Search

Treatment of bifurcation lesions has advanced with the development of second-generation drug-eluting stents and state-of-the-art percutaneous coronary interventions techniques. This subanalysis of SYNTAX II demonstrates similar major adverse cardiac or cerebrovascular events in patients with bifurcation and nonbifurcation lesions, with a trend toward higher target lesion failure in the bifurcation cohort. The results, while compelling, require larger studies with longer follow-up, stratified by bifurcation strategy.

Stroke occurs infrequently following percutaneous coronary intervention (PCI) with 30-day and 1-year cumulative incidence of 0.4 and 1.5%, respectively. Patient comorbidities, acute presentations, and complex coronary lesions are more prevalent among patients who sustain a stroke. The occurrence of stroke is associated with higher short-term and overall mortality compared with bleeding or myocardial infarction.

Prosthesis-patient mismatch (PPM) is defined as a small effective orifice area (EOA) of a normally functioning prosthetic valve in relation to patient body size. Even moderate impediment to forward flow has been associated with an increase in all-cause mortality. We report an unusual cause of PPM where a transcatheter implantation of a large EOA valve in an aortic position results in relative PPM in a patient with morbid obesity. © 2016 Wiley Periodicals, Inc.

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document

Endothelial progenitor cells (EPCs) may allow accelerated and functional endothelialization of stents, theoretically reducing late stent complications as well reducing the duration of DAPT. In a pilot study of 193 patients at high risk of target vessel failure (TVF), the Genous EPC capturing stent (ESC) and TAXUS Liberte paclitaxel-eluting second-generation stent (PES) were similar at 5-years. Events rates appear higher for ESC within the first-year followed by higher rate of complications for PES during years 2-5. A larger randomized multi-center trials powered for non-inferiority of ECS to PES is underway.

As indications for TAVR expand, there is a need for predictive models of procedural complications. Application of the HAS-BLED score demonstrated patient comorbidities that contribute to increased bleeding events and mortality. Further adequately powered studies will be needed to validate the HAS-BLED score for use in the TAVR population or further elucidate important risk factor to incorporate into future predictive risk models.

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the SCAI publications committee concisely summarizes and provides editorial commentary on the most important trials from recent, large international meetings. The intent is to provide this summary every six months to allow quick assimilation of trial results into interventional practice. © 2014 Wiley Periodicals, Inc.

With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the Society for Cardiovascular Angiography and Interventions (SCAI) publications committee concisely summarized and provided editorial commentary on the most important trials from recent, large international meetings. The intent is to provide this summary every six months to allow quick assimilation of trial results into interventional practice.

Transcatheter aortic valve replacement is being used with increasing frequency in patients with severe aortic stenosis who are otherwise deemed to be at high surgical risk. Aortic dissection is a rare complication of transcatheter aortic valve replacement and poses a unique management dilemma. We describe the treatment of an acute Stanford type A aortic dissection after transcatheter aortic valve replacement with a modified thoracic endovascular stent graft in a 95-year-old woman.

The American College of Cardiology Foundation, in collaboration with the Society for Cardiovascular Angiography and Interventions and key specialty and subspecialty societies, conducted a review of common clinical scenarios where diagnostic catheterization is frequently considered. The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of noninvasive imaging appropriate use criteria. The 166 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median 7 to 9), uncertain use (median 4 to 6), and inappropriate use (median 1 to 3). Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease with other procedure components (e.g., hemodynamic measurements, ventriculography) at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the use of coronary angiography at the discretion of the operator. Seventy-five indications were rated as appropriate, 49 were rated as uncertain, and 42 were rated as inappropriate. The appropriate use criteria for diagnostic catheterization have the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research. © 2012 Wiley Periodicals, Inc.

Key Points Pressure-bound (pb) coronary flow reserve (CFR) is a novel estimation of CFR, calculated from easily obtained baseline and hyperemic pressure assessment Validation of pb-CFR in previously reported lesions showed accuracy of 84% to CFR with sensitivity of 96% and specificity of 60% FFR >0.75 and low pb-CFR in DEFER was associated with increased angina and complications compared to high pb-CFR and this risk was not modified by elective revascularization.

