13th Annual Complex Cardiovascular Catheter Therapeutics: Advanced Endovascular and Coronary Intervention Global Summit (C3)

CARDIOVASCULAR PHARMACOLOGY

C3 2017-1 Effect of Beta-Blocker Therapy on Readmissions and Mortality in Heart Failure Patients With Ongoing Cocaine Use

Obiora Egbuche, MD, MPH; Ifunanya Ekechukwu, MD; Nnamdi Maduabum, MD, MPH; Udoka Obinwa, MPH; Kelechi Ukpaka, MPH; Anekwe Onwuanyi, MD

Background: Beta-blockers are first-line agents for reduction of symptoms, hospitalization, and mortality in heart failure patients with reduced ejection fraction (HFrEF). However, the safety and efficacy of continuous beta-blocker therapy (BBT) in patients who actively use cocaine remains controversial and available literature is limited. We aimed to evaluate the effect of BBT on readmissions and mortality in HFrEF patients with ongoing cocaine use.

Methods: We conducted a retrospective chart review of patients with a new diagnosis of HFrEF between 2011 and 2014 based on ICD9-CM codes. We included patients aged 18 and older who tested positive for cocaine on a urine toxicology test obtained at the time of index admission. Patients were followed for 1 year. We assessed for beta-blocker prescription rate at the time of discharge from the index admission. A multivariate logistic regression was used to assess the effect of BBT on the 30-day all-cause and heart-failure related readmissions. The 1-year mortality rate was also reported.

Results: In our study population (n = 268; mean age 54 ± 6.9 years), the beta-blocker prescription rate was 86.2%. The 30-day readmission rates for BBT vs no BBT groups were 20% vs 41% (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.05-0.56; P=.004) for heart-failure related readmissions and 25% vs 46% (OR 0.19; 95% CI, 0.06-0.64; P=.007) for all-cause readmissions. The 1-year mortality rates for BBT vs no BBT groups were 5% vs 8% (OR, 0.88; 95% CI, 0.17-7.19; P=.91).

Conclusion: Physicians continue to prescribe outpatient beta-blocker therapy for most HFrEF patients regardless of cocaine-use status. BBT reduces readmission rate but not 1-year mortality in HFrEF patients with ongoing cocaine use. Large observational studies are needed to further elucidate the efficacy and safety of continuous BBT in this population.

C3 2017-2 Beta-Blocker Therapy in Cocaine Users With Heart Failure: Insights From an Urban Academic Center

Obiora Egbuche, MD, MPH; Valery Effoe, MD, MS; Heather R. Millard, MPH; Leonard Addae, MD; Demilade Adedinsewo, MD; MPH; Anekwe Onwuanyi, MD

Background: Beta-blockers are first-line agents for reduction of symptoms, hospitalization, and mortality in heart failure patients with reduced ejection fraction (HFrEF). The safety and efficacy of continuous beta-blocker therapy (BBT) in patients who use cocaine remains controversial and available literature is limited. We aimed to evaluate clinical outcomes of BBT among HFrEF patients who use cocaine.

Methods: We conducted a retrospective chart review of 90 patients with a diagnosis of heart failure based on ICD9-CM codes and baseline ejection fraction (EF) <40% who tested positive for cocaine on urine toxicology test at the time of index admission. We included patients 18 years or older with at least 3 months of follow-up. Baseline EF was obtained from the earliest available echocardiogram report in 2011 and repeat EF was obtained from follow-up echocardiogram reports while on BBT. We described baseline patient characteristics, comorbidities, and outcomes (change in EF during study period, re-hospitalizations, and mortality).

Results: In our study population (mean age, 56.1 ± 7.8 years), the mean baseline EF was 24.1 ± 9.0%. The mean overall change in EF among patients on continuous BBT was 1.9 ± 14.6 (P=.20) over a mean follow-up of 15.5 ± 8.6 months. Thirty-nine percent (n = 35; mean follow-up, 15.7 months) of our study population had a decrease in EF (mean change, -10.6 ± 6.8%), 22% (n = 20; mean follow-up, 17.4 months) had no change in EF and 39% (n = 35; mean follow-up, 14.3 months) had an increase in EF (mean change, 14.3 ± 7.5%). There was an average of 3.2 ± 3.3 re-hospitalizations. Ninety-two percent (n = 83) were alive at the end of the study period.

Conclusion: Continuous BBT in HFrEF patients who abuse cocaine has variable effects on left ventricular EF. Large observational studies are needed to further elucidate the efficacy and safety of long-term BBT in this population. 

C3 2017-3 Comparison of Clinical Outcomes – Bivalirudin With Transfemoral Access vs Heparin With Transradial Access in Patients With ST-Segment Elevation Myocardial Infarction

Jaya Mallidi¹; John Ulahannan¹; Vinod K. Chaubey¹; Auras Atreya¹; Muhammad T. Shakoor¹; Jane Garb¹; Daniel Fisher²; Kurt Barringhaus²; Amir Lotfi¹

¹Baystate Medical Center, Springfield, Massachusetts and ²UMass Medical Center, Worchester, Massachusetts

Introduction: The interaction between access site and anticoagulant used during primary percutaneous coronary intervention (PCI) in patients presenting with ST-segment elevation myocardial infarction (STEMI) is not well studied. 

Hypothesis: Our aim was to compare clinical outcomes among STEMI patients undergoing primary PCI using bivalirudin via femoral route (bival/fem) with heparin via radial route (hep/rad). We hypothesized that there would be no difference in clinical outcomes between the two groups. 

Methods: We conducted a retrospective cohort study of all patients >18 years who presented with STEMI and underwent primary PCI in two large regional STEMI centers in Massachusetts between October 1, 2012 to December 31, 2014. Data were obtained using the electronic system that is routinely used to collect data on all STEMI patients. The cohort was divided into three groups – bival/fem or hep/rad or off-protocol, based on the access site and anticoagulation used. We used multiple logistic regression model to compare major adverse cardiovascular events (composite of death, myocardial infarction, stroke, stent thrombosis) and bleeding complications between the two on-protocol groups (bival/fem and hep/rad). 

Results: A total of 1074 patients were included in this study. Of these, there are 443 (41%), 501 (47%), and 130 (12%) patients in the bival/fem, hep/rad, and off-protocol groups, respectively. The number of patients presenting with cardiogenic shock was significantly higher in the bival/fem group (6.5% vs 3.0%; P<.001). In a multivariable analysis, major adverse cardiovascular event rates were significantly lower in the hep/rad group compared with the bival/fem group (3.0% vs 5.6%; P=.045). The rate of mortality was significantly lower in the hep/rad group compared to the bival/fem group (1.4% vs 5.0%; P=.019) without any significant difference in rates of major bleeding (hep/rad 2.6% vs bival/fem 3.2%; P=.60). 

Conclusion: This study shows that among patients presenting with STEMI, primary PCI done via radial route using heparin may be associated with better clinical outcomes compared with femoral route using bivalirudin. 

C3 2017-4 Diuretic Dosing Strategies in Heart Failure with Reduced and Preserved Ejection Fractions: A Retrospective Comparison

Perry Fisher, MD; Jenny Placido-Disla, MD; Jose Paz, MD; Carlos Bonilla, MD; Dalia Rizk, DO

Purpose: To examine the efficacies of various diuretic dosing strategies with regard to heart-failure classifications.

Introduction: Based on the findings of the DOSE trial, our institution – a university hospital in a major United States city – implemented a protocol whereby any heart-failure exacerbation admission would receive an initial dose of 80 mg of intravenous furosemide 3 times daily for the first 72 hours of hospitalization. This was meant to have a multifaceted benefit on such admissions; namely on the length of hospital stays for patients. However, we hypothesized that standardizing high-dose furosemide for all patient populations may lead to negative inpatient consequences.

Methods: A total of 333 consecutive patients admitted for acute systolic or diastolic heart failure were identified in an urban, academic medical center and reviewed from July 2014 to June 2015. The amount of diuretics administered within the first 72 hours of hospitalization was ascertained. Analysis of variance statistical testing was used to compare total diuretic dosing and lengths of stay in patients with heart failure with reduced and preserved ejection fractions (HFrEF and HFpEF).

Results: Patient characteristics included mean age of 70.4 years, 43% female, 31.8% white, mean ejection fraction of 35.5%, and mean creatinine on admission of 1.37. Higher total diuretic dose in the first 72 hours was significantly associated with longer length of stay in both the HFrEF and HFpEF groups.

Conclusions: Our study elucidated a longer average length of stay in both the HFrEF and HFpEF cohorts given higher diuretic doses in the first 72 hours of hospitalization. This contradicts the findings of prior studies and suggests that individualization of diuretic dosing is prudent in heart-failure management.

CORONARY

C3 2017-5 The Relationship Between Carotid Atherosclerosis and Severity of Coronary Artery Disease

Mohamed Abdel Ghany, MD; Mohamed Abdel Wakeel, MD; Hosam Hasan, MD; Salwa Roshdy, MD

Cardiology Department, Asyut University, Egypt

Background: Carotid intima media thickness may not only be associated with coronary artery disease extent and severity but also with its complexity. 

Purpose: The aim of this study was to evaluate the relationship between carotid atherosclerosis assessed by carotid intima media thickness and plaque score and severity of coronary artery disease.

Methods: SYNTAX score was calculated for 180 patients scheduled for coronary angiography. Severity, extent, and pattern indices for coronary artery disease were assessed for all patients. Severity pertains exclusively to the degree of narrowing (transverse disease), and was evaluated by counting the number of major epicardial vessels with ≥70% narrowing of the lumen diameter. 

The maximum number of vessels was three. Left main stenosis of ≥50% was counted as two vessels. Extent considers the proportion of each coronary segment that appears abnormal (longitudinal disease). The coronary arteries were classified into 15 segments. Carotid intima media thickness was measured in the far wall of the distal common carotid artery; it was measured as the distance between the lumen-intima interface and the media-adventia interface. At least three measurements were taken and the maximum was considered on each side. Plaque was designated as focal intima media thickening >1.1 mm, the plaque score was computed by summing up the thickness of all plaques located in both carotid arteries. 

Results: Increased mean carotid intima media thickness was found to have a significant positive correlation with SYNTAX score (r = 0.475; P<.005), coronary extent index (r = 0.485; P<.005) and coronary pattern index (r = 0.464; P<.005), with a sensitivity of 81.25%, specificity of 57.43%, and negative predictive value 93.4%. Plaque score also correlates significantly with SYNTAX score (r = 535; P<.001), coronary extent index (r = 532; P<.001), and coronary pattern index (r = 0.502; P<.001), with sensitivity of 56.62%, specificity of 72.97%, and negative predictive value of 90.8%.

Conclusion: Increased carotid intima media thickness not only associated with the presence of coronary artery disease but also with lesion complexity, severity, and extent. The carotid plaque score and the mean carotid intima media thickness showed high negative predictive value for the presence of complex coronary artery lesions.

C3 2017-6 Hepatitis-C Virus Infection is a Risk Factor for Coronary Artery Disease in Egypt

 Abdel Mohsen M. Aboualia, MD; Mohamed Osama Kayed, MD; Mahmoud Samir Rehan, Msc; Mohamed Abood, MD; Mamdouh Attia Mohamed, MD 

Al-Azhar Faculty of Medicine, Cairo, Egypt

Aim: To study the presence of atherosclerotic coronary artery disease in patients with chronic hepatitis C virus (HCV) infection.

Patients: This study included two main groups of patients with symptomatic ischemic heart disease (according to HCV serology), presented as acute coronary syndrome or for elective or emergent coronary angiography: group I = 100 HCV seropositive patients as a test group; and group II = 32 HCV seronegative patients as a control group. 

Methods: All patients were studied along the following scheme: informed consent, full history taking, complete physical examination, full routine labs, HCV rapid test, resting 12-lead electrocardiogram, transthoracic echocardiography, pelvi-abdominal ultrasound, and coronary angiography.

Results: The two groups were matched in age after exclusion of diabetes, hypertension, chronic renal diseases, clinical liver cirrhosis, and history of ischemic heart disease. There was male predominance in group I with statistical significance. In this study, 99% of patients with HCV seropositive had abnormal coronary angiography while 65.6% of HCV seronegative patients had abnormal coronary angiography; this difference showed statistical significance (<.001). The number of affected vessels was higher in the HCV seropositive group vs the seronegative group (1-vessel disease, 49% vs 56.3%; 2-vessel disease, 25% vs 6.3%; multivessel disease, 25% vs 3.1% in the HCV seropositive and seronegative groups, respectively; P<.001). 

Left main was present in 5 patients in group I and no patient in group II. In univariate logistic regression analysis, the predictors of coronary artery disease were sex (P<.001), smoking (P=.037), and HCV seropositivity (P=.041). In multivariate logistic regression analysis, the predictors of coronary artery disease were smoking (P=.011), HCV seropositivity (P=.032), and age (P=.40).

Conclusion: HCV is a risk factor for coronary artery disease and associated with increased angiographic burden of coronary artery disease in patients with HCV seropositivity.

C3 2017-7 Allergic Myocardial Infarction: Can You Differentiate?

A. Sami Abuzaid, Jr.

Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System

Introduction: Kunis syndrome describes the combination of acute coronary syndrome (ACS) in the setting of allergic or anaphylactic insults. The pathophysiology of Kunis syndrome involves coronary artery spasm and/or atheromatous plaque erosion or rupture during an allergic reaction. In type I variant (72.6%; no coronary artery disease), the release of inflammatory mediators induces coronary spasm with or without increase of cardiac biomarkers. Endothelial dysfunction and/or microvascular angina could be a reasonable explanation. In type II variant (22.3%), the release of inflammatory mediators induces coronary artery spasm together with plaque erosion or rupture manifesting as acute myocardial infarction. Type III variant (5.1%) includes patients with coronary artery stent thrombosis as a result of an allergic reaction.

Case Presentation: An 82-year-old female ex-smoker with a past medical history of chronic obstructive pulmonary disease and systemic hypertension presented with angioedema. Home medications include hydrochlorothiazide, amlodipine, Quinapril, Proventil HFA, Singulair, and Spiriva. Intramuscular epinephrine and intravenous (IV) Solu-Medrol were given by Emergency Medical Services. In the Emergency Department, another dose of epinephrine was given together with IV famotidine. Following the second dose of epinephrine, the patient had jaw pain and became hypotensive (80/40). Electrocardiogram revealed marked ST depression in leads 1, AvL, and V2-V4, which was resolved in a repeat echocardiogram a few minutes later. Aspirin and high-dose atorvastatin were started. Transthoracic echocardiogram showed grade II diastolic dysfunction. SPECT-MPI study showed a medium size, moderate to severe, partially reversible basal inferior-wall perfusion defect, and a small, mild, predominantly reversible perfusion defect involving the apical inferolateral wall. Coronary angiography showed significant coronary disease in the right coronary artery, first diagonal, and a chronic total occlusion of the distal left circumflex. 

Discussion: Patients presenting with KS/ACS should be treated accordingly based on the ACS guidelines. In type I variant, anti H1/H2, corticosteroids, cause suppression of arterial hyper-reactivity and alleviation of inflammation and prevent biphasic anaphylactic reactions. Epinephrine should be used with caution in KS as it can worsen myocardial ischemia, prolong the QTc interval and induce coronary vasospasm and arrhythmias. Vasodilators such as calcium-channel blockers and nitrates can resolve hypersensitivity-induced vasospasm. In type II variant, the use of beta-blockers can exaggerate coronary spasm due to unopposed action of α-adrenergic receptors. In type III variant, aspiration of intrastent thrombus is of unique importance as histological examination of aspirated material and staining for eosinophils (hematoxylin and eosin) and mast cells (Giemsa) can suggest allergic reaction, with possible subsequent change of the management. Our patient was diagnosed with type II KS. This case demonstrates the importance of a high index of clinical suspicion for diagnosis and management of KS in an effort to improve patients’ outcomes in daily cardiac catheterization laboratories. 

C3 2017-8 Clinical Significance of Multi-Detector Computed Tomography in the Assessment of Coronary Chronic Total Occlusion Prior to Revascularization

Islam Abdelmoneim, MD; Yasser Radwan, MD; Khaled Shokry, MD; Ayman Sadek, MD; Ahmed Magdy, MD

Introduction: Although coronary angiography (CA) remains a fundamental part of chronic total occlusion (CTO) revascularization procedures, this modality has several limitations. In this study, we aimed to compare multi-slice computed tomography (MSCT) vs CA for the assessment of CTO lesions prior to revascularization.

Methods: Our study enrolled 50 patients, with a confirmed CTO of at least 1 coronary artery, of which 41 patients were operated using the antegrade approach and 9 patients were operated using the combined antegrade/retrograde approach. All patients underwent MSCT and CA prior to percutaneous coronary intervention (PCI) and data on the determinants of failure and their detection using each modality were collected. We used SPSS version 23 (IBM) to conduct the statistical analysis.

Results: We recorded successful revascularization in 36 patients (72%) who underwent antegrade approach and 6 patients (66.6%) who underwent combined approaches. According to MSCT results, several factors, such as increased length of the occlusion (P=.01), small vessel size (P=.002), atherosclerotic vessel wall (P=.021), proximal side branching (P=.013), and calcification of proximal cap (P=.007) or distal stump (P=.015) increase the failure rate of PCI. MSCT was slightly less sensitive than CA in detecting proximal stump details, presence of side branches, distal arterial visualization, and sizable collaterals. However, MSCT was as sensitive as CA in detecting CTO segment calcification. Based on MSCT findings, we found lesion length >18 mm, vessel size ≤2.75 mm, and CTO duration >7 months to be associated with more incidence of failure of revascularization.

Conclusion: Although MSCT has a similar sensitivity to CA in detecting coronary calcification, it has a lower sensitivity in detecting other determinants of failure, such as side branching or proximal stump details. Future improvements in MSCT technology are warranted to address these limitations.

C3 2017-9 Association Between Gout and Outcomes Among Postmenopausal Women Hospitalized for Acute Myocardial Infarction: Insights From a Nationwide Sample

Akintunde Akinjero, MD, MS; Oluwole Adegbala, MD, MPH; Eseosa Edo-Osagie, MD; Nike Akinjero, RN, BSN; Tomi Akinyemiju, PhD

Background: Gout has been shown to increase the risk of cardiovascular diseases among postmenopausal women. The mechanisms remain unclear. We sought to evaluate in-hospital outcomes among postmenopausal women hospitalized with coexisting gout and acute myocardial infarction (AMI).

Methods: Data were retrieved from the Nationwide Inpatient Sample (NIS), using ICD-9-CM codes. We excluded women <55 years old. Patients with AMI and co-occurring gout were compared with those without gout. We then tested for associations with stroke, in-hospital mortality, and length of stay using multivariate analysis to adjust for confounders. All analyses were performed using SAS.

Results: There was a total of 335,403 hospital admissions for AMI. Out of these, 484 had co-occurring gout. Women with both co-occurring conditions were more likely to be white (64.1%). In adjusted models, co-occurring gout and AMI were significantly associated with a reduced likelihood of in-hospital mortality (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.35-0.72). However, co-occurring gout and AMI were not significantly associated with stroke rates (aOR, 0.95; 95% CI, 0.59-1.55) or length of stay (aOR, 1.46; 95% CI, 0.77-2.16).

Conclusion: Results from this nationally representative sample suggests that co-occurring gout is associated with reduced in-hospital mortality among postmenopausal women admitted for AMI, while no significant associations were found for length of stay and stroke rates. Further prospective studies are needed to explore these associations.

C3 2017-10 Atrial Fibrillation is Associated With Higher Stroke Rates in Takotsubo Cardiomyopathy

Akintunde Akinjero, MD, MS; Oluwole Adegbala, MD, MPH; Nike Akinjero, RN, BSN; Eseosa Edo-Osagie, MD; Tomi Akinyemiju, PhD

Background: The prognosis of Takotsubo cardiomyopathy (TTCM) is worse than in the general population. It is unclear how atrial fibrillation (AF) impacts this prognosis. We sought to evaluate the effect of concurrent AF on outcomes in patients with TTCM. 

Methods: We used the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) to extract all hospitalizations between 2007 and 2011 with concurrent diagnosis of AF and TTCM. The ICD-9-CM codes for AF and TTCM were used. We compared patients admitted for TTCM who had coexisting AF to those without. We excluded patients below the age of 18 years as well as those diagnosed with TTCM who later underwent percutaneous coronary intervention (PCI). Multivariate regression was used to assess the independent effect of coexisting AF on clinical outcomes (length of stay, stroke, and in-hospital mortality). 

Results: A total of 13,136 TTCM patients were studied. Of these, 2083 (15.86%) had coexisting AF. Compared with those without, TTCM patients with coexisting AF had a greater multivariate-adjusted risk for increased stroke rate (adjusted odds ratio [aOR], 1.66; 95% confidence interval [CI], 1.27-2.18). We found no significant association with in-hospital mortality (aOR, 1.21; 95% CI, 0.96-1.52) or LOS (aOR, 1.21; 95% CI, 0.83-1.58). 

Conclusions: In this large, nationally representative study, we found higher stroke rates in patients with coexisting AF and TTCM. Our findings suggest the need for closer monitoring during hospitalization.

C3 2017-11 Platelet Function Monitoring After Percutaneous Coronary Intervention: Updated Meta-Analysis of Randomized Trials

Akintunde Akinjero, MD, MS; Oluwole Adegbala, MD, MPH; Eseosa Edo-Osagie, MD; Nike Akinjero, RN, BSN; Tomi Akinyemiju, PhD

Background: The need to balance bleeding and clotting risks after percutaneous coronary intervention (PCI) has led to interest in platelet function monitoring as a strategy to improve post-PCI outcomes. The prognostic value of platelet function testing in monitoring response to antiplatelet therapy after PCI remains unclear. Prior studies have been inconclusive. We sought to conduct an updated meta-analysis to address this gap in knowledge. 

