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Background: During takotsubo syndrome (TS), QTc prolongation is common, reflecting repolarization injury and providing the substrate for torsades de pointes (TdP). TdP has been reported sporadically in TS, yet QTc prolongation and TdP risk are often overlooked during management. Objectives: In TS patients, we sought to document TdP incidence, characteristics of patients with TdP, and association of QTc with postdischarge survival. Methods: Among consecutive TS patients at a single institution, we documented admission and discharge QTc, TdP incidence, and postdischarge 1-year mortality from 2006 to 2019. For perspective regarding TdP-TS risk, we characterized all published TdP cases from 2003 to 2022. Results: Of 259 patients, median age was 68 (range: 59-77) years; 92% were female. The QTc interval was prolonged (≥460 ms) on admission in 129 (49.8%) patients and at discharge in 140 (54%) patients. QTc was ≥500 ms either on admission or at discharge in 98 (37.8%) patients. In-hospital TdP incidence was 0.8%. Postdischarge mortality was associated with admission but not discharge, QTc: 98% survival at 1-year postdischarge.

Background Coronary microvascular dysfunction (CMD) is a common complication of ST‐segment–elevation myocardial infarction (STEMI) and can lead to adverse cardiovascular events. Whether CMD after STEMI is associated with functional left ventricular remodeling (FLVR) and diastolic dysfunction, has not been investigated. Methods and Results This is a nonrandomized, observational, prospective study of patients with STEMI with multivessel disease. Coronary flow reserve and index of microcirculatory resistance of the culprit vessel were measured at 3 months post‐STEMI. CMD was defined as index of microcirculatory resistance ≥25 or coronary flow reserve

Abstract Coronary microvascular dysfunction (CMD) is a common complication of ST-segment elevation myocardial infarction (STEMI) and can lead to adverse cardiovascular events. This is a non-randomized, observational, prospective study of STEMI patients with multivessel disease who underwent primary PCI, grouped based on whether they underwent balloon pre-dilatation stenting or direct stenting of the culprit lesion. Coronary physiology measurements were performed 3 months post-PCI including coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) measurements at the culprit vessel. The primary endpoint was the prevalence of CMD at 3 months, defined as IMR ≥ 25 or CFR

Chronic total occlusions (CTOs) represent the most complex subset of coronary artery disease and therefore careful planning of CTO percutaneous coronary recanalization (PCI) strategy is of paramount importance aiming to achieve procedural success, and improve patient's safety and post CTO PCI outcomes. Intravascular imaging has an essential role in facilitating CTO PCΙ. First, intravascular ultrasound (IVUS), due to its higher penetration depth compared to optical coherence tomography (OCT), and the additional capacity of real-time imaging without need for contrast injection is considered the preferred imaging modality for CTO PCI. Secondly, IVUS can be used to resolve proximal cap ambiguity, facilitate wire re-entry when dissection and re-entry strategies are applied and most importantly to guide stent deployment and optimization post implantation. The role of OCT during CTO PCI is currently limited to stent sizing and optimization, however, due to its high spatial resolution, OCT is ideal for detecting stent edge dissections and strut malapposition. In this review, we describe the use of intravascular imaging for lesion crossing, plaque characterization and wire tracking, extra- or intra-plaque, and stent sizing and optimization during CTO PCI and summarize the findings of the major studies in this field.

Abstract Background Epinephrine is routinely utilized in cardiac arrest; however, it is unclear if the route of administration affects outcomes in acute myocardial infarction patients with cardiac arrest. Objectives To compare the efficacy of epinephrine administered via the peripheral intravenous (IV), central IV, and intracoronary (IC) routes. Methods Prospective two-center pilot cohort study of acute myocardial infarction patients who suffered cardiac arrest in the cardiac catheterization laboratory during percutaneous coronary intervention. We compared the outcomes of patients who received epinephrine via peripheral IV, central IV, or IC. Results 158 participants were enrolled, 48 (30.4%), 50 (31.6%), and 60 (38.0%) in the central IV, IC, and peripheral IV arms, respectively. Peripheral IV epinephrine administration route was associated with lower odds of achieving return of spontaneous circulation (ROSC, odds ratio = 0.14, 95% confidence interval = 0.05–0.36, p

