January 2021 Table of Contents

Chronic Total Occlusion

Clinical Impact of Medical Therapy Versus Revascularization in Patients With Chronic Coronary Total Occlusions 

Luis Álvarez-Contreras, MD^*;  Eduardo Flores-Umanzor, MD^*;  Pedro Cepas-Guillen, MD;  Ignacio Ferreira-González, MD, PhD;  Xavier Freixa, MD, PhD;  Ander Regueiro, MD, PhD;  Salvatore Brugaletta, MD, PhD;  Manel Sabaté, MD, PhD;  Victoria Martín-Yuste, MD, PhD         ^*Joint first authors

Chronic total occlusions (CTOs) are prevalent angiographic findings in patients with suspected coronary artery disease. Conflicting results of randomized controlled trials and registries have not clarified the therapeutic approach for patients with CTO in clinical practice. Therefore, we sought to analyze variables influencing the decision-making process and their relationship with clinical outcomes according to the type of selected therapy by identifying a total of 1248 consecutive patients with at least 1 CTO between 2010 and 2014 at our institution. Clinical and angiographic variables were collected to allow the calculation of several predictive scores. 

J INVASIVE CARDIOL 2021;33(1):E2-E8. 

COVID-19 in the Cath Lab

Logistical, Financial, and Psychological Impact of the COVID-19 Pandemic on Cardiac Catheterization Lab Nurses and Technologists: A U.S. National Survey 

Bailey Ann Estes, BSN;  Joji J. Varghese, MD;  Jared Jacques, BS;
Srihari S. Naidu, MD

Coronavirus 2019 (COVID-19) significantly impacted cardiac care delivery in a manner that has not been previously experienced in the United States. Attention and resources have focused on physicians, patients, and healthcare systems with little information regarding the effects on nurses and technologists in the cardiac catheterization laboratory (CCL). Therefore, a national, online survey was conducted for nurses and technologists working in the CCL in the United States. The survey was self administered, anonymous, and included 45 questions assessing baseline demographics, logistical changes to workflow and responsibilities, staff preparedness, and mental health. 

J INVASIVE CARDIOL 2021;33(1):E9-E15. Epub 2020 December 6.

Peripheral Vascular Disease

Predicting Significant Iliac Vein Compression Using a Probability Scoring System Derived From Minimal Luminal Area on Computed Tomography Angiography in Patients 65 Years of Age or Younger

Nicolas W. Shammas, MD, MS;  Sue Jones-Miller, MS;  Torin Kovach; Qais Radaideh, MD, MS;  Neel Patel, DO;  Gail A. Shammas, BS, RN; Andrew N. Shammas;  Srikanth R. Kasula, MD;  Rafat Padaria, MD; Istvan Z. Kovach;  W. John Shammas, MBA

The presence of 50% or more stenosis on intravascular ultrasound (IVUS) is considered diagnostic of iliac vein compression (ILVC) by most operators. We have previously developed a scoring system combining minimal luminal area (MLA) at the compression site and age to predict ILVC as seen on IVUS. We present a revised and improved scoring system following an additional number of patients and limited to patients 65 years of age and younger. Patients were included from retrospective (n = 52) and prospective (n = 18) registries of consecutive patients who underwent computed tomography angiography (CTA) of the pelvis with venous filling and IVUS within a few weeks apart to evaluate for symptomatic ILVC at a single cardiovascular practice. Quantitative vascular analysis was performed on all images obtained. 

J INVASIVE CARDIOL 2021;33(1):E16-E18. 

Coronary Artery Disease

Prognosis of Patients With Left Circumflex Artery Acute Myocardial Infarction in Relation to ST-Segment on Admission Electrocardiogram

Ofer Kobo, MD, MHA^*;  Erez Marcusohn, MD^*;  Ariel Roguin, MD, PhD;  Robert Zukermann, MD;  Naama Amsalem;  Eugenia Nikolsky, MD, PhD;  Simcha R. Meisel, MD              ^*Joint first authors

Total thrombotic occlusion of the left circumflex artery may present without ST-segment elevations; the clinical outcomes of such patients remain unclear. Our objective was to examine the difference in clinical outcomes between patients with acute myocardial infarction due to left circumflex occlusion or stenosis with and without ST-segment elevation. Our study is based on an observational, retrospective cohort comprising all patients admitted to 2 centers between 2009 and 2019 with myocardial infarction due to left circumflex disease. Clinical outcomes included recurrent percutaneous coronary intervention, hospitalization due to acute coronary syndrome, and mortality. 

J INVASIVE CARDIOL 2021;33(1):E20-E24.

Coronary Artery Disease

Intravascular Lithotripsy for the Treatment of Calcium-Mediated Coronary In-Stent Restenoses

Fabian J. Brunner, MD;  Peter Moritz Becher, MD;  Christoph
Waldeyer, MD;  Elvin Zengin-Sahm, MD;  Renate B. Schnabel, MD;  Peter Clemmensen, MD;  Dirk Westermann, MD;  Stefan
Blankenberg, MD;  Moritz Seiffert, MD

Coronary intravascular lithotripsy has recently been evaluated for the treatment of severely calcified native coronary lesions. Evidence for its use for in-stent restenosis is sparse and still an off-label indication. Therefore, we aimed to evaluate the feasibility, safety, and acute and mid-term angiographic outcomes after intravascular lithotripsy for the treatment of calcium-mediated coronary in-stent restenosis.  

