Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

Dual-Prep registry: atherectomy devices and intravascUlAr lithotripsy for the PREParation of heavily calcified coronary lesions registry

Evaluation of calcified lesions by intravascular imaging has revealed that atherectomy devices have only limited impact. However, subsequent use of coronary intravascular lithotripsy (IVL) may increase treatment effectiveness without increasing risk of complications. This study was designed to evaluate the safety and effectiveness of IVL use after atherectomy in severely calcified coronary lesions as pre-treatment for drug-eluting stents (DES). The Dual-Prep registry is a multicenter, prospective registry of consecutive image-guided percutaneous coronary interventions (PCI). The primary effectiveness and safety endpoints were procedural success (residual stenosis < 50% by quantitative coronary angiography) without an in-hospital major adverse cardiac event (MACE) and 30-day freedom from MACE, respectively. Baseline vessel calcification score and final DES expansion were evaluated by optical coherence tomography (OCT). A total of 118 patients with 120 lesions were enrolled at 20 sites. The calcification score of lesions after atherectomy by core-lab assessment was 4.0 in all cases. Rotational atherectomy was applied prior to IVL in 83.9% cases with mean burr size of 1.57 ± 0.20 mm; IVL was subsequently successfully delivered in all cases (mean balloon diameter 3.02 ± 0.45 mm), followed by DES deployment (mean diameter 3.19 ± 0.51 mm, length of 36.3 ± 16.0 mm). The primary efficacy and safety endpoints were met in 98.3% and 98.3% of cases, respectively. A DES expansion index < 0.8 was seen in 42.2%, and an eccentricity index < 0.7 was not observed in any patient. In severely calcified lesions, image-guided atherectomy followed by IVL lesion preparation demonstrated high procedural success rates and satisfactory non-eccentric stent expansion. This approach may be considered for lesions where an 'IVL-first' strategy may not be feasible. jRCT1032230384 (Oct 7, 2023).

Safety and efficacy of low-temperature RA-flush solution in patients with moderate-to-severe calcified lesions (LOTA-II): a randomized, double-blind, multicenter study

Rotational atherectomy (RA) is an effective, mature, and specific treatment for calcified lesions. However, the incidence of RA-related myocardial injury remains high and has not been adequately addressed. To assess the safety and efficacy of low-temperature RA-flush solution versus room-temperature RA-flush solution during RA. A total of 132 patients with moderate-to-severe calcified lesions who underwent RA were randomly assigned to the low-temperature RA-flush solution group or the room-temperature RA-flush solution group. The primary endpoint was RA-related myocardial injury, defined as any increase in myocardial biomarkers within 72 h after percutaneous coronary intervention (PCI). Secondary endpoints included RA-related myocardial infarction (MI), RA-related transient slow/no flow, or transient coronary spasm. A total of 78 patients (59.1%) had increased cardiac troponin I (cTnI) levels, and 60 patients (45.5%) had increased creatine kinase isoenzyme (CK-MB) levels after PCI. The number of patients with myocardial injury (primary endpoint), defined as elevated cTnI (47.0% vs. 71.2%, p = 0.005) or elevated CK-MB (28.8% vs. 62.1%, p < 0.001), was significantly lower in the low temperature group than in the room temperature group. The number of patients with RA-related transient slow/no flow (6.1% vs. 34.8%, p < 0.001) and transient coronary spasm (9.1% vs. 25.8%, p = 0.012) (secondary endpoints) was significantly lower in the low temperature group than in the room temperature group; no significant difference in the incidence of RA-related MI was observed between the two groups. Compared with room-temperature RA-flush solution, low-temperature RA-flush solution is associated with reduced RA-related myocardial injury in patients treated with RA.Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03701230; first submitted registration date: 09/10/2018.

Safety and efficacy of different rotational speed during rotational atherectomy in coronary heart disease patients (RACE): study protocol for a randomized controlled trial

INTRODUCTION

The increasing incidence of coronary heart disease, driven by socio-economic development and population aging, poses significant challenges. Coronary calcification, a major factor complicating percutaneous coronary interventions (PCI), often necessitates rotational atherectomy (RA) for lesion preparation. However, the impact of different RA rotational speeds on procedural and clinical outcomes remains unclear. While low-speed RA (LSRA) has been suggested to reduce intraoperative slow flow, evidence is inconsistent, and the benefits of combining LSRA with high-speed RA (HSRA) are not well established. This study aims to evaluate the effectiveness of different rotational speed protocols to guide clinical practice.

