Best Practice in Intravascular Lithotripsy

Intravascular lithotripsy (IVL) is a novel approach to lesion preparation of severely calcified plaques in coronary and peripheral vessels. Lithotripsy is delivered by vaporising fluid to create an expanding bubble that generates sonic pressure waves that interact with arterial calcification. Available data indicate that IVL leads to increased vessel compliance before stent implantation with high efficacy and an excellent safety profile. Since it gained the CE mark in 2017, and with improved operator experience, the use of IVL has expanded into more complex clinical situations. This review focuses on the best practice for IVL use in the cath lab, based on 3 years of experience with the technology and the latest scientific data from the Disrupt CAD clinical trials

0254: Updated reference levels for radiation doses to patients undergoing coronary angiography and coronary percutaneous interventions: the RAY’ACT2 study

PurposeThe RAY’ACT project is a nationwide, multicentre survey program aimed at evaluating patient radiation protection (RP) during coronary angiography (CA) and percutaneous coronary interventions (PCI) in French non-university public hospitals, which represent>30% of the national activity for PCIs, and 60% of the emergency cases. We present the updated reference levels based on the results of the second survey conducted in 2013 (RAY’ACT2).MethodsRP parameters from 48,547 CAs and 40,026 PCIs performed at 61 centres during 2013 and routinely registered in professional software were extracted and analysed retrospectively. Kerma-area product (KAP), fluoroscopy time (FT), number of acquired frames (Nb F) and runs (NR), and total Air Kerma at interventional reference point (KA, r) were analysed separately for CAs and PCIs (elective and ad hoc pooled). All procedures of the year were included.ResultsThe table shows the medians (Q1-Q3) of the RP parameters, updated RLs based on the 75th percentiles of the values for CA and PCI (bold), and previous RLs (RAY’ACT1, 2010).ConclusionsBetween 2010 and 2013, a 20 to 30% decrease was observed in medians and Reference Levels (Q3) for main RP parameters, including KAP and total Air Kerma.Abstract 0254 – Table: Results2013 (RAY’ACT2) 61 centres2010 (RAY’ACT1) 44 centresCAN=48,547N=31,066KAP (Gy.cm²)20.9 (11.8-35.7)27.2 (15.5-45.2)FT (min)3.3 (2.1-5.7)3.7 (2.3-6.3)Nb Frames404 (284-566)553 (388-769)KA,r (mGy)294 (164-498)421 (240-695)PCIN=40,026N=25,356KAP (Gy.cm²)45.2 (25.6-77.6)56.8 (32.8-94.6)FT (min)9.8 (6.3-15.4)10.3 (6.7-16.2)Nb Frames676 (465-960)837 (578-1193)KA,r (mGy)747 (421-1285)1052 (589-1788

TCT-367 Gender impact on patients treated with drug-eluting stents – 3 year follow-up data

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Overview of the current use of levosimendan in France: a prospective observational cohort study

Abstract Background Following the results of randomized controlled trials on levosimendan, French health authorities requested an update of the current use and side-effects of this medication on a national scale. Method The France-LEVO registry was a prospective observational cohort study reflecting the indications, dosing regimens, and side-effects of levosimendan, as well as patient outcomes over a year. Results The patients included ( n = 602) represented 29.6% of the national yearly use of levosimendan in France. They were treated for cardiogenic shock ( n = 250, 41.5%), decompensated heart failure ( n = 127, 21.1%), cardiac surgery-related low cardiac output prophylaxis and/or treatment ( n = 86, 14.3%), and weaning from veno-arterial extracorporeal membrane oxygenation ( n = 82, 13.6%). They received 0.18 ± 0.07 µg/kg/min levosimendan over 26 ± 8 h. An initial bolus was administered in 45 patients (7.5%), 103 (17.1%) received repeated infusions, and 461 (76.6%) received inotropes and or vasoactive agents concomitantly. Hypotension was reported in 218 patients (36.2%), atrial fibrillation in 85 (14.1%), and serious adverse events in 17 (2.8%). 136 patients (22.6%) died in hospital, and 26 (4.3%) during the 90-day follow-up. Conclusions We observed that levosimendan was used in accordance with recent recommendations by French physicians. Hypotension and atrial fibrillation remained the most frequent side-effects, while serious adverse event potentially attributable to levosimendan were infrequent. The results suggest that this medication was safe and potentially associated with some benefit in the population studied

Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score

International audienceObjectives Risk scores are recommended in guidelines to facilitate the management of patients who present with acute coronary syndromes (ACS). Internationally, such scores are not systematically used because they are not easy to apply and some risk indicators are not available at first presentation. We aimed to derive and externally validate a more accurate version of the Global Registry of Acute Coronary Events (GRACE) risk score for predicting the risk of death or death/myocardial infarction (MI) both acutely and over the longer term. The risk score was designed to be suitable for acute and emergency clinical settings and usable in electronic devices.Design and setting The GRACE risk score (2.0) was derived in 32 037 patients from the GRACE registry (14 countries, 94 hospitals) and validated externally in the French registry of Acute ST-elevation and non-ST-elevation MI (FAST-MI) 2005.Participants Patients presenting with ST-elevation and non-ST elevation ACS and with long-term outcomes.Outcome measures The GRACE Score (2.0) predicts the risk of short-term and long-term mortality, and death/MI, overall and in hospital survivors.Results For key independent risk predictors of death (1 year), non-linear associations (vs linear) were found for age (p<0.0005), systolic blood pressure (p<0.0001), pulse (p<0.0001) and creatinine (p<0.0001). By employing non-linear algorithms, there was improved model discrimination, validated externally. Using the FAST-MI 2005 cohort, the c indices for death exceeded 0.82 for the overall population at 1 year and also at 3 years. Discrimination for death or MI was slightly lower than for death alone (c=0.78). Similar results were obtained for hospital survivors, and with substitutions for creatinine and Killip class, the model performed nearly as well.Conclusions The updated GRACE risk score has better discrimination and is easier to use than the previous score based on linear associations. GRACE Risk (2.0) performed equally well acutely and over the longer term and can be used in a variety of clinical settings to aid management decisions

Third generation drug eluting stent (DES) with biodegradable polymer in diabetic patients: 5 years follow-up

To report the long-term safety and efficacy data of a third generation drug eluting stent (DES) with biodegradable polymer in the complex patient population of diabetes mellitus after a follow-up period of 5 years