Validation of a definition of excessive postoperative bleeding in infants undergoing cardiac surgery with cardiopulmonary bypass

Objective

To derive and validate an objective definition of postoperative bleeding in neonates and infants undergoing cardiac surgery with cardiopulmonary bypass.

An algorithmic approach to balloon-uncrossable coronary lesions

Balloon uncrossable coronary lesions are lesions that cannot be crossed with a balloon after successful guidewire crossing. The strategies used to facilitate the treatment of such lesions can be classified into strategies that provide lesion modification and strategies that increase support. We describe a systematic, algorithmic approach to treat balloon uncrossable lesions, starting with use of small balloons, followed by increase in guide catheter support, use of microcatheters, wire cutting or puncture techniques, laser, atherectomy, and subintimal modification techniques. Sequential and simultaneous application of the aforementioned techniques can result in successful treatment of these challenging lesions.     

A Contemporary Definition of Periprocedural Myocardial Injury After Percutaneous Coronary Intervention of Chronic Total Occlusions

ObjectivesThe aim of this study was to assess the prognostic impact of post-procedural troponin T increase and mortality in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) to define the threshold at which procedure-related myocardial injury drives mortality.BackgroundCoronary CTO recanalization represents the most technically challenging PCI. The complexity harbors a significant increased risk for complications with CTO PCI with compared with non-CTO PCI. However, there are evidenced biomarker cutoff levels that help identify those patients at risk for unfavorable clinical outcomes.MethodsA total of 3,712 consecutive patients undergoing PCI for at least 1 CTO lesion were enrolled, and comprehensive troponin T measurements were performed 6, 8, and 24 h after the procedure. All-cause mortality was defined as the primary study endpoint.ResultsUsing spline curve analysis, a more than 18-fold increase of troponin above the upper reference limit was significantly associated with mortality. In a Cox regression analysis, the crude hazard ratio was 2.32 (95% confidence interval: 1.83 to 2.93; p < 0.001) for a ≥18-fold increase compared with patients with post-procedural troponin increase <18-fold of the upper reference limit. Results remained virtually unchanged after bootstrap- or clinical confounder–based adjustment.ConclusionsThis large-scale outcome study demonstrates for the first time the prognostic value of post-procedural troponin T elevation after PCI in patients with CTOs. A threshold was defined for procedure-related myocardial injury in patients with CTOs to differentiate them from those without CTOs that may help guide post-procedural clinical care in this high-risk patient population.     

Coronary lithotripsy for failed rotational atherectomy,cutting balloon,scoring balloon,and ultra‐high‐pressure non‐compliant balloon

Calcified and undilatable stenosis still represents a challenge in percutaneous coronary interventions (PCI), due to the higher risk of suboptimal result with consequent worse clinical outcomes. Unfortunately, the dedicated technologies and devices, such as specialized balloon and atherectomy systems, do not always provide adequate plaque modification and optimal vessel preparation allowing optimal stent delivery. The intravascular lithotripsy (IVL) is a technology derived from urology that has been tested in peripheral and coronary calcified plaques, with promising preliminary results. We present a case of a patient undergoing planned PCI of the right coronary artery targeting an undilatable lesion, already resistant to both specialized balloons and rotational atherectomy. Using the IVL system, we were able to break the calcium, guarantying optimal stent expansion with good final result.     

Saphenous Vein Graft Sacrifice Following Native Vessel PCI is Safe and Associated with Favourable Longer-Term Outcomes

BackgroundCompetitive flow from saphenous vein grafts (SVG) that remain patent following percutaneous coronary intervention (PCI) of the native vessel may compromise durability of the reconstructed vessel. SVG sacrifice has been advocated, but the safety and longer-term outcomes of this are unknown.MethodsWe retrospectively reviewed all post-bypass patients who following successful PCI of the native vessel underwent attempted saphenous vein graft (SVG) closure between January 2014 and July 2018 in two institutions. The co-primary end-points of interest were safety and target lesion failure (TLF), defined as a composite of cardiac death, target vessel recurrent myocardial infarction or clinically driven target lesion revascularisation (TLR).ResultsOf the 33 consecutive patients included, the reconstructed native vessel was a chronic total occlusion (CTO) in 93.9% of patients (n = 31) with a mean J-CTO score of 3.2 (±1.1) SVG closure was successful in 97.0% of patients (n = 32). Amplatzer Vascular Plugs (AVP; Abbott Vascular) were used in all patients with most grafts closed by a single plug (72.7%). The average procedure time was 20.1 min with evidence of a short learning curve. Over a mean follow up of 602 (±393) days from the date of SVG closure, the incidence of TLF was 9.1% (n = 3). There was an additional case of targe vessel failure (TVF) due to progression of native vessel disease not treated at the index procedure. SVG closure resulted in only 1 episode of “slow flow” that was transient and self-resolving. There were no other associated peri-procedural or in-hospital complications.ConclusionFollowing native vessel PCI, SVG sacrifice may be considered to terminate the potentially deleterious effects of residual competitive flow. In selected cases, this approach achieves high success rate and favourable longer-term outcomes.