The introduction of coronary stents marked a major turning point in the practice of interventional cardiology. Whereas the efficacy of balloon angioplasty was challenged both by immediate mechanical complications and by a high incidence of restenosis, coronary stents offered cardiologists a means by which to not only augment immediate procedural success, but also to reduce the incidence of restenosis following coronary intervention. However, despite technological advances and an improved understanding of the restenotic process, the overall rate of in-stent restenosis following bare metal stent implantation remains high. Although the introduction of drug-eluting stents has further reduced the incidence of restenosis, the "real-world" application of drug-eluting stents in increasingly complex lesion and patient subsets has given way to the even greater clinical challenge of managing drug-eluting stent restenosis. Although the standard treatment of bare metal stent restenosis typically involves placement of a drug-eluting stent, the optimal therapeutic approach to drug-eluting stent restenosis remains less defined. The issue of in-stent restenosis (especially following implantation of a drug-eluting stent) remains a clinical challenge, and investigation into therapeutic options remains ongoing. As technology evolves, such investigation will likely incorporate novel approaches including drug-coated balloons novel stent designs.

With the plethora of clinical trials, it is difficult for busy interventional cardiologists to stay up to date. Therefore, the SCAI Publications Committee concisely summarizes and provides editorial commentary on the most important structural heart and peripheral arterial disease trials from the large international meetings of 2014. The intent is to allow quick assimilation of trial results into interventional practice.

Key Points Provisional use of rotational atherectomy (RA) is indicated for procedural success in heavily calcified lesions. In the current study, RA use at three high volume percutaneous coronary intervention (PCI) centers between 2005 and 2013 was 1.4%. MACE rate was 17.8% at median follow-up of 22 months. Peripheral vascular disease (PVD), diabetes mellitus (DM), acute coronary syndrome (ACS), and SYNTAX > 23 were found to be independently associated with MACE. With increasing complexity of disease and SYNTAX score, there is usually an increase in severity of calcification and need for atherectomy. Complete revascularization with residual SYNTAX reduced to 33 rather than procedural success of the target vessel with atherectomy may have contributed to the adverse outcomes.

Subintimal tracking and reentry (STAR) has been used as a bailout strategy and involves an uncontrolled dissection and recanalization into the distal lumen to reestablish vessel patency. In the current study, thrombolysis in myocardial infarction (TIMI) flow

With the evolution of transcatheter valve replacement, an important opportunity has arisen for cardiologists and surgeons to collaborate in identifying the criteria for performing these procedures. Therefore, The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), and The Society of Thoracic Surgeons (STS) have partnered to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns transcatheter pulmonic valve replacement (tPVR). tPVR procedures are in their infancy with few reports available on which to base an expert consensus statement. Therefore, many of these recommendations are based on expert consensus and the few reports available. As the procedures evolve, technology advances, experience grows, and more data accumulate, there will certainly be a need to update this consensus statement. The writing committee and participating societies believe that the recommendations in this report serve as appropriate requisites. In some ways, these recommendations apply to institutions more than to individuals. There is a strong consensus that these new valve therapies are best performed using a Heart Team approach; thus, these credentialing criteria should be applied at the institutional level. Partnering societies used the ACC's policy on relationships with industry (RWI) and other entities to author this document (http://www.acc.org/guidelines/about-guidelines-and-clinical-documents). To avoid actual, potential, or perceived conflicts of interest due to industry relationships or personal interests, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current healthcare-related relationships including those existing 12 months before the initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI and to be led by an interventional cardiology cochair and a surgical cochair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in the Appendices. In addition, to ensure complete transparency, authors' comprehensive disclosure information (including RWI not pertinent to this document) is available in Appendix AII. The work of the writing committee was supported exclusively by the partnering societies without commercial support. SCAI, AATS, ACC, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.

