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Background There is equipoise about the optimal initial strategy for crossing coronary chronic total occlusions. Objectives We performed a multicenter, randomized-controlled, clinical trial comparing upfront use of the CrossBoss catheter vs. antegrade wire escalation for antegrade crossing of coronary chronic total occlusions. Methods The primary endpoints were: the time required to cross the chronic total occlusion or abort the procedure, and the frequency of procedural major adverse cardiovascular events. The secondary endpoints were: technical and procedural success, total procedure time, fluoroscopy time required to cross and total fluoroscopy time, total air kerma radiation dose, total contrast volume, and equipment utilization. Results Between 2015 and 2017, 246 patients were randomized to CrossBoss (n=122) or wire escalation (n=124) at 11 US centers. The baseline clinical and angiographic characteristics of the study groups were similar. Technical and procedural success were 87.8% and 84.1%, respectively and were similar in the two groups. Crossing time was similar: 56 (interquartile ranges: 33, 93) min in the CrossBoss and 66 (36, 105) min in the wire escalation group (p=0.323), as was as the incidence of procedural major adverse cardiovascular events (3.28% vs. 4.03%, p=1.000). There were no significant differences in the secondary study endpoints. Conclusions As compared with wire escalation, upfront use of the CrossBoss catheter for antegrade crossing of coronary chronic total occlusions was associated with similar crossing time, similar success and complication rates and similar equipment utilization and cost.

Objectives We sought to examine near-infrared spectroscopy (NIRS) imaging findings of aortocoronary saphenous vein grafts (SVGs). Background SVGs are prone to develop atherosclerosis similar to native coronary arteries. They have received little study using NIRS. Methods We examined the clinical characteristics and imaging findings from 43 patients who underwent NIRS imaging of 45 SVGs at our institution between 2009 and 2016. Results The mean patient age was 67 ± 7 years and 98% were men, with high prevalence of diabetes mellitus (56%), hypertension (95%), and dyslipidemia (95%). Mean SVG age was 7 ± 7 years, mean SVG lipid core burden index (LCBI) was 53 ± 60 and mean maxLCBI4 mm was 194 ± 234. Twelve SVGs (27%) had lipid core plaques (2 yellow blocks on the block chemogram), with a higher prevalence in SVGs older than 5 years (46% vs. 5%, P = 0.002). Older SVG age was associated with higher LCBI (r = 0.480, P

Background The Flash Ostial system (Ostial Corporation, Sunnyvale, CA) was designed to optimize implantation of aorto-ostial coronary stents by flaring the proximal stent struts against the aortic wall. Methods We retrospectively reviewed the medical record, angiograms, and intravascular ultrasound images of 22 aorto-ostial percutaneous coronary interventions performed at our institution between March and September 2015. The Flash Ostial system was used in 13 cases (59%). Results Mean age was 67 ± 8 years and all patients were men. The target vessel was the right coronary artery (59%), left main (27%), or a saphenous vein graft (14%); 59% of the lesions had moderate/severe calcification. The mean number of predilation balloons was 1.8 ± 1.6, mean Flash ostial balloon diameter was 3.3 ± 0.5 mm and mean inflation pressure was 13.1 ± 4.0 atmospheres. Intravascular ultrasonography (available for 19 patients) revealed mean ostial minimum lumen cross-sectional area (MLA) of 9.2 ± 3.0 mm2 and reference MLA of 8.5 ± 2.7 mm2. The percent difference between ostial and reference MLA was higher in cases in which the Flash Ostial system was used versus those where it was not (9.6 ± 5.5% vs. 4.0 ± 2.8%, P = 0.03). All stent struts were well apposed. Technical success was 100%. One patient developed a left groin pseudoaneurysm treated with thrombin injection and one patient had a periprocedural myocardial infarction. Median contrast, fluoroscopy time, and procedure time were 235 mL, 33 min, and 118 min, respectively. Conclusions The Flash Ostial system can be successfully used in aorto-ostial stenting, resulting in large ostial vessel MLA. © 2016 Wiley Periodicals, Inc.

