Percutaneous coronary intervention of unprotected left main disease: Five-year outcome of a single-center registry

Introduction and AimsPercutaneous coronary intervention (PCI) is increasingly used as a treatment option for unprotected left main coronary artery (ULMCA) lesions. We aimed to evaluate the long-term outcome of patients undergoing ULMCA PCI.Methods and ResultsWe retrospectively analyzed 95 consecutive patients (median EuroSCORE I 2.9 [IQR 1.4;6.1]) who underwent ULMCA PCI between 1999 and 2006, included in a single-center prospective registry. The primary outcome was major adverse cardiovascular events (MACE) defined as all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR) at five years. Forty patients (42.1%) were treated in the setting of acute coronary syndrome and 81 patients (85%) had at least one additional significant lesion (SYNTAX score 24.2±11.8). Single ULMCA PCI was performed in 33% (81.1% with drug-eluting stents) and complete functional revascularization was achieved in 79% of the patients. During the observation period, 20 patients died (21.1%), 6 (6.3%) had MI and 11 (11.6%) had TLR (total combined MACE 28.4%). Independent predictors of MACE were previous MI (HR 2.9 95% CI 1.23–6.92; p=0.015), hypertension (HR 5.7 95% CI 1.86–17.47; p=0.002) and the EuroSCORE I (HR 1.1 95% CI 1.03–1.12; p=0.001). Drug-eluting stent implantation was associated with a significantly lower MACE rate, even after propensity score adjustment (AUC=0.84; HR [corrected] 0.1; 95% CI 0.04–0.26; p<0.001).ConclusionsUnprotected left main percutaneous coronary intervention, particularly using drug-eluting stents, can be considered a valid alternative to coronary artery bypass grafting, especially in high-risk surgical patients and with favorable anatomic features.     

Rescue of trapped Rotablator with knuckle technique for chronic total occlusion

A 71-year-old man with Chagas disease and stable angina on minimum exertion underwent coronary computed tomography angiography and cine angiography that revealed heavily calcified multivessel disease involving the left main artery (LM). Due to the degree of calcification, it was decided to perform rotablation. The first-stage percutaneous coronary intervention (PCI) with rotablation was performed on the LM, left anterior descending artery and second diagonal branch without complications. Almost 30 days later he returned for right coronary artery (RCA) PCI. The proposed strategy was rotational atherectomy in the posterior descending artery (PDA) and right posterolateral artery (RPLA) with a 1.5 mm burr, followed by implantation of two drug-eluting stents (DES). Through right femoral artery access the RPLA lesion was ablated with success. As there were no signs of dissection and TIMI 3 flow was maintained, the 0.009″ RotaWire was repositioned to cross the PDA lesion and debulking of the lesion was performed. After two attempts we succeeded in crossing the lesion with the 1.5 mm burr, however entrapment of the burr ensued. The system was pulled back until the guiding catheter penetrated deep into the RCA, and attempts were made to release the Rotablator by moving it forward and backward, but the burr did not even spin. The contralateral femoral artery was therefore punctured and a 6F JR guiding catheter was inserted, in order to move a guidewire and small angioplasty balloon tangentially to the burr, but without success. Finally we advanced the guidewire using the ‘knuckle’ technique, taking advantage of the kinking of the distal portion of the PT2 guidewire, performing a subintimal dissection and re-entry, and could then easily cross the balloon, inflate it and release the trapped burr. Through the 6F system, two programmed and one bailout DES were successfully implanted in the PDA, RPLA and RCA, obtaining final TIMI 3 flow without complications.     

