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Aim: To conduct a systematic review and meta-analysis on retrograde wiring in chronic total occlusions (CTOs) with focus on its safety and feasibility., Methods and Results: We searched publications from 1990 to December 2013 in PubMed, Ovid, EMBASE, and the Cochrane database inserting a number of terms relating to the collateral circulation of the heart in CTOs. A total of 18 case series (n range17-462) with a total of 2280 CTO revascularization attempts fulfilled criteria for a study of retrograde wiring of collateral channels in CTOs. There were no randomized studies comparing a primary antegrade with a primary retrograde approach. Procedural CTO revascularization rates ranged from 67% to 90.6% with a large proportion having previously failed an "antegrade" approach. The septal perforator collaterals and epicardial channels were used in 73.2% (n = 1670) and 21.7% (n = 495) of cases. Although collateral/coronary perforation was not infrequent (n = 90, 5%), serious acute complications were uncommon; in the combined population 18 cases of cardiac tamponade (0.8%) and 3 deaths (0.1%). Septal perforating wiring (79.3%) was significantly more likely to be successful compared to epicardial coronary artery wiring (72.5%) when chosen by the operator as a route of retrograde access to the CTO body (relative risk 1.11 [95% confidence interval: 1.02-1.20; P = .013])., Conclusion: Successful retrograde wiring of collateral channels in selected patients undertaken by "CTO dedicated" operators can significantly enhance the chances of revascularization of complex CTOs with a low risk of acute serious complications. Septal perforator channels are significantly more likely to be successfully retrogradely wired compared to epicardial vessels when either is selected, by reference to their anatomical suitability by the operator, as a route of access., (© The Author(s) 2015.)

Background: Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure., Methods: In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3-5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518., Findings: Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09-2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70-1·89, p=0·59)., Interpretation: Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially., Funding: Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK)., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Previous angiographic lesion classification systems were derived from analysis of outcomes and lesion complexity in the early stent era. Advances in equipment design and techniques have altered the association between lesion and target vessel characteristics and procedural outcome in modern percutaneous coronary intervention (PCI). We evaluated the precise relationship between lesion characteristics and technical outcome on a lesion by lesion basis in a large dataset. We developed a multivariate model to predict technical failure in PCI., Methods: Analysis of prospectively collected data on 10,800 lesions in 6,719 consecutive PCI cases between January 2000 and December 2004. Multivariate logistic regression was undertaken to identify predictors of angiographic outcome at each treated lesion (success/failure). Statistical model validation was carried out using data from a further 3,340 treated lesions in 1,940 consecutive cases., Results: Independent variables associated with an increased risk of technical failure included total occlusion, severe calcification, proximal vessel tortuosity >90 degrees, lesion in a degenerate vein graft, and lesion angulation > or =90 degrees. The receiver operating characteristics (ROC) curve for the predicted probability of technical failure was 0.85. Failure occurred in 2.2% of treated lesions in the validation set (ROC curve 0.82, model predicted 2.5%)., Conclusions: We have re-evaluated the association between lesion characteristics and technical outcome in modern PCI. We have thereby developed a contemporary prediction model for angiographic outcome at each treated lesion.

Objective: To assess the impact of diabetes on 2-year mortality in current PCI practice., Background: In patients with coronary artery disease undergoing revascularization, diabetes mellitus is associated with higher mortality., Methods: A retrospective analysis was done of all patients undergoing PCI at our tertiary center between January 2000 and December 2004. There were 6,160 PCI procedures performed in 5,759 patients who received at least one stent. Of these patients, 801 (13.9%) were diabetic and 4,958 (86.1%) were nondiabetic. The primary outcome measure of the study was all-cause mortality. All patients were followed up for a period of 2 years. Multivariate logistic regression analysis was used to test for a potential independent association between diabetic status and follow-up mortality., Results: Before adjustment, a trend toward higher mortality was observed in diabetic patients compared to non-diabetics at 1 year (3.2% vs 2.4%) and 2 years (5.1% vs 3.8%), P = 0.12. Independent predictors for mortality were increasing age, renal dysfunction, peripheral vascular disease, NYHA class >2, urgent PCI, treating left main stem lesions, vessel diameter < or = 2.5 mm, and 3-vessel disease. The use of drug-eluting stent was associated with a reduction in mortality. Diabetes was found to have no independent impact on mortality following PCI (odds ratio = 1.08; 95% confidence intervals = 0.73-1.60; P = 0.71)., Conclusion: The presence of diabetes was not an independent predictor of mortality following PCI. A diabetic patient that does not require insulin treatment and has no evidence of macro- or microvascular diabetic disease could enjoy a PCI outcome similar to nondiabetic subjects.

