Training standards and recommendations for intervention on chronic total occlusions

Despite major advances in coronary intervention, the recanalization of a chronic total occlusion (CTO) remains a challenge for many interventional cardiologists. Complex anatomy and lesion characteristics demand a special set of skills for procedural success. Provided patient selection is appropriate, CTO intervention can confer a variety of benefits including relief of angina, improvement in left ventricular function and reduction in ischemic burden. The chances of procedural success are enhanced by having a dedicated CTO program. This involves adequate training of staff, quality control and availability of equipment. A diverse toolkit allows variation in strategy and increases procedural success. Further, skills and equipment are required to manage complications like vessel dissection, perforation and the resultant ischemic or mechanical complications. These procedures can often be lengthy and giving careful consideration to peri-procedural issues like radiation exposure and contrast dose plays a vital role in ensuring optimal patient outcomes and radiation hygiene. In this article we review the evidence behind indications for CTO intervention and discuss the development of a CTO program

Baseline and residual SYNTAX score in predicting outcomes after acute infarct angioplasty

Aims: The aim of this study was to explore the utility of baseline SYNTAX score (BSS) and residual SYNTAX score (rSS) in predicting 12-month outcomes after primary percutaneous coronary intervention (PPCI). Methods and results: Five hundred and ninety all-comers with acute STEMI presenting for PPCI over a two-year period were identified. Of these, 173 were excluded because of unsuitability for SYNTAX score calculation for this study. Two experienced observers calculated the BSS and rSS. Mortality data were sourced from the government registry. Logistic regression was used to assess the predictive power of BSS and rSS for mortality. Sensitivity analysis and a Cox proportional hazards model were used to evaluate the best cut-off for increased mortality. Of the 417 patients analysed (mean age 59 years), 81% were male and 18% were known diabetics. At 12 months, the overall mortality rate was 5.5% (23/417). An rSS of >12 was associated with a 13.95% mortality rate. The hazard ratio for mortality was 3.88 (95% CI: 1.49-10.09, p=0.005) for rSS of >12 and 3.01 (95% CI: 1.18-7.64, p=0.02) for BSS >12. The odds ratio (OR) for mortality was 1.06 (95% CI: 1.02-1.11, p=0.009) for rSS and 1.05 (95% CI: 1.02-1.1, p=0.007) for BSS. Conclusions: In STEMI patients undergoing PPCI, both BSS and rSS can predict mortality at 12 months. Every point on the rSS confers an additional 6% mortality risk. Calculation of the rSS after culprit lesion intervention may help guide management of non-culprit lesions

Inpatient mortality and its predictors after pericardiocentesis: an analysis from the Nationwide Inpatient Sample 2009–2013

Background: National registries have provided data on in-hospital outcomes for several cardiac procedures. The available data on in-hospital outcomes and its predictors after pericardiocentesis are mostly derived from single center studies. Furthermore, the outcomes after pericardiocentesis for iatrogenic pericardial effusion and the impact of procedural volume on in-hospital outcomes in the United States are largely unknown. Methods: We used national inpatient database files for the years 2009–2013 to estimate the inpatient outcomes after pericardiocentesis in all-comers and in the subgroups with iatrogenic effusion. We also studied the impact of hospital procedural volume, among other predictors, on inpatient mortality. Results: About 64,070 (95%CI 61 008-67 051) pericardiocentesis were performed in the United States during 2009-2013. Of these, 57.15% (56.02-58.26%) of the pericardiocentesis were in hemodynamically unstable patients. Percutaneous cardiac procedures were performed in 17.7% of patients (percutaneous coronary intervention (PCI) 4.02%, electrophysiologic procedures 13.58%, and structural heart intervention (SHI) 0.76%). Overall inpatient mortality was 12.30% (95%CI 11.66-12.96%). Inpatient mortality after PCI, electrophysiologic procedures, SHI and cardiac surgery were 27.67% (95%CI 24-31.67%), 7.8% (95%CI 6.67-9.31%), 22.36% (95%CI 15.06-31.85%) and 18.97% (95%CI 15.84-22.57%), respectively. There was an inverse association between hospital procedural volume and inpatient mortality, with a mortality of 14.01% (12.84-15.26%) at the lowest and 10.82% (9.44-12.37%) at highest quartile hospitals by procedure volume (p= 0.001). Conclusion: The inpatient mortality after pericardiocentesis is high, particularly when associated with PCI and SHI

Late Incomplete stent apposition is associated with late/very late stent thrombosis: A meta-analysis

There is a lingering controversy in the current literature about the impact of late incomplete stent apposition (LISA) on clinical outcomes, especially stent thrombosis (ST). Therefore, we aimed to synthesize the available evidence evaluating the association between LISA and adverse clinical outcomes.We systematically searched electronic databases for studies reporting clinical outcomes in patients with and without LISA. Relevant study characteristics and clinical outcomes were extracted. Incidence rate ratios (IRR) and 95% Confidence Interval (CI) were computed. Sensitivity analyses were done.Sixteen studies with 4,946 patients; 666 patients with 20,035 patient-months follow up with LISA and 4,280 patients with 121,855 patient-months follow up without LISA were included. The estimated prevalence of LISA at follow up was 16% (95% CI 12-20%). The incidences of late/very late ST (IRR = 4.81, 95% CI 2.68-8.62) and myocardial infarction (MI) (IRR = 3.09, 95% CI 1.72-5.55) were significantly higher in the LISA group compared to patients without LISA. Subset analysis of studies reporting Academic Research Consortium definitive/probable ST (IRR = 4.98; 95% CI 2.51-9.89) and acquired LISA (IRR = 3.67, 95% CI 1.5-9.0) similarly showed increased risk of late/very late ST. The results of sensitivity analyses were consistent. There was no difference in cardiac death and target lesion revascularization.The presence of LISA at a follow up of 6-18 months after stent implantation is associated with a higher risk of late/very late ST and MI. Additional studies are required to establish a cause and effect, and inform the management strategy. © 2017 Wiley Periodicals, Inc

Exploring the role of non-invasive tricuspid dP/dt as a marker of right ventricular function

BackgroundRight ventricular (RV) function assumes prognostic significance in various disease states, but RV geometry is not amenable to volumetric assessment by two-dimensional echocardiography. Intra-ventricular pressure rate of rise (dP/dt) predicts myocardial contractility and adjusting for the maximal regurgitant velocity (V-max) corrects for preload. We examined the relationship of noninvasive tricuspid dP/dt and dP/dt/V-max with RV ejection fraction (RVEF) by cardiac magnetic resonance imaging (CMR) as a measure of RV function