Search

BACKGROUNDS: To compare the complication rates and overall costs of self-expandable metal stents (SEMS) and plastic stents (PS) in clinically indicated preoperative biliary drainage (PBD) prior to a pancreatoduodenectomy (PD). METHOD(S): We conducted an Australian multicentre retrospective cohort study using the databases of four tertiary hospitals. Adult patients who underwent clinically indicated endoscopic PBD prior to PD from 2010 to 2019 were included. Rates of complications attributable to PBD, surgical complications and pre-operative endoscopic re-intervention were calculated. Costing data were retrieved from our Financial department. RESULT(S): Among the 157 included patients (mean age 66.6+/-9.8years, 45.2% male), 49 (31.2%) received SEMS and 108 received PS (68.8%). Baseline bilirubin was 187.5+/-122.6 mumol/L. Resection histopathology showed mainly adenocarcinoma (93.0%). Overall SEMS was associated less complications (12.2% vs. 28.7%, p = 0.02) and a lower pre-operative endoscopic re-intervention rate (4.3 vs. 20.8%, p = 0.03) compared with PS. There was no difference in post-PD complication rates. On multivariate logistic regression analysis, stent type was an independent risk factor of PBD complication (OR of SEMS compared to PS 0.24, 95% CI 0.07-0.79, p = 0.02) but not for any secondary outcome measures. Upfront material costs were $56USD for PS and $1991USD for SEMS. Accounting for rates of complications, average costs were similar ($3110USD for PS and $3026USD for SEMS). CONCLUSION(S): In resectable pancreaticobiliary tumours, SEMS for PBD was associated with reduced risk of overall PBD-related complications and pre-surgical endoscopic reintervention rates and was comparable to PS in terms of overall cost.Copyright © 2021 Royal Australasian College of Surgeons.

Background/purpose: Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR), although its prognostic significance is questionable. Significant CAD stratified using SYNTAX score (SS) has been associated with greater mortality, yet it is unknown whether the functional impact of CAD also impacts outcomes in this cohort. DILEMMA score (DS) is a validated angiographic functional scoring tool that correlates with fractional flow reserve and instantaneous wave-free ratio. This study sought to assess the functional impact of CAD on outcomes in patients undergoing TAVR for severe aortic stenosis (AS). Methods/materials: 229 patients were included in this analysis. Patients underwent angiographic DS and SS and were classified using predefined values. The primary endpoint was one-year all-cause mortality, with secondary endpoints of 30-day major adverse cardiac and cerebrovascular events (MACCE). Result(s): The mean age was 83.9 +/- 0.5 years (55.0% female), with 11.8% all-cause mortality. CAD defined by >=30% stenosis in any vessel was not associated with adverse outcomes (HR = 1.08, p = 0.84). However, the risk of one-year mortality was greater in patients with either SS > 9 (20.8% vs. 9.4%, HR 2.34, p = 0.03) or DS > 2 (18.4% vs. 8.5%, HR = 2.28, p = 0.03). Both scoring systems were also associated with 30-day MACCE (both p < 0.05). After multivariate adjustment, independent predictors of one-year mortality were DS > 2 (HR = 2.29, p = 0.04), left ventricular ejection fraction <50% (HR 2.66, p = 0.04) and COPD (HR 2.43, p = 0.04). Conclusion(s): Our results demonstrate that angiographic functional scoring is independently predictive of both 12-month mortality and 30-day MACCE following TAVR.Copyright © 2020 Elsevier Inc.

