15th Annual Complex Cardiovascular Catheter Therapeutics (C3): Advanced Endovascular and Coronary Intervention Global Summit

C3 2019-1:  Clinical Outcome of Patients With Small Coronary Vessel Disease Treated With Sirolimus-Coated Balloon: Results From NANOLUTE Study

Bernardo Cortese, MD; Sameer Dani, MD; Keyur Parikh, MD; Prathap Kumar, MD; Jagdish Hiremath, MD; Ranjan Shetty, MD; Dinesh Shah, MD

BACKGROUND: Small-vessel (≤2.5 mm) coronary artery disease (CAD) is common and has been identified as an independent predictor of restenosis after percutaneous coronary intervention. Introduction of drug-coated balloon (DCB) has resulted in significant reduction in restenosis and the need for repeat revascularization.

OBJECTIVE: The aim of this study was to assess the clinical outcome of coronary revascularization with Magic Touch sirolimus-coated balloon (Concept Medical) in patients with lesions located in small coronary vessels (≤2.5 mm).

METHODS: A total of 450 patients were enrolled in the NANOLUTE Indian registry; 172 (38.2%) had lesions located in vessels with diameter ≤2.5 mm. We specifically included these high-risk patients in the present analysis. Primary endpoint was major adverse cardiac event (MACE) rate, defined as the composite of cardiac death, target-vessel myocardial infarction (TV-MI), or target-lesion revascularization (TLR) at 6 months. The secondary endpoint was MACE at 1 year.

RESULTS: A total of 172 patients with mean age of 58.8 ± 10.4 years were enrolled and 42.2% of the cohort had hypertension. Almost half of the patients (51.7%) clinically presented with acute coronary syndromes. Among the 183 lesions treated, most were located in the left anterior descending artery (52.5%) followed by the left circumflex (25.1%), right coronary artery (18%), and ramus (4.4%). All patients had complete clinical follow-up at 1 year. The mean sirolimus-coated balloon diameter and length were recorded as 2.3 ± 0.2 mm and 22.0 ± 7.6 mm, respectively. At 6 months, the incidence of MACE was reported as 2.3%, with 1.7% TLR and 0.6% cardiac death. The 1-year MACE was 2.9% (TLR, 2.3%; cardiac death, 0.6%; TV-MI, 0.0%). There was no TV-MI reported in this cohort at 1 year. 

CONCLUSION: This study demonstrated that the use of Magic Touch sirolimus-coated balloon in small coronary vessels was reasonably safe and efficacious in the context of a “real-world” practice in an Indian population.

C3-2019 2: Sirolimus-Coated Balloon Use for In-Stent Restenosis: 2-Year Clinical Outcome From a Real-World Multicenter Experience

Bernardo Cortese, MD; Sameer Dani, MD; Keyur Parikh, MD; Prathap Kumar, MD; Jagdish Hiremath, MD; Ranjan Shetty, MD; Dinesh Shah, MD

OBJECTIVE: We aimed to report the 2-year clinical outcomes of Magic Touch sirolimus-coated balloon (Concept Medical) in patients with coronary in-stent restenosis (ISR). 

METHODS: Patients treated with Magic Touch sirolimus-coated balloon for coronary ISR were studied prospectively. The measured endpoint was major adverse cardiac event (MACE), defined as a combination of cardiac death, target-vessel myocardial infarction (TV-MI), and target-lesion revascularization (TLR) at 1 year. The extended clinical follow-up was also performed at 2 years to assess the long-term performance of sirolimus-coated balloons. 

RESULTS: We analyzed 211 patients with coronary ISR, of whom 54% patients had diabetes mellitus and 51.7% patients were hypertensive; 48.3% of patients presented with stable angina while 46% patients presented with acute coronary syndromes. A total of 225 ISR lesions were treated with 258 devices; 80.9% of lesions were associated with drug-eluting stent ISR. Most lesions treated (53.8%) were focal type. Procedural success was achieved in the majority of cases (99.5%). Clinical follow-up was completed in 100% and 89.6% of patients at 1 year and 2 years, respectively. The 1-year MACE rate was reported as 6.2% (TLR, 5.2%; TV-MI, 0.9%; cardiac death, 0.0%) and the 2-year MACE rate was 7.4%. No thrombotic event occurred in the treated segments. The 2-year follow-up is still ongoing.

CONCLUSIONS: Magic Touch sirolimus-coated balloon proved a valid revascularization strategy in an all-comers population of patients with ISR, with an acceptable rate of cardiac events up to 2-year follow-up.

C3-2019 3: The Angiographic Predictors of Optimal Coronary Microcirculation of Infarct-Related Artery After Primary Percutaneous Coronary Intervention

Wael Ali Khalil, MD and Ahmed Said Eldamanhory, MD                                                              

Cardiology Department, Faculty of Medicine — Zagazig University, Egypt 

BACKGROUND: The early left ventricular remodeling detection in patients with acute coronary syndromes post primary percutaneous coronary intervention (PCI) is still challenging. The early restored epicardial reperfusion post primary PCI as assessed by TIMI flow cannot detect coronary microcirculation and cardiac myocyte reperfusion. We can use simple angiographic parameters, such as coronary sinus filling time (CSFT) and myocardial blush grading (MBG), to assess the coronary microcirculation and cardiac myocyte reperfusion. 

OBJECTIVES: Assess early coronary reperfusion and optimal coronary microcirculation by simple angiographic parameters in acute coronary syndrome patients post primary PCI.     

PATIENTS AND METHODS: This study included 100 patients who presented to our cardiac catheterization unit with acute ST-segment elevation myocardial infarction (STEMI) for primary PCI. Simple angiographic parameters (TIMI flow, MBG, and estimation of CSFT) were used to assess the optimal coronary reperfusion post primary PCI. TIMI flow grading and MBG were used to assess coronary perfusion before and after primary PCI. The CSFT was calculated as: CSFT (in seconds) = (last frame count − first frame count/15). 

RESULTS: We compared the angiographic parameters (TIMI, MBG, and CSFT) before and after primary PCI were made. There was a significant difference between the study groups regarding MBG and CSFT (P<.001). The cut-off value of CSFT before primary PCI was >3.7 seconds (sensitivity 75.6% and specificity 62.3%; positive and negative predictive values, 50% and 84.6%, respectively; accuracy, 66.7%; and area under the ROC curve, 0.246).

CONCLUSION: MBG and CSFT were used as simple angiographic tools and were significant predictors of non-optimal coronary microcirculation and early detection of left ventricular remodeling post primary PCI in acute STEMI. 

KEY WORDS: coronary microcirculation, coronary sinus filling time, myocardial blush grade, primary percutaneous intervention, TIMI flow 

C3-2019 4: Impact of Fluoroscopy Dose Utilized During Coronary Angiography on Major Adverse Cardiac Events

Sajjad Haider MBBS, MD; Akash Doshi, MBBS, MPH;  Atif Tatari, DO; Douglas M. McLeroy, PhD; Erin Wallace, RN, BSN; Melinda Joyce, PharmD, FAPhE, FACHE; Nicole Bennett, AAS, RSO, CNMT, RT(R); Mohammed Kazimuddin, MD; Mohammad Shoaib Akbar, MD; Mohammad Abdul-Waheed, MD; Aniruddha Singh, MD

The Medical Center of Bowling Green, Kentucky   

BACKGROUND: A cardiac catheterization laboratory is a large contributor of radiation exposure to the public. Efforts have been made to minimize the radiation exposure during coronary angiograms by adhering to the principle of “as low as reasonably achievable” (ALARA).  

OBJECTIVE: To evaluate the impact of fluoroscopy dose (air kerma rate) on major adverse cardiac event (MACE), defined as a composite of all-cause mortality and repeat coronary angiography over 6 months after initial coronary angiography.    

METHODS: A cross-sectional study was conducted at The Medical Center in Bowling Green, Kentucky. A total of 13,677 patients who underwent coronary angiography between May 1, 2012 and July 31, 2017 were included in the study to see an association between radiation dose and occurrence of MACE in 6 months. The radiation dose was reported as air kerma rate (mGy/sec), calculated by dividing cumulative air kerma in mGy with fluoroscopy time in seconds. Binary logistic regression analysis was performed to assess the effect of air kerma rate on the occurrence of MACE in 6 months, adjusting other risk factors. 

RESULTS: Out of 13,677 patients (mean age, 61.95 ± 12.26 years) undergoing coronary angiogram, a total of  1592 patients (11.6%) had MACE within 6 months of sentinel angiogram. A total of 1444 patients (10.5%) had repeat coronary angiograms, and 183 patients (1.33%) died within 6 months. Mean radiation exposure was 2.82 mGy/sec with a standard deviation of ± 1.66. Descriptive study revealed that 63.7% of patients had hypertension, 30.5% had diabetes, 53.9% had dyslipidemia, and 21.2% had smoking history. Binary logistic regression showed a significant inverse correlation between mGy/sec (P=.042; 95% CI, 0.933-0.999) and occurrence of MACE. Odds ratio showed that by increasing every one unit in mGy/sec, we would expect to see a 3.5% decrease in the odds of having a MACE over 6 months. A significant correlation of MACE was also seen with age (P<.0001; 95% CI, 1.007-1.016), diabetes (P<.0001; 95% CI, 1.134-1.418), smoking (P=.038; 95% CI, 1.008-1.300), and systolic congestive heart failure (P<.0001; 95% CI, 1.648-2.286).

