Background/Objectives: A novel CT dynamic angiographic imaging (CT-DAI) analytic algorithm was evaluated against the clinical gold standard for fractional flow reserve (FFR) measurement in patients with coronary artery disease (CAD) characterized by diffuse dense calcification and previous stent implantation. Methods: This retrospective feasibility study included 24 coronary arteries in 16 patients (age 69.9 ± 8.9 years, 11 males) with CAD who underwent dynamic CT myocardial perfusion scanning using a dual-source CT scanner after intravenous infusion of adenosine triphosphate. The included patients had analyzable proximal and distal coronary artery segments adjacent to the stenosis in the myocardial perfusion images and had corresponding invasive catheter-based FFR measurements for that stenosis. An in-house software based on the CT-DAI algorithm was used to compute FFR using the coronary time-enhancement curves sampled across the stenosis from stress myocardial CT perfusion images. The CT-DAI derived FFR values were then compared to the corresponding catheter-based FFR values. A coronary stenosis was considered functionally significant for FFR values below 0.8. Results: The mean axial length and calcium score of the coronary stenoses were 47.9 mm and 1911.63 Agatston Units, respectively. Eight coronary arteries received stents from previous treatments. The CT-DAI derived FFR values (0.822 ± 0.143) showed an excellent linear correlation (R = 0.974) with and were indifferent from the invasive FFR values (0.826 ± 0.147, p = 0.537), resulting in 100% per-vessel and per-patient sensitivity and specificity for the detection of functionally significant coronary stenosis. Bland-Altman analysis revealed a minimal mean difference in FFR measurements (0.004) between the two modalities with the lower and upper limits of agreement at -0.061 and 0.069, respectively. Conclusions: The findings suggest that CT-DAI can derive FFR for the coronary arteries with heavy calcification and stents from dynamic myocardial CT perfusion images.

Previous studies have shown the safety of early discharge pathways in selected patients and using selected transcatheter heart valves. Hence, we sought to evaluate the safety of next-day discharge (NDD) in patients who underwent transfemoral transcatheter aortic valve implantation (TF-TAVI) with the ACURATE neo/neo2 (Boston Scientific, Marlborough, Massachusetts) self-expanding aortic bioprosthesis. Patients who underwent TF-TAVI between January 2018 and April 2023 were prospectively included. Patients were stratified into 3 groups according to discharge times within 24 hours (NDD), between 24 and 48 hours, and those discharged >48 hours after TAVI. The primary outcome was the first unplanned readmission at 30 days after TAVI. Log-rank test was used to assess the differences in the outcome of interest between the groups. A total of 368 all-comers were included in this study. According to discharge times, 204 patients followed NDD, 69 patients 24 to 48 hours discharge, and 95 patients >48 hours discharge after TAVI. The mean age was 84 ± 6.3 years and 61% were women, without differences between the groups. The mean Society of Thoracic Surgeons score was lower in those with NDD versus 24 to 48 hours and >48 hours (2.9 ± 1.0, 3.2 ± 1.2, and 3.4 ± 1.4, respectively, p = 0.014). There were no differences between the groups in terms of preprocedural right bundle branch block or pacemaker. The need for new permanent pacemaker implantation was the leading postprocedural complication; it occurred more frequently in the >48 hours group than the 24 to 48 hours, and <24 hours groups (24% vs 8.6% and 2.2%, p <0.001). There were 5 strokes (1.4%) and all of them occurred in the >48 hours group (p = 0.005). At 30 days after discharge, there were no deaths and no differences in all-cause readmissions (9.3% in <24 hours, 8.6% in 24 to 48 hours, and 19% in >48 hours, log-rank p = 0.087). The readmission rates for new permanent pacemaker implantation requirement were 3.3% (n = 6) in NDD, 0% in 24 to 48 hours, and 1.6% (n = 5) in the >48 hours groups (p = 0.27). In conclusion, in unselected patients who underwent TF-TAVI with the ACURATE neo/neo2 self-expanding bioprosthesis, the NDD pathway is feasible and appears to be safe, without an increased risk of death or all-cause rehospitalization through 30 days after hospital discharge.

