Management of Percutaneous Coronary Intervention Complications: Algorithms From the 2018 and 2019 Seattle Percutaneous Coronary Intervention Complications Conference

Acute Limb Ischemia After Percutaneous Coronary Intervention for Stable Coronary Artery Disease

INTRODUCTION

Despite its severity, there is limited information on the incidence, predictors, and outcomes of acute limb ischemia (ALI) after percutaneous coronary interventions (PCIs) in stable coronary artery disease.

METHODS AND RESULTS

We included all patients undergoing PCI for stable coronary artery disease in the Nationwide Readmissions Database from 2016 to 2020, identifying them using appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), codes. Our primary outcomes were the incidence and predictors of ALI. A total of 629 656 patients underwent PCI for stable coronary artery disease. Of this sample, 3456 (0.55%) had ALI. Peripheral artery disease was the strongest predictor of post-PCI ALI (odds ratio, 53.03 [95% CI, 43.76-64.28], P<0.001). Patients with ALI had a 1.6 times greater risk of in-hospital mortality and a 4.7 times greater risk of in-hospital major amputation. Forty point nine percent of patients with ALI underwent embolectomy, while 11.6% received thrombolysis. Outcomes were similar between ALI of the upper and lower extremity. Patients undergoing embolectomy had greater in-hospital mortality, while the thrombolysis group had greater in-hospital major amputation.

CONCLUSION

ALI is an uncommon complication of PCI but is associated with a high risk of mortality and amputation. Peripheral artery disease is the strongest predictor of post-PCI ALI.

LDL-cholesterol levels and lipid lowering therapy in secondary prevention. Baseline data from the BRING-UP prospective registry

AIMS

To narrow the gap between guidelines recommendation for secondary cardiovascular prevention and clinical practice, we designed a national project based on educational programs and patient data collection.

METHODS

BRING-UP Prevention is an observational, prospective, multicentre study on patients with an atherothrombotic event enrolled in 2 phases: an educational intervention followed by two 3-months data collection, followed by 6 and 12-month follow-up, when the primary, secondary and exploratory endpoints will be evaluated. Clinical characteristics, treatments and target achievement for LDL cholesterol and other modifiable risk factors at baseline are reported in this manuscript.

RESULTS

From September 2023 to February 2024, 189 cardiology centers included 4790 patients, 2500 hospitalized, and 2290 managed as outpatients. Of the 4790 patients, 98 % had CAD, 6.1 % CVD, and 6.9 % PAD. Mean age was 67 ± 11 years, 20 % were females. Patients with LDL-C levels <55 mg/dL were 32.6 %. Patients at target for blood pressure were 39.2 %. Diabetic patients were 27.5 %, HbA1c <7 % was reported in 43.5 % of them. Statins prescription increased from 69 % at entry to 96 % at discharge/end of visit. In 74.5 % of patients, statins were prescribed in combination with ezetimibe. PCSK9-i or inclisiran were prescribed in a low rate of patients.

CONCLUSION

These data show that a low percentage of patients was at goal for LDL-C level and blood pressure. The 6-month follow-up visit will allow us to evaluate the changes in modifiable risk factors.

Psychological consistency network characteristics and influencing factors in patients after percutaneous coronary intervention treatment

BACKGROUND

A psychological sense of coherence (SOC) in percutaneous coronary intervention (PCI) patients is important for disease prognosis, and there is considerable variation between their symptoms. In contrast, network analysis provides a new approach to gaining insight into the complex nature of symptoms and symptom clusters and identifying core symptoms.

AIM

To explore the psychological coherence of symptoms experienced by PCI patients, we aim to analyze differences in their associated factors and employ network analysis to characterize the symptom networks.

METHODS

A total of 472 patients who underwent PCI were selected for a cross-sectional study. The objective was to investigate the association between general patient demographics, medical coping styles, perceived stress status, and symptoms of psychological coherence. Data analysis was conducted using a linear regression model and a network model to visualize psychological coherence and calculate a centrality index.

RESULTS

Post-PCI patients exhibited low levels of psychological coherence, which correlated with factors such as education, income, age, place of residence, adherence to medical examinations, perceived stress, and medical coping style. Network analysis revealed that symptoms within the sense of psychological coherence were strongly interconnected, particularly with SOC2 and SOC8, demonstrating the strongest correlations. Among these, SOC10 emerged as the symptom with the highest intensity, centrality, and proximity, identifying it as the most central symptom.

CONCLUSION

The network model has strong explanatory power in describing the psychological consistency symptoms of patients after PCI, identifying the central SOC symptoms, among which SOC10 is the key to overall SOC enhancement, and there is a strong positive correlation between SOC2 and SOC8, emphasizing the need to consider the synergistic effect of symptoms in intervention measures.

Fractional flow reserve-guided complete vs. culprit-only revascularization in ST-elevation myocardial infarction patients with multivessel disease: a meta-analysis

Background

Among patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, whether fractional flow reserve (FFR) guided complete revascularization (CR) is superior to the now widely used culprit-only (COR) revascularization is unclear.

Methods

We conducted a search of PubMed, Embase, the Cochrane Library, and CNKI for randomized controlled trials comparing FFR-guided CR with COR in STEMI patients with multivessel disease. Data extraction and analysis adhered to Cochrane guidelines, with major adverse cardiac events as the primary outcome.

Results

This meta-analysis included 6 trials involving 3,482 patients. FFR-guided CR was associated with a reduction in major adverse cardiac events (RR: 0.66, 95% CI: 0.46-0.94, 95% PI: 0.20-2.19), ischemia-driven revascularization (RR: 0.27, 95% CI: 0.19-0.40, 95% PI: 0.16-0.46), and repeat percutaneous coronary interventions (RR: 0.35, 95% CI: 0.22-0.50, 95% PI: 0.16-0.78) compared to COR. However, no difference was observed in all-cause mortality (RR: 1.12, 95% CI: 0.86-1.46, 95% PI: 0.79-1.58) or safety outcomes.

Conclusion

FFR-guided CR reduces major adverse cardiac events compared to COR, though benefits may vary across settings. It significantly lowers ischemia-driven revascularization and repeat percutaneous coronary interventions, with no difference in all-cause mortality compared to COR.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/view/CRD42024567524, PROSPERO (CRD42024567524).

Safety and feasibility of cardiac electrophysiology procedures in ambulatory surgery centers

BACKGROUND

Despite their improved safety, by and large, cardiac electrophysiology procedures including catheter ablation (CA), are presently performed in hospital outpatient departments.

OBJECTIVE

This large multicenter study investigated the safety and outcomes associated with various cardiac electrophysiology procedures performed at 6 ambulatory surgery centers (ASCs), primarily during the coronavirus disease 2019 pandemic under the Center for Medicare and Medicaid Services Hospitals Without Walls program.

METHODS

We retrospectively analyzed the outcomes from consecutive electrophysiology procedures performed in ASCs with same-day discharge, including transesophageal echocardiography, cardioversion, cardiac implantable electronic device (CIED) implantation, electrophysiology studies, and CA for atrial fibrillation (AF), atrial flutter (AFL)/supraventricular tachycardia, ventricular premature complexes (VPCs), and atrioventricular node.