Aim: We sought to examine the association of epicardial adipose tissue (EAT) quantified on chest computed tomography (CT) with the extent of pneumonia and adverse outcomes in patients with coronavirus disease 2019 (COVID-19). Method(s): We performed a post-hoc analysis of a prospective international registry comprising 109 consecutive patients (age 64 +/- 16 years; 62% male) with laboratory-confirmed COVID-19 and noncontrast chest CT imaging. Using semi-automated software, we quantified the burden (%) of lung abnormalities associated with COVID-19 pneumonia. EAT volume (mL) and attenuation (Hounsfield units) were measured using deep learning software. The primary outcome was clinical deterioration (intensive care unit admission, invasive mechanical ventilation, or vasopressor therapy) or in-hospital death. Result(s): In multivariable linear regression analysis adjusted for patient comorbidities, the total burden of COVID-19 pneumonia was associated with EAT volume (beta = 10.6, p = 0.005) and EAT attenuation (beta = 5.2, p = 0.004). EAT volume correlated with serum levels of lactate dehydrogenase (r = 0.361, p = 0.001) and C-reactive protein (r = 0.450, p < 0.001). Clinical deterioration or death occurred in 23 (21.1%) patients at a median of 3 days (IQR 1-13 days) following the chest CT. In multivariable logistic regression analysis, EAT volume (OR 5.1 [95% CI 1.8-14.1] per doubling p = 0.011) and EAT attenuation (OR 3.4 [95% CI 1.5-7.5] per 5 Hounsfield unit increase, p = 0.003) were independent predictors of clinical deterioration or death, as was total pneumonia burden (OR 2.5, 95% CI 1.4-4.6, p = 0.002), chronic lung disease (OR 1.3 [95% CI 1.1-1.7], p = 0.011), and history of heart failure (OR 3.5 [95% 1.1-8.2], p = 0.037). Conclusion(s): EAT measures quantified from chest CT are independently associated with extent of pneumonia and adverse outcomes in patients with COVID-19, lending support to their use in clinical risk stratification.Copyright © 2020 Elsevie

Background: Left ventricular thrombus (LVT) has a 5% incidence after anterior ST-elevation myocardial infarction (STEMI). Multiple risk factors predispose to LVT formation, including left ventricular systolic dysfunction and infarct size, however measurable predictors during index left heart catheterization (LHC) have not been determined. Method(s): We performed a retrospective analysis of patients presenting between January 2010 and September 2017 with anterior STEMI who had in-hospital transthoracic echocardiography (TTE). LHC variables that were assessed included coronary anatomy, location of culprit stenosis, presence of diffuse stenosis, number of severely diseased vessels, apical akinesis on left ventriculogram (LVG), left ventricular end diastolic pressure, and success of percutaneous coronary intervention (PCI). Result(s): Of 598 consecutive anterior STEMI patients, records and inpatient TTE results were available in 425 patients. The incidence of LVT was 6.8% (n = 29). After multivariate adjustment, severe triple vessel coronary disease (OR = 8.27, CI = 2.97-23.00, p <=0.001), apical akinesis on LVG (OR = 6.74, CI = 1.48-30.73, p = 0.014), wrap-around left anterior descending (LAD) anatomy (OR = 5.10, CI = 1.97-13.23, p = 0.001), and failure of recanalization after PCI (OR = 3.94, CI = 1.06-14.66, p = 0.04) were predictors for LVT formation. The combined negative predictive value (NPV) for the absence of these four indices was 99.2%. Conclusion(s): Severe triple vessel disease, apical akinesis on LVG during index admission, wrap-around LAD, and failure of recanalization after PCI are associated with increased risk of LVT formation after anterior STEMI. The high NPV for the absence of these indices could serve as a risk stratification tool for LVT risk to guide early TTE utilization.Copyright © 2021 Elsevier Inc.

Background: Studies have observed higher incidence of cardiovascular mortality in South Asians (SA), and lower prevalence in East Asians (EA), compared with Caucasians. These observations are not entirely explained by ethnic differences in cardiovascular risk factors and mechanistic factors such as variations in cardiac anatomy and physiology may play a role. This study compared ethnic differences in CT-assessed left ventricular (LV) mass, coronary anatomy and non-invasive fractional flow reserve (FFRCT). Method(s): Three-hundred symptomatic patients (age 59 +/- 7.9, male 51%) underwent clinically-mandated CT-coronary-angiography (CTA) were matched for age, gender, BMI and diabetes (100 each ethnicity). Assessment of coronary stenosis, luminal dimensions and vessel dominance was performed by independent observers. LV mass, coronary luminal volume and FFRCT were quantified by blinded core-laboratory. A sub-analysis was performed on patients (n = 187) with normal/minimal disease (0-25% stenosis). Result(s): Stenosis severity was comparable across ethnic groups. EA demonstrated less left-dominant circulation (2%) compared with SA (8.2%) and Caucasians (10.1%). SA compared with EA and Caucasians demonstrated smallest indexed LV mass, coronary luminal volumes and dimensions. EA compared with Caucasians had comparable indexed LV mass, coronary luminal dimensions and highest luminal volumes. The latter was driven by higher prevalence of right-dominance including larger and longer right posterior left ventricular artery. FFRCT in the left anterior descending artery (LAD) was lowest in SA (0.87) compared with EA (0.89; P = 0.009) and Caucasians (0.89; P < 0.001), with no difference in other vessels. All observed differences were consistent in patients with minimal disease. Conclusion(s): This single-centre study identified significant ethnic differences in CT-assessed LV mass, coronary anatomy and LAD FFRCT. These hypotheses generating results may provide a mechanistic expla

