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Percutaneous coronary intervention (PCI) of coronary bifurcation lesions (CBL) remains a challenge in contemporary practice due to the procedural and technical difficulties involved. We sought to review the current evidence on the safety and clinical outcomes of dedicated bifurcation stent (DBS) implantation in comparison with established treatment strategies for CBL-PCI.We conducted a comprehensive search to identify randomized control trials (RCTs) reporting 1-year clinical and angiographic outcomes of patients undergoing CBL-PCI with DBS vs conventional CBL-PCI strategies. Random-effects meta-analyses were performed to estimate the effect of DBS compared with conventional CBL-PCI using aggregate data.A total of 5 RCTs comprising 1249 participants met the inclusion criteria. The use of DBS was comparable to conventional stenting techniques in terms of major adverse cardiovascular event (MACE) rate (odds ratio [OR], 1.28; 95% confidence interval [CI], 0.90- 1.82; I²=0%), all-cause mortality (OR, 0.80; 95% CI, 0.31-2.07; I²=0%), cardiac mortality (OR, 0.16; 95% CI, 0.02-1.39; I²=0%), myocardial infarction (OR, 1.26; 95% CI, 0.84-1.89; I²=0%), definite stent thrombosis (OR, 1.75; 95% CI, 0.36-8.52; I²=0%), cumulative target-lesion revascularization (OR, 1.39; 95% CI, 0.85-2.27; I²=0%), clinically driven target-lesion revascularization (OR, 1.23; 95% CI, 0.68-2.22; I²=0%), or target-vessel revascularization (OR, 1.43; 95% CI, 0.92-2.22; I²=0%).The present analysis suggests that CBL-PCI with DBS may be associated with similar 1-year clinical and angiographic outcomes compared with conventional CBL-PCI strategies. However, the low quality of evidence and limited follow-up warrant further studies to ascertain any significant differences in patient-important outcomes before the adoption of DBS into routine CBL-PCI practice.

Rotational atherectomy (RA) has been traditionally performed via the transfemoral approach, mostly utilizing large guide catheters (≥7 Fr), which can accommodate the passage of large burrs (≥1.75 mm). However, contemporary data show that using smaller sheath and catheter sizes reduces the risk of procedural access-site related complications. Therefore, the aim of this study was to assess the feasibility of performing RA using smaller burrs and subsequently smaller-sized sheath catheters.A total of 220 patients underwent RA procedures between January 2011 and July 2017. We compared 162 patients who underwent RA using a maximal burr size of 1.5 mm (small-burr group) with 58 patients who underwent RA using burrs1.5 mm in diameter (large-burr group). Clinical, procedural, safety, and feasibility data were evaluated and compared between the two groups.Baseline characteristics of the two groups were quite similar other than a higher prevalence of smoking (21.0% vs 5.2%; P.01) and a lower body weight (80.9 ± 17.5 kg vs 86.8 ± 17.2 kg; P=.03) in the small-burr group vs the large-burr group. The indications for the procedure for the small-burr group vs large-burr group were stable angina in 53% vs 62%, unstable angina in 16% vs 17%, non-ST elevation myocardial infarction (MI) in 26% vs 17%, and ST-elevation MI in 3.7% vs 3.4%, respectively (P=NS for all). The target-vessel (TV) diameter was significantly larger in the large-burr group vs the small-burr group (3.5 ± 0.3 mm vs 3.2 ± 0.5 mm, respectively; P.01). Importantly, a sheath size6 Fr was used in 56.0% of the small-burr group vs 89.5% of the large-burr group (P.01). Moreover, in 53% of the small-burr group, a guide catheter6 Fr was used. Radial access was used in 33% of the small-burr group and 17% of the large-burr group (P=.03). Procedural success was achieved in 93% of the small-burr group and 100% of the large-burr group (P=.07).In the majority of cases, RA can be successfully performed using smaller-sized burrs while achieving a high procedural success rate. Notably, our study also highlights the overuse of large sheaths and catheters to deliver small burrs. These results further support the contemporary strategy of using 6 Fr guide catheters, thereby increasing the possibility of using the radial approach for more complex interventional procedures.

