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.

Real-World Experience of Coronary Intravascular Lithotripsy in an Asian Population: A Retrospective, Observational, Single-Center, All-Comers Registry

OBJECTIVES

To assess the clinical and angiographic outcomes of coronary intravascular lithotripsy (IVL) use in an all-comers population with moderate-to-severely calcified coronary lesions.

BACKGROUND

IVL has been shown to modify coronary calcific plaques with minimal vascular complications.

METHODS

This was a retrospective, observational study of patients treated with IVL. The primary endpoint was in-hospital major adverse cardiovascular event (MACE), which included cardiac death, myocardial infarction (MI), and target-vessel revascularization (TVR). Secondary endpoints were clinical success (stent expansion with <30% in-stent residual stenosis and no in-hospital MACE) and angiographic success.

RESULTS

Between August 2019 and December 2019, a total of 50 calcified lesions were treated in 45 patients using the Shockwave C2 IVL catheter (Shockwave Medical). They were further studied in 3 treatment subgroups: (1) primary IVL group with de novo lesions (n = 23 lesions); (2) secondary IVL group in which non-compliant balloon dilation failed (n = 15 lesions); and (3) tertiary IVL group with IVL to underexpanded stents (n = 12 lesions). The mean diameter stenosis of calcified lesions was 63.2 ± 10.2% at baseline, and decreased to 33.5 ± 10.9% immediately post IVL (P<.001) and 15 ± 7.1% post stenting (P<.001). Mean minimal lumen diameter was 1.1 ± 0.3 mm at baseline, and increased to 1.90 ± 0.5 mm post IVL (P<.001) and 2.80 ± 0.50 mm post stenting (P<.001). In-hospital and 30-day MACE occurred in 3 and 4 patients, respectively. Overall, clinical success and angiographic success were achieved in 90% and 94% of cases, respectively.

CONCLUSIONS

IVL appears to be a safe, effective, and feasible strategy for calcium modification in an all-comers cohort with high success rate, minimal procedural complications, and low MACE rates.

Absent 'superimposed-line' sign: novel marker in early diagnosis of cleft of fetal secondary palate

OBJECTIVES

To describe a novel sign, the 'superimposed-line' sign, for early diagnosis of cleft of the fetal secondary palate on two-dimensional imaging of the vomeromaxillary junction in the midsagittal view.

METHODS

This was a prospective evaluation of the superimposed-line sign using two-dimensional sonography (midsagittal view) in 9576 singleton fetuses referred for routine screening between 12 and 20 weeks of gestation. In this view, the vomer bone appears as a line superimposed on the distal two-thirds of the maxillary line, as the vomer fuses with the secondary palate in the midline. If there is a midline cleft of the secondary palate, the line formed by the palate is absent and hence only the vomer bone is visualized, creating a single line instead of the normal superimposed double line. Multiplanar three-dimensional (3D) views were assessed in cases in which the superimposed-line sign was absent.

RESULTS

The superimposed line was absent in 17 fetuses with a cleft of the secondary palate that was confirmed by 3D evaluation. Of these, 13 had defects involving the premaxilla and four had an isolated cleft of the secondary palate. Postnatal confirmation was available in all cases. The sign was useful in ruling out cleft of the fetal secondary palate in 32 high-risk cases with a family history of cleft palate. The superimposed-line sign had a sensitivity of 89.5% in detecting cleft of the secondary palate.

CONCLUSIONS

The superimposed-line sign is a new sonographic marker for evaluation of cleft of the fetal secondary palate; documentation of this sign proves the presence of both the palate and vomer in the midline. This marker can be demonstrated clearly in the late first trimester, allowing early diagnosis of secondary palatine cleft. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prognostic significance of fragmented QRS in patients with ST-elevation myocardial infarction undergoing revascularization

BACKGROUND & OBJECTIVES

This longitudinal study was carried out to evaluate the prognostic significance of fragmented QRS (fQRS) in patients with acute ST elevation myocardial infarction (STEMI) undergoing revascularization.

METHODS

This study included 103 STEMI patients belonging to Killip class I and II who underwent primary revascularization. All patients underwent twelve lead ECG at admission before PCI. Serial ECG were done after PCI at 3 hours, 6 hours, 24 hours, 48 hours and at discharge for detection of fQRS and echocardiography on day 3 post revascularization. Patients developing fQRS within 48 hours and with persistence of fQRS till discharge were included in "persistent fQRS" group. They were followed up after 30 days for major adverse cardiac events (MACE) and assessment of LV function by echocardiography.

RESULTS

fQRS was present in 64 patients (61.5%) of study population with 37 patients (57.8%) having persistent fQRS. MACE rates were low (4.8%) and did not differ with respect to fQRS. fQRS significantly correlated with LV dysfunction at 30 days on univariate analysis (p-0.003) but not on multivariate analysis (p -0.10). fQRS was significantly related to impaired myocardial reperfusion as assessed by ΣSTR (percent of total ST segment resolution) (adjusted odds ratio, 95% CI [4.265 (1.034 - 17.58)], p = 0.04).

CONCLUSION

In our study, fQRS did not predict MACE and LV dysfunction in acute STEMI patients belonging to Killip class I and II on short term follow-up of 30 days. But, fQRS independently predicted impaired microvascular myocardial reperfusion as assessed by ΣSTR.

