Faculty Bibliography

Background: Exposure to low-dose ionizing radiation is associated with malignancies. Lead garment specifications in the cardiac catheterization laboratory are not currently regulated, potentially resulting in unprotected areas.
Method(s): Interventional cardiology attendings and fellows wore 7 dosimeters, one externally on the thyroid shield and six inside the lead apron: bilateral axilla, chest wall, and pelvis. Radiation protection included a lower table-mounted lead drape, upper ceiling-mounted lead shield, and use of 7.5 frames per second during fluoroscopy. All procedures were performed with operators standing to the right of the patient. The primary endpoint was operator radiation exposure to the left versus right axilla. Radiation exposures in millirem (mrem) per participant over the study period are shown as median [interquartile range] and compared between left- and right-sided measures using paired Wilcoxon tests.
Result(s): Nine participants (66% female) wore dosimeters during 231 cases. Transradial coronary angiography was selected in 81.1% of cases and PCI was performed in 32.1%. A sterile radiation drape placed on the patient abdomen was used in 18.6% of cases. Median dose area product and fluoroscopy time for the participants ranged from 29.0-60.5 Gy cm² and 6.2-13.5 minutes, respectively. Radiation exposure at the left axilla was higher than the right axilla (5 vs. 0.9 mrem, p=0.018) but did not differ between left or right chest wall and left or right pelvis (Figure).
Conclusion(s): This analysis demonstrates insufficient protection in the left axillary area. The use of additional left axillary protection should be evaluated. (Figure Presented)

PURPOSE: Heart transplantation from Hepatitis C (HCV) viremic donors is becoming increasingly used due to advent of direct acting antiviral drugs with almost 100% cure. There are limited data about its impact on cardiac allograft vasculopathy (CAV). We report the incidence of CAV in heart transplant recipients from HCV viremic donors (nucleic amplification test positive; NAT+) compared to non-HCV infected donors (NAT-).
METHOD(S): We retrospectively reviewed coronary angiograms with intravascular ultrasound (IVUS) of heart transplant recipients at our institution from January 5, 2018 to September 17, 2019. The presence of CAV was graded according to ISHLT guidelines. IVUS was performed as per our lab protocol on the left main and left anterior descending arteries. Maximal intimal thickness (MIT) was measured with advanced quantification software as per protocol. MIT >= 5mm was considered significant for future adverse outcomes.
RESULT(S): LHC and IVUS was performed on 24 heart transplant recipients (mean age 56; 70% male) at 1- year post transplant. Eleven of these patients were transplanted from NAT+ donors. Thirteen patients received a NAT- donor heart. Two recipients (18.7%) of NAT+ donors had CAV grade >= 1 compared to 2 (16.7%) from NAT- donors (p=1). MIT >= 5mm was seen in 88.9% of NAT+ vs 50% of NAT- recipients (p=0.14) (Figure). The mean MIT was 76mm and 65mm for NAT+ and NAT- group, respectively. Both NAT+ and NAT- donor recipients exhibit mostly eccentric (84.2%) and few (15.7%) demonstrated concentric plaques. There was no heterogeneity in the data after adjusting for risk factors for CAD and donor LHC.
CONCLUSION(S): Our data show no difference in the presence of (CAV >= grade 1) or subclinical atherosclerosis at 1 year among NAT+ donor recipients. HCV viremia is a known risk factor for accelerated atherosclerosis and the consequence of prolonged donor viremia on the recipient is not known. A larger cohort and further longitudinal follow-up is needed to assess the validity of this trend and its prognostic implications.
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BACKGROUND:Intravascular imaging with intravascular ultrasound (IVUS) and optical coherence tomography (OCT) is an important adjunct to invasive coronary angiography. OBJECTIVES/OBJECTIVE:The primary objective was to examine the frequency of intravascular coronary imaging, trends in imaging use, and outcomes of patients undergoing angiography and/or percutaneous coronary intervention (PCI) in the United States. METHODS:Adult patients ≥18 years of age undergoing in-hospital cardiac catheterization from January 2004 to December 2014 were identified from the National Inpatient Sample (NIS). International Classification of Diseases, Ninth Revision (ICD-9) diagnosis and procedure codes were used to identify IVUS and OCT use during diagnostic angiography and PCI. RESULTS:Among 3,211,872 hospitalizations with coronary angiography, intracoronary imaging was performed in 88,775 cases (4.8% of PCI and 1.0% of diagnostic procedures), with IVUS in 98.9% and OCT in 1.1% of cases. Among patients undergoing PCI, the rate of intravascular coronary imaging increased from 2.1% in 2004-2005 to 6.6% in 2013-2014 (P < 0.001 for trend). Use of intravascular coronary imaging was associated with lower in-hospital mortality in patients undergoing PCI (adjusted OR 0.77; 95% CI 0.71-0.83). There was marked variability in intravascular imaging by hospital, with 63% and 13% of facilities using intravascular imaging in <5% and >15% of PCIs, respectively. CONCLUSIONS:In a large administrative database from the United States, intravascular imaging use was low, increased over time, and imaging was associated with reduced in-hospital mortality. Substantial variation in the frequency of intravascular imaging by hospital was observed. Additional investigation to determine clinical benefits of IVUS and OCT are warranted.

