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Frailty is a well-documented risk factor for increased morbidity and mortality among patients undergoing percutaneous coronary intervention (PCI). There remains a lack of knowledge regarding the impact of patient frailty in cardiac patient management and outcomes. Thus, this study examined whether the Heart Team, without using frailty assessments, made decisions regarding coronary interventions [medical management (MM) vs. PCI vs. coronary artery bypass grafting (CABG)] that aligned with formally quantified frailty status.This cross-sectional quality-improvement (QI) study was performed at a single, large, urban Veterans Affairs Hospital. From September 2019 to November 2020, heart team nurses approached patients prior to coronary angiograms and assessed for frailty using the Risk Analysis Index Questionnaire (RAIC). Interventional cardiologists were blinded to the results. This study's independent variable was RAI-C score. The outcome variables were "intervention performed" (MM, PCI, or CABG) and presence of a "reduced invasiveness intervention" (RI).Ninety-five of the 182 participants had obstructive coronary artery disease. Among them, there were 69 PCIs, 10 CABGs, and 16 MMs. 26 received RIs. The primary outcomes demonstrated that frailty score was positively associated with receiving RI [adjusted OR = 1.13, 95% CI = 1.02-1.24, p = 0.02] and MM [adjusted OR = 1.13, CI = 1.02-1.25, p = 0.02], and negatively associated with receiving PCI [adjusted OR = 0.94, CI = 0.88-0.998, p = 0.04]. There was no significant association between frailty and the likelihood of undergoing CABG [AOR = 0.95, CI = 0.81-1.10, p = 0.47].This study demonstrated that the Heart Team and patients at baseline reduced high-risk interventions in frailer patients. A Heart Team, shared-decision-making model utilizing the RAI-C was found to be efficient and effective at measuring frailty in coronary angiogram patients and should be considered for use in the clinical setting.

Aims: :To evaluate safety and efficacy of distal right radial access (DRRA) compared to right radial access (RRA), for coronary procedures, in patients with smaller diameter radial arteries (SDRA) (radial artery diameter (RAD)

Transradial angiography and intervention continues to become increasingly common as an access site for coronary procedures. Since the first "Best Practices" paper in 2013, ongoing trials have shed further light onto the safest and most efficient methods to perform these procedures. Specifically, this document comments on the use of ultrasound to facilitate radial access, the role of ulnar artery access, the utility of non-invasive testing of collateral flow, strategies to prevent radial artery occlusion, radial access for primary PCI and topics that require further study.

OBJECTIVES We aimed to compare clinical characteristics and procedural outcomes of left main percutaneous interventions (LM-PCI) by transradial (TRA) versus transfemoral (TFA) approach in the VA healthcare system. BACKGROUND TRA for percutaneous coronary intervention (PCI) is steadily increasing. However, the frequency and efficacy of TRA for LM-PCI remain less studied. METHODS All LM-PCIs performed in the VA healthcare system were identified for fiscal year 2008 through 2018. Patients' baseline characteristics and procedure-related variables were compared by access site. Both short- and long-term clinical outcomes were analyzed using propensity score matching. RESULTS A total of 4004 LM-PCI were performed in the VA via either radial or femoral access from 2008 to 2018. Among these, 596 (14.9%) LM PCIs were performed via TRA. Use of TRA for LM-PCI increased from 2.2% to 31.5% over the study period. Propensity matched outcome analysis, comparing TRA versus TFA, showed a similar procedural success (98.4% for TRA vs. 97.8% for TFA; RR: 1.01 [0.98, 1.03]) and 1-year major adverse cardiovascular events (MACE) (25.9% for TRA vs. 26.8% TFA; RR: 0.96 [0.74, 1.25]). There were no statistically significant differences among secondary outcomes analyses including major bleeding. CONCLUSION Use of TRA for LM-PCI has been steadily increasing in the VA healthcare system. These findings demonstrate similar procedural success and 1-year MACE across access strategies, suggesting an opportunity to continue increasing TRA use for LM-PCI.

