A Randomized Controlled Trial of Prasugrel for Prevention of Early Saphenous Vein Graft Thrombosis

OBJECTIVES

To test whether administration of prasugrel after coronary artery bypass grafting (CABG) reduces saphenous vein graft (SVG) thrombosis. Use of aspirin after CABG improves graft patency, but administration of other antiplatelet agents has yielded equivocal results.

METHODS

We performed a double-blind trial randomizing patients to prasugrel or placebo after CABG at four United States centers. Almost all patients were receiving aspirin. Follow-up angiography, optical coherence tomography (OCT), intravascular ultrasound (IVUS), and near-infrared spectroscopy (NIRS) were performed at 12 months. The primary efficacy endpoint was prevalence of OCT-detected SVG thrombus. The primary safety endpoint was incidence of Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) severe bleeding.

RESULTS

The study was stopped early due to slow enrollment after randomizing 84 patients. Mean age was 64 ± 6 years; 98% of the patients were men. Follow-up angiography was performed in 59 patients. IVUS was performed in 52 patients, OCT in 53 patients, and NIRS in 33 patients. Thrombus was identified by OCT in 56% vs 50% of patients in the prasugrel vs placebo groups, respectively (P=.78). Angiographic SVG failure occurred in 24% of patients in the prasugrel arm vs 40% in the placebo arm (P=.19). The 1-year incidence of major adverse cardiovascular events was 14.3% vs 2.4% in the prasugrel and placebo groups, respectively (P=.20), without significant differences in GUSTO severe bleeding (P=.32).

CONCLUSION

Early SVG failure occurred in approximately one-third of patients. Prasugrel did not decrease prevalence of SVG thrombus 12 months after CABG.

A Meta-Analysis of Contemporary Lesion Modification Strategies During Percutaneous Coronary Intervention in 244,795 Patients From 22 Studies

OBJECTIVES

Outcomes with use of lesion-modification strategies in the drug-eluting stent era have received limited study.

METHODS

We conducted a meta-analysis of 22 studies published between 2004-2016 reporting outcomes after use of rotational atherectomy, cutting-balloon, and scoring-balloon angioplasty.

RESULTS

In observational trials, acute luminal gain was higher after lesion modification as compared with control (standardized mean difference, 0.23 mm; 95% confidence interval [CI], 0.01-0.44; P=.04), with no difference in acute gain in randomized studies. Compared with control, lesion modification was associated with lower restenosis in randomized trials (odds ratio [OR], 0.64; 95% CI, 0.45-0.90; P=.01). Ninety-day incidence of major adverse cardiovascular event (MACE) was higher after lesion modification in observational studies (OR, 1.39; 95% CI, 1.05-1.83; P=.02), but similar in randomized trials. Ninety-day incidence of target-lesion or target-vessel revascularization (TLR-TVR) and myocardial infarction (MI) was similar. Ninety-day incidence of death was higher after lesion modification in observational studies (OR, 1.42; 95% CI, 1.04-1.95; P=.03), but similar in randomized trials. At 1 year, the MACE rate was similar for lesion modification compared with control in observational studies, but lower after lesion modification in randomized trials (OR, 0.65; 95% CI, 0.48-0.88; P<.01). TLR-TVR was higher with lesion modification in observational studies, but lower in randomized trials (OR, 0.64; 95% CI, 0.46-0.88; P<.01).

CONCLUSIONS

While observational studies suggest a higher early MACE rate and more restenosis, randomized trials show similar short-term and improved long-term outcomes with pre-stenting lesion modification compared with control.

Comparison of the American College of Cardiology/American Heart Association and the European Society of Cardiology Guidelines for the Management of Patients With Valvular Heart Disease

BACKGROUND

The American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) have developed guidelines to assist clinicians in making evidence-based decisions. This study compares the ACC/AHA and ESC guidelines for the management of patients with valvular heart disease (VHD).

METHODS

The current ACC/AHA and ESC guidelines for VHD, last updated in 2014 and 2012, respectively, were compared by class of recommendation (COR), level of evidence (LOE), and content.

RESULTS

The ACC/AHA and ESC VHD guidelines contain 229 and 85 recommendations, respectively. The COR distributions of the ACC/AHA and ESC VHD guidelines were 47.6% vs 44.7% class I [P=.65]; 46.3% vs 55.3% class II [P=.16]; and 6.1% vs 0.0% class III [P=.01], respectively. The LOE distributions were 3.1% vs 0.0% LOE A [P=.20]; 47.2% vs 10.6% LOE B [P<.001]; and 49.8% vs 89.4% LOE C [P<.001], respectively. The recommendation type distributions were 31.0% vs 2.4% diagnostic [P<.001]; 23.1% vs 16.5% medical therapy [P=.20]; and 45.9% vs 81.2% interventional/surgical recommendations [P<.001], respectively. The content of the guidelines was similar, with only minor differences in a few recommendations.

