The Current Landscape of Artificial Intelligence in Imaging for Transcatheter Aortic Valve Replacement

Purpose

This review explores the current landscape of AI applications in imaging for TAVR, emphasizing the potential and limitations of these tools for (1) automating the image analysis and reporting process, (2) improving procedural planning, and (3) offering additional insight into post-TAVR outcomes. Finally, the direction of future research necessary to bridge these tools towards clinical integration is discussed.

Recent Findings

Transcatheter aortic valve replacement (TAVR) has become a pivotal treatment option for select patients with severe aortic stenosis, and its indication for use continues to broaden. Noninvasive imaging techniques such as CTA and MRA have become routine for patient selection, preprocedural planning, and predicting the risk of complications. As the current methods for pre-TAVR image analysis are labor-intensive and have significant inter-operator variability, experts are looking towards artificial intelligence (AI) as a potential solution.

Summary

AI has the potential to significantly enhance the planning, execution, and post-procedural follow up of TAVR. While AI tools are promising, the irreplaceable value of nuanced clinical judgment by skilled physician teams must not be overlooked. With continued research, collaboration, and careful implementation, AI can become an integral part in imaging for TAVR, ultimately improving patient care and outcomes.

Inequalities in access to and outcomes of cardiac surgery in England: retrospective analysis of Hospital Episode Statistics (2010-2019)

BACKGROUND

We aimed to characterise the variation in access to and outcomes of cardiac surgery for people in England.

METHODS

We included people >18 years of age with hospital admission for ischaemic heart disease (IHD) and heart valve disease (HVD) between 2010 and 2019. Within these populations, we identified people who had coronary artery bypass graft (CABG) and/or valve surgery, respectively. We fitted logistic regression models to examine the effects of age, sex, ethnicity and socioeconomic deprivation on having access to surgery and in-hospital mortality, 1-year mortality and hospital readmission.

RESULTS

We included 292 140 people, of whom 28% were women, 11% were from an ethnic minority and 17% were from the most deprived areas. Across all types of surgery, one in five people are readmitted to hospital within 1 year, rising to almost one in four for valve surgery. Women, black people and people living in the most deprived areas were less likely to have access to surgery (CABG: 59%, 32% and 35% less likely; valve: 31%, 33% and 39% less likely, respectively) and more likely to die within 1 year of surgery (CABG: 24%, 85% and 18% more likely, respectively; valve: 19% (women) and 10% (people from most deprived areas) more likely).

CONCLUSIONS

Female sex, black ethnicity and economic deprivation are independently associated with limited access to cardiac surgery and higher post-surgery mortality. Actions are required to address these inequalities.

Microcatheter tip fracture and acute vessel occlusion rescued with subintimal tracking and re-entry: Move the tip

The development of microcatheters capable of advancing through long, calcified, and tortuous vessels, produced an increase in the success rate of complex percutaneous coronary interventions. However, the aggressive manipulation of these materials may lead to potentially severe and threatening complications. We present a case of Turnpike Spiral (Teleflex) tip fracture, which caused an acute occlusion of the proximal right coronary artery. The coronary artery was tortuous and had two heavily calcified lesions in the proximal segment, uncrossable to both small angioplasty balloons and standard microcatheters. After the incarceration of the tip of the Turnpike Spiral in the calcium, it got fractured during the attempt of removing it from the vessel. This led to ST-segment elevation and patient instability. Due to the impossibility of advancing a second guidewire into the true lumen, we decided to proceed to antegrade dissection and re-entry using the scratch-and-go and subintimal tracking and re-entry technique. We placed a guide-extension and we used a Gaia II (Asahi Intecc) to enter the subintimal space and advance over the fractured tip. The wire was exchanged for a Gladius MG (Asahi Intecc), which re-entered the true lumen at the level of the acute margin of the heart. Intravascular ultrasound was used to confirm the re-entry point, and three drug eluting stents were placed. In this way we rapidly restored the flow in the right coronary artery, and we prevented a myocardial infarction.

Management of Acute Coronary Syndrome in Elderly Patients: A Narrative Review through Decisional Crossroads

Diagnosis and treatment of acute coronary syndrome (ACS) pose particular challenges in elderly patients. When high troponin levels are detected, the distinction between non-ischemic myocardial injury (NIMI), type 1, and type 2 myocardial infarction (MI) is the necessary first step to guide further care. However, the assessment of signs of ischemia is hindered in older patients, and no simple clinical or laboratory tool proved useful in this discrimination task. Current evidence suggests a benefit of an invasive vs. conservative approach in terms of recurrence of MI, with no significant impact on mortality. In patients with multivessel disease in which the culprit lesion has been treated, a physiology-guided complete percutaneous revascularization significantly reduced major events. The management of ACS in elderly patients is an example of the actual need for a multimodal, thorough clinical approach, coupled with shared decision-making, in order to ensure the best treatment and avoid futility. Such a need will likely grow throughout the next decades, with the aging of the world population. In this narrative review, we address pivotal yet common questions arising in clinical practice while caring for elderly patients with ACS.

Prevention of radial artery occlusion after transradial angiography and intervention: a best practice implementation project

INTRODUCTION

Among the complications associated with transradial artery access, radial artery occlusion (RAO) is the most frequent and serious, limiting the reuse of the same radial artery for subsequent procedures and as a graft for coronary artery bypass grafting.

OBJECTIVE

The objective of this project was to implement best practices to reduce the incidence of RAO, thereby enhancing the quality of patient care after transradial coronary angiography or intervention.

METHODS

The project was conducted in cardiology department of the Huadong Hospital, Shanghai, China. The seven-phase JBI Evidence Implementation Framework was used to guide the project. Eight audit criteria were developed and a baseline audit was conducted to compare current practice with best practices for RAO prevention. Following the implementation of improvement strategies, a follow-up audit was conducted to evaluate the success of the strategies.

RESULTS

The implementation of best practices led to significant improvements in reducing the sheath/catheter size and systematically assessing radial artery patency before discharge, with both criteria reaching 100% compliance. The use of prophylactic ulnar compression increased from 0% to 90%, and the adoption of a minimal pressure strategy improved from 0% to 70%. The use of pre-puncture and post-procedural pre-hemostasis nitrates also increased from 23% to 93%. Barriers to implementation included the lack of dedicated devices for prophylactic ulnar artery compression, the possibility of bleeding after removal of the compression device, absence of an evidence-based care workflow, and absence of nursing assessment record forms for RAO prevention.

CONCLUSIONS

This project promoted evidence-based practices among nurses for the care of RAO patients following transradial angiography and intervention. Efforts should be made to sustain the best practices in the future.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A261.

Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis

Importance

The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate.

Objectives

To analyze the efficacy and safety of DAPT strategies in patients with ACS using a bayesian network meta-analysis.

Data Sources

MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024.

Study Selection

Randomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing PCI were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT.

Data Extraction and Synthesis

This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA).

Main Outcomes and Measures

The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding.

Results

A total of 15 RCTs randomizing 35 326 patients (mean [SD] age, 63.1 [11.1] years; 26 954 male [76.3%]; 11 339 STEMI [32.1%]) with ACS were included. A total of 24 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21).

Conclusion and Relevance

Results of this systematic review and network meta-analysis reveal that, in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT. However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.

Preferences of patients with multiple chronic diseases for medication in rural areas of an Eastern Province China: a discrete choice experiment

Background

Multiple Chronic Diseases (MCD) are the co-occurrence of two or more chronic conditions within an individual. Compared to patients with a single chronic disease, those with MCD face challenges related to polypharmacy, which increases the risk of adverse drug events, side effects, and drug-drug interactions. Understanding the specific medication preferences of patients with MCD is crucial to optimize treatment plans and enhance treatment safety.

Objective

This study aims to evaluate the medication preferences among patients with multiple chronic diseases in rural areas of an eastern province of China.

Methods

A discrete choice experiment (DCE) was used to measure patients' medication preferences. According to literature research, expert panel discussions, and in-depth patient interviews, we identified six attributes: monthly out-of-pocket cost, onset speed of action, adverse effects, whether it is covered by health insurance, origin of medications, and types of medications. The conditional logit models (CLM) and mixed logit models (MIXL) were used to evaluate the choice data. Willingness to pay (WTP) was used to reflect the monetary value that patients were willing to pay or receive reimbursement after changes in different attribute levels.

