Transcatheter aortic valve replacement (TAVR) has revolutionized the management of patients with symptomatic severe aortic stenosis, and indications are expanding towards treating younger patients ...with lower-risk profiles. Given the progressive nature of coronary artery disease and its high prevalence in those with severe aortic stenosis, coronary angiography and percutaneous coronary intervention will become increasingly necessary in patients after TAVR. There are some data suggesting that there are technical difficulties with coronary re-engagement, particularly in patients with self-expanding valves that, by design, extend above the coronary ostia. The authors review the challenges of coronary angiography and percutaneous coronary intervention post-TAVR and examine the geometric interactions between currently approved transcatheter aortic valves and coronary ostia, while providing a practical guide on how to manage these potentially complex situations.
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Bleeding following percutaneous coronary intervention has important prognostic implications. The Academic Research Consortium (ARC) recently proposed a list of clinical criteria to define patients at ...high bleeding risk (HBR).
This study sought to validate the ARC definition for HBR patients in a contemporary real-world cohort.
Patients undergoing coronary stenting between 2014 and 2017 at a tertiary-care center were defined as HBR if they met at least 1 major or 2 minor ARC-HBR criteria. To account for the presence of multiple criteria, patients were further stratified by the number of times they fulfilled the ARC-HBR definition. The primary endpoint was a composite of peri-procedural in-hospital or post-discharge bleeding at 1 year. Secondary endpoints included individual components of the primary bleeding endpoint, myocardial infarction, and all-cause mortality.
Among 9,623 patients, 4,278 (44.4%) qualified as HBR. Moderate or severe anemia was the most common major criterion (33.2%); age ≥75 years was the most frequent minor criterion and the most common overall (46.8%). The rate of the primary bleeding endpoint at 1 year was 9.1% in HBR patients compared with 3.2% in non-HBR patients (p < 0.001), with a stepwise increase in bleeding risk corresponding to the number of times the ARC-HBR definition was fulfilled. HBR patients also experienced significantly higher rates of all secondary endpoints.
This study validates the ARC-HBR definition in a contemporary group of patients who underwent percutaneous coronary intervention. The ARC-HBR definition identified patients at increased risk not only for bleeding but also for thrombotic events, including all-cause mortality. Coexistence of multiple ARC-HBR criteria showed additive prognostic value.
Current Status of Rotational Atherectomy Tomey, Matthew I., MD; Kini, Annapoorna S., MD; Sharma, Samin K., MD
JACC. Cardiovascular interventions,
04/2014, Letnik:
7, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Rotational atherectomy facilitates percutaneous coronary intervention for complex de novo lesions with severe calcification. A strategy of routine rotational atherectomy has not, however, conferred ...reduction in restenosis or major adverse cardiac events. As it is technically demanding, rotational atherectomy is also uncommon. At this 25-year anniversary since the introduction of rotational atherectomy, we sought to review the current state-of-the-art in rotational atherectomy technique, safety, and efficacy data in the modern era of drug-eluting stents, strategies to prevent and manage complications, including slow-flow/no-reflow and burr entrapment, and appropriate use in the context of the broader evolution in the management of stable ischemic heart disease. Fundamental elements of optimal technique include use of a single burr with burr-to-artery ratio of 0.5 to 0.6-rotational speed of 140,000 to 150,000 rpm, gradual burr advancement using a pecking motion, short ablation runs of 15 to 20 s, and avoidance of decelerations >5,000 rpm. Combined with meticulous technique, optimal antiplatelet therapy, vasodilators, flush solution, and provisional use of atropine, temporary pacing, vasopressors, and mechanical support may prevent slow-flow/no-reflow, which in contemporary series is reported in 0.0% to 2.6% of cases. On the basis of the results of recent large clinical trials, a subset of patients with complex coronary artery disease previously assigned to rotational atherectomy may be directed instead to medical therapy alone or bypass surgery. For patients with de novo severely calcified lesions for which rotational atherectomy remains appropriate, referral centers of excellence are required.
The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is unclear, and its risks and benefits may vary according to DES generation.
The goal of this ...study was to evaluate the efficacy and safety of DAPT after DES implantation.
We included randomized controlled trials that tested different durations of DAPT after DES implantation: shorter dual antiplatelet therapy (S-DAPT) was defined as the per-protocol minimum duration of DAPT after the procedure, and longer dual antiplatelet therapy (L-DAPT) was defined as the per-protocol period of more prolonged DAPT. The primary efficacy and safety outcomes were definite/probable stent thrombosis and clinically significant bleeding (CSB), respectively.