RESULTS

Altogether, 4037 procedures were performed, including 779 transesophageal echocardiography/cardioversion procedures (19.3%), 1453 CIED implantation procedures (36.0%), 26 electrophysiology studies (0.6%), and 1779 CA procedures (44.1%) for AF (75.4%), AFL/supraventricular tachycardia (18.8%), VPC (4.7%), and atrioventricular node (1.1%). Overall, 80.2% of CA procedures were for left-sided atrial arrhythmias (AF/atypical AFL) requiring transseptal catheterization. Left-sided VPC ablation procedures (42.2%) were performed using a transseptal/retrograde approach. Adverse event rates were low, but comparable between CIED implantation and CA (0.76% vs 0.73%; P = .93), as were the incidences of urgent/unplanned postprocedure hospitalization (0.48% vs 0.45%; P = .89), respectively. Moreover, the adverse event rates in ASCs vs hospital outpatient departments did not differ for CIED (0.76% vs 0.65%; P = .71) or CA (0.73% vs 0.80%; P = .79).

CONCLUSION

The results from this large multicenter study suggest that ASCs represent a safe and effective setting to perform a variety of cardiac electrophysiology procedures including CA. These findings bear important implications for healthcare delivery and policy.

Clinical characteristics and outcomes of patients undergoing percutaneous coronary intervention at Gesund Cardiac and Medical Center, Addis Ababa, Ethiopia, 2024

INTRODUCTION

Percutaneous coronary intervention (PCI) is a critical procedure for improving blood flow by alleviating arterial blockage. However, its availability in Ethiopia is limited because of insufficient resources, staff, and infrastructure.

OBJECTIVE

To evaluate the clinical characteristics and outcomes of patients who underwent percutaneous coronary intervention at Gesund Cardiac and Medical Center in Addis Ababa, Ethiopia, in 2024.

METHODS

This retrospective observational chart review included 224 patients who underwent percutaneous coronary intervention. Data were collected using a standardized checklist, imported into EPI information v7, and analyzed using SPSS v26. A binary logistic regression model was used to identify factors associated with percutaneous coronary intervention.

RESULTS

The study found that most participants (n = 186, 83%) were male, with a mean age of 57.82 ± 11.5 years. Diabetes mellitus was prevalent among participants (n = 135, 60.3%), followed by hypertension (n = 127, 56.7%). A notable portion (n = 31, 13.8%) had previously undergone percutaneous coronary intervention. Most patients presented with typical chest pain, with ST-Elevation Myocardial Infarction (STEMI) being the primary indication for percutaneous coronary intervention. Post-procedure complications includes significant bleeding (n = 6, 2.6%), myocardial infarction (n = 20, 8.9%), death (n = 2, 0.9%), transfer to another hospital (n = 12, 5.4%), and acute kidney injury (n = 16, 7.14%). The use of bare metal stents was significantly associated with transfer to other hospitals (AOR = 5; 95% CI = 1.69-10.29). Male gender (AOR = 0.09; 95% CI = 0.03-0.34) and a history of myocardial infarction (AOR = 10; 95% CI = 2.31-13.31) were linked to an increased risk of post-percutaneous coronary intervention death.

CONCLUSION AND RECOMMENDATIONS

Our findings suggest that coronary artery stenosis (CAS) is more prevalent in older individuals and men. Chronic illnesses often coexist with coronary artery stenosis, thereby complicating the prognosis. Interestingly, men exhibited a lower risk of unfavorable outcomes compared to women. Adherence to procedural guidelines and effective management techniques are essential for improving patient outcomes following percutaneous coronary intervention.

Retrieving a Stent: Navigating Deep Complications

Objective

The authors describe a case of an infrequent complication of percutaneous coronary intervention in a patient with acute ST-segment elevation myocardial infarction and discuss considerations for its prevention, recognition, and treatment.

Key steps

Diagnostic coronary angiography confirmed an acute total occlusion of the proximal right coronary artery. Angioplasty and stenting were performed without complications. A second stent was advanced to treat a distal lesion. During the advancement, stent dislodgement from the guidewire, with entrapment in the struts of the previously placed stent and migration to the proximal aorta, was identified. A multisnare device was used for stent retrieval, with embolization to the right femoral artery during the process.

Potential pitfalls

Operators should be aware of this potential complication and its management techniques. Stent dislodgement and migration should be rapidly identified and addressed because these adverse events can lead to embolization, thrombosis, and vascular damage.

Heparin Reversal for Coronary Artery Perforation

BACKGROUND

Reversing heparin when managing coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) can provide hemostasis but may cause coronary thrombosis if a device is still present in a coronary artery.

AIMS

To assess the impact of heparin reversal while an intracoronary artery device is in place for CAP.

METHODS

This study analyzed CAP cases during PCI from January 2006 to October 2023. Patients were grouped according to implementing heparin reversal while an intracoronary artery device was in place. The safety outcome was coronary thrombosis after CAP. The efficacy outcomes were successful hemostasis and death from any cause.

RESULTS

CAP occurred in 368 of 22,368 cases (1.6%). Patients who had heparin reversal with a device in place comprised 211 (57%). Among these, coronary thrombosis occurred in 16 (7.6%). An activated clotting time (ACT) 〈150 seconds was significantly correlated with coronary thrombosis. Heparin reversal with a device in place was significantly associated with successful hemostasis (heparin reversal 91% vs. no heparin reversal 73%; adjusted odds ratio 2.78; 95% confidence interval 1.27-6.13; p = 0.011), but was not different for death from any cause (heparin reversal 4.3% vs. no heparin reversal 5.7%; adjusted odds ratio 0.97; 95% confidence interval 0.28-3.43; p = 0.964).

CONCLUSION

Heparin reversal with a device in place was associated with an increased risk of coronary thrombosis when ACT was less than 150 seconds. While it may not have a substantial association with a reduced risk of mortality, it offers an advantage in achieving successful hemostasis.

The Effect of Intravascular Imaging-Guided Percutaneous Coronary Intervention on Coronary Artery Perforation

Background

Intravascular imaging (IVI) complements coronary angiography and may help prevent coronary artery perforation (CAP) during percutaneous coronary intervention (PCI).

Objectives

The authors evaluated whether IVI-guided PCI is associated with a lower risk of PCI-related CAP in a real-world cohort.

Methods

This observational study analyzed consecutive PCI procedures from January 2006 to October 2023. The procedures were divided into 4 groups according to the year performed: 2006 to 2010 (P1), 2011 to 2015 (P2), 2016 to 2020 (P3), and 2021 to 2023 (P4). We evaluated the trend of IVI-guided PCI and the incidence of CAP. A mixed effects logistic model was employed to assess their relationship.

Results

CAP occurred in 368 (1.6%) of 22,368 PCIs. IVI-guided PCI accounted for 63% of all cases, of which 95% were intravascular ultrasound procedures. From P1 to P3, the ratio of IVI-guided PCI increased linearly (P1: 30%, P2: 61%, P3: 93%, P4: 97%), while the incidence of CAP decreased (P1: 2.10%, P2: 1.74%, P3: 1.13%, P4: 1.18%). IVI-guided PCI showed a significant association with a lower risk of the overall incidence of CAP (adjusted OR: 0.78; 95% CI: 0.61-0.99; P = 0.047). This relationship was particularly significant for chronic total occlusion PCI (adjusted OR: 0.59; 95% CI: 0.43-0.80; P = 0.001) and PCI for moderate or severe calcification (adjusted OR: 0.50; 95% CI: 0.33-0.74; P = 0.001).

Conclusions

IVI-guided PCI may help prevent PCI-related CAP, especially in the setting of chronic total occlusion PCI and PCI for moderate or severe calcification.