Purposes:The objective was to evaluate the accuracy of a novel CT dynamic angiographic imaging (CT-DAI) algorithm for rapid fractional flow reserve (FFR) measurement in patients with coronary artery disease (CAD). Materials and Methods:This retrospective study included 14 patients (age 58.5 ± 10.6 years, 11 males) with CAD who underwent stress dynamic CT myocardial perfusion scanning with a dual-source CT scanner. The included patients had analyzable proximal and distal coronary artery segments adjacent to the stenosis in the perfusion images and had corresponding invasive catheter-based FFR measurements for that stenosis. An in-house software based on the CT-DAI algorithm was used to compute FFR using the pre- and post- lesion coronary time-enhancement curves obtained from the stress myocardial perfusion images. The CT-DAI derived FFR values were then compared to the corresponding catheter-based invasive FFR values. A coronary artery stenosis was considered functionally significant for FFR value <0.8. Results:The CT-DAI derived FFR values were in agreement with the invasive FFR values in all 15 coronary arteries in 14 patients, resulting in 100% per-vessel and per-patient diagnostic accuracy. FFR derived using CT-DAI (M = 0.768, SD = 0.156) showed an excellent linear correlation (R = 0.910, P < .001) and statistical indifference (P= .655) with that measured using invasive catheter-based method (M = 0.796, SD = 0.149). Bland-Altman analysis showed no significant proportional bias. Conclusion:The novel CT-DAI algorithm can reliably compute FFR across a coronary artery stenosis directly from dynamic CT myocardial perfusion images, facilitating rapid on-site hemodynamic assessment of the epicardial coronary artery stenosis in patients with CAD.

BackgroundSymptomatic patients with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (SAVR) sustain comparable improvements in health status over 5 years after transcatheter aortic valve replacement (TAVR) or SAVR. Whether a similar long-term benefit is observed among intermediate-risk AS patients is unknown.ObjectivesThe purpose of this study was to assess health status outcomes through 5 years in intermediate risk patients treated with a self-expanding TAVR prosthesis or SAVR using data from the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial.MethodsIntermediate-risk patients randomized to transfemoral TAVR or SAVR in the SURTAVI trial had disease-specific health status assessed at baseline, 30 days, and annually to 5 years using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Health status was compared between groups using fixed effects repeated measures modelling.ResultsOf the 1,584 patients (TAVR, n = 805; SAVR, n = 779) included in the analysis, health status improved more rapidly after TAVR compared with SAVR. However, by 1 year, both groups experienced large health status benefits (mean change in KCCQ-Overall Summary Score (KCCQ-OS) from baseline: TAVR: 20.5 ± 22.4; SAVR: 20.5 ± 22.2). This benefit was sustained, albeit modestly attenuated, at 5 years (mean change in KCCQ-OS from baseline: TAVR: 15.4 ± 25.1; SAVR: 14.3 ± 24.2). There were no significant differences in health status between the cohorts at 1 year or beyond. Similar findings were observed in the KCCQ subscales, although a substantial attenuation of benefit was noted in the physical limitation subscale over time in both groups.ConclusionsIn intermediate-risk AS patients, both transfemoral TAVR and SAVR resulted in comparable and durable health status benefits to 5 years. Further research is necessary to elucidate the mechanisms for the small decline in health status noted at 5 years compared with 1 year in both groups. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI]; NCT01586910)

