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The frequency of burnout is rising among cardiologists, affecting not only their well-being but also the quality of patient care. Computerization of practice, bureaucracy, excessive workload, lack of control/autonomy, hostile and hectic work environments, insufficient income, and work life imbalance are the main categories listed as contributing factors to cardiologists' burnout. Organization- and physician-directed interventions can be impactful; however, the effectiveness and feasibility of these interventions have rarely been assessed in cardiology. This review summarizes recent publications on burnout in cardiology, discusses the contributing factors and implications of burnout on physicians' health and patient safety, and explores possible interventions.

Several studies suggest differences in burnout and coping mechanisms between female and male physicians. We conducted an international, online survey exploring sex-based differences in the well-being of interventional cardiologists. Of 1251 participants, 121 (9.7%) were women. Compared with men, women were more likely to be single and under 50 years old, and they asked more often for development opportunities and better communication with administration. Overall burnout was similar between women and men, but women interventional cardiology attendings were more likely to think that they were achieving less than they should. Improved communication with administration and access to career development opportunities may help prevent or mitigate burnout in women interventional cardiologists.

Background: There is limited information on the impact of the target vessel on the procedural techniques and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 11,580 CTO PCIs performed between 2012 and 2022 at 44 centers., Results: The most common CTO target vessel was the right coronary artery (RCA) (53.1%) followed by the left anterior descending artery (LAD) (26.0%) and the left circumflex artery (LCX) (19.8%). RCA CTOs were longer and more complex, with a higher Japanese CTO score compared with LAD or LCX CTOs. Technical success was higher among LAD (88.8%) lesions when compared with RCA (85.7%) or LCX (85.8%) lesions (P less than .001). The incidence of major adverse cardiovascular events (MACE) was overall 1.9% (n = 220) and was similar among target vessels (P=.916). There was a tendency toward more frequent utilization of the retrograde approach for more proximal occlusions in all 3 target vessels. When compared with all other RCA lesions combined, distal RCA lesions had higher technical success (87.7% vs 85.3%; P=.048). Technical success was similar between various locations of LAD CTOs (P=.704). First/second/third obtuse marginal branch had lower technical success when compared with all other LCX lesion locations (82.7% vs 86.8%; P=.014). There was no association between MACE and CTO location in all 3 target vessels., Conclusions: LAD CTO PCIs had higher technical and procedural success rates among target vessels. The incidence of MACE was similar among target vessels and among various locations within the target vessel.

Background: We examined the effect of atrial fibrillation on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the baseline characteristics and procedural outcomes of 9,166 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023., Results: Atrial fibrillation was present in 1122 (12%) patients. These patients were older and had a higher incidence of comorbidities, such as hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease, lower left ventricular ejection fraction, and lower eGFR. Their CTOs were more likely to have moderate to severe calcification and longer lesion length. They also had higher mean J-CTO and PROGRESS-CTO complications (Acute MI, MACE, Mortality, Perforation, and Pericardiocentesis) scores. Patients with atrial fibrillation had higher prevalence of uncrossable and undilatable CTO lesions and required longer procedure (107 vs 119 min; P less than .001) and fluoroscopy (40 vs 43 min; P=.005) time. Technical success and MACE, including procedural/in-hospital bleeding, were similar in patients with and without atrial fibrillation. Although the crude incidence of MACE on follow-up (median 61 days) was significantly higher in patients with atrial fibrillation, the latter was not independently associated with adverse events on Cox proportional hazards analysis., Conclusions: Patients with atrial fibrillation undergoing CTO PCI are older, have more comorbidities, higher lesion complexity, and longer procedure time, but similar technical success and in-hospital MACE. They have higher MACE and mortality during follow-up, but the difference is not significant after adjusting for potential confounding variables.

Background: Coronary artery dissection is a feared and potentially life-threatening complication of percutaneous coronary intervention (PCI)., Methods: We examined the clinical, angiographic, and procedural characteristics, and outcomes of coronary dissection at a tertiary care institution., Results: Between 2014 and 2019, unplanned coronary dissection occurred in 141 of 10,278 PCIs (1.4%). Median patient age was 68 (60, 78) years, 68% were men, and 83% had hypertension. The prevalence of diabetes (29%), and prior PCI (37%) was high. Most target vessels were significantly diseased: 48% had moderate/severe tortuosity and 62% had moderate/severe calcification. The most common cause of dissection was guidewire advancement (30%), followed by stenting (22%), balloon angioplasty (20%), and guide-catheter engagement (18%). TIMI flow was 0 in 33% and 1-2 in 41% of cases. Intravascular imaging was used in 17% of the cases. Stenting was used to treat the dissection in 73% of patients. There was no consequence of dissection in 43% of patients. Technical and procedural success was 65% and 55%, respectively. In-hospital major adverse cardiovascular events occurred in 23% of patients: 13 (9%) had an acute myocardial infarction (MI), 3 (2%) had emergency coronary artery bypass graft surgery, and 10 (7%) died. During a mean follow up of 1612 days, 28 (20%) patients died, and the rate of target lesion revascularization was 11.3% (n=16)., Conclusion: Coronary artery dissection is an infrequent complication of PCI, but is associated with adverse clinical outcomes, such as death and acute MI.