METHODS AND ANALYSIS

This single-center, randomized controlled trial will target patients with severe coronary artery calcification scheduled for RA. An estimated 210 patients will be enrolled based on sample size calculation, randomly assigned in a 1:1:1 ratio to different rotational speed protocols using a random number table. These will include a continuous low-speed rotation (LSRA) group (140,000 rpm), a continuous high-speed rotation (HSRA) group (180,000 rpm), and a high-speed to low-speed rotation (HSRA + LSRA) group (initially 180,000 rpm, followed by 100,000 rpm). The primary endpoint is the incidence of complications during RA, including coronary artery spasm, slow/no reflow, dissection, burr entrapment, guidewire fracture, and perforation. Secondary outcomes encompass intravascular imaging (IVUS or OCT) assessments (detecting calcific ring disruption and measuring the target lesion's minimum lumen area (MLA) and minimum lumen diameter (MLD)); in-hospital cardiac death, acute stent thrombosis, and heart failure occurrences; and the 1-year incidence of major adverse cardiovascular and cerebrovascular events (MACCE).

DISCUSSION

The RACE study evaluates the impact of different rotational speeds in coronary rotational atherectomy, aiming to provide guidance for clinical practice. The findings may help standardize RA procedures and inform future clinical guidelines, improving procedural consistency and patient outcomes.

REGISTRATION NUMBER

ChiCTR2300076194. Registered on September 27, 2023.

Fracture of Rotational Atherectomy Burr: Pre-Fracture Signs, Mechanisms, and Management Strategies

BACKGROUND

Burr fracture during rotational atherectomy (RA) is a rare but potentially devastating complication. Due to its infrequency, comprehensive data on its incidence, mechanisms, and management are lacking. This study aimed to investigate the incidence, contributing factors, and management strategies for burr fractures during RA procedures.

METHODS

This retrospective analysis included all patients who underwent PCI with RA at a single center between January 2013 and October 2024. Data were collected from a prospective registry.

RESULTS

Among 3738 patients, three cases of burr fracture without entrapment were identified (incidence: 0.08%). Burr fractures occurred at the burr-driveshaft junction (tip fracture) in two cases and at the driveshaft in one case. Pre-fracture warning signs included incoherent burr-advancer knob movement, fluoroscopic translucency, and frequent driveshaft prolapse. Significant proximal tortuosity or enlargement and non-coaxiality between the RA device and the coronary artery were identified as potential contributing factors. In two cases involving tip fractures, simple manual traction removed the fractured burr. In the third case involving driveshaft fracture, coronary rupture necessitated covered stent implantation and urgent surgery.

CONCLUSION

Burr fractures during RA are rare but potentially serious complications. Significant proximal tortuosity or enlargement and non-coaxiality between the RA device and the coronary artery may increase the risk of burr fracture. Recognizing pre-fracture warning signs and understanding the underlying mechanisms are crucial for minimizing complications and optimizing procedural safety.

'RotaShock' - A Revolution in Calcium Modification: Long-term Follow-up from a Single High-volume Centre

Background

Rotational atherectomy (RA) and intravascular lithotripsy (IVL) are well-established technologies for modification of coronary calcification. Given their contrasting mechanisms of action, there has been interest in whether the use of these devices in conjunction could potentially be synergistic and offer improved procedural results. The aim of this study was therefore to evaluate the efficacy, procedural safety and long-term outcomes of combining RA and IVL, termed 'RotaShock' (RSK), for the treatment of severe coronary calcification.

Methods

A single- centre retrospective analysis was carried out of consecutive patients treated with an RSK strategy for coronary calcification from January 2019 until September 2022. Baseline demographics, comorbidity details, details of the percutaneous coronary intervention procedure, angiographic and/or intracoronary imaging (ICI) results and presence of target vessel revascularisation or mortality were recorded.

Results

A total of 36 patients were treated with RSK; the majority of patients were male (n=29; 80.6%) and the median age was 75 years (IQR 70-79 years). The majority of cases involved treating the left anterior descending artery (63.4%) but one-third involved percutaneous coronary intervention to the left main coronary artery. The vast majority of cases were guided by ICI (88.9%) and were performed through radial access (80.6%). In patients with ICI available for analysis, the median minimum stent area was 7.7 mm2 (IQR 6.2-10.0 mm2). There were two access site complications but no other periprocedural complications. The median follow-up was 942 days (IQR 645-1,306 days). Despite the high complexity of lesions treated, follow-up identified only two cases of target vessel revascularisation. There were five cases of non-adjudicated all-cause mortality.

