June 2019 Table of Contents

Original Contributions

Radial Access Technique

Feasibility of 5 Fr Contralateral Radial Access for Hybrid Chronic Total Occlusion Percutaneous Coronary Intervention: Experience From a Single Tertiary Center in the United Kingdom

Andrew Peter Vanezis, MBChB, MRCP, PhDWilliam Wilson, MBBS, FRACPWilliam Smith, MB, BChir, MA, MRCP, PhD, FRCP

Chronic total occlusion percutaneous coronary intervention using the hybrid algorithm has traditionally been performed femorally using 8 Fr sheaths. Antegrade dissection and re-entry has facilitated procedures using 6 Fr and 7 Fr guides via the radial artery. Radial artery dysfunction and occlusion is a recognized complication preventing future radial procedures, but is significantly less common with 5 Fr sheaths.

J INVASIVE CARDIOL 2019;31(6):159-165. Epub 2019 February 15.

Aortic Valve Disease

An Observational Study of Elderly Veterans With Initially Asymptomatic Severe Aortic Stenosis

Stephen A. George, MD, PhDSasha Prisco, MD, PhDTakeshi Onizuka, MDFernando Ortiz, MDUmair Malik, MDMackenzie Mbai, MD; Mahesh Anantha-Narayanan, MD; Santiago Garcia, MD

Optimal timing of aortic valve replacement among patients with asymptomatic severe aortic stenosis remains uncertain. We conducted a cohort study of consecutive patients with severe aortic stenosis who were asymptomatic at the time of echocardiography. A total of 324 patients met our study criteria; mean age of the study cohort was 78 ± 10 years and 97% were male. A significant proportion of elderly patients with initially asymptomatic severe aortic stenosis died before symptoms were identified. Our study highlights the difficulty of relying on symptoms alone for timely referral to aortic valve replacement surgery.

J INVASIVE CARDIOL 2019;31(6):166-170. Epub 2019 March 15.

Transcatheter Aortic Valve Replacement

Alternative Access Versus Transfemoral Transcatheter Aortic Valve Replacement in Nonagenarians

Sotiris C. Stamou, MD, PhDNicole Lin, BS; Taylor James, BSMark Rothenberg, MD; Larry Lovitz, MDCristiano Faber, MD; Arvind Kapila, MD; Marcos A. Nores, MD

Studies suggest that alternative access to transcatheter aortic valve replacement (TAVR), such as transapical approach, is inferior to transfemoral approach. However, there is a paucity of data characterizing these outcomes, and studies often do not consider transaortic and transaxillary TAVR approaches. Therefore, the purpose of this study was to compare the outcomes of nonagenarians undergoing alternative access TAVR compared with transfemoral TAVR. A concurrent cohort study of 148 consecutive nonagenarian patients undergoing TAVR from April 2012 to July 2017 was carried out. We stratified the patient cohort into two groups based on access approach and analyzed preoperative, operative, and postoperative outcomes and 5-year actuarial survival rates.

J INVASIVE CARDIOL 2019;31(6):171-175. Epub 2019 April 15.

Cardiac Imaging / Complications

Ultra-Low Contrast Percutaneous Coronary Intervention to Minimize the Risk for Contrast-Induced Acute Kidney Injury in Patients With Severe Chronic Kidney Disease

Lorenzo Azzalini, MD, PhD, MScAlessandra Laricchia, MDDamiano Regazzoli, MD; Satoru Mitomo, MD;  Daisuke Hachinohe, MD; Barbara Bellini, MDOzan M. Demir, MBBSEnrico Poletti, MDDavide Maccagni, RT; Antonio Colombo, MD

The incidence of contrast-induced acute kidney injury is particularly high in patients with severe chronic kidney disease. Novel contrast-sparing strategies are warranted to guarantee the benefit of revascularization in this challenging and growing patient population. We aimed to evaluate the feasibility of an ultra-low contrast volume percutaneous coronary intervention (PCI) protocol in patients with severe chronic kidney disease. We created a retrospective registry to compare the outcomes of the ultra-low contrast volume PCI protocol vs conventional angiography-based PCI in patients with estimated glomerular filtration rate <30 mL/min/1.73 m2, applying no angiographic or procedural restriction criteria.

J INVASIVE CARDIOL 2019;31(6):176-182. Epub 2019 March 15.

Coronary Artery Disease

Small-Size vs Large-Size Burr for Rotational Atherectomy

Yaniv Levi, MDShahar Lavi, MDAmir Solomonica, MD, MPHZeev Israeli, MDRodrigo Bagur, MD, PhD

Rotational atherectomy has been traditionally performed via the transfemoral approach, mostly utilizing large guide catheters. However, contemporary data show that using smaller sheath and catheter sizes reduces the risk of procedural access-site related complications. Therefore, the aim of this study was to assess the feasibility of performing rotational atherectomy using smaller burrs and subsequently smaller-sheath size catheters.