Background Endovascular intervention of femoropopliteal chronic total occlusions (CTOs) is technically more complex. However, there is lack of comparative analysis between CTO and non‐CTO femoropopliteal interventions. Methods and Results We report procedural details and outcomes of patients treated for femoropopliteal CTO and non‐CTO lesions in the XLPAD (Excellence in Peripheral Artery Disease) registry (NCT01904851) between 2006 and 2019. Primary outcomes were procedural success and 1‐year major adverse limb events, a composite of all‐cause death, target limb revascularization, or major amputation. Analysis included 2895 patients (CTO: n=1516 patients; non‐CTO: n=1379 patients) with 3658 lesions (CTO: n=1998 lesions; non‐CTO: n=1660 lesions). Conventional balloon angioplasty (20.86% versus 33.48%, P

Background: The impact of bifurcations at the proximal or distal cap on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. Methods: We analyzed the clinical, angiographic, and procedural data of 4,584 cases performed in patients between 2012 and 2020 in a global CTO PCI registry. We compared 4 groups according to the bifurcation location: “proximal cap,” “distal cap,” “proximal and distal cap,” and “no bifurcation.” Results: The CTO involved a bifurcation in 67% cases, as follows: proximal cap (n = 1451, 33%), distal cap (n = 622, 14%), or both caps (n = 954, 21%). “Proximal and distal cap” cases had higher J-CTO compared with “proximal cap,” “distal cap,” and “no bifurcation” cases (2.9 ± 1.1 vs 2.5 ± 1.1 vs 2.4 ± 1.2 vs 2.0 ± 1.2, P

BackgroundPercutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) has been performed for the improvement of symptoms and quality of life in patients with stable angina. The ORBITA study demonstrated the role of the placebo effect in contemporary PCI in non-CTO chronic coronary syndromes. However, the benefit of CTO PCI beyond that of a placebo has not been demonstrated.AimsThe ORBITA-CTO pilot study will be a double-blind, placebo-controlled study of CTO PCI randomising patients who have: (1) been accepted by a CTO operator for PCI; (2) experienced symptoms due to a CTO; (3) evidence of ischaemia; (4) evidence of viability within the CTO territory; and (5) a J-CTO score ≤3.MethodsPatients will undergo medication optimisation that will ensure they are on at least a minimum amount of anti-anginals and complete questionnaires. Patients will record their symptoms on an app daily throughout the study. Patients will undergo randomisation procedures, including an overnight stay, and be discharged the following day. All anti-anginals will be stopped after randomisation and re-initiated on a patient-led basis during the 6-month follow-up period. At follow-up, patients will undergo repeat questionnaires and unblinding, with a further 2-week unblinded follow-up.ResultsThe co-primary outcomes are feasibility (blinding) in this cohort and angina symptom score using an ordinal clinical outcome scale for angina. Secondary outcomes include changes in quality-of-life measures, Seattle Angina Questionnaire (SAQ), peak VO2, and anaerobic threshold on the cardiopulmonary exercise test.ConclusionThe feasibility of a placebo-controlled CTO PCI study will lead to future studies assessing efficacy. The impact of CTO PCI on angina measured using a novel daily symptom app may provide improved fidelity in assessing symptoms in patients with CTO's.

Abstract Patient-specific and lesion-specific computational simulation of bifurcation stenting is an attractive approach to achieve individualized pre-procedural planning that could improve outcomes. The objectives of this work were to describe and validate a novel platform for fully computational patient-specific coronary bifurcation stenting. Our computational stent simulation platform was trained using n = 4 patient-specific bench bifurcation models (n = 17 simulations), and n = 5 clinical bifurcation cases (training group, n = 23 simulations). The platform was blindly tested in n = 5 clinical bifurcation cases (testing group, n = 29 simulations). A variety of stent platforms and stent techniques with 1- or 2-stents was used. Post-stenting imaging with micro-computed tomography (μCT) for bench group and optical coherence tomography (OCT) for clinical groups were used as reference for the training and testing of computational coronary bifurcation stenting. There was a very high agreement for mean lumen diameter (MLD) between stent simulations and post-stenting μCT in bench cases yielding an overall bias of 0.03 (− 0.28 to 0.34) mm. Similarly, there was a high agreement for MLD between stent simulation and OCT in clinical training group [bias 0.08 (− 0.24 to 0.41) mm], and clinical testing group [bias 0.08 (− 0.29 to 0.46) mm]. Quantitatively and qualitatively stent size and shape in computational stenting was in high agreement with clinical cases, yielding an overall bias of