Complications of percutaneous coronary intervention

Complications of percutaneous coronary intervention (PCI) can lead to significant morbidity and mortality. In-depth understanding of the mechanisms and management options of these complications as well as timely recognition and action can sometimes be lifesaving. In this review we discuss the mechanisms, prevention methods, diagnosis, and management of three major PCI complications: a) perforation b) acute vessel closure, and c) equipment loss.

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.

Continuous Mechanical Suction Use During Chronic Total Occlusion Revascularization

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is high risk compared to non-CTO PCI. Iatrogenic coronary artery hematoma formation is a common occurrence during CTO PCI, impairing true lumen visualization. We describe the use of a continuous mechanical suction (CMS) device in 2 applications in which it was used for successful subintimal hematoma decompression and distal vessel re-entry. Additionally, we briefly review CMS utilization within the published literature. CMS use during CTO may be a viable technique in future revascularization attempts.

Novel retrieving device for coronary stent dislodgement

BACKGROUND

Stent dislodgement is a rare but particularly challenging complication. However, current treatment strategies are suboptimal.

OBJECTIVE

This study sought to preliminarily assess the feasibility of a novel self-expanding basket (SEB) catheter to successfully retrieve dislodged stent during percutaneous coronary intervention (PCI).

METHOD

The novel SEB catheter is designed as a self-expanding basket tip made of superelastic shape nitinol memory alloy, which could automatically expand to tightly wrap and flatten the deformed struts regardless of whether the stent come off the guidewire. Consecutive patients with coronary artery disease who experienced stent dislodgement during PCI were included. The primary outcome was procedure success defined as completely removing the stent without surgical incision of blood vessels, or hemostatic forceps, or injury of access vessels.

RESULTS

From May 2020 to May 2023, a total of 6 patients encountering stent dislodgment were enrolled. Five presented as stent dislodgment with the guidewire in situ and the rest one as total stent and guidewire loss. Successful retrieving of dislodged stent with SEB catheter was achieved in 100% (6 of 6) subjects. After retracting lost stent, 5 of 6 patients received new stent implantation, and one only underwent balloon angioplasty with acceptable imaging results. No safety events were observed.

CONCLUSIONS

This preliminary report of the novel stent retrieving device presents favorable efficacy and safety profile. Further multicenter study is required to confirm these findings.

CLINICAL TRIAL NUMBER

Not applicable.

Exploring research trends and hotspots on PCSK9 inhibitor studies: a bibliometric and visual analysis spanning 2007 to 2023

Background

Following the identification of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, research in this area has experienced significant growth. However, a thorough bibliometric analysis of this burgeoning field remains conspicuously absent. The current study aims to delineate research hotspots and anticipate future trends on PCSK9 inhibitors employing bibliometric analysis.

Methods

A systematic search was conducted in the Web of Science Core Collection (WoSCC) to identify scholarly articles and reviews pertaining to PCSK9 inhibitors, yielding 1,812 documents. Data extraction was followed by analysis and visualization using Excel, VOSviewer, and CiteSpace software.

Results

A total of 1,812 publications were included in the final analysis. Ray, KK from the UK was the most prolific author, followed by Pordy, R from the USA. The USA led in publication output [number of publications (Np):776] and number of citations without self-citations (Nc) at 34,289, as well as an H-index of 93. "Cardiovascular System Cardiology" emerged as the predominant subject area. Amgen and the Journal of Clinical Lipidology were identified as the most active institution and journal, respectively. Keywords such as "lipoprotein(a)," "bempedoic acid," "percutaneous coronary intervention," "inclisiran," "peripheral artery disease," "mortality," and "endothelial dysfunction" are gaining prominence in the field.

Conclusion

The research on PCSK9 inhibitors is experiencing a sustained growth trajectory. The USA exerts considerable influence in this area, with the Journal of Clinical Lipidology expected to feature more groundbreaking studies. Research on "lipoprotein(a)", "bempedoic acid", "percutaneous coronary intervention", "peripheral artery disease", and "endothelial dysfunction" are poised to become focal points of future investigation.

Future Training Pathways in Percutaneous Coronary Interventions: Interventional Critical Care, Complex Coronary Interventions, and Interventional Heart Failure

While there has been a proliferation of training and practice paradigms in the realm of noncoronary interventions, coronary disease remains the predominant pathology necessitating interventional cardiology expertise. The landscape of coronary disease has also experienced a significant transformation due to rapidly evolving technologies, clinical application of mechanical circulatory support and other device innovations, and increasing acuity and complexity of patients. The modern interventional cardiologist is subject to challenges including decreasing coronary procedural volume, need to maintain clinical and financial productivity, and often also requirements of continued scholastic pursuit. Therefore, in the coming decade, there will be greater impetus to develop expertise in multiple new domains of practice. In this document, we propose 3 training paradigms that may assist the tertiary/quaternary center coronary interventional cardiologist to develop a unique clinical/scholastic niche, maintain clinical skills and productivity, and develop care models for complex patients within local and regional tertiary/quaternary hospitals.

Bezafibrate mitigates cardiac injury against coronary microembolization by preventing activation of p38 MAPK/NF-κB signaling

Coronary microembolization (CME)-induced inflammatory response and cardiomyocyte apoptosis are the main contributors to CME-associated myocardial dysfunction. Bezafibrate, a peroxisome proliferator-activated receptors (PPARs) agonist, has displayed various benefits in different types of diseases. However, it is unknown whether Bezafibrate possesses a protective effect in myocardial dysfunction against CME. In this study, we aimed to investigate the pharmacological function of Bezafibrate in CME-induced insults in myocardial injury and progressive cardiac dysfunction and explore the underlying mechanism. A CME model was established in rats, and cardiac function was detected. The levels of injury biomarkers in serum including CK-MB, AST, and LDH were determined using commercial kits, and pro-inflammatory mediators including TNF-α and IL-6 were detected using ELISA kits. Our results indicate that Bezafibrate improved cardiac function after CME induction. Bezafibrate reduced the release of myocardial injury indicators such as CK-MB, AST, and LDH in CME rats. We also found that Bezafibrate ameliorated oxidative stress by increasing the levels of the antioxidant GPx and the activity of SOD and reducing the levels of TBARS and the activity of NOX. Bezafibrate inhibited the expression of pro-inflammatory cytokines such as TNF-α and IL-6. Importantly, Bezafibrate was found to mitigate CME-induced myocardial apoptosis by increasing the expression of Bcl-2 and reducing the levels of Bax and cleaved caspase-3. Mechanistically, Bezafibrate could prevent the activation of p38 MAPK/NF-κB signaling. These findings suggest that Bezafibrate may be a candidate therapeutic agent for cardioprotection against CME in clinical applications.

Mechanical Barrier for Prevention of Dislodged Stent Embolization in Saphenous Vein Graft

Percutaneous coronary interventions in vein grafts can be quite challenging, and many complications can occur during the procedure. We present a case of stent dislodgment during percutaneous coronary intervention in a vein graft. It was migrating to the proximal part of the graft and a covered stent was placed in the native vessel in order to isolate the graft. During follow-up, the position of the stent was evaluated by coronary computed tomography angiography. Dislocation of the stent from the balloon can cause undesirable effects. In cases of vein grafts, isolation of the graft could be an effective strategy for avoiding further difficulties. Coronary computed tomography angiography can be used for follow-up imaging.

