Percutaneous Intervention Techniques Research Articles

TCT-376 SIMPLIPHieDE Study - Single center IMPella LVAD supported Pci in High Risk group of patients – Detroit Medical Center Experience – Clinical Outcomes

Advances in percutaneous interventional techniques and technology have made percutaneous coronary intervention (PCI) for left main and or triple vessel disease a viable option. Left main intervention was re-classified in the recent ACC guidelines from III to IIb based on the large randomized Syntax

TCT-375 Optimizing Rotational Atherectomy in High-Risk Percutaneous Coronary Interventions. Insights from the PROTECT II study

Rotational Atherectomy (RA) is currently recommended for heavily calcified lesions in which standard percutaneous coronary intervention (PCI) techniques would result in suboptimal stent expansion. We sought to determine the optimal RA use associated with minimal incidence of myonecrosis in patients

Secondary revascularization after CABG surgery

CABG surgery is an effective way to improve symptoms and prognosis in patients with advanced coronary atherosclerotic disease. Despite multiple improvements in surgical technique and patient treatment, graft failure after CABG surgery occurs in a time-dependent fashion, particularly in the second decade after the intervention, in a substantial number of patients because of atherosclerotic progression and saphenous-vein graft (SVG) disease. Until 2010, repeat revascularization by either percutaneous coronary intervention (PCI) or surgical techniques was performed in these high-risk patients in the absence of specific recommendations in clinical practice guidelines, and within a culture of inadequate communication between cardiac surgeons and interventional cardiologists. Indeed, some of the specific technologies developed to reduce procedural risk, such as embolic protection devices for SVG interventions, are largely underused. Additionally, the implementation of secondary prevention, which reduces the need for reintervention in these patients, is still suboptimal. In this Review, graft failure after CABG surgery is examined as a clinical problem from the perspective of holistic patient management. Issues such as the substrate and epidemiology of graft failure, the choice of revascularization modality, the specific problems inherent in repeat CABG surgery and PCI, and the importance of secondary prevention are discussed.

Rheolytic thrombectomy in patients with massive pulmonary embolism: A report of two cases and review of literature

We present two cases of massive pulmonary embolism with persistent systolic hypotension but both have contraindications for thrombolysis. Therefore, rheolytic thrombectomy using AngioJet was performed and immediate haemodynamic improvement was achieved including blood pressure and symptoms. According to guidelines, catheter embolectomy or fragmentation may be considered as alternative to surgical treatment in massive pulmonary embolism patients when thrombolysis is absolutely contraindicated or has failed. Percutaneous catheter-based interventional techniques include thrombus fragmentation, rheolytic thrombectomy, suction thrombectomy and rotational thrombectomy. With the existing literature review and our case, rheolytic thrombectomy for treatment of massive pulmonary embolism using AngioJet achieves a high procedural success rate (approximately 90%) n terms of improvement of haemodynamics, pulmonary perfusion and angiographic result but low complication rate.

Anticoagulant for primary percutaneous coronary intervention – the last dance for unfractionated heparin?

MOTS CLES Infarctus myocarde ; Anticoagulation ; Heparine ; Heparine de bas poids moleculaire ; Bivalirudine Rates of shortand long-term mortality after an acute coronary syndrome (ACS) have been reduced dramatically through advances in percutaneous coronary intervention (PCI) techniques and the availability of new antithrombotic agents. This is particularly true for patients with ST-elevation myocardial infarction (STEMI) treated with primary PCI. On the antiplatelet side, we have, besides clopidogrel, two new P2Y12 inhibitors — prasugrel and ticagrelor — for which data and subset analyses have allowed a better understanding of which patients with an ACS would truly benefit from these drugs. On the anticoagulant side, besides unfractionated heparin (UFH), we have three newer anticoagulants that can be used in ACS: enoxaparin, fondaparinux and bivalirudin. In this competitive field, the past decade has provided a large flow of evidence-based information in terms of the safety and efficacy of these antithrombotic agents. This information needs to be implemented both in guidelines and in our daily clinical practice. As always, there is no simple rule or conclusion; rather, different options exist according to current practice and our own personal environment and experiences. The efficacy of anticoagulation therapy is evaluated on the basis of ischaemic complications of ACS and sometimes the outcome of PCI itself, both of which have a real impact on shortand long-term mortality. The first goal of anticoagulation therapy during primary PCI of STEMI is therefore to avoid or control at all times the development of thrombus and in doing so obtain or maintain blood flow through the coronary circulation and protect the myocardium from harmful damage related to ischaemia and necrosis. If the drug efficacy translates into a mortality reduction, there is a good chance of recognition and acceptation of the new treatment by practising physicians.