Abstract The structural morphology of coronary stents (e.g. stent expansion, lumen scaffolding, strut apposition, tissue protrusion, side branch jailing, strut fracture), and the local hemodynamic environment after stent deployment are key determinants of procedural success and subsequent clinical outcomes. High-resolution intracoronary imaging has the potential to enable the geometrically accurate three-dimensional (3D) reconstruction of coronary stents. The aim of this work was to present a novel algorithm for 3D stent reconstruction of coronary artery stents based on optical coherence tomography (OCT) and angiography, and test experimentally its accuracy, reproducibility, clinical feasibility, and ability to perform computational fluid dynamics (CFD) studies. Our method has the following steps: 3D lumen reconstruction based on OCT and angiography, stent strut segmentation in OCT images, packaging, rotation and straightening of the segmented struts, planar unrolling of the segmented struts, planar stent wireframe reconstruction, rolling back of the planar stent wireframe to the 3D reconstructed lumen, and final stent volume reconstruction. We tested the accuracy and reproducibility of our method in stented patient-specific silicone models using micro-computed tomography (μCT) and stereoscopy as references. The clinical feasibility and CFD studies were performed in clinically stented coronary bifurcations. The experimental and clinical studies showed that our algorithm (1) can reproduce the complex spatial stent configuration with high precision and reproducibility, (2) is feasible in 3D reconstructing stents deployed in bifurcations, and (3) enables CFD studies to assess the local hemodynamic environment within the stent. Notably, the high accuracy of our algorithm was consistent across different stent designs and diameters. Our method coupled with patient-specific CFD studies can lay the ground for optimization of stenting procedures, patient-specific computational stenting simulations, and research and development of new stent scaffolds and stenting techniques.

Percutaneous coronary intervention was performed in a flush in-stent right coronary artery chronic total occlusion. Successful retrograde recanalization was performed but the lesion was balloon undilatable as confirmed by intravascular ultrasound. High-pressure post-dilation with noncompliant and plaque modification balloons failed, but intravascular lithotripsy successfully expanded the lesion. (Level of Difficulty: Advanced.)

La perforación de las coronarias es una de las complicaciones más temidas de las intervenciones coronarias percutáneas (ICP) que se realizan para resolver oclusiones coronarias totales crónicas (OTC) puesto que puede desembocar en fugas pericárdicas, taponamientos cardiacos, deterioros hemodinámicos, necesidad de pericardiocentesis, cirugía urgente o muerte1. La incidencia de estas perforaciones es más alta en las PCI realizadas sobre OTC que en las no realizadas sobre OTC probablemente por la mayor complejidad anatómica de las OTC y por el uso de técnicas tales como la disección y reentrada anterógrada y el abordaje retrógrado de la guía2. Tradicionalmente, las perforaciones coronarias se clasifican atendiendo a su gravedad según la clasificación de Ellis3. Como la localización de la perforación tiene importantes implicaciones en lo referente al manejo de la lesión, otra clasificación importante de las perforaciones coronarias se hace atendiendo a su localización: a) perforación de grandes vasos; b) perforación de vasos distales y c) perforación de vasos colaterales en una rama colateral septal o epicárdica4. El primer paso para tratar una perforación es inflar inmediatamente un balón en sentido proximal o en el punto mismo de la perforación para evitar la acumulación de sangre en el espacio pericárdico y el taponamiento cardiaco. El...