Fractional flow reserve (FFR) is routinely used to determine lesion severity prior to percutaneous coronary intervention (PCI). However, there is an increasing recognition that FFR may also be useful following PCI to identify mechanisms leading to restenosis and the need for repeat revascularization. Post-PCI FFR is associated with the presence and severity of stent under-expansion and may help identify peri-stent-related complications. FFR pullback may also unmask other functionally significant lesions within the target vessel that were not appreciable on angiography. Recent studies have confirmed the prognostic utility of performing routine post-PCI FFR and suggest possible interventional targets that would improve stent durability. In this review, we detail the theoretical basis underlying post-PCI FFR, provide practical tips to facilitate measurement, and discuss the growing evidence supporting its use.Copyright © 2020 Udit Thakur et al.

Background. Despite the high prevalence of coronary bifurcation lesions in routine interventional cardiology practice, the best strategy for managing this challenging lesion subset remains debatable. Due to potential for complications, the routine practice of side-branch (SB) predilation is controversial. Methods. An electronic search was performed of online databases up until April 2018 for studies reporting periprocedural angiographic outcomes comparing provisional main-branch stenting with and without SB predilation. Random-effects model odds ratios (ORs) were calculated. Results. Eight studies were selected for a qualitative review, with 47.3% (1367/2890) of included subjects having angiographic outcomes following SB predilation reported. Of these, four studies included details of periangiographic outcomes comparing two groups. Bifurcation lesions stented without SB predilation demonstrated lower odds of requiring further SB intervention compared with lesions receiving upfront SB predilation (OR, 2.44; 95% confidence interval [CI], 1.71-3.47; I2=21%; P<.001). No difference was demonstrated regarding final SB TIMI flow <3, SB dissection, or intraprocedural SB occlusion. Although the odds of performing final kissing-balloon inflation were in favor of the group without SB predilation (OR, 1.62; 95%CI, 1.11-2.37; I2=61%; P=.01), there was no statistical difference in long-term major cardiovascular outcome (MACE) between the two groups (risk ratio, 1.29; 95%CI, 0.94-1.75; I2=11%; P=.33). Conclusion. SB predilation during coronary bifurcation percutaneous coronary intervention did not alter overall procedural angiographic outcomes. However, SB predilation is associated with increased SB intervention, including increased requirement for SB stenting, without demonstrable long-term MACE benefit, compared with a standard strategy without SB predilation.Copyright © 2020 HMP Communications. All rights reserved.

Background: Coronary artery disease is common in patients with severe aortic stenosis. Computed tomography-derived fractional flow reserve (CT-FFR) is a clinically used modality for assessing coronary artery disease, however, its use has not been validated in patients with severe aortic stenosis. This study assesses the safety, feasibility, and validity of CT-FFR in patients with severe aortic stenosis. Method(s): Prospectively recruited patients underwent standard-protocol invasive FFR and coronary CT angiography (CTA). CTA images were analyzed by central core laboratory (HeartFlow, Inc) for independent evaluation of CT-FFR. CT-FFR data were compared with FFR (ischemia defined as FFR <=0.80). Result(s): Forty-two patients (68 vessels) underwent FFR and CTA; 39 patients (92.3%) and 60 vessels (88.2%) had interpretable CTA enabling CT-FFR computation. Mean age was 76.2+/-6.7 years (71.8% male). No patients incurred complications relating to premedication, CTA, or FFR protocol. Mean FFR and CT-FFR were 0.83+/-0.10 and 0.77+/-0.14, respectively. CT calcium score was 1373.3+/-1392.9 Agatston units. On per vessel analysis, there was positive correlation between FFR and CT-FFR (Pearson correlation coefficient, R=0.64, P<0.0001). Sensitivity, specificity, positive predictive value, and negative predictive values were 73.9%, 78.4%, 68.0%, and 82.9%, respectively, with 76.7% diagnostic accuracy. The area under the receiver-operating characteristic curve for CT-FFR was 0.83 (0.72-0.93, P<0.0001), which was higher than that of CTA and quantitative coronary angiography (P=0.01 and P<0.001, respectively). Bland-Altman plot showed mean bias between FFR and CT-FFR as 0.059+/-0.110. On per patient analysis, the sensitivity, specificity, positive predictive, and negative predictive values were 76.5%, 77.3%, 72.2%, and 81.0% with 76.9% diagnostic accuracy. The per patient area under the receiver-operating characteristic curve analysis was 0.81 (0.67-0.95, P<0.0001). Conclusion(s): CT

