Catheterization and Cardiovascular Interventions最新文献

Intravascular ultrasound (IVUS) is an essential tool in the diagnostic and therapeutic management of coronary artery disease. In daily practice, IVUS is particularly useful for plaque characterization, optimizing stent implantation, and identifying the cause of in-stent restenosis. In acute coronary syndromes, it helps to detect culprit lesions that are not clearly visible on angiography and plays a key role in the diagnostic algorithm for myocardial infarction with non-obstructive coronary arteries (MINOCA). Additionally, IVUS is frequently used in complex and calcified lesions to guide optimal plaque modification strategies and improve procedural and long term outcomes. Beyond these common applications, IVUS is crucial in managing coronary complications, such as coronary dissection, perforation, intramural hematoma, and side-branch occlusion. In these challenging cases, IVUS allows us to overcome some of the limitations of angiography. This review explores the role of IVUS in bail out situations, offering practical tips and techniques for navigating coronary complications and improving procedural success in a safer and more refined manner.

Background: Reduction in cross-sectional area (CSA) of extracardiac Fontan conduits (EFC) is a known complication of the Fontan operation. Relief of obstruction is crucial for optimal Fontan physiology. The aim of this study is to describe technical aspects and outcomes of EFC stenting and short-term follow-up.

Methods: A retrospective study was performed of patients who underwent stent implantation in EFCs with reduced CSA from July 2011 to February 2024. The expected conduit CSA was calculated based on the implanted EFC diameter. The minimum CSA before and after stent implantation was calculated. The minimum EFC diameter and CSA were compared pre- and post-intervention. Data are presented as median [interquartile range].

Results: Sixty-five patients with reduced EFC CSA underwent stent implantation (median age: 13.3 [12.5, 16.8] years, median weight: 49.5 [41.6, 65.4] kg). Forty-seven (72.3%) catheterizations were performed for routine surveillance. In the 63 patients with a known original EFC size, the median reduction in EFC CSA was 36.0 [29,46] %. The minimum CSA was significantly smaller than the expected CSA (157.2 [133.7, 180.1] mm² vs. 254.5 [254.5, 254.5] mm², p < 0.0001). Including all patients the minimum EFC diameter and CSA were 12.5 [11.6, 13.4] mm and 153.8 [133.7, 179.7] mm², respectively. Following stent placement EFC diameter and CSA improved to 16.8 [16.2, 17.8] mm (p < 0.0001) and 234.8 [223.4, 269.2] mm² (p < 0.0001), respectively. The EFC CSA was 96.8 [89.2, 108.4] % of the expected CSA based on the original EFC diameter. In 24 (36.9%) patients the EFC CSA following stent placement was greater than the expected CSA. There were nine complications in total, of which two were related to EFC stenting.

Conclusions: Stent implantation can safely and effectively restore EFC CSA. In select cases, conduits can be expanded beyond the stated diameter.

Background: Biodegradable polymer stents may reduce the risk of neoatherosclerosis and stent thrombosis. Limited data is available for biodegradable polymer sirolimus-eluting stent (BP-SES) and durable polymer drug-eluting stents (DP-EES) in chronic total occlusions (CTO).

Aim: This study was to evaluate healing patterns of BP-SES versus DP-EES in CTO at 3 and 13 months based on optical coherence tomography (OCT).

Methods: The TARGET-CTO study is a prospective, multicenter, randomized noninferiority controlled trial for BP-SES compared to DP-EES in CTO. In the current predefined subanalysis, 44 consecutive patients underwent OCT follow-up at 3 and 13 months. The primary endpoint was mean neo-intimal thickness at 3 months.

Results: At 3 months, mean neo-intimal thickness was 47.6 ± 15.7 µm in BP-SES and 62.5 ± 37.3 µm in DP-EES (p = 0.384), meeting the noninferiority for BP-SES (p_{noninferiority} < 0.001). Mean neo-intimal thickness at 13 months was 76.4 ± 34.1 µm in BP-SES and 106.6 ± 54.9 µm in DP-EES (p = 0.086). No significant differences in strut coverage were observed at 3 or 13 months. At 13 months significantly higher percentages of frames with layered neo-intima and neoatherosclerosis were observed in DP-EES compared to BP-SES (p = 0.015 and p = 0.021, respectively).

Conclusions: BP-SES was noninferior to DP-EES in terms of neo-intimal thickness at 3 months and healing responses at 3-month follow-up were comparable. At 13 months, less advanced neoatherosclerosis patterns were observed in BP-SES as compared to DP-EES.