Saphenous vein graft (SVG) intervention has been associated with an increased incidence of distal embolization. Long lesions and lesions associated with thrombus are particularly at increased risk. This study was performed to determine whether abciximab may decrease this risk in high risk SVG angioplasty. From June 1994 to June 1998, 84 patients with at least one high risk factor, i.e., lesion length >20 mm or angiographic evidence of thrombus, underwent Transluminal extraction atherectomy (TEC) procedure followed by balloon dilatation or stenting. Of these 84 patients, 37 who had procedure after September 1995 underwent TEC with abciximab (Abciximab Group) and 47 who had their procedure before that date had TEC without abciximab thereby serving as historic control (Non-Abciximab Group). All patients had normal pre-procedure CK and CK-MB. Total creatine kinase (CK) and CK-MB were measured every 8 hr post-procedure for 24 hr. Baseline demographics, angiographic characteristics, incidence of LV dysfunction and triple vessel disease were similar between the two groups. Graft age was similar between two groups (122 ± 70 vs. 117 ± 54 months). Graft diameter, pre and post-procedure percent stenoses were not different between the two groups. Stents were used in 65% in the Abciximab group and 45% in Non-Abciximab group (P = 0.14). There was no in-hospital repeat PTCA, urgent bypass surgery, or cardiac death. There was no difference between the two groups in regards to the incidence of any elevation of total CK (27% vs. 21.3%) or CK-MB (54% vs. 51%). When used in conjunction with TEC in treating high risk vein graft lesions, abciximab did not reduce post procedure CK-MB elevation in this patient population. Cathet Cardiovasc Intervent 2001;52:40–44. © 2001 Wiley-Liss, Inc.

This study examined whether estrogen replacement therapy (ERT) in postmenopausal women impacts intermediate and long-term outcome after successful coronary stenting. Our findings offer evidence that ERT significantly reduces target lesion revascularization after intracoronary stenting in postmenopausal patients who are on ERT before the intervention.

Left main coronary artery dissection complicating selective coronary angiography is uncommon. Moreover, aortic root dissection associated with coronary intervention is underreported and may require urgent surgical intervention. During percutaneous coronary angioplasty of a catheter-induced left main coronary artery dissection, retrograde dissection of the adjacent aortic root occurred. Both were successfully treated by stenting of the left main coronary artery. Cathet. Cardiovasc. Intervent. 49:86–89, 2000. © 2000 Wiley-Liss, Inc.

Coronary stenting in acute coronary syndromes probably increases the risk of acute stent thrombosis. Recently, use of platelet glycoprotein IIb/IIIa receptor antibody has been shown to improve percutaneous transluminal coronary angioplasty (PTCA) outcomes in high risk lesions. The purpose of this analysis was to determine safety and efficacy of platelet glycoprotein IIb/IIIa receptor antibody administration in patients receiving coronary stents in high-risk lesions. Between October 1995 and November 1996, 282 patients with acute ischemic syndromes received coronary stents at our center: 73 had thrombus containing lesions--40 presented with AMI and 33 with unstable angina and make up the study population. The mean age of these patients was 61+/-13 years, 56 were male, 35 had a history of myocardial infarctions (MI), 21 had prior coronary artery bypass graft (CABG), and 21 had prior PTCA. Coronary stenting was used for suboptimal result in 46 patients (63%), threatened closure in 25 patients (34%), and acute closure in 2 patients (3%). Platelet glycoprotein IIb/IIIa receptor antibody was administered during the procedure in 74% and after the procedure in 26%. A total of 115 stents were deployed (Gianturco-Roubin 80, Palmaz-Schatz 29, and Wallstent 6) in 24 LAD, 21 RCA, 15 LCX, and 13 saphenous vein graft (SVG) lesions. Procedural success was 100%. The mean diameter stenosis before and after intervention was 60%+/-31% and 4%+/-14%, respectively. In-hospital events included 1 Q-wave MI (1.4%), 13 non-Q-wave MI (18%), and 1 death (1.4%). There was no subacute stent thrombosis, emergency CABG, or repeat PTCA. Significant in-hospital bleeding complications were noted in seven (10%) patients, with five patients (6.8%) requiring blood transfusions. In this series of patients with acute ischemic syndromes associated with angiographic evidence of thrombus, combined use of platelet glycoprotein IIb/IIIa receptor antibody and stenting resulted in a very low incidence of subacute stent thrombosis and emergency target lesion revascularization. However, bleeding complications were higher than expected with conventional antiplatelet therapy following routine stenting.

