Showing papers in "Interventional Cardiology in 2009"
TL;DR: The hemodynamic indices derived from intracoronary pressure or flow measurements, fractional flow reserve and coronary flow reserve, show a high agreement with noninvasive stress testing and deferral of percutaneous coronary intervention for hemodynamically nonsignificant lesions is associated with a low major adverse cardiac event rate.
Abstract: Adequate patient selection for percutaneous coronary intervention is of the greatest importance in order to minimize early and late complications. Therefore, objective evidence for myocardial ischemia is mandatory for the management of patients with coronary artery disease, in particular in multivessel disease and those with intermediate lesions (40–70% diameter stenosis on angiography). The use of sensor-equipped guidewires for the assessment of functional coronary lesion severity has become extensive in the cardiac catheterization laboratory. The hemodynamic indices derived from intracoronary pressure or flow measurements, fractional flow reserve and coronary flow reserve, show a high agreement with noninvasive stress testing. Furthermore, deferral of percutaneous coronary intervention for hemodynamically nonsignificant lesions is associated with a low major adverse cardiac event rate. However, since these indices are based on either intracoronary pressure or flow, they do not investigate the hemodynami...
30 citations
TL;DR: Percutaneous coronary interventions are central to the treatment of coronary artery disease, but their invasive nature in conjunction with the use of anticoagulants makes bleeding complications an important peri-procedural risk.
Abstract: Percutaneous coronary interventions (PCIs) are central to the treatment of coronary artery disease, but their invasive nature in conjunction with the use of anticoagulants makes bleeding complications an important peri-procedural risk. Any amount of bleeding, including minor bleeding, that results from PCI is associated with worse ischemic outcomes such as myocardial infarction, stent thrombosis and death. Establishing the incidence of bleeding associated with PCI is challenging owing to the lack of consistency in definitions used to define bleeding events and differences between clinical trial and registry data. The factors that translate bleeding events into worse clinical outcomes are not fully understood, but likely involve hypotension, tachycardia, reduced oxygen-carrying capacity and systemic inflammation. The use of blood transfusions does not appear to mitigate this risk, but actually appears to be independently associated with increased morbidity and mortality. A number of studies have demonstrat...
18 citations
TL;DR: Noninvasive imaging modalities such as cardiac computed tomography have high sensitivity and specificity for the left main coronary artery and will likely have an increasing surveillance role in the future, especially in ruling out disease.
Abstract: Despite its short length, the left main coronary artery remains one of the most challenging areas of disease in interventional cardiology today. This challenge draws from the need for an accurate diagnosis as well as a changing management strategy. Since the consequences are significant, the use of intravascular ultrasound or fractional flow reserve should be considered when making the diagnosis, especially in cases of intermediate disease. Noninvasive imaging modalities such as cardiac computed tomography have high sensitivity and specificity for the left main coronary artery and will likely have an increasing surveillance role in the future, especially in ruling out disease. Although coronary artery bypass grafting remains the standard of care for the revascularization of this area, advances in interventional cardiology have improved outcomes in selected patients so that they are now comparable to coronary artery bypass grafting at least up to medium-term follow-up. Going forward the preferred revascula...
8 citations
TL;DR: Percutaneous closure of atrial septal defect has replaced surgical closure in most centers and the overall complication rate of the percutaneous procedure is lower than the surgical complication rate, but some of the major complications of device closure are potentially lethal.
Abstract: Percutaneous closure of atrial septal defect has replaced surgical closure in most centers Percutaneous closure of patent foramen ovale is proposed as an alternative to medical therapy in the prevention of recurrent thromboembolic events in stroke patients The overall complication rate of the percutaneous procedure is lower than the surgical complication rate However, some of the major complications of device closure are potentially lethal The complications vary with device type, age, defect morphology and center volume load The most significant complications are device embolization, vascular complications at the puncture site, thrombus on the device, recurrent thromboembolic events, atrial arrhythmias and cardiac erosion or perforation Meticulous technique, careful peri- and post-procedural monitoring and adequate device choice could lower the incidence of complications If they occur, early recognition and treatment are warranted
7 citations
TL;DR: OCT is, and will continue to be a unique imaging modality that is able to help improve the understanding of the atherosclerotic process and shed light on the all important interaction between coronary stents and the vessel wall.