Coronary artery perforation is one of the most feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI), as it can lead to pericardial effusion, tamponade, hemodynamic deterioration, need for emergency pericardiocentesis or surgery, or death.1 The incidence of perforation is higher in CTO PCI compared with non-CTO PCI, likely due to higher anatomic complexity of CTOs and the use of advanced wiring techniques, such as antegrade dissection and re-entry and retrograde crossing.2 Coronary perforations have traditionally been classified according to severity using the Ellis classification.3 Because perforation location has important implications for management, another key classification of coronary perforations is according to location, as follows: a) large vessel perforation; b) distal vessel perforation; and c) collateral vessel perforation, in either a septal or an epicardial collateral.4 The first step in perforation management is immediate balloon inflation proximal to or at the site of perforation to prevent accumulation of blood in the pericardial space and tamponade. The balloon should be the same size as the perforated vessel and the inflation often last for several minutes unless the patient develops severe ischemic symptoms.5 Large vessel perforations are usually treated with covered stents, such as the PK Papyrus (Biotronik, United States), and the Graftmaster...

Background. There is limited “real-world” evidence examining treatment modalities and outcomes in patients with symptomatic peripheral arterial disease undergoing endovascular treatment of femoropopliteal (FP) in-stent restenosis (ISR). Materials and Methods. We compared outcomes in 2,895 patients from the XLPAD registry (NCT01904851) between 2006 and 2019 treated for FP ISR (n = 347) and non-ISR (n = 2,548) lesions. Primary endpoint included major adverse limb events (MALE) at 1 year, a composite of all-cause death, target limb repeat revascularization, or major amputation. Results. ISR patients were more frequently on antiplatelet (94.5% vs 89.4%, p=0.007) and statin (68.9% vs 60.3%, p=0.003) therapies. Lesion length was similar (ISR: 145 ± 99 mm vs. non-ISR: 142 ± 99 mm, p=0.55). Fewer treated ISR lesions were chronic total occlusions (47.3% vs. 53.7%, p=0.02) and severely calcified (22.4% vs. 44.7%, p

Background Contrast‐induced acute kidney injury (CI‐AKI) is a serious complication after percutaneous coronary intervention. The mainstay of CI‐AKI prevention is represented by intravenous hydration. Tailoring infusion rate to patient volume status has emerged as advantageous over fixed infusion‐rate hydration strategies. Methods and Results A systematic review and network meta‐analysis with a frequentist approach were conducted. A total of 8 randomized controlled trials comprising 2312 patients comparing fixed versus tailored hydration strategies to prevent CI‐AKI after percutaneous coronary intervention were included in the final analysis. Tailored hydration strategies included urine flow rate–guided, central venous pressure–guided, left ventricular end‐diastolic pressure–guided, and bioimpedance vector analysis–guided hydration. Primary endpoint was CI‐AKI incidence. Safety endpoint was incidence of pulmonary edema. Urine flow rate–guided and central venous pressure–guided hydration were associated with a lower incidence of CI‐AKI compared with fixed‐rate hydration (odds ratio [OR], 0.32 [95% CI, 0.19–0.54] and OR, 0.45 [95% CI, 0.21–0.97]). No significant difference in pulmonary edema incidence was observed between the different hydration strategies. P score analysis showed that urine flow rate–guided hydration is advantageous in terms of both CI‐AKI prevention and pulmonary edema incidence when compared with other approaches. Conclusions Currently available hydration strategies tailored on patients' volume status appear to offer an advantage over guideline‐supported fixed‐rate hydration for CI‐AKI prevention after percutaneous coronary intervention. Current evidence suggests that urine flow rate–guided hydration as the most convenient strategy in terms of effectiveness and safety.

Cardiogenic shock develops in up to 10% of patients with acute myocardial infarction and continues to have high mortality. Early invasive treatment is the default therapeutic approach in these patients. On the basis of the results of the CULPRIT-SHOCK trial, culprit-only revascularization during the acute phase is preferred over multivessel revascularization. Routine use of intra-aortic balloon pump (IABP) is not recommended; however, the use of mechanical circulatory support has been increasing despite limited observational data to support its use. Several studies support multivessel revascularization in patients with uncomplicated ST-segment elevation acute myocardial infarction and simple nonculprit lesions to improve subsequent clinical outcomes. Keywords: Multivessel coronary artery disease, Cardiogenic shock, Acute coronary syndromes, STEMI, Non-STEMI