CONCLUSIONS

The ACC/AHA VHD guidelines contain significantly more recommendations. The distribution of COR was similar, but the ACC/AHA guidelines included more LOE B recommendations and fewer LOE C recommendations, suggesting that the ACC/AHA guidelines place greater emphasis on published data than expert opinion. Overall, the ACC/AHA and ESC guidelines provide similar recommendations, suggesting consistency in practice; however, the relative paucity of LOE A recommendations highlights the need for additional research.

Percutaneous Coronary Intervention of Coronary Chronic Total Occlusions Improves Peak Oxygen Uptake During Cardiopulmonary Exercise Testing

OBJECTIVES

Although coronary chronic total occlusions (CTOs) are treated with percutaneous coronary intervention (PCI) to improve symptoms, studies demonstrating symptom improvement have been mostly limited to questionnaire responses. The current study assessed for changes in peak oxygen uptake during cardiopulmonary exercise testing after CTO-PCI.

METHODS

Patients with heart failure or angina symptoms referred for CTO-PCI were prospectively enrolled. The primary outcome of the study was improvement in peak oxygen uptake during cardiopulmonary exercise (CPX) testing 5 months after CTO-PCI. Secondary outcomes included improvement in physical capacity, angina, and self perception of health as assessed by questionnaires, and in plasma brain natriuretic peptide (BNP) levels.

RESULTS

CTO-PCI was attempted in 32 men (mean age, 62 ± 6 years; CTO vessel: 47% right coronary, 44% left anterior descending). CTO-PCI was unsuccessful in 1 patient, and 3 patients had restenosis of their CTO vessel at follow-up. In the 28 patients with patent CTO vessel at follow-up, significant improvements were noted in self-reported physical capacity, angina, and several aspects of health perception. In the 25 patients who underwent baseline and follow-up CPX testing, peak oxygen uptake significantly improved from 17.7 ± 4.3 mL/kg/min to 19.1 ± 4.0 mL/kg/min (P=.02). Plasma BNP levels significantly decreased from 143 ± 138 pg/mL to 102 ± 123 pg/mL (P=.01).

CONCLUSIONS

CTO-PCI in symptomatic patients was associated with improvements in cardiovascular exercise capacity, as assessed by peak oxygen uptake. These results suggest that in symptomatic patients with CTOs, PCI appears clinically beneficial.

Impact of Chronic Total Occlusion Revascularization Attempts on Subsequent Clinical Outcomes

OBJECTIVES

We examined a contemporary, unselected cohort of patients with coronary chronic total occlusions (CTOs) to determine the impact of CTO revascularization on long-term outcomes.

METHODS

We retrospectively assessed the impact of CTO revascularization on clinical outcomes of consecutive patients found to have a CTO during coronary angiography performed at our institution during 2011 and 2012. The primary endpoint was the incidence of a major adverse cardiac event (MACE, defined as a composite of death, myocardial infarction, stroke, and target-vessel revascularization [TVR]). Survival analysis was performed in the overall and propensity-matched retrospective cohorts of patients stratified by prior coronary artery bypass graft (CABG) surgery. Propensity-adjusted hazard ratio (HR) and 95% confidence interval (95% CI) were calculated with Cox proportional hazards analysis. All analyses were by intention to treat.

RESULTS

Of 624 patients (319 without prior CABG and 305 with prior CABG) included in the present analysis, CTO revascularization (surgical or percutaneous) was attempted in 60% and 16% of patients without and with prior CABG, respectively. During a median follow-up of 26 months (range, 18-40 months), the incidence of MACE was 20.6%. CTO revascularization (achieved or attempted) was associated with lower incidence of MACE among patients without prior CABG (propensity-adjusted HR, 0.51; 95% CI, 0.27-0.94; P=.03), but not among prior CABG patients (propensity-adjusted HR, 1.38; 95% CI, 0.64-2.96; P=.41).

CONCLUSION

In a large, unselected patient population with coronary CTOs, a CTO revascularization attempt was associated with lower incidence of subsequent MACE among patients without prior CABG, but not among prior CABG patients.

Near-Infrared Spectroscopy Analysis of Coronary Chronic Total Occlusions

OBJECTIVE

To examine the presence and localization of lipid-core plaque (LCP) in coronary vessels with chronic total occlusions (CTOs) using near-infrared spectroscopy (NIRS).

METHODS

NIRS imaging was performed after guidewire crossing of the occlusion in 15 patients with CTOs. LCP was defined as ≥2 adjacent 2 mm yellow blocks on the block chemogram. We also measured the maximum lipid-core burden index (LCBI) in a 4 mm length of artery (maxLCBI4mm). Large LCP was defined as maxLCBI4mm ≥500.