Conclusion

RSK is an effective and safe strategy for modification of severe coronary calcification, with long-term results suggesting a highly durable result. Further and randomised data are now mandated to evaluate the relative merits of RSK compared with RA or IVL alone.

The DELIVER Technique: Deep Engagement of Guide or ChiLd-guIde Catheter for Burr DeliVEry and Rotational Atherectomy

The delivery of the rotational atherectomy burr can sometimes be hindered in distal calcified lesions complicated by proximal vessel tortuosity or other obstacles. This problem may result in procedural failure or fatal complications, including coronary perforation, burr entrapment, or driveshaft fracture. To prevent these catastrophic outcomes and ensure successful burr delivery, we introduce the DELIVER (Deep Engagement of guide catheter or 5-F chiLd-guIde catheter for burr deliVEry and subsequent Rotational atherectomy) technique. This method involves deep catheter insertion beyond proximal vessel tortuosity or other obstacles, using strategies such as the distal balloon anchoring technique. Once the catheter is positioned, the rotational atherectomy burr is advanced through it to facilitate the atherectomy of the distal target lesion. This report presents 3 cases where the DELIVER technique was applied successfully to treat distal lesions. The technique enabled smooth and atraumatic burr delivery, even through tortuous arterial segments or other challenging anatomical structures.

Crush Technique as Ultimate Bailout Treatment for Rotablator Burr Entrapment

This case demonstrates the feasibility of a crush technique as an ultimate bailout treatment for Rotablator (Boston Scientific) burr entrapment during a complex percutaneous coronary intervention of the left main artery. This paper reports the case of a 77-year-old patient successfully treated by crushing the burr by a stent in the left main artery after complete burr entrapment. The patient had a calcified distal stenosis of the left main coronary with stenosis of the distal anastomosis of the saphenous vein graft to the obtuse marginal artery. The patient had several controls with optical coherence tomography imaging at 3 months. Immediate and 1-year clinical outcomes were satisfying. To our knowledge, this case is the first report of crushing technique as bail out option for entrapped rotablation burr.

Give it time to SOBER up - GITSU- a new strategy in percutaneous coronary intervention for chronic total occlusion

BACKGROUND

The prevalence of coronary chronic total occlusion (CTO) in coronary angiography (CAG) has risen with ageing populations, along with the expansion of CTO percutaneous coronary interventions (CTO-PCI). However, CTO-PCI encounters challenges such as undersized stents, dissection risks, and limited access to intravascular imaging (IVI), particularly in regions with limited health budgets. This study introduces the 'GIVE IT TIME TO SOBER UP - GITSU strategy', a two-session CTO-PCI approach where Thrombolysis in Myocardial Infarction (TIMI-3) antegrade flow is achieved without stent placement in the first session. We aim to present its key attributes, outcomes, and implications for invasive cardiology.

METHODS

Demographic data, CTO lesion characteristics in the first PCI session, procedural features, in-hospital major adverse cardiovascular adverse events (MACE), technical features of the second PCI session, and in-hospital MACE were examined.

RESULTS

We applied the GITSU strategy to 53 CTO lesions between August 2020 and June 2023. The mean lesion length was shortened compared to the first session (21.3 ± 10.5%). There was an increase in mean distal reference vessel diameter (2.52 ± 0.49 mm), and the increase was 24.2%±11.3% compared to the first session. There was 24.4%±11.5% stent length savings. We achieved an increase in stent size of 20.3% to 10.1% compared to the mean stent diameter. The technical success and procedural success rate were 92.5% and 90.6%, respectively.

CONCLUSION

Patients who underwent GITSU used shorter and wider stents in the second PCI session. This strategy is likely to reduce TLR and ISR rates.

The efficacy of an intracoronary cocktail administration in preventing no-reflow during excimer laser coronary angioplasty in patients with in-stent restenosis: A pilot study. (ELCA- cocktail study)

BACKGROUND

The no-reflow phenomenon is a significant complication during excimer laser coronary angioplasty (ELCA) procedures, which can lead to adverse outcomes. This study explores the efficacy of intracoronary administration of a cocktail solution comprising nitroglycerin, heparin, and verapamil on preventing no-reflow during ELCA in patients with in-stent restenosis (ISR).

