Latest Developments in Robotic Percutaneous Coronary Interventions

Since the first robotic-assisted percutaneous coronary intervention procedure (R-PCI) was performed in 2004, there has been a steady evolution in robotic technology, combined with a growth in the number of robotic installations worldwide and operator experience. This review summarises the latest developments in R-PCI with a focus on developments in robotic technology, procedural complexity, tele-stenting and training methods, which have all contributed to the global expansion in R-PCI.

Performance of a novel artificial intelligence software developed to derive coronary fractional flow reserve values from diagnostic angiograms

BACKGROUND

Although invasive measurement of fractional flow reserve (FFR) is recommended to guide revascularization, its routine use is underutilized. Recently, a novel non-invasive software that can instantaneously produce FFR values from the diagnostic angiograms, derived completely from artificial intelligence (AI) algorithms has been developed. We aim to assess the accuracy and diagnostic performance of AI-FFR in a real-world retrospective study.

METHODS

Retrospective, three-center study comparing AI-FFR values with invasive pressure wire-derived FFR obtained in patients undergoing routine diagnostic angiography. The accuracy, sensitivity, and specificity of AI-FFR were analyzed.

RESULTS

A total of 304 vessels from 297 patients were included. Mean invasive FFR was 0.86 vs. 0.85 AI-FFR (mean difference: -0.005, P  = 0.159). The diagnostic performance of AI-FFR demonstrated sensitivity of 91%, specificity 95%, positive predictive value 83% and negative predictive value 97%. Overall accuracy was 94% and the area under curve was 0.93 (95% CI 0.88-0.97). 105 lesions fell around the cutoff value (FFR = 0.75-0.85); in this sub-group, AI-FFR demonstrated sensitivity of 95%, and specificity 94%, with an AUC of 0.94 (95% CI 88.2-98.0). AI-FFR calculation time was 37.5 ± 7.4 s for each angiographic video. In 89% of cases, the software located the target lesion and in 11%, the operator manually marked the target lesion.

CONCLUSION

AI-FFR calculated by an AI-based, angio-derived method, demonstrated excellent diagnostic performance against invasive FFR. AI-FFR calculation was fast with high reproducibility.

Release Our Hostages Now!

It has been the policy of Rambam Maimonides Medical Journal to limit the number of editorials published. However, silence and standing on the sidelines is not an option in light of the atrocities and inhumanity we witnessed on October 7. The savagery of the Hamas massacre was executed indiscriminately upon children, women, older people (some of whom are Holocaust survivors), infants, and even medical professionals caring for the casualties. Currently, there are about 230 women, men, children, and babies being held hostage by Hamas; among them are cancer patients and others with serious disorders, doctors, and other medical professionals. We cannot rest and must address the plight of our hostages who are being held by terrorists motivated by hatred and showing no respect for life, whether that of their enemies, their own people, or even themselves. ...

Robotics, imaging, and artificial intelligence in the catheterisation laboratory

The catheterisation laboratory today combines diagnosis and therapeutics, through various imaging modalities and a prolific list of interventional tools, led by balloons and stents. In this review, we focus primarily on advances in image-based coronary interventions. The X-ray images that are the primary modality for diagnosis and interventions are combined with novel tools for visualisation and display, including multi-imaging co-registration modalities with three- and four-dimensional presentations. Interpretation of the physiologic significance of coronary stenosis based on prior angiographic images is being explored and implemented. Major efforts to reduce X-ray exposure to the staff and the patients, using computer-based algorithms for image processing, and novel methods to limit the radiation spread are being explored. The use of artificial intelligence (AI) and machine learning for better patient care requires attention to universal methods for sharing and combining large data sets and for allowing interpretation and analysis of large cohorts of patients. Barriers to data sharing using integrated and universal protocols should be overcome to allow these methods to become widely applicable. Robotic catheterisation takes the physician away from the ionising radiation spot, enables coronary angioplasty and stenting without compromising safety, and may allow increased precision. Remote coronary procedures over the internet, that have been explored in virtual and animal studies and already applied to patients in a small pilot study, open possibilities for sharing experience across the world without travelling. Application of those technologies to neurovascular, and particularly stroke interventions, may be very timely in view of the need for expert neuro-interventionalists located mostly in central areas.

