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Unintended deformation of implanted coronary stents can lead to loss of coronary access, stent thrombosis and coronary events during follow-up. The incidence, mechanisms and clinical outcomes of unintended stent deformations (USD) during complex bifurcation stenting are not well characterized. In a prespecified analysis of the OCTOBER (European Trial on Optical Coherence Tomography Optimized Bifurcation Event Reduction) trial, we aimed to: 1) determine the incidence and characterize mechanisms of USD identified by optical coherence tomography (OCT); and 2) evaluate physician's detection and correction of accidental abluminal rewiring and USD. OCT scans were analyzed for accidental abluminal rewiring and USD. When USD was identified, the plausible mechanism was determined by analysis of all procedural OCT scans and the corresponding angiograms. USD was identified by the core lab in 9.3% (55/589) of OCT-guided cases. Accidental abluminal rewiring was the cause in 44% (24/55), and guide catheter collision was the cause in 40% (22/55) of cases. USD was found in 18.5% of all cases with left main bifurcation percutaneous coronary intervention. The total incidence of abluminal rewiring was 33 in 32 OCT-guided cases (5.4%) and was corrected by physicians in 18 of 33 appearances (54.5%). The 2-year major adverse cardiac event rate for patients with untreated USD (n = 30) was 23.3%, whereas patients with confirmed or possibly corrected USD (n = 25) had no events during follow-up. USD was associated with adverse procedural complications and cardiac events during follow-up when not identified and corrected. The predominant mechanisms were undetected abluminal rewiring and guide catheter collision. Left main bifurcation percutaneous coronary intervention was a particular risk with USD detected in 18.5% of cases. [Display omitted] [ABSTRACT FROM AUTHOR]

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Artificial intelligence, computational simulations, and extended reality, among other 21st century computational technologies, are changing the health care system. To collectively highlight the most recent advances and benefits of artificial intelligence, computational simulations, and extended reality in cardiovascular therapies, we coined the abbreviation AISER. The review particularly focuses on the following applications of AISER: 1) preprocedural planning and clinical decision making; 2) virtual clinical trials, and cardiovascular device research, development, and regulatory approval; and 3) education and training of interventional health care professionals and medical technology innovators. We also discuss the obstacles and constraints associated with the application of AISER technologies, as well as the proposed solutions. Interventional health care professionals, computer scientists, biomedical engineers, experts in bioinformatics and visualization, the device industry, ethics committees, and regulatory agencies are expected to streamline the use of AISER technologies in cardiovascular interventions and medicine in general. [Display omitted] • In the era of evidence-based medicine, computational technologies such as artificial intelligence, computational simulations, and extended reality have the potential to reshape the health care systems worldwide. • This review collectively highlights the latest technological advancements and synergies of artificial intelligence, computational simulations, and extended reality in cardiovascular interventions. • Artificial intelligence, computational simulations, and extended reality could improve preprocedural planning, real-time decision making, device research and development, device regulatory approval, and education and training of interventional health care providers and medical device innovators. [ABSTRACT FROM AUTHOR]

