In-Hospital and 1-Year Outcomes of Rotational Atherectomy and Stent Implantation in Patients With Severely Calcified Unprotected Left Main Narrowings (from the Multicenter ROTATE Registry)

Rotational atherectomy of calcified coronary lesions: current practice and insights from two randomized trials

With growing experience, technical improvements and use of newer generation drug-eluting stents (DES), recent data showed satisfactory acute and long-term results after rotational atherectomy (RA) in calcified coronary lesions. The randomized ROTAXUS and PREPARE-CALC trials compared RA to balloon-based strategies in two different time periods in the DES era. In this manuscript, we assessed the technical evolution in RA practice from a pooled analysis of the RA groups of both trials and established a link to further recent literature. Furthermore, we sought to summarize and analyze the available experience with RA in different patient and lesion subsets, and propose recommendations to improve RA practice. We also illustrated the combination of RA with other methods of lesion preparation. Finally, based on the available evidence, we propose a simple and practical approach to treat severely calcified lesions.

Percutaneous Treatment of Left Main Disease: A Review of Current Status

Percutaneous treatment of the left main coronary artery is one of the most challenging scenarios in interventional cardiology, due to the large portion of myocardium at risk the technical complexity of treating a complex bifurcation with large branches. Our aim is to provide un updated overview of the current indications for percutaneous treatment of the left main, the different techniques and the rationale underlying the choice for provisional versus upfront two-stent strategies, intravascular imaging and physiology guidance in the management of left main disease, and the role of mechanical support devices in complex high-risk PCI.

Outcomes after Percutaneous Coronary Intervention in Patients with Extremely Calcified Left Main Lesions

Background and Objectives: Available data with regard to the outcomes of patients with severely calcified left main (LM) lesions after revascularization by percutaneous coronary intervention (PCI) when compared to non-calcified LM lesions is unclear. Materials and Methods: The present study sought to retrospectively investigate in hospital and 1 year post-intervention outcomes of patients with extremely calcified LM lesions after PCI facilitated by calcium-dedicated devices (CdD). Seventy consecutive patients with LM PCI were included. CdD requirement was based on suboptimal results after balloon angioplasty. Results: Twenty-two patients (31.4%) required at least one CdD, while nine patients (12.8%) required at least two. Intravascular lithotripsy and rotational atherectomy were the predominantly used methods(59.1% and 40.9% respectively, for in-group ratios), while ultra-high pressure and scoring balloons contributed the least to lesion preparation (9%). In 20 patients (28.5%), severe or moderate calcifications were angiographically identified, but non-compliant balloon predilation was adequate and CdD were not necessary. Total procedural time was significantly higher in CdD group (p-value 0.02). Procedural and clinical success were obtained in 100% of cases. There were no major adverse cardiac and cerebrovascular events (MACCE) recorded during hospitalization. MACCE at 1 year post-procedure were recorded in three patients (4.2% overall). All three events were documented in the control group (6.2%), and no events were recorded in CdD group (p-value 0.23). There was one cardiac death at 10 months and two target lesion revascularizations for side-branch restenosis. Conclusions: Patients with extremely calcified LM lesions treated by PCI present a favorable prognosis if angioplasty is facilitated by more aggressive lesion debulking using calcium-dedicated devices.

Clinical Outcomes of Left Main Coronary Artery PCI With Rotational Atherectomy

Data regarding rotational atherectomy percutaneous coronary intervention (RA PCI) angioplasty in the left main (LM) coronary artery are scarce, and mostly outdated. We aimed to describe clinical outcomes of RA PCI in LM. Patients requiring RA in 8 European countries and 19 centers were prospectively and consecutively included in the European registry of Cardiac Care of Calcified and Complex patients registry. In-hospital data collection and 1-year follow-up were performed for each patient. Between October 2016 and July 2018, 966 patients with complete data were included. Among them, 241 presented with an LM lesion, and 171 required an LM lesion preparation by RA. The latter, allocated to the LM-RA group, were compared with the 725 patients in the non-LM-RA group. Clinical success of the RA procedure was comparable in both groups, but in-hospital major adverse cardiac events were higher in the RA-LM group (7.6% vs 3.2%, adjusted p = 0.04), mainly driven by a higher in-hospital mortality rate (5.3 vs 0.3%, adjusted p = 0.005). At 1-year follow-up, mortality and major adverse cardiac event rates were comparable in both groups (12.9% vs 8.0%, adjusted p value: 0.821, and 15.8% vs 10.9%, adjusted p value: 0.329, respectively), but the rate of target vessel revascularization remained higher in the RA-LM group (5.3% vs 3.2%, adjusted p = 0.021). In conclusion, RA PCI is an efficient option for calcified LM lesions, providing acceptable outcomes regarding this population with high risk at 1 year, and yields comparable outcomes with RA PCI performed on non-LM lesions.

Intravascular Lithotripsy as a Novel Treatment Method for Calcified Unprotected Left Main Diseases-Comparison to Rotational Atherectomy-Short-Term Outcomes

Background: The unprotected calcified Left Main disease represents a high-risk subset for percutaneous coronary intervention (PCI), and it is associated with a higher number of periprocedural complications and an increased rate of in-stent thrombosis and restenosis. Adequate lesion preparation plays a crucial role in achieving a favorable PCI outcome. Rotational Atherectomy (RA) is a well-established plaque-modifying method; nevertheless, the data regarding the effectiveness of RA in LM diseases is scarce. Recently, the novel ShockWave-Intravascular-Lithotripsy(S-IVL) device has been introduced to the PCI armamentarium in order to modify the calcified plaque. Methods: We performed a retrospective evaluation of 44 consecutive subjects who underwent the LM-PCI, and who were supported by either the RA or S-IVL. Results: The Rota group consisted of 29 patients with a mean syntax score of 28.0 ± 7.5. The S-IVL group was composed of 15 subjects with a syntax score of 23.3 ± 13.0 There were no statistical differences regarding MACE between the RA and Shockwave arms of the in-hospital group (10.3% vs. 6.7%), or in the six month (17.2% vs. 13.3%) follow-up group. Conclusions: RA and S-IVL could be safe and effective therapeutic strategies for calcified LM disease. Further studies with a higher number of participants and longer follow-up times are warranted to establish the potential benefits of RA and S-IVL for the management of LM stenosis.

