Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

Development and Validation of Artificial Intelligence-Based Algorithms for Predicting the Segments Debulked by Rotational Atherectomy Using Intravascular Ultrasound Images

We develop and evaluate an artificial intelligence (AI)-based algorithm that uses pre-rotation atherectomy (RA) intravascular ultrasound (IVUS) images to automatically predict regions debulked by RA. A total of 2106 IVUS cross-sections from 60 patients with de novo severely calcified coronary lesions who underwent IVUS-guided RA were consecutively collected. The 2 identical IVUS images of pre- and post-RA were merged, and the orientations of the debulked segments identified in the merged images were marked on the outer circle of each IVUS image. The AI model was developed based on ResNet (deep residual learning for image recognition). The architecture connected 36 fully connected layers, each corresponding to 1 of the 36 orientations segmented every 10°, to a single feature extractor. In each cross-sectional analysis, our AI model achieved an average sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 72%, 46%, 90%, and 75%, respectively. In conclusion, the AI-based algorithm can use information from pre-RA IVUS images to accurately predict regions debulked by RA and will assist interventional cardiologists in determining the treatment strategies for severely calcified coronary lesions.

Halftime rotational atherectomy: a unique concept for diffuse long severely calcified lesions

Rotational atherectomy (RA) is technically more difficult in a diffuse calcified lesion than in a focal calcified lesion. We hypothesized that taking a halftime can be another option for RA to the diffuse calcified lesions. Halftime was defined as at least one long break during RA, in which an operator pulled out the Rotablator system from the guide catheter before crossing the lesion. This study aimed to compare the complications between RA with and without halftime. We included 177 diffuse long severely calcified lesions (lesion lengths ≥ 30 mm) that required RA, and divided those lesions into a halftime group (n = 29) and a no-halftime group (n = 148). The primary outcome was periprocedural myocardial infarction (MI). The reference diameter was smaller in the halftime group than in the no-halftime group [1.82 (1.70-2.06) mm versus 2.17 (1.89-2.59) mm, p = 0.002]. The total run time was longer in the halftime group than in the non-halftime group [133.0 (102.0-223.0) seconds versus 71.5 (42.0-108.0) seconds, p < 0.001]. Although creatinine kinase (CK) and CK-myocardial band (MB) was significantly higher in the halftime group than in the no-halftime group [CK: 156 (97-308) U/L versus 99 (59-216) U/L, p = 0.021; CK-MB: 15 (8-24) U/L versus 5 (3-15) U/L, p < 0.001], periprocedural MI was not observed in the halftime group. In conclusion, periprocedural MI was not observed in RA with halftime. This preliminary study suggests that halftime RA may be a safe option for diffuse severely calcified lesions.

The Burden of Cardiovascular Diseases Attributed to Diet High in Sugar-Sweetened Beverages in 204 Countries and Territories From 1990 to 2019

This study examines the impact of sugar-sweetened beverage (SSB) consumption on cardiovascular diseases (CVDs) and aims to provide evidence for preventive measures. The analysis involved a comprehensive scrutiny of CVD-related data from 1990 to 2019. Temporal trends of ASMR and ASDR were assessed using the Estimated Annual Percentage Change (EAPC). Globally, there was an increase in deaths and DALYs from 1990 to 2019, despite decreasing ASMR and ASDR. In 2019, SSB-related CVDs accounted for approximately 193.1 thousand deaths and 3973.2 thousand DALYs. China had the highest number of deaths, Tajikistan had the highest ASMR, and Yemen had the highest ASDR in 2019. ASMR and ASDR increased with age and were higher in males. Deaths and DALYs increased overall, except in high Socio-demographic Index (SDI) regions. ASMR and ASDR declined across SDI regions, with the steepest decline in high SDI regions (EAPC: -2.8 for ASMR, -2.36 for ASDR). ASDR increased in low SDI countries but decreased in high SDI countries. This study provides comprehensive insights into the global burden of SSB-related CVDs. Urgent interventions and policies are needed to reduce SSB consumption and mitigate the impact on cardiovascular health.

Emergency transvenous temporary pacing during rotational atherectomy

Background

Rotational atherectomy (RA) during percutaneous coronary intervention may cause transient bradycardia or a higher-degree heart block. Traditionally, some operators use prophylactic transvenous pacing wire (TPW) to avoid haemodynamic complications associated with bradycardia.

Objective

We sought to establish the frequency of bail-out need for emergency TPW insertion in patients undergoing RA that have received no upfront TPW insertion.

Methods

We performed a single-centre retrospective study of all patients undergoing RA between October 2009 and October 2022. Patient characteristics, procedural variables, and in-hospital complications were registered.

Results

A total of 331 patients who underwent RA procedure were analysed. No patients underwent prophylactic TPW insertion. The mean age was 73.3 ± 9.1 years, 71.6% (n = 237) were male, while nearly half of the patients were diabetic [N = 158 (47.7%)]. The right coronary artery was the most common target for RA (40.8%), followed by the left anterior descending (34.1%), left circumflex (14.8%), and left main stem artery (10.3%). Altogether 20 (6%) patients required intraprocedural atropine therapy. Emergency TPW insertion was needed in one (0.3%) patient only. Eight (2.4%) patients died, although only one (0.3%) was adjudicated as being possibly related to RA-induced bradycardia. Five patients (1.5%) had ventricular fibrillation arrest, while nine (2.7%) required cardiopulmonary resuscitation. Six (1.8%) procedures were complicated by coronary perforation, two (0.6%) were complicated by tamponade, while 17 (5.1%) patients experienced vascular access complications.