The contemporary use and outcomes of excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI) are not well described.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.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).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.

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).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.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.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.

The American College of Cardiology (ACC), the American Heart Association (AHA), and the European Society of Cardiology (ESC) have been developing guidelines to assist clinicians in making evidence-based decisions.The current ACC/AHA and ESC guidelines for non-ST-segment elevation acute coronary syndromes (NSTE-ACS) that were updated in 2014 and 2015, respectively, were compared to assess the number of recommendations on the basis of class of recommendation and level of evidence (LOE), the sources cited, and the content.The total number of recommendations in the ACC/AHA and ESC guidelines was 182 and 147, respectively. The recommendation class distribution of the ACC/AHA guidelines was 61.0% class I (compared with 61.9% in the ESC guidelines, P=0.865), 29.7% class II (compared with 32.0% in the ESC guidelines, P=0.653), and 9.3% class III (compared with 6.1% in the ESC guidelines, P=0.282). The LOE distribution among ACC/AHA guidelines was 15.9% LOE A (compared with 27.9% in the ESC guidelines, P=0.008), 50.0% LOE B (compared with 33.3% in the ESC guidelines, P=0.002), and 34.1% LOE C (compared with 38.8% in the ESC guidelines, P=0.377). The ACC/AHA guidelines cited 827 publications and the ESC guidelines cited 551 publications, 124 of which were shared by both sets of guidelines. The guidelines' approaches to NSTE-ACS were consistent, with minor differences in diagnostic and medical therapy recommendations.Overall, the ACC/AHA and ESC guidelines contain a comparable number of recommendations and provide similar guidance for the management of patients with NSTE-ACS.

Objective To examine the relationship between occupational exposure to ionizing radiation and the prevalence of lens changes in interventional cardiologists (ICs) and catheterization laboratory (“cath-lab”) staff. Background Exposure to ionizing radiation is associated with the development of lens opacities. ICs and cath-lab staff can receive high doses of ionizing radiation without protection, and may thus be at risk for lens opacity formation. Methods We conducted a cross-sectional study at an interventional cardiology conference. Study participants completed a questionnaire pertaining to occupational exposure to radiation and potential confounders for the development of cataracts, followed by slit-lamp examination and grading of lens findings. Results A total of 117 attendees participated in the study, including 99 (85%; 49 ± 11 years-old; 82% male) with occupational exposure to ionizing radiation and 18 (15%; 39 ± 12 years-old; 61% male) unexposed controls. The prevalence of overall cortical and posterior subcapsular lens changes (including subclinical findings) was higher in exposed participants compared with controls (47 vs. 17%, P = 0.015). Occupational exposure and age over 60 were independent predictors of lens changes (odds ratio [95% CI]: 6.07 [1.38–43.45] and 7.72 [1.60–43.34], respectively). The prevalence of frank opacities was low and similar between the two groups (14 vs. 6%, P = 0.461). Most lens findings consisted of subclinical changes in the periphery of the lens without impact on visual acuity. Conclusions Compared with unexposed controls, ICs and cath-lab staff had a higher prevalence of lens changes that may be attributable to ionizing radiation exposure. While most of these changes were subclinical, they are important due to the potential to progress to clinical symptoms, highlighting the importance of minimizing staff radiation exposure.

