Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Radial access site for percutaneous coronary intervention (PCI) is recommended by clinical practice guidelines because of superior outcomes compared with femoral access site. Historically, the adoption of radial access site in the USA has lagged behind much of the rest of the world, but contemporary data on access site selection across the spectrum of clinical presentations and its association with outcomes are lacking. METHODS:A retrospective cohort study from the National Cardiovascular Data Registry's CathPCI Registry was conducted including PCIs performed between 1 January 2013 and 30 June 2022. The comparative safety of radial vs femoral access site for PCI was evaluated with instrumental variable analysis, a technique that can be used to support causal inference, exploiting operator variation in access site preferences as the instrumental variable. RESULTS:Overall, 6 658 479 PCI procedures were performed during the study period, of which 40.4% (n = 2 690 355) were performed via radial access site, increasing from 20.3% in 2013 to 57.5% in 2022. This increase was seen in all geographic regions and across the full spectrum of presentations, with the largest relative increase seen in patients with ST-elevation myocardial infarction. Overall, 2 420 805 PCIs met inclusion criteria for the comparative safety analysis. In instrumental variable analyses, radial access site was associated with lower in-hospital mortality [absolute risk difference (ARD) -.15%, 95% confidence interval (CI) -.20 to -.10], major access site bleeding (ARD -.64%, 95% CI -.68 to -.60), and other major vascular complications (ARD -.21%, 95% CI -.23 to -.18) but a higher risk of ischaemic stroke (ARD .05%, 95% CI .03-.08). There was no association with the falsification endpoint of gastrointestinal or genitourinary bleeding (ARD .00%, 95% CI -.03-.03). CONCLUSIONS:Over the past decade, use of radial access site for PCI has increased 2.8-fold in the USA and now represents the dominant form of access site across all procedural indications. Based on instrumental variable analyses, PCI with radial access site had lower rates of in-hospital mortality, major access site bleeding, and other major vascular complications compared with femoral access site but a slightly higher risk of ischaemic stroke in contemporary practice.

Despite providing relatively modest circulatory support, the intra-aortic balloon pump (IABP) remains the most utilized mechanical support device. IABP therapy specifically provides utility in transferring critically ill patients from resource-limited hospital settings. In a single-center series, 71 patients who received IABP were identified from 2018 to 2023. In this group, 66 (93%) patients presented with acute myocardial infarction (AMI), of which 40 (61%) patients presented with STEMI. Sixty-three (89%) patients presented in cardiogenic shock. In total, 15 (21%) patients died during their hospital stay. In-hospital death was found to be associated with higher age (p < 0.001), female sex (p = 0.004), and chronic heart failure (p = 0.009). Serologic markers of end-organ perfusion, such as lactate, creatinine, and hepatic enzymes, were associated with increased mortality risk. Thirty (41%) patients were successfully transferred to a hub institution for care escalation, including 17 (57%) patients receiving cardiac surgery, five (17%) receiving advanced PCI, and 12 (40%) receiving more robust mechanical support. Therefore, in the real-world setting, IABP therapy provides an accessible form of circulatory support at resource-limited institutions, especially when patient transfer is required within a larger hospital system.

Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is a complex, high-radiation procedure that requires careful radiation management to protect both patients and health care providers. This review outlines the biological risks of radiation exposure, differentiating deterministic and stochastic effects, and highlights key safety thresholds and regulatory guidelines. It presents a range of mitigation strategies across procedural phases, including advanced shielding systems, low-dose imaging platforms, and real-time monitoring tools. Institutional protocols and a culture of shared accountability are emphasized to support the ALARA principle. Emerging technologies offer promising solutions to reduce operator exposure and improve safety outcomes in modern CTO-PCI practice.

BACKGROUND:The volume of percutaneous coronary intervention (PCI) at ambulatory surgical centers (ASC) is expected to increase. METHODS:We surveyed US interventional cardiologists with a 58-question, anonymous online survey to evaluate their knowledge of and perspectives on ASC PCI. RESULTS:A total of 114 interventional cardiologists (9 fellows) responded. Participants were most commonly between 45 and 54 years old (33%). Most participants identified as male (95%), white (58%), non-Hispanic (95%), and with an academic affiliation (61%); 13 participants (11%) were PCI operators at an ASC. Most participants (59%) were in support of ASC PCI, 63% were very confident in their ability to decide if a patient is well-suited for ASC PCI, and 43% were not familiar with national and state-level laws/regulations of ASC PCI. Perceived benefits of ASC PCI included positive patient experience (69%), greater efficiency (79%), and lower costs for patients (50%) and institutions (53%). Participants reported a high level of concern about private equity involvement in ASC PCI (58%), occurrence of adverse events away from the hospital (47%), lower quality of care (39%), inappropriate patient selection (40%), inadequate regulatory standards (35%), and institutional pressures (47%). Supporters of ASC PCI reported a better self-assessed knowledge of it and perceived more benefits with fewer concerns. CONCLUSIONS:Most survey participants expressed support for ASC PCI, citing benefits such as improved patient experience, greater efficiency, and reduced costs. However, participants expressed concern for private equity involvement and the risk of adverse events occurring away from the hospital setting.

