Interventional Cardiology Review最新文献

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.

Pulmonary embolism (PE) is the third major cause of cardiovascular death in western countries. High-risk PE, defined by haemodynamic instability, necessitates immediate reperfusion therapy. Intermediate-high-risk patients, although stable, are vulnerable to rapid deterioration and therefore require intensive monitoring. To accurately stratify these patients, predict mortality and identify those who may benefit from more aggressive therapies, it is essential to consider various clinical and imaging parameters. Catheter-directed therapy (CDT) has been shown to reduce clot burden and right ventricle overload with fewer bleeding complications than systemic thrombolysis. CDT's clinical utility in the management of PE continues to expand, guided by the expertise of pulmonary embolism response teams, ensuring a multidisciplinary approach tailored to each patient's risk and clinical profile. As PE management advances, ongoing research and large-scale trials are essential for validating CDT's role in reducing morbidity and mortality in intermediate-high-risk PE cases. This review aims to provide a more in-depth perspective on intermediate-high-risk PE.

Heart failure is a life-threatening condition that affects women and men differently. Due to increases in mean patient age, heart failure prevalence and mortality rates are expected to increase rapidly. Heart failure is characterised as a syndrome leading to a high burden of disease for the individual patient and increased healthcare costs for society related to rehospitalisation. This review highlights sex differences across the entire spectrum of heart failure.

Degenerative aortic valve disease is the third most common cause of heart disease in the developed world. Calcific deposits accrue in the valve endothelium causing progressive stenosis of the orifice. Increasingly, transcatheter aortic valve implantation is being used in place of surgery as treatment for aortic stenosis, particularly for patients who are considered high surgical risk. Although echocardiography remains the gold standard for the diagnosis and grading of aortic valve stenosis, there is an increasing interest in the role that aortic valve calcification scoring may play in these areas. In this review, the authors evaluate the current evidence for aortic valve calcium scoring as an adjunct to echocardiography in grading, and as a prognostic marker in challenging cases. They also explore the ability of calcium scoring to predict outcomes following transcatheter aortic valve implantation.

Background: In primary percutaneous coronary intervention (pPCI), balloon predilation is frequently carried out before stenting but there is a lack of data regarding optimal balloon size and the effect of balloon size on procedural and clinical outcomes.

Aims: This study compares small balloon predilation (≤50% of proximal vessel diameter) with large balloon predilation (>50% of proximal vessel diameter) in pPCI.

Methods: This multicentre prospective observational study included consecutive ST elevation MI (STEMI) patients undergoing pPCI at three tertiary centres in Egypt. Demographic, clinical and angiographic data were collected for all the patients. The primary outcome was the presence of no reflow at the conclusion of the procedure and secondary outcomes included procedural complications - no reflow, dissection, abrupt vessel closure, fluoroscopy time and procedural time - and clinical outcomes - in-hospital left ventricular ejection fraction (LVEF), cardiogenic shock, stent thrombosis, ventricular fibrillation, stroke, death, ST-segment resolution >50% 1 hour after PCI and LVEF at discharge.

Results: A total of 384 pPCI procedures were included. The small balloon group (n=222) and the large balloon group (n=162) were comparable in terms of baseline characteristics. The large balloon group had a significantly higher incidence of no reflow (n=23 [14.2%] versus n=6 [2.7%], p<0.001), procedural complications: n=31 [19.4%] versus n=10 [4.5%], p<0.001) and contrast volume (190.4 ± 40.2 ml versus 177.4 ± 29.4 ml, p=0.0003) compared to the small balloon group. ST-segment resolution >50% after PCI was more frequent in the small balloon group (n=182 [81.98%] versus n=109 [67.28%], p<0.001).

Conclusion: This study suggests that using a smaller balloon size for predilation in pPCI is associated with improved coronary flow, reduced procedural complications and better ST-segment resolution.

Transcatheter mitral leaflet repair is a non-surgical technique used to treat severe mitral regurgitation. The technique has matured significantly since its commercial introduction, and with device iteration and increasing operator experience, it is now an important treatment option for patients at higher risk for conventional mitral valve surgery. Randomised clinical trials have established the safety and efficacy of the technique in the treatment of primary and secondary mitral regurgitation, and its use was approved by the National Institute for Health and Care Excellence in 2019. This position statement summarises the clinical evidence and indications for the procedure and provides expert consensus on best practice in terms of patient selection, the procedure and post-procedure care. Standards are also described with respect to team composition, minimum case volume and collection of procedural and outcome data.

The development and progression of coronary calcification is of growing interest with the emergence of new imaging modalities and calcium modifying technologies that can facilitate optimal results during complex percutaneous coronary intervention (PCI). Coronary atherosclerotic disease typically begins within the intima with pathological intimal thickening and microcalcifications (>0.5 μm and <15 μm). These microcalcifications can coalesce into larger areas of calcification, including sheet calcium, which is typically seen in fibrocalcific plaque, nodular calcification and calcified nodules. Calcified nodules typically protrude into the vessel lumen. Erosive calcified nodules lack the coverage of protective anti-aggregatory endothelium and frequently show adherence of intraluminal thrombus. Greater calcification within coronary plaque does not correlate with an increased risk of acute coronary syndrome, however, coronary calcium can lead to challenges with stent delivery and full stent expansion during PCI. An understanding of plaque morphology, distribution of calcium, degree of calcification and underlying shape will enable interventional cardiologists to appropriately interpret intravascular ultrasound and optical coherence tomography imaging findings and optimise results during complex PCI.

[This corrects the article DOI: 10.15420/icr.2024.25.].