Percutaneous coronary intervention versus coronary artery bypass grafting in left main coronary artery disease: A review

The left main coronary artery is responsible for most of the irrigation of the left ventricle. Left main coronary artery disease (LMCAD) therefore leads to important morbidity and mortality. Coronary artery bypass grafting (CABG) is considered the standard treatment, however, percutaneous coronary intervention (PCI) has become a frequent alternative in the treatment of LMCAD. In the current review, four randomized clinical trials comparing PCI with CABG in patients with LMCAD, including new longer follow-up results, are reviewed. Major adverse cardiac and cerebrovascular event rates were similar between the two intervention groups in both the SYNTAX and PRECOMBAT trials, and favored the CABG group in the EXCEL and NOBLE trials. The composite of death, stroke and myocardial infarction was similar in all trials. Mortality rates were similar across all trials except for the EXCEL trial at five years, which favored CABG. Cardiac mortality was similar in all trials. Stroke rates were similar, apart from the SYNTAX trial, which favored PCI. CABG was more favorable concerning myocardial infarction in the NOBLE trial, but not in the other trials. Repeat revascularization was generally less frequent in the CABG group. Stent thrombosis and graft occlusion were less frequent with PCI in the EXCEL trial, with no differences in the other trials. Based on the overall similarity in the primary endpoint rates, as well as favorable short-term outcomes, it is plausible to state that PCI can be considered a good alternative to CABG, although the higher risk of repeat revascularization should be taken into consideration.     

Coronary artery perforations: Four different cases and a review

Coronary artery perforation (CAP) is a rare but feared complication of percutaneous coronary intervention. With the advent of new devices and technologies, interventionalists attempt more complex lesions, including more calcified or tortuous vessels and chronic total occlusions, which increases the incidence of CAP. A short literature review, in addition to four cases of CAP, is presented in this report.     

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

IntroductionPatients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min.ObjectivesTo assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI.MethodsWe performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017.ResultsMedian DIDO time was 82 min (interquartile range, 61–132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062–1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011).ConclusionA DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.     

Spontaneous coronary artery dissection: A single-center case series and literature review

Background

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome (ACS). Better recognition and diagnosis has raised awareness of this condition. However, the pathophysiology of SCAD and its prognosis are still little understood. We aimed to investigate the characteristics and prognosis of patients with SCAD, and subsequently performed a review of literature.

The CTo-aBCDE score: A new predictor of success in chronic total occlusions

IntroductionPatient selection for percutaneous coronary intervention (PCI) in chronic total occlusions (CTOs) is crucial to procedural success. Our aim was to identify independent predictors of success in CTO PCI in order to create an accurate score.MethodsIn a single-center observational registry of CTO PCI, demographic and clinical data and anatomical characteristics of coronary lesions were recorded. Linear and logistic regression analysis were used to identify predictors of success. A score to predict success was created and its accuracy was measured by receiver operating curve analysis.ResultsA total of 377 interventions were performed (334 patients, age 68±11 years, 75% male). The success rate was 65% per patient and 60% per procedure. Predictors of success in univariate analysis were absence of active smoking (OR 2.02, 95% CI 1.243-3.29; p=0.005), presence of tapered stump (OR 5.2, 95% CI 2.7-10.2; p<0.001), absence of tortuosity (OR 6.44; 95% CI 3.02-13.75; p<0.001), absence of bifurcation (OR 1.95; 95% CI 1.08-3.51; p=0.026), absence of calcification (OR 3.1; 95% CI 3.10-5.41; p<0.001), LAD as target vessel (OR 1.9, 95% CI 1.0-3.5; p=0.048), and CTO length <20 mm (OR 3.00, 95% CI 1.69-5.3; p<0.001). Only anatomical factors were independent predictors of success, and an anatomical score (0-11 points) with high accuracy (area under the curve 0.831) was subsequently created. A score <3 was associated with low probability of success (15%), 3-8 with intermediate probability (55%), and >8 with high probability (95%).ConclusionIn our sample only anatomical characteristics were predictors of success. The creation of a score to predict success, with good accuracy, may enable selection of cases that can be treated by any operator, those in which a dedicated operator will be desirable, and those with an extremely low probability of success, which should be considered individually for conservative management, surgical revascularization or PCI by a team experienced in CTO.     