BACKGROUND:No data compare newer-generation transcatheter heart valves (THVs) in terms of next-day discharge (NDD) following transfemoral (TF) transcatheter aortic valve implantation (TAVI). AIMS:We aimed to evaluate the safety of NDD in unselected patients who received ACURATE (neo/neo2), Evolut (PRO/PRO+/FX) and the SAPIEN (3/Ultra) THVs. METHODS:This multicentre registry included patients who underwent TF-TAVI without a preprocedural permanent pacemaker implantation (PPI) and were discharged the next day without a new PPI. The primary endpoint was unplanned readmissions at 30 days. Multinomial gradient-boosted inverse probability of treatment-weighted (IPTW) propensity scores (stage 1) followed by the modified Poisson regression (stage 2) approach were used to compare the average effects of the THVs on the primary outcome. RESULTS:A total of 963 all-comer patients (ACURATE=264, Evolut=306, and SAPIEN=393) were included in this study. ACURATE patients were older (p<0.001) and included a greater proportion of females (p<0.001), whereas Evolut patients had a higher risk profile as assessed by the Society of Thoracic Surgeons score (p=0.01). There were no differences between the groups in terms of right or left bundle branch block (p=0.75). At 30 days, the overall readmission rate was 8%, and there were no differences in cardiac (ACURATE 4.6% vs Evolut 4.2% vs SAPIEN 3.1%; p=0.56) or non-cardiac readmissions (ACURATE 4.6% vs Evolut 3.3% vs SAPIEN 4.6%; p=0.64). Readmission for new PPI was 2.7%, 1.0% and 1.8% (p=0.32) and for heart failure (HF) was 1.5%, 2.0% and 1.3% (p=0.76) in ACURATE, Evolut and SAPIEN patients, respectively. The IPTW propensity score model followed by modified Poisson regression indicate that, using ACURATE as the reference, no significant differences were found in 30-day readmissions (relative risk [RR] 0.76, 95% confidence interval [CI]: 0.38-1.52; p=0.38 for Evolut and RR 0.74, 95% CI: 0.44-1.22; p=0.28 for SAPIEN). CONCLUSIONS:In pacemaker-naïve patients undergoing TF-TAVI with newer-generation THVs, NDD was not associated with a negative impact on overall 30-day readmissions, cardiac or non-cardiac readmissions, readmissions for PPI or HF after discharge, or mortality, regardless of the type of THV.

Transcatheter aortic valve implantation (TAVI) technologies have led to a reduction in delivery systems profiles and, along with expandable introducer sheaths, reducing the incidence of vascular complications. Nonetheless, a second arterial access is needed to landmark the aortic cusps and obtain a coplanar view for valve positioning and implantation.1,2 We aimed to report our single-centre experience of using a single-arterial access for TAVI with the Acurate neo/neo 2 (Boston Scientific, Marlborough, MA) self-expanding aortic bioprosthesis.

This study sought to evaluate patient-centered metrics in intermediate-surgical-risk aortic stenosis patients enrolled in the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial treated with self-expanding transcatheter aortic valve replacement (TAVR) or surgery.Studies have shown TAVR to be an alternative to surgery in patients with severe symptomatic aortic stenosis but have focused on "hard endpoints," including all-cause mortality and stroke, rather than on comparative patient-centered metrics, such as functional status and symptom burden.The study analyzed functional status (6-minute walk test [6MWT]) and symptom burden (Kansas City Cardiomyopathy Questionnaire) in 1,492 patients from the SURTAVI trial at baseline, 30 days, 1 year, and 2 years. Patients were categorized by baseline functional status into tertiles of slow, medium, and fast walkers.Patients with lowest capacity baseline functional status were commonly women, had higher Society of Thoracic Surgeons scores, and had more New York Heart Association functional class III or IV symptoms; reduced baseline functional status was associated with higher aortic valve- and heart failure-related hospitalization at 2 years. There was greater improvement in 6MWT distance in TAVR compared with surgery patients at 30 days (P < 0.001) and 1 year (P = 0.012), but at 2 years, both groups had similar improvement (P = 0.091). The percentage of patients with large improvement in 6MWT was greatest in patients categorized as slow walkers and lowest in fast walkers. Symptom burden improved after TAVR at 30 days and after both procedures at 1 and 2 years.In this substudy of patients from the SURTAVI trial, patients receiving TAVR demonstrated a more rapid improvement in functional status and symptom burden compared with patients undergoing surgery; however, both groups had similar improvements in long-term follow-up. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI]; NCT01586910).