J INVASIVE CARDIOL 2021;33(1):E25-E31.

Transcatheter Aortic Valve Replacement

Preventing or Minimizing Acute Kidney Injury in Patients Undergoing Transcatheter Aortic Valve Replacement

Anwar Tandar, MD;  Vikas Sharma, MD;  Mark Ibrahim, MD;  Tara Jones, MD;  David Morgan, MD;  Candice Montzingo, MD;
James Lee, MD;  Nathaniel Birgenheier, MD;  Natalie Silverton, MD;  Anu Abraham, MD;  Frederick G.P. Welt, MD;  Jason P. Glotzbach, MD

Transcatheter aortic valve implantation is now routinely performed in patients with aortic stenosis with low mortality and complication rates. Although periprocedural risks have been substantially minimized, procedure- and contrast-induced acute kidney injury (AKI) remains a major concern. AKI is a frequent complication of contrast-guided interventional procedures and is associated with a significantly adverse prognosis. We review the currently available clinical data related to AKI, with emphasis on contrast-induced nephropathy, and discuss a novel, integrated approach aiming to minimize AKI in high-risk patients. A stepwise algorithm is also proposed for the management of these complex patients. 

J INVASIVE CARDIOL 2021;33(1):E32-E39.

Stroke Prevention

Preserved Left Atrial Function Following Left Atrial Appendage Closure for Stroke Prevention

Obayda Azizy, MD;  Alexander Lind, MD;  Rolf Alexander Janosi, MD; Tienush Rassaf, MD;  Christos Rammos, MD

Patients with atrial fibrillation (AF) are at high risk of thromboembolism, with most thrombi forming in the left atrial (LA) appendage. LA appendage closure is an alternative therapy to oral anticoagulation for stroke prevention in AF patients with contraindication to oral anticoagulation. LA function is critical for cardiovascular function, and recent studies suggest a direct relationship between LA function and AF recurrence. Deformation imaging characterizes and quantifies myocardial function. This study investigates the impact of LA appendage closure on LA function in patients with paroxysmal AF. 

J INVASIVE CARDIOL 2021;33(1):E40-E44.

Plaque Composition and Dynamics

Impaired Myocardial Perfusion on Stress CMR Correlates With Invasive FFR in Children With Coronary Anomalies

Hitesh Agrawal, MD, MBA;  J. Chris Wilkinson, MD;  Cory V. Noel, MD;  Athar M. Qureshi, MD;  Prakash M. Masand, MD;  Carlos M. Mery, MD, MPH;  S. Kristen Sexson-Tejtel, MD, PhD;  Silvana Molossi, MD, PhD

Invasive fractional flow reserve (FFR) is considered the gold standard to evaluate coronary artery flow. Stress cardiovascular magnetic resonance (sCMR) is an emerging non-invasive tool to evaluate myocardial perfusion in children. We sought to compare sCMR with FFR to determine impaired intracoronary flow in children with anomalous aortic origin of a coronary artery (AAOCA) and/or myocardial bridge (MB) who presented concern for myocardial ischemia. From December 2012 to May 2019, AAOCA and/or MB patients (<20 years old) were prospectively enrolled and underwent sCMR and FFR. Assessment of myocardial perfusion using non-invasive sCMR concurred with FFR, particularly if performed with close proximity in time, and may contribute to risk stratification and decision making in children with AAOCA and/or MB.

J INVASIVE CARDIOL 2021;33(1):E45-E51. 

Chronic Total Occlusions

Complex Chronic Total Occlusion Revascularization — A Comparison of Biradial Versus Femoral Access

Mohammed N. Meah, MBChB, MRCP(UK);  Wern Yew Ding, MBChB, MRCP(UK);  Tobin Joseph, MBBS, BSc;  Jonathan Hasleton, MBChB, MRCP(UK), MD;  Matthew Shaw, MSc, PhD;  Nick D. Palmer, MD, MBBS, FRCP

Complex chronic total occlusion (CTO) cases often require dual access. Evidence suggests that radial access is associated with lower success rates in complex CTOs. Our primary outcome was to determine efficacy of biradial access compared with femoral access. This was a retrospective, single-center, observational study. Patients who underwent dual-access CTO percutaneous coronary intervention (PCI) between January 2014 and January 2018 were enrolled and separated into biradial and femoral access groups. Standard univariate analyses were performed to identify predictors for revascularization failure. With shorter length of stay, fewer complications, and less radiation used in radial cases, we suggest biradial access is an effective and safe alternative in CTO-PCI. Prospective studies are needed to determine superiority.

J INVASIVE CARDIOL 2021;33(1):E52-E58.

