Complexity assessment and technical aspect of coronary angiogram and percutaneous coronary intervention following transcatheter aortic valve implantation

Background: Performing selective coronary angiogram (CA) and percutaneous coronary intervention (PCI) post transcatheter aortic valve implantation (TAVI) may be challenging with various success rates of coronary ostia engagement. Methods: Among all patients who underwent CA and/or PCI after TAVI from our single center TAVI registry, ostia cannulation success was reported according to the quality of ostia engagement and artery opacification, and was classified as either selective, partially selective or non-selective but sufficient for diagnosis. Results: Among the 424 consecutive TAVI procedures performed at the aforementioned institution, 20 (4.7%) CA were performed in 19 (4.5%) patients at a median time of 464 days post TAVI (25–75% IQ: 213–634 days). CA were performed in 7 CoreValve, 9 Evolut R, 1 Evolut PRO and 2 Edwards Sapien 3 devices. Transradial vascular approach was attempted in 9 procedures (45%, right n = 6 and left n = 3) and was successful in 8 (40%) patients. A total of 20 left main artery ostium cannulation were attempted leading to a diagnostic CA in all of them with selective engagement in 65%.  Engagement of the right coronary artery in 2 out of 15 attempted cases failed due to a low ostium in conjunction with a high implantation of a CoreValve prosthesis. 11 PCI (55% of CA) including 2 left main lesions were performed. In 4 patients (36.4% of the PCI), an extension catheter was required to engage the left main. All planned PCI were successful. Conclusions: Post TAVI CA and PCI are challenging but feasible even after supra-annular self-expandable valve implantation

Outcomes and regional differences in practice in a worldwide coronary stent registry

Objective: The primary objective was to assess the performance of a new generation thin-strut sirolimus-eluting coronary stent with abluminal biodegradable polymer in an all comer population. The secondary objective was to detail differences in contemporary percutaneous coronary intervention (PCI) practice worldwide. Methods: e-Ultimaster was an all-comer, prospective, global registry (NCT02188355) with independent event adjudication enrolling patients undergoing PCI with the study stent. The primary outcome measure was target lesion failure (TLF) at 1 year, defined as the composite of cardiac death, target vessel myocardial infarction and clinically driven target lesion revascularisation. Data were stratified according to 4 geographical regions. Results: A total of 37 198 patients were enrolled (Europe 69.2%, Asia 17.8%, Africa/Middle East 6.6% and South America/Mexico 6.5%) and 1-year follow-up was available for 35 389 patients (95.1%). One-year TLF occurred in 3.2% of the patients, ranging from 2% (Africa/Middle East) to 4.1% (South America/Mexico). In patients with acute coronary syndrome, potent P2Y(12) inhibitors were prescribed in 48% of patients at discharge, while at 1 year 72% were on any dual antiplatelet therapy. Lipid-lowering treatment was administered in 80.9% and 75.5% of patients at discharge and 1 year, respectively. Regional differences in the profile of the treated patients as well as in PCI practice were reported. Conclusions: In this investigation with worldwide representation, contemporary PCI using a new generation thin-strut sirolimus-eluting coronary stent with abluminal biodegradable polymer was associated with low 1-year TLF across clinical presentations and continents. Suboptimal adherence to current recommendations around antiplatelet and lipid lowering treatments was detected

Acute coronary syndrome in the elderly

The fast population ageing and the delay in the age of presentation of acute coronary syndrome (ACS) is leading to a rapid increase in the proportion of old patients with ACS. Although elderly patients with ACS deserves a specific clinical approach due to aging physiology, increased incidence of comorbidities and different patient expectations, paradoxically this patient population is usually underrepresented in clinical studies. The up-to-date European Society of Cardiology Guidelines on NSTEACS recommends an invasive strategy after taking the consideration of estimated life expectancy, comorbidities, quality of life and patients preferences. A comprehensive follow-up strategy involving cardiac rehabilitation and medical management should be implemented

Covered stents for the percutaneous management of delayed coronary wall rupture following subadventitial rotational atherectomy

We present herein the case of a delayed covered coronary wall rupture occurring as a rare complication of rotational atherectomy performed in the subintimal space after antegrade dissection reentry for percutaneous recanalization of a long and heavily calcified left anterior descending chronic total occlusion, which was successfully managed percutaneously with the implantation of 2 covered stents. (Level of Difficulty: Intermediate.)

