Coronary Atherectomy in the United States (from a Nationwide Inpatient Sample)

Systematic Review of the Efficacy of Orbital Atherectomy in Improving the Outcome of Percutaneous Corornary Intervention in People With Diabetes

The optimal approach to deal with severe coronary artery calcification (CAC) in people with diabetes remains ill-defined. People with diabetes have a significant risk of developing severe vessel calcification and coronary artery disease (CAD). CAD is the leading cause of death in people with diabetes. Individuals with diabetes mainly present with severe multivessel stenosis, diffuse coronary calcification, and severe atherosclerosis, which are poor prognostic factors of revascularization procedures. Studies have shown that the revascularization of arteries in people with diabetes often results in worse outcomes than in people without diabetes. Coronary artery bypass grafting (CABG) has been recommended as the standard of care for people with DM and complex anatomic diseases, including left main CAD. However, percutaneous coronary intervention (PCI) is more acceptable to patients in clinical practice because of decreased trauma and rapid recovery. Severe CAC has traditionally been challenging for PCI and a frequent indication for surgical revascularization. This study aims to determine the effectiveness of orbital atherectomy (OA) in improving PCI outcomes in patients with diabetes and identify possible adverse effects that preclude its use.  The study is reported according to PRISMA and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search of EMBASE, Scopus, Web of Science, Cochrane Library, CINAHL, and MEDLINE was conducted for studies that utilized OA before PCI in people with diabetes. A reference list of the eligible articles was also screened. A narrative synthesis was done by representing the data on the effect direction plot, followed by vote counting. Eighteen studies were included in the analysis. Success rate/successful stent delivery was >90%, while freedom from angiographic complication and major adverse cardiovascular and cerebrovascular events (MACCE) were both >80% on the effect direction plot for people with diabetes and those without diabetes. People with diabetes had low event rates similar to those without diabetes. OA appears to be a viable treatment approach for people with diabetes. However, RCTs with a longer duration of follow-up are required to establish the appropriate treatment strategy for severe CAC in people with diabetes.

Impact of concomitant aortic stenosis on the management and outcomes of acute myocardial infarction hospitalizations in the United States

Objective:

To evaluate the prevalence, management and outcomes of concomitant aortic stenosis (AS) in admissions with acute myocardial infarction (AMI).

Methods:

We used the HCUP-NIS database (2000–2017) to identify adult AMI admissions with concomitant AS. Outcomes of interest included prevalence of AS, in-hospital mortality, use of cardiac procedures, hospitalization costs, length of stay, and discharge disposition.

Results:

Among a total of 11,622,528 AMI admissions, 513,688 (4.4 %) were identified with concomitant AS. Adjusted temporal trends revealed an increase in STEMI and NSTEMI hospitalizations with concomitant AS. Compared to admissions without AS, those with AS were on average older, of female sex, had higher comorbidity, higher rates of NSTEMI (78.9 % vs 62.1 %), acute non-cardiac organ failure, and cardiogenic shock. Concomitant AS was associated with significantly lower use of coronary angiography (45.5 % vs 64.4 %), percutaneous coronary intervention (20.1 % vs 42.5 %), coronary atherectomy (1.7 % vs. 2.8 %) and mechanical circulatory support (3.5 % vs 4.8 %) (all p < 0.001). Admissions with AS had higher rates of coronary artery bypass surgery and surgical aortic valve replacement (5.9 % vs 0.1 %) compared to those without AS. Admissions with AMI and AS had higher in-hospital mortality (9.2 % vs. 6.0 %; adjusted OR 1.12 [95 % CI 1.10–1.13]; p <0.001). Concomitant AS was associated with longer hospital stay, more frequent palliative care consultations and less frequent discharges to home.

Conclusions:

In this 18-year study, an increase in prevalence of AS in AMI hospitalization was noted. Concomitant AS was associated with lower use of guideline-directed therapies and worse clinical outcomes among AMI admissions.

Coronary Intravascular Lithotripsy Versus Rotational Atherectomy in an Asian Population: Clinical Outcomes in Real-World Patients

Intravascular lithotripsy (IVL) is a newer calcium modification therapy with limited clinical experience compared to other established techniques. Single-armed studies have shown IVL is safe and effective for heavily calcified coronary lesions. This study compares our initial IVL experience with rotational atherectomy in real-world high-risk patients. We found that in-hospital adverse outcomes were not statistically significant, although 30-day major adverse cardiovascular events was higher with IVL. Differences in baseline characteristics and the small cohort numbers preclude definitive conclusions. With better experience and case selection, these outcomes are likely to improve, allowing IVL to effectively treat complex calcified coronary lesions.