Background: Conduction disturbances are common after transcatheter aortic valve implantation (TAVI) and frequently require permanent pacemaker implantation (PPI). Data regarding its impact on mortality and morbidity are conflicting. This study aims to assess the impact of PPI before or within 30 days after TAVI on mortality and health-related Quality of Life (QoL) during the first year after TAVI.

Methods: In this POPular TAVI substudy, 978 patients were included and categorized into three groups: Neither PPI before or within 30 days after TAVI (no PPI, n = 779), PPI before TAVI (PPI pre-TAVI, n = 102), PPI within 30 days after TAVI (PPI post-TAVI, n = 97). All-cause death and cardiac death were evaluated at 1 year. QoL was assessed using the SF-12 and EQ-5D-5L questionnaires at baseline and 3, 6, and 12 months.

Results: At 1-year, all-cause death was seen in 6.9% (PPI pre-TAVI, p = 0.53) and 10.3% (PPI post-TAVI, p = 0.66) of the patients compared to 8.7% of the patients (no PPI). Cardiac death was observed in 4.9% (PPI pre-TAVI, p = 0.58) and 6.2% (PPI post-TAVI, p = 0.94) of the patients compared to 6.2% of patients (no PPI). Regarding QoL, the PPI pre-TAVI group showed lower PCS-12 over time compared to the no PPI group (p = 0.04), while MCS-12, EQ-5D Index and EQ-5D VAS scores were equal. No significant differences in QoL were seen between the PPI post-TAVI group and the no PPI group.

Conclusion: PPI before or within 30 days after TAVI was not associated with increased mortality within 1 year. PPI pre-TAVI was associated with lower physical QoL.

We present an 18-year-old male with Fallot's tetralogy (ToF) repaired with a transannular and main pulmonary artery (PA) patch, who suffered an acute coronary artery compression after a Harmony-TPV deployment. Left main coronary artery compression was confirmed with angiography and IVUS. He underwent emergent surgery, with a bioprosthetic valve replacement.

Background and aims: Drug-eluting stents (DES) are not designed for overexpansion to supra-nominal diameters or intentional stent fracture (ISF). The optimal dilation technique to minimize stent shortening (SS) and achieve ISF to accommodate pediatric somatic growth has not been described.

Methods: Three sizes of two commonly used DES were implanted within a silicone model to simulate blood vessels. Each stent was serially dilated in 1 mm increments under fluoroscopy using three techniques: 2 cm length, semi-compliant balloons (Technique 1), 2 cm, noncompliant balloons straddling the entire stent (Technique 2), or noncompliant balloons in an "inside-out" manner (balloon shorter than stent or 2 cm balloon aligned with distal end of stent (no straddle); (Technique 3). Technique 1 crossed over to noncompliant balloons once stent "napkin-ringed" (NR). Percent SS = (L_nominal - L_final)/L_nominal* 100.

Results: Technique 1 resulted in the greatest SS (median 85%, IQR 82, 87) and universal napkin ringing. Technique 2 caused less SS (median 14%, IQR 7, 15), and Technique 3 caused the least SS (median 7%, IQR 3, 11). ISF was achieved in all, however, the inside-out technique caused ISF at smaller stent diameters (median 114% recommended postdilation limit vs. 122%-131%) and lower inflation pressures (median 15 vs. 28-29 ATM). ISF was achieved in Technique 1 after napkin ringing but required larger noncompliant balloons than other techniques (median 8.5 vs. 7 mm).

Conclusion: Inside-out dilation resulted in less SS and fracture at smaller diameters with lower inflation pressures. This technique may improve the ISF success rate of DES in pediatric patients.

Patients with type 2 diabetes mellitus (DM) are more susceptible to microvascular complications. However, whether DM is associated with coronary microvascular dysfunction (CMD) is unclear. This observational study used data from the Coronary Microvascular Disease Registry (CMDR) (NCT05960474) and included patients with angina and no obstructive coronary artery disease (ANOCA) who underwent invasive CMD evaluation using the CoroVentis CoroFlow System (Abbott Vascular, Santa Clara, CA). Patient demographics, comorbidities, laboratory data, echocardiography, coronary angiography, and microvascular physiology results were analyzed. Among the 271 patients, 73 (26.9%) had DM. These patients were more likely to be African American (68.1% vs. 47.0%) and had higher rates of hypertension (93.2% vs. 74.2%), hyperlipidemia (89.0% vs. 68.7%), and chronic kidney disease (17.8% vs. 8.1%) than those without DM. Invasive coronary functional testing showed no significant differences in the index of microcirculatory resistance (IMR) (17.82 ± 8.17 vs. 19.37 ± 13.14, p = 0.268) or coronary flow reserve (CFR) (3.24 ± 1.73 vs. 3.21 ± 1.86, p = 0.909) between diabetic and nondiabetic patients. Similarly, in those testing positive for CMD, there were no significant differences in IMR (27.8 ± 7.4 vs. 32.35 ± 15.22, p = 0.108) or CFR (2.42 ± 1.09 vs. 2.05 ± 0.94, p = 0.199). Although patients with DM exhibited more comorbidities, CMD physiology indices were comparable between the groups.

