Interventional Cardiology Review最新文献

Several historical studies reported a higher rate of complications following transcatheter aortic valve replacement (TAVR) in women compared with men, especially major bleeding, vascular complications and stroke. More recent publications have demonstrated lower stroke rates following TAVR. The growing experience of modern TAVR operators played a crucial role in the reduction of early postprocedural stroke events. In addition, the improved transcatheter heart valve technology, the emphasis on a heart team-based selection process, and the inclusion of intermediate- and low-risk patients in the latest landmark randomised trials have all contributed to the lower stroke rates in contemporary trials. It is important to note, however, that at an individual level, stroke can significantly affect both quality of life and overall prognosis. Certain factors that increase the risk of periprocedural stroke include the distribution of calcification of native aortic valves, small aortic valve annuli, left ventricular dysfunction and fibrosis, and AF. These tend to occur more frequently in women. However, the role of cerebral embolic protection devices has not been shown to reduce procedure-related strokes in men or women. The overall incidence of factors predisposing to late-onset stroke is higher in women. Currently, there are no trials that have identified sex differences in the incidence and management of stroke following TAVR. This review aims to examine potential sex differences in the pathophysiology, preventive strategies and therapeutic options for stroke following TAVR.

Coronary artery calcification (CAC) remains one of the greatest challenges in percutaneous coronary interventions, since it adversely affects procedural and long-term clinical outcomes. Compared with angiography, intravascular imaging increases diagnostic accuracy of CAC and enables assessment of morphological features of CAC, which help determine the need for advanced calcium modification therapies, including speciality balloons, atherectomy and intravascular lithotripsy. Since the ultimate goal of the advanced calcium modification therapies is to induce calcium fracture and facilitate subsequent stent implantation, intravascular imaging can be used to confirm calcium fracture and optimise percutaneous coronary interventions. Being able to interpret and understand the role of intravascular imaging in the diagnosis and management of CAC is valuable in attempting to improve outcomes after percutaneous coronary interventions.

Pulmonary embolism represents a major cause of morbidity and mortality worldwide, and remains a diagnostic challenge due to its highly nonspecific clinical presentation. Early recognition is critical because timely diagnosis not only improves prognosis but also guides risk stratification, which is essential for therapeutic decision-making. Non-invasive diagnostic modalities - including clinical prediction rules, biomarkers, imaging techniques and bedside assessments - have become indispensable tools for rapid and accurate identification of patients with suspected pulmonary embolism. These methods enable clinicians to stratify risk, predict outcomes and tailor treatment strategies to individual patients, reducing both underdiagnosis and overtreatment. Despite their significant impact, limitations persist, such as access disparities, overdiagnosis of subsegmental events and interpretation challenges in special populations. Ongoing advances, including artificial intelligence and novel biomarkers, hold promise for refining diagnostic accuracy and personalised risk assessment. Ultimately, the integration of non-invasive tests into structured algorithms ensures earlier detection, better prognostic evaluation and improved clinical outcomes for patients with acute pulmonary embolism.

Treatment of pure aortic regurgitation (AR) has historically been addressed via surgical aortic valve repair or replacement. A less invasive option for patients affected by AR has been attempted with the advent of transcatheter aortic valve replacement (TAVR). Here, we review the rationale, benefits and challenges of TAVR for the treatment of native pure AR. In particular, we explore upcoming dedicated technologies with labelling for transcatheter treatment of AR, detailing both device and procedural specifics. Finally, evidence from recent studies conducted in patients with pure AR is appraised in light of available evidence from TAVR with non-dedicated devices in this setting.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality, with clinical outcomes strongly influenced by the anatomical distribution of emboli. This review explores the impact of PE anatomy on ventilatory distress and haemodynamics, emphasising the distinction between proximal and distal emboli. Proximal emboli, located in the main or lobar pulmonary arteries, significantly impairing pulmonary flow, increase pulmonary artery pressure and cause severe right ventricular dysfunction, necessitating prompt intervention. Distal emboli, while less severe, still pose risks, especially in patients with cardiopulmonary comorbidities, potentially leading to localised ventilation-perfusion mismatch and hypoxaemia. Therapeutic approaches vary by clinical status and embolus location, with systemic thrombolysis or catheter-directed therapy preferred for unstable patients with usually proximal PE, while anticoagulation suffices in stable cases, most of which involve distal emboli. Understanding PE anatomy and its relationship with PE haemodynamic and ventilatory failure is critical for risk stratification, treatment guidance and improvement of patient outcomes.

