Selected Research Abstracts From The Journal of Invasive Cardiology

Outcomes of Patients Undergoing Elective Percutaneous Coronary Interventions in the Ambulatory Versus In-Hospital Setting

Mark R. Kahn, MD, Arzhang Fallahi, MD, Robert Kulina, MD, George D. Dangas, MD, PhD, Annapoorna S. Kini, MD, Samin K. Sharma, MD, Michael C. Kim, MD

Objectives. To compare outcomes of elective percutaneous coronary interventions (PCI) in same-day discharge and overnight hospital stays. Background. Advances in PCI techniques and equipment have allowed same-day discharge after elective PCI. In this study, we investigated the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores. Methods. The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. Patients were stratified into tertiles based on ACEF score: low (<1.08), mid (≥1.08 and <1.31), and high (≥1.31). The primary endpoint was 30-day major adverse cardiac events, defined as readmission, all-cause mortality, non-fatal myocardial infarction, and target lesion revascularization. Propensity score matching was done to evaluate outcomes based on similar baseline characteristics. Results. There were 16,407 elective PCIs, of which 21.2% were in the ambulatory group. Patients who stayed overnight had similar 30-day composite outcomes as their same-day discharge counterparts in the high ACEF score (odds ratio [OR], 1.213; 95% confidence interval [CI], 0.625-2.355; P=.57) and mid ACEF score (OR, 0.636; 95% CI, 0.356-1.134; P=.13) comparisons, but had worse outcomes in the low ACEF score comparison (OR, 1.867; 95% CI, 1.134-3.074; P=.01). Conclusions. In this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories.

J INVASIVE CARDIOL 2014; 26(3): 106-113

One-Year Clinical Outcome of Elderly Patients Undergoing Angioplasty for ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: The Importance of 3-Vessel Disease and Final TIMI-3 Flow Grade

Francesco De Felice, MD, Elena Guerra, MD, Rosario Fiorilli, MD, Antonio Parma, MD, Carmine Musto, MD, Marco Stefano Nazzaro, MD, Roberto Violini, MD

Background. The influence of age on clinical results of primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarctions (STEMI) complicated by cardiogenic shock (CS) is poorly investigated. Methods. In this study, we evaluated the outcome of 216 consecutive all-comer patients with STEMI and CS undergoing PCI who were divided into 2 groups according to age: <75 years (n = 131) or ≥75 years (n = 81). The study endpoint was the incidence of death at 1-year follow-up. The predictors of mortality at 1 year were also investigated. Results. The group <75 years had a significantly lower incidence of death compared with the group ≥75 years at 30 days (39% vs 69%; P=.01) and 1 year (51% vs 79%; P<.001). Cox proportional hazards model identified: age (adjusted hazard ratio [HR] = 1.02; 95% confidence interval [CI], 1.00-1.03; P=.02), 3-vessel disease (HR = 1.47; 95% CI, 1.00-2.17; P=.05), post-PCI TIMI flow grade 0-1 (HR = 2.48; 95% CI, 1.66-3.70; P=.01) and grade 2 (HR = 1.68; 95% CI, 1.01-2.80; P=.05) after PCI as independent predictors of death at 1-year follow-up. Conclusions. Patients ≥75 years with STEMI complicated by CS and treated by PCI have higher 1-year mortality compared with younger counterparts. Final TIMI 0-2 and 3-vessel disease are strong predictors of death. This finding may be valuable in risk stratification of these patients.  

J INVASIVE CARDIOL 2014;26(3):114-118

Effects of Intracoronary Sodium Nitroprusside Compared With Adenosine on Fractional Flow Reserve Measurement

Xiaozeng Wang, MD, Shaosheng Li, MD, Xin Zhao, MD, Jie Deng, MD, Yaling Han, MD

The purpose of this study was to compare the efficacy and safety of intracoronary (IC) sodium nitroprusside (SNP) and IC adenosine (AD) for fractional flow reserve (FFR) measurement. We compared the FFR response and side effect profiles of IC AD and IC SNP in 40 patients with a combined total of 53 moderate coronary stenoses. Boluses of AD at doses of 40 µg (A1) and 60 µg (A2), and SNP at doses of 0.3 µg/kg (S1), 0.6 µg/kg (S2), and 0.9 µg/kg (S3) were used to achieve coronary hyperemia. The mean FFR value decreased significantly by 7.96% (A1), 10.51% (A2), 8.74% (S1), 10.58% (S2), and 10.73% (S3) compared with the baseline distal coronary pressure/aortic pressure. IC SNP delayed the mean time to peak value of FFR by 87.5%, 79.0%, and 88.6% in S1, S2, and S3, respectively, compared with A2 (P<.001). The mean duration of the plateau phase was longer in S1 (50.47 ± 14.25 s), S2 (51.33 ± 16.41 s) and S3 (57.60 ± 18.07 s) compared with A2 (27.93 ± 11.90 s; P<.01). IC AD caused shortness of breath in 11 patients (27.5%), flushing in 4 patients (10%), headache in 8 patients (20%), and transient second-degree atrioventricular block (AVB) in 6 patients (15%). IC SNP may be used as a hyperemic agent in FFR measurements. It may be preferable to IC AD as a routine clinical stimulus and has the additional advantage of showing a longer plateau phase.  