Background: Although discouraged, ad hoc chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is occasionally performed., Methods: We examined the clinical, angiographic characteristics, and procedural outcomes of patients who underwent ad hoc CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436)., Results: Of the 10,998 patients included in the registry, 899 (8.2%) underwent ad hoc CTO PCI. The incidence of ad hoc CTO PCI decreased from 18% in 2016 to 3% in 2022. Ad hoc CTO PCI patients had a lower prevalence of comorbidities and less complex angiographic characteristics demonstrated by lower J-CTO score (1.9±1.2 vs 2.4±1.3, P < .001). In these patients, PROGRESS-CTO major adverse cardiovascular events (MACE) (1.9±1.4 vs 2.5±1.7), mortality (1.2±1.0 vs 1.6±1.1), and perforation (1.5±1.2±2.2 vs 1.5) scores were lower (P < .001). Technical success was similar between the groups (86%). MACE were lower in the ad hoc CTO PCI group (.8% vs 2.0%, P=.009). Ad hoc CTO PCI was not associated with MACE after adjusting for potential confounders, odds ratio: .69 (95% confidence interval, .30-1.57). In patients with higher J-CTO scores, planned CTO PCI was associated with higher technical success (P < .001)., Conclusion: Approximately 8% of CTO PCI procedures are performed ad hoc, usually in less complex lesions and patients with lower complication risk. While ad hoc CTO PCI might be appropriate for carefully selected cases, a staged approach is recommended for most CTO PCI.

Background: The retrograde strategy is a common approach used in complex chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The ERCTO Retrograde score is a tool that aims to predict the likelihood of technical success for retrograde CTO PCI procedures by evaluating 5 parameters: calcification, distal opacification, proximal tortuosity, collateral connection classification, and operator volume., Methods: We evaluated the performance of the ERCTO Retrograde score using data from 2341 patients enrolled in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) at 35 centers between 2013 and 2023., Results: Retrograde CTO PCI was the primary crossing strategy in 871 cases (37.2%) and a secondary crossing strategy in 1467 cases (62.8%). Technical success was achieved in 1,810 cases (77.3%). The technical success rate was higher for primary retrograde cases compared with secondary retrograde cases (79.8% vs 75.9%; P=.031). The ERCTO Retrograde score was positively associated with the likelihood of procedural success. The c-statistic of the ERCTO retrograde score was 0.636 (95% confidence intervals [CI]: .610-.662) for all cases and 0.651 (95% CI: .607-.695) for primary retrograde cases., Conclusions: The ERCTO Retrograde score has modest predictive capacity for technical success in retrograde CTO PCI.

Background: Intravascular ultrasound (IVUS) can assist percutaneous coronary intervention (PCI) of chronic total occlusions (CTO)., Methods: We analyzed 8,983 CTO PCIs performed in 8,771 patients between 2012 and 2022 at 39 centers., Results: Overall, IVUS was used in 44.5% of the cases, for crossing in 11.5% and for stent optimization in 33.1%. IVUS for stent optimization was used more often for complex lesions with higher prevalence of calcification (51.2% vs 34.3%; P<.001); was associated with lower air kerma radiation dose (1.78 [1.00, 3.09] vs 2.30 (1.35, 3.91) min, P<.001) and contrast volume (190 [138, 258] vs 220 [160, 300] ml, P<.001). Among cases with successful guidewire crossing, those that used IVUS for stent optimization had higher technical (99.3% vs 96.3%; P<.001) and procedural (96.1% vs 94.6%, P=.002) success rates and similar major adverse complication event rates (2.04% vs 1.62%; P=.176). The use of IVUS for stent optimization significantly increased over time., Conclusion: In a contemporary, multicenter registry, IVUS was used in 44.5% and its use for stent optimization significantly increased over time. Cases where IVUS was used for stent optimization had higher technical and procedural success and similar risk of complications compared with cases where IVUS was not used for stent optimization.

Background: The incidence, indications, and outcomes of coronary angiography (CAG) performed within 30 days following coronary artery bypass graft surgery (CABG) have received limited study., Methods: We reviewed patients who underwent CAG within 30 days following CABG between April 2018 and September 2021 at a large quaternary healthcare system., Results: Of 2209 patients who underwent CABG during the study, 111 (5%) underwent CAG within 30 days following CABG. Mean age was 65 ± 10 years and they had high prevalence of comorbidities. Graft utilization was as follows: left internal mammary artery (LIMA) (84%); saphenous vein graft(s) (SVG) (81%); and right internal mammary artery (RIMA) (22%). The most common presentations/indications for angiography were cardiogenic shock (41%), ST-segment-elevation myocardial infarction (32%), and achieving complete revascularization by percutaneous coronary intervention (PCI) (16%). The LIMA, RIMA, and SVGs were completely/partially occluded in 41 (44%), 10 (42%), and 11 (50%) of patients, respectively. Of the 111 patients who underwent CAG, 55 (50%) underwent PCI, including 47 (85%) to the native vessel and 8 (15%) to the bypass graft, and 19 (17%) underwent repeat sternotomy. Overall, 29 patients (26%) required 30-day readmission following CAG and 19 (17%) died., Conclusion: The incidence of CAG within 30 days following CABG is approximately 5%. Patients who need CAG following CABG have high complication rates (26% readmission and 17% mortality, respectively, at 30 days).