DISCUSSION: The balance between benefits and risks associated with ionizing radiation must be evaluated in every clinical scenario in order to provide optimal care. Use of low-dose fluoroscopy during coronary angiography increased the odds of MACE in our study, which is likely due to image degradation. Advanced age, smoking, diabetes, and systolic congestive heart failure are independent risk factors that increase the odds of MACE following sentinel coronary angiography in 6 months. Our study is limited, as it is a cross-sectional study. Our results should be validated with clinical trials in the future. 

CONCLUSION: Use of low-dose fluoroscopy during coronary angiography can increase the odds of MACE by 6-month follow-up.

C3-2019 5: Impact of Low-Dose Intracoronary Alteplase Infusion After Successful Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Ismail Mohamed Ibrahim, MD; Mahmoud Abdelaziz, MD

OBJECTIVES: Microvascular obstruction occurs in up to 50% of patients undergoing primary percutaneous coronary intervention (PPCI), is an independent predictor of heart failure and mortality, and may hypothetically improve with intracoronary thrombolysis. We aimed to study the effect of low-dose intracoronary alteplase after successful PPCI on left ventricular (LV) longitudinal function as a surrogate measure of microvascular perfusion.

METHODS: A total of 106 anterior STEMI patients eligible for PPCI were randomized into an alteplase group (53 patients who received 0.3 mg/kg intracoronary alteplase after PPCI) and a control group (53 patients treated with PPCI only). LV longitudinal function and synchrony were assessed using tissue Doppler imaging (to measure mean S´ and maximum Q-S´ time difference) and speckle tracking (to measure global longitudinal strain [GLS]) 48 hours and 6 months after PPCI. 

RESULTS: In the alteplase group, epicardial (P-value <.001 for corrected TIMI frame count) and myocardial perfusion (P-value for myocardial blush grade = .03) were significantly higher. Mean GLS and LV synchrony were higher in the alteplase group both at 48 hours (P=.02 and P<.001, respectively) and at 6 months (P<.001 for each). No difference in bleeding rates was found between groups. 

CONCLUSION: Low-dose intracoronary alteplase infusion after technically successful PPCI resulted in better epicardial and myocardial coronary flow. In addition, LV longitudinal function and synchrony were better at 48 hours and 6 months, possibly reflecting better microvascular perfusion and smaller final infarct size. These beneficial effects come without increasing bleeding risk.

C3-2019 6: Relationship Between Circulating Sclerostin Level and Coronary Artery Tortuosity in Postmenopausal Females

Ismail Mohamed Ibrahim, MD and Mahmoud Abdelaziz, MD

OBJECTIVES: Coronary tortuosity (CT) is commonly encountered in postmenopausal females and is negatively associated with coronary atherosclerosis. Circulating sclerostin levels are elevated in postmenopausal females. In view of sclerostin’s antiatherogenic effect, we aimed to find an association between CT and circulating sclerostin. 

METHODS: In our cross-sectional observational study, we enrolled 273 postmenopausal females with non-obstructive coronary artery disease diagnosed by coronary angiography. Presence and severity (by tortuosity score) of CT as well as serum sclerostin levels were assessed for each patient. 

RESULTS: Patients with CT (128; 47% of study group) were significantly older (P<.001), with higher prevalence of hypertension (P=.001) and had significantly higher sclerostin (P<.001) and hs-CRP (P=.001) levels. Using ROC curve analysis, sclerostin >650 pg/mL was predictive of CT. After multivariate regression analysis, sclerostin >650 pg/mL was found to be an independent predictor for the presence of CT (OR, 8.909; 95% CI, 4.9-16.2; P<.001). Moreover, a significant positive correlation between sclerostin and severity of CT was found (r=0.29; P=.001).

CONCLUSION: Circulating sclerostin is an independent predictor of CT and correlates positively with tortuosity score in postmenopausal females.

C3-2019 7: PCI to CTO Lesion Through Transradial Approach Using 5 Fr vs 6 Fr Guiding Catheter With Least Hardware

C.M. Shaheen Kabir, MD and Saidur Rahman Khan, MD, PhD

BACKGROUND: Treating CTOs by antegrade approach needs skill and appropriate devices. The guide catheter is an important factor for success. The 5 Fr guide catheter for treating CTOs is an alternate choice for a diabetic population with narrow-caliber radial arteries.

METHODS: In an absolute radial center like ours, PCI to CTO lesions for 1 year (July 2017 to June 2018) were evaluated retrospectively by antegrade approach through transradial access. A total of 147 CTO lesions were attempted over this period. Use of 5 Fr or 6 Fr guide catheter was the operator’s choice. 

RESULTS: Out of 147 CTOs in diabetic patients, 66 (45%) were by 5 Fr guide catheter and 81 (55%) were by 6 Fr guide catheter. Success rate in both groups was similar (63.6% vs 65.4%; P=.82). Smaller profile balloon support was needed in both groups in similar numbers (66.7% vs 69.1%; P=.75). Workhorse CTO guidewire in our lab was thin hydrophilic PT2 (Boston Scientific) and was used in similar percentages (94% vs 89%; P=.28). Microcatheter was used in only 5 cases in each group. CTO of the LAD was more common in the 5 Fr group (45.5% vs 34.6%). CTO of the RCA was 35% vs 40%. Contrast volume was lower in the 5 Fr group, although not statistically significant (152 mL vs 165 mL; P=.26). Fluoroscopy time was similar in both groups. 

CONCLUSION: Back-up support of the guide catheter is an important prerequisite for PCI to CTO. Active back-up support by 5 Fr guide catheter is better in our experience especially for the left system. Other than using bulky devices like IVUS catheter and rotablation, 5 Fr guide catheter can be a feasible, comfortable choice for CTO-PCI.

C3-2019 8: Association of Diastolic Dysfunction With Contrast-Induced Nephropathy on the Basis of Measured Left Ventricular End Diastolic Pressure During Coronary Angioplasty

Muhammad Zubair Khan, MD; Rayaan Faruqi; Muhammad Hamdan Gul, MD; Umang Patel, DO; Yasir Hayat, MBBS

INTRODUCTION: Contrast-induced nephropathy (CIN) is one of the complications after percutaneous transluminal coronary angioplasty (PTCA), and is associated with short-term and long-term mortality. Diastolic dysfunction assessed by echocardiography parameters (E/E´ ratio) has correlated with incidence of CIN, and E/E´ ratio >15 had a high incidence of CIN. Echocardiography parameters are indirect measurements of left ventricular end-diastolic pressure (LVEDP), which is not reliable to determine the diastolic dysfunction. The purpose of this study was to determine the relationship of diastolic dysfunction with CIN on the basis of measured LVEDP during PTCA.

METHODS: We conducted a retrospective study that included 984 patients who underwent PTCA at Virginia Commonwealth University Hospital from March 2015 to December 2016. Among these 984 patients, a total of 161 patients had hemodialysis and were excluded. Of 823 patients, a total of 647 subjects had their LVEDP measured. NCDR defined the CIN on the basis of Acute Kidney Injury Network criteria (10), which is an increase in serum creatinine by 50% or 0.3 mg/dL after PCI compared with the baseline. T-test, Chi-square, and one-way ANOVA tests were used for data analysis. Multivariate binary logistic regression analyses were conducted in the stepwise selection with entry and exit criteria of P<.10 to identify risk factors predicting the development of CIN. All patients with ejection fraction <45% were excluded during the multivariate regression analysis.

RESULTS: Of the 924 patients, a total of 109 had CIN after the procedure. The mean age was 64.8 ± 12.3 years and 23.5% were female. The mean values of creatinine and estimated glomerular filtration rate (eGFR) before the procedure were 1.147 ± 0.54 mg/dL and 74.47 ± 26.54 mL/min/1.73 m², respectively. Patients with contrast-induced acute kidney injury had higher prevalence of diabetes mellitus, emergency/urgent procedure, cardiogenic shock, history of heart failure, IV diuretics, and intra-aortic balloon pump use during the PTCA than the non-CIN group. Patients with CIN demonstrated significantly lower eGFR and hemoglobin, while creatinine levels were significantly higher compared with the non-CIN group. LVEDP in the CIN group (18.48 ± 9.237 mm Hg) was high as compared with the non-CIN group (16.606 ± 9.105 mm Hg; P=.05). When patients were classified into three groups based on the LVEDP of 10 mm Hg and 20 mm Hg, CIN occurred in 38 patients (34.9%) in the highest tertile and 44 patients (40.4%) in the middle compared with 27 patients (24.8%) in the lowest tertile (P<.03). In addition, patients with LVEDP >20 mm Hg experienced more acute heart failure events and had cardiogenic shock more frequently during the procedure than patients in the middle and lowest tertiles. In multivariate regression analysis, LVEDP >20 mm Hg (OR, 3.75; 95% CI, 2.08-7.23; P=.002) was identified as an independent risk factor for the development of CIN after adjustment for age, diabetes, dose of contrast media, intra-aortic balloon pump use, eGFR, hs-CRP, and left ventricular ejection fraction <45%.

