In the context of chronic coronary syndromes (CCS), coronary computed tomography angiography (CCTA) has gained broad acceptance as a noninvasive anatomical imaging tool with ability of excluding coronary stenosis with strong negative predictive value. Atherosclerotic plaque lesions are independent predictors of cardiovascular outcomes in high risk patients with known coronary artery disease (CAD). Calcium detection is commonly expressed through the coronary artery calcium score (CACS), but further research is warranted to confirm the powerness of a CACS-only strategy in both diagnosis and prognosis assessment. Recent studies evidence how defined plaque composition characteristics effectively relate to the risk of plaque instabilization and the overall ischemic burden. Fractional flow reserve from CCTA (FFR-CT) has been demonstrated as a reliable method for noninvasive functional evaluation of coronary lesions severity, while the assessment of perfusion imaging under stress conditions is growing as a useful tool for assessment of myocardial ischemia. Moreover, specific applications in procedural planning of transcatheter valve substitution and follow-up of heart transplantation have gained recent importance. This review illustrates the incremental role of CCTA, which can potentially revolutionize the diagnosis and management pathway within the wide clinical spectrum of CCS.

https://www.mdpi.com/2077-0383/9/12/3925/pdf

The Incremental Role of Coronary Computed Tomography in Chronic Coronary Syndromes.

OBJECTIVES The aim of this study was to identify barriers to transradial access percutaneous coronary intervention (PCI). BACKGROUND Transradial access yields fewer vascular complications, earlier ambulation, and more patient comfort. However, the adoption to practice is slow, and transfemoral access is still commonly used. METHODS We identified all PCIs done by one operator in a radial-first trainee-driven practice. The individual charts were reviewed for all PCIs using femoral access. Reasons for not using radial access were identified. Descriptive statistics were used to report reasons for not using transradial access. Analyses were performed on a per-procedure basis. RESULTS Of 1,948 PCIs, 1,790 (92%) were via radial access and 158 (8%) via femoral access. Femoral access was used to bail out unsuccessful radial access in 21 PCIs (13% of all femoral PCIs, 1% of all PCIs). Radial access was unsuccessful due to failure to cannulate radial artery, radial artery spasm, and radial loop in majority of radial access failure PCIs (n = 13). Femoral access was used as a primary strategy in 137 PCIs (87% of all femoral PCIs, 7% of all PCIs), mostly due to undetectable radial artery pulse (both left and right) (n = 40). CONCLUSIONS Radial access can be used for PCI safely and effectively. Inadequate radial pulse is the main barrier. Adjunctive strategies such as ulnar access and use of ultrasound may further increase the success rate of arterial access from the upper extremities.

Barriers to use of radial access for percutaneous coronary intervention.

Knowing the patient's current cardiovascular disease (CVD) status, as well as the patient's current and future CVD risk, helps the clinician make more informed patient-centered management recommendations towards the goal of preventing future CVD events. Imaging tests that can assist the clinician with the diagnosis and prognosis of CVD include imaging studies of the heart and vascular system, as well as imaging studies of other body organs applicable to CVD risk. The American Society for Preventive Cardiology (ASPC) has published "Ten Things to Know About Ten Cardiovascular Disease Risk Factors." Similarly, this "ASPC Top Ten Imaging" summarizes ten things to know about ten imaging studies related to assessing CVD and CVD risk, listed in tabular form. The ten imaging studies herein include: (1) coronary artery calcium imaging (CAC), (2) coronary computed tomography angiography (CCTA), (3) cardiac ultrasound (echocardiography), (4) nuclear myocardial perfusion imaging (MPI), (5) cardiac magnetic resonance (CMR), (6) cardiac catheterization [with or without intravascular ultrasound (IVUS) or coronary optical coherence tomography (OCT)], (7) dual x-ray absorptiometry (DXA) body composition, (8) hepatic imaging [ultrasound of liver, vibration-controlled transient elastography (VCTE), CT, MRI proton density fat fraction (PDFF), magnetic resonance spectroscopy (MRS)], (9) peripheral artery / endothelial function imaging (e.g., carotid ultrasound, peripheral doppler imaging, ultrasound flow-mediated dilation, other tests of endothelial function and peripheral vascular imaging) and (10) images of other body organs applicable to preventive cardiology (brain, kidney, ovary). Many cardiologists perform cardiovascular-related imaging. Many non-cardiologists perform applicable non-cardiovascular imaging. Cardiologists and non-cardiologists alike may benefit from a working knowledge of imaging studies applicable to the diagnosis and prognosis of CVD and CVD risk - both important in preventive cardiology.