To gain insight into the pathophysiology of late drug-eluting stent (DES) restenosis.Restenosis of DES has a different time course from that of bare metal stents.Patients who underwent follow-up coronary angiography (CAG) twice (six to nine months and 18 to 24 months) after DES implantation were examined using optical coherence tomography (OCT). All lesions with target lesion revascularization at first follow-up were excluded. Late catch-up was defined as lesions that progressed from less than 50% diameter stenosis (DS) at the first CAG to more than 50% DS at the second CAG. Lesions with the late catch-up were further divided into two groups; lesions with jump-up (less than 25% DS at the first CAG) and lesions with gradual progression (25–50% DS at the first CAG).Of the 25 patients who had late ISR, 23 patients (10 jump-up/13 gradual progression) were examined with OCT at late follow-up and enrolled in this study. In the qualitative OCT assessment, each ratio of homogeneous, layered, heterogeneous with or without attenuation tissue morphologies were in jump-up group, and gradual progression group were 0% and 15%, 0% and 23%, and 60% and 8%, and 40% and 54%, respectively. All of jump-up group showed heterogeneous restenotic tissue, while 62% of gradual progression group showed heterogeneous restenotic tissue (P = .04).These findings suggest different pathophysiology of the late catch-up after DES implantation between the jump-up and gradual progression groups.

OBJECTIVES This study sought to evaluate patient-centered metrics in intermediate-surgical-risk aortic stenosis patients enrolled in the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial treated with self-expanding transcatheter aortic valve replacement (TAVR) or surgery. BACKGROUND Studies have shown TAVR to be an alternative to surgery in patients with severe symptomatic aortic stenosis but have focused on "hard endpoints," including all-cause mortality and stroke, rather than on comparative patient-centered metrics, such as functional status and symptom burden. METHODS The study analyzed functional status (6-minute walk test [6MWT]) and symptom burden (Kansas City Cardiomyopathy Questionnaire) in 1,492 patients from the SURTAVI trial at baseline, 30 days, 1 year, and 2 years. Patients were categorized by baseline functional status into tertiles of slow, medium, and fast walkers. RESULTS Patients with lowest capacity baseline functional status were commonly women, had higher Society of Thoracic Surgeons scores, and had more New York Heart Association functional class III or IV symptoms; reduced baseline functional status was associated with higher aortic valve- and heart failure-related hospitalization at 2 years. There was greater improvement in 6MWT distance in TAVR compared with surgery patients at 30 days (P < 0.001) and 1 year (P = 0.012), but at 2 years, both groups had similar improvement (P = 0.091). The percentage of patients with large improvement in 6MWT was greatest in patients categorized as slow walkers and lowest in fast walkers. Symptom burden improved after TAVR at 30 days and after both procedures at 1 and 2 years. CONCLUSIONS In this substudy of patients from the SURTAVI trial, patients receiving TAVR demonstrated a more rapid improvement in functional status and symptom burden compared with patients undergoing surgery; however, both groups had similar improvements in long-term follow-up. (Safety and Efficacy Study of the Medtronic CoreValve (R) System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI]; NCT01586910) (C) 2022 by the American College of Cardiology Foundation.

BACKGROUND:Chronic total occlusions (CTO) are common and are associated with lower percutaneous coronary intervention (PCI) success rates, often due to failure of antegrade guidewire crossing. Local, intralesional delivery of collagenase (MZ-004) may facilitate guidewire crossing in CTO.AIMS:To evaluate the effect of MZ-004 in facilitating antegrade wire crossing in CTO angioplasty.METHODS:A total of 76 patients undergoing CTO PCI were enrolled at 13 international sites: 38 in the randomized training stage (collagenase [MZ-004] 900 or 1200 μg) and 38 in the placebo-controlled stage (MZ-004 900 or 1200 μg or placebo). Patients received the MZ-004 or identical volume saline (placebo group) in a double-blind design, injected via microcatheter directly into the proximal cap of the CTO. The following day patients underwent CTO PCI using antegrade wire techniques only.RESULTS:Patients were generally similar except for a trend for higher Japanese chronic total occlusion (J-CTO) score in the MZ-004 group (MZ-004 J-CTO score 1.9 vs. 1.4, p = 0.07). There was a numerical increase in the rates of guidewire crossing in the MZ-004 groups compared to placebo (74% vs. 63%, p = 0.52). Guidewire crossing with a soft-tip guidewire (≤1.5 g tip load) was significantly higher in the MZ-004 groups (0% in placebo, 17% in 900 μg, and 29% in 1200 μg MZ-004 group, p = 0.03). Rates of the major adverse cardiovascular event were similar between groups.CONCLUSION:Local delivery of MZ-004 into coronary CTOs appears safe and may facilitate CTO crossing, particularly with softer tipped guidewires. These data support the development of a pivotal trial to further evaluate this agent.