Introduction. Coronary arteries are exposed to a variety of complex biomechanical forces during a normal cardiac cycle. These forces have the potential to contribute to coronary stent failure. Recent advances in stent design allow for the transmission of native pulsatile biomechanical forces in the stented vessel. However, there is a significant lack of evidence in a human model to measure vessel motion in native coronary arteries and stent conformability. Thus, we aimed to characterize and define coronary artery radial deformation and the effect of stent implantation on arterial deformation. Materials and Methods. Intravascular ultrasound (IVUS) pullback DICOM images were obtained from human coronary arteries using a coronary ultrasound catheter. Using two-dimensional speckle tracking, coronary artery radial deformation was defined as the inward and outward displacement (mm) and velocity (cm/s) of the arterial wall during the cardiac cycle. These deformation values were obtained in native and third-generation drug-eluting stented artery segments. Results. A total of 20 coronary artery segments were independently analyzed pre and poststent implantation for a total of 40 IVUS runs. Stent implantation impacted the degree of radial deformation and velocity. Mean radial deformation in native coronary arteries was 0.1230 mm ± 0.0522 mm compared to 0.0775 mm ± 0.0376 mm in stented vessels ( p = 0.0031 ). Mean radial velocity in native coronary arteries was 0.1194 cm/s ± 0.0535 cm/s compared to 0.0840 cm/s ± 0.0399 cm/s in stented vessels ( p = 0.0228 ). Conclusion. In this in vivo analysis of third-generation stents, stent implantation attenuates normal human coronary deformation during the cardiac cycle. The implications of these findings on stent failure and improved clinical outcomes require further investigation.

Background Caged drug-eluting stents impede natural coronary rotational motion and increase vessel stress, which can contribute towards adverse events. The DynamX™ Drug-Eluting Bioadaptor is a cobalt‑chromium platform with a novel mechanism that uncages the vessel after the bioresorbable coating resorbs over six months. This study aimed to analyze the effects of the rotational uncaging in a finite element analysis (FEA) model, validating its effect on coronary artery rotational motion through in-vivo stationary intravascular ultrasound (IVUS). Methods Maximum Von Mises stresses were measured in an FEA model and compared for caged and uncaged bioadaptors. Stationary IVUS images from 20 patients enrolled in a single center were acquired post implantation and at 9–12-month follow-up to evaluate coronary artery rotational motion. Results The FEA model showed that rotational uncaging of the bioadaptor reduces peak stress by 70%. In-vivo, the in-bioadaptor segment was significantly distorted post-implant compared to the native distal and proximal vessel, measured by IVUS: The sum of clockwise and counterclockwise rotational motion (net-effect rotational motion) was −2.7 ± 4.3° versus 0.5 ± 5.0° (proximal vessel), p = 0.036, and versus 0.2 ± 3.8° (distal vessel), p = 0.042. At follow up, when the bioadaptor had uncaged, the vessel returned towards its equilibrium (net-effect rotational motion −0.2 ± 5.6°), with no significant difference between the vessel segments. Conclusions In concurrence with the FEA observation, the in-vivo IVUS-analysis demonstrates that uncaging of the bioadaptor affects coronary artery rotational motion. The effect of these findings on reducing clinical events warrants further investigation.

