Calcified Coronary Disease Research Articles

TCT-488 Characteristics and Outcomes of Shockwave Intravascular Lithotripsy for Calcific Coronary Disease: A New Zealand Single-Center Experience

TCT-488 Characteristics and Outcomes of Shockwave Intravascular Lithotripsy for Calcific Coronary Disease: A New Zealand Single-Center Experience

Coronary perforation incidence and temporal trends (COPIT): systematic review and meta-analysis

Abstract Background Despite advancements in Percutaneous Coronary Intervention (PCI) technology and techniques, iatrogenic coronary artery perforation (CAP) remains a dreaded potential complication within the cardiac catheterisation laboratory. Data detailing the incidence of coronary perforation during PCI has previously been obtained from relatively small datasets. A swell of large data published in recent times provides invaluable information regarding PCI related CAP. Purpose COPIT is a systematic review and meta-analysis targeted at detailing the incidence, outcomes, etiology and treatment modalities of PCI related CAP including evaluation of temporal trends since the inception of PCI to contemporary practice. Additionally, COPIT provides hypothesis generating data regarding predictors of CAP during PCI. Methods A prospective systematic review and meta-analysis using MEDLINE and EMBASE via the OVID interface (PROSPERO ID: CRD42020207881) was performed according to the PRISMA guidelines. Identified relevant studies were used in a pre-specified sensitivity analysis to detail incidence, outcomes, etiology, treatment modalities and risk factors of PCI complicated by CAP. Studies limited to PCI in high risk populations only such as CTO-PCI or rotational atherectomy only were excluded. Results 67 studies met eligibility criteria detailing 5,568,191 PCIs over a 38-year period (1982–2020). The pooled incidence of CAP was 0.39% (95% CI: 0.34–0.45%) with no change in incidence over that time. Approximately 1 in 5 perforations led to cardiac tamponade (21.1%). Ellis 3 perforations are increasing in frequency and account for 43% of all perforations. Mortality due to perforation occurs in 7.5% of all CAP (95% CI 6.7% - 8.4%) but has declined over the studied period. Meta-regression suggested that female gender, hypertension, chronic kidney disease and previous coronary bypass grafting were all associated with higher incidence of CAP. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%. Conclusion Coronary perforations occurs in approximately 1 in 250 all-comer PCI procedures. A tendency towards increase in coronary perforations is likely reflective of contemporary trends towards high pressure post-dilatation with 1:1 vessel sizing as well as an ageing population with increasingly complex, calcific coronary disease. However, reduction in CAP related mortality suggests earlier recognition and effective treatment with transcatheter techniques. Funding Acknowledgement Type of funding sources: None.

Local Experience Using Intravascular Lithotripsy Treatment for Severe Calcific Coronary Disease in Acute Coronary Syndrome

Percutaneous treatment of heavily calcified coronary lesions remains a challenge with an increased risk of procedural failure and complications. Intravascular lithotripsy (IVL) can facilitate lesion preparation with trials in stable calcified lesions demonstrating favourable outcomes. The safety and efficacy of IVL in acute coronary syndrome (ACS) is unclear. We aim to assess the safety and efficacy of IVL in ACS compared with stable coronary artery disease (CAD).

Combined use of rotational and excimer lASER coronary atherectomy (RASER) during complex coronary angioplasty-An analysis of cases (2006-2016) from the British Cardiovascular Intervention Society database.

Combining rotational (RA) and excimer laser coronary atherectomy (ELCA)-RASER atherectomy-is technique utilized in the percutaneous management of calcific coronary disease. The evidence base examining its safety and utility is sparse and limited to small case-series. This study examines the patterns and outcomes of RASER atherectomy use in the largest cohort to date. Using the British Cardiac Intervention Society database, data were analyzed on all PCI procedures in the UK between 2006 and 2016. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural, and outcome associations with RASER. We identified 153 (0.02%) RASER atherectomy cases out of 686,358 PCI procedures. Baseline covariates associated with RASER use were age, BMI, diabetes, stable coronary disease, and previous CABG. Procedural co-variates associated with RASER were CTO-PCI, the use of more/longer stents, intravascular imaging, cutting balloons, and microcatheters. Adjusted rates of in-hospital major adverse cardiac/cerebrovascular events (MACCE) were not significantly different with RASER. However, there were higher odds of arterial complications (OR 3.23, 95% CI: 1.58-6.61), slow flow (OR 3.50, 95% CI: 1.29-9.55), and shock induction (OR 9.66, 95% CI: 3.44-27.06). RASER atherectomy use in complex PCI is associated with higher risk baseline and procedural characteristics. Although increased rates of shock induction, slow flow, and arterial complications were observed, RASER does not increase the likelihood of in-hospital MACCE, major bleeding, or death.