Background: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesions can be challenging to perform. In the present review we summarize recent publications in this rapidly evolving area grouped according to indications, outcomes, technique, and complications.

Background: There are limited data on the use of bivalirudin for chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We compared CTO-PCIs performed using bivalirudin vs unfractionated heparin in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO; NCT02061436). The primary endpoint was net adverse cardiac events (NACE), defined as major adverse cardiac events (MACE) and vascular complications., Results: Between 2012 and 2022, a total of 73 of 9723 procedures (0.75%) were performed using bivalirudin. The J-CTO score (2.4 ± 1.2 vs 2.4 ± 1.3; P=.73) and the PROGRESS-CTO score (1.4 ± 0.9 vs 1.2 ± 1.0; P=.31) were similar in both groups, and the retrograde approach was used less often in the bivalirudin group (15% vs 30%; P<.01). Procedural success (89% vs 85%; P=.35), in-hospital NACE (1.4% vs 2.1%; P>.99), incidence of MACE (0% vs 0.76%; P=.64), and vascular access complications (1.4% vs 0.9%; P=.48) were not different between the 2 groups. On multivariable analysis, use of bivalirudin was not associated with an increased risk of NACE (odds ratio, 0.99; 95% confidence interval, 0.13-7.27)., Conclusion: Bivalirudin is infrequently used during retrograde CTO-PCI. While the incidence of adverse events was similar with unfractionated heparin, larger studies are needed to assess the safety of bivalirudin.

Background: Although high body mass index (BMI) is a known risk factor for the development of cardiovascular diseases, people who are overweight or obese often have better outcomes after cardiac procedures. Whether this "obesity paradox" is observed in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is unknown. Therefore, we examined the association of BMI with the outcomes of CTO-PCI in patients from the large, multicenter PROGRESS-CTO registry after stratifying patients into 3 BMI groups.

Background: The prevalence and outcomes of patients who presented with an acute coronary syndrome (ACS) and underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study., Methods: We examined the clinical characteristics and procedural outcomes of ACS patients who underwent CTO-PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO; NCT02061436)., Results: Of the 8826 patients who underwent CTO-PCI between 2012 and 2022 at 38 centers, 558 (6.3%) presented with ACS. ACS presentation was with non-ST-segment elevation myocardial infarction (MI) in 54%, unstable angina in 33%, and ST-segment elevation MI in 6.5%. ACS patients were older (66 ± 11 years vs 64 ± 10 years; P<.001) and had higher prevalence of comorbidities such as diabetes mellitus (48% vs 42%; P=.02), prior MI (52% vs 45%; P<.01), and lower left ventricular ejection fraction (49 ± 14% vs 51 ± 13%; P<.01). While the PROGRESS-CTO score (1.4 ± 1.0 vs 1.2 ± 1.0; P<.001) was higher in the ACS group, the J-CTO score was comparable (2.3 ± 1.2 vs 2.4 ± 1.3; P=.68). Technical success (88% vs 86%; P=.12) and the incidence of in-hospital major adverse cardiovascular event (MACE) (0.9% vs 2.1%; P=.06) and adverse events at 3-month follow-up (3.4% vs 7.2%; Kaplan-Meier log-rank P=.16) were similar between ACS and non-ACS patients, respectively., Conclusion: Approximately 6% of patients who underwent CTO-PCI presented with an ACS. Technical success, in-hospital MACE, and the incidence of adverse events up to 3 months were similar between patients who presented with vs without an ACS.

Background: Whether saphenous vein grafts (SVGs) should be occluded after successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of the corresponding native vessel remains controversial., Methods: We analyzed the clinical and angiographic characteristics and procedural outcomes of 51 patients who underwent SVG occlusion following successful CTO-PCI of the corresponding native vessel between 2015 and 2022 at 14 centers., Results: Mean patient age was 71 ± 8 years and 80% were men. The most common CTO target vessel was the right coronary artery (41%), followed by the left circumflex (37%). Retrograde crossing through the SVG was the successful crossing strategy in 40 cases (78%). SVG occlusion was achieved with coils (1.9 ± 1.0) in 35 of 51 patients (69%) and vascular plugs in the other 16 cases (31%). All procedures were technically successful and the SVG was occluded completely (TIMI 0 flow) in 38 of the cases (75%), with the remaining cases having TIMI 1 flow. Follow-up was available for 37 patients (73%); during a mean follow-up of 312 days from CTO-PCI, the incidence of target-lesion failure due to restenosis was 5.4% (n = 2) with no other major events reported., Conclusion: Following native vessel CTO-PCI, SVG occlusion is often performed and is associated with favorable mid-term outcomes.

