2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine

Closing the gap between acceptable and ideal in catheterisation for paediatric and congenital heart disease-A global view

In recent issues of the Journal of the Society for Cardiovascular Angiography and Interventions and the Journal of the American College of Cardiology: Cardiovascular Interventions, Holzer and colleagues presented an Expert Consensus Document titled: "PICS / AEPC / APPCS / CSANZ / SCAI / SOLACI: Expert consensus statement on cardiac catheterization for pediatric patients and adults with congenital heart disease." This Expert Consensus Document is a massively important contribution to the community of paediatric and congenital cardiac care. This document was developed as an Expert Consensus Document by the Pediatric and Congenital Interventional Cardiovascular Society, the Association for European Paediatric and Congenital Cardiology, the Asia-Pacific Pediatric Cardiac Society, the Cardiac Society of Australia and New Zealand, the Society for Cardiovascular Angiography and Interventions, and the Latin American Society of Interventional Cardiology, as well as the Congenital Cardiac Anesthesia Society and the American Association of Physicists in Medicine.As perfectly stated in the Preamble of this Expert Consensus Document, "This expert consensus document is intended to inform practitioners, payors, hospital administrators and other parties as to the opinion of the aforementioned societies about best practices for cardiac catheterisation and transcatheter management of paediatric and adult patients with congenital heart disease, with added accommodations for resource-limited environments." And, the fact that the authorship of this Expert Consensus Document includes global representation is notable, commendable, and important.This Expert Consensus Document has the potential to fill an important gap for this patient population. National guideline documents for specific aspects of interventions in patients with paediatric heart disease, including training guidelines, do exist. However, this current Expert Consensus Document authored by Holzer and colleagues provides truly globally applicable standards on cardiac catheterisation for both paediatric patients and adults with congenital heart disease (CHD).Our current Editorial provides different regional perspectives from senior physicians dedicated to paediatric and congenital cardiac care who are practicing in Europe, the Asia-Pacific region, Latin America, Australia/New Zealand, and North America. Establishing worldwide standards for cardiac catheterisation laboratories for children and adults with CHD is a significant stride towards improving the quality and consistency of care. These standards should not only reflect the current state of medical knowledge but should also be adaptable to future advancements, ultimately fostering better outcomes and enhancing the lives of individuals affected by CHD worldwide.Ensuring that these standards are accessible and adaptable across different healthcare settings globally is a critical step. Given the variability in resources and infrastructure globally, the need exists for flexibility and tailoring to implement recommendations.The potential impact of the Expert Consensus Document and its recommendations is likely significant, but heterogeneity of healthcare systems will pose continuing challenges on healthcare professionals. Indeed, this heterogeneity of healthcare systems will challenge healthcare professionals to finally close the gap between acceptable and ideal in the catheterisation of patients with paediatric and/or congenital heart disease.

Evaluation of the reduction of radiation dose received by pediatric patients in new-generation biplane angiocardiography: Randomized controlled study

Objective

We aimed to evaluate the safety and efficacy of radiation dose reduction with a new-generation biplane angiocardiography system in patients undergoing transcatheter isolated patent ductus arteriosus (PDA) closure.

Materials and methods

Fifty pediatric patients who underwent transcatheter PDA closure were randomly divided into two groups as normal radiation dose and low dose. Patients who required additional procedures other than PDA closure were excluded. PDA closure was performed according to the angiographic measurement of the defect. After the procedure, age, weight, sex, PDA measurements, and radiation measurements such as dose-area product (DAP, Gy.cm2) and air kerma (AK, mGy) were compared between the groups.

Results

There was no statistically significant difference between the groups in age, sex, weight, PDA diameter, PDA type, device used, and device diameter (p > 0.05). While there was no statistically significant difference between the groups in terms of cine recording, number of recorded images, and fluoroscopy time (p > 0.05), there was a statistically significant difference between the total DAP, cine and fluoroscopy DAP, total AK, frontal and lateral tube AK, and DAP/kg (mGy.m2/kg) measurements (p < 0.05).

Conclusion

Transcatheter PDA closure with a low radiation dose is as effective as that with a normal radiation dose. The radiation dose received by the patient during the procedure was significantly reduced. With the vision provided by this study, it seems possible to work with a low radiation dose in other groups of patients.

Coronary CT Angiography-based Morphologic Index for Predicting Hemodynamically Significant Coronary Stenosis

Purpose To develop a new coronary CT angiography (CCTA)-based index, α×LL/MLD4, that considers lesion entrance angle (α) in addition to lesion length (LL) and minimal lumen diameter (MLD) and to evaluate its efficacy in predicting hemodynamically significant coronary stenosis compared with invasive coronary angiography (ICA)-derived fractional flow reserve (FFR). Materials and Methods This prospective study enrolled participants (September 2016-March 2020) from two centers who underwent CCTA followed by ICA (ClinicalTrials.gov identifier: NCT03054324). CCTA images were processed semiautomatically to measure LL, MLD, and α for calculating α×LL/MLD4. Diagnostic performance and accuracy of α×LL/MLD4 and LL/MLD4 in detecting hemodynamically significant coronary stenosis were compared against the reference standard (invasive FFR ≤ 0.80). Results In total, 133 participants (mean age, 63 years ± 9 [SD]; 99 [74%] men) with 210 stenosed coronary arteries were analyzed. Median α×LL/MLD4 was 54.0 degree/mm3 (IQR, 25.3-128.7) in participants with invasive FFR of 0.80 or less and 6.7 degree/mm3 (IQR, 3.3-12.8) in participants with invasive FFR of more than 0.80 (P < .001). The per-vessel accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for discriminating ischemic lesions were 86.2%, 83.1%, 88.4%, 84.1%, and 87.7% for α×LL/MLD4 and 80.5%, 66.3%, 90.9%, 84.3%, and 78.6% for LL/MLD4, respectively. Area under the receiver operating characteristic curve for discriminating hemodynamically significant stenosis was 0.93 for α×LL/MLD4, which was significantly greater than the values of 0.84 for LL/MLD4 and 0.63 for diameter stenosis (both P < .001). Conclusion The new morphologic index, α×LL/MLD4, incorporating lesion entrance angle achieved higher diagnostic performance in detecting hemodynamically significant lesions compared with diameter stenosis and LL/MLD4. Keywords: CT Angiography, Cardiac, Coronary Arteries, Ischemia, Infarction, Technology Assessment Clinical trial registration no. NCT03054324 Supplemental material is available for this article. © RSNA, 2023 See also the commentary by Fairbairn and Nørgaard in this issue.

