Interventional Cardiology Review最新文献

Acute MI (AMI) is a leading cause of mortality globally. Swift diagnosis is imperative, with timely reperfusion crucial to minimise adverse outcomes. Revascularisation strategies include culprit-vessel-only therapy, staged complete revascularisation or immediate complete revascularisation. Evidence from randomised trials strongly favours complete revascularisation in ST-elevation MI (STEMI). Data regarding immediate complete revascularisation compared to a staged approach are limited, with uncertainties regarding the advantages of physiology-guided treatment compared to angiographic assessment alone. Non-STEMI (NSTEMI) patients with multivessel disease are often complex and current guidelines offer limited recommendations for this patient group, emphasising the need for individualised treatment. Observational studies have sought to find the optimal approach, yet conflicting data prevails. Dedicated trials for this issue in NSTEMI patients are currently unavailable. To enhance the decision-making processes for patients with AMI, future trials should consider the inclusion of functional health status and health-related quality of life outcomes. The existing gaps in knowledge underscore the intricacies of managing AMI and the ongoing necessity for comprehensive research to refine treatment strategies.

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis characterised by multiorgan pathological histiocytic infiltration. Cardiac involvement occurs in 40-75% of patients and increases mortality. A 55-year-old woman with chest pain and dyspnoea was found to have an interatrial septal mass and aortitis suspicious for ECD without other organ involvement. After two inadequate transcatheter interatrial biopsies were obtained using ultrasound guidance alone, diagnostic samples were successfully obtained using intraprocedural frozen section examination. The patient started genotype-targeted treatment with good response. Biopsy confirmation of ECD is required to guide treatment; however, cardiac biopsies are uncommonly performed when other organs are affected. Our unique case of isolated cardiovascular involvement highlights how frozen sectioning with multimodal intraprocedural imaging guidance can improve diagnostic yield of endomyocardial biopsies. It also highlights how diagnosis of rare conditions requires careful multidisciplinary evaluation of affected organs, procedural risk and diagnostic yield. The use of frozen sectioning can improve diagnostic yield of endomyocardial biopsies.

Background: Rotational atherectomy (RA) and intravascular lithotripsy (IVL) are well-established technologies for modification of coronary calcification. Given their contrasting mechanisms of action, there has been interest in whether the use of these devices in conjunction could potentially be synergistic and offer improved procedural results. The aim of this study was therefore to evaluate the efficacy, procedural safety and long-term outcomes of combining RA and IVL, termed 'RotaShock' (RSK), for the treatment of severe coronary calcification.

Methods: A single- centre retrospective analysis was carried out of consecutive patients treated with an RSK strategy for coronary calcification from January 2019 until September 2022. Baseline demographics, comorbidity details, details of the percutaneous coronary intervention procedure, angiographic and/or intracoronary imaging (ICI) results and presence of target vessel revascularisation or mortality were recorded.

Results: A total of 36 patients were treated with RSK; the majority of patients were male (n=29; 80.6%) and the median age was 75 years (IQR 70-79 years). The majority of cases involved treating the left anterior descending artery (63.4%) but one-third involved percutaneous coronary intervention to the left main coronary artery. The vast majority of cases were guided by ICI (88.9%) and were performed through radial access (80.6%). In patients with ICI available for analysis, the median minimum stent area was 7.7 mm² (IQR 6.2-10.0 mm²). There were two access site complications but no other periprocedural complications. The median follow-up was 942 days (IQR 645-1,306 days). Despite the high complexity of lesions treated, follow-up identified only two cases of target vessel revascularisation. There were five cases of non-adjudicated all-cause mortality.

Conclusion: RSK is an effective and safe strategy for modification of severe coronary calcification, with long-term results suggesting a highly durable result. Further and randomised data are now mandated to evaluate the relative merits of RSK compared with RA or IVL alone.

An algorithmic approach to chronic total occlusion (CTO) percutaneous coronary intervention has led to an increase in the success rate and safety of the procedure. The global CTO crossing algorithm is a consensus document that was developed by 121 expert operators from 50 countries and published during the COVID-19 pandemic. It provides standardisation while allowing flexibility in CTO crossing strategy selection, and can facilitate teaching of CTO percutaneous coronary intervention across various regions of the world. In this review, the 10 steps of the global CTO crossing algorithm are discussed in detail.

An 80-year-old patient presented with a rare complication: a late coronary-cameral fistula following implantation of an Amulet (Abbott) left atrial appendage occlusion device. Microperforations from the device's anchoring tines have previously been suggested as a possible mechanism of fistula formation, a complication reported in two other cases. We propose an alternative theory of potential collateralisation of the threatened appendage from the nearby circumflex artery.

Aortic regurgitation (AR) is the third most common valvular heart disease, with its prevalence and severity increasing with age. AR can arise from degenerative, congenital, inflammatory and infectious aetiologies, manifesting as primary AR with intrinsic leaflet disease, secondary AR due to aortopathy or annular dilatation, or a combination. Furthermore, AR can be acute, as observed in endocarditis and aortic dissection, or chronic, as seen in calcific aortic valve disease, connective tissue disorders, or bicuspid valve phenotypes. This review discusses the aetiopathology of these various AR manifestations (primary, secondary, acute and chronic AR), highlighting diagnostic challenges and implications for aortic valve replacement and transcatheter aortic valve implantation.

The foramen ovale is a flap in the atrial septum that is open in the fetus to allow oxygenated blood returning from the placenta to pass to the systemic circulation. In early life, the primum septal flap should close, but in 25% of people the flap does not seal fully. Most patent foramen ovale (PFO) are small and open only following Valsalva. Resting right-to-left shunts are less common, occurring in 5% of individuals. This British Cardiovascular Intervention Society position statement describes the diagnosis, indications and procedure for PFO closure.

Iodinated contrast media is integral to the evaluation for transcatheter aortic valve implantation; however, some patients may have contraindications to the use of iodinated contrast media. The study reports successful use of a gadolinium-based contrast agent in a patient with severe symptomatic aortic stenosis, contrast allergy and post-contrast acute kidney injury.

Calcified coronary artery disease is a common clinical finding and is visible angiographically in 25-30% of patients presenting for percutaneous coronary intervention. The presence of coronary calcium, even without coronary artery obstruction, confers an adverse clinical prognosis. Coronary calcium score on CT is additive in predicting risk of cardiovascular events beyond traditional scoring systems. Deposition of calcium in coronary arteries is initiated by the formation of an atherosclerotic plaque. Thereafter, multiple processes and pathways are involved, resulting in initial microcalcifications that coalesce into calcium sheets. Calcified nodules are thought to occur from rupture of these sheets. Calcified coronary stenoses requiring revascularisation result in greater target lesion failure and overall major adverse cardiovascular events than noncalcified lesions, regardless of the mode of revascularisation. Modifying calcium prior to stenting to optimise stent expansion is required and intracoronary imaging can greatly facilitate not only the detection of coronary calcium, but also the confirmation of adequate modification and stent optimisation. In this review, the authors examine the pathophysiology, prevalence, predictors and impact on outcomes of coronary calcium.