Management of stent underexpansion using intravascular lithotripsy-Defining the utility of a novel device.

This study aimed to present a case series of patient treated for stent underexpansion resistant to conventional treatment with intravascular lithotripsy (IVL). Stent underexpansion is a powerful predictor of long-term stent patency and correlates with unfavorable clinical outcomes. This case series demonstrates the utility of IVL in managing stent underexpansion resistant to conventional treatment. We describe a case series of patients with stent underexpansion due to calcific coronary artery disease treated with IVL. Stent underexpansion was identified as an inability to adequately expand stents with conventional treatment. Only cases that failed to achieve adequate expansion with high-pressure noncompliant balloon inflation were included. Thirteen patients from six institutions have been included in this case series. The average age was 70.25 years with 76.9% of male patients. The average pre-IVL minimal stent area (MSA) was 2.71 mm2 , which improved to 6.44 mm2 post-IVL treatment, representing an average MSA gain of 238%. There were no procedural, peri-procedural, or 30-day major adverse cardiac and cerebrovascular event. This case series demonstrates that IVL is a feasible, safe alternative for the management of stent underexpansion due to calcific coronary disease.

One Year Outcomes of Orbital versus Rotational Atherectomy for the Treatment of Heavily Calcified Coronary Disease

Objectives: Compare long term outcomes between orbital versus rotational atherectomy for the treatment of heavily calcified coronary disease at a single institution. Background: Plaque modification with atherectomy facilitates stent delivery and optimization in severely calcified coronaries. Rotational Atherectomy (RA) (Boston Scientific) has been in use for several decades while orbital atherectomy (OA) (CSI Diamondback 360®) is a newer atherectomy device that is rapidly gaining momentum. Small trials and meta-analyses have compared these 2 devices; however, longer term outcomes have not been evaluated. Methods: We retrospectively identified 75 patients who underwent RA or OA, and had at least 1-year follow up, at a single veteran center from March 2016 to October 2017. The primary endpoint was 1-year major adverse cardiac and cerebrovascular events (MACCE) (composite of all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), and stroke). The secondary endpoint was cardiovascular death at 1 year. Results: Out of 75 patients, 46 underwent 54 unique RA procedures and 28 underwent 28 unique OA procedures. More patients in the RA group had a prior MI (45.8% vs. 20.7%, p=0.03). Otherwise, baseline demographics and comorbidities were similar in both groups. Procedural success was achieved in all patients. Angiographic complications were uncommon. There was no statistically significant difference in the primary endpoint at one year between RA and OA groups (26% vs. 11%, p=0.14), respectively, as well as the individual components of all-cause-mortality (13% vs. 7%, p=0.70), MI (11% vs. 0%, p=0.15), TVR (13% vs. 7%, p=0.71), and stroke (0% vs. 4%, p=0.38). No significant difference in cardiovascular death was observed at 1 year (9% vs. 4%, p=0.64). Conclusion: Both RA and OA are safe and effective in treating severe coronary artery calcification as they provide similar outcomes at 1 year

Coronary artery calcification in middle-aged women with premature ovarian insufficiency.