J INVASIVE CARDIOL 2019;31(6):183-186.

Radiation Safety

Efficacy of Low-Dose Compared With Standard-Dose Radiation for Cardiac Catheterization and Intervention (KAR RAD Study)

Subrata Kar, DO; Mohamed Teleb, MD; Aymen Albaghdadi, MD;

Ahmed Ibrahim, MD; Debabrata Mukherjee, MD

We evaluated the efficacy of low-dose radiation (≤7.5 frames/second) compared with standard-dose radiation (≥10 frames/second) in cardiac catheterization and PCI by observing 452 consecutive patients who had coronary angiography or PCI from September 2016 to September 2017.

J INVASIVE CARDIOL 2019;31(6):187-194. Epub 2019 March 15.

Practice Management

Sleep Deprivation in Cardiology: A Multidisciplinary Survey

Angie S. Lobo, MD;  Yader Sandoval, MD;  M. Nicholas Burke, MD;  Paul Sorajja, MD;  Michael Mooney, MD;  Jay Traverse, MD;  Timothy D. Henry, MD;  Ivan Chavez, MD;  Mario Gössl, MD;  Daniel L. Lips, MD;  Steven M. Bradley, MD;  Anil Poulose, MD;  Yale Wang, MD;  Emmanouil S. Brilakis, MD, PhD

The burden and impact of sleep deprivation on cardiology have received limited study. Our multidisciplinary, online survey provides insights into sleep health patterns among cardiovascular workers and potential factors contributing to sleep deprivation.

J INVASIVE CARDIOL 2019;31(6):195-198. Epub 2019 April 15.

Online Exclusive

Clinical Conference Proceedings

Clinical Conference Proceedings: 15th Biennial International Andreas Gruentzig Society Meeting  

H. Vernon Anderson, MD;  Robert M. Bersin, MD;  J. Dawn Abbott, MD;  Herbert D. Aronow, MD;  Theodore A. Bass, MD;  Emmanouil S. Brilakis, MD, PhD;  Douglas M. Cavaye, MD;  Mauricio G. Cohen, MD;  Larry S. Dean, MD;  Eric J. Dippel, MD;  Kirk N. Garratt, MD;  Adam B. Greenbaum, MD;  George S. Hanzel, MD;  Tarek Helmy, MD;  Amir Lerman, MD;  Ayman A. Magd, MD;  J. Jeffrey Marshall, MD;  Anthony Medigo;  Michael R. Mooney, MD;  Srihari S. Naidu, MD;  Brian O’Neill, MD;  Augusto D. Pichard, MD;  Michael J. Rinaldi, MD;  Paul Sorajja, MD;  Molly A. Szerlip, MD;  David A. Wood, MD;  James P. Zidar, MD

The International Andreas Gruentzig Society is an educational society of physicians and scientists interested in cardiovascular and related fields. Members cooperate in the advancement of knowledge and education through research, publication, study, and teaching in the fields of cardiovascular disease. This summary reflects the proceedings from the recent scientific meeting to assess current clinical problems and propose future directions and possible solutions.

Puerto Natales, Chile, February 3-7, 2019

Original Contribution

Outcomes Following Balloon Aortic Valvuloplasty Versus Surgical Valvotomy in Congenital Aortic Valve Stenosis: A Meta-Analysis

May Thu Saung, MD;  Courtney McCracken, PhD;  Ritu Sachdeva, MD;  Christopher J. Petit, MD

The optimal treatment for congenital aortic stenosis has been debated over the past three decades of experience with both balloon aortic valvuloplasty and surgical aortic valvotomy. While balloon aortic valvuloplasty has been the mainstay of therapy for children with aortic stenosis in most centers, recent single-center reports suggest superior results following surgical aortic valvotomy. We performed a meta-analysis of 18 studies: SAV alone (n = 3), BAV alone (n = 10), and both (n = 5).

J INVASIVE CARDIOL 2019;31(6):E133-E142.

Case Series

Treatment of Heavily Calcified Unprotected Left Main Disease With Lithotripsy: The First Case Series

Bernard Wong, MBChB;  Seif El-Jack, MBBS;  Ali Khan, MBBS;  Ruth Newcombe, DCR;  Timothy Glenie, MBChB;  Aleksandar Cicovic, MBChB;  Guy Armstrong, MBChB

In this first case series, we present the use of Shockwave Intravascular Lithotripsy in a patient with left main coronary artery disease with multivessel disease who declined surgery, a patient with isolated left main coronary artery disease and severe cardiomyopathy, and a late nonagenarian patient where surgical revascularization was not an option. The use of Shockwave Intravascular Lithotripsy in these cases simplified lesion preparation and optimized procedural outcomes.

J INVASIVE CARDIOL 2019;31(6):E143-E147.