Simultaneous Percutaneous Coronary Intervention (PCI) and Endovascular Aneurysm Repair (EVAR): A Preliminary Report

Background: Performing percutaneous coronary intervention (PCI) and endovascular aneurysm repair (EVAR) at the same time represents a groundbreaking development in the multidisciplinary treatment of cardiovascular disease. This combined PCI-EVAR approach bridges a critical gap by offering treatment for patients who have both coronary artery disease and aortic aneurysms. This innovative strategy exemplifies the evolving landscape of cardiovascular care, providing a new solution for complex clinical situations that previously required separate procedures. Methods: Six patients with critical coronary artery lesions and asymptomatic infrarenal aortic aneurysms (AAAs) ≥ 6 cm diameter, as well as one patient with critical coronary artery lesions and endoleak type 1A with aneurysms ≥ 6 cm, underwent simultaneous coronary artery revascularization through percutaneous intervention (PCI) and endovascular aneurysm repair (EVAR). The occurrence of any intraoperative or postoperative complication was considered to be the primary endpoint of the study, including the abortion or failure of either PCI or EVAR, bleeding requiring a conversion to open surgical procedures, the failure of local anesthesia, postoperative myocardial or lower limb ischemia, and a postoperative serum creatinine level of >125 mmol/L or of >180 mmol/L in patients affected by chronic renal failure. The overall length of the procedure, X-ray exposure, the quantity of iodine contrast medium administered, and the length of recovery were considered to be secondary endpoints. Results: Postoperative complications included two episodes of acute renal failure in the two patients already affected by chronic renal failure, which were easily resolved with adequate daily hydration and the elimination of nephrotoxic drugs. In no cases did cardiac ischemia or lower limb ischemia occur. The average procedure duration was 198 min (range: 180-240 min), the average fluoroscopy duration was 41.7 min (range: 35-50 min), the average amount of iodinated contrast medium was 34.8 mL (range: 30-40 mL), and the mean length of hospitalization was 2.7 days (range: 2-5 days). Conclusions: In selected patients, this surgical approach has demonstrated safety, reduced hospitalization times, minimized risks associated with complications from the untreated condition if procedures were performed at different times, and facilitated the effective management of intraoperative complications due to the presence of a multidisciplinary team. However, the limited number of patients necessitates further research.

Oral mitochondrial transplantation using nanomotors to treat ischaemic heart disease

Mitochondrial transplantation is an important therapeutic strategy for restoring energy supply in patients with ischaemic heart disease (IHD); however, it is limited by the invasiveness of the transplantation method and loss of mitochondrial activity. Here we report successful mitochondrial transplantation by oral administration for IHD therapy. A nitric-oxide-releasing nanomotor is modified on the mitochondria surface to obtain nanomotorized mitochondria with chemotactic targeting ability towards damaged heart tissue due to nanomotor action. The nanomotorized mitochondria are packaged in enteric capsules to protect them from gastric acid erosion. After oral delivery the mitochondria are released in the intestine, where they are quickly absorbed by intestinal cells and secreted into the bloodstream, allowing delivery to the damaged heart tissue. The regulation of disease microenvironment by the nanomotorized mitochondria can not only achieve rapid uptake and high retention of mitochondria by damaged cardiomyocytes but also maintains high activity of the transplanted mitochondria. Furthermore, results from animal models of IHD indicate that the accumulated nanomotorized mitochondria in the damaged heart tissue can regulate cardiac metabolism at the transcriptional level, thus preventing IHD progression. This strategy has the potential to change the therapeutic strategy used to treat IHD.

Comparative Analysis of Right vs. Left Radial Access in Percutaneous Coronary Intervention: Impact on Silent Cerebral Ischemia

Background and Objectives: Silent cerebral ischemia (SCI) is defined as a condition that can be detected by biochemical markers or cranial imaging methods but does not produce clinical symptom. This study aims both to compare the frequency of SCI in PCIs performed with right transradial access and left transradial access and to evaluate the influencing factors. Materials and Methods: A prospective, single-center study included 197 patients undergoing PCI via transradial access between November 2020 and July 2022. The patients were categorized into right radial and left radial groups. Neuron-specific enolase (NSE) values were measured and recorded before and 18 h after the procedure. A post-procedure NSE level higher than 20 ng/dL was defined as SCI. Results: SCI occurred in 60 of the 197 patients. NSE elevation was observed in 37.4% (n = 37) of the right radial group and in 23.5% (n = 23) of the left radial group (p = 0.032). Patients with SCI had higher rates of smoking (p = 0.043), presence of subclavian tortuosity (p = 0.027), and HbA1c (p = 0.031). In the multivariate logistic regression analysis, the level of EF (ejection fraction) (OR: 0.958 95% CI 0.920-0.998, p = 0.039), right radial preference (OR: 2.104 95% CI 1.102-3.995 p = 0.023), and smoking (OR: 2.088 95% CI 1.105-3.944, p = 0.023) were observed as independent variables of NSE elevation. Conclusions: Our findings suggest that PCI via right radial access poses a greater risk of SCI compared to left radial access. Anatomical considerations and technical challenges associated with right radial procedures and factors such as smoking and low ejection fraction contribute to this elevated risk.

Chronic Total Occlusion Percutaneous Coronary Intervention: Mindset, Culture, and Continuous Improvement

The development of complex and higher-risk indicated procedures (CHIP) and chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has brought new challenges in terms of operator training. Although the technical aspects of learning CHIP/CTO PCI have been described in detail, very little has been discussed concerning the mental skills that the operator must possess or develop to be successful. Moreover, an at least equally important aspect of CHIP/CTO PCI program development is the professional culture of the institution where these complex procedures are performed, because this can mark the difference between a thriving and long-lasting program and one that is quickly bound to fail. This article analyzes the mental attributes of the CHIP/CTO PCI operator and outlines several leadership principles that can be applied to foster a growth culture and develop a thriving program.

Assessing the impact of tear direction in coronary artery dissection on thrombosis development: A hemodynamic computational study

OBJECTIVE

Iatrogenic coronary artery dissection is a complication of coronary intimal injury and dissection due to improper catheter manipulation. The impact of tear direction on the prognosis of coronary artery dissection (CAD) remains unclear. This study examines the hemodynamic effects of different tear directions (transverse and longitudinal) of CAD and evaluates the risk of thrombosis, rupture and further dilatation of CAD.

METHODS

Two types of CAD models (Type I: transverse tear, Type II: longitudinal tear) were reconstructed from the aorto-coronary CTA dataset of 8 healthy cases. Four WSS-based indicators were analyzed, including time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and cross flow index (CFI). A thrombus growth model was also introduced to predict the trend of thrombus growth in CAD with two different tear directions.

RESULTS

For most of the WSS-based indicators, including TAWSS, RRT, and CFI, no statistically significant differences were observed across the CAD models with varying tear directions, except for OSI, where a significant difference was noted (p < 0.05). Meanwhile, in terms of thrombus growth, the thrombus growing at the tear of the Type I (transverse tear) CAD model extended into the true lumen earlier than that of the Type II (longitudinal tear) model.

CONCLUSIONS

Numerical simulations suggest that: (1) The CAD with transverse tear have a high risk of further tearing of the dissection at the distal end of the tear. (2) The CAD with longitudinal tear create a hemodynamic environment characterized by low TAWSS and high OSI in the false lumen, which may additionally increase the risk of vessel wall injury. (3) The CAD with transverse tear may have a higher risk of thrombosis and coronary obstruction and myocardial ischemia in the early phase of the dissection.