Background: Percutaneous coronary interventions (PCI) with intravascular ultrasound (IVUS) guidance have been associated with better long-term outcomes, but adoption remains limited. There are limited data on the impact of IVUS on chronic total occlusion (CTO)-PCI., Objectives: To examine the impact of IVUS guidance on the outcomes of CTO-PCI., Methods: We performed a systematic review and study-level meta-analysis of IVUS vs angiography-guided CTO-PCI. Electronic databases were systematically searched for all pertinent studies from inception through January 2021. Randomized controlled trials (RCT), registry data, and abstracts published in peer-reviewed indexed journals were included. We examined the following in-hospital and long-term outcomes: major adverse cardiac events; all-cause mortality; cardiovascular mortality; myocardial infarction (MI); target-vessel revascularization (TVR); target-lesion revascularization (TLR); and stent thrombosis (ST). We also evaluated the following procedural metrics: procedure time; fluoroscopy time; contrast volume; total stent length; and total number of stents. Random-effects models were used to pool individual study results., Results: Four (2 observational, 2 randomized) studies including 1975 patients (IVUS-guided PCI, 861 patients; angiography-guided PCI, 1114 patients) were included in the analysis. IVUS-guided CTO-PCI had similar all-cause mortality, major adverse cardiac events, cardiovascular mortality, MI, TVR, and TLR compared with angiography-guided CTO-PCI, but lower risk of stent thrombosis (odds ratio, 0.24; 95% confidence interval, 0.08-0.76; P=.02; I²=0%), shorter procedure time (P<.001; I²=88%), shorter fluoroscopy time (P<.001; I²=63%), and less contrast volume use (P<.001; I²=59%). Total stent length (P<.001; I²=39%) and total number of stents (P<.001; I²=72%) were lower with IVUS-guided CTO-PCI., Conclusion: IVUS-guided CTO-PCI is associated with lower risk of ST.

Background: The outcomes of distal radial access (dRA) in chronic total occlusion percutaneous coronary intervention (CTO-PCI) have received limited study., Methods: We compared the clinical, angiographic, and procedural characteristics of 120 CTO-PCIs performed via dRA access with 2625 CTO-PCIs performed via proximal radial access (pRA) in a large, multicenter registry., Results: The dRA group had lower mean PROGRESS-CTO score than the pRA group (1.0 ± 1 vs 1.2 ± 1, respectively; P=.05), while J-CTO score (2.4 ± 1.2 vs 2.3 ± 1.3; P=.43) and PROGRESS-CTO Complications score (2.8 ± 1.8 vs 2.6 ± 1.9; P=.16) were similar in the dRA vs pRA groups, respectively. Technical success was similar in the 2 groups (90% dRA vs 86% pRA; P=.14). Concomitant use of femoral access did not alter procedural success. The incidence of major periprocedural adverse cardiac events was similar in the 2 groups (0.8% dRA vs 2.4% pRA; P=.26), whereas the incidence of tamponade requiring pericardiocentesis was lower with dRA (0% dRA vs 4.69% pRA; P<.001), as was air kerma radiation dose (median, 1.7 Gy; interquartile range [IQR], 0.97-2.63 Gy in the dRA group vs median, 2.27 Gy; IQR, 1.2-3.9 Gy in the pRA group; P<.001)., Conclusions: Use of dRA in CTO-PCI is associated with similar procedural success and risk of complications as compared with pRA.

Background: For patients needing coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI), a planned, staged intervention has been recommended by experts. Ad hoc CTO-PCI, however, occurs in practice., Methods: Observational, contemporary, multicenter, international registry. Our goals were to determine the frequency, characteristics, procedural techniques, and outcomes of patients who underwent ad hoc vs planned CTO-PCI., Results: Among 2282 patients who underwent CTO-PCI between 2012 and 2017, 318 (14%) were ad hoc. Patients undergoing ad hoc CTO-PCI had lower J-CTO, PROGRESS CTO, and PROGRESS Complications scores. Antegrade-wire escalation was used more often in ad hoc PCI (96% vs 81%; P<.001), whereas antegrade-dissection re-entry (22% vs 32%) and retrograde approaches (14% vs 38%) were more common in planned PCI (P<.001). There was no difference in ad hoc vs planned PCI in technical (85% vs 86%) and procedural success (84% vs 84%). In-hospital major adverse cardiac events (MACE) were more common in patients who underwent planned procedures (0.6% vs 2.9%; P=.02). Multivariable analyses showed that ad hoc CTO-PCI was not associated with technical success or MACE., Conclusions: Ad hoc CTO-PCI occurs more commonly in less complex lesions and is associated with similarly high success rates as planned CTO-PCI in lower J-CTO score lesions, suggesting that ad hoc CTO-PCI may be an acceptable option for experienced hybrid operators in carefully selected cases. Complex cases, as quantified by the J-CTO score, have a higher in-hospital MACE rate and should preferably be performed following proper planning and preparation.

Balloon shaft fracture can be challenging to treat in the setting of retrograde CTO-PCI with guidewire externalization; withdrawal of the guide catheter may allow successful removal of the balloon shaft fragment.

Background: There is great variability in radiation safety practices in cardiac catheterization laboratories around the world., Methods: We performed an international online survey on radiation safety including interventional cardiologists, electrophysiologists, interventional radiologists, and vascular surgeons., Results: A total of 570 responses were received from various geographic locations, including the United States (77.9%), Asia (7.9%), Europe (6.8%), Canada (2.8%), and Mexico and Central America (2.1%). Most respondents (73%) were interventional cardiologists and 23% were electrophysiologists, with 14.4 ± 10.2 years in practice. Most respondents (75%) were not aware of their radiation dose during the past year and 21.2% had never attended a radiation safety course; 58.9% are "somewhat worried" and 31.5% are "very worried" about chronic radiation exposure. Back pain due to lead use was reported by 43.0% and radiation-related health complications including cataracts and malignancies were reported by 6.3%. Only 37.5% of respondents had an established radiation dose threshold for initiating patient follow-up. When comparing United States operators with the other respondents, the former were more likely to attend radiation safety courses (P<.001), wear dosimeters (P<.001), know their annual personal radiation exposure (P<.001), and have an established patient radiation dose threshold (P<.001). They were also more likely to use the fluoro store function, under-table shields, leaded glasses, ceiling lead glass, and disposable radiation shields, and were more concerned about the adverse effects of radiation., Conclusions: Radiation safety is of concern to catheterization laboratory personnel, yet there is significant variability in radiation protection practices, highlighting several opportunities for standardization and improvement.

