Performance Of Percutaneous Coronary Intervention Research Articles

Percutaneous coronary intervention and risk of major adverse cardiovascular events in patients with coronary artery ectasia and acute coronary syndrome

Abstract Funding Acknowledgements None. Background Coronary artery ectasia (CAE) is defined as segmental or diffuse dilation of a coronary artery with a diameter of at least 1.5 times the normal adjacent segment, affecting more than one-third of the length of the artery. It has been described as a relatively infrequent finding with a prevalence from 0.3% to 5%, however, in our population we have previously found it higher, up to 6.7%. In patients with STEMI and ectatic infarct-related artery (EIRA), performing percutaneous coronary intervention (PCI) has been reported to provide better in-hospital outcomes (3), but long-term prognosis remains controversial, with a high mortality risk and cardiovascular events after PCI. No standard approach has been defined for interventional treatment in the acute setting. High thrombus burden and coronary dilation make interventional treatment more challenging. Aim The aim of the present study was to assess the rate of MACE in the long-term according to the use of PCI in patients with CAE and ACS. Methods This was a retrospective analysis of a randomized controlled trial (OVERTIME NCT). Sixty-two consecutive patients with ACS (STEMI or NSTEMI) in whom coronary angiography demonstrated CAE were included. Results The mean age of the 62 patients was 55.7+/- 10.6 years. Of them, 12.9% were women and 87.1% were men. The most common presentation was STEMI in 52 patients (83.8%) and 10 patients (19.2%) presented with NSTEMI. After coronary angiography, 48.4% received PCI and 51.6% did not. Baseline clinical characteristics were not different between groups. During follow up, 8 patients (12.9%) presented a MACE. We found that the risk of MACE was not statistically different, by PCI use (HR 0.67, 95% CI 0.16-2.84, p = 0.5) (Figure 1). We also analyzed the intracoronary use of glycoprotein IIb/IIIa inhibitors, with no long-term differences between groups. Conclusions In patients with CAE and ACS, we found non-statistically significant differences in the risk of MACE between patients who were treated with PCI compared to those without PCI.

Design and hierarchical analysis of magnetic actuated robot: A governing equation based approach

As the alternative solution to the conventional guidewire, the magnetic robot can help interventionists perform percutaneous coronary intervention (PCI) because magnetic fields are transparent and safe for biological tissues. Despite extensive research on magnetic robots, the exploration of their deflection control for practical applications still requires further research. In this paper, a hierarchical analysis framework (HAF) is proposed to control the magnetic robot’s deflection. Six deflection subpatterns are analyzed through HAF, incorporating statistical and regression analyses to establish governing equations of magnetic robots. The performance of the control equations is validated through precise control of the magnetic continuum robot (MCR) and magnet-tipped robot (MTR) in both uniform and gradient magnetic fields. Experimental results show that under the uniform magnetic field, the average root mean square error (RMSE) of governing equation of MCR is 0.08±0.05°, 0.41±0.34°, 1.47±0.49° and 1.07±0.66° for four-types horizontal deflection, 0.19±0.07mm and 0.16±0.10mm for two-types vertical deflection, respectively. Based on the governing equations, the MTR is able to precisely navigate to coronary arteries with various degrees of stenosis (30%, 52%, and 60%), and successfully pass through a series of rings, with an average error of 1.05 mm. The research successfully demonstrates the potential of HAF in creating robust and reliable governing equations for magnetic actuation in medical robotics, with significant implications for enhancing the precision and safety of PCI procedures.

Statewide Initiative to Reduce Patient Radiation Doses During Percutaneous Coronary Intervention.