J INVASIVE CARDIOL 2014;26(3):119-122

Transcatheter Aortic Valve Implantation in Patients With LV Dysfunction: Impact on Mortality and Predictors of LV Function Recovery

Yacine Elhmidi, MD, Sabine Bleiziffer, MD, Marcus-André Deutsch, MD, Markus Krane, MD, Domenico Mazzitelli, MD, Rüdiger Lange, MD, PhD, Nicolo Piazza, MD, PhD

Background. Aortic stenosis patients with left ventricular dysfunction are at increased risk for morbidity and mortality following surgical aortic valve replacement. There are few published data regarding the outcomes of patients with severe aortic stenosis and left ventricular (LV) dysfunction undergoing transcatheter aortic valve implantation (TAVI) and possible predictors of LV recovery. Aims. To compare the baseline characteristics and outcomes between patients with normal LV function and those with LV dysfunction and to assess the predictors of LV recovery after TAVI. Methods. We enrolled 505 consecutive patients with severe aortic stenosis who underwent TAVI between November 2007 and January 2010. Patients were stratified according to LV function as follows: normal LV function (ejection fraction [EF] >50%), moderate LV dysfunction (EF 35%-50%) and severe LV dysfunction (EF ≤35%). The baseline characteristics and clinical outcomes, up to 6 months, were subsequently compared among the 3 patient subgroups. Univariable and multivariable logistic regression analyses were used to identify independent predictors of LV recovery. Results. Normal LV function was identified in 324 patients (64%) and LV dysfunction in 181 patients (36%); in those with LV dysfunction, 111 patients (22%) had moderate LV dysfunction and 70 patients (14%) had severe LV dysfunction. As compared to patients with normal LV function, those with severe LV dysfunction were more likely to be male, had higher STS and logistic EuroSCORE, more coronary artery disease/previous coronary artery bypass surgery, higher NT-proBNP levels, lower mean transaortic valve gradients, and smaller aortic valve areas. No significant difference in 30-day mortality was observed between the LV function subgroups. The 6-month mortality, however, was 2-fold higher in patients with severe LV dysfunction (27% vs 15%, respectively; P=.03). Recovery of LVEF to more than 50% was observed in 15% of patients with baseline EF ≤35%. Baseline EF was the strongest independent predictor of LV recovery after TAVI (odds ratio, 85; 95% confidence interval, 19-380; P<.001). Conclusions. Despite a similar periprocedural outcome, patients with aortic stenosis and severe LV dysfunction exhibit a significantly increased 6-month mortality after TAVI. Survivors with LV dysfunction, however, show a significant potential for LV function recovery.  

J INVASIVE CARDIOL 2014;26(3):132-138

“Seesaw Balloon-Wire Cutting” Technique as a Novel Approach to “Balloon Uncrossable” Chronic Total Occlusions

Yue Li, MD, Jianqiang Li, MD, Li Sheng, MD, Yongtai Gong, MD, Weimin Li, MD, Danghui Sun, MD, Jingyi Xue, MD

Background. Balloon crossing failure after passing a guidewire usually leads to unsuccessful percutaneous recanalization of chronic total occlusions (CTOs). We sought to investigate a novel technique for solving this problem. Methods. Twenty-one patients with failed balloon crossing through CTOs after successful guidewire passing were treated with the “seesaw balloon-wire cutting” technique between July 2012 and May 2013. The main process of this technique was to insert two guidewires (guidewire A and guidewire B) into the distal true lumen of CTOs and then to advance two short and low-profile balloons (balloon A and balloon B) over the two guidewires, respectively. Balloon A was first advanced over guidewire A as distally as possible, and then was inflated with high pressure (≥18 atm) to press guidewire B, producing a cutting power to crush the proximal fibrous cap of the CTO. Subsequently, balloon A was withdrawn slightly, and balloon B was advanced as distally as possible and then was inflated to press guidewire A, producing a similar cutting effect to crush the proximal fibrous cap on the other side. The two balloons were progressed alternatively until one of them was able to cross through the occluded segment. Results. This new technique was successfully applied in 17 patients (81.0%), leading to procedural success of their CTOs. The technique failed in 4 patients (19.0%) due to heavy calcification. No complications occurred in all patients. Conclusion. The seesaw balloon-wire cutting technique is an effective and safe approach to facilitate balloon crossing during CTO interventions.   