There is concern about potential detrimental effects of transradial access (TRA) on radial artery structure, endothelial and hand function. This thermography study evaluated TRA impact on hand microvascular perfusion.We prospectively measured hand thermography, radial and ulnar artery size and blood flow velocities in both catheterization and non-catheterization hands at baseline and 30-days after TRA in 158 patients. There were no differences in radial or ulnar arterial diameters or velocities pre- and post-TRA in catheterization and non-catheterization hands (p = NS). The absolute total hand thermography values post-TRA were increased in both catheterization and non-catheterization hand (pre-TRA 30.4 ± 2.9 vs. post-TRA 31.6 ± 2.6 p 0.01; pre-TRA 30.2 ± 2.9, post-TRA 31.6 ± 2.6 p 0.01, respectively). After ulnar artery occlusion, hand temperatures decreased in both catheterization and non-catheterization hands, both pre- and post-TRA and were similar in the catheterization and non-catheterization hands (p = NS). Total hand temperature decreased with ulnar artery occlusion and was significantly attenuated post-TRA (p 0.001 both catheterization and non-catheterization hands).TRA is associated with temperature changes in both catheterization and non-catheterization hands at one month after the index procedure. These changes likely represent a systemic response to local TRA stimulus.

Interventional cardiology has witnessed tremendous changes over the years from a mainly diagnostic approach in an elective population to therapeutic strategies in critically ill patients. Currently, we can treat a broad spectrum of coronary artery, peripheral artery, and structural heart diseases with less invasive, percutaneous approaches that we did not anticipate to be possible just a decade ago. It is certain that the interventional techniques will see further development and we will be able to treat by percutaneous methods more conditions previously thought beyond our reach. Regardless of the advances in catheter-based diagnostic and therapeutic techniques, one thing remains constant. They all require vascular access. And, vascular access is the first technical part of any percutaneous cardiovascular procedure that can determine its overall success. High-quality data together with the availability of training courses for interventional cardiologists and fellows-in-training ensure systematic use of the transradial approach (TRA) which has demonstrated a considerable benefit compared to transfemoral approach both in chronic and acute coronary syndromes. Constant improvement of TRA techniques will further facilitate transradial endovascular and structural interventions, and the growing use for high-risk and complex percutaneous coronary interventions. A continuously growing body of evidence is focused on surpassing current TRA limitations (specifically radial artery occlusion) and expanding alternative vascular accesses such as transulnar approach or distal TRA (“snuff-box” technique). Should this downsizing trend continue, we could see a further paradigm shift toward using the snuff-box technique.

The S1S2S3 pattern, in conjunction with right-dominant forces on a 12-lead electrocardiogram including a tall R-wave in lead V1 (R:S >1), deep S waves in the left precordial leads V5 and V6 (R:S 2.5 mm), is highly specific for right ventricular dysfunction with pulmonary hypertension. (Level of Difficulty: Intermediate.), Central Illustration

Objectives To gain insight into current practice of transradial angiography and intervention in the United States and around the world. Background Transradial access (TRA) has grown worldwide. In a prior survey, there was significant practice variation and there was minimal US participation which limited the generalizability to US operators. Methods We used an internet-based survey software program to solicit input from practicing interventional cardiologists from the United States and around the world. US operators were compared with outside the United States (OUS) operators and respondent-level comparisons were made with the prior survey to assess for temporal changes in practice. Results Between August 2016 and January 1, 2017, 125 interventional cardiologists completed the survey representing 91 countries with the United States having 449 (39.9%) respondents. Preprocedure, noninvasive testing for collateral circulation is used more commonly in the United States (54.1%) than around the world (26.6%) but its use has decreased since 2010. In the US, 48.8% of operators never use ultrasound and 92.6% of OUS operators never use it; only 4.4% overall use ultrasound in >50% of cases. Use of bivalirudin has decreased in the US and OUS. Nearly, 30% of operators do not assess for radial artery patency following hemostasis. US respondents used TRA less commonly for primary PCI for STEMI than their global counterparts. Conclusions There is wide variation in how TRA procedures are performed including relatively low rates of adherence to practices that are known to improve outcomes. Further education aimed at increasing use of best practices will impact patient outcomes.