Abstract: Optical coherence tomography (OCT) has offered a greater understanding of coronary atherosclerosis with the ability to visualize plaque and quantify the thin, fibrous cap. Furthermore, OCT is able to traverse many of the limitations of angiography and intravascular ultrasound when imaging coronary stents in vivo. These applications are as a result of the use of near-infrared light, permitting an almost ‘histological’ resolution of the coronary artery. Novel developments with faster OCT pullback speeds (up to 20 mm/s with the next generation Fourier-domain systems) will further simplify the procedural requirements, meaning that the use of a proximal occlusion balloon is eliminated. Hence, OCT is, and will continue to be a unique imaging modality that is able to help improve our understanding of the atherosclerotic process and shed light on the all important interaction between coronary stents and the vessel wall.
5 citations
TL;DR: In most cases of AF in particular, the administration of oral anticoagulants (OACs) is warranted; applying the CHADS2 score reduced the number of thromboembolic events by 60 to 70%.
Abstract: Atrial fibrillation (AF) is a frequently observed arrhythmia. Its incidence increases with age, reaching approximately 10% in octogenarians. Furthermore, AF is responsible for 15% of all ischemic strokes and up to 25% of all ischemic strokes in octogenarians. In patients with nonrheumatic AF, 90% of all thrombi in the left atrium are found in the left atrial appendage (LAA). In most cases of AF in particular, the administration of oral anticoagulants (OACs) is warranted. To guide the usage of OACs in AF patients, the CHADS2 score (C: congestive heart failure, H: hypertension, A: age greater than or equal to 75 years, D: diabetes, S: prior stroke or transient ischemic attack) was developed; applying this score reduced the number of thromboembolic events by 60 to 70%. However, when contra-indications for OACs are present, or when OACs have failed, no equivalent therapeutic alternative is available. OACs are then frequently replaced by antiplatelets, but these are much less effective than OACs in preventing ...
5 citations
TL;DR: correlation of intravascular ultrasound findings with histopathological analysis of thrombus aspirates in patients with very late DES thrombosis showed eosinophilic infiltrates were associated with intravascul...
Abstract: The introduction of drug-eluting stents (DES) has significantly reduced restenosis when compared with bare-metal stents and are considered the standard of care in the treatment of symptomatic coronary artery disease. However, late stent thrombosis (LST), potentially resulting in a fatal occlusion of the vessel, emerged as a major concern in first-generation DES (polymer-based sirolimus- and paclitaxel-eluting stents). Pathologic studies of patients dying from late DES thrombosis showed that the underlying mechanism is delayed healing, characterized by poor endothelialization of stent struts and persistence of fibrin. Additional risk factors for LST include long lesions, left main coronary artery disease, bifurcation stenting, underlying ruptured plaques and hypersensitivity reactions. Most recently, correlation of intravascular ultrasound findings with histopathological analysis of thrombus aspirates in patients with very late DES thrombosis showed eosinophilic infiltrates were associated with intravascul...
4 citations
TL;DR: Cerebral protection devices are intended to control the emboli generated by carotid artery stenting and thereby reduce the embolic complications of the procedure.
Abstract: Endovascular carotid intervention has undergone a dramatic and rapid evolution since its early inception in the 1990s at which time it comprised a rudimentary angioplasty technique. Quite apart from changes in the size and format of the guidewires used (0.014 inch, rapid-exchange compatible) and stents and balloons (dedicated, low-profile), perhaps one of the most interesting developments has been the introduction of cerebral protection devices. These devices are intended to control the emboli generated by carotid artery stenting and thereby reduce the embolic complications of the procedure. A number of different cerebral protection systems are available but this article will focus on the most popular: the filter.
3 citations
TL;DR: Catheter ablation of persistent AF has demonstrated promising results concerning improved morbidity and quality of life, and also potential benefits in terms of mortality, and is now included in the guidelines as a reasonable alternative to pharmacological therapy to prevent recurrent AF in symptomatic patients.