METHODS

This study included patients undergoing ELCA with contrast infusion for ISR. Based on whether receiving the intracoronary cocktail solution during ELCA, participants were divided into two groups: the cocktail (+) group and the cocktail (-) group. The primary endpoint was the incidence of no-reflow, which was defined as the cessation of blood flow into the distal coronary artery in the absence of a clear angiographic explanation for impairment of flow.

RESULTS

A total of 54 lesions in 51 patients were included. The mean age of the study population was 61.8 ± 9.7 years, with 84.3 % male. Baseline clinical characteristics were well-balanced. The incidence of no-reflow was significantly lower in the cocktail (+) group compared to the cocktail (-) group (0 % vs. 17.9 %, P = 0.024). No cases of hypotension, major bleeding or coronary perforation in either group. Major adverse cardiac events (MACE) within 6-month were no significant difference between the groups (4.0 % vs. 3.8 %, P = 0.977).

CONCLUSIONS

The pilot study suggests that intracoronary administration of a cocktail comprising heparin, nitroglycerin, and verapamil may reduce the incidence of no-reflow during ELCA in patients with ISR. However, given the limited sample size and the non-randomized design, these findings should be considered hypothesis-generating. Future validation needs to be confirmed through multicenter studies with larger sample sizes.

Clinical expert consensus document on bailout algorithms for complications in percutaneous coronary intervention from the Japanese Association of Cardiovascular Intervention and Therapeutics

The efficacy and safety of percutaneous coronary intervention (PCI) for coronary artery disease has been established, and approximately 250,000 PCI procedures are performed annually in Japan. However, various complications including life-threatening complications can occur during PCI. Although several bailout procedures have been proposed to address complications during PCI, it is critically important for operators to manage each complication in real catheter rooms with confidence even in emergent situations. Standard bailout methods including specific techniques should be clarified as algorithms and shared with inexperienced operators as well as experienced operators. The Task Force of the Japanese Society for Cardiovascular Intervention and Therapeutics (CVIT) has developed the expert consensus document on bailout algorithms for complications in PCI.

Rota-Tripsy or step-up-approach rotational atherectomy for severe coronary artery calcification treatment: a comparative effectiveness study

Step-up-approach rotational atherectomy has been widely recognized in the treatment of severe calcified plaques. As an alternative, the rota-tripsy procedure is a novel strategy for the modification of calcification lesions. This study aimed to evaluate and compare the efficacy and safety of rota-tripsy and step-up-approach rotational atherectomy, given the limited clinical data available. Clinical data of 3652 patients with coronary calcification were retrospectively collected from February 2021 to February 2024. The cases were divided into two groups based on the technical approach. The primary efficacy endpoint was procedural success (stent expansion rate > 70% and no hospital major adverse cardiac events [MACEs]). The primary safety endpoint was the absence of serious angiographic complications and 30 days MACEs. A total of 37 patients (38 calcified lesions) screened and included in the study, with 18 cases (19 lesions) in group A and 19 cases in group B. The results showed no significant differences in primary efficacy endpoint. However, group A recorded a lower incidence of angiographic complications (P = 0.02) and shorter dose area product and fluoroscopy/interval times compared with group B (P < 0.01). For management of severe coronary calcification, both rota-tripsy and step-up-approach rotational atherectomy had favorable short-term clinical results; however, rota-tripsy provided improved safety and efficiency.

Modified Balloon Use After Rotational Atherectomy Reduces Major Adverse Cardiovascular Event Rates in Severely Calcified Coronary Lesions: A Systematic Review and Meta-Analysis

Background/Objectives: Calcified coronary lesions require plaque modification techniques for optimal stent apposition, of which rotational atherectomy (RA) is the most commonly used one. Challenging cases require the use of additional dedicated devices (such as modified balloons, MB); however, data available for evidence-based device selection are limited. The aim of this study is to determine the impact of the balloon-based technology used after successful RA treatment on outcomes. Methods: This study was carried out according to the PRISMA guidelines. MEDLINE, CENTRAL and Embase databases were systematically searched for eligible randomized and non-randomized studies. Results: A total of nine studies and 1024 patients were included in the analysis. Patients were treated with RA followed by either plain balloon angioplasty (RA + BA) or modified balloon (RA + MB) treatment prior to stent implantation. There was no significant difference in MACE (major adverse cardiovascular events; OR: 0.53; 95% CI: 0.21-1.34; p = 0.153), all-cause mortality (OR: 0.68; 95% CI: 0.33-1.42; p = 0.265), and target lesion revascularization (OR: 0.64; 95% CI: 0.27-1.55; p = 0.264) between the two groups. However, a sensitivity analysis demonstrated a significant decrease in MACE for patients with severely calcified lesions (OR: 0.42; 95% CI: 0.25-0.70; p = 0.009) in the RA + MB group. The analyses of the safety outcomes of slow flow/no reflow (OR: 0.59; 95% CI: 0.29-1.22; p = 0.128) and coronary artery perforation (OR: 1.18; 95% CI: 0.70-1.99; p = 0.480) showed no difference between the two groups. Conclusions: Our meta-analysis suggests that the benefit of the more invasive RA + MB treatment is statistically significant for severely calcified lesions, but is not associated with additional procedural complications.