Impact of the COVID-19 pandemic on percutaneous coronary interventions in Portugal

IntroductionThe COVID-19 pandemic has imposed an unprecedented burden on healthcare systems worldwide, changing the profile of interventional cardiology activity.ObjectivesTo quantify and compare the number of percutaneous coronary interventions (PCIs) performed for acute and chronic coronary syndromes during the first COVID-19 outbreak with the corresponding period in previous years.MethodsData on PCI from the prospective multicenter Portuguese Registry on Interventional Cardiology (RNCI) were used to analyze changes in PCI for ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndromes (NSTE-ACS) and chronic coronary syndromes (CCS). The number of PCIs performed during the initial period of the COVID-19 outbreak in Portugal, from March 1 to May 2, 2020, was compared with the mean frequency of PCIs performed during the corresponding period in the previous three years (2017–2019).ResultsThe total number of PCIs procedures was significantly decreased during the initial COVID-19 outbreak in Portugal (?36%, p<0.001). The reduction in PCI procedures for STEMI, NSTE-ACS and CCS was, respectively, ?25% (p<0.019), ?20% (p<0.068) and ?59% (p<0.001).ConclusionsCompared with the corresponding period in the previous three years, the number of PCI procedures performed for STEMI and CCS decreased markedly during the first wave of the COVID-19 pandemic in Portugal.     

The impact of the COVID-19 pandemic on acute coronary syndrome admissions to a tertiary care hospital in Portugal

Introduction and objectivesThe coronavirus SARS-CoV-2 (COVID-19) pandemic has been an unmatched challenge to global healthcare. Although the majority of patients admitted with acute coronary syndrome (ACS) may not be infected with COVID-19, the quarantine and public health emergency measures may have affected this particular high risk group. The objective of this study is to assess the impact of the early period of the COVID-19 pandemic on ACS admissions and clinical course in a tertiary care hospital in Portugal's most affected region.MethodsThis retrospective, case-control study included patients admitted with a diagnosis of ACS during March and April 2020 (pandemic group) and in the same period in 2019 (control group). Clinical course and complications were also assessed.ResultsDuring the pandemic, there were fewer ACS admissions but presentation was more severe, with a larger proportion of acute ST-elevation myocardial infarctions (54.9% vs. 38.8%, p=0.047), higher maximum troponin levels and greater prevalence of left ventricular systolic dysfunction at discharge (58.0% vs. 35.0%, p=0.01). In this population, although not statistically significant, it was observed a delay between the onset of symptoms and percutaneous coronary intervention, which may traduce a deferred search for urgent medical care during the pandemic.ConclusionThe lockdown phase of COVID-19 pandemic was associated with fewer and more severe ACS in a Tertiary Care Hospital in Portugal's most affected region by the pandemic.     

Congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery: An interesting case report

Intercoronary communication is a very rare coronary artery anomaly. It is defined as an open-ended circulation with bidirectional blood flow between two coronary arteries. Coronary artery fistulas are abnormal communications between a coronary artery and a cardiac chamber or major vessel. A 62-year-old man was admitted to our hospital with sudden development of general weakness, dizziness and a sensation of compression in his chest. At presentation his blood pressure was 80/40 mmHg and heart rate was 65 beats/min. The ECG revealed sinus rhythm and 1–2 mm ST elevation in the anterior leads. The patient was taken to the catheterization laboratory for percutaneous coronary intervention. The left main and left circumflex coronary arteries were normal. Coronary angiography showed a communication between the left main and the diagonal branch of the left anterior descending and a fistula between the intercoronary connection and the left atrium. The other coronary arteries were normal. Laboratory test results, including cardiac troponin I and creatine kinase–MB levels, were normal. The angina symptoms disappeared and the ST elevation resolved within four hours. We report an interesting case of congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery presenting as an acute coronary syndrome. To the best of our knowledge, this is the first case in the literature involving a coronary artery fistula in an intercoronary communication.     