Methods: We conducted a systematic search of Embase, Pubmed, and the Cochrane libraries for studies since inception to December 2016 on platelet function monitoring. Our search yielded 203 studies, out of which 83 were extracted for full-text review. Only 3 studies met inclusion criteria. We pooled odds ratios using random-effects statistics, Mantel-Haenszel method. I² and Chi² statistics were used to evaluate for heterogeneity. Publication bias was assessed using the funnel plot. Primary outcome was major adverse cardiovascular event (MACE) rate. This was defined in the studies as a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and bleeding complications.

Results: The 3 randomized controlled trials that were analyzed involved 3701 patients. There were 550 MACE (29.76%) in the platelet function monitored group compared with 514 (27.74%) in the control. MACE was not significantly higher for the platelet function monitored group during follow-up compared with control (pooled odds ratio, 1.11; 95% confidence interval, 0.96-1.28; P=.15). Tests for heterogeneity were not significant, with I² = 0%, Chi² = 1.52 (P=.47), and small study bias was absent on visual inspection of the funnel plot. 

Conclusion: Platelet function monitoring continues to be used in practice. Results from this meta-analysis show no benefit of platelet function monitoring compared with conventional strategy with regard to MACE after PCI. Future research is needed to further evaluate this finding. 

C3 2017-12 Effect of Non-Compliant Balloon Postdilatation on Magnesium-Based Bioresorbable Vascular Scaffolds (Magmaris) – OCT Evaluation in a Real-World Population 

F. Blachutzik, MD¹; S. Achenbach, MD¹; M. Tröbs, MD¹; J. Röther, MD¹; M. Marwan, MD¹; R. Schneider, MD¹; M. Weissner²; C. Schlundt, MD¹

¹Friedrich-Alexander Universität Erlangen-Nürnberg, University Hospital Erlangen, Department of Cardiology, Erlangen, Germany

²Zentrum für Kardiologie, University Hospital Mainz, Mainz, Germany, and the German Center for Cardiac and Vascular Research (DZHK), Standort Rhein-Main, Mainz, Germany

Background: For percutaneous coronary intervention (PCI) with bioresorbable vascular scaffold (BRS), achieving optimal apposition seems to be relevant in order to minimize event rates. For this reason, postdilatation with non-compliant (NC) balloons is usually mandated. Knowledge about the effect of NC balloon postdilatation in vivo is required to achieve optimal results. We therefore evaluated the effect of NC balloon postdilatation on magnesium-based BRS (Magmaris; Biotronik AG).

Methods: In 8 patients (mean age, 66±12 years, 7 males, 1 female), 10 Magmaris BRS were implanted to treat de novo coronary artery stenoses. Following appropriately sized NC balloon predilatation (1:1:1 vessel:balloon:scaffold ratio), Magmaris BRS were implanted at 8 atm, followed by NC balloon postdilatation at nominal BRS size (16 atm). OCT was performed before and after postdilatation to measure BRS dimensions and determine apposition as well as strut fractures. Scaffold and lumen area were contoured and measured at a spacing of 1 mm.  

Results: PCI with Magmaris BRS (mean diameter, 3.2 ± 0.3 mm; mean length, 20 ± 4mm) was successful in all cases; in 1 case, a non-flow-limiting distal edge dissection occurred after implantation and before postdilatation. NC balloon postdilatation led to significantly larger mean scaffold diameter (3.0 ± 0.3 vs 2.8 ± 0.3 mm; P<.001), scaffold area (6.9 ± 1.3 mm² vs 6.2 ± 1.2 mm²; P<.001), and functional lumen area (6.5 ± 1.3 mm² vs 6.0 ± 1.4 mm²; P<.001). Incomplete scaffold apposition area was significantly lower if postdilatation was performed (0.003 mm² vs 0.165 mm²; P<.001). Strut fractures could neither be observed before nor after postdilatation. 

Conclusion: NC balloon postdilatation of Magmaris BRS is required to achieve optimal expansion. It significantly reduces malapposition and can safely be performed without relevant rates of strut fracture.

C3 2017-13 Influence of the SYNTAX Score on Procedural Parameters and Short-Term Outcome of Unprotected Left Main PCI

F. Blachutzik, MD; S. Achenbach, MD; J. Röther, MD; M. Tröbs, MD; M. Marwan, MD; R. Schneider, MD; C. Schlundt, MD

Friedrich-Alexander Universität Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany

Purpose: Procedure length and complexity as well as contrast load may contribute to adverse outcomes of complex left main percutaneous coronary intervention (PCI). We analyzed the relationship between the SYNTAX score and procedural parameters as well as short-term outcome for PCI of unprotected left main coronary artery stenosis. 

Methods: In 105 consecutive patients who underwent PCI of unprotected left main coronary artery stenoses between April 2014 and September 2016, clinical parameters as well as PCI strategy, number of stents placed, procedure duration, dose-area product, volume of contrast media, and intrahospital follow-up were analyzed in a prospective fashion. Results were compared between patients with low-to-intermediate vs high stenosis complexity (SYNTAX score ≤32 vs SYNTAX score >32).  

Results: Mean patient age was 77 ± 8 years (28 females, 77 males), mean left ventricular ejection fraction was 51 ± 13%. Nineteen patients presented with acute coronary syndrome (16 with non-ST elevation myocardial infarction, 3 with ST-elevation myocardial infarction), the other 86 patients presented with stable angina. The mean SYNTAX score was 29 ± 9, with 66 patients having a SYNTAX score ≤32 and 39 patients a SYNTAX score >32. There were no significant differences between patients with high and low-to-intermediate SYNTAX score regarding age, sex, and left ventricular ejection fraction. In patients with high SYNTAX score vs low-to-intermediate SYNTAX score, provisional T-stenting was performed significantly less frequently (18% vs 68%; P<.001), while crush (44% vs 4%; P<.001) and culotte techniques (20% vs 6%; P=.03) were performed significantly more frequently. The number of stents implanted was 4 ± 2 vs 2 ± 1 in patients with high vs low-to-intermediate SYNTAX score (P<.001). Procedure time was significantly longer (78 ± 30 min vs 58 ± 29 min; P=.001), the amount of contrast agent significantly higher (241 ± 76 mL vs 192 ± 67 mL; P=.001), and dose-area product was significantly higher in patients with high SYNTAX score (11488 ± 7221 Gy•cm² vs 8200 ± 5429 Gy•cm²; P=.02). Procedural success was achieved in all 105 cases without periprocedural mortality. Periprocedural myocardial infarction occurred in 8 cases. Two patients died during intrahospital follow-up (mean, 5 ± 6 days), both for reasons unrelated to PCI.

Conclusion: PCI strategies for the treatment of left main coronary artery stenoses get significantly more complex with increasing SYNTAX scores. This concerns all procedural aspects, including a significantly higher contrast load in complex lesions. Nevertheless, our data indicate that PCI can be performed with high procedural success rates even in patients with high SYNTAX scores.

C3 2017-14 Major Coronary Evaginations Following Implantation of Bioresorbable Vascular Scaffolds – Clinical and OCT Characteristics

Florian Blachutzik, MD¹; Stephan Achenbach, MD¹; Mohamed Marwan, MD¹; Jens Röther, MD¹; Monique Tröbs, MD¹; Melissa Weissner²; Christian Schlundt, MD¹

¹Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg, University Hospital Erlangen, Department of Cardiology, Erlangen, Germany

²University of Mainz, Department of Cardiology 1, Mainz, Germany

Purpose: Coronary evaginations can occur after implantation of bioresorbable vascular scaffold (BRS) and may be associated with scaffold thrombosis. The objective was to clarify the clinical manifestation, extent and time course of coronary artery remodeling in vessel segments that develop angiographically detectable evaginations following BRS implantation.

Methods: In 8 patients, 10 BRS devices that displayed coronary evaginations in clinically driven invasive coronary angiograms following implantation of BRS (Absorb; Abbott Vascular) were identified. Vessel and device geometry were analyzed in serial optical coherence tomography (OCT) cross-sections at a spacing of 200 µm. Measured BRS dimensions were normalized to the original implant size. Results were analyzed in relation to the time interval since BRS implantation and findings were compared to 10 BRS devices without coronary evaginations.

Results: The mean time interval since implantation was 20 ± 10 months (range, 4-33 months). Seven of 8 patients both with evaginations and in the control group presented with stable angina, 1 patient in each group with non-ST elevation myocardial infarction. In OCT, major evaginations on average affected 24 ± 19% of the scaffold length. Scaffolds with major evaginations had a significantly larger lumen area than scaffolds without evaginations (mean normalized lumen area 1.19 ± 0.58 mm² vs 0.77 ± 0.38 mm²; P<.001), and also displayed significantly larger scaffold area (mean normalized scaffold area, 1.36 ± 0.6 mm² vs 1.13 ± 0.43 mm²; P<.001), and scaffold diameter (mean normalized scaffold diameter, 1.17 ± 0.33 mmvs 1.04 ± 0.19 mm; P<.001). In BRS segments with evaginations, normalized scaffold area (1.37 ± 0.45 mm² vs 1.36 ± 0.64 mm²; P=.01) and normalized scaffold diameter (1.18 ± 0.33 mmvs 1.16 ± 0.20 mm; P=.03) were significantly, but only very slightly larger than in segments without evaginations. BRS segments with evaginations showed significantly higher rates of strut fracture (rate per cross section, 0.08 ± 0.11 vs 0.02 ± 0.18; P=.03) and malapposed struts (0.13 ± 0.24 vs 0.03 ± 0.07; P=.006) compared to areas without evaginations. There were no significant differences regarding edge dissections or scaffold eccentricity between scaffolds with and without evaginations. Lumen area (r = 0.47; P<.001), scaffold area (r = 0.52; P<.001), and scaffold diameter (r = 0.56; P<.001) in the evagination group were positively correlated to the time since scaffold implantation. 

Conclusion: Coronary evaginations following BRS implantation are associated with an increased scaffold area, indicating that the scaffold follows the outward remodeling of the artery. The process affects the entire scaffold length and seems to be continuously progressing following implantation. The occurrence of evaginations is associated with higher rates of strut fracture and malapposed struts.

C3 2017-15 Three Years Follow-up of ERACI IV Registry – A Modified SYNTAX Score for the Treatment of Multiple Vessel Disease and Left Main Stenosis

M.Y. Cho; C. Haiek; C. Fernández-Pereira; O. Santaera; J. Mieres; J.F. Del Pozo; H. Pavlovsky; A.M. Rodriguez-Granillo; I. Rifourcat; J. Lloberas; M. Larribau; A. Pocoví, R.A. Sarmiento; D. Antoniucci; A.E. Rodriguez

Purpose: To evaluate the long-term efficacy and safety of newer drug-eluting stent generation (2-DES) for the treatment of multiple-vessel disease (MVD) and left main stenosis compared to the first generation of DES (1-DES) and to validate a new score based in functional revascularization of coronary artery disease.

Methods: ERACI IV was a prospective, observational, and controlled study in patients with MVD including left main and treated with 2-DES (Firebird 2; Microport, Inc). We included 225 patients in 15 sites from Argentina and the primary endpoint was the incidence of major adverse cardiovascular and cerebrovascular event (MACCE) defined as death, myocardial infarction (MI), cerebrovascular accident (CVA), and unplanned revascularization, and to compare with 225 patients from the ERACI III study (1-DES). PCI strategy was planned to treat lesions ≥70% in vessels ≥2.00 mm and provisional stenting was preferred in all bifurcations. In ERACI IV patients, original SYNTAX score (SS) was calculated; however, we also used a modification of the original SS (ERACI SS), excluding from the analysis all intermediate lesions and/or severe stenosis in vessels <2.0 mm; in-stent restenosis was scored as a heavy calcified stenosis.

The sample size was estimated in accordance with the ERACI III 1-DES arm. Continuous variables (mean ± standard deviation) were compared using ANOVA with Bonferroni correction and categorical variables (percentages) using Chi² or Fisher’s exact test. We used Kaplan-Meier curves for survival curves. We used univariate and multivariate Cox regression analysis to determine independent predictors of outcome at follow-up (all variables introduced in block in a single step). We also performed a propensity score to analyze results in matched population used by logistic regression model. We used a greedy matching algorithm to identify pairs of patients, one of whom received a 1DES and one of whom received a Firebird 2.

Results: Baseline characteristics showed that compared to ERACI III, ERACI IV patients had higher number of diabetics (P=.02), previous revascularization (P=.007), unstable angina IIb/IIIc (P<.001) and 3-vessel/left main disease (P=.003). Modified SS was 22.2 ± 11. At 3 years of follow-up, the ERACI IV group had significantly lower incidence of death + MI + CVA (4.9% vs 13.7%; P<.001) and MACCE (9.3% vs 22.7%; P<.001). MACCE rate was similar in diabetics (8.7%) and non-diabetics (9.6%). After performing a matched propensity score, MACCE remain significantly lower in ERACI IV (P=.005).

Conclusion: This registry showed that 2-DES in MVD have a remarkable low incidence of MACCE in unadjusted and adjusted analysis.

C3 2017-16 Association of Serum Ferritin Levels With Cardiovascular Disease Incidence Among African-Americans: The Jackson Heart Study

Obiora Egbuche, MD, MPH; Heather R. Millard, MPH; Benjamin Renelus, MD; Maihemuti Axiyan, MD; Solomon K. Musani, PhD; Ervin R. Fox, MD, MPH; Jiankang Liu, MD, PhD; Herman A. Taylor, MD, MPH; Aurelian Bidulescu, MD, MPH, PhD

Background: There have been conflicting results regarding the role of ferritin, a non-specific marker of systemic inflammation, in the development of coronary heart disease (CHD). We aimed to evaluate the association of serum ferritin with incident CHD, incident stroke, and subclinical measures of atherosclerosis among African-Americans. We also sought to identify any effect measure modification by cholesterol levels. 

Methods: We utilized data from the Jackson Heart Study for our prospective study. Eligible participants (n = 4679) who were free from CHD were enrolled between 2000 and 2004. Their baseline serum ferritin levels were obtained, and they were followed for an average of 7 years to identify incident CHD events and incident stroke. We used a multivariate linear regression and a Cox proportional hazard model to evaluate the associations of serum ferritin with incident CHD events and incident stroke. The age-adjusted correlations between ferritin and specific study covariates including carotid intima-media thickness, coronary artery calcium, and abdominal aortic calcium were obtained.

Results: During an average of 7 years of follow-up, 158 incident CHD events and 116 incident stroke events were documented. There was no significant association between ferritin levels and incident CHD events (P=.54 in males; P=.31 in females) or incident stroke (P=.17 in males; P=.56 in females). Among participants with total cholesterol levels above 200 mg/dL, there was a reduced risk of incident stroke among individuals with serum ferritin levels in the third quartile compared to those with serum ferritin levels in the lowest quartile (hazard ratio, 0.34; 95% confidence interval, 0.14-0.80; P=.01) when adjusted for age. No significant association was noted in this population after adjusting for all covariates (P=.07). Ferritin was significantly correlated with abdominal aortic calcium (r = 0.09; P<.001) in women but not in men. 

Conclusion: In our African-American population, a higher serum ferritin level was not associated with an increased risk of incident CHD events or incident stroke. Our study suggests that serum ferritin levels are not useful independent predictors of incident CHD or stroke in African-Americans. Large observational studies may be needed to further elucidate the association between serum ferritin and abdominal aortic calcium among African-American women.

C3 2017-17 Pacing-Induced Cardiomyopathy in Bradycardia-Induced Polymorphic Ventricular Tachycardia 

Obiora Egbuche, MD, MPH; Ifunanya Ekechukwu, MD; Nnamdi Maduabum, MD, MPH; Tulani Washington-Plaskett, MD; Koreen Hall, NP; Kelechi Ukpaka, MPH; Rajesh Sachdeva, MD

Background: Pacing-induced cardiomyopathy (PiCM) is frequently associated with right ventricular (RV) pacing. This may occur in patients who require pacing more than 40%-50% of the time. We present a case of PiCM in a patient with bradycardia-induced polymorphic ventricular tachycardia (BiPVT). 

Case Presentation: A 48-year-old African-American lady with a medical history of hypertension presented with cardiac arrest because of BiPVT. She had multiple episodes that were because of bradycardia secondary to mobitz-type 2 atrioventricular block. Coronary angiography showed normal coronary arteries, echocardiogram showed normal left ventricular systolic function with an ejection fraction (EF) of 60%. She underwent successful automatic implantable cardioverter-defibrillator (AICD) placement. Five months later, she presented with new-onset heart failure with BNP of 2369 pg/mL. A repeat echocardiogram showed severe left ventricular systolic dysfunction with EF <25%. Her device interrogation revealed no episodes of ventricular tachycardia and she was paced 90% of the time. She was upgraded to cardiac resynchronization therapy-D (CRT-D) with improvement in EF to 55% and resolution of symptoms after 3 months.

Discussion: PiCM is a known complication of chronic RV pacing in patients with high pacer demand. Patients with BiPVT require higher rate pacing to prevent bradycardia that may predispose to ventricular tachycardia. Our patient had AICD with high-rate RV pacing set at 60 beats/min. She developed PiCM due to RV pacing and high pacing burden. Though all patients with BiPVT may not meet criteria for CRT, selected patients who have high pacing burden should be considered for CRT as opposed to RV pacing at the time of initial device implantation.

Conclusion: CRT may be preferred to RV pacing in patients with BiPVT who are suspected to have high pacing burden. 

C3 2017-18 Ventricular Fibrillation Storm: An Uncommon Presentation of Idiopathic Heart Block

Obiora Egbuche, MD, MPH; Demilade Adedinsewo, MD, MPH; Pradyumna Agasthi, MD; Anekwe Onwuanyi, MD

Introduction: Ventricular fibrillation (VF) is known to occur commonly in the setting of organic heart disease – most often, myocardial infarction resulting from coronary stenosis. However, recurrent VF is less frequently encountered with heart block. We present a case of recurrent VF in a middle-aged female with idiopathic second-degree atrioventricular block (AVB) without coronary artery disease.

Case Presentation: A 48-year-old African-American female with a medical history of hypertension presented to the Emergency Department following a syncopal episode. During her hospital stay, she had repeated episodes of VF and cardiopulmonary resuscitation, and achieved return of spontaneous circulation each time. Her electrocardiogram showed sinus rhythm with 2:1 AVB. She had no electrolyte abnormalities. Echocardiogram showed normal left ventricular systolic function. Cardiac catheterization showed normal coronary arteries. Electrophysiology study, cardiac magnetic resonance imaging, and a cardiac biopsy did not reveal any abnormalities. She eventually had a dual-chamber automatic implantable cardioverter-defibrillator (AICD) placed with pacing set at 60 beats/min. She had complete resolution of her VF. On follow-up, she had no further episodes of VF on AICD interrogation.

Discussion: Our patient had recurrent VF arrest due to bradycardia resulting from 2:1 AVB. She had an exhaustive work-up that revealed no abnormalities. Her AVB was surmised to be idiopathic as no clear cause was found.

Conclusions: VF storm is a potential but rare occurrence in patients with idiopathic AVB. Prompt identification of VF arrests and early institution of resuscitative measures can be lifesaving. Transcutaneous and transvenous pacing are temporary measures to control the heart rate and should only serve as a bridge to definitive therapy, which includes permanent pacemaker or ICD implantation.

C3 2017-19 The Impact of Transradial vs Transfemoral Approach for Percutaneous Coronary Intervention on the Outcome of Patients Presenting With Acute Coronary Syndrome

Shehab El Etriby, MD; Ahmed Nassar, MD; Osama Rifaie, MD; Ahmed El Mahmoudy, MD; Ahmed El Missiry, MD

Background: The transfemoral approach (TFA) has been until presently the mainstay for arterial access for percutaneous coronary intervention (PCI) in the setting of acute ST-elevation myocardial infarction (STEMI), while the transradial approach (TRA) is gaining ground in elective as well as primary procedures.

Objectives: To assess the impact of TRA vs TFA for PCI on the outcome of patients presenting with acute coronary syndrome (ACS).

Patients and Methods: This prospective study was conducted on 100 patients presenting to Ain Shams University Hospitals Coronary Care Unit (CCU) with recent-onset acute coronary syndrome (whether unstable angina [UA]/non–ST segment elevation myocardial infarction [NSTEMI] or STEMI) undergoing revascularization via PCI. Patients were randomized into two equal groups (group 1 = TFA-PCI; group 2 = TRA-PCI).

Results: Our study found that TRA resulted in less bleeding and fewer local vascular complications (8 [16%] vs 2 [4%]; P=.045) and less amount of dye used (169.60 ± 21.28 mL vs 187.00 ± 37.65 mL; P=.006) without significant increase in fluoroscopy time (10.86 ± 4.88 min vs 9.76 ± 4.74 min; P=.256) or radiation exposure. Although there was no significant difference in mortality and morbidity, TRA offers the patient a more simple procedure with shorter hospital stay (3.4 ± 0.948 days vs 3.86 ± 0.808 days; P<.01).

Conclusion: TRA is safe and effective for the management of ACS. If performed by experienced operators, TRA should be the standard access in managing ACS, specifically in STEMI.

C3 2017-20 Left Ventricular Perforation During Ventriculogram Using a Universal Jacky Radial Catheter

Perry Fisher, MD; Rajbir Sidhu, MD; Supreeti Behuria, MD; Ramesh M. Gowda, MD

Background: Left ventricular perforation during ventriculogram is a known complication of coronary angiography. However, it is not well documented in the literature as it is only now that transradial multipurpose catheters are being universally adopted.    