Purpose: South Asian (SA) have been observed to have higher cardiovascular mortality rates compared to East Asians (EA) and Caucasians. Pericoronary adipose tissue (PCAT) attenuation around the right coronary artery (RCA) from coronary CT angiography (CTA) has been associated with coronary inflammation and cardiac death. We aimed to investigate i) the relationship between plaque characteristics and PCAT attenuation and ii) to assess gender and ethnic differences in PCAT attenuation using a matched cohort of SA, EA and Caucasians. Method(s): Three-hundred symptomatic patients who underwent CTA were matched for age, gender, BMI and diabetes (100 in each ethnic group). Semi-automated software was used to quantify the total volumes and burden of non-calcified plaque (NCP), low-density non-calcified plaque (LD-NCP) and calcified plaque (CP) in blinded core-lab analysis. PCAT CT attenuation was measured around the RCA (10-50 mm from RCA ostium), the most standardized model for PCAT analysis. Result(s): The total volumes and burden of NCP, LD-NCP and CP were comparable in the ethnic groups (each p > 0.05). PCAT attenuation was higher in patients with coronary plaque. PCAT attenuation correlated with the total volumes and burden of NCP, LD-NCP and CP (r>0.17; p < 0.003). Within the RCA this correlation persisted only for NCP features (r>0.39;p < 0.001). Males showed higher PCAT attenuation (p < 0.001). PCAT attenuation was similar between Caucasian, EA and SA (p = 0.32). Conclusion(s): PCAT CT attenuation correlated most with its surrounded NCP features further highlighting its role as surrogate measure of coronary inflammation. As coronary plaque burden and RCA PCAT attenuation did not differ between ethnic groups, causes of increased cardiac mortality in South Asians needs further investigations.Copyright © 2020

Left ventricular thrombus (LVT) has a 5% incidence after anterior ST elevation myocardial infarction (aSTEMI) in the primary percutaneous coronary intervention (PCI) era. Numerous risk factors predispose to LVT formation, including history of left ventricular dysfunction and infarct size, however measurable predictors during left heart catheterisation (LHC) have not been determined. We sought to investigate the predictive utility of LHC indices for LVT formation. We performed a dual-centre retrospective analysis of patients presenting between January 2010 and September 2017 with aSTEMI who had inpatient transthoracic echocardiography (TTE). LHC indices that were assessed on index LHC included location of culprit stenosis, presence of focal or diffuse stenosis, number of severely diseased vessels, presence of apical akinesis on left ventriculogram, left ventricular end diastolic pressure (LVEDP), and whether PCI was performed. Analysis was performed using multivariate analysis with results reported as odds ratios (OR) with 95% confidence intervals (CI). Of 514 consecutive aSTEMI patients, TTE results were available in 425 patients. The incidence of LVT was 6.8% (n=29). After multivariate adjustment, severe triple vessel disease (OR=6.82, CI=2.73-17.02, p=<0.001), apical akinesis (OR=4.58, CI=1.31-16.08, p=0.02), and LVEDP >20mmHg (OR=2.88, CI=1.03-8.05, p=0.04) were predictors of LVT formation. Negative predictive values for triple vessel disease, apical akinesis and LVEDP >20mmHg were 95.3%, 97.7%, and 97% respectively. Triple vessel disease, apical akinesis, and LVEDP >20mmHg are associated with increased risk of LVT in patients with aSTEMI. The high NPV for these indices could serve as a stratification tool for LVT risk to guide inpatient TTE utilisation.Copyright © 2020