Background Conventional balloon angioplasty of very long de novo coronary lesions or very long coronary dissection caused by angioplasty is associated with low success and high complication rates. Multiple intracoronary stents have been used to treat both conditions, although long-term efficacy has not been defined. Methods and Results Between June 1993 and December 1995, 47 consecutive patients underwent native coronary angioplasty and stenting with 4 or more stents covering at least 2 consecutive diseased coronary segments. Preangioplasty and poststenting diameter stenoses were 81% ± 13% and 21% ± 12%, respectively. Reference vessel diameters were 3.53 ± 0.55 mm proximal to the stents and 2.95 ± 0.62 mm distal to the stents. Average lesion length was 63 ± 20 mm. The number of stents used was 4.5 ± 1 per vessel (from 4 to 7). Gianturco Roubin I stents were used in all patients. Coronary Palmaz-Schatz stents were used as supplementary stents in 3 patients. Angiographic success was 100%. In-hospital outcomes include 1 death, 1 coronary bypass surgery, no Q-wave myocardial infarction, and 7 non–Q-wave myocardial infarctions. Long-term follow-up at 430 ± 199 days was completed in all patients. Thirty-five (76%) patients were asymptomatic, 8 (17%) had class 1 or 2 angina, 1 had a myocardial infarction, 13 (28%) underwent repeat angioplasty, 2 patients had subsequent elective bypass surgery, and 3 died during follow-up. Conclusions Multiple intracoronary stents for very long lesions or dissection can be performed with acceptable immediate and long-term outcomes. (Am Heart J 1999;137:292-7.)

Stenting of the internal carotid artery is facilitated by stenting across the carotid bifurcation and sizing the diameter of a self-expanding stent to the large common carotid segment. This usually results in marked oversizing of the self-expanding stent in the internal carotid segment. This study was done to determine the relationship between stent oversizing and late luminal loss index after stenting of the internal carotid artery. Between September 1995 and March 1997, there were 165 patients (189 vessels) who underwent successful carotid stenting with self-expanding stents. Fifty-nine patients (63 vessels) had six-month follow-up carotid angiograms and on-line quantitative angiographic analysis. The mean reference diameter of the internal carotid arteries was 4.93 ± 1.31 mm. Nominal stent size was 5 mm in 4 patients, 6 mm in 6 patients, 8 mm in 106 patients, 10 mm in 77 patients, and 12 mm in 1 patient. The average stent/patient was 1.03 ± 0.16. There were three patients who had more than 50% diameter renarrowing at follow-up. The mean late loss index was 0.25 ± 0.41. By linear regression analysis, there was no clear linear relationship between stent oversizing and late loss index after stenting (correlation coefficient = -0.21, P = 0.09). When analysis of variance with linear contrast was used to analyze six groups of different stent/artery ratios (from 1.4 to ≥ 2), late loss indexes are significantly lower in the groups of high stent/artery ratio than the groups of low stent/artery ratio (P = 0.01). The process of oversizing of self-expanding stents deployed in the internal carotid artery does not appear to be associated with late restenosis and high stent/artery ratio seems to be associated with low late loss index. Cathet. Cardiovasc. Diagn. 45:139–143, 1998. © 1998 Wiley-Liss, Inc.

Objectives. The purpose of this study was to evaluate the safety, feasibility, optimal deployment technique and 1-year clinical outcome for the Advanced Cardiovascular Systems (ACS) MultiLink stent.Background. Optimal stent deployment assessed by quantitative coronary angiography and intravascular ultrasound (IVUS) is associated with improved clinical outcome.Methods. Forty-nine consecutive patients with a discrete stenosis in a native coronary artery 3 to 4 mm in diameter were treated with the new, balloon-expandable ACS MultiLink stent. Stent expansion was assessed in all patients using quantitative coronary angiography and serial IVUS imaging after 8-, 12- and 16-atm inflations. Clinical follow-up was obtained at 30 days and 1 year.Results. All 49 patients had successful placement of a MultiLink stent without death, emergency coronary artery bypass graft surgery or Q wave myocardial infarction. After placement of the MultiLink stent, the minimal lumen diameter increased from 1.24 to 2.98 mm (p < 0.001), and diameter stenosis decreased from 61% to 7% (p = 0.001). Minimal lumen cross-sectional area by IVUS increased progressively after 8, 12 and 16 atm (5.6 to 6.8 to 7.4 mm2, respectively, p < 0.001). However, only 64% of stents achieved a lumen/reference area ratio ≥70%. No adverse clinical events occurred by 30 days, and by 1 year only one patient (2.0%) required revascularization of the stented artery.Conclusions. Treatment of stenoses in native coronary arteries with the MultiLink stent is associated with a high success rate and a low incidence of adverse events by 1 year, despite the fact that the majority of stents did not meet IVUS-defined criteria for “optimal stenting” derived from first-generation devices.