Background and Objectives

We compared real-world clinical outcomes of patients receiving intravascular lithotripsy (IVL) versus rotational atherectomy (RA) for heavily calcified coronary lesions.

Methods

Fifty-three patients who received IVL from January 2017 to July 2020 were retrospectively compared to 271 patients who received RA from January 2017 to December 2018. Primary endpoints were in-hospital and 30-day major adverse cardiovascular events (MACE).

Results

IVL patients had a higher prevalence of acute coronary syndrome (56.6% vs 24.4, p<0.001), multivessel disease (96.2% vs 73.3%, p<0.001) and emergency procedures (17.0% vs 2.2%, p<0.001) compared to RA. In-hospital MACE (11.3% vs 5.9%, p=0.152), MI (7.5% vs 3.3%, p=0.152), and mortality (5.7% vs 3.0%, p=0.319) were not statistically significant. 30-day MACE was higher in the IVL cohort vs RA (17.0% vs 7.4%, p=0.035). Propensity score adjusted regression using IVL was also performed on in-hospital MACE (odds ratio [OR], 1.677; 95% confidence interval [CI], 0.588–4.779) and 30-day MACE (OR, 1.910; 95% CI, 0.774–4.718).

Conclusions

These findings represent our initial IVL experience in a high-risk, real-world cohort. Although the event rate in the IVL arm was numerically higher compared to RA, the small numbers and retrospective nature of this study preclude definitive conclusions. These clinical outcomes are likely to improve with greater experience and better case selection, allowing IVL to effectively treat complex calcified coronary lesions.

Shockwave coronary intravascular lithotripsy system for heavily calcified de novo lesions and the need for a cost-effectiveness analysis

The optimal management for severely calcified coronary artery disease is multi-adjunctive. Different strategies with dedicated devices should be available in the cardiac catheterization laboratory with their selection depending on the nature of the calcific disease and its anatomical distribution. Shockwave Intravascular Lithotripsy (S-IVL) system offers a novel option for lesion preparation of heavily calcified plaques in coronary and peripheral vessels. S-IVL is based on the fundamental principles of lithotripsy, a technology that has been used to modify renal stones for over 30 years. Pulsatile mechanical energy is used to fragment selectively amorphous calcium, sparing soft tissue. S-IVL has the potential of more widespread adoption because of its proven safety, efficacy and operational simplicity, but cost-effectiveness of such advanced technology will need to be analyzed.

Acute Angulation and Sequential Lesion Increase the Risk of Rotational Atherectomy Failure

BACKGROUND

The aim of the study was to assess anatomical and procedural predictors of clinical and procedural failure of rotational atherectomy (RA) in an all-comers population.Methods and Results:A total of 534 consecutive patients who underwent RA were included in a double-center observational study. The primary composite endpoint consisted of: rota-wire introduction failure, burr-passage failure, periprocedural complications and procedure-related major adverse events. The second primary endpoint included rota-wire introduction failure and burr-passage failure. The primary endpoint occurred in 76 (14.2%) patients and the second primary endpoint occurred in 64 (12%) Periprocedural complications occurred in 23 (4.3%) and procedure-related adverse events in 23 (4.3%) patients. Multivariable analysis revealed angulation on lesion ≤90° (HR=2.18, 95% CI: 1.21-3.94, P=0.0096) and sequential lesion (HR=1.89, 95% CI: 1.01-3.54, P=0.046) as independent predictors of no clinical success of RA. Multivariable analysis revealed again that angulation on lesion ≤90° (HR=2.26, 95% CI: 1.16-4.40, P=0.02) and sequential lesion (HR=3.77, 95% CI: 1.64-8.69, P<0.01) as independent predictors of no procedural success of RA.

CONCLUSIONS

The presence of an acute angulation on lesion and sequential lesion are independent determinants of clinical and procedural failure of RA. Further research is necessary to establish a score predicting RA failure, which can help in preproceduralrisk stratification of patients undergoing complex percutaneous coronary intervention with RA.