Background: The contemporary use and outcomes of excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) are not well described., Methods: We examined the baseline clinical and angiographic characteristics and procedural outcomes of 130 target lesions in 121 consecutive PCIs (n = 116 patients) in which ELCA was performed at three United States Department of Veterans Affairs (VA) medical centers between 2008 and 2016., Results: Mean age was 68.5 ± 9 years and 97% of the patients were men. Patients had high prevalence of diabetes mellitus (63%), prior coronary artery bypass graft surgery (41%), and prior myocardial infarction (60%). The most common target vessel was the left anterior descending (32%), followed by the right coronary artery (30%), circumflex artery (20%), and saphenous vein graft (12%). The target lesions were highly complex, with moderate/severe calcification in 62% and in-stent restenosis in 37%. The most common indication for ELCA was balloon-uncrossable lesions (43.8%), followed by balloon-undilatable lesions (40.8%) and thrombotic lesions (12.3%). Use of ELCA was associated with high technical success rate (90.0%) and procedural success rate (88.8%), and low major adverse cardiac event (MACE) rate (3.45%). Mean procedure time was 120 min (interquartile range [IQR], 81-191 min), air kerma radiation dose was 2.76 Gy (IQR, 1.32-5.01 Gy), and contrast volume was 273 mL (IQR, 201-362 mL)., Conclusion: In a contemporary multicenter United States registry, ELCA was commonly used in highly complex lesions and was associated with high technical and procedural success rates and low incidence of MACE.

Objective: To study outcomes with use of percutaneous mechanical circulatory support (MCS) devices in chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined characteristics and outcomes of 1598 CTO-PCIs performed from 2012-2017 at 12 high-volume centers., Results: Patient age was 66 ± 10 years; 86% were men. An MCS device was used electively in 69 procedures (4%) and urgently in 22 procedures (1%). The most commonly used elective MCS device was Impella 2.5 or CP (62%). Compared to patients without elective MCS, patients with elective MCS had higher prevalence of prior heart failure (55% vs 29%; P<.001), prior coronary artery bypass graft surgery (49% vs 35%; P=.02), and lower left ventricular ejection fraction (34 ± 14% vs 50 ± 14%; P<.001). MCS patients had a higher prevalence of moderate/ severe calcification (88% vs 55%; P<.001) and higher J-CTO scores (3.1 ± 1.2 vs 2.6 ± 1.2; P<.01), and a greater proportion underwent retrograde crossing attempts (55% vs 39%; P<.01). Despite more complex characteristics in MCS patients, technical success rates (88% vs 87%; P=.70) and procedural success rates (83% vs 87%; P=.32) were similar in the two groups. Use of elective MCS was associated with longer procedure and fluoroscopy times, and higher incidences of in-hospital major adverse cardiovascular events (8.7% vs 2.5%; P<.01) and bleeding (7.3% vs 1.0%; P<.001)., Conclusion: Elective MCS was used in 4% of patients undergoing CTO-PCI. Despite more complex clinical and angiographic characteristics, elective use of MCS in high-risk patients is associated with similar technical and procedural success rates, but higher risk of complications, compared to cases without elective MCS.

Background: Retrograde percutaneous coronary intervention (PCI) of native coronary artery chronic total occlusion (CTO) via left internal mammary artery (LIMA) graft has received limited study., Methods and Results: We compared the clinical and procedural characteristics and outcomes of retrograde CTO-PCI through LIMA grafts vs other conduits in a contemporary multicenter CTO registry. The LIMA was used as the collateral channel in 20 of 990 retrograde CTO-PCIs (2.02%) performed at 18 United States centers. The mean age of the study patients was 69 ± 7 years and 95% were men. The most common CTO target vessel was the right coronary artery (55%). The mean J-CTO score in the LIMA group was high (3.45 ± 0.76). The technical success rates were 70% for retrograde PCI via LIMA graft vs 81.05% for retrograde via other conduits (P=.25), while procedural success rates were 70% for retrograde PCI via LIMA graft and 78.19% for retrograde via other conduits (P=.41). The incidence of major in-hospital complications was also similar between the LIMA and non-LIMA retrograde groups (5% vs 6%; P>.99). Use of guide-catheter extensions (40% vs 28%; P=.22), intravascular ultrasound (45% vs 31%; P=.20), and left ventricular assist devices (24% vs 10%; P=.08) was numerically higher in retrograde CTO-PCIs via LIMA grafts., Conclusions: Retrograde CTO-PCI is infrequently performed via LIMA grafts and is associated with similar success and major in-hospital complication rates as retrograde CTO-PCI performed via other conduits.