J INVASIVE CARDIOL 2014;26(4):167-170

Transradial Versus Transfemoral Coronary Intervention for Acute Myocardial Infarction Complicated by Cardiogenic Shock: Is Transradial Coronary Intervention Suitable for Emergency PCI in High-Risk Acute Myocardial Infarction?

Atsushi Iga, MD, Kenji Wagatsuma, MD, PhD, Junichi Yamazaki, MD, PhD, Takanori Ikeda, MD, PhD

Background. Data are limited regarding the clinical results of transradial coronary intervention (TRI) in acute myocardial infarction (AMI) complicated by cardiogenic shock. Objective. The aim of this study was to compare the clinical results of TRI and transfemoral coronary intervention (TFI) in AMI patients who had cardiogenic shock and underwent emergency percutaneous coronary intervention (PCI). Methods. Between January 1, 2006, and August 31, 2012, a total of 507 consecutive patients with AMI underwent emergency PCI within 12 hours of onset. Eighty-five patients presented with cardiogenic shock and were enrolled. Among these patients, 60 underwent TRI and 25 underwent TFI. Outcome measures included the following: major bleeding and vascular complications; major adverse cardiac or cerebrovascular events (MACCE); all-cause death; door-to-balloon time; and PCI procedural success. Results. TRI had a significantly lower rate of major bleeding and vascular complications within 30 days (6.7% vs 28.0%; P<.05 and >.99). Conclusion. TRI is associated with fewer major bleeding and vascular complications than TFI, and it appears suitable for both low- and high-risk AMI patients, especially when AMI is complicated by cardiogenic shock.

J INVASIVE CARDIOL 2014;26(5):196-202

Novel Use of a Guide Extension Mother-and-Child Catheter for Adjunctive Thrombectomy During Percutaneous Coronary Intervention for Acute Coronary Syndromes

Anil J. Mani, MBBS

Background. The use of adjunctive thrombectomy during primary percutaneous coronary intervention (PCI) has steadily increased with recent trials demonstrating an improved clinical and mortality benefit for manual aspiration thrombectomy. The use of an in-dwelling guide extension mother-and-child catheter allows direct aspiration of thrombus from the vessel with its larger extraction area. Methods. Between December 2011 and September 2013, a total of 17 patients who presented with acute coronary syndromes (ACS) in whom a guide extension catheter was utilized specifically for manual thrombus aspiration were identified and studied. Results. The guide extension catheter was utilized specifically for thrombus aspiration in 18 vessels involving 17 patients presenting with ACS where severe thrombus burden was noted. The cases involved 4 saphenous vein grafts and 14 native coronary arteries, with 4 cases involving vessels with late stent thrombosis. Successful outcomes with thrombus aspiration and TIMI-3 flow were achieved in 17/18 vessels treated, with no adverse outcomes of vessel trauma or strokes noted. Conclusions. Adjunctive manual aspiration thrombectomy utilizing a guide extension mother-and-child catheter affords a novel method of thrombus aspiration, offering a larger extraction area within the conventional 6 Fr system, with demonstrated efficacy for vessel lesions with a large thrombus burden.

J INVASIVE CARDIOL 2014;26(6):249-254

Clinical Outcome of Successful Percutaneous Coronary Intervention for Chronic Total Occlusion: Results From the Multicenter Korean Chronic Total Occlusion (K-CTO) Registry

Byeong-Keuk Kim, MD;  Sanghoon Shin, MD;  Dong-Ho Shin, MD;  Myeong-Ki Hong, MD;  Hyeon-Cheol Gwon, MD;  Hyo-Soo Kim, MD;  Cheol Woong Yu, MD;  Hun Sik Park, MD;  In-Ho Chae, MD;  Seung-Woon Rha, MD;  Seung-Hwan Lee, MD;  Moo-Hyun Kim, MD;  Seung-Ho Hur, MD;  Yangsoo Jang, MD