Objectives. We sought to determine the in-hospital clinical outcome and angiographic results of patients prospectively entered into the National Heart, Lung, and Blood Institute/New Approaches to Coronary Intervention (NHLBI/NACI) Registry who received Gianturco-Roubin stents as an unplanned new device. Background. Between August 1990 and March 1994, nine centers implanted Gianturco-Roubin flex stents as an unplanned new device in the initial treatment of 350 patients (389 lesions) who were prospectively enrolled in the NHLBI/NACI Registry. Methods. Patients undergoing implantation of the Gianturco-Roubin flex stent were prospectively entered into the Gianturco-Roubin stent portion of the NHLBI/NACI Registry. Only subjects receiving the Gianturco-Roubin stent as a new device in an unplanned fashion are included. Results. The mean age of the patient group was 61.8 years, and the majority of the patients were men. A history of percutaneous transluminal coronary angioplasty (PTCA) was present in 35.4% of the group, and 16.9% had previous coronary artery bypass graft surgery. Unstable angina was present in 67.7%. Double- or triple-vessel coronary artery disease was present in 55.4%, and the average ejection fraction was 58%. The presence of thrombus was noted in 7.3%, and 7.2% had moderate to severe tortuosity of the lesion. The angiographic success rate was 92%. Individual clinical sites reported that 66.3% of the stents were placed after suboptimal PTCA, 20.3% for abrupt closure and 13.4% for some other technical PTCA failure. Major in-hospital events occurred in 9.7% of patients, including death in 1.7%, Q wave myocardial infarction in 3.1% and emergency bypass surgery in 6%. Abrupt closure of a stented segment occurred in 3.1% of patients at a mean of 3.9 days. Cerebrovascular accident occurred in 0.3%, and transfusion was required in 10.6%. Vascular events with surgical repair occurred in 8.6% of patients. Conclusions. Despite these complications, the use of this device for the treatment of a failed or suboptimal PTCA result remains promising given the adverse outcome of abrupt closure with conventional (nonstent) treatment. (J Am Coll Cardiol 1997;29:934–40) © 1997 by the American College of Cardiology

Objectives.This study sought to ascertain whether early and 12-month clinical outcomes after percutaneous coronary revascularization have improved between 1986–1987 and 1991.Background.Since the mid-1980s, when the results of percutaneous revascularization were considered to be somewhat static, justifying large-scale clinical trials of percutaneous transluminal coronary angioplasty versus other modes of therapy, balloon technology has improved, and several new percutaneous revascularization techniques have become available. The clinical results of the current integrated approach to revascularization compared with those for coronary angioplasty alone in the late 1980s are not known.Methods.In this prospective case-control study, 200 consecutively treated patients with multivessel disease in 1991 were studied prospectively and compared with 400 consecutive patients from the same centers during 1986–1987. Patients from 1991 were matched with earlier patients on the basis of four previously described prognostic determinants (left ventricular ejection fraction, presence of unstable angina, diabetes and target lesion morphology score) and the treating institution and were assessed for treatment outcome (completeness of revascularization, procedural success and event-free survival [freedom from death, myocardial infarction and further revascularization]).Results.The 1991 cohort of patients was older (mean [±SD] age 62 ± 11 vs. 58 ± 11 years, p < 0.001) and tended to have slightly worse left ventricular function (ejection fraction 56 ± 10% vs. 58 ± 11%, p = 0.009) than the 1986–1987 cohort. Overall lesion morphology risk scores were similar. New devices (other than coronary angioplasty) were used in 26% of patients. The 1991 patient cohort had more frequent total revascularization (35% vs. 21%, p = 0.003), fewer emergency bypass operations (1.0% vs. 5.5%, p = 0.006) and an improved overall procedural success rate (90% vs. 84%, p = 0.04). In addition, at 12 months the event-free survival rate was superior in the 1991 cohort (73.3% vs. 63.6%, p = 0.02), although there was no difference in infarct-free survival rate (94.6% vs. 93.2%, p = NS).Conclusions.Improved results with percutaneous revascularization in 1991 have important implications for patient care and interpretation of ongoing randomized trials enrolling patients in the late 1980s and intending to compare standard coronary angioplasty with other forms of therapy.