Objectives: We sought to examine contemporary perspectives and practices on chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Background: The frequency and success of CTO-PCI have been increasing in recent years., Methods: An online questionnaire was created and distributed to cardiologists within the United States and internationally., Results: A total of 1149 responses were obtained. The United States (n = 845; 73.5%), Asia (n = 98; 8.5%), Europe (n = 88; 7.7%), South America (n = 42; 3.7%), and Canada (n = 33; 2.9%) accounted for most responses. Mean practice duration of the respondents was 16.4 ± 11.5 years and 66.9% were interventional cardiologists. Most respondents agreed that CTO-PCI results in an improvement of patient symptoms (90.7%), left ventricular function (79.3%), arrhythmia risk (69.2%), and overall survival (63.1%). Interventional cardiologists had a more favorable view of the benefits of CTO-PCI as compared with non-interventional cardiologists (P<.001). Most respondents estimated the procedural success rates of contemporary CTO-PCI to be between 51%-75% (34.2%) and 76%-85% (30.2%), with interventional cardiologists estimating higher success rates than non-interventionalists (P<.001). Perforation, mortality, and tamponade were the three most concerning complications. Time and procedure complexity were reported to be the most significant barriers to the development of a CTO-PCI program., Conclusions: Most cardiologists believe that CTO-PCI can provide significant clinical benefits and can be accomplished with moderate to high success rates. Interventional cardiologists have a more favorable view of CTO-PCI as compared with non-invasive cardiologists.

Objectives: Outcomes with use of lesion-modification strategies in the drug-eluting stent era have received limited study., Methods: We conducted a meta-analysis of 22 studies published between 2004-2016 reporting outcomes after use of rotational atherectomy, cutting-balloon, and scoring-balloon angioplasty., Results: In observational trials, acute luminal gain was higher after lesion modification as compared with control (standardized mean difference, 0.23 mm; 95% confidence interval [CI], 0.01-0.44; P=.04), with no difference in acute gain in randomized studies. Compared with control, lesion modification was associated with lower restenosis in randomized trials (odds ratio [OR], 0.64; 95% CI, 0.45-0.90; P=.01). Ninety-day incidence of major adverse cardiovascular event (MACE) was higher after lesion modification in observational studies (OR, 1.39; 95% CI, 1.05-1.83; P=.02), but similar in randomized trials. Ninety-day incidence of target-lesion or target-vessel revascularization (TLR-TVR) and myocardial infarction (MI) was similar. Ninety-day incidence of death was higher after lesion modification in observational studies (OR, 1.42; 95% CI, 1.04-1.95; P=.03), but similar in randomized trials. At 1 year, the MACE rate was similar for lesion modification compared with control in observational studies, but lower after lesion modification in randomized trials (OR, 0.65; 95% CI, 0.48-0.88; P<.01). TLR-TVR was higher with lesion modification in observational studies, but lower in randomized trials (OR, 0.64; 95% CI, 0.46-0.88; P<.01)., Conclusions: While observational studies suggest a higher early MACE rate and more restenosis, randomized trials show similar short-term and improved long-term outcomes with pre-stenting lesion modification compared with control.

Background: The American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) have developed guidelines to assist clinicians in making evidence-based decisions. This study compares the ACC/AHA and ESC guidelines for the management of patients with valvular heart disease (VHD)., Methods: The current ACC/AHA and ESC guidelines for VHD, last updated in 2014 and 2012, respectively, were compared by class of recommendation (COR), level of evidence (LOE), and content., Results: The ACC/AHA and ESC VHD guidelines contain 229 and 85 recommendations, respectively. The COR distributions of the ACC/AHA and ESC VHD guidelines were 47.6% vs 44.7% class I [P=.65]; 46.3% vs 55.3% class II [P=.16]; and 6.1% vs 0.0% class III [P=.01], respectively. The LOE distributions were 3.1% vs 0.0% LOE A [P=.20]; 47.2% vs 10.6% LOE B [P<.001]; and 49.8% vs 89.4% LOE C [P<.001], respectively. The recommendation type distributions were 31.0% vs 2.4% diagnostic [P<.001]; 23.1% vs 16.5% medical therapy [P=.20]; and 45.9% vs 81.2% interventional/surgical recommendations [P<.001], respectively. The content of the guidelines was similar, with only minor differences in a few recommendations., Conclusions: The ACC/AHA VHD guidelines contain significantly more recommendations. The distribution of COR was similar, but the ACC/AHA guidelines included more LOE B recommendations and fewer LOE C recommendations, suggesting that the ACC/AHA guidelines place greater emphasis on published data than expert opinion. Overall, the ACC/AHA and ESC guidelines provide similar recommendations, suggesting consistency in practice; however, the relative paucity of LOE A recommendations highlights the need for additional research.