Bed Rest Reduction Following Cardiac Catheterizations Using Vascular Closure Devices

BACKGROUND

Bed rest duration following deployment of a vascular closure device after transfemoral left-sided cardiac catheterization is not standardized. Despite research supporting reduced bed rest, many hospitals require prolonged bed rest. Delayed ambulation is associated with back pain, urine retention, difficulty eating, and longer stay.

OBJECTIVE

To study length of stay, safety, and opportunity cost savings of reduced bed rest at a large urban hospital.

METHODS

A single-site 12-week study of 1-hour bed rest after transfemoral cardiac catheterizations using vascular closure devices. Results were compared with historical controls treated similarly.

RESULTS

The standard bed rest group included 295 patients (207 male, 88 female; mean [SD] age, 64.4 [8.6] years). The early ambulation group included 260 patients (188 male, 72 female; mean [SD] age, 64 [9.3] years). The groups had no significant difference in age (t634 = 1.18, P = .21) or sex (χ12=0.2, P = .64). Three patients in the standard bed rest group and 1 in the early ambulation group had hematomas (P = .36). The stay for diagnostic cardiac catheterizations was longer in the standard bed rest group (mean [SD], 220.7 [55.2] minutes) than in the early ambulation group (mean [SD], 182.1 [78.5] minutes; t196 = 4.06; P < .001). Stay for percutaneous coronary interventions was longer in the standard bed rest group (mean [SD], 400.2 [50.8] minutes) than in the early ambulation group (mean [SD], 381.6 [54.7] minutes; t262 = 2.86; P = .005).

CONCLUSION

Reduced bed rest was safe, shortened stays, and improved efficiency by creating opportunity cost savings.

Use of Intravascular Ultrasound and Coronary Angiography to Measure the Prevalence of Myocardial Bridge in Heart Transplant Patients

Myocardial bridge (MB) detection rates vary across methods and most studies that have assessed MB include symptomatic patients. Intravascular ultrasound (IVUS) is a sensitive tool for MB detection and donor hearts may serve as a surrogate measure of asymptomatic patients. We used IVUS and coronary angiography to measure MB prevalence in heart transplant patients during routine follow-up invasive coronary assessments. This was a retrospective, single-center study of heart transplant patients who received follow-up coronary assessments at the University of Chicago Heart and Vascular Center between December 2014 and December 2021. A single experienced interventional cardiologist assessed incidental findings of MB in IVUS and coronary angiography. Detection rates were compared with meta-analysis-reported prevalence. Of 129 patients, IVUS-detected MB in 87 patients (67.4%), whereas coronary angiography detected 41 (31.8%). All MB found by coronary angiography were detected by IVUS. Some level of cardiac allograft vasculopathy was found in 92 patients (71.3%). Our IVUS-detected MB prevalence was greater than meta-analysis-reported pooled prevalence across all methods: autopsy, computed tomography angiography, and coronary angiography (67.4% [95% confidence interval [CI] 59.4 to 75.5] vs 42% [95% CI 30 to 55]; 22% [95% CI 18 to 25]; 6% [95% CI 5 to 8], p ≤0.005). The difference between our observed IVUS-detected MB prevalence and meta-analysis autopsy reported MB prevalence was 1.25 (95% CI 1.11 to 1.40). In conclusion, the high prevalence of MB recorded in donor hearts emphasizes the need to further investigate the causes of chest pain in patients who are found to have MB.

Preprocedure care for outpatients in the cardiac catheterization lab in an acute care hospital in central Mississippi: a best practice implementation project

OBJECTIVES

The objective of this implementation project was to improve the cardiac catheterization lab multidisciplinary team's compliance with best practices regarding preprocedural care.

INTRODUCTION

The cardiac catheterization lab performs numerous diagnostic and interventional outpatient procedures. Preprocedural care is a crucial step in preparing patients and clinical staff.

METHODS

The JBI Evidence Implementation framework was used for this project. The baseline audit for the project included a review of 30 electronic health records for best practice adherence. The Getting Research into Practice tool guided leadership to increase awareness and compliance to evidence-based practice. A follow-up audit of 30 electronic health records followed implementation of strategies.

RESULTS

Baseline audit data suggested all best practices combined were only followed at 79%, and revealed the need for improvement in preprocedural phone calls to patients and documentation related to patient education regarding the procedure and expectations for procedure recovery. Four barriers were identified and multiple strategies were implemented in an attempt to improve compliance with evidence-based practices. Follow-up audits showed an overall improvement to 81% after project implementation.

CONCLUSIONS

The project showed improvements with best practices for preprocedural care in the outpatient setting. However, more work remains to obtain sustainability of best practices, including preprocedural assessment undertaken prior to the cardiac catheterization procedure, information provided to the patient prior to the cardiac catheterization procedure explaining the test and expected recovery, and patients receiving a phone call prior to the procedure for reminders of procedural details.

Best Practices for Cardiac Catheterization Laboratory Morbidity and Mortality Conferences

Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct.

Effects of time of bed rest on vascular complications after cardiac catheterization in pediatric patients with congenital heart disease: A randomized controlled trial

BACKGROUND

Pediatric cardiac catheterization, which is performed by accessing the femoral vessel, requires immobilization and bed rest for 4-6 h to prevent vascular complications. Studies in adults suggest that the immobilization time for the same access can be safely reduced to approximately 2 h after catheterization. However, it is unclear whether bed-rest time can be safely decreased after catheterization in children.

OBJECTIVE

To assess the effects of bed-rest duration on bleeding, vascular complications, pain level, and the use of additional sedatives after transfemoral cardiac catheterization in children with congenital heart disease.

METHODS

This study was an open-label, randomized, controlled, posttest-only design, including 86 children who underwent cardiac catheterization. Children were allocated to receive either 2 h of bed rest (n = 42) in the experimental group or 4 h of bed rest (n = 42) in the control group following catheterization.