/pdf/ten-things-to-know-about-ten-imaging-studies-a-preventive-2sd4nbldq7.pdf

Ten things to know about ten imaging studies: A preventive cardiology perspective ("ASPC top ten imaging").

Background: Worsening aortic insufficiency (AI) is a known sequela of prolonged continuous-flow left ventricular assist device (LVAD) support with a significant impact on patient outcomes. While medical treatment may relieve symptoms, it is unlikely to halt progression. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are among non-medical interventions available to address post-LVAD AI. Limited data are available on outcomes with either SAVR or TAVR for the management of post-LVAD AI. Methods: The National Inpatient Sample data collected for hospital admissions between the years 2015 and 2018 for patients with pre-existing continuous-flow LVAD undergoing TAVR or SAVR for AI were queried. The primary outcome of interest was a composite of in-hospital mortality, stroke, transient ischaemic attack, MI, pacemaker implantation, need for open aortic valve surgery, vascular complications and cardiac tamponade. Results: Patients undergoing TAVR were more likely to receive their procedure during an elective admission (57.1 versus 30%, p=0.002), and a significantly higher prevalence of comorbidities, as assessed by the Elixhauser Comorbidity Index, was observed in the SAVR group (29 versus 18; p=0.0001). We observed a significantly higher prevalence of the primary composite outcome in patients undergoing SAVR (30%) compared with TAVR (14.3%; p=0.001). Upon multivariable analysis adjusting for the type of admission and Elixhauser Comorbidity Index, TAVR was associated with significantly lower odds of the composite outcome (odds ratio 0.243; 95% CI [0.06–0.97]; p=0.045). Conclusion: In this nationally representative cohort of LVAD patients with post-implant AI, it was observed that TAVR was associated with a lower risk of adverse short-term outcomes compared with SAVR.

/pdf/transcatheter-aortic-valve-replacement-and-surgical-aortic-26ptk7ae.pdf

Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Outcomes in Left Ventricular Assist Device Patients with Aortic Insufficiency

Early revascularization is the gold standard for management of patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The use of transradial artery access (TRA) in percutaneous coronary intervention (PCI) has increased in recent years and has emerged as a safe and effective approach to PCI in high-risk patients, with advantages in reduced major bleeding events, other peri-procedural complications, and all-cause mortality when compared with transfemoral artery access (TFA). Multiple randomized clinical trials have demonstrated these advantages of TRA vs. TFA PCI in STEMI patients. Although there remains a lack of dedicated randomized trials in CS, observational data suggest benefits on the same endpoints as in STEMI with TRA vs. TFA PCI in CS. This review summarizes the existing literature on the use of TRA compared to TFA for STEMI and CS patients; the reduction of major bleeding events, other peri-procedural complications, and mortality associated with TRA in STEMI and CS; and technical considerations and challenges in the care of these high-risk patient populations.

Transradial Artery Access in Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock.

OBJECTIVE This prospective study assesses balloon-assisted tracking (BAT) in reducing radial access failure during percutaneous coronary intervention (PCI). BACKGROUND Arterial spasm prevents PCI from the radial artery in a small percentage of cases. METHODS A total of 2223 consecutive patients undergoing PCI from the radial approach were analyzed. Radial access failure mode and requirement for crossover to femoral access during a 12-month run-in period were compared with the following 14-month period with routine BAT usage. RESULTS During the 14-month study period, 1334 radial PCIs were attempted. Twenty-six patients switched to femoral at an early stage, while 76 encountered radial spasm and underwent successful BAT in 69 cases (91%), giving a total crossover rate to femoral of 33/1334 (2.5%). Utilizing BAT rather than a femoral puncture reduced our institution's radial-femoral crossover rate from 7.6% to 2.5% (P<.01), which is also significantly lower than the radial-femoral crossover rate in the 12 months before BAT implementation (6.1%; P<.01). Mean procedure times were similar for those requiring BAT compared with conventional radial access (51.3 ± 21.3 min vs 47.9 ± 23.7 min; P=.23), and those crossing straight to femoral (BAT not attempted) (60.7 ± 31.9 min; P=.10). Mean first device/balloon time for the BAT-assisted primary PCI cases (22.6 ± 9.4 min) was similar to cases that had radial difficulties and converted to femoral without attempting BAT (25.8 ± 13.4 min; P=.54). CONCLUSION BAT allowed catheter passage despite radial spasm in 91% of cases, significantly reducing the institution's rate of femoral crossover. During radial spasm in primary PCI, using BAT did not delay reperfusion compared with femoral crossover.