CONCLUSION: This study demonstrates that LVEDP >20 mm Hg is an independent risk factor of CIN, which suggests that diastolic dysfunction has a correlation with CIN.

C3-2019 9: Impact of Left Ventricular End-Diastolic Pressure on Development of Contrast-Induced Nephropathy After Percutaneous Coronary Intervention

Muhammad Zubair Khan, MD; Sampath Gunda, MD; Jose E. Exaire, MD; Luis Guzman, MD

INTRODUCTION: Intravenous hydration is the only proven treatment to prevent contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI). A recent randomized trial showed that targeting a left ventricular end-diastolic pressure (LVEDP) >13 mm Hg was associated with reduction in CIN. However, there is little information regarding the role of LVEDP and the development of CIN. The aim of our study was to investigate the impact of LVEDP on the incidence CIN after PCI. 

METHODS: From March, 2015 to September, 2016, PCI was performed in 880 patients. Patients with renal failure on dialysis, cardiogenic shock, and immediately post cardiac arrest were excluded. Among the 780 remaining patients, LVEDP was measured in 613 patients (80%) prior to PCI. CIN was defined as in the current NCDR (any increase in creatinine >0.3 mg/dL within 7 days after the procedure).

RESULTS: CIN was observed in 111 patients (14. 2%). Unadjusted predictors of CIN were older age, female gender, non-African American, diabetes, emergency PCI, history of heart failure, use of IV diuretics, need for vasopressor agents, low ejection fraction, low hemoglobin (Hb), and high creatinine. Mean LVEDP was 16. 3 ± 8. 8 mm Hg in patients without CIN and 18. 6 ± 9. 5 mm Hg in those with CIN (P=.02). During binary logistic regression analysis, the odds ratios of diabetes (OR, 1.9), preprocedure creatinine (OR, 2.34), and preprocedure Hb (OR, 0.73) were statistically significant but the LVEDP (OR, 1.01) and ejection fraction (OR, 0.97) were insignificant. Further evaluation showed that among patients with ejection fraction >40% (n=554), LVEDP was not an independent predictor of CIN (OR, 1.0; 95% CI, 0.97-1.04; P=.63).

CONCLUSION: Our study shows a poor association between LVEDP and the development of CIN in patients undergoing PCI. Given the multiple factors that impact LVEDP, this may be a poor marker of volume status. No association was noted in those with normal ejection fraction, questioning the utility of LVEDP as a target to adjusting volume status. Further prospective evaluation of the role of volume status and the use of LVEDP to prevent CIN is warranted.

C3-2019 10: Safety of Rotational and Orbital Atherectomy for Calcific Coronary Interventions:  A Systematic Review and Meta-Analysis

Qasim Malik, MD; Muhammad Siddique Pir, MD; Najam Saqib, MD; Raza Mian, MD; Vikas Yellapu, MD; David Prutzman, DO; Jamshid Shirani, MD; Peter Puleo, MD

BACKGROUND: Calcified coronary lesions present a challenging task for coronary interventionalists. The use of rotational (RA) and orbital atherectomy (OA) has increased in recent years in the percutaneous coronary intervention of these lesions. There are limited data directly comparing the two techniques, however.

METHODS: We performed a systematic review of the literature and identified 6 studies that specifically addressed this issue. Meta-analysis was performed to compare procedural complications as well as outcomes for RA vs OA. Forest plots were obtained for each outcome. 

RESULTS: A total of 3493 patients (OA = 960, RA = 2533) were included in this meta-analysis from 6 studies. The mean patient age was 71.1 years and 69.6% were male. There was no significant difference in all-cause mortality (P=.48), myocardial infarction (P=.20) or dissection (P=.23) between the two techniques. Though RA was associated with higher fluoroscopy times (relative risk, 3.35; 95% CI, 2.35-4.35; P<.01) as compared with orbital atherectomy, it was associated with lower rates of device-related perforation (OR, 0.25; 95% CI, 0.10-0.63; P<.01). 

CONCLUSION: Both RA and OA have similar all-cause mortality and rates of myocardial infarction, with shorter fluoroscopy times for OA at the expense of higher rates of device-related perforation. 

C3-2019 11: In-Hospital Outcomes for Acute Coronary Syndrome in Patients With and Without Peripheral Artery Disease

Vishnu Priya Mallipeddi, MD; Gezzer Ortega, MD, MPH; Julius Ngwa, PhD; Basharat Ahmad, MD; Isaac Opoku-Asare, MD

BACKGROUND: Peripheral artery disease (PAD) is atherosclerosis of non-coronary vascular beds. No study in the literature, to the best of our knowledge, has addressed the question of whether the presence of PAD results in adverse outcomes in patients hospitalized with acute coronary syndrome (ACS). Hence, we used contemporary data available in the United States to investigate the effect of concurrent PAD on the in-hospital outcomes in patients admitted with ACS.

METHODS: We identified 4,590,657 patients with a diagnosis of ACS from the National Inpatient Sample (NIS) database using the International Classification of Diseases, Ninth Edition (ICD-9) codes from 2005 to 2014. A one-to-one propensity-score matching for age, gender, race, income, insurance, hospital region, and teaching hospital resulted in 66,328 patients with ACS. In-hospital mortality, length of hospital stay, and cost of hospitalization were estimated.

RESULTS: Among 4,590,657 patients admitted with ACS, a total of 547,583 patients had PAD (mean age, 71.32 ± 11.33 years; 62.8% male). Among ACS hospitalizations, in-hospital mortality was 3.3% vs 2.8%, length of hospitalization was 4 days vs 3 days, and cost of hospitalization was $31,323 vs $26,685 in PAD vs non-PAD patients, respectively. On adjusted analysis, we found that in-hospital mortality was lower in PAD patients vs non-PAD patients (OR, 0.88; 95% CI, 0.86-0.90; P<.001), whereas length of stay (estimate=-0.120; se=0.0082; P<.001) and cost of hospitalization (P<.001) were increased in PAD patients. After propensity-score matching, we identified 33,164 patients with PAD (mean age, 65.75 ±  14.39 years; 56.08% male) among ACS hospitalizations. In-hospital mortality was 3.24% vs 3.06%, median length of hospitalization was 4 days vs 3 days, and cost of hospitalization was $35,104 vs $27,408 in PAD vs non-PAD patients, respectively, among ACS hospitalizations. On adjusted analysis, we found that in-hospital mortality was decreased in PAD patients (OR, 0.86; 95% CI, 0.78-0.95; P=.003) whereas length of stay (estimate=-0.13; se=0.06; P=.022) and cost of hospitalization (P<.001) were increased in PAD patients vs non-PAD patients among ACS hospitalizations. Charlson comorbidity index (CCI) was 2.75 in PAD patients vs 2.31 in non-PAD patients (P<.0001).

DISCUSSION: We found that ACS hospitalizations with PAD had lower rates of in-hospital mortality compared with non-PAD patients. This may be due to a timely capture of ACS cases by over-admitting patients with PAD presenting with chest pain, since PAD was regarded as a CAD risk equivalent. However, the length of stay, costs of hospitalization, and comorbidity burden were higher in PAD patients compared with non-PAD patients.

CONCLUSION: Patients with PAD who get admitted to the hospital with ACS had decreased in-hospital mortality but prolonged length of hospital stay and increased cost of hospitalization in the United States. Further studies are warranted, and future research should be designed to focus on developing a precise risk stratification tool to prevent over-admission of patients with a history of PAD.

C3-2019 12: Therapeutic Strategies for Coexisting Carotid and Coronary Artery Disease: Which Technique and in Which Order?

Sina Manthey, MD; Yousif Al-Saiegh, MD; Jenna Spears, MD; Sheldon Goldberg, MD

INTRODUCTION: Coexisting carotid artery stenosis and coronary artery disease (CAD) is frequent, with prevalence of significant carotid lesions in patients undergoing coronary artery bypass graft (CABG) reported as high as 8%-14%. In patients undergoing carotid endarterectomy (CEA), the prevalence of CAD is 40%-50%. There is a risk of stroke in patients undergoing CABG (0.5%-7%) and a risk of cardiac complications in patients undergoing CEA (5%-8%). There is currently no consensus in treatment guidelines on the sequence of revascularization. Treatment strategies include: (1) combined or synchronous surgery, where CABG and CEA are performed in the same procedure or anesthetic setting; (2) staged surgeries, consisting of CABG with subsequent CEA or CEA with subsequent CABG; and (3) hybrid procedures, which can be synchronous or staged, and consist of CABG with carotid artery stenting, PCI with CEA, or PCI with carotid artery stenting. 