RESULTS

The mean age of children was 3.93 (±3.82) years in the experimental group and 5.63 (±3.97) years in the control group. There was no difference in site bleeding incidence (P = 0.214), vascular complication score (P = 0.082), pain level (P = 0.445), or additional sedation use (P = 1.000) between the two groups.

CONCLUSIONS

There were no significant hemostatic complications after 2 h of bed rest following pediatric catheterization; therefore, 2 h of bed rest was as safe as 4 h of bed rest. (Trial registration: KCT0007737).

Sex differences in computed tomography angiography-derived coronary plaque burden in relation to invasive fractional flow reserve

BACKGROUND

Distinct sex-related differences exist in coronary artery plaque burden and distribution. We aimed to explore sex differences in quantitative plaque burden by coronary CT angiography (CCTA) in relation to ischemia by invasive fractional flow reserve (FFR).

METHODS

This post-hoc analysis of the PACIFIC trial included 581 vessels in 203 patients (mean age 58.1 ​± ​8.7 years, 63.5% male) who underwent CCTA and per-vessel invasive FFR. Quantitative assessment of total, calcified, non-calcified, and low-density non-calcified plaque burden were performed using semiautomated software. Significant ischemia was defined as invasive FFR ≤0.8.

RESULTS

The per-vessel frequency of ischemia was higher in men than women (33.5% vs. 7.5%, p ​< ​0.001). Women had a smaller burden of all plaque subtypes (all p ​< ​0.01). There was no sex difference on total, calcified, or non-calcified plaque burdens in vessels with ischemia; only low-density non-calcified plaque burden was significantly lower in women (beta: -0.183, p ​= ​0.035). The burdens of all plaque subtypes were independently associated with ischemia in both men and women (For total plaque burden (5% increase): Men, OR: 1.15, 95%CI: 1.06-1.24, p ​= ​0.001; Women, OR: 1.96, 95%CI: 1.11-3.46, p ​= ​0.02). No significant interaction existed between sex and total plaque burden for predicting ischemia (interaction p ​= ​0.108). The addition of quantitative plaque burdens to stenosis severity and adverse plaque characteristics improved the discrimination of ischemia in both men and women.

CONCLUSIONS

In symptomatic patients with suspected CAD, women have a lower CCTA-derived burden of all plaque subtypes compared to men. Quantitative plaque burden provides independent and incremental predictive value for ischemia, irrespective of sex.

The Need for Surgery After Vascular or Cardiac Trauma, or Technical Adverse Events in the Congenital Cardiac Catheterization Laboratory

Data on the frequency and outcome of surgical interventions as a result of adverse events (AE) encountered in the pediatric and congenital cardiac catheterization laboratory are limited. This study analyzes the outcomes of specific types of AE that are most likely to require immediate surgical intervention. Data from the C3PO registry were analyzed to identify specific types of significant vascular/cardiac trauma or technical adverse events (stent/device/coil embolization/migration). The relationship between these AE and an "adverse outcome" (defined as either surgery, ECMO, or death) were analyzed. Between 01/2014 and 12/2017, 25,731 cases were entered into the C3PO registry. Vascular or cardiac trauma were observed in 92 cases (0.36% cases in C3PO), and technical adverse events were observed in 176 cases (0.68% cases in C3PO). The two highest procedure type risk categories (PREDIC3T) accounted for 61% of the cases in the cardiac/vascular trauma cohort, and 34% in the technical AE cohort. For vascular/cardiac trauma, 24 (26%) had an adverse outcome, with ECMO in 8 (9%), surgery in 19 (20%), and death in 9 (10%). For technical AE 25 (14%) had an adverse outcome, with ECMO in 3 (2%), surgery in 23 (13%), and death in 3 (2%). Survival after cardiac surgery secondary to an AE was 68% for cardiac/vascular trauma, and 96% for technical adverse events. RF perforation of the pulmonary valve was the procedure most likely to result in cardiac/vascular trauma (10%), with 57% of those having an adverse outcome. Atrial septal interventions accounted for 29% of all adverse outcomes in the cardiac/vascular trauma cohort. Non-elective or emergent cases were associated with a significantly higher incidence of an adverse outcome for both, cardiac/vascular trauma (OR 7.1) and technical adverse events (OR 2.7). Surgery within the last 30 days was associated with a significantly higher incidence of an adverse outcome for cardiac/vascular trauma only (OR 4.2). Significant cardiac/vascular trauma or stent/device/coil embolization/migration are rare, but high consequence AE. With appropriate surgical and ECMO backup, a high survival can be achieved. The potential need for and impact of immediate surgical backup seems to be higher for cardiac/vascular trauma (in particular after specific case types), than for device/coil migration/embolization, and as such case specific backup arrangements are required.

DyeVert Contrast Reduction System Use in Patients Undergoing Coronary and/or Peripheral Angiography: A Systematic Literature Review and Meta-Analysis

Background

Contrast-associated acute kidney injury (CA-AKI) is an important adverse effect associated with injecting iodinated intra-arterial contrast media (CM) during coronary angiography. The DyeVert™ Contrast Reduction System is a medical device intended to reduce the intra-arterial CM volume (CMV) administered. The aim of this study was to assess DyeVert System clinical effectiveness and safety by implementing a systematic review and meta-analysis of existing evidence.

Methods

Systematic electronic literature searches were conducted in MEDLINE, Embase, the Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and the International Clinical Trials Registry Platform database. Relevant data were extracted from included studies and meta-analyses were performed to synthesize evidence across studies.

Results

The review included 17 eligible studies involving 1,731 DyeVert System cases and 1,387 control cases (without the use of DyeVert). Meta-analyses demonstrated use of the DyeVert System reduced CMV delivered to the patient by 39.27% (95% CI, 36.10-42.48%, P < 0.001), reduced CMV/baseline renal function ratios (Hedges's g, -0.56; 95% CI, -0.70 to -0.42, P < 0.001) and percentage of cases exceeding the maximum CMV threshold (risk difference -0.31, 95% CI, -0.48 to -0.13, P < 0.001) while maintaining adequate image quality in 98% of cases. DyeVert System cases demonstrated lower CA-AKI incidence vs. controls (absolute risk reduction 5.00% (95% CI, 0.40-9.80%; P = 0.03), relative risk 0.60 (95% CI, 0.40-0.90; P = 0.01) with a pooled estimate of the number needed to treat with the DyeVert System to avoid 1 CA-AKI event of 20.