There is limited evidence regarding the association between right ventricular-to-pulmonary artery (RV-PA) coupling and outcomes after transcatheter aortic valve replacement (TAVR). This study aimed to explore the evolution of RV-PA coupling in patients with severe aortic stenosis undergoing TAVR and its prognostic impact. A total of 900 patients who underwent TAVR in 2 tertiary centers and with echocardiographic analysis performed within 3 months before and after the procedure were included. RV-PA coupling was measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). RV-PA uncoupling was defined by TAPSE/PASP <0.55, whereas a TAPSE/PASP <0.32 identified a severe uncoupling. The primary endpoint was all-cause mortality. A total of 520 patients (58%) showed RV-PA uncoupling before TAVR, whereas post-TAVR RV-PA uncoupling was observed in 407 patients (45%). During a median follow-up of 40 months, 250 deaths (28%) occurred. Post-TAVR RV-PA uncoupling was independently associated with an increased risk of mortality (adjusted HR: 1.474; 95% CI: 1.115-1.948; P = 0.006), whereas pre-TAVR uncoupling did not. Among patients with post-TAVR RV-PA uncoupling, the presence of severe uncoupling identified a subgroup with the worst survival (P = 0.008). Patients with RV-PA coupling recovery after TAVR showed similar outcomes as compared with patients with normal coupling. Conversely, the presence of either persistent or new-onset RV-PA uncoupling following TAVR was associated with an increased mortality risk. Post-TAVR RV-PA uncoupling is an independent predictor of long-term mortality, irrespective of coupling before intervention. Assessment of TAPSE/PASP response after TAVR may be helpful to improve risk stratification. [Display omitted] [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The optimal access route in patients with severe peripheral artery disease (PAD) undergoing transcatheter aortic valve replacement (TAVR) remains undetermined. This study sought to compare clinical outcomes with transfemoral access (TFA), transthoracic access (TTA), and nonthoracic transalternative access (TAA) in TAVR patients with severe PAD. Patients with PAD and hostile femoral access (TFA impossible, or possible only after percutaneous treatment) undergoing TAVR at 28 international centers were included in this registry. The primary endpoint was the propensity-adjusted risk of 30-day major adverse events (MAE) defined as the composite of all-cause mortality, stroke/transient ischemic attack (TIA), or main access site–related Valve Academic Research Consortium 3 major vascular complications. Outcomes were also stratified according to the severity of PAD using a novel risk score (Hostile score). Among the 1,707 patients included in the registry, 518 (30.3%) underwent TAVR with TFA after percutaneous treatment, 642 (37.6%) with TTA, and 547 (32.0%) with TAA (mostly transaxillary). Compared with TTA, both TFA (adjusted HR: 0.58; 95% CI: 0.45-0.75) and TAA (adjusted HR: 0.60; 95% CI: 0.47-0.78) were associated with lower 30-day rates of MAE, driven by fewer access site–related complications. Composite risks at 1 year were also lower with TFA and TAA compared with TTA. TFA compared with TAA was associated with lower 1-year risk of stroke/TIA (adjusted HR: 0.49; 95% CI: 0.24-0.98), a finding confined to patients with low Hostile scores (P interaction = 0.049). Among patients with PAD undergoing TAVR, both TFA and TAA were associated with lower 30-day and 1-year rates of MAE compared with TTA, but 1-year stroke/TIA rates were higher with TAA compared with TFA. [Display omitted] [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2010.08.009 Byline: Italo Porto, Christian Hamilton-Craig, Marta Brancati, Francesco Burzotta, Leonarda Galiuto, Filippo Crea Abbreviations: AMI, acute myocardial infarction; CMR, cardiovascular magnetic resonance; IRA, infarct-related artery; MBG, myocardial blush grade; MCE, myocardial contrast echocardiography; PCI, percutaneous coronary intervention; pPCI, primary percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction; TMPG, TIMI myocardial perfusion grading; cTFC, corrected TIMI frame count Abstract: Assessment of myocardial 'blush' by either Myocardial Blush Grade or TIMI Myocardial Perfusion Grade, is the angiographic method currently preferred to confirm myocardial tissue-level perfusion after primary percutaneous intervention. This review focuses on the utility of angiographic 'blush' as a simple, widely available, and virtually costless technique for the immediate diagnosis of microvascular impairment at the time of acute catheterization. We comprehensively outline the available evidence behind the 'blush,' its use in clinical practice, and draw comparisons with other new technologies for assessment of microvascular integrity. Article History: Received 24 April 2010; Accepted 14 August 2010

Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with higher rates of adverse events, and currently it is unclear whether PCI or coronary artery bypass grafting (CABG) is the safer treatment for these patients at very long-term follow-up. The aim of this study was to investigate the impact of bifurcation lesions on individual predicted and observed all-cause 10-year mortality in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial. In the SYNTAXES (SYNTAX Extended Survival) study, 10-year observed and individual predicted mortality derived from the SYNTAX score 2020 (SS-2020) was compared between patients with ≥1 bifurcation (n = 1,300) and those with no bifurcations (n = 487). Among patients treated with PCI, patients with >1 bifurcation lesion compared with those without bifurcation lesions had a significantly higher risk for all-cause death (19.8% vs 30.1%; HR: 1.55; 95% CI: 1.12-2.14; P = 0.007), whereas following CABG, mortality was similar in patients with and those without bifurcation lesions (23.3% vs 23.0%; HR: 0.81; 95% CI: 0.59-1.12; P = 0.207; P interaction = 0.006). In PCI patients, a 2-stent vs a 1-stent technique was associated with higher mortality (33.3% vs 25.9%; HR: 1.51; 95% CI: 1.06-2.14; P = 0.021). According to the SS-2020, among those with ≥1 bifurcation, there was equipoise for all-cause mortality between PCI and CABG in 2 quartiles of the population, whereas CABG was superior to PCI in the 2 remaining quartiles. Bifurcation lesions require special attention from the heart team, considering the higher 10-year all-cause mortality associated with PCI. Careful evaluation of bifurcation lesion complexity and calculation of individualized 10-year prognosis using the SS-2020 may therefore be helpful in decision making. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050 ; Taxus Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972) [Display omitted] [ABSTRACT FROM AUTHOR]

In one multicenter and several single-center studies involving 202 cases, new shapes of transradial access PCI guide catheters were tested following a standardized original protocol. The evaluation included a newly designed score for PCI complexity. Three operators successfully performed the 40 cases of the multicenter study, scoring intermediate to difficult 66% of the cases. New shapes were tested for left and right coronary artery and saphenous vein graft PCIs, with right or left transradial access. The new shapes performed adequately, including in 5F sizing. PCI success and fluoroscopy time were related to the score of complexity. [ABSTRACT FROM AUTHOR]

Coronary artery obstruction (CAO) during transcatheter-aortic-valve replacement (TAVR) represents a main concern for TAVR safety in patients with low coronary take-off. To date, "snorkel" (also called chimney) technique, consisting of stent implantation from the coronary ostium to the aorta within the space between the valve frame and the aortic wall, is the most adopted strategy to prevent CAO. This technique is associated with the creation of complex valve/stent configuration that can hinder repeat coronary interventions. Due to this concern, we set up an original sequence for coronary protection aiming to ensure a more physiological TAVR frame/stent configuration. According to this technique, TAVR prosthesis is released with a "protection" system consisting of guiding catheter (GC), wire and stent inside the coronary artery with high CAO risk. In the case of CAO occurrence, the stent is released according to the snorkel technique. In the absence of complete CAO, a new GC is advanced inside the implanted TAVR prosthesis and the stent is deployed from the coronary artery up to the prosthesis. We herein report two cases of very high CAO risk where this technique was successfully used during last-generation self-expandable prostheses implantation (in a native aortic valve and in one prosthetic aortic valve). In conclusion, this "orthotopic snorkel-stenting in TAVR" (OST) technique represents a novel option for treating impeding CAO during TAVR. As compared with the "classic" snorkel technique, it allows avoiding stent implantation in some patients (who do not experience CAO) and may provide a more predictable and physiologic TAVR prosthesis/stent configuration in the case of stent implantation need. [ABSTRACT FROM AUTHOR]

