Clinical Outcomes of Unprotected Left Main Coronary Artery Stenting in Nonsurgical Patients: A Single-Center Experience

Purpose: Coronary artery bypass graft is the standard treatment for unprotected left main disease; however, some patients are poor surgical candidates due to comorbidities. We assessed the safety and clinical outcome of elective, unprotected left main coronary artery stenting in nonsurgical patients. Methods: Between October 2004 and June 2006, 50 consecutive patients underwent elective, unprotected left main coronary artery stenting at our institution. Patients were followed for a median of 16 and 96 months and clinical outcomes monitored. Results: Median logistic euroSCORE was 28.6 (interquartile range: 14.6-43.4). Median baseline left ventricular ejection fraction (LVEF) was 50%. Procedural success rate was 100%. The rates of cerebrovascular accident, myocardial infarction, target vessel revascularization and cardiovascular death were 2%, 4%, 4% and 2%, respectively, at 30 days, 2%, 6%, 6% and 2% at 16 months, and 2%, 6%, 12% and 4% at 96 months. Major adverse cardiac and cerebrovascular event rate was 12% at 30 days, 16% at 16 months and 24% at 96 months. Median LVEF at 16 months was 55%, significantly improved from baseline (P<0.001). Conclusion: In nonsurgical patients with left main disease, stenting of the unprotected left main coronary artery is safe, with acceptable rates of major adverse cardiac and cerebrovascular event up to 96 months poststenting

Reduced esophageal cooling with left atrial roof and posterior wall cryoablation

Background: Thermal esophageal injury is a rare but devastating complication of pulmonary vein isolation using radiofrequency energy or cryoablation (CRYO) and also radiofrequency ablation of posterior wall (PW). Risk of esophageal injury with PW and roof CRYO is unknown. Since PW and roof CRYO has recently been advocated, we studied minimum esophageal temperature (MET) to assess safety of PW and roof CRYO. Purpose: To assess safety of PW and roof CRYO for atrial fibrillation. Methods: CRYO was performed in 16 patients (mean age: 64 ± 9 years; mean left atrial volume: 59 ± 24 mL/m2 ; male sex: 12) with atrial fibrillation (8 paroxysmal, 8 persistent). Following pulmonary vein isolation, CRYO balloon was dragged across the roof and PW with lesions delivered at half-balloon-width intervals. CRYO balloon and esophagus were precisely localized to 1 mm accuracy with Navik 3D mapping system (APN Health, LLC, Waukesha, WI). Lesions were maintained for 3 minutes unless a MET of \u3c28°C was encountered. Incidence of lesions with a MET of 28°C was compared between pulmonary veins, PW, and roof sites using Fisher’s exact test. Results: Lesions were distributed as follows: roof (n=81), PW (n=34), and pulmonary veins (right superior [RSPV, n=19], right inferior [RIPV, n=21], left superior [LSPV, n=19], and left inferior [LIPV, n=17]). Occurrence of MET of \u3c28°C was: 1 of 81 roof, 2 of 34 PW, 2 of 21 RIPV, 2 of 17 LIPV, and no RSPV/LSPV lesions. MET of \u3c28°C was more common in RIPV (9.5%) and LIPV (11.8%) when compared to roof (1.2%) and PW (5.9%); these differences were statistically significant (P\u3c0.001 for all comparisons). Conclusion: Significant esophageal cooling with CRYO is less common at the roof and PW than in inferior pulmonary veins, and the overall incidence is low. CRYO of PW and roof may be safer than CRYO of pulmonary veins

Zero-Fluoroscopy Cavotricuspid Isthmus Ablation Using Carto Mapping System as Sole Guiding Method

Background: Catheter ablation of the cavotricuspid isthmus (CTI) is traditionally performed using fluoroscopy and electroanatomical mapping systems. Zero-fluoroscopy approaches have recently been studied, mostly using the EnSite® mapping system (St. Jude Medical Inc., St. Paul, MN). We studied the feasibility and efficacy of zero-fluoroscopic mapping and ablation of the CTI using the Carto® 3 system (Biosense Webster Inc., South Diamond Bar, CA). Purpose: To evaluate the efficacy and safety of a zero-fluoroscopic approach to CTI ablation. Methods: We included 9 patients with typical atrial flutter for whom mapping and ablation of the CTI was done using Carto mapping as the sole guiding modality. Zero fluoroscopy was achieved in all of them. Another group of 9 matched patients whose ablations were done using the traditional method (i.e. fluoroscopy and Carto guidance) were included as a control. Results: Both groups had similar baseline characteristics. The total fluoroscopy time and radiation dose in the control group were 12.8 ± 4.8 minutes, 230.2 ± 131.9 mGy, respectively. The zero-fluoroscopy group were done while wearing no lead aprons. The average total procedure time was 114.8 ± 16.9 minutes in the zero-fluoroscopy group, significantly less than that of the control group (138.6 ± 24.3 minutes; P = 0.0286). The total radiofrequency time was similar in both groups (15.2 ± 7.4 minutes in zero-fluoroscopy group vs 16 ± 2.9 minutes in control group; P = 0.9294). Bidirectional block was achieved in all patients of both groups. No complications were encountered in either group. Conclusion: To our knowledge, this is the first study of a zero-fluoroscopic approach using the Carto mapping system for ablation of the cavotricuspid isthmus in the United States. The approach is feasible and effective in achieving bidirectional block with less average total procedure time

Stent fracture, an incidental finding or a significant marker of clinical in-stent restenosis?