Conclusion

DyeVert System use significantly reduces CMV delivered to the patient, CMV/baseline renal function ratios, and CA-AKI incidence while maintaining image quality. Accordingly, the device may serve as an adjunctive, procedure-based strategy to prevent CA-AKI. Future multi-center studies are needed to further assess effects of minimizing CMV on endpoints such as CA-AKI prevention, incidence of adverse cardiac and renal events, and health care costs.

Development of a Clinical Risk Score for Prediction of Life-Threatening Arrhythmia Events in Patients with ST Elevated Acute Coronary Syndrome after Primary Percutaneous Coronary Intervention

ST-elevated acute coronary syndrome (STEACS) is a serious condition requiring timely treatment. Reperfusion with primary percutaneous coronary intervention (pPCI) is recommended and preferred over fibrinolysis. Despite its efficacy, lethal complications, such as life-threatening arrhythmia (LTA), are common in post-PCI patients. Although various risk assessment tools were developed, only a few focus on LTA prediction. This study aimed to develop a risk score to predict LTA events after pPCI. A risk score was developed using a retrospective cohort of consecutive patients with STEACS who underwent pPCI at Chiangrai Prachanukroh Hospital from January 2012 to December 2016. LTA is defined as the occurrence of malignant arrhythmia that requires advanced cardiovascular life support (ACLS) within 72 h after pPCI. Logistic regression was used for model derivation. Among 273 patients, 43 (15.8%) developed LTA events. Seven independent predictors were identified: female sex, hemoglobin < 12 gm/dL, pre- and intra-procedural events (i.e., respiratory failure and pulseless arrest), IABP insertion, intervention duration > 60 min, and desaturation after pPCI. The LTA score showed an AuROC of 0.93 (95%CI 0.90, 0.97). The score was categorized into three risk categories: low (<2.5), moderate (2.5–4), and high risk (>4) for LTA events. The LTA score demonstrated high predictive performance and potential clinical utility for predicting LTA events after pPCI.

Effect of Coronary Calcification Severity on Measurements and Diagnostic Performance of CT-FFR With Computational Fluid Dynamics: Results From CT-FFR CHINA Trial

Aims: To explore the effect of coronary calcification severity on the measurements and diagnostic performance of computed tomography-derived fractional flow reserve (FFR; CT-FFR).

Methods: This study included 305 patients (348 target vessels) with evaluable coronary calcification (CAC) scores from CT-FFR CHINA clinical trial. The enrolled patients all received coronary CT angiography (CCTA), CT-FFR, and invasive FFR examinations within 7 days. On both per-patient and per-vessel levels, the measured values, accuracy, and diagnostic performance of CT-FFR in identifying hemodynamically significant lesions were analyzed in all CAC score groups (CAC = 0, > 0 to <100, ≥ 100 to <400, and ≥ 400), with FFR as reference standard.

Results: In total, the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and area under receiver operating characteristics curve (AUC) of CT-FFR were 85.8, 88.7, 86.9, 87.8, 87.1%, 0.90 on a per-patient level and 88.3, 89.3, 89.5, 88.2, 88.9%, 0.88 on a per-vessel level, respectively. Absolute difference of CT-FFR and FFR values tended to elevate with increased CAC scores (CAC = 0: 0.09 ± 0.10; CAC > 0 to <100: 0.06 ± 0.06; CAC ≥ 100 to <400: 0.09 ± 0.10; CAC ≥ 400: 0.11 ± 0.13; p = 0.246). However, no statistically significant difference was found in patient-based and vessel-based diagnostic performance of CT-FFR among all CAC score groups.

Conclusion: This prospective multicenter trial supported CT-FFR as a viable tool in assessing coronary calcified lesions. Although large deviation of CT-FFR has a tendency to correlate with severe calcification, coronary calcification has no significant influence on CT-FFR diagnostic performance using the widely-recognized cut-off value of 0.8.

Diastolic versus systolic coronary computed tomography angiography derived fractional flow reserve for the identification of lesion-specific ischemia

OBJECTIVES

To investigate the measurement discrepancy of coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFR) between diastolic (CT-FFR-D) and systolic (CT-FFR-S) phases using FFR as the reference standard.

METHODS

Participants, suspected of coronary artery disease and indicated for invasive coronary angiography (ICA) and FFR and coronary CTA and CT-FFR, were enrolled in this study (Clinicaltrials.gov:NCT03692936) from September 2018 to October 2019. For every participant, coronary CTA of both systolic and diastolic phases was postprocessed to calculate CT-FFR-S and CT-FFR-D, respectively. Diagnostic sensitivity, specificity, accuracy, and the area under the receiver operating characteristic (ROC) curve were compared.

RESULTS

A total of 181 lesions from 151 participants (mean age 54.5 ± 7.8 years, 113 males) were analyzed. Of these, 129 lesions from 110 participants were successfully measured both in diastolic and systolic phases. Sensitivity, specificity, and accuracy of CT-FFR-D and CT-FFR-S on per-patient level were 88.9%, 91.3%, 90.1% and 66.7%, 87.7%, 76.7%, on per-vessel level were 89.5%, 91.5%, 90.6% and 66.7%, 87.0%, 77.9%, respectively. The ROC curve of CT-FFR-D was significantly higher than that of CT-FFR-S on both per-patient and per-vessel levels (0.938 vs. 0.771, 0.935 vs. 0.772, both p < 0.0001). In severe hemodynamic lesions (FFR ≤ 0.7), the absolute difference between CT-FFR-S and FFR was significantly higher than that between CT-FFR-D and FFR [0.1636, inter-quartile range (IQR): 0.0662-0.2586 vs. 0.0953, IQR: 0.0496-0.1702, p = 0.035].

CONCLUSION

CT-FFR derived in diastole was superior to that derived in systole in detecting coronary ischemic lesions. For lesions with FFR < 0.7, CT-FFR measured in the diastolic phase was noted to be more closely approximated to FFR.