CASE PRESENTATION: A 55-year-old female with insulin-dependent diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease, and severe triple-vessel CAD status post three-vessel stenting, presented with anterior NSTEMI. Her ECG showed new T-wave inversions in V1-V4. A transthoracic echocardiogram demonstrated normal ejection fraction. Coronary angiography demonstrated triple-vessel disease, with severe left anterior descending (LAD) stenosis as well as high-grade left circumflex (LCX) and right coronary artery (RCA) lesions. In preparation for surgery, screening carotid Doppler showed severe stenosis of the right internal carotid artery (RICA). Carotid angiography showed 90% stenosis of the RICA and 50% stenosis of the left internal carotid artery. It was decided to proceed with single CABG utilizing left internal mammary artery (LIMA) to the LAD and to defer stenting of the other coronary lesions. The plan was to treat the carotid disease after myocardial revascularization and resolution of active myocardial ischemia. Ten days after CABG, the patient again presented with recurrent severe unstable angina and repeat coronary angiogram showed a kink in the LIMA, which had been inserted proximal to the LAD lesion. PCI of the LAD through the LIMA was performed with excellent results and complete relief of symptoms. After complete resolution of the angina symptoms, attention was shifted to the carotid lesion, and a stent was placed in the RICA. She experienced hypotension for approximately 12 hours as a result of baroreceptor response requiring low-dose vasopressors. There was no myocardial ischemia during this period.

DISCUSSION: Coexisting carotid and CAD occurs not infrequently, and the timing and sequence of myocardial and carotid revascularization are controversial. This patient underwent myocardial revascularization before carotid stenting because she presented with unstable angina and was asymptomatic neurologically. This approach is consistent with recent guidelines, which suggest treating the more symptomatic region first. The development of hypotension following carotid stenting may result in worsening myocardial ischemia in patients with active coronary lesions. Advances in technology allow a minimally invasive approach in selected patients with appropriate anatomy. Our case demonstrates successful approach by revascularizing the more symptomatic vascular bed first.

C3-2019 13: Anomalous Left Coronary System

Keyur Mavani, MD; Yasir Nawaz, MD; Pranjal Boruah, MD

CASE PRESENTATION AND FOLLOW-UP: A 66-year-old male with hypertension, diabetes, hyperlipidemia and ESRD on peritoneal dialysis presented to clinic for renal transplant evaluation. He had recent normal stress test and echocardiogram. Being high risk for coronary artery disease (CAD), he was advised for cardiac catheterization to rule out CAD definitively. Cardiac catheterization showed no significant obstructive CAD, but left main coronary artery was anomalous (arising from the right cusp). He remained asymptomatic and able to do more than 8 METs. Cardiac CT showed a very anterior course of the left system.

LITERATURE REVIEW: Coronary artery anomalies usually affect about 1% of the general population. Although congenital coronary artery anomalies are uncommon, they are the second most common cause of sudden cardiac death among young athletes. The most commonly associated anomaly with sudden cardiac death is the anomalous origin of a coronary artery, in particular with a course between the aorta and the pulmonary artery (PA). The origin of the left main coronary artery (LMCA) from posterior sinus of Valsalva is usually seen in patients with cardiac structural anomalies. This is extremely rare (0.0008%). Anomalous origin of the LMCA, the left anterior descending, or circumflex branch from the proximal PA or more distally to the proximal right PA is a rare congenital anomaly, occurring in 0.26% of patients with congenital heart disease. When a coronary artery anomaly is found, the course and its relationship with other cardiac structures must be described. Coronary angiography is considered the reference standard for coronary artery anomaly (CAA) evaluation. Coronary CT is considered the diagnostic standard for visualization of coronary artery course. Coronary artery CT offers the best performance in terms of spatial resolution, acquisition time, and image contrast. A recent study showed that the prevalence of CAAs is substantially higher with CT than coronary angiography, suggesting a possible under-estimation of CAAs based on invasive angiography. The diagnosis of anomalous left coronary artery from the pulmonary artery (ALCAPA) in an infant, usually seriously ill, is an indication for urgent surgery; diagnosis in older patients should also be an indication for surgery. Excellent surgical results have been reported following re-establishment of a dual coronary artery system. Symptomatic carriers of CAAs have 3 treatment options: (1) medical treatment/observation; (2) coronary angioplasty with stent deployment; and (3) surgical repair. Despite the limitations of our current knowledge of such anomalies, intervention may be justified in some cases to prevent sudden death and improve the quality of life. Medical treatment (essentially with beta-blockers) is probably as effective as restriction of high-intensity activity in these patients. 

PREVENTION OF SUDDEN CARDIAC DEATH: Athletes and military personnel known to be CAA carriers should be advised by a specially trained cardiologist about permitted versus prohibited physical activities before and after intervention. Current guidelines issued by professional associations state that untreated carriers of anomalous coronaries should not be involved in competitive sports or other strenuous activities. Treated patients should be re-evaluated before being allowed to resume exercise at maximal capacity.

C3-2019 14: Chronic Type A Aortic Dissection in TAVR

James McAleer, DO; Jomel Jacinto, DO; Jessica Joseph, DO; Rami Akel, MD

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) was initially developed for patients with severe aortic stenosis who were otherwise not candidates for surgery. While procedural advances have improved outcomes immediately post procedure and on long-term follow-up, stroke, paravalvular leak, and vascular complications remain a persistent concern to these patients. While aortic dissection is a known complication, previous reports were in the acute setting. We present a novel case of chronic aortic dissection (Stanford type A) as seen on routine outpatient CT 5 months after TAVR.

CASE PRESENTATION: An 80-year-old male with a past medical history of type II diabetes mellitus, hypertension, coronary artery disease, and former 40 pack-year smoking history initially underwent TAVR in early 2018 using a 29 mm Medtronic Evolut Pro bioprosthesis for treatment of severe symptomatic aortic stenosis. Preprocedure left heart catheterization demonstrated an aberrant right coronary artery that arose from the left coronary cusp. The TAVR procedure was uncomplicated; transthoracic echocardiogram completed 24 hours post TAVR confirmed valve position without paravalvular leak or dissection. Five months later, the patient presented to the hospital after outpatient CT imaging showed possible aortic dissection. At the time of evaluation, he was asymptomatic of chest pain, back pain, and shortness of breath, but did note a week-long episode of self-limited back pain 2 months prior. Initial blood work was negative for evidence of organ ischemia. Repeat echocardiogram studies confirmed dissection with flow in both true and false lumina, but verified appropriate valvular position and function. Subsequent CT angiography of the chest/abdomen/pelvis showed aortic dissection with extension from the TAVR stent-graft to the juxtarenal abdominal aorta. The major branches of the aortic arch, celiac, and superior mesenteric arteries were supplied by the smaller true lumen with sparing of the infrarenal abdominal aorta and iliac vessels. After extensive multidisciplinary discussions with cardiology and cardiac surgery, the patient opted for aggressive medical therapy. He was discharged on an antihypertensive regimen and plans for strict outpatient follow-up and repeat imaging in 1 month.

DISCUSSION: During TAVR procedure, aortic dissection is estimated to occur in 0.12%-2% and contributes to 8.9% of all conversions to open-heart intervention. However, previous studies do not delineate acute from chronic aortic dissection. Chronic dissections have been posited to have pathologic or physiologic differences that separate them from acute dissections, lending additional stability and greater latitude when it comes to management. Retrospective analysis of Stanford type A dissections indicated as many as 50% had previously undergone cardiac surgery. This may affect outcomes three-fold: (1) that history of intravascular procedure may directly increase likelihood of dissection; (2) that decreased sensation secondary to denervation may allow for delayed presentation; and (3) that increased mediastinal adhesions may strengthen against cardiac tamponade preventing death. In the case of TAVR, reinforcement of the aortic valve with prosthesis may protect against the aortic insufficiency classically used to indicate surgical intervention.

C3-2019 15: Long-Term Outcomes Following Transcatheter Mitral Valve Replacement for the Treatment of Degenerated Mitral Bioprostheses

Giorgio A Medranda, MD; Kunal Brahmbhatt, MD; Richard Schwartz, DO; Stephen Green, MD

BACKGROUND: The advent of transcatheter aortic valve replacement (TAVR) has ignited the search for a mitral equivalent. Ongoing trials will attempt to design a safe and effective transcatheter mitral valve replacement (TMVR) device. In the interim, the FDA has approved the balloon-expandable transcatheter heart valve system for the treatment of degenerate mitral bioprostheses. The purpose of this study was to detail the short- and long-term outcomes of high-risk patients undergoing TMVR at our institution.

METHODS: In this retrospective, observational study, we reviewed data on the first 26 patients with previous surgical mitral valve replacement (MVR) (76.9%) or repair with ring (23.1%) who underwent TMVR using the third-generation transcatheter balloon-expandable valve at our institution from 2015 to 2019. We reviewed pre/post-TMVR echocardiographic data, inpatient data, and 30-day data. Statistical analysis was performed using t-test and Wilcoxon signed rank test. 

