James W. Choi M.D.

Sudhakaran, S., Tandon, A., Rafael, A.E. and Choi, J.W. (2021). “Severe Mitral Paravalvular Leak Treated with Percutaneous Paravalvular Leak Closure with Underlying Severe Mitral Annular Calcium.” Am J Cardiol Jun 20;S0002-9149(21)00425-2. [Epub ahead of print].

Full text of this article.

Standard operative mitral valve replacement for mitral stenosis in the setting of severe mitral annular calcium has been associated with increased morbidity and mortality. Inability to ensure a well seated prosthesis may lead to periprosthetic leak. We present a case of severe paravalvular leak, causing significant hemolysis, after mitral valve replacement with underling severe mitral annular calcium. The leak was successfully repaired using a transseptal percutaneous approach, with subsequent resolution of hemolysis.

Vemmou, E., Quadros, A.S., Dens, J.A., Rafeh, N.A., Agostoni, P., Alaswad, K., Avran, A., Bellli, K.C., Carlino, M., Choi, J.W., El-Guindy, A., Jaffer, F.A., Karmpaliotis, D., Khatri, J.J., Khelimskii, D., Knaapen, P., La Manna, A., Krestyaninov, O., Lamelas, P., Ojeda, S., Padilla, L., Pan, M., Piccaro de Oliveira, P., Rinfret, S., Spratt, J.C., Tanabe, M., Walsh, S., Nikolakopoulos, I., Karacsonyi, J., Rangan, B.V., Brilakis, E.S. and Azzalini, L. (2021). “In-Stent CTO Percutaneous Coronary Intervention: Individual Patient Data Pooled Analysis of 4 Multicenter Registries.” JACC Cardiovasc Interv May 19;S1936-8798(21)00677-4. [Epub ahead of print].

Full text of this article.

OBJECTIVES: The authors sought to examine the outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusions (CTOs). BACKGROUND: The outcomes of PCI for ISR CTOs have received limited study. METHODS: The authors examined the clinical and angiographic characteristics and procedural outcomes of 11,961 CTO PCIs performed in 11,728 patients at 107 centers in Europe, North America, Latin America, and Asia between 2012 and 2020, pooling patient-level data from 4 multicenter registries. In-hospital major adverse cardiovascular events (MACE) included death, myocardial infarction, stroke, and tamponade. Long-term MACE were defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization. RESULTS: ISR represented 15% of the CTOs (n = 1,755). Patients with ISR CTOs had higher prevalence of diabetes (44% vs. 38%; p < 0.0001) and prior coronary artery bypass graft surgery (27% vs. 24%; p = 0.03). Mean J-CTO (Multicenter CTO Registry in Japan) score was 2.32 ± 1.27 in the ISR group and 2.22 ± 1.27 in the de novo group (p = 0.01). Technical (85% vs. 85%; p = 0.75) and procedural (84% vs. 84%; p = 0.82) success was similar for ISR and de novo CTOs, as was the incidence of in-hospital MACE (1.7% vs. 2.2%; p = 0.25). Antegrade wiring was the most common successful strategy, in 70% of ISR and 60% of de novo CTOs, followed by retrograde crossing (16% vs. 23%) and antegrade dissection and re-entry (15% vs. 16%; p < 0.0001). At 12 months, patients with ISR CTOs had a higher incidence of MACE (hazard ratio: 1.31; 95% confidence intervals: 1.01 to 1.70; p = 0.04). CONCLUSIONS: ISR CTOs represent 15% of all CTO PCIs and can be recanalized with similar success and in-hospital MACE as de novo CTOs.

Karacsonyi, J., Alaswad, K., Choi, J.W., Vemmou, E., Nikolakopoulos, I., Poommipanit, P., Rafeh, N.A., ElGuindy, A., Ungi, I., Egred, M. and Brilakis, E.S. (2021). “Laser for balloon uncrossable and undilatable chronic total occlusion interventions.” Int J Cardiol May 19;S0167-5273(21)00827-5. [Epub ahead of print].

Full text of this article.

