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Intravascular imaging has become an integral part of the diagnostic and management strategies for intracoronary pathologies. In this White Paper we summarize current evidence and its implications on the use of intravascular imaging in interventional cardiology practice. The areas addressed are planning and optimization of percutaneous coronary intervention, management of stent failure, and evaluation of ambiguous coronary lesions and myocardial infarction with nonobstructive coronary disease. The findings presented followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system in an expert consensus process that involved a diverse writing group vetted by a review group. Expert consensus was achieved around 9 statements. Use of intravascular imaging in guiding percutaneous revascularization is supported by high-quality evidence, particularly for lesions with increased risk of recurrent events or stent failure. Specific considerations for intravascular imaging guidance of intervention in left main lesions, chronic occlusion lesions, and in patients at high risk of contrast nephropathy are explored. Use of intravascular imaging to identify pathologies associated with stent failure and guide repeat intervention, resolve ambiguities in lesion assessment, and establish diagnoses in patients who present with myocardial infarction with nonobstructive coronary disease is supported by moderate- to low-quality evidence. Each topic is accompanied by clinical pointers to aid the practicing interventional cardiologist in implementation of the White Paper findings. The findings presented in this White Paper will help to guide the use of intravascular imaging toward situations in which the balance of efficacy, safety, and cost are most optimal., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS., Methods and Results: By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS 2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy., Conclusion: In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS., Competing Interests: Declaration of competing interest James K ChowNone Mary K TanNone Bryan J HarResearch grants and/or speaking consulting honoraria from Abbott, Astra Zeneca, Bayer, BMS/Pfizer, CSL Behring, Novartis, Opsens Amelia MC YipNone Mario PaniaguaNone Basem ElbarouniNone Kevin R Bainey,Research grants and/or speaking consulting honoraria from Astra Zeneca, Bayer, BMS. Jean-Michel ParadisNone Akshay BagaiResearch grants and/or speaking consulting honoraria from Servier, Bayer Inc., BMS/Pfizer, Boehringer Ingelheim, Teleflex, Abbott Vascular, Astra Zeneca, JAMP Pharma, HLS Therapeutics. Robert MarandaResearch grants and/or speaking consulting honoraria from Bayer, Bristol Myers Squibb, CHRC, Novartis, Servier. Investments, Abbvie, Amgen, McKesson Warren J CantorNone Mark J EisenbergNone Jean-Pierre DeryResearch grants and/or speaking consulting honoraria from JAMP Pharma, AstraZeneca, Bayer, BMS-Pfizer, Servier Mina MadanNone Tomas CiezaResearch grants and/or speaking consulting honoraria from Bayer, Boehringer-Ingelheim, Pfizer-BMS, Servier, Lilly, Astra Zeneca Alexis MatteauResearch grants and/or speaking consulting honoraria from Bristol Myers Squibb Sherryn RothNone Shahar LaviNone Anthony GlanzResearch grants and/or speaking consulting honoraria from BMS/Pfizer, Novartis, Bayer, Amgen Dongsheng GaoNone Ravi TahilianiResearch grants and/or speaking consulting honoraria from Pfizer-BMS, Novartis, Bayer, Daiichi Sankyo, Robert C WelshResearch grants and/or speaking consulting honoraria from Astra Zeneca, Bayer, BMS/Pfizer Hahn Hoe KimBMS/Pfizer Simon D RobinsonResearch grants and/or speaking consulting honoraria from Bayer and Servier Benoit DaneaultResearch grants and/or speaking consulting honoraria from BMS/Pfizer, Novartis, Edwards Lifesciences, Bayer, Abbott, Sanofi Aun-Yeong ChongResearch grants and/or speaking consulting honoraria from Servier Michel R Le MayNone Vineeta AhoojaResearch grants and/or speaking consulting honoraria from Amgen, Sanofi, Novo Nordisk, Bayer, Boehringer-Ingelheim, BMS/ Pfizer Jean C GregoireResearch grants and/or speaking consulting honoraria from Bayer, Boehringer Ingelheim, BMS/Pfizer alliance and Servier Pierre-Louis NadeauNone Zachary LaksmanNone Brett HeilbronNone Derek YungResearch grants and/or speaking consulting honoraria from Novartis, Amgen, Boehringer Ingleheim, Pfizer, Abbott, Medtronic, Boston Scientific Kunal MinhasNone Ronald BourgeoisResearch grants and/or speaking consulting honoraria from BMS/Pfizer, Canadian Collaborative Research Network (CCRN), HLS, Novartis Christopher OvergaardNone Hamid BonakdarNone Giridhar LogsettyResearch grants and/or speaking consulting honoraria from BMS/Pfizer Robert DeLaRochelliereNone Samer MansourResearch grants and/or speaking consulting honoraria from Astra-Zeneca, Pfizer, BMS, Sanofi, Amgen, HLS, Boehringer