Background Coronary artery calcium (CAC) scoring is a robust cardiovascular risk marker, yet the prognostic value of serial assessment and the relative importance of incident calcium versus progression from elevated baseline CAC remains incompletely defined. Methods We analyzed 4,166 CLARIFY registry participants (NCT04075162) who underwent ≥2 CAC scans ≥11 months apart (mean interval 4.5 years). Defining CAC progression (ΔCAC>10 Agatston units, AU) identified 1,982 progressors and 2,184 non-progressors. Annualized absolute, square-root, and log-transformed progression were evaluated for association with major adverse cardiovascular events (MACE: myocardial infarction, stroke, mortality, revascularization, and heart failure). Incremental prognostic value was assessed by adding annualized progression to the base MESA-CAC model incorporating baseline CAC, demographics, and traditional risk factors. Results Over a median 5.9 year follow-up, progressors had higher MACE incidence, though risk gradients differed by baseline CAC. Incident CAC from a baseline zero score was not associated with increased MACE (all p>0.60). However, progression of established CAC was associated with nearly double 5-point MACE (HR 1.96 [1.38–2.80]; p<0.001) which persisted across baseline CAC strata of 1–100, 101–200, and >200 AU (HR 1.74–2.65; all p<0.01). Annualized progression independently predicted events, most strongly using log-transformed metrics (overall cohort HR 1.27 [1.15–1.41]; p<0.0001). Associations persisted across smokers, diabetics and statin-users. Adding annualized progression to the base MESA-CAC model improved net risk reclassification (NRI ∼0.10). Conclusions Serial CAC imaging may provide incremental prognostic value in individuals with pre-existing atherosclerosis. While incident CAC after a baseline zero score may confer limited short-term risk, it may present a window for preventive intervention.

Background The Onyx ONE Clear study demonstrated favorable 1-year efficacy and safety outcomes in patients with high bleeding risk (HBR) and 1 month of event-free dual antiplatelet therapy (DAPT) after treatment with Resolute Onyx zotarolimus-eluting stents (ZES). Differences in outcomes after early DAPT discontinuation by sex have not been fully defined. Methods Eligible patients had ≥1 HBR criterion and underwent percutaneous coronary intervention with the Resolute Onyx ZES. Outcomes were evaluated in patients “clear” of 30-day adverse events. The primary end point was a composite of cardiac death or myocardial infarction (CD/MI). Bleeding and ischemic outcomes at 2 years were compared by sex in this prespecified subgroup analysis. Results Among 1507 patients included, 32.2% were women. Women were older and more likely to present with acute coronary syndrome. The 2-year rates of CD/MI were 10.6% in women vs 12.6% in men (P = .29), and all-cause mortality was 10.1% vs 14.6% (P = .018), respectively. No sex-related differences were observed for the other ischemic outcomes. After propensity score adjustment, all-cause mortality did not differ significantly between groups. Based on multivariable Cox regression analysis, the number of HBR criteria, diabetes, and acute coronary syndrome presentation, but not sex, were associated with Bleeding Academic Research Consortium 3 to 5 bleeding through 2 years. Conclusions In HBR patients treated with Resolute Onyx ZES and 1-month abbreviated DAPT, rates of CD or MI at 2 years were low, with no significant sex-related differences in ischemic and bleeding events. These data support the use of abbreviated DAPT after ZES in women and men with HBR.

Background: A single phosphorylation in kindlin-3 at S484 (human) or S485 (mouse) has been shown to regulate its function in a variety of cells in vitro. However, whether this posttranslational modification of kindlin-3 plays a role in platelets and in hemostasis and thrombosis in vivo remains totally unknown. Objectives: To create a strain of mice expressing kindlin-3 that bears the S485A substitution and utilize these mice to determine if kindlin-3 phosphorylation influences platelet responses, hemostasis, and thrombosis in vivo. Methods: By clustered regularly interspaced short palindromic repeats/CRISPR-associated protein 9 gene editing, we generated a mouse strain that expressed a kindlin-3 mutant bearing the S485A substitution. S485A kindlin-3 mice were born normally, and the platelet and red blood cells numbers were similar to their wild-type counterparts. Wild-type and S485A kindlin-3 platelets showed similar expression of αIIbβ3 integrin, kindlin-3, and talin. Results: Platelets isolated from S485A kindlin-3 mice did not undergo agonist-induced kindlin-3 phosphorylation. Functional analysis revealed that S485A kindlin-3 mice exhibited prolonged tail bleeding time, increased blood loss, and delayed thrombosis in the carotid artery injury model in vivo. Platelets isolated from S485A kindlin-3 mice showed defective platelet function, including impaired integrin αIIbβ3 activation, platelet aggregation, clot retraction, and adhesion. Conclusion: Our observations demonstrate that kindlin-3 phosphorylation on S485 in mice is crucial for supporting activation of αIIbβ3 integrin and αIIbβ3 integrin-dependent platelet responses and consequently contributes to hemostasis and thrombosis in vivo.