Results

A total of 956 respondents were included in the analysis. Of which, 68.62% were female, with an average age of 68 years, and 65.89% had a Body Mass Index (BMI) greater than or equal to 24. Statistical significance was observed for all attributes (p < 0.001). The preferred medication for patients encompassed low monthly out-of-pocket costs, rapid onset of action, rare adverse effects, and a preference for Western medicine, health insurance-covered medication and domestic medication. The onset speed of action was a primary consideration for patients, who demonstrated a willingness to pay an additional CNY151.37 per month for a medication with a rapid onset of action.

Conclusion

Rural patients with multiple chronic diseases preferred medications with rapid onset, rare adverse, Western medications, domestic medication, and health insurance-covered medication. Medical staff can effectively combine the Health Belief Model (HBM) to help patients with multiple chronic diseases improve their confidence and understanding of medication selection, to improve their health management.

Long-term outcomes of DCB and DES for the treatment of in-stent restenosis in relation to the vessel size

BACKGROUND

Percutaneous coronary intervention (PCI) with drug-coated balloons (DCB) or drug-eluting stents (DES) are well-established treatments for in-stent restenosis, however little is known about the impact of vessel size on the outcomes. The study aimed to evaluate the efficacy and safety profile of DCB versus DES in DES in-stent restenosis depending on the vessel size.

METHODS

Consecutive patients with DES in-stent restenosis who underwent PCI between January 2010 and February 2018 entered the registry with a long-term follow-up. Patients who received DCB at the index procedure were compared with those who received DES in three subgroups depending on the vessel size (≤2.5 mm; 2.5-3.5 mm; >3.5 mm). Data were analyzed using propensity score matching and Kaplan-Meier estimator plots.

RESULTS

Among 1,374 patients with DES in-stent restenosis, 615 were treated with DES and 759 with DCB. After propensity score matching, we analyzed 752 patients in the DES and DCB groups at a long-term follow-up. The risk of DOCE did not differ significantly between the DES and DCB groups, both in the overall population (HR 0.85; 95%CI [0.58; 1.26], log-rank p = 0.41) and when divided into small (HR 0.84; 95%CI [0.36; 1.95], log-rank p = 0.70), medium-sized (HR 0.90; 95%CI [0.49; 1.65], log-rank p = 0.73), and large-sized (HR 0.81; 95%CI [0.42; 1.53], log-rank p = 0.50) coronary arteries. The incidence of all-cause death was significantly higher in the overall DES population (HR 4.03; 95%CI [2.40; 6.79], log-rank p < 0.001) and subgroup of small (HR 5.54; 95%CI [1.80; 17.02], log-rank p = 0.003), medium-sized (HR 4.37; 95%CI [1.92; 9.94], log-rank p = 0.009) and large-sized coronary arteries (HR 3.26; 95%CI [1.35; 7.86], log-rank p = 0.02).

CONCLUSIONS

DES and DCB strategies are comparable methods of treating ISR regardless of the diameter of the treated vessel in a long-term follow-up.

Feasibility of Intraoperative 3-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Aortic Valve Replacement: A Prospective Observational Pilot Study

OBJECTIVES

To assess the feasibility of intraoperative 3-dimensional speckle-tracking-based myocardial deformation analysis for evaluation of twist, torsion, and strain using speckle tracking, and to investigate the immediate changes in these parameters after aortic valve replacement.

DESIGN

Prospective observational study SETTING: Single-center study at a tertiary academic cardiac center PARTICIPANTS: Forty-nine patients undergoing minimally invasive surgical aortic valve replacement INTERVENTIONS: Acquisition of full-volume images of the left ventricle after induction of anesthesia and at the end of surgery using transesophageal echocardiography (TEE), and analysis of the datasets using 3D speckle-tracking-based myocardial deformation analysis (Tomtec Arena).

MEASUREMENTS AND MAIN RESULTS

Of the 49 complete volume datasets, 30 (61%) had quality sufficient for speckle tracking. No significant differences were observed between the examinations in terms of ejection fraction (EF) (p = 0.177), global longitudinal strain (GLS) (p = 0.276), circumferential strain (CS) (p = 0.238), twist (p = 0.970), or torsion (p = 0.417).

CONCLUSIONS

3D speckle-tracking-based myocardial deformation analysis from intraoperative TEE datasets is feasible in >60% of patients with aortic valve stenosis. There were no statistically significant differences in GLS, CS, twist, or torsion between the intraoperative examinations.

Systematic review of case reports on COVID-19 associated myocarditis: a discussion on treatments

Although COVID-19 is a disease consisting of mostly upper and lower respiratory symptoms, a subset of patients develop cardiac sequelae including myocarditis and pericarditis. For these patients, a standardized set of diagnostic imaging techniques and treatments has not been established. While there have been numerous case reports on this topic, there are few reviews that evaluate the effectiveness of different treatment modalities with a significant number of cases. We reviewed 146 cases of patients (ages ranging from 2 months old to mid 80 s) obtained from searches on PubMed, Google Scholar, and several case report journals. ECG abnormalities, elevated inflammatory markers, and reduced left ventricular ejection fraction were most associated with COVID-19 myocarditis. While classic symptoms of COVID-19 include upper respiratory symptoms, a subset of patients diagnosed with COVID-19 displayed no signs of respiratory disease at all. In 22% of cases, cardiac sequelae was not present until after the patient recovered from COVID-19. Steroids were given in 57.5% of cases. Cardiac MRI was used in 40.4% of cases for diagnosis of myocarditis. Of all the patients who were treated with ECMO, 82.1% of these patients were able to fully recover. The use of cardiac MRI and transthoracic echocardiogram for diagnosis of COVID-19 myocarditis should be heavily considered in any patient with COVID-19 infection. ECMO, IVIG, steroids, and anticoagulants should also be heavily considered. A randomized controlled trial should be conducted to better associate treatments with outcomes.

ProGlide-AngioSeal versus ProGlide-FemoSeal for vascular access hemostasis posttranscatheter aortic valve implantation

BACKGROUND

The hybrid strategy combining plug-based and suture-based vascular closure devices (VCD) was introduced as a promising technique for vascular access hemostasis after transcatheter aortic valve implantation (TAVI) with satisfactory outcomes. However, data comparing two plug-based VCDs each in the combination with a suture-based VCD, namely ProGlide/AngioSeal (P/AS) with ProGlide/FemoSeal (P/FS) VCDs, is still lacking.

AIMS

To compare the 30-day outcome of the hybrid strategy using P/AS versus P/FS for vascular access site closure after TAVI.

METHODS

A retrospective single-center observational study included 608 patients recruited from a prospective TAVI registry between 2016 and 2022. The composite endpoint was defined as any VCD-related major vascular complications and/or bleeding more than type 1 according to Valve Academic Research Consortium criteria.

RESULTS

The current study reported a significantly higher rate of composite endpoint in P/AS group, which was driven by a higher rate of major bleeding (5.4% vs. 1.4%, p = 0.036). We also found a higher rate of VCD-related minor bleeding in P/AS group (16.3% vs. 8.1%, p = 0.013). Successful access site hemostasis was achieved in 71.7% of P/AS group versus 83.1% in P/FS group (p = 0.006). The presence of anterior wall calcification at the access site was significantly associated with the composite endpoint (adj odds ratio 2.49; 95% confidence interval (1.08-5.75), p = 0.032).

CONCLUSION

The hybrid strategy for large bore vascular access closure using P/FS showed a potentially better 30-day outcomes compared with P/AS. The presence of anterior calcification at the access site carries a significant risk of VCD-related complications.

Cardiac CT vs Echocardiography for Intracardiac Thrombus Detection in Ischemic Stroke: A Systematic Review and Meta-Analysis of 43 Studies

BACKGROUND AND OBJECTIVES

Ischemic stroke, a leading cause of mortality, necessitates understanding its mechanism for effective prevention. Echocardiography, especially transesophageal echocardiography (TEE), is the gold standard for detection of cardiac sources of stroke including left atrial thrombus, although its invasiveness, operator skill dependence, and limited availability in some centers prompt exploration of alternatives, such as cardiac CT (CCT). We conducted a systematic review and meta-analysis assessing the ability of CCT in the detection of intracardiac thrombus compared with echocardiography.

METHODS

We searched 4 databases up through September 8, 2023. Major search terms included a combination of the terms "echocardiograph," "CT," "TEE," "imaging," "stroke," "undetermined," and "cryptogenic." The current systematic literature review of the English language literature was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. We assessed risk of bias using the QUADAS-2 tool and used random-effects meta-analysis to calculate different diagnostic metrics.