Prevalence, clinical determinants and prognostic implications of coronary procedural complications of percutaneous coronary intervention in non-ST-segment elevation myocardial infarction: Insights from the contemporary multinational TAO trial

BACKGROUND

Few data are available on procedural complications of percutaneous coronary intervention (PCI) in the setting of acute coronary syndrome in the contemporary era.

AIM

We sought to describe the prevalence of procedural complications of PCI in a non-ST-segment elevation acute coronary syndrome (NSTE ACS) cohort, and to identify their clinical characteristics and association with clinical outcomes.

METHODS

Patients randomized in TAO (Treatment of Acute coronary syndrome with Otamixaban), an international randomized controlled trial (ClinicalTrials.gov Identifier: NCT01076764) that compared otamixaban with unfractionated heparin plus eptifibatide in patients with NSTE ACS who underwent PCI, were included in the analysis. Procedural complications were collected prospectively, categorized and adjudicated by a blinded Clinical Events Committee, with review of angiograms. A multivariable model was constructed to identify independent clinical characteristics associated with procedural complications.

RESULTS

A total of 8656 patients with NSTE ACS who were enrolled in the TAO trial underwent PCI, and 451 (5.2%) experienced at least one complication. The most frequent complications were no/slow reflow (1.5%) and dissection with decreased flow (1.2%). Procedural complications were associated with the 7-day ischaemic outcome of death, myocardial infarction or stroke (24.2% vs. 6.0%, odds ratio 5.01, 95% confidence interval 3.96-6.33; P<0.0001) and with Thrombolysis In Myocardial Infarction major and minor bleeding (6.2% vs. 2.3%, odds ratio 2.79, 95% confidence interval 1.86-4.2; P<0.0001). Except for previous coronary artery bypass grafting, multivariable analysis did not identify preprocedural clinical predictors of complications.

CONCLUSIONS

In a contemporary NSTE ACS population, procedural complications with PCI remain frequent, are difficult to predict based on clinical characteristics, and are associated with worse ischaemic and haemorrhagic outcomes.

Rotational atherectomy and same day discharge: Safety and growth from a national perspective

OBJECTIVES

We explore whether same day discharge (SDD) is a feasible and safe practice following rotational atherectomy (ROTA) treatment during elective percutaneous coronary intervention (PCI), and examine which baseline characteristics are independently associated with SDD.

BACKGROUND

SDD following elective ROTA PCI is not recommended as per the recent SCAI consensus. However, reports show it is practiced and no previous study has evaluated its safety and feasibility.

METHODS

Our dataset included 4,591 patients undergoing elective ROTA PCI in England & Wales within an 8-years period. Independent associations with SDD were quantified via a multiple logistic regression model and the BCIS 30-day mortality risk model was used to evaluate the safety of SDD.

RESULTS

The majority of elective ROTA PCI cases remain at the hospital for overnight (ON) observation, although SDD rates increased substantially from 6.7% in 2007 to 35.5% in 2014. The use of glycoprotein IIb/IIIa antagonists, Q wave AMI, left main PCI and valvular heart disease were independently associated with ON, while patients operated underwent transradial PCI were more likely to be SDD (OR = 1.77, 95% CI [1.45-2.15]). Over the study period, observed mortality rates were not significantly higher than those expected from the BCIS risk model.

CONCLUSIONS

Our findings did not show superiority of the ON strategy over SDD for higher risk cases undergoing elective ROTA PCI, in terms of 30-day mortality. This is the first study to examine the safety of SDD after elective ROTA PCI and more should follow.

Trends in Usage and Clinical Outcomes of Coronary Atherectomy

Background:

Adjunctive coronary atherectomy (CA) can be utilized in treating severely calcified coronary lesions; however, the temporal trends, patient selection, and variation in use of CA have not been well described. We sought to assess the trends in usage, interhospital variability, and outcomes with CA among patients undergoing percutaneous coronary intervention (PCI).

Methods:

All patients undergoing PCI in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009 to December 31, 2016 (N=3 864 377) were analyzed based on utilization of either rotational or orbital CA. Intervals using date of index CA grouped into 2009 Q3 to 2010, 2011 to 2012, 2013 to 2014, and 2015 to 2016 and hospital-level quartiles based on annual CA volumes were evaluated. The primary outcome measure was in-hospital major adverse cardiac events defined as a composite of all-cause mortality, periprocedural myocardial infarction, or stroke. Independent variables associated with outcomes were determined.

