Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIHR Background Anthracyclines, which are commonly used in cancer treatment can induce myocardial damage, result in heart failure during treatment and have cardiac effects even decades after treatment. Monitoring of cardiotoxicity during treatment is largely based on the use of echocardiographic functional markers like ejection fraction and more recently myocardial strain imaging. Some studies have also looked at the utility of biomarkers like troponin and BNP. The utility of this surveillance strategy remains controversial as larger prospective studies are lacking. Purpose The aim of this study was to prospectively describe the impact of anthracycline treatment on echocardiographic functional parameters and cardiac biomarkers (high sensitivity troponin T and NT-Pro BNP) during the treatment period and twelve months after completion of treatment. In the current study we wanted to look at whether monitoring parameters during treatment were predictive of left ventricular function 12 months after treatment. Methods This was a prospective multi-centre nested case-control study of 256 children diagnosed with cancer requiring anthracycline therapy. Baseline functional echocardiographic parameters and cardiac biomarkers were obtained prior to starting anthracycline therapy, during the treatment protocol, and 12 months after treatment completion. Patients were assigned to one of two comparison groups based on the fractional shortening at the12-month echocardiogram: patients in group 1 had normal fractional shortening, (FS ³ 28%) while patients in group 2 had reduced fractional shortening (FS < 28%). Results A total of 917 echoes were performed, 376 of these occurred during the treatment period. FS was reduced in 27 (7%) of echoes obtained during the treatment period with 22 patients developing new onset dysfunction. Twelve months after treatment completion 232 patients had normal FS (Group 1), while 24 patients showed reduced FS (Group 2). Both groups had normal systolic function and cardiac biomarkers at baseline, however patients in group 2 were older at diagnosis (13.2 years (11.8-16) vs 6.5 years (3.4-13.2), p = 0.003) and received a higher cumulative anthracycline dose (200 mg/m2 (143-318) vs 125 mg/m2 (75-200), p= 0.005). One third (8/24) of patients in group 2 had at least 1 abnormal echo during the treatment period compared to 7% (16/232) in the normal group P < 0.001. The proportion of patients with at least one abnormal biomarker during this period however, was similar between groups. Conclusion(s) Patients receiving higher accumulative anthracycline doses and those with abnormal FS during the treatment period are at higher risk of having reduced cardiac function 12 months after treatment. High sensitivity troponin and NT-Pro BNP levels during the treatment period fail to discriminate patients at risk of developing early reduced systolic function. The relationship of these early results to long term cardiac function remains to be demonstrated.

Abstract Background Pediatric dilated cardiomyopathy (DCM) affects left ventricular (LV) function and carries a high risk of death or heart transplantation. However, the relation of LV regional function and inefficiency to clinical outcomes is underexplored. Purpose The aim of this study was to understand the relationship of regional LV mechanics, global LV function and clinical characteristics to the outcomes of death or heart transplant in children with DCM; through the integration of a vast amount of information enabled by unsupervised machine learning techniques. Methods DCM was defined by a LV end-diastolic dimension z-score > 2 and LV ejection fraction (EF) <55%. Longitudinal strain curves were sampled at 6 LV lateral wall and septal locations from the 4ch apical view. In addition, we analyzed other echo parameters including the aortic outflow pattern as a measure of LV pump function, QRS duration, LV EF, indexed end-diastolic LV dimension, global longitudinal strain and patient characteristics including age, weight, body surface area and medications (diuretics, ACE inhibitor, beta-blockers, mineralocorticoid receptor antagonist, digoxin, inotropes, antiarrhythmics). We used an unsupervised machine learning algorithm (multiple