RESULTS

The meta-analysis investigating CCT vs echocardiography for intracardiac thrombus detection yielded a total of 43 studies of 9,552 patients. Risk-of-bias assessment revealed a predominantly low risk of bias in the flow and timing, index test, and patient selection domains and a predominantly unclear risk of bias in the reference standard domain. The analysis revealed an overall sensitivity of 98.38% (95% CI 89.2-99.78) and specificity of 96.0% (95% CI 92.55-97.88). Subgroup analyses demonstrated that delayed-phase, electrocardiogram-gated CCT had the highest sensitivity (100%; 95% CI 0-100) while early-phase, nongated CCT exhibited a sensitivity of 94.31% (95% CI 28.58-99.85). The diagnostic odds ratio was 98.59 (95% CI 44.05-220.69). Heterogeneity was observed, particularly in specificity and diagnostic odds ratio estimates.

DISCUSSION

CCT demonstrates high sensitivity, specificity, and diagnostic odds ratios in detecting intracardiac thrombus compared with traditional echocardiography. Limitations include the lack of randomized controlled studies, and other cardioembolic sources of stroke such as valvular disease, cardiac function, and aortic arch disease were not examined in our analysis. Large-scale studies are warranted to further evaluate CCT as a promising alternative for identifying intracardiac thrombus and other sources of cardioembolic stroke.

Thromboembolic Complications in Takotsubo Cardiomyopathy

Apical ballooning syndrome, commonly known as Takotsubo syndrome, is a distinct cardiomyopathy often resembling acute myocardial infarction in presentation. Takotsubo syndrome patients exhibit varied patterns of left ventricular wall motion abnormalities, most frequently apical dyskinesis with basal hyperkinesis, that are characteristically transient. Although emotional or physical stressors precipitate Takotsubo syndrome in most cases, a significant proportion presents without identifiable triggers, with a pronounced female predominance. Despite recovery of left ventricular function, Takotsubo syndrome may lead to serious complications akin to acute coronary syndromes. The pathophysiology remains incompletely understood, with catecholamine surge implicated in the genesis of myocardial injury, although direct causation remains debated. Diagnosis involves integrating clinical history, imaging modalities like echocardiography, and cardiac MRI. Psychiatric disorders, particularly anxiety and depression, are frequently associated with Takotsubo syndrome, suggesting a role of chronic stress in disease susceptibility. Management includes supportive care, with anticoagulation considered in cases of apical thrombus, alongside close monitoring for complications and recovery of left ventricular function. This article reviews the current understanding, challenges in diagnosis, and management strategies for Takotsubo syndrome.

Performance of the Mammoth Balloon Catheter in Patients with Severe Aortic Valve Stenosis Undergoing Percutaneous Treatment

Background: Balloon aortic valvuloplasty (BAV) is currently used as pre-treatment for patients undergoing trans-catheter aortic valve replacement (TAVR) as well as a stand-alone option for subjects with significant contraindications to TAVR. Mammoth is a newly available non-compliant balloon catheter (BC) included in the balloon-expandable Myval THV system (Meril Life Sciences Pvt. Ltd., India). As limited data on the performance of this BC are available, we here report the results following its use for BAV as pre-dilatation during TAVR or as a stand-alone procedure. Methods: A retrospective, single-center cohort analysis was performed on patients with severe aortic valve stenosis (AS) treated with the Mammoth BC at IRCCS Ospedale Galeazzi Sant'Ambrogio, Milan, Italy. The primary endpoint was technical success defined as successful Mammoth BC advancement across the AS followed by its full and homogeneous inflation without major complications such as aortic root/left ventricular outflow tract injury and/or stroke. Results: A total of 121 patients were treated by BAV with Mammoth BC during the study period. Among these, 105 patients underwent BAV pre-dilatation before TAVR while 16 patients underwent a stand-alone BAV procedure. Mammoth BC was delivered and successfully inflated at the target site in all of the 121 cases without BC-related complications (100% technical success). However, in the BAV "stand-alone group", three patients required two different balloon sizes while in nine patients multiple rounds (two to three) of balloon inflation were needed to significantly lower the transvalvular gradient. No cases of aortic root injury or massive aortic regurgitation due to Mammoth BC-related aortic leaflet injury were reported while one major stroke occurred late after TAVR. No intra-procedural deaths occurred nor bleeding (BARC 3-4) or major vascular complication. Conclusions: Mammoth BC use in patients with severe AS proved safe and effective, either before TAVR or as a stand-alone procedure, expanding the range of available tools for structural operators.

Absolute coronary flow and microvascular resistance before and after transcatheter aortic valve implantation

BACKGROUND

Severe aortic stenosis (AS) is associated with left ventricular (LV) remodelling, likely causing alterations in coronary blood flow and microvascular resistance.

AIMS

We aimed to evaluate changes in absolute coronary flow and microvascular resistance in patients with AS undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Consecutive patients with AS undergoing TAVI with non-obstructive coronary artery disease in the left anterior descending artery (LAD) were included. Absolute coronary flow (Q) and microvascular resistance (Rμ) were measured in the LAD using continuous intracoronary thermodilution at rest and during hyperaemia before and after TAVI, and at 6-month follow-up. Total myocardial mass and LAD-specific mass were quantified by echocardiography and cardiac computed tomography. Regional myocardial perfusion (QN) was calculated by dividing absolute flow by the subtended myocardial mass.

RESULTS

In 51 patients, Q and R were measured at rest and during hyperaemia before and after TAVI; in 20 (39%) patients, measurements were also obtained 6 months after TAVI. No changes occurred in resting and hyperaemic flow and resistance before and after TAVI nor after 6 months. However, at 6-month follow-up, a notable reverse LV remodelling resulted in a significant increase in hyperaemic perfusion (QN,hyper: 0.86 [interquartile range {IQR} 0.691.06] vs 1.20 [IQR 0.99-1.32] mL/min/g; p=0.008; pre-TAVI and follow-up, respectively) but not in resting perfusion (QN,rest: 0.34 [IQR 0.30-0.48] vs 0.47 [IQR 0.36-0.67] mL/min/g; p=0.06).

CONCLUSIONS

Immediately after TAVI, no changes occurred in absolute coronary flow or coronary flow reserve. Over time, the remodelling of the left ventricle is associated with increased hyperaemic perfusion.

Mediastinal and thoracic hematoma following transradial cerebral angiography: a case report

BACKGROUND

Cerebral angiography through the transradial approach (TRA) is associated with a low risk of complications, but in rare cases, these complications can be life-threatening.

CASE PRESENTATION

A 56-year-old female patient was admitted for transradial cerebral angiography due to the complaint of right limb weakness and the diagnosis of cerebral infarction and cerebral artery stenosis. During the procedure, the patient coughed with expectoration and complained of throat discomfort, palpitations, and pains in the right shoulder and back. Emergency CT scan indicated hematoma in the middle mediastinum and the right thoracic cavity, and perforation of a branch of the subclavian artery was highly suspected. Subclavian artery angiography was conducted immediately, which revealed a patchy contrast medium overflow in a branch of the right costocervical trunk. Selective endovascular occlusion therapy was performed successfully with gelfoam particles and placement of 2 microcoils. At 12 days after cerebral angiography, the patient recovered well and was discharged from the hospital.

CONCLUSION

Mediastinal and thoracic hematoma may occur due to vessel perforation during TRA cerebral angiography, in which guidewire advancement must be cautious. Early detection and appropriate countermeasures can reduce the severity of vascular perforation and subsequent hematoma.

Comparative Analysis of Transradial and Transfemoral Approaches in Transarterial Radioembolization for Liver Tumors: A Systematic Review and Meta-Analysis

PURPOSE

Transarterial radioembolization (TARE) is a minimally invasive therapy combining embolization and radiation for cancer treatment. This meta-analysis compares radiation exposure, quality of life, and safety of the transradial (TRA) versus transfemoral (TFA) approaches in TARE for liver tumors.

MATERIALS AND METHODS

We searched PubMed, SCOPUS, Cochrane, EMBASE, and Web of Science for studies comparing TRA versus TFA in TARE for liver tumors. Our primary outcomes focused on various measures of patient radiation exposure, including procedure time, fluoroscopy time, air kerma, and dose-area product (DAP). For secondary outcomes, we evaluated safety parameters, such as overall pain experienced during the procedure, pain in the recovery room post-procedure, the incidence of adverse events, and the impact on quality of life. Study quality was assessed using Cochrane's ROB 2 tool for RCTs and the Newcastle-Ottawa scale for observational studies. Data analysis was conducted with REVMAN 5.4.1 software.

RESULTS

Six studies, comprising one RCT and five cohort studies with 1,209 patients, underwent comprehensive analysis. The aggregated findings revealed a significant reduction in procedure duration associated with TRA (MD =- 6.30, 95% CI [- 9.88, - 2.73], P = 0.005). However, no statistically significant differences were found between TRA and TFA groups concerning fluoroscopy time, recovery time, air kerma, DAP, pain in the recovery room, overall pain during the procedure, quality of life measuring mental health and physical function or adverse events.

