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The use of mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We analyzed the clinical and angiographic characteristics, and procedural outcomes of 7,171 CTO PCIs performed between 2012 and 2021 at 35 international centers. Mean age was 64.5 ± 10 years, mean left ventricular ejection fraction was 50 ± 13%. MCS was used in 4.5%, prophylactically in 78.7%, and urgently in 21.3%. The most common type of MCS overall was Impella CP (Abiomed) (55.5%), followed by intra-aortic balloon pump (14.8%) and TandemHeart (LivaNova Inc.) (10.0%). Prophylactic MCS patients were more likely to have diabetes mellitus (55% vs 42%, p0.001) and had more complex lesions compared with cases without prophylactic MCS (Japan-CTO score: 2.80 ± 1.22 vs 2.39 ± 1.27, p0.001). Cases with prophylactic MCS had similar technical (86% vs 87%, p = 0.643) but lower procedural (80% vs 86%, p = 0.028) success rates and higher rates of periprocedural major cardiac adverse events compared with no prophylactic MCS use (6.55% vs 1.68%, p0.001). Urgent MCS use was associated with lower technical (68% vs 87%, p0.001) and procedural (39% vs 86%, p0.001) success rates and higher major cardiac adverse events compared with no-MCS use (32.26% vs 1.68%, p0.001). The differences persisted in multivariable analyses. In summary, in this contemporary multicenter registry, MCS was used in 4.5% of CTO PCIs, mostly prophylactically (78.7%). Elective MCS cases had similar technical success but a higher risk of complications. Urgent MCS cases had lower technical and procedural success and higher periprocedural major complication rates.

BackgroundEstimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).MethodsWe analyzed 2,784 CTO PCIs performed between 2012 and 2021 at 12 centers. The variable importance was estimated by a bootstrap applying a random forest algorithm to a propensity-matched sample (a ratio of 1:5 matching cases with controls on center). The identified variables were used to predict the risk of urgent MCS. The performance of the risk model was assessed in-sample as well as on 2411 out-of-sample procedures who did not require urgent MCS.ResultsUrgent MCS was used in 62 (2.2%) of cases. Patients who required urgent MCS were older (70 [63, 77] vs. 66 [58, 73] years, p=0.003) compared with those who did not require urgent MCS. Technical (68% vs. 87%, pConclusionThe PROGRESS CTO MCS score can help estimate the risk of urgent MCS use during CTO PCI.What Is Known?Estimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).What the Study Adds?We developed a risk model for urgent MCS use during CTO PCI using retrograde crossing strategy, left ventricular ejection fraction, and lesion length.Use of the PROGRESS CTO urgent MCS score may facilitate patient selection for prophylactic hemodynamic support optimizing the risk benefit ratio of the procedure.

Introduction: The use of mechanical circulatory support (MCS) in complex percutaneous coronary intervention (PCI) is the subject of ongoing investigation, but the role of MCS in chronic total occlusion (CTO) PCI is not well studied. Methods: We analyzed the patient and angiographic characteristics and procedural outcomes of 7,171 CTO PCIs performed between 2012 and June 2021 at 35 international centers. Results: Mean patient age was 64.5±10 years, mean left ventricular ejection fraction was 50 ± 13 % and 82% were men. MCS was used in 4.5% of the overall cases, MCS use was elective in 78.7% and urgent in 21.3%. The most common type of MCS was Impella CP (55.5%) followed by intra-aortic balloon pump (14.8%), Tandem Heart (10.0%) and Impella 2.5 (8.7%). Diabetes mellitus (51.0% vs. 42.4%, p=0.003), prior congestive heart failure (60.6% vs. 27.9%, p Conclusions: In a contemporary, multicenter registry MCS was used in 4.5% of CTO PCI. Cases where MCS was used were associated with lower technical and procedural success with higher periprocedural major complication rates. Further investigation is required to see if elective use of MCS can improve outcomes in patients with increased comorbidities and higher lesion complexity.

Currently, the Impella CP (Abiomed, Danvers, Massachusetts) percutaneous ventricular assist catheter requires implantation through a 14 French sheath. Additional arterial access is commonly obtained to perform therapeutic or diagnostic procedures. Multiple arterial access requires time and results in increased risk for vascular complications. Some patients may have limited arterial access. We describe the Single‐access for Hi‐risk PCI (SHiP) technique to allow for rapid and safer single access utilizing only the Impella access site. After the Impella catheter is placed in the standard fashion, a micropuncture needle is used to pierce the hemostasis valve of the Impella insertion sheath. After dilating the hemostasis valve and exchanging for a 0.035″ wire, up to a 7 French sheath can be inserted for PCI within the 14 French access sheath and alongside the 9 French portion of the Impella catheter. After PCI, the sheath is removed. We report on a case series of 17 patients using this technique. There were no instances of bleeding during the procedure or after removal of the PCI sheath, and no evidence of disruption of the Impella sheath.

© 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC By-NC-ND License (http://creativecommons.org/licenses/by-nc-nd/4), The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.

Patients with advanced age, complex coronary anatomy, and multiple comorbidities are often unsuitable for surgical revascularization. In this setting, hemodynamic support devices are used as an adjunct to percutaneous coronary intervention to maintain hemodynamic stability and enable optimal revascularization. This article provides an overview of percutaneous hemodynamic support devices currently used in clinical practice for high-risk percutaneous coronary intervention. These include the intra-aortic balloon pump, centrifugal pumps (TandemHeart, venous arterial extracorporeal membrane oxygenation), and micro-axial Impella pump. The hemodynamic effects, clinical evidence supporting improved outcomes and recovery of heart function, and associated complications with these devices are highlighted, with a special focus on Impella pumps.