Case Presentation: A 65-year-old Burmese gentleman with a history of hypertension and unstable angina was referred for a cardiac catheterization. A universal Jacky radial catheter (Terumo) was placed in the left ventricle via transradial approach. After confirming free-floating catheter position and obtaining adequate pressure waveforms, a gentle hand injection of about 3 cc of contrast dye was given. Abnormal opacification of the left ventricular myocardial wall without any immediate clinical or hemodynamic sequelae was noted. Angiography was completed, which showed a non-obstructive left system and subtotal occlusion of the mid right coronary artery (RCA). Upon review of the cine loop, contrast layering in the inferior and diaphragmatic locations was noted. A stat bedside echocardiogram then revealed a small pericardial effusion. Therefore, the plan to proceed with percutaneous coronary intervention was aborted.                                    

Discussion: The decision was made to keep the patient on the catheterization table for continual evaluation until it was determined that the size of the effusion was not increasing. Cardiothoracic surgery was made aware in case emergent surgical intervention was required. The patient was chest-pain free but rapidly became hemodynamically unstable. An emergent pericardiocentesis was performed via the subxiphoid approach. The pericardial drain was left in place and the patient was monitored in the CCU. He had serial echocardiograms that did not show reaccumulation of fluid and the drain was removed in about 24 hours. Moreover, left ventricular perforation is a well-known complication of coronary angiography. With increasing use of transradial catheters, it is imperative to be cognizant of this complication. Hand injections for left ventriculograms are not recommended with end-hole catheters. A pigtail multi-hole catheter should be used. 

C3 2017-21 The Management of Ventricular Fibrillation Cardiac Arrest During Exercise Stress Testing

Perry Fisher, MD; Rajbir Sidhu, MD; Supreeti Behuria, MD; Ramesh M. Gowda, MD

Introduction: There is a risk of sudden cardiac death during exercise stress testing, albeit a small one. This usually happens in the recovery phase and most patients are able to be successfully defibrillated. The management henceforth may be complex and warrants discussion as below.                                       

Case Presentation: A 71-year-old man with a history of coronary artery disease with percutaneous coronary intervention (PCI) 4 years prior underwent a routine exercise stress test. He exercised for 6 minutes and developed significant dyspnea, with 2 mm ST depressions in the inferolateral leads and ST elevation in aVR. The test was stopped, but as soon as the patient sat in the stretcher, he had a ventricular fibrillation cardiac arrest. He was successfully defibrillated and transferred to the nearest emergency room (ER). On arrival to the ER, he was awake and alert but having chest pain. Electrocardiogram showed ST elevation in aVR and anterolateral ST depressions. He underwent emergent invasive angiography, which revealed a distal left main 85% focal calcified stenosis involving the ostial left anterior descending (LAD), patent stents in the proximal and mid LAD, an 80% ostial diagonal lesion, 100% ostial left circumflex disease. He had a 95% distal right coronary artery lesion as well.                                

Discussion: At this time, the decision was made to consult cardiac surgery. However, the patient continued to have chest discomfort despite intravenous nitroglycerin, intravenous heparin, and eptifibatide bolus. Because of this unstable situation, urgent PCI of the left main was done. The patient was chest-pain free at the end of the procedure and transferred to the CCU in stable condition. Because of the severity of the patient’s remaining coronary disease, a heart team discussion was convened and coronary artery bypass graft surgery was deemed appropriate and scheduled for the next week. Meanwhile, the patient was monitored in the CCU with an intraaortic balloon pump, and on heparin and aggrastat infusion. There were no post-surgical complications. Moreover, although the risk of cardiac arrest during exercise stress testing is small, it does exist. Patients who have ischemic electrocardiograms post resuscitation should be taken for invasive angiography as the likelihood of an ischemic cause is high. Decisions regarding revascularization strategies should then be made on a case by case basis. 

C3 2017-22 Primary Angioplasty in a Case of Single Coronary Artery Presenting as Inferior Wall Myocardial Infarction

Hitesh Gurjar, MD, DM

Introduction: Single coronary artery is a rare anomaly with varied presentations. In situations presenting as an acute coronary event, coronary anomalies present a challenge with need for interventionist to be familiar with the anatomy and various hardware to avoid potentially catastrophic events.

Case Description: We describe a 50-year-old patient who presented with acute-onset chest pain of 3-hour duration. He did not have any prior risk factors including diabetes mellitus, hypertension, dyslipidemia, smoking, drug abuse, etc. His initial evaluation included electrocardiogram revealing ST-segment in leads II, III, and aVF. He was taken up for coronary angiography through femoral route and left-sided injection with JL 4.0 catheter did not reveal any coronary ostium. Injection of right coronary sinus revealed single coronary stem from which arose left anterior descending, left circumflex, and right coronary artery (RCA). There was complete occlusion of RCA with thrombus. Thrombus aspiration was done with export thrombus aspiration catheter (Medtronic, Inc). A 3.0 x 28 mm Promus Element stent (Boston Scientific) was deployed at 13 atm. Good result was achieved with TIMI III flow in distal RCA bed. Aortic root angiography was performed at completion of the procedure, and confirmed the findings of single coronary artery arising from right coronary sinus.

Discussion: Lipton and colleagues were the first to propose angiographic classification system for single coronary arteries (SCAs) in 1979. They found incidence of SCA to be 0.024% in the general population. They found typical angina to be absent unless there was coexisting coronary artery disease or aortic stenosis. SCA can be potentially serious, with sequelae such as angina pectoris, myocardial infarction, syncope, cardiac arrhythmias, congestive cardiac failure, and sudden cardiac death. Its clinical relevance also depends upon anatomical distribution and course of the transverse branch, with interarterial segment being the most malignant one. Diagnosis relies upon multidetector computed tomography (MDCT) coronary angiography or conventional angiography. In a study by Rao et al, it was found that MDCT was even useful in visualizing small branches like conus artery (96.25%), sinus node artery (83.07%), and septal branches (95.27%).

Conclusion: SCA intervention pose a challenge in acute coronary syndrome cases. Engaging the coronary ostia require knowledge of different catheters useful in such scenarios. It should be based on sinus of origin and not on the artery to be engaged. Completion of various procedures like thrombus aspiration, exchanging balloons, and deploying stents requires special care to avoid potentially serious complications by jeopardizing other coronary arteries, which can very easily get involved by thrombus migration, dissections, deep engagement of guiding catheter, etc. It should be treated using methods similar to those used in left main coronary artery interventions.

C3 2017-23 Innominate Artery Stenosis: Successful Treatment With Covered Stent Utilizing Cerebral Protection

Jessica Joseph, DO; Jordan Klein, DO; David Ain, MD; Danielle McCormick, DO; Sheldon Goldberg, MD

Introduction: Innominate artery lesions are uncommon and represent 0.5%-2% of all vascular lesions. Atherosclerosis remains the leading cause of supraaortic lesions. Surgical treatment was associated with high complication rates of 15%-25%. Angioplasty with stenting of the innominate artery has become the treatment of choice, as it results in fewer complications, lower mortality, and reduced length of stay. The indications for treating symptomatic patients with innominate artery stenosis are well established and include transient ischemic attacks, subclavian steal syndrome, vertebrobasilar insufficiency, and upper-limb ischemia. However, techniques of endovascular repair have varied in terms of stent choices and the need for cerebral protection. We present a case of treatment of severe innominate artery stenosis, using polytetrafluoroethylene (PTFE)-covered stent and cerebral protection, utilizing the double-wire technique.

Case Presentation: A 60-year-old man with hyperlipidemia and tobacco use presented for the evaluation of 7 years of right arm claudication, amaurosis fugax, dizziness, and presyncope, occurring with right arm exertion. Examination was notable for absent right radial pulse and undetectable blood pressure in the right arm. Duplex ultrasonography was suggestive of innominate artery stenosis, and subsequent angiography demonstrated a 95% stenosis of the proximal innominate artery with markedly diminished flow in the right subclavian artery. Endovascular repair was performed using PTFE-covered stent and cerebral protection, utilizing the double-wire technique. Immediately following the procedure, the right radial pulse was present, and the blood pressures were equal in both arms. All symptoms resolved and the patient remains asymptomatic at 2-month follow-up.

Discussion: Treatment of innominate artery stenosis in symptomatic patients can be accomplished using endovascular techniques. The use of appropriate-sized guide catheters, double-wire technique, cerebral protection, and covered stents is feasible. Rapid, dramatic improvement in symptoms can be achieved with this technique.

C3 2017-24 Slipped Stent During Post Cardiac Arrest Primary PCI: The Optimal Solution for the Worst Scenario

Ahmed M. Kasem, MD; Wesam A. Alhejily, MD; Mohamed Qutub, Nabil Alama, MD; Ramzy Almohamady, MD

King Abdulaziz University Hospital

Introduction: A stent loss or dislodgment is a rare, but nightmarish, complication and a challenge to the interventionalist. The risk of stent loss is high when the stent balloon assembly is pulled back into the guiding catheter due to failure to cross the target lesion. Other factors contributing to stent loss are marked tortuosity or severe calcification of the vessel proximal to the target lesion, or poor support of the guiding catheter with insufficient attention to the use of appropriate guiding catheters and wires. Direct stenting may also pose higher risk for stent loss due to greater resistance during stent advancement through calcified lesion (compared to predilation). 

Case Presentation: A 63-year-old Indian male with known history of hypertension (on amlodipine 5 mg) and chest pain on/off in the last 3 days presented to our hospital. He had visited another hospital but was not admitted since his electrocardiogram (ECG) was normal. Six hours prior to presentation to our hospital (on Friday early morning), his chest pain became severe, persistent, and typical. Upon arrival to the emergency room, he had agonizing pain with marked distress and agitation where ECG showed anterior wall myocardial infarction, but he suddenly arrested with ventricular fibrillation, which successfully defibrillated by DC shock after cardiopulmonary resuscitation for 2 min. Blood pressure was low (82/55), then very low (70/40) with pulmonary congestion where intravenous dobutamine 15 µg/kg/min and dopamine 20 µg/kg/min, and eventually norepinephrine intravenous infusion was started 20 µg/kg/min. He was intubated due to a decreased level of consciousness and mechanically ventilated (pressure-regulated volume-control mode, FIO₂ 100%) and shifted to the cath lab for emergency 1y percutaneous coronary intervention, where coronary angiography revealed a normal right coronary artery, total occlusion of the left anterior descending (LAD) with high thrombus burden. Export catheter successfully recanalized the LAD then 3 drug-eluting stents were deployed from proximal to distal. However, final angiography showed a severe lesion more distally even after we give intracoronary nitroglycerin 100 µg and sodium nitroprusside 50 µg. We decided to deploy a small, short stent more distally, but suddenly with stent advancement, it slipped at the ostium of the LAD (the nurse was preparing and connecting the Indeflator during advancement of the stent). We stopped briefly to consider the best strategy. Eventually, we decided to use a small 1.5 mm balloon at 6 atm, not to retrieve the stent but to engage it tightly at the proximal half of the small balloon, then pushing and advancing it to the preplanned distal LAD site. Finally, we succeeded in pushing the stent more distally into the LAD just before the lesion and deployed at 12 atm and 16 atm, but there was a minor dissection at the lesion; therefore, a new stent was deployed successfully with excellent final results. 

Discussion: There are different strategies to approach a slipped stent, such as snaring or deploying at its slipped site, or crushing it against the wall. Some have used a small balloon inflation distal to the stent to retrieve it or two twisted guidewires, but all strategies are suboptimal solutions. We believe the best strategy is to use a small balloon inflation to engage the proximal half of the stent (especially if the wire is still crossed inside the slipped stent and no distal obstructing/calcified lesion) and then pushing the slipped stent to its preplanned lesion. 

C3 2017-25 Unpredictable Severe Tirofiban-Induced Thrombocytopenia During PCI

Ahmed M. Kasem, MD; Wesam A. Alhejily, MD; Mohamed Qutub, Nabil Alama, MD; Ramzy Almohamady, MD

King Abdulaziz University Hospital

Case Presentation: A 56-year-old Chadian male presented 16 hours after the onset of typical chest pain. He was stable hemodynamically. His troponin was 37 and electrocardiogram showed ST-elevation myocardial infarction in leads v1-v6. Echocardiogram showed reduced left ventricular ejection fraction to 35% with left ventricular diastolic dysfunction grade II and severe hypokinesia of mid and apical segment of septum and lateral wall with preserved left ventricular wall thickness (0.7 cm). 

Difficult Aspects: After pretreatment with 300 mg of aspirin, 600 mg of clopidogrel, and 8000 IU of intravenous (IV) bolus unfractionated heparin, he underwent coronary angiography that showed total left anterior descending (LAD) occlusion with no significant lesions in other vessels. Percutaneous coronary intervention (PCI) was done to the LAD where the lesion was successfully crossed by modified open-sesame technique using 2 wires (BMW wire with Minitrek balloon 2 x 12 mm in the side branch and Fielder wire) where an underlying high thrombus burden lesion was seen. An aspiration catheter was used to partially aspirate some thrombus fragments, but residual thrombus remained. Drug-eluting stent implantation with a 3.5 x 28 mm Xience Xpedition deployed at 16 atm was performed, but suddenly the patient developed severe chest pain and became irritable and agitated. Pain was controlled by pethidine 25 mg IV and CA cine was replayed to check for complications; it showed total occlusion of the first septal branch (due to retrograde embolization during stent deployment by squeezing the residual thrombus) then rapidly BMW rewiring of the first septal branch (S1) and mechanical fragmentation by repeated inflation of the 2 x 15 mm Minitrek balloon using only low pressure (4-6 atm) with successful recanalization of the S1. An intracoronary bolus dose of 500 µg tirofiban was given, but again the patient developed sudden shivering, nausea, and vomiting. These symptoms were improved after IV metoclopramide 10 mg and hydrocortisone 100 mg. The patient was transferred to the Cardiac Care Unit (CCU) in stable condition with a combination therapy of aspirin, clopidogrel, enoxaparin, and tirofiban infusion for 24 h. On the second day, morning platelet count was only 2 × 10⁹/L); the baseline platelet count was 321 × 10⁹/L before percutaneous coronary intervention, then immediately complete blood count was repeated with citrate where platelet count was 12 × 10⁹/L). The patient did not report any history of bleeding disorders, hematologic or renal problems, or previous heparin exposure. After heart team discussion and consultation with a hematologist, the low-molecular-weight heparin, tirofiban, and aspirin were discontinued and only clopidogrel was continued, in addition to venous thromboembolism prophylaxis (elastic stoking, intermittent pneumatic compression).The patient’s CCU course went smoothly for 4 days without any symptoms or signs of bleeding or thrombotic complication; he was then shifted to the medical ward for a daily follow-up complete blood count, where the platelet count was increased gradually up to 290 × 10⁹/L after 14 days. The patient was then sent home in a stable good condition. 

Conclusions: Acute severe thrombocytopenia is an unpredicted serious side effect of tirofiban. Asymptomatic severe thrombocytopenia (without serious bleeding) can be managed conservatively without blood transfusion (as it can recover spontaneously). It is safe to continue use of clopidogril in severe thrombocytopenia (especially in patients without active bleeding).

C3 2017-26 Nightmare in Normal Coronaries

Violet Andrawes, FEBIC; M. Gharib, FEB; Ayman Shahin, FEB

Introduction: Iatrogenic coronary artery dissection during diagnostic coronary catheterization is a rare but life-threatening event. It results from mechanical injury to the arterial wall during catheter or wire manipulation, passage of an interventional device, forceful injection of contrast medium, balloon dilatation, or stenting. Patients with ostial coronary artery stenosis, hypertension, Marfan syndrome, and congenitally unicuspid and bicuspid aortic valves are reported to be at higher risk of dissection. But, in normal coronaries, is it a risk for dissection? And if it does occur, what are the complications and how do we deal with them? We discuss these issues in our case below. 

Case Presentation: A 55-year-old female patient, neither hypertensive nor diabetic, presented to our clinic with repetitive episodes of shortness of breath and chest pain of 4-month duration. Pain was reported to be exertional in some instances and if so was relieved with rest. Resting electrocardiogram showed non-specific changes. Resting echocardiogram was quite normal. Dobutamine stress echocardiogram was positive. Decision making favored performing coronary angiography as other diagnostic modalities (for example, computed tomography coronary angiography was not available at our locality). The femoral approach was chosen (no radial sets were available). Left coronary system was cannulated by a JL4, 6 Fr catheter, and there were no lesions. Right coronary artery (RCA) was cannulated by JR 3.5, 6 Fr catheter; there was no forceful manipulations of the catheter and an easy cannulation was done. Catheter-induced dissection of the proximal RCA was inadvertently committed, and trials of non-selective cannulation were done. The patient suddenly complained of severe chest pain. There was an ST-segment elevation in the inferior lead and dissection was noticed. Rapid measures were prepared to fix that dissection before spreading retrograde into the ascending aorta 10,000 units of unfractionated heparin, JR 4, 6 Fr guide catheter was used, BMW wire was successfully crossed to the distal end of the RCA, the inlet segment was fixed by SUNA 3.5 x 28 mm bare-metal stent deployed at 14 atm, while the exit was fixed by a second stent (SUNA 3 x 34 bare-metal stent deployed at 12 atm). Patient arrested on ventricular fibrillation and received DC shock and a third stent (Coroflex 2.75 x 24 mm deployed at 14 atm). The patient’s chest pain was resolved and hemodynamic changes improved. The patient was then transferred to the Coronary Care Unit and discharged the third day after improvement.

Discussion: Diagnostic coronary angiography is simple but not without complications and may end up to be a nightmare if dissection occurs and complicates by inducing a life-threatening arrhythmia. Our patient’s diagnostic angiogram was complicated by dissection in normal RCA and arrested. Always expect and be prepared for any complications, be calm, and act rapidly and wisely. It is better to avoid complication by making efforts to avoid deep engagement of the catheter and check the pressure waveform before every coronary injection. 

C3 2017-27 Application of Cerebral Hemodynamic Parameters to Assess Patient Outcomes During Cardiopulmonary Resuscitation

Cornelius C. Nwora, MD, RCIS, RDMS, RT(S), MASCP

Center for Cardiovascular Diseases, Texas Southern University, Houston, Texas

Background: Over a half century ago, the standard protocol for assisted cardiopulmonary resuscitation (CPR) was formulated and practiced. Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Recently, the scientific community weighed on the practical utility for rescue breathing (RB) in a reversed protocol, which suggests that unabridged chest compressions (CC) alone and limited defibrillation time supports better survival for cardiac arrest patients. 

Purpose: To assess the clinical outcomes of CPR using data pulled from published large randomized trials, as well as meta-analytic investigations that support the new guidelines of the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR). “Aside from early defibrillation, there are no clear adjuncts to CPR that improve survival.”A new paradigm – that which uses non-invasive parallel measurement of regional blood flow to the brain – as adjunct practice in assessment of patient survival after CPR is proposed. 

Methods: Real-time measurement of blood flow to the brain by transcranial Doppler (TCD) scanning of the mid-cerebral artery consistently yields more accurate results. Peak flow velocity measured at systole, and at end-diastolic pressure. Other vital parameters included calculation of cardiac output, finger-tip oximetry, pulse rate, and electrocardiography. 

Results: In one large randomized trial comparing the outcome in 960 patients who received (CC plus RB) with 981 patients who received only CC, the average time until arrival of emergency medical services was 6-7 min. No difference was found in the proportion of patients who were eventually discharged from the hospital: 11% for standard CPR vs 12. 5% for chest compression only (P=.31). A 2010 meta-analysis by Hüpfl et al concluded that “chest compression-only bystander CPR was associated with a statistically significant 22% improved chance of survival (risk ratio [RR], 1. 22; 95% confidence interval [CI], 1. 01-1. 47]) compared to standard CPR. The absolute increase in survival was 2.4% and the number needed to treat was 41.” Some uncertainty, however, remains about how well neurological function is preserved in this population and there is no information available regarding adverse effects. Large-scale prospective cohort studies suggest that standard CPR might be better than compressions-only CPR in patients whose cardiac arrest has a non-cardiac origin, such as drowning, trauma, or asphyxia – common with children. 

Conclusions: The effectiveness of CPR should be judged on how well maintaining a continuous uninterrupted coronary perfusion pressure increases the probability of a successful outcome. AHA and ILCOR released new guidelines on CPR recommending that lay rescuers and dispatchers assisting them should focus on chest compressions and not worry about ventilations. Defibrillation time or any other adjunct procedures should therefore be minimized.

C3 2017-28 When Nothing Goes Right, Go Left 

Yasser Sadek, MD; Hesham Bahaa, MSc 

Introduction: Patients with severe coronary artery disease involving the left main (LM) stem have been debatable on which practice is the best for those patients whether stenting or percutaneous coronary intervention (PCI). In the light of recently published EXCEL and NOBEL studies, the shift has been to the adoption of more complex PCI procedures.

Case Presentation: Our patient is a 70-year-old male. He is hypertensive and diabetic. In 2007, he was admitted in the Cardiac Care Unit (CCU) and diagnosed with acute coronary syndrome. His coronary angiography revealed multivessel disease for coronary artery bypass graft surgery. The patient refused any intervention at that time. In 2015, the patient presented with non-ST elevation myocardial infarction and complicated by cardiogenic shock and massive doses of inotropes were initiated to maintain his hemodynamics. 