kernel learning) to reduce the dimensionality of these data, and position patients based on similarities. We subsequently used k-means clustering to recover homogeneous groups of patients. We then interpreted the data patterns associated to each of the groups for the occurrence of death or transplant through non-linear regression analysis (multi-scale kernel regression). Results 50 children with DCM (age 0 to 18 years) were analyzed. Clustering on the two first dimensions of the low-dimensional space resulted in three clusters (Figure A), with significantly different proportions of the composite outcome of death or heart transplant (Cl1 = 79%, Cl2 = 50%, Cl3 = 20%; p = 0.01). The group with the highest proportion of death or transplant (cluster 1) comprised the oldest and most frequently medicated subjects, with impaired LVEF and GLS, and with the widest QRS duration (p < 0.01) (Figure B). The group with the second highest proportion of death or transplant (cluster 2) comprised patients with the lowest LVEF (p < 0.01) and GLS (p < 0.001), reduced and delayed peak aortic outflow velocity and severely impaired basal and apical LV strain (Figure C). In contrast, the group with highest transplant-free survival (cluster 3) had the highest LVEF and GLS values, the most synchronous LV contraction as assessed by strain and QRS duration and the highest amplitude and earliest peaking aortic flow. Conclusion Our results serve as a proof-of-concept that machine-learning based approaches can be useful to explore and understand which regional and global echo parameters in combination with clinical parameters are associated with a higher risk of death or transplant in pediatric DCM. Abstract 546 Figure

A dedicated super-high pressure noncompliant balloon (OPN NC; SIS Medical AG, Winterthur, Switzerland) has been designed to optimize dilatation of rigid coronary lesion with heavy calcification. A performance of this balloon either in in-stent restenosis or native coronary disease, both in elective cases and in acute coronary syndrome, has never been studied in our hospital. From September 2016 to August 2017 in Royal Alexandra Hospital, 13 consecutive patients with extremely calcified coronary stenotic lesions in which conventional dilatation with NC balloon at rated burst pressure remained incapable of obtaining adequate lumen gain necessitating further dilatation with OPN NC balloon were retrospectively evaluated. Residual luminal diameter stenosis <30% was considered angiographic success. We measured baseline, post NC balloon and post OPN NC balloon minimal lumen diameter (MLD) as well as percentage of diameter stenosis (%DS). 12 out of 13 extremely calcified lesions were successfully dilated (92.3%). In two patients with NSTEMI, the lesions were unable to be crossed with either such OPN NC balloon or any very low-profile balloon mandating rotational atherectomy. In one of these two patients, however, OPN NC balloon was still required for stent optimization after successful lesion preparation with rotational atherectomy. One extremely calcified lesion with in-stent restenosis in previously under deployed lesion even ruptured two OPN balloons, luminal dilatation was achieved perfectly, nevertheless. This balloon was also successfully applied in the case with acute lateral wall STEMI. With OPN NC balloon acute luminal gain were greater while %DS was lower. There was no evidence of complication observed regarding coronary dissection, vessel perforation or balloon entrapment. Additionally, no MACE was revealed immediately post dilatation as well as at 30-day follow up. In detail, our study illustrated mean lesion reference diameter of 3.32 mm(+/- 0.3), mean pretreatment MLD of 0.4mm(+/-0.2), mean diameter stenosis of 87.8% (+/- 7.3), mean lumen gain post conventional NC balloon of 1.79 mm (+/- 0.42), and mean lumen gain post OPN NC balloon of 2.67mm(+/-0.44) Very high-pressure dilatation resorting OPN NC balloon should be considered as not only effective but also safe approach when experiencing extremely calcified lesions undilatable by conventional high-pressure NC balloon. This strategy helped avoid employing rotational atherectomy in most cases; however, such atherectomy device remained indispensable in extremely rigid coronary lesions.