CONCLUSION

TRA and TFA showed comparable results in TARE for liver tumors, but TRA offered a shorter procedure time. Further RCTs with larger samples are needed to confirm these findings. Future studies should assess long-term efficacy for a more complete evaluation.

Contemporary characteristics, outcomes and novel risk score for Takotsubo cardiomyopathy: a national inpatient sample analysis

BACKGROUND

Takotsubo cardiomyopathy (TC) is an established differential diagnosis of myocardial infarction with non-obstructive coronaries with significant interest but limited data on prognostication. We reviewed the characteristics and in-hospital outcomes and developed a novel risk score for TC.

METHODS

Using the National Inpatient Sample data from 2016 to 2020, we identified adult patients (≥18 years) with acute coronary syndrome (ACS) and TC. We divided the cohort into ACS with and without TC and retrieved baseline data. Multivariable regression analysis was conducted to identify factors associated with TC diagnosis and adverse outcomes, leading to the development of a risk-scoring system.

RESULTS

Among 7 219 004 adult ACS admissions, 78 214 (1.0%) were diagnosed with TC, with a mean age of 68.2 years, 64 526 (82.5%) being female and 5475 (7.0%, compared with 8.4% for other ACS) in-hospital mortality events. Factors significantly associated with TC were female sex (OR 6.78 (95% CI 6.47 to 7.09), p<0.001) and chronic heart failure (OR 1.60 (95% CI 1.54 to 1.66), p<0.001). A novel risk score was developed, including the following parameters: male sex, age >70 years, non-white race, hypertension, hyperlipidemia, history of coronary artery bypass grafting, history of percutaneous coronary intervention, cardiac arrhythmias, renal failure, cardiogenic shock and vasopressor use. The area under curves for in-hospital mortality was 0.716 in the derivation and 0.725 in the validation cohorts.

CONCLUSIONS

TC remains a high-risk diagnosis in a minority of ACS cases, with mortality rates similar to other ACS causes. Our novel risk score offers a valuable tool for risk stratification in patients with TC, but external validation is needed to confirm its utility.

Interaction of a self-expandable stent with the arterial wall in the presence of hypocellular and calcified plaques

Self-expandable stents manufactured from nitinol alloys are commonly utilized alongside traditional balloon-expandable stents to provide scaffolding to stenosed arteries. However, a significant limitation hampering stent efficacy is restenosis, triggered by neointimal hyperplasia and resulting in the loss of gain in lumen size, post-intervention. In this study, a nonlinear finite element model was developed to simulate stent crimping and expansion and its interaction with the surrounding vessel in the presence of a plaque. The main aim was to determine contact pressures and forces induced at the interface between an artery wall with hypocellular and calcified plaques and an expanded stent. The results demonstrated the drawbacks of plaque calcification, which triggered a sharp contact pressure and radial force surge at the interface as well as a significant rise in von Mises stress within the vessel, potentially leading to rupture and restenosis. A regression line was then established to relate hypocellular and calcified plaques. The adjusted coefficient of determination indicated a good correlation between contact pressures for calcified and hypocellular plaque models. Regarding the directionality of wall properties, contact pressure and force observations were not significantly different between isotropic and anisotropic arteries. Moreover, variations in friction coefficients did not substantially affect the interfacial contact pressures.

Prognostic Impact of Target Vessel in Chronic Total Occlusions: A Population-Based Cohort Study

Successful percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) in the coronary arteries in the left anterior descending (LAD) artery is associated with better outcome than unsuccessful PCI. Randomized data have not found invasive treatment of non-CTO LAD lesion to be associated with better outcome. This study aimed to investigate the prognostic impact of CTO revascularization stratified on target treated vessel compared with non-CTO LAD PCI. The hypothesis was that successful PCI of LAD CTO and non-LAD CTO and unsuccessful non-LAD CTO were associated with the same prognosis as non-CTO LAD lesions, whereas patients with unsuccessful LAD CTO were associated with a poorer prognosis. The study was a population-based cohort study, including consecutive patients who underwent PCI from 2009 to 2019 in the Central Denmark Region. Patients with acute myocardial infarction within 30 days were excluded. Patients with CTO were stratified by occluded vessel and procedural success. The primary end point was long-term all-cause mortality and was calculated as a hazard ratio with a 95% confidence interval. Secondary end points were myocardial infarction and target vessel revascularization. In total, 21,141 patients were screened, 4,518 had non-CTO LAD PCI, and 1,475 had CTO PCI. The median (interquartile range) follow-up was 5.8 years (3.6 to 8.8). In the successful CTO groups, the adjusted risk for all-cause mortality was equal to patients with non-CTO LAD (LAD CTO hazard ratio [95% confidence interval] 1.14 [0.90 to 1.44], non-LAD CTO 1.09 [0.95 to 1.27]). Patients with unsuccessful LAD CTO had a higher risk than patients with non-CTO LAD, whereas unsuccessful non-LAD CTO had not (unsuccessful LAD 1.88 [1.33 to 2.65], unsuccessful non-LAD 1.26 [0.97 to 1.63]). In conclusion, successful LAD and non-LAD CTO PCI had the same prognosis as non-CTO LAD PCI, whereas only unsuccessful LAD CTO PCI had a poorer prognosis. Patients with LAD CTO are a high-risk population, and dedicated CTO trials are needed to confirm this finding and establish guideline recommendations.

Using novel machine learning tools to predict optimal discharge following transcatheter aortic valve replacement

BACKGROUND

Although transcatheter aortic valve replacement has emerged as an alternative to surgical aortic valve replacement, it requires extensive healthcare resources, and optimal length of hospital stay has become increasingly important. This study was conducted to assess the potential of novel machine learning models (artificial neural network and eXtreme Gradient Boost) in predicting optimal hospital discharge following transcatheter aortic valve replacement.

AIM

To determine whether artificial neural network and eXtreme Gradient Boost models can be used to accurately predict optimal discharge following transcatheter aortic valve replacement.

METHODS

Data were collected from the 2016-2018 National Inpatient Sample database using International Classification of Diseases, Tenth Revision codes. Patients were divided into two cohorts based on length of hospital stay: optimal discharge (length of hospital stay 0-3 days); and late discharge (length of hospital stay 4-9 days). χ2 and t tests were performed to compare patient characteristics with optimal discharge and prolonged discharge. Logistic regression, artificial neural network and eXtreme Gradient Boost models were used to predict optimal discharge. Model performance was determined using area under the curve and F1 score. An area under the curve≥0.80 and an F1 score≥0.70 were considered strong predictive accuracy.

RESULTS

Twenty-five thousand and eight hundred and seventy-four patients who underwent transcatheter aortic valve replacement were analysed. Predictability of optimal discharge was similar amongst the models (area under the curve 0.80 in all models). In all models, patient disposition and elective procedure were the most important predictive factors. Coagulation disorder was the strongest co-morbidity predictor of whether a patient had an optimal discharge.

CONCLUSIONS

Artificial neural network and eXtreme Gradient Boost models had satisfactory performances, demonstrating similar accuracy to binary logistic regression in predicting optimal discharge following transcatheter aortic valve replacement. Further validation and refinement of these models may lead to broader clinical adoption.

Chronic total occlusion percutaneous coronary intervention of anomalous coronary arteries: insights from the PROGRESS CTO registry

BACKGROUND

There is limited information about the frequency and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in anomalous coronary arteries (ACA).

METHODS

We examined the clinical and angiographic characteristics and procedural outcomes of CTO PCI in ACA among 14,173 patients who underwent 14,470 CTO PCIs at 46 US and non-US centers between 2012 and 2023.

RESULTS

Of 14,470 CTO PCIs, 36 (0.24%) were CTO PCIs in an ACA. ACA patients had similar baseline characteristics as those without an ACA. The type of ACA in which the CTO lesion was found were as follows: anomalous origin of the right coronary artery (ARCA) (17, 48.5%), anomalous origin of left circumflex coronary artery (9, 25.7%), left anterior descending artery and left circumflex artery with separate origins (4, 11.4%), anomalous origin of the left anterior descending artery (2, 5.7%), dual left anterior descending artery (2, 5.7%) and woven coronary artery 1 (2.8%). The Japan CTO score was similar between both groups (2.17 ± 1.32 vs 2.38 ± 1.26, p = 0.30). The target CTO in ACA patients was more likely to have moderate/severe tortuosity (44% vs 28%, p = 0.035), required more often use of retrograde approach (27% vs 12%, p = 0.028), and was associated with longer procedure (142.5 min vs 112.00 min [74.0, 164.0], p = 0.028) and fluoroscopy (56 min [40, 79 ml] vs 42 min [25, 67], p = 0.014) time and higher contrast volume (260 ml [190, 450] vs 200 ml [150, 300], p = 0.004) but had similar procedural (91.4% vs 85.6%, p = 0.46) and technical (91.4% vs 87.0%, p = 0.59) success. No major adverse cardiac events (MACE) were seen in ACA patients (0% [0] vs 1.9% [281] in non-ACA patients, p = 1.00). Two coronary perforations were reported in ACA CTO PCI (p = 0.7 vs. non-ACA CTO PCI).