A 57-year-old female presented with Canadian Cardiovascular Society class 2 angina and a positive stress test. Angiography was performed via right radial approach, resulting in spiral dissection and TIMI 0 flow.

To assess the predictive value of Pd/Pa after nitroglycerin administration (Pd/Pa[N]) as compared with standard fractional flow reserve (FFR).Consecutive patients with intermediate coronary lesions assessed by FFR between January 2014 and October 2015 were included. We measured Pd/Pa at baseline, Pd/Pa(N), and Pd/Pa after incremental doses of intracoronary adenosine.A total of 134 patients (27% females; mean age, 65 years) were included. The diagnostic performance of Pd/Pa(N) and identification of cut-off value for Pd/Pa(N) compared with FFR threshold of 0.8 using receiver-operating characteristic (ROC) area under the curve analysis was between 0.98 (95% confidence interval, 0.95-1.00; P.05) for 48 μg and 0.86 (95% confidence interval, 0.79-0.94; P.05) for 240 μg adenosine. Pd/Pa(N) ≤0.8 had 100% positive predictive value. Pd/Pa(N) ≥0.94 provided 100% negative predictive value with a high sensitivity (92%). Optimal diagnostic accuracy of Pd/Pa(N) was achieved for values ≤0.84. The Pearson's correlation between Pd/Pa(N) and FFR varied between 0.89 for 24 μg adenosine and 0.77 for 240 μg (P.01).Pd/Pa(N) values can be used for diagnosis of hemodynamically significant lesions. Pd/Pa(N) correlates well with standard FFR. Pd/Pa(N) cut-off of ≤0.8 can be considered significant without need for adenosine injection. The value of using adenosine whenever Pd/Pa(N) is ≥0.94 is limited.

We assessed the value of routine real-time ultrasound (RTUS) guidance to improve transradial access (TRA) for cardiac catheterization.A prospective, single-center descriptive observational study of patients presenting for cardiac catheterization via the transradial approach. The first phase of the study enrolled 100 consecutive patients who underwent TRA without the assistance of RTUS followed by 100 consecutive patients who underwent TRA using RTUS guidance. The primary outcome measure was time between needle attempts for arterial access and sheath insertion.There were no statistically significant differences in any outcome measures. Median time between commencing needle attempts for arterial access to sheath insertion was 82.5 seconds (interquartile range [IQR], 64-161.5 seconds) with no RTUS guidance vs 84 seconds (IQR, 52.75-122.5 seconds) with RTUS; P=.19. Median number of needle passes through the skin required was 1 (IQR, 1-3) with no RTUS guidance vs 2 (IQR, 1-3) with RTUS; P=.25. Median number of arterial punctures was 1 (IQR, 1-1) with no RTUS guidance vs 1 (IQR, 1-1) with RTUS; P=.21.Routine RTUS guidance to assist in TRA does not significantly improve parameters of successful vascular access among high-volume radial operators. However, RTUS guidance should still be considered in selected cases and among less experienced radial practitioners.

The use of glycoprotein (GP) IIb/IIIa inhibitors during percutaneous coronary interventions (PCI) in the acute phase of myocardial infarction (AMI) is still a matter of debate. The aim of the present study was to compare the outcomes of patients with acute ST-segment elevation myocardial infarction who underwent primary PCI and were concomitantly treated with GP IIb/IIIa inhibitors with those who were not treated with these drugs. Between January 1996 and November 2003, a total of 418 consecutive patients underwent PCI in the setting of ST-segment elevation AMI. At the operator's discretion, 287 patients were concomitantly treated with GP IIb/IIIa inhibitors and 115 patients were not. Angiographic success and final TIMI 3 flow in the infarct-related artery was achieved more frequently in patients treated with GP IIb/IIIa inhibitors (90% vs. 77%; p=0.001). The in-hospital composite endpoint of death, reinfarction and bleeding complications was significantly better in patients treated with GP IIb/IIIa inhibitors (4% vs. 12%; p=0.005). Furthermore, the adjusted 12-month survival rate was significantly better in these patients (RR: 2.99, CI: 1.29-6.9; p=0.01). Therefore, adjunctive therapy with GP IIbIIIa inhibitors during primary PCI is associated with improved short-term outcomes and one-year survival without an increased risk of bleeding.