Attempted retrieval of guidewire fragment using the twisting wire technique causes coronary perfusion: Case report

RATIONALE

Guidewire fracture is one of the biggest risks of percutaneous coronary intervention, twisting wire technique is very useful for retrieving the fractured wire, but the potential risks have been inadequately reported. Herein, we present a case of retrieval of guidewire fragments using the twisting wire technique that causes coronary perfusion.

PATIENT CONCERNS

A 37-year-old male patient was admitted to our hospital for elective percutaneous coronary intervention of the left circumflex coronary artery.

CLINICAL FINDINGS

For chronic total occlusion of the distal left circumflex coronary artery, antegrade recanalization by wire escalation, and parallel wire techniques were attempted. However, we shockingly found that the BMW guidewire, anchored in the right coronary artery, spontaneously fractured from the proximal right coronary artery, and a lengthy fragment of the guidewire remained in the coronary.

DIAGNOSES, INTERVENTIONS, AND OUTCOMES

Many attempts were made to retrieve the remnant guidewire including the twisting wire technique, which leads to the perforation of the coronary.

OUTCOMES

Finally, percutaneous retrieving procedures were stopped in favor of surgical extraction via a small coronary arteriotomy. This procedure was successful.

LESSONS

To the best of our knowledge, the present case is the first reported spontaneous fracture of the guidewire. Leaving such a lengthy remnant guidewire in the artery, or leaving stenting over the wire, would impose a high risk of coronary thrombosis, perforation, and embolization. Yet, the perforation of the artery that occurred in this case, which could have had life-threatening consequences, resulted from our attempts to retrieve the guidewire using the twisting wire technique.

Practice differences and knowledge gaps in complex and high-risk interventions between Japan and the USA: A case-based discussion

Advances in percutaneous coronary intervention (PCI) devices and techniques have expanded the pool of eligible patients for revascularization, including those with comorbidities, reduced left ventricular function, or anatomical complexity (defined as CHIP: complex and high-risk interventions in indicated patients). CHIP interventions are typically performed by selected operators who specialize in complex PCI. This review presents two cases performed in the USA, to discuss the similarities and differences in practice patterns between CHIP operators in Japan and the USA. The first case involves a 58-year-old male presenting with myocardial infarction and cardiogenic shock, and the second case involves a 51-year-old female with a history of coronary artery bypass grafting presenting with a chronic total occlusion and PCI complicated by vessel perforation. The discussion focuses on appropriate patient selection, the role of the heart team approach for decision-making, the use of hemodynamic support devices, and other relevant factors. By comparing practices in Japan and the USA, this review highlights opportunities for knowledge exchange and potential areas for improving patient outcomes.

To Repair a Broken Heart: Stem Cells in Ischemic Heart Disease

Despite improvements in contemporary medical and surgical therapies, cardiovascular disease (CVD) remains a significant cause of worldwide morbidity and mortality; more specifically, ischemic heart disease (IHD) may affect individuals as young as 20 years old. Typically managed with guideline-directed medical therapy, interventional or surgical methods, the incurred cardiomyocyte loss is not always completely reversible; however, recent research into various stem cell (SC) populations has highlighted their potential for the treatment and perhaps regeneration of injured cardiac tissue, either directly through cellular replacement or indirectly through local paracrine effects. Different stem cell (SC) types have been employed in studies of infarcted myocardium, both in animal models of myocardial infarction (MI) as well as in clinical studies of MI patients, including embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs), Muse cells, multipotent stem cells such as bone marrow-derived cells, mesenchymal stem cells (MSCs) and cardiac stem and progenitor cells (CSC/CPCs). These have been delivered as is, in the form of cell therapies, or have been used to generate tissue-engineered (TE) constructs with variable results. In this text, we sought to perform a narrative review of experimental and clinical studies employing various stem cells (SC) for the treatment of infarcted myocardium within the last two decades, with an emphasis on therapies administered through thoracic incision or through percutaneous coronary interventions (PCI), to elucidate possible mechanisms of action and therapeutic effects of such cell therapies when employed in a surgical or interventional manner.

The Significance of Coronary Artery Calcification for Percutaneous Coronary Interventions

The prevalence of calcium deposits in coronary arteries grows with age. Risk factors include, e.g., diabetes and chronic kidney disease. There are several underlying pathophysiological mechanisms of calcium deposition. Severe calcification increases the complexity of percutaneous coronary interventions. Invasive techniques to modify the calcified atherosclerotic plaque before stenting have been developed over the last years. They include balloon- and non-balloon-based techniques. Rotational atherectomy has been the most common technique to treat calcified lesions but new techniques are emerging (orbital atherectomy, intravascular lithotripsy, laser atherectomy). The use of intravascular imaging (intravascular ultrasound and optical coherence tomography) is especially important during the procedures in order to choose the optimal strategy and to assess the final effect of the procedure. This review provides an overview of the role of coronary calcification for percutaneous coronary interventions.

A non-interventional cardiologist's guide to coronary chronic total occlusions

Coronary chronic total occlusions (CTO) are present in up to one-third of patients with coronary artery disease (CAD). It is thus essential for all clinical cardiologists to possess a basic awareness and understanding of CTOs, including optimal evaluation and management. While percutaneous coronary intervention (PCI) for CTO lesions has many similarities to non-CTO PCI, there are important considerations pertaining to pre-procedural evaluation, interventional techniques, procedural complications, and post-procedure management and follow-up unique to patients undergoing this highly specialized intervention. Distinct from other existing topical reviews, the current manuscript focuses on key knowledge relevant to non-interventional cardiologists.

The Association Between Myocardial Bridging and Hypertrophic Cardiomyopathy and Their Implications on Percutaneous Coronary Intervention Outcomes: A Retrospective Study

Hypertrophic cardiomyopathy (HCM) is a complex cardiac disorder, often associated with adverse outcomes, including sudden cardiac death. Myocardial bridging (MB), where a coronary artery segment traverses intramurally within the myocardium, complicates coronary blood flow dynamics. This retrospective study investigates the relationship between MB and HCM and their impact on percutaneous coronary intervention (PCI) outcomes. Data from the 2019 National Inpatient Sample (NIS), representing 20% of U.S. hospitalizations, was utilized. Patients with both HCM and MB undergoing PCI were identified and analyzed. The study assessed inpatient outcomes, including mortality, length of stay, hospital cost, and post-PCI complications (atrial fibrillation, acute kidney injury, bleeding, coronary dissection). Patients with HCM and MB exhibited distinct demographics. The study did not find significant associations between HCM/MB and inpatient mortality, length of stay, or hospital cost. However, HCM patients had a higher incidence of atrial fibrillation and acute kidney injury post-PCI (aOR 2.33, 95% CI 1.46 to 3.71, p ≤ 0.001). MB was linked to increased occurrences of acute heart failure (aOR 0.62, 95% CI 0.42-0.92, p = 0.02) and post-PCI bleeding (aOR 4.88, 95% CI 1.17-20.2, p = 0.03). This nationwide study reveals unique demographic profiles for HCM and MB patients. Notably, HCM patients face higher risks of post-PCI complications, including atrial fibrillation and acute kidney injury. These findings provide fresh insights into the MB-HCM relationship and its implications for PCI outcomes. They emphasize the need for tailored interventions and improved patient management in cases involving both HCM and MB.

Impact of same-admission percutaneous coronary intervention on periprocedural outcomes of transcatheter aortic valve implantation

Background

Current guidelines recommend percutaneous coronary intervention (PCI) prior to transcatheter aortic valve implantation (TAVI) if significant coronary artery disease is present, but whether PCI should be done in the same admission as TAVI is not determined.