Israeli underground hospital conversion for treating COVID-19 patients

OBJECTIVE

This paper describes how a large academic medical center solved the challenges of war preparedness and subsequently adapted them for the COVID-19 pandemic.

SETTING

A 1,000-bed academic medical center in Northern Israel has faced two extreme challenges since 2006: operating under missile attack during the 2006 Second Lebanon War, and rapid establishment of a scalable infrastructure for COVID-19 patients. The first challenge led to construction of a dual-use facility: a parking lot during peacetime, and a fully functioning fortified underground emergency hospital (FUEH) in times of emergency. Several drills have confirmed readiness for various scenarios including conventional and unconventional warfare, and treating isolated patients during the Ebola and SARS threats.

RESULTS

The hospital achieved preparedness for patient care during the COVID-19 pandemic, including all facilities and personnel, including infrastructure, laboratories, and innovations, to maintain standard patient care and separate COVID-19 treatment facilities. The hospital's second challenge represented by the COVID-19 pandemic led to adaptation of the FUEH as a key strategic facility in Northern Israel for treating hundreds of COVID-19 patients. Each solution was supported by innovations targeted for specific purposes and needs.

CONCLUSIONS

The function and unique mechanisms used to leverage use of a dual facility was proven viable for several emergency conditions, including the COVID-19 pandemic. Infrastructure and technological flexibility is essential when planning for handling different emergencies situations.

Analyzing Medical Research Results Based on Synthetic Data and Their Relation to Real Data Results: Systematic Comparison From Five Observational Studies

Background

Privacy restrictions limit access to protected patient-derived health information for research purposes. Consequently, data anonymization is required to allow researchers data access for initial analysis before granting institutional review board approval. A system installed and activated at our institution enables synthetic data generation that mimics data from real electronic medical records, wherein only fictitious patients are listed.

Objective

This paper aimed to validate the results obtained when analyzing synthetic structured data for medical research. A comprehensive validation process concerning meaningful clinical questions and various types of data was conducted to assess the accuracy and precision of statistical estimates derived from synthetic patient data.

Methods

A cross-hospital project was conducted to validate results obtained from synthetic data produced for five contemporary studies on various topics. For each study, results derived from synthetic data were compared with those based on real data. In addition, repeatedly generated synthetic datasets were used to estimate the bias and stability of results obtained from synthetic data.

Results

This study demonstrated that results derived from synthetic data were predictive of results from real data. When the number of patients was large relative to the number of variables used, highly accurate and strongly consistent results were observed between synthetic and real data. For studies based on smaller populations that accounted for confounders and modifiers by multivariate models, predictions were of moderate accuracy, yet clear trends were correctly observed.

Conclusions

The use of synthetic structured data provides a close estimate to real data results and is thus a powerful tool in shaping research hypotheses and accessing estimated analyses, without risking patient privacy. Synthetic data enable broad access to data (eg, for out-of-organization researchers), and rapid, safe, and repeatable analysis of data in hospitals or other health organizations where patient privacy is a primary value.

Occluded mammary graft post-coronary bypass surgery: do we need to look for the second one? A case report

Background

Anatomic variations of the left internal mammary artery (LIMA) can influence coronary artery bypass surgical technique as well as posing definite difficulties in the interpretation of angiographic findings. We present an unusual anatomic variant of two LIMAs originating from the left subclavian artery discovered post-coronary artery bypass grafting surgery.

Case summary

A 60-year-old man post-LIMA grafting of the left anterior descending (LAD) coronary artery underwent diagnostic cardiac catheterization. Selective angiography revealed occluded LIMA; therefore, it was decided to proceed with percutaneous coronary intervention (PCI) to the occluded native LAD. Once antegrade flow in the LAD was restored, retrograde filling of a vessel corresponding to the previously grafted LIMA was also detected. Additional contrast injection in the left subclavian artery (LSCA) showed a second patent LIMA originating from the distal segment of the LSCA.

Discussion

This patient has an unusual anatomic variant of two LIMAs originating from the LCSA. The proximal rudimentary LIMA was misinterpreted as an occluded arterial graft while the second, well-developed LIMA connected to the LAD had an unusually distal origin and had therefore been overlooked. This anatomical variant should be kept in mind when the internal mammary graft seems to be occluded.