Almanac 2011: valvular heart disease. The national society journals present selected research that has driven recent advances in clinical cardiology

With an ageing population and improved diagnostic modalities, the number of patients with valvular heart disease is dramatically increasing. Considering projected changes in the age distribution, a further accentuation of this trend can be expected and this may indeed be considered “the next cardiac epidemic”.1 Obviously, we are faced with more complex decisions in patients with advanced age and increasing comorbidities. Advances in percutaneous valve interventional techniques have entered into routine practice. At the same time, new data on the natural history of disease and the identification of predictors of outcome permit improvement in the decision-making process and management of patients with valvular heart disease. ### Disease progression In a population-based study which followed up 953 subjects for 10 years, a high prevalence of calcific aortic valve disease (28%) associated with long-term exposure to raised cholesterol levels and active smoking was described.2 Intraleaflet haemorrhage (detected by immunohistochemistry at the moment of aortic valve replacement surgery) was frequently present in the valve leaflets of degenerative aortic stenosis (AS) and was associated with rapid progression of AS.3 In a small study of 164 patients with rheumatic AS (of whom 30 were treated with a statin), progression of AS was slower in patients receiving statins than in untreated patients (annual change of peak aortic velocity: 0.05±0.07 m/s/year vs 0.12±0.11 m/s/year, p=0.001).4 On the other hand in the ASTRONOMER trial, a randomised double-blind study, that allocated 269 patients to rosuvastatin 40 mg daily or to placebo, statin treatment did not reduce progression of the disease in patients with AS.5 ### Predictors of outcome Based on the aortic jet velocity and the B-type natriuretic peptide (BNP) level, a risk score predicting outcome in patients with moderate-to-severe asymptomatic AS was derived and validated in an independent cohort: score=(peak velocity (m/s) × 2)+(ln of BNP × 1.5)+1.5 (if female sex). Event-free survival after …

Almanac 2011: valvular heart disease. The national society journals present selected research that has driven recent advances in clinical cardiology

With an ageing population and improved diagnostic modalities, the number of patients with valvular heart disease is dramatically increasing. Considering projected changes in the age distribution, a further accentuation of this trend can be expected and this may indeed be considered “the next cardiac epidemic”.1 Obviously, we are faced with more complex decisions in patients with advanced age and increasing comorbidities. Advances in percutaneous valve interventional techniques have entered into routine practice. At the same time, new data on the natural history of disease and the identification of predictors of outcome permit improvement in the decision-making process and management of patients with valvular heart disease. ### Disease progression In a population-based study which followed up 953 subjects for 10 years, a high prevalence of calcific aortic valve disease (28%) associated with long-term exposure to raised cholesterol levels and active smoking was described.2 Intraleaflet haemorrhage (detected by immunohistochemistry at the moment of aortic valve replacement surgery) was frequently present in the valve leaflets of degenerative aortic stenosis (AS) and was associated with rapid progression of AS.3 In a small study of 164 patients with rheumatic AS (of whom 30 were treated with a statin), progression of AS was slower in patients receiving statins than in untreated patients (annual change of peak aortic velocity: 0.05±0.07 m/s/year vs 0.12±0.11 m/s/year, p=0.001).4 On the other hand in the ASTRONOMER trial, a randomised double-blind study, that allocated 269 patients to rosuvastatin 40 mg daily or to placebo, statin treatment did not reduce progression of the disease in patients with AS.5 ### Predictors of outcome Based on the aortic jet velocity and the B-type natriuretic peptide (BNP) level, a risk score predicting outcome in patients with moderate-to-severe asymptomatic AS was derived and validated in an independent cohort: score=(peak velocity (m/s) × 2)+(ln of BNP × 1.5)+1.5 (if female sex). Event-free survival after …

Percutaneous interventional techniques to remove embolized silicone port catheters from heart and great vessels

Rupture of a silicon port catheter is a relatively rare complication and sometimes it is difficult to remove it. We experienced three cases of retrieval of silicone port catheters migrating into cardiac ventricle or pulmonary artery. Several devices such as a snare wire, an ablation catheter, and a basket catheter in combination with interventional guiding catheter were applied to retrieve them. These interventional techniques are applicable for retrieval of embolized vascular access port system and other catheter fragments.