His creatinine was 3.2 mg/dL and urea was 111 mg/dL. Echocardiography showed ejection fraction (EF) of 40%, mildly dilated left ventricular (LV) dimensions, akinetic inferior wall, and hypokinesia of posterior wall. After LM engagement by APU 3.5/7 Fr guiding catheter, the patient arrested and cardiopulmonary resuscitation was initiated for 5 min; after stabilization, the LM was assessed by intravascular ultrasound, which showed significant lesion containing thrombus/dissection. Stenting of LM to the left anterior descending and left circumflex by (TAP) was done successfully. Postdilation and final kissing and flaring of the ostium and POT of LM was achieved. The patient was weaned off inotropic support and was discharged after 3 days with improvement of renal function without dialysis. Nine months later, he started to suffer from chest pain on minimal exertion and his coronary angiography revealed in-stent restenosis at the distal LM, so angioplasty with a drug-eluting balloon was done. He presented to the Emergency Department 6 months later with severe chest pain and cardiogenic shock. Echocardiography showed EF of 30% with dilated LV dimensions, akinetic inferior wall and hypokinetic of entire apex with severe mitral regurgitation; immediate cardiothoracic consultation insisted to do preoperative CA. After 2 hours of his admission in CCU, the patient was arrested (persistent ventricular tachycardia) and the surgeon decided to insert intraaortic balloon pump (IABP). After IABP, blood pressure was 70/50 on adrenaline and noradrenaline and he was agitated and not fully conscious. The heart team discussion was conducted and we agreed that the patient was at extreme high-risk mortality for surgery and extreme high-risk mortality for coronary intervention. High-risk PCI with IABP support was done and the patient was discharged from the hospital after 15 days with EF 40% and moderate mitral regurgitation.

Discussion: SYNTAX score was highly recommended for such anatomy. In addition, the clinical condition and the preference of the patient plays an important role. Selection of a two-stent strategy in this patient was chosen as the left anterior descending and left circumflex were diffusely diseased as shown by use of intravascular ultrasound. Hemodynamic support by IABP during high-risk PCI has a lot of advantages.

C3 2017-29 Successful Multivessel PCI in a Nonagenarian in Cardiogenic Shock Complicated by Cardiac Arrest

Mohsin Saif, MRCP (UK)

Introduction: Percutaneous stenting remains the cornerstone for treating patients with ST-elevation myocardial infarction/non-ST elevation myocardial infarction, especially if they are in cardiogenic shock. The prevalence of multivessel disease and the possibility of ischemia at a distance from the infarct zone and of progressive deterioration in left ventricular function may argue for a strategy of more complete revascularization with multivessel percutaneous coronary intervention (PCI) or surgery. 

Case Presentation: A 93-year-old gentleman with a known history of diabetes and smoking presented to the emergency department with 2-hr history of central chest pain and sweating. Five days prior to this presentation, he had an elective total knee replacement (right knee). Clinical examination revealed a blood pressure of 60 mm Hg systolic. Electrocardiogram revealed 2 mm ST sagging in anterior chest leads. Two-dimensional echocardiogram revealed an ejection fraction (EF) of 40%. The patient was given emergency medications and put on inotropic support. He was immediately shifted to the cath lab for PCI. Coronary angiogram revealed critical disease in left anterior descending (LAD), diagonal, obtuse marginal (OM) branch, and right coronary artery (RCA). An intraaortic balloon pump was inserted by left femoral artery. LAD/first diagonal (D1) was wired with a Runthrough wire. A 3.5 Acrostak Grip balloon was inflated in the LAD, but it failed to expand fully. Therefore, rotablation was done in the proximal LAD. After lesion preparation, one drug-eluting stent was placed from proximal to mid LAD. In spite of PCI to the LAD, the patient remained in cardiogenic shock and therefore PCI to the left circumflex (OM branch) and to RCA was planned. OM was calcified. It was wired, but a balloon could not cross the lesion. The patient went into cardiac arrest (PEA). Immediate cardiopulmonary resuscitation was started and the patient put on autopulse. He was intubated and put on ventilatory support. Even a low-profile balloon could not be passed. Due to concerns about rotablation in the OM branch, a Tornus catheter was used to create a channel in the OM branch. A guideliner was used to deploy a drug-eluting stent in OM branch. Then two drug-eluting stents were placed in dominant RCA. He was then transferred to the Intensive Care Unit. He remained hemodynamically stable and was extubated 24 hours later. Thereafter, he remained stable and was subsequently discharged on day 7. He underwent cardiac rehabilitation and remained asymptomatic at 3-month follow-up.

Discussion: Although PCI tends to be successful less often in elderly patients, successful PCI is associated with increased survival. Higher survival rates were noted for the 17% of patients ≥75 years of age in the SHOCK registry who were clinically selected to undergo early revascularization compared with those with late or no revascularization. It seems reasonable to conclude that early revascularization may be appropriate for selected elderly patients and that management must be individualized.

C3 2017-30 Clinical Outcomes of Atherectomy Prior to Percutaneous Coronary Intervention (COAP-PCI Study)

Evan Shlofmitz; Rajkumar Doshi; Barry Kaplan; Rajiv Jauhar; Perwaiz Meraj

Background: As a result of the challenges in treating calcified coronary disease, lesion preparation has become increasingly important prior to percutaneous coronary intervention (PCI). Despite the growing data for both rotational atherectomy and orbital atherectomy, to date there have been no studies directly comparing the safety and efficacy of orbital atherectomy and rotational atherectomy. We sought to examine the clinical outcomes of patients with calcified coronary artery disease who underwent atherectomy prior to PCI. 

Methods: A total of 35,590 patients from five tertiary-care hospitals who had PCI from January 2011 to April 2016 were identified. Of these, 708 patients who had rotational or orbital atherectomy prior to PCI were included in our analysis. This multicenter observational analysis compared orbital atherectomy and rotational atherectomy in patients with coronary artery calcification who had atherectomy prior to PCI.

Results: A total of 416 patients were included in the rotational atherectomy arm and 292 patients were included in the orbital atherectomy group. The primary endpoint, death on discharge, occurred in 6 of the 416 patients in the rotational atherectomy group as compared with 0 of the 292 patients in the orbital atherectomy group (1.4% vs 0%; 95% confidence interval [CI]; P=.039 unadjusted analysis, P=.024 adjusted analysis). Secondary outcomes of myocardial infarction and stroke were similar between the groups, whereas heart failure was higher with rotational atherectomy (4.1% vs 1.4%; 95% CI, P=.022 unadjusted analysis, P=.025 adjusted analysis). Fluoroscopy time was significantly decreased with orbital atherectomy compared with rotational atherectomy (22.07 min vs 27.67 min; P<.001).

Discussion: In the first multicenter comparison on contemporary atherectomy devices, we found orbital atherectomy to be non-inferior to rotational atherectomy. In patients with coronary artery calcification who undergo atherectomy prior to PCI, orbital atherectomy was associated with significantly decreased in-hospital mortality, heart failure, and procedural radiation time compared with rotational atherectomy. 

C3 2017-31 LMCA Bifurcation Stenting – Mini-Crush Technique

Ajit Pal Singh, MD, DM

Abstract: Significant stenosis of the left main coronary artery (LMCA) is a high-risk condition. LMCA bifurcation stenting remains a challenging intervention despite the recent advancements in percutaneous coronary intervention (PCI) techniques. The mini-crush technique is a safe and reliable option for such cases. We present a case demonstrating successful outcome of this technique.

Case Presentation: A 55-year-old male was evaluated for class III New York Heart Association angina. Echocardiography was normal and TMT was strongly positive. Coronary angiogram showed severe stenosis of distal LMCA and proximal left anterior descending (LAD) and left circumflex (LCX) coronary arteries. Patient refused coronary bypass surgery and was taken up for PCI. Predilation of the lesions was done using 2 x 10 mm balloon at 12 atm. A 3.0 x 32 mm drug-eluting stent (DES) was deployed in the LAD with 1-2 mm protrusion into LMCA followed by removal of wire and balloon. A 3.5 x 21 mm DES was deployed from LMCA to LCX crushing the proximal part of the LAD stent. LAD was rewired and the ostium of the stent dilated with 1.5 mm and 2 mm balloons. Final kissing-balloon inflation was done at 12 atm with 3.0 mm NC balloon in LAD and 3.5 mm NC balloon in LCX. Final angiogram showed good result.

Conclusion: Distal LMCA stenting remains a challenge for the interventionist. Selecting the proper bifurcation strategy is crucial for the final outcome. The mini-crush technique involves minimal retraction (1-2 mm) of the side-branch stent into the main branch, thus minimizing the three metallic strut layers created by the classic crush technique. Our case demonstrates successful outcome of this technique in distal LMCA.

C3 2017-32 Coronary Subclavian Steal in Post-CABG Patient

Vivek Tripathi, MD, DM

Introduction: Post-coronary artery bypass graft (CABG) patients start becoming symptomatic over time as they develop neoatherosclerosis in the grafts, especially venous grafts. Arterial grafts, especially the left internal mammary artery (LIMA) are resistant to atherosclerosis. One of the rare causes of angina in these patients is development of proximal subclavian artery stenosis compromising LIMA flow, hence leading to coronary steal. We describe a case of angina secondary to subclavian coronary steal that was relieved simply by doing percutaneous transluminal angioplasty (PTA) with stenting to the proximal subclavian artery.

Case Presentation: A 65-year-old male presented with progressive class II angina of 6-month duration. This pain was more when he used his left arm to do work. His CABG was done 10 years prior with LIMA to left anterior descending (LAD) and saphenous vein graft (SVG) to obtuse marginal (OM) and posterior descending artery (PDA). There was significant difference in blood pressure in both arms. His electrocardiogram didn’t show any new ST-T changes. He was subjected to coronary angiogram. Native vessel showed triple-vessel disease; however, the LAD had proximal 70% stenosis with good anterograde flow. Graft angiogram showed occluded SVG to right PDA. His LIMA graft and SVG to OM were patent. There were good collaterals from distal LAD to right PDA. However, a tight stenosis was found in the proximal left subclavian artery. LIMA had retrograde flow up to its origin from left subclavian artery. His venous graft to right PDA looked to have been occluded for some time and couldn’t be attributed to accelerating angina as there were good collaterals from the LAD. Hence, it was thought to be due to coronary subclavian steal secondary to tight proximal stenosis in proximal left subclavian artery. He was subjected to PTA with stenting to the left subclavian artery. His coronary angiography post procedure was carried out immediately and demonstrated significant absence of retrograde flow through LIMA to left subclavian artery. His symptoms were also relieved completely.

Discussion: Coronary subclavian steal is a well-known entity that is an important cause of angina. Incidence is variable. The onset of symptoms has ranged from 2 to 31 years after CABG. Any patient going for CABG surgery should have evaluation of proximal subclavian artery, as this can be the cause of angina in these patients early after surgery. Graft atherosclerosis has variable incidence, but approximately 70% of venous grafts are occluded at 10 years. These patients develop progressive stable angina, which can be managed by percutaneous coronary intervention of native vessels where feasible. LIMA is resistant to atherosclerosis and survives a long time. We should suspect coronary subclavian steal in a patient who has typical symptoms aggravated by left arm movement and difference of pulse volume in bilateral arm. Our case was unique as we could demonstrate retrograde flow in the LIMA in a symptomatic patient. This patient underwent PTA with stenting of left subclavian artery with complete disappearance of symptoms.

C3 2017-33 Use of Monorail Coronary Balloon Catheter for Intracoronary Drug Delivery in No Reflow Phenomenon

Flavio Volpi, MD; José Escalante, MD; Daniel Orquera, MD; Marisa Pagés, MD; Aldo M. Rodriguez Saavedra, MD; Gustavo A. Samaja, MD, FSCAI

Background: No reflow (NR) is a serious and potentially grave complication that occurs ranging from 2% in elective percutaneous coronary intervention (PCI) up to 26% in acute myocardial infarction (AMI) mechanical reperfusion. NR requires prompt identification and treatment, ie, intracoronary (IC) administration of agents so that it ensures drug delivery to the distal vascular bed. Current alternatives include infusion catheter, the central lumen of an over-the-wire balloon, or thrombectomy catheters. We propose to administer IC drugs through the central lumen of a monorail coronary balloon catheter (MCBC) after a simple and quick maneuver.

Methods: In order to allow IC administration of drugs into the distal vascular bed, we performed a longitudinal excision on the balloon component of the MCBC with a surgical blade; the drug injected through the balloon port of the MCBC exits out the shaft at the site of excision. In order to optimize time, we performed the excision on the balloon without removing it from the 0.014˝ guidewire, but only just pulling the balloon out of the Y-connector. We analyzed the first 50 consecutive cases of NR in PCI that were treated with this maneuver. We evaluated clinical characteristics, interventions done, feasibility of the maneuver (success in reaching the distal vessel and performing IC drug administration), time consumed (time from diagnosis of NR until IC administration of the drug), and complications derived from the maneuver (catheter entrapment, stent dislodgment, vessel injury).

Results: Thirty-nine AMI, 9 acute coronary syndrome non-ST elevation, 2 stable coronary disease. We administered IC verapamil (400-1800 µg). TIMI flow improved in all but 5 cases, treated with IC epinephrine (200-300 µg). Vessels treated: 24 left anterior descending, 12 right coronary artery, 7 left circumflex, 2 left main, and 5 saphenous vein grafts. The maneuver was successful in all cases, with a medium time of 45 s (30-80 s). There were no complications derived from the maneuver.

Conclusions: The use of a MCBC for IC drug delivery is feasible and it is an alternative to be considered for simplicity and quickness. It was safe in this cohort of patients, but there is a risk of complications that must be measured and evaluated. 

ENDOVASCULAR

C3 2017-34 LIBERTY 360: 6-Month Outcomes of Endovascular Device Intervention in Patients With Symptomatic Lower-Extremity PAD

George L. Adams, MD, MHS, on behalf of the LIBERTY Investigators

Purpose: The majority of peripheral artery disease (PAD) clinical device trials are supported by commercial manufacturers and designed for regulatory device approval, with extensive inclusion/exclusion criteria to support homogeneous, non-confounded patient populations. High-risk patients with advanced PAD are often excluded to reduce the risk of adverse outcomes, leading to difficulty in translating trial results into real-world clinical practice. As a result, physicians have no direct guidance regarding the use of endovascular devices in these difficult but common scenarios. There is a need for objectively assessed studies to evaluate clinical, functional and economic outcomes in a broader PAD patient population.

Methods: LIBERTY 360 is a prospective, observational, multicenter study with liberal inclusion criteria and few exclusion criteria, designed to evaluate outcomes of endovascular device interventions in patients with symptomatic lower-extremity PAD. LIBERTY enrolled 1204 patients (501 Rutherford class [RC] 2-3; 603 RC 4-5; 100 RC 6). Six-month outcomes were assessed by Rutherford group and include major adverse events (MAE), defined as target-vessel revascularization (TVR), death within 30 days of procedure, and unplanned major amputation of the target limb.

Results: Procedural success, defined as final residual stenosis <50% for all treated target lesions without significant angiographic complications, was achieved in 84.6%, 77.2%, and 69.5% of subjects in the RC 2-3, RC 4-5, and RC 6 groups, respectively. The 6-month freedom from MAE rates were 92.6%, 81.2%, and 73.7% in the RC 2-3, RC 4-5, and RC 6 groups, respectively. High freedom from TVR was reported across all RCs (93.0% in RC 2-3, 83.1% in RC 4-5, and 85.1% in RC 6). In RC 6 subjects, the freedom from death (85.1%) and freedom from major amputation (87.1%) rates suggest that endovascular device intervention may be considered the primary therapy in RC 6 patients felt to have a salvageable limb. At 6 months, the mean RC was 1.4 ± 1.3 in the RC 2-3 group, 2.3 ± 2.0 in the RC 4-5 group, and 4.6 ± 2.3 in the RC 6 group. 

Conclusions: LIBERTY 360 represents as close to a real-world experience with various endovascular strategies across RCs. There was high freedom from 6-month MAEs seen across all RCs. Additionally, there was marked improvement in RC at 6 months – RC 4-5 and RC 6 showed continued improvement from 30 days to 6 months, while RC 2-3 maintained improvement at 6 months. The results of this novel study suggest that “watchful waiting” in RC 2-3 and “primary amputation” in RC 6 may not be necessary – endovascular device interventions can be successful in these patient populations as well.

C3 2017-35 Gender-Related Differences in Mortality After Endovascular Repair of Abdominal Aortic 

Aneurysm: Systematic Review and Meta-Analysis

Akintunde Akinjero, MD, MS; Oluwole Adegbala, MD, MPH; Samson Aliu, MD, MPH; Adeyinka Adejumo, MD, MS; 

Nike Akinjero, RN, BSN; Eseosa Edo-Osagie, MD; Tomi Akinyemiju, PhD

Objectives: Women have been shown to have worse outcomes after open abdominal aortic aneurysm repair. This has not been conclusively shown after endovascular repair of abdominal aortic aneurysm (EVAR). We sought to evaluate gender differences in mortality after EVAR. 

Methods: We systematically searched the Pubmed, Embase, and Cochrane library for studies on “gender differences in outcomes after endovascular repair of abdominal aortic aneurysm.” Inclusion criteria: all studies of the defined population that look at mortality as an outcome. We identified 256 studies, of which 43 were assessed at the full text level. The Mantel-Haenszel random effects model was used to generate summary-effect estimates for the main endpoint of mortality. All data analyses were performed using Review Manager (RevMan, version 5.3). Publication bias was investigated using the funnel plot. 

Results: Eleven studies that met the inclusion criteria, involving 56,012 patients, were meta-analyzed. There were 49,937 men and 6075 women. We found no significant difference in all-cause mortality (odds ratio, 0.75; 95% confidence interval, 0.32-1.77). The funnel plot suggested no publication bias. 

Conclusions: There was no difference in all-cause mortality between men and women after EVAR. Future prospective, larger studies with longer follow-up period are needed to further explore outcomes in this population.

C3 2017-36 Common Femoral Artery Occlusion After AngioSeal Deployment

I.V. Georg; J.S. Jeevaneson; A. Oliveira

Introduction: AngioSeal is a preferred vascular closure device (VCD) to achieve hemostasis after a catheterization procedure performed via femoral access. Occlusion after AngioSeal deployment is rare; however, in extreme cases it can lead to critical limb ischemia. Consideration of patient’s contributory factors, femoral angiogram, and use of good technique will avoid or at least minimize the risk of developing complications. We describe a case where AngioSeal caused the occlusion of a common femoral artery.

Case Presentation: An 83-year-old female with a history of chest discomfort, dyspnea on exertion for 3 months underwent coronary angiogram via right femoral artery. AngioSeal was successfully deployed to achieve hemostasis, and the patient was discharged without any complications on the same day. One month later, during an unrelated hospital visit, the patient expressed discomfort in the right groin area and lower extremity and was referred for an expert opinion. On examination, reasonable right pedal pulse was palpable. Right ankle-brachial pressure index (rABPI) was calculated as 0.51 (70/138) which indicates severe stenosis of arteries in the right lower limb. Ultrasound revealed reduced blood supply to right lower extremity and an opaque visualization in the proximal right common femoral artery.

Discussion: Although arterial access-site complications are common, occlusion of common femoral artery by AngioSeal is an extremely rare and unfortunate complication of cardiovascular catheterization procedures. Recently, there has been an increase in catheterization procedures in high-risk patients such as those using anticoagulants, and there is a need to identify contributory factors to minimize the risk of complications. Use of a femoral angiogram to identify the suitability of AngioSeal along with proper technique and consideration of patient factors including the size of the artery will significantly reduce the risk of postoperative arterial-site complications. However, a small percentage of complications may occur, and these rare cases will have to be managed clinically along with multidisciplinary team input. In this case, after the occurrence of this untoward event, the multidisciplinary team decision was made to perform a peripheral angiogram and jail the collagen using a stent if confirmed. A peripheral angiogram of the lower extremities confirmed a short occlusion in the proximal common femoral artery, with reasonable filling distally via 3 patent calf vessels. Angioplasty to the common femoral artery with a stent was carried out; reasonable flow was achieved with no complications. Further follow-up showed good flow and no complications.    

C3 2017-37 Cardiopulmonary Exercise Testing Limitation in PAD

Zulfiqar Qutrio Baloch, MD¹; Shabber Agha Abbas, MD²; Abbas Ali, MD³; Luke Marone, MD³; Sumera Bukhari, MD⁴

Brandon Regional Hospital, Florida; ²R-Endocrinology Hamilton, New Jersey; ³West Virginia University Morgantown, West Virginia; and ⁴St. Francis Medical Center, Trenton, New Jersey

Background: Peripheral artery disease (PAD) is prevalent in 20%-40% in those with known coronary artery and cerebrovascular disease. PAD is associated with a markedly increased risk of cardiovascular mortality by increasing risk of myocardial infarction, stroke, and cardiovascular death. Patients with PAD remain under-recognized and under-treated. New approaches are urgently needed to prevent disability in patients with PAD by implementing early recognition strategies.

Methods: We performed a retrospective analysis of clinically stable cardiovascular patients who were referred for cariopulmonary exercise testing (CPET) due to shortness of breath, dyspnea on exertion, angina, bradycardia, coronary artery disease, pulmonary hypertension and PAD. Among the patients who prematurely terminated CPET, available angiograms were assessed. Estimated functional capacity in metabolic equivalents was also obtained from monitored bicycle exercise at the visit.