We investigated whether side-branch loss during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) could adversely impact clinical outcomes.Side-branch occlusion during PCI has been associated with periprocedural myocardial infarction and higher incidence of major adverse cardiac event (MACE), but has received limited study in CTO-PCI.We retrospectively reviewed the medical records and coronary angiograms for 109 consecutive CTOPCI cases performed at our institution during 2012 and 2013. Post-PCI patency of ≥1 mm diameter side branches and associated clinical outcomes were assessed.Mean age was 65 ± 8 years and 99.1% of the patients were men. The CTO target vessel was the right coronary artery (54%), circumflex (26%), and left anterior descending artery (20%). Side-branch loss occurred in 28 cases (25.7%) due to antegrade dissection/reentry (n = 9), retrograde dissection/reentry (n = 5), stenting over the branch (n = 12), and dissection during antegrade crossing attempts (n = 2). Recanalization of the occluded side branch was pursued in 8 cases (28.6%) and was successful in 4 patients. Patients with side-branch loss had higher post-PCI increase in CK-MB levels (8.4 ng/mL [interquartile range, 2.7-33.5 ng/mL] vs 1.8 ng/mL [interquartile range, 0.025-6.775 ng/mL]; P.001) and higher 12-month incidence of all-cause death (17.3% vs 2.8%; P=.02) and cardiovascular death (7.4% vs 0.0%; P=.02).Side-branch loss occurs in approximately 1 in 4 CTO-PCIs and is associated with higher risk for periprocedural myocardial infarction and higher mortality.

The Flash Ostial system (Ostial Corporation, Sunnyvale, CA) was designed to optimize implantation of aorto-ostial coronary stents by flaring the proximal stent struts against the aortic wall.We retrospectively reviewed the medical record, angiograms, and intravascular ultrasound images of 22 aorto-ostial percutaneous coronary interventions performed at our institution between March and September 2015. The Flash Ostial system was used in 13 cases (59%).Mean age was 67 ± 8 years and all patients were men. The target vessel was the right coronary artery (59%), left main (27%), or a saphenous vein graft (14%); 59% of the lesions had moderate/severe calcification. The mean number of predilation balloons was 1.8 ± 1.6, mean Flash ostial balloon diameter was 3.3 ± 0.5 mm and mean inflation pressure was 13.1 ± 4.0 atmospheres. Intravascular ultrasonography (available for 19 patients) revealed mean ostial minimum lumen cross-sectional area (MLA) of 9.2 ± 3.0 mmThe Flash Ostial system can be successfully used in aorto-ostial stenting, resulting in large ostial vessel MLA. © 2016 Wiley Periodicals, Inc.

We sought to examine the impact of prior failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 1,213 consecutive patients who underwent 1,232 CTO PCIs between 2012 and 2015 at 12 US centers. Mean age was 65 ± 10 years and 84.8% of patients were men. A prior failed attempt had been performed in 215 (17.5%) patients. As compared with patients without prior CTO PCI failure, patients with prior failure had higher Japanese Chronic Total Occlusion (J-CTO) score (2.40 ± 1.13 vs. 3.28 ± 1.29, p

We assessed the efficacy and safety of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using antegrade dissection re-entry (ADR). We examined outcomes of ADR CTO PCI cases among 1794 procedures performed at 14 experienced US centers from 2012-2016. Mean age was 65±10 years

There is limited study on the impact of contemporary X-ray systems on patient radiation dose. An anthropomorphic phantom was used in a series of standardized experiments which included 7 projections each lasting 15 sec. Five to twelve tests were performed in four commonly used X-ray systems

Background: We examined contemporary use and outcomes of excimer laser coronary atherectomy (ELCA) in percutaneous coronary intervention (PCI). Methods: The baseline clinical and angiographic characteristics; procedural outcomes of 119 consecutive PCIs in which ELCA was performed between 2008 and

Intravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the frequency of use and outcomes of intravascular imaging among 619 chronic total occlusion (CTO) percutaneous coronary interventions (PCIs) performed between 2012 and 2015 at 7

We evaluated the use of Google Glass for remote transthoracic echocardiography (TTE) video capture and interpretation. Google Glass was used to record 17 TTE studies with 25 key findings. Ten physicians (3 faculty and 7 fellow cardiologists) interpreted recordings on a) desktop, b) iPhone, c) iPad

We sought to examine the impact of prior failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and procedural outcomes of 1,213 consecutive patients who underwent 1,232 CTO PCI between 2012 and