N8-GP (turoctocog alfa pegol; Esperoct®) is a recombinant, glycoPEGylated, extended half-life, factor VIII replacement product. Here, we examined the immunogenicity, safety, and efficacy of N8-GP in previously untreated patients (PUPs). pathfinder6 (NCT02137850) is an ongoing, open-label, phase 3 trial that enrolled PUPs with severe hemophilia A, <6 years old. The primary endpoint was the incidence of FVIII inhibitors (≥0.6 Bethesda units [BU)). Eighty patients received ≥1 N8-GP dose and were included in this analysis with ≥50 patients having ≥50 exposure days to N8-GP. The inhibitor incidence was 29.9% (14.9% high-titer ≥5 BU). Sixty-five patients received N8-GP prophylaxis for an average of 2.17 years with a median annualized bleeding rate (interquartile range) of 1.42 (0.76; 3.13), and a 90.5% hemostatic success rate. Temporarily decreased incremental recovery (IR; defined as ≥2 consecutive measurements of IR <0.6 (IU/dL)/(IU/kg) but no inhibitors) was observed in 17 patients within 5 exposure days to N8-GP and had a strong temporal correlation with anti-PEG IgG antibody titers. IR returned within the expected range with continued N8-GP dosing. During the period of decreased IR, hemostatic response was similar to the overall trial population, and no hypersensitivity related to N8-GP or unexpected new adverse events were reported. N8-GP prophylaxis was efficacious for the prevention and treatment of bleeding episodes in PUPs with severe hemophilia A. The inhibitor incidence was 29.9%. All patients with temporarily decreased IR continuing on N8-GP dosing returned within the expected range and had no evident lack of efficacy.

Background: Registries show international variations in the characteristics and outcome of patients with heart failure (HF), but national samples are rarely large, and case selection may be biased owing to enrolment in academic centers. National administrative datasets provide large samples with a low risk of bias. In this study, we compared the characteristics, health care resource use (HRU) and outcomes of patients with primary HF hospitalizations (HFH) using electronic health records (EHR) from 4 high-income countries (United States, UK, Taiwan, Japan) on 3 continents. Methods and Results: We used electronic health record to identify unplanned HFH between 2012 and 2014. We identified 231,512, 10,991, 36,900, and 133,982 patients with a primary HFH from the United States, the UK, Taiwan, and Japan, respectively. HFH per 100,000 population was highest in the United States and lowest in Taiwan. Fewer patients in Taiwan and Japan were obese or had chronic kidney disease. The length of hospital stay was shortest in the United States (median 4 days) and longer in the UK, Taiwan, and Japan (medians of 7, 9, and 17 days, respectively). HRU during hospitalization was highest in Japan and lowest in UK. Crude and direct standardized in-hospital mortality was lowest in the United States (direct standardized rates 1.8, 95% confidence interval 1.7%-1.9%) and progressively higher in Taiwan (direct standardized rates 3.9, 95% CI 3.8%-4.1%), the UK (direct standardized rates 6.4, 95% CI 6.1%-6.7%), and Japan (direct standardized rates 6.7, 95% CI 6.6%-6.8%). The 30-day all-cause (25.8%) and HF (7.2%) readmissions were highest in the United States and lowest in Japan (11.9% and 5.1%, respectively). Conclusions: Marked international variations in patient characteristics, HRU, and clinical outcomes exist; understanding them might inform health care policy and international trial design.Y