CONCLUSIONS

CTO PCI of ACA comprise 0.24% of all CTO PCIs performed in the PROGRESS CTO registry and was associated with higher procedural complexity but similar technical and procedural success rates and similar MACE compared with non-ACA CTO PCI.

Sex disparities in outcomes of transcatheter aortic valve implantation- a multi-year propensity-matched nationwide study

Transcatheter Aortic Valve Implantation (TAVI) has revolutionized the management of severe aortic stenosis (AS), but the impact of sex on TAVI outcomes remains unclear. In this study, we examined differences between men and women in the post-procedural outcomes of TAVI, including healthcare burden and readmission rates. The Nationwide Readmissions Database (2016-2020) was utilized to identify hospitalizations for TAVI. A propensity score matching (PSM) model was used to match males and females. Outcomes were examined using Pearson's chi-squared test. Among 320,324 hospitalizations for TAVI, 142,054 (44.3 %) procedures were performed in women. After propensity matching (N = 165,894 with 82,947 hospitalizations in each group), women had higher in-hospital mortality (2.48 % vs 2.11 %, p: 0.001), stroke (2.14 % vs 1.49 %, p < 0.001), post-procedural bleeding (2.34 % vs 1.72 %, p < 0.001), vascular complications (1.2 % vs 0.7 %, p < 0.001), pericardial complications (1.13 % vs 0.60 %, p < 0.001), acute respiratory failure (ARF) (5.10 % vs 4.63 %, p < 0.001), need for transfusion (7 % vs 5.56 %, p < 0.001), need for vasopressors (2.48 % vs 2.11 %, p < 0.001) and major adverse cardiac and cerebrovascular events (MACCE) (7.53 % vs 6.85 %, p < 0.001). Meanwhile, women had modestly lower incidence of acute kidney injury (AKI) (10.17 % vs 11.88 %, p < 0.001), sudden cardiac arrest (SCA) (0.96 % vs 1.06 %, p: 0.042), cardiogenic shock (1.69 % vs 2.05 %, p < 0.001) and mechanical circulatory support (MCS) requirement (0.69 % vs 0.84 %, p < 0.001). With regard to readmissions, men had higher readmission rates at 30 days (16.07 % vs 14.75 %, p < 0.001) and 90 days (23.8 % vs 21.9 %, p < 0.001). No significant difference was observed in 180-day readmission rates between men and women after TAVI. Notably, procedure-related mortality decreased for both sexes from 2016 to 2020, accompanied by faster recovery times and reduced hospitalization costs (p-trend <0.001). In conclusion, women had higher mortality and post-procedural complication rates, while men had higher readmission rates, cardiogenic shock, AKI and need for mechanical circulatory support. While procedure-related mortality and resource utilization for TAVI have improved over time from 2016 to 2020, irrespective of sex, our findings highlight that significant disparities exist in TAVI outcomes.

Successful Percutaneous Rescue Treatment of Acute Carotid Stent Thrombosis Utilizing a Modified Embolic Protection Device

Acute Carotid Stent Thrombosis (ACST) is a rare complication of Carotid Artery Stenting (CAS) with a potentially fatal outcome. We report a case of ACST occurring five minutes after the end of a successful CAS procedure that was promptly treated by carotid stent-in-stent implantation using a new percutaneous strategy based on the creation of a modified embolic protection device. Following the procedure, we did not observe brain lesions suggestive of acute cerebral ischemic events at the CT scan performed at 48 hours, as well as no neurological deficits in the following days.

The role of coronary microcirculation in heart failure with preserved ejection fraction: An unceasing odyssey

Heart failure with preserved ejection fraction (HFpEF) represents an entity with complex pathophysiologic pathways, among which coronary microvascular dysfunction (CMD) is believed to be an important orchestrator. Research in the field of CMD has highlighted impaired vasoreactivity, capillary rarefaction, and inflammation as potential mediators of its development. CMD can be diagnosed via several noninvasive methods including transthoracic echocardiography, cardiac magnetic resonance, and positron emission tomography. Moreover, invasive methods such as coronary flow reserve and index of microcirculatory resistance are commonly employed in the assessment of CMD. As far as the association between CMD and HFpEF is concerned, numerous studies have highlighted the coexistence of CMD in the majority of HFpEF patients. Additionally, patients affected by both conditions may be facing an adverse prognosis. Finally, there is limited evidence suggesting a beneficial effect of renin-angiotensin-aldosterone system blockers, ranolazine, and sodium-glucose cotransporter-2 inhibitors in CMD, with further evidence being awaited regarding the impact of other pharmacotherapies such as anti-inflammatory agents.

Assessing post-TAVR cardiac conduction abnormalities risk using an electromechanically coupled beating heart

Transcatheter aortic valve replacement (TAVR) has rapidly displaced surgical aortic valve replacement (SAVR). However, certain post-TAVR complications persist, with cardiac conduction abnormalities (CCA) being one of the major ones. The elevated pressure exerted by the TAVR stent onto the conduction fibers situated between the aortic annulus and the His bundle, in proximity to the atrioventricular (AV) node, may disrupt the cardiac conduction leading to the emergence of CCA. In this study, an in silico framework was developed to assess the CCA risk, incorporating the effect of a dynamic beating heart and preprocedural parameters such as implantation depth and preexisting cardiac asynchrony in the new onset of post-TAVR CCA. A self-expandable TAVR device deployment was simulated inside an electromechanically coupled beating heart model in five patient scenarios, including three implantation depths and two preexisting cardiac asynchronies: (i) a right bundle branch block (RBBB) and (ii) a left bundle branch block (LBBB). Subsequently, several biomechanical parameters were analyzed to assess the post-TAVR CCA risk. The results manifested a lower cumulative contact pressure on the conduction fibers following TAVR for aortic deployment (0.018 MPa) compared to nominal condition (0.29 MPa) and ventricular deployment (0.52 MPa). Notably, the preexisting RBBB demonstrated a higher cumulative contact pressure (0.34 MPa) compared to the nominal condition and preexisting LBBB (0.25 MPa). Deeper implantation and preexisting RBBB cause higher stresses and contact pressure on the conduction fibers leading to an increased risk of post-TAVR CCA. Conversely, implantation above the MS landmark and preexisting LBBB reduces the risk.

Subacute in-stent thrombosis after carotid artery stenting in a patient with gene polymorphisms associated with aspirin and clopidogrel resistance: a case report

BACKGROUND

Carotid artery stenting (CAS) is a key treatment option for moderate to severe carotid artery stenosis. Carotid stent thrombosis (CST), a rare complication of CAS, has gained significant attention because of its catastrophic nature. More evidences are needed to guide the diagnosis and treatment of CST.

CASE PRESENTATION

This study reports a rare case of sub-acute CST following CAS in a 50-year-old male patient who had experienced repeated cerebrovascular events on the premise of taking antiplatelet drugs. He also suffered an occlusion of the left middle cerebral artery (MCA) in the M2 segment, likely caused by an embolus detached from the stent thrombus. The cause of CST in this patient was presumed to be dual antiplatelet resistance (AR), as indicated by genetic testing. After treated with guide catheter-directed thrombolysis, thrombus aspiration, and a second round of thrombolysis, his in-stent thrombus was basically cleared. His M2 occlusion was resolved by mechanical thrombectomy using the Solitaire FR/Stent with Intermediate Catheter Assisting technique. The patient recovered well after replacement of antiplatelet drugs, and no new thromboembolic event occurred during the 13-month follow-up period.

CONCLUSIONS

The occurrence rate of AR-related CST may be underestimated as the cause of majority CST cases remains unclear. Implementation of genetic test for aspirin and clopidogrel resistance may be helpful to find the possible cause of CST and to avoid future repeated cerebrovascular events by replacement of antiplatelet drugs.