Refinements in transcatheter aortic valve technologies have led to a reduction in delivery systems profiles and, along with expandable introducer sheaths, reducing the incidence of vascular complications. Nonetheless, a second arterial access is needed to landmark the aortic cusps while obtaining a coplanar view. We aimed to report our single-center experience of using a single-arterial access for transcatheter aortic valve implantation (TAVI) with the Acurate neo (Boston Scientific, Marlborough, USA) self-expanding aortic bioprosthesis. TAVI with the Acurate neo system was performed by transfemoral access in a hybrid operating room. Femoral arterial access was obtained using fluoroscopy and ultrasound guided and two suture-mediated Perclose ProGlide (Abbott Laboratories, Chicago, IL, USA) devices were deployed for preclosure technique. A 14-French expandable iSleeve sheath (Boston Scientific, Marlborough, USA) was then inserted. The hemostatic valve of the iSleeve sheath was punctured at 2 o’clock (close to the outer edge, Figure) using an 18G needle, a 0.035” J-type wire advanced, and a 5-French pigtail was inserted over-the-wire. Balloon aortic valvuloplasty was performed in all patients using rapid pacing over the Safari 2 (Boston Scientific, Marlborough, USA) preshaped wire. Afterwards, the delivery system with the Acurate neo was advanced over the Safari 2 wire and TAVI performed as per standard practice. Outcomes were assessed according to valvular academic research consortium (VARC-3) criteria at 30 days. A total of 100 patients (mean age of 85±6 years, 60% women) were included. Procedures were successfully performed in all patients. There were no conversions to surgery, and 2 (2%) needed surgical repairs of the femoral artery. One (1%) patient had an in-hospital stroke. Length of hospital stay was 1.4±1.6 days. Six (out of 93 [6.5%] without prior pacemaker) required new permanent pacemaker implantation, and there were no deaths at 30 days. Single access for TAVI with the Acurate neo and iSleeve is safe and effective in avoiding the need for a secondary access, thereby reducing the risks of further vascular non-access site related complications.