Complete fracture of a guiding catheter is a rare, but potentially serious, complication of percutaneous coronary intervention. Options for removal include endovascular retrieval devices or surgery. A rare case of a fractured guiding catheter with its tip in the ascending aorta and its successful retrieval using a combination of home-made snare, kissing guiding catheter and balloon trekking technique is reported.

Background: Transcatheter aortic valve implantation (TAVI) is widely performed for severe aortic stenosis (AS), often accompanied by coronary artery disease (CAD). The optimal management of CAD in TAVI patients remains uncertain. This study reviews the evidence on percutaneous coronary intervention (PCI) timing in TAVI, and proposes an algorithmic approach for CAD management.

Methods: A comprehensive search of PubMed, EMBASE and Cochrane identified studies comparing PCI timing strategies in TAVI patients.

Results: Thirteen studies with 15,412 participants were included. Mortality at 30 days (OR 5.70; 95% CI [1.34-24.36]) and 2 years (OR 4.40; 95% CI [2.60-7.44]) were significantly higher in the combined pre-TAVI and concomitant PCI group than in the post-TAVI cohort. Rates of other periprocedural complications, such as stroke and bleeding, varied across studies.

Conclusion: There is no clear consensus on PCI timing in TAVI due to a lack of high-quality randomised data. An individualised, algorithmic approach is proposed for managing CAD in patients undergoing TAVI.

Transcatheter aortic valve implantation (TAVI) has evolved from an alternative therapy for high-surgical risk patients with symptomatic severe aortic stenosis (AS) into the main treatment modality for most patients with severe AS. The indication for TAVI was initially based mainly on surgical risk profiles, but following positive trial results in intermediate- and low-risk patients, clinical decision pathways regarding the optimal treatment modality for AS patients, either TAVI or surgical valve replacement, changed considerably and a lifetime management approach incorporating several other additional patient characteristics evolved. This review aims to elucidate the evolution of TAVI and surgical valve replacement indications over the past two decades. Relevant clinical aspects beyond surgical risk including age, life expectancy, comorbidities, aortic anatomy and patient preference influencing decision-making regarding the modality of intervention in patients with severe AS, will be discussed in the context of lifetime management of AS.

Background: Interventional cardiology (IC) is a competitive and oversubscribed subspecialty. The UK cardiology programme is currently in a state of transition of curricula, and concerns have arisen about the impact of this change on the standard of training. This study aimed to provide a snapshot of UK IC training at present.

Methods: A 68-question survey was disseminated through the British Cardiovascular Interventional Society mailing list in November 2023 to all UK intervention trainees across both curricula. Questions included procedural numbers, exposure to adjunct techniques and confidence in the transition to consultancy.

Results: The survey was completed by 60 participants, providing a response rate of 38% for training grades. A total of 87% of participants were men, and 78% remained on the 2010 curriculum. For the 2010 curriculum trainees, the median number of first-operator percutaneous coronary intervention was 101-200 in their first year. Confidence levels were higher for radial (98%) than femoral (62%) access. A total of 83% felt comfortable or confident using intravascular lithotripsy (83%) compared with 23% for rotational atherectomy. Comfort was higher with intravascular ultrasound (82%) compared with optical coherence tomography (53%). Half felt unprepared for consultancy, citing insufficient procedural experience. To address this, 65% plan to extend training with a fellowship year. Overall, 72% rated the programme as excellent or good, and 10% as poor.

Conclusion: While many trainees report a positive experience with UK IC training, several areas need improvement, including procedural volume and requirement for extended training. Moving forward, it will be crucial to monitor the impact of the 2022 curriculum on IC training.