Abstract: Atrial fibrillation (AF) is the most frequent human arrhythmia and constitutes a major socioeconomic and healthcare problem. Different studies have clearly shown the superiority of catheter ablation compared with pharmacological therapy for reducing AF burden. Catheter ablation for persistent AF targets all structures potentially contributing to initiation and maintenance of AF, and has resulted in unprecedented success in maintaining sinus rhythm in the medium term, with recovery of atrial mechanical function. Periprocedural complications may rarely occur; however, catheter ablation of persistent AF has demonstrated promising results concerning improved morbidity and quality of life, and also potential benefits in terms of mortality. Therefore, it is now included in the guidelines as a reasonable alternative to pharmacological therapy to prevent recurrent AF in symptomatic patients.
2 citations
TL;DR: The records of 116 patients who had a response panel ordered between 1st January 2005 to 31st July 2007 were reviewed to determine the management of patients with impaired response to antiplatelet agents.
Abstract: Aims: To determine the management of patients with impaired response to antiplatelet agents. Methods: We reviewed the records of 116 patients who had a response panel ordered between 1st January 2005 to 31st July 2007. Aspirin impaired response was defined as a mean platelet aggregation greater than or equal to 20% with 0.5% mg/ml arachidonic acid and/or greater than or equal to 70% with 10 µM adenosine diphosphate. Clopidogrel impaired response was defined as a mean platelet aggregation greater than or equal to 40% with 10 µM ADP. Management change was defined as any change occurring immediately after testing. Results: Of patients on aspirin (n = 112), 34% had an impaired response to aspirin leading to a management change in 58% of impaired response patients compared with 29% of responsive patients (p = 0.003). The aspirin impaired-response group was changed to higher dosages of aspirin and clopidogrel after testing. Clopidogrel impaired response occurred in 19.5% of patients on clopidogrel (n = 92). Man...
2 citations
TL;DR: From a mechanistic perspective, achieving early vessel patency limits the extent of myocardial injury.
Abstract: occlusion. Thus, from a mechanistic perspective, achieving early vessel patency limits the extent of myocardial injury. The term ‘door-to-balloon (DTB) time’, defined as the time from first medical contact to the time of first coronary device deployment, has become a mantra of STEMI management. First medical contact, often poorly characterized in the field, is usually defined by time of hospital door arrival. Clinical trial and observational data have shown that shorter DTB times correlate with improved outcomes [6–8]. In the GUSTO-IIb clinical trial, 30-day mortality was 1.0% for PPCI performed within 60 min of study enrollment, 3.7% for PPCI between 61 and 75 min, 4.0% for PPCI between 76 and 90 min and 6.4% for PPCI performed after 90 min, the odds of death increasing 1.6-fold for each increasing time interval. A recent large registry study analyzed data from 43,801 patients in the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) and showed that adjusted in-hospital mortality was 3.5, 4.3, 5.6 and 7.0% for DTB times of 30, 60, 90 and 120 min, respectively [9]. Current ACC/American Heart Association (AHA) and European Society of Cardiology guidelines both recommend that PPCI be performed within 90 min of the patient’s first contact with m edical personnel [1,10].
TL;DR: There is an urgent need to understand and integrate new technologies and developments coupled with new biological approaches to avoid unnecessary complications in interventional cardiology.
Abstract: Interventional cardiology has established itself as an important treatment strategy for patients with cardiac disease throughout the world. As the invasive approach becomes more complex both in technique and skills, the need for sophisticated imaging to guide assessment and treatment is necessary. Interventional cardiology today is marked by new technology and new devices coupled with new biological approaches. There is an urgent need to understand and integrate these different technologies and developments to avoid unnecessary complications. It is commonly accepted that the majority of complications in the field of interventional cardiology result from the decision-making process and from underestimation of the downstream effects of these decisions.
TL;DR: Infrapopliteal vascular disease is a common finding in patients presenting with symptomatic chronic critical limb ischemia and the multilevel distribution of the disease process may be appreciated and assessed by multidetector computed tomography or magnetic resonance angiography prior to intervention, to determine the approach to treatment.
