Low burr-to-artery ratio predict stent underexpansion in patients with high OCT based calcium score underwent rotablator atherectomy

Background

Stent under-expansion is the potent predictor for stent thrombosis.

Purpose

We aim to determine the incidence of stent under-expansion and its predictors in patient who undergoing rotational atherectomy (RA) assisted percutaneous coronary intervention (PCI) assessed by optical coherence tomography (OCT).

Method

The study included 83 consecutive patients who undergoing OCT guidance RA assisted PCI during January 2016 through September 2020. Baseline clinical characteristics and intracoronary imaging data were recorded. Stent under-expansion was defined as the minimal stent area divided by average of proximal and distal reference lumen area <80%.

Results

Majority of patients (83%) had OCT based calcium score 3–4. The incidence of stent under-expansion was 9.6%. Comparing between the patient with optimized stent expansion and stent under-expansion, patients with stent under-expansion has older age (79.1±6 vs 69.8±10.4, p=0.015), higher calcium thickness (1.01±0.83 vs 0.65±0.22, p<0.001), longer calcium length (18.68±1.88 vs 12.69±5.33, p<0.001). and lower burr to artery ratio (0.53±0.09 vs 0.65±0.09, p<0.001). The optimal cut-off values of burr to artery ratio <0.54 predict stent under-expansion.

Conclusion

In the patients with high OCT based calcium score underwent RA assisted PCI, burr to artery ratio<0.54 is a predictor for stent underexpansion.

Funding Acknowledgement

Type of funding sources: None.

A risk predictive model for coronary perforation in patients undergoing percutaneous coronary intervention – APOLLO-XI score

Background

Coronary perforation (CP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). Although several variables are associated with the risk of coronary perforation, a cumulative risk predictive model has not been established yet.

Purpose

To assess an incidence, risk factors and to develop risk predictive model for coronary perforation following PCI.

Methods

A single center, retrospective study of patients who underwent PCI from March 2010 to December 2019. Multivariate regression analysis was performed to identify independent predictors of CP. A risk predictive model was constructed with incremental weights attributed to each component variable according to their beta coefficients.

Results

10,671 PCI procedures were enrolled. The incidence of CP was 0.94%. Adverse in-hospital outcomes were significant higher in CP group, including death (odds ratio [OR]: 3.58), mechanical circulatory support; including IABP and ECMO (OR: 3.79) and urgent revascularization (OR: 7.35). Multivariable analysis identified seven independent risk factors for CP, which were age (OR: 1.02), insulin-treated diabetes (OR: 2.50), prior CABG (OR: 2.03), hydrophilic guidewire (OR: 1.62), rotational atherectomy (OR: 2.60), excimer laser coronary atherectomy (ELCA) (OR: 3.39) and chronic total occlusion PCI (OR: 4.21). Risk predictive model (APOLLO-XI score) was calculated from the total points of each variables as follows: age (1 point per 10-year increase), hydrophilic guidewire (2 points), prior CABG (3 points), insulin-treated diabetes or rotational atherectomy (4 points), ELCA (5 points) and chronic total occlusion PCI (6 points). Cumulative risk score more than 11 points had increased risk for coronary perforation more than 1%. The validation of the risk predictive model (C-statistic) was 0.75 (95% CI: 0.70–0.80).

Conclusions

Coronary perforation is a rare but lethal complication. Our study demonstrates the risk predictive model which could enhance cardiovascular team to precisely estimate risk of coronary perforation before complex PCI procedure.

Funding Acknowledgement

Type of funding sources: None. Baseline charecteristicsAPOLLO-XI score

Prospective external validation of PRECISE-DAPT score for prediction of bleeding and thrombosis after coronary stent implantation

Background

Optimal duration of dual antiplatelet therapy (DAPT) after coronary stent implantation depends on bleeding and thrombotic risk in an individual patient. The PRECISE-DAPT score is recommended for adjusting of optimal DAPT duration.

Purpose

To assess external validation of PRECISE-DAPT score for prediction of out-of-hospital bleeding and thrombosis after coronary stent implantation in prospective manner.

Methods

We prospectively enrolled patients who underwent coronary stent implantation and received DAPT in our institution during June 2018 through December 2019. Out-of-hospital bleeding and thrombotic events were assessed for validation of PRECISE-DAPT score.

Results

Six hundred and two patients were enrolled. The mean age was 65.0±11.7 years and 28.2% were female. STEMI, NSTEMI/UA and chronic coronary syndrome were 24.4%, 22.6%, 53% respectively. Prevalence of prior bleeding was 6.3%. Mean follow-up period was 312±72 days. Bleeding events were 5.1%. High PRECISE-DAPT score (score ≥25) had significantly higher bleeding events (9.4% vs 2.4%, P-value <0.001), which were divided into major TIMI bleeding (3.4% vs 0.3%, P-valve 0.003) and minor TIMI bleeding (6.0% vs 2.2%, P-valve 0.014). MACE (CV death, MI, stroke) were 7% and significantly higher in high PRECISE-DAPT score (10.7% vs 4.6%, P-valve 0.004), compared with low PRECISE-DAPT score.

