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With an aging population and an increase in the comorbidity burden of patients undergoing percutaneous coronary intervention (PCI), the management of coronary calcification for optimal PCI is critical in contemporary practice. This study sought to examine the trends and outcomes of coronary intravascular lithotripsy (IVL), rotational/orbital atherectomy, or both among patients who underwent PCI in Michigan. We included all PCIs between January 1, 2021, and June 30, 2022, performed at 48 Michigan hospitals. Outcomes included in-hospital major adverse cardiac events (MACEs) and procedural success. IVL was used in 1,090 patients (2.57%), atherectomy was used in 1,743 (4.10%) patients, and both were used in 240 patients (0.57% of all PCIs). IVL use increased from 0.04% of PCI cases in January 2021 to 4.28% of cases in June 2022, ultimately exceeding the rate of atherectomy use. The rate of MACEs (4.3% vs 5.4%; P = 0.23) and procedural success (89.4% vs 89.1%; P = 0.88) were similar among patients treated with IVL compared with atherectomy, respectively. Only 15.6% of patients treated with IVL in contemporary practice were similar to the population enrolled in the pivotal IVL trials. Among such patients (n = 169), the rate of MACEs (0.0%) and procedural success (94.7%) were similar to the outcomes reported in the pivotal IVL trials. Since its introduction in February 2021, coronary IVL use has steadily increased, exceeding atherectomy use in Michigan by February 2022. Contemporary use of IVL and atherectomy is generally associated with high rates of procedural success and low rates of complications. [Display omitted] [ABSTRACT FROM AUTHOR]

Left ventricular (LV) systolic dysfunction worsens outcomes in patients undergoing percutaneous coronary intervention (PCI). The objective of this study, therefore, was to evaluate outcomes of pLVAD-supported high-risk PCI (HRPCI) patients according to LV ejection fraction (LVEF). Patients from the PROTECT III study undergoing pLVAD-supported HRPCI were stratified according to baseline LVEF: severe LV dysfunction (LVEF <30%), mild and moderate LV dysfunction (LVEF ≥30% to <50%), or preserved LV function (LVEF ≥50%). Major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization), and PCI-related complications were assessed at 90 days and mortality was assessed at 1-year. From March 2017 to March 2020, 940 patients had evaluable baseline LVEF recorded in the study database. Patients with preserved LV function were older, more frequently presented with myocardial infarction, and underwent more left main PCI and atherectomy. Immediate PCI-related coronary complications were infrequent (2.7%, overall), similar between groups (P = 0. 98), and not associated with LVEF. Unadjusted 90-day MACCE rates were similar among LVEF groups; however, as a continuous variable, LVEF was associated with both 90-day MACCE (adj.HR per 5% 0.89, 95% CI [0.80, 0.98], P = 0. 018) and 1-year mortality (adj.HR per 5% 0.84 [0.78, 0.90], P < 0. 0001). Patients who underwent pLVAD-supported HRPCI exhibited low incidence of PCI-related complications, regardless of baseline LVEF. However, LVEF was associated with 90-day MACCE and 1-year mortality. [Display omitted] [ABSTRACT FROM AUTHOR]

This study sought to evaluate the differences in cardiogenic shock patient characteristics in trial patients and real-life patients. Cardiogenic shock (CS) is a leading cause of mortality in patients presenting with acute myocardial infarction (AMI). However, the enrollment of patients into clinical trials is challenging and may not be representative of real-world patients. We performed a systematic review of studies in patients presenting with AMI-related CS and compared patient characteristics of those enrolled into randomized controlled trials (RCTs) with those in registries. We included 14 RCTs (n = 2,154) and 12 registries (n = 133,617). RCTs included more men (73% vs 67.7%, P < 0.001) compared with registries. Patients enrolled in RCTs had fewer comorbidities, including less hypertension (61.6% vs 65.9%, P < 0.001), dyslipidemia (36.4% vs 53.6%, P < 0.001), a history of stroke or transient ischemic attack (7.1% vs 10.7%, P < 0.001), and prior coronary artery bypass graft surgery (5.4% vs 7.5%, P < 0.001). Patients enrolled in RCTs also had lower lactate levels (4.7 ± 2.3 mmol/L vs 5.9 ± 1.9 mmol/L, P < 0.001) and higher mean arterial pressure (73.0 ± 8.8 mm Hg vs 62.5 ± 12.2 mm Hg, P < 0.001). Percutaneous coronary intervention (97.5% vs 58.4%, P < 0.001) and extracorporeal membrane oxygenation (11.6% vs 3.4%, P < 0.001) were used more often in RCTs. The in-hospital mortality (23.9% vs 38.4%, P < 0.001) and 30-day mortality (39.9% vs 45.9%, P < 0.001) were lower in RCT patients. RCTs in AMI-related CS tend to enroll fewer women and lower-risk patients compared with registries. Patients enrolled in RCTs are more likely to receive aggressive treatment with percutaneous coronary intervention and extracorporeal membrane oxygenation and have lower in-hospital and 30-day mortality. [Display omitted] [ABSTRACT FROM AUTHOR]