RESULTS

Median patient age was 64 years (interquartile range [IQR], 61-67 years) and all patients were men with high prevalence of diabetes mellitus (64%) and prior coronary artery bypass graft surgery (27%). The CTO target vessel was the right coronary artery (46%), left anterior descending artery (27%), or circumflex artery (27%). Median occlusion length was 35 mm (IQR, 30-50 mm). LCP was present in 11 of 15 CTO vessels (73%) and a large LCP in 4 of 15 CTO vessels (27%). LCP was located at the proximal cap in 6 CTOs (55%), the CTO body in 6 CTOs (55%), and the distal cap in 2 CTOs (18%). The median overall LCBI and maxLCBI4mm were 145 (IQR, 79-243) and 415 (IQR, 267-505), respectively. All patients underwent successful stenting without any complications. The 12-month incidence of in-stent restenosis and target-lesion revascularization was 25%, and all patients who developed restenosis had an LCP at baseline.

CONCLUSIONS

LCPs are commonly encountered in coronary CTO vessels, suggesting an active intraplaque atherosclerotic process. The impact of LCP on postintervention outcomes requires further study.

Saphenous vein graft near-infrared spectroscopy imaging insights from the lipid core plaque association with clinical events near-infrared spectroscopy (ORACLE-NIRS) registry

OBJECTIVES

We sought to examine near-infrared spectroscopy (NIRS) imaging findings of aortocoronary saphenous vein grafts (SVGs).

BACKGROUND

SVGs are prone to develop atherosclerosis similar to native coronary arteries. They have received little study using NIRS.

METHODS

We examined the clinical characteristics and imaging findings from 43 patients who underwent NIRS imaging of 45 SVGs at our institution between 2009 and 2016.

RESULTS

The mean patient age was 67 ± 7 years and 98% were men, with high prevalence of diabetes mellitus (56%), hypertension (95%), and dyslipidemia (95%). Mean SVG age was 7 ± 7 years, mean SVG lipid core burden index (LCBI) was 53 ± 60 and mean maxLCBI_{4 mm} was 194 ± 234. Twelve SVGs (27%) had lipid core plaques (2 yellow blocks on the block chemogram), with a higher prevalence in SVGs older than 5 years (46% vs. 5%, P = 0.002). Older SVG age was associated with higher LCBI (r = 0.480, P < 0.001) and higher maxLCBI_{4 mm} (r = 0.567, P < 0.001). On univariate analysis, greater annual total cholesterol exposure was associated with higher SVG LCBI (r = 0.30, P = 0.042) and annual LDL-cholesterol and triglyceride exposure were associated with higher SVG maxLCBI_{4 mm} (LDL-C: r = 0.41, P = 0.020; triglycerides: r = 0.36, P = 0.043). On multivariate analysis, the only independent predictor of SVG LCBI and maxLCBI_4mm was SVG age. SVG percutaneous coronary intervention was performed in 63% of the patients. An embolic protection device was used in 96% of SVG PCIs. Periprocedural myocardial infarction occurred in one patient.

CONCLUSIONS

Older SVG age and greater lipid exposure are associated with higher SVG lipid burden. © 2016 Wiley Periodicals, Inc.

Prospective Evaluation of the Impact of Side-Holes and Guide-Catheter Disengagement From the Coronary Ostium on Fractional Flow Reserve Measurements

BACKGROUND

We prospectively examined the impact of side-holes and guide-catheter disengagement on fractional flow reserve (FFR) measurements.

METHODS

Twenty-five patients undergoing clinically indicated FFR measurement for intermediate coronary artery stenosis were enrolled. Four FFR measurements were made in random order during intravenous adenosine infusion with: (a) an engaged side-hole guide catheter; (b) a disengaged side-hole guide catheter; (c) an engaged non-side-hole guide catheter; and (d) disengaged non-side-hole guide catheter.

RESULTS

Mean patient age was 65 ± 9 years and 100% were men. The mean distal poststenotic pressure/proximal aortic pressure (Pd/Pa) at baseline was 0.93 ± 0.05 mm Hg. Using intravenous adenosine infusion, the mean FFR measured with engaged vs disengaged non-side-hole guide catheters was 0.87 ± 0.09 vs 0.83 ± 0.10, respectively (mean difference, 0.039 ± 0.04; P<.001). The mean FFR with engaged vs disengaged side-hole guide catheters was 0.85 ± 0.10 vs 0.83 ± 0.10 (mean difference, 0.020 ± 0.02; P<.001). The mean difference in FFR measurements was 0.024 ± 0.03 (P<.001) among engaged guide catheters and 0.005 ± 0.03 (P=.47) among disengaged guide catheters.

CONCLUSIONS

When FFR measurements are performed with engaged guide catheters, side-hole catheters provide lower measurements. When FFR measurements are obtained with disengaged guide catheters, they are even lower and similar between guide catheter types.

Procedural outcomes with use of the flash ostial system in aorto-coronary ostial lesions

BACKGROUND

The Flash Ostial system (Ostial Corporation, Sunnyvale, CA) was designed to optimize implantation of aorto-ostial coronary stents by flaring the proximal stent struts against the aortic wall.