Percutaneous left ventricular assist device with TandemHeart for high‐risk percutaneous coronary intervention: The Mayo Clinic experience

In patients with poor left ventricular function and severe left main or multivessel coronary disease, coronary artery bypass grafting (CABG) surgery has been the preferred therapy. However, a number of these patients are either inoperable or poor surgical candidates due to comorbid conditions and previous cardiac surgical procedures. These patients are generally poor candidates for standard percutaneous coronary intervention (PCI) techniques. A hybrid PCI approach with hemodynamic support may be a viable strategy for these patients. We report our experience using the TandemHeart percutaneous left ventricular assist device during high-risk PCI. Retrospective cross-sectional analysis of prospectively collected data in 54 patients undergoing high-risk PCI using the TandemHeart device for support. Hemodynamic and clinical data were collected and analyzed. Baseline clinical characteristics were as follows: mean age 72 ± 1.7 years, males 78%, median ejection fraction 20%, mean serum creatinine 1.6 ± 0.3 2 mg/dL, recent myocardial infarction 52%, COPD 33%, previous CABG 50%, diabetes mellitus 41%, and hypertension 83%. The median SYNTAX score was 33, and the median Jeopardy score was 10. The predicted surgical revascularization mortality was 13% by the Society for Thoracic Surgery risk score and 33% by Euroscore. There was a significant decrease in right and left heart pressures (P < 0.05) with a concomitant increase in the cardiac output from 4.7 to 5.7 L/min (P = 0.03) during TandemHeart support. Left main and multivessel PCI was performed in 62% of patients, and rotablation was used in 48%. Procedural success rate was 97%, whereas 30-day and 6 month survival were 90% and 87%, respectively. Major vascular complications occurred in 13% of cases. None of our patients developed contrast induced nephropathy or needed dialysis. High-risk PCI with percutaneous left ventricular support using TandemHeart is a viable therapeutic strategy for a select subset of patients at very high risk with standard percutaneous revascularization techniques.

Almanac 2011: Valvular Heart Disease. The National Society Journals Present Selected Research That Has Driven Recent Advances in Clinical Cardiology

With an ageing population and improved diagnostic modalities, the number of patients with valvular heart disease is dramatically increasing. Considering projected changes in the age distribution, a further accentuation of this trend can be expected and this may indeed be considered “the next cardiac epidemic”.1 Obviously, we are faced with more complex decisions in patients with advanced age and increasing comorbidities. Advances in percutaneous valve interventional techniques have entered into routine practice. At the same time, new data on the natural history of disease and the identification of predictors of outcome permit improvement in the decision-making process and management of patients with valvular heart disease. ### Disease progression In a population-based study which followed up 953 subjects for 10 years, a high prevalence of calcific aortic valve disease (28%) associated with long-term exposure to raised cholesterol levels and active smoking was described.2 Intraleaflet haemorrhage (detected by immunohistochemistry at the moment of aortic valve replacement surgery) was frequently present in the valve leaflets of degenerative aortic stenosis (AS) and was associated with rapid progression of AS.3 In a small study of 164 patients with rheumatic AS (of whom 30 were treated with a statin), progression of AS was slower in patients receiving statins than in untreated patients (annual change of peak aortic velocity: 0.05±0.07 m/s/year vs 0.12±0.11 m/s/year, p=0.001).4 On the other hand in the ASTRONOMER trial, a randomised double-blind study, that allocated 269 patients to rosuvastatin 40 mg daily or to placebo, statin treatment did not reduce progression of the disease in patients with AS.5 ### Predictors of outcome Based on the aortic jet velocity and the B-type natriuretic peptide (BNP) level, a risk score predicting outcome in patients with moderate-to-severe asymptomatic AS was derived and validated in an independent cohort: score=(peak velocity (m/s) × 2)+(ln of BNP × 1.5)+1.5 (if female sex). Event-free survival after …

New era of left main coronary artery treatment strategy

For several decades of medical history, coronary-artery bypass grafting (CABG) has been regarded as the best treatment option for patients with unprotected left main coronary artery (LMCA) disease, considering lesion priority and its clinical consequences. Over the time, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with DES implantation has appeared to be new and alternative option for optimal revascularization therapy for these patients. The available cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction and stroke are similar among PCI and CABG for patients with LMCA disease, the only difference was the rate of repeat revascularization. Current evidence and ongoing large clinical trials may encourage interventional cardiologists to choose PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease in future. Finally, this evidence will change the current clinical practice and the guideline of optimal revascularization strategy for unprotected LMCA disease.