Diagnostic Performance of Fractional Flow Reserve From CT Coronary Angiography With Analytical Method

The aim of this study was to evaluate a new analytical method for calculating non-invasive fractional flow reserve (FFR_AM) to diagnose ischemic coronary lesions. Patients with suspected or known coronary artery disease (CAD) who underwent computed tomography coronary angiography (CTCA) and invasive coronary angiography (ICA) with FFR measurements from two sites were prospectively recruited. Obstructive CAD was defined as diameter stenosis (DS) ≥50% on CTCA or ICA. FFR_AM was derived from CTCA images and anatomical features using analytical method and was compared with computational fluid dynamics (CFD)-based FFR (FFR_B) and invasive ICA-based FFR. FFR_AM, FFR_B, and invasive FFR ≤ 0.80 defined ischemia. A total of 108 participants (mean age 60, range: 30–83 years, 75% men) with 169 stenosed coronary arteries were analyzed. The per-vessel accuracy, sensitivity, specificity, and positive predictive and negative predictive values were, respectively, 81, 75, 86, 81, and 82% for FFR_AM and 87, 88, 86, 83, and 90% for FFR_B. The area under the receiver operating characteristics curve for FFR_AM (0.89 and 0.87) and FFR_B (0.90 and 0.86) were higher than both CTCA- and ICA-derived DS (all p < 0.0001) on per-vessel and per-patient bases for discriminating ischemic lesions. The computational time for FFR_AM was much shorter than FFR_B (2.2 ± 0.9 min vs. 48 ± 36 min, excluding image acquisition and segmentation). FFR_AM calculated from a novel and expeditious non-CFD approach possesses a comparable diagnostic performance to CFD-derived FFR_B, with a significantly shorter computational time.

Computed Tomography Coronary Angiography and Computational Fluid Dynamics Based Fractional Flow Reserve Before and After Percutaneous Coronary Intervention

Invasive fractional flow reserve (FFR) is recommended to guide stent deployment. We previously introduced a non-invasive FFR calculation (FFR_B) based on computed tomography coronary angiography (CTCA) with reduced-order computational fluid dynamics (CFD) and resistance boundary conditions. Current study aimed to assess the feasibility and accuracy of FFR_B for predicting coronary hemodynamics before and after stenting, with invasive FFR as the reference. Twenty-five patients who had undergone CTCA were prospectively enrolled before invasive coronary angiography (ICA) and FFR-guided percutaneous coronary intervention (PCI) on 30 coronary vessels. Using reduced-order CFD with novel boundary conditions on three-dimensional (3D) patient-specific anatomic models reconstructed from CTCA, we calculated FFR_B before and after virtual stenting. The latter simulated PCI by clipping stenotic segments from the 3D coronary models and replacing them with segments to mimic the deployed coronary stents. Pre- and post-virtual stenting FFR_B were compared with FFR measured pre- and post-PCI by investigators blinded to FFR_B results. Among 30 coronary lesions, pre-stenting FFR_B (mean 0.69 ± 0.12) and FFR (mean 0.67 ± 0.13) exhibited good correlation (r = 0.86, p < 0.001) and agreement [mean difference 0.024, 95% limits of agreement (LoA): −0.11, 0.15]. Similarly, post-stenting FFR_B (mean 0.84 ± 0.10) and FFR (mean 0.86 ± 0.08) exhibited fair correlation (r = 0.50, p < 0.001) and good agreement (mean difference 0.024, 95% LoA: −0.20, 0.16). The accuracy of FFR_B for identifying post-stenting ischemic lesions (FFR ≤ 0.8) (residual ischemia) was 87% (sensitivity 80%, specificity 88%). Our novel FFR_B, based on CTCA with reduced-order CFD and resistance boundary conditions, accurately predicts the hemodynamic effects of stenting which may serve as a tool in PCI planning.

Enhancing occupational safety in the X-ray laboratory

Despite more than 80% of interventional operators reporting one or more orthopedic injuries attributed to the X-ray laboratory, there has been limited adoption of various strategies and equipment to minimize these injuries. A comprehensive review of these methods to reduce musculoskeletal strain is lacking in the current literature, and is essential in order to ensure a long, healthy, and productive interventional career.

Coronary Evaluation Before Heart Valvular Surgery by Using Coronary Computed Tomographic Angiography Versus Invasive Coronary Angiography

Background

Coronary computed tomography angiography (CCTA) is a noninvasive, less expensive, low‐radiation alternative to invasive coronary angiography (ICA). ICA is recommended for coronary evaluation before heart valvular surgery, and the supporting evidence for CCTA is insufficient. Our study is a single‐center, prospective cohort study designed to evaluate the feasibility of CCTA instead of ICA in detection of coronary artery disease before surgery.

Methods and Results

Heart valvular surgery candidates were consecutively enrolled between April 2017 and December 2018. Nine hundred fifty‐eight patients in the CCTA group underwent CCTA primarily, and those with ≥50% coronary stenosis or uncertain diagnosis underwent subsequent ICA. One thousand five hundred twenty‐five patients in the ICA group underwent ICA directly before surgery. Coronary artery bypass grafting decision was made by surgeons according to CCTA or ICA results. Most of the patients (78.8%) in the CCTA group avoided invasive angiography. Thirty‐day mortality (0.7% versus 0.9%, P=0.821), myocardial infarction (6.4% versus 6.9%, P=0.680 ), and low cardiac output syndrome (4.2% versus 2.8%, P=0.085) were similar in the CCTA and ICA groups. Median duration of follow‐up was 19.3 months (interquartile range, 14.2–30.0 months), cumulative rates of mortality (2.6% versus 2.6%, P=0.882) and major adverse cardiac events (9.6% versus 9.0%, P=0.607) showed no difference between the 2 groups. Coronary evaluation expense was lower in the CCTA group ($149.6 versus $636.0, P<0.001).

Conclusions

The strategy of using CCTA as a doorkeeper in coronary evaluation before heart valvular surgery showed noninferiority in identification of candidates for coronary artery bypass grafting and postoperative safety.

CT-FFR vs a model of combined plaque characteristics for identifying ischemia: Results from CT-FFR CHINA trial

OBJECTIVES

To evaluate the diagnostic performance of fractional flow reserve (FFR) derived from coronary computed tomography angiography (CCTA; CT-FFR) and combined plaque characteristics for ischemia in different CCTA stenosis levels.