Covid-19 related lockdowns have resulted in a shortage of iodinated contrast media (ICM) in 2022. Health care providers have reacted with implementing conservation strategies to stay operational without compromising patient care. Although articles describing the implemented Interventions have been published, possible chances of the shortage have not yet been mentioned in the literature.We conducted a literature search in PubMed and Google Scholar, and analysed the background, interventions, and possible benefits of low-dose ICM regimens.We included 22 articles dealing with “ICM shortage” for the analysis. The delivery bottlenecks in the USA and Australia led to two different countermeasures, 1. reduction of the number of contrast-enhanced image-guided examinations and 2. reduction of the (single) ICM dose. Interventions from both groups have resulted in significant reduction of ICM usage; however, group 1 has contributed more to overall ICM reduction. As benefit of the ICM reduction, we revealed an increased safety for patients at risk (e.g. hypersensitivity reactions, contrast-induced acute kidney injury, thyroid toxic effects).The ICM shortage of 2022 has forced health care providers to implement conservation strategies to stay operational. Although there were already proposals for dose reduction before the corona pandemic and the associated supply bottlenecks, this situation led to the use of a reduced amount of contrast agent on a large scale. This presents a good opportunity to reconsider protocols and the use of contrast-enhanced imaging in general for future practice as it offers chances and advantages regarding costs, environmental impact, and patient safety.

Prevention of cardiovascular disease is currently guided by probabilistic risk scores that may misclassify individual risk and commit many middle-aged patients to prolonged pharmacotherapy. The coronary artery calcium (CAC) score, although endorsed for intermediate-risk patients, is not widely adopted because of barriers in reimbursement. The impact of removing cost barrier on cardiovascular outcomes in real-world settings is not known. Within the University Hospitals Health System (Cleveland, Ohio), CAC was offered to patients with at least 1 cardiovascular risk factor at low charge between 2014 and 2017 ($99) and no charge from January 1, 2018 onward. CAC use and access, patient characteristics, reclassification of risk compared with the pooled cohort equations (PCEs) for atherosclerotic vascular disease, statin use, changes in parameters of cardiometabolic health, downstream cardiovascular testing, downstream coronary revascularization, and cardiovascular outcomes were evaluated. A total of 52,151 patients underwent CAC testing over the study period. Median 10-year PCE for atherosclerotic vascular disease, in the entire cohort was 8.3% (4.0% to 15.9%). Among patients with PCE >20%, 21% had CAC <100, whereas 37% of those with PCE <7.5% had CAC ≥100. Among patients who were not on statin before CAC testing, 1-year statin prescription was 24% and was significantly associated with higher CAC scores. Total cholesterol, low-density lipoprotein cholesterol, and triglycerides all decreased significantly 1-year after CAC, and the degree of decrease was strongly linked with CAC scores. One year after CAC, 14% underwent noninvasive ischemic evaluation, 1.4% underwent invasive coronary angiography, and 0.9% underwent revascularization. The majority (74%) of revascularization procedures occurred in patients with CAC >400. In conclusion, reducing or removing the cost burden of CAC leads to significant test uptake by patients, which is followed by reclassification of statin eligibility, increases in the use of preventive medications, and improvement in risk factors, with very low rates of invasive downstream testing.

Recent evidence suggests interaction of platelets with dendritic cells (DCs), while the molecular mechanisms mediating this heterotypic cell cross-talk are largely unknown. We evaluated the role of integrin Mac-1 (aMb2, CD11b/CD18) on DCs as a counterreceptor for platelet glycoprotein (GP) Iba. In a dynamic coincubation model, we observed interaction of human platelets with monocyte-derived DCs, but also that platelet activation induced a sharp increase in heterotypic cell binding. Inhibition of CD11b or GPIba led to significant reduction of DC adhesion to platelets in vitro independent of GPIIbIIIa, which we confirmed using platelets from Glanzmann thrombasthenia patients and transgenic mouse lines on C57BL/6 background (GPIba-/-, IL4RGPIba-tg, and muMac1 mice). In vivo, inhibition or genetic deletion of CD11b and GPIba induced a significant reduction of platelet-mediated DC adhesion to the injured arterial wall. Interestingly, only intravascular antiCD11b inhibited DC recruitment, suggesting a dynamic DC -platelet interaction. Indeed, we could show that activated platelets induced CD11b upregulation on Mg2+-preactivated DCs, which was related to protein kinase B (Akt) and dependent on P-selectin and P-selectin glycoprotein ligand 1. Importantly, specific pharmacological targeting of the GPIba-Mac-1 interaction site blocked DC -platelet interaction in vitro and in vivo. These results demonstrate that cross-talk of platelets with DCs is mediated by GPIba and Mac-1, which is upregulated on DCs by activated platelets in a P-selectin glycoprotein ligand 1 -dependent manner. The Journal of Immunology, 2022, 208: 1729-1741.