[RAMBAM - WHERE MEDICINE, TECHNOLOGY AND HUMANITY INTERTWINE]

In this issue, we present a series of articles written by Rambam's physicians, which reflect the scope of research that takes place in the hospital. This incorporates physicians, nurses and related professions, and progress in health care attained through research and technology-based medicine. A central part of our values is a combination of medicine, technology and humanity. Thanks to our unique location in close proximity to the Technion's Baruch and Ruth Rappaport Faculty of Medicine, our commitment to the combination of research and medicine has a unique impact. We invest in the development and promotion of the physician-researcher and the allied health professions involved in the research. We provide a range of research grants throughout the researchers' careers. The "Futures" grant is for a young doctor who wants to be exposed to basic or applied research under the guidance of a senior scientist. The "Ofakim" grant is intended for the senior physician in his initial steps, who is interested in establishing research activity. The "Nitzotz" grant is intended for an entrepreneur who has an idea for a product and wants to build a prototype, as a first step towards establishing a medical technology company. The "Maof" grant is intended for the nurse-investigator, and there are additional grants for other disciplines. In addition, there is a variety of national and international sources to fund research on a competitive basis in all fields, and we encourage our teams to turn to these sources. Cooperation with our neighboring universities, the Technion and the University of Haifa, with the industry around us and with other research and educational institutions, is of paramount importance for the continued development of the basic, applied and clinical research culture on our campus. We recently published an article describing the reasons why Israel has become a medical start-up country in many fields, and one of the leading reasons is the combination of clinical medicine, research and industry. The papers presented in this issue reflect our wide interest in the entire scope of medical professions. It spans internal medicine, surgery, nephrology, cardiology and cardiac surgery, genetics, organ transplantation and other topics. I wish you an interesting and joyful reading of this special issue.

Acute Kidney Injury After Primary Angioplasty: Is Contrast-Induced Nephropathy the Culprit?

Background

Acute kidney injury (AKI) following primary percutaneous coronary intervention (pPCI) is frequently interpreted as contrast‐induced AKI but may result from other insults. We aimed to determine the causal association of contrast material exposure and the incidence of AKI following pPCI using a control group of propensity score–matched patients with ST‐segment–elevation myocardial infarction who were not exposed to contrast material.

Methods and Results

We studied 2025 patients with ST‐segment–elevation myocardial infarction who underwent pPCI and 1025 patients receiving fibrinolysis or no reperfusion who were not exposed to contrast material during the first 72 hours of hospital stay (control group). AKI was defined as creatinine of ≥0.5 mg/dL or >25% rise within 72 hours. AKI rates were similar in the pPCI and control groups (10.3% versus 12.1%, respectively; P=0.38). Propensity score matching resulted in 931 matched pairs with PCI and no PCI, with balanced baseline covariates (standardized difference <0.1). Among propensity score–matched patients, AKI rates were not significantly different with and without PCI (8.6% versus 10.9%, P=0.12). In the pPCI cohort, independent predictors of AKI included age ≥70 years, insulin‐treated diabetes mellitus, diuretic therapy, anterior infarction, baseline estimated glomerular filtration rate, and variables related to the presence of pump failure (higher Killip class, intra‐aortic balloon pump use) and reduced left ventricular ejection fraction but not contrast material dose. A risk score based on the PCI cohort had similar discriminatory capacity for AKI in the control group (C statistic 0.81±0.02 and 0.78±0.02, respectively; P=0.26).

Conclusions

The development of AKI in patients with ST‐segment–elevation myocardial infarction undergoing pPCI is mainly related to older age, baseline estimated glomerular filtration rate, heart failure, and hemodynamic instability. Risk for AKI is similar among ST‐segment–elevation myocardial infarction patients with and without contrast material exposure.

Clinical Experience with a New Nitinol Self-Expanding Stent in Peripheral Arteries

Purpose:

To evaluate a new self-expanding nitinol coil stent in stenotic or occluded peripheral arteries.

Methods:

Seventy-three symptomatic patients (58 men; mean age 67 years) were treated with nitinol stents for lesions in the iliac artery (9 stenoses); superficial femoral artery (SFA) (39 stenoses, 6 occlusions); popliteal artery and tibioperoneal trunk (9 stenoses, 7 occlusions); and 3 bypass grafts. Mean diameter stenosis was 84.4% ± 9.9% (range 75% to 100%), and mean lesion length was 45 ± 23 mm (range 20 to 120 mm).