Improved radiation safety practices are needed across hospitals performing percutaneous coronary intervention (PCI). This study was performed to assess the temporal trend in PCI radiation doses concurrent with the conduct of a statewide radiation safety initiative. A statewide initiative to reduce PCI radiation doses was conducted in Michigan between 2017 and 2021 and included focused radiation safety education, reporting of institutional radiation doses, and implementation of radiation performance metrics for hospitals. Using data from a large statewide registry, PCI discharges between July 1, 2016, and July 1, 2022, having a procedural air kerma (AK) recorded were analyzed for temporal trends. A multivariable regression analysis was performed to determine whether declines in procedural AK over time were attributable to changes in known predictors of radiation doses. Among 131 619 PCI procedures performed during the study period, a reduction in procedural AK was observed over time, from a median dose of 1.46 (0.86-2.37) Gy in the first year of the study to 0.97 (0.56-1.64) Gy in the last year of the study (P<0.001). The proportion of cases with an AK ≥5 Gy declined from 4.24% to 0.86% over the same time period (P<0.0001). After adjusting for variables known to impact radiation doses, a 1-year increase in the date of PCI was associated with a 7.61% (95% CI, 7.38%-7.84%) reduction in procedural AK (P<0.0001). Concurrent with the conduct of a statewide initiative to reduce procedural radiation doses, a progressive and significant decline in procedural radiation doses was observed among patients undergoing PCI in the state of Michigan.

Selection criteria in the era of perfect competition for drug-eluting stents - a survey of interventional cardiologists in Japan: the selection-DES study

ABSTRACT Background More than 20 years have passed since the first company introduced drug-eluting stent (DES) in 2002, but competing companies still have improved their DESs under regulatory approval. This study aimed to investigate the criteria for interventional cardiologists performing percutaneous coronary intervention (PCI) in selecting a DES. Research design and methods From 10 April 2023, to 30 April 2023, 3,422 cardiologists were requested to complete a questionnaire, of whom 126 responded to the survey. Results Overall, 86.5% of the respondents used Xience cobalt-chromium everolimus-eluting stent (Xience) in > 10% of PCI procedures. For Xience, brand loyalty and calcified lesions were important independent variables for the DES selection criteria. Ultimaster sirolimus-eluting stent (Ultimaster) was not affected by the clinical data delivered by the company, whereas the respondents were shown to seek support for their activities from the Ultimaster supplier. The relationship with the company and/or sales representative and the planned surgical procedure affected the use of Coroflex ISAR NEO sirolimus-eluting polymer-free stent. Conclusions Patient background and lesion characteristics had little impact on the DES selection criteria, suggesting that DES performance has already reached its physical limitations to the extent that respondents may not value further improvements in performance or characteristics of DES.

Acute ischemic stroke patients admitted to hospitals that perform percutaneous coronary interventions in the United States

BackgroundWe explored the potential of mechanical thrombectomy (MT) for acute ischemic stroke patients at hospitals that perform percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in the United States. MethodsWe analyzed nationally representative data between 2017 and 2020 to determine the numbers, characteristics, and outcomes of acute ischemic stroke patients admitted to hospitals that perform both primary PCI and MT, hospitals that perform primary PCI but not MT and hospitals that perform neither PCI or MT. Multiple logistic regressions were performed to evaluate the effect of hospital type on in-hospital mortality and discharge home (without palliative care). ResultsA total of 1,210,415, 1,002,950, and 488,845 acute ischemic stroke patients were admitted to hospitals that performed both primary PCI and MT, performed primary PCI but not MT, or performed neither PCI nor MT, respectively. Compared with hospitals that performed both PCI and MT, the odds of in-hospital mortality were lower in hospitals that performed PCI only (odds ratio (OR) 0.88 95 % confidence interval (CI) 0.86-0.91, p<0.001) and hospitals that performed neither PCI or MT (OR 0.85 95 %CI 0.82-0.89, p<0.0010). There was no significant difference in the odds of discharge home between the three types of hospitals. ConclusionsAlmost 37 % the patients with acute ischemic stroke are admitted to hospitals that perform primary PCI (but not MT) supporting strategies to increase the performance of MT in such hospitals as an option to increase rapid availability of MT in the United States.

Safety and Efficacy of Orbital Atherectomy in the All-Comer Population: Mid-Term Results of the Lower Silesian Orbital Atherectomy Registry (LOAR).

Coronary calcifications represent a challenging subset for the interventional cardiologist performing percutaneous coronary intervention (PCI) and are well-established risk factors for adverse outcomes. Adequate plaque modification prior to stent implantation is critical to achieve an optimal outcome following PCI. Recently, a novel orbital atherectomy device has been introduced into clinical practice to modify calcified plaques. We evaluated the mid-term safety and efficacy of OA in a high-risk "all-comers" population. We evaluated 96 consecutive patients with severely calcified coronary lesions who underwent PCI facilitated by the orbital atherectomy device. In-hospital MACCE was 5.2% without target lesion revascularization. At 6-month follow-up, the MACCE rate was 10.4% with a concomitant TLR rate of 1%. Our mid-term data showed good safety and efficacy of orbital atherectomy as a plaque-modifying tool in an all-comers cohort with severely calcified coronary lesions.