METHODS

We retrospectively reviewed the medical record, angiograms, and intravascular ultrasound images of 22 aorto-ostial percutaneous coronary interventions performed at our institution between March and September 2015. The Flash Ostial system was used in 13 cases (59%).

RESULTS

Mean age was 67 ± 8 years and all patients were men. The target vessel was the right coronary artery (59%), left main (27%), or a saphenous vein graft (14%); 59% of the lesions had moderate/severe calcification. The mean number of predilation balloons was 1.8 ± 1.6, mean Flash ostial balloon diameter was 3.3 ± 0.5 mm and mean inflation pressure was 13.1 ± 4.0 atmospheres. Intravascular ultrasonography (available for 19 patients) revealed mean ostial minimum lumen cross-sectional area (MLA) of 9.2 ± 3.0 mm² and reference MLA of 8.5 ± 2.7 mm² . The percent difference between ostial and reference MLA was higher in cases in which the Flash Ostial system was used versus those where it was not (9.6 ± 5.5% vs. 4.0 ± 2.8%, P = 0.03). All stent struts were well apposed. Technical success was 100%. One patient developed a left groin pseudoaneurysm treated with thrombin injection and one patient had a periprocedural myocardial infarction. Median contrast, fluoroscopy time, and procedure time were 235 mL, 33 min, and 118 min, respectively.

CONCLUSIONS

The Flash Ostial system can be successfully used in aorto-ostial stenting, resulting in large ostial vessel MLA. © 2016 Wiley Periodicals, Inc.

Use of Saphenous Vein Bypass Grafts for Retrograde Recanalization of Coronary Chronic Total Occlusions: Insights From a Multicenter Registry

BACKGROUND

The use of saphenous vein grafts (SVGs) for retrograde native-vessel chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.

METHODS

We retrospectively reviewed the medical records and coronary angiograms of retrograde CTO-PCI performed through an SVG at four United States institutions between 2012 and 2013.

RESULTS

During the study period, retrograde CTO-PCI was performed in 144 of 572 cases (25.2%) and retrograde CTO-PCI via SVG in 21 patients (14.6% of all retrograde cases). Mean age was 71 ± 7 years and 95.2% of the patients were men. The CTO target vessel was the right coronary (38%), circumflex (38%), and left anterior descending (24%) artery. Mean J-CTO score was 3.5 ± 1.0. The most common reentry technique was reverse controlled antegrade dissection and reentry. Technical and procedural success rates were 86% and 81%, respectively, with retrograde SVG-PCI attempts being successful in 67%. A major adverse cardiac event occurred in 2 patients (1 periprocedural myocardial infarction and 1 tamponade resulting in death). Median contrast volume, fluoroscopy time, and procedure time were 250 mL, 91.6 minutes, and 214 minutes, respectively. Two SVGs were coiled due to competitive flow after CTO recanalization.

CONCLUSION

Retrograde native-vessel CTO-PCI via SVG represents a small proportion of retrograde CTO-PCIs and was associated with high technical success rates, but may carry increased risk for complications.

Accuracy of remote chest X-ray interpretation using Google Glass technology

OBJECTIVES

We sought to explore the accuracy of remote chest X-ray reading using hands-free, wearable technology (Google Glass, Google, Mountain View, California).

METHODS

We compared interpretation of twelve chest X-rays with 23 major cardiopulmonary findings by faculty and fellows from cardiology, radiology, and pulmonary-critical care via: (1) viewing the chest X-ray image on the Google Glass screen; (2) viewing a photograph of the chest X-ray taken using Google Glass and interpreted on a mobile device; (3) viewing the original chest X-ray on a desktop computer screen. One point was given for identification of each correct finding and a subjective rating of user experience was recorded.

RESULTS

Fifteen physicians (5 faculty and 10 fellows) participated. The average chest X-ray reading score (maximum 23 points) as viewed through the Google Glass, Google Glass photograph on a mobile device, and the original X-ray viewed on a desktop computer was 14.1±2.2, 18.5±1.5 and 21.3±1.7, respectively (p<0.0001 between Google Glass and mobile device, p<0.0001 between Google Glass and desktop computer and p=0.0004 between mobile device and desktop computer). Of 15 physicians, 11 (73.3%) felt confident in detecting findings using the photograph taken by Google Glass as viewed on a mobile device.

CONCLUSION

Remote chest X-ray interpretation using hands-free, wearable technology (Google Glass) is less accurate than interpretation using a desktop computer or a mobile device, suggesting that further technical improvements are needed before widespread application of this novel technology.

Impact of Crossing Strategy on Intermediate-term Outcomes After Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND

There is ongoing controversy about the optimal crossing strategy selection for chronic total occlusion (CTO) percutaneous coronary intervention (PCI), especially regarding the relative merits of antegrade dissection/re-entry and the retrograde approach.

METHODS

We retrospectively examined the clinical outcomes of 173 consecutive patients who underwent successful CTO PCI at our institution between January 2012 and March 2015.

