Cardiology

Tajti, P., K. Alaswad, D. Karmpaliotis, F. A. Jaffer, R. W. Yeh, M. Patel, E. Mahmud, J. W. Choi, M. N. Burke, A. H. Doing, P. Dattilo, C. Toma, A. J. C. Smith, B. F. Uretsky, E. Holper, S. Potluri, R. M. Wyman, D. E. Kandzari, S. Garcia, O. Krestyaninov, D. Khelimskii, M. Koutouzis, I. Tsiafoutis, J. J. Khatri, W. Jaber, H. Samady, B. Jefferson, T. Patel, S. Abdullah, J. W. Moses, N. J. Lembo, M. Parikh, A. J. Kirtane, Z. A. Ali, D. Doshi, I. Xenogiannis, L. I. Stanberry, B. V. Rangan, I. Ungi, S. Banerjee and E. S. Brilakis (2019). “Procedural Outcomes of Percutaneous Coronary Interventions for Chronic Total Occlusions Via the Radial Approach: Insights From an International Chronic Total Occlusion Registry.” JACC Cardiovasc Interv 12(4): 346-358.

Full text of this article.

OBJECTIVES: This study examined the frequency and outcomes of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: Radial access improves the safety of PCI, but its role in CTO PCI remains controversial. METHODS: We compared the clinical, angiographic, and procedural characteristics of 3,790 CTO interventions performed between 2012 and 2018 via radial-only access (RA) (n = 747) radial-femoral access (RFA) (n = 844) and femoral-only access (n = 2,199) access at 23 centers in the United States, Europe, and Russia. RESULTS: Patients’ mean age was 65 +/- 10 years, and 85% were men. Transradial access (RA and RFA) was used in 42% of CTO interventions and significantly increased over time from 11% in 2012 to 67% in 2018 (p < 0.001). RA patients were younger (age 62 +/- 10 years vs. 64 +/- 10 years and 65 +/- 10 years; p < 0.001), less likely to have undergone prior coronary artery bypass graft surgery (18% vs. 39% and 35%; p < 0.001), and less likely to have undergone prior PCI (60% vs. 63% and 66%; p = 0.005) compared with those who underwent RFA and femoral-only access PCI. RA CTO PCI lesions had lower J-CTO (Multicenter CTO Registry in Japan) (2.1 +/- 1.4 vs. 2.6 +/- 1.3 and 2.5 +/- 1.3; p < 0.001) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) complication (2.3 +/- 1.9 vs. 3.2 +/- 2.0 and 3.2 +/- 1.9; p < 0.001) scores. The mean sheath size was significantly smaller in the RA group (6.6 +/- 0.7 vs. 7.0 +/- 0.6 and 7.3 +/- 0.8; p < 0.0001), although it increased with lesion complexity. Antegrade dissection re-entry (20% vs. 33% and 32%; p < 0.001) was less commonly used with RA, whereas use of retrograde techniques was highest with RFA (47%). The overall rates of technical success (89% vs. 88% vs. 86%; p = 0.061), procedural success (86% vs. 85% vs. 85%; p = 0.528), and in-hospital major complication (2.47% vs. 3.40% vs. 2.18%; p = 0.830) were similar in all 3 groups, whereas major bleeding was lower in the RA group (0.55% vs. 1.94% and 0.88%; p = 0.013). CONCLUSIONS: Transradial access is increasingly being used for CTO PCI and is associated with similar technical and procedural success and lower major bleeding rates compared with femoral-only access interventions. (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO]; NCT02061436).

Roberts, W. C. (2019). “Hazards of Mitral Valve Replacement for Mitral Stenosis Caused by Massive Mitral Annular Calcium With or Without Aortic Valve Replacement for Aortic Stenosis.” Am J Cardiol 123(4): 650-657.

Full text of this article.

Mitral annular calcium (MAC) is common in older adults in the Western World and if extensive may cause mitral stenosis. The purpose of this report is to describe outcomes of 12 patients having mitral valve replacement for mitral stenosis secondary to massive MAC. Operatively excised deposits of calcium removed from the mitral annular area and the accompanying stenotic mitral valves were examined and then the patients’ medical records were examined to confirm the diagnosis and the degree of valvular dysfunction. A total of 12 patients with massive MAC causing mitral stenosis and receiving mitral valve replacement with or without aortic valve replacement for aortic stenosis were observed in 2013 to 2015. Of the 12 patients, 7 died from 5 to 44 days (mean 19) after the valve operation and all had “stormy” postoperative courses; one survived 150 days and another, 600 days; the remaining 3 were improved by the operation and are alive 22, 27, and 59 months postoperatively. In conclusion, the high mortality in these patients suggests that mitral valve replacement in the setting of massive MAC be considered with caution.

Roberts, W. C. (2019). “From the Editor Pellagra, Osler, Roberts, Goldberger, the Atherosclerotic Diet, Niacin, the Beginning of the Atherosclerotic Epidemic, and the First Lipid-Altering Drug.” Am J Cardiol 123(4): 697-700

Full text of this article.

[An appreciation of Drs. Joseph Goldberger, Conrad A. Elvehjem, and Tom Spies for their work in the etiology and treatment of pellagra during the period 1914-1938; no abstract available.]

Rendon, R., K. Mannoia, S. Reiman, L. Hitchman and W. Shutze (2019). “Rotational vertebral artery occlusion secondary to completely extraosseous vertebral artery.” J Vasc Surg Cases Innov Tech 5(1): 14-17.

Full text of this article.

Rotational vertebral artery (VA) occlusion is a possible cause of reduced blood flow through the posterior circulation of the brain due to compression of the VA on head turning when blood flow from the contralateral VA is compromised. When compression occurs in the V2 segment of the VA, it is usually due to compression from the longus colli muscle or cervical osteophytes. We present a unique case of a patient with a completely extraosseous course of the V2 segment of her dominant right VA that resulted in symptomatic rotational VA occlusion.

Packer, M. (2019). “When Cardiovascular Trials Collide.” Eur Heart J 40(6): 501-504.

Full text of this article.

In the modern era of clinical trials, we do not expect large-scale, definitively designed and executed studies to yield misleading results if they are meticulously analysed in an unbiased manner. Fortunately, the discordant results of the MITRA-FR and COAPT trials do not undermine this conventional wisdom. Instead, the reporting of discordant results from the two studies has led us to rediscover a conceptual framework in which the results of both trials are valid. With respect to MITRA-FR and COAPT, the combined results of the trials tell us that patients with functional MR do not have a homogenous disorder. By providing complementary information, the trials (when considered together) indicate that we must now make a clear distinction between MR that is proportionate or disproportionate to the degree of LV enlargement. Optimal medical therapy seems to be the best choice for patients with proportionate MR, whereas mitral valve repair is highly desirable in those with disproportionate MR. Such a coherent understanding could not have been achieved if the MITRA-FR and COAPT trials had studied the same patients and yielded the same results. Integration of the results of MITRA-FR and COAPT allows us to optimally individualize the management of the heterogeneous group of patients who present with functional MR, heart failure, and LV dysfunction. (Excerpt from text, p. 503; no abstract available.)