We report the impact of pulmonary hypertension (PH) on patients undergoing transcatheter valve replacement (TAVR), evaluating the interaction of PH due to primary lung disease. A retrospective cohort study was performed on patients who underwent TAVR from 2010 to 2015 from the TVT registry.

Percutaneous coronary intervention remains a mainstay in the daily practice of interventional cardiologists. While overall volumes of PCI in the United States are declining, one can argue that with the advent of newer technology and devices, the volume of anatomically high-risk PCI (i.e., left main stenting, diffuse coronary artery disease) and/or PCI in high-risk patients (i.e., cardiogenic shock, poor LV function, and last remaining conduit) will continue to rise. As a result, interventionalists in contemporary practice must be more vigilant than ever in performing thoughtful assessments of the indications and/or risks of PCI, as well as remain current on available data and devices in order to optimally guide their intra-lab decision making while caring for patients undergoing PCI in the catheterization laboratory.

PREAMBLE The granting of staff privileges to physicians is an important mechanism to ensure quality care. The Joint Commission on Accreditation of Healthcare Organizations requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians are charged with defining the criteria that constitute professional competence and with evaluating their peers accordingly. With the evolution of transcatheter aortic valve replacement (TAVR), an important opportunity arises for both cardiologists and surgeons to come together to identify the criteria for performing these procedures. The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology Foundation (ACCF), and the Society of Thoracic Surgeons (STS) have, therefore, joined together to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns TAVR. As TAVR is in its infancy, there are few data on which to base this consensus statement. Therefore, many of these recommendations are based on expert consensus. As the procedures

To determine the relative merits of primary percutaneous transluminal coronary angioplasty (PICA) and intravenous thrombolytic therapy for acute myocardial infarction, 12 tertiary care hospitals entered patients who had ≥30 minutes of chest pain and were admitted to a cardiac intensive care unit within 12 hours of symptom onset into a prospective registry. Of 1,170 such patients, 118 (10%) underwent primary PTCA and 230 (19%) received intravenous thrombolytic therapy within 6 hours of registry hospital admission (144 at the registry hospital and 86 prior to arrival at the registry hospital). Baseline demographic characteristics of PTCA and thrombolytic subgroups were remarkably similar. The interval from initial evaluation at the registry hospital to treatment was shorter with intravenous thrombolytic therapy than with primary PTCA (64 vs 104 minutes, p < 0.001), as was the interval from pain onset to treatment (184 vs 252 minutes, p < 0.001). Among the 230 thrombolytic patients, coronary arteriography and PTCA were performed within the first 24 hours in 44% and 18%, respectively, and during the entire hospitalization in 90% and 49%, respectively. During hospitalization, blood was transfused in 16% of the 230 thrombolytic patients versus 5.9% of the 118 PTCA patients (p < 0.001). Otherwise, adverse events during the initial hospitalization were similar in PTCA and thrombolytic groups. Survival at 1-year follow-up was 88% in the PTCA group and 91% in the thrombolytic group (p = NS), and survival free of reinfarction was 85% and 88%, respectively (p = NS). Multivariable analysis, adjusting for baseline characteristics, found no evidence that use of PTCA rather than thrombolytic therapy significantly impacted survival or survival free of reinfarction at 1 year. These observational registry data suggest that patients undergoing primary PTCA for acute myocardial infarction have similar demographic characteristics and similar outcome as patients receiving intravenous thrombolytic therapy.

Background— There is speculation that the volume of percutaneous coronary interventions (PCIs) has been decreasing over the past several years. Published studies of PCI volume have evaluated regional or hospital trends, but few have captured national data. This study describes the use of coronary angiography and revascularization methods in Medicare patients from 2001 to 2009. Methods and Results— This retrospective study used data from the Centers for Medicare & Medicaid Services from 2001 to 2009. The annual number of coronary angiograms, PCI, intravascular ultrasound, fractional flow reserve, and coronary artery bypass graft (CABG) surgery procedures were determined from billing data and adjusted for the number of Medicare recipients. From 2001 to 2009, the average year-to-year increase for PCI was 1.3% per 1000 beneficiaries, whereas the mean annual decrease for CABG surgery was 5%. However, the increase in PCI volume occurred primarily from 2001 to 2004, as there was a mean annual rate of decline of 2.5% from 2004 to 2009; similar trends were seen with diagnostic angiography. The use of intravascular ultrasound and fractional flow reserve steadily increased over time. Conclusions— This study confirms recent speculation that PCI volume has begun to decrease. Although rates of CABG have waned for several decades, all forms of coronary revascularization have been declining since 2004.