An Unusual Acute Coronary Syndrome Due to a Septic Embolism: A Case Presentation and Review of Revascularization Strategies

Vassili Panagides;  Marc Laine, MD;  Franck Paganelli, MD, PhD;  Laurent Bonello, MD, PhD

Optimal treatment of acute coronary syndromes secondary to septic coronary valvular embolism in endocarditis patients remains unclear. Several revascularization strategies have been described, including thromboaspiration, stent implantation, balloon angioplasty, and surgical intervention. We present an atypical case of an acute coronary syndrome related to a coronary bifurcation occlusion due to a septic embolism in a patient presenting with infective endocarditis and summarize previous similar cases and their management.

J INVASIVE CARDIOL 2019;31(6):E148-E153.

Clinical images

Percutaneous Closure of a Poorly Tolerated Ventricular Septal Defect After Triple Valvular Prosthesis Surgery

Leire Unzue, PhD, MD;  Eulogio García, MD;  Belén Díaz-Antón, MD;  Pilar Agudo

We describe the case of an 81-year-old woman with three biological prostheses at the aortic valve, mitral valve, and tricuspid valve with recurrent hospitalizations due to heart failure. To the best of our knowledge, this is the first percutaneous closure of ventricular septal defect in the presence of three valvular prostheses.

J INVASIVE CARDIOL 2019;31(6):E154.

Clinical images

A Dangerous Miss — Angioplasty of Chronic Total Occlusion of Entire Length of Inferior Vena Cava and Bilateral Iliac Veins

Rajeev Bhardwaj, MD, DM;  Anupam Jogta, MD;  Malay Sarkar, MD

We present a 48-year-old male patient with extensive lower-limb swelling and chronic kidney disease. Angiography revealed evidence of thrombus in the iliacs and the inferior vena cava was not visualized. Angioplasty of the entire length of the inferior vena cava is a challenging procedure. Surgery is rarely an option. Extensive skill and patience are needed and stenting is usually advised. In many cases, plain angioplasty may be done with favorable results.

J INVASIVE CARDIOL 2019;31(6):E155-E156.

Clinical images

Ambidextrous Angiography: Mother-and-Child Telescopic Catheter Technique to Evaluate LIMA and RIMA Grafts From the Radial Approach

Zaki Akhtar, MBBS;  Nikunj Shah, MBBS;  Richard Bogle, PhD, FRCP

Left heart catheterization graft study is commonly performed via the femoral approach to allow selective angiography of internal mammary grafts, which originate from either subclavian artery. A straightforward mother-and-child catheter-extension technique allows this procedure to be performed successfully via radial approach, which improves patient comfort and offers less likelihood of vascular complications.

J INVASIVE CARDIOL 2019;31(6):E157.

Clinical images

Emergency Venous Angioplasty of a Complete Superior Vena Cava Thrombosis

Tobias Petzold, MD;  Manuela Thienel, MD;  Enzo Lüsebrink, MD;  Steffen Massberg MD

A patient with a history of colon cancer was admitted to our emergency department due to progressive dyspnea, chest pain, and swelling of the upper limbs and face. A central venous port device had been implanted into the right subclavian vein for administration of systemic chemotherapy several months prior. Thoracic computed tomography scan revealed a 2.8 cm-long thrombus arising from the tip of the venous catheter, which completely occluded the superior vena cava in close proximity to the right atrium.

J INVASIVE CARDIOL 2019;31(6):E158.

Clinical images

Post-Close Technique for Arteriotomy Hemostasis After Impella Removal

Mohammad Thawabi, MD;  Marc Cohen, MD;  Najam Wasty, MD   

Utilization of large-bore sheaths has increased dramatically with the advancement of hemodynamic support devices. The pre-close technique is widely used to achieve hemostasis after device removal. However, this technique might fail or be deferred in certain situations, such as planned extended hemodynamic support or emergencies. Perclose employment in arteriotomies larger than 8 Fr might not be successful, as the device foot does not catch the vessel’s anterior wall. We describe a simple “post-close” technique for large arteriotomies (13-14 Fr) after removal of Impella 2.5 or CP systems (Abiomed) from the common femoral artery, using two Perclose devices.

J INVASIVE CARDIOL 2019;31(6):E159.

Clinical images

Adventitial Cystic Disease of the Popliteal Artery Contributing to Supera Stent Fracture

Nachiket J. Patel, MD;  Grant Gordon, BS;  Ajay U. Mhatre, MD;  Divya R. Verma, MD;  Ashish Pershad, MD; Richard R. Heuser, MD

A 60-year-old male presented with complaints of a non-healing wound on his right shin. Initial angiography showed a 100% occlusion of the right superficial femoral artery thought to be thrombotic in nature; he was treated with percutaneous transluminal angioplasty and stenting. Three weeks later, he presented with continuing symptoms of claudication. Angiography revealed stent fracture. Careful review of his prior angiogram was consistent with adventitial cystic disease of the popliteal artery as the cause of the popliteal artery occlusion. He was then referred for femoral-popliteal bypass.

J INVASIVE CARDIOL 2019;31(6):E160-E161.