Ten randomized controlled trials (N = 32,135) were included. Compared with L-DAPT, S-DAPT had an overall higher rate of stent thrombosis (odds ratio OR: 1.71 95% confidence interval (CI): 1.26 to 2.32; p = 0.001). The effect of S-DAPT on stent thrombosis was attenuated with the use of second-generation DES (OR: 1.54 95% CI: 0.96 to 2.47) compared with the use of first-generation DES (OR: 3.94 95% CI: 2.20 to 7.05; p for interaction = 0.008). S-DAPT had an overall significantly lower risk of CSB (OR: 0.63 95% CI: 0.52 to 0.75; p < 0.001). Finally, a numerically lower all-cause mortality rate was observed with S-DAPT (OR: 0.87 95% CI: 0.74 to 1.01; p = 0.073).
S-DAPT had overall lower rates of bleeding yet higher rates of stent thrombosis compared with L-DAPT; the latter effect was significantly attenuated with the use of second-generation DES, although the analysis may have been limited by the varying DAPT durations among studies. All-cause mortality was numerically higher with L-DAPT without reaching statistical significance. Prolonging DAPT requires careful assessment of the trade-off between ischemic and bleeding complications.
Abstract
Aims
The prognostic importance of cardiac procedural myocardial injury and myocardial infarction (MI) in chronic coronary syndrome (CCS) patients undergoing elective percutaneous coronary ...intervention (PCI) is still debated.
Methods and results
We analysed individual data of 9081 patients undergoing elective PCI with normal pre-PCI baseline cardiac troponin (cTn) levels. Multivariate models evaluated the association between post-PCI elevations in cTn and 1-year mortality, while an interval analysis evaluated the impact of the size of the myocardial injury on mortality. Our analysis was performed in the overall population and also according to the type of cTn used 52.0% had high-sensitivity cTn (hs-cTn). Procedural myocardial injury, as defined by the Fourth Universal Definition of MI (UDMI) post-PCI cTn elevation ≥1 × 99th percentile upper reference limit (URL), occurred in 52.8% of patients and was not associated with 1-year mortality adj odds ratio (OR), 1.35, 95% confidence interval (CI) (0.84–1.77), P = 0.21. The association between post-PCI cTn elevation and 1-year mortality was significant starting ≥3 × 99th percentile URL. Major myocardial injury defined by post-PCI ≥5 × 99th percentile URL occurred in 18.2% of patients and was associated with a two-fold increase in the adjusted odds of 1-year mortality 2.29, 95% CI (1.32–3.97), P = 0.004. In the subset of patients for whom periprocedural evidence of ischaemia was collected (n = 2316), Type 4a MI defined by the Fourth UDMI occurred in 12.7% of patients and was strongly associated with 1-year mortality adj OR 3.21, 95% CI (1.42–7.27), P = 0.005. We also present our results according to the type of troponin used (hs-cTn or conventional troponin).
Conclusion
Our analysis has demonstrated that in CCS patients with normal baseline cTn levels, the post-PCI cTn elevation of ≥5 × 99th percentile URL used to define Type 4a MI is associated with 1-year mortality and could be used to detect ‘major’ procedural myocardial injury in the absence of procedural complications or evidence of new myocardial ischaemia.
Graphical Abstract
Rotational atherectomy (RA) is an established tool in interventional cardiology for treatment of calcified coronary lesions. Over 3 decades of clinical experience and research, techniques have ...matured and outcomes have improved. Heterogeneity exists, however, in RA utilization and technique. We assembled a group of experienced RA operators and device experts to summarize and critique key elements of contemporary RA technique, to identify areas of consensus and controversy, and to offer recommendations for optimal performance for the practicing interventional cardiologist. Evolution in RA strategy toward a focus on lesion modification to facilitate balloon angioplasty and stenting has underpinned major advances in procedural safety, including opportunity to use smaller caliber equipment and radial access. Optimal technique and improved safety have permitted exploratory use of RA for different lesion types and reevaluation of procedural requirements, including flush solution composition and transvenous pacing. Preparedness to manage complications remains paramount and recommendations for operators and institutions are outlined.
Abstract Dyslipidemia is the most important atherosclerotic risk factor. Review of population based studies in India shows increasing mean total cholesterol levels. Recent studies have reported that ...high cholesterol is present in 25–30% of urban and 15–20% rural subjects. This prevalence is lower than high-income countries. The most common dyslipidemia in India are borderline high LDL cholesterol, low HDL cholesterol and high triglycerides. Studies have reported that over a 20-year period total cholesterol, LDL cholesterol and triglyceride levels have increased among urban populations. Case-control studies have reported that there is significant association of coronary events with raised apolipoproteinB, total cholesterol, LDL cholesterol and non-HDL cholesterol and inverse association with high apolipoproteinA and HDL cholesterol. Prevalence of suspected familial hypercholesterolemia in urban subjects varies from 1:125 to 1:450. Only limited studies exist regarding lipid abnormalities in children. There is low awareness, treatment and control of hypercholesterolemia in India.
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