BACKGROUND Resolute Onyx polymer-based zotarolimus-eluting stents (ZES) were noninferior in safety and effectiveness to BioFreedom polymer-free biolimus A9-coated stents (DCS) in high-bleeding-risk (HBR) patients treated with 1-month dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT) at 1 year. OBJECTIVES This study reports the final 2-year results of the randomized Onyx ONE trial. METHODS The Onyx ONE (A Randomized Controlled Trial With Resolute Onyx in One Month Dual Antiplatelet Therapy (DAPT) for High-Bleeding Risk Patients) trial randomly assigned HBR patients to treatment with ZES or DCS. Following 1-month DAPT, event-free patients received SAPT (either aspirin or a P2Y(12) inhibitor at physician discretion). The primary safety endpoint, a composite of cardiac death, myocardial infarction, or stent thrombosis at 1 year, was determined at 1 year. Rates of primary and secondary endpoints were calculated after final follow-up at 2 years. RESULTS A total of 1,003 patients were randomly allocated to ZES and 993 patients to DCS. Follow-up was complete in 980 (97.7%) ZES patients and 962 (96.9%) DCS patients at 2 years. The primary safety endpoint occurred in 208 (21.2%) patients in the ZES group and 199 (20.7%) patients in the DCS group (risk difference: 0.5%; 95% CI: -3.1% to 4.2%; P = 0.78) at 2 years without significant differences in individual components of the composite endpoint. The secondary effectiveness endpoint occurred in 217 (22.1%) patients in the ZES group and 202 (21.0%) patients in the DCS group (risk difference: 1.1%; 95% CI: -2.5% to 4.8%; P = 0.54). CONCLUSIONS Among patients at HBR treated with 1-month DAPT followed by SAPT, the Resolute Onyx polymer-based ZES had similar 2-year outcomes for the primary safety and secondary effectiveness endpoint compared with the BioFreedom polymer-free DCS. (A Randomized Controlled Trial With Resolute Onyx in One Month Dual Antiplatelet Therapy [DAPT] for High-Bleeding Risk Patients [Onyx ONE]; NCT03344653) (C) 2022 by the American College of Cardiology Foundation.

Background: Prior studies have suggested significant underutilization of statins in women and worse cardiovascular outcomes. Data examining the impact of real-world coronary artery calcium (CAC) scoring to improve utilization of preventive therapies and outcomes is limited. Methods: In a prospective registry study of low cost or no-cost CAC scoring between 2014 and 19 (CLARIFY Study, Clinicaltrials.gov NCT04075162), we sought to study the association of CAC scoring on statin utilization, blood lipids (LDL, total cholesterol, triglycerides), downstream ischemic testing (coronary angiography and stress testing), coronary revascularization and outcomes (MI, stroke, death) in women compared with men. Eligibility for statin initiation was defined as atherosclerotic cardiovascular disease pooled cohort equation (ASCVD-PCE) >= 7.5% and CAC >= 100/>= 75th percentile. Results: A total of 52,151 patients (26,336 women and 25,815 men) were enrolled. Women were more likely to have CAC 0 (51% vs 30%, P<0.001). Among patients not eligible for statin by PCE, CAC reclassified statin eligibility in a smaller proportion of women than men (25.4% vs 30%, P<0.001), while among patients eligible for statin by PCE, CAC was more likely to downgrade risk/statin eligibility in women than men (30.1% vs 48.4%, P<0.001). After CAC scoring, statin initiation was similar in women and men, but high-intensity statin use was lower in women (CAC-adjusted HR 0.76 [0.70-0.83], P<0.001). Women had similar reduction in LDL cholesterol levels compared with men. There was no difference between men and women with respect to CAC-stratified major adverse cardiovascular events. Conclusion: CAC scoring primarily served to downgrade statin eligibility in women compared with men. Women had similar CAC risk-guided reductions in LDL cholesterol compared with men.