Comparison of different percutaneous revascularisation timing strategies in patients undergoing transcatheter aortic valve implantation.

The optimal timing to perform percutaneous coronary interventions (PCI) in transcatheter aortic valve implantation (TAVI) patients remains unknown. We sought to compare different PCI timing strategies in TAVI patients. The REVASC-TAVI registry is an international registry including patients undergoing TAVI with significant, stable coronary artery disease (CAD) at preprocedural workup. In this analysis, patients scheduled to undergo PCI before, after or concomitantly with TAVI were included. The main endpoints were all-cause death and acomposite of all-cause death, stroke, myocardial infarction (MI) or rehospitalisation for congestive heart failure (CHF) at 2years. Outcomes were adjusted using the inverse probability treatment weighting (IPTW) method. Atotal of 1,603patients were included. PCI was performed before, after or concomitantly with TAVI in 65.6% (n=1,052), 9.8% (n=157) or 24.6% (n=394), respectively. At 2years, all-cause death was significantly lower in patients undergoing PCI after TAVI as compared with PCI before or concomitantly with TAVI (6.8% vs 20.1% vs 20.6%; p<0.001). Likewise, the composite endpoint was significantly lower in patients undergoing PCI after TAVI as compared with PCI before or concomitantly with TAVI (17.4% vs 30.4% vs 30.0%; p=0.003). Results were confirmed at landmark analyses considering events from 0 to 30days and from 31 to 720days. In patients with severe aortic stenosis and stable coronary artery disease scheduled for TAVI, performance of PCI after TAVI seems to be associated with improved 2-year clinical outcomes compared with other revascularisation timing strategies. These results need to be confirmed in randomised clinical trials.

Current status and future perspectives of fractional flow reserve derived from invasive coronary angiography.

Assessment of the functional significance of coronary artery stenosis using invasive measurement of fractional flow reserve (FFR) or non-hyperemic indices has been shown to be safe and effective in making clinical decisions on whether to perform percutaneous coronary intervention (PCI). Despite strong evidence from clinical trials, utilization of these techniques is still relatively low worldwide. This may be to some extent attributed to factors that are inherent to invasive measurements like prolongation of the procedure, side effects of drugs that induce hyperemia, additional steps that the operator should perform, the possibility to damage the vessel with the wire, and additional costs. During the last few years, there was a growing interest in the non-invasive assessment of coronary artery lesions, which may provide interventionalist with important physiological information regarding lesion severity and overcome some of the limitations. Several dedicated software solutions are available on the market that could provide an estimation of FFR using 3D reconstruction of the interrogated vessel derived from two separated angiographic projections taken during diagnostic coronary angiography. Furthermore, some of them use data about aortic pressure and frame count to more accurately calculate pressure drop (and FFR). The ideal non-invasive system should be integrated into the workflow of the cath lab and performed online (during the diagnostic procedure), thereby not prolonging procedural time significantly, and giving the operator additional information like vessel size, lesion length, and possible post-PCI FFR value. Following the development of these technologies, they were all evaluated in clinical trials where good correlation and agreement with invasive FFR (considered the gold standard) were demonstrated. Currently, only one trial (FAVOR III China) with clinical outcomes was completed and demonstrated that QFR-guided PCI may provide better results at 1-year follow-up as compared to the angiography-guided approach. We are awaiting the results of a few other trials with clinical outcomes that test the performance of these indices in guiding PCI against either FFR or angiography-based approach, in various clinical settings. Herein we will present an overview of the currently available data, a critical review of the major clinical trials, and further directions of development for the five most widely available non-invasive indices: QFR, vFFR, FFRangio, caFFR, and AccuFFRangio.

