Srinivasa P. Potluri M.D.

Potluri, S.P., Hamandi, M., Basra, S.S., Shinn, K.V., Tabachnick, D., Vasudevan, A., Filardo, G., DiMaio, J.M., Brinkman, W.T., Harrington, K., Squiers, J.J., Szerlip, M.I., Brown, D.L., Holper, E. and Mack, M.J. (2020). “Comparison of Frequency of Vascular Complications With Ultrasound-Guided Versus Fluroscopic Roadmap-Guided Femoral Arterial Access in Patients Who Underwent Transcatheter Aortic Valve Implantation.” Am J Cardiol 132: 93-99.

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To compare outcomes of ultrasound guidance (USG) versus fluoroscopy roadmap guidance (FG) angiography for femoral artery access in patients who underwent transfemoral (TF) transcatheter aortic valve implantation (TAVI) to determine whether routine USG use was associated with fewer vascular complications. Vascular complications are the most frequent procedural adverse events associated with TAVI. USG may provide a decreased rate of access site complications during vascular access compared with FG. Patients who underwent TF TAVI between July 2012 and July 2017 were reviewed and outcomes were compared. Vascular complications were categorized by Valve Academic Research Consortium-2 criteria and analyzed by a multivariable logistic regression adjusting for potential confounding risk factors including age, gender, body mass index, peripheral vascular disease, Society of Thoracic Surgeons score and sheath to femoral artery ratio. Of the 612 TAVI patients treated, 380 (63.1%) were performed using USG for access. Routine use of USG began in March 2015 and increased over time. Vascular complications occurred in 63 (10.3%) patients and decreased from 20% to 3.9% during the study period. There were fewer vascular complications with USG versus FG (7.9% vs 14.2%, p = 0.014). After adjusting for potential confounding risk factors that included newer valve systems, smaller sheath sizes and lower risk patients, there was still a 49% reduction in vascular complications with USG (odds ratio 0.51, 95% confidence interval 0.29 to 0.88, p = 0.02). In conclusion, USG for TF TAVI was associated with reduced vascular access site complications compared with FG access even after accounting for potential confounding risk factors and should be considered for routine use for TF TAVI.

Xenogiannis, I., F. Gkargkoulas, D. Karmpaliotis, K. Alaswad, O. Krestyaninov, D. Khelimskii, J. W. Choi [ . . . ] S. Potluri, J. W. Moses, N. J. Lembo, M. Parikh, A. J. Kirtane, Z. A. Ali, A. B. Hall, E. Vemmou, I. Nikolakopoulos, B. B. Dargham, B. V. Rangan, S. Abdullah, S. Garcia, S. Banerjee, M. N. Burke and E. S. Brilakis (2019). “The Impact of Peripheral Artery Disease in Chronic Total Occlusion Percutaneous Coronary Intervention (Insights From PROGRESS-CTO Registry).” Angiology Dec 17. [Epub ahead of print].

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The impact of peripheral artery disease (PAD) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We reviewed 3999 CTO PCIs performed in 3914 patients between 2012 and 2018 at 25 centers, 14% of whom had a history of PAD. We compared the clinical and angiographic characteristics and procedural outcomes of patients with versus without history of PAD. Patients with PAD were older (67 +/- 9 vs 64 +/- 10 years, P < .001) and had a higher prevalence of cardiovascular risk factors. They also had more complex lesions as illustrated by higher Japanese CTO score (2.7 +/- 1.2 vs 2.4 +/- 1.3, P < .001). In patients with PAD, the final crossing technique was less often antegrade wire escalation (40% vs 51%, P < .001) and more often the retrograde approach (23 vs 20%, P < .001) and antegrade dissection/reentry (20% vs 16%, P < .001). Technical success was similar between the 2 study groups (84% vs 87%, P = .127), but procedural success was lower for patients with PAD (81% vs 85%, P = .015). The incidence of in-hospital major adverse cardiac events was higher among patients with PAD (3% vs 2%, P = .046). In conclusion, patients with PAD undergoing CTO PCI have more comorbidities, more complex lesions, and lower procedural success.

Sannino, A., S. Potluri, B. Pollock, G. Filardo, A. Gopal, R. C. Stoler, M. Szerlip, A. Chowdhury, M. J. Mack and P. A. Grayburn (2019). “Impact of Mitral Stenosis on Survival in Patients Undergoing Isolated Transcatheter Aortic Valve Implantation.” Am J Cardiol 123(8): 1314-1320.