Background The coronavirus disease 2019 pandemic is expected to affect operations and lifestyles of interventional cardiologists around the world in unprecedented ways. Timely gathering of information on this topic can provide valuable insight and improve the handling of the ongoing and future pandemic outbreaks. Methods and Results A survey instrument developed by the authors was disseminated via e‐mail, text messaging, WhatsApp, and social media to interventional cardiologists between April 6, 2020, and April 11, 2020. A total of 509 responses were collected from 18 countries, mainly from the United States (51%) and Italy (36%). Operators reported significant decline in coronary, structural heart, and endovascular procedure volumes. Personal protective equipment was available to 95% of respondents; however FIT‐tested N95 or equivalent masks were available to only 70%, and 74% indicated absence of coronavirus disease 2019 pretesting. Most (83%) operators expressed concern when asked to perform cardiac catheterization on a suspected or confirmed coronavirus disease 2019 patient, primarily because of fear of viral transmission (88%). Although the survey demonstrated significant compliance with social distancing, high use of telemedicine (69%), and online education platforms (80%), there was concern over impending financial loss. Conclusions Our survey indicates significant reduction in invasive procedure volumes and concern for viral transmission. There is near universal adoption of personal protective equipment; however, coronavirus disease 2019 pretesting and access to FIT‐tested N95 masks is suboptimal. Although there is concern over impending financial loss, substantial engagement in telemedicine and online education is reported.

Background: The role of women and foreign medical graduates (FMGs) in cardiology research published in the United States has received limited study. Methods: We examined the characteristics of the first and last authors of all original contributions and review articles published in the Journal of the American College of Cardiology from October 1, 2015, to October 1, 2016. Results: A total of 345 articles were identified, with 687 first and last authors originating from ≥50 different countries. Overall, 17% of authors were women (20% of the first and 14% of the last authors). Overall, 86% of authors held a medical degree (MD) or equivalent, and 25% of those also held another advanced degree (PhD, MPH, and/or MBA). The proportion of authors with an advanced degree in addition to an MD/equivalent was higher among foreign graduates and international contributors as compared with American graduates (31% vs. 30% vs. 17%, respectively, p

BackgroundWe sought to examine the efficacy and safety of 2 PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors: alirocumab and evolocumab. Methods and ResultsWe performed a systematic review and meta‐analysis of randomized controlled trials comparing treatment with and without PCSK9 inhibitors; 35 randomized controlled trials comprising 45 539 patients (mean follow‐up: 85.5 weeks) were included. Mean age was 61.0±2.8 years, and mean baseline low‐density lipoprotein cholesterol was 106±22 mg/dL. Compared with no PCSK9 inhibitor therapy, treatment with a PCSK9 inhibitor was associated with a lower rate of myocardial infarction (2.3% versus 3.6%; odds ratio [OR]: 0.72 [95% confidence interval (CI), 0.64–0.81]; P

BackgroundRemote ischemic preconditioning (RIPC) has been shown to reduce infarct size in animal models. We hypothesized that RIPC before an elective vascular operation would reduce the incidence and amount of a postoperative rise of the cardiac troponin level. Methods and ResultsCardiac Remote Ischemic Preconditioning Prior to Elective Vascular Surgery (CRIPES) was a prospective, randomized, sham‐controlled phase 2 trial using RIPC before elective vascular procedures. The RIPC protocol consisted of 3 cycles of 5‐minute forearm ischemia followed by 5 minutes of reperfusion. The primary endpoint was the proportion of subjects with a detectable increase in cardiac troponin I (cTnI) and the distribution of such increases. From June 2011 to September 2015, 201 male patients (69±7, years) were randomized to either RIPC (n=100) or a sham procedure (n=101). Indications for vascular surgery included an expanding abdominal aortic aneurysm (n=115), occlusive peripheral arterial disease of the lower extremities (n=37), or internal carotid artery stenosis (n=49). Of the 201 patients, 47 (23.5%) had an increase in cTnI above the upper reference limit within 72 hours of the vascular operation, with no statistically significant difference between those patients assigned to RIPC (n=22; 22.2%) versus sham procedure (n=25; 24.7%; P=0.67). Among the cohort with increased cTnI, the median peak values (interquartile range) in the RIPC and control group were 0.048 (0.004–0.174) and 0.017 (0.003–0.105), respectively (P=0.54). ConclusionsIn this randomized, controlled trial of men with increased perioperative cardiac risks, elevation in cardiac troponins was common following vascular surgery, but was not reduced by a strategy of RIPC. Clinical Trial RegistrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT01558596.