Renoprotective effect of febuxostat on contrast-induced acute kidney injury in chronic kidney disease patients stage 3: randomized controlled trial

IntroductionContrast-induced acute kidney injury (CI-AKI) is known to be a complication of using intravascular contrast injection. Unfortunately, it is associated with adverse outcomes such as prolonged length of hospitalization and increased burden of health care costs. So, we aimed to determine the efficacy of febuxostat in the prevention of contrast-induced acute kidney injury among patients with chronic kidney disease Stage 3 performing percutaneous coronary intervention (PCI).MethodsIn a randomized controlled trial we enrolled 120 CKD stage 3 Patients with acute coronary syndrome referred to the cardiology department Ain-Shams University hospital for performing PCI and stenting. Patients were randomly assigned to two arms: Group I (study group): Included 60 patients who received Febuxostat added to the traditional treatment (IV hydration and N-acetylcysteine). The patients received Feburic 80 mg within 6–18 h before and within 6–18 h after the coronary intervention (a time gap of 24 h between two doses). Group II (control group): included 60 patients who received only traditional treatment.ResultsThe incidence of AKI was higher in the control group with a statistically significant difference. We found that Independent Significant risk factors that led to AKI were febuxostate avoidance, DM, high urea level, high creatinine level, CKD stage 3B, high Mehran score and high AKI risk.ConclusionWe demonstrated that febuxostat has a Reno protective effect and it can help to reduce the incidence CI-AKI in CKD patients stage 3 performing PCI.

Unravelling the Fate of Coronary Artery Disease in Patients Undergoing Valve Replacement for Severe Aortic Valve Stenosis

Severe aortic valve stenosis is the most frequent valve pathology in the western world and approximately 50% of these patients have concomitant coronary artery disease (CAD). Revascularization of proximal obstructive CAD in patients undergoing surgical aortic valve replacement (SAVR) is common practice considered appropriate. However, the management of patients with CAD undergoing transcatheter aortic valve implantation (TAVI) is more controversial. Nevertheless, performing percutaneous coronary intervention (PCI) of significant (&gt;70%) proximal coronary lesions is a widely adopted strategy, but robust supporting scientific evidence is missing. Some studies suggest that complex CAD with incomplete revascularization negatively impacts outcomes post-TAVI. As increasingly younger patients are undergoing TAVI, optimizing the long-term outcomes will become more important. Although PCI in TAVI patients is safe, no benefit on outcomes has been demonstrated, possibly due to an inadequate selection of prognostically important lesions for revascularization. A possible solution might be the use of coronary physiological indices, but these have their own limitations and more data is needed to support widespread adoption. In this review we provide an overview of current evidence on the outcomes after aortic valve replacement (AVR) and the evidence regarding revascularization in this population.

Abstract 12936: Higher In-Hospital Mortality After TAVR and PCI on Same Hospitalization: A Systematic Review and Meta-Analysis

Introduction: Aortic stenosis (AS) patients admitted for elective transcatheter aortic valve replacement (TAVR) frequently present significant coronary artery disease (CAD). Despite the increasing number of TAVR procedures, it remains unclear if the strategy of performing percutaneous coronary intervention (PCI) and TAVR during the same hospitalization differs from isolated TAVR. Methods: We performed a systematic review and meta-analysis of observational studies in patients with AS and significant CAD (lesions ≥50%). The aim of the study was to compare TAVR and PCI on same hospitalization (with no regard for whether in the same procedure) to TAVR and deferred PCI. In-hospital mortality, acute kidney injury and major bleeding were our outcomes of interest. Results: We included 4 studies with 2917 patients, 665 treated with TAVR+PCI and 2252 treated with TAVR alone. TAVR+PCI was associated with higher in-hospital mortality (OR 1.66; 95% CI 1.21 - 2.27; p=0.002; Fig. 1). However, there was no difference in acute kidney injury (OR 0.59; 95% CI 0.26 - 1.32; p=0.20; Fig. 2A). Furthermore, TAVR+PCI seemed to lower the rate of major bleeding (OR 0.65; 95% CI 0.46 - 0.93; p=0.02 Fig. 2B). Conclusions: In this meta-analysis of retrospective studies, TAVR and PCI on same hospital admission was associated with higher in-hospital mortality when compared to isolated TAVR.