Coronary Artery Disease

Association Between Primary Coronary Slow-Flow Phenomenon and Epicardial Fat Tissue 

Maren Weferling, MD;  Julia Vietheer, MD;  Till Keller, MD;  Ulrich Fischer-Rasokat, MD;  Christian W. Hamm, MD;  Christoph Liebetrau, MD

Primary coronary slow-flow phenomenon (CSFP) is defined as delayed opacification of contrast media in at least 1 coronary vessel in the absence of obstructive epicardial coronary artery disease (CAD) during coronary angiography. Epicardial fat tissue (EFT) surrounding coronary vessels provides paracrine effects. Released cytokines diffusing in the vessel wall may induce local inflammatory reactions that potentially result in endothelial dysfunction. The latter is thought to be the underlying cause of primary CSFP. However, to date, there are no data describing an association between EFT and CSFP. Therefore, the aim of the present study was to compare EFT thickness, clinical parameters, and outcomes in patients with and without CSFP. Coronary angiograms with primary CSFP obtained during a 10-year period were included in the analysis. EFT was measured in the 2-dimensional echocardiographic records. Clinical and diagnostic data were compared with non-CSFP patients who were matched for age, sex, and body mass index. Long-term follow-up was conducted by telephone interview. EFT is thicker in CSFP patients than in matched controls, but this appears to have no impact on long-term outcomes. Further studies are needed to elucidate the role of EFT in CSFP.

J INVASIVE CARDIOL 2021;33(1):E59-E64.

Clinical Images

Complex Coronary Intervention Via Right Distal Transradial Access With Lusoria Subclavian Artery Under Refractory Electrical Storm: A Really Challenging Case

Marcos Danillo P. Oliveira, MD;  Ednelson Cunha Navarro, MD;  Glenda Alves de Sá, MD;  Giovanna Mezzalira Santos, MD;  Maria Eduarda Vieira Ribeiro Garcia, MD;  Rafael Alves Banzatti Viana, MD;  Adriano Caixeta, MD, PhD

The adoption of distal transradial access (TRA) as default approach for coronary angiography and interventions was recently published. As a refinement of conventional (proximal) TRA, this technique has advantages in terms of patient and operator comfort and risk of radial artery occlusion. We report herein a very challenging case of coronary angiography followed by complex percutaneous coronary intervention via right distal TRA, with aberrant (lusoria) subclavian artery, in the setting of non-ST segment elevation acute myocardial infarction complicated by refractory electrical storm.

J INVASIVE CARDIOL 2021;33(1):E65-E66.

Clinical Images

Shockwave Intravascular Lithotripsy of Undilatable STEMI Lesion in Primary PCI

Ioannis Tsiafoutis, MD;  Konstatina Katsanou, MD;  Michael Koutouzis, MD, PhD;  Apostolos Katsivas, MD, PhD

Percutaneous coronary intervention in STEMI patients may be complicated by the presence of calcium. The Shockwave IVL technique seems to be a safe and useful option, even in STEMI cases, to achieve procedural success. Nevertheless, extra support techniques may be needed in order to deliver the Shockwave balloon.

J INVASIVE CARDIOL 2021;33(1):E67-E68.

Clinical Images

Balloon Angioplasty of the Radial Artery to Solve a Challenging Radial Sheath Insertion

Giuseppe Talanas, MD;  Simona Guarino, MD;  Mario Enrico Canonico, MD;  Guido Parodi, MD, PhD

The inability to advance the dedicated wire of the transradial sheath in a radial artery with a good pulsatile blood flow is a very rare event. In this case, the advancement of a high-performance 0.014˝ coronary wire is the only option to gain the vessel. Then, if the transradial sheath is stuck in the proximal radial artery wall, balloon angioplasty of the radial artery may allow successful reinsertion of the transradial sheath. This technique allows the preservation of radial artery access, avoiding a shift to an alternative arterial approach. 

J INVASIVE CARDIOL 2021;33(1):E69.

Clinical Images

Coronary-Cameral Fistula to Pulmonary Artery: An Innocent Bystander?

Dinkar Bhasin, MD, DM;  Gaurav Kumar Arora, MD, DM;  Priya Giridhara, MD, DM;  Anunay Gupta, MD, DM;  H.S. Isser, MD, DM;  Sandeep Bansal, MD, DM

Coronary-cameral fistula (CCF) is a rare congenital communication between a coronary artery and a cardiac chamber or a great vessel. Most patients are asymptomatic and these lesions are incidentally detected during coronary angiography, with the reported incidence being up to 0.2%. The most frequent draining sites are right ventricle, right atrium, and pulmonary arteries, with less frequent drainage to the left side of the heart. The majority of CCFs are hemodynamically inconsequential and do not require treatment. However, when large, these lesions can cause myocardial ischemia by causing coronary steal or high-output heart failure, and should be treated. Treatment modalities include transcatheter closure with embolic agents (microcoil or gelfoam) and surgical ligation. Choice of therapy is governed by size of the CCF, tortuosity of the feeder channel, size of the communication to prevent embolization, and concomitant coronary artery disease.

J INVASIVE CARDIOL 2021;33(1):E70.