Case series of high-risk percutaneous coronary intervention with rotational atherectomy under short-term mechanical circulatory support with TandemHeart in the setting of acute myocardial infarction

Background 

TandemHeart is a percutaneous Ventricular Assist Device, most commonly used to provide mechanical circulatory support during high-risk percutaneous coronary intervention and postcardiotomy cardiac failure. However, TandemHeart has not been applied in patients with severe heart failure due to myocardial infarction during high-risk percutaneous coronary intervention with the need for rotational artherectomy (RA) before, so we present a first-in-man case series.

Case summary 

Three patients with severe HF[Please spell out HF, LA and MI (if necessary).] due to acute myocardial infarction revealed severely calcified lesions of the unprotected left main artery. We successfully used the TandemHeart as percutaneous Ventricular Assist Device during high-risk percutaneous coronary intervention with RA.

Discussion 

We here report our experience and show that RA under TandemHeart mechanical circulatory support is feasible and safe in case of acute MI.

Rotational Atherectomy: A Contemporary Appraisal

Rotational atherectomy (RA) is an atheroablative technology that enables percutaneous coronary intervention for complex, calcified coronary lesions. RA works on the principle of 'differential cutting' and preferentially ablates hard, inelastic, calcified plaque. The objective of RA use has evolved from plaque debulking to plaque modification to enable balloon angioplasty and optimal stent expansion. The clinical experience over the past 30 years has informed the current best practices for RA with use of smaller burr sizes, short ablation runs a 'pecking' motion, and avoidance of sudden decelerations. This has led to significant improvements in procedural safety and a reduced rate of associated complications. This article reviews the principles, clinical indications, contemporary evidence, technical considerations and complications associated with the use of RA.

Long-Term Outcomes of Drug-Eluting Stent Implantation After Rotational Atherectomy for Left Main Coronary Artery Bifurcation Lesions

The clinical outcomes of drug-eluting stent (DES) implantation after rotational atherectomy (RA) for complex left main coronary artery (LMCA) bifurcation lesions remain unclear. Among 1,809 patients retrospectively enrolled in the Assessing Optimal percutaneous coronary Intervention for LMCA Registry, we identified 1,199 patients with LMCA bifurcation lesions treated by crossover stenting with DES for the main vessel. The study population was divided according to the use of RA. The patients in the RA group were further subdivided into the 2 subgroups on the basis of the stenting approach. The rates of periprocedural myocardial infarction and in-hospital death in the RA group were comparable to those in the non-RA group. The cumulative 5-year incidences of all-cause death and target lesion revascularization (TLR) were significantly higher in the RA group than those in the non-RA group. However, after adjusting confounders, the excess risks of the RA group relative to the non-RA group for all-cause death and TLR were no longer significant (hazard ratio 0.95, 95% confidence intervals 0.59 to 1.52, p = 0.83, and hazard ratio 1.46, 95% confidence intervals 0.82 to 2.60, p = 0.20, respectively). In the RA group, the cumulative 5-year incidences of all-cause death and TLR were markedly higher in the 2-stent subgroup than in the 1-stent subgroup (58.1% vs 26.0%, p = 0.001, and 43.0% vs 16.3%, p = 0.001, respectively). In conclusion, DES implantation after RA was a safe and feasible strategy in treating those patients with complex LMCA bifurcation lesions. In this strategy, the 2-stent approach was associated with markedly worse 5-year clinical outcomes than the 1-stent approach.

The Current State of Left Main Percutaneous Coronary Intervention

PURPOSE OF REVIEW

While coronary artery bypass grafting (CABG) remains the standard of care, advances in stenting technology and procedural technique are changing the role of percutaneous coronary intervention (PCI) in the treatment of severe left main coronary artery (LMCA) disease. We review contemporary evidence comparing PCI and CABG for the treatment of severe LMCA disease, discuss optimal techniques during left main PCI, and provide guidance on studied revascularization strategies within specific patient subgroups.

RECENT FINDINGS

Results from randomized control trials of patients treated with PCI or CABG for severe LMCA disease demonstrate comparable short- and mid-term rates of death, myocardial infarction (MI), and stroke, but increased rates of repeat or target-vessel revascularization after PCI. Though extended follow-up data has suggested lower long-term rates of MI and stroke in patients with severe LMCA disease treated with CABG, results from patients undergoing PCI with second-generation drug-eluting stents (DES) demonstrate non-inferiority in these outcomes. These findings are generalizable to patients with severe LMCA disease having low to intermediate anatomic complexity. Intravascular ultrasound and double kissing (DK) crush stenting also reduce adverse event rates among patients undergoing left main PCI and improve long-term outcomes. In patients with severe LMCA disease having low to intermediate anatomic complexity, both CABG and PCI with second-generation DES are effective methods of revascularization with comparable long-term rates of death, MI, and stroke. The roles of multi-vessel coronary artery disease and anatomic complexity on long-term outcomes after CABG or PCI for severe LMCA disease remain under investigation.