Atherectomy Techniques: Rotablation, Orbital and Laser

Coronary artery disease remains the leading cause of morbidity and mortality worldwide despite advancements in percutaneous coronary intervention (PCI). With an increasing ageing population, there is a significant challenge in addressing severe calcification in atherosclerotic plaque during angioplasty. This review article focuses on atherectomy strategies such as rotational atherectomy (RA), orbital atherectomy (OA) and excimer laser coronary angioplasty (ELCA) aimed at modifying calcified lesions and improving PCI outcomes. RA modifies plaque through rotational ablation, OA uses eccentrically mounted diamond-coated crown and has a reduced entrapment risk compared to RA. ELCA uses pulsatile laser energy to precisely ablate plaque tissue. This review provides insights into the mechanisms, procedural techniques and clinical outcomes associated with these calcium modification techniques. The selection of appropriate devices and adequate training are crucial for optimising lesion modification and enhancing procedural success. Further research and standardised protocols are required to overcome challenges associated with using these devices and expand their usage in clinical practice.

Pharmacological and Device-Based Intervention for Preventing Heart Failure After Acute Myocardial Infarction - A Clinical Review

In patients with acute myocardial infarction (MI), heart failure (HF) is one of the most common complications that is associated with a significant burden of mortality and healthcare resources. The clinical benefits of key HF drugs, the so-called "4 pillars" or "fantastic 4", namely β-blockers, mineralocorticoid receptor antagonists, angiotensin receptor-neprilysin inhibitor, and sodium-glucose cotransporter 2 inhibitors, have been established in patients with HF with reduced ejection fraction, whereas the effects of these drugs are not comprehensively appreciated in patients with acute MI. This review summarizes current evidence on pharmacological and device-based interventions for preventing HF after acute MI.

Practices and outcomes of rotational atherectomy in China: The Rota China registry

BACKGROUND

Rotational atherectomy (RA) remains an integral tool for the treatment of severe coronary calcified lesions despite emergence of newer techniques. We aimed to evaluate the contemporary clinical practices and outcomes of RA in China.

METHODS

The Rota China Registry (NCT03806621) was an investigator-initiated, prospective, multicenter registry based on China Rota Elite Group. Consecutive patients treated with RA were recruited. A pre-designed, standardized protocol was recommended for the RA procedure. The primary safety endpoint was major adverse cardiovascular events (MACE: composite of cardiac death, myocardial infarction, or ischemia-driven target lesion revascularization) at 30 days. The primary efficacy endpoint was procedural success.

RESULTS

Between July 2018 and December 2020, 980 patients were enrolled at 19 sites in China. Mean patient age was 68.4 years, and 61.4% were men. Radial access was used in 79.1% patients, and 32.7% procedures were guided by intravascular imaging. A total of 22.6% procedures used more than 1 burr, and the maximal burr size was ≥1.75 mm in 24.4% cases, with burr upsizing in 19.3% cases, achieving a final burr-to-artery ratio of 0.52. Procedural success was achieved in 91.1% of patients, and the rate of 30-day and 1-year MACE was 4.9% and 8.2%, respectively. Multivariable analysis identified the total lesion length (HR 1.014, 95% CI: 1.002-1.027; p = 0.021) as predictor of 30-day MACE, and renal insufficiency (HR 1.916, 95% CI: 1.073-3.420; p = 0.028) as predictor of 1-year MACE.

CONCLUSIONS

In this contemporary prospective registry in China, the use of RA was effective in achieving high procedural success rate with good short- and long-term outcomes in patients with severely calcified lesions.