BACKGROUND:Same-day discharge (SDD) following left atrial appendage closure (LAAC) is increasingly common but predictors of successful SDD and 1-year clinical outcomes have not been described.OBJECTIVE:The purpose of this study was to explore predictors of successful SDD and report 1-year outcomes in patients undergoing LAAC with SDD.METHODS:A prospective analysis was performed over a 20-month period of 225 consecutive patients that underwent LAAC in a large, academic hospital. All patients included in the study underwent a SDD protocol. Baseline characteristics and 1-year outcomes of patients discharged same day of the procedure versus those that required at least one overnight stay were compared. Adverse events, procedural success, and procedure times were evaluated.RESULTS:One hundred and sixty-one patients (72%) of patients were discharged the same day and 64 patients (28%) required at least an overnight stay (non-SDD: NSDD). NSDD patients were older and more often female. Procedure time was also longer in the NSDD group than in the SDD (63.4 vs. 55.1 min; p = 0.01). While overall procedural success rates were similar between the SDD and NSDD groups (99.4% vs. 98.4%; p = 0.39), NSDD patients had more complications (9.4% vs. 0%; p = 0.01) and higher number of devices per procedure (1.2 vs. 1.0; p = 0.01) as compared to SDD. At 1 year, there were no significant difference between the SDD and NSDD groups in stroke (1.1% vs. 0%; log-rank p = 0.44) and all-cause mortality (3.9% vs. 4.7%; log-rank p = 0.70).CONCLUSION:In this single-center LAAC experience, female sex, older age, and longer procedure duration were associated with higher likelihood for need of overnight stay. At 1-year follow-up, there were no significant differences in stroke events and death rates between SDD and NSDD groups.

Aims Despite the common occurrence of coronary artery disease (CAD) and heart failure (HF) with preserved ejection fraction (HFpEF), there is limited evidence to guide revascularization. Methods and Results We investigated the long‐term outcomes of coronary artery bypass grafting (CABG) in patients with HF and significant CAD across the spectrum of ejection fraction, using a large national cohort of patients from the Veteran Affairs (VA) Medical Centers in the US. Patients with HF were stratified into groups, HFpEF, HF with mid‐range ejection fraction (HFmrEF), and HF with reduced ejection fraction (HFrEF) and compared to patients with no preoperative HF. We analysed 10 396 patients. Despite an increased hazard in the first year following revascularization, the long‐term survival (median follow‐up 6.6 years; interquartile range 3.7–10.1) of HFpEF post‐CABG was similar to controls (hazard ratio 0.85, 95% confidence interval 0.68‐1.06), but survival progressively declined with HFmrEF and HFrEF. Similar trends were seen with recurrent HF hospitalization with lower risk with baseline HFpEF (43.9 ± 6.9/100 patient‐years) compared to HFmrEF (65.9 ± 3.8/100 patient‐years) and HFrEF (93.4 ± 4.8/100 patient‐years). Although HFpEF patients had lower mortality and HF hospitalization post‐CABG compared to patients with a lower ejection fraction, they experienced the highest rates of future myocardial infarction. Conclusion Although HFpEF patients with CAD have greater short‐term risk post‐CABG, their long‐term survival is comparable to controls. However, they are at increased risk for HF hospitalizations and myocardial infarction. These data support the safety of CABG in HFpEF patients and suggest continuum of mortality risk for ischaemic HF when stratified by baseline ejection fraction before revascularization.

BackgroundSmall reference vessel diameters (RVDs) are a predictor of ischemic events after coronary stenting. Among patients at high bleeding risk (HBR) precluding long-term dual antiplatelet therapy (DAPT), those with small vessel disease (SVD) constitute an especially high-risk subgroup. Here, we evaluated the results of a durable-polymer, coronary zotarolimus-eluting stent (ZES) for the treatment of patients with SVD at HBR with 1-month DAPT.MethodsIn the prospective, multicenter Onyx ONE (One-Month DAPT) Clear study, 1506 patients at HBR treated with a ZES that discontinued DAPT at 30 days were included. The clinical outcomes of patients undergoing treatment of lesions with an RVD of ≤2.5 mm (SVD group, as determined by the angiographic core laboratory) were compared with patients without SVD. The primary end point was the composite of cardiac death or myocardial infarction between 1 and 12 months.ResultsSmall vessel diameter treatment was performed in 489 (32.5%) patients. Patients with SVD were more likely to be women, have undergone a previous percutaneous intervention, and have multivessel coronary artery disease than patients without SVD. There were no significant differences in lesion, device, or procedural success between the groups. The Kaplan-Meier rate estimate of the primary end point was 8.5% and 6.8% in patients with SVD and those without SVD, respectively (P = .425). No significant differences were found in any secondary end point. The Kaplan-Meier rate of stent thrombosis was 0.6% and 0.8% in patients with SVD and those without SVD, respectively (P = .50).ConclusionsAmong patients at HBR treated with a ZES and 1-month DAPT, those with SVD had favorable 12-month ischemic and bleeding outcomes, which were comparable with those of patients with larger caliber vessels.