• The eSPM technique provides a treatment strategy for resistant stent underexpansion. • e-SPM technique is most helpful with fibrotic or fibrocalcific plaques. • eSPM risks should be weighed against benefits. [ABSTRACT FROM AUTHOR]

Acute myocardial infarction and cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Early mechanical revascularization improves survival, and development of STEMI systems of care has increased the utilization of revascularization in AMI-CS from 19% in 2001 to 60% in 2014. Mechanical circulatory support devices are increasingly used to support and prevent hemodynamic collapse. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Herein, the authors review the definition, incidence, pathophysiology, and treatment of AMI-CS. [ABSTRACT FROM AUTHOR]

Mechanical circulatory support devices are increasingly used for the treatment of acute myocardial infarction complicated by cardiogenic shock. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Institutions require expert teams to safely implant and manage these devices. This article reviews the mechanism of action, physiologic effects, and data as they relate to the utilization of these devices. [ABSTRACT FROM AUTHOR]

Despite early reperfusion and coordinated systems of care, cardiogenic shock (CS) remains the number one cause of morbidity and in-hospital mortality following acute myocardial infarction (AMI). CS is a complex clinical syndrome that begins with hemodynamic instability and can progress to multi-organ failure and profound hemo-metabolic compromise. To improve outcomes, a clear understanding of the treatment objectives in CS and developing time-sensitive management strategies aimed at stabilizing hemodynamics and restoring myocardial perfusion are critical. Left ventricular (LV) load has been identified as an independent predictor of heart failure and mortality following AMI. Decades of preclinical and clinical research have identified several effective LV unloading strategies. Recent initiatives from single and multi-center registries and more recently the Door to Unload (DTU)-STEMI pilot study have provided valuable insight to developing a standardized treatment approach to AMI, based on early invasive hemodynamics and tailored circulatory support to unload the LV. To follow is a review of the pathophysiology and prevalence of shock, limitations of current therapies, and the pre-clinical and translational basis for incorporating LV unloading into contemporary AMI and shock care. [ABSTRACT FROM AUTHOR]

This study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). In patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). From July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. Of 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). In patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the success rates and outcome of the hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) by a single operator in two different clinical settings.Methods: We compared 279 consecutive CTO PCIs performed by a single, high-volume operator using the hybrid algorithm in two different clinical settings. Data were collected through the PROGRESS CTO Registry. We compared 145 interventions performed in a community program (cohort A) with 134 interventions performed in a referral center (cohort B).Results: Patient in cohort B had more complex lesions with higher J-CTO (3.0 vs. 3.41; p<0.001) and Progress CTO (1.5 vs.1.8, P=0.003) scores, more moderate to severe tortuosity (38% vs. 64%; p<0.001), longer total occlusion length (25 vs. 40mm; p<0.001) and higher prevalence of prior failed CTO PCI attempts (15% vs. 35%; p=0.001). Both technical (95% vs. 91%; p=0.266) and procedural (94% vs. 88%; p=0.088) success rates were similar between the two cohorts despite significantly different lesion complexity. Overall major adverse cardiovascular events were higher in cohort B (1.4% vs. 7.8%; p=0.012) without any significant difference in mortality (0.7% vs. 2.3%, p=0.351).Conclusions: In spite of higher lesion complexity in the setting of a quaternary-care referral center, use of the hybrid algorithm for CTO PCI enabled similarly high technical and procedural success rates as compared with those previously achieved by the same operator in a community-based program at the expense of a higher rate of MACE. [ABSTRACT FROM AUTHOR]

Background: Percutaneous ventricular assist devices and extracorporeal membrane oxygenation (ECMO) are increasingly used for mechanical circulatory support (MCS) in patients with acute myocardial infarction with cardiogenic shock (AMI-CS) in hospitals throughout the United States.Methods: Using the National Inpatient Sample from October 2015 to December 2017, we identified hospital admissions that underwent percutaneous coronary intervention (PCI) and non-elective Impella or ECMO placement for AMI-CS using ICD-10 codes. Propensity-score matching was performed to compare both groups for primary and secondary outcomes.Results: We identified 6290 admissions for AMI-CS who underwent PCI and were treated with Impella (n = 5730, 91%) or ECMO (n = 560, 9%) from October 2015 to December 2017. After propensity-match analysis, the ECMO cohort had significantly higher in-hospital mortality (43.3% vs 26.7%, OR: 2.10, p = 0.021). The incidence of acute respiratory failure and vascular complications were significantly lower in the Impella cohort. We observed a shorter duration of hospital stay and lower hospital costs in the Impella cohort compared to those who received ECMO.Conclusions: In AMI-CS, the use of Impella was associated with better clinical outcomes, fewer complications, shorter length of hospital stay and lower hospital cost compared to those undergoing ECMO placement. [ABSTRACT FROM AUTHOR]