Women with premature ovarian insufficiency (POI) enter menopause before age 40. Early menopause was associated with increased risk for coronary artery disease (CAD), death from cardiovascular disease and all-cause mortality. We compared the prevalence of CAD between middle-aged women on average 10years following the initial POI diagnosis, with a population-based cohort. Cross-sectional case-control study. Women from two Dutch University Medical Centers above 45years of age previously diagnosed with POI (n=98) were selected and compared with age- and race-matched controls from the Multi-Ethnic Study of Atherosclerosis (MESA). The primary outcome was detectable coronary artery calcium (CAC) determined by coronary computed tomography (CCT). Women with POI had significantly higher blood pressure, cholesterol and glucose, despite lower BMI compared to controls. Similar proportions of detectable CAC (CAC score >0 Agatston Units) were observed in women with POI and controls (POI n=16 (16%), controls n=52 (18%), P=0.40 and Padj =0.93). In women with POI separately, we were not able to identify associations between CVD risk factors and CAC. The following CVD risk factors in controls were positively associated with CAC: age, diabetes mellitus, hypertension and LDL cholesterol. HRT use was negatively associated with CAC in controls. The presence of CAC did not differ significantly in women with POI around 50years of age, compared to an age- and race-matched control group. We observe no increased calcified coronary disease in POI patients, despite the presence of unfavourable cardiovascular risk factors in these women.

Management of percutaneous coronary intervention complications

### Learning objectives In the 40 years since Gruntzig’s first angioplasty,1 percutaneous coronary intervention (PCI) has become one of the most frequently performed therapeutic interventions in medicine.2 Devices and techniques...

Açık Koroner Endarterektomi Sonrası Koroner Arter Revaskülarizasyonunun İzole Koroner Arter Baypas ile Karşılaştırılması

Objective: The coronary endarterectomy combined with coronary artery bypass grafting (CABG) is an effective and well-accepted surgical strategy in diffuse coronary artery disease. This study aimed to analyze the early and mid-term results of the patients who underwent coronary endarterectomy combined with CABG.Material and Methods: This retrospective study was conducted between January 2012 and December 2014. A total of 24 patients who underwent coronary endarterectomy combined with CABG (Group-1) and also 84 patients who underwent isolated CABG (Group-2) were investigated. Results: The early mortality was similar in both groups (Group-1: 4.2%, Group-2: 4.8%; P=1.000). The aortic cross-clamping time (ACCT) and total perfusion time (TPT) in the Group-1 were longer than those in the Group-2 (ACCT: 108.75 min vs. 82.89 min; P=0.001; TPT: 157.44 min vs. 107.18 min; P= 0.001, respectively. Duration of intensive care unit was longer for the Group-1 than that for the Group-2 (7.21 days vs. 4.13 days; P=0.013, respectively). At the end of the follow-up time (Group-1: 38.96±3.61 vs. Group-2: 44.42±1.54 months), the cumulative survival rates including hospital mortality were similar between the two groups (Group-1: 79.2±8.3% vs. Group-2 77.4±7.2%, p=0.350). Conclusion: The coronary endarterectomy is an effective method in early and midterm results and outcomes. Open coronary endarterectomy with long arteriotomy should be applied to obtain complete revascularization in diffuse and calcified coronary disease in proper indication.

Replication of LC–MS untargeted lipidomics results in patients with calcific coronary disease: An interlaboratory reproducibility study

BackgroundRecently a lipidomics approach was able to identify perturbed fatty acyl chain (FAC) and sphingolipid moieties that could stratify patients according to the severity of coronary calcification, a form of subclinical atherosclerosis. Nevertheless, these findings have not yet been reproduced before generalising their application. The aim of this study was to evaluate the reproducibility of lipidomics approaches by replicating previous lipidomic findings in groups of patients with calcific coronary artery disease (CCAD). MethodsPatients were separated into the following groups based on their calcium score (CS); no calcification (CS: 0; n=26), mild calcification (CS: 1–250; n=27) and severe calcification (CS: >250; n=17). Two serum samples were collected from each patient and used for comparative analyses by 2 different laboratories, in different countries and time points using liquid chromatography coupled to mass spectrometry untargeted lipidomics methods. ResultsSix identical metabolites differentiated patients with severe coronary artery calcification from those with no calcification were found by both laboratories independently. Additionally, relative intensities from the two analyses demonstrated high correlation coefficients. Phosphatidylcholine moieties with 18-carbon FAC were identified in lower intensities and 20:4 FAC in higher intensities in the serum of diseased group. Moreover, 3 common sphingomyelins were detected. ConclusionThis is the first interlaboratory reproducibility study utilising lipidomics applications in general and specifically in patients with CCAD. Lipid profiling applications in patients with CCAD are very reproducible in highly specialised and experienced laboratories and could be applied in clinical practice in order to spare patients diagnostic radiation.