Results:

Eighty-eight 40-mm-long stents with diameters between 5 and 8 mm were implanted percutaneously for suboptimal dilation (n = 45); dissection (n = 21); and restenosis (n = 7). All stents but one were implanted successfully; the malpositioned stent was removed, and another stent was successfully deployed. There were 3 (4.1%) failures due to thrombosis at 24 hours. During the mean 16-month follow-up (range to 44 months), 4 restenoses (3 femoral, 1 popliteal) have occurred; 2 were treated with repeat dilation and 2 underwent bypass. Primary and secondary patency rates at 18 months were 87% and 90%, respectively, for all lesions (iliac: 100% for both; femoral: 85% and 88%; popliteal: 87% and 100%).

Conclusions:

This new nitinol stent seems to be safe and effective with favorable long-term results, even in distal SFA lesions and popliteal arteries. Its flexibility and resistance to external compression allow its placement in tortuous arteries and near joints.

TCD Evaluation before and after Stenting in Patients with Severe Primary Carotid Artery Stenosis versus Restenosis

Purpose:

To evaluate cerebral hemodynamics before and after carotid angioplasty and stenting (CAS) using transcranial Doppler (TCD).

Methods:

Sixty-eight patients (52 men; mean age 69±9.5 years) with severe carotid stenosis (83.4%±10.2%) were examined by TCD before and 2 months after CAS. Thirty-two (47%) patients had primary carotid stenosis and 36 (53%) had restenosis after carotid endarterectomy (CEA). A broad TCD protocol was employed to estimate cerebral hemodynamics, including assessment of velocities (V) and asymmetry of cerebral blood flow velocity (CBFV) in the middle cerebral artery, (MCA) anterior cerebral artery (ACA), and basilar artery (BA); the pulsatility indexes; and flow acceleration.

Results:

Ipsilateral MCA mean velocities before stenting were 46.3±12.6 cm/s in the primary stenosis group and 47.1±12.3 cm/s in restenosis group; after stenting, the velocities were 53.8±12.1 and 52.7±9.6 cm/s, respectively (p<0.005 for both groups). MCA asymmetry by Vmean before CAS was higher in the primary stenosis group (27.6%±2.4% versus 19.8%±2.3%, p<0.05). After stenting, this index was significantly lower in both groups: 16.4%±2.4% and 12.3%±2.3%, respectively (p<0.0001 for each group). All other TCD parameters improved significantly in both groups after CAS as well (p<0.05), showing the strong hemodynamic effect of this procedure.

Conclusion:

CAS effectively improves cerebral hemodynamics in patients with severe primary and restenosis of the internal carotid artery.

Heart failure in patients with diabetes undergoing primary percutaneous coronary intervention

INTRODUCTION

Diabetes mellitus is associated with increased risk after acute coronary syndromes. Primary percutaneous coronary intervention is the most effective method of reperfusion for acute ST-elevation myocardial infarction and can limit the ischaemic damage to the left ventricle. However, there are few data on the impact of diabetes mellitus on the risk of heart failure following primary percutaneous coronary intervention.

METHODS

We studied 958 ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention, of whom 263 (27.5%) had diabetes mellitus, with 67 (7.0%) treated with insulin. The primary end points of the study were re-admission for heart failure. Secondary end points were all-cause mortality and recurrent infarctions. The follow-up period was 5 years after hospital discharge.

RESULTS

The cumulative incidence of re-admission for heart failure was 8.4%, 15.2% and 26.7% in patients without diabetes mellitus, non-insulin-treated and insulin-treated diabetes mellitus, respectively. Compared with patients without diabetes mellitus, the adjusted hazard ratio for heart failure was 1.95 (95% confidence intervals 1.30-2.93) and 3.09 (95% confidence intervals 1.71-5.60) in non-insulin-treated and insulin-treated diabetes mellitus, respectively. The corresponding hazard ratios for mortality were 1.03 (95% confidence intervals 0.68-1.55) and 2.04 (95% confidence intervals 1.22-3.42), respectively. There was a J-shaped association between fasting glucose levels in the acute phase and risk of mortality (P=0.0001) and a direct association with heart failure (P=0.03).