Use of sirolimus-coated balloon in de novo coronary lesions; long-term clinical outcomes from a multi-center real-world population

BACKGROUND

Sirolimus-coated balloon (SCB), a relatively novel technology appears attractive due to the drug properties (safety and efficacy) and sirolimus remains the drug of choice in stents. However, there is limited data long-term data on SCB. In this study, we have explored the clinical outcomes following the use of SCB in de-novo lesions from a real-world practice.

AIMS

To report long-term clinical outcomes following the use of Siroliumus coated balloon in de novo lesions.

METHODS AND RESULTS

We analyzed all patients treated with an SCB in de novo lesions between 2016 and 2023 at four high-volume centers in UK and Italy. The outcomes measured included cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularization (TLR) and major adverse cardiac events (MACE). During the study period, 771 patients had SCB in de novo lesions. Diabetes mellitus was noted in 36% of patients (n = 280), of which 14% (n = 108) were insulin dependent. Fifteen percent (n = 117) had chronic kidney disease, Fifty-two percent (n = 398) of cases were in the setting acute coronary syndrome (ACS) and of which 51 cases (7%) were ST-segment elevation myocardial infarction. Small vessels (<3.0 mm) accounted for 78% (n = 601) of cases and 76% (n = 584) were long lesions (≥ $\ge $ 20 mm). The mean diameter of SCB was 2.6 ± 0.4 mm and the mean length was 25 ± 10.39 mm. Bailout stenting following SCB was required in 9% lesions (n = 67). During the median follow-up 640 days, total death occurred in 39 (5%) patients and of which, cardiac death occurred in 10 patients (1.3%). TVMI occurred in 20 patients (2.6%). TLR and TVR were 5.6% and 5.8% respectively. The overall MACE rate was 8%. We had no documented case of acute vessel closure.

CONCLUSIONS

The results from this long-term follow-up in a real-world population are encouraging with low rates of hard endpoints and acceptable rates of TLR and MACE despite a complex group of patients. Our data suggest that SCBs are safe in coronary intervention with good clinical outcomes in the long term.

One-month DAPT after biodegradable-polymer everolimus-eluting stent implantation in women at high-bleeding risk: Insights from the POEM trial

AIMS

We conducted a prespecified subanalysis of the POEM trial to assess the association between sex and clinical outcomes following a short 1-month dual-antiplatelet-therapy (DAPT) period after percutaneous coronary intervention (PCI) with bioresorbable polymer everolimus-eluting stent (BP-EES) among patients at high bleeding risk (HBR).

BACKGROUND

Shortening the DAPT period after PCI is an effective bleeding avoidance strategy with contemporary drug-eluting stents. Whether sex affects the risk of adverse events following PCI is still debated.

METHODS

Patients at HBR undergoing PCI with BP-EES were enrolled and treated with 1-month DAPT. If anticoagulation was needed, study participants received an oral anticoagulant (OAC) in addition to a P2Y12 inhibitor for 1 month, followed by OAC only thereafter. The primary endpoint was a composite of cardiac death, myocardial infarction, or definite/probable stent thrombosis at 12 months. We report sex-based outcomes of patients included in the POEM study.

RESULTS

We enrolled 129 (29.1%) women and 314 (70.9%) men. Women were older, with lower hemoglobin levels, and worse renal function. Accordingly, they had a trend for a greater number of HBR criteria fulfilled and a higher PARIS bleeding score. However, they were not at a significantly higher risk for the primary endpoint (men vs. women: 5.17% vs. 3.94%; HR 1.30; 95% CI: 0.48-3.54, p = 0.61), or any of the hemorrhagic and ischemic secondary endpoints.

CONCLUSIONS

This prespecified subanalysis of the POEM trial suggests that 1-month DAPT following PCI with BP-EES may be a safe and effective therapeutic strategy for women at HBR.

Incidence and Predictors of Early and Late Radial Artery Occlusion after Percutaneous Coronary Intervention and Coronary Angiography: A Systematic Review and Meta-Analysis

Introduction: Trans-radial access for coronary angiography and percutaneous coronary intervention (PCI) has gained popularity due to its advantages over the traditional transfemoral approach. However, radial artery occlusion (RAO) remains a common complication following trans-radial procedures. This study aimed to investigate the incidence of early and late RAO along with their risk factors. Methods: Six databases, Medline (Ovid), National Library of Medicine (MeSH), Cochrane Database of Systematic Reviews (Wiley), Embase, Scopus, and Global Index Medicus, were searched. The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted and analyzed. Using a random-effect model, the primary endpoint was the overall incidence of RAO after invasive coronary procedures. Subgroup analysis and meta-regression were also performed to identify possible predictors of RAO. Results: A total of 41 studies with 30,020 patients were included. The overall incidence of RAO was 13% (95% CI = 0.09-0.16). The incidence of early RAO (within 24 h) was 14% (95% CI = 0.10-0.18) in 26 studies, while the incidence of late RAO (after 24 h) was 10% (95% CI = 0.04-0.16) in 22 studies. The average incidence rates of early RAO in studies with catheter sizes of <6 Fr, 6 Fr, and >6 Fr were 9.8%, 9.4%, and 8.8%. The overall effect size of female gender as a predictor was 0.22 with a 95% CI of 0.00-0.44. Age was a potential predictor of early RAO (B = 0.000357; 95% CI = -0.015-0.0027, p: 0.006). Conclusions: This meta-analysis provides essential information on the incidence of early (14%) and late (10%) RAO following angiographic procedures. Additionally, our findings suggest that female sex and age are possible predictors of RAO. A larger catheter, especially (6 Fr) and hemostatic compression time <90 min post-procedure, substantially reduced the incidence of RAO. The use of oral anticoagulation and the appropriate dosage of low-molecular-weight heparin (LMWH) does reduce RAO, but a comparison between them showed no statistical significance.

The status of diversity in the heart transplant workforce

Cardiac surgery and cardiology consistently have the lowest representation of women and racial minorities among all the specialties. The poor representation of minorities and women in cardiology and cardiac surgery is compounded by the fact that heart failure risk continues to rise in the United States (US) and disproportionately affects non-white patients. Inclusion in academia is imperative in diversifying the workforce and in turn, in improving the care we provide to all of our patients.

Comprehensive Optical Coherence Tomography-Guided RotaTripsy for Massive Coronary Calcified Nodule: A Decision-Making Approach

Objectives

We aim to describe the step-by-step optical coherence tomography-guided rotational atherectomy and intravascular lithotripsy for treating substantial coronary calcified nodules.

Key Steps

These include initial rotational atherectomy with a 1.5-mm burr, multiple optical coherence tomography imaging studies to assess lesion morphology, upsizing the rotational burr to 2.0 mm for further debulking, performing adjunctive intravascular lithotripsy with a 3.5-mm Shockwave balloon (Shockwave Medical Inc), and final stent deployment and optimization.

Potential Pitfalls

Potential complications include burr entrapment during rotational atherectomy, inadequate lesion modification with initial rotational atherectomy, and failure to achieve deep calcium fractures leading to stent underexpansion. To avoid these complications, start with a smaller burr size and use a slow pecking motion, conduct a meticulous intravascular imaging assessment, and upsize the burr and adjunctive intravascular lithotripsy on the basis of intravascular imaging findings.

Take-Home Messages

Detailed intravascular imaging is crucial for guiding personalized treatment strategies. Combining rotational atherectomy and intravascular lithotripsy (RotaTripsy) provides a synergistic approach for treating extensive calcified nodules.

Challenges in the diagnosis and management of dry tamponade

Dry tamponade is a rare complication of percutaneous coronary intervention. It encompasses a heterogenous pathophysiology and is used to describe hemodynamic compromise secondary to a coronary artery perforation, without free-flowing fluid in the pericardium. Tamponade physiology can result from compressive epicardial, intramyocardial, subepicardial hematomas, or dissecting intramyocardial hematomas. The diagnosis of dry tamponade requires hemodynamic derangement in the context of a compressive hematoma as demonstrated by imaging. Although echocardiography can often help identify dry tamponade, additional studies including right heart catheterization, computed tomography, or cardiac magnetic resonance imaging can inform the exact mechanism and help guide management. This article describes a case of dry tamponade, reviews the existing literature on the topic, and offers expert recommendations on diagnosis and management.