Methods

We retrospectively analyzed the National Inpatient Sample from 2016 to 2019 to compare TAVI with and without same-admission PCI and compare in-hospital outcomes after propensity score matching.

Results

Among 170,030 hospitalizations for TAVI, 4425 (2.6%) had same-admission PCI performed. After propensity score matching, 4425 hospitalizations were allocated to those with and without same-admission PCI. No difference in in-hospital mortality (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.81-3.12) was observed between the two groups. However, TAVI with same-admission PCI was associated with higher odds of cardiac arrest (OR 2.25, 95% CI 1.02-4.98), cardiogenic shock (OR 2.21, 95% CI 1.29-3.79), and acute myocardial infarction (OR 3.23, 95% CI 2.11-4.93). It was also associated with longer length of stay and more expensive hospital cost.

Conclusion

TAVI with same-admission PCI was associated with higher odds of periprocedural complications and higher immediate cost. Our findings should be interpreted in the context of the same-admission PCI and TAVI cohort potentially being sicker and the isolated TAVI control group may or may not having obstructive coronary artery disease.

Construction of nursing-sensitive quality indicator system for cardiac rehabilitation of patients undergoing percutaneous coronary intervention based on structure-process-outcome model

BACKGROUND

Coronary heart disease (CHD) is a cardiovascular disease with high mortality. At present, percutaneous coronary intervention (PCI) is considered as the main effective treatment for CHD due to less trauma, shorter course of treatment, and better curative effect. However, PCI alone is not a permanent cure, so cardiac rehabilitation (CR) is needed for a supplement. Nowadays, the evaluation of the nursing-sensitive quality of CR after PCI focuses on the outcomes of patients, lacks a complete evaluation indicator system, and is prone to problems such as nursing management imbalance.

OBJECTIVE

A scientific, sensitive, comprehensive and practical nursing-sensitive quality indicator system based on the structure-process-outcome model was constructed to provide a reference for evaluating nursing-sensitive quality of CR after PCI.

METHODS

Firstly, through literature analysis and semi-structured interview, the indicator system was collected, screened and determined. Then, the framework of the indicator system was established, and the draft of nursing-sensitive quality indicator system of CR after PCI was formed. Subsequently, the nursing-sensitive quality indicator system of CR after PCI was initially established using Delphi method. Finally, the specific weight was determined by analytic hierarchy process (AHP), and the nursing-sensitive quality indicator system of CR after PCI was established and perfected.

RESULTS

Two rounds of expert consultations were separately given 15 questionnaires, and all these questionnaires were returned, with a questionnaire response rate of 100%. Such result indicated that experts were highly motivated. Besides, the authoritative coefficients for two rounds of expert consultations were 0.865 and 0.888, and the coordination coefficients were 0.491 and 0.522, respectively. Hence, the experts' authority and coordination were high and the results were reliable. After the second round of expert consultation, the nursing-sensitive quality indicator system of CR after PCI was established, eventually. This system consisted of 3 first-level indicators (structural indicator, process indicator and outcome indicator), 11 s-level indicators and 29 third-level indicators.

CONCLUSION

A relatively complete and reliable nursing-sensitive quality indicator system of CR after PCI has been established in this study. Such system is scientific and reliable and can provide a reference for the evaluation of clinical teaching quality of CR after PCI.

Rotational Atherectomy, Orbital Atherectomy, and Intravascular Lithotripsy Comparison for Calcified Coronary Lesions

In order to improve the percutaneous treatment of coronary artery calcifications (CAC) before stent implantation, methods such as rotational atherectomy (RA), orbital atherectomy (OA), and coronary intravascular lithotripsy (IVL) were invented. These techniques use different mechanisms of action and therefore have various short- and long-term outcomes. IVL employs sonic waves to modify CAC, whereas RA and OA use a rapidly rotating burr or crown. These methods have specific advantages and limitations, regarding their cost-efficiency, the movement of the device, their usefulness given the individual anatomy of both the lesion and the vessel, and the risk of specified complications. This study reviews the key findings of peer-reviewed articles available on Google Scholar with the keywords RA, OA, and IVL. Based on the collected data, successful stent delivery was assessed as 97.7% for OA, 92.4% for IVL, and 92.5% for RA, and 30-day prevalence of MACE (Major Adverse Cardiac Events) in OA-10.4%, IVL-7.2%, and RA-5%. There were no significant differences in the 1-year MACE. Compared to RA, OA and IVL are cost-effective approaches, but this is substantially dependent on the reimbursement system of the particular country. There is no standard method of CAC modification; therefore, a tailor-made approach is required.

Delayed coronary perforation four days after percutaneous coronary intervention with subsequent cardiac tamponade: A case report

Coronary artery perforation (CAP) is a rare but lethal complication of percutaneous coronary interventions (PCIs), and its incidence has been increasing with advances in PCI techniques. Delayed CAP presents a highly challenging complication, as it occurs 30 min-9 days after intervention, making subsequent diagnosis and treatment difficult. We present the case of a 63-year-old male patient who underwent PCI for an obtuse marginalis II because of posterior wall myocardial infarction. Following 4 days of uneventful postoperative stay, the patient developed angina pectoris and hypotension 4 h after reinitiation of anticoagulant therapy with edoxaban. Angiography revealed distal vessel perforation from a side branch of the obtuse marginalis II. The vessel was occluded using autologous fat embolization via a microcatheter, resulting in complete sealing of the perforation. After discharge, 4 weeks after the infarction, the patient started rehabilitation therapy. Distal vessel perforations are typically caused by wire damage. In our case, we also suspected distal wire perforation, which was initially not recognized possibly due to distal occlusion through the thrombotic material. The temporal correlation between the re-initiation of anticoagulant therapy and the occurrence of cardiac tamponade suggests that the thrombotic material was resolved due to the former. The management of delayed CAP does not differ from that of CAP; thus, this rare complication should be considered even days after PCI as it could prove lethal if not recognized early.

In-hospital outcomes and conditions in patients with acute coronary syndrome and coronary artery aneurysms who undergo percutaneous coronary intervention

BACKGROUND

Coronary artery aneurysms (CAA) are uncommon, often incidental findings in patients with acute coronary syndrome (ACS) that represent a management challenge due to as there is a paucity of literature in this area.

METHODS

We analyzed the National Inpatient Sample database from 2016 to 2020 by including all patients with the admission diagnosis of the ACS who underwent percutaneous coronary intervention (PCI). We sought to evaluate the association of CAA with other relevant systemic conditions and determine the impact of CAA on in-hospital outcomes.

RESULTS

Among 1,733,655 hospital admission with ACS who underwent PCI, 2675 had CAA. There was a 2-fold increase in odds of CAA if the patient had coronary artery dissection (OR 2.05 95%CI 1.12-3.75, p = 0.020) or extracoronary aneurysm (OR 2.47 95%CI 1.46-4.16, p = 0.001) and a 3-fold increase in odds if they had a systematic inflammatory disorder (OR 3.24 95%CI 2.08-5.07, p < 0.001). CAA was not associated with increased odds of mortality (OR 1.22 95%CI 0.76-1.95, p = 0.42), bleeding (OR 1.29 95%CI 0.86-1.95, p = 0.22), acute stroke (OR 0.91 95%CI 0.40-2.07, p = 0.83), major adverse cardiac and cerebrovascular events (OR 1.08 95%CI 0.72-1.61, p = 0.71) or cardiac complications (OR 0.85 95%CI 0.49-1.47, p = 0.55). However, it was significantly associated with increased odds of vascular complications (OR 2.17 95%CI 1.47-3.19, p < 0.001).