Acute rheumatic fever presenting as complete heart block: report of an adolescent case and review of literature

A 14-year-old boy suffering from chronic rheumatic heart disease came to the emergency department with recurrent episodes of presyncope and syncope. He was found to have complete heart block (CHB) and required temporary pacemaker insertion. Further workup revealed that CHB was secondary to acute rheumatic carditis. His atrioventricular (AV) conduction abnormalities recovered in a stepwise fashion over 5 days while he was being treated with corticosteroids, without the need for permanent pacemaker insertion. This case illustrates that acute rheumatic carditis can rarely present with advanced AV conduction block, which may be reversible.

Minimal hepatic encephalopathy impairs quality of life

Minimal hepatic encephalopathy (MHE) is the mildest form of the spectrum of neurocognitive impairment in cirrhosis. It is a frequent occurrence in patients of cirrhosis and is detectable only by specialized neurocognitive testing. MHE is a clinically significant disorder which impairs daily functioning, driving performance, work capability and learning ability. It also predisposes to the development of overt hepatic encephalopathy, increased falls and increased mortality. This results in impaired quality of life for the patient as well as significant social and economic burden for health providers and care givers. Early detection and treatment of MHE with ammonia lowering therapy can reverse MHE and improve quality of life.

Nuclear magnetic resonance, vibrational spectroscopic studies, physico-chemical properties and computational calculations on (nitrophenyl) octahydroquinolindiones by DFT method

In the present study, 2'-nitrophenyloctahydroquinolinedione and its 3'-nitrophenyl isomer were synthesized and characterized by FT-IR, FT-Raman, (1)H NMR and (13)C NMR spectroscopy. The molecular geometry, vibrational frequencies, (1)H and (13)C NMR chemical shift values of the synthesized compounds in the ground state have been calculated by using the density functional theory (DFT) method with the 6-311++G (d,p) basis set and compared with the experimental data. The complete vibrational assignments of wave numbers were made on the basis of potential energy distribution using GAR2PED programme. Isotropic chemical shifts for (1)H and (13)C NMR were calculated using gauge-invariant atomic orbital (GIAO) method. The experimental vibrational frequencies, (1)H and (13)C NMR chemical shift values were found to be in good agreement with the theoretical values. On the basis of vibrational analysis, molecular electrostatic potential and the standard thermodynamic functions have been investigated.

Functionalized and postfunctionalizable porous polymeric films through evaporation-induced phase separation using mixed solvents

Condensation of water droplets during rapid evaporation of a polymer solution, under humid conditions, has been known to generate uniformly porous polymer films. Similar porous films are also formed when a solution of the polymer in THF containing small amounts of water, is allowed to evaporate rapidly under air flow; this suggests that water droplets may be formed during the final stages of film formation. In the presence of added surfactants, the interface of water droplets could become lined with the surfactants and consequently the internal walls of the pores generated, upon removal of the water, could become decorated with the hydrophilic head groups of the surfactant molecules. In a series of carefully designed experiments, we have examined the effect of added surfactants, both anionic and cationic, on the formation of porous PMMA films; the films were prepared by evaporating a solution of the polymer in THF containing controlled amounts of aqueous surfactant solutions. We observed that the average size of the pores decreases with increasing surfactant concentration, while it increases with increasing amounts of added water. The size of the pores and their distribution were examined using AFM and IR imaging methods. Although IR imaging possessed inadequate resolution to confirm the presence of surfactants at the pore surface, exchange of the inorganic counterion, such as the sodium-ion of SDS, with suitable ionic organic dyes permitted the unequivocal demonstration of the presence of the surfactants at the interface by the use of confocal fluorescence microscopy.

Thermal properties of PMMA/montmorillonite clay nanocomposites

Polymer/Clay offer tremendous improvement in wide range of physical and engineering properties for polymers with low filler loading. In nanotechnology polymer/clay nanocomposites use smectitetype clays that have layered structures. In this work, Poly (methyl methacrylate) (PMMA) was synthesized by free radical addition polymerization in the presence of high power ultrasound. The Poly (methyl methacrylate) (PMMA)-Montmorillonite (MMT) clay nanocomposites were synthesized by two different techniques viz., ultrasonic mixing and magnetic stirring. An analysis of the XRD data confirms that the composites are in the nanometer scale. The FTIR spectra show that there is strong interaction between the clay and the polymer that enhances the thermal stability. The thermal stability of the experimental nanocomposite prepared by the two processes is compared. Further analysis of XRD data shows that intercalation as well as exfoliation has taken place in both the types of nanocomposites preparation. An analysis of the TG, DTG curves reveal that the thermal stability is found to increase by nearly 30% for ultrasonic mixing than that of magnetic stirring.

Resonance Raman and infrared spectral studies on radical anions of model photosynthetic reaction center quinones (naphthoquinone derivatives)

Quinones play a vital role in the processes of electron transfer in bacterial photosynthetic reaction centers. It is of interest to investigate photochemical reactions involving quinones with a view to elucidate structure-function relationships in biological processes. Resonance Raman and FTIR spectra of electrochemically generated radical anions of 2-methyl-1,4-naphthoquinone, and 2-methyl-3-phytyl-1,4-naphthoquinone, also known as Vitamin K3 and Vitamin K1, respectively, (model compound for QA in Rhodopseudomonas viridis, a bacterial photosynthetic reaction center) have been reported. The same study has also been extended to 1,4-naphthoquinone for comparison. The vibrational assignments were carried out on the basis of comparison with our earlier time resolved resonance Raman studies on photochemically generated radical anions of 1,4-naphthoquinone and 2-methyl-1,4-naphthoquinone (Balakrishnan et al., J. Phys. Chem., 100, (1996), 16472-16478). These in vitro results have been compared with the reported vibrational spectral data under in vivo conditions.