BACKGROUND The Royal College of Physicians and Surgeons of Canada (RCPSC) provides training objectives for cardiac catheterization and hemodynamics for adult cardiology training in Canada. We evaluated current core cardiology trainee perspectives on cardiac catheterization training across Canada and identified potential barriers to pursuing a career in interventional cardiology (IC). METHODS AND RESULTS Residents from all cardiology training programs across Canada (n=15 programs) were provided open and closed ended questions regarding the ability of their programs to address the mandatory components of their core angiography rotations. Programs were divided based on size for analysis. A small program was defined as ≤ 10 total trainees, a medium program as 11-15 trainees and a large program as > 15 trainees. Survey responses were received from 82 residents (82/206, 40% response rate). There was equal representation from all three years of training (post-graduate year (PGY)-4: n=24, 30%, PGY-5: n=28, 35%, PGY-6: n=29, 36%) and 39% of respondents were female (n=32). Overall 91% of trainees (n=70/77) felt that their program met the RCPSC requirements for cardiac catheterization. Of the trainees who felt that their training was inadequate, most common reasons indicated were lack of right heart catheterization exposure and lack of structured teaching specifically related to hemodynamics. When stratified by PGY of training or program size, there were no statistically significant differences in comfort with procedural skills or hemodynamic interpretation. The proportion of teaching by faculty was higher in small programs (p=0.039). There was a higher proportion of trainees who indicated that they had no structured cardiac catheterization teaching in medium sized programs (p=0.041). Only 22% of residents (n=18) identified IC as a career goal. Trainee-identified barriers to a career in IC are outlined in Figure 1 and stratified by gender. Lifestyle and family considerations were the two most common barriers with no statistically significant difference between genders (p=1.000 and p=0.18 respectively). Sexism was identified as a barrier only by female trainees (n=12/32, 38%, p < 0.0001) and length of training was identified more frequently as a barrier by male trainees (n=25/50, 50%, p=0.037). CONCLUSION Regardless of program size, the majority of Canadian cardiology trainees feel the RCPSC requirements for cardiac catheterization are met by their programs. Lifestyle and family considerations were the most common barriers to interventional training. Sexism was also identified as a common barrier amongst women. Creating an environment that promotes diversity, equity and inclusivity is crucial for all programs across Canada. The Royal College of Physicians and Surgeons of Canada (RCPSC) provides training objectives for cardiac catheterization and hemodynamics for adult cardiology training in Canada. We evaluated current core cardiology trainee perspectives on cardiac catheterization training across Canada and identified potential barriers to pursuing a career in interventional cardiology (IC). Residents from all cardiology training programs across Canada (n=15 programs) were provided open and closed ended questions regarding the ability of their programs to address the mandatory components of their core angiography rotations. Programs were divided based on size for analysis. A small program was defined as ≤ 10 total trainees, a medium program as 11-15 trainees and a large program as > 15 trainees. Survey responses were received from 82 residents (82/206, 40% response rate). There was equal representation from all three years of training (post-graduate year (PGY)-4: n=24, 30%, PGY-5: n=28, 35%, PGY-6: n=29, 36%) and 39% of respondents were female (n=32). Overall 91% of trainees (n=70/77) felt that their program met the RCPSC requirements for cardiac catheterization. Of the trainees who felt that their training was inadequate, most common reasons indicated were lack of right heart catheterization exposure and lack of structured teaching specifically related to hemodynamics. When stratified by PGY of training or program size, there were no statistically significant differences in comfort with procedural skills or hemodynamic interpretation. The proportion of teaching by faculty was higher in small programs (p=0.039). There was a higher proportion of trainees who indicated that they had no structured cardiac catheterization teaching in medium sized programs (p=0.041). Only 22% of residents (n=18) identified IC as a career goal. Trainee-identified barriers to a career in IC are outlined in Figure 1 and stratified by gender. Lifestyle and family considerations were the two most common barriers with no statistically significant difference between genders (p=1.000 and p=0.18 respectively). Sexism was identified as a barrier only by female trainees (n=12/32, 38%, p < 0.0001) and length of training was identified more frequently as a barrier by male trainees (n=25/50, 50%, p=0.037). Regardless of program size, the majority of Canadian cardiology trainees feel the RCPSC requirements for cardiac catheterization are met by their programs. Lifestyle and family considerations were the most common barriers to interventional training. Sexism was also identified as a common barrier amongst women. Creating an environment that promotes diversity, equity and inclusivity is crucial for all programs across Canada.

OBJECTIVE:Hybrid coronary revascularization (HCR) combines both surgical and percutaneous coronary revascularization procedures. It offers a minimally invasive strategy for multivessel coronary artery disease and combines the advantages of both. However, quantitative long-term patency and clinical outcomes remain understudied. The objective of this study was to assess clinical outcomes and graft and stent patency at 5-year follow-up.METHODS:From January 2004 to January 2015, 120 patients were enrolled in this study. They underwent robotically assisted minimally invasive coronary artery bypass grafting of left internal thoracic artery (LITA) to the left descending artery (LAD) and percutaneous coronary intervention of non-LAD vessels. Primary outcome was graft (LITA-LAD) patency determined at 5 years of follow-up, assessed by computed tomography angiography and rest and stress myocardial perfusion scintigraphy (MPS-MIBI). Secondary outcomes were stent patency and major adverse major cardiac and cerebrovascular events (MACCE). Also, freedom from recurrence of angina was assessed.RESULTS:At follow-up, 18 of 120 patients (15%) had died (in 5 patients the cause of death was cardiovascular). Among survivors, follow-up was achieved in 83 of 102 (81%). In 76 of 83 patients (92%) there was a patent LITA-LAD graft and in 75 of 83 (90%) a patent stent was demonstrated. MACCE occurred in 36 of 120 patients (30%). Freedom from recurrence of angina occurred in 92 of 120 patients (77%).CONCLUSIONS:HCR is a safe and a promising procedure. It provides a minimally invasive approach and results in complete revascularization with good 5-year patency and clinical outcomes.

