Faculty Bibliography

BACKGROUND:Cognitive decline after coronary artery bypass graft (CABG) is common and affects morbidity, mortality, and quality of life. We systematically reviewed randomized CABG trial control arms to characterize cognitive assessments, testing frequency, attrition, and ability to detect perioperative change. METHODS:We searched MEDLINE, Embase, Cochrane Library, and PsycINFO for randomized controlled trials of CABG surgery that included at least one arm of patients solely undergoing CABG and that reported at least one objective cognitive assessment, from January 2005 to February 2025. Trials with mixed cardiac surgery or only subjective measures were excluded. We summarized task frequency, cognitive domains, and attrition. For tasks assessed preoperatively and postoperatively in ≥3 trials, we reported control group means and SDs. Risk of bias was assessed using the Cochrane Risk of Bias tool among 6 bias domains. This study was supported by NIH-R01NS123639. RESULTS:Of 3494 screened studies, 2284 were CABG trials, and only 71 (3.1%) reported cognitive evaluation. These involved 15 925 patients (79% men; mean age, 64.2 years; median follow-up, 90 days) and used 145 unique cognitive tasks, with the Trail Making Test Part B (40 of 71; 56.3%) and Part A (38 of 71; 53.5%) being the most frequently administered. Among 7 tasks with sufficient data, none detected preoperative to postoperative changes. Attrition rates averaged 18.9%, with a broad range of 0 to 62%. CONCLUSIONS:Cognitive assessment is uncommon in CABG trials, and commonly used tests rarely detect change. Heterogeneity precluded meta-analysis, and high attrition raises concerns about selection and survivorship bias. To evaluate cognitive impact after CABG, trials need standardized, sensitive assessment strategies resilient to attrition and feasible for broad deployment.

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/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.

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.