RESULTS: Of the 26 patients, the primary indication for TMVR was bioprosthetic valve regurgitation in 9 patients, bioprosthetic transvalvular stenosis in 9 patients, and mixed mitral disease in 8 patients.  The average STS score for MVR was 13.0%. Of the 26 TMVRs, a total of 19 were transseptal and 7 were transapical. There was a 100% device implantation success rate and a 96.2% inpatient survival rate. At 30 days, there was a 96% survival rate. Mitral valve mean gradient (MG) (13.3 mm Hg to 6.8 mm Hg; P<.0001) and mitral regurgitation (3+ to 1+; P<.0001) showed significant improvement after TMVR. There were significant 30-day and 1-year improvements in patients’ Kansas City Cardiomyopathy Questionnaire score following TM valve-in-valve/TM valve-in-ring (47.8 to 75.7 to 84.0; P<.0001).

CONCLUSION: We found that treatment of degenerated mitral bioprosthesis using TMVR with the third-generation balloon-expandable transcatheter heart valve in high-risk patients resulted in significant improvements in short-term and long-term heart failure symptoms, which translated to robust short-term and long-term survival. 

C3-2019 16: The Utility of Transcatheter Aortic Valve Replacement in Very Low-Gradient Severe Aortic Stenosis

Giorgio A. Medranda, MD; Khaled Salhab, MD; Richard Schwartz, DO; Stephen Green, MD

BACKGROUND: Hemodynamic improvements following transcatheter aortic valve replacement (TAVR) have been shown to correlate with outcomes. Patients with severe aortic stenosis (AS) and low mean gradients (MGs) (<40 mm Hg) have been shown to have significant improvements in their MGs post TAVR. However, data on low-, intermediate-, and high-risk patients with severe AS and very low MGs (<20 mm Hg) are lacking. The purpose of this study was to determine the changes in MGs following TAVR in patients with baseline very low MGs.  

METHODS: This was a retrospective, observational study of 716 low-, intermediate-, or high-risk patients who underwent TAVR at our institution. We trichotomized our population based on their pre-TAVR MG: cohort 1, <20 mm Hg (n=38); cohort 2, 20-39 mm Hg (n=319); and cohort 3, >40 mm Hg (n=357). We examined pre-TAVR and post-TAVR echocardiographic data. Our outcome of interest was a composite of inpatient stroke and death. Statistical analysis of outcomes was performed using two-sided t-test and one-way ANOVA.

RESULTS: We screened 716 low-, intermediate-, or high-risk patients who underwent TAVR at our institution. Excluded were 2 patients with bicuspid aortic valves. Among the 714 remaining patients who underwent TAVR, a total of 530 utilized the third-generation balloon-expandable heart valve and 184 utilized the third-generation self-expanding heart valve. Mean patient age was 81.1 years, 48.7% were male, and mean Society of Thoracic Surgeons (STS) score was 7.4%.  Patients in cohort 1 (15.8 mm Hg to 9.8 mm Hg; P<.0001), cohort 2 (30.3 mm Hg to 10.4 mm Hg, P<.0001), and cohort 3 (53.7 mm Hg to 12.5 mm Hg; P<.0001) all saw significant improvement in their MG post TAVR. There were no differences among the cohorts in rates of our inpatient composite of stroke and death (P=.8782).

CONCLUSION: The utility of TAVR in patients with very low MGs remains unclear. Our study of 714 low-, intermediate-, and high-risk patients who underwent TAVR using third-generation valves demonstrated significant improvements in post-TAVR MGs across all variants of severe AS, which translated to a similar composite rate of inpatient stroke and death.

C3-2019 17: Quality of Life Outcomes After Transcatheter Aortic Valve Replacement in Nonagenarians

Ramez Morcos, MD; Haider Al Taii, MD; Priya Bansal, MD; Michael Kucharik, MD; Rupesh Manam, MD;  Joel Casale, MD; Houman Khalili, MD; Brijeshwar Maini, MD

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is being increasingly utilized for treating severe aortic stenosis (AS) in intermediate  and high surgical risk patients. Symptoms and quality of life (QoL) outcomes are not well established in nonagenarian TAVR patients, an under-represented population in landmark clinical trials.

METHODS: All patients who underwent TAVR between January 2015 and December 2018 at Delray Medical Center were included. QoL outcomes were assessed using the 12-item Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ OS) score at baseline and 30 days. KCCQ OS score was compared at 30 days in patients ≥90 years old and <90 years old. Frailty assessment included grip strength, gait speed, and activities of daily living. Unadjusted and adjusted analyses (baseline KCCQ OS score, frailty, and STS risk score) were performed to assess the impact of age on QoL outcomes in both groups.

RESULTS: Of the 224 patients who received TAVR, a total of 47 patients (21%) were nonagenarians, and 118 (52.7%) were male. Frailty score (0-3; 0 least frail, 3 most frail) was significantly different between nonagenarians and the younger group (1.17 ± 0.56 vs 1.36 ± 0.56; P=.04). KCCQ OS scores were lower at baseline and 30-day follow-up in nonagenarians compared to younger patients (P=.70). There was a significant improvement in the 30-day KCCQ OS score in both age groups (P<.001). Age was a significant predictor of 30-day KCCQ OS in unadjusted analysis. After adjustment for baseline KCCQ OS, frailty, and STS score, age remained a significant predictor of improvement in 30-day KCCQ OS (P=.011). Nonagenarians had on average 9.38 points lower in their 30-day KCCQ OS scores than the younger patients in adjusted analysis. Frailty score (P=.63) and STS score (P=.173) were not independent predictors of QoL outcomes in nonagenarians.

CONCLUSION: TAVR improves QoL in nonagenarians at 30 days; however, there is less improvement compared with younger patients. Frailty and STS score are not strong predictors of improvement in QoL with TAVR in this age group.

C3-2019 18: Catheter Lab Emergency Management Simulation (CLEMS)

Jaydeep Sarma, MD, PhD; Timothy Strang, MD; Lisa Wee, MD; Susan Murray, DCR; Samantha Cummins, RCN; Emily Murtagh, BSc(Hons); Lajos Szentgyorgyi, MD

INTRODUCTION: A multidisciplinary team of catheter lab staff from Manchester University NHS Foundation Trust developed a two-day training course for effective team approach to critical situations in the cardiac catheterization laboratory.  It comprises a multimodal format of lectures, simulations, and small-group workshops.

BACKGROUND: Cardiac catheterization laboratory procedures have become increasingly complex in a multi-morbid patient group. Situational awareness and effective teamwork are essential when responding to emergency situations. Simulation technology provides a safe and realistic environment in which to develop important non-technical skills as part of a multidisciplinary team.

OBJECTIVE: Our aim was to develop an advanced life support (ALS) equivalent course for catheterization  laboratory staff  training.

METHODS: The course is designed to accommodate four cardiac catheter laboratory teams, with each team comprising a minimum of 2 doctors, 2 nurses, a radiographer, and a physiologist. 

Core elements of the course are:

1. An enhanced WHO (safer surgery) style checklist approach with a “team huddle” for the review of preprocedure checklists and resuscitation team role allocation. Key elements include role allocation for effective team work and promotion of the use of a communication whiteboard as a point of reference in the event of an emergency situation.

2. Recognition that the procedural cardiologist is concentrating on technical tasks and is not best placed to lead resuscitation efforts. Any of the team can provide a team-lead role and all are empowered to develop this skill.

3. Development of a structured approach to the recognition, assessment, and management of the critically ill patient and development of non-technical human factor skills through experiential learning and simulation of clinical scenarios.

4. Six high-fidelity simulations based in the catheter lab and recovery room, followed by a detailed structured debriefing. Each team has the opportunity to participate in the simulations and alternate to observe another team.

5. Workshops designed to provide knowledge and practical skills required in the initial management of a deteriorating or critically ill patient, including safe sedation, basic airway skills, intra-aortic balloon pump management, and mechanical chest compression device use.

Candidates attending the course were asked to complete a survey and provide feedback.

RESULTS: Since 2014, several courses have been completed at Wythenshawe Hospital, Manchester and across the United Kingdom. Almost 100% of candidates agreed or strongly agreed that the varied learning formats were easy to understand, relevant, and useful for future clinical practice. These candidates believed that the knowledge and skills gained would be useful to their future clinical practice, that it helped consolidate their learning, and that the facilitation of their debriefing was effective. 

CONCLUSION: This catheterization laboratory emergency medical simulation (CLEMS) course provides an effective means of training for emergency management in the cardiac catheterization laboratory. We consider that the principles and practice of this course promote a better patient safety culture and have the potential to improve outcomes in emergency situations.