Sudden cardiac arrest is a significant cause of death worldwide. Good quality cardiopulmonary resuscitation increases patients' survival. Manual cardiopulmonary resuscitation is often ineffective as rescuers may experience physical and mental fatigue. Mechanical cardiopulmonary resuscitation devices are designed to address this issue, providing an automated approach for high-quality resuscitation. In the present comprehensive umbrella review we summarize current evidence on mechanical devices. We searched systematic reviews on mechanical devices in MEDLINE/PubMed. Effect estimates were obtained from original reports, including 95% confidence intervals and p values, when applicable and available, focusing on return of spontaneous circulation, survival to discharge or 30 days, survival with good neurological outcome, and resuscitation-related injuries. From 21 potentially pertinent publications, we shortlisted 10 reviews, each including between 5 and 22 studies. AutoPulse, LUCAS, and LUCAS-2 were among the investigated devices. Most reviews concluded toward mechanical devices being similar or better than manual resuscitation for return of spontaneous circulation and 30-days survival. Regarding survival with good neurological function, some reviews lacked data, while the remaining ones reported similar results or worse outcomes in patients undergoing mechanical resuscitation. Focusing on resuscitation-related injuries, data were limited or conflicting with one review reporting higher rates of injuries with mechanical devices, and two others suggesting similar outcomes. Manual and mechanical cardiopulmonary resuscitation appear to be similar in terms of return of spontaneous circulation and short-term survival. Mechanical devices appear to be associated with higher resuscitation-related injuries, while there are conflicting data in terms of survival with good neurological outcomes. A comprehensive and large dedicated randomized trial is urgently needed. [ABSTRACT FROM AUTHOR]

Percutaneous coronary intervention (PCI) is establishing as the last remaining revascularization option in an increasing number of patients affected by complex coronary artery disease not suitable for surgery. Over the past decade, percutaneous left ventricular assist device (pLVAD) has increasingly replaced intra-aortic balloon pump to provide hemodynamic support during such non-emergent complex high-risk indicated procedures (CHIP) averting the risk of circulatory collapse and of adverse events in long lasting and/or complicated procedures. This review article aims to report the key factors to define CHIP, to summarize the available pLVAD which have CE mark for temporary mechanical LV support and to discuss the rationale of their use in this subset of patients. Based on the expertise of the Italian Society of Interventional Cardiology working group, with the endorsement from Spanish and Portuguese Society of Interventional Cardiology working groups, it will provide several practical suggestions in regards to the use of pLVAD in different clinical CHIP scenarios. • PCI may be the only option in an increasing number of patients with complex CAD. • Percutaneous LVAD may effectively support long lasting and/or complicated PCI. • pLVAD use should be assessed by a multiparametric/disciplinary evaluation. • This report aim to advise practical suggestions on pLVAD use during high-risk PCI. [ABSTRACT FROM AUTHOR]

Background: Optical-coherence-tomography (OCT) is an emerging invasive coronary imaging with still undefined clinical value. Recent data have underlined daily impact of such technique in several clinical settings such as acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI) guidance. We aimed at assessing the trends and outcomes of OCT use in a high-volume percutaneous coronary interventions (PCI)-center.Methods: Over 6 years, 1025 coronary artery segments in 877 patients underwent OCT evaluation. Clinical and procedural characteristics were prospectively collected. Clinical setting for OCT was: "Diagnostic OCT" (OCT for lesion evaluation after coronary angiography without further PCI); "PCI-guidance OCT" (OCT as a guidance for complex PCI, both by intention or after diagnostic OCT). Primary study end-point was the occurrence of target-vessel-failure (TVF) during the follow-up.Results: Overall, OCT was successful in 99.1% of attempted lesions. Only one complication (coronary dissection requiring urgent PCI) occurred during OCT. After a follow-up of 695 ± 562 days, TVF occurred in 8.2% of cases. Despite similar baseline characteristics, TVF-free survival curves were different in the two populations (5.4% after diagnostic OCT and 9.9% after PCI-guidance OCT). Minimal-lumen-area (MLA) of target lesion was independently associated with TVF (HR 0.7, 95% CI 0.6-0.8). This was mainly driven by a significant impact of MLA in patients not revascularized (HR 0.6, 95% CI 0.4-0.9). TVF did not change according to the study period despite the selection of patients with increasing complexity.Conclusions: OCT has a good safety profile across a broad spectrum of patients encountered in daily practice. The easy-to-assess MLA parameter may help stratify prognosis of patients undergoing OCT. These data call for further evaluations of OCT clinical impact.Summary: OCT is a light-based imaging tool which had subvert the quite ordinary world of coronary imaging and the present study evaluates OCT use in a high-volume center. Our results suggest that application of OCT in "real world" patients presenting higher risk has a good safety profile. Several factors could predict a worse long-term outcome in patients undergoing OCT evaluation, mostly related to more complex clinical conditions. These findings could encourage even low-to intermediate volume centers to improve their OCT use in daily practice. [ABSTRACT FROM AUTHOR]