Results: According to our analysis, 351 patients were unable to complete the CPET due to some limiting factor. Of these patients, a total of 216 had available angiographic assessment done, of whom 42.6% were males and 57.4% were females and the mean age was 67 years. A total of 135 patients with a similar gender distribution and a mean age of 53 years did not undergo angiography. A majority of the patients who underwent assessment were found to have lesions. In particular, 55 had iliac, 67 had femoral, and 162 had below-the-knee lesions. There was a significant difference observed in oxygen volume (VO₂) max in patients with lesions. Patient with severe below-the-knee disease had the highest VO₂ max, whereas those with severe femoral disease had the next second highest, while those with severe iliac disease had the lowest VO₂ max of all groups. In all vessel groups, the existence of PAD was associated with a significantly reduced VO₂ max during CPET.    

Conclusions: CPET provides valuable and pertinent physiologic information on the integrated cardiopulmonary responses to exercise and remains underutilized in the context of PAD. The data obtained in this study provide a preliminary understanding of the underlying effects of PAD and provide a basis for further utilization of CPET termination as a potential screening signal for further PAD investigation. 

C3 2017-38 Iatrogenic Carotid Dissection

Tisa Saha, MD; Daniel McCormick, DO; Sheldon Goldberg, MD 

Division of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System

Introduction: Risk factors for a procedural complication in carotid stenting includes presence of clinical characteristics such as advanced age and patient’s cerebral reserve, as well as angiographic characteristics such as elongated arch, excessive tortuosity, and heavy calcification. 

Case Presentation: A 75-year-old male with a history of coronary artery disease, hyperlipidemia, and prior left carotid endarterectomy presented with a transient ischemic attack. Carotid Doppler showed 60%-69% stenosis in the right internal carotid artery and more than 80% stenosis in the left internal carotid artery. His diagnostic angiogram revealed a type I arch with a bovine origin of the left common carotid artery and severe tortuosity of the proximal left common carotid artery. The patient was offered carotid endarterectomy, but refused. Access was obtained with 5 Fr hydrophilic catheter via the right brachial artery. A 3 cm transition Amplatz super-stiff wire was positioned into the distal left common carotid artery and subsequently the hydrophilic catheter and sheath were removed and exchanged for a 6 Fr x 90 cm Arrowflex sheath, which was positioned in the proximal left common carotid artery. Following this, a spiral dissection was noted in the proximal portion of the left common carotid artery. Attempts made to cross the dissection with a Glidewire were unsuccessful. A coronary 0.014˝ Run-through wire was passed through the dissected segment via a 5 Fr internal mammary artery diagnostic catheter and successfully positioned into the distal internal carotid artery across the original severe left internal carotid artery stenosis. After this, the catheter was removed and a 5 x 30 mm balloon was used to dilate the left internal carotid artery stenosis. We could not deliver an Acculink stent to the left internal carotid artery. Therefore, a 0.035˝ Wholey wire was positioned into the distal portion of the internal carotid artery and a 10 x 20 mm Abbott Pro self-expanding stent was successfully deployed across the left internal carotid artery stenosis. Following this, a 10 x 60 mm Absolute Pro self-expanding stent was deployed across the proximal common carotid dissection extending back to the ostium. This sealed the dissection. Postintervention angiography revealed good flow as well as patency of the anterior cerebral artery and middle cerebral artery distributions. Follow-up ultrasound at 2 years showed widely patent stents and the patient remained asymptomatic at 4-year follow-up. 

Discussion: The risk of carotid stenting depends on tortuosity of the carotid circulation in addition to elongation of the aortic arch. Strong consideration should be given to surgical endarterectomy with such unfavorable anatomy. These dissections can be successfully treated with self-expanding stents with good long-term results. 

C3 2017-39 Micro-Net Covered Embolic Prevention Stent System, C-Guard Stent in Tandem Critical Restenosis of Internal Carotid Artery After Endarterectomy of Graft After 13 Years of Follow-up

M.E. Segovia; C. Fernandez-Pereira; J.R. Mieres; O. Santaera; J.F. Del Pozo; R. Farfan; A.E. Rodríguez

Introduction: Severe carotid restenosis after surgical carotid endarterectomy (CEA) remains a challenging scenario for angioplasty due to the risk of vessel rupture.

Case Presentation: We report the case of a 76-year-old female with smoking history of 30 packs/year, hypertension, peripheral vascular disease with a left internal CEA 13 years ago due to a severe ulcerated stenosis and neurological symptoms, severe chronic obstructive pulmonary disease, and lung cancer treated with surgery, chemotherapy, and radiotherapy 7 years ago. Six months prior to index procedure, she was treated for an intermittent claudication with percutaneous revascularization of left iliac artery.  

At the time of admission, she presented with paresthesias of her right limb and a left carotid ultrasound showing a lesion >90% in the CEA. A computed tomography angiography was performed, revealing a critical lesion of the left internal carotid artery (LICA) on the site of the CEA and a confirmatory carotid angiogram showed two critical tandem lesions at LICA on CEA. Both heart and neurological teams agreed to perform a percutaneous approach due to high surgical risk. We decided to use femoral access and a balloon angioplasty was performed in the left iliac artery before main procedure to regain better access to the neck vessels due to previous stenting 13 years ago. After this, a JR guiding catheter (Boston Scientific) was crossed through the LICA with a Runthrough floppy guidewire (Terumo); immediately, a direct stenting with a 7.0 x 40 mm C-guard Micro-Net Inspired MD (Boston Scientific) was successfully deployed and safely postdilated with a compliant 5.0 mm balloon. No embolic protection devices were used pre- or post-stent implantation. The procedure was successful and the patient was discharged 24 hours later with complete medical treatment, including dual-antiplatelet therapy with clopidogrel.

Discussion: The treatment option for high-risk patients is carotid angioplasty. Intervention in carotid disease is extremely complex and requires the articulation of a team with experience. Thrombi may be found inside the graft; the C-guard Micro-Net stent can be use in this special situation, preventing embolization. The excellent navigability of this type of stent puts the C-Guard at the forefront of all situations that can be faced in carotid angioplasty. In high-experience centers, carotid angioplasty is a safe alternative for symptomatic patients, as well as asymptomatic patients with indication for revascularization.   

C3 2017-40 CAD With Bilateral Aorto-Iliac Occlusion

Rajbir Sidhu, MD; Shunsuke Aoi, MD; Supreeti Behuria, MD; Perry Fisher, MD; Neil Patel, MD; Ramesh Gowda, MD

Case Presentation: A 61-year-old man with no significant past medical history, but a history of active tobacco use, presented to our hospital with chest pain and shortness of breath. Initial electrocardiogram showed diffuse ST-segment depressions in the anterolateral leads, and his troponin uptrended to 22.121 ng/mL. Diagnosis of non-ST elevation myocardial infarction was made and urgent coronary angiography was performed. This confirmed a right dominant system with chronic total occlusion of the right coronary artery. Collaterals distal to the chronic total occlusion originated from the left anterior descending artery. In addition, the left anterior descending had a proximal 80%-90% stenosis and the left circumflex artery showed distal subtotal thrombotic occlusion. Left ventriculogram confirmed akinesis of the inferolateral-posterolateral wall, moderate hypokinesis of the apex, and an ejection fraction of 30%. Bilateral femoral injection showed bilateral common iliac artery occlusion. As such, an aortic balloon pump was unable to be placed. 

Cardiothoracic surgery was consulted for possible coronary artery bypass graft; however, the patient developed hypertensive emergency with flash pulmonary edema requiring intubation, followed by septic shock requiring pressors. After discussion regarding the optimal method of revascularization given his complex aorto-iliac artery disease and need for mechanical perioperative left ventricular assist device, it was decided that a percutaneous approach would be the treatment of choice due to his high risk for surgery. The patient underwent successful peripheral intervention to the distal aorta and bilateral common iliac artery, and subsequent Impella-supported percutaneous coronary intervention to the left anterior descending coronary artery. 

Discussion: In aorto-iliac occlusive disease, a variety of collateral circulations can develop in the lower extremities. The Winslow Collateral Pathway is one that involves the internal mammary artery, the superior epigastric artery, and the inferior epigastric artery, which reconstitute the external iliac artery. The inferior epigastric artery is extensively used in coronary artery bypass graft; however, the presence of bilateral aorto-iliac occlusion and peripheral vascular disease may be overlooked without the preoperative evaluation of the collaterals. Use of the inferior epigastric artery for coronary artery bypass graft in aorto-iliac occlusion results in interruption of circulation to the lower extremity and may result in acute limb ischemia. In our patient, evaluation of collaterals was significant for the Winslow pathway, and as such, the risk of developing acute limb ischemia would have been high if the inferior epigastric arteries were used for coronary artery bypass graft. Our case highlights the importance of recognizing aorto-iliac occlusion and properly assessing the collateral circulation to determine the optimal revascularization option in the setting of coronary artery disease requiring coronary artery bypass graft.

C3 2017-41 Mixed Aortic Valve Disease: Impact on Outcome After Transcatheter Aortic Valve Replacement

K. Stathogiannis; K. Toutouzas; M. Drakopoulou; G. Latsios; A. Synetos; G. Trantalis; O. Kaitozis; A. Michelongona; C. Aggeli; E. Tsiamis; D. Tousoulis

First Department of Cardiology, Athens Medical School, Hippokration Hospital, Athens, Greece

Background: The introduction of transcatheter aortic valve replacement (TAVR) into clinical practice has provided new treatment options for patients with severe aortic valve stenosis. Mixed aortic valve disease with concomitant aortic regurgitation is common among these patients. Whether mixed aortic valve disease has an impact on the outcome of patients scheduled for TAVR remains uncertain. 

Purpose: We sought to investigate in symptomatic patients with severe aortic stenosis the impact of concomitant aortic valve regurgitation on clinical outcomes after TAVR with a self-expanding valve. 

Methods: Consecutive patients with severe symptomatic aortic stenosis scheduled for TAVR in a tertiary center were included in the study. Prospectively collected data before and after TAVR were retrospectively analyzed in all patients. Patients with no aortic regurgitation were considered “isolated aortic stenosis” patients, whereas patients with at least mild aortic regurgitation were considered “mixed aortic valve disease” (MAVD) patients. All outcomes were evaluated according to the Valve Academic Research Consortium (VARC)-2 criteria. Primary clinical endpoint was considered 4-year all-cause mortality. 

Results: We included 185 patients (age, 79 ± 7 years; logistic EuroSCORE, 25 ± 10%; 57% females; New York Heart Association class III, 79%) in the study. Forty-one patients (22%) had isolated aortic stenosis and 144 patients (78%) had mixed aortic valve disease. The primary clinical endpoint occurred in 8 patients with isolated aortic stenosis and in 34 patients with mixed aortic valve disease (19% vs 23%; P=.60). No major differences were observed in cardiovascular death (12% vs 17%; P=.50), stroke (8% vs 3%; P=.10), and acute kidney injury (8% vs 5%; P=.20) between the two groups. 

At univariate analysis, predictors for mortality were: severe aortic regurgitation before TAVR (P=.046; odds ratio, 1.564; 95% confidence interval, 1.008-2.426) and mean gradient (P=.247; odds ratio, 0.985; 95% confidence interval, 0.961-1.010). At multivariate analysis, severe aortic regurgitation before TAVI (P=.034; odds ratio, 1.587; 95% confidence interval, 1.036-2.432) was an independent predictor of long-term mortality. 

Conclusion: Mixed aortic valve disease with severe aortic regurgitation before TAVR is associated with increased long-term mortality and further studies are needed to explore possible implications in patient selection. Several factors should be considered, including the severity of aortic regurgitation.

STRUCTURAL

C3 2017-42 Transcatheter Aortic Valve Replacement in a Young Patient With Degenerated Aortic Homograft

Juan Álvarez Sevillano, MD; Juan Quirós Hernández, MD; Ángeles Videla Lynch, MD; José L. Barisani, MD; Manuel Estigarribia, MD; Alejandro Cherro, MD

Introduction: Aortic root homografts are rarely used for surgical aortic valve replacement (SAVR), mainly in infective endocarditis. Like other bioprosthetic tissue valves, homografts are prone to structural deterioration (tissue calcification and valve dysfunction), and reoperation is needed in 10%-25% within 15 years. We report a case of transcatheter aortic valve replacement (TAVR) in a young patient who had previously undergone two SAVRs and who developed severe aortic valve stenosis and regurgitation due to homograft failure. 

Case Presentation: A 24-year-old male patient with congenital aortic stenosis had undergone an aortic valvuloplasty in his first month of life, and two previous cardiac surgeries: aortic mechanical valve replacement at the age of 13 and then aortic homograft due to prosthetic valve endocarditis (5 months later). He evolved in the last year with symptoms of cardiac failure after hospitalization for acute endocarditis. Computed tomographic angiograms and transesophageal echocardiogram revealed a degenerated aortic root homograft with severe calcification, severe aortic valve regurgitation, and severe stenosis. In addition, two hyperrefringent images were seen in the aortic side (aseptic vegetation). He was considered inoperable in another institution and cardiac transplant was proposed (not being accepted by the patient and his family). He was admitted to our institution for a Heart Team evaluation. Due to the surgical risk (logistic EuroSCORE II 10.46%; STS score 30.36% morbidity and mortality) and the extended calcification of the homograft, he was rejected for a third reoperation and decided to undergo a transfemoral TAVR using a repositionable self-expanding valve. Under general anesthesia and without predilation (because of severe regurgitation), we carried out a TAVR with a 23 mm Lotus Valve System (Boston Scientific). Echocardiographic parameters and symptoms improved dramatically after the intervention. He had an uneventful recovery and was discharged on postoperative day 3. At 5-month follow-up, he remained in New York Heart Association functional class I and echocardiogram showed good valve functioning without paravalvular leak. 

Discussion: Surgery is the treatment of choice for failing homograft, but in patients with extensive calcification the only option is to remove the calcified homograft root and replace it completely. This kind of surgery is technically challenging and leads to significant mortality and morbidity. In this context, TAVR could be an alternative for the treatment of degenerated aortic homograft in high-risk patients. The feasibility of this valve-in-homograft technique – an off-label use – has been discussed in a few case reports (only 2 in young patients). Although the long-term durability of TAVR devices is not well known, we think that young patients with high-risk profile might benefit from valve-in-homograft technique, leaving cardiac transplant as the last option.

C3 2017-43 Severe Aortic Stenosis and Left Ventricular Dysfunction in Patient With a History of Bentall-Bono Surgery With Homograft

Luciano Aramberry, MD; Marcelo Menendez, MD; Anibal Gentiletti, MD; Liliana Rojo, MD; Giordano Carlos, MD

Introduction: Patients with a bicuspid aortic valve constitute a heterogeneous population with variable clinical presentation and complications. More than 50% of the patients who require aortic valve replacement have a bicuspid aortic valve, a condition that may be associated with dilation of ascending aorta and aortic insufficiency. Transcatheter aortic valve implantation is increasingly used to treat bioprosthetic degeneration. 

Case Presentation: A 63-year-old patient presented with deterioration of an aortic homograft, aortic valve bioprosthesis severe stenosis, and severe left ventricular dysfunction with history of bicuspid aortic valve treated in 2002 with aortic replacement with mechanical valve complicated with infective endocarditis and that required new replacement with bioprosthesis and homograft aortic root replacement with reimplantation of the coronary artery in 2003. The patient progressed with multiple episodes of decompensated heart failure. In 2004, a cardiodefibrillator was implanted due to ventricular tachycardia. The patient was admitted to the Coronary Unit due to progression of New York Heart Association dyspnea II to IV decompensated heart failure, with anasarca a requirement of inotropic treatment. Coronary angiography showed no obstructions. Severe deterioration of left ventricular function (20% ejection fraction) was observed on the echocardiogram with positive reserve contractile in stress echocardiogram with dobutamine. A preprocedural evaluation demonstrated a porcelain aorta with severe calcification in the previous homograft valve on computed tomography. After discussion with the Heart Team and due to the high surgical risk, transcatheter valve implantation was decided. We chose a self-expanding nitinol valve type CoreValve number 26 that was successfully placed without complications through transfemoral access. The patient progressed with resolution of the signs of heart failure and 6 days later was discharged with subsequent controls that showed improvement of the ventricular function without evidence of paravalvular leak. 

Discussion: The rate of re-interventions in patients with bioprosthesis is low. Valve-in-valve technique has been used with good results in patients with bioprosthesis dysfunction as well as in patients with a history of Bentall operation. This case demonstrates that this technique is a safe option in very high-risk patients with ventricular dysfunction and heart failure.

C3 2017-44 Decision Making: Bifurcation PCI and TAVI vs Open Heart Surgery

Ahmad E. Mostafa; Diaa Kamal; M. Baraka 

Cardiology Department, Ain Shams University, Cairo, Egypt

Introduction: Aortic stenosis (AS) is a common disorder affecting elderly patients. Surgical aortic valve replacement (SAVR) was the mainstay of definitive treatment of AS until this decade. Recent studies have shown that transcatheter aortic valve replacement (TAVR) has comparable results with SAVR. Given that coronary artery disease (CAD) and AS usually coexist, the weight of surgery to correct both conditions is greater. However, both conditions can be corrected percutaneously with the advantage of giving time to correct one condition and assess the significance of the other. 

Case Presentation: An 82-year-old male presented to our clinic complaining of chest tightness with exertion for 1 month. He recalled an attack of chest pain lasting for 4 hours 1 month ago. His past history included diabetes mellitus controlled on insulin and hypertension. His Katz index was 6/6. Echocardiography was done, revealing fair left ventricular (LV) systolic function, hypokinesis of anterior wall, mild mitral regurgitation, and severe AS (mean pressure gradient, 55 mm Hg, aortic valve area, 0.6 cm²). Coronary angiography showed a significant bifurcation lesion in the left anterior descending (LAD) and first diagonal branch (D1). Our Heart Team calculated surgical risk scores for the patient (EuroSCORE II, 6.3; STS score, 5) stating that overall estimated risk of SAVR and CABG was intermediate risk. The Heart Team decided to perform computed tomography (CT) aortography to assess anatomical eligibility of TAVR; if no contraindications were found for TAVR, the plan was to perform percutaneous coronary intervention to LAD and D1 followed by treadmill exercise testing (TMET) after 1 month to assess symptoms of AS. CT showed no contraindication for TAVR. Percutaneous coronary intervention was done with bifurcation stenting of LAD and D1 using T and minimal protrusion (TAP) technique. Thereafter, the patient was symptom free and TMET was done after 1 month showing marked symptoms at low workload, with blunting response of systolic arterial blood pressure. TAVR was done using a self-expandable valve (Evolut R). Follow-up echocardiogram showed improvement of LV systolic function (aortic valve mean pressure gradient, 9.7 mm Hg) with only mild paravalvular regurgitation.

Discussion: Calcific AS is generally a disease of the elderly and co-morbidities are frequent; a percutaneous approach to AVR is therefore an attractive alternative. A Heart Team to assess individual patient’s risk, as well as anatomical and technical suitability of TAVR, should be best able to make decisions in this patient population. Risk assessment should mostly rely on the clinical judgment of a Heart Team as well as combination of logistic risk scores. Our patient had a structural defect and CAD, which collectively resulted in LV systolic dysfunction; staged percutaneous procedures were able not only to improve symptoms but also to achieve LV recovery. 

C3 2017-45 The Utility of Postextrasystolic Potentiation in the Diagnosis of Low-Flow Low-Gradient Aortic Stenosis

Perry Fisher, MD¹; Nicholas Amoroso, MD²; Blase Carabello²; Tatyana Danilov² 

¹Internal Medicine, Beth Israel – Icahn School of Medicine at Mount Sinai, New York, New York

²Department of Cardiovascular Diseases, Beth Israel – Icahn School of Medicine at Mount Sinai, New York, New York

Background: Abnormalities of aortic valve morphology and function comprise the most common cardiac valvular lesions. Of these, severe aortic stenosis (SAS) poses a particularly eminent burden. Although SAS presents with classic echocardiographic findings, variants exist. One example is low-flow low-gradient (LF-LG) SAS. Classification depends greatly on findings of dobutamine stress echocardiography. Postextrasystolic potentiation (PesP) can provide hemodynamic information to arrive at appropriate SAS diagnoses. These post-systolic beats tend to match those seen with dobutamine. Therefore, they may provide similar prognostic information as has been validated in ischemic cardiomyopathy.

Methods: Retrospective chart review of 357 total patients who underwent dobutamine stress echocardiography. Inclusion criteria were a low ejection fraction (<40%) and suspected SAS. Upon review of echocardiography, premature ventricular complexes (PVCs) were noted in 8 patients. These 8 patients’ echocardiographies were evaluated for PesP in order to measure the differences in pre-PVC and post-PVC velocities.

Results: Eight patients were selected based on their low ejection fractions, suspected SAS, and PVCs. Five of the eight displayed PesP, and had LF-LG SAS confirmed with dobutamine stress testing. The other 3 patients were without PesP (2 of whom were without contractile reserve on dobutamine stress testing, and 1 who had atrial fibrillation and therefore, no clear PesP.

Conclusions: In studies of PesP, there was a positive correlation with contractile reserve. However, this was observed in ischemic heart disease and not evaluated in aortic stenosis. Our data demonstrate that this correlation presents in LF-LG SAS. There was concordance between achieving contractile reserve with dobutamine stress echocardiography and demonstrating PesP (exhibited in 100% [5/5] cases). This outcome provides a promising model for future study, and suggests that PesP documentation for clarifying the severity of aortic stenosis is feasible and may alleviate the diagnostic necessity for dobutamine stress echocardiography.

C3 2017-46 Persistent Dyspnea on Exertion: Recurrence of Sporadic Atrial Myxoma

Hisham Hakeem, MBBS; Mustapha Serhan, MBchB; Raghav Chaudhary, MBBS; Aron Schwarcz, MD, FACC

Introduction: Primary cardiac tumors are rare entities with an autopsy frequency of 0.001%-0.030%. Cardiac myxomas are the most common primary cardiac neoplasm in adults, accounting for 50%-90% of cases. We present an unusual case of recurrence of an atrial myxoma. 