Results:

CA represented 1.7% (n=65 033) of the total PCI volume. Among hospitals performing PCI (n=1672), 577 (34.5%) did not perform any CA. Patients treated with CA were elderly, more often male, and had a history of diabetes, prior myocardial infarction, PCI, and coronary artery bypass grafting. The utilization of CA increased from 1.1% in Q3 2009 to 3.0% in Q4 of 2016 (5% quarterly increase in odds of CA; OR [95% CI], 1.05 [1.04–1.06], P <0.001). Among patients undergoing CA, there was a temporal decline in major adverse cardiac events (0.98 [0.97–0.99], P <0.001) and myocardial infarction (0.97 [0.96–0.98], P <0.001). In adjusted analyses, increasing hospital CA volume was associated with lower mortality (0.85 [0.76–0.96], P =0.01) and lower rates of PCI failure or complication requiring coronary artery bypass grafting (0.67 [0.56–0.79], P <0.001) but was associated with small increase in coronary perforation (1.18 [1.04–1.35], P <0.01).

Conclusions:

Although CA is performed infrequently, its use has increased over time. After accounting for potential confounders, higher CA volume was associated with lower risk of major adverse events counterbalanced by small risk of coronary perforation.

Outcomes of coronary rotational atherectomy in patients with reduced left ventricular ejection fraction

Objective

We evaluated the safety and efficacy of rotational atherectomy (RA) in patients with a reduced left ventricular ejection fraction (LVEF).

Methods

In total, 140 consecutive patients with severe coronary artery calcification (CAC) who underwent RA were retrospectively enrolled. Patients were grouped based on LVEF: ≤35% (n = 10), 36% to 50% (n = 11), and >50% (n = 119). We assessed procedural success and periprocedural complication rates as well as the incidences of in-hospital and 2-year major adverse cardiac events (MACEs), defined as hospitalization for myocardial infarction and worsening heart failure, target vessel revascularization, and cardiac death.

Results

Procedural success was achieved in nearly all patients in each group. Most periprocedural complications were minor, and major complications were uncommon. The 2-year MACE rate was significantly higher in the LVEF ≤35% than LVEF >50% group (40.0% vs. 6.7%, respectively). Multivariable regression analysis revealed that the LVEF was the only independent predictor of 2-year MACEs in patients who underwent RA.

Conclusions

Patients with a reduced LVEF who underwent RA had procedural success rates similar to those of patients with preserved left ventricular systolic function. The LVEF might be an independent predictor of 2-year MACEs in patients with severe CAC after percutaneous coronary intervention following RA.

Modern-Day Nationwide Utilization of Intravascular Ultrasound and Its Impact on the Outcomes of Percutaneous Coronary Intervention With Coronary Atherectomy in the United States

OBJECTIVES

Intravascular ultrasonography (IVUS) and coronary atherectomy (CA) are useful modalities in managing calcified coronary lesions. Considering an inadequacy of data, we aimed to compare the outcomes with versus without IVUS assistance in percutaneous coronary interventions (PCIs) with CA.

METHODS

From the National (Nationwide) Inpatient Sample data set for the years 2012 to 2014, we identified adult patients undergoing PCI and CA with or without IVUS assistance using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We assessed the impact of IVUS on procedural outcomes, length of stay, total hospital charges, and predictors of IVUS utilization by multivariable analyses. Discharge weights were used to calculate national estimates.

RESULTS

A total of 46,095 PCIs with CA procedures were performed from 2012 to 2014, of these, 4800 (10.4%) procedures were IVUS-assisted. IVUS-assisted procedures showed lower odds of in-hospital mortality (odds ratio, 0.57; P = .024) but higher odds of any cardiac complication (odds ratio, 1.25; P = .025). Total hospital charges were higher in IVUS-assisted procedures without any substantial difference in the length of stay between the groups. Cardiac complication rates declined (from 16.2% to 14.8%) from 2012 to 2014, whereas inpatient mortality increased (1.1%-4.4%) in IVUS-assisted procedures during the same period. The odds of IVUS utilization were higher in Asian/Pacific Islander and urban teaching and western region hospitals. Comorbidities, including hypertension, obesity, and chronic pulmonary disease, raised odds of IVUS utilization.

CONCLUSIONS

IVUS-assisted procedures showed lower in-hospital mortality and higher iatrogenic and overall cardiac complications. The mortality rate in patients undergoing IVUS-assisted PCI with CA was on the rise, with declining cardiac complication rates from 2012 to 2014.