BACKGROUND/UNASSIGNED:Stenting of bifurcation and non-aorto-ostial coronary lesions presents significant challenges due to geographic miss and restenosis. Drug-coated balloons (DCBs) offer an attractive alternative to drug-eluting stents in the treatment of these lesions. METHODS/UNASSIGNED:We conducted a systematic review of studies published from 2001 to 2024 comparing DCBs with plain old balloon angioplasty and/or drug-eluting stents (DES) in de novo coronary bifurcation lesions and non-aorto-ostial (NAO) lesions. A meta-analysis was performed with target lesion failure (TLF) as the selected outcome, defined as a composite of target lesion revascularization, target vessel myocardial infarction, or cardiovascular death. RESULTS/UNASSIGNED:= .0015), respectively. CONCLUSIONS/UNASSIGNED:In our meta-analysis, DCBs were associated with a lower rate of TLF compared with plain old balloon angioplasty and DES. These findings suggest that DCBs could be preferred for the treatment of bifurcation and NAO lesions.

BACKGROUND:Increased vessel tortuosity may hinder the success of transradial procedures. Longer thin-walled, hydrophilic sheaths ≥ 75 cm can be placed into the ascending aorta and have the potential to avoid femoral access crossover. METHODS:We studied consecutive cases of patients undergoing left heart catheterization (LHC) where a 75 cm long thin-walled, hydrophilic sheath was used from 1/1/22 to 9/30/24. Patient and procedural characteristics were collected. Procedural data included indication, contrast load, radiation dose, procedural time, procedural complications, and the need to convert to femoral access. RESULTS:Our study sample included 71 patients (mean age 69, 45% male). Comorbidities included hypertension (82%), hyperlipidemia (76%), and congestive heart failure (30%). Previous coronary artery disease was present in 31% of patients, and 20% of patients had undergone previous percutaneous coronary intervention (PCI). Indications for LHC included symptoms of stable ischemic heart disease (21%), abnormal non-invasive ischemic testing (52%), acute coronary syndrome (18%), and pre-operative evaluation for surgery (8%). The reason to switch to the long thin-walled, hydrophilic sheath was inability to engage the coronaries due to subclavian/brachiocephalic artery tortuosity (86%) or radial artery spasm (14%). After switching to the long thin-walled, hydrophilic sheath, 62/71 (87%) cases successfully engaged the coronaries without converting to femoral access. The mean procedure time was 36 min for diagnostic LHC cases (n = 46) and 72 min for PCI cases (n = 25). No procedural complications occurred. CONCLUSION/CONCLUSIONS:This case series suggests that use of the long thin-walled, hydrophilic radial sheaths can avoid femoral access crossover in selected cases.

Therapeutic anticoagulation is essential to prevent and treat venous and arterial thromboembolism. The available agents target coagulation factors involved in thrombus formation but are associated with an increased risk of bleeding. Factor XI plays a minor role in haemostasis but contributes substantially to thrombus expansion, making it an attractive target to mitigate bleeding while maintaining antithrombotic efficacy. Various novel inhibitors, including antisense oligonucleotides, monoclonal antibodies and small molecules, have been developed. Phase II trials in orthopaedic surgery showed dose-dependent reductions in venous thromboembolism without significantly increasing bleeding compared with enoxaparin. In the first phase III trial of a small-molecule inhibitor of activated factor XI in patients with atrial fibrillation, asundexian was associated with a reduction in bleeding but also a higher risk of stroke, compared with apixaban. Factor XI inhibitors appear safe and hold promise for secondary prevention in myocardial infarction and ischaemic stroke, with ongoing phase III trials assessing their broader efficacy and safety. This Review discusses the rationale, pharmacology, evidence and future directions of factor XI inhibitors across various clinical settings.

BACKGROUND:Cardiogenic shock (CS) is a common complication of acute coronary syndrome (ACS) and is associated with significant morbidity and mortality. Revascularization has been shown to reduce mortality in ACS-CS. Patients with cancer are at high risk of ACS and CS. However, patients with cancer are often undertreated with invasive procedures and outcomes of patients with cancer and ACS-CS have not been thoroughly characterized. METHODS:Patients with ACS-CS from 2014 to 2020 with and without cancer were identified using the National Readmission Database (NRD). Primary outcome was death at 90-days. Secondary outcomes were 90-day cardiovascular (CV) and bleeding readmissions, and index hospitalization major bleeding and thrombotic complications. Patients with cancer were compared to patients without cancer using multivariable logistic and Cox proportional hazards regression. Temporal trends in revascularization among patients with and without cancer were examined. Effect of revascularization among patients with cancer and ACS-CS was assessed using propensity score weighting (PSW). RESULTS:A total of 140,205 patients were identified, of whom 6118 (4.4 %) with cancer were identified. Patients with cancer were less likely to undergo percutaneous coronary intervention (45.5 % vs 53.5 %) or be managed with mechanical circulatory support (36.6 % vs 46.0 %). After multivariable logistic regression, there was no difference in primary outcome (adjusted OR 0.98, 95 % CI 0.92-1.06) but patients with cancer had higher risk of 90-day CV (HR 1.11, 95 % CI 1.01-1.22) and bleeding readmissions (HR 1.39, 95 % CI 1.10-1.76). Among patients with cancer and ACS-CS, revascularization was associated with lower primary outcome (OR 0.54, 95 % CI 0.50-0.58) and 90-day CV readmission (HR 0.68, 95 % CI 0.59-0.77) after PSW. CONCLUSIONS:Among patients with ACS-CS, patients with cancer have similar 90-day death but higher risk of 90-day CV and bleeding readmissions. Additionally, revascularization was associated with improved outcomes among patients with cancer and ACS-CS. Further studies are needed to optimize patient selection for invasive management among patients with cancer.