Interventional Cardiology Review最新文献

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.

Percutaneous techniques to treat obstructive coronary artery disease continue to evolve and the evidence base informing our practice is shared and summarised in international guidelines. In the UK, the British Cardiovascular Intervention Society represents and supports interventional cardiologists undertaking both coronary and structural interventions. Procedural data are collected in a national registry and these inform our understanding of UK practice and outcomes. These recommendations, pertaining to coronary intervention alone, are an update of those published in 2015 and describe the provision of percutaneous coronary intervention in the UK intended to provide optimal patient care.

Stent underexpansion (SU) and aorto-ostial lesions (AOL) are challenging conditions commonly faced during clinical practice in the setting of percutaneous coronary interventions. Compared to other interventional settings, both SU and AOL are associated with an increased risk of immediate and late events following percutaneous coronary intervention. Several specific strategies including the systematic use of intracoronary imaging and dedicated techniques for lesions' preparation and calcium debulking have been described. This narrative review summarises the currently available options for the diagnosis and treatment of both SU and AOL, highlighting the potential benefits and limits of each technique in these specific settings.

Coronary artery ectasia (CAE) is an abnormal dilatation of coronary artery segments, often linked with atherosclerosis. This report discusses two cases of CAE presenting as acute coronary syndrome. A 36-year-old man had proximal blockage in the left circumflex artery (LCx) and ectasia in the obtuse marginal artery and left anterior descending artery (LAD), while a 53-year-old male smoker had an ectatic LAD with a substantial thrombus. Both were treated with dual antiplatelet therapy (aspirin and clopidogrel) and non-vitamin K antagonist oral anticoagulants (NOACs), specifically apixaban, along with atorvastatin. The first patient had complete resolution of LCx occlusion after 1 year, and the second patient had complete thrombus dissolution in the LAD in 2 months. These cases highlight the potential benefits of NOACs in managing CAE in acute coronary syndrome, suggesting that triple therapy can significantly improve clinical outcomes.

Coronary chronic total occlusions (CTO) are frequently identified during coronary angiography and remain the most challenging subset of coronary artery lesions to treat; however, advancements in techniques and materials have greatly improved success rates. Various crossing algorithms have been developed to standardise the approach to CTO interventions based on angiographic criteria. Antegrade wiring is typically the initial strategy of choice, particularly in cases of short and straight CTOs with tapered proximal cap. Similarly, retrograde crossing can be achieved through retrograde wiring, although this approach has a very low success rate. This review aims to outline how to perform a CTO analysis, clarify the fundamental features of guidewires and provide insights into both antegrade and retrograde wire-based approaches.

Unprofessional behaviour within cardiology has been well documented and commonly occurs within the cardiac catheterisation laboratory, with higher rates in interventional subspecialities. While most trainees have positive experiences and encounters within the catheterisation laboratory, around one in five report experiencing bullying. This not only has a significant negative impact on the individuals directly involved, but also on the wider multidisciplinary team; importantly, it will have a deleterious effect on patient safety. The British Cardiovascular Intervention Society established the Training Culture Focus Group in 2022 to analyse and offer potential solutions to this pressing issue. We recommend that a cohesive approach between trainers and trainees is the most effective way to reduce unprofessional behaviour incidents, thus improving departmental workplace culture and a subsequent reduction in adverse patient safety events.

Coronary artery disease remains the leading cause of morbidity and mortality worldwide despite advancements in percutaneous coronary intervention (PCI). With an increasing ageing population, there is a significant challenge in addressing severe calcification in atherosclerotic plaque during angioplasty. This review article focuses on atherectomy strategies such as rotational atherectomy (RA), orbital atherectomy (OA) and excimer laser coronary angioplasty (ELCA) aimed at modifying calcified lesions and improving PCI outcomes. RA modifies plaque through rotational ablation, OA uses eccentrically mounted diamond-coated crown and has a reduced entrapment risk compared to RA. ELCA uses pulsatile laser energy to precisely ablate plaque tissue. This review provides insights into the mechanisms, procedural techniques and clinical outcomes associated with these calcium modification techniques. The selection of appropriate devices and adequate training are crucial for optimising lesion modification and enhancing procedural success. Further research and standardised protocols are required to overcome challenges associated with using these devices and expand their usage in clinical practice.