Background: Long-term safety of drug-eluting stent (DES) is still a concern. We aimed to assess the impact of DES use on all-cause mortality and target-lesion revascularisation (TLR) in routine clinical practice., Methods: Retrospective analysis of all patients undergoing percutaneous coronary intervention with stent implantation at our institution between January 2003 and December 2004. To account for differences in patient characteristics, logistic regression was used to produce a propensity score for DES group membership. Patients receiving DES were then matched to patients receiving bare metal stents (BMS) with identical propensity scores. These two groups were then compared with respect to the incidence of TLR and all-cause mortality., Results: During the study period 995 patients received DES. Of these, 82 patients had combined DES and BMS use and were therefore excluded; leaving 913 DES patients compared to 2105 BMS patients. Patients who received DES were more likely to be diabetic, hypertensive, had more lesions treated, restenotic lesions treated, left anterior descending and left main stem interventions, long lesions treated, small diameter lesions treated, and American Heart Association C-type lesions treated. After performing propensity-matching, to account for differences in patient characteristics, we were able to successfully match 777 DES patients to 777 BMS patients. The TLR rates at 24 months were significantly lower for DES patients (DES-4.2% vs BMS-9.2%, p<0.001). All-cause mortality was also significantly lower for DES patients (DES-1.8% vs BMS-4.0%, p=0.01)., Conclusions: In routine clinical practice DES implantation continued to demonstrate a significant reduction in the need for repeat intervention at 24 months. All-cause and cardiac mortality was also significantly lower for DES patients compared to BMS patients.

Background: Data on effectiveness and safety following the implantation of very long segments of drug-eluting stents (DES) are lacking., Aim: To describe our experience of consecutive patients undergoing implantation of very long segments of DES (> 50 mm) in de novo coronary lesions., Methods: We evaluated major in-hospital complications, target lesion revascularization (TLR) rates and long-term outcomes in 88 consecutive patients (91 procedures) who underwent a single-vessel intervention with implantation of > 50 mm of overlapping DES to de novo lesions between October 2002 and October 2007. An additional 14 patients with long segments of in-stent restenosis, 10 receiving both DES and bare-metal stents for long-segment disease and 1 with long-segment disease in a saphenous vein graft were excluded from the study. Baseline clinical data, procedural outcomes and completed follow up were collected prospectively., Results: Follow up was 100% complete up to April 30, 2008. The mean follow up was 26.5 months (6-60 months). The mean stent length was 70.6 mm (51-135 mm) and the average number of stents per vessel was 2.7 (2-5 stents). Acute complications included 1 case of acute stent thrombosis which was treated successfully, 1 case of aortic root dissection, and 1 case of retroperitoneal hemorrhage. The rate of non-Q-wave myocardial infarction (CKMB > 3 times normal) was 8%. During follow up, the rate of TLR was 6.5%. Five patients died, 4 of them due to noncardiac conditions. One death was attributed to possible late stent thrombosis (18 months) occurring suddenly 2 days post keloid repair. Two patients had definite very late stent thrombosis at 14 and 17 months., Conclusion: In our experience, the use of very long segments of DES is effective in treating diffuse de novo coronary artery lesions. However, longer-term follow up is necessary and more data are required to determine the optimum duration of dual antiplatelet therapy.