Recanalization of acute left internal mammary artery graft failure by percutaneous coronary intervention

Acute occlusion of the left internal mammary artery (LIMA) immediately following coronary artery bypass surgery (CABG) is a rare complication that is usually treated by repeat emergency surgery. We described the case of a 65-year-old man known for dyslipidemia and family history of coronary artery disease who was admitted for non-ST elevation myocardial infarction as a result of a severe stenosis of the left anterior descending (LAD) coronary artery. After the discussion within the Heart Team, the patient underwent CABG with LIMA to LAD. As intraoperative blood flow control by transit time flowmeter showed intermittent flow despite optimal anastomosis, immediate coronary angiogram was performed following CABG and an occlusion of the LIMA graft was documented. By contrast injection though a microcatheter advanced into the occluded LIMA it could be demonstrated that the anastomosis was patent and that flow was obstructed by a focal lesion, most likely due to a bend/torsion of the LIMA or a focal vessel wall hematoma. Following multidisciplinary discussion within the Heart Team, a percutaneous coronary intervention (PCI) with a drug eluting stent of LIMA was performed with a good angiographic result and normalization of the flow. The clinical course of the patient was uneventful. This case suggests that, in selected cases, emergent PCI may be an alternative to repeat-CABG in patients with acute perioperative LIMA occlusion

Significance and Usefulness of Narrow Fragmented QRS Complex on 12-Lead Electrocardiogram in Acute ST-Segment Elevation Myocardial Infarction for Prediction of Early Mortality and Morbidity

Background: The presence of notched R or S waves without accompanying typical bundle branch blocks, or the existence of an additional wave like RSR' pattern in the original QRS complex (with a duration of <120 ms) has been defined as narrow QRS fragmentation. Persistence of the fQRS found on the admission electrocardiogram (ECG) in patients with acute ST segment elevation myocardial infarction (STEMI) will have prognostic significance in the short term

Differential Effects of Newer-Generation Ultrathin-Strut Versus Thicker-Strut Drug-Eluting Stents in Chronic and Acute Coronary Syndromes.

OBJECTIVES The authors sought to compare the differential effects of ultrathin-strut and thicker-strut drug-eluting stents (DES) in patients with chronic (CCS) versus acute (ACS) coronary syndromes. BACKGROUND Newest-generation ultrathin-strut DES reduce target lesion failure (TLF) compared with thicker-strut second-generation DES in patients undergoing percutaneous coronary intervention. METHODS PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing newer-generation ultrathin-strut (<70 μm) versus thicker-strut (≥70 μm) DES. Patients were divided based on baseline clinical presentation (CCS versus ACS). The primary endpoint was TLF, a composite of cardiac death, target vessel myocardial infarction, or clinically indicated target lesion revascularization (TLR). RESULTS A total of 22,766 patients from 16 randomized controlled trials were included, of which 9 trials reported TLF rates in ACS patients. At a mean follow-up of 12.2 months, the risk of TLF was lower among patients treated with ultrathin-strut compared with thicker-strut DES (risk ratio [RR]: 0.85; 95% CI: 0.75-0.95; P = 0.006). The difference was driven by a lower risk of clinically-indicated TLR (RR: 0.75; 95% CI: 0.63-0.89; P < 0.001) among patients treated with ultrathin-strut DES. The treatment effect was consistent between patients presenting with CCS and ACS (relative RR: 0.97; 95% CI: 0.73-1.31; P for interaction = 0.854). In patients with ST-segment elevation myocardial infarction, TLF risk was lower among those treated with ultrathin- compared with thicker-strut DES (RR: 0.74; 95% CI: 0.54-0.99; P = 0.049). CONCLUSIONS Ultrathin-strut DES reduce the risk of TLF compared with thicker-strut second-generation DES in patients undergoing percutaneous coronary intervention, a difference caused by a lower risk of ischemia-driven TLR. The treatment effect was consistent among patients with CCS and ACS