Abstract: Crural vessel occlusive disease is a common finding in patients presenting with symptomatic chronic critical limb ischemia. This patient group has poor treatment prospects with high morbidity and mortality. Furthermore, infrapopliteal vascular disease is by its very nature technically challenging to deal with by endovascular or surgical techniques. The multilevel distribution of the disease process may be appreciated and assessed by multidetector computed tomography or magnetic resonance angiography prior to intervention, to determine the approach to treatment. Many patients are candidates for nothing more than conservative treatment. In the remaining patients, transluminal and subintimal angioplasty achieve good clinical success and limb salvage with low complications. When used in this anatomical territory these techniques require: meticulous attention to detail; a sound knowledge of suitable balloon, catheter and wire combinations; and familiarity with techniques to deal with complications.
TL;DR: In this article, the authors summarize complications and their predictors, and suggest possible preventive and therapeutic strategies for carotid artery stenting, which has not fulfilled the promise of replacing traditional thromboendartarterectomy because of the rate of complications.
Abstract: Following extensive efforts to improve technique and design proper devices, carotid artery stenting received progressive attention and diffusion. However, it has not fulfilled the promise of replacing traditional thromboendarterectomy because of the rate of complications, which is still not negligible. The aim of this article is to summarize complications and their predictors, and to suggest possible preventive and therapeutic strategies.
TL;DR: The effective dose is computed by Adding up the weighted equivalent doses of all organs, the effective dose (E) is computed and has become the most frequently used quantity to compare the radiation risks of differ ent diagnostic tests.
Abstract: calculations, since there is no directly measur able quantity that adequately reflects radiation exposure [1,2]. Nevertheless, the most adequate approach to describe risks associated with ion izing radiation is to describe it in terms of dose. Adding up the weighted equivalent doses of all organs, the effective dose (E) is computed. Since it is a single number, E – which is measured in mSv – has become the most frequently used quantity to compare the radiation risks of differ ent diagnostic tests. Nevertheless, the effective dose must be applied with caution: its applica tion is defined for populations, not for the esti mation of radiation dose for one examination on one single patient. Accordingly, it is, in itself, not ideally suited to describe the individual esti mated cancer risk attributed to an examination using ionizing radiation, as it is always subject to uncertainty [3,4].
TL;DR: Occlusion of the left atrial appendage with transcatheter devices is feasible, reduces anticipated stroke rates and has been found to be noninferior to warfarin therapy in a large, randomized trial.
Abstract: For patients with atrial fibrillation, successful warfarin therapy is difficult in clinical practice. Thus, it seems logical to find alternative therapies to chronic anticoagulation. The major source of thromboembolism in such patients is the left atrial appendage, and occlusion of the appendage with transcatheter devices is feasible, reduces anticipated stroke rates and has been found to be noninferior to warfarin therapy in a large, randomized trial. Trials with new devices are planned. In light of the current data, how patients with atrial fibrillation who need warfarin, who are either at risk with anticoagulation or who desire not to undergo warfarin therapy should best be treated is not clear. Hopefully, with more experience and longer term outcomes of clinical trials, these issues will finally be laid to rest.
TL;DR: Volumetric scanning allows for CTA in conjunction with myocardial perfusion imaging in a single examination and heart beat and the main advantages are decreased scan time, contrast administration and radiation dose.
Abstract: “While diagnostic accuracy of 320âÂÂslice CTA will most likely be similar to 64âÂÂslice systems, the main advantages of this technique are decreased scan time, contrast administration and radiation dose. Furthermore, volumetric scanning allows for CTA in conjunction with myocardial perfusion imaging in a single examination and heart beat.”
TL;DR: Percutaneous left ventricular assist devices improve hemodynamics in acute heart failure and may offer potential advantages compared with surgical assist systems in the critically ill.
Abstract: Percutaneous left ventricular assist devices improve hemodynamics in acute heart failure. The devices can be deployed rapidly and with a low risk of complications, and may thereby offer potential advantages compared with surgical assist systems in the critically ill. Cerebral hypoperfusion with cerebral injury is a major challenge in acutely ill cardiac patients, especially when cardio–pulmonary resuscitation is performed. There is no indication that catheter-based left ventricular assist devices confer more cerebrovascular complications than current percutaneous angiographic and interventional procedures. Recent data suggest that microcirculation in the head may be improved during percutaneous assist device support in cardiogenic shock. Specific assessment of the effect of a percutaneous device during cardiac arrest and impaired cerebral circulation has been performed in newly published experimental protocols. The available data indicate that a percutaneous intracardiac impeller device may be able to sus...