Ingelheim, Servier, Bayer, Abbott Vasculaire, Novartis Caroline SpindlerNone Andrew T YanNone Shaun G GoodmanResearch grant support (e.g., steering committee or data and safety monitoring committee) and/or speaker/consulting honoraria (e.g., advisory boards) from: Amgen, Anthos Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL Behring, Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, HLS Therapeutics, JAMP Pharma, Merck, Novartis, Novo Nordisk A/C, Pendopharm/Pharmascience, Pfizer, Regeneron, Sanofi, Servier, Tolmar Pharmaceuticals, Valeo Pharma; and salary support/honoraria from the Heart and Stroke Foundation of Ontario/University of Toronto (Polo) Chair, Canadian Heart Research Centre and MD Primer, Canadian VIGOUR Centre, Cleveland Clinic Coordinating Centre for Clinical Research, Duke Clinical Research Institute, New York University Clinical Coordinating Centre, PERFUSE Research Institute, TIMI Study Group (Brigham Health), (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Dietary restriction of sodium has been suggested to prevent fluid overload and adverse outcomes for patients with heart failure. We designed the Study of Dietary Intervention under 100 mmol in Heart Failure (SODIUM-HF) to test whether or not a reduction in dietary sodium reduces the incidence of future clinical events., Methods: SODIUM-HF is an international, open-label, randomised, controlled trial that enrolled patients at 26 sites in six countries (Australia, Canada, Chile, Colombia, Mexico, and New Zealand). Eligible patients were aged 18 years or older, with chronic heart failure (New York Heart Association [NYHA] functional class 2-3), and receiving optimally tolerated guideline-directed medical treatment. Patients were randomly assigned (1:1), using a standard number generator and varying block sizes of two, four, or six, stratified by site, to either usual care according to local guidelines or a low sodium diet of less than 100 mmol (ie, <1500 mg/day). The primary outcome was the composite of cardiovascular-related admission to hospital, cardiovascular-related emergency department visit, or all-cause death within 12 months in the intention-to-treat (ITT) population (ie, all randomly assigned patients). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT02012179, and is closed to accrual., Findings: Between March 24, 2014, and Dec 9, 2020, 806 patients were randomly assigned to a low sodium diet (n=397) or usual care (n=409). Median age was 67 years (IQR 58-74) and 268 (33%) were women and 538 (66%) were men. Between baseline and 12 months, the median sodium intake decreased from 2286 mg/day (IQR 1653-3005) to 1658 mg/day (1301-2189) in the low sodium group and from 2119 mg/day (1673-2804) to 2073 mg/day (1541-2900) in the usual care group. By 12 months, events comprising the primary outcome had occurred in 60 (15%) of 397 patients in the low sodium diet group and 70 (17%) of 409 in the usual care group (hazard ratio [HR] 0·89 [95% CI 0·63-1·26]; p=0·53). All-cause death occurred in 22 (6%) patients in the low sodium diet group and 17 (4%) in the usual care group (HR 1·38 [0·73-2·60]; p=0·32), cardiovascular-related hospitalisation occurred in 40 (10%) patients in the low sodium diet group and 51 (12%) patients in the usual care group (HR 0·82 [0·54-1·24]; p=0·36), and cardiovascular-related emergency department visits occurred in 17 (4%) patients in the low sodium diet group and 15 (4%) patients in the usual care group (HR 1·21 [0·60-2·41]; p=0·60). No safety events related to the study treatment were reported in either group., Interpretation: In ambulatory patients with heart failure, a dietary intervention to reduce sodium intake did not reduce clinical events., Funding: Canadian Institutes of Health Research and the University Hospital Foundation, Edmonton, Alberta, Canada, and Health Research Council of New Zealand., Competing Interests: Declaration of interests JAE reports research grants from American Regent, Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb/Pfizer, eko.ai, US2.ai, Merck, Novartis, Otsuka, Sanofi, and Servier, and consulting fees from American Regent, Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb/Pfizer, Merck, Novartis, Otsuka, Sanofi, and Servier. PM reports research grants from National Health & Medical Research Committee, New South Wales Department of Health, and St Vincent's Clinic Foundation; consulting fees from AstraZeneca, Boehringer Ingelheim, and Novartis; honoraria payments from Japanese Circulation Society; support for attending meetings or travel from Astellas; and stock or stock options from Infensa Biologics. RT reports research grants from Health Research Council of New Zealand; consulting fees from Merck and Roche Diagnostics; and honoraria payments from Roche Diagnostics. CS reports research grants from Medtronic; consulting fees from AstraZeneca, Bayer, Merck, and Boehringer Ingelheim; honoraria payments from