BackgroundHigh success rates are achievable for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid approach, but periprocedural complications remain of concern. Although scores estimating success and efficiency in CTO PCI have been developed, there is currently no available score for estimation of the risk for periprocedural complications. We sought to develop a scoring tool for prediction of periprocedural complications during CTO PCI. Methods and ResultsWe analyzed data from 1569 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) using a derivation and validation sampling ratio of 2:1. Variables independently associated with periprocedural complications in multivariable analysis in the derivation set were assigned points based on their respective odds ratios. Forty‐four (2.8%) patients experienced complications. Three factors were independent predictors of complications and were included in the score: patient age >65 years, +3 points (odds ratio, OR=4.85, CI 1.82‐16.77); lesion length ≥23 mm, +2 points (OR=3.22, CI 1.08‐13.89); and use of the retrograde approach +1 point (OR=2.41, CI 1.04‐6.05). The resulting score showed good calibration and discriminatory capacity in the derivation (Hosmer‐Lemeshow χ2 6.271, P=0.281, receiver‐operating characteristic [ROC] area=0.758) and validation (Hosmer‐Lemeshow χ2 4.551, P=0.473, ROC area=0.793) sets. Score values of 0 to 2, 3 to 4, and ≥5 were defined as low, intermediate, and high risk of complications (derivation cohort 0.4%, 1.8%, 6.5%, P

BackgroundIntravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention. Methods and ResultsWe examined the frequency of use and outcomes of intravascular imaging among 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers. Mean age was 65.4±10 years and 85% of the patients were men. Intravascular imaging was used in 38%: intravascular ultrasound in 36%, optical coherence tomography in 3%, and both in 1.45%. Intravascular imaging was used for stent sizing (26.3%), stent optimization (38.0%), and CTO crossing (35.7%, antegrade in 27.9%, and retrograde in 7.8%). Intravascular imaging to facilitate crossing was used more frequently in lesions with proximal cap ambiguity (49% versus 26%, P

The relationship between autoantibodies to oxidized low density lipoprotein (OxLDL) and coronary artery disease (CAD) remains controversial. IgM and IgG OxLDL autoantibodies to malondialdehyde (MDA)-modified LDL, copper oxidized low density lipoprotein (CuOxLDL), and oxidized cholesterol linoleate (OxCL), as well as apolipoprotein B-100 immune complexes (apoB-ICs), were measured in 504 patients undergoing clinically indicated coronary angiography. Patients were followed for cardiovascular events for a median of 4 years. In univariate analysis, IgM OxLDL autoantibodies and IgM apoB-ICs were inversely associated with the presence of angiographically determined CAD, whereas IgG OxLDL autoantibodies and IgG apoB-ICs were positively associated. In logistic regression analysis, compared with the first quartile, patients in the fourth quartile of IgM OxLDL autoantibodies and apoB-ICs showed a lower probability of angiographically determined CAD (>50% diameter stenosis). Odds ratios and (95% confidence intervals) were as follows: MDA-LDL, 0.51 (0.32–0.82; P = 0.005); CuOxLDL, 0.63 (0.39–1.01; P = 0.05); OxCL, 0.63 (0.39–1.01; P = 0.05); and apoB-IC, 0.55 (0.34–0.88; P = 0.013). These relationships were accentuated in the setting of hypercholesterolemia, with the highest IgM levels showing the lowest risk of CAD for the same level of hypercholesterolemia. Multivariable analysis revealed that neither IgM or IgG OxLDL autoantibodies nor apoB-ICs were independently associated with angiographically determined CAD or cardiovascular events. In conclusion, IgG and IgM OxLDL biomarkers have divergent associations with CAD in univariate analysis but are not independent predictors of CAD or clinical events.