Debate: PCI vs CABG: a moving target, but we are gaining

The treatment of patients with coronary artery disease continues to evolve; all three strategies – medical therapy, surgical revascularization, and percutaneous coronary intervention – have changed. Medical therapy with intense risk-factor modification and treatment with a statin, aspirin, and angiotensin-converting enzyme (ACE) inhibitors, should be used unless contraindicated. Surgical therapy has also changed with the introduction of minimally invasive, beating heart surgery. Percutaneous coronary intervention has perhaps changed the most radically with adjunctive therapy – glycoprotein IIb/IIIa inhibitors, thienopyridines, and reliance on stent implantation. The future, with new distal protection devices and drug-coated stents, should continue to see increased numbers of patients who can benefit from percutaneous intervention

Left atrial appendage closure: a percutaneous transcatheter approach for stroke prevention in atrial fibrillation

Atrial fibrillation is a frequent cause of stroke; in the elderly, more than 20% of strokes are attributed to this common arrhythmia. Anticoagulation with warfarin reduces the risk of stroke by ∼60%; however, a large proportion of patients with atrial fibrillation do not receive this treatment because of relative/absolute contraindications. Moreover, patients often discontinue warfarin for a variety of reasons and chronic warfarin administration rates remain suboptimal. Although the compliance with anticoagulation may improve with novel anticoagulants and bleeding risk can be somewhat reduced when compared with warfarin, there is still a progressive increase in bleeding complications over time. Accordingly, new approaches for stroke prevention in these patients are being explored and tested. In transoesophageal echocardiographic (TEE) studies, more than 90% of thrombi were found in the left atrial appendage (LAA) in non-valvular atrial fibrillation, and transcatheter LAA closure is developed and examined as a novel approach to reduce the risk of stroke in these patients. The PROTECT-AF study provides first evidence from a randomized clinical trial that a strategy of LAA occlusion using the Watchman device can be non-inferior to anticoagulation with warfarin for a combined endpoint in patients with non-valvular atrial fibrillation (mean CHADS2 score 1.8). In successfully occluded patients fulfilling TEE criteria (86%), warfarin was stopped after 45 days, followed by aspirin and clopidogrel for 6 months after randomization and subsequently aspirin. The PREVAIL trial is further evaluating this concept. Limited data are available for another LAA occlusion system, the Amplatzer Cardiac Plug (ACP) device, for which the ACP trial has been initiated. Left atrial appendage occlusion needs to be performed with meticulous care by experienced operators because periprocedural complications such as pericardial effusion or stroke have been documented. With increased operator experience and technical improvements of the device, these complications can be minimize

Strategies to Incorporate Left Atrial Appendage Occlusion Into Clinical Practice

AbstractThe left atrial appendage (LAA) has been identified as a predominant source of thrombus formation leading to significant thromboembolic events in patients with nonvalvular atrial fibrillation. Medical therapy to eliminate thrombus formation in the LAA has been the standard of care for several decades, but mechanical approaches designed to exclude the LAA from the circulation have recently been developed. The largest body of randomized and nonrandomized data to date has been for the Watchman device (Boston Scientific, Natick, Massachusetts), which was recently approved by the Food and Drug Administration for selected patients in the United States. There are no current guidelines or guidance for institutions and operators looking to become involved in this therapy. This perspective is aimed at exploring these issues and providing necessary information and guidance to these programs and operators to help ensure a successful launch of a LAA occlusion program and optimize patient selection, procedural performance, and outcome

Paper Session I-B - Robust Low Cost Aerospike/RLV Combustion Chamber By Advanced Vacuum Plasma Process

Next-generation, regeneratively cooled rocket engines will require materials that can withstand high temperatures while retaining high thermal conductivity. At the same time, fabrication techniques must be cost efficient so that engine components can be manufactured within the constraints of a shrinking NASA budget. In recent years, combustion chambers of equivalent size to the Aerospike chamber have been fabricated at NASA-Marshall Space Flight Center (MSFC) using innovative, relatively low-cost, vacuum-plasma-spray (VPS) techniques (1,2). Typically, such combustion chambers are made of the copper alloy NARloy-Z. However, current research and development conducted by NASA-Lewis Research Center (LeRC) has identified a Cu-8Cr-4Nb alloy which possesses excellent high-temperature strength, creep resistance, and low cycle fatigue behavior combined with exceptional thermal stability. In fact, researchers at NASA-LeRC have demonstrated that powder metallurgy (P/M) Cu-8Cr-4Nb exhibits better mechanical properties at 650°C (1200°F) than NARloy-Z does at 538°C (1000°F}. The objective of this program is to develop and demonstrate the technology to fabricate high-performance, robust, inexpensive combustion chambers for advanced propulsion systems such as Lockheed-Martin\u27s VentureSta( and NASA\u27s Reusable Launch Vehicle (RLV) using the VPS process. The VPS Cu-8Cr-4Nb had mechanical properties that match or exceed those of P/M Cu-8Cr-4Nb. In addition, oxidation resistant and thermal barrier coatings can be incorporated as an integral part of the hot wall of the liner during the VPS process, significantly extending the life/performance. Tensile properties of Cu-8Cr-4Nb material produced by VPS are reviewed and compared to material produced previously by extrusion. VPS formed combustion chamber liners have also been prepared and will be reported on, following scheduled hot firing tests at NASA-LeRC

Variability in Fluoroscopic X-Ray Exposure in Contemporary Cardiac Catheterization Laboratories

ObjectivesThis study sought to assess fluoroscopic exposure rates in contemporary cardiac catheterization laboratories (CCL).BackgroundIncreasing attention is being focused on X-ray exposure during diagnostic and therapeutic cardiovascular procedures.MethodsWe measured fluoroscopic exposure rates (R/min) in 41 systems using a standardized methodology (National Electrical Manufacturers Association XR21 phantom). Measurements were obtained at 2 different phantom thicknesses to simulate varying patient body habitus.ResultsFluoroscopic exposure rates under medium (median 3.0 R/min, interquartile range 1.4 R/min) and large (median 12.5 R/min, interquartile range 4.8 R/min) habitus conditions showed substantial variation. Fluoroscopic exposure was associated with simulated patient habitus, X-ray system type, vendor, and geographic region. Under medium habitus conditions, only 25% of systems operated within a zone of lower than average exposure rates and satisfactory image quality; this frequency diminished to 7% under large habitus conditions (p < 0.001).ConclusionsThere is substantial variation (4- to 6-fold) in fluoroscopic exposure rates. This variation was not consistently associated with improved image quality. In the absence of a predictable benefit of higher (or lower) than average exposure rates, CCL quality improvement programs must minimize such potentially harmful variability in X-ray exposure