Abstract 14084: Safety and Outcomes of Percutaneous Coronary Intervention in Patients Presenting With Acute Coronary Syndrome With Prior Liver Transplantation

Background: There is a paucity of data about the outcomes of performing Percutaneous coronary intervention (PCI) for Liver transplant (LT) patients presenting with acute coronary syndrome (ACS). Methods: We queried the national readmission database for patients who underwent PCI hospitalized between 2016 and 2019, patient were classified into two groups based on prior LT status. International classification of disease codes (ICD-10) were used for diagnosis and procedures codes. Our outcomes were In-hospital mortality and 90-day readmission rate. A multivariate adjusted regression model was performed to risk adjust for predictors of 90-day readmission (all-cause). Results: A total of 1400,861 patients underwent PCI between the years 2016 and 2019 for ACS and underwent PCI. 1,532 patients had a history of LT (0.1%). Hospitalized patients with prior LT were of similar age (65.2 ±0.31 vs 65.3 ±0.04 years, p=0.9), and less likely to be women (20.8.6% vs. 32.5%, p&lt;0.01) compared with those without prior LT history. Hospitalized patients with prior LT had similar In-hospital mortality rate (3.9% vs 2.9%, p=0.3), shock (5.3% vs 4.5%, p=0.34), and Mechanical circulatory support utilization rate (4.9% vs 4.3%, p=0.452) but longer length of stay (5.8±0.3 vs 4.1±0.02, P&lt;0.001) compared to the cohort that had no prior LT. Patients with prior LT had a higher readmission rate within 90 days 29.6% vs 19.4%, p= 0.001), and were less likely to have repeat PCI in the readmission (7.9% vs 12.3%, p&lt;0.001), however more likely and acute kidney injury. Both cohorts had similar rates of acute heart failure exacerbation, bleeding complications, or in-hospital mortality in the readmission. Conclusion: There was no significant difference in mortality between both cohorts, however, readmission rate was higher in the LT cohort, Further studies exploring these differences may help to mitigate these readmissions.

Uric Acid to High-Density Lipoprotein Cholesterol Ratio is a Novel Marker to Predict Functionally Significant Coronary Artery Stenosis.

Background Intermediate coronary stenosis (ICS) is defined as a visually estimated percentage of diameter stenosis ranging between 40% and 70% by conventional coronary angiography (CAG). Whether to perform percutaneous coronary intervention (PCI) for these lesions is a challenge in clinical practice. The fractional flow reserve (FFR) can guide treatment by determining the functional significance of ICS. Studies have shown that some clinical indicators can be used to predict FFR. However, there is little research on this in the Chinese population. Methods We retrospectively analyzed 690 patients who underwent FFR measurements to determine the functional significance of a single ICS. Patients were divided into 2 groups: FFR ≤0.8 (n = 280) and FFR >0.8 (n = 410). We compared the clinical factors between the two groups and performed multivariate logistic regression analyses to explore the risk factors. In addition, receiver-operating characteristic (ROC) curves were constructed for FFR ≤0.8 diagnoses. Results The mean UHR (uric acid to high-density lipoprotein cholesterol ratio) level was significantly higher in the FFR ≤0.8 group (p < 0.001). UHR corrects negatively with FFR (r = −0.44, p < 0.001). High-level UHR was an independent risk factor for the FFR ≤0.8 (OR = 7.17, 95% CI 4.17–12.34). The area under the curve (AUC) of the UHR diagnostic capacity for the FFR ≤0.8 is 0.77, with 77.3% sensitivity and 68.2% specificity. Conclusion UHR levels were significantly increased in patients with hemodynamically significant coronary lesions. UHR is a novel predictor of functionally significant lesions in patients with a single-vessel disease of ICS.

Secondary rotational atherectomy strategy may reduce the occurrence of prolonged ST-segment elevation following ablation