RESULTS

The mean age was 65 ± 8 years, and 98% of the patients were men with a high prevalence of diabetes (60%), previous coronary artery bypass grafting (CABG) (31%), and previous PCI (54%). The successful CTO crossing strategy was antegrade wire escalation in 79 patients (45.5%), antegrade dissection/re-entry in 58 patients (33.5%), retrograde wire escalation in 11 patients (6.4%), and retrograde dissection and re-entry in 25 patients (14.5%). The retrograde approach was more commonly used in lesions with interventional collaterals (P < 0.0001), moderate/severe calcification (P = 0.02), blunt stump (P = 0.01), and a higher Japan Chronic Total Occlusion score (P = 0.0002). Use of dissection and re-entry (both antegrade and retrograde) was associated with bifurcation and the distal cap (P = 0.004), longer CTO occlusion length (P < 0.0001), and longer stent length (P < 0.0001). Median follow-up was 11 months. The 12-month incidence of death, myocardial infarction, and the composite of acute coronary syndrome/target lesion revascularization/target vessel revascularization was 2.5%, 4.9%, and 24.4%, respectively, and was similar with intimal and subintimal crossing strategies.

CONCLUSIONS

Antegrade dissection/re-entry and retrograde approaches are frequently used during CTO PCI and were associated with similarly favorable intermediate-term outcomes as antegrade wire escalation.

Effect of Extended-Release Niacin on Carotid Intima Media Thickness, Reactive Hyperemia, and Endothelial Progenitor Cell Mobilization: Insights From the Atherosclerosis Lesion Progression Intervention Using Niacin Extended Release in Saphenous Vein Grafts (ALPINE-SVG) Pilot Trial

BACKGROUND

Thirty-eight patients with intermediate (30%-60% diameter stenosis) saphenous vein graft lesions were randomized to extended-release niacin (ER-niacin) or placebo for 12 months. We sought to evaluate the impact of ER-niacin on carotid intima media thickness (CIMT), endothelial function, and endothelial progenitor cell (EPC) mobilization.

METHODS

Carotid B-mode ultrasound was used to image the common and internal carotid arteries, at baseline and at 12 months after enrollment. Reactive hyperemia peripheral arterial tonometry, as assessed with EndoPAT 2000 (Itamar Medical, Inc) and EPC mobilization assessed with flow cytometry, were measured at enrollment, and at 1 and 12 months.

RESULTS

The baseline clinical characteristics were similar in the two study groups. High-density lipoprotein cholesterol levels tended to increase more in the ER-niacin group (5.9 ± 8.7 mg/dL vs 1.4 ± 7.1 mg/dL; P=.14). Between baseline and 12 months, right common carotid artery (0.96 ± 0.44 mm vs 0.70 ± 0.24 mm; P=.04), and left common carotid artery (0.80 ± 0.30 mm vs 0.70 ± 0.20 mm; P=.08) CIMT tended to decrease in the ER-niacin group, compared with no change in the placebo group. The change in logarithmic reactive hyperemia index between 1 month and 12 months was similar in patients receiving ER-niacin vs placebo (0.003 ± 0.12 vs -0.058 ± 0.12; P=.39), whereas EPC mobilization increased in the ER-niacin group and decreased in the placebo group (8.65 ± 28.41 vs -5.87 ± 30.23 EPC colony forming units/mL of peripheral blood; P=.02).

CONCLUSIONS

ER-niacin did not have a significant impact on CIMT or endothelial function, but increased EPC mobilization.

Comparison of Iodixanol and Ioxaglate for Coronary Optical Coherence Tomography Imaging

BACKGROUND

The impact of contrast type on coronary imaging using optical coherence tomography (OCT) has received limited study. We compared OCT imaging obtained using the non-ionic, iso-osmolar iodixanol with the ionic, low-osmolar ioxaglate.

METHODS

Twenty-two vessels in 20 patients were imaged twice using manual injection of iodixanol and ioxaglate in random order. OCT images were analyzed at 1 mm intervals to determine lumen area, artifact diameter and area, as well as stent strut coverage and malapposition in OCT pullbacks that included stents.

RESULTS

There were no complications related to OCT imaging or to contrast administration. A total of 2184 cross-sections (1092 with iodixanol and 1092 with ioxaglate) were analyzed. Compared with iodixanol, imaging using ioxaglate provided similar mean lumen area (6.21 ± 2.83 mm2 vs 6.27 ± 2.83 mm2; Spearman's rho, 0.982), mean minimum lumen diameter (2.47 ± 0.59 mm vs 2.50 ± 0.58 mm; Spearman's rho, 0.939), and mean maximum lumen diameter (2.99 ± 0.71 mm vs 3.01 ± 0.70 mm; Spearman's rho, 0.964), but lower mean artifact area per cross-section (0.099 ± 0.325 mm2 vs 0.068 ± 0.329 mm2; P<.001). Analyses of 3303 stent struts in 388 cross-sections (194 with iodixanol and 194 with ioxaglate) demonstrated similar strut malapposition rates (11.82% vs 13.90%; P=.10) and strut coverage (41.92% vs 40.33%; P=.35).