CONCLUSIONS

For patients with ACS who undergo PCI, the presence of CAA is associated with greater odds of vascular complications but after adjustments there was no difference in mortality or other complications. In this population, CAA is more prevalent in patients with coronary dissection, extracoronary aneurysms and systemic inflammatory disorders.

Safe and predictable transcatheter removal of broken coronary guidewires: the 'knuckle-twister' technique: a case series report

Background

Guidewire fracture and loss is a rare but well-known and feared complication of percutaneous coronary interventions. With the increasing number of complex coronary interventions and procedures for chronic total occlusions, operators face new challenges and boundaries, and the need for solutions to otherwise rare complications is increasing.

Case summary

We have developed a simple and practical method for retrieving fractured and lost guidewires, called the 'knuckle-twister' technique. This article summarizes seven cases in which guidewires lost in the coronary vasculature have been successfully removed and describes this technique in detail. The goal was to gather different clinical scenarios: free wire lost in situ, wire jailed behind stent struts, wire in small branches, part of the wire protruding into the aorta, 'invisible' guidewire microfilaments/coils, etc.

Discussion

The innovation of the knuckle-twister consists in folding a polymer-jacketed guidewire and transforming it into an open lasso that tightens when twisted. In vitro, its grip strength and pulling force was tested and exceeded 1.5 kg. Moreover, in all in vivo cases, the lost material could be efficiently and quite rapidly retrieved with this simple and highly reproducible technique.

Key clinical message

Broken guidewires that were lost in the coronary vasculature can be safely retrieved with this novel and simple technique requiring no special safety equipment.

Single versus Dual-Operator Approaches for Percutaneous Coronary Interventions within Chronic Total Occlusion-An Analysis of 27,788 Patients

(1) Background: Since the treatment of chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) is associated with high procedural complexity, it has been suggested to use a multi-operator approach. This study was aimed at evaluating the procedural outcomes of single (SO) versus dual-operator (DO) CTO-PCI approaches. (2) Methods: This retrospective analysis included data from the Polish Registry of Invasive Cardiology Procedures (ORPKI), collected between January 2014 and December 2020. To compare the DO and SO approaches, propensity score matching was introduced with equalized baseline features. (3) Results: The DO approach was applied in 3604 (13%) out of 27,788 CTO-PCI cases. Patients undergoing DO CTO-PCI experienced puncture-site bleeding less often than the SO group (0.1% vs. 0.3%, p = 0.03). No differences were found in the technical success rate (successful revascularization with thrombolysis in myocardial infarction flow grade 2/3) of the SO (72.4%) versus the DO approach (71.2%). Moreover, the presence of either multi-vessel (MVD) or left main coronary artery disease (LMCA) (odds ratio (OR), 1.67 (95% confidence interval (CI), 1.20-2.32); p = 0.002), as well as lower annual and total operator volumes of PCI and CTO-PCI, could be noted as factors linked with the DO approach. (4) Conclusions: Due to the retrospective character, the findings of this study have to be considered only as hypothesis-generating. DO CTO-PCI was infrequent and was performed on patients who were more likely to have LMCA lesions or MVD. Operators collaboratively performing CTO-PCIs were more likely to have less experience. Puncture-site bleeding occurred less often in the dual-operator group; however, second-operator involvement had no impact on the technical success of the intervention.

Same-Day Discharge After Elective Percutaneous Transcatheter Cardiovascular Interventions

Percutaneous transcatheter interventions have evolved as standard therapies for a variety of cardiovascular diseases, from revascularization for atherosclerotic vascular lesions to the treatment of structural cardiac diseases. Concomitant technological innovations, procedural advancements, and operator experience have contributed to effective therapies with low complication rates, making early hospital discharge safe and common. Same-day discharge presents numerous potential benefits for patients, providers, and health care systems. There are several key elements that are shared across the spectrum of interventional cardiology procedures to create a successful same-day discharge pathway. These include appropriate patient and procedure selection, close postprocedural observation, predischarge assessments specific for each type of procedure, and the existence of a patient support system beyond hospital discharge. This review provides the rationale, available data, and a framework for same-day discharge across the spectrum of coronary, peripheral, and structural cardiovascular interventions.

Percutaneous Coronary Intervention for Chronic Total Occlusion-Contemporary Approach and Future Directions

In the aging society, the issue of coronary chronic total occlusion (CTO) has become a challenge for invasive cardiologists. Despite the lack of clear indications in European and American guidelines, the rates of percutaneous coronary interventions (PCI) for CTO increased over the last years. Well-conducted randomized clinical trials (RCT) and large observational studies brought significant and substantial progress in many CTO blind spots. However, the results regarding the rationale behind revascularization and the long-term benefit of CTO are inconclusive. Knowing the uncertainties regarding PCI CTO, our work sought to sum up and provide a comprehensive review of the latest evidence on percutaneous recanalization of coronary artery chronic total occlusion.

The lost balloon at midnight: a case report reveals the inevitability of heart team existence

BACKGROUND

Dislodgement of a coronary stent-balloon catheter during percutaneous coronary intervention (PCI) is rare but is a life-threatening complication. A 57- year-old male presented with a non-ST elevation myocardial infarction (NSTEMI). Coronary angiography revealed total thrombotic occlusion of the Right coronary artery (RCA). Following the balloon dilatation of the RCA and while trying to retrieve the balloon catheter, the balloon was dislodged from the catheter shaft and entrapped in the coronary vessel. Under cardiopulmonary bypass, with antegrade cardioplegic arrest, the balloon was extracted through a coronary arteriotomy. Right coronary revascularization was done with reversed saphenous vein graft (SVG).

DISCUSSION

Given the variety of equipment that can be retained in the coronary artery and the multitude of mechanisms by which it may be entrapped, there are no straightforward techniques applicable to all situations. Specific guidelines or recommendations on properly managing these potentially life-threatening complications do not exist. However, the most crucial issue in the management of these cases is the hemodynamic status of the patient as well as the coronary flow in the vessel with entrapped device or stent. In our case, the RCA was retrogradely perfused from the left coronary artery, which provided time to transfer the patient to cardiovascular surgical backup.

Diagnostic performance of IVUS-FFR analysis based on generative adversarial network and bifurcation fractal law for assessing myocardial ischemia

Background

IVUS-based virtual FFR (IVUS-FFR) can provide additional functional assessment information to IVUS imaging for the diagnosis of coronary stenosis. IVUS image segmentation and side branch blood flow can affect the accuracy of virtual FFR. The purpose of this study was to evaluate the diagnostic performance of an IVUS-FFR analysis based on generative adversarial networks and bifurcation fractal law, using invasive FFR as a reference.

Method

In this study, a total of 108 vessels were retrospectively collected from 87 patients who underwent IVUS and invasive FFR. IVUS-FFR was performed by analysts who were blinded to invasive FFR. We evaluated the diagnostic performance and computation time of IVUS-FFR, and compared it with that of the FFR-branch (considering side branch blood flow by manually extending the side branch from the bifurcation ostia). We also compared the effects of three bifurcation fractal laws on the accuracy of IVUS-FFR.