METHODS

This clinical trial analyzed 317 patients with 30 %-90 % coronary stenosis in 366 vessels from 5 centers undergoing CCTA and invasive FFR. 366 vessels were assigned into < 50 % (nonobstructive) and ≥ 50 % (obstructive) stenosis groups. Lesion length (LL), plaque burden (PB), diameter stenosis (DS), volume ratio of plaque subcomponents < 30 HU (VR < 30HU), and high-risk features were analyzed. Logistic regression models were used to identify plaque characteristic predictors for lesion-specific ischemia in different stenosis grades. The area under receiver operating characteristics curve (AUC) of integrated plaque characteristics and CT-FFR were calculated and compared.

RESULTS

In < 50 % stenosis lesions, PB (OR: 1.296, p = 0.002), LL (OR:1.075, p = 0.020), and DS (OR:1.085, p = 0.031) were independent predictors of ischemia. In ≥ 50 % stenosis lesions, VR < 30HU (OR:1.031, p = 0.005) and DS (OR: 1.020, p =  0.044) were independent predictors for ischemia. AUC of plaque characteristic (VR < 30HU plus DS) for ischemia was 0.67 (95 % CI: 0.61-0.72) in ≥ 50 % stenosis level, which was significantly lower than CT-FFR (AUC=0.90; 95 % CI: 0.86-0.93) (p <  0.001). For lesions causing < 50 % stenosis, AUC of combined plaque model (VR < 30HU plus DS) was 0.88 (95 % CI: 0.80-0.95), equivalent to AUC of CT-FFR (AUC = 0.88; 95 % CI: 0.80-0.96; p =  0.957).

CONCLUSION

CT-FFR is a powerful functional assessment tool for both obstructive and nonobstructive diseases. However, for nonobstructive CAD confirmed by CCTA, a model of a combination of plaque characteristics could be a valuable alternative to CT-FFR.

AntimiR-21 Prevents Myocardial Dysfunction in a Pig Model of Ischemia/Reperfusion Injury

BACKGROUND

miR-21 is a central regulator of cardiac fibrosis, and its inhibition in small-animal models has been shown to be an effective antifibrotic strategy in various organs, including the heart. Effective delivery of therapeutic antisense micro-ribonucleic acid (antimiR) molecules to the myocardium in larger organisms is challenging, though, and remains to be established for models of chronic heart failure.

OBJECTIVES

The aims of this study were to test the applicability and therapeutic efficacy of local, catheter-based delivery of antimiR-21 in a pig model of heart failure and determine its effect on the cardiac transcriptomic signature and cellular composition.

METHODS

Pigs underwent transient percutaneous occlusion of the left coronary artery and were followed up for 33 days. AntimiR-21 (10 mg) was applied by intracoronary infusion at days 5 and 19 after the injury. Cardiac function was assessed in vivo, followed by histological analyses and deep ribonucleic acid sequencing (RNA-seq) of the myocardium and genetic deconvolution analysis.

RESULTS

AntimiR-21 effectively suppressed the remodeling-associated increase of miR-21. At 33 days after ischemia/reperfusion injury, LNA-21-treated hearts exhibited reduced cardiac fibrosis and hypertrophy and improved cardiac function. Deep RNA-seq revealed a significant derepression of the miR-21 targetome in antimiR-21-treated myocardium and a suppression of the inflammatory response and mitogen-activated protein kinase signaling. A genetic deconvolution approach built on deep RNA-seq and single-cell RNA-seq data identified reductions in macrophage and fibroblast numbers as the key cell types affected by antimiR-21 treatment.

CONCLUSIONS

This study provides the first evidence for the feasibility and therapeutic efficacy of miR-21 inhibition in a large animal model of heart failure.

The interventionist mindset: The ten eyes rule in cath lab

This article addresses the skillfulness role of the interventionist in the Cath lab. It argues that the interventionist plays a crucial role and should possess certain mental-manual dexterity and hand-eye coordination skills. The article suggests a series of measures that collectively determine the successful role of the interventionist in the Cath lab. This is of utmost importance given the sensitive nature of the cardiovascular procedures, the potential costs of its failure for the patient, and the key action played by the interventionist in determining the failure or success of the procedure.

Safety and feasibility of upper limb vascular access for cardiac catheterization in anticoagulated and non-anticoagulated patients

BACKGROUND

The upper limb approach utilizing transradial access for combined left and right heart catheterization (CLRHC) and ultrasound-guided antecubital venous access for isolated right heart catheterization (IRHC) are strategies that may reduce risks, especially in anticoagulated patients. combined left and right heart catheterization.

OBJECTIVES

To assess safety and feasibility of upper limb approach for IRHC or CLRHC in anticoagulated versus non-anticoagulated patients.

METHODS

Ninety-three patients who underwent IRHC or CLRHC with ultrasound-guided antecubital venous access and transradial arterial access were prospectively enrolled. The primary outcome was a composite of procedure failure and incidence of immediate vascular complications.

RESULTS

Of the 93 patients, 44 (47%) were on anticoagulation and 49 (53%) were not. Mean age was 54 ± 17 and 53 ± 15 years, respectively. Atrial fibrillation (39% vs 15%) and chronic kidney disease (21% vs 6%) were more common in anticoagulated patients. The main indication for anticoagulation was deep vein thrombosis/pulmonary thromboembolism in 22 patients (50%). The primary outcome occurred in 4 (8%) patients in the non-anticoagulated group as compared with 0 in the anticoagulated group (p = 0.12). Procedure failure occurred in two patients (4%) and immediate vascular complications in two patients (4%) in the non-anticoagulated group (p = 0.3 for all). There was no difference between groups regarding duration of the procedure, radiation dose, fluoroscopy time, post-procedure recovery room time and median time to venous or arterial hemostasis.

CONCLUSIONS

The upper limb approach for heart catheterization had similar rates of procedure failure and immediate vascular complications in anticoagulated patients when compared to non-anticoagulated patients.