Spontaneous coronary artery dissection (SCAD) is a common cause of myocardial infarction in young and middle-aged women. Patients with SCAD present rarely with hemodynamic collapse and cardiogenic shock, requiring immediate resuscitation and mechanical circulatory support. Percutaneous mechanical circulatory support may serve as a bridge to recovery, decision or heart transplantation. We present a case of a young woman with SCAD of the left main coronary artery, presenting with ST-elevation myocardial infarction, cardiac arrest and cardiogenic shock. She was stabilized emergently with Impella and early escalation with extracorporeal membrane oxygenation (ECPELLA) at a non-surgical community hospital. Despite revascularization with percutaneous coronary intervention (PCI), her left ventricular recovery was poor, and ultimately required cardiac transplantation on day 5 of her presentation. • Mechanical circulatory support is key to stabilize patients with refractory cardiogenic shock in order to perform revascularization • Access to mechanical circulatory support in the community and timely escalation of mechanical circulatory support are fundamental to achieve favorable outcomes in cardiogenic shock. • Early evaluation by advanced heart failure team in a tertiary experienced center is recommended. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of the study is to develop an optimal TR-Band weaning strategy while minimizing vascular access site complications of hematoma or radial artery occlusion (RAO).Methods: The trial was a randomized, prospective, single center study of 129 patients who underwent cardiac catheterization via the radial artery. Group A was an accelerated protocol in which weaning was initiated 20 min after sheath removal. Group B was an adjusted protocol, in which weaning was dependent on the amount of anti-platelet or anti-coagulation used. All patients underwent radial artery ultrasound to demonstrate arterial patency.Results: Baseline characteristics were similar in both groups, and PCI was performed in 36.7% of patients in Group A and 37.7% of patients in Group B. RAO occurred in 7.7% of patients overall, with no statistical difference between groups (Group A 5% versus Group B 10.1%, p-value = 0.337). Hematoma formation >5 cm in diameter occurred in 4.6% of patients in the overall cohort, without statistical difference between groups (Group A 5% versus Group B 4.3%, p-value = 1). The TR-Band duration was significantly shorter in Group A compared to Group B (112.9 ± 50.7 versus 130.7 ± 51.1 in minutes, respectively, p-value = 0.013).Conclusion: We have demonstrated an accelerated weaning protocol is simple to utilize for nursing staff without increased vascular site complications of RAO or hematoma formation. [ABSTRACT FROM AUTHOR]

Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short-term mortality; however, there are limited data on long-term outcomes and trends. This study sought to examine long-term outcomes of AMI-CS patients. This was a population-based, retrospective cohort study in Ontario, Canada of critically ill adult patients with AMI-CS who were admitted to hospitals between April 1, 2009 and March 31, 2019. Outcome data were captured using linked health administrative databases. A total of 9,789 consecutive patients with AMI-CS from 135 centers were included. The mean age was 70.5 ± 12.3 years, and 67.7% were male. The incidence of AMI-CS was 8.2 per 100,000 person-years, and it increased over the study period. Critical care interventions were common, with 5,422 (55.4%) undergoing invasive mechanical ventilation, 1,425 (14.6%) undergoing renal replacement therapy, and 1,484 (15.2%) receiving mechanical circulatory support. A total of 2,961 patients (30.2%) died in the hospital, and 4,004 (40.9%) died by 1 year. Mortality at 5 years was 58.9%. Small improvements in short- and long-term mortality were seen over the study period. Among survivors to discharge, 2,870 (42.0%) required increased support in care from their preadmission baseline, 3,244 (47.5%) were readmitted to the hospital within 1 year, and 1,047 (15.3%) died within 1 year. The mean number of days at home in the year following discharge was 307.9 ± 109.6. Short- and long-term mortality among patients with AMI-CS is high, with minimal improvement over time. AMI-CS survivors experience significant morbidity, with high risks of readmission and death. Future studies should evaluate interventions to minimize postdischarge morbidity and mortality among AMI-CS survivors. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: The modes of failure of coronary polymer-jacketed guidewires have received limited study.Methods: We queried the Manufacturer and User Facility Device Experience (MAUDE) database between January 2011 and December 2020 for reports on coronary polymer-jacketed guidewires and retrieved 254 reports.Results: The most common failure mode was failure of the guidewire to cross (36.2%), followed by guidewire fracture (35%), peeling of the polymer jacket (13.8%), failure to retrieve the guidewire (13.8%), and guidewire unraveling (4.7%). Guidewire fracture was more common with soft (37.3%) compared with stiff (23.8%) guidewires. Failure of retrieval was only reported with soft guidewires (9%). Coronary perforation and dissection occurred in 19.7% and 7.9% of the reports, with more reports with stiff as compared with soft guidewires (45.2% vs. 14.6% for perforation and 21.4% vs. 5.3% for dissection).Conclusions: The most common failure modes of polymer-jacketed guidewires during percutaneous coronary intervention are failure to cross the lesion, guidewire fracture, and peeling of the polymer jacket. Coronary perforations were more common with stiff whereas wire fracture was more common with soft polymer-jacketed guidewires. [ABSTRACT FROM AUTHOR]