BACKGROUND: There is limited information on use of laser in complex percutaneous coronary interventions (PCI). We examined the impact of laser on the outcomes of balloon uncrossable and balloon undilatable chronic total occlusions (CTO) PCI. METHODS: We reviewed baseline clinical and angiographic characteristics and procedural outcomes of 4845 CTO PCIs performed between 2012 and 2020 at 32 centers. RESULTS: Of the 4845 CTO lesions, 752 (15.5%) were balloon uncrossable (523 cases) or balloon undilatable (356 cases) and were included in this analysis. Mean patient age was 66.9 ± 10 years and 83% were men. Laser was used in 20.3% of the lesions. Compared with cases in which laser was not used, laser was more commonly used in longer length occlusions (33 [21, 50] vs. 25 [15, 40] mm, p = 0.0004) and in-stent restenotic lesions (41% vs. 20%, p < 0.0001). Laser use was associated with higher technical (91.5% vs. 83.1%, p = 0.010) and procedural (88.9% vs. 81.6%, p = 0.033) success rates and similar incidence of major adverse cardiac events (3.92% vs. 3.51%, p = 0.805). Laser use was associated with longer procedural (169 [109, 231] vs. 130 [87, 199], p < 0.0001) and fluoroscopy time (64 [40, 94] vs. 50 [31, 81], p = 0.003). CONCLUSIONS: In a contemporary, multicenter registry balloon uncrossable and balloon undilatable lesions represented 15.5% of all CTO PCIs. Laser was used in approximately one-fifth of these cases and was associated with high technical and procedural success and similar major complication rates.

Vemmou, E., Alaswad, K., Patel, M., Mahmud, E., Choi, J.W., Jaffer, F.A., Doing, A.H., Dattilo, P., Karmpaliotis, D., Krestyaninov, O., Khelimskii, D., Nikolakopoulos, I., Karacsonyi, J., Xenogiannis, I., Garcia, S., Burke, M.N., Abi Rafeh, N., ElGuindy, A., Goktekin, O., Abdo, A., Rangan, B.V., Abdullah, S. and Brilakis, E.S. (2021). “Chronic total occlusion percutaneous coronary intervention in octogenarians and nonagenarians.” J Am Geriatr Soc Feb 16. [Epub ahead of print].

Full text of this article.

OBJECTIVE: The outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in octogenarians and nonagenarians have received limited study. METHODS: We compared in-hospital outcomes of CTO PCI between patients ≥80 vs. <80-years-old in 6233 CTO PCIs performed between 2012 and 2020 at 33 U.S. and international centers. RESULTS: There were 415 octogenarians and nonagenarians in our study (7% of the total population). Compared with younger patients, octo- and nonagenarians were less likely to be men (73% vs. 83.2%, p < 0.0001) and more likely to have atrial fibrillation (27% vs. 12%, p < 0.0001) and prior coronary artery bypass graft surgery (CABG) (43% vs. 29%, p < 0.0001). They were more likely to have CTOs with moderate/severe calcification (71% vs. 46%, p < 0.0001), but had similar mean J-CTO scores (2.5 ± 1.3 vs. 2.4 ± 1.3, p = 0.08). They had lower technical and procedural success (82.2% vs. 86.3%, p = 0.0201; 80.3% vs. 84.8%, p = 0.016, respectively) and higher incidence of in-hospital major adverse cardiovascular events (3.4% vs. 1.8%, p = 0.021). On multivariable analysis PCI in octo- and nonagenarians was not independently associated with technical and procedural success or with in-hospital MACE. CONCLUSION: CTO PCI is feasible in octo- and nonagenarians, although success rates are lower, and the risk of complications is higher compared with younger patients, likely related to more comorbidities and higher coronary lesion complexity.

Karacsonyi, J., Stanberry, L., Alaswad, K., Krestyaninov, O., Choi, J.W., Rangan, B.V., Nikolakopoulos, I., Vemmou, E., Ungi, I. and Brilakis, E.S. (2021). “Predicting Technical Success of Chronic Total Occlusion Percutaneous Coronary Intervention: Comparison of 3 Scores.” Circ Cardiovasc Interv 14(1): e009860.

Full text of this article.

The success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) significantly increased from 77% between 2000 and 20111 to 85% to 90% currently at experienced centers and depends on center and operator experience and lesion characteristics. Several CTO PCI scoring systems have been developed to assess procedural difficulty. The first one was the Japan chronic total occlusion (J-CTO) score that estimates the likelihood of successful guidewire crossing within the first 30 minutes based on 5 variables: blunt stump, calcification, lesion tortuosity, prior failed attempt, and occlusion length ≥20 mm. Another widely used score is the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score that uses 4 angiographic characteristics: moderate/severe proximal vessel tortuosity, proximal cap ambiguity, circumflex coronary artery CTO, and absence of interventional collaterals to predict technical success.The EuroCTO CASTLE score utilizes 6 variables for assessing the likelihood of success: prior Coronary artery bypass graft surgery, age (≥70 years), stump anatomy (blunt or invisible), tortuosity degree (severe or unseen), length of occlusion (≥20 mm), and extent of calcification (>50% of the segment). [No abstract; excerpt from article].