CONCLUSIONS

Compared with iodixanol, OCT imaging using ioxaglate provided similar lumen and diameter measurements and stent strut characterization, but smaller area of artifact.

Interpretation of Coronary Angiograms Recorded Using Google Glass: A Comparative Analysis

INTRODUCTION

Google Glass (Google, Inc) is a voice-activated, hands-free, optical head-mounted display device capable of taking pictures, recording videos, and transmitting data via wi-fi. In the present study, we examined the accuracy of coronary angiogram interpretation, recorded using Google Glass.

METHODS

Google Glass was used to record 15 angiograms with 17 major findings and the participants were asked to interpret those recordings on: (1) an iPad (Apple, Inc); or (2) a desktop computer. Interpretation was compared with the original angiograms viewed on a desktop. Ten physicians (2 interventional cardiologists and 8 cardiology fellows) participated. One point was assigned for each correct finding, for a maximum of 17 points.

RESULTS

The mean angiogram interpretation score for Google Glass angiogram recordings viewed on an iPad or a desktop vs the original angiograms viewed on a desktop was 14.9 ± 1.1, 15.2 ± 1.8, and 15.9 ± 1.1, respectively (P=.06 between the iPad and the original angiograms, P=.51 between the iPad and recordings viewed on a desktop, and P=.43 between the recordings viewed on a desktop and the original angiograms). In a post-study survey, one of the 10 physicians (10%) was "neutral" with the quality of the recordings using Google Glass, 6 physicians (60%) were "somewhat satisfied," and 3 physicians (30%) were "very satisfied."

CONCLUSION

This small pilot study suggests that the quality of coronary angiogram video recordings obtained using Google Glass may be adequate for recognition of major findings, supporting its expanding use in telemedicine.

Frequency, Indications, and Outcomes of Guide Catheter Extension Use in Percutaneous Coronary Intervention

BACKGROUND

The frequency and outcomes of guide catheter extension use during percutaneous coronary intervention (PCI) have received limited study.

METHODS

We retrospectively examined 1539 consecutive PCIs performed between May 2010 and November 2013 to determine the frequency and outcomes of guide catheter extension utilization.

RESULTS

During the study period, a guide catheter extension was used in 83 cases (5.4%; 95% confidence interval, 4.3%-6.6%) in 86 vessels. The PCI target vessel was the left anterior descending artery (11%), circumflex (23%), right coronary artery (50%), left main (1%), or a saphenous vein bypass graft (15%). The indications for use (non-mutually exclusive) were to facilitate equipment delivery or provide vessel support/ engagement (84.7%), thrombus aspiration (10.5%), retrieval of lost devices (2.3%), facilitation of reverse controlled antegrade and retrograde tracking and dissection (1%), and selective vessel visualization with contrast (1%). Guide catheter extension success rate was 73.3% and technical and procedural success rates were 91.6% and 90.4%, respectively. Four patients (4.8%) experienced a guide catheter extension-related complication: vessel dissection/injury in 2 cases (1 case required emergency coronary artery bypass graft surgery and 1 case required stenting) and equipment loss in 2 cases (1 detachment of the distal guide-extension marker and 1 shearing of a guidewire tip that embolized to the renal artery).

CONCLUSIONS

In a contemporary patient population undergoing PCI, a guide catheter extension was used in approximately 1 of 20 PCIs. Guide catheter extensions can facilitate procedural success, but also carry low risk for device-related complications.

Effect of Extended-Release Niacin on Saphenous Vein Graft Atherosclerosis: Insights from the Atherosclerosis Lesion Progression Intervention Using Niacin Extended Release in Saphenous Vein Grafts (ALPINE-SVG) Pilot Trial

BACKGROUND

Intermediate saphenous vein graft (SVG) lesions have high rates of progression. The purpose of this study was to examine the impact of extended-release niacin (ER-niacin) vs placebo on intermediate SVG lesions.

METHODS

Patients with intermediate (30%-60% diameter stenosis) SVG lesions were randomized to ER-niacin vs placebo for 12 months. Quantitative coronary angiography (QCA), intravascular ultrasonography (IVUS), and optical coherence tomography (OCT) were performed at baseline and at 12 months. The primary endpoint was change in percent atheroma volume (ΔPAV). Enrollment was planned for 138 patients for 90% power to detect ≥2.5% difference in the primary endpoint of ΔPAV, but stopped early after publication of two negative outcome trials of ER-niacin, with enrolled patients completing the 12-month trial protocol.

RESULTS

Thirty-eight patients were randomized to niacin (n = 19) or placebo (n = 19), yielding power of 47% to detect the primary planned treatment effect of 2.5 ± 4.0% difference in ΔPAV. Between baseline and 12-month follow-up, no significant difference was found between study groups in ΔPAV (-1.31 ± 6.05% vs 1.05 ± 17.8%; P=.60). By OCT, the ER-niacin vs placebo group had less plaque rupture within the intermediate SVG lesion (0.0% vs 36.0%; P=.01).