Background: To describe the national trends and outcomes of contemporary thrombectomy use for primary percutaneous coronary intervention (PCI) from 2016 to 2018.Methods: We queried the Nationwide Readmission Database (NRD) from January 2016 to December 2018 to identify patients who underwent primary PCI and thrombectomy. We conducted a multivariate regression analysis to identify variables associated with in-hospital mortality and stroke in patients undergoing primary PCI and those who underwent thrombectomy.Results: We identified 409,910 total hospitalizations who underwent primary PCI. Thrombectomy was used in 62,446 records (15.2%) with no change in the trend over the study period (p trend = 0.52). Thrombectomy was more utilized in patients who had more cardiogenic shock and use of mechanical circulatory devices. The overall incidence of in-hospital mortality and stroke were 5.6% and 1.1%, respectively. The incidence of in-hospital mortality (6.7% vs. 5.4%, p < 0.001) and strokes (1.3% vs. 1.0%, p < 0.001) were higher in the thrombectomy group. On multivariable regression analysis adjusting for high-risk features, thrombectomy was not independently associated with in-hospital mortality [1.036, 95% CI (0.993-1.080), p = 0.100], but was associated with a higher risk of stroke [OR 1.186, 95% CI (1.097-1.283), p < 0.001].Conclusion: During primary PCI, thrombectomy was used in 1 of 6 cases, and its use has been stable over 2016-2018. The use of thrombectomy was associated with a higher risk of stroke, but not in-hospital death. [ABSTRACT FROM AUTHOR]

Background: Data on the mechanisms of failure of covered coronary stents [Graftmaster, PK Papyrus] are limited.Methods: We queried the "Manufacturer and User Facility Device Experience" (MAUDE) database between August 2018 (when the PK Papyrus stent was FDA approved) and December 2020 for reports on covered coronary stents.Results: We identified 299 reports in the MAUDE database (after excluding duplicates, peripheral vascular reports, and incomplete records) (Graftmaster n = 225, PK Papyrus n = 74). The most common mechanism of failure of covered stents was failure to deliver the stent (46.2%), followed by stent dislodgement (22.4%) and failure to seal the perforation (19.7%). Failure to deliver the stent was more often reported with Graftmaster compared with PK Papyrus (59.1% vs. 6.8%, p < 0.001). Stent dislodgement was more often reported with PK Papyrus compared with Graftmaster (75.7% vs. 4.9%, p < 0.001) and was managed by device retrieval or by crushing the stent.Conclusions: The most common failure mechanisms of covered stents are failure of delivery, stent dislodgement, and failure to seal the perforation. Failure of delivery was more common with Graftmaster, while stent dislodgement was more common with PK Papyrus. Further improvements in covered stent design are needed to optimize deliverability and minimize the risk of complications. [ABSTRACT FROM AUTHOR]

Background: Evidence is limited regarding the role of mechanical circulatory support (MCS) in patients with acute coronary syndromes (ACS) complicated by cardiogenic shock (CGS). In particular, the role of MCS in patients with out-of-hospital cardiac arrest (OHCA) is unknown.Methods: The National Cardiogenic Shock Initiative (NCSI) is a multicenter United States registry of patients with ACS complicated by CGS treated with MCS. We compared the rate of survival to hospital discharge among patients with OHCA, in-hospital cardiac arrest (IHCA), or no cardiac arrest. We subsequently used multivariable analyses to determine independent predictors of OHCA survival.Results: Survival to hospital discharge occurred in 85.7% (42/49) of OHCA, 72.4% (50/69) of IHCA, and 74.5% (111/149) of non-cardiac arrest patients. By multivariable analysis, pre-procedural predictors of survival included younger age, female sex, fewer diseased vessels, left anterior descending coronary artery culprit, lower troponin, higher lactate, and delayed initiation of MCS. Procedural and post-procedural predictors of survival included fewer vessels treated, complete revascularization, higher post-MCS cardiac power output, and fewer inotropic medications required.Conclusions: This study demonstrates that excellent outcomes may be achieved following OHCA when MCS is employed for patients appropriately selected by prognostic demographic, anatomic, and health status characteristics. A larger study population, currently being enrolled, is needed to validate the observation further. [ABSTRACT FROM AUTHOR]