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Background: Prior studies have found that female patients have worse outcomes following high-risk percutaneous coronary intervention (HRPCI)., Objectives: The authors sought to evaluate sex-based differences in patient and procedural characteristics, clinical outcomes, and safety of Impella-supported HRPCI in the PROTECT III study., Methods: We evaluated sex-based differences in the PROTECT III study; a prospective, multicenter, observational study of patients undergoing Impella-supported HRPCI. The primary outcome was 90-day major adverse cardiac and cerebrovascular events (MACCE)-the composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization., Results: From March 2017 to March 2020, 1,237 patients (27% female) were enrolled. Female patients were older, more often Black, more often anemic, and had more prior strokes and worse renal function, but higher ejection fractions compared to male patients. Preprocedural SYNTAX score was similar between sexes (28.0 ± 12.3). Female patients were more likely to present with acute myocardial infarction (40.7% vs 33.2%; P = 0.02) and more often had femoral access used for PCI and nonfemoral access used for Impella device implantation. Female patients had higher rates of immediate PCI-related coronary complications (4.2% vs 2.1%; P = 0.004) and a greater drop in SYNTAX score post-procedure (-22.6 vs -21.0; P = 0.04). There were no sex differences in 90-day MACCE, vascular complications requiring surgery, major bleeding, or acute limb ischemia. After adjustment using propensity matching and multivariable regression, immediate PCI-related complications was the only safety or clinical outcome that was significantly different by sex., Conclusions: In this study, rates of 90-day MACCE compared favorably to prior cohorts of HRPCI patients and there was no significant sex differences. (The PROTECT III Study is a substudy of The Global cVAD Study [cVAD]; NCT04136392)., Competing Interests: Funding Support and Author Disclosures The PROTECT III study, as part of The Global cVAD study, was sponsored by Abiomed Inc. Dr Batchelor has received speaker honoraria from Boston Scientific, Abbott Medical, and Medtronic. Dr Grines has served on the advisory boards for Philips and Abiomed. Dr Baron has received consulting fees from Abbott, Abiomed, Edwards Lifesciences, and MitraLabs; has received speaker fees from Boston Scientific Corporation; and has served on an advisory board for Boston Scientific. Dr Wollmuth has received consulting fees/honoraria from Abbott Vascular, Abiomed, Biotronik, Boston Scientific, Cardiovascular Systems, Inc, and Shockwave Medical. Dr Basir has received consultant fees from Abbott Vascular, Abiomed, Cardiovascular Systems, Chiesi, and Zoll. Dr O’Neill has received grant/research support from St. Jude Medical, Edwards Lifesciences, and Biomed; has received consulting fees/honoraria from Medtronic and Abiomed; and has major stock shareholder/equity in Synecor, Accumed, Neovasc, Tendyne, and Mitral Align. Dr Lansky has received speaker fees from Keystone Heart. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Background: Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing. Methods: We analyzed the association between balloon uncrossable lesions and procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers. Results: The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10, p < 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%, p < 0.001) and diabetes mellitus (50% vs. 42%, p < 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%. p < 0.001), moderate/severe calcification (68% vs. 40%, p < 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%, p < 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min, p < 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min, p < 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%, p < 0.001) and procedural (88% vs. 96%, p < 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%, p < 0.001). Several techniques were required for balloon uncrossable lesions. Conclusion: In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions.

Patients with advanced age, complex coronary anatomy, and multiple comorbidities are often unsuitable for surgical revascularization. In this setting, hemodynamic support devices are used as an adjunct to percutaneous coronary intervention to maintain hemodynamic stability and enable optimal revascularization. This article provides an overview of percutaneous hemodynamic support devices currently used in clinical practice for high-risk percutaneous coronary intervention. These include the intra-aortic balloon pump, centrifugal pumps (TandemHeart, venous arterial extracorporeal membrane oxygenation), and micro-axial Impella pump. The hemodynamic effects, clinical evidence supporting improved outcomes and recovery of heart function, and associated complications with these devices are highlighted, with a special focus on Impella pumps., Competing Interests: Disclosure: CS is a consultant for Abiomed. CT is a consultant for Boston Scientific and Abiomed. JRW is a consultant, proctor, speaker, and advisory board member for Boston Scientific and Abbott Vascular; a consultant, speaker, and advisory board member and has received research support for Abiomed; is on an advisory board for Phillips, and is a proctor for Asahi Intecc. DLM is a consultant and speaker, and has received research support from Abiomed. TGD is a speaker and proctor for Abiomed., (Copyright © The Author(s), 2020. Published by Radcliffe Group Ltd.)