Objectives The aim of this study was to determine predictors and outcomes associated with staged percutaneous coronary intervention (PCI) versus one-time multivessel revascularization (OTMVR) in patients with multivessel coronary artery disease. Background Prior observational studies have not evaluated predictors and outcomes of staged PCI versus OTMVR in a heterogenous population of patients with multivessel coronary artery disease who undergo multivessel revascularization. Methods Data from the Veterans Affairs (VA) CART (Clinical Assessment, Reporting, and Tracking) Program were used to evaluate patients who underwent PCI of >2 vessels between October 1, 2007, and September 3, 2014. Associations between individual factors and the decision to perform staged PCI were assessed. Additionally, the impact of measured patient and procedural factors, site factors, and unmeasured site factors on the decision to perform staged PCI was compared. Cox proportional hazards models were used to determine the association between staged PCI and mortality. Results A total of 7,599 patients at 61 sites were included. The decision to perform staged PCI was driven by procedural characteristics and unmeasured site factors. Staged PCI was associated with lower risk-adjusted mortality compared with OTMVR (adjusted hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.72 to 0.84; p Conclusions The decision to pursue staged PCI was driven by procedural characteristics and unmeasured site variation and was associated with lower mortality compared with OTMVR. After adjustment, there was an association between staged PCI and reduced mortality. Given the observational nature of these findings, a randomized trial comparing the 2 is needed to guide practice.

INTRODUCTION Percutaneous coronary intervention (PCI) is typically performed with vascular access provided by the radial or femoral artery. However, little is known about how patients value aspects of these different vascular access approaches. METHODS Conjoint analysis is a survey-based statistical technique used in market research that helps determine how individuals value different attributes that make up a particular product or services. We utilized conjoint analysis to assess the relative importance of four attributes associated with PCI: access site, risk of bleeding, hospital stay, and radiation exposure. Participants were healthy individuals recruited by Amazon Mechanical Turk (MTURK). After completing a conjoint analysis survey, the software Conjoint.ly was used to calculate the relative importance for these four different attributes of PCI. RESULTS The relative importance of hospital stay, radiation exposure, bleeding risk, and procedure site was 32.7% (95% CI 29.5-35.8), 27.3% (95% CI 24.8-29.8), 24.4% (95% CI 22.3-26.5), and 15.7% (95% CI 13.6-17.8), respectively. The difference between these groups was statistically significant (P-value < 0.00001). The difference between duration of hospital stay and radiation exposure was statistically significant (P-value < 0.00433). CONCLUSION Patients undergoing PCI place largest relative value on duration of hospital stay. Access site appears the least valued attribute. These findings carry implications to guide further research on access site choices and the consent process in the context of shared decision-making.

BACKGROUND: Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors. HYPOTHESIS: Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization METHODS: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1‐year all‐cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine. RESULTS: 3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08‐1.39), MI (HR: 1.40, 95% CI: 1.07‐1.83), and CVA (HR: 1.88, 95% CI: 1.38‐2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine. CONCLUSIONS: Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.

Device embolization during transcatheter aortic valve replacement (TAVR) is a rare but potentially life-threatening complication. The reported device embolization (DE) incidence in TAVR in clinical trials was low―0.1% in PARTNER II (Placement of AoRTic TraNscathetER valves II) (Sapien XT

Acute myocardial infarction (AMI) during pregnancy or the early postpartum period is rare, but can be devastating for both the mother and the fetus. There have been major advances in the diagnosis and treatment of acute coronary syndromes in the general population, but there is little consensus on the approach to diagnosis and treatment of pregnant women. This article reviews the literature relating to the pathophysiology of AMI in pregnant patients and the challenges in diagnosis and treatment of ST-elevation myocardial infarction (STEMI) in this unique population. From a cardiologist, maternal-fetal medicine specialist, and anesthesiologist's perspective, we provide recommendations for the diagnosis and management of STEMI occurring during pregnancy.