Abstract Background Rotational atherectomy (RA) has been widely used for severely calcified lesions in performing percutaneous coronary intervention (PCI). The slow flow phenomenon is the most frequently observed complication of RA and leads to prolonged ST-segment elevation. The incidence of the slow flow phenomenon was reported as approximately 5–20%. Several methods have been recommended to treat the slow flow phenomenon; however, the elevation of ST-segment may often persist after disappearance of slow flow phenomenon on angiography. Purpose The aim of the present study was to investigate the clinical factors on the incidence of prolonged ST-segment elevation following ablation of RA. Methods The subject comprised 140 consecutive stable angina patients with severe calcified lesions. All patients had undergone successfully elective PCI using RA and intravascular ultrasound, and had been prescribed strong statins more than 2 week before PCI regardless dyslipidemia. We investigated the occurrence of prolonged ST-segment elevation following ablation of RA with resistance to use of nitroprusside as intra-coronary vasodilators, and the clinical factors including of primary or secondary RA strategy for calcification lesions. Secondary RA strategy was defined as RA performed after pre-dilatation with small balloon (balloon/artery ratio = 0.6). Results Median of age was 71 years (66–80) and 98 cases (70%) were male. Of 140 target lesions, 82 (59%) were LAD (RCA; 24%, LCX; 16%, and LMT; 1%, respectively). The rates of hemodialysis and diabetes mellitus were 31% and 61%. The incidence of prolonged ST-segment elevation with resistance to use of nitroprusside as intra-coronary vasodilators was 8 cases (6%). Major complications of RA including coronary perforation, coronary rupture, burr entrapment and cardiogenic shock requiring the mechanical support were none. Univariate logistic regression analysis showed that age [Odds ratio (OR); 1.07, 95% confidence interval (CI) 0.99–1.17, p=0.103], hemodialysis (OR; 0.71, 95% CI: 0.10–3.25, p=0.688), diabetes mellitus (OR; 1.08, 95% CI: 0.25–5.46, p=0.915), use of β-blocker (OR; 0.70, 95% CI: 0.14–2.96, p=0.633), left ventricular ejection fraction (OR; 0.99, 95% CI: 0.94–1.05, p=0.781), lesion length ≥20mm (OR; 1.04, 95% CI: 0.23–7.33, p=0.962), and burr size (OR; 2.42, 95% CI: 0.53–16.95, p=0.289) were not associated with the incidence of prolonged ST-segment elevation. Multivariate logistic regression analysis for the incidence of prolonged ST-segment elevation revealed that secondary RA strategy and levels of low-density lipoprotein cholesterol (LDL-C) were independent factors of the incidence of prolonged ST-segment elevation following ablation of RA (OR; 0.05, 95% CI: 0.01–0.39, p=0.017 and LDL-C: OR 0.91, 95% CI 0.83–0.96, p=0.010, respectively). Conclusion Secondary RA strategy may be useful to reduce the occurrence of prolonged ST-segment elevation following ablation of RA. Funding Acknowledgement Type of funding sources: None.

Optimal timing for percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation

BackgroundThe best timing to perform percutaneous coronary interventions (PCI) in patients undergoing TAVI is unknown. Most PCI are performed before TAVI, because of concerns about potential ischemic complications during valve implantation. In this study we aimed to compare short-and long-term outcomes of patients undergoing PCI before or after TAVI. MethodsPatients undergoing TAVI and PCI from 2010 to 2021 were analyzed. PCI was defined as high-risk when involving unprotected left main, proximal left anterior descending, proximal dominant right coronary artery or 3-vessel disease. The primary endpoint was the cumulative incidence of any TAVI procedural complication and in-hospital adverse events (VARC-3 criteria). ResultsOut of 1162 patients, 144 underwent PCI, 68% after TAVI, 78.4% of which were at high-risk. The primary endpoint occurred in 28.4% of patients in PCI pre-TAVI group vs 21.4% in PCI post-TAVI group (p = 0.403) and in 34.4% vs 17.3% of patients respectively among high-risk patients (p = 0.075). A higher rate of stroke was observed in the PCI pre-TAVI group regardless of the PCI complexity (6.5% vs 0.0%, p = 0.031; 9.3% vs 0.0% p = 0.025 in the high-risk group).At 24 months, MACCE-free survival was lower in patients who underwent PCI before TAVI (84.4% vs 97.9%, adjusted HR 10.16, 95% CI 1.19–86.57, p = 0.019; and 84.4% vs 97.3%, adjusted HR 7.34 95% CI 0.78–62.28 p = 0.082 in the high-risk group). ConclusionsPCI performed after TAVI does not expose patients to higher risks of peri-procedural hazards and provides a trend towards favourable clinical outcome at mid-to-long term.