Balloon uncrossable coronary lesions are lesions that cannot be crossed with a balloon after successful guidewire crossing. The strategies used to facilitate the treatment of such lesions can be classified into strategies that provide lesion modification and strategies that increase support. We describe a systematic, algorithmic approach to treat balloon uncrossable lesions, starting with use of small balloons, followed by increase in guide catheter support, use of microcatheters, wire cutting or puncture techniques, laser, atherectomy, and subintimal modification techniques. Sequential and simultaneous application of the aforementioned techniques can result in successful treatment of these challenging lesions.

© American Heart Association, Inc., Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

The availability of drug-eluting stents has resulted in a paradigm shift in the management of patients with coronary artery disease with a substantial increase in the percentage of patients being revascularized percutaneously rather than surgically. Since its introduction, there has been a tremendous increase in the use of drug-eluting stents with nearly 90% of patients in the US who undergo percutaneous interventions receiving drug-eluting stents. The promising results of several randomized trials that demonstrated a profound reduction in restenosis rates compared with bare-metal stents, underscores the unprecedented enthusiasm among the cardiology community to adopt this new technology swiftly. Data regarding the safety and superiority of drug-eluting stents abound, and it is imperative for the practicing clinician to review and apply them in appropriate clinical settings. In this review, we present general concepts of drug-eluting stents, and attempt to summarize the available data on the approved drug-eluting stents in a variety of patient and lesion subsets. In addition, we share some insights regarding the potential limitations, and issues specific to drug-eluting stents.

Background— Tissue-tagged magnetic resonance imaging (MRI) with 3-dimensional (3D) myocardial strain analysis allows quantitative assessment of myocardial contractility. We assessed the hypothesis that 3D strain determination at rest and with low-dose dobutamine would discriminate between viable and nonviable myocardium in patients with ischemic cardiomyopathy (ICM). Methods and Results— MRI with radiofrequency tissue-tagging at rest and with low-dose dobutamine was performed in 16 normal volunteers and 14 patients with ICM. Three-dimensional global and regional circumferential strains (Ecc) were computed for all subjects at rest and with dobutamine. Results were compared with clinically indicated conventional viability studies. Compared with normal volunteers, global left ventricular Ecc was significantly decreased in patients with ICM at rest (−0.15±0.06 versus −0.27±0.03; P P P P P =0.04), whereas Ecc did not change in nonviable segments ( P =0.50). Normal controls (96 segments) had increased Ecc at rest (−0.27±0.07) and with dobutamine (−0.37±0.15) compared with both viable and nonviable regions in ICM patients ( P Conclusions— Noninvasive dobutamine tissue-tagged MRI with calculation of 3D strain allows the identification, quantification and display of regionally varying ventricular function. The response of systolic strain to low-dose dobutamine has significant promise in discriminating between viable and nonviable myocardium.

Background and aim Left ventricular (LV) 3D systolic strain decreases in absolute value postoperatively and does not recover in patients who undergo aortic valve replacement (AVR) for chronic aortic insufficiency (AI). We investigated whether choice of valve prosthesis (mechanical [St. Jude], bioprosthetic [bovine pericardial], Ross procedure) had a significant impact on strain recovery in this surgical population. Methods MRI with tissue-tagging was performed on 14 patients with chronic AI both before and 28 +/- 13 months after AVR. Average values of LV systolic strain and end-systolic stress (ESS) were computed from MRI data for the LV. Three types of prosthetic valve were examined (Ross procedure n = 4, bovine pericardial n = 5, and St. Jude n = 5). Results Overall, systolic strain, ESS, LV volumes, ejection fraction, and LV mass all changed significantly following AVR. Comparisons between individual valve types revealed no differences in any of these measurements. Patients who received a mechanical valve had a greater decrease in the absolute value of systolic strain following surgery compared to patients from the nonmechanical group (Ross procedure and bioprosthetic valve). Comparisons between the Ross group and the prosthetic group (St. Jude and bioprosthetic) produced no significant differences in strain, ESS, LV volume, and mass. Conclusions These early results suggest that valve prosthetic type may be a factor in efforts to improve strain recovery after AVR for AI, although further investigation is warranted. MRI with tissue-tagging may be a useful tool for comparing the impact of prosthetic valve choice on incompletely recovered systolic strain following AVR for chronic AI.

Left ventricular three-dimensional nonlinear systolic strain determinations have potential to detect small decrements in ventricular function in patients with aortic insufficiency before and after aortic valve replacement.Magnetic resonance imaging with tissue-tagging was performed on 42 normal volunteers and 14 patients with chronic aortic insufficiency both before and 28 +/- 11 months after aortic valve replacement. Preoperative and postoperative left ventricular volume, dimensions and ejection fraction were determined for all subjects. Left ventricular systolic radial, circumferential, longitudinal, and minimum principal strain were calculated for six left ventricular regions.After aortic valve replacement, left ventricular volume and dimensions decreased significantly (p0.001) and ejection fraction increased nonsignificantly (p = 0.096). Strain values in preoperative aortic insufficiency patients did not differ significantly from controls. At an average of 28 +/- 11 months postoperatively, however, regional three-dimensional minimum principal and longitudinal strain was decreased in all six ventricular regions as well as globally (p0.03) compared with normal control values. Circumferential strain was significantly decreased globally and in all but two regions (p0.03).These magnetic resonance imaging-based techniques are sensitive enough to detect a previously unrecognized, significant decrease in both global and regional three-dimensional left ventricular systolic strain 2 years after aortic valve replacement for minimally symptomatic chronic aortic insufficiency despite improvement in ejection fraction and a decrease in left ventricular size. The reasons for a significant decline in left ventricular systolic strain after successful aortic valve replacement in minimally symptomatic chronic aortic insufficiency patients are not clear and warrant further investigation.