Case Presentation: Our patient was a 57-year-old male who presented to the cardiology clinic with shortness of breath. His past medical history was significant for dyslipidemia, pre-diabetes, Barrett’s esophagus, and history of tuberculosis as a child. He had undergone resection of an atrial myxoma occupying the anterior two-thirds of the left atrium in 2013 at another facility. He endorsed having dyspnea on exertion, which was non-progressive since the surgery. The patient denied any chest pain, palpitations, paroxysmal nocturnal dyspnea, or orthopnea. There was no family history of ischemic heart disease or malignancies. His physical exam was unremarkable. He underwent an exercise treadmill stress test, which showed excellent exercise capacity with no baseline electrocardiographic changes. His transthoracic echocardiography (TTE) revealed a pedunculated mass attached to the interatrial septum consistent with an atrial myxoma and normal left ventricular systolic function. The patient underwent a cardiac catheterization, which revealed normal coronaries. During cardiac surgery, a mass was seen arising at the confluence of the interatrial septum and the roof of the left atrium. Recurrence of atrial myxoma was likely considering the location. The mass and part of the interatrial septum were resected. Intraoperative transesophageal echocardiography (TEE) showed no atrial septal defect or residual mass post resection. The pathology report revealed a red and irregularly shaped mass measuring 3.5 x 2.5 x 2.5 cm, consistent with left atrial myxoma surrounded by severe endocardial fibrosis. The postoperative course was uncomplicated. TTE obtained 2 months later was normal.

Discussion: Cardiac myxomas are most commonly located in the left atrium with the majority attached to the interatrial septum. The most common presenting symptoms are dyspnea, chest pain, palpitations, and related to systemic embolism. Recurrence of sporadic myxoma is rare even in cases of irradical removal. It is seen in 1%-3% of cases. These could be related to inadequate resection, multicentricity, origin in a chamber other than the left atrium, familial tumors, or disease complexes such as Carney’s syndrome

Conclusion: We present herein an atypical case of recurrence of sporadic left atrial myxoma. Management is immediate surgical resection due to the risk of complications and favorable long-term surgical outcomes. Echocardiography is an essential modality to delineate tumor for resection as well as to follow-up young individuals or those with suspected Carney complex.

C3 2017-47 Stentless Percutaneous Sapien XT Pulmonic Valve Implantation in a Pulmonary Artery Homograft in Repaired Tetralogy of Fallot

Ahmed Seliem, MD; Hisham Hakeem, MBBS; Michael Amponsah, MD; Lakshmi Gokanapudy, MD; Marc Cohen, MD; Rajiv Verma, MD

Introduction: Surgical reconstruction of right ventricular outflow tract (RVOT) is often performed in patients undergoing repair of tetralogy of Fallot (TOF). Pulmonary homograft valve deterioration is expected over time. Previously, correction of pulmonary insufficiency (PI) or stenosis required repeat cardiac surgery. 

Case Presentation: Our patient was a 24-year-old female with TOF and absent pulmonary valve syndrome. At age 6, she underwent complete surgical repair: Dacron patch closure of the ventricular septal defect and a 21 mm pulmonary homograft reconstruction of the RVOT. At age 16, cardiac magnetic resonance imaging revealed a cardiac index of 4.7 L/min/m², right ventricular end-diastolic volume of 98 mL/m², ejection fraction of 46%, and pulmonary regurgitant fraction of 25%. She has chronic hemodynamically significant pulmonary insufficiency with right pulmonary artery (RPA) stenosis, which required RPA stent angioplasty. She continued to have increasing fatigue disproportionate to increase in right ventricle size but refused surgery. In 2016, cardiac catheterization revealed an aneurysmal RVOT conduit measuring 34.8 mm and a distance of 9-12 mm to the mouth of the RPA stent. A decision was made to implant the Edward Sapien XT valve of 26 mm diameter without pre-stenting.

Discussion: Percutaneous pulmonary valve implantation (PPVI) has emerged as a viable alternative in patients with RVOT dysfunction. The Sapien XT system has recently been approved for PPVI with conduit pre-stenting necessary. We present a 24-year-old female with surgically repaired TOF who presented with worsening dyspnea attributed to pulmonary homograft deterioration. An Edwards Sapien XT 26 mm valve was implanted without pre-stenting. Post stent deployment, angiography revealed good valve position with no paravalvular leak, minimal central PI, and trivial obstructive gradient.

Conclusion: Traditionally, pre-stenting of the conduit with a bare-metal stent (BMS) is performed to provide a landing zone for the stented valve. This allows a greater margin of safety when positioning the relatively short valve prosthesis and maintains its circular configuration. It also reduces the risk of distal or proximal obstruction in conduits that were significantly longer than the valve. In our case, pre-stenting was not performed because of significant proximal aneurysmal dilation and concern for possible compromise in RPA blood flow. The RPA stent to annulus measured 15.3 mm and it was thought that the 17 mm post-deployment diameter of the Sapien XT valve was acceptable given that the distal 40% of valve is un-cuffed with free stents and less likely to compromise RPA flow. This case demonstrated that the Sapien XT is potentially more suitable than the Melody valve for PPVI in large-diameter conduits, native outflow tracts, and in anatomies not favorable to pre-stenting. 

C3 2017-48 Impact of Transcatheter Aortic Valve Replacement on Symptomatic Mitral Regurgitation

Giorgio A. Medranda, MD; Richard Schwartz, DO; Kevin Marzo, MD; Stephen Green, MD; Srihari Naidu, MD; Ramesh Daggubati, MD

Purpose: Mitral regurgitation frequently accompanies symptomatic severe aortic stenosis (AS) and contributes to mortality. Traditionally, in patients who undergo surgical aortic valve replacement (SAVR), pre-SAVR mitral regurgitation results in concomitant surgical replacement/repair. For those who undergo transcatheter aortic valve replacement (TAVR), mitral regurgitation is often left untreated. Changes in untreated mitral regurgitation following TAVR remain unclear. 

Methods: In a retrospective observational study from 2012-2016, we reviewed data from 709 patients who underwent TAVR at our institution. We reviewed AS and mitral regurgitation on transthoracic echocardiogram (TTE). Statistical analyses of outcomes were performed using paired t-test (aortic valve [AV] area, peak velocity, mean gradient), Wilcoxon Signed Rank test (mitral regurgitation grade), and Spearman’s Rank correlation.

Results: The 709 patients had a mean age of 82.7 ± 8.26 years, were 96.46% non-Hispanic Caucasian, and were 47.11% male. Of these patients, 595 were found to have pre-existing mitral regurgitation (mild/1+, moderate/2+, moderate-severe/3+, or severe/4+) and of those, 69 patients were found to have had pre-existing clinically significant mitral regurgitation (3+/4+). In those with pre-existing mitral regurgitation, there was a significant improvement in mitral regurgitation post TAVR (2+ to 1+; P<.001). In those with pre-existing clinically significant mitral regurgitation, there was an even stronger improvement in mitral regurgitation post TAVR (4+ to 2+; P<.001). In these patients, there was a significant improvement in atrioventricular peak velocity (4.11 m/s vs 2.09 m/s; P<.001), AV area (0.62 cm² vs 1.77 cm²; P<.001), and AV mean gradient post TAVR (43.44 mm Hg vs 11.38 mm Hg; P<.001). In particular, the AV area was found to significantly correlate with degree of improvement in AV area (P=.006). 

Conclusions: In patients with severe AS and moderate-severe/severe mitral regurgitation, treatment with TAVR improved mitral regurgitation grade in 82.61% of patients (P<.001). Furthermore, there was a strong trend for greater MR grade improvement in patients who displayed greater improvements of AV area following TAVR (P=.006). A staged approach, with percutaneous mitral valve repair, may be required for patients with severe AS and significant mitral regurgitation who fail to improve following TAVR.

C3 2017-49 Stretching the Valve May Be An Option 

Yasser Sadek, MD; Hesham Bahaaeldin, MSc

Introduction: Transcatheter aortic valve implantation (TAVI) has emerged as an important therapeutic option for treating patients with severe aortic stenosis with prohibitive or high risk for surgical aortic valve replacement (SAVR). The PARTNER trials illustrated that the overall outcome with TAVI is superior to medical therapy in patients with prohibitive surgical risk (cohort B) and similar to SAVR in high-risk patients (cohort A) We describe a case of CoreValve TAVI in a patient who had a challenging annular size and very high risk of aortic valve surgery.

Case Presentation: The patients was a 75-year-old male, diabetic on insulin for the past 20 years, and hypertensive on bisoprolol and amlodipine for the past 15 years. He underwent coronary artery bypass graft in 2001 and he had no reports of the previously implanted grafts. He also had severe claudication in his left lower limb on walking less than 50 meters. He suffered from chronic obstructive pulmonary disease and was on chronic inhalers. He suffered from multiple fractures after a motor car accident 10 years ago. He underwent multiple orthopedic surgeries for his fractures and an intervertebral disc prolapse. Our patient also had two cataract surgeries in 2003. He was poorly mobile due to his musculoskeletal problems. He was complaining of severe shortness of breath on mild exertion. Echocardiography revealed severe calcific aortic stenosis with good systolic function, and moderate mitral regurgitation. Computed tomography revealed a mean annular diameter of 30.5 mm, a perimeter of 99 mm, and an area of 71.8 mm². Also, there was severe left common iliac stenosis and patent grafts could be seen.
Our challenges were: annular size; valve choice, as there is very limited oversizing if any; single peripheral access; and finally, the high gradient and the turbulence of blood stream in a very wide coronary sinus, and how to stabilize the valve in its position.

Discussion: Balloon angioplasty was performed for the iliac stenosis and this was considered the passive access site for the pigtail. A 31 mm CoreValve was deployed with postdilation using a Zmed balloon. The active site was mechanically closed. Stenting was done at the left common iliac. The patient was discharged after 5 days and has been followed for the past year. 

C3 2017-50 Comparison of Patients Undergoing Transcatheter Aortic Valve Implantation With and Without Balloon Aortic Predilatation: Clinical and Echocardiographic Outcomes

Konstantinos Stathogiannis¹; Konstantinos Toutouzas¹; George Latsios¹; Andreas Synetos¹; Maria Drakopoulou¹; George Trantalis¹; Antonios Mastrokostopoulos¹; Seyrani Yuecel²; Ulrich Gerckens²; Eberhard Grube³; Dimitrios Tousoulis¹

¹First Department of Cardiology, Athens Medical School, Hippokration Hospital, Athens, Greece

²Gemeinschaftskrankenhaus Bonn, Bonn, Germany

³University Hospital, Dept of Medicine II, Bonn, Germany

Background: Balloon aortic valvuloplasty (BAV) is commonly performed during transcatheter aortic valve implantation (TAVI). We sought to evaluate the efficacy of BAV in TAVI with self-expanding bioprosthesis.

Methods: Prospectively collected data from two high-volume centers were analyzed for 210 patients (120 patients for non-direct TAVI and 90 patients for direct TAVI) with severe aortic valve stenosis. All patients underwent transthoracic echocardiogram prior to the procedure and before discharge. All outcomes were evaluated according to the VARC-2 criteria. 

Results: All-cause mortality at 30 days and at 1 year was similar in both groups (4% in non-direct vs 2% in direct; [P=.6] and 15% in non-direct vs 11% in direct [P=.5], respectively). Device success rate was similar in both groups (77% in non-direct vs 83% in direct; P=.2). Major vascular complications were comparable for both groups (5% in non-direct vs 3% in direct; P=.5). The non-direct group had lower mean gradient (9 ± 4 mm Hg vs 10 ± 6 mm Hg; P=.1) and aortic valve area (1.4 ± 0.3 cm² vs 1.6 ± 0.5 cm²; P=.054) post TAVI compared to the direct group, although not statistically significant. The direct group had less moderate/severe paravalvular leakage post TAVI compared to the non-direct group (8% vs 27%; P<.01). The table depicts the clinical outcomes at 30 days and at 1 year.

Conclusions: Patients undergoing direct TAVI with a self-expanding bioprosthesis have less moderate/severe paravalvular leakage and similar mortality rates compared to patients with non-direct TAVI. 

ADDITIONAL SUBMISSIONS

C3 2017-51 Clinical Significance of Multi-Detector Computed Tomography in the Assessment of Coronary Chronic Total Occlusion Prior to Revascularization

Islam Abdelmoneim, MD; Yasser Radwan, MD; Khaled Shokry, MD; Ayman Sadek, MD; Ahmed Magdy, MD

Introduction: Although coronary angiography (CA) remains a fundamental part of chronic total occlusion (CTO) revascularization procedures, this modality has several limitations. In this study, we aimed to compare multi-slice computed tomography (MSCT) vs CA for the assessment of CTO lesions prior to revascularization.

Methods: Our study enrolled 50 patients, with a confirmed CTO of at least one coronary artery, of which 41 were operated using the antegrade approach and 9 patients were operated using the combined antegrade/retrograde approach. All patients underwent MSCT and CA prior to percutaneous coronary intervention (PCI) and data on the determinants of failure and their detection using each modality were collected. We used SPSS v. 23 to conduct the statistical analysis. 

Results: We recorded successful revascularization in 36 patients (72 %) and 6 patients (66.6%) of those who used antegrade and combined approaches, respectively. According to MSCT results, several factors, such as increased length (P=.01) of the occlusion, small vessel size (P=.002), atherosclerotic vessel wall (P=.021), proximal side branching (P=.013), and calcification of proximal cap (P=.007) or distal stump (P=.015) increase the failure rate of PCI. MSCT was slightly less sensitive than CA in detecting proximal stump details, presence of side branches, distal arterial visualization, and sizable collaterals. However, MSCT was as sensitive as CA in detecting CTO segment calcification based on MSCT findings; we found lesion length >18 mm, vessel size ≤2.75 mm, and CTO duration >7 months to be associated with higher incidence of revascularization failure.

Conclusion: Although MSCT has a similar sensitivity to CA in detecting coronary calcification, it has a lower sensitivity in detecting other determinants of failure, such as side branching or proximal stump details. Future improvements in MSCT technology are warranted to address these limitations.

C3 2017-52 Endovascular Treatment of Paravalvular Leak

Amicone Sebastian, MD; Diego Grinfeld, MD; Ignacio Rifourcat, MD; Pablo Pollono, MD; Fernando Fuertes, MD

Introduction: Paravalvular regurgitation affects 5% to 17% of all surgically implanted prosthetic heart valves. Patients can be asymptomatic or present with hemolysis or heart failure. Reoperation is associated with increased morbidity and is not always successful. Percutaneous treatment of paravalvular leaks has emerged as a therapeutic alternative for high-risk patients.

Case Presentation: A 69-year-old male presented with history of aortic valve replacement (with mechanical valve Nº 25) 3 months ago. Develops heart failure with dyspnea (New York Heart Association class III-IV). Physical examination revealed a diastolic murmur (2/4 intensity) and blood pressure of 150/70 mm Hg. Transesophageal echocardiogram (TEE) revealed paravalvular leak in relation to non-coronary sinus and severe aortic regurgitation. Due to high risk and patient decision, we suggested endovascular treatment. The procedure was performed under general anesthesia with angiographic and TEE guidance. We used two 12 x 4 mm AVP III devices. The patient was discharged after 2 days in the coronary unit. At 1-year follow-up, he continues with clinical improvement and without aortic regurgitation.

Discussion: Surgical reintervention of patients with paravalvular leak is a highly invasive procedure with high morbidity and mortality. Endovascular treatment is a minimally invasive, safe, and effective alternative. 

C3 2017-53 Stroke Prevention in High-Risk Patients With PFO – Unclear Guidelines/Increasing Evidence

Omar A. Ayah, MD; Christina W. Al Malouf, MD; Olayiwola E. Amoran, MD; Zainab Mahmoud, MD; Sheldon Goldberg, MD

Introduction: Patent foramen ovales (PFOs) are detected in about 25% of the general population at autopsy and in about 10%-26% of normal individuals by contrast transesophageal echocardiography (TEE). PFO size ranges from 1-19 mm (mean size, 3.4 mm). PFO size increases with age, while prevalence declines with age. One of the feared complications of a PFO is paradoxical embolism leading to cryptogenic stroke. The guidelines concerning closure vs medical therapy are unclear. Patients with history of venous thromboembolic events with high-risk anatomical features of PFO are particularly prone to suffer paradoxical embolism.

Case Presentation: A 61-year-old surgeon presented for PFO closure after he developed a pontine stroke. His medical history included deep venous thrombosis (DVT) and pulmonary embolism (PE), for which he was being treated with apixaban, diabetes mellitus, depression, and obesity. Three months prior, he suffered a pontine stroke after interruption of anticoagulation for a tympanoplasty. TEE detected a PFO with a large right-to-left shunt and an atrial septal aneurysm. The patient sought cardiology advice and his PFO was successfully closed with an Amplatzer cribiform device. Follow-up transthoracic echo demonstrated a well-seated device without residual shunt, and the patient is doing well 24 months post closure.

Discussion: Long-term results of the RESPECT trial demonstrated superiority of PFO closure vs medical therapy alone, showing a 50.8% risk reduction for device over medical therapy. Certain features including large shunt size, atrial septal aneurysm, prior recurrent strokes, DVT, and PE place patients at particularly high risk for recurrent stroke. Mortality is reportedly higher in patients with a PFO who develop DVT and PE. In these patients, PFO closure should be strongly considered. The guidelines have been conflicting for PFO closure after a stroke. The July 2016 Neurology guidelines recommend PFO closure with level of evidence (LOE) grade C “in rare circumstances such as recurrent stroke despite adequate medical therapy with no other mechanism identified.” Similarly, the 2014 American Heart Association (AHA) guidelines state that closure might be considered in the setting of PFO and DVT, as a class IIb LOE C. With the United States Food and Drug Administration approval of the Amplatzer device for PFO closure on 10/28/2016 based on the long-term results of the RESPECT trial, we hope that newer AHA guidelines will bring more clarity to this topic.

Conclusion: Patients with cerebrovascular accidents secondary to PFO may be denied closure due to confusion in interpretation of guidelines. Risk of stroke is especially high in patients with high-risk features of PFO, as described above. The RESPECT trial demonstrated a 50.8% risk reduction of stroke in favor of the device. 

C3 2017-54 Snare Technique to Remove Retained Central Line Guidewire in Left Saphenous Vein to Superior Vena Cava

Karthik Balasubramaniam, MD, PhD; Nicholas Linker, MD; Douglas Muir, MD

The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom

Introduction: More than 5 million central venous catheters (CVCs) are inserted in the United States every year. Guidewire (GW) retention is a rare, serious, and preventable complication during CVC insertion. True incidence of this complication is unknown but has been attributed mainly to operator inattention. Retention of GW can lead to GW fracture, dysrhythmia, vascular damage, thromboembolism, infection, cardiac perforation, and tamponade. Hence, removal of a retained GW is important. We describe a technique that we have used to retrieve a GW that was inadvertently retained during CVC placement.

Case Presentation: A 48-year-old male with history of schizophrenia was admitted with a major road traffic accident. During CVC insertion, the GW was inadvertently left in his vena cava (left saphenous vein to superior vena cava). He made an uneventful recovery and was discharged. Further radiological investigations identified the retained GW and he was referred to us for its extraction. Multidisciplinary team agreed that it was desirable to remove the GW, but the degree of fibrosis was unpredictable. Decision was made for percutaneous attempt with cardiothoracic surgical standby. Access was obtained via right femoral vein, 6 Fr sheath. Needle’s eye snare wouldn’t catch the GW at iliac bifurcation. A 12 Fr sheath was then inserted into the superior vena cava. Byrd workstation caught the wire in the right atrium, but caused severe pain in the iliac region due to fibrosis. Hence this approach was stopped. Distal end of the wire was then snared in the superior vena cava using EN snare and was pulled into the 12 Fr sheath. A 6 mm angioplasty balloon was used inside the sheath to trap the wire. Right side was then externalized and extended. Byrd dilator sheath was used to free adhesions. Attempts to retrieve the wire resulted in severe pain as the left femoral system was completely thrombosed around the wire. Left femoral venous access was obtained, but EN snare would not open due to extensive venous thrombosis. Hence, vascular cut-down was performed, the free end of the wire was caught, adhesions were freed with the Byrd dilator, and the GW was successfully retrieved. 

Conclusion: Retained GW is a preventable complication and should be a Never Event. To reduce the incidence of this complication, the following should be implemented: structured educational training program, standardization of the CVC insertion procedure, documentation of whether the GW was removed in every case, holding of the GW tip at all times, provision of reminder stickers in the CVC insertion kit, and transition from a solo operator model to a team-based model.

C3 2017-55 Percutaneous Intervention for Congenital Left Circumflex Artery and Coronary Sinus Fistula 

Karthik Balasubramaniam, MD, PhD; Richard Hartley, MD; Douglas Muir, MD

The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom

Introduction: Coronary artery fistula (CAF) is a rare congenital anomaly, incidentally found in patients undergoing angiogram, with a prevalence of 0.3%-0.8%. Coronary aneurysm associated with coronary fistula is even more rare, and is speculated to be seen in 10% of CAF patients. We describe a case of congenital left circumflex (LCX) artery and coronary sinus (CS) fistula that we successfully managed with percutaneous intervention.