A New Era for Rotational Atherectomy: An Australian Perspective

Background:

Rotational atherectomy (RA) has been used in percutaneous coronary intervention (PCI) for 30 years. With advances in technology, this observational study looks at how rates of RA have changed over the past decade in Australia in relation to PCI and coronary artery bypass graft (CABG) rates.

Methods:

Retrospective analysis of RA, PCI, and CABG rates per Australian state from Australian Government Department of Human Services’ data on Medicare items from 2007 to 2017 was carried out.

Results:

There were 149 RA procedures in 2007, increasing to 452 in 2017. Rotational atherectomy accounted for 0.67% of PCI procedures in 2007, increasing to 1.48% in 2018 (+0.81%, 95% confidence interval [CI] = [0.64%-0.91%]; P < .001). Most of this increase has come from procedures in New South Wales (441% increase). Australian PCI rate increased from 22 301 to 30 480. Rate of CABG decreased from 5418 to 5206.

Conclusions:

From 2007 to 2017, rates of RA trebled in Australia. This is despite stable rates of PCI and a fall in rates of CABG. There are several clinical explanations for this trend.

Association of Medicare Spending With Subspecialty Consultation for Elderly Hospitalized Adults

IMPORTANCE

High use of subspecialty care is an important source of health care spending. Medical subspecialty care in particular may duplicate the scope of practice of the primary attending physicians for patients hospitalized for medical conditions. Under value-based payments, which aim to control overall spending during an episode of hospitalization (including Part B physician fees), subspecialty consultations may be a target for hospitals working to reduce costs.

OBJECTIVES

To measure the use of subspecialty consultation for Medicare beneficiaries hospitalized for nonsurgical conditions; to compare payments for consultative and nonconsultative care, adjusted for case mix and demographics; and to measure variation in payments across hospital referral regions (HRRs).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included a 15% random sample of Medicare fee-for-service beneficiaries enrolled in Parts A and B and identified all discharges after acute care hospital stays for nonsurgical conditions from January 1 through December 31, 2014. A total of 735 627 discharges were included. The analyses were conducted from December 1, 2017, through February 12, 2019. Total Part B payments were extrapolated to the population of Medicare fee-for-service beneficiaries.

MAIN OUTCOMES AND MEASURES

Probability of any consultation during a hospitalization was estimated using logistic regression. The number of consultations per stay and the number of consultative visits per hospital day were estimated using Poisson regression. Part B payments for consultative and nonconsultative care were estimated using generalized linear regression with gamma-log link. All models were adjusted for patient demographics and case mix. Payment models also included HRR fixed effects.

RESULTS

A total of 735 627 discharges from 4534 hospitals in 2014 were included in the analysis (41.2% men and 58.8% women; mean [SD] age, 79.6 [8.9] years; 84.7% white, 10.1% black, and 5.2% other race). After adjusting for patient case mix and demographics, a 6-fold variation between the top and bottom quintiles of hospitals (relative difference, $401 [95% CI, $368-$434]) and HRRs (relative difference, $363 [95% CI, $337-$389]) was found in payments per stay for consultative care. Part B payments for consultative care by medical subspecialists accounted for 41.3% of payments for physician visits during hospitalization and totaled $1.3 billion in 2014.

CONCLUSIONS AND RELEVANCE

The substantial variation in the use of subspecialty consultative care suggests potential opportunities for cost savings.

Orbital Atherectomy: A Comprehensive Review

Successful percutaneous coronary intervention (PCI) can be challenging in the presence of heavily calcified lesions. Severely calcified lesions are associated with worse clinical outcomes. Recognition of calcification is important before stenting to ensure adequate stent expansion can be attained. Orbital atherectomy is a safe and effective method to ablate calcified plaque. Lesion preparation through plaque modification with orbital atherectomy before stent implantation can help to optimize the results of PCI in these complex lesions.

Long-term cardiovascular prognosis after rotational atherectomy in hemodialysis patients: Data from the J2T multicenter registry

BACKGROUND

Hemodialysis (HD) patients have heavy calcium deposits in their stenotic coronary arteries and worse post-percutaneous coronary intervention (PCI) prognoses than those who do not undergo HD. Rotational atherectomy (RA) facilitates PCI success in severely calcified lesions. We aimed to identify clinical and procedural characteristics that predict HD patients' long-term prognoses after PCI that included RA in the drug-eluting stent (DES) era.