State-of-the-art percutaneous coronary intervention for left main coronary artery disease in Japan

Percutaneous coronary intervention for left main coronary artery disease (LM-PCI) represents a high-risk yet life-saving procedure that has evolved significantly over the years. This review outlines the current state-of-the-art practices for LM-PCI in Japan in detail, emphasizing the integration of coronary physiology and intracoronary imaging alongside with evidence-based standardized technique using latest drug-eluting stents. These advancements enable precise lesion assessment, stent sizing, and optimal deployment, thereby enhancing procedural safety and efficacy. Despite discrepancies between current guidelines favoring coronary artery bypass grafting and real-world practice trends towards increased LM-PCI adoption, particularly in elderly populations with multiple comorbidities, careful patient selection and procedural planning are critical. Future perspectives include further refining LM-PCI through conducting randomized controlled trials integrating advanced techniques and addressing the issue of ostial left circumflex lesions and nationwide standardization of medical care for LM disease.

Advances in Technology and Technique in Percutaneous Coronary Intervention: A Clinical Review

Percutaneous coronary intervention (PCI) has become the standard procedure for patients with angina and acute coronary syndrome. From the perspective of technology and technique, PCI has advanced over the last four decades, resulting in considerably improved clinical outcomes in patients with coronary artery disease in the current era. In this review article, we summarize recent advances, promising technologies, and areas for research in the field of PCI.

Combination Tools for Calcium Modification from RASER to Orbitalshock

Coronary artery calcification is frequently encountered during percutaneous coronary intervention and its presence is associated with a higher risk of stent under-expansion which has been associated with long-term risk of stent failure. There are several different calcium modification strategies available, whether they be balloon-based devices (cutting/scoring and intravascular lithotripsy) or atherectomy devices (orbital atherectomy, rotational atherectomy, excimer laser coronary atherectomy) that are established for the modification of coronary calcification. Each strategy applies a different mechanism of action for calcium modulation and consequently the potential to combine modifying tools may offer synergistic advantages over device monotherapy. This article will focus on reviewing the evidence for the use of multiple calcium modification techniques and examine whether there really is any such synergistic effect of combining these tools.

Development and Validation of Artificial Intelligence-Based Algorithms for Predicting the Segments Debulked by Rotational Atherectomy Using Intravascular Ultrasound Images

We develop and evaluate an artificial intelligence (AI)-based algorithm that uses pre-rotation atherectomy (RA) intravascular ultrasound (IVUS) images to automatically predict regions debulked by RA. A total of 2106 IVUS cross-sections from 60 patients with de novo severely calcified coronary lesions who underwent IVUS-guided RA were consecutively collected. The 2 identical IVUS images of pre- and post-RA were merged, and the orientations of the debulked segments identified in the merged images were marked on the outer circle of each IVUS image. The AI model was developed based on ResNet (deep residual learning for image recognition). The architecture connected 36 fully connected layers, each corresponding to 1 of the 36 orientations segmented every 10°, to a single feature extractor. In each cross-sectional analysis, our AI model achieved an average sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 72%, 46%, 90%, and 75%, respectively. In conclusion, the AI-based algorithm can use information from pre-RA IVUS images to accurately predict regions debulked by RA and will assist interventional cardiologists in determining the treatment strategies for severely calcified coronary lesions.

Halftime rotational atherectomy: a unique concept for diffuse long severely calcified lesions

Rotational atherectomy (RA) is technically more difficult in a diffuse calcified lesion than in a focal calcified lesion. We hypothesized that taking a halftime can be another option for RA to the diffuse calcified lesions. Halftime was defined as at least one long break during RA, in which an operator pulled out the Rotablator system from the guide catheter before crossing the lesion. This study aimed to compare the complications between RA with and without halftime. We included 177 diffuse long severely calcified lesions (lesion lengths ≥ 30 mm) that required RA, and divided those lesions into a halftime group (n = 29) and a no-halftime group (n = 148). The primary outcome was periprocedural myocardial infarction (MI). The reference diameter was smaller in the halftime group than in the no-halftime group [1.82 (1.70-2.06) mm versus 2.17 (1.89-2.59) mm, p = 0.002]. The total run time was longer in the halftime group than in the non-halftime group [133.0 (102.0-223.0) seconds versus 71.5 (42.0-108.0) seconds, p < 0.001]. Although creatinine kinase (CK) and CK-myocardial band (MB) was significantly higher in the halftime group than in the no-halftime group [CK: 156 (97-308) U/L versus 99 (59-216) U/L, p = 0.021; CK-MB: 15 (8-24) U/L versus 5 (3-15) U/L, p < 0.001], periprocedural MI was not observed in the halftime group. In conclusion, periprocedural MI was not observed in RA with halftime. This preliminary study suggests that halftime RA may be a safe option for diffuse severely calcified lesions.