PURPOSE OF REVIEW: Patients with type 2 diabetes mellitus (T2DM) are at an increased risk of systemic atherosclerosis and advanced coronary artery disease (CAD). Herein, we review clinical trials comparing surgical to percutaneous revascularization in the context of the unique pathophysiology in this patient population, and seek to answer the question of optimal strategy of revascularization. RECENT FINDINGS: Early studies showed a signal towards benefit of surgical revascularization over percutaneous revascularization in this group, but there was a paucity of randomized clinical trials (RCT) to directly support this finding. The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM), a large-scale international RCT, was then undertaken and established the benefit of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in terms of mortality, myocardial infarction and repeat revascularization; CABG was inferior to PCI with regards to stroke. The quality of life and cost effectiveness also demonstrated a long-term benefit for surgery. The decision as to choice of mode of revascularization in patients with T2DM and advanced CAD depends upon a multitude of factors, including the coronary anatomy, co-morbidities and the patient's surgical risk. These factors influence the recommendation of the cardiovascular team, which should result in a balanced presentation of the short and long-term risks and benefits of either mode of revascularization to the patient and his/her family.

A 48-year-old man with hypertension presented with heart failure and reduced left ventricular systolic function. Coronary angiography revealed a non-dominant right coronary artery and a long anomalous branch of the proximal left anterior descending coronary artery that coursed inferiorly to give rise to the posterior descending artery. No epicardial coronary artery disease was visualized. The highly unusual anomalous branch was considered to be an incidental finding, with no pathological contribution to the clinical presentation.

The pathophysiology of diabetes and systemic insulin resistance contributes to the nature of diffuse atherosclerosis and a high prevalence of multivessel coronary artery disease (CAD) in diabetic patients. The optimal approach to this patient population remains a subject of an ongoing discussion. In this review, we give an overview of the unique pathophysiology of CAD in patients with diabetes, summarize the current state of therapies available, and compare modalities of revascularization that have been investigated in recent clinical trials. We conclude by highlighting the importance of a comprehensive heart team approach to every patient while accommodating both patient preference and quality-of-life decisions.

BACKGROUND: Atherosclerosis is a systemic vascular disorder, involving multiple arterial territories. This project sought to investigate the relationship between lower extremity peripheral artery disease (PAD) and carotid artery stenosis (CAS) in a large self-referred population. METHODS: Data from the ankle brachial index (ABI) and carotid duplex ultrasound were analyzed from 3.67 million US subjects in the Life Line Screening program between 2004 and 2008. PAD was defined by ABI<0.9 and CAS was defined by greater than 50% stenosis. Multivariate logistic regression analysis was used to estimate odds of CAS by PAD status and severity. RESULTS: Mean age of the population was 63.7 +/- 10.6 years and 64% were women. The prevalence of PAD and CAS was 4.1% and 3.9%, respectively. Subjects with PAD had a higher prevalence of CAS than those without PAD (18.8% vs. 3.3%, P < 0.0001). In multivariate analysis, PAD was associated with greater odds of CAS (OR 3.28, 95% CI 3.22-3.34). Both symptomatic (OR 3.66, 95% CI 3.58-3.75) and asymptomatic PAD (OR 2.91, 95% CI 2.84-2.98) was associated with CAS. Increasing severity of PAD was associated with greater odds of CAS (OR 2.32, 3.61, 4.19, 5.14, and 7.59 for ABI categories 0.81-0.90, 0.71-0.80, 0.61-0.70, 0.41-0.60,