Epicardial adipose tissue (EAT) is associated with cardiovascular risk. The longitudinal change in EAT volume (EATv) and density (EATd), and potential modulators of these parameters, has not been described. We prospectively recruited 90 patients with non-obstructive coronary atherosclerosis on baseline computed tomography coronary angiography (CTCA) performed for suspected coronary artery disease to undergo a repeat research CTCA. EATv in millilitres (mL) and EATd in Hounsfield units (HU) were analysed and multivariable regression analysis controlling for traditional cardiovascular risk factors (CVRF) performed to assess for any predictors of change. Secondary analysis was performed based on statin therapy. The median duration between CTCA was 4.3years. Mean EATv increased at follow-up (72+/-33mL to 89+/-43mL, p<0.001) and mean EATd decreased (baseline -76+/-6 HU vs. -86+/-5 HU, p<0.001). There were no associations between baseline variables of body mass index, age, sex, hypertension, hyperlipidaemia, diabetes or smoking on change in EATv or EATd. No difference in baseline, follow-up or delta EATv or EATd was seen in patients with (60%) or without baseline statin therapy. In this select group of patients, EATv consistently increased and EATd consistently decreased at long-term follow-up and these changes were independent of CVRF, age and statin use. Together with the knowledge of strong associations between EAT and cardiac disease, these findings may suggest that EAT is an independent parameter rather than a surrogate for cardiovascular risk.

Background: Coronary physiology in aortic stenosis (AS) is affected by pathological alterations within epicardial and microcirculatory environments. The hyperaemic response in AS is attenuated, with increases in baseline coronary flow velocities. We assessed whether alterations in AS influenced discordance between fractional flow reserve (FFR) and alternate non-hyperaemic pressure ratios (NHPR). Method(s): Forty-one patients with severe AS and angiographically confirmed CAD underwent invasive pressure-wire measurements. Data were extracted to derive FFR, instantaneous wave-free ratio (iFR), diastolic pressure ratio (DPR) and resting Pd/Pa. Data were compared against lesion matched historic non-AS controls. Physiological significance was determined as FFR<0.80, iFR/DPR<0.89 and Pd/Pa<0.92. Result(s): Patients with AS were older (75.3+/-7.5 vs 62.5+/-10.4yrs, p<0.0001), but otherwise comparable to controls. Mean gradient was 44.3+/-11.6mmHg and DI was 0.23+/-0.04. In the AS cohort, mean FFR was 0.82+/-0.09, iFR was 0.84+/-0.1, DPR was 0.84+/-0.1 and Pd/Pa was 0.90+/-0.05. There were no significant differences in FFR and Pd/Pa between cohorts, although resting iFR and DPR were lower in AS patients (p=0.02). Discordance between FFR, Pd/Pa, iFR and DPR was 29%, 22% and 24% respectively in the AS cohort, compared with 25%, 22.5% and 22.5% in controls (p>0.05). Detailed analysis determined that almost all discordance in severe AS was in the NHPR+/FFR- group (92%, 100% and 90%, respectively), differing significantly from controls (40%, 33% and 33%) (p<0.05). Conclusion(s): Overall discordance rates between FFR and NHPR are similar between AS and controls however almost all discordance is in the NHPR+/FFR- quadrant. Therefore, NHPR indices may overestimate lesion severity in severe AS patients.Copyright © 2020

Intermediate coronary artery stenosis, defined as visual angiographic stenosis severity of between 30-70%, is present in up to one quarter of patients undergoing coronary angiography. Patients with this particular lesion subset represent a distinct clinical challenge, with operators often uncertain on the need for revascularization. Although international guidelines appropriately recommend physiological pressure-based assessment of these lesions utilizing either fractional flow reserve (FFR) or quantitative flow ratio (QFR), there are specific clinical scenarios and lesion subsets where the use of such indices may not be reliable. Intravascular imaging, mainly utilizing intravascular ultrasound (IVUS) and optical coherence tomography (OCT) represents an alternate and at times complementary diagnostic modality for the evaluation of intermediate coronary stenoses. Studies have attempted to validate these specific imaging measures with physiological markers of lesion-specific ischaemia with varied results. Intravascular imaging however also provides additional benefits that include portrayal of plaque morphology, guidance on stent implantation and sizing and may portend improved clinical outcomes. Looking forward, research in computational fluid dynamics now seeks to integrate both lesion-based physiology and anatomical assessment using intravascular imaging. This review will discuss the rationale and indications for the use of intravascular imaging assessment of intermediate lesions, while highlighting the current limitations and benefits to this approach.Copyright © Cardiovascular Diagnosis and Therapy. All rights reserved.