A new flow-adjustable pump for coronary hemoperfusion to prevent ischemia during routine coronary angioplasty was evaluated in a multicenter prospective study of 110 patients. The protocol included patients who had angina or ST segment elevation during a control balloon inflation of ≤3 min. Hemoperfusion was performed by means of a new large lumen angioplasty catheter utilizing the patient's renal vein or femoral artery blood. Vessels perfused were the left anterior descending coronary artery (n = 74), right coronary artery (n = 39), left circumflex artery (n = 9) and coronary vein grafts (n = IS).Mean (± SD) perfusion flow was 41 ± 9 ml/min (range 17 to 70); mean perfusion time was 9.3 ± 4 min (median 8.5, range 2 to 30). Chest pain score (0 to 4) decreased from 2.9 ± 1 to 1.4 ± 1 during hemoperfusion (p < 0.001); ST segment elevation score (0 to 4) decreased from 2.6 ± 1 to 0.7 ± 1 (p < 0.005) and inflation time increased from 1.3 ± 0.9 to 7 ± 4 min, (p < 0.001). At least a 50% increase in tolerated inflation time was obtained in 104 patients (95%). Free plasma hemoglobin and creatine kinase levels did not increase significantly over baseline values.Angioplasty was successful in 107 patients (97%), with mean stenosis reduced from 87 ± 11% to 20 ± 17%; 3 patients had urgent bypass surgery, 2 (1.8%) had a myocardial infarction (1Q wave, 1 non-Q wave) and 2 (1.8%) died later in the hospital of probable noncoronary causes. Complications related to hemoperfusion were transient heart block during dilation of the right coronary artery in two patients and hematoma requiring transfusion in five (4.5%).Thus, this initial feasibility study indicates that this new hemoperfusion system is safe and effective in ameliorating ischemia and allowing longer balloon inflations during coronary angioplasty.

This study was performed to evaluate the importance of the duration of balloon inflation during PTCA, by comparing two common inflation durations. Patients were randomized to a 30-second inflation protocol (group I, 83 procedures, 109 lesions), or a 60-second protocol (group II, 83 procedures, 115 lesions). There were no differences in baseline characteristics between the two groups, and no subsequent differences in mean inflation number (3.4 +/- 1.6 vs 3.1 +/- 1.6), residual stenosis (34% +/- 17% vs 33% +/- 16%), presence of dissection (29% vs 34%), or clinical success (89% vs 84%), group I versus group II, respectively. The 30-second inflations caused significantly less chest pain score (147 +/- 239 vs 399 +/- 516, P less than 0.001), and ST segment alteration (75 +/- 94 seconds vs 136 +/- 163, P less than 0.05). These results indicate that 60-second inflations do not produce a superior result to 30-second inflations. Furthermore, shorter inflations are much better tolerated.

The limitations of 2-dimensional and pulsed Doppler echocardiography in patients undergoing mitral valvuloplasty are well known. This study was undertaken to assess the value of color Doppler flow imaging in 36 symptomatic mitral stenosis patients who subsequently underwent successful balloon mitral valvuloplasty by comparing the results to those obtained at cardiac catheterization. Color Doppler-guided conventional Doppler assessment agreed well with cardiac catheterization results in classifying mitral stenosis as mild, moderately severe and severe, both before and after valvuloplasty. Color Doppler was also useful in identifying patients who had moderate to severe mitral regurgitation before and after valvuloplasty. Color Doppler flow mapping was more sensitive than oximetry in the detection of iatrogenic atrial septal defects, which were noted in 25 patients. The defects of those patients with smaller defects by color Doppler (diameter less than 0.7 cm) or echocardiographic shunt volume less than 0.7 liters/min tended to close, usually within 6 months, as opposed to those with larger defects or higher shunt volumes, which tended to persist. Echocardiographic shunt volumes revealed a fair correlation with oximetric results.

