Faculty Bibliography

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.

BACKGROUND:In patients with diabetes and multivessel coronary artery disease, percutaneous coronary intervention (PCI) has been associated with higher long-term cardiovascular mortality compared to coronary artery bypass grafting (CABG), but the specific causes of death are not well known. We aimed to determine the causes of death among patients with diabetes and multivessel disease undergoing coronary revascularization with PCI versus CABG. METHODS:We analyzed the centrally adjudicated causes of death of 1,900 participants in the FREEDOM trial. Cause-specific hazard ratios (csHR) were used to compare mortality rates. RESULTS:There were 197 deaths during the five years of follow-up, 63.5% were classified as cardiovascular deaths and the remaining (36.5%), non-cardiovascular deaths. Sudden cardiac death was the most common cause of cardiovascular mortality (40% of all cardiovascular deaths), followed by myocardial infarction deaths (16% of all cardiovascular deaths). Compared to CABG, PCI was associated with increased ischemic-related mortality, namely sudden cardiac death (csHR: 2.04;95%CI: 1.13 to 3.70; p=0.02) and the composite of sudden cardiac death and myocardial infarction death (csHR: 2.10, 95%CI: 1.27 to 3.48, p=0.004). PCI was associated with a non-significant increase in overall cardiovascular mortality compared to CABG (csHR: 1.35;95%CI: 0.95 to 1.93; p=0.09). CONCLUSIONS:Sudden cardiac death was the most common cause of long-term mortality among patients with diabetes and multivessel coronary artery disease undergoing a revascularization procedure. Compared to CABG, PCI was associated with increased long-term rates of ischemic-related mortality. Operative techniques and secondary prevention should target reducing post-revascularization spontaneous myocardial infarction in patients treated with PCI.

OBJECTIVE:Hybrid coronary revascularization is a clinical strategy that uses a combination of surgical revascularization and percutaneous coronary intervention (PCI). Data on the hybrid approach for coronary artery disease involving the left main (LM) are scarce. We analyzed our cohort of hybrid coronary revascularizations with minimally invasive direct coronary artery bypass (MIDCAB) using robotic left internal mammary artery harvesting and PCI for multivessel disease with and without LM involvement. METHODS:= 40, 64.5%). RESULTS:= 0.699). CONCLUSIONS:Hybrid robotic MIDCAB for patients with and without LM disease can be performed with acceptable results in selected patients. However, it is not possible to draw definitive conclusions regarding safety and efficacy compared with conventional coronary artery bypass grafting.

BACKGROUND/UNASSIGNED:Myocardial injury detected after percutaneous coronary intervention (PCI) is associated with increased mortality. Predictors of post-PCI myocardial injury are not well established. The long-term prognostic relevance of post-PCI myocardial injury remains uncertain. METHODS/UNASSIGNED:Consecutive adults aged ≥18 years with stable ischemic heart disease who underwent elective PCI at NYU Langone Health between 2011 and 2020 were included in a retrospective, observational study. Patients with acute myocardial infarction or creatinine kinase myocardial band (CKMB) or troponin concentrations >99% of the upper reference limit before PCI were excluded. All patients had routine measurement of CKMB concentrations at 1 and 3 hours post-PCI. Post-PCI myocardial injury was defined as a peak CKMB concentration >99% upper reference limit. Linear regression models were used to identify clinical factors associated with post-PCI myocardial injury. Cox proportional hazard models were generated to evaluate relationships between post-PCI myocardial injury and all-cause mortality at long-term follow-up. RESULTS/UNASSIGNED:<0.001). After adjustment for demographics and clinical covariates, post-PCI myocardial injury was associated with an excess hazard for long-term mortality (hazard ratio, 1.46 [95% CI, 1.20-1.78]). CONCLUSIONS/UNASSIGNED:Myocardial injury defined by elevated CKMB early after PCI is common and associated with all-cause, long-term mortality. More complex coronary anatomy is predictive of post-PCI myocardial injury.

Hypertrophic cardiomyopathy is a common but underrecognized cardiac disorder characterized by a heterogenous phenotype that includes increased left ventricular thickness, outflow obstruction, diastolic dysfunction, and arrhythmia. Hypertrophic cardiomyopathy is often heritable and associated with pathogenic variants in sarcomeric genes. While not curable, an integrated approach involving medical, interventional, and surgical care can have a considerable impact on disease burden, quality of life, and mortality. This review provides a practical overview of important topics in hypertrophic cardiomyopathy, including evaluation of differential diagnosis, imaging, provocation of left ventricular outflow obstruction, treatment of obstructive and nonobstructive hypertrophic cardiomyopathy with negative inotropic therapy and myosin inhibition, as well as surgical and interventional approaches to septal reduction and mitral valve intervention.

Ventricular arrhythmias (VA) are a major cause of morbidity and mortality in patients with coronary artery disease (CAD). Current guidelines recommend revascularization of significant CAD to improve survival in patients with ventricular fibrillation (VF), polymorphic ventricular tachycardia (VT), or those who are post-cardiac arrest. However, revascularization is not recommended for CAD patients with suspected scar-mediated monomorphic VT. There is a paucity of data detailing the utility of revascularization in reducing VA in CAD patients who do not present with acute coronary syndrome (ACS) and are not immediately post-cardiac arrest, which is the focus of this review. Medline, Scopus, and the Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies addressing this question. Studies that included patients presenting with ACS or those who were immediately post-cardiac arrest at the time of revascularization were excluded. In total, five studies comprising 2663 patients were reviewed.

The field of interventional cardiology (IC) has evolved dramatically over the past 40 years. Training and certification in IC have kept pace, with the development of accredited IC fellowship training programs, training statements, and subspecialty board certification. The application process, however, remained fragmented with lack of a universal process or time frame. In recent years, growing competition among training programs for the strongest candidates resulted in time-limited offers and high-pressure situations that disadvantaged candidates. A grassroots effort was recently undertaken by a Society for Cardiovascular Angiography & Interventions task force, to create equity in the system by establishing a national Match for IC fellowship. This manuscript explores the rationale, process, and implications of this endeavor.