•Diabetic patients are at high risk of ischemic events after coronary intervention.•Shortened dual antiplatelet therapy after intervention is an emerging strategy.•Diabetic patients received the Onyx stent and short dual antiplatelet therapy.•Diabetic patients had acceptable 1-year outcomes.

Objectives To compare clinical outcomes in high bleeding risk (HBR) patients with and without complex percutaneous coronary intervention (PCI) treated with Resolute Onyx zotarolimus-eluting stents (ZES) after 1-month dual antiplatelet therapy (DAPT). Background PCI with 1-month DAPT has been demonstrated to be safe in HBR patients treated with Resolute Onyx ZES. Whether these outcomes are consistent in patients with complex lesions is uncertain. Methods Among HBR patients who were event-free 1 month after PCI with ZES and treated thereafter with single antiplatelet therapy (SAPT), the clinical outcomes between 1 month and 1 year were compared after complex PCI (3 vessels treated, >= 3 lesions treated, total stent length > 60 mm, bifurcation with >= 2 stents implanted, atherectomy, or left main, surgical bypass graft or chronic total occlusion PCI) versus noncomplex PCI. Propensity score adjustment was performed to adjust for baseline differences among complex and noncomplex patients. Results Complex patients (N = 401, 26.6% of total) had a higher prevalence of hyperlipidemia, diabetes mellitus and previous myocardial infarction (MI). Between 1 month and 1 year, rates of MI (7.1% vs. 4.0%, p = 0.02) and cardiac death/MI (9.3% vs. 6.1%, p = 0.04) were higher among complex versus noncomplex patients, although stent thrombosis rates were similar. After adjustment for baseline characteristics, differences in outcomes were no longer significant between groups. Conclusions Higher rates of ischemic outcomes in complex PCI patients were largely explained by baseline clinical differences, rather than lesion complexity, among HBR patients treated with 1-month DAPT following PCI with Resolute Onyx ZES.

BACKGROUND:Percutaneous left atrial appendage occlusion (LAAO) with the Watchman device is FDA approved for stroke prevention in patients with nonvalvular atrial fibrillation who have an appropriate indication. During the COVID-19 pandemic, a same-day discharge protocol (SDDP) was employed to improve resource utilization, relieve hospital occupation, and reduce the possible risk of in-hospital virus transmission. OBJECTIVES:We sought to analyze the safety, feasibility, and cost effectiveness for SDDP in patients receiving LAAO. METHODS:A prospective analysis of 142 consecutive patients, 119 treated prior to SDDP and 23 who underwent SDDP following LAAO with cardiac computed tomography angiography (CTA)-guided pre-procedural planning and intracardiac echocardiogram (ICE). Procedures were performed in a single, large academic hospital in the United States. In-hospital and 45-day procedural success, adverse events, length of procedure, and length-of-stay were evaluated. RESULTS:Baseline patient characteristics including mean CHA2DS2VASc scores and mean HAS-BLED scores were similar in both groups. All procedures were successful. There was no significant difference in rates of procedural complications or in-hospital adverse events. The mean procedure time in the SDDP group was 11 minutes longer than in the conventional group (62.1 ± 5.9 vs 51.1 ± 21; P=.01). Outcomes at 45-day follow-up were similar. SDDP was associated with a reduced length of stay compared with conventional strategy and a 15% reduction in total costs. CONCLUSIONS:Same-day discharge strategy for LAAO appears safe, feasible and could become the new standard approach for LAAO. A protocol including CTA pre-procedural planning, ICE-guided deployment and conscious sedation reduces hospital occupation and lowers costs.