AstraZeneca, Bayer, Merck, Boehringer Ingelheim, and Novartis; and fees for participation in advisory boards from Servier, AstraZeneca, Bayer, Merck, Boehringer Ingelheim, and Novartis. JAt reports consulting fees from AstraZeneca, Boehringer Ingelheim, and Eli Lilly and support for attending meetings from AstraZeneca, Novartis, and Shire. MG reports research grants from the University of Alberta. JH reports research grants from AstraZeneca; consulting fees from Servier, Otsuka, Alnylam, Boehringer Ingelheim, Lilly, Novo Nordisk, Bayer Canada, AstraZeneca, and Novartis; and honoraria payments from Servier, Otsuka, Alnylam, Boehringer Ingelheim, Lilly, Novo Nordisk, Bayer Canada, AstraZeneca, and Novartis. SJ reports research payments from the University of Alberta. ML reports consulting fees from New Zealand Formulary and honoraria payment from Novartis. JS reports consulting fees from Servier and Novartis; honoraria payments from Bayer; and receipt of equipment, materials, drugs, medical writing, gifts, or other services from Servier, Novartis, Bayer, and HLS Therapeutics. SZ reports consulting fees from Abbott, Akcea, AstraZeneca, Amgen, Alnylam, Bayer, Boehringer Ingelheim, Eli Lilly, Merck, Novartis, Otsuka, Pfizer, Servier, and Vifor; and honoraria payments from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, HLS Therapeutics, Janssen, Novartis, Novo Nordisk, Servier, and Vifor. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Postextrasystolic potentiation (PESP)-associated augmentation in left ventricular-aorta pressure gradient (LVAoG) observed after incidental premature ventricular contraction (PVC) during resting echocardiography is similar to dobutamine stress echocardiography (DSE)-associated augmentation in LVAoG in patients with low-flow, low-gradient (LF-LG) aortic stenosis (AS). What is not known is whether a similar relationship exists when unintended PVC causes PESP during cardiac catheterization in patients with AS., Methods: We retrospectively reviewed all catheterizations performed for patients with at least moderate AS who had LVAoG assessment. Univariate and multivariate analyses were conducted to determine the predictors of pre- and post-PVC mean LVAoG ≥ 40 mmHg., Results: Between September 2015 to September 2017, of 140 individuals undergoing cardiac catheterization, 34 met study criteria. Mean pre-PVC gradient was 38.9 ± 22.8 mmHg. All patients exhibited PESP-associated augmentation of LVAoG by an average of 28 ± 12%. In multivariate analysis, the only significant predictor of post-PVC mean LVAoG ≥ 40 mmHg was preserved LV function (OR 6.81; 95% CI 1.41-32.82, p = 0.02). Inability to generate ≥ 40 mmHg of mean LVAoG post-PVC had 100% specificity for nonsevere AS in our observational cohort., Conclusions: Unintended but interpretable PVCs occurred in one in four patients with AS undergoing cardiac catheterization with measurable hemodynamics. All of our patients with PVCs, regardless of underlying LVEF, exhibited PESP-associated augmentation of LVAoG. Our exploratory analysis suggests that inability to generate ≥40 mmHg of mean LVAoG post-PVC is highly specific for nonsevere AS., Competing Interests: Declaration of competing interest No grants, contracts, and other forms of financial support were provided for this project. The authors have no conflicts of interest to note., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The globe is currently in the midst of a COVID-19 pandemic, resulting in significant morbidity and mortality. This pandemic has placed considerable stress on health care resources and providers. This document from the Canadian Association of Interventional Cardiology- Association Canadienne de Cardiologie d'intervention, specifically addresses the implications for the care of patients in the cardiac catheterization laboratory (CCL) in Canada during the COVID-19 pandemic. The key principles of this document are to maintain essential interventional cardiovascular care while minimizing risks of COVID-19 to patients and staff and maintaining the overall health care resources. As the COVID-19 pandemic evolves, procedures will be increased or reduced based on the current level of restriction to health care services. Although some consistency across the country is desirable, provincial and regional considerations will influence how these recommendations are implemented. We believe the framework and recommendations in this document will provide crucial guidance for clinicians and policy makers on the management of coronary and structural procedures in the CCL as the COVID-19 pandemic escalates and eventually abates., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The Mosaic bioprosthesis is a third-generation stented porcine bioprosthesis. This study was performed to evaluate long-term survival and durability associated with this device., Methods: A total of 1,029 patients (797 aortic valve replacements, 232 