Result

The diagnostic accuracy, sensitivity, and specificity for IVUS-FFR to identify invasive FFR≤0.80 were 90.7% (95% CI, 83.6–95.5), 89.7% (95% CI, 78.8–96.1), 92.0% (95% CI, 80.8–97.8), respectively. A good correlation and agreement between IVUS-FFR and invasive FFR were observed. And the average computation time of IVUS-FFR was shorter than that of FFR-branch. In addition to this, we also observe that the HK model is the most accurate among the three bifurcation fractal laws.

Conclusion

Our proposed IVUS-FFR analysis correlates and agrees well with invasive FFR and shows good diagnostic performance. Compared with FFR-branch, IVUS-FFR has the same level of diagnostic performance with significantly lower computation time.

The many roles of urgent catheter interventions: from myocardial infarction to acute stroke and pulmonary embolism

INTRODUCTION

Cardiovascular diseases (CVDs) are the leading cause of cardiovascular mortality and a major contributor to disability worldwide. The prevalence of CVDs is continuously increasing, and from 1990 to 2019, it has doubled. Global cardiovascular mortality has increased from 12.1 million in 1990 to 18.6 million cases in 2019. The development of therapeutic options for these diseases is at the forefront of interest concerning the extensive socio-economic consequences. Modern endovascular transcatheter therapeutic options contribute to the reduction of cardiovascular morbidity and mortality.

AREAS COVERED

The article concentrates on the triad of the most common causes of acute cardiovascular mortality and morbidity - myocardial infarction, ischemic stroke, and pulmonary embolism. Current evidence-based indications, specific interventional techniques, and remaining unsolved issues are reviewed and compared. A personal perspective on the possible implications for the future is provided.

EXPERT OPINION

Primary angioplasty for ST-segment elevation myocardial infarction is a well-established therapeutic option with proven mortality benefits. We suppose that catheter-based interventions for acute stroke will spread quickly from centers of excellence to routine clinical practice. We believe that ongoing research will provide a basis for the expansion of interventional treatment of pulmonary embolism soon.

Validation of the OPEN-CLEAN Chronic Total Occlusion Percutaneous Coronary Intervention Perforation Score in a Multicenter Registry

Coronary artery perforation is one of the most common and feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We evaluated the utility of the recently presented OPEN-CLEAN (Coronary artery bypass graft, Length of occlusion, Ejection fraction, Age, calcificatioN) perforation score in an independent multicenter CTO PCI dataset. Of the 2,270 patients who underwent CTO PCI at 7 centers, 150 (6.6%) suffered coronary artery perforation. Patients with perforations were older (69 ± 10 vs 65 ± 10, p <0.001), more likely to be women (89% vs 82%, p = 0.010), more likely to have history of previous coronary artery bypass graft (38% vs 20%, p <0.001), and unfavorable angiographic characteristics such as blunt stump (64% vs 42%, p <0.001), proximal cap ambiguity (51% vs 33%, p <0.001), and moderate-severe calcification (57% vs 43%, p = 0.001). Technical success was lower in patients with perforations (69% vs 85%, p <0.001). The area under the receiver operating characteristic curve of the OPEN-CLEAN perforation risk model was 0.74 (95% confidence interval 0.68 to 0.79), with good calibration (Hosmer-Lemeshow p = 0.72). We found that the CTO PCI perforation risk increased with higher OPEN-CLEAN scores: 3.5% (score 0 to 1), 3.1% (score 2), 5.3% (score 3), 7.1% (score 4), 11.5% (score 5), 19.8% (score 6 to 7). In conclusion, given its good performance and ease of preprocedural calculation, the OPEN-CLEAN perforation score appears to be useful for quantifying the perforation risk for patients who underwent CTO PCI.

Acute mesenteric ischemia due to percutaneous coronary intervention: A case report

BACKGROUND

Percutaneous coronary intervention (PCI) is extensively used to treat acute coronary syndromes (ACS). Acute mesenteric ischemia is a life-threatening disease if untreated.

CASE SUMMARY

An 81-year-old female presented with 3 d of lethargy and 1 d of dyspnea. On November 16, 2021, the patient developed a coma. Her oxygen saturation dropped to 70%-80%, the patient was admitted to the intensive care unit for further treatment. Chest computed tomography (CT) showed chronic bronchitis, emphysema, and multiple lung infections. Abdominal CT scan showed no obvious abnormalities, but have severely calcified abdominal vessels. The patient received assisted ventilation, and vasoactive, and anti-infection drugs. Troponin level was elevated. Since the patient was in a coma, it could not be determined whether she had chest pain. The cardiologist assumed that the patient had developed ACS; therefore, the patient underwent PCI via the left femoral artery approach, and no obvious abnormalities were found in the left and right coronary arteries. On the second postoperative day, the patient presented with abdominal distension and decreased bowel sounds; constipation was considered and a glycerin enema was administered. On day 4, the patient suddenly lost consciousness, and had decreased blood pressure, abdominal wall swelling with increased tension, and absence of bowel sounds. An urgent abdominal CT scan revealed gas in her hepatic portal system with extensive bowel wall necrosis. The patient died on day 5 due to intractable shock.

CONCLUSION

The potential serious complications in patients undergoing PCI, especially the patients who are hemodynamically unstable and have severely calcified abdominal vessels, should all be considered.

Managing coronary artery perforation after percutaneous coronary intervention

INTRODUCTION

Coronary artery perforation is a serious complication during percutaneous coronary intervention that results in significant increase in morbidity and mortality. In this article, we provide a state-of-the-art overview of the contemporary management of coronary perforation and the possible scenarios that operators may run into during percutaneous coronary interventions.

AREA COVERED

Coronary perforation during percutaneous coronary intervention. Literature search was performed using PubMed and Google Scholar to identify the most recently published articles covering this topic.

EXPERT OPINION

As part of this review, we also provide an expert commentary discussing the nuances in the recognition and management of coronary artery perforation, in addition to future directions, and improvements in technology that could make the management of coronary perforation safer and more effective.

International percutaneous coronary intervention complication survey

OBJECTIVES

To investigate the perceptions of interventional cardiologists (IC) regarding the frequency, impact, and management strategies of percutaneous coronary intervention (PCI) complications.

BACKGROUND

The perceptions and management strategies of ICs of PCI complications have received limited study.

METHODS

Online survey on PCI complications: 46 questions were distributed via email lists and Twitter to ICs.

RESULTS

Of 11,663 contacts, 821 responded (7% response rate): 60% were from the United States and the median age was 46-50 years. Annual PCI case numbers were <100 (26%), 100-199 (37%), 200-299 (21%), and ≥300 (16%); 42% do not perform structural interventions, others reported performing <40 (30%), or >100 (11%) structural cases annually. On a scale of 0-10, participating ICs were highly concerned about potential complications with a median score of 7.2 (interquartile range: 5.0-8.7). The most feared complication was death (39%), followed by coronary perforation (26%) and stroke (9%). Covered stents were never deployed by 21%, and 32% deployed at least one during the past year; 79% have never used fat to seal perforations; 64% have never used coils for perforations. Complications were attributed to higher patient/angiographic complexity by 68% and seen as opportunities for improvement by 70%; 97% of participants were interested in learning more about the management of PCI complications. The most useful learning methods were meetings (66%), webinars (48%), YouTube (32%), and Twitter (29%).

CONCLUSION

ICs who participated in the survey are highly concerned about complications. Following complication management algorithms and having access to more experienced operators might alleviate stress and optimize patient outcomes.