Shared decision-making is a strategy to assist with patient involvement in medical decisions. One of its pillars is patient knowledge and understanding of the risks and benefits associated with specific procedures. We studied patient knowledge about transradial (TRA) and transfemoral (TFA) cardiac catheterization. A prospective study was conducted in 100 patients hospitalized following diagnostic and therapeutic cardiac catheterization—TRA in 71% of patients and remaining TFA. All patients were presented a standard balanced informed consent outlining risks and benefits. Following catheterization, patients were verbally administered an 11-item open-ended questionnaire to assess knowledge of cardiac catheterization and the associated risks and benefits. A patient knowledge index (PKI) was developed with 1 point given for: identifying the procedure; correctly describing the procedure; identifying at least 1 risk of TRA; and/or TFA; and at least 1 benefit of TRA; and/or TFA. Maximum PKI score was 6. The mean PKI score was 2.6 ± 1.1. A PKI score ≥4 was observed in 21% of patients with only 1 patient obtaining the maximum 6 points. Over 80% of patients were unable to recall procedure risks provided at the time of informed consent. The majority of patients were unable to discriminate between TRA and TFA risks and benefits, PKI 2.52 versus 2.60, respectively (p = 0.718). On multivariate analysis, higher education levels were correlated with increased PKI scores (odds ratio = 0.65, p = 0.014) whereas black race was associated with lower PKI scores (odds ratio = −0.48, p = 0.045). In conclusion, patient retention of information from the informed consent was low. The majority of patients had no preference or deferred to their physician's expertise when deciding TRA compared with TFA. This study identifies challenges with implementing shared decision-making and the need for improved patient education and involvement regarding cardiac catheterization.

Objectives To determine ambulation times after right heart catheterization (RHC) via upper extremity access compared to femoral venous access. Background Transradial coronary angiography has been associated with shorter times to ambulation. We hypothesized that RHC from the upper extremity would be similarly associated with shorter ambulation times when compared to traditional femoral access. Methods We performed a single-center retrospective analysis of 379 consecutive patients who underwent a variety of diagnostic and interventional left- and right-heart procedures through upper extremity and femoral access sites. Results The time to ambulation for RHC through the arm veins versus the femoral vein was lower (42.6 min ± 14.2 vs. 175.0 min ± 65.0, P

Background The use of simulator-based teaching in cardiology has unfortunately lagged behind other procedural specialties. This study investigates the utility of a simulator-based training program for fellows in cardiovascular disease with no prior experience in diagnostic coronary angiography. Methods First-year cardiology fellows at University of Illinois-Chicago (UIC) using AngioMentor ™ simulators completed benchmark cases requiring basic coronary engagement. Subsequently, benchmark cases were completed one day later and at 9months following 2–3months of training in the cardiac catheterization lab. In addition, 1st year cardiology fellows were compared to 3rd year fellows. Objective measures assessed from benchmark cases were total procedural time, total contrast used, and total fluoroscopy time. Results All 1st year fellows improved their total time to complete the benchmark case from initial to second attempt one day later (14:56 on Day 1, 8:30 on Day 2, P=0.03). Total contrast used (60mL on Day 1, 39mL on Day 2, P=0.11) and total fluoroscopic time (6:30 on Day 1 and 4:26 on Day 2, P=0.16) also both decreased. Overall procedure time and contrast use were similar among 1st and 3rd year fellows after simulation training. Decreases in procedure and fluoroscopy time were maintained in 1st year fellows after 2–3months of training. Conclusion Fellows displayed technical and procedural improvement at diagnostic coronary angiography in a short period of time and in a safe, patient free environment. In this study, a computer-based simulator was successfully incorporated into a first year cardiovascular fellowship curriculum and represents a contemporary means to provide the fellow increased procedural training without added risk to the patient. Sentence summary The use of simulator-based teaching in cardiology has unfortunately lagged behind other procedural specialties. In this study, a computer-based simulator was successfully incorporated into a first year cardiovascular fellowship curriculum. A firm teaching curriculum is the next step towards implementing this modality in an organized fashion.

