Modes of failure with fractional flow reserve guidewires: Insights from the manufacturer and user facility device experience database

BACKGROUND

Fractional flow reserve (FFR) measurement is commonly used in the cardiac catheterization laboratory to assess the functional significance of coronary arterial plaques. Robust real-world data on complications and modes of failure of FFR guidewires are limited.

AIM

To characterize these outcomes by analyzing the post-marketing surveillance data from the United States Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database for commonly used FFR guidewires.

METHODS

The MAUDE database was queried from January 2010 through April 2020 for 3 FFR guidewires [PressureWire^TM X (Abbott), Comet^TM (Boston Scientific), and Verrata^TM (Philips)] by searching for the following events: “Injury”, “malfunction”, “death”, and “other”. This yielded 544 reports. After excluding incomplete reports, 486 reports were analyzed.

RESULTS

Guidewire tip fracture was the most commonly reported mode of failure, in 174 (35.8%) cases followed by guidewire kinking (n = 152, 31.3%), communication failure (n = 141, 29.0%), and shaft fracture (n = 67, 13.8%). In total, 133 (27.4%) device failures resulted in patient adverse events. The most common adverse event was retained guidewire tip, in 71 (53.4%) cases, followed by freshly deployed stent dislodgment (n = 26, 19.6%) and coronary artery dissection (n = 23, 17.3%). Seven deaths were reported.

CONCLUSION

FFR guidewire failures can occur because of various mechanisms and cause patient adverse events. The MAUDE database serves as an important platform for improved collaboration among clinicians, device manufacturers, and regulators to improve device performance and optimize patient outcomes. Our analysis provides mechanistic insights of FFR guidewire failure and associated adverse events but cannot verify causality or provide a comparison among different guidewires.

Expression and functional role of IGFs during early pregnancy in placenta of water buffalo

Adequate vascularisation is a key factor for successful fetal development. We hypothesized that Insulin-Like Growth Factor (IGF) family members regulate angiogenesis along with promoting fetal development and growth. In this experiment, we determined the expression and functional role of IGF family in placental compartments (caruncle; CAR, cotyledon; COT) during different stages of early pregnancy in the water buffalo (Bubalus bubalis). Samples were collected from early pregnancy 1 (EP1, 28-45 days), early pregnancy 2 (EP2, 45-90 days), and third stage of estrous cycle (11-16 days), which was taken as control. In addition, the role of IGF1 on mRNA expression of vWF, StAR, CYP11A1, 3βHSD, PCNA, and BAX were elucidated in cultured trophoblast cells (TCC) obtained from EP2. Quantitative real-time PCR (q-PCR), westernblot, and immunohistochemistry were done to investigate the gene expression, protein expression, and localization of examined factors, and RIA was also done to assess progesterone (P₄) concentration. Expression of IGFs, its receptors and binding proteins were found to be significantly higher (p < 0.05) in both CAR and COT as compared to control during early pregnancy, except binding proteins IGFBP1, 3 and 4 which were significantly (p < 0.05) downregulated in COT with advancement of pregnancy. mRNA expression was consistent with the findings of immunoblotting and immunolocalization experiments. Trophoblasts cell culture (TCC) study showed a significant time and dose-dependent effect of IGF1 onsteroidogenic transcript, which was found to be maximum at 100 ng/ml that paralleled with P₄ accretion in the media (p < 0.05). Further, IGF1 upregulated the transcripts of vWF, PCNA, and downregulated BAX at the same concentration (p < 0.05). Overall, our results demonstrated that the expression of IGFs is a site-specific phenomenon in placentome, which indicates autocrine/paracrine and endocrine function. Our in-vitro finding support that IGF1 plays a critical role in placental development by promoting angiogenesis, steroid synthesis, and cell proliferation during early pregnancy.