Carina: A major determinant in the pathophysiology and treatment of coronary bifurcation lesions

Over the last decade, several in vivo and computational investigations have significantly advanced our understanding of the pathophysiology of coronary bifurcations, contributing to the enhancement of their percutaneous revascularization. The carina of the coronary bifurcations plays a substantial role in generating their main hemodynamic features, including distinctive flow patterns with secondary flows and specific shear stress patterns. These factors play a pivotal role in determining the susceptibility, development, and progression of atherosclerosis. The underlying pathophysiological mechanisms of atherosclerosis in coronary bifurcations are complex and multifactorial. Understanding these mechanisms is fundamental to comprehending lesions at the bifurcation level and informing future treatment strategies. This review aims to present the currently available data regarding the pathophysiological and prognostic role of the carina in coronary bifurcations, offering an interpretation of these findings from the perspective of interventional cardiologists, providing valuable insights for their clinical practice.

In Patients Presenting with an ST-Elevation Myocardial Infarction, Overweight and Obese Patients Have the Lowest Inpatient Mortality whereas Cachexia Patients Have the Highest Inpatient Mortality Followed by Patients with Morbid Obesity

Introduction: The obesity paradox has been observed in patients with cardiovascular disease. The goal of this study was to evaluate whether obesity has a protective effect in patients presenting with an ST elevation myocardial infarction (STEMI). Method: Using the large Nationwide Inpatient (NIS) sample database, we evaluated the mortality in patients with a STEMI based on weight categories. Results: A total of 2,161,640 STEMI patients were found in the database over age 18. We found that overweight and obesity had the lowest mortality using univariate (overweight mortality of 5% vs. obesity mortality of 6.5% vs. 10.9% for normal weights) and multivariate analyses (overweight OR: 0.52, CI: 0.43-063; p < 0.001 and obesity OR: 0.7, CI: 0.67-0.74; p < 0.001), whereas cachexia was associated with the highest mortality in the univariate (cachexia 24.5%) and multivariate (OR: 2.28, CI: 2.13-2.44; p < 0.001) analyses, followed by morbid obesity in the multivariate analysis (OR: 1.07, CI: 1.02-1.12; p = 0.004). Conclusions: We observed a partial obesity paradox in patients with a STEMI showing that overweight have the best survival rates followed by obesity. Cachexia followed by morbid obesity had the lowest survival rates.

Common Criticisms and Rebuttals of the Best Endovascular Versus Best Surgical Therapy in Patients with Chronic Limb-Threatening Ischemia (BEST-CLI) Trial

The Best Endovascular Versus Best Surgical Therapy in Patients With Chronic Limb-Threatening Ischemia trial was a landmark trial which provides high-quality data for the decision-making regarding the treatment of chronic-limb threatening ischemia. Overall, the trial suggests that in patients with adequate greater saphenous vein conduit, bypass surgery should be offered as a first line treatment given superior outcomes. In this article, we outline the common critiques of the trial, followed by responses to provide a deeper understanding of the strengths and limitations of this important trial.

CLINICAL OUTCOMES OF PATIENTS WITH CARDIOGENIC SHOCK COMPLICATING ACUTE MYOCARDIAL INFARCTION: THE GULF-CARDIOGENIC SHOCK REGISTRY

ABSTRACT

Background: There is a paucity of data regarding acute myocardial infarction (MI) complicated by cardiogenic shock (AMI-CS) in the Gulf region. This study addressed this knowledge gap by examining patients experiencing AMI-CS in the Gulf region and analyzing hospital and short-term follow-up mortality. Methods: The Gulf-Cardiogenic Shock registry included 1,513 patients with AMI-CS diagnosed between January 2020 and December 2022. Results: The incidence of AMI-CS was 4.1% (1,513/37,379). The median age was 60 years. The most common presentation was ST-elevation MI (73.83%). In-hospital mortality was 45.5%. Majority of patients were in SCAI (Society for Cardiovascular Angiography and Interventions shock classification) stage D and E (68.94%). Factors associated with hospital mortality were previous coronary artery bypass graft (odds ratio [OR]: 2.49; 95% confidence interval [CI]: 1.321-4.693), cerebrovascular accident (OR: 1.621; 95% CI: 1.032-2.547), chronic kidney disease (OR: 1.572; 95% CI: 1.158-2.136), non-ST-elevation MI (OR: 1.744; 95% CI: 1.058-2.873), cardiac arrest (OR: 5.702; 95% CI: 3.640-8.933), SCAI stage D and E (OR: 19.146; 95% CI: 9.902-37.017), prolonged QRS (OR: 10.012; 95% CI: 1.006-1.019), right ventricular dysfunction (OR: 1.679; 95% CI: 1.267-2.226), and ventricular septal rupture (OR: 6.008; 95% CI: 2.256-15.998). Forty percent had invasive hemodynamic monitoring, 90.02% underwent revascularization, and 45.80% received mechanical circulatory support (41.31% had intra-aortic balloon pump and 14.21% had extracorporeal membrane oxygenation/Impella devices). Survival at 12 months was 51.49% (95% CI: 46.44%-56.29%). Conclusions: The study highlighted the significant burden of AMI-CS in this region, with high in-hospital mortality. The study identified several key risk factors associated with increased hospital mortality. Despite the utilization of invasive hemodynamic monitoring, revascularization, and mechanical circulatory support in a substantial proportion of patients, the 12-month survival rate remained relatively low.

Cardiac Magnetic Resonance Feature Tracking Analysis for Change in Right Ventricular Function After Cardioplegic Arrest

BACKGROUND

Using echocardiography to assess right ventricular (RV) function after cardioplegic arrest is challenging. Cardiac magnetic resonance (CMR) imaging is a superior alternative, with the feature tracking technique enabling quantitative assessment of myocardial deformation.

METHODS

This single-centre, prospective study from 2020 to 2022 assessed RV function in 42 patients who underwent open heart surgery with cardioplegic arrest. CMR data were collected preoperatively, one week postoperatively, and at follow-up (6-12 months after surgery), and assessed using the CMR feature tracking technique.

RESULTS

Postoperatively, there was no significant change in RV end-diastolic volume, but RV end-systolic volume significantly decreased, leading to a notable increase in RV ejection fraction. By follow-up, both RV end-diastolic and end-systolic volumes had significantly reduced compared with the preoperative values. Right ventricular longitudinal contractility decreased after surgery but recovered to the preoperative values by follow-up, while RV circumferential contractility improved postoperatively and remained superior to the preoperative levels at follow-up.

CONCLUSION

On CMR imaging, significant changes in RV systolic motion were observed after cardioplegic arrest, with decreased longitudinal but increased circumferential contractility. At follow up, these changes had reverted to the preoperative patterns by the mid-term (6-12 months).

Mesenchymal stem cell-derived cell-free technologies: a patent landscape

Mesenchymal stem/stromal cells (MSC) play a pivotal role in regenerative therapies. Recent studies show that factors secreted by MSC can replicate their biological activity, driving the emergence of cell-free therapy, likely to surpass stem cell therapy. Patents are an objective measure of R&D and innovation activities, and patent mapping allows us to verify the state of the art and technology, anticipate trends, and identify emerging lines of research. This review performed a search on Derwent World Patents Index™ and retrieved 269 patent families related to the MSC-derived cell-free products. Analysis reveals an exponential increase in patents from the mid-2010s, primarily focusing on exosomes. The patent's contents offer a great diversity of applications and associated technologies by using the products as medicinal agents or drug delivery systems. Nevertheless, numerous application branches remain unexplored, suggesting vast potential for cell-free technologies alone or combined with other approaches.

The Emerging and Important Role of Artificial Intelligence in Cardiac Surgery

Artificial Intelligence (AI) has greatly affected our everyday lives and holds great promise to change the landscape of medicine. AI is particularly positioned to improve care for the increasingly complex patients undergoing cardiac surgery using the immense amount of data generated in the course of their care. When deployed, AI can be used to analyze this information at the patient's bedside more expediently and accurately, all while providing new insights. This review summarizes the current applications of AI in cardiac surgery from the vantage point of a patient's journey. Applications of AI include preoperative risk assessment, intraoperative planning, postoperative patient care, and outpatient telemonitoring, encompassing the spectrum of cardiac surgical care. Offloading of administrative processes and enhanced experience with information gathering also represent a unique and under-represented avenue for future use of AI. As clinicians, understanding the nomenclature and applications of AI is important to contextualize issues, to ensure problem-driven solutions, and for clinical benefit. Precision medicine, and thus clinically relevant AI, remains dependent on data curation and warehousing to gather insights from large multicentre repositories while treating privacy with the utmost importance. AI tasks should not be siloed but rather holistically integrated into clinical workflow to retain context and relevance. As cardiac surgeons, AI allows us to look forward to a bright future of more efficient use of our clinical expertise toward high-level decision making and technical prowess.