Balloon-Assisted Tracking Use Reduces Radial Artery Access Failure in an Experienced Radial Center and is Feasible During Primary PCI for STEMI.

Aim This study sought to evaluate the feasibility and effectiveness of TAVI for treatment of aortic stenosis in the ACHD population. Methods and Results Review of 802 patients that underwent TAVI from January 2008 to November 2019. 13 ACHD patients with different underlying congenital anatomy were identified (isolated bicuspid aortic valve was excluded and not defined as ACHD). The main endpoints were: paravalvular aortic regurgitation> grade 2 post-procedure, and all-cause 30-day mortality. Periprocedural and post-procedural complications were defined according to the UK TAVI registry. Median age was 66.7 years (range 29–84 years). Eleven patients had severe aortic stenosis (AS), 1 had both severe AS and severe aortic regurgitation (AR) and 1 had severe AR. Median hospital stay was 9 days (range 6–28 days). One patient required a pacemaker post-TAVI. No mortality or paravalvular AR > grade 2 at 30-days. Twelve patients had a reduction in NYHA class on their first post TAVI follow-up. Conclusion TAVI is viable option as an alternative to surgery for ACHD patients. Further experience with the use of TAVI in the ACHD patients is required to assess long-term outcomes in this unique group of patients.

Feasibility and Effectiveness of Transcatheter Aortic Valve Implantation in Adults with Congenital Heart Disease

### Learning objectives

Selective coronary angiography initially required surgical cut down to access the brachial artery.1 Subsequently, in 1967 Melvin Judkins described a direct percutaneous approach via the femoral artery,2 an easily palpated vessel with high procedural success that would go on to become the default arterial access route. However, despite decades of experience with femoral access, vascular complications and bleeding remain a concern and are still a significant cause of mortality in cardiovascular intervention.3 Percutaneous coronary intervention (PCI) via the radial artery was first described by Kiemeneij in 1993,4 and early studies appeared to show a virtual elimination of access site complications.5 Initially the technique remained a niche interest of early radial pioneers, but usage in the United Kingdom has increased from 14% in 2005 to 84% in 2016 replacing the femoral artery as the most popular access site for intervention.6 

### Selection of radial or femoral arterial access

Radial artery access reduces vascular complications across all patient groups7 and is now recommended as the standard route for PCI.8 However, there are groups where the benefit is more pronounced. The superficial course and small calibre of the radial artery simplifies haemostasis allowing early ambulation9 and reducing cost10 making it ideal for patients who cannot tolerate prolonged bed rest, on anticoagulants or are undergoing PCI in the day case setting. A mortality benefit for radial access has been shown in patients with acute coronary syndrome and ST elevation myocardial infarction in both large randomised controlled trials11 and meta-analysis12 making this a strong indication for radial PCI. However, there remain procedural reasons when femoral access is required (large-bore access for transcatheter …

/pdf/vascular-access-and-closure-for-cardiovascular-intervention-4i6qg2kv7e.pdf

Vascular access and closure for cardiovascular intervention

We present the case of a 76-year-old man with recently treated infective endocarditis and severe residual native pure aortic regurgitation that was causing recurrent pulmonary edema. In view of his prohibitive surgical risk, he underwent transcatheter aortic valve implant with an excellent clinical outcome. (Level of Difficulty: Intermediate.).

Transcatheter Aortic Valve Implantation in Severe Native Pure Aortic Regurgitation Following Endocarditis With Large Vegetation.

Ileofemoral access complications are less commonly encountered in an era of increasing transradial intervention. Femoral access site complications vary significantly from minor haematomas to life-threatening bleeding and vascular rupture. Operators need to be able to be able to predict, prevent and where necessary treat ileofemoral access site complications when they do occur.

Iliofemoral Artery Dissection, Rupture, or Distal Ischaemia

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