mitral valve replacements) previously enrolled at 6 centers as part of the original regulatory study were included. We evaluated freedom from death, valve-related reoperation, and explant due to structural valve deterioration (SVD), and compared these outcomes by age (<60 and ≥60 years) at the time of implant., Results: Cumulative follow-up was 7021.2 patient-years in the aortic cohort and 1969.5 patient-years in the mitral cohort. Mean age was 69.5 ± 8.6 and 67.9 ± 10.5 years; 66% and 48% were male, respectively. In the aortic cohort at 17 years, freedom from death was 54.0% in patients younger than 60 years and 24.0% in patients aged 60 years and older (p < 0.01); freedom from reoperation was 36.4% and 81.2%, respectively (p < 0.01); and freedom from explant due to SVD was 47.5% and 89.1% (p < 0.01). At 16 years in the mitral cohort, freedom from death was 67.6% and 20.6% (p < 0.01); freedom from reoperation was 51.3% versus 77.9% (p = 0.04); and freedom from explant due to SVD was 65.2% versus 83.8% (p = 0.23)., Conclusions: This study demonstrates acceptable long-term rates of death, reoperation, and explant due to SVD with the Mosaic bioprosthesis implanted in either the aortic or mitral position. Freedom from explant due to SVD was lower in patients younger than 60 years in the aortic cohort at 17 years, but it was not significantly different between patients younger than 60 years or 60 years and older in the mitral cohort at 16 years., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Currently there are more than 40 centres in Canada that perform more than 65,000 percutaneous coronary interventions (PCIs) in a year. Considering the high volume of procedures and number of operators, the potential for variation in processes of care is high, and might lead to variation in the quality of care. As part of its quality initiative, the Canadian Cardiovascular Society convened a working group to develop a set of PCI Quality Indicators (QIs) that would be relevant, scientifically acceptable, and feasible to measure and report. The working group was comprised of clinical experts from across Canada and members of provincial and federal organizations involved in promoting the quality of health care. Using the Canadian Cardiovascular Society "Best Practices for Developing Cardiovascular Quality Indicators" methodology, a total of 23 QIs were proposed. Subsequent ranking and discussion led to the selection of 8 QIs. The selection and ranking of QIs were on the basis of clinical importance and relevance, scientific acceptability, and feasibility of their operationalization at a national level. The data definitions and technical notes of the QIs were refined after feasibility testing and Web consultation. Feasibility testing indicated that standardization and enhancements of knowledge infrastructure are essential to provide the comprehensive patient data necessary to evaluate the quality of PCI across Canada., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: We investigated attenuated plaque (hypoechoic plaque with deep ultrasonic attenuation despite absence of bright calcium) in nonculprit lesions., Background: Recent intravascular ultrasound (IVUS) studies describe acoustic shadowing behind large, echolucent, acute culprit lesion sites in the absence of bright calcium. Such "attenuated plaque" is considered a characteristic of high-risk lesions, but its prevalence in stable nonculprit lesions is incompletely known., Methods: We reviewed IVUS pullback data from nonculprit vessels in 159 patients from the ASTEROID (A Study to Evaluate the Effect of Rosuvastatin on Intravascular Ultrasound-Derived Coronary Atheroma Burden) trial. We identified attenuated plaque and compared volumetric IVUS data in the segments with and without attenuation. In addition, we described plaque morphology in segments with attenuation at baseline and follow-up., Results: Attenuated plaque was found in 17 of 159 patients (10.7%, 95% confidence interval: 6% to 17%). At baseline, there were no significant differences in clinical presentation and cardiovascular risk factors between patients with and without attenuation. Other than a greater plaque eccentricity index (p = 0.008), there were no significant differences between segments with and without attenuation. In segments with attenuated plaque, expansive remodeling was observed in 53%, and calcified plaque adjacent to the attenuation site in 70% of patients. During follow-up, attenuation remained stable, and no events occurred in the patients with attenuation., Conclusions: Attenuated plaque is present in a significant number of nonculprit segments in patients enrolled in IVUS progression trials and remains stable during follow-up. There is a relationship with mixed calcified lesions. These findings challenge the prior assumption that attenuated plaque is a finding limited to culprit lesions associated with acute clinical presentation.