Background: Access-related vascular complications (VCs) after percutaneous transfemoral transcatheter aortic valve replacement (TAVR) are associated with poor clinical outcomes and remain a significant challenge despite technological advances. The aim of this study was to identify anatomic predictors of access-related VCs after TAVR on preprocedural contrast-enhanced multidetector computed tomography (MDCT).

Aims: The aim of this study was to identify anatomical predictors of access-related VCs after TAVR on preprocedural contrast-enhanced MDCT.

Methods: A total of 348 consecutive patients with symptomatic severe AS who underwent transfemoral TAVR were included retrospectively. The primary endpoint of the study was the composite of minor and major access site complications as defined by the Valve Academic Research Consortium-3 (VARC-3) criteria. The study population was divided into two groups according to the VC including VC (+) and VC (-).

Results: A total of 101 patients (29%) developed VC (8.7% major, 20.3% minor) following TAVR. Regression analysis identified severe CFA calcification (p = 0.004), CFA depth (p < 0.001), minimum CFA diameter (p < 0.001), CFA depth-to-diameter ratio ≥ 5.6 (p < 0.001), and sheath-to-femoral artery ratio (SFAR) (p < 0.001) as significant predictors of VC. ROC curves generated for the occurrence of VC, the AUC for the femoral artery depth-to-diameter ratio (0.720) was higher than the AUC for the SFAR and the depth of the femoral artery (0.636, 0.630).

Conclusion: Complications related to vascular access sites continue to be a significant concern for patients undergoing TF-TAVR. The CFA depth-to-diameter ratio has demonstrated superior predictive performance for VC compared to SFAR as expressed in the literature. Utilizing this criterion may enhance risk stratification for VC in high-risk patients, potentially reducing associated morbidity and mortality.

We report the case of a 73-year-old male with a history of recurrent coronary interventions who presented with progressive angina and was diagnosed with a chronic total occlusion (CTO) of a heavily calcified and tortuous right coronary artery (RCA). Standard antegrade and retrograde techniques were attempted but failed due to the complexity of the lesion. A novel "Drag-Drill" technique was employed, utilizing a retrogradely externalized RG3 guidewire as a rotational atherectomy wire, enabling successful rotational atherectomy and percutaneous coronary intervention (PCI). The technique involved protecting the distal tip of the guidewire with a retrograde microcatheter to maintain stability and prevent vascular injury. At the 3-month follow-up, the patient remained angina-free. This case highlights the "Drag-Drill" strategy as an innovative and effective approach for the treatment of severely calcified and tortuous CTO lesions, underscoring the importance of tailored techniques in complex cases.

Background: Intravascular lithotripsy (IVL), that generates shockwaves through spark gap discharge between emitters, has been increasingly used to treat severely calcified coronary artery lesions. However, there is a question as to whether IVL has no electrical effects on endocardial tissues or cardiac implantable devices (CIEDs).

Aims: The aim of this study was to investigate the effects of IVL-induced intracardiac potentials on cardiac electrophysiology and CIEDs. Specifically, we examined how spark gap discharge of IVL influence myocardial electrical activity and the sensing function of CIEDs.

Methods and results: We conducted a preliminary in vitro experiment using an IVL and a pacemaker placed in a saline-filled container, where we observed that the pacemaker did indeed detect the discharge of IVL, leading to pacing inhibition. Then, 13 patients undergoing PCI with IVL were investigated with real-time monitoring of in vivo intracardiac electrogram (EGM) synchronized with body surface ECG, with an external temporary pacing lead placed in the right ventricle. Similar to the above experiment, we found that IVL pulses were indeed detected on the EGM and sensed by the temporary pacemaker. Of the 287 IVL pulses outside the range of absolute refractory period, 59 (20.6%) captured the ventricle, while the remaining 228 (79.4%) did not elicit any electrical myocardial activity.

Conclusions: Our observations indicate concerns about the use of IVL: the risk of inducing fatal arrhythmia and the occurrence of cardiac arrest or bradycardia in the CIED-dependent patients. IVL users should be aware of the potential risk of such events.