This study aimed to compare the outcomes of different revascularization strategies among patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD) undergoing primary percutaneous coronary intervention (PCI). MVD is present in about one-half of patients presenting with STEMI. Despite several randomized controlled trials (RCTs) comparing complete revascularization (CR) and culprit-only revascularization (COR), the optimal PCI strategy for STEMI patients with MVD remains unsettled. Moreover, it is unclear whether angiography-guided CR or fractional flow reserve (FFR)-guided CR is associated with better outcomes. PubMed, Scopus, and Cochrane Library were searched for RCTs comparing CR strategies with COR strategy in patients with STEMI between January 1, 2000 and September 30, 2021 were identified. A frequentist network meta-analyses were performed for three PCI strategies: (1) COR; (2) angiography-guided CR; and (3) FFR-guided CR. Ten RCTs including 7979 patients were included. A strategy of angiography-guided CR or FFR-guided CR was associated with a significantly lower rate of major adverse cardiac events (MACE) and unplanned revascularization compared with COR. Although there were no statistical significant difference between angiography-guided CR and FFR-guided CR, P score analysis showed that angiography-guided CR was ranked as the best strategy for reducing MACE, all-cause mortality, cardiovascular death, recurrent myocardial infarction, and unplanned revascularization. In patients presenting with STEMI and MVD undergoing primary PCI, angiography-guided CR or FFR-guided CR improve outcomes compared with COR. Furthermore, the strategy of angiography-guided CR ranked as the best revascularization strategy in those patients.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 05 Jul 2022; epub ahead of print

Clinical outcomes of percutaneous coronary intervention in high-risk patients turned down for surgical revascularization.

Farag M, Al-Atta A, Abdalazeem I, Salim T, Alkhalil M, Egred M
Aims
There are limited data on outcomes of PCI in surgical turndown patientsespecially in those presenting with ACS.
Methods and results
A retrospective analysis of prospectively collected data of patients who were turned down for CABG and had PCI between 2013 and 2020. All consecutive patients (449), ACS (n = 245) and no-ACS (n = 204) were included. In-hospital complications occurred in 28 patients (6.2%). At 30 days, 27 patients (6.0%) died (18 patients in the ACS group [7.3%] vs. 9 patients in the no-ACS group [4.4%], p = 0.23). Following multivariate analysis, no significant difference in long-term mortality was observed between the two groups (median follow-up of 4 [2-6] years, hazard ratio [HR]: 1.08, 95% confidence interval [CI]: 0.75-1.58, p = 0.667). In propensity score-matched analysis, the adjusted mortality risk was also not different between the groups (HR: 0.74, 95% CI: 0.25-1.26, p = 0.374). Independent predictors of mortality included chronic kidney disease stage ≥ 3 (HR: 1.64, 95% CI: 1.13-2.39, p = 0.009), high European System for Cardiac Operative Risk Evaluation II (HR: 1.02, 95% CI: 1.00-1.05, p = 0.035), and laser atherectomy use (HR: 3.35, 95% CI: 1.32-8.54, p = 0.011).
Conclusions
PCI in surgical patients turndown patients appears safe. ACSpresentation was associated with more comorbid illnesses; however, afteradjustment, ACS did not independently confer additional risk of mortality.

© 2022 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 01 Jul 2022; epub ahead of print