Treatment of Patients with Left Main Coronary Artery Disease

Considering lesion priority and its clinical consequences, coronary artery bypass grafting (CABG) has been a treatment of choice for revascularization in patients with significant left main coronary artery (LMCA) disease, However, with remarkable advancements in techniques of percutaneous coronary intervention (PCI), supporting devices, and adjunctive pharmacologic therapy, PCI with stenting has emerged to be a less invasive and feasible revascularization treatment for these patients. The cumulative evidence suggests that the safety outcomes such as mortality or composite of death, myocardial infarction, and stroke are similar among PCI and CABG, with the only difference being the rate of repeat revascularization. Based on these data, the current guideline of revascularization of LMCA disease has adopted an increasing off-label experience with stenting and clinical studies and been updated to partly approve PCI as a viable alternative (in level of class IIb) in selected patients. The choice of PCI or CABG for unprotected LMCA disease depends on several clinical and anatomic features, ensuring crucial patient selection to be a cornerstone for achieving favorable long-term outcomes. In patients with very complex anatomic features and concomitant diffuse multivessel disease, CABG is preferred so as to avoid procedural and future thrombotic risks and to provide more complete revascularization. By contrast, in patients with relatively simple LMCA disease, such as ostial/shaft LMCA disease, isolated LMCA disease (with or without one or two-vessel involvement), and LMCA disease with low SYNTAX score, PCI is an alternative, and in some cases a preferred, strategy to reduce surgical risks (eg, stroke and in-hospital events following major surgery). For the future, ongoing large clinical trials might also boost interventional cardiologists to select PCI with stenting as an alternative revascularization strategy for unprotected LMCA disease. This evidence will most likely change the current clinical practice and guidelines of optimal revascularization strategy for unprotected LMCA disease.

Current status of hybrid coronary revascularization

Hybrid coronary revascularization combines coronary artery bypass surgery with percutaneous coronary intervention techniques to treat coronary artery disease. The potential benefits of such a technique are to offer the patients the best available treatments for coronary artery disease while minimizing the risks of the surgery. Hybrid coronary revascularization has resulted in the establishment of new ‘hybrid operating suites’, which incorporate and integrate the capabilities of a cardiac surgery operating room with that of an interventional cardiology laboratory. Hybrid coronary revascularization has greatly augmented teamwork and cooperation between both fields and has demonstrated encouraging as well as good initial outcomes.

Prise en charge de l’infarctus du myocarde : comment améliorer l’angioplastie primaire ?

Besides the reduction of the delay for the myocardium reperfusion, the revascularization must be optimized by tools and techniques of percutaneous intervention. These are pharmacological, mechanical and procedural. The appeal to antiGP2b3a can be useful in the cathlab. Its intracoronary administration seems to improve drug efficiency. Among the protection devices against the coronary clot embolism, only thrombectomy by manual aspiration gives an evidence of its efficiency. During the primary angioplasty, the drug eluting stent could to be implanted only for the patients and the lesions with high risk of TLR. In some cases, still difficult to identify, a more controlled revascularization would allow to minimize the reperfusion injury. The radial access, decreasing the rate of haemorrhagic complications, must be preferred in first intention.

Outcomes of Nonemergent Percutaneous Coronary Intervention With and Without On-site Surgical Backup: A Meta-Analysis

Despite major advances in percutaneous coronary intervention (PCI) techniques, the current guidelines recommend against elective PCI at hospitals without on-site cardiac surgery backup. Nonetheless, an increasing number of hospitals without on-site cardiac surgery in the United States have developed programs for elective PCI. Studies evaluating outcome in this setting have yielded mixed results, leaving the question unanswered. Hence, a meta-analysis comparing outcomes of nonemergent PCI in hospitals with and without on-site surgical backup was performed. A systematic review of literature identified four studies involving 6817 patients. Three clinical end points were extracted from each study and included in-hospital death, myocardial infarction, and the need for emergency coronary artery bypass grafting. The studies were homogenous for each outcome studied. Therefore, the combined relative risks (RRs) across all the studies and the 95% confidence intervals (CIs) were computed using the Mantel-Haenszel fixed-effect model. A two-sided alpha error less than 0.05 was considered to be statistically significant. Compared with facilities with on-site surgical backup, the risk of in-hospital death (RR, 2.7; CI, 0.6-12.9; P = 0.18), nonfatal myocardial infarction (RR, 1.3; CI, 0.7- 2.2; P = 0.29), and need of emergent coronary artery bypass grafting (RR, 0.46; CI, 0.06- 3.1; P = 0.43) was similar in those lacking on-site surgical backup. The present meta-analysis suggests that there is no difference in the outcome with regard to risk of nonfatal myocardial infarction, need for emergency coronary artery bypass grafting, and the risk of death in patients undergoing elective PCI in hospitals with and without on-site cardiac surgery backup.