Conclusions

In real-world prospective study, high PRECISE DAPT score (score ≥25) is associated with high bleeding and thrombotic events. Because of increased both events in high PRECEISE-DAPT score, shortening DAPT duration requires physician final decision-making to balance future bleeding and thrombosis.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Siriraj grants for medical research and education, Faculty of Medicine Siriraj Hospital, Mahidol University

Indoleamine 2,3 dioxygenase (IDO) as a new predictor for advance coronary artery diseases

Background

Indoleamine 2,3 dioxygenase (IDO), the rate-limiting enzyme in in the kynurenine (Kyn) pathway of tryptophan (Trp) degradation, is modulated by inflammation and regarded as a key molecule driving immunotolerance and immunosuppressive mechanisms. This response accelerates the resolution of inflamed tissues to protect them against collateral damage and facilitate tissue healing. A growing body of evidence indicates that IDO-mediated Trp metabolism is involved directly or indirectly in atherogenesis. Little is known about IDO activity in patients with active coronary artery disease (CAD).

Purpose

We hypothesized that IDO activity as reflected by Kyn/Trp ratio and Kyn levels correlated with coronary artery disease (CAD) severity and predicted 1-year major adverse cardiac events (MACE).

Method

We prospectively enrolled the patients whom underwent coronary angiography in our institute. We excluded the patients whom might have other non-cardiac causes of elevated inflammatory biomarkers such as rheumatoid arthritis, allergic asthma, and so on. Measurements of IDO, hs-troponin and hs-CRP levels were performed at baseline and IDO activity was monitored every 6 month at interval. Baseline demographic, coronary angiogram/interventions data were recorded. Significant CAD defined as >70% stenosis in major epicardial vessel. Patients were followed up for 1-year. MACE were pre-specified.

Results

Three-hundred and five patients were enrolled. Ninety-eight patients (32%) presented with acute coronary syndrome. There was a significant difference in IDO, kynurenine, and hs-troponin between patients with and without significant CAD (Table 1). In addition, baseline IDO activity, kynurenine and hs-troponin levels were significantly higher in significant CAD patients with 3-vessel, 2-vessel and 1-vessel involvements than those with insignificant CAD; (0.17 vs 0.14 vs 0.14 vs 0.04, p<0.01), (5.8 vs 4.5 vs 5.1 vs 2.9 μM/g, p<0.01) and (18.2 vs 12.4 vs 12.7 vs 11.1 mg/dL, p<0.001), respectively. Preliminary data in 287 patients with completion of 1-year follow up showed that 1-year mortality was 2.9%. In comparison between patients who survived and death, it demonstrated markedly higher baseline kynurenine (5.12 vs 0.54 μM/g, p<0.03) and IDO (0.15 vs 0.01, p<0.02) in the patients without 1-year mortality.

Conclusion

Immunometabolic response mediated through IDO function were enhanced in patients with CAD and correlated with the severity and extent of the disease. Patient with inadequate IDO response had a higher 1-year mortality.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Siriraj grant for research development and medical education of the Faculty of Medicine Siriraj Hospital

P861 Immediate aortic dissection after transcatheter aortic valve replacement (TAVR)

Transcatheter aortic valve replacement (TAVR) is a treatment of choice for treating symptomatic severe aortic stenosis patient whose condition is considered the high and intermediate operative risk for surgical aortic valve replacement. Here, we present a case of 67-year-old man with symptomatic severe aortic stenosis, triple vessels disease, type 2 diabetes mellitus and end-stage renal disease who was treated with TAVR. After the valve was deployed, we found the abnormal leakage at descending aorta by transesophageal echocardiogram (TEE). Under intraoperative close monitoring, the dissection was slowly expanding so we decided to perform thoracic endovascular repair (TEVAR). In conclusion, TEE after TAVR procedure is helpful to detect this rare complication.