METHODS

This study included 302 patients who underwent regular HD from J2T Multicenter Registry database of 1090 consecutive patients who underwent RA to treat de novo calcified lesions at three university hospitals between 2004 and 2015. The primary endpoint was cardiovascular (CV) death.

RESULTS

During the 5-year observation period, 59 CV deaths (19.5%) occurred. The CV death group and non-CV death group had comparable profiles except significantly lower left ventricular ejection fraction, higher brain natriuretic peptide (BNP), lower rate of RA burr upsizing, and lower rate of final thrombolysis in myocardial infarction (TIMI) 3 flow achievement in the CV death group. Cox regression analysis revealed that increasing ablation burr size (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.13-0.81), final TIMI 3 flow (HR: 0.07; 95% CI: 0.02-0.28), lower BNP level, and optimal medication were independently associated with better CV mortality in HD patients.

CONCLUSION

In the DES era, oral medications at the time of PCI and stepwise calcium ablation were associated with improved long-term CV mortality in HD patients who are scheduled to undergo RA to treat severely calcified coronary artery stenoses, as therapeutic strategies.

Novel predictors of outcome after coronary angioplasty with rotational atherectomy. Not only low ejection fraction and clinical parameters matter

Introduction

Most established risk factors after rotational atherectomy (RA) of heavily fibro-calcified lesions are associated with patients' general risk and clinical related factors and are not specific for either coronary and culprit lesion anatomy or the RA procedure.

Aim

To assess novel predictors of poor outcome after percutaneous coronary intervention using RA in an all-comers population.

Material and methods

A total of 207 consecutive patients after RA were included in a single-center observational study. Primary endpoints were 1-year mortality and 1-year major adverse cardiac events (MACE). Secondary endpoints were angiographic and procedural success and in-hospital complications.

Results

Procedural complications occurred in 19 (8%) patients. In-hospital mortality was 1%, peri-procedural myocardial infarction (MI) was 9%, and acute stroke occurred in one patient. The 1-year MACE rate was 20% with all-cause mortality 10%, MI 10% and stroke 1%. Multivariable analysis revealed heart failure with left ventricle ejection fraction (LVEF) ≤ 35% (p = 0.02) and uncrossable lesion, as compared to undilatable lesion (p = 0.01), as independent predictors of 1-year mortality and residual SYNTAX score ≤ 8 as an independent predictor of favorable outcome (p = 0.04). Heart failure with LVEF ≤ 35% (p < 0.01) and uncrossable lesion (p = 0.04) were independent predictors of 1-year MACE.

Conclusions

The presence of a novel factor, uncrossable lesion, as compared to undilatable lesion, is associated with poor outcome, and low residual SYNTAX score ≤ 8 is associated with favorable outcome in 1-year follow-up after the RA procedure and can help in risk stratification of patients undergoing complex coronary intervention with RA.

Comparison of the Efficacy and Safety of Orbital and Rotational Atherectomy in Calcified Narrowings in Patients Who Underwent Percutaneous Coronary Intervention

We aimed to compare the safety and efficacy of rotational atherectomy (RA) and orbital atherectomy (OA) during percutaneous coronary intervention in an all-comer population with severely calcified lesions. We included all patients who underwent percutaneous coronary intervention with OA or RA in our institution from October 2013 until October 2016. Comparison of baseline and procedural characteristics, along with acute complication rates and postprocedural cardiac enzyme elevation, was performed. There were 191 RA and 57 OA patients. Other than creatinine clearance, which was lower in patients with OA (p = 0.01), there were no differences in baseline characteristics. OA was more frequent in left anterior descending artery lesions (p = 0.02), whereas RA was more common in right coronary artery lesions (p = 0.01). Intracoronary imaging rates were above 60% in both groups. There was a higher rate of coronary dissections with OA compared with RA (p = 0.003), but there was no difference in periprocedural events. Maximal troponin levels were similar in both groups. Residual stenosis measured by intravascular ultrasound in 29 patients revealed no significant differences between OA and RA (p = 0.58). In conclusion, RA and OA have similar safety and efficacy profiles in treating patients with calcified coronary lesions, and intracoronary imaging is highly beneficial in identifying coronary injury after atherectomy procedures.