Multivessel Traumatic Coronary Artery Dissection After a Motor Vehicle Accident With Successful Percutaneous Coronary Intervention

Coronary artery dissection is a rare complication of blunt chest wall trauma. We report a case of acute left anterior descending and right coronary artery dissections after a motor vehicle accident. The musculoskeletal injuries obscured the cardiac symptoms. Electrocardiogram and bedside echocardiogram revealed cardiac pathology, which prompted urgent coronary angiography and intervention. (Level of Difficulty: Advanced.)

Expression and functional role of fibroblast growth factors (FGF) in placenta during different stages of pregnancy in water buffalo (Bubalus bubalis)

The present study documented the expression and functional role of Fibroblast growth factors (FGFs) family and their receptors (Fibroblast growth factor receptor, FGFRs) in placenta (Cotyledon; COT, Caruncle; CAR) during different stages of pregnancy in water buffalo. Samples were collected from Early pregnancy 1 (EP1); Early pregnancy 2 (EP2); Mid pregnancy (MP) and Late pregnancy (LP) while diestrus stage of oestrus cycle (NP) was taken as control. In addition, modulatory role of FGF2 on mRNA expression of von Willebrand factor (vWF), Proliferating cell nuclear antigen (PCNA), steroidogenic acute regulatory protein (StAR), cytochrome P450 cholesterol side-chain cleavage (CYP11A1), 3β-hydroxysteroid dehydrogenase (3βHSD) and BCL2 Associated X (BAX) were studied in cultured trophoblast cells (TCC), obtained from EP2. Real-time PCR (qPCR), Western blot, and immunohistochemistry were applied to investigate mRNA and protein expressions, and the localization of examined factors whereas, P4 secretion was assessed by RIA. The mRNA and protein expression of FGFs and its receptors were maximum (P < 0.05) during EP (EP1 and EP2) in COT. However, FGFR1 and FGFR4 were upregulated (P < 0.05) during EP2 and MP in COT. Similarly, the mRNA and protein expression of FGFs and its receptors were upregulated (P < 0.05) during all stages of pregnancy in CAR. FGF family members were localized in the cytoplasm of trophoblast cells as well as in fetal blood vessels. At 100 ng/ml dosage, FGF2 stimulated the transcript of vWF maximally (P < 0.05). P4 secretion in trophoblast cells treated with FGF2 was maximum with the highest dose at 72 h. These findings corroborate that FGF acts locally in the trophoblast cells to modulate steroid hormone viz. progesterone synthesis, promote angiogenesis and favors cell survivability indicating that this factor may play an essential role in the regulation of placental formation and function in buffalo.

Image noise reduction technology reduces radiation in a radial-first cardiac catheterization laboratory

BACKGROUND

Transradial coronary angiography (TRA) has been associated with increased radiation doses. We hypothesized that contemporary image noise reduction technology would reduce radiation doses in the cardiac catheterization laboratory in a typical clinical setting.

METHODS AND RESULTS

We performed a single-center, retrospective analysis of 400 consecutive patients who underwent diagnostic and interventional cardiac catheterizations in a predominantly TRA laboratory with traditional fluoroscopy (N=200) and a new image noise reduction fluoroscopy system (N=200). The primary endpoint was radiation dose (mGy cm²). Secondary endpoints were contrast dose, fluoroscopy times, number of cineangiograms, and radiation dose by operator between the two study periods. Radiation was reduced by 44.7% between the old and new cardiac catheterization laboratory (75.8mGycm²±74.0 vs. 41.9mGycm²±40.7, p<0.0001). Radiation was reduced for both diagnostic procedures (45.9%, p<0.0001) and interventional procedures (37.7%, p<0.0001). There was no statistically significant difference in radiation dose between individual operators (p=0.84). In multivariate analysis, radiation dose remained significantly decreased with the use of the new system (p<0.0001) and was associated with weight (p<0.0001), previous coronary artery bypass grafting (p<0.0007) and greater than 3 stents used (p<0.0004). TRA was used in 90% of all cases in both periods. Compared with a transfemoral approach (TFA), TRA was not associated with higher radiation doses (p=0.20).

CONCLUSIONS

Image noise reduction technology significantly reduces radiation dose in a contemporary radial-first cardiac catheterization clinical practice.