Unstable angina pectoris (UA) is a variant of acute coronary syndrome without ST segment elevation (NSTEACS), which is characterized by the absence of biochemical criteria for myocardial damage, a change in the clinical picture of angina pectoris (an increase in the functional class of angina pectoris, the appearance of resting angina and a high probability of transformation of the process into myocardial infarction (MI). UA and the developed MI without ST segment elevation (NSTEMI) are not accompanied by the appearance of a pathological Q wave and are characterized by a general complex pathogenesis associated with progressive atherosclerosis, a non-occlusive thrombus in the area of erosion or rupture of an atherosclerotic plaque, vasospasm, coronary microcirculatory dysfunction or other causes of imbalance between oxygen intake and oxygen consumption resulting in myocardial ischemia, and are distinguished by increased levels of myocardial necrosis in the blood in case of NSTEMI. It is difficult to differentiate UA and NSTEMI in the first hours of the development of the process when a decision is made on reperfusion technologies and drug therapy without laboratory, and in some cases, additional examination with visualization of the probable new loss of viable myocardium, therefore, the diagnosis and management of these two clinical conditions are usually considered in the same clinical recommendations. A fairly common point of view that the risk of death in UA is significantly lower and the patient is less in need of an intensive strategy than with verified NSTEMI, is controversial given the likely cases of sudden cardiac death of ischemic genesis at the prehospital stage and the difficulties of differential diagnosis of these clinical states. The factors contributing to diagnostic errors include severity of the patient's condition, a variety of clinical atypical manifestations and pathophysiological mechanisms of myocardial ischemia, the presence of comorbid pathology. The article discusses various mechanisms of the development of myocardial ischemia, diagnostic and therapeutic invasive and non-invasive technologies that improve the prognosis of patients with UA. The optimal management tactics of NSTEACS includes early diagnosis and risk stratification, emergency hospitalization, monitoring, the use of non-invasive and invasive strategies, including coronary angiography and revascularization, as well as emergency and long-term treatment aimed at preventing acute cardiovascular events taking into account the age, gender differences and comorbid pathology. A differentiated approach to the administration of emergency therapy is the key to improving the prognosis of this high-risk category of patients. Due to the lack of the possibility of using revascularizing technologies in patients with obstructive coronary disease, non-pharmacological technologies that positively affect microcirculation processes are likely to be used: exposure of the patient’s blood to an alternating magnetic field (extracorporeal autohemomagnetotherapy) or to ultraviolet optical radiation (ultraviolet blood modification). In view of the difficulty in identifying the mechanism of myocardial ischemia in each individual patient with UA and a high likelihood of combination of various pathophysiological factors, myocardium rescue should be in the focus of therapeutic intervention, which dictates the validity and utility of all the recommended and available methods of pharmacological and non-pharmacological therapy and revascularization to reduce the effects of myocardial ischemia.