Clinical Characteristics and Long-Term Outcomes of Rotational Atherectomy - J2T Multicenter Registry

BACKGROUND

Rotational atherectomy (RA) is an adjunct tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the long-term clinical outcomes of RA use remain unclear in this drug-eluting stent era.Methods and Results:This multi-center registry assessed the characteristics and outcomes of patients treated by RA for calcified coronary lesions between 2004 and 2015. Among 1,090 registered patients, mean age was 70±10 years and 815 (75%) were male. Sixty percent of patients had diabetes mellitus and 27.7% were receiving hemodialysis. The procedure was successful in 96.2%. In-hospital death occurred in 33 patients (3.0%), and 14 patients (1.3%) developed definite/probable stent thrombosis. During the median follow-up period of 3.8 years, the incidence of major adverse cardiac events (MACE), defined as all-cause death, acute coronary syndrome, stent thrombosis, target vessel revascularization and stroke, was 46.7%. On multivariable Cox hazard analysis, hemodialysis (HR, 2.08; 95% CI: 1.53-2.86; P<0.0001) and age (HR, 1.03; 95% CI: 1.01-1.04; P<0.0001) were strong independent predictors of MACE. Conversely, statin treatment was associated with lower incidence of MACE (P=0.035).

CONCLUSIONS

This study has provided the largest Japanese dataset for long-term follow-up of RA. Although RA in calcified lesions appears feasible with a high rate of procedural success, a high incidence of MACE was observed.

Comparison of Rotational Atherectomy Versus Orbital Atherectomy for the Treatment of Heavily Calcified Coronary Plaques

We evaluated the outcomes of patients with severe coronary artery calcification (CAC) who underwent rotational atherectomy (RA) and orbital atherectomy (OA). Severe CAC increases the complexity of percutaneous coronary intervention (PCI) because of the difficulty in optimizing stent expansion, leading to worse clinical outcomes. Both devices are effective treatment strategies for severe CAC. No comparisons have been performed to evaluate the clinical outcomes after RA and OA. The outcomes of 67 patients with severe CAC who underwent RA from July 2012 to June 2015 and 60 patients who underwent OA from February 2014 to September 2016 were evaluated. The primary end point was the rate of 30-day major adverse cardiac and cerebrovascular events, comprising cardiac death, myocardial infarction, target vessel revascularization, and stroke. The primary end point was similar in the RA and OA groups (6% vs 6%, p >0.9), as were the individual end points of death (0% vs 2%, p = 0.8), myocardial infarction (6% vs 4%, p = 0.7), target vessel revascularization (0% vs 0%, p >0.9), and stroke (0% vs 0%, p >9). Procedural success was achieved in all patients. Angiographic complications were uncommon in both groups. No patient had stent thrombosis. In conclusion, both RA and OA are safe and effective for the treatment of severe CAC as they provided similar clinical outcomes at short-term follow-up.

Incidence and Determinants of Complications in Rotational Atherectomy

Background—

The usage of rotational atherectomy (RA) is growing in the current percutaneous coronary intervention (PCI) because of the expansion of PCI indication to more complex lesions. However, the complications after RA have been linked to procedure-related morbidity and mortality. The purpose of this study was to investigate the incidence and determinants of complications in RA using a large nationwide registration system in Japan (J-PCI).

Methods and Results—

The primary composite outcome of this study was defined as the occurrence of in-hospital death, cardiac tamponade, and emergent surgery after RA. A total of 13 335 RA cases (3.2% of registered PCI cases) were analyzed. The composite outcome was observed in 175 cases (1.31%) and included 80 in-hospital deaths (0.60%), 86 tamponades (0.64%), and 24 emergent surgeries (0.18%). The clinical variables associated with occurrence of the composite outcome were age (odds ratio [OR] 1.03 per unit increment, 95% confidence interval [CI] 1.02–1.05), impaired kidney function (OR 1.59, 95% CI 1.15–2.19), previous myocardial infarction (OR 1.69, 95% CI 1.21–2.35), emergent PCI (OR 4.02, 95% CI 1.66–8.27), and triple-vessel disease (versus single-vessel disease: OR 2.17, 95% CI 1.43–3.28). Notably, institutional volume of RA cases was inversely associated with the composite outcomes (high- versus low-volume institution: OR 0.56, 95% CI 0.36–0.89).

Conclusions—

The reported incidence of important procedure-related complication rate was 1.3%, with each component ranging between 0.2% and 0.6% in J-PCI. Its determinants were both patient related (age, impaired kidney function, and previous myocardial infarction) and procedure related (emergent procedures, number of diseased vessels, and institutional volume of RA).