BACKGROUND: The predictors and clinical significance for stent fracture (SF) in drug-eluting stents (DES) remain unknown. We identified procedural factors leading to SF and its clinical consequences in DES. METHODS: Percutaneous coronary interventions were performed on 3,920 patients with DES over 12 months. In-stent restenosis (ISR) of DES was observed in 188 cases with 121 cases (64.4%) receiving a sirolimus-eluting stent (SES) and 67 (35.6%) a paclitaxol-eluting stent (PES). RESULTS: SF was identified in 35 (18.6%) of the 188 cases. The 35 cases were then compared with 153 cases of ISR without angiographic evidence of SF. SF was identified in 29 (23.9%) SES compared with 6 (9.0%) in PES (P \u3c 0.05). With univariate analysis, additional factors associated with SF included longer mean stented segment length, male gender, overlapping stents, vessel segment angulation \u3e75 degrees , and more stents (all P \u3c 0.05). With multivariate adjustment, three factors, i.e., stenting on a bend \u3e75 degrees (OR = 13.8, 95%CI 3.7 to 51; P \u3c 0.001), SES (OR = 4.1, 95%CI 1.3 to 13.4; P \u3c 0.018) and overlapping stented segments (OR = 3.9, 95%CI 1.1 to 14.1; P \u3c 0.041) were statistically significant independent predictors of SF while larger stent diameter was protective (OR = 0.14, 95%CI 0.04 to 0.70; P \u3c 0.017). CONCLUSION: SF proved to be associated with angiographically-documented clinical ISR. Although the exact mechanism is unknown, factors that appear to play a negative role in SF include vessel tortuosity, use of SES and overlapping stents. Larger stent diameter was protective. Further studies are needed to better define the factors important in the mechanism of SF

Clinical Outcomes of Unprotected Left Main Coronary Artery Stenting in Nonsurgical Patients: A Single-Center Experience

Purpose: Coronary artery bypass graft is the standard treatment for unprotected left main disease; however, some patients are poor surgical candidates due to comorbidities. We assessed the safety and clinical outcome of elective, unprotected left main coronary artery stenting in nonsurgical patients. Methods: Between October 2004 and June 2006, 50 consecutive patients underwent elective, unprotected left main coronary artery stenting at our institution. Patients were followed for a median of 16 and 96 months and clinical outcomes monitored. Results: Median logistic euroSCORE was 28.6 (interquartile range: 14.6-43.4). Median baseline left ventricular ejection fraction (LVEF) was 50%. Procedural success rate was 100%. The rates of cerebrovascular accident, myocardial infarction, target vessel revascularization and cardiovascular death were 2%, 4%, 4% and 2%, respectively, at 30 days, 2%, 6%, 6% and 2% at 16 months, and 2%, 6%, 12% and 4% at 96 months. Major adverse cardiac and cerebrovascular event rate was 12% at 30 days, 16% at 16 months and 24% at 96 months. Median LVEF at 16 months was 55%, significantly improved from baseline (P<0.001). Conclusion: In nonsurgical patients with left main disease, stenting of the unprotected left main coronary artery is safe, with acceptable rates of major adverse cardiac and cerebrovascular event up to 96 months poststenting

Clinical Outcomes of Unprotected Left Main Coronary Artery Stenting in Nonsurgical Patients: A Single-Center Experience

Purpose: Coronary artery bypass graft is the standard treatment for unprotected left main disease; however, some patients are poor surgical candidates due to comorbidities. We assessed the safety and clinical outcome of elective, unprotected left main coronary artery stenting in nonsurgical patients. Methods: Between October 2004 and June 2006, 50 consecutive patients underwent elective, unprotected left main coronary artery stenting at our institution. Patients were followed for a median of 16 and 96 months and clinical outcomes monitored. Results: Median logistic euroSCORE was 28.6 (interquartile range: 14.6-43.4). Median baseline left ventricular ejection fraction (LVEF) was 50%. Procedural success rate was 100%. The rates of cerebrovascular accident, myocardial infarction, target vessel revascularization and cardiovascular death were 2%, 4%, 4% and 2%, respectively, at 30 days, 2%, 6%, 6% and 2% at 16 months, and 2%, 6%, 12% and 4% at 96 months. Major adverse cardiac and cerebrovascular event rate was 12% at 30 days, 16% at 16 months and 24% at 96 months. Median LVEF at 16 months was 55%, significantly improved from baseline (P\u3c0.001). Conclusion: In nonsurgical patients with left main disease, stenting of the unprotected left main coronary artery is safe, with acceptable rates of major adverse cardiac and cerebrovascular event up to 96 months poststenting

Clinical Outcomes of Unprotected Left Main Coronary Artery Stenting in Nonsurgical Patients: A Single-Center Experience

Purpose: Coronary artery bypass graft is the standard treatment for unprotected left main disease; however, some patients are poor surgical candidates due to comorbidities. We assessed the safety and clinical outcome of elective, unprotected left main coronary artery stenting in nonsurgical patients. Methods: Between October 2004 and June 2006, 50 consecutive patients underwent elective, unprotected left main coronary artery stenting at our institution. Patients were followed for a median of 16 and 96 months and clinical outcomes monitored. Results: Median logistic euroSCORE was 28.6 (interquartile range: 14.6-43.4). Median baseline left ventricular ejection fraction (LVEF) was 50%. Procedural success rate was 100%. The rates of cerebrovascular accident, myocardial infarction, target vessel revascularization and cardiovascular death were 2%, 4%, 4% and 2%, respectively, at 30 days, 2%, 6%, 6% and 2% at 16 months, and 2%, 6%, 12% and 4% at 96 months. Major adverse cardiac and cerebrovascular event rate was 12% at 30 days, 16% at 16 months and 24% at 96 months. Median LVEF at 16 months was 55%, significantly improved from baseline (P<0.001). Conclusion: In nonsurgical patients with left main disease, stenting of the unprotected left main coronary artery is safe, with acceptable rates of major adverse cardiac and cerebrovascular event up to 96 months poststenting