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This study was performed to investigate the prevalence and impact on survival of baseline mitral stenosis (MS) in patients who underwent transcatheter aortic valve implantation (TAVI) due to the presence of severe symptomatic aortic stenosis. This retrospective study included 928 consecutive patients with severe, symptomatic aortic stenosis who underwent TAVI in 2 institutions, from January 2012 to August 2016. Mean follow-up was 40.8 +/- 13.9 months. Based on the mean mitral gradient (MMG) at baseline, 3 groups were identified: MMG <5 mm Hg (n=737, 81.7%); MMG >/=5 and <10 mm Hg (n=147, 16.3%); MMG >/=10 mm Hg (n=17, 1.9%). These latter were more frequently women, with a smaller body surface area, a higher prevalence of atrial fibrillation, chronic obstructive pulmonary disease, and previous history of coronary-artery bypass graft/percutaneous coronary intervention. At baseline, patients with MMG >/=10 mm Hg compared with >/=5 and <10 mm Hg and <5 mm Hg patients had a lower mitral valve area (2.4 +/- 0.94 vs 2.1 +/- 0.86 vs 1.5 +/- 0.44 cm(2)), a lower prevalence of MR >/=2+ (5.9% vs 28.6% and 15.6%, p <0.0001), a higher prevalence of severe mitral annular calcium (70.6% vs 45.6% and 13.0%, p <0.0001) and a higher systolic pulmonary arterial pressure (50.6 +/- 12.1 vs 47.2 +/- 14.5 and 41.6 +/- 14.4, p <0.0001). Despite the low prevalence of MMG >/=10 mm Hg, these patients had higher 5-year mortality compared with the other groups (adjusted hazard ratio 2.91, 95% confidence interval 1.17 to 7.20, p=0.02). In conclusion, severe calcific MS is uncommon in patients who underwent TAVI. Its presence is associated with higher long-term mortality whereas moderate MS is not.

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.

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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).

Sannino, A., S. Potluri, B. Pollock, G. Filardo, A. Gopal, R. C. Stoler, M. Szerlip, A. Chowdhury, M. J. Mack and P. A. Grayburn (2019). “Impact of Mitral Stenosis on Survival in Patients Undergoing Isolated Transcatheter Aortic Valve Implantation.” Am J Cardiol Jan 25. [Epub ahead of print].

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This study was performed to investigate the prevalence and impact on survival of baseline mitral stenosis (MS) in patients who underwent transcatheter aortic valve implantation (TAVI) due to the presence of severe symptomatic aortic stenosis. This retrospective study included 928 consecutive patients with severe, symptomatic aortic stenosis who underwent TAVI in 2 institutions, from January 2012 to August 2016. Mean follow-up was 40.8 +/- 13.9 months. Based on the mean mitral gradient (MMG) at baseline, 3 groups were identified: MMG <5 mm Hg (n=737, 81.7%); MMG >/=5 and <10 mm Hg (n=147, 16.3%); MMG >/=10 mm Hg (n=17, 1.9%). These latter were more frequently women, with a smaller body surface area, a higher prevalence of atrial fibrillation, chronic obstructive pulmonary disease, and previous history of coronary-artery bypass graft/percutaneous coronary intervention. At baseline, patients with MMG >/=10 mm Hg compared with >/=5 and <10 mm Hg and <5 mm Hg patients had a lower mitral valve area (2.4 +/- 0.94 vs 2.1 +/- 0.86 vs 1.5 +/- 0.44 cm(2)), a lower prevalence of MR >/=2+ (5.9% vs 28.6% and 15.6%, p <0.0001), a higher prevalence of severe mitral annular calcium (70.6% vs 45.6% and 13.0%, p <0.0001) and a higher systolic pulmonary arterial pressure (50.6 +/- 12.1 vs 47.2 +/- 14.5 and 41.6 +/- 14.4, p <0.0001). Despite the low prevalence of MMG >/=10 mm Hg, these patients had higher 5-year mortality compared with the other groups (adjusted hazard ratio 2.91, 95% confidence interval 1.17 to 7.20, p=0.02). In conclusion, severe calcific MS is uncommon in patients who underwent TAVI. Its presence is associated with higher long-term mortality whereas moderate MS is not.