CONCLUSION

Despite modern treatment of ST-elevation myocardial infarction and high levels of guideline-based medical care, diabetes mellitus had an independent adverse effect on the risk of re-admissions for heart failure, which was particularly high among insulin-treated patients.

The Long and Winding Road to Innovation

Medicine is developing through biomedical technology and innovations. The goal of any innovation in medicine is to improve patient care. Exponential growth in technology has led to the unprecedented growth of medical technology over the last 50 years. Clinician-scientists need to understand the complexity of the innovation process, from concept to product release, when working to bring new clinical solutions to the bedside. Hence, an overview of the innovation process is provided herein. The process involves an invention designed to solve an unmet need, followed by prototype design and optimization, animal studies, pilot and pivotal studies, and regulatory approval. The post-marketing strategy relative to funding, along with analysis of cost benefit, is a critical component for the adoption of new technologies. Examples of the road to innovation are provided, based on the experience with development of the transcatheter aortic valve. Finally, ideas are presented to contribute to the further development of this worldwide trend in innovation.

The formation of an anti-restenotic/anti-thrombotic surface by immobilization of nitric oxide synthase on a metallic carrier

Coronary stenosis due to atherosclerosis, the primary cause of coronary artery disease, is generally treated by balloon dilatation and stent implantation, which can result in damage to the endothelial lining of blood vessels. This leads to the restenosis of the lumen as a consequence of migration and proliferation of smooth muscle cells (SMCs). Nitric oxide (NO), which is produced and secreted by vascular endothelial cells (ECs), is a central anti-inflammatory and anti-atherogenic player in the vasculature. The goal of the present study was to develop an enzymatically active surface capable of converting the prodrug l-arginine, to the active drug, NO, thus providing a targeted drug delivery interface. NO synthase (NOS) was chemically immobilized on the surface of a stainless steel carrier with preservation of its activity. The ability of this functionalized NO-producing surface to prevent or delay processes involved in restenosis and thrombus formation was tested. This surface was found to significantly promote EC adhesion and proliferation while inhibiting that of SMCs. Furthermore, platelet adherence to this surface was markedly inhibited. Beyond the application considered here, this approach can be implemented for the local conversion of any systemically administered prodrug to the active drug, using catalysts attached to the surface of the implant.

Moral dilemmas faced by hospitals in time of war: the Rambam Medical Center during the second Lebanon war

Rambam Medical Center, the only tertiary care center and largest hospital in northern Israel, was subjected to continuous rocket attacks in 2006. This extreme situation posed serious and unprecedented ethical dilemmas to the hospital management. An ambiguous situation arose that required routine patient care in a tertiary modern hospital together with implementation of emergency measures while under direct fire. The physicians responsible for hospital management at that time share some of the moral dilemmas faced, the policy they chose to follow, and offer a retrospective critical reflection in this paper. The hospital's first priority was defined as delivery of emergency surgical and medical services to the wounded from the battlefields and home front, while concomitantly providing the civilian population with all elective medical and surgical services. The need for acute medical service was even more apparent as the situation of conflict led to closure of many ambulatory clinics, while urgent or planned medical care such as open heart surgery and chemotherapy continued. The hospital management took actions to minimize risks to patients, staff, and visitors during the ongoing attacks. Wards were relocated to unused underground spaces and corridors. However due to the shortage of shielded spaces, not all wards and patients could be relocated to safer areas. Modern warfare will most likely continue to involve civilian populations and institutes, blurring the division between peaceful high-tech medicine and the rough battlefront. Hospitals in high war-risk areas must be prepared to function and deliver treatment while under fire or facing similar threats.

High technology in medicine: lessons from cardiovascular innovations and future perspective

Four decades of innovations in the field of interventional cardiology are presented as an example for the great growth of high technology in medicine, side by side with the development of general technology and science. The field of percutaneous coronary intervention (PCI) was enabled by the development of X-ray systems, allowing us to view the pathology, and was critically dependent on courageous and imaginative physicians and scientists who developed percutaneous transluminal coronary angioplasty (PTCA), stents, and transarterial aortic valve replacement (TAVR). Today, outstanding research continues to progress, with stem cell research and IPC technologies presenting new challenges and yet taller mountains to climb. The rapid development we have witnessed was due to tight collaborations between clinical and academic institutions and industry. The combination of all these elements, with a proper mechanism to handle conflict of interest, is an essential linkage for any progress in this field. We will continue to see exponential growth of innovations and must be prepared with appropriate bodies to encourage such developments and to provide early-stage funding and support for novel ideas.

Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law

Israel's organ donation rate has always been among the lowest in Western countries. In 2008 two new laws relevant to organ transplantation were introduced. The Brain-Respiratory Death Law defines the precise circumstances and mechanisms to determine brain death. The Organ Transplantation Law bans reimbursing transplant tourism involving organ trade, grants prioritization in organ allocation to candidates who are registered donors and removes disincentives for living donation by providing modest insurance reimbursement and social supportive services. The preliminary impact of the gradual introduction and implementation of these laws has been witnessed in 2011. Compared to previous years, in 2011 there was a significant increase in the number of deceased organ donors directly related to an increase in organ donation rate (from 7.8 to 11.4 donors per million population), in parallel to a significant increase in the number of new registered donors. In addition the number of kidney transplantations from living donors significantly increased in parallel to a significant decrease in the number of kidney transplantations performed abroad (from 155 in 2006 to 35 in 2011). The new laws have significantly increased both deceased and living organ donation while sharply decreasing transplant tourism.

Repeat in-stent restenosis of drug-eluting stents in a bifurcation treated successfully with kissing drug eluting balloons

The use of drug-coated balloons (DEB) for preventing restenosis is new and has received increasing interest. We present a patient who was admitted with recurrent angina with repeat interventions for restenosis events in a very short time using both BMS and DES. The restenosis was treated with kissing drug eluting balloons in the LAD-Diagonal bifurcation. More than one year after the DEB PCI, the patient is free from symptoms.

Challenges in organ transplantation

Organ transplantation has progressed tremendously with improvements in surgical methods, organ preservation, and pharmaco-immunologic therapies and has become a critical pathway in the management of severe organ failure worldwide. The major sources of organs are deceased donors after brain death; however, a substantial number of organs come from live donations, and a significant number can also be obtained from non-heart-beating donors. Yet, despite progress in medical, pharmacologic, and surgical techniques, the shortage of organs is a worldwide problem that needs to be addressed internationally at the highest possible levels. This particular field involves medical ethics, religion, and society behavior and beliefs. Some of the critical ethical issues that require aggressive interference are organ trafficking, payments for organs, and the delicate balance in live donations between the benefit to the recipient and the possible harm to the donor and others. A major issue in organ transplantation is the definition of death and particularly brain death. Another major critical factor is the internal tendency of a specific society to donate organs. In the review below, we will discuss the various challenges that face organ donation worldwide, and particularly in Israel, and some proposed mechanisms to overcome this difficulty.

Highlights from the Innovations in Cardiovascular Interventions Meeting: in favor of creativity and ingenuity

The annual Innovations in Cardiovascular Interventions Meeting was organized in close collaboration with the Cardiovascular Research Foundation and was co-sponsored by the Society for Coronary Angiography and Interventions. The meeting was co-chaired by Rafael Beyar and Chaim Lotan, and took place in Tel Aviv, Israel, on 6-8 December 2009. It was a continuation of the series of international conferences in interventional cardiology held in Israel since 1995. The meeting is distinctive in that it provides a wide perspective on the innovative technologies and therapies for cardiovascular applications. Unique sessions covering emerging technologies, relationships between academia and industry, as well as regulatory aspects of medical devices provided participants with a wide perspective on current and future technologies. The Innovations in Cardiovascular Interventions Meeting was attended by over 700 participants from over 40 countries, including cardiologists, surgeons, nurses, pharmacists and allied health professionals. The world's leading experts in the field of interventional cardiology, cardiac surgery and radiology presented the latest information on innovative diagnostic and treatment modalities for cardiovascular pathology, and delivered expert lectures and clinical overviews, as well as presentations on the advances and controversies in basic, translational and clinical research. The meeting was accompanied by thematic live cases and a parade of new technology companies. Innovations in Cardiovascular Interventions Meeting 2009 presentations are available to watch and download at www.congress.co.il/ici2009 .