TL;DR: Comparative effectiveness of catheter ablation for atrial fibrillation: moving with the rhythm.
Abstract: Ann C Garlitski Author for correspondence: New England Cardiac Arrhythmia Center, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA Tel.: +1 617 636 5902 Fax: +1 617 636 4586 agarlitski@ tuftsmedicalcenter.org Alawi A Alsheikh-Ali Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Stanley Ip Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA Comparative effectiveness of catheter ablation for atrial fibrillation: moving with the rhythm
TL;DR: The issue of filter design in embolic protection for carotid artery stenting and the role of coronary flow reserve in decision ana lysis of intermediate coronary lesions is introduced.
Abstract: of filter design in embolic protection for carotid artery stenting [8]. There are reviews on structural cardiac interventions. Dr De Wolf presents complications associated with atrial septal defect closure [9] and Dr Block discusses the role of left atrial appendage closure [10]. The technology associated with left ventricular assist devices is rapidly evolving, and Drs Tuseth and Nordrehaug present the role of percutaneous left ventricular assist devices in preventing cerebral ischemia [11]. Dr Meuwissen et al. discuss the role of coronary flow reserve in decision ana lysis of intermediate coronary lesions [12]. Drs Bolia and Adair present their techniques on treating very complex i nfrapopliteal lesions [13]. We are very excited to introduce this issue on cardiovascular interventions to you.
TL;DR: “..newer antiplatelet agents such as cangelor and prasugrel ... may be the solution for patients with impaired response to ASA and clopidogrel, however, the authors should be cautious to make such a recommendation as data are limited and bleeding risks are high.
Abstract: “..newer antiplatelet agents such as cangelor and prasugrel ... may be the solution for patients with impaired response to ASA and clopidogrel. However, we should be cautious to make such a recommendation as data with newer antiplatelet agents are limited and bleeding risks are high.” Aravinda Nanjundappa† †Author for correspondence: 3110 Mc Corkle Avenue SE, Charleston, WV 25304 USA Tel.: +1 252 412 1134 Fax: +1 304 388 4885 dappamd@yahoo.com
TL;DR: “...many trial investigators tend to overextend the generalizability of their trials, which is a disservice to the medical community.”
Abstract: “...many trial investigators tend to overextend the generalizability of their trials. Such tendencies are a disservice to the medical community. The trials cannot be extended beyond the populations recruited.”
TL;DR: Dr Wilensky is Professor of Medicine at the University of Pennsylvania, Philadelphia, where he divides his time in the cardiac catheterization laboratory and a large animal laboratory.
Abstract: Dr Wilensky is Professor of Medicine at the University of Pennsylvania (PA, USA) and an interventional cardiologist at the Hospital of the University of Pennsylvania. He obtained his MD from the University of Amsterdam where he graduated cum laude. He performed his internship/residency at Georgetown University/VA Medical Center in Washington DC and his fellowship in Cardiovascular Diseases at the Krannert Institute of Cardiology, Indiana University, where he was Chief Fellow. After 4 years on faculty at Indiana University he moved to the University of Pennsylvania, Philadelphia, where he divides his time in the cardiac catheterization laboratory and a large animal laboratory. He is author of over 150 papers and lectures internationally.
TL;DR: An alternative algorithm based on published high-patient and lesion profiles for suboptimal carotid artery stenting outcome was successfully introduced in two high-volume centers and might help in lowering the 30-day complication rates for bothcarotid revascularization strategies.
Abstract: Different approaches can be followed to allocate patients eligible for carotid revascularization to either stenting or endarterectomy. Recently, the Society for Vascular Surgery published in their clinical practice guidelines for carotid revascularization an allocation algorithm based on the patients’ surgical risk. Although the algorithm is firmly based on the available evidence from different randomized controlled trials, taking into account more recently published data on the same trials and the constant evolution in interventional techniques, it is questionable whether this conventional algorithm will resist time. An alternative algorithm allocating patients to either carotid endarterectomy or stenting is based on published high-patient and lesion profiles for suboptimal carotid artery stenting outcome. It was successfully introduced in two high-volume centers and might help in lowering the 30-day complication rates for both carotid revascularization strategies.