Radiation dose has widely been studied, focusing on the impacts of source distance, patient access site, type of imaging used, and availability of protective equipment. However, as more female operators come into practice, the impact of lower table and operator height during cardiac catheterization

This review aims to summarize and discuss the safety and efficacy of ulnar arterial approach for cardiac catheterization. Ulnar access has been found to be as safe and efficacious as radial access. However, the number of access attempts and cross-over rates is higher than with radial access. Ulnar access is an excellent alternative after failed radial access as femoral access is associated with more bleeding and worse clinical outcomes. Future research should focus on ultrasound-guided ulnar access to reduce the number of puncture attempts.

Shared decision-making (SDM) has become a cornerstone of patient-centered medicine. In order to better understand SDM related to arterial access site choices, we studied patient understanding of risks and benefits associated with transradial (TRA) and transfemoral (TFA) cardiac catheterization. A

Brachial artery flow–mediated vasodilation in exercise-trained (ET) individuals is maintained after a single bout of heavy resistance exercise compared with sedentary individuals. The purpose of this study was to determine whether vasodilation is also maintained in the microcirculation of ET individuals. A total of 51 sedentary and ET individuals underwent gluteal subcutaneous fat biopsy before and after performing a single bout of leg press exercise. Adipose arterioles were cannulated in an organ bath, and vasodilation to acetylcholine was assessed±the endothelial nitric oxide inhibitor l -NG-nitroarginine methyl ester, the cyclooxygenase inhibitor indomethacin, or the hydrogen peroxide scavenger polyethylene glycol catalase. Separate vessels (isolated from the same groups) were exposed to an intraluminal pressure of 150 mm Hg for 30 minutes to mimic the pressor response, which occurs with isometric exercise. Vasodilation to acetylcholine was reduced in microvessels from sedentary subjects after either a single weight lifting session or exposure to increased intraluminal pressure, whereas microvessels from ET individuals maintained acetylcholine-mediated vasodilation. Before weight lifting, vasodilation of microvessels from ET individuals was reduced in the presence of l -NG-nitroarginine methyl ester and indomethacin. After weight lifting or exposure to increased intraluminal pressure, polyethylene glycol catalase significantly reduced vasodilation, whereas l -NG-nitroarginine methyl ester and indomethacin had no effect. These results indicate that (1) endothelium-dependent vasodilation in the microvasculature is maintained after heavy resistance exercise in ET individuals but not in sedentary subjects and that (2) high pressure alone or during weight lifting may induce a mechanistic switch in the microvasculature to favor hydrogen peroxide as the vasoactive mediator of dilation.

We sought to determine whether there are differences in enrolled patients' risk factors in published percutaneous coronary intervention (PCI) trials between various continents.We systematically identified clinical trials evaluating PCI interventions through PubMed. We reviewed 701 studies between 1990 and 2014 from North America (N=135), Europe (N=403), and Asia (N=163), examining the prevalence of cardiovascular risk factors-hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HL), smoking, sex, and body mass index. We performed meta-regression with random- and mixed-effects models to compare patient baseline characteristics between continents and linear meta-regression analysis to test trends over time.In meta-regression with random-effects model, North American trials recruited the lowest proportion of male participants (71.32%), followed by Asian (74.41%) and European trials (76.47%; P.0001). North American trials enrolled the highest proportion of patients with HTN (63.17%, P=.0035) and HL (63.72%, P.0001), whereas Asia enrolled the highest proportion of DM patients (29.64%, P.0001) and smoking (38.41%, P=.0144). When adjusting for other moderators such as publication date, body mass index, and sex in meta-regression with mixed-effects model, age was significantly positively correlated with HTN, HL, DM, and smoking (P.001). Body mass index was significantly higher in Europe and North America than in Asia. All enrollment risk factors demonstrated (β0.02) statistically significant temporal trends over time, except for sex.There are major continental differences in risk factors among patients enrolled in PCI trials from various continents. Clinical trial results may not be applicable to patient populations from another region.