Background: Regional myocardial contractility can be characterized by three-dimensional left ventricular (LV) multiparametric strain maps generated from sequential magnetic resonance imaging of radiofrequency tissue-tagging grid point displacements., Methods: Normal average and standard deviation values for each of three strain indices at 15,300 LV points were determined from a normal volunteer human strain database (n = 50) by application of magnetic resonance-based three-dimensional strain analysis. Patient-specific multiparametric strain data from each ischemic cardiomyopathy patient (n = 20) were then submitted to a point-by-point comparison (n = 15,300 LV points) to the normal strain database. The resulting 15,300 composite multiparametric Z-score values (standard deviation from normal average) were color-contour mapped over patient-specific three-dimensional LV geometry to detect the abnormal contractile patterns associated with myocardial infarction and nonviable myocardium., Results: The average multiparametric strain composite Z-score from each LV region (n = 120) was compared with the respective clinical standard viability testing result and used to construct a receiver-operator characteristic curve. The area under the curve was 0.941 (p < 0.001; 95% confidence interval: 0.897 to 0.985). A regional average Z-score threshold of 1.525 (> 1.525 being nonviable) resulted in a sensitivity of 90% and a specificity of 90%. Corresponding positive and negative predictive values were 84% and 95%, respectively., Conclusions: The clinical application of magnetic resonance-based multiparametric strain analysis allowed accurate regional characterization and visualization of LV myocardial viability.

Background: Severe aortic insufficiency (AI) with preserved left ventricular (LV) function may be associated with a long asymptomatic period and unpredictable course on medical therapy. Since myocardial wall stress is closely related to both pathologic cardiac remodeling and ultimately to LV decompensation, a more accurate description of regional wall stress may improve our ability to appropriately manage these patients. The objective of this study was to define differences in instantaneous global and regional three-dimensional end-systolic maximum principal stress (ESS) between normal patients and patients with AI, both before and after aortic valve replacement (AVR) using magnetic resonance imaging (MRI) and finite element analysis (FEA)., Methods: Magnetic resonance imaging was performed on 20 normal volunteers and 14 patients with moderate to severe AI with normal systolic function (ejection fraction: 57 +/- 0.6) before and after AVR. Finite element analysis was utilized to estimate global and regional ESS., Results: Both global (p < 0.001) and regional (p < 0.001 in all segments) ESS were significantly higher in the preoperative AI patients when compared with their postoperative values and normal controls. Postoperative ESS was significantly lower than the normal controls (p = 0.002)., Conclusions: Three-dimensional regional and global end-systolic LV wall stress can be determined by MRI and finite element analysis. Values of ESS in patients with chronic AI were elevated prior to AVR and normalized after AVR. This method may have considerable potential as a noninvasive, clinically applicable index of regional LV geometry and function that may help with the serial evaluation of patients with AI.

Background: Left ventricular three-dimensional nonlinear systolic strain determinations have potential to detect small decrements in ventricular function in patients with aortic insufficiency before and after aortic valve replacement., Methods: Magnetic resonance imaging with tissue-tagging was performed on 42 normal volunteers and 14 patients with chronic aortic insufficiency both before and 28 +/- 11 months after aortic valve replacement. Preoperative and postoperative left ventricular volume, dimensions and ejection fraction were determined for all subjects. Left ventricular systolic radial, circumferential, longitudinal, and minimum principal strain were calculated for six left ventricular regions., Results: After aortic valve replacement, left ventricular volume and dimensions decreased significantly (p < 0.001) and ejection fraction increased nonsignificantly (p = 0.096). Strain values in preoperative aortic insufficiency patients did not differ significantly from controls. At an average of 28 +/- 11 months postoperatively, however, regional three-dimensional minimum principal and longitudinal strain was decreased in all six ventricular regions as well as globally (p < 0.03) compared with normal control values. Circumferential strain was significantly decreased globally and in all but two regions (p < 0.03)., Conclusions: These magnetic resonance imaging-based techniques are sensitive enough to detect a previously unrecognized, significant decrease in both global and regional three-dimensional left ventricular systolic strain 2 years after aortic valve replacement for minimally symptomatic chronic aortic insufficiency despite improvement in ejection fraction and a decrease in left ventricular size. The reasons for a significant decline in left ventricular systolic strain after successful aortic valve replacement in minimally symptomatic chronic aortic insufficiency patients are not clear and warrant further investigation.