Faculty Bibliography

Background: In percutaneous coronary interventions (PCIs), radial (R) rather than femoral (F) access is recommended due to lower rates of bleeding and vascular complications. Although the safety and effectiveness of intravascular lithotripsy (IVL) for the treatment of coronary artery calcification have been shown, whether IVL procedural success or complication rates differ between R and F access sites is not known.
Method(s): Individual patient-level data were pooled from the Disrupt CAD III and CAD IV studies, which collected access site data and shared uniform study inclusion/exclusion criteria, endpoint definitions, and use of independent angiographic core laboratory and clinical event committee adjudication. Procedural success, defined as stent delivery with residual stenosis <=30% without in-hospital major adverse cardiovascular events (MACE), and vascular complications were compared based on R vs F access.
Result(s): The pooled population included 444 patients, with 281 (63.3%) cases performed using R access. Patient baseline comorbidities were similar between the 2 groups. All lesions in both groups were severely calcified by core lab assessment. Baseline diameter stenosis (R 66% +/- 11% vs F 64% +/- 11%; P = 0.14) and lesion length (R 27 +/- 12 mm vs F 26 +/- 11 mm; P = 0.62) were similar between the groups. Procedural success and rates of 30-day MACE were similar by access site (Table 1). [Formula presented]
Conclusion(s): The current pooled analysis represents the largest comparison of R vs F access with coronary IVL for target lesion preparation. In the Disrupt CAD III and CAD IV trials, the majority of patients enrolled had R access despite high lesion complexity and device profile. Successful IVL catheter delivery was achieved and procedural outcomes for treatment of coronary artery calcification were similar regardless of access site. Categories: CORONARY: Coronary Atherectomy, Plaque Modification, Lithotripsy, and Thrombectomy
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OBJECTIVES/OBJECTIVE:To assess whether contrast media type is associated with outcomes in veterans undergoing percutaneous coronary intervention (PCI). BACKGROUND:There is uncertainty about the impact of iso-osmolar contrast medium (IOCM) versus low-osmolar contrast medium (LOCM) on acute kidney injury (AKI) and other major adverse renal or cardiovascular events (MARCE) after PCI. We assessed the association between contrast media type and MARCE in patients who underwent PCI within the Veterans Administration Healthcare System. METHODS:We reviewed PCIs performed between 2009 and 2019 using data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. The primary endpoint was MARCE, a composite of myocardial infarction, stroke, all-cause death, AKI, and dialysis onset at 30 days. RESULTS:The analysis cohort consisted of 50,389 patients of whom 25,555 received LOCM and 24,834 received IOCM. There was significant variation in contrast type across sites. After adjustment for comorbidities, no significant association between contrast media type and MARCE was observed in both site-unadjusted (odds ratio [OR] for IOCM: 0.99; 95% confidence interval [CI]: 0.92-1.08; p = 0.97) and site-adjusted (OR: 1.06; 95% CI: 0.95-1.18; p = 0.30) analyses. Similar results were obtained when contrast volume was imputed or the data was subset to individuals with available contrast volume. CONCLUSION/CONCLUSIONS:In a large cohort of veterans undergoing PCI, we found considerable site variation in the type of contrast media used but no significant association between contrast media type and the incidence of MARCE, both before and after adjustment for the site.

BACKGROUND:Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox. METHODS:In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test. RESULTS:=0.20). Femoral access patients had a higher predicted risk for bleeding. CONCLUSIONS:A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.

BACKGROUND:Mechanical circulatory support (MCS) devices can be used in high-risk percutaneous coronary intervention (PCI). Our objective was to describe trends and outcomes of prophylactic MCS use in elective PCI for patients with stable coronary artery disease in the American College of Cardiology National Cardiovascular Data Registry's CathPCI registry. METHODS:Among 2 108 715 consecutive patients with stable coronary artery disease undergoing elective PCI in the CathPCI registry between 2009 and 2018, we examined patterns of prophylactic use of MCS. Propensity score models with inverse probability of treatment weighting compared effectiveness (in-hospital death, cardiogenic shock, or new heart failure) and safety (stroke, tamponade, major bleeding, or vascular complication requiring treatment) between patients treated with intra-aortic balloon pump versus other MCS (Impella or extracorporeal membrane oxygenation). RESULTS:=0.12). In-hospital major adverse cardiac events and cardiovascular complications occurred in 7.1% and 18.8% of elective PCI patients with prophylactic MCS use and 0.5% and 2.3% of patients without prophylactic MCS use. Intra-aortic balloon pump use was associated with a higher risk of major adverse cardiac events (9.6% versus 6.0%, adjusted odds ratio, 1.59 [95% CI, 1.32-1.91]) but lower risk of complications (18.2% versus 19.1%, adjusted odds ratio, 0.88 [95% CI, 0.77-0.99]) than use of other MCS. CONCLUSIONS:The use of prophylactic MCS has increased over time for elective PCI in patients with stable coronary artery disease. Intra-aortic balloon pump was associated with higher major adverse cardiac events but lower risk of procedural complications compared with other MCS.

BACKGROUND:Optimal dual antiplatelet therapy (DAPT) duration in patients at high bleeding risk (HBR) is not fully defined. We aimed to compare the safety and effectiveness of short-term DAPT (S-DAPT) with longer duration DAPT (L-DAPT) after percutaneous coronary intervention (PCI) with drug eluting stents (DES) in patients at HBR. METHODS:We searched for studies comparing S-DAPT (≤3 months) followed by aspirin or P2Y 12 inhibitor monotherapy against L-DAPT (6-12 months) after PCI in HBR patients. Primary end-points of interest were major bleeding and myocardial infarction (MI). Random-effects meta-analyses were performed to calculate odds ratios with 95% CIs. RESULTS:Six randomized trials and three propensity-matched studies (n= 16,848) were included in the primary analysis. Compared with L-DAPT (n=8,422), major bleeding was lower with S-DAPT (n=8,426) [OR 0.68; 95% CI 0.51-0.89] whereas MI did not differ significantly between the two groups [1.16; 0.94-1.44]. There were no significant differences in risks of death, stroke or stent thrombosis (ST) between S-DAPT and L-DAPT groups. These findings were consistent when propensity-matched studies were analysed separately. Finally, there was a numerically higher, albeit statistically non-significant, ST in the S-DAPT arm of patients without an indication for OAC [1.98; 0.86-4.58]. CONCLUSION/CONCLUSIONS:Among HBR patients undergoing current generation DES implantation, S-DAPT reduces bleeding without an increased risk of death or MI compared with L-DAPT.

Purpose: In the U.S., heart transplantation from donation after circulatory death (DCD) is increasing. We present our institutional experience of DCD transplantation by using a thoracoabdominal-normothermic regional perfusion (TA-NRP) protocol and compare the results to a cohort concomitantly transplanted, from standard brain death (