Introduction: We examined the impact of proximal vessel tortuosity on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: The baseline clinical and angiographic characteristics and procedural outcomes of 1618 consecutive CTO-PCIs performed between 2012 and 2016 at 14 United States centers in 1589 patients were reviewed., Results: Mean patient age was 65.3 ± 10.0 years and 85% were men. Moderate/severe proximal vessel tortuosity was present in 35.7% of target lesions. Compared with non-tortuous lesions, tortuous lesions had longer length (30 mm [interquartile range, 20-50 mm] vs 28 mm [interquartile range, 16-40 mm]; P<.001), more proximal cap ambiguity (36% vs 28%; P<.01), and more frequent utilization of the retrograde approach (52% vs 37%; P<.001). Moderate/severe proximal vessel tortuosity was associated with lower technical success rates (84.1% vs 91.3%; P<.001) and procedural success rates (82.3% vs 89.9%; P<.001), but similar incidence of major cardiac adverse events (3.0% vs 2.5%; P=.59). Moderate/severe tortuosity was associated with longer procedure time and fluoroscopy time, higher air kerma radiation dose, and larger contrast volume., Conclusion: In a contemporary multicenter registry, moderate/severe proximal vessel tortuosity was present in approximately one-third of target CTO lesions and was associated with more frequent use of the retrograde approach and lower success rates, but similar complication rates.

A 62-year-old man was referred for percutaneous coronary intervention of a severe circumflex lesion. The guidewire became entangled in the previously implanted left anterior descending artery stent. The left main was engaged with a second guide catheter, followed by balloon dilations, various microcatheters, and laser atherectomy. The wire eventually fractured without protruding into the aorta. The circumflex lesion was stented with two stents, followed by left main stenting that covered the fragment. Caution should be used when wiring through stents; wire fracture can be treated with stent implantation, as long as the wire fragment does not protrude into the aorta.

Objectives: We sought to determine the effect of age and sex on procedural outcomes and efficiency of chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the clinical and angiographic characteristics and outcomes of 1675 CTO-PCIs performed in 1644 patients between 2012 and 2016 at 15 United States centers., Results: Mean age was 65.3 ± 10 years and 1408 (86%) were men. Overall technical and procedural success rates were 88% and 87%, respectively. Increasing age was associated with more comorbidities (dyslipidemia, hypertension, prior coronary artery bypass graft surgery, prior stroke, peripheral arterial disease, and chronic lung disease) and more lesion calcification. As compared with the reference age of <65 years, age >75 years was independently associated with technical failure (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.20-4.28). Increasing age was also independently associated with the incidence of major adverse cardiovascular events (MACEs; OR, 2.93; 95% CI, 1.10-9.23 for 65-75 years and OR, 5.71; 95% CI, 1.89-19.60 for >75 years). Compared with men, women (n = 236; 14%) were older (66.8 ± 11.1 years vs 65.0 ± 9.8 years; P=.02), but had similar clinical characteristics and lower J-CTO scores (2.3 ± 1.3 vs 2.5 ± 1.2; P=.02). Although crude technical success rate was higher in women compared with men (92% vs 87%; P=.04), multivariable analysis did not show independent association between sex and technical failure (OR, men/women, 1.66; 95% CI, 0.86-3.50) or MACE (OR, 0.61; 95% CI, 0.25-1.73)., Conclusions: Older age, but not sex, is associated with lower technical success and higher in-hospital complication rate for CTO-PCI. CTO-PCI is relatively infrequently attempted in women, despite high technical success and acceptable complication rates.

Objectives: Although coronary chronic total occlusions (CTOs) are treated with percutaneous coronary intervention (PCI) to improve symptoms, studies demonstrating symptom improvement have been mostly limited to questionnaire responses. The current study assessed for changes in peak oxygen uptake during cardiopulmonary exercise testing after CTO-PCI., Methods: Patients with heart failure or angina symptoms referred for CTO-PCI were prospectively enrolled. The primary outcome of the study was improvement in peak oxygen uptake during cardiopulmonary exercise (CPX) testing 5 months after CTO-PCI. Secondary outcomes included improvement in physical capacity, angina, and self perception of health as assessed by questionnaires, and in plasma brain natriuretic peptide (BNP) levels., Results: CTO-PCI was attempted in 32 men (mean age, 62 ± 6 years; CTO vessel: 47% right coronary, 44% left anterior descending). CTO-PCI was unsuccessful in 1 patient, and 3 patients had restenosis of their CTO vessel at follow-up. In the 28 patients with patent CTO vessel at follow-up, significant improvements were noted in self-reported physical capacity, angina, and several aspects of health perception. In the 25 patients who underwent baseline and follow-up CPX testing, peak oxygen uptake significantly improved from 17.7 ± 4.3 mL/kg/min to 19.1 ± 4.0 mL/kg/min (P=.02). Plasma BNP levels significantly decreased from 143 ± 138 pg/mL to 102 ± 123 pg/mL (P=.01)., Conclusions: CTO-PCI in symptomatic patients was associated with improvements in cardiovascular exercise capacity, as assessed by peak oxygen uptake. These results suggest that in symptomatic patients with CTOs, PCI appears clinically beneficial.