Introduction: There is conflicting evidence regarding whether routine preoperative biliary drainage (PBD) should be performed if clinically warranted prior to a pylorus-preserving pancreaticoduodenectomy (PPP) for resectable pancreatic head cancer. In addition, there are limited studies that investigated whether PBD with metal or plastic biliary stents have differing impacts on PBD-related complication rates, post PPP surgical outcomes, and healthcare resource utilisation. Aims & Methods: An Australian multicentre retrospective cohort study was conducted which included patients who underwent PBD prior to PPP from 2010 to 2019. Patients included received PBD based on one or more of: cholangitis defined by revised Tokyo guidelines, level of total bilirubin >=40 mumol/L, expected time to operation >=7 days, or receiving neoadjuvant chemotherapy. The aim of this study was to compare PBD with fully covered self-expandable metal stent (FCSEMS) compared to plastic stents in terms of the rate of endoscopic reintervention, stent related complication and surgical complications in patients with resectable pancreatic head cancer who later underwent a PPD. Result(s): 106 patients underwent PBD. 32 patients (30.19%) received a FCSEMS versus 74 (69.81%) with plastic). The mean age was 66.75 +/- 9.79 years, 47.17% were male and the baseline bilirubin was 184.91 +/- 113.59 mumol/L. Both FCSEMS and plastic effectively reduced bilirubin (DELTA140.04 +/- 113.04 mumol/L from baseline) with no difference between the FCSEMS arm and the plastic arm (DELTA134.56 +/- 108.35 mumol/L vs DELTA152.19 +/- 123.74 mumol/L, p-value:0.47). There was no difference in the PBD complication rates in the FCSEMS and plastic stent groups respectively: readmission (p-value=0.40), pancreatitis (p-value=0.25), cholangitis (p-value=0.35), haemorrhage (p-value=0.51), stent occlusion without cholangitis (p-value=0.09), and reintervention with either ERCP or PTC (p-value=0.21). There were no cases of stent related

Background: Coronary artery disease (CAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR). Clinical outcomes following TAVR are determined by anatomical CAD complexity as determined by SYNTAX score (SS). However it remains unclear on whether the functional significance of lesions can also predict outcome. In this study we sought to compare the prognostic utility of two angiographic scoring systems in patients undergoing TAVR. Method(s): CAD physiological significance was determined by DILEMMA scoring (DS); a validated angiographic tool that strongly correlates with fractional flow reserve. Both DS and SS were classified using predefined values. The primary endpoint was 1-year all-cause mortality, with secondary endpoint of 30-day major adverse cardiac and cerebrovascular events (MACCE). Result(s): Mean age was 83.9+/-0.5yrs (n=229, 55.0% female) and all-cause mortality was 11.8%. Presence of CAD (>=30% stenosis in any vessel) was not associated with outcome (HR=1.08, p=0.84). However, both SS>9 (20.8% vs 9.4%, HR 2.34, p=0.03) and DS>2 (18.4% vs 8.5%, HR=2.28, p=0.03) were associated with increased mortality at 1-year and also predictive of 30-day MACCE (both p<0.05). After multivariate adjustment, the only independent predictors of 1-year mortality were DS>2 (HR=2.29, p=0.04), LVEF<50% (HR 2.66, p=0.04) and COPD (HR 2.43, p=0.04). Conclusion(s): Our results demonstrate that SS and DS both predict 12-month mortality and 30-day MACCE following TAVR. However, only DS remains independently predictive after multivariate adjustment, implying that the functional significance of CAD may be more relevant than anatomical complexity when planning pre-TAVR revascularisation.Copyright © 2020