Abstract Background Percutaneous ventricular-assistance by Impella (IMP) represents an emerging strategy to manage patients with reduced left-ventricular (LV) ejection-fraction (EF) undergoing percutaneous-coronary-intervention (PCI). The hemodynamic behave during IMP-protected PCI has been scarcely investigated. Methods We reviewed the IMP console's function and hemodynamic data (which are continuously recorded during assistance) in a consecutive series of 37 patients who underwent elective IMP-protected PCI in two high-volume centers. All patients had multivessel disease and impaired LVEF. Coronary artery disease burden was graded using the British-Cardiovascular-Intervention-Society jeopardy-score (BCIS-JS) score. IMP motor speed and pressure signals (systolic blood pressure, SBP, and mean blood pressure, MBP) were analyzed. Primary hemodynamic end-points were "critical systolic blood pressure (SBP) drop" (SBP decrease ≥ 20 mm Hg reaching ≤90 mm Hg values) and "critical mean blood pressure (MBP) drop" (MBP decrease reaching ≤60 mm Hg). Results Over mean assistance duration of 254 ± 549 min, no IMP motor drop occurred. During PCI, SBP and MBP significantly decreased but all patients had SBP values >78 mm Hg. Critical SBP and MBP drops occurred in 10.8% of patients. Among all baseline and procedural characteristics, BCIS-JS was the only significant predictor of SBP drop (p = 0.001) while BCIS-JS and LV end-diastolic volume significantly predicted MBP drop (p = 0.001 for both). Conclusions In patients with reduced EF undergoing IMP-protected PCI, a significant pressure decrease occurs during PCI but pressure is systematically maintained at levels warranting vital organ perfusion. Critical pressure drops during PCI occur in some patients with higher jeopardized myocardium and left ventricular diastolic volumes. Highlights • During high-risk PCI no Impella malfunctioning occurred. • Throughout the procedure systolic and mean blood pressure significantly decreased. • Some patients experienced a major pressure drop. • Coronary anatomy complexity and left ventricle dimension could predict major pressure drop. [ABSTRACT FROM AUTHOR]

Copyright of American Heart Journal is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

This article summarizes the current research on the benefits of using the transradial approach for percutaneous procedures and the radial artery as a conduit for coronary artery bypass surgery. Based on the available evidence, the authors provide recommendations for the use of the radial artery in patients undergoing percutaneous or surgical coronary procedures. [ABSTRACT FROM AUTHOR]

Mechanical circulatory support represents an evolving field of clinical research and practice. Currently, several cardiac assist devices have been developed but, among different institutions and countries, a large variation in indications for use and device selection exists. The Impella platform is an easy to use percutaneous circulatory support device which is increasingly used worldwide. During 2014, we established a working group of European physicians who have collected considerable experience with the Impella device in recent years. By critically comparing the individual experiences and the operative protocols, this working group attempted to establish the best clinical practice with the technology. The present paper reviews the main theoretical principles of Impella and provides an up-to-date summary of the best practical aspects of device use which may help others gain the maximal advantage with Impella technology in a variety of clinical settings. [ABSTRACT FROM AUTHOR]

