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The coronary risk

OBJECTIVES The aim of this study was to investigate the influences of accumulated experience on rotational atherectomy (RA) operation regarding to in-hospital outcomes in the drug-eluting stent (DES) era. METHODS Between 2015 and 2019, 540 de novo lesions with calcified coronary lesions treated by RA and DES implantation at our center were retrospectively assessed. In-hospital major adverse cardiac events (MACE) were defined as all cause death, cardiac death, target vessel revascularization, and stroke. RESULTS From 2015 to 2019, RA operations were 22, 60, 102, 157, and 199 cases, respectively. Rates of procedural complications were 4.5, 3.3, 11.8, 8.3, and 7.5%, respectively. Rates of in-hospital MACE were 0, 0, 3.9, 2.5, and 2.0%, respectively. Compared with planned RA, bailout RA was associated with more contrast use (207.5 ± 82.8 ml vs. 189.2 ± 70.0 ml, p = .008). As for procedural complications and in-hospital outcomes, no differences were observed between two strategies. Logistic regression revealed that hypertension was independently associated with complications (OR 5.830, 95% CI 1.382-24.591, p = .016). For MACE, independent risk factors were heart failure (OR 17.593, 95% CI 1.475-209.816, p = .023) and procedural complications (OR 127.629, 95% CI 15.135-1,076.258, p < .001). CONCLUSIONS Along with the rapid increase of RA use and accumulated experience, rates of complications and MACE went up first and then dropped down. Hypertension was found to be an independent risk factor of procedural complications. For in-hospital MACE, independent risk factors were heart failure and procedural complications.

Outcomes of rotational atherectomy for severely calcified coronary lesions: A single center 5-year experience.

Planned versus bailout rotational atherectomy: A systematic review and meta-analysis

Objectives
We sought to assess a new modality of radiofrequency intravascular ultrasound (IVUS) called iMAP-IVUS (Boston Scientific, Santa Clara, California) during the evaluation of patients presenting with high-risk acute coronary syndromes.

Background
There are limited data on plaque tissue characterization and phenotype classification using iMAP-IVUS.

Methods
In the iWonder study patients presenting with ST-elevation myocardial infarction (STEMI) or non-STEMI underwent three-vessel grayscale IVUS and iMAP-IVUS tissue characterization prior to percutaneous intervention. In total 385 lesions from 100 patients were divided into culprit (n = 100) and nonculprit (n = 285) lesions. Lesion phenotype was classified as (i) thin-cap fibroatheroma (iMAP-derived TCFA); (ii) thick-cap fibroatheroma; (iii) pathological intimal thickening; (iv) fibrotic plaque; and (v) fibrocalcific plaque.

Results
Culprit lesions had smaller minimum lumen cross-sectional area (MLA) with greater plaque burden compared to non-culprit lesions. Volumetric analysis showed that culprit lesions had longer length and larger vessel and plaque volumes compared to non-culprit lesions. iMAP-IVUS revealed that culprit lesions presented more NC and fibrofatty volume, both at lesion level and at the MLA site (all P < 0.001). Any fibroatheroma was more frequently identified in culprit lesions compared with non-culprit lesions (93% vs. 78.9%, P = 0.001), anywhere within the lesion 19.0%, P < 0.001) as well as at the MLA site (18.0% vs. 9.5%, P = 0.07).

Conclusions
Three-vessel radiofrequency iMAP-IVUS demonstrated a greater plaque burden and higher prevalence of any fibroatheroma as well as iMAP-derived TCFAs in culprit versus non-culprit lesions in patients presenting with STEMI or non-STEMI undergoing percutaneous coronary intervention. © 2017 Wiley Periodicals, Inc.

Tissue characterization and phenotype classification in patients presenting with acute myocardial infarction: Insights from the iWonder study.

Planned Versus Bailout Rotational Atherectomy: A Systematic Review and Meta-Analysis.

To compare outcomes of bailout and planned rotational atherectomy (RA) in the treatment of severe calcified coronary lesions. Data of patients treated with RA from 2017 to 2018 at a single-center registry were retrospectively analyzed. All patients were divided into planned RA and bailout RA groups, data between two groups were compared. A total of 190 patients were included in this study, 138 patients received planned RA and 52 patients received bailout RA. Baseline clinical characteristics had no significant differences between groups. The number of implanted stents and total stents length were similar. But the number of balloon (1.6 ± 0.8 vs. 2.7 ± 1.3, P < 0.001), procedure time (83.5 ± 26.2 vs. 100.8 ± 36.4 min, P = 0.007), fluoroscopy volume (941 ± 482 vs. 1227 ± 872 mGy, P = 0.012] and contrast amount (237 ± 62 vs. 275 ± 90 ml, P = 0.003) were all lower in planned RA group. Planned RA had a higher procedural success rate (99.3% vs. 92.3%, P = 0.007) and a lower complication incidence (4.3% vs. 17.3%, P = 0.009). But the primary outcomes at 3 years (9.2 and 16.6%, log rank p = 0.24) had no difference between groups. For severe coronary artery calcification, although planned RA did not improved the long term prognosis compared with bailout RA, but it can improve the immediate procedural success rate, reduce the incidence of complications, the procedure time and the volume of contrast.

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Comparison of bailout and planned rotational atherectomy for severe coronary calcified lesions.