Optical coherence tomography versus intravascular ultrasound to evaluate stent implantation in patients with calcific coronary artery disease

AimsStent underexpansion and malapposition are associated with adverse outcomes following percutaneous coronary intervention, but detection and treatment can be challenging in the presence of extensive coronary artery calcification. Frequency domain...

2 Incidental coronary artery calcification detection on non-cardiac CT

Aims The aim of this three month retrospective study was to evaluate the incidental prevalence and burden of coronary artery calcification on CT Pulmonary Angiography (CTPAs) used for the assessment of patients presenting with chest pain suspicious for PE and whether this finding was reported upon by Radiologists. Methods The National Integrated Medical Imaging System (NIMIS) was manually searched to ascertain all CTPA examinations performed in our institution from 01/07/2014 to 30/09/2014. The Radiologist issued reports were analysed and the images of selected studies were reviewed as described below. Results 261 CTPAs were performed over this three month period on 257 patients and 104 of these scans were performed on patients between the ages of 40 and 70 which were selected for this review. Of these, 53 were male and 51 were female with a mean age of 57.09 years. Only 25/104 (24%) of these scans commented on the presence of coronary artery calcification and none commented on the absence of calcification. Of the 25 (24%) positive reports, 10 (40%) commented on presence only without localising it or grading its severity, while 10 (40%) reported LAD disease and only 4 (16%) reported three vessel calcification. A total of 7 (28%) reports graded the calcification as severe. The images of the 79/104 (76%) remaining CTPAs whose reports did not comment on coronary calcification were reviewed. 8 (10.1%) were uninterpretable due to either artefact from motion/pacing leads or due to the presence of contrast in the coronary system and these were excluded from the analysis. 25/79 (31.6%) of these CTPAs had calcification of varying degrees present. 5 (20%) had left main deposits while 9 (36%) had three vessel calcification (LAD, LCx and RCA). The LAD was the most commonly involved vessel, with lesions detected in 20/25 scans. 2 patients had evidence of previous stent placement in the LAD. Calcification in the RCA was difficult to visualise well in most cases due to close proximity to contrast filling both the right atrium and ventricle. In summary only 24% of Radiologist reported CTPAs commented upon the presence of coronary artery calcification, while a further 24% of CTPAs were found to have significant calcific coronary disease with 20% of these having left main disease and 36% having three vessel disease. Conclusions This initial study demonstrates significant variance in reporting of incidental coronary artery calcification in non-cardiac CT in patients between 40–70 years being assessed for chest pain for suspected PE. A longer prospective study is planned to evaluate if such findings have incremental clinical benefit in identifying a cardiac aetiology for chest pain syndromes in these patients and to correlate such findings with clinical outcomes.

Rotational atherectomy: Technical update

Percutaneous coronary intervention is currently the most common form of revascularization for symptomatic coronary artery disease. In elderly, diabetic and renal patients, there is an increased prevalence of calcified coronary disease. Rotational atherectomy (RA) can be useful in the treatment of these lesions.Plaque removal was initially proposed as an alternative to balloon angioplasty, hence RA required high-velocity protocols with large-sized burrs (over 2.0 mm). With a high incidence of acute complications and disappointing restenosis rates, the use of RA dwindled. However, the advent of drug-eluting stents, which significantly decreased the rate of restenosis, led to the repositioning of RA as an adjunctive technique in the preparation of densely calcified lesions, improving stent delivery and expansion.In recent years, a better understanding of the mechanism of action of RA has changed it from a plaque debulking to a compliance modifying technique. As a result, RA has become less aggressive, using smaller size burrs and lower rotational speeds. This conservative approach has improved immediate results, with increased safety and better long-term outcomes.In this review paper, the technique of RA is explained in the light of current knowledge.