Impella support for cardiogenic shock and high-risk percutaneous coronary intervention: A single-center experience

Introduction and ObjectivesThe use of mechanical circulatory support is increasing in cases of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The Impella® is a percutaneous ventricular assist device that unloads the left ventricle by ejecting blood to the ascending aorta. We report our center's experience with the use of the Impella® device in these two clinical settings.MethodsWe performed a single-center retrospective study including all consecutive patients implanted with the Impella® between 2007 and 2019 for CS treatment or prophylactic support of HR-PCI. Data on clinical and safety endpoints were collected and analyzed.ResultsTwenty-two patients were included: 12 were treated for CS and 10 underwent an HR-PCI procedure. In the CS-treated population, the main cause of CS was acute myocardial infarction (five patients); hemolysis was the most frequent device-related complication (63.7%). In-hospital, cumulative 30-day and one-year mortality were 58.3%, 66.6% and 83.3%, respectively. In the HR-PCI group, all patients had multivessel disease (mean baseline SYNTAX I score: 44.1±13.7). In-hospital, 30-day and one-year mortality were 10.0%, 10.0% and 20.0%, respectively. There were no device- or procedure-related deaths in either group.ConclusionThe short- and long-term results of Impella®-supported HR-PCI were comparable to those in the literature. In the CS group, in-hospital and short-term outcomes were poor, with high mortality and non-negligible complication rates.     

Development of deep learning segmentation models for coronary X-ray angiography: Quality assessment by a new global segmentation score and comparison with human performance

Introduction and objectivesAlthough automatic artificial intelligence (AI) coronary angiography (CAG) segmentation is arguably the first step toward future clinical application, it is underexplored. We aimed to (1) develop AI models for CAG segmentation and (2) assess the results using similarity scores and a set of criteria defined by expert physicians.MethodsPatients undergoing CAG were randomly selected in a retrospective study at a single center. Per incidence, an ideal frame was segmented, forming a baseline human dataset (BH), used for training a baseline AI model (BAI). Enhanced human segmentation (EH) was created by combining the best of both. An enhanced AI model (EAI) was trained using the EH. Results were assessed by experts using 11 weighted criteria, combined into a Global Segmentation Score (GSS: 0–100 points). Generalized Dice Score (GDS) and Dice Similarity Coefficient (DSC) were also used for AI models assessment.Results1664 processed images were generated. GSS for BH, EH, BAI and EAI were 96.9+/-5.7; 98.9+/-3.1; 86.1+/-10.1 and 90+/-7.6, respectively (95% confidence interval, p<0.001 for both paired and global differences). The GDS for the BAI and EAI was 0.9234±0.0361 and 0.9348±0.0284, respectively. The DSC for the coronary tree was 0.8904±0.0464 and 0.9134±0.0410 for the BAI and EAI, respectively. The EAI outperformed the BAI in all coronary segmentation tasks, but performed less well in some catheter segmentation tasks.ConclusionsWe successfully developed AI models capable of CAG segmentation, with good performance as assessed by all scores.     

The role of Impella in high-risk percutaneous coronary intervention

Percutaneous coronary intervention (PCI) has been increasingly performed in patients with severely depressed left ventricular function and complex coronary lesions, including multivessel disease.Mechanical ventricular assist devices play an increasingly important role in high-risk PCI. Impella CP^® (Abiomed, Inc.) is a new percutaneous left ventricular assist device, designed for short-term circulatory support. It is a promising option for hemodynamic support in high-risk procedures and can potentially reduce PCI-related complications.The authors present two case reports of high-risk PCI using the Impella CP^® device.In the setting of low coronary flow reserve, severely depressed left ventricular function and potential hemodynamic instability, the Impella CP^® device has made it possible to maintain hemodynamic stability during procedures, without being associated with vascular complications.     