C3-2019 19: Clinical and Pathophysiological Diagnosis of Silent Myocardial Infarction (SMI)

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

BACKGROUND: Silent, covert, or unrecognized myocardial infarction (MI) is defined as evidence of MI on electrocardiography (ECG) in the absence of a history of MI, and is associated with a greater risk of all-cause death, heart failure, and fatal MI. More recently, silent MI has been defined as “an imaging evidence of a region of loss of viable myocardium in the absence of a non-ischemic cause.” The clinical definition of MI denotes the presence of acute myocardial injury as detected by elevated cardiac troponin (cTn) value in the setting of evidence of acute myocardial ischemia. Pathologically, MI is defined as myocardial cell death due to prolonged ischemia. Diminished cellular glycogen, and relaxed myofibrils and sarcolemmal disruption, are the first ultrastructural changes usually seen as early as 10 to 15 minutes after the onset of ischemia. The time course may be prolonged by increased collateral flow, reduced determinants of myocardial oxygen consumption, and intermittent occlusion/reperfusion, which can precondition the heart. Timely implementation of reperfusion therapy, when appropriate, reduces ischemic injury of the myocardium. 

ETIOLOGY AND DIAGNOSIS: SMI has been diagnosed among patients suffering from the following: diabetes mellitus or diabetic cardiac autonomic neuropathy; peripheral autonomic neuropathy; sickle cell disease; cardiac transplant recipients (due to denervation syndrome); and old age (as pain may not be the cardinal symptom among geriatrics); similarly, in a retrospective study of elderly patients with peritonitis, abdominal pain was absent in nearly half of the cases. The physiologic basis of these observations is uncertain. There are widespread morphologic, electrophysiologic, neurochemical, and functional changes within the nociceptive pathways, and psychological factors that may alter pain experience in elderly people. Age-related loss of neurochemicals, such as serotonin, glutamate, GABA, and opioid receptors implicated in pain modulation, may contribute to altered pain processing in older adults. 

METHODS OR INSTRUMENTAL DIAGNOSIS: The following methods have been used to diagnose SMI. ECG; MRI (T2-weighted clinical at 1.5 Tesla); MRI (arterial spin-tagging or gadolinium as tracer); positron emission tomography (particularly in those with cerebrovascular disease); and diffusion tensor imaging.

RESULTS: With their asymptomatic nature, identification of SMIs remains difficult in the clinical setting, where symptoms drive testing. For this reason, cohort studies present the best opportunity to further diagnose and study this elusive entity. Analyzing longitudinal data from over 9000 participants in the Atherosclerosis Risk in Communities Study, Selvin et al discovered that participants with diabetes and prediabetes had higher troponin levels than those with normal glucose metabolism, a finding that indicates subclinical myocardial damage. There was a higher prevalence of SMI in those with prediabetes compared with those with normal fasting glucose (3.5% [n=72] vs 1.4% [n=30]). 

CONCLUSION: SMI is a difficult and elusive pathology to diagnose. Clinicians must distinguish whether patients have suffered a non-ischemic myocardial injury or one of the MI subtypes. Non-ischemic myocardial injury may arise secondary to many cardiac conditions, such as myocarditis, or may be associated with non-cardiac conditions, such as renal failure. Clinicians must never under-estimate the potential seriousness of underlying pathology in an older person because of the absence of severe pain. The current Fourth Universal Definition of Myocardial Infarction Consensus Document reflects these considerations through adhering to the clinical approach of the definition of MI. 

C3-2019 20: Intermediate-Term Outcome After Electrogram-Guided Segmental Ostialpulmonary Vein Isolation Using an 8 mm Tip Catheter for Paroxysmal Atrial Fibrillation

Rash Lokhandwala, DM; Prashant Pawar, DNB; Vadi Velu, DM; Neeta Bachani, MBBS

Holy Family Hospital, Mumbai, India

INTRODUCTION: There are no Indian data on the outcome following conventional radiofrequency catheter ablation (RFA) for patients with paroxysmal atrial fibrillation (AF). In spite of recent advancements in this field, including sophisticated 3D-based imaging and advanced ablation catheters with contact force technology, many Indian  patients will not afford such an expensive therapeutic procedure. We summarized the immediate- and long-term outcomes following RFA of Indian patients with paroxysmal AF using pulmonary vein (PV) electrogram-based mapping using an 8 mm tip ablation catheter.

METHODS: A total of 42 consecutive patients who underwent RFA for symptomatic paroxysmal AF not controlled with at least 1 antiarrhythmic drug were studied in a tertiary-care institute from March 2015 to December  2018. Inclusion criteria: all patients ≥18 years who had symptomatic non-rheumatic paroxysmal AF not controlled with at least 1 antiarrhythmic drug were included in the study. Exclusion criteria: patients with rheumatic AF were excluded. Persistent AF or long-standing persistent AF, left atrial thrombus, left atrial anteroposterior diameter >50 mm, unstable angina in the previous 3 months, bleeding disorders, pregnancy, contraindications to anticoagulation, decompensated heart failure, and unwillingness to give consent. PV intervention was performed solely by conventional electrophysiology procedure using 8 mm tip RF catheter and PV potential electrogram-based mapping. 3D mapping was not used. Only PV intervention was performed. Substrate modification was not performed. Elimination of all ostial PV potentials and complete entrance block into the PV were considered indicative of complete electrical isolation. Follow-up visits were scheduled at 4 weeks, 3 months, and 6 months post procedure, and every 6 months thereafter. 

RESULTS: After the procedure, a total of 34 patients were arrhythmia free, while 8 continued to have AF. The mean age of the study population was 51.5 ± 11.7 years.The mean follow-up duration was 44 ± 21 months (range, 6 months to 84 months).The number of PVs isolated included 1 PV in 5 patients (11.9%), 2 PVs in 20 patients (47.6%), 3 PVs in 12 patients (28.6%), and 4 PVs in 5 patients (11.9%). In 42 patients, a total of 101 PVs were isolated. The right superior PV was isolated in 37 patients, the left superior PV was isolated in 39 patients, the left inferior PV was isolated in 14 patients, and the right inferior PV was isolated in 6 patients. The procedure duration was 125 ± 29 minutes and the fluoroscopy time was 47 ± 13 minutes. The number of patients who remained in sinus rhythm at 1 month, 6 months, 12 months, and 24 months was 34 (81%), 32 (76%), 30 (71%), and 26 (62%), respectively. Two of these patients underwent repeat PV intervention; these interventions were successful and they had no further recurrences. Complications were rare. One patient had a minor pericardial effusion and 1 patient had transient sinus pauses, which were conservatively managed.

CONCLUSION: Conventional RFA using PV potential electrogram-based mapping and ablation with 8 mm tip catheter is safe and effective for patients with paroxysmal AF with satisfactory immediate- and long-term outcomes and negligible complications; it is also very cost effective in our setting with limited resources.

C3-2019 21: Severity of Mitral Regurgitation Post Transcatheter Aortic Valve Replacement in Patients With Coexisting Moderate Mitral Regurgitation According to BSE Guidelines 

Faiza Raja, BSc(Hons)

BACKGROUND: Aortic stenosis (AS) is one of the most commonly treated valvular diseases in Europe. Many patients with severe AS present with concomitant mitral regurgitation (MR). The majority of patients with severe AS are >70 years old; hence, they may also have coronary artery disease, explaining the increased likelihood of secondary MR. Additionally, AS patients may have primary MR. In the presence of AS, the transmitral pressure gradient is amplified, resulting in an increased back-flow rate and volume. The coexistence of MR and AS alters clinical presentation of AS. The left ventricle (LV) can dilate to concerning levels and a hypertrophic pattern may be present (Unger et al, 2009). Moreover, the mitral valve closes prematurely to limit regurgitation to the left atrium. These patients have worse LV function and higher mortality rates than those with a single valve disease (Nombela-Franco et al, 2014).

OBJECTIVES: The aim of this study was to determine if moderate to severe MR improves post TAVR. This was done by assessing the clinical significance of MR and how MR affects mortality.

HYPOTHESIS: A reduction in the level of secondary MR post TAVR should be seen in patients with significant preprocedure MR.

METHODS: This is a retrospective study of 92 patients who underwent TAVR. Data were collected from various NHS databases between July 2013 and October 2018. Inclusion criteria: patients with severe AS who had at least moderate MR before TAVR in accordance with BSE guidelines, ie, moderate and severe. Exclusion criteria: patients with mild MR and mild or moderate AS. MR was graded as trivial, mild, moderate, or severe. A decrease of MR to at least mild post TAVR was considered an improvement. Statistical analysis was undertaken using SPSS statistics (IBM).

RESULTS: There was a significant difference in MR pre and post TAVR. At 1 day, a reduction in MR was observed in approximately 72% of patients, with no change in 27% and worsened MR in 1%. At 7 days, improvement was seen in 71% of patients, with no improvement in 28% and worsened MR in 1%.

DISCUSSION: Physiologically, secondary MR should improve post TAVR as AS is resolved, decreasing LV afterload. This relieves stress from the mitral valve, reducing MR. This process is defined as LV remodeling and improves LV hemodynamics as well as mitral valve leaflet tethering (Barbanti et al, 2013). Primary MR affects the valve directly; hence, no change in etiology is expected. The severity of MR is strongly correlated with mortality (Cortés et al, 2016). The low mortality rate of this cohort can be attributed to the reduction in MR. A meta-analysis by Sannino et al (2014) highlighted the link between preoperative severity of MR and mortality. They stated that the mortality rate significantly increased post TAVR in patients who had moderate/severe MR beforehand in comparison to those who had mild MR or less. Another meta-analysis was undertaken by Nombela-Franco et al (2016), whereby mitral severity was assessed in relation to mortality. The study included randomized trials and national TAVR registries. Analysis was performed and overall, significant heterogeneity was found across the studies, concluding a strong correlation between MR and mortality rates. 