The long-term patency of saphenous vein graft (SVG) lesions after intervention has been shown to be improved with new interventional techniques such as stents. Long-term outcome of patients undergoing successful angioplasty of totally occluded old SVGs with new devices is unknown. From July 1994 to June 1996, 19 patients with totally occluded old SVGs had successful angioplasty with new interventional techniques. Mean SVG age was 123 +/- 8 mo. Thrombolysis in myocardial infarction trial (TIMI) flow was 0 in all target lesions. TIMI 2 or 3 flow was restored after angioplasty in all patients. Intracoronary urokinase, transluminal extractional atherectomy, and stenting were used in 14, 12, and 6 patients, respectively. There was one in-hospital death due to ongoing myocardial infarction, no recurrent infarction, and no repeat angioplasty or bypass surgery in the hospital. At follow-up of 21 +/- 1 mo, there was one sudden death and one myocardial infarction. Five patients had repeat coronary bypass surgery, and 4 had repeat angioplasty. Thirteen patients remained asymptomatic, and 4 had angina. The long-term outcome of patients who had successful reopening of occluded old SVGs is encouraging in this small sample.

This prospective nonrandomized study was performed comparing aspirin alone (n = 46) versus aspirin and ticlopidine (p = 338) following native coronary artery stenting. There were significantly more stent thrombosis events in the aspirin-only group than in the aspirin and ticlopidine group (6.5% vs 0.9%, p = 0.02) and significantly more Q-wave myocardial infarctions and cardiac-related deaths in the aspirin-only group than in the aspirin and ticlopidine group (6.5% vs 0%, p = 0.002 and 4.4% vs 0.3% p = 0.02, respectively).

Fifty-one patients with severe coexisting carotid and symptomatic coronary artery occlusive disease successfully underwent staged or simultaneous coronary angioplasty and carotid stenting. One pericardial effusion and 2 minor strokes with full recovery occurred in the hospital, but no major neurologic events, myocardial infarction, or death were observed and no repeat revascularization was required within the 30-day follow-up.

Information describing outcome after myocardial revascularization and renal transplantation in patients with end-stage renal disease and coronary artery disease is limited in scope. There are several case reports that describe the results of cardiac operations in small numbers of renal transplant patients. 1–9 If these reports are considered together, there are 35 renal allograft patients who subsequently underwent cardiac operations. Of these 35 patients, 29 had isolated coronary artery bypass grafting (CABG). The aggregate immediate postoperative survival rate in these patients was 97%; however, intermediate- and long-term survival rates cannot be determined from the information contained in these reports. A larger study by Bolman et al published in 1984 included 14 patients who had cardiac operations. 10 Ten of the patients in this series had isolated CABG. There were two deaths; 12 patients were alive at 8 to 93 months after surgery. More recent studies of cardiac operations performed in renal transplant recipients 11,12 include more patients and a more complete outcome analysis. These studies, together with the earlier analysis of Bolman et al, indicate that surgical revascularization can be performed in renal transplant recipients without an unusually high incidence of postoperative infection despite immunosuppression, and with an acceptable short-term mortality rate relative to cardiac operations performed in patients without renal disease. In all three series, the short-term preservation of renal allograft function was good. Data have also been published that describe the outcome of patients who are maintained on dialysis and who receive either CABG or percutaneous transluminal coronary angioplasty (PTCA). 5,13–20 Several of these reports describe individual patients who had renal transplantation after revascularization; however, there is no report that describes long-term outcome and defines risk factors for patients with chronic renal failure who undergo a myocardial revascularization procedure and renal transplantation. The present report takes advantage of the large population of patients with renal disease treated at this institution. The goal was to generate a comprehensive review of myocardial revascularization in patients with chronic renal failure who also receive, at some point in their lives, a renal allograft. The specific aims of this analysis were to quantify the number of deaths in patients who had renal transplantation and myocardial revascularization at this institution, and to identify risk factors that influenced survival in these patients.

Removal of endoscopically placed biliary stents that have migrated proximal to the duodenal papilla is possible with a wide variety of techniques.1,2 Although similar techniques may be used to retrieve proximally migrated pancreatic duct stents3,4, the smaller diameters of the pancreatic duct and the associated stents used in this ductal system limit the possibilities for endoscopic removal. Endoscopically irretrievable pancreatic duct stents may have to be removed surgically, and resection of a portion of the pancreatic parenchyma may be necessary.4,5 We describe endoscopic retrieval of a proximally migrated 5F pancreatic duct stent in which we used interventional cardiology accessories when other endoscopic methods of stent extraction failed.