Case Presentation: AA 52-year-old lady with hypertension and atrial fibrillation presented with exertional breathlessness. Computed tomography (CT) coronary angiography and invasive coronary angiography confirmed the presence of congenital LCX and CS fistula. Multidisciplinary team consensus was to attempt percutaneous closure of the fistula. Right brachial artery (RBA) and right femoral vein (RFV) access were obtained with 7 Fr sheaths. An EBU4 7 Fr guide catheter was used to engage the left coronary artery from RBA approach. Sion blue wire and Corsair microcatheter were then advanced into the fistula. The Sion blue wire was exchanged for a Pilot 200 wire. This wire traversed the fistula completely and went into the right atrium. Corsair microcatheter was then advanced toward the venous side of the fistula. The Pilot 200 wire was then replaced by RG3 wire. This was then snared using Ensnare from RFV and externalized to form a full arteriovenous (AV) loop. Unfortunately, the delivery catheter prolapsed out when exchanged for a stiff wire. Antegrade rewiring was again performed followed by balloon anchoring of the wire. Delivery sheath was then successfully advanced and an Amplatz 14 mm coil was successfully delivered at the fistula site with excellent positioning. A reduction in blood flow in the fistula was demonstrated immediately. In 3 months, there was a complete resolution of symptoms. Follow-up echocardiography and coronary angiogram demonstrated a significant shrinkage of dilated CS. 

Conclusion: Management of CAF includes transcatheter embolization or surgical ligation of the fistula. Long-term follow-up is recommended due to possible postoperative recanalization, persistent dilation of the involved artery, thrombus formation, and myocardial infarction.

C3 2017-56 Observational Monocentric Registry “Cardio-STEMI Sanremo”: Effects of Morphine 

Administration in STEMI Patients and its Association With Clinical-Hospital Outcomes and Long-Term Mortality 

Valentina Boasi; Matteo Vercellino; Federico Sanchez; Chiara Tacchi; Dino Perri; Eliana Pansecco; Stefano Cattunar; Giovanni Mascelli; Giovanni Pistis

Introduction: Patients with ST-elevation myocardial infarction (STEMI) benefit from morphine treatment for pain relief, but that can lead to a delayed absorption of the oral antiplatelet therapies with potential decreased treatment efficacy.

Purpose: To assess the burden of morphine on reperfusion therapy success and its impact on in-hospital clinical outcome and on long-term follow-up.

Methods: From February 2011 and December 2014, a total of 533 patients (pts) enrolled in the monocentric Cardio-STEMI San Remo registry underwent urgent percutaneous coronary intervention (PCI). Two groups were identified according to morphine use: morphine yes (My) and morphine no (Mn). 

Results: Over the 533 pts analyzed, 281 (52.7%) received morphine before PCI. The My group pts were younger (average age, 63.8 vs 67.4 years; P<.01) and had a lower rate of hypertension (51.2% vs 61.5%; P=.02), but were more often smokers (47.7% vs 32.5%; P<.01). The call to the emergency medical service instead of driving themselves to an emergency room, the onset of symptoms overnight, and anterior STEMI were more frequent in the My group (all P<.05). New oral P2Y12 receptor inhibitors (ticagrelor or prasugrel) were administrated in 65.8% of pts in My group vs 57.1% in Mn group (P=.04). Morphine use was not associated with differences in pre-PCI TIMI flow of the culprit vessel, in administration of glycoprotein IIb/IIIa receptor inhibitors, or in the use of manual aspiration thrombectomy. ST-segment resolution ≥50%, considered as a reperfusion endpoint, was similar in the two groups (77.0% vs 77.9%; P=.81). In-hospital mortality (2.1% vs 4.4%), in-hospital major adverse cardiovascular events, defined as death, reinfarction, stroke, or stent thrombosis (3.9% vs 1.6%), and Blood Academic Research Consortium bleeding ≥2 (7.1% vs 7.9%) were not different between the two groups. After adjusting for propensity score, no significant differences in the endpoints between the two groups were found. At a median follow-up of 1038 days, Kaplan-Meier curves were similar, with a survival rate of 89.7% in My group vs 88.6% in Mn group (log rank P=.971). After propensity-score matching, the risk for all-cause mortality was not increased according to morphine use (hazard ratio, 1.142; 95% confidence interval, 0.606-2.153). 

Conclusion: Although some studies point out pharmacokinetic interaction between morphine and P2Y12 receptor inhibitors, in our experience, morphine use in STEMI patients is not associated with worse in-hospital outcome and long-term mortality.

C3 2017-57 Impact of Renal Failure and Acute Kidney Injury in Patients With STEMI: Results From the Italian Cardio-STEMI Sanremo Registry 

Valentina Boasi; Matteo Vercellino; Giovanni Mascelli; Maurizio Reale; Gioel Secco; Dino Perri; Stefano Cattunar; Federico Sanchez

Introduction: Among patients presenting with STEMI, the associations between clinical outcomes and both baseline renal function and the development of acute kidney injury (AKI) have not been reported in a real-world population with a long-term follow-up.

Methods: STEMI enrolled in the observational Cardio-STEMI Sanremo registry from February 2011 to June 2015 were screened. Each patient was stratified according to baseline estimated glomerular filtration rate (eGFR): Group 1: eGFR>60 mL/min/1.73 m²; Group 2: eGFR 31-60 mL/min/1.73 m²; Group 3: eGFR≤30 mL/min/1.73 m². AKI was defined as serum creatinine level ≥25% from baseline during the hospital phase. Clinical and procedural data, AKI incidence, major adverse cardiovascular and cerebrovascular event (MACCE, defined as cardiovascular death/reinfarction/stroke), and bleedings according to Bleeding Academic Research Consortium (BARC) classification were examined. The multivariate analysis has been used to identify the independent predictors of in-hospital MACCE, BARC ≥3 bleedings, and long-term survival. 

Results: A total of 673 patients were analyzed (490 in Group 1 [73%]; 156 in Group 2 [23%]; 27 in Group 3 [4%]). Patients with lower eGFR were significantly older, more often female, and showed the highest prevalence of hypertension and diabetes. Ejection fraction was progressively lower from Group 1 to Group 3 (P<.01); conversely, Killip class, GRACE risk score, and CRUSADE score were progressively higher from Group 1 to Group 3 (P<.01). The procedural success decreased from 93.6% in Group 1 to 80.8% in Group 3 (P=.03). The incidence of AKI was 8.8% in Group 1, 14.7% in Group 2, and 40.7% in Group 3 (P<.01). The incidences of in-hospital MACCE and BARC ≥3 bleedings, respectively, were 2.2% and 3.5% in Group 1, 9.0% and 5.1% in Group 2, and 25.9% and 14.8% in Group 3 (P<.01). After a median follow-up of 1150 days (range, 614-1661 days), the survival probability decreased from 89.2% in Group 1 to 76.3% in Group 2 and 42.3% in Group 3 (log rank P<.01). In the multivariate model, AKI incidence (odds ratio [OR], 3.58; 95% confidence interval [CI], 1.79-7.12; P<.01) and GRACE risk score (OR, 1.02; 95% CI, 1.02-1.04; P<.01) resulted as the best independent predictor of in-hospital MACCE and BARC ≥3 bleedings. The long-term survival was independently predicted by AKI (hazard ratio, 2.58; 95% CI, 1.56-4.27; P<.01) but not by the level of baseline eGFR. 

Conclusion: Among STEMI patients, impaired baseline renal function was highly associated with worse clinical ischemic and hemorrhagic outcomes during the hospital phase. The AKI incidence was increased by the reduced level of baseline renal function. AKI development, but not basal renal function, resulted as a strong independent predictor of in-hospital MACCE and death during follow-up at multivariate analysis.

C3 2017-58 Outcomes After Atherectomy Treatment of Severely Calcified Coronary Bifurcation Lesions: A Single-Center Experience 

Jeffrey W. Chambers, MD; Charles Warner; Ann N. Behrens, BS; Brad J. Martinsen, PhD

Purpose: Coronary bifurcation and calcified lesions account for 15%-20% and 6%-20% of percutaneous coronary interventions (PCIs), respectively. Treatment of these lesions is associated with high periprocedural complication rates and unfavorable long-term clinical outcomes, including high rates of revascularization. This retrospective, single-center study evaluated the outcomes of atherectomy treatment for severely calcified coronary bifurcation lesions.

Methods: Patients who underwent a coronary atherectomy procedure to treat a severely calcified lesion between January 2010 and March 2016 at Metropolitan Heart and Vascular Institute (Minneapolis, MN) were included in this retrospective study. Data were stratified to compare atherectomy treatment of coronary bifurcation lesions vs non-bifurcation lesions. Additionally, data were compared based on type of atherectomy utilized during the index procedure, either orbital (OAS) or rotational (RA) atherectomy. Major adverse cardiac event (MACE) rate, defined as a composite of death, myocardial infarction (MI), and target-vessel revascularization (TVR), was assessed at 30 days post procedure. 

Results: Among the 177 patients treated with atherectomy, 72 patients had bifurcation lesions and 105 patients had non-bifurcation lesions. Compared to patients with non-bifurcation lesions, patients with bifurcation lesions were more likely to have a history of prior PCI (65.3% vs 43.8%; P<.01) or coronary artery bypass graft surgery (44.4% vs 24.8%; P<.01). Bifurcation lesions required a higher volume of contrast (251 mL vs 219 mL; P=.03). There were similar low rates of slow flow/no-reflow (2.8% vs 1.0%; P=.36). The 30-day rates of MACE (1.4% vs 1.9%; P=.79), death (1.4% vs 1.9%; P=.79), MI (0% vs 0%; P=NA), and TVR (0% vs 1.0%; P=.41) were similar in patients with bifurcation lesions vs those without, respectively. An atherectomy subanalysis (OAS, N=33 vs RA, N=39) of the patients with bifurcation lesions showed that OAS utilization resulted in shorter procedure time (81 min vs 109 min; P=.03) and fluoroscopy time (18 min vs 27 min; P<.01) compared to RA, respectively – no significant differences in baseline demographic or lesion characteristics were noted in the bifurcation atherectomy subgroups. 

Conclusion: The results of this study demonstrated that atherectomy treatment in patients with severely calcified coronary bifurcation lesions is feasible, resulting in similar low 30-day MACE rates as compared to patients with non-bifurcation lesions. In addition, in this study, OAS vs RA utilization in bifurcation lesions resulted in significantly shorter procedure and fluoroscopy times. Further studies are needed to assess the safety and efficacy of atherectomy in patients with severely calcified bifurcation lesions.

C3 2017-59 Contrast-Induced Encephalopathy as a Rare Complication of Percutaneous Coronary Procedures

Nihtyan Chilingirov, MD; Valeri Gelev, MD; Ivan Stoyanov, MD; Ivan Staykov, MD, PhD; Magdalena Peneva, MD;  Galina Kirova-Nedialkova, MD, PhD

Aims: To demonstrate the profile of patients developing a rare neurologic complication after intra-arterial application of contrast media – contrast-induced encephalopathy (CIE).

Methods: Retrospective single-center review of patients with CIE at Tokuda Hosptal Sofia, Bulgaria, from January 2014 to May 2017. A total of 9474 percutaneous coronary procedures were performed (6148 diagnostic angiographies and 3326 interventions). Forty-eight patients had neurologic symptoms; 16 of them (0.17%) met the inclusion criteria. Cranial computed tomography scan was performed in each case.

Results: Mean age was 73.5 years (range, 51-84 years), predominantly male (75%). Fourteen patients had arterial hypertension, 15 patients were stable, 1 had inferior STEMI. A total of 68% had coronary and 19% had peripheral artery disease, 1 patient had severe aortic stenosis and 1 hypertrophic non-obstructive cardiomyopathy. None of the patients had chronic kidney disease, 6 patients had diabetes mellitus (1 insulin dependent). Low-osmolar contrast agent (iomeprol 87.5%) with mean volume of 191 mL (range, 70-400 mL) was injected. The average Ro-time duration was 12:56 min and the absorbed dose as dose-area product was 8324 cGy•cm². 

Neurologic deficit presented usually 140 min (range, 35-280 min) after the contrast injection. A total of 62.5% of the patients showed vision (diplopia, amaurosis, ophthalmoplegia) and coordination disorders (8 males and 2 females). Two patients had monoplegia, mimicking ischemic event in right or left middle cerebral artery (12.5%). A total of 18.7% (male only) had confusion, disorientation, agitation, hallucination. One male had severe headache with vomiting, nausea, mimicking meningoradicular irritation. Conservative neuroprotective and vasodilatative therapy (piracetam, nimodipine, vinpocetine) and hydration was initiated and full neurologic recovery occurred with no neurologic deficit at discharge. Direct neuronal injury due to disruption of the blood-brain barrier seems to be the most likely mechanism. High systemic blood pressure can exceed the autoregulatory capacity of the cerebral vessels and may lead to separation of the endothelium, which can cause contrast extravasation and direct neuronal stimulation and toxicity. Lipid solubility of the contrast media also leads to neuronal toxicity. 

Cranial CT scans were performed 13 hours (range, 2-26 hours) after symptom onset. Normal cerebral anatomy was found in 3 patients (18.7%), cerebral small vessel disease in 7 patients (43.8%), global cerebral atrophy disease in 5 patients (31.2%), and Wernicke encephalopathy in 1 patient. Global cerebral atrophy and cerebral small-vessel disease were associated predominantly with vision and coordination disorders (7 patients), confusion, disorientation, agitation, hallucination (3 patients). Normal cerebral anatomy was also connected with more events in the vertebrobasilar system (77%). 

Conclusion: CIE is a rare acute neurological complication of cardiac catheterization with unexplored mechanism, which should be differentiated from stroke, manifesting with vision and coordination disorders. Full recovery occurs only with conservative therapy within 48 hours. 

C3 2017-60 Ventricular Fibrillation Masquerading as Complete Heart Block

Jeffrey Baum, BTL; Basha Behrman, BS; Abraham Shugarman; Grace Thomas, BA; Jerald Insel, MD, FACC, FSCAI 

Lifebridge Health Baltimore, Baltimore, Maryland

Introduction: Ventricular tachycardia and ventricular fibrillation are the most lethal arrhythmias experienced by patients. It is frequently difficult when a patient has syncope to determine its cause. If appropriate investigations are not done, then this puts the patient at great risk for sudden cardiac death. We will discuss the implications and the importance of making certain that one knows the underlying etiology of the cardiac arrest before treating and discharging a patient.

Case Presentation: A 74-year-old obese gentlemen with a history of hypertension and mild coronary artery disease passed out at the beach. He was pulseless and apneic. The lifeguards started cardiopulmonary resuscitation; after approximately 3 minutes, the patient was defibrillated with an automated external defibrillator (AED). The patient went into complete heart block at a rate of ventricular response of 50 beats/min and was transferred to the local hospital. Electrocardiogram showed the patient to be in complete heart block with an atrial response of approximately 80 beats/min, ventricular response of 50 beats/min. There were no acute ST-T wave changes and initial troponin was negative. He received an echocardiogram and ejection fraction was 45%. The patient was ruled out from myocardial infarction and the next day he had a dual-chamber permanent pacemaker placed in the setting of a cardiac arrest and negative cardiac enzymes. He did not undergo electrophysiology study or catheterization. 

The patient presented to our office for a second opinion, and his exam was unremarkable. Electrocardiogram showed a paced QRS complex with intrinsic sinus rate of 70 beats/min. Echocardiogram showed estimated ejection fraction of 40%. Given the fact that the patient had suffered a full cardiac arrest, it was very unlikely that this was due to complete heart block. With difficulty, we were able to contact the local fire department and the Emergency Medical Services and retrieve the patient’s AED results, which showed the patient to have ventricular tachycardia that degenerated into ventricular fibrillation. The patient was appropriately shocked by the AED into complete heart block. We performed a cardiac catheterization on the patient, which showed an ejection fraction between 35%-40%. The patient had diffuse disease. His apex was akinetic and his septum was mildly hypokinetic. Given this finding, the patient was referred to an electrophysiologist, who placed an automated implantable cardioverter defibrillator.  

Discussion: This is a very important case that has major implications for the way we care for patients. Clearly this patient had an episode of ventricular tachycardia and ventricular fibrillation that was appropriately treated. However, given the fact the results of the AED were not sent with the patient to the hospital, he was inappropriately treated. In this case, the difficult detective work done by the cardiology heart team clearly improved this patient’s prognosis. 

C3 2017-61 Not All Obstructions Are Created Equal: An Unintentional Discovery of Fibromuscular Dysplasia

Basha Behrman BS, Abraham Sugarman, Grace Thomas, BA, Jerald Insel, MD, FACC, FSCAI

Lifebridge Health Baltimore, Baltimore, Maryland

Introduction: Fibromuscular dysplasia (FMD) is a rare vascular disease that causes sequential thickening and thinning of the arteries, which accounts for the classical “string of beads” appearance on imaging. Although FMD frequently manifests in the renal and carotid arteries, involvement of the upper extremities has been reported in a small number of cases.

Case Presentation: A 67-year-old female with a history of hypertension and hyperlipidemia presented with chest pain and underwent coronary angiography after otherwise negative workup. A transradial approach using a 0.25 guidewire was met with resistance in the proximal brachial artery of the right arm. Brachial artery stenosis was suspected and confirmed by angiography revealing a “string of beads” appearance. Diagnosis of FMD was made and later confirmed by a vascular surgeon. Coronary angiography was completed via femoral route with no further FMD changes observed. Coronary angiography revealed mild coronary disease with non-critical 20% stenosis. The patient was a smoker with a positive family history of hypertension. No history of collagen vascular disease was noted. Diagnosis of FMD in the brachial and renal arteries was made, and no significant coronary disease was found. FMD of the brachial artery remains a rare site of the disease, especially in this case of a patient who exhibited no complaints. Only a handful of cases of FMD in the brachial artery have been reported in asymptomatic patients undergoing cardiac catheterization. It is believed that a large number of FMD cases are asymptomatic and, as a result, remain undiagnosed. To our knowledge, only 3 cases of FMD of the brachial artery have been described in asymptomatic patients. 

Discussion: The preferred treatment modality for coronary angiography is radial artery catheterization, and this case highlights the importance of considering FMD as a possibility in transradial angiography patients with difficult access. This is a rare occurrence, but operators should be aware that FMD is a possibility in a patient in which there is an impedance to the advancement of the guidewire. FMD must be considered as a differential in challenging catheterization patients, along with the classic considerations of vasculitis, atherosclerosis, and marked tortuosity of the vessel. Patients with FMD are at increased risk of spontaneous coronary artery dissection, and manipulation of the guidewire will substantially increase the likelihood of dissection, as arteries with FMD are exceptionally friable. When FMD is discovered in the brachial artery, the transradial approach must be abandoned for the safety of the patient.

C3 2017-62 Quality Improvement Project: De-Prescribing Cardiovascular Medications in Older Adults: Is the Process More Difficult vs Non-Cardiac Classes of Medications? A Quality Improvement Initiative 

Sheikh Islam, MD; K. Kanagala, MD; M. Nashid, MD; E. Chijioke, MD; S. Reddy, MD; A. Lebelt; P. Murakonda, MD;  T.S. Dharmarajan, MD, MACP, AGSF

Division of Geriatrics, Montefiore Medical Center (Wakefield Campus), Bronx, New York

Background: De-prescribing (DeP) refers to the process of safe, appropriate tapering, stopping, or withdrawing medications that are unnecessary or inappropriate; the process aims to minimize adverse drug events (ADEs), improve health outcomes, and reduce costs. Polypharmacy refers to the inappropriate and excessive medication use, particularly common in older adults. Polypharmacy contributes to ADEs, which manifest as falls, cognitive impairment, syncope, and organ dysfunction, besides non-adherence, hospitalization, and mortality. While feasible and relatively safe, clinicians find DeP difficult to carry out in practice.

Methods: As a quality improvement initiative, DeP was attempted in our community (C) and long-term care (LTC) patients by fellows in geriatrics under faculty supervision. Data gathered on demographics (age, gender, residence), comorbidity, medication classes, and patient willingness/reluctance to reduce or discontinue medication; data were tabulated using a tool. 

Aim: Discontinue or reduce medication dosage in an appropriate, safe manner if patient was agreeable. Data gathered from 330 patients; 30 eliminated (incomplete data). Male 118/300 (39%); females 182/300 (61%); age range: <65 years (8%), <66-75 years (20%), and >76 years (72%). LTC 218 (73%), rest community. Data from 300 patients presented below. 

Results: Medications were classified as gradual dose reduction (GDR) or discontinued (DC). Anticoagulant: 0% GDR and 8.10% DC; antihypertensive: 4.87% GDR and 5.85% DC; antilipidemic: 1.91% GDR and 5.09% DC; antiplatelets: 0.59% GDR and 1.76% DC; diuretics: 4.08% GDR and 8.16% DC; non-cardiac medications (antipsychotics, antidepressants, proton-pump inhibitors, vitamins, minerals, oral hypoglycemic, laxatives, others): 9.91% GDR and 26.85% DC.

Conclusion: Ethical considerations: factor comorbidity, life expectancy, quality of life, and opinions of the patient with capacity or caregiver if capacity lacking. DeP is a commendable practice in Canada, with older community adults eager to undertake DeP, especially if experiencing polypharmacy or ADEs. Yet, the process is gaining momentum very slowly with no incentive for providers to engage patients in long-drawn discussions. In this pilot QI project, DeP was better achieved with non-cardiac medication classes compared to cardiovascular medications. Factors influencing the project success were presence of cardiac comorbidity, and patient and provider perceptions regarding risk-benefit of DeP.

References: (1) American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227-2246. (2) Page AT, et al. The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82:583-623.