CONCLUSION: Significant MR commonly coexists with severe AS. MR is strongly correlated with mortality; hence, a reduction in MR will increase patient life expectancy. TAVR improves LV function, reducing concomitant symptoms. The TAVR procedure improves the level of MR, thus supporting the hypothesis of this study. 

C3-2019 22: Review of Common Structural Heart Diseases on MRI

Amit Ramjit, MD; Varun Mehta, MD; Mamatha Gowda, MD

INTRODUCTION: Structural heart disease is a common indication for cardiac magnetic resonance imaging (MRI) to identify lesions that may benefit from percutaneous interventions. Many structural heart diseases can be identified on MRI, which guides the interventional cardiologist in preprocedural planning. In additional, early identification of structural abnormalities assists the cardiologist in appropriate long-term patient management. We retrospectively reviewed our institution’s cardiac MRIs that identified structural heart disease and summarized our findings.

METHODS: A retrospective review was performed between September 1, 2018 and February 1, 2019 for cardiac MRIs interpreted by the two fellowship-trained cardiac radiologists at our institutions. This search revealed 94 reports. Each report was reviewed for significant findings of structural cardiac disease.

RESULTS: Several common cardiac abnormalities were found. The studies with abnormal findings were subclassified as ischemic, valvular, septal, pericardial, infiltrative, and neoplastic. Each of these structural heart diseases was reviewed for representative imaging findings to assist the cardiac radiologist with the interpretation of their studies. Ischemic heart disease is the most common structural pathology encountered on cardiac MRI. Infarctions involve the endocardium and extend peripherally. Aneurysmal dilation of the left ventricle can also occur. Finally, abnormal left ventricular motion creates a predisposition to thrombus. Valvular disease is another pathology seen on cardiac MRI. Common variants include aortic, mitral, and tricuspid regurgitation, and aortic stenosis. Bicuspid aortic valve is one of the most common valvular abnormalities, with an approximate 1% to 2% incidence in the general population. Structural abnormalities of the intra-atrial and intraventricular septum include atrial and septal defects. Perimembranous ventricular septal defect (VSD) is the most common variant of VSD. Typically, a signal drop-out occurs at the region adjacent to the tricuspid septal leaflet and below the right border of the aortic annulus. Atrial septal defect (ASD) is divided into 4 major subtypes, with each variant distinguished by its location within the intra-atrial septum. Secundum ASD represents the most common ASD. Pericardial diseases include a variety of pathological processes, including post surgery, prior chest irradiation, and infectious and neoplastic processes. Infiltrative cardiac disease processes include amyloidosis and sarcoidosis. Finally, primary benign and malignant tumors are readily detected on cardiac MRI. 

CONCLUSION: Structural abnormalities on cardiac MRI represent a wide range of pathologies, each with distinct imaging characteristics. Understanding of these appearances helps the cardiac imager successfully identify and correctly classify pathology in their studies.

C3-2019 23: Prior Coronary Artery Bypass Graft Surgery and Outcome After Percutaneous Coronary Intervention (PCI): An Observational Study From the Pan-London PCI (BCIS) Registry

Krishnaraj S. Rathod, MBBS, MRCP, PhD; Anne-Marie Beirne, MBBS, MRCP; Richard Bogle, MBBS, FRCP, PhD; Sam Firoozi, MBBS, MRCP; Pitt Lim, MBBS, MRCP; Jonathan Hill, MBChB, FRCP; Miles C. Dalby, MBBS, MRCP; Ajay K. Jain, MBBS, FRCP; Iqbal S. Malik, MBBS, FRCP; Anthony Mathur, MBBS, FRCP, PhD; Sundeep Singh Kalra, MBBS, FRCP; Ranil DeSilva, MBBS, FRCP; Simon Redwood, MBBS, FRCP; Philip A. MacCarthy, FBBS, MRCP; Andrew Wragg, MBBS, FRCP, PhD; Elliot J.Smith, MBBS, FRCP; Daniel A. Jones, MBBS, FRCP, PhD

BACKGROUND: Limited information exists regarding procedural success and clinical outcomes in patients with previous CABG undergoing PCI. We sought to compare outcomes in patients undergoing PCI with or without previous CABG.

METHODS: This was an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry, from January 2005 to December 2015. The primary endpoint was all-cause mortality at a median follow-up of 3.0 years (interquartile range, 1.2-4.6 years).

RESULTS: A total of 12,641 patients (10.2%) had a history of previous CABG, of whom 29.3% (n=3703) underwent PCI to native vessels and 70.7% (n=8938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow-up was significantly higher in patients with prior CABG (23.2%) (P=.0005) compared to patients with no history of prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%; P<.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (HR, 1.02; 95% CI, 0.77-1.34; P=.89), but a significant increase in mortality among patients with PCI to bypass grafts (HR, 1.33; 95% CI, 1.03-1.71; P=.026). This was seen after multivariate adjustment and propensity matching.

CONCLUSIONS: Patients with prior CABG were older, with a greater comorbid burden and more complex procedural characteristics; however, after adjustment for these differences, clinical outcomes are similar to patients undergoing PCI without prior CABG. In these patients, native-vessel PCI was associated with better outcomes compared to the treatment of vein grafts.

C3-2019 24: A Single-Center Study Evaluating Real-Life Usage of Excimer-Laser Facilitated Angioplasty in Complex Coronary Lesions: Procedural Success and Medium- to Long-Term Outcomes

Azeem S. Sheikh, FCPS, MRCP; Senthil Elangovan, MRCP; Hussain Hussain, MRCP; Ayush Khurana, MRCP; Nicholas Ossei-Gerning, FRCP; Tim Kinnaird, FRCP; Anirban Choudhury, MRCP

INTRODUCTION: Excimer-laser coronary atherectomy (ELCA) can be a useful adjunctive tool for the treatment of complex coronary lesions, such as calcific stenosis, chronic total occlusions, non-compliant plaques, in-stent restenosis, and under-expanded/recoiled stents. We retrospectively assessed the indications, procedural success, and medium- to long-term safety and efficacy of ELCA in a high-volume tertiary cardiac center.

METHODS: Data were evaluated from our center’s laser dataset from January 2009 to August 2018. Primary endpoint was target-vessel failure (TVF): a combination of cardiac death, target-vessel myocardial infarction (TV-MI), and target-lesion revascularization/target-vessel revascularization (TLR/TVR). Secondary endpoints were technical success (successful usage of laser) and procedural success (successful procedure using laser without in-hospital major adverse cardiovascular event [MACE]).

RESULTS: During the study period, a total of 62 patients were treated with ELCA. The most-frequently used ELCA catheters were 0.9 mm and 1.7 mm-diameter (33.8%), followed by 1.4 mm-diameter catheters (24.1%). Of 62 patients, a total of 27 (43.5%) were treated for compliance modification, 13 (20.9%) for in-stent restenosis (ISR), 14 (22.5%) for thrombus vaporization, 5 (8.0%) for plaque debulking, 1 (1.6%) for under-expanded stent, and 2 (3.2%) for stent recoil. Patients (not unexpectedly) were comparatively older, with an average age of 68 years and a higher than usual prior history of myocardial infarction (43%), revascularization (66%), and left ventricular systolic dysfunction (61%). Vessels treated included right coronary artery (37%), left anterior descending (35%), saphenous vein graft (18%), circumflex (8%), and intermediate artery (2%). ELCA was unsuccessful in 7 cases (11.2%). This was mostly (5 out of 7) due to inability to cross the lesion despite laser usage. One developed no-reflow after laser use, while another became hypotensive and developed complete heart block and the procedure had to be abandoned. Stents were deployed in 50 cases (80.6%), while 2 cases (3.2%) had POBA only and 3 cases (4.8%) had their stents optimized. Seventy-seven percent of patients had long lesions (>20 mm) treated. Technical success was achieved in 88.8%. Postprocedure adverse events included major bleeding in 1 case (1.6%) and cardiac death in 2 cases (3.2%), thus giving an overall procedural success rate of 82.4%. TV-MI was seen in 3 cases (4.8%), TLR in 5 cases (8.0%), non-target-vessel revascularization in 2 cases (3.2%), and TVR in 1 case (1.6%). No patient had stent thrombosis. Minimum follow-up of patients was 4 months, with mean follow-up of 543 days. Primary endpoint of TVF was observed in 11.2% of patients after a mean follow-up of 543 days. Landmark analysis after 12 months revealed cardiac death in 3 cases (4.8%), stent thrombosis in 0 cases (0.0%), TLR in 5 cases (8.0%), TVR in 1 case (1.6%), and TVF in 7 cases (11.2%).