Objective: To compare the plaque composition between stable and unstable plaques, characterize unstable plaque by using iMap-intravascular ultrasound (IVUS), and quantify the diagnostic criteria for unstable plaque. Methods: Thirty-three acute coronary syndrome (ACS) patients who had undergone coronary angiography and IVUS from February 19, 2014 to December 19, 2014 at Peking University People’s Hospital were enrolled in the study. Baseline data were collected. The patients were divided into two groups according to their gray-scale IVUS imaging, stable plaque and unstable plaque. A difference-in-difference evaluation was performed using the baseline data and off-line iMap imaging results between the two groups. A receiver operating characteristic (ROC) curve was constructed to obtain the optimal cut-off value to diagnose unstable plaque. Results: Percentages of fibrotic and necrotic tissues, absolute values of lipidic, necrotic, and calcified tissues, and plaque burden were independent predictors for unstable plaque. Absolute necrotic area was the best predictor and exhibited the highest diagnostic value for plaque vulnerability (area under the curve (AUC)=0.806, P=0.000, 95% CI (0.718, 0.894)). The cut-off score for predicting unstable plaque was 4.0 mm2. Conclusions: This study attempted to propose a cut-off value based on absolute necrotic area using iMap-IVUS to predict plaque vulnerability in patients with ACS. This score might provide a valuable reference for diagnosing unstable plaque.

/pdf/feasibility-of-diagnosing-unstable-plaque-in-patients-with-wx1opk2sh3.pdf

Feasibility of diagnosing unstable plaque in patients with acute coronary syndrome using iMap-IVUS

To compare the effect and outcomes of optical coherence tomography (OCT)-guided rotational atherectomy (RA) with intravascular ultrasound (IVUS)-guided RA in the treatment of calcified coronary lesions. Data of calcified coronary lesions treated with RA that underwent OCT-guided or IVUS-guided from January 2016 to December 2019 at a single-center registry were retrospectively analyzed. The effect and outcomes between underwent OCT-guided RA and IVUS-guided RA were compared. A total of 33 lesions in 32 patients received OCT-guided RA and 51 lesions in 47 patients received IVUS-guided RA. There was no significant difference between OCT-guided RA group and IVUS-guided RA group in clinical baselines characteristics. Comparing the procedural and lesions characteristics of the two groups, the contrast volume was larger [(348.8 ± 110.6) ml vs. (275.2 ± 76.8) ml, P = 0.002] and the scoring balloon was more frequently performed (33.3% vs. 3.9%, P = 0.001) after RA and before stenting in the OCT-guided RA group. Comparing the intravascular imaging findings of the two groups, stent expansion was significantly larger in the OCT-guided RA group ([82 ± 8]% vs. [75 ± 9]%, P = 0.001). Both groups achieved procedural success immediately. There were no significantly differences in the incidence of complications. Although there was no statistical difference in the occurrence of MACE at 1 year between OCT-guided RA group and IVUS-guided RA group (3.1% vs. 6.4%, P = 0.517), no cardiovascular death, TVR and stent thrombosis occurred in OCT-guided RA group. OCT-guided RA compared to IVUS-guided RA for treating calcified coronary lesions resulted in better stent expansion and may have improved prognosis.

/pdf/comparison-of-optical-coherence-tomography-guided-and-475w8sbmnj.pdf

Comparison of optical coherence tomography-guided and intravascular ultrasound-guided rotational atherectomy for calcified coronary lesions.

Objective To identify clinical characteristics associated with the minimum lumen area (MLA) of proximal or middle intermediate lesions in the left anterior descending (LAD) artery, and to develop a model to predict MLA. Methods We retrospectively analyzed demographic data, medical history, and intravascular ultrasound findings for 90 patients with intermediate lesions in the LAD artery. Linear regression was used to identify factors affecting MLA, and multiple regression was used to develop a model for predicting MLA. Results Age, number of lesions, and diabetes mellitus correlated significantly with MLA of proximal or middle intermediate lesions. A regression model for predicting MLA (mm(2)) was derived from the data: 7.00 - 0.05 × (age) - 0.50 × (number of lesions). A cut-off value of 3.1 mm(2) was proposed for deciding when to perform percutaneous coronary intervention. Conclusion This model for predicting MLA of proximal or middle intermediate lesions in the LAD artery showed high accuracy, sensitivity, and specificity, indicating good diagnostic potential.

Intravascular ultrasound-based analysis of factors affecting minimum lumen area in coronary artery intermediate lesions.

Kounis syndrome is an acute coronary syndrome that appears in the setting of anaphylactic reaction or hypersensitivity. Many drugs and environmental exposures have been identified as potential offenders, and diagnosis and treatment can be challenging. A 62-year-old man with recurrent bladder cancer underwent an intra-iliac artery epirubicin injection. After the injection, he developed chest pain and a systemic allergic reaction, with electrocardiographic alterations and elevated troponin-I levels. Emergent coronary angiography showed right coronary artery spasm and no stenosis of the other coronary arteries. This reaction was considered compatible with an allergic coronary vasospasm. A diagnosis of Kounis syndrome was made. Kounis syndrome is common, but a prompt diagnosis is often not possible. ﻿This case is the first to suggest that an intraarterial epirubicin injection could potentially be one of its triggers. All physicians should be aware of the pathophysiology of this condition to better recognize it and start appropriate treatment; this will prevent aggravation of the vasospastic cardiac attacks and yield a better outcome.

/pdf/epirubicin-induced-kounis-syndrome-2xvhqnm4s4.pdf

Hong Zhao

Papers

Comparison of bailout and planned rotational atherectomy for severe coronary calcified lesions.

Feasibility of diagnosing unstable plaque in patients with acute coronary syndrome using iMap-IVUS

Comparison of optical coherence tomography-guided and intravascular ultrasound-guided rotational atherectomy for calcified coronary lesions.

Intravascular ultrasound-based analysis of factors affecting minimum lumen area in coronary artery intermediate lesions.

Epirubicin-induced Kounis syndrome