Background: Percutaneous coronary intervention (PCI) is increasingly performed from the radial arterial (RA) access site. Few studies have examined the interaction between a default radial approach, lesion complexity, and angiographic outcome. This study investigates lesion complexity, arterial access route, and angiographic outcome in routine clinical practice by default radial operators., Methods: All cases of PCI over a 12-month period (Jan 2005 to Jan 2006) at our regional cardiac center were prospectively entered into a database detailing arterial access route, target vessel and lesion characteristics, and lesion-specific angiographic outcome. Angiographic success was defined as residual stenosis <50% for balloon angioplasty alone or <20% for a stented lesion in the presence of TIMI 3 flow in the target vessel. All procedures carried out by default radial operators were selected for further retrospective analysis. Reasons for not completing a case via the radial route were recorded. Radial and femoral cases by default radial operators were evaluated on grounds of lesion complexity and angiographic outcome for each treated lesion., Results: RA was the intended route in 91.5% of 1,324 procedures (91.5% of 2,239 lesions), and the final route in 90.1% of procedures (90.2% of lesions). There were 19 crossover procedures (30 lesions), all from radial to femoral access (FA). Crossovers were due to failed radial artery cannulation or sheath placement (9 procedures), inability to advance the guide catheter into the aortic root (7 procedures), and other guide catheter handling or support issues (3 procedures). Counting crossovers as failures, angiographic success rate was 96% among lesions for which RA was the primary intention. Complexity of cases was high (80.1% of RA lesions ACC/AHA type B2 or C)., Conclusions: A default radial approach is compatible with successful treatment of a wide range of coronary lesions, with a low incidence of crossover to femoral access. When the radial approach fails, it is usually due to access problems rather than issues of guide catheter handling and support.

Unlabelled: There has been an exponential growth in the number of percutaneous coronary intervention (PCI) procedures carried out via the transradial route. Traditionally, high-speed rotational atherectomy (HSRA) has been performed through 8 and 9 Fr catheters, which has limited its use during radial PCI., Aim: To review the applicability and outcomes of HSRA as a primary debulking tool during radial PCI., Methods: Case-note review and retrospective analysis of all patients undergoing HSRA during transradial PCI. Twenty-nine consecutive procedures in 28 patients were performed between January 2005 and April 2007., Results: Eighteen (64%) of the patients were males, and the mean age was 71 +/- 9.4 years (46-89). Three procedures were urgent, and 14 proceeded to HSRA, though this was not the initial strategy. The majority of procedures, 23 (79.3%), were carried out using a 6 Fr system, and a 7 Fr system was used in the remainder of cases. There were 15 lesions in the left anterior descending artery, 11 in the right coronary artery and 3 in the left circumflex. Lesion classification was type C in 21, and type B2 in 5. HSRA was carried out successfully in all cases, with uneventful subsequent stent deployment. A 1.5 mm burr was used in 25 lesions, 1.25 mm in 4, and 1.75 mm in 2 lesions. The vessel diameter was 2.7 +/- 0.5 mm (range 2.25-4.0 mm), and the mean length of stents used was 23.5 +/- 6.7 mm (range 18-63 mm). The mean procedure time was 94 +/- 35 minutes (range 50-180). CK-MB postprocedure was available in 26 patients; no patients experienced a greater than two-fold rise in CK-MB. There were no major procedural complications. One patient had evidence of minor brachial artery dissection when the guide catheter was upsized to 7 Fr, but there were no sequelae. Another patient had evidence of pericardial effusion after the procedure that was treated successfully with pericardial drain with no consequences. There were no major adverse cardiac events., Conclusion: Transradial HSRA can be carried out safely with good results. In this series, the procedure was not the initial strategy in the majority of patients, but allowed successful revascularization. Use of the transradial route should not preclude consideration of HSRA in suitable patient subgroups.

Objective: To evaluate the incidence of periprocedural creatine kinase-MB (CK-MB) release and its impact on longterm mortality in contemporary percutaneous coronary intervention (PCI) at a tertiary referral center., Methods: Retrospective analysis of 4,958 patients undergoing PCI with deployment of at least 1 stent at our center between January 1, 2003 and December 31, 2005. Patients admitted with acute ST-elevation myocardial infarction or cardiogenic shock (n = 617), and patients with no available CK-MB levels (n = 477) were excluded, leaving 3,864 patients for analysis. The outcome measure was all-cause mortality obtained from the National Strategic Tracing Service with patients followed up to June 30, 2006 (mean follow up 22 months). The association between CK-MB level and mortality was examined using Cox proportional hazards analysis., Results: CK-MB elevation above the upper limit of normal (ULN) was detected in 29.4% patients. A total of 127 deaths were observed during follow up. By multivariate analysis, periprocedural CK-MB was independently associated with an increased risk of death (adjusted hazard ratio for every 10 units: 1.09; 95% CI: 1.05-1.12; p < 0.001). The relationship between the level of CK-MB and mortality was further examined by applying strata of CK-MB levels to the multivariate analysis (adjusted hazard ratio: 1.30, 1.76 and 2.26 for CK-MB levels of 1-3, 3-5 and > 5 the ULN, respectively)., Conclusion: In the current era of PCI, periprocedural myonecrosis, evidenced by CK-MB elevation, is common and is associated with less favorable long-term mortality.