Material modeling and recent findings in transcatheter aortic valve implantation simulations

BACKGROUND AND OBJECTIVE

Transcatheter aortic valve implantation (TAVI) has significantly transformed the management of aortic valve (AV) diseases, presenting a minimally invasive option compared to traditional surgical valve replacement. Computational simulations of TAVI become more popular and offer a detailed investigation by employing patient-specific models. On the other hand, employing accurate material modeling procedures and applying basic modeling steps are crucial to determining reliable numerical results. Therefore, this review aims to outline the basic modeling approaches for TAVI, focusing on material modeling and geometry extraction, as well as summarizing the important findings from recent computational studies to guide future research in the field.

METHODS

This paper explains the basic steps and important points in setting up and running TAVI simulations. The material properties of the leaflets, valves, stents, and tissues utilized in TAVI simulations are provided, along with a comprehensive explanation of the geometric extraction methods employed. The differences between the finite element analysis, computational fluid dynamics, and fluid-structure interaction approaches are pointed out and the important aspects of TAVI modeling are described by elucidating the recent computational studies.

RESULTS

The results of the recent findings on TAVI simulations are summarized to demonstrate its powerful potential. It is observed that the material properties of aortic tissues and components of implanted valves should be modeled realistically to determine accurate results. For patient-specific AV geometries, incorporating calcific deposits on the leaflets is essential for ensuring the accuracy of computational findings. The results of numerical TAVI simulations indicate the significance of the selection of optimal valves and precise deployment within the appropriate anatomical position. These factors collectively contribute to the effective functionality of the implanted valve.

CONCLUSIONS

Recent studies in the literature have revealed the critical importance of patient-specific modeling, the selection of accurate material models, and bio-prosthetic valve diameters. Additionally, these studies emphasize the necessity of precise positioning of bio-prosthetic valves to achieve optimal performance in TAVI, characterized by an increased effective orifice area and minimal paravalvular leakage.

Aspects of renal function and renal artery anatomy as indications for renal denervation

Renal denervation (RDN) is a minimally invasive, endovascular catheter-based procedure using radiofrequency, ultrasound, or alcohol-mediated ablation to treat resistant hypertension. As more attention is focused on the renal sympathetic nerve as a cause and treatment target of hypertension, understanding the anatomy of the renal artery may have important implications for determining endovascular treatment strategies as well as for future selection of devices and appropriate candidates for RDN treatment. However, the anatomical structure of the renal artery (RA) is complex, and standardized morphological evaluations of the RA structure are lacking. Computed tomography angiography or magnetic resonance angiography imaging is useful for assessing RA anatomy before conducting RDN. RA echocardiography is an established noninvasive screening method for significant stenosis. Major randomized controlled trials have limited enrollment to patients with preserved renal function, usually defined as an estimated glomerular filtration rate (eGFR) ≥ 45 mL/min/1.73 m2. Therefore, the level of renal function at which RDN is indicated has not yet been determined. This mini-review summarizes the characteristics of renal artery anatomy and renal function that constitute indications for renal denervation. (Role of Clinical Trials: K. Kario is an Executive Committee Principal Investigator for the Spyral OFF MED, the Spyral ON MED, the DUO and the REQUIRE; a Coordinating investigator for the TCD-16164 study; a Site Principal Investigator for the HTN-J, the Spyral OFF MED, the Spyral ON MED, the DUO, the REQUIRE and the TCD-16164 study). Evaluation of renal arteries for radiofrequency renal denervation. A Simultaneous quadrantal ablations at four sites in the main renal artery or the equivalent renal artery to the main renal artery. B If there is a renal artery branch with a diameter >3 mm in the middle of the main renal artery, this branch is the distal end of the main renal artery. In this case, four simultaneous and quadrantal ablations can be performed on the equivalent renal arteries. C Four simultaneous and quadrantal ablations can be performed in the branch renal artery. D Sonication should be spaced at least 5 mm (one transducer*) apart. Perform 2 to 3 mm proximal to the arterial bifurcation. Perform 2 to 3 mm distal to the abdominal aortic inlet.

Transradial access for the endovascular treatment of intracranial aneurysms using the Woven EndoBridge device: A systematic review and pooled analysis

BACKGROUND

The Woven EndoBridge (WEB) device is a minimally invasive endovascular treatment option for patients with cerebral aneurysms. Transradial access (TRA) is a technique that involves accessing the arterial system through the radial artery in the wrist rather than the femoral artery in the groin. Several studies have investigated the use of TRA for WEB device deployment in treating intracranial aneurysms.

METHODS

A systematic review was conducted to evaluate the TRA for WEB device deployment in treating intracranial aneurysms. The databases PubMed, Cochrane, Embase, Scopus, and Web of Science were searched. To reduce the risk of bias, this systematic review only included studies reporting on using TRA in WEB device deployment for intracranial aneurysm treatment with a minimum of four patients.

RESULTS

In this systematic review, 186 patients were included across five studies, with TRA used in 183 cases analyzed. The study population had a higher proportion of females (n = 118%-69%) than males, with a mean age of 62 years old. Among the aneurysms treated, 46 were ruptured, and 119 were located at bifurcation sites, with a mean maximum diameter/width of 6.6 mm and mean height of 5.9 mm. Adjunctive coiling was used in three cases, and adjunctive stenting was used in nine cases. In two cases, conversion to a femoral artery access was necessary.

CONCLUSION

The available results suggest TRA with the WEB device is a safe and effective alternative. However, using TRA versus TFA should be individualized based on patient factors and operator experience.

PET myocardial perfusion imaging: Trends, challenges, and opportunities

Various non-invasive images are used in clinical practice for the diagnosis and prognostication of chronic coronary syndromes. Notably, quantitative myocardial perfusion imaging (MPI) through positron emission tomography (PET) has seen significant technical advancements and a substantial increase in its use over the past two decades. This progress has generated an unprecedented wealth of clinical information, which, when properly applied, can diagnose and fine-tune the management of patients with different types of ischemic syndromes. This state-of-art review focuses on quantitative PET MPI, its integration into clinical practice, and how it holds up at the eyes of modern cardiac imaging and revascularization clinical trials, along with future perspectives.

Hybrid approach to deep vein arterialization as an adjunct for patients with severe medial calcinosis

Patients with no-option chronic limb-threatening ischemia are not candidates for conventional revascularization options and will inevitably require major amputation. Deep venous arterialization (DVA) is a potential option for these patients. A complete endovascular system to perform DVA has recently received great acclaim and US Foor and Drug Administration approval. However, patients with severe tibial medial calcinosis such as those with diabetes or renal failure may not be candidates for this because most endovascular needles cannot penetrate severe calcium. Here we describe a novel hybrid approach to DVA that provided technical success in three patients with end-stage renal disease and severe medial calcinosis.

Distal Adjuncts for High-Risk Lower Extremity Bypasses

BACKGROUND

This review will discuss the use of distal adjuncts for improving graft patency in high-risk lower extremity bypasses.

METHODS

Factors that contribute to the increased risk of failure in high-risk lower extremity bypasses, such as the use of nonautogenous conduits, the creation of bypasses to very distal arterial targets, and bypasses in patients with significant tibial arterial disease, will be discussed.

RESULTS

The use of surgical techniques such as creating venous cuffs, venous patches, and arteriovenous fistulas have been shown to improve the patency of high-risk bypasses.

CONCLUSIONS

Despite the increased risk of failure, the use of surgical adjuncts such as cuffs, patches, and arteriovenous fistulas can improve the patency rates of high-risk lower extremity bypasses.

Cardiogenic shock in the context of acute coronary syndromes in Latin America ("LATIN Shock")

Cardiogenic shock (CS) is a serious complication of heart attack and constitutes one of its main causes of death. To date, there is no data on its treatment and evolution in Latin America.

OBJECTIVES

To know the clinical characteristics, treatment strategies, evolution and in-hospital mortality of CS in Latin America.

MATERIALS AND METHODS

This is a prospective, multicenter registry of patients hospitalized with CS in the context of acute coronary syndromes (ACS) with and without ST segment elevation for 24 months.

RESULTS

41 Latin American centers participated incorporating patients during the period between October 2021 and September 2023. 278 patients were included. Age: 66 (59-75) years, 70.1 % men. 74.8 % of the cases correspond to ACS with ST elevation, 14.4 % to ACS without ST elevation, 5.7 % to right ventricular infarction and 5.1 % to mechanical complications. CS was present from admission in 60 % of cases. Revascularization: 81.3 %, inotropic use: 97.8 %, ARM: 52.5 %, Swan Ganz: 17 %, intra-aortic balloon pump: 22.2 %. Overall in-hospital mortality was 52.7 %, with no differences between ACS with or without ST.

CONCLUSIONS

Morbidity and mortality is very high despite the high reperfusion used.