Surgical management of iatrogenic coronary artery perforations: when percutaneous treatment fails

Coronary perforation is a rare complication of percutaneous coronary interventions and a challenging scenario which imposes prompt recognition and treatment. Although it may be successfully managed percutaneously, a surgical treatment may be preferable in some cases. We report the case of a patient with a coronary perforation with initial percutaneous treatment complicated with extravascular implantation of a covered stent and liver laceration, who was succesfully treated by cardiac surgery. This case suggests the importance of the proximity of an onsite cardiac surgery center when complex coronary artery percutaneous interventions are performed in hospitals with offsite surgical support.

Trends and outcomes of non-primary PCI at sites without cardiac surgery on-site: The early Michigan experience

Introduction

Non-primary percutaneous coronary intervention (non-PPCI) recently received certificate of need approval in the state of Michigan at sites without cardiac surgery on-site (cSoS). This requires quality oversight through participation in the BMC2 registry. While previous studies have indicated the safety of this practice, real-world comprehensive outcomes, case volume changes, economic impacts, and readmission rates at diverse healthcare centers with and without cSoS remain poorly understood.

Methods

Consecutive patients undergoing non-PPCI at 47 hospitals (33 cSoS and 14 non-cSoS) in Michigan from April 2016 to March 2018 were included. Using propensity-matching, patients were analyzed to assess outcomes and trends in non-PPCI performance at sites with and without cSOS.

Results

Of 61,864 PCI’s performed, 50,817 were non-PPCI, with 46,096 (90.7%) performed at sites with cSoS and 4,721 (9.3%) at sites without cSoS. From this cohort, 4,643 propensity-matched patients were analyzed. Rates of major adverse cardiac events (2.6% vs. 2.8%; p = 0.443), in-hospital mortality (0.6% vs. 0.5%; p = 0.465), and several secondary clinical and quality outcomes showed no clinically significant differences. Among a small subset with available post-discharge data, there were no differences in 90-day readmission rates, standardized episode costs, or post-discharge mortality. Overall PCI volume remained stable, with a near three-fold rise in non-PPCI at sites without cSoS.

Conclusions

Non-PPCI at centers without cardiac SoS was associated with similar comprehensive outcomes, quality of care, 90-day episode costs, and post-discharge mortality compared with surgical sites. Mandatory quality oversight serves to maintain appropriate equivalent outcomes and may be considered for other programs, including the performance of non-PPCI at ambulatory surgical centers in the near future.

Quantification of effects of mean blood pressure and left ventricular mass on noninvasive fast fractional flow reserve

While brachial mean blood pressure (MBP) and left ventricular mass (LVM) measured from CTCA are the two CFD simulation input parameters, their effects on noninvasive fractional flow reserve (FFRB) have not been systematically investigated. We demonstrate that inaccurate MBP and LVM inputs differing from patient-specific values could result in misclassification of borderline ischemic lesions. This is important in the clinical application of noninvasive FFR in coronary artery disease diagnosis.

Diabetic vasculopathy: macro and microvascular injury

PURPOSE OF REVIEW

Diabetes is a common and prevalent medical condition as it affects many lives around the globe. Specifically, type-2 Diabetes (T2D) is characterized by chronic systemic inflammation alongside hyperglycemia and insulin resistance in the body, which can result in atherosclerotic legion formation in the arteries and thus progression of related conditions called diabetic vasculopathies. T2D patients are especially at risk for vascular injury; adjunct in many of these patients heir cholesterol and triglyceride levels reach dangerously high levels and accumulate in the lumen of their vascular system.

RECENT FINDINGS

Microvascular and macrovascular vasculopathies as complications of diabetes can accentuate the onset of organ illnesses, thus it is imperative that research efforts help identify more effective methods for prevention and diagnosis of early vascular injuries. Current research into vasculopathy identification/treatment will aid in the amelioration of diabetes-related symptoms and thus reduce the large number of deaths that this disease accounts annually.

SUMMARY

This review aims to showcase the evolution and effects of diabetic vasculopathy from development to clinical disease as macrovascular and microvascular complications with a concerted reference to sex-specific disease progression as well.

Perceptions of Public and Nonpublic Reporting of Interventional Cardiology Outcomes and Its Impact on Practice: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

Background

Physicians have expressed significant mistrust with public reporting of interventional cardiology outcomes. Similar data are not available on alternative reporting structures, including nonpublic quality improvement programs with internally distributed measures of interventional quality. We thus sought to evaluate the perceptions of public and nonpublic reporting of interventional cardiology outcomes and its impact on clinical practice.

Methods and Results

A standardized survey was distributed to 218 interventional cardiologists in the Veterans Affairs Healthcare System, with responses received from 62 (28%). The majority of respondents (90%) expressed some or a great deal of trust in the analytic methods used to generate reports in a nonpublic quality improvement system within Veterans Affairs, while a minority (35%) expressed similar trust in the analytic methods in a public reporting system that operates outside Veterans Affairs (P<0.001). Similarly, a minority of respondents (44%) felt that in‐hospital and 30‐day mortality accurately reflected interventional quality in a nonpublic quality improvement system, though a smaller proportion of survey participants (15%) felt that the same outcome reflected procedural quality in public reporting systems (P<0.001). Despite these sentiments, the majority of operators did not feel pressured to avoid (82% and 75%; P=0.383) or perform (72% and 63%; P=0.096) high‐risk procedures within or outside Veterans Affairs.

Conclusions

Interventional cardiologists express greater trust in analytic methods and clinical outcomes reported in a nonpublic quality improvement program than external public reporting environments. The majority of physicians did not feel pressured to avoid or perform high‐risk procedures, which may improve access to interventional care among high‐risk patients.

Routine iso-osmolar contrast media use and acute kidney injury following percutaneous coronary intervention for ST elevation myocardial infarction

BACKGROUND

Temporal changes in contrast-induced acute kidney injury (CI-AKI) incidence following primary percutaneous coronary intervention (PPCI) are poorly defined. Additionally, the benefits of iso-osmolar contrast media (IOCM) compared to low osmolar CM (LOCM) are uncertain.

METHODS

Using data from a regional PPCI service, temporal changes in baseline risk and annual incidence of CI-AKI were studied. A CM protocol change occurred in 2013 allowing a comparison of the incidence of CI-AKI between LOCM (2012-13) and IOCM (2013-15).