C3 2017-63 Chest Discomfort in an Older Adult With Risk Factors: Coronary Artery Disease Often Presents Atypically in the Elderly

Sheikh Islam, MD; T.S. Dharmarajan, MD, MACP, AGSF

Division of Geriatric Medicine, Montefiore Medical Center (Wakefield Campus), Bronx, New York

Introduction: Cardiovascular disease is the number one cause of death in the United States. Common typical manifestations such as precordial chest pain or pressure with radiation patterns are well recognized; however, presentations may be atypical in the old and diagnosis warrants a high index of suspicion with prompt evaluation.

Case Presentation: A 72-year-old, obese, African-American male (body mass index, 32.6 kg/m²) with hypertension (140/95), prostate cancer (treated), prior deep vein thrombosis, pre-diabetes (HbA1c, 6.3%), prior smoker, and hyperlipidemia (TC, 232; LDL, 161; HDL, 52; TG, 95) evaluated during first office visit. He reported occasional chest discomfort on exertion for several blocks, noted over 3 months, on and off, especially if he did not eat for a while. Discomfort was mid-sternal and over the left mammary region, radiating to left chest without associated symptoms; relief with rest and sometimes with antacids. He denied dyspnea, palpitation, nausea, sweating and trauma, fever, cough, or leg swelling. Electrocardiogram showed NSR and mild increase in QT interval. Patient was referred to cardiology for evaluation. Echocardiogram showed ejection fraction >55%, impaired left ventricular relaxation on transmitral spectral Doppler flow; left ventricular wall motion normal, mild concentric left ventricular hypertrophy, mild TR, mild to moderately dilated ascending aorta measuring 4.1 cm. Exercise treadmill test was negative for ischemia. Exercise tolerance was good. Abnormal stress echocardiogram showed echocardiographic evidence of distal lateral and apical wall exercise-induced ischemia. His atherosclerotic cardiovascular disease (ASCVD) score was 24%, suggesting significant 10-year risk of heart disease or stroke. Cardiac catheterization showed normal coronaries, ectatic ascending aorta, and right coronary artery. The patient was placed on aspirin and initiated on omeprazole. Recommended elective abdominal ultrasound and vascular evaluation. 

Discussion: Chest pain is a common, often non-specific manifestation, yet full evaluation may be indicated in presence of comorbidities and/or risk factors. Coronary artery disease is common in the old; however, the presentation can be atypical, especially in diabetics, who manifest little to no chest pain. Classic crushing chest pain or pressure suggesting angina is less common, while the presentation of dyspnea, lethargy, “indigestion or dyspepsia” is more likely. The elderly have less pain perception; silent myocardial ischemia is not uncommon. Neurological manifestations such as confusional states (or delirium), weakness, and worsening heart failure are other presentations of myocardial ischemia or acute infarction. Silent infarctions carry poor prognostic outcomes. Our patient had no pain, but in the presence of his ASCVD risk, a full evaluation appeared indicated. Ascending aortic aneurysm was an incidental finding during evaluation. Key point: Although presentation was atypical in this patient, the presence of several risk factors and ASCVD risk warranted a complete evaluation.

C3 2017-64 Trends in Cardiac Resynchronization Therapy Device Implantation in the United States from 2004-2011

A.A. Khan; B. Brooks; H.B. Panchal; S.I.M. Zaidi; Z. Rahman; T. Paul; V. Ramu

Objective: The study sought to assess the national trends in cardiac resynchronization therapy (CRT) device implantation by analyzing the National Inpatient Sample (NIS) database.

Background: Limited data exist regarding temporal trends in CRT implantation. In 2008, the American College of Cardiology/American Heart Association/Heart Rhythm Society issued revised guidelines for cardiac pacemakers and anti-arrhythmic device implantation. We hypothesized that these guidelines have significantly influenced CRT-D and CRT-P implantation rates over the last few years.

Methods: We queried the Nationwide Inpatient Sample to identify CRT-D and CRT-P implantations between 2004 and 2011 using the International Classification of Diseases-Ninth Revision-Clinical Modification procedure codes for CRT-D and CRT-P. Annual device implantation rates were analyzed. All trend analyses were conducted using SAS 9.4. Yearly weighted frequencies for each procedure were generated using the “trendwt” variable included in the data. The effect of 2008 HRS guidelines was assessed by grouping years 2004-2009 and 2010-2011, and then testing for mean difference. 

Results: Over 7700 CRT-P devices were placed in the United States in 2004. This rate remained relatively steady over the years and in 2011 around 6600 devices were placed. Between 2004 and 2009, the mean number of CRT devices with pacemaker (CRT-P) per state was 174 (95% confidence interval [CI], 151-197). After publications of revised guidelines in 2008, the mean number of procedures per state was 162 (95% CI, 127-199). Assuming equal variance between the two groups (folded-F P=.5149) this decline was not significant at alpha=0.05 (P=.5950). However, CRT-D devices had a higher implantation rate. In 2004, over 34,000 implantations took place. By 2011, the implantation trend declined to under 31,000 devices per year. Across all states, the mean number of cardiac resynchronization therapy with pacemaker (CRT-D) procedures between 2004 and 2009 was 1147 (95% CI, 995-1300) per state. After publications of revised guidelines, the mean procedure volume per state dropped to 816 (95% CI, 638-995). Assuming unequal variance between the two groups (folded-F P=.0003), this drop was significant at alpha=0.05 (P=.0056).

Conclusion: These results suggest a significant impact of 2008 Heart Rhythm Society guidelines on CRT-D implantations and negligible impact on CRT-P implantations. These trends have important health-care policy implications.

C3 2017-65 A Coronary Perforation

Faisal Khan, MRCP; Maciej Marciniak, PhD, MRCP

Introduction: Coronary perforation during primary angioplasty is an uncommon but life-threatening complication. We describe a case in which this complication occurred and was successfully managed. We also discuss practical tips for managing this scenario.

Case Presentation: A 50-year-old male smoker developed severe central chest pain at rest. Electrocardiogram performed by the ambulance service revealed inferior ST elevation and the patient was brought to the cath lab within an hour of symptom onset. Coronary angiography revealed an unobstructed left system, but an occluded proximal right coronary artery. A BMW wire was advanced to the distal vessel and an aspiration catheter run restored TIMI 3 flow revealing a critical proximal lesion and a severe mid vessel lesion. A ReoPro bolus was delivered. The mid vessel was directly stented with a 3.0 x 12 mm Medtronic Resolute drug-eluting stent (DES) and the proximal lesion was directly stented with a 4.0 x 18 mm Medtronic Resolute DES. Coronary angiography subsequently revealed a type 3 perforation at the site of the proximal stent. Despite a period of balloon tamponade and reversal of anticoagulation with protamine, there remained a brisk leak; therefore, a 3.5 x 19 mm Graftmaster covered stent was deployed. A small residual leak remained and was treated with an overlapping 3.5 x 15 mm Graftmaster covered stent with good final results. No pericardial drainage was required. 

Discussion: After using a large or high-pressured PTCA balloon, always assess for signs of perforation with a contrast injection before taking the balloon off the wire. Small perforations can often be treated with a period of balloon tamponade. Covered stents are difficult to deliver and are best suited to larger, more proximal perforations. Pericardial covered stents should be selected in a 1:1 size as over-expansion can cause tears in membrane. Often, a longer length than initially appreciated is required as the membrane can shorten during delivery. Prompt echocardiographic evaluation of the pericardial space and consideration of drainage is mandatory in cases of hemodynamic compromise. If there is a large leak, it may be undesirable to remove a balloon that is providing tamponade. In these situations, a second access site allows a second guide catheter with a new wire prepared with a covered stent reducing the “balloon down” time. Platelet infusions may be useful to reverse the effects of glycoprotein IIb/IIIa inhibitor. If percutaneous hemostasis cannot be achieved, then operative repair involving ligation of the vessel and bypass grafting to the distal vessel should be undertaken, although this carries a higher morbidity and mortality.

C3 2017-66 TAVI Associated With Abdominal Aortic Endoprosthesis and Femoral Bypass Using Spinal Anesthesia

Massano Marco, MD; Luciano Juan, MD; Gerbaudo,Lucas, MD; Garelli Guillermo; Bordonava Anselmo, MD

Clínica del Prado, Córdoba, Argentina

Introduction: As is well known, life expectancy has been increasing over the last years, resulting in rising aortic stenosis prevalence and within this, the implementation of new treatments such as percutaneous valve replacement. Aortic stenosis is associated with some other pathologies, such as ischemic heart disease and vascular peripheral disease, which is why the heart team has to make some challenging decisions in aged patients, bearing in mind their often complex characteristics, panvascular with aortic stenosis, and quality of life.

Case Presentation: An 82-year-old male patient was referred to our hospital with history of ischemic cardiopathology, aortic stenosis, type II diabetes, and former heavy smoking. During the hospitalization, echocardiogram showed severe aortic stenosis, pulmonary hypertension, and low ejection fraction of 45%. Cinecoronariography showed mild lesion in the right coronary,  mild ostium in the left main, 90% segmental proximal restenosis in the anterior descending, and 100% third medial  in the circumflex. Coronary angioplasty was performed with a drug-eluting stent without complications. The heart team decided on percutaneous treatment. Multislice computed axial tomography scan suggested a 31 mm valve, and an abdominal aortic aneurysm with a diameter of 6 x 5.5 cm was found, with a total occlusion of the right superficial femoral artery. A permanent pacemaker was implanted. The next day, the heart team placed the patient under spinal anesthesia for percutaneous aortic valve replacement followed by the placement of endoprothesis in the abdominal aorta. The procedure was performed via left femoral access, ending with a femoro-femoral bypass. The procedure was successful. The patient was discharged 5 days later and today he is in FC I-II.

Discussion: Octogenarian patients are a reality nowadays. These patients present with many risk factors and multiple comorbidities for a good quality of life, so there is a need to offer effective treatments. Minimalist percutaneous procedures are a solution for this patient type, but the decision has to be made by a heart team. The combined percutaneous treatment of aortic valve replacement and abdominal aortic endoprothesis can be realized under experienced professionals who prioritize the benefit to patients.

C3 2017-67 Right Myocardial Bridge in the Setting of Severe 2-Vessel Disease

Neil Patel, MD; Rajbir Sidhu, MD; Perry Fisher, MD; Supreeti Behuria, MD; Ramesh Gowda, MD    

Introduction: Myocardial bridges (MBs) have a prevalence of approximately 25% during autopsy; however, the reported prevalence in patients undergoing coronary angiography is 1.7%. They are most often seen in the left anterior descending (LAD) artery, and this is approximately 70% of MBs. By comparison, right MBs are much rarer, with an estimated 5.7% of cases involving the right coronary artery (RCA).

Case Presentation: Here we present the case of a 73-year-old male who presented after a syncopal episode. The only antecedent symptom he experienced prior to admission was shortness of breath with exertion. His electrocardiogram on admission revealed bifascicular block (right bundle-branch block/left anterior fascicular block). His relevant cardiac past medical history consisted of coronary artery disease requiring two percutaneous coronary interventions (PCIs) in 1999 and a coronary artery bypass graft (CABG) surgery in 2001, and atrial flutter. Transthoracic echocardiography showed right ventricular dilation with severely reduced left anterior fascicular block systolic function, right atrial and left atrial dilation, normal-sized left ventricle with normal systolic function, and signs of mitral rheumatic heart disease. He subsequently underwent left heart catheterization, which showed 2-vessel disease: mid LAD (80% obstruction), in-stent restenosis of the RCA (85% occlusion), mid RCA (90% obstruction), and what appeared to be distal MB of the RPL. The saphenous vein graft (SVG) to posterior descending artery (PDA) had 70% distal and 95% anastomotic stenosis. Transesophageal echocardiography confirmed moderate rheumatic mitral stenosis with a Wilkins score of 9, severe tricuspid regurgitation. After a multidisciplinary team discussion between interventional cardiology, cardiothoracic surgery, and pulmonology, the patient was sent for CABG (SVG to RCA and PDA, SVG to distal RCA), mitral valve replacement, and tricuspid valve repair.

Discussion: Our review of the medical literature revealed that MB discovered during angiography is rare, and RCA bridging is even more rare. What makes our case even more intriguing is that the bridge was in the distal RCA. MBs have been known to have multiple manifestations ranging from angina to sudden cardiac death. There currently is no consensus regarding management of symptomatic MBs. The largest study of PCI in MB showed a significantly higher rate of major adverse cardiovascular events (death, myocardial infarction, target-lesion revascularization, target-vessel revascularization, and stent thrombosis), 33% in MB stents vs 11% in non-MB stents. While there have been no major randomized trials to date comparing PCI and CABG, CABG appears to be safe and effective in patients with symptomatic MB.

C3 2017-68 Randomized Trial of Proximal or Distal Main Vessel Stent Sizing Strategy for Implantation of Bioresorbable Vascular Scaffolds at Coronary Bifurcation Lesions 

Rajiv Rampat, MBBS; Thomas Mayo, MBBS; David Hildick-Smith, MD; James Cockburn, MD

Background: Limited information is available on the use of bioresorbable vascular scaffold (BVS) in bifurcations involving significant side branches. When treating bifurcation disease with metal stents, the recommendation is to choose a stent diameter based on the distal main vessel diameter. Whether this sizing strategy is applicable to BVS is currently unknown, and is of interest because of the limited degree to which BVS may be overexpanded.

Aims: To investigate the effect of sizing strategy on procedural and clinical outcomes in the treatment of “false” bifurcation disease involving a sizable side branch with BVS (side branch >2 mm in diameter).

Methods: We randomized 30 patients undergoing elective percutaneous coronary intervention for “false” bifurcation disease (Medina 0,1,0; 1,0,0; 1,1,0) to receive BVS based either on proximal or distal reference diameters. The inclusion criteria specified a side branch (SB) of >2 mm in diameter by visual assessment. Optical frequency domain imaging (OFDI) measurements were performed pre BVS insertion to obtain proximal and distal reference diameters. BVS size was chosen according to the proximal or distal reference diameter as per randomization. OFDI measurements were repeated post implantation. Scaffold apposition and complications were assessed. Quantitative coronary angiography (QCA) analysis of the SB was performed pre and post BVS implantation. 

Results: Baseline demographics between the two groups were similar. Patients were aged 62.4 ± 10.2 years; 70% were male. Mean SB diameter was 2.3 ± 0.3 mm. Left anterior descending/diagonal lesions accounted for >80% of cases. Procedural success with TIMI 3 flow in the main vessel was achieved in all cases. OFDI data after scaffold implantation were obtained in 26 of 30 cases. In the proximal sizing arm, there was 1 case of SB dissection and 1 postprocedural non-Q wave myocardial infarction. In the distal sizing arm, there was a numerically greater incidence of scaffold malapposition at the proximal stent end (40% vs 27%) with a total malapposition area of 10.4 mm² for the proximal strategy and 7.4 mm² for the distal one. In the proximal sizing arm, distal stent-edge dissection was numerically more frequent (27% vs 13%) and 1 patient required an additional stent as a result. Significant proximal-edge dissection was higher with a proximal sizing strategy (13% v 0%) but additional stenting was not required. After scaffold implantation, there was a numerically higher degree of SB ostial stenosis in the distal sizing cohort (50 ± 16% vs 39 ± 22%). 

Conclusion: Our study shows that when using BVS in “false” bifurcation disease, proximal and distal sizing strategies have similar complication rates, with neither approach showing a distinct superiority. Larger studies are needed to corroborate our findings.

C3 2017-69 Use of Child-in-Mother Catheters During Percutaneous Coronary Interventions 

A. Theocharidis, X. Makos, V. Mpellos, A. Tsiakou, V. Argyris, S. Pappas, D. Nikas 

1st Cardiology Department of University Hospital of Ioannina, Greece

Purpose: Percutaneous coronary intervention (PCI) is increasingly being used even among patients with complex coronary anatomy, a very challenging setting that can result in complications or procedural failure. The purpose of the present study is to evaluate the efficacy of the Guidion Flexible Guide Extension child-in-mother (C-I-M) catheters in our department.

Methods: Among 161 patients who underwent PCI in our department during the period of January to March 2017, C-I-M catheters were used in 26 patients. IBM SPSS v. 20 was used for data analysis, with P significance levels set at .05. 

Results: Among 161 patients (median age, 67 years; range, 34-91 years) who underwent PCI, 21 (13%) were female and 140 (87%) were male. Guidion catheters were used in 26 cases (16.1%). The use of Guidion was not statistically significantly related to patient gender (P=.376). However, the necessity of using C-I-M was statistically significantly related to older age. Mean age of the patients who underwent PCI with the use of C-I-M catheter (74.5 years) was statistically significantly higher than the mean age of the patients whose procedure didn’t demand the use of Guidion (65.4 years; P=.001). In the 26 Guidion patients, 24 were males (92.3%) and 7 suffered from type II diabetes. Unstable angina was the reason for PCI in 7 patients, while 7 patients presented with non-ST elevation myocardial infarction, 6 patients suffered from ST-elevation myocardial infarction and had primary PCI, and 6 patients underwent PCI due to positive SPECT imaging. During the PCI procedure, the Guidion catheter was used in 21 cases because of difficulty in balloon/stent advancement, and in 5 cases due to poor mother-catheter support or difficulty in approaching stenosis. In 1 case, stent distortion was noted during the delivery attempt before using the C-I-M catheter. Coronary evaluation revealed severely calcified lesions at 14 cases. Five cases needed rotational atherectomy. Most complications related to Guidion catheter use were minor coronary dissection (n = 7), and 1 case of dissection faced with stenting was also reported. Although device delivery was successful in all cases of C-I-M catheter use, only 1 case was reported with unsatisfactory results (TIMI 2 flow) despite satisfactory positioning of the stent.

Conclusion: Guidion Extension catheter was used with great success in complex lesions, especially in elderly patients with extensively calcified lesions. Major complications may infrequently occur, and mainly regard coronary dissection, which can be successfully treated with stent. All authors declare that they have no competing interests.

C3 2017-70 Assessment of the Immediate and Short-Term Cardioprotection Effects of Myocardial Postconditioning on Patients Undergoing PPCI 

R. El-Shalakany; A. Saleh; A. Samir; M. Zahran 

Department of Cardiology, Ain Shams University, Cairo, Egypt

Objective: Assessment of the effect of myocardial postconditioning on myocardial blush grade (MBG), pattern of rise of cardiac enzymes, and wall-motion abnormality in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI).

Methods: A total of 110 STEMI patients treated with PPCI were randomly assigned to either the postconditioning (n = 55) or the standard PPCI group (control group; n = 55). Blood samples were obtained for creatine kinase (CK) and its MB isoform (CK-MB) at 0, 8, and 16 hours. The angiographic MBG in the final angiogram after PPCI was done and inpatient echocardiographic data were evaluated and compared between the two groups.

Results: The areas under the curve of CK and CK-MB release to study the pattern of rise, peaking, and fall of CPK and MB showed that there was statistically significant reduction of the CPK-MB isoform value at 8 hours in the case group vs control group (185 ± 90 vs 130 ± 70; P=.023), but this significance was not consistent with the MBG in the two groups. The number of patients who had MBG 3 was higher in the case group than the control group (36 [65.5%] vs 29 [52.7%], respectively) but not strong enough to reach statistical significance (median, 45 vs 50; P=.201). However, there was a significantly higher proportion of akinesia in the affected territory as assessed by transthoracic echocardiography among the control group (n = 22 vs n = 43; P<.001).

Conclusion: Myocardial postconditioning had a significantly better effect on post-infarction pattern of rise and fall of CPK-MB isoform, significantly reduced the akinesia detected by transthoracic echocardiography in the affected territory and leads to a better – yet not significant – final MBG in the post-PPCI coronary angiogram.

C3 2017-71 Neutrophil Extracellular Traps Promote Stent Restenosis and Thrombosis

Dimitrios A. Stakos; Anastasios Barmpas; Evangelia I. Angelidou; Akrivi Chrysanthopoulou; Konstantinos Kambas; Konstantinos Ritis Laboratory of Molecular Hematology and Cardiology Dept, Democritus University of Thrace, Alexandroupolis, Greece

Purpose: A role of neutrophils in thrombotic disorders has recently emerged mainly due to their ability to form neutrophil extracellular traps (NETs). NETs are released upon interaction of neutrophils with platelets and are composed of DNA, histones, and neutrophil proteins. We have recently shown that NETs are operative in ST-elevation myocardial infarction (STEMI) and are decorated with prothrombotic proteins such as functional tissue factor. In relation to this, there was a publication by our team in February 2015 in the European Heart Journal, which has shown that the interaction of thrombin-activated platelets with neutrophils at the site of plaque rupture during acute STEMI results in local NET formation and delivery of active tissue factor (TF). Although it is known that biomaterials induce the formation of NETs, their role in stent thrombosis and restenosis has not been addressed.

Methods: Control neutrophils were incubated with bare-metal stent (BMS) and drug-eluting stent (DES) for 2 hours. Supernatants were then collected and used for both imaging studies after appropriate staining in confocal microscopy and in vitro stimulation studies in human fibroblast (FB) cultures. 

Results: After 2 hours of incubation, both BMS and DES induce the formation of NETs bearing neutrophil elastase (NE) and interleukin-17 (IL-17). Stimulation of human FB with IL-17 bearing NETs induced activation of FB to myoFB and collagen production. This was significantly attenuated after treatment of supernatant with DNase. Further, pretreatment of human neutrophils with human STEMI-derived serum and subsequent incubation with BMS and DES led to the formation of NETs bearing functional TF.

Conclusion: Stents induce the formation of NETs, which are able to activate human FB to produce collagen. In the setting of acute STEMI, stents induce the formation of thrombogenic NETs bearing TF. These observations may suggest a role of neutrophils in stent restenosis and thrombosis.