Rotational atherectomy: Technical update

Percutaneous coronary intervention is currently the most common form of revascularization for symptomatic coronary artery disease. In elderly, diabetic and renal patients, there is an increased prevalence of calcified coronary disease. Rotational atherectomy (RA) can be useful in the treatment of these lesions.Plaque removal was initially proposed as an alternative to balloon angioplasty, hence RA required high-velocity protocols with large-sized burrs (over 2.0 mm). With a high incidence of acute complications and disappointing restenosis rates, the use of RA dwindled. However, the advent of drug-eluting stents, which significantly decreased the rate of restenosis, led to the repositioning of RA as an adjunctive technique in the preparation of densely calcified lesions, improving stent delivery and expansion.In recent years, a better understanding of the mechanism of action of RA has changed it from a plaque debulking to a compliance modifying technique. As a result, RA has become less aggressive, using smaller size burrs and lower rotational speeds. This conservative approach has improved immediate results, with increased safety and better long-term outcomes.In this review paper, the technique of RA is explained in the light of current knowledge.

Rescuing an Entrapped Guidewire Using a Tornus Catheter

Entrapment of a guidewire is a rare event, but it could happen especially in severe calcified stenotic lesion. This complication is life-threatening because it can lead to myocardial ischemia, infarction, or lethal arrhythmia due to intracoronary thrombosis. In the event of failed retrieval and persistent signs of ischemia, patients should be urgently referred to surgery. During percutaneous coronary intervention, the Tornus catheter has been applied to patients with severe coronary artery disease when balloon catheter or microcatheter cannot be crossed across the lesion after successful wire crossing. This is a case of a patient that a Tornus catheter rescued an entrapped guidewire in severe calcified coronary disease.

Surrogate markers for cardiovascular disease: structural markers.

Pignoli et al1 validated the concept that intima-media thickness (IMT), as measured by B-mode ultrasound and applied either in vitro or in situ at the time of autopsy, reflected direct measurements of aortic and/or carotid specimens. Values obtained by ultrasound at autopsy and by direct measurement were similar to those obtained from living subjects. The characteristic double-line pattern was most consistently found in the far wall of postmortem specimens judged to be relatively normal or affected only by fatty streaks. Histologically, these segments showed homogeneous intima with varying amounts of intimal thickening, intimal fibrosis, internal elastic lamina fragmentation, and duplication. In specimens with more advanced atherosclerosis, the double-line pattern was sometimes perturbed and more complex; these samples showed evidence of a fibrous/muscular cap with a lipid and/or necrotic core and, histologically, the intima showed focal areas of fibrotic smooth muscle cell proliferation, microcalcification, and necrosis. Based on this important article, it is clear that carotid IMT is a direct measure of the status of the vascular wall, and abnormalities are not a surrogate but a direct measure of atherosclerotic and arteriosclerotic processes. The issue of surrogacy pertains to whether a measurement in the carotid bed is associated with atherosclerosis in other beds, particularly the coronary bed and, even more important, whether this measurement is predictive of vascular events that result from atherothrombotic disease. ### Methodology Carotid ultrasound is routinely applied for evaluation of ischemic cerebrovascular signs (eg, bruits) and symptoms. In the context of risk stratification, however, the goal is to identify preclinical disease. The degree of carotid disease that appears to be of prognostic value is much subtler, requiring meticulous and detailed measurements of IMT through B-mode ultrasound. These measurements can be made in a reproducible and reliable fashion if sonographers and those making the measurements are trained comprehensively and …

Relationship between coronary artery calcification and other measures of subclinical cardiovascular disease in older adults.

In the Cardiovascular Health Study, subclinical cardiovascular disease (CVD) predicted CVD events in older adults. The extent to which this measure or its components reflect calcified coronary disease is unknown. Coronary artery calcium (CAC) was assessed with electron beam tomography in 414 participants without clinical CVD and examined using cut points (CAC> or =400 and CAC> or =800) and the log(CAC); 274 had subclinical CVD by ankle-arm index, ECG, or carotid ultrasound. Cut points for subclinical disease as previously defined in the Cardiovascular Health Study were examined as well as continuous measures to produce receiver operating characteristic curve curves. A low ankle-arm index was highly specific for a high CAC score. The internal carotid artery intima-media thickness was most strongly correlated with CAC (r=0.30) and was significantly related to both CAC cut points and to the log(CAC) score independently of all other measures. In these community-dwelling older adults without clinical CVD, internal carotid artery intima-media thickness was most closely related to CAC. However, 17.5% of those with a CAC> or =400 would be missed in the ascertainment of subclinical atherosclerosis using the previously published composite of subclinical atherosclerosis. Prospective follow-up will determine whether the CAC score improves prediction of CVD events over other noninvasive measures.