RESULTS

Between 2012 and 2015, 208 of 1310 patients experienced CI-AKI (15.9%). The Mehran AKI risk score did not change during the study period although there was an increase in the incidence of CI-AKI in later study years (P<0.001 for trend) when IOCM was used. Factors independently associated with CI-AKI were IOCM use (OR=1.96, [95% CI: 1.39-2.75]), age per year (OR=1.02, 95% CI: 1.01-1.04), baseline creatinine per µmol/L (OR=1.006, 95% CI: 1.003-1.01) and contrast volume per milliliter (OR=1.002, 95% CI: 1.001-1.004). The baseline characteristics of patients treated using IOCM (N.=783) vs. LOCM (N.=527) were similar (Mehran Score 6.6 vs. 6.9, P=0.173) but CI-AKI occurred more frequently with IOCM compared to LOCM (19.2% vs. 11.2%, P<0.001). Use of IOCM was independently associated with CI-AKI (OR=1.98, 95% CI: 1.339-2.774, P<0.001) with consistency across all sub-groups of age, gender, baseline creatinine, contrast volume, shock and diabetes. The adjusted in-hospital mortality was increased with IOCM compared to LOCM (OR=3.03, 95% CI: 1.313-6.994, P=0.009).

CONCLUSIONS

IOCM use was observed to be associated with an increased occurrence of CI-AKI, and an increase in in-hospital mortality after primary PCI.

Characteristics of the Quality Improvement Content of Cardiac Catheterization Peer Reviews in the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

IMPORTANCE

Peer review is recommended for quality assessment in all cardiac catheterization programs, but, to our knowledge, the content of peer reviews and the potential for quality improvement has not been described.

OBJECTIVE

To characterize the quality improvement content of cardiac catheterization peer reviews.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used retrospective case review of diagnostic angiography and percutaneous coronary intervention procedures to characterize the major adverse event review process of the US Department of Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program from January 1, 2012, to December 31, 2016. Data review and analysis took place from November 2017 to August 2018.

MAIN OUTCOMES AND MEASURES

Percentage of peer reviews reporting substandard care and opportunities for quality improvement.

RESULTS

A total of 196 643 diagnostic coronary angiograms and 62 576 percutaneous coronary interventions were performed in the Department of Veterans Affairs. Of these, 168 (0.1%) were triggered for review because of a self-reported major adverse event during the procedure. Of 152 cases with complete peer review data, care was adjudicated as not meeting the standard of care in 25 cases (16.4%). Concerns about operator judgment were identified in 46 cases (30.3%), about case selection in 26 (17.1%), about trainee supervision in 21 (13.8%), and about technical performance in 46 (30.3%). Reviewers made recommendations to improve operator performance in 63 cases (41.4%) and catheterization laboratory or hospital processes in 58 (38.2%).

CONCLUSIONS AND RELEVANCE

While substandard care is infrequently identified in peer review of catheterization laboratory complications in the Department of Veterans Affairs, the process often generates recommendations for quality improvement. Peer review programs should focus on identifying quality improvement opportunities and providing meaningful feedback to operators.

Transient Cortical Blindness Following Coronary Angiography

Transient cortical blindness (TCB) is an uncommon complication following coronary angiography. This report describes a case of TCB after coronary angiography in a patient admitted for acute myocardial infarction. The patient’s vision recovered completely within 16 h, and cardiac magnetic resonance imaging performed 2 months later revealed no significant abnormalities. (Level of Difficulty: Beginner.)

The functional assessment of patients with non-obstructive coronary artery disease: expert review from an international microcirculation working group

Symptomatic non-obstructive coronary artery disease (NOCAD) is an increasingly recognised entity that is associated with poor cardiovascular outcomes. Nearly half of those undergoing coronary angiography for appropriate indications, such as typical angina, or a positive stress test have no obstructive lesion. There are no guideline recommendations as to how to care properly for these patients. Physiologic assessment of the coronary arteries beyond two-dimensional angiography is not standardised, yet it can provide valuable information in patients presenting with typical angina in the setting of NOCAD. In this consensus document, we detail steps for the interventional cardiologist to evaluate the patient with symptomatic NOCAD in the cardiac catheterisation laboratory, first with the assessment of coronary flow reserve (CFR), and then with delineation of deficiencies in non-endothelium-dependent CFR (CFRne) versus endothelium-dependent CFR (CFRe) using provocative agents such as adenosine and acetylcholine, respectively, followed by the evaluation of smooth muscle function with nitroglycerine (NTG). Once the mechanism behind the anginal symptoms is established, one can identify the appropriate treatment strategies to address the physiologic deficiency that is present. Despite an established safety profile, a comprehensive assessment may be considered for selected patients which requires an understanding of the appropriate invasive evaluation by the practising interventional cardiologist when evaluating not only patients with obstructive CAD but also those with NOCAD.

Validation of a low-dose contrast 64-slice cardiac computed tomography angiography protocol for aortic valve annulus sizing

Cardiac computed tomography angiography (CCTA) is the gold standard for accurately sizing the aortic valve annulus prior to aortic valve replacement. A reduction of contrast volume administered for CCTA, without sacrificing image quality, is desirable. Signal-to-noise ratio represents final CCTA image quality. Consecutive patients referred to CCTA for aortic valve annulus sizing were retrospectively analyzed. Patients were grouped into a low-dose contrast (LDCT) group and traditional dose contrast (TDCT) group. In the LDCT group, contrast dose was <50% of the maximal allowable dose (3.7 × estimated glomerular filtration rate). Guided by a time-density curve, the contrast was administered in a two-stage infusion, and retrospectively gated images were acquired with a 64-multidetector computed tomography scanner. Out of 123 patients (age 80 ± 9 years; 46% female), 65 (52.9%) underwent LDCT and 58 (47.2%) underwent TDCT. Contrast volume was significantly lower in the LDCT group (LDCT 41.2 ± 9.8 vs TDCT 76.2 ± 14.2 mL; P < 0.001). The signal-to-noise ratio of the aortic root was 10.4 ± 4.1 for the LDCT group and 8.4 ± 3.3 for the TDCT group (P = 0.004). Aortic root dimensions could be measured in both LDCT and TDCT groups. In conclusion, LDCT with 64-slice CCTA can effectively size the aortic valve annulus to direct aortic valve replacement while offering reduced contrast exposure.