Unlabelled: Percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO) has become increasingly utilized. The indications and results of percutaneous closure are diverse., Aim: To assess the indications, results, and complications of percutaneous closure of ASD and PFO in our tertiary center., Method: Case note review and retrospective analysis of all consecutive patients undergoing percutaneous closure over a 3-year period from January 2003 to October 2005 with a mean follow-up of 19 months (4-36)., Results: There were 185 consecutive patients. The mean age was 44.9 years (SD 12.9) and 53% (n = 98) were males. There was 59% (n = 109) PFO and 41% (n = 76) ASD. The predominant indication for PFO closure was cerebrovascular accident (CVA) (42.2%, n = 46)- and for ASD, dilated right ventricle (68.4%, n = 52). Of all procedures, 94.6% (n = 175) were first time and 5.4% (n = 10) were redo for residual shunt. Overall, the success rate was 96.8% (n = 179) with two patients referred for surgical closure due to the large size of ASD and unsuitability for percutaneous closure, two procedures abandoned due to pericardial effusion, and two abandoned because the PFO was too small to cross. The Amplatzer device was used in 92.7% (n = 166) and the Starflex in 7.3% (n = 13). Minor complications were recorded in 10 patients (5.4%), of which 4 (2.2%) had minor venous access bleeding, 1 patient (0.5%) had retroperitoneal hematoma, and 2 patients (1.1%) had transient atrial fibrillation. One patient (0.5%) had transient inferior ST elevation during the procedure, one patient (0.5%) reported chest pain postprocedure, and one patient (0.5%) developed septicemia 3 weeks postprocedure. Major complications were recorded in three patients (1.5%), one patient (0.5%) with retroperitoneal hematoma requiring blood transfusion and two patients (1%) with pericardial effusion following transseptal puncture, requiring aspiration. No death, stroke, or device embolization was recorded., Conclusion: Our experience with percutaneous closure in adults demonstrates excellent results and safety with few complications. Percutaneous device closure will replace surgical closure for many ASDs and PFOs.

The mortality and incidence of chronic obstructive pulmonary disease (COPD) and coronary heart disease increase with age. Despite the clear evidence of beta blockers (BBs) effectiveness, there is a general reluctance to use them in patients with COPD due to a perceived contraindication and fear of inducing adverse reactions and bronchspasm. BBs are well tolerated in patients with cardiac disease and concomitant COPD with no evidence of worsening of respiratory symptoms or FEV1, and the safety of BBs in patients with COPD has been demonstrated, but their use in this group of patients remains low. The cumulative evidence from trials and meta-analysis indicates that cardioselective BBs should not be withheld in patients with reactive airway disease or COPD. Patients with COPD have a high incidence of cardiac events necessitating careful consideration of prophylactic treatment. The benefits of beta blockade in this group appear to outweigh any potential risk of side effects according to the available evidence. In this article, we will discuss the use of BBs in patients with COPD and review the evidence for their use and safety in this group of patients.

Objective: It has been suggested that macrovascular disease is more common in patients with scleroderma (SSc). We investigated the prevalence of coronary artery disease (CAD) in SSc using coronary angiography., Methods: Coronary angiography was performed in 172 patients with SSc and suspected CAD to examine the prevalence of significant CAD. The prevalence of CAD was estimated in the whole group and also according to age, gender and type of symptoms (typical angina, atypical angina and non-anginal pain or breathlessness). Standardized prevalence ratios (SPRs) were calculated in each symptomatic group in order to compare CAD rates amongst our observed population with those predicted using the Diamond and Forrester (D & F) probability analysis. This analysis provides an estimate of the probability of CAD based on gender, age and symptoms in subjects aged between 30-69 yrs., Results: The observed prevalence of CAD in the whole population was 22% (38/172); 17% (6/36) in males and 23% (32/136) in females. A total of 41 patients were excluded because they were outside the age range for D & F analysis. Compared with the reference population, the SPRs for CAD in the three SSc groups were: 47% (95% CI 21.7-89.9) in the typical angina group (22 patients), 50% (95% CI 13.6-128) in the atypical angina group (22 patients) and 93% (95% CI 49.4-158.8) in the non-anginal pain or breathlessness group (87 patients)., Conclusion: The prevalence of CAD in patients with SSc is similar and not greater to that expected in individuals without SSc.