The use of reperfusion and revascularization procedures in acute coronary syndrome in Portugal: A systematic review

Introduction and ObjectivesReperfusion and revascularization therapies play an important role in the management of coronary heart disease and have contributed to decreases in case fatality rates. We aimed to describe the use of these therapies for the treatment of acute coronary syndrome (ACS) patients over time in Portugal.MethodsPubMed was searched in July 2012. The proportion of patients treated with fibrinolysis, primary percutaneous coronary intervention (PCI), any PCI and coronary artery bypass grafting (CABG) was described according to type of ACS: STEMI (≥90% patients with ST-segment elevation or Q-wave myocardial infarction), NSTE-ACS (≥90% patients with non-ST-segment elevation ACS) and mixed ACS (all others).ResultsWe identified 41 eligible studies, published between 1989 and 2011. Twenty-eight reported on samples considered representative of ACS patients treated in Portugal. The small number of estimates of the use of each treatment in STEMI and NSTE-ACS patients precluded identification of any time trend. In the last 20 years, the proportion of mixed ACS patients treated with fibrinolysis decreased and the use of PCI increased, while the use of CABG did not change.ConclusionsThe general pattern of the use of reperfusion and revascularization is in accordance with that reported in other developed countries, reflecting a favorable trend in the quality of care of ACS patients. The relatively small number of estimates on the same procedure in comparable patients limits the generalizability of the conclusions, and highlights the need for systematic approaches to monitor the use of treatments over time.     

Adoption and patterns of use of invasive physiological assessment of coronary artery disease in a large cohort of 40 821 real-world procedures over a 12-year period

Introduction and ObjectivesUse of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame.MethodsWe retrospectively determined the per-procedure prevalence of physiological assessment in 40 821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed.ResultsOverall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages <40, 40-55 and >55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology.ConclusionsOur study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes.     

Impact of a brief psychological intervention on lifestyle,risk factors and disease knowledge during phase I of cardiac rehabilitation after acute coronary syndrome

IntroductionThis study examined the efficacy of a brief inpatient psychoeducational intervention on knowledge about acute coronary syndromes (ACS), control of risk factors, and adaptive health habits and lifestyle. The intervention was intended to facilitate rehabilitation after ACS and its short- and medium-term impact was assessed.MethodsOne hundred and twenty-one patients with ACS, admitted to a central cardiology unit in Portugal, were randomized to an experimental group (EG, n=65) or a control group (CG, n=56). We used the Portuguese versions of the Knowledge Questionnaire and the Health Habits Questionnaire. Patients were assessed at hospital admission, hospital discharge and one- and two-month follow-up.ResultsThe intervention had a significant impact, increasing knowledge about ACS (F=500.834; p=0.000) in the EG, which was maintained at two-month follow-up, and changing health habits at two-month follow-up (F=218.129; p=0.000). The CG demonstrated decreased knowledge (F=3.368; p=0.069) during the same period.ConclusionsA brief inpatient psychoeducational intervention has a positive effect on knowledge about ACS, risk factor control and promotion of positive health habits, and is effective in improving cardiac rehabilitation.     

Functional assessment of coronary artery disease by intravascular ultrasound and computational fluid dynamics simulation

Clinical trials have shown that functional assessment of coronary stenosis by fractional flow reserve (FFR) improves clinical outcomes. Intravascular ultrasound (IVUS) complements conventional angiography, and is a powerful tool to assess atherosclerotic plaques and to guide percutaneous coronary intervention (PCI). Computational fluid dynamics (CFD) simulation represents a novel method for the functional assessment of coronary flow. A CFD simulation can be calculated from the data normally acquired by IVUS images. A case of coronary heart disease studied with FFR and IVUS, before and after PCI, is presented. A three-dimensional model was constructed based on IVUS images, to which CFD was applied. A discussion of the literature concerning the clinical utility of CFD simulation is provided.