Reported cases of AD status post TAVR Author Sex/Age Comorbidity Detection time of AD Site of AD Detection of AD Treatment for AD Result Route access of TAVR This case 2018 M/67 DM, ESRD Immediate after implant Ds TEE TEVAR Recovery Femoral Losmanova et al. 2018 F/81 NA 3 yrs As Autopsy Conservative Died NR Kratimenos et al. 2016 F/81 COPD, renal dysfunction, angiodysplasia 12 days Ds CT TEVAR Recovery Femoral Nagasawa et al. 2016 F/86 Heart failure During the procedure Ds TEE Conservative Recovery Femoral Yashima et al. 2015(14) F/88 NA 3 days As CT Conservative Recovery Femoral Van Mieghem et al. 2013 F/86 Coronary artery disease, post total knee prosthesis 1-2 hours As Angiogram TEVAR Recovery Femoral Loeser et al. 2013 F/89 NA 2-5 hours As Autopsy NA Cardiogenic shock and died Femoral Bibombe et al. 2013 M/83 Previous CBG, HT, DLP During the procedure As and Ds TEE, CTA, angiogram Open surgery Recovery Femoral Al-Attar et al. 2013 F/84 HT, thrombophlebitis 8 months 2 weeks As CT Open surgery Arrest and died Femoral D"Onofrio et al. 2012 F/79 RA, pulmonary edema, cerebral hemorrhage Immediate after implant As TEE Open surgery Died 32 day later due to septic shock Aortic Ong et al. 2011 M/90 HT, CA prostate, CKD, gastric and duodenal ulcer Immediate after implant As TEE Conservative Recovery Femoral Gerber et al. 2010 F/83 DM, LE 22 days As Autopsy NA Cardiac arrest and died Femoral Abbreviations M Male; F Female; DM Diabetes mellitus; ESRD End-stage renal disease; NA Not available; COPD Chronic obstructive pulmonary disease; CBG Coronary bypass graft; HT hypertension; DLP Dyslipidemia; RA Rheumatoid arthritis; CA cancer; CKD Chronic kidney disease; LE Lupus erythematosus; AD Aortic dissection; As Ascending; Ds Descending; TEVAR Thoracic endovascular aortic repair.

Abstract P861 Figure. Intraoperative TEE after TAVR

Ortner's syndrome in association with mitral valve prolapse

The case of an 83-year-old woman with a history of hypertension, valvular heart disease, atrial fibrillation, and cardiomegaly is presented. The patient also had progressive hoarseness of her voice and intermittent dysphagia. Ear, nose, and throat examination revealed left vocal cord paralysis. Echocardiography revealed severely dilated left (LA) and right atria (RA), moderate mitral regurgitation, severe tricuspid regurgitation, and prolapse of both these valves. A review of literature of Ortner's or cardiovocal syndrome is presented. Ortner's syndrome due to mitral valve prolapse has not been reported previously.

Pituitary apoplexy in a patient with acute myeloid leukemia and thrombocytopenia

We describe a 72-year-old woman with a history of acute myeloid leukemia who developed pituitary apoplexy associated with thrombocytopenia secondary to chemotherapy. She presented with new onset severe headache, nausea, vomiting and blurred vision. Initial physical examination was unremarkable. CT scan of the head was initially negative. Upon admission for further work up, She developed a high-grade fever, hypotension and obtundation. Subsequent physical examination revealed bitemporal visual fields defects and decreased visual acuity. Repeat imaging of head revealed a hemorrhagic pituitary mass compressing the optic chiasm. Laboratory results were compatible with the diagnosis of pan-hypopituitary syndrome. She received high dose steroids and was transferred for transnasal sphenoidotomy decompression surgery. The visual defects improved postoperatively. A literature review of Pituitary apoplexy is presented. Pituitary apoplexy secondary to thrombocytopenia has never been reported.

Cardiac manifestations of acquired immunodeficiency syndrome

Acquired immunodeficiency syndrome is a serious problem worldwide. Recent advances in the knowledge about human immunodeficiency virus (HIV) replication and the treatment of HIV infection have improved survival in HIV patients. Because of the longer survival in HIV patients, the more manifestations of late-stage HIV infection will be seen, including HIV-related cardiac diseases. The common cardiac manifestations in patients with the acquired immunodeficiency virus are pericardial effusion, myocarditis, dilated cardiomyopathy, endocarditis, pulmonary hypertension, malignant neoplasms, and drug-related cardiotoxicity. This review focuses on these cardiac manifestations in patients with the acquired immunodeficiency syndrome.

Incidence of bleeding complications associated with abciximab use in conjunction with thrombolytic therapy in patients requiring percutaneous transluminal coronary angioplasty

The use of abciximab after full-dose failed thrombolytics within 15 hours of acute myocardial infarction significantly increases the risk of major bleeding complications.

Use of stents to treat kinks causing obstruction in a left internal mammary artery graft

Left internal mammary arteries (LIMA) are used routinely as grafts to the left anterior descending coronary artery (LAD) in selected patients undergoing coronary artery bypass graft (CABG) surgery because of better long-term patency rates. Pathology other than fibrointimal hyperplasia, accelerated atherosclerosis, or thrombus can sometimes cause obstructive lesions in such grafts. This report illustrates a kink in a LIMA graft to the LAD causing an obstructive lesion shortly after surgery and describes the subsequent management of this lesion with intracoronary stents.