Percutaneous Catheter-based Intracoronary Infusion of Insulin - A Dose Finding Study in the Porcine Model

Insulin given at immediate reperfusion reduces myocardial infarct size in the in vitro and the ex vivo rat heart. In vivo, insulin may cause hypoglycaemia, hypokalaemia and elevation of catecholamines, potentially harmful during an acute myocardial infarction. The purpose of this study was to evaluate tolerance and safety of intracoronary insulin infusions in a porcine model applying percutaneous intervention techniques.

CardioPulse Articles * The percutaneous approach to mitral valve repair * The future treatment of most cardiovascular diseases lies in percutaneous interventional techniques * Information for all: the American Heart Association * Personal experiences of emigre cardiologist: Johannes Waltenberger

CardioPulse Articles * The percutaneous approach to mitral valve repair * The future treatment of most cardiovascular diseases lies in percutaneous interventional techniques * Information for all: the American Heart Association * Personal experiences of emigre cardiologist: Johannes Waltenberger

Left Main Stenting - Now and Future -

For several decades, based on clinical trials comparing coronary-artery bypass grafting (CABG) with medical therapy, bypass surgery has been regarded as the treatment of choice for patients with unprotected left main coronary artery (LMCA) disease. However, because of marked advancements in the techniques of percutaneous coronary intervention (PCI) with stenting and CABG and adjunctive pharmacologic therapy, reevaluation and review of current indications for optimal revascularization therapy for LMCA disease are required to determine the standard of care for these patients. The available current evidence suggests that the composite outcome of death, myocardial infarction and stroke is similar in patients with LMCA disease who are treated with either PCI with stenting or CABG, the only difference being the rate of repeat revascularization. Cumulative and emerging data from several extensive registries and a large clinical trial may have prompted many interventional cardiologists to select PCI with stenting as an alternative revascularization strategy for such patients. In addition, these data not only may change future guidelines, but support the need for prospective, large randomized trials comparing the 2 revascularization treatments. Finally, this evidence will change the current clinical practice of revascularization strategy for unprotected LMCA disease.

State of the art papers Is there an additional benefit from coronary revascularization in diabetic patients with acute coronary syndromes or stable angina who are already on optimal medical treatment?

Cardiovascular disease (CVD) is common in patients with diabetes mellitus (DM) and related clinical outcomes are worse compared with non-diabetics. The optimal treatment in diabetic patients with coronary heart disease (CHD) is currently not established. We searched MEDLINE (1975-2010) using the key terms diabetes mellitus, coronary heart disease, revascularization, coronary artery bypass, angioplasty, coronary intervention and medical treatment. Most studies comparing different revascularization procedures in patients with CHD favoured coronary artery bypass graft (CABG) surgery in patients with DM. However, most of this evidence comes from subgroup analyses. Recent evidence suggests that advanced percutaneous coronary intervention (PCI) techniques along with best medical treatment may be non-inferior and more cost-effective compared with CABG. Treatment of vascular risk factors is a key option in terms of improving CVD outcomes in diabetic patients with CHD. The choice between medical therapy and revascularization warrants further assessment.

Left main stenting: is it a different animal?

For several decades, coronary-artery bypass grafting (CABG) has been regarded as the treatment of choice for patients with unprotected left main coronary artery (LMCA) disease. However, because of marked advancements in techniques of percutaneous coronary intervention (PCI) with stenting and CABG, as well as adjunctive pharmacologic therapy, a new evaluation and review of current indications for optimal revascularisation therapy for LMCA disease may be required to determine the standard of care for these patients. The available current evidence suggests that the composite outcome of death, myocardial infarction and stroke is similar in patients with LMCA disease who are treated with PCI with stenting or CABG, the only difference was the rate of repeat revascularisation. Although PCI can be performed successfully in most LMCA lesions, "high-risk" anatomic subsets, especially involving distal LMCA bifurcation lesions, continue to present unique technical challenges to interventional cardiologists, and, therefore, an integrated approach combing advanced devices, tailored techniques, adjunctive support of physiologic and morphologic evaluation, and adjunctive pharmacologic agents should be reinforced to improve clinical outcomes.