CONCLUSIONS: ELCA can be a safe and effective option in a subset of patients with complex coronary disease, with satisfactory medium- to long-term outcomes.

C3-2019 25: The In-Hospital Clinical Outcomes of Immediate Coronary Angiography and Percutaneous Coronary Intervention After Out-of-Hospital Cardiac Arrest

Azeem S. Sheikh, FCPS, MRCP; Nisar Shah, FCPS, MRCP; Samira Yahya, MMEd; Tim Kinnaird, FRCP 

BACKGROUND: Survivors of out-of-hospital cardiac arrest have a significantly high mortality and morbidity. Out-of-hospital cardiac arrest is frequently attributed to coronary artery disease and the current guidelines recommend coronary angiography for survivors of out-of-hospital cardiac arrest. 

OBJECTIVES: The objective of the study was to assess 30-day clinical outcomes of patients who underwent emergency coronary angiography after having a successfully resuscitated out-of-hospital cardiac arrest.    

METHODS: We assessed the outcomes in a consecutive patient cohort from January 2016 to December 2017, who were admitted to a high-volume tertiary cardiac center for emergency coronary angiography after successfully resuscitated out-of-hospital cardiac arrest within 24 hours after cardiac arrest. The primary endpoint was 30-day mortality. The demographic and clinical data were collected from the electronic medical records. 

RESULTS: Using the database, we identified 90 consecutive patients admitted after successful resuscitation from out-of-hospital cardiac arrest because of ventricular fibrillation (95.5%), pulseless ventricular tachycardia (2.2%), and pulseless electrical activity (2.2%). Only 12 patients (13.3%) complained of chest pain prior to collapse. After return-of-spontaneous circulation (ROSC), electrocardiography (ECG) demonstrated ST-segment elevation/left bundle-branch block in 43 patients (47.7%). On admission, Glasgow Coma Scale was 3/15 in 80 patients (88.8%), mean pH was 7.16 ± 0.15, and mean lactate was 6.05 ± 4.41. Prior history of myocardial infarction was found in 6 patients (6.6%), prior CABG in 1 patient (1.1%), and prior PCI in 2 patients (2.2%). The left ventricular systolic function was found to be severely impaired in 19 patients (21.1%). Coronary angiography revealed unobstructed coronaries in 24 patients (26.6%), moderate disease in 6 patients (6.6%), and severe coronary artery disease in 60 patients (66.6%). Significant (≥70%) single-vessel coronary artery disease was found in 43 patients (47.7%), two-vessel disease in 12 patients (13.3%), and three-vessel disease in 5 patients (5.5%). Left anterior descending coronary artery was found to be the culprit vessel in 38 patients (42.2%), followed by right coronary artery in 26 patients (28.8%), left circumflex in 9 patients (10.0%), and left main stem in 7 patients (7.7%). Acute coronary artery occlusion was seen in 39 patients (43.3%). Successful percutaneous coronary intervention was performed in 56 cases (62.2%). Fifty-four patients (60%) were discharged alive from the intensive care unit, out of which 4 (4.4%) had significant hypoxic brain damage. Thirty-one patients (34.4%) died in hospital (5.5% in the cardiac catheterization laboratory, 28.8% in the intensive care unit). The mean hospital stay was 10.67 ± 10.62 days. 

CONCLUSION: In our cohort of patients, two-third were found to have severe coronary artery disease and underwent successful coronary intervention and over half of the patients had a successful 30-day outcome with complete neurological recovery. Immediate bystander resuscitation, ROSC, and emergency coronary angiography with a view to revascularization are the best markers of a positive outcome in this group of patients. 

C3-2019 26: Clinical Outcomes of Incidental Findings in Initial Body Computed Tomography Angiography Prior to Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Jian Liang Tan, MD; Justin Z. Lee, MD; Hee Kong Fong, MD; Usman Ali, MD; Kwan S. Lee, MD; Muhammad Raza, MD 

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly performed in patients with severe symptomatic aortic valve stenosis and intermediate/high surgical risk with life expectancy of >12 months. Multislice computed tomography (MSCT) imaging of the aorta and peripheral vessels is usually performed prior to TAVR. As MSCT imaging extends from thorax to iliofemoral vessels, numerous incidental pathologies, also known as incidental findings (IFs), not directly relevant to the TAVR procedure may be identified.

OBJECTIVE: The aim of this meta-analysis was to systematically review the available data on the prevalence and clinical outcomes of IFs with respect to 1-year survival and time to treatment, on MSCT in the work-up prior to TAVR.

METHODS: A systematic literature search was performed in accordance with PRISMA guidelines using PubMed, EMBASE, Web of Science, CINAHL, ClinicalTrials.gov, and the Cochrane Library databases for studies comparing long-term outcomes of patients with and without IFs on MSCT prior to TAVR. Pooled analysis was conducted and the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI) was calculated. Random-effects model was used based on I² statistics. All P-values were 2-tailed, and the statistical significance was considered at <.05.  

RESULTS: Data from 6 studies (n=2269 patients) were included in our analysis. The overall prevalence of clinical significant IF (eg, aortic aneurysm and pulmonary or kidney mass) and highly suspicious malignant findings was 23.4% and 3.3%, respectively. Analysis of 1-year mortality in TAVR patients (n=2269 patients) showed no significant difference between patients with clinically significant IFs and with non-significant/no IFs (RR, 0.97; 95% CI, 0.69-1.37; P=.87). There was no difference in the mean time from CT angiography scanning to therapeutic decision (TAVR intervention) in patients with IF and patients with non-significant/no IF (weighted mean difference, 2.35; 95% CI, -0.91-5.62; P=.16). Among patients with IF evaluated for TAVR, TAVR was associated with lower 1-year mortality compared with no TAVR (17% vs 49%, respectively; P<.0001).

DISCUSSION: The exact definition of clinically significant IFs remains a subject of debate. Although this analysis of 2269 patients who underwent TAVR showed that patients with clinically significant IFs had a lower 1-year mortality rate (16%) compared to patients with non-significant/no IFs (21%), the difference did not reach statistical significance. This result may be attributed to early identification of treatable IFs and a non-standardized definition of clinically significant IFs (some findings do not necessarily affect patient survival). The decision whether to proceed with TAVR after picking up IFs on CT angiography still requires a multidisciplinary heart team approach for optimal treatment.

CONCLUSION: There was no significant difference in 1-year mortality in patients with vs without clinically significant IF undergoing TAVR. This suggests that clinically significant IF detected during TAVR evaluation should not be an absolute contraindication for TAVR.

C3-2019 27: Contrast FFR in the Real World: Insights From the PRESSURE Wire Registry

Gautam Kumar, MD; Stephan Achenbach, MD; Stefano Galli, MD; Erick Schampaert, MD; Nobuhiro Tanaka, MD; Tarn Teraphongphom, PhD; Greg Ginn, MS; Zhen Zhang, PhD; Kreton Mavromatis, MD; Samer Somi, MD; Giovanni Amoroso, MD; Guus Brueren, MD; Joshua Krasnow, MD; Paul Knaapen, MD; Colin Berry, MD, PhD

OBJECTIVES: Contrast-induced fractional flow reserve (cFFR) is a pressure ratio between the distal coronary artery and aorta during hyperemia after intracoronary injection of contrast medium. cFFR reflects the physiological severity of a coronary artery stenosis without the use of adenosine. cFFR has higher precision and accuracy than resting indices for predicting FFR. This study aims to compare the diagnostic ability of cFFR against adenosine-derived fractional flow reserve (FFR) in a real-world population. 

METHODS: The PRESSUREwire study (ClinicalTrials.gov identifier: NCT02935088) is a prospective, multicenter, global registry of coronary physiologic measurements during clinically indicated coronary angiography. Paired measurements of cFFR and FFR were prospectively collected and analyzed. cFFR was assessed for diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), areas under the curve (AUC), and correlations compared to FFR. 

RESULTS: The cFFR and FFR were measured in 669 patients from 11 countries. The mean values for FFR and cFFR were 0.85 ± 0.08 and 0.88 ± 0.07, respectively. Based on standard cut-off of cFFR ≤0.83 and FFR ≤0.80 for flow-limiting disease, cFFR had a sensitivity of 69%, specificity of 96%, PPV of 86%, NPV of 90%, overall diagnostic accuracy of 89%, and AUC of 0.931 (0.909 to 0.949; P<.0001). The optimal binary cut-off determined using Youden’s index for cFFR (against FFR ≤0.80) was 0.87. Using the optimal cut-off, cFFR could achieve a sensitivity of 92%, specificity of 81%, PPV of 62%, and NPV of 97%. cFFR was well correlated with FFR (R=0.88; P<.0001). Bland-Altman analysis identified a mean bias of 0.036 (0.011, -0.040).

CONCLUSIONS: Based on this registry, cFFR offers high diagnostic performance and can be used as an alternative method to FFR and resting indices to assess the functional significance of coronary artery disease without the use of adenosine.