Background: Percutaneous coronary intervention (PCI) remains an established therapeutic option for myocardial revascularisation. Use of intravascular imaging to guide PCI is known to improve clinical outcomes, with this benefit most pronounced when tackling complex lesion subsets. We therefore sought to ascertain the current uptake and use of intravascular imaging based on anonymised data from the Victorian Cardiac Outcomes Registry (VCOR). Method(s): All consecutive patients undergoing PCI for coronary artery disease (CAD) were included (n=51,044) from January 2013 through December 2018. Intravascular imaging included intravascular ultrasound (IVUS) and optical coherence tomography (OCT) use. Patient/lesion characteristics were obtained and compared between angiographic- and imaging-PCI guided groups. Result(s): Overall, 873 (1.7%) of patients had intravascular imaging to guide PCI during the study period, with IVUS used in 602 (1.2%), OCT in 246 (0.48%) and both in 25 (0.05%) cases. There was an increase in case rates of intravascular imaging year on year (p=0.001). Intravascular imaging was more commonly used in patients with diabetes (p=0.04) and those with stable CAD (p<0.001). Although angiographically-guided PCI remained the default modality used for treatment of all complex lesion subsets, rates of intravascular imaging use were higher for left-main stem intervention (14.7%), stent thrombosis (9.4%), in-stent restenosis (4.6%), treatment of chronic total occlusions (3.0%) and AHA Type B2/C lesions (1.9%). Conclusion(s): The uptake of intravascular imaging use during PCI remains limited in Victoria, even when considering more complex PCI procedures. These data should renew our focus on education, reimbursement and support for using intravascular imaging in Australia.Copyright © 2020

Background: Angiographic assessment of left main coronary artery (LMCA) stenosis is challenging. When uncertainty exists, intravascular ultrasound (IVUS) minimal lumen area (MLA) >=6 mm2 is used as safe threshold for deferral of revascularization. With emergence of Computed Tomography Coronary Angiography (CTCA) as a first-line investigation, we sought to assess which quantitative CT-measure best compared with current IVUS standards. Method(s): Patients who underwent both IVUS and CTCA assessment of angiographically intermediate LMCA stenosis (n=48) were included. All CTCA were performed <90 days prior to IVUS. The cohort was divided into those with significant (S-LMCA) versus non-significant (NS-LMCA) disease, using IVUS >=6 vs <6 mm2. Result(s): Mean age (60.3+/-12.4 vs 59.9+/-11.9yrs, p=0.91) and % male (57.7% vs 54.6%, p=0.83) were similar between groups. Mean time from CTCA to IVUS assessment was 17.4+/-19.8 days, with mean QCA stenosis severity of 46.0+/-18.6%. On CTCA, patients with NS-LMCA had significantly higher luminal area (8.3+/-3.8 vs 5.2+/-1.6 mm2, p=0.005), minimal lumen diameter (MLD) (3.2+/-0.7 vs 2.5+/-0.4 mm, p<0.001), with similar luminal volumes (99.9+/-50.5 vs 113.5+/-73.9 mm3, p=0.47). There was a significant positive correlation between CTCA and IVUS MLA (r=0.77, p <0.001) and MLD (r=0.73, p<0.001). ROC analysis demonstrated CTCA MLA <8.29 mm2 had the best diagnostic accuracy for predicting IVUS MLA <6 mm2 (area under the curve=0.76, sensitivity=100%, specificity=54% p=0.002). Conclusion(s): CTCA luminal measures correlate well with IVUS within the LMCA. These results suggest that CTCA measures could potentially be used to safely defer revascularisation for LMCA disease.Copyright © 2020

Fractional flow reserve (FFR) is routinely used to determine lesion severity prior to percutaneous coronary intervention (PCI). However, there is an increasing recognition that FFR may also be useful following PCI to identify mechanisms leading to restenosis and the need for repeat revascularization. Post-PCI FFR is associated with the presence and severity of stent under-expansion and may help identify peri-stent-related complications. FFR pullback may also unmask other functionally significant lesions within the target vessel that were not appreciable on angiography. Recent studies have confirmed the prognostic utility of performing routine post-PCI FFR and suggest possible interventional targets that would improve stent durability. In this review, we detail the theoretical basis underlying post-PCI FFR, provide practical tips to facilitate measurement, and discuss the growing evidence supporting its use.