Navigation within the heart and vessels in clinical practice

The field of interventional cardiology has developed at an unprecedented pace on account of the visual and imaging power provided by constantly improving biomedical technologies. Transcatheter-based technology is now routinely used for coronary revascularization and noncoronary interventions using balloon angioplasty, stents, and many other devices. In the early days of interventional practice, the operating physician had to manually navigate catheters and devices under fluoroscopic imaging and was exposed to radiation, with its comcomitant necessity for wearing heavy lead aprons for protection. Until recently, very little has changed in the way procedures have been carried out in the catheterization laboratory. The technological capacity to remotely manipulate devices, using robotic arms and computational tools, has been developed for surgery and other medical procedures. This has brought to practice the powerful combination of the abilities afforded by imaging, navigational tools, and remote control manipulation. This review covers recent developments in navigational tools for catheter positioning, electromagnetic mapping, magnetic resonance imaging (MRI)-based cardiac electrophysiological interventions, and navigation tools through coronary arteries.

Real case virtual reality training prior to carotid artery stenting

BACKGROUND

The majority of procedural training especially in interventional cardiology, still occurs on patients with direct mentoring by experienced physicians during an actual clinical procedure. In recent years there is an increase use of simulators especially for carotid artery stenting. However, most simulators use "generic" predefined cases.

METHODS AND RESULT

We report here a simulation done on data of a real patient prior to intervention. The patient's specific carotid anatomy was modeled using CTA on an endovascular simulator. Pre-procedure patient-specific case rehearsal accurately predicted procedure experience.

CONCLUSIONS

A case rehearsal prior to an intervention may be useful in the planning and execution of carotid artery stenting. The use of patient specific simulation helps with planning of procedure and device selection, and may lead to use of less contrast and radiation, and shorter procedure duration. These may benefit the patient with increased success and lower complication rates.

An academic medical center under prolonged rocket attack--organizational, medical, and financial considerations

The Rambam Medical Center, the major academic health center in northern Israel, serving a population of two million and providing specialized tertiary care, was exposed to an unprecedented experience during the Second Lebanon War in the summer of 2006. For more than one month, it was subjected to continuous rocket attacks, but it continued to provide emergency and routine medical services to the civilian population and also served the military personnel who were evacuated from the battlefront. To accomplish the goals of serving the population while itself being under fire, the Rambam Medical Center had to undertake major organizational decisions, which included maximizing safety within the hospital by shifting patients and departments, ensuring that the hospital was properly fortified, managing the health professional teams' work schedules, and providing needed services for the families of employees. The Rambam Medical Center's Level I trauma center expertise included multidisciplinary teams and extensive collaborations; modern imaging modalities usually reserved for peacetime medical practice were frequently used. The function of the hospital teams during the war was efficient and smooth, based on the long-term actions taken to prepare for disasters and wartime conditions. Routine hospital services continued, although at 60% of normal occupancy. Financial losses incurred were primarily due to the decrease in revenue-generating activity. The two most important components of managing the hospital under these conditions are (1) the ability to arrive at prompt and meaningful decisions with respect to the organizational and medical hospital operations and (2) the leadership and management of the professional staff and teams.

Contrast enhanced multi‐detector computed tomography coronary angiography versus conventional invasive quantitative coronary angiography in acute coronary syndrome patients–correlation and bias

BACKGROUND

Previous studies that compared multi-detector computed tomography (MDCT) non-invasive coronary angiography with conventional coronary angiography, did not assessed the ability of MDCT to detect stenotic lesions correctly in acute coronary syndromes (ACS) patients. The aim of the present study was to assess prospectively the correlation and bias between 16-slice MDCT coronary angiography and quantitative coronary angiography analysis (QCA) in these patients.

METHODS

Patients underwent electrocardiogram-gated, 16-slice MDCT coronary angiography and routine invasive percutaneous coronary angiography with quantitative coronary angiography (QCA) analysis blinded to MDCT results. The correlation and the bias between the results of MDCT and QCA were assessed in segments observed by both modalities in vessels > or = 2 mm in diameter.

RESULTS

59 patients (81% male, age 56 +/- 11 years), admitted due to ACS, underwent MDCT and invasive coronary angiography. 544 segments were analyzed. The correlations between MDCT and QCA observed for the left anterior descending coronary artery (LAD), the left circumflex coronary artery (Cx), the right coronary artery (RCA) and for all analyzed segments were 0.74 (P < 0.0001), 0.54 (P < 0.009), 0.72 (P < 0.0001) and 0.70 (P < 0.0001), respectively. By Bland-Altman analysis, a small overestimation of the lesion severity with MDCT of 4.8% for the LAD, 5.9% for the Cx, and 3.3% for the RCA was observed.