Clinical Case of Unprotected Left Main Percutaneous Coronary Intervention in Elderly Patient With Porcelain Aorta

Coronary artery bypass grafting (CABG) has long been considered the gold standard in the treatment of patients with lesions of the left main (LM) coronary artery. Elderly patients are one of the most difficult categories of patients with LM lesions due to severe coronary artery calcification. Thanks to constant progress in the field of engineering and technology, it has become possible to perform percutaneous coronary interventions (PCI) for patients with unprotected stenosis of the LM. Drug-eluting stents and the development of pharmacotherapy have improved the results of PCI in these lesions. Comparative studies of the efficacy and safety of PCI and CABG have shown similar results in terms of the need for revascularization. Patients with severe calcification of the coronary arteries mostly belong to the older age group and hold large part in this cohort. Technological advances enabled to treat patients with complex coronary anatomy and LM lesions not only through CABG, but also through PCI. Comparative studies show that the efficacy and safety of PCI and CABG have similar results in terms of the need in revascularization.&#x0D; The aim. To highlight the importance of discussion of each clinical case by the heart team and comprehensive approach with the use of modern equipment.&#x0D; Stage 1. A 80-year-old woman with type 2 diabetes mellitus was delivered by an ambulance team to the National Amosov Institute of Cardiovascular Surgery with severe pain; the patient was diagnosed with non-ST-elevation myocardial infarction (NSTEMI). Electrocardiography revealed ST-segment depression in leads V1-V5. After performing echocardiographic examination, valvular pathology and segmental contraction defects were not detected, EF 52%.&#x0D; Urgent coronary angiography revealed significant calcification of the ascending aorta (porcelain aorta) and coronary arteries. Coronary artery lesions: 90% unstable LM stenosis, significant calcified stenosis of the circumflex artery (CA), middle left anterior descending artery (mid-LAD), and chronic coronary occlusion of the right coronary artery, besides, 5 episodes of ventricular tachycardia were recorded. Despite the high SYNTAX Score I and SYNTAX Score II, due to the clinical picture and heart rhythm disorders, the heart team decided to perform emergency PCI. Bare-metal stent for LM – mid-LAD was implanted and angioplasty of mid-LAD was performed. Rough calcification of LM caused stent recoil; postdilatation of LM stent by high pressure balloon (p = 25 atm) was performed. The operation ended with a good angiographic result. The woman was discharged in a stable condition to plan further intervention in 1 month.&#x0D; Stage 2. A 81-year-old woman with complaints of severe chest pain was re-hospitalized with NSTEMI to the National Amosov Institute of Cardiovascular Surgery 3 months after the primary PCI. Echocardiography revealed EF 53%; valvular pathology and segmental contraction defects were not detected. Urgent coronary angiography revealed 90% of LM stenosis (stent recoil – loss of radial rigidity). Gradual angioplasty of LM stenosis and CA stenosis were performed.&#x0D; Stage 3. For reinforcing the radial rigidity in LM, LM – CA drug-eluting stent was implanted. Angioplasty of LM and CA using kissing balloon technique was performed. Final proximal optimization of LM showed good angiographic result.

P64 COVERED STENT IN A CHEST TRAUMA: CONGENITAL CORONARY ARTERIAL FISTULA OR TRAUMATIC CORONARY PERFORATION?

Abstract Coronary arterial fistula consists in a communication between a coronary artery and a cardiac cavity. It is tipically a congenital condition, but it can also be a result of invasive cardiac procedure. Although chest truama generally evolve to massive pericardial effusion, in some cases it can determine also a coronary perforation, with a consequent coronary arterial fistula. A 22–year–old male patient, with no cardiovascular history, was admitted after a road accident, reporting pelvis break, 17 costal break, and sternal break, with consequent chest pain. On admission the patient had a heart rate of 100 b.p.m. and a blood pressure of 130/80 mmHg. Elettrocardiogram (ECG) reported ST elevation in antero–septal derivations (V1–V4). Echocardiogram showed a global left ventricular (LV) ejection fraction of 55%, with an apical–septal akinesia, with a minimal anterior pericardial effusion, not emodinamically significant. So, an emergency coronary angiography was performed, showing a fistula of the distal segment of the left anterior discendent coronary (LAD). In this case there were two possible options, a previously unknown congenital coronary arterial fistula, or a traumatic coronary perforation, determining a coronary arterial fistula. Considering the possibility of a traumatic coronary perforation, with the consequent risk of rapid pericardial effusion worsening, the decision was to perform percutaneous coronary intervention (PCI) with a covered stent (Biotronik Papyrus 2.5 x 20 mm, 8 atm), with a good final result, with total occlusion of fistula. At 1 month follow up, the patient was asymptomatic for dyspnea or chest pain, with a heart rate of 70 b.p.m. and a blood pressure of 130/80 mmHg. ECG showed no anomalies in ST–T tract.