Objectives The goal of this study was to assess the clinical impact of optical coherence tomography (OCT) findings during percutaneous coronary intervention (PCI). Background OCT provides unprecedented high-definition visualization of plaque/stent structures during PCI; however, the impact of OCT findings on outcome remains undefined. Methods In the context of the multicenter CLI-OPCI (Centro per la Lotta contro l’Infarto–Optimisation of Percutaneous Coronary Intervention) registry, we retrospectively analyzed patients undergoing end-procedural OCT assessment and compared the findings with clinical outcomes. Results A total of 1,002 lesions (832 patients) were assessed. Appropriate OCT assessment was obtained in 98.2% of cases and revealed suboptimal stent implantation in 31.0% of lesions, with increased incidence in patients experiencing major adverse cardiac events (MACE) during follow-up (59.2% vs. 26.9%; p < 0.001). In particular, in-stent minimum lumen area <4.5 mm 2 (hazards ratio [HR]: 1.64; p = 0.040), dissection >200 μm at the distal stent edge (HR: 2.54; p = 0.004), and reference lumen area <4.5 mm 2 at either distal (HR: 4.65; p < 0.001) or proximal (HR: 5.73; p < 0.001) stent edges were independent predictors of MACE. Conversely, in-stent minimum lumen area/mean reference lumen area <70% (HR: 1.21; p = 0.45), stent malapposition >200 μm (HR: 1.15; p = 0.52), intrastent plaque/thrombus protrusion >500 μm (HR: 1.00; p = 0.99), and dissection >200 μm at the proximal stent edge (HR: 0.83; p = 0.65) were not associated with worse outcomes. Using multivariable Cox hazard analysis, the presence of at least 1 significant criterion for suboptimal OCT stent deployment was confirmed as an independent predictor of MACE (HR: 3.53; 95% confidence interval: 2.2 to 5.8; p < 0.001). Conclusions Suboptimal stent deployment defined according to specific quantitative OCT criteria was associated with an increased risk of MACE during follow-up. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to evaluate the diagnostic and therapeutic role of emergency coronary angiography (ECA) in the setting of acute ischemic or hemodynamic instability after cardiac surgery. Methods Between January 2005 and September 2014 we prospectively collected data from a consecutive cohort of 5,275 patients who underwent cardiac surgery. Patients who underwent ECA due to new ST-segment changes on electrocardiogram (ECG), ventricular arrhythmias, cardiac arrest or hemodynamic collapse, new changes in regional wall motion, or any other relevant suspect of myocardial ischemia during postoperative intensive care unit stay were included. Results Forty patients (0.7% of the overall population) were enrolled. Nineteen patients (47.5%) received isolated coronary surgery, 21 (52.5%) underwent valve or aortic or combined operations. The most common indications to ECA were new ECG or echo signs of acute ischemia (62.5%). The mean time from primary operation to ECA was 51 hours (27 minutes to 9 days). Graft failure was found in 17 cases (42.5%), native coronary artery occlusion in 7 (20%), and coronary spasm in 5 (12.5%). No pathologic alterations were found in 7 cases (17.5%). Three patients (7.5%) underwent reoperation (group 1), 15 (37.5%) underwent percutaneous interventions (PCI) (group 2), and 22 (55%) were managed conservatively (group 3). In-hospital mortality was 100% in group 1, 6% in group 2, and 0% in group 3; 93% of the patients who underwent PCI had complete resolution of the ischemic or hemodynamic problems. No complications related to angiography occurred. Kaplan-Meier survival curves differed significantly according to the post-angiography management. At multivariate analysis combined surgery and the strategy of treatment were independent predictors of long-term mortality. Conclusions Emergency coronary angiography is safe and allows diagnosis and resolution of the instability in the great majority of cases. An ECA should be the first-line measure in case of acute ischemic or hemodynamic instability after cardiac surgery. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Cardiología (18855857) is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)