CONCLUSIONS

In ACS patients, MDCT contrast-enhanced coronary angiography provides good quantification of the luminal diameter as compared to coronary angiography, and it is characterized by a small overestimation bias.

Chronic total occlusion due to diffuse in‐stent restenosis: is brachytherapy the solution?

Percutaneous coronary intervention of chronic total occlusions (CTO) is associated with a significantly higher incidence of reocclusion and restenosis compared with non-total occlusions. Randomized and observational trials have demonstrated the effectiveness of intracoronary brachytherapy (ICBT) for the prevention of recurrent in-stent restenosis. However, limited data are available on the effectiveness of ICBT in patients with totally occluded in-stent restenosis. The authors assessed the long-term outcome of patients treated with intracoronary gamma radiation for totally occluded in-stent restenotic lesions. Percutaneous coronary intervention and subsequent catheter-based irradiation with iridium-192 was performed in 100 patients (103 vessels) with diffuse in-stent restenosis. At baseline, CTO of the target vessel at the site of the stent was present in 15 vessels (14.5%). Follow-up data were collected during follow-up visits and from telephone interviews. Repeat coronary angiography was performed in symptomatic patients with clinical restenosis. Clinical and angiographic characteristics were similar between the two groups, although there was a trend towards more unstable angina at the index procedure in CTO patients (66.7% versus 41.4%; p = 0.12) compared with patients without non-total occlusions. A higher percentage of patients (53.3%) with CTO required longer radiation sources (14 seeds, covering a length of 55 mm), compared with 23.9% of patients with non-total occlusion (p = 0.04). With a mean follow-up period of 47.5 +/- 24.0 months, major adverse cardiac events (MACE) were observed in 10 of 15 patients (66.7%) with CTO compared with 25 out of 88 patients (28.4%) without CTO (p = 0.009). According to multivariate analysis, total occlusion of the target vessel at baseline was the single independent predictor of MACE at one-year follow-up (relative risk 16.2, 95% confidence interval 4.2-62.9; p < 0.0001). This study shows that the use of gamma radiation for the prevention of recurrence of in-stent restenosis in patients with CTO does not seem to be as effective as in patients with non-total occlusions. Furthermore, CTO was an independent predictor of worse outcome at long-term follow-up in this study.

Neointimal vascularization and intimal thickening in response to self‐expanding stents: a swine model

BACKGROUND

Neovascularization has been suggested as a biological response to vessel injury and associated with restenosis. Self-expanding (SE) stents generate a lasting force on the arterial wall and may lead to an increased arterial response with time.

OBJECTIVES

To characterize the process of neovascularization with SE stents, and to correlate it with vascular injury, inflammation and intimal proliferation.

METHODS

Sixty-nine SE stents were im-planted in 37 non-atherosclerotic pigs.Detailed, multisection histological examination was performed at 15 days, 1, 3 and 6 months post-deployment. Neo-vascularization in addition to other histologic parameters where determined and scored.

RESULTS

Intravascular-ultrasound-based average vessel diameter was 3.3 +/- 0.04 mm; stent size was 3.75 +/- 0.35 mm leading to an oversizing ratio of 1.14 +/- 0.15. Intimal thickness (IT), inflammatory score (IFS) and vascularization score(VAS) reached peak values at three months (IT = 344 +/- 202 1m, IFS = 0.91 +/- 0.5, and VAS = 1.56 +/- 0.8). In contrast,the injury score (INS) continued to increase at all time-points, with maximum value at six months (INS = 1.6 +/- 0.7). Both vascularization and inflammation indices increased with an increase in the injury score (p < 0.01). When vessels were divided according to vascularization score (VAS <1.5 and >1.5) there was a significant difference in IT.

CONCLUSION

Neovascularization in response to SE stents is a time-dependent phenomenon and interacts with injury and inflammation. The remodeling of the vessel wall caused by the sustained force of the SE stent on the arterial wall enhances the formation of neovascularization. Neointimal formation is related to the degree of neovascularization.