Objective: To examine the presence and localization of lipid-core plaque (LCP) in coronary vessels with chronic total occlusions (CTOs) using near-infrared spectroscopy (NIRS)., Methods: NIRS imaging was performed after guidewire crossing of the occlusion in 15 patients with CTOs. LCP was defined as ≥2 adjacent 2 mm yellow blocks on the block chemogram. We also measured the maximum lipid-core burden index (LCBI) in a 4 mm length of artery (maxLCBI4mm). Large LCP was defined as maxLCBI4mm ≥500., Results: Median patient age was 64 years (interquartile range [IQR], 61-67 years) and all patients were men with high prevalence of diabetes mellitus (64%) and prior coronary artery bypass graft surgery (27%). The CTO target vessel was the right coronary artery (46%), left anterior descending artery (27%), or circumflex artery (27%). Median occlusion length was 35 mm (IQR, 30-50 mm). LCP was present in 11 of 15 CTO vessels (73%) and a large LCP in 4 of 15 CTO vessels (27%). LCP was located at the proximal cap in 6 CTOs (55%), the CTO body in 6 CTOs (55%), and the distal cap in 2 CTOs (18%). The median overall LCBI and maxLCBI4mm were 145 (IQR, 79-243) and 415 (IQR, 267-505), respectively. All patients underwent successful stenting without any complications. The 12-month incidence of in-stent restenosis and target-lesion revascularization was 25%, and all patients who developed restenosis had an LCP at baseline., Conclusions: LCPs are commonly encountered in coronary CTO vessels, suggesting an active intraplaque atherosclerotic process. The impact of LCP on postintervention outcomes requires further study.

Objectives: We examined a contemporary, unselected cohort of patients with coronary chronic total occlusions (CTOs) to determine the impact of CTO revascularization on long-term outcomes., Methods: We retrospectively assessed the impact of CTO revascularization on clinical outcomes of consecutive patients found to have a CTO during coronary angiography performed at our institution during 2011 and 2012. The primary endpoint was the incidence of a major adverse cardiac event (MACE, defined as a composite of death, myocardial infarction, stroke, and target-vessel revascularization [TVR]). Survival analysis was performed in the overall and propensity-matched retrospective cohorts of patients stratified by prior coronary artery bypass graft (CABG) surgery. Propensity-adjusted hazard ratio (HR) and 95% confidence interval (95% CI) were calculated with Cox proportional hazards analysis. All analyses were by intention to treat., Results: Of 624 patients (319 without prior CABG and 305 with prior CABG) included in the present analysis, CTO revascularization (surgical or percutaneous) was attempted in 60% and 16% of patients without and with prior CABG, respectively. During a median follow-up of 26 months (range, 18-40 months), the incidence of MACE was 20.6%. CTO revascularization (achieved or attempted) was associated with lower incidence of MACE among patients without prior CABG (propensity-adjusted HR, 0.51; 95% CI, 0.27-0.94; P=.03), but not among prior CABG patients (propensity-adjusted HR, 1.38; 95% CI, 0.64-2.96; P=.41)., Conclusion: In a large, unselected patient population with coronary CTOs, a CTO revascularization attempt was associated with lower incidence of subsequent MACE among patients without prior CABG, but not among prior CABG patients.

Objectives: We sought to determine the impact of proximal cap ambiguity on procedural techniques and outcomes for coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI)., Methods: We examined the clinical and angiographic characteristics and outcomes of 1021 CTO-PCIs performed between 2012 and 2015 at 11 United States centers., Results: Proximal cap ambiguity was present in 31% of target lesions and was associated with increased clinical and angiographic complexity (prior coronary artery bypass graft surgery: 43% vs 33%; P=.01; moderate/severe calcification 66% vs 51%; P<.001) and lower technical success (85% vs 93%; P<.001) and procedural success (84% vs 91%; P=.01), but similar incidence of major adverse cardiac events (3.2% vs 2.9%; P=.77). A retrograde approach was more commonly utilized among cases with proximal cap ambiguity (68% vs 33%; P<.001), and was more likely to be the initial (39% vs 13%; P<.001) and successful approach (42% vs 20%; P<.001). Proximal cap ambiguity was associated with increased use of intravascular ultrasound (49% vs 36%; P=.01) and contrast (281 mL vs 250 mL; P<.001), higher air kerma radiation dose (4.0 Gy vs 3.0 Gy; P<.001), and longer procedure time (161 min vs 119 min; P<.001)., Conclusions: Proximal cap ambiguity is present in one-third of CTO-PCI target lesions and is associated with lower success rates, higher utilization of the retrograde approach, and lower procedural efficiency, but no significant difference in the incidence of major adverse cardiac events.

Background: The use of saphenous vein grafts (SVGs) for retrograde native-vessel chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study., Methods: We retrospectively reviewed the medical records and coronary angiograms of retrograde CTO-PCI performed through an SVG at four United States institutions between 2012 and 2013., Results: During the study period, retrograde CTO-PCI was performed in 144 of 572 cases (25.2%) and retrograde CTO-PCI via SVG in 21 patients (14.6% of all retrograde cases). Mean age was 71 ± 7 years and 95.2% of the patients were men. The CTO target vessel was the right coronary (38%), circumflex (38%), and left anterior descending (24%) artery. Mean J-CTO score was 3.5 ± 1.0. The most common reentry technique was reverse controlled antegrade dissection and reentry. Technical and procedural success rates were 86% and 81%, respectively, with retrograde SVG-PCI attempts being successful in 67%. A major adverse cardiac event occurred in 2 patients (1 periprocedural myocardial infarction and 1 tamponade resulting in death). Median contrast volume, fluoroscopy time, and procedure time were 250 mL, 91.6 minutes, and 214 minutes, respectively. Two SVGs were coiled due to competitive flow after CTO recanalization., Conclusion: Retrograde native-vessel CTO-PCI via SVG represents a small proportion of retrograde CTO-PCIs and was associated with high technical success rates, but may carry increased risk for complications.