The Burden of Cardiovascular Diseases Attributed to Diet High in Sugar-Sweetened Beverages in 204 Countries and Territories From 1990 to 2019

This study examines the impact of sugar-sweetened beverage (SSB) consumption on cardiovascular diseases (CVDs) and aims to provide evidence for preventive measures. The analysis involved a comprehensive scrutiny of CVD-related data from 1990 to 2019. Temporal trends of ASMR and ASDR were assessed using the Estimated Annual Percentage Change (EAPC). Globally, there was an increase in deaths and DALYs from 1990 to 2019, despite decreasing ASMR and ASDR. In 2019, SSB-related CVDs accounted for approximately 193.1 thousand deaths and 3973.2 thousand DALYs. China had the highest number of deaths, Tajikistan had the highest ASMR, and Yemen had the highest ASDR in 2019. ASMR and ASDR increased with age and were higher in males. Deaths and DALYs increased overall, except in high Socio-demographic Index (SDI) regions. ASMR and ASDR declined across SDI regions, with the steepest decline in high SDI regions (EAPC: -2.8 for ASMR, -2.36 for ASDR). ASDR increased in low SDI countries but decreased in high SDI countries. This study provides comprehensive insights into the global burden of SSB-related CVDs. Urgent interventions and policies are needed to reduce SSB consumption and mitigate the impact on cardiovascular health.

Emergency transvenous temporary pacing during rotational atherectomy

Background

Rotational atherectomy (RA) during percutaneous coronary intervention may cause transient bradycardia or a higher-degree heart block. Traditionally, some operators use prophylactic transvenous pacing wire (TPW) to avoid haemodynamic complications associated with bradycardia.

Objective

We sought to establish the frequency of bail-out need for emergency TPW insertion in patients undergoing RA that have received no upfront TPW insertion.

Methods

We performed a single-centre retrospective study of all patients undergoing RA between October 2009 and October 2022. Patient characteristics, procedural variables, and in-hospital complications were registered.

Results

A total of 331 patients who underwent RA procedure were analysed. No patients underwent prophylactic TPW insertion. The mean age was 73.3 ± 9.1 years, 71.6% (n = 237) were male, while nearly half of the patients were diabetic [N = 158 (47.7%)]. The right coronary artery was the most common target for RA (40.8%), followed by the left anterior descending (34.1%), left circumflex (14.8%), and left main stem artery (10.3%). Altogether 20 (6%) patients required intraprocedural atropine therapy. Emergency TPW insertion was needed in one (0.3%) patient only. Eight (2.4%) patients died, although only one (0.3%) was adjudicated as being possibly related to RA-induced bradycardia. Five patients (1.5%) had ventricular fibrillation arrest, while nine (2.7%) required cardiopulmonary resuscitation. Six (1.8%) procedures were complicated by coronary perforation, two (0.6%) were complicated by tamponade, while 17 (5.1%) patients experienced vascular access complications.

Conclusions

Bail-out transvenous temporary pacing is very rarely required during RA. A standby temporary pacing strategy seems reasonable and may avoid unnecessary TPW complications compared with routine use.

Analyzing drilling noise in rotational atherectomy: Improving safety and effectiveness through visualization and anomaly detection using autoencoder-A preclinical study

Background and Aims

As the population of aging societies continues to grow, the prevalence of complex coronary artery diseases, including calcification, is expected to increase. Rotational atherectomy (RA) is an essential technique for treating calcified lesions. This study aimed to assess the usefulness of the drilling noise produced during rotablation as a parameter for evaluating the safety and effectiveness of the procedure.

Methods

A human body model mimicking calcified stenotic coronary lesions was constructed using plastic resin, and burrs of sizes 1.25 and 1.5 mm were utilized. To identify the noise source during rotablation, we activated the ROTAPRO™ rotablator at a rotational speed of 180,000 rpm, recording the noise near the burr (inside the mock model) and advancer (outside). In addition to regular operation, we simulated two major complications: burr entrapment and guidewire transection. The drilling noise recorded in Waveform Audio File Format files was converted into spectrograms for analysis and an autoencoder analyzed the image data for anomalies.