CONCLUSION

Administration of ER-niacin did not significantly impact intermediate SVG disease, with the notable limitation of compromised statistical power due to early termination of enrollment.

The AngiographiC Evaluation of the Everolimus-Eluting Stent in Chronic Total Occlusion (ACE-CTO) Study

BACKGROUND

There are limited data on outcomes after implantation of second-generation drug-eluting stents in coronary chronic total occlusions (CTOs). We aimed to evaluate the frequency of angiographic restenosis and clinical outcomes after implantation of the everolimus-eluting stent (EES) in coronary CTOs.

METHODS

One hundred patients undergoing successful CTO percutaneous coronary intervention using EES at our institution between 2009 and 2012 were enrolled. The primary study endpoint was binary in-segment restenosis at 8-month follow-up quantitative coronary angiography. Secondary endpoints included death, myocardial infarction, target-lesion and target-vessel revascularization, and symptom improvement.

RESULTS

Mean age was 64 ± 7 years and 99% of the patients were men. The successful crossing technique was antegrade wiring in 51 patients, antegrade dissection/reentry in 24 patients, and retrograde in 25 patients. Binary angiographic restenosis occurred in 46% of the patients (95% confidence interval [CI], 35%-57%). The pattern of restenosis was focal, proliferative, and total occlusion in 19 lesions (46%), 14 lesions (34%), and 8 lesions (20%), respectively. At 12 months, the incidences of death, myocardial infarction, target-lesion revascularization, and target-vessel revascularization were 2%, 2%, 37%, and 39%, respectively. At 12 months, symptoms were improved, unchanged, or worse compared with baseline in 89 patients, 8 patients, and 1 patient, respectively (2 patients died before the 12-month follow-up). On multivariable analysis, smaller stent diameter was associated with higher risk for binary angiographic restenosis.

CONCLUSION

High rates of angiographic restenosis and repeat revascularization were observed among patients receiving EES in coronary CTOs, but most had significant symptom improvement.

Systematic Review of the BridgePoint System for Crossing Coronary and Peripheral Chronic Total Occlusions

BACKGROUND

The BridgePoint system consists of the CrossBoss coronary catheter and Stingray CTO system (Boston Scientific) for coronary chronic total occlusions (CTOs), and the Viance crossing catheter and Enteer re-entry system (Covidien) for peripheral CTOs.

METHODS

We performed a systematic review of the literature on the BridgePoint system published between October 2008 and August 2014, in accordance with the standards set forth in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

We identified a total of 20 studies: 12 studies on coronary CTOs (10 retrospective with 2 prospective case series) and 8 studies on peripheral CTOs (all retrospective). Among 320 patients undergoing coronary CTO intervention, pooled technical success and major adverse cardiac event rates were 77.1% and 3.8%, respectively. Among 175 patients undergoing peripheral CTO intervention, pooled technical success and major adverse events were 82.2% and 4.6%, respectively. Only 1 study reported long-term outcomes after use of the coronary BridgePoint system, demonstrating similar incidence of major adverse cardiac events between BridgePoint-treated and non-BridgePoint treated patients; however, the study had low power.

CONCLUSIONS

The BridgePoint system is associated with high procedural success rates and low complication rates when used for crossing both coronary and peripheral CTOs.

Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions

Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris.

Effect of a Real-Time Radiation Monitoring Device on Operator Radiation Exposure During Cardiac Catheterization

Background—

The Radiation Reduction During Cardiac Catheterization Using Real-Time Monitoring study sought to examine the effect of a radiation detection device that provides real-time operator dose reporting through auditory feedback (Bleeper Sv; Vertec Scientific Ltd; Berkshire, UK) on patient dose and operator exposure during cardiac catheterization.

Methods and Results—

Between January 2012 and May 2014, 505 patients undergoing coronary angiography, percutaneous coronary intervention, or both were randomized to use (n=253) or no use (n=252) of the Bleeper Sv radiation monitor. Operator radiation exposure was measured in both groups using a second, silent radiation exposure monitoring device. Mean patient age was 65±8 years, most patients (99%) were men, and 30% had prior coronary artery bypass graft surgery. Baseline clinical characteristics were similar in the 2 study groups. Radial access was used in 18% and chronic total occlusion percutaneous coronary intervention constituted 7% of the total procedures. Median procedure time was 17 (12–27) minutes for diagnostic angiography, 42 (28–70) minutes for percutaneous coronary intervention, and 27 (14–51) minutes in the overall study population, with similar distribution between the study groups. First (9 [4–17] versus 14 [7–25] μSv; P <0.001) and second (5 [2–10] versus 7 [4–14] μSv; P <0.001) operator radiation exposure was significantly lower in the Bleeper Sv group. Use of the device did not result in a significant reduction in patient radiation dose. The effect of the Bleeper Sv device on operator radiation exposure was consistent among various study subgroups.