Objectives. To investigate the impact of the success or failure of chronic total occlusion (CTO) interventions on the clinical outcomes in the current drug-eluting stent (DES) era. Background. The impact of the successful CTO intervention on long-term clinical outcomes still remains unclear. Methods. Between 2007 and 2009, a total of 2568 patients with CTO were followed in a multicenter Korean CTO registry. Of these, successful recanalization with DESs occurred in 2045 patients (successful CTO group), whereas failure occurred in 523 patients (failed CTO group). Results. The occurrence of the composite of cardiac death and myocardial infarction (MI) was compared between the successful CTO and failed CTO groups. During follow-up (median duration, 729 days), the occurrence of cardiac death or MI was significantly lower in the successful CTO group than in the failed CTO group (1.7% vs 3.3%; hazard ratio, 0.50; 95% confidence interval, 0.28-0.91; P=.02) and the cumulative occurrence in the successful CTO group was also significantly lower than in the failed CTO group (1.7% vs 3.0%; P=.03) by the Kaplan-Meier method. The successful CTO group had a significantly lower need for bypass surgery than the failed CTO group (0.2% vs 2.5%; P<.001). In multivariate analysis, procedural success of CTO (odds ratio, 0.51; 95% CI, 0.29-0.92) was significantly predictive of the occurrence of cardiac death or MI, together with age and left ventricular ejection fraction <40%. Conclusion. This registry study demonstrated that successful CTO intervention with DESs compared to failed CTO intervention was associated with lower event rates during follow-up.

J INVASIVE CARDIOL 2014;26(6):255-259

Robotic-Enhanced PCI Compared to the Traditional Manual Approach

Nathaniel R. Smilowitz, MD;  Jeffrey W. Moses, MD;  Fernando A. Sosa, BA;  Benjamin Lerman, BA; Yasir Qureshi, MD;  Kate E. Dalton, MS;  Lauren T. Privitera, MPH;  Diane Canone-Weber, MPH; Varinder Singh, MD;  Martin B. Leon, MD;  Giora Weisz, MD

Abstract: Remote-controlled robotic-enhanced percutaneous coronary intervention (PCI) was developed to improve procedural outcomes, reduce operator radiation exposure, and improve ergonomics. Critics questioned whether protection of the operator might result in increased radiation exposure to the patient and increase contrast media use. We studied this in a single-center comparison of robotic-enhanced versus traditional PCIs. A total of 40 patients who enrolled in the PRECISE study and had PCI with the CorPath 200 robotic system (Corindus Vascular Robotics) were compared to 80 consecutive patients who underwent conventional PCI. All patients had obstructive coronary artery disease, evidence of myocardial ischemia, and clinical indications for single-vessel PCI. Baseline demographics of the 40 robotic and 80 traditional PCIs were similar. Only 2 robotic-assisted cases required conversion to manual PCI. All patients had a final residual stenosis <30%. Robotic-enhanced PCI was associated with trends toward lower duration of fluoroscopy (10.1 ± 4.7 min vs 12.3 ± 7.6 min; P=.05), radiation dose (1389 ± 599 mGy vs 1665 ± 1026 mGy; P=.07), and contrast volume (121 ± 47 mL vs 137 ± 62 mL; P=.11). In conclusion, the initial experience with robotic-enhanced PCI was not associated with increased fluoroscopy duration, radiation, or contrast media exposure to patients, and compared favorably to the traditional approach. 

J INVASIVE CARDIOL 2014;26(7):318-321

Incidence and Predictors of Side-Branch Compromise in Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

Valerie Khoo;  Liang Shen, PhD;  Vanessa Khoo;  Germaine Loo;  Mark Richards, MD;  Tiong-Cheng Yeo, MD;  Chi-Hang Lee, MD

Objective. We aimed to determine the incidence and predictors of side-branch compromise (SBC) in patients who underwent primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Background. Little data exist on SBC in AMI patients, especially in the drug-eluting stent era. Methods. We recruited 174 patients who underwent primary PCI over a 12-month period. After reviewing their coronary angiograms, we included for analysis 102 patients with a side branch >2 mm arising from the culprit lesion and that was spanned by a coronary stent. SBC was defined as post-stent implantation TIMI flow of <3 in the side branch. Results. Among the 102 patients analyzed, drug-eluting stents (n = 77), bare-metal stents (n = 17), and bioresorbable vascular scaffolds (n = 8) were used to treat the culprit lesions. Final TIMI flow of the main vessel was 2 or 3 in 101 patients (99%). SBC occurred in 23 patients (final side branch TIMI flow 0, n = 6; TIMI 1, n = 4; TIMI 2, n = 13), giving an incidence of 22.5%. Multivariate analysis showed non-left anterior descending (LAD) culprit vessel (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.22-10.95; P=.02), higher peak creatine kinase level (OR, 1.03 for every 100-unit increase; 95% CI, 1.01-1.05; P=.01), and Rentrop score of 2/3 (OR, 3.57; 95% CI, 0.98-13.04; P=.055) to be independent predictors of SBC. Conclusions. The incidence of SBC was 22.5%. The independent predictors of SBC were non-LAD culprit vessel, larger infarct size, and good collateral vessel formation.

J INVASIVE CARDIOL 2014;26(7):297-302