A Comparison of Barrier Factors between Hospitals with and without Cardiac Rehabilitation Programs in Korea: A Nation-Wide Survey Research.

The percentage of patients undergoing cardiac rehabilitation programs (CRP) is very low (30–40%), and hospitals providing CRP are either insufficient or lacking, even in countries with advanced medical care; therefore, this study aims to investigate the barriers, as well as compare the differences between hospitals, with or without CRP. We conducted a survey, in which the questionnaire was distributed through post or email to 607 specialists who work at 164 hospitals performing percutaneous coronary interventions (PCI). The results were as follows: (1) of the 164 hospitals, 132 responded (response rate: 80.5%). While all 47 hospitals with CRP responded (100%), from among the 117 hospitals without CRP, 85 responded (72.7%). (2) Of the 607 specialists, 227 responded (response rate: 36.9%). The response rates according to specialties were as follows: cardiologists (28.9%), cardiac surgeons (24.5%), and physiatrists (64.1%). (3) While the specialists at hospitals with CRP identified patient referral, transportation, and cost as the major barriers, for those at hospitals without CRP, all items were considered barriers, especially the items related to equipment, space, workforce, and budget as being more serious barriers. Therefore, in order to actively promote CRP, it is suggested that governments consider the customized support system according to the performance of CRPs.

214 Covered stent in a chest trauma: congenital coronary arterial fistula or traumatic coronary perforation?

Abstract Aims Coronary arterial fistula consists in a communication between a coronary artery and a cardiac cavity. It is tipically a congenital condition, but it can also be a result of invasive cardiac procedure. Although chest truama generally evolve to massive pericardial effusion, in some cases it can determine also a coronary perforation, with a consequent coronary arterial fistula. Methods and results A 22-year-old male patient, with no cardiovascular history, was admitted after a road accident, reporting pelvis break, 17 costal break, and sternal break, with consequent chest pain. On admission the patient had a heart rate of 100 b.p.m. and a blood pressure of 130/80 mmHg. Elettrocardiogram (ECG) reported ST elevation in antero-septal derivations (V1–V4). Echocardiogram showed a global left ventricular (LV) ejection fraction of 55%, with an apical-septal akinesia, with a minimal anterior pericardial effusion, not emodinamically significant. So, an emergency coronary angiography was performed, showing a fistula of the distal segment of the left anterior discendent coronary (LAD). In this case there were two possible options, a previously unknown congenital coronary arterial fistula, or a traumatic coronary perforation, determining a coronary arterial fistula. Considering the possibility of a traumatic coronary perforation, with the consequent risk of rapid pericardial effusion worsening, the decision was to perform percutaneous coronary intervention (PCI) with a covered stent (Biotronik Papyrus 2.5 × 20 mm, 8 atm), with a good final result, with total occlusion of fistula. Conclusions At 1 month follow-up, the patient was asymptomatic for dyspnoea or chest pain, with a heart rate of 70 b.p.m. and a blood pressure of 130/80 mmHg. ECG showed no anomalies in ST-T tract.

C70. Performing Percutaneous Coronary Intervention in Dextrocardia: A Case Report

Abstract Background Dextrocardia is defined as the heart location in the right hemithorax with the apex pointing inferiorly and to the right. Performing percutaneous coronary intervention (PCI) in patient with dextrocardia can be difficult and requires some modification. Case Summary A 55-years old male with chest pain 3 hours before admission, apex in right side, a chest X-ray confirm the heart in the right hemithorax, electrocardiogram (ECG) was consistent with dextrocardia and showed inferior ST-segment elevation myocardial infarction (STEMI). We performed primary PCI with femoral access. During coronary angiography, it was a challenge to engage the diagnostic catheter to both of ostium right and left coronary artery. Coronary angiography showed total occlusion in the proximal of right coronary artery (RCA). We inversed the engagement technique and radiological angles for RCA from the left anterior oblique 35º to the right anterior oblique 30º and finally revascularization could be done easier. Discussion Performing PCI in patient with dextrocardia can be challenging. Inversion the engagement technique and radiological angles and views will give an advantage to the operator for imaging and doing intervention. Using image reversal technology is also help to get the image like a normal position.