Conclusions—

Use of a real-time radiation monitoring device that provides auditory feedback can significantly reduce operator radiation exposure during cardiac catheterization.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01510353.

Randomized controlled trial on the impact of music therapy during cardiac catheterization on reactive hyperemia index and patient satisfaction: the Functional Change in Endothelium After Cardiac Catheterization, With and Without Music Therapy (FEAT) study

OBJECTIVES

To determine the impact of music intervention on endothelial function, hemodynamics, and patient anxiety before, during, and after cardiac catheterization.

BACKGROUND

The effect of music therapy during cardiac catheterization on endothelial function and patient satisfaction has received limited study.

METHODS

Seventy patients undergoing elective cardiac catheterization were randomized to music therapy (n=36) or no music therapy (n=34). Peripheral arterial tonometry was performed before and after catheterization. A 6 item (24-point scale) questionnaire evaluating patient anxiety and discomfort levels was also administered after the procedure.

RESULTS

Both study groups had similar baseline characteristics, fluoroscopy time, and contrast administration. Reactive hyperemia index (RHI) change was 0.14 ± 0.72 in the music group and 0.30 ± 0.58 in the control group (P=.35). Systolic and diastolic blood pressure (BP) changes did not significantly differ between the two groups (systolic BP change -3.3 ± 17.3 mm Hg vs -2.3 ± 19.4 mm Hg; P=.83 and diastolic BP change -1.9 ± 12.2 mm Hg vs. 2.0 ± 13.4 mm Hg; P=.23). Heart rate changes were also comparable between the two groups (-1 ± 6 beats/ min vs -1 ± 7 beats/min; P=.22). Patient satisfaction questionnaire measurements were found to be similar in patients with and without music therapy (8 [7-11] vs 9 [8-12]; P=.36).

CONCLUSIONS

In this study, music intervention did not elicit a vasodilator response, did not lower blood pressure or heart rate, and did not relieve anxiety or stress discomfort in patients who underwent coronary angiography.

Perioperative complications after noncardiac surgery in patients with insertion of second-generation drug-eluting stents

The perioperative outcomes of noncardiac surgery in patients who have received second-generation drug-eluting stents (DESs) have received limited study. We reviewed the medical records of 1,748 consecutive patients who received DES at our institution (1,789 procedures) from January 1, 2009, to July 1, 2012, to determine the outcomes of subsequent noncardiac surgery. During a median follow-up of 43 months, 221 patients underwent 345 noncardiac surgeries (138 low risk, 130 intermediate risk, and 77 high risk), of which 278 were in patients with previous second-generation DES implantation. The incidence of noncardiac surgery in patients with previous second-generation DES implantation was 4.5% at 1 year, 11.6% at 2 years, and 15.2% at 3 years. The mean time from stent implantation to surgery was 21±12.9 months. Mean age was 66±8 years, 99% were men, and 11% had a perioperative complication, including 5.8% major bleeding, 2.5% acute kidney injury, 2.2% major adverse cardiac event, and 1.4% stroke. Perioperative stent thrombosis occurred in 2 patients (0.7%, 95% confidence interval 0.2% to 2.6%): 1 patient had received a DES 14 months before surgery and had stent thrombosis on the day of surgery and the other had a DES implanted 21 months before surgery and developed stent thrombosis the day after surgery. In conclusion, the incidence of perioperative complications with noncardiac surgery after second-generation DES implantation was 11% and consisted mainly of bleeding (5.8%). The incidence of definite stent thrombosis was 0.7%.

Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital

OBJECTIVES

We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population.

BACKGROUND

The prevalence and management of CTOs in various populations has received limited study.

METHODS

We collected clinical and angiographic data in consecutive patients that underwent coronary angiography at our institution between January 2011 and December 2012. Coronary artery disease (CAD) was defined as ≥50% diameter stenosis in ≥1 coronary artery. CTO was defined as total coronary artery occlusion of ≥3 month duration.

RESULTS

Among 1,699 patients who underwent angiography during the study period, 20% did not have CAD, 20% had CAD and prior coronary artery bypass graft surgery (CABG), and 60% had CAD but no prior CABG. The prevalence of CTO among CAD patients with and without prior CABG was 89 and 31%, respectively. Compared to patients without CTO, CTO patients had more co-morbidities, more extensive CAD and were more frequently referred for CABG. Percutaneous coronary intervention (PCI) to any vessel was performed with similar frequency in patients with and without CTO (50% vs. 53%). CTO PCI was performed in 30% of patients without and 15% of patients with prior CABG with high technical (82 and 75%, respectively) and procedural success rates (80 and 73%, respectively).

CONCLUSIONS

In a contemporary veteran population, coronary CTOs are highly prevalent and are associated with more extensive co-morbidities and higher likelihood for CABG referral. PCI was equally likely to be performed in patients with and without CTO.