OBJECTIVES The aim of this study was to report the 2-year results of the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial and confirm the interim Bayesian analysis. BACKGROUND Transcatheter aortic valve replacement (TAVR) with a self-expanding valve was noninferior to surgery in patients with severe aortic stenosis and intermediate operative risk using Bayesian statistical methods. Novel Bayesian designs have been used to shorten the time to primary endpoint analysis in randomized clinical trials, although the predictive value of Bayesian analysis compared with frequentist approaches remains debated. METHODS The SURTAVI trial randomized 1,660 patients. An interim analysis was performed 1 year after the 1,400th patient was treated to estimate the primary 2-year endpoint of all-cause mortality or disabling strokes for all patients. RESULTS The Kaplan-Meier rate for the complete 2-year primary endpoint was 12.7% in the TAVR group and 12.6% in the surgery group (0.0% difference; 95% confidence interval: -3.4% to 3.5%), compared with 12.6% with TAVR and 14.0% with surgery (-1.4% difference; Bayesian credible interval: -5.2% to 2.3%) in the interim Bayesian analysis. A comparison of individual clinical, hemodynamic, and quality-of-life endpoints using Bayesian and frequentist methods found no significant differences. CONCLUSIONS The complete analysis of all patients with aortic stenosis at intermediate risk for surgery in the SURTAVI trial confirmed the noninferiority, with respect to the frequency of all-cause mortality or disabling stroke, of TAVR to surgery, as determined in the interim Bayesian analysis. Follow-up will extend out to 10 years. (C) 2020 by the American College of Cardiology Foundation.

We investigated a projection interpolation method for reconstructing dynamic contrast-enhanced (DCE) heart images from undersampled x-ray projections with filtered backprojecton (FBP). This method may facilitate the application of sparse-view dynamic acquisition for ultralow-dose quantitative computed tomography (CT) myocardial perfusion (MP) imaging. We conducted CT perfusion studies on 5 pigs with a standard full-view acquisition protocol (984 projections). We reconstructed DCE heart images with FBP from all and a quarter of the measured projections evenly distributed over 360°. We interpolated the sparse-view (quarter) projections to a full-view setting using a cubic-spline interpolation method before applying FBP to reconstruct the DCE heart images (synthesized full-view). To generate MP maps, we used 3 sets of DCE heart images, and compared mean MP values and biases among the 3 protocols. Compared with synthesized full-view DCE images, sparse-view DCE images were more affected by streak artifacts arising from projection undersampling. Relative to the full-view protocol, mean bias in MP measurement associated with the sparse-view protocol was 10.0 mL/min/100 g (95%CI: −8.9 to 28.9), which was >3 times higher than that associated with the synthesized full-view protocol (3.3 mL/min/100 g, 95% CI: −6.7 to 13.2). The cubic-spline-view interpolation method improved MP measurement from DCE heart images reconstructed from only a quarter of the full projection set. This method can be used with the industry-standard FBP algorithm to reconstruct DCE images of the heart, and it can reduce the radiation dose of a whole-heart quantitative CT MP study to <2 mSv (at 8-cm coverage).

Objective: The role of hybrid coronary revascularization (HCR), which utilizes the combination of minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery and percutaneous coronary intervention (PCI) of non-left anterior descending vessels to treat multivessel coronary artery disease, is expanding.We set out to provide a review of this technology. Methods: We conducted a retrospective analysis of all minimally invasive hybrid operations performed at our institution from September 2004 to December 2018. An effective analysis comparing patients undergoing HCR vs off-pump or on-pump surgical coronary artery revascularization was undertaken using an adjusted analysis with inverse-probability weighting based on the propensity score. Outcomes that were assessed include death, myocardial infarction, stroke, atrial fibrillation, renal failure, requirement of blood transfusion, conversion to open procedure (in the hybrid group), length of stay in intensive care unit, and total length of stay in hospital. Intention-to-treat analysis was performed. An up-to-date literature review of HCR complements this study. Results: Since 2004 a total of 191 consecutive patients (61.4 +/- 11.1 years; 142 males and 49 females) underwent HCR (robotic-assisted coronary artery bypass graft of the left internal thoracic artery to the left anterior descending coronary artery (LAD) and PCI of a non-LAD vessel) in a single- or double-stage fashion. Successful HCR occurred in 183 of the 191 patients (8 patients required intraoperative conversion to conventional coronary bypass). From our comparative analysis and literature review we found no significant difference between HCR and coronary artery bypass grafting groups with respect to in-hospital and I -year follow-up. Conclusions: Current evidences suggest that HCR is a feasible, safe, and effective coronary artery revascularization strategy in selected patients with multivessel coronary artery disease.

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. Percutaneous coronary intervention in patients with TAVI can be challenging. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent rotational atherectomy.