Conclusions

Bail-out transvenous temporary pacing is very rarely required during RA. A standby temporary pacing strategy seems reasonable and may avoid unnecessary TPW complications compared with routine use.

Analyzing drilling noise in rotational atherectomy: Improving safety and effectiveness through visualization and anomaly detection using autoencoder-A preclinical study

Background and Aims

As the population of aging societies continues to grow, the prevalence of complex coronary artery diseases, including calcification, is expected to increase. Rotational atherectomy (RA) is an essential technique for treating calcified lesions. This study aimed to assess the usefulness of the drilling noise produced during rotablation as a parameter for evaluating the safety and effectiveness of the procedure.

Methods

A human body model mimicking calcified stenotic coronary lesions was constructed using plastic resin, and burrs of sizes 1.25 and 1.5 mm were utilized. To identify the noise source during rotablation, we activated the ROTAPRO™ rotablator at a rotational speed of 180,000 rpm, recording the noise near the burr (inside the mock model) and advancer (outside). In addition to regular operation, we simulated two major complications: burr entrapment and guidewire transection. The drilling noise recorded in Waveform Audio File Format files was converted into spectrograms for analysis and an autoencoder analyzed the image data for anomalies.

Results

The drilling noise from both inside and outside the mock model was predominantly within the 3000 Hz frequency domain. During standard operation, intermittent noise within this range was observed. However, during simulated complications, there were noticeable changes: a drop to 2000 Hz during burr entrapment and a distinct squealing noise during guidewire transection. The autoencoder effectively reduced the spectrogram data into a two-dimensional representation suitable for anomaly detection in potential clinical applications.

Conclusion

By analyzing drilling noise, the evaluation of procedural safety and efficacy during RA can be enhanced.

Rotational atherectomy to left circumflex ostial lesions: tips and tricks

Serious complications including vessel perforation may occur during rotational atherectomy (RA) to left circumflex (LCX) ostial lesions. In fact, if perforation occurs around LCX ostium, bailout procedures including deployment of covered stents may cause fatal ischemia in the territory of left anterior descending artery, which results in broad anterior acute myocardial infarction and subsequent death. In this review article, we described tips and tricks for RA to LCX ostial lesions. First, we should cautiously decide the indication for RA to LCX ostial lesions, because there are several reasons to avoid RA to LCX ostial lesions. Before procedures, we should estimate the difficulty of RA to LCX ostial lesions, which is mainly determined by the combination of the bifurcation angle and the severity of stenosis. Thus, the combination of the large bifurcation angle and the tight stenosis makes RA to LCX ostial lesions most difficult. Appropriate position of guide catheter and RotaWire is a key to successful RA to LCX ostial lesions. Differential cutting is an essential concept for RA to LCX ostial lesions. However, since there is no guarantee that differential cutting always works, small burr (≤ 1.5 mm) would be a safe choice as initial burr for RA to LCX ostial lesions.

Lifetime management of severely calcified coronary lesions: the treatment algorithm focused on the shape of calcification

The concept of lifetime management has not been discussed in the field of percutaneous coronary intervention (PCI), because the durability of drug-eluting stent (DES) is considered to be long enough for most patients. Furthermore, even if in-stent restenosis occurs, the treatment for in-stent restenosis is simple in most cases. On the other hand, the long-term clinical outcomes after DES implantation are worse in severely calcified coronary lesions than in non-calcified lesions. Moreover, the treatment for in-stent calcified restenosis or restenosis due to stent underexpansion is not simple. The concept of lifetime management of severely calcified lesions may be necessary like that of aortic stenosis. Recently, several algorithms have been published in PCI to severely calcified lesions, partly because of the emergence of IVL. These algorithms focus on the selection of cracking and debulking devices for the preparation of stenting. However, the optimal stent expansion does not guarantee the long-term patency, when the target lesion includes calcified nodules. Stent restenosis due to calcified nodules is difficult to manage. In this review article, we propose the algorithm for severely calcified lesions focused on the shape of calcification. We do not need to hesitate stenting when multiple cracks on circumferential calcification are observed by intravascular imaging devices. However, DCB may be an option as final device in some situations, when lifetime management of severely calcified lesions is considered.

Prediction of the debulking effect of rotational atherectomy using optical frequency domain imaging: a prospective study

This study determined the predictive accuracy of optical frequency domain imaging (OFDI) on debulking effects of rotational atherectomy (RA) and compared the predictive accuracy of OFDI catheter-based with Rota wire-based prediction methods. This prospective, single-center, observational study included 55 consecutive patients who underwent OFDI-guided RA. On pre-RA OFDI images, a circle, identical to the Rota burr was drawn at the center of the OFDI catheter (OFDI catheter-based prediction method) or wire (wire-based prediction method). The area overlapping the vessel wall was defined as the predicted ablation area (P-area). The actual ablated area (A-area) was measured by superimposing the OFDI images before and after RA. The overlapping P-area and A-area were defined as overlapped ablation area (O-area), and the predictive accuracy was evaluated by %Correct area (O-area/P-area) and %Error area (A-area  - O-area/A-area). The median %Correct and %Error areas were 47.8% and 41.6%, respectively. Irrelevant ablation (low %Correct-/high % Error areas) and over ablation (high %Correct-/high % Error areas) were related to deep vessel injury and intimal flap outside the P-area. The predictive accuracy was better in the OFDI catheter-based prediction method than the wire-based prediction method in the cross sections where the OFDI catheter and wire came in contact. However, it was better in the latter than the former where the OFDI catheter and wire were not in contact. OFDI-based simulation of the RA effect is feasible though accuracy may be affected by the OFDI catheter and wire position. OFDI-based simulation of RA effect might reduce peri-procedural complications during RA.