Results

The drilling noise from both inside and outside the mock model was predominantly within the 3000 Hz frequency domain. During standard operation, intermittent noise within this range was observed. However, during simulated complications, there were noticeable changes: a drop to 2000 Hz during burr entrapment and a distinct squealing noise during guidewire transection. The autoencoder effectively reduced the spectrogram data into a two-dimensional representation suitable for anomaly detection in potential clinical applications.

Conclusion

By analyzing drilling noise, the evaluation of procedural safety and efficacy during RA can be enhanced.

Rotational atherectomy to left circumflex ostial lesions: tips and tricks

Serious complications including vessel perforation may occur during rotational atherectomy (RA) to left circumflex (LCX) ostial lesions. In fact, if perforation occurs around LCX ostium, bailout procedures including deployment of covered stents may cause fatal ischemia in the territory of left anterior descending artery, which results in broad anterior acute myocardial infarction and subsequent death. In this review article, we described tips and tricks for RA to LCX ostial lesions. First, we should cautiously decide the indication for RA to LCX ostial lesions, because there are several reasons to avoid RA to LCX ostial lesions. Before procedures, we should estimate the difficulty of RA to LCX ostial lesions, which is mainly determined by the combination of the bifurcation angle and the severity of stenosis. Thus, the combination of the large bifurcation angle and the tight stenosis makes RA to LCX ostial lesions most difficult. Appropriate position of guide catheter and RotaWire is a key to successful RA to LCX ostial lesions. Differential cutting is an essential concept for RA to LCX ostial lesions. However, since there is no guarantee that differential cutting always works, small burr (≤ 1.5 mm) would be a safe choice as initial burr for RA to LCX ostial lesions.

Lifetime management of severely calcified coronary lesions: the treatment algorithm focused on the shape of calcification

The concept of lifetime management has not been discussed in the field of percutaneous coronary intervention (PCI), because the durability of drug-eluting stent (DES) is considered to be long enough for most patients. Furthermore, even if in-stent restenosis occurs, the treatment for in-stent restenosis is simple in most cases. On the other hand, the long-term clinical outcomes after DES implantation are worse in severely calcified coronary lesions than in non-calcified lesions. Moreover, the treatment for in-stent calcified restenosis or restenosis due to stent underexpansion is not simple. The concept of lifetime management of severely calcified lesions may be necessary like that of aortic stenosis. Recently, several algorithms have been published in PCI to severely calcified lesions, partly because of the emergence of IVL. These algorithms focus on the selection of cracking and debulking devices for the preparation of stenting. However, the optimal stent expansion does not guarantee the long-term patency, when the target lesion includes calcified nodules. Stent restenosis due to calcified nodules is difficult to manage. In this review article, we propose the algorithm for severely calcified lesions focused on the shape of calcification. We do not need to hesitate stenting when multiple cracks on circumferential calcification are observed by intravascular imaging devices. However, DCB may be an option as final device in some situations, when lifetime management of severely calcified lesions is considered.

Prediction of the debulking effect of rotational atherectomy using optical frequency domain imaging: a prospective study

This study determined the predictive accuracy of optical frequency domain imaging (OFDI) on debulking effects of rotational atherectomy (RA) and compared the predictive accuracy of OFDI catheter-based with Rota wire-based prediction methods. This prospective, single-center, observational study included 55 consecutive patients who underwent OFDI-guided RA. On pre-RA OFDI images, a circle, identical to the Rota burr was drawn at the center of the OFDI catheter (OFDI catheter-based prediction method) or wire (wire-based prediction method). The area overlapping the vessel wall was defined as the predicted ablation area (P-area). The actual ablated area (A-area) was measured by superimposing the OFDI images before and after RA. The overlapping P-area and A-area were defined as overlapped ablation area (O-area), and the predictive accuracy was evaluated by %Correct area (O-area/P-area) and %Error area (A-area  - O-area/A-area). The median %Correct and %Error areas were 47.8% and 41.6%, respectively. Irrelevant ablation (low %Correct-/high % Error areas) and over ablation (high %Correct-/high % Error areas) were related to deep vessel injury and intimal flap outside the P-area. The predictive accuracy was better in the OFDI catheter-based prediction method than the wire-based prediction method in the cross sections where the OFDI catheter and wire came in contact. However, it was better in the latter than the former where the OFDI catheter and wire were not in contact. OFDI-based simulation of the RA effect is feasible though accuracy may be affected by the OFDI catheter and wire position. OFDI-based simulation of RA effect might reduce peri-procedural complications during RA.