In pediatric echocardiography, myocardial strain is increasingly being used to improve evaluation of regional and global ventricular function. It is likely that myocardial strain measurements are influenced by cardiac size and growth in healthy children but results have so far been inconsistent. Studies proposing reference values are scarce and are sometimes based on incomplete methodologies for body size adjustment. In this study, we aimed to determine reference values and Z score equations for circumferential and longitudinal strain in a large healthy pediatric population. We used a standardized approach for normalization in pediatric echocardiography that take into account heteroscedasticity and non-linear relationship with body size. 233 healthy pediatric subjects 1-18 years of age were prospectively recruited. Thirty-seven myocardial strain measurements were recorded (26 circumferential, 7 LV longitudinal and 4 RV longitudinal strain values). Normalization for body size was done via a complete and standardized approach for parametric non-linear regression modeling. Several analyses were then performed to ensure adequate Z scores distribution and to detect potential residual associations with body size or residual heteroscedasticity. We found a weak but significant non-linear association between body size and most strain values. Body surface area was superior to adjust for body size compared to age, height and weight. Heteroscedasticity was often present (uneven variance across the whole range of body surface areas) and weighted models were used to normalize the distribution of residual values. Most strain values displayed a 2nd order polynomial relationship with body surface area. Third order polynomial models sometimes had better goodness-of-fit but were potentially over-adjusted. Overall, weighed 2nd order polynomial models allowed us to compute Z score equations with adequate normal distribution and without residual association with body size. Examples of Z scores boundaries and Z score distribution for basal septal circumferential strain value are presented in the figure. In this study, we found a weak but significant influence of body size on most circumferential and longitudinal strain values used in pediatric echocardiography. We present Z scores for normalized measurements that are adjusted for body size and heteroscedasticity. We believe that the use of these normalized values should reduce the risk of misclassification caused by normal variation in myocardial strain values during growth.

BackgroundAdolescents with type 1 diabetes (T1D) are at increased risk of early adult-onset cardiovascular disease. This study compared standard echocardiographic parameters in patients screened for the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) with healthy controls.MethodsStandard M-mode, B-mode and Doppler echocardiography was performed in all subjects. In subgroup analysis, T1D separated into tertiles according to risk of developing microalbuminuria as per the AdDIT protocol, were compared with the subgroup of healthy controls that underwent the same baseline clinical assessment including glycemic measures and serum lipids. Between groups comparisons were performed using Student’s t-tests, with p-values <0.05 considered significant.ResultsWe studied 188 T1D patients (M:F 93:95; age 14.4±2.1 years; disease duration 7.0 [1.7-15.0] years) and compared to 178 controls (M:F 84:94; age 14.5±1.6 years). Sex, age and height were similar, but T1D were heavier. T1D had increased systolic (114±10 vs. 110±9 mmHg; p=0.0001) and diastolic blood pressures (62±7 vs. 58±7 mmHg; <0.0001), but decreased resting heart rates (65±9 vs. 68±12 beats per minute; p=0.0312). Left ventricular (LV) dimensions along with indexed LV mass were all similar, except for posterior wall thickness which was increased in T1D (0.66±0.11 vs. 0.64±0.11cm; p=0.0258), as has been previously reported. Systolic function indices, ejection fraction (68±5 vs. 66±5 %; p=0.0020) and mean velocity of circumferential shortening (1.18±0.18 vs. 1.14±0.16 circ/sec; p=0.0161), were increased in T1D. Diastolic function indices, mitral valve E, A and E/A were all similar, but deceleration (154±17 vs. 149±20 msec; p=0.0235) and isovolumetric relaxation times (74±17 vs. 76±8 msec; p=0.0070) were increased. In sub-group analysis, we compared 53 high-risk, 71 medium-risk and 64 low-risk T1D vs. 59 controls. As expected all the T1D sub-groups had increased fasting blood glucose and HbA1c, and also HDL cholesterol. Total and LDL cholesterol and triglycerides were similar. Only LV posterior wall thickness remained increased when comparing the T1D subgroups vs. controls (0.67±0.11 high-risk, 0.66±0.11 medium-risk, 0.67±0.13 low-risk vs. 0.62±0.10 cm controls; p=0.0172, p=0.0327, p=0.0182, respectively).ConclusionAdolescent T1D of short to intermediate disease duration, have early suggestion of blood pressure, diastolic dysfunction and left ventricular geometric changes, which may contribute to increased risk of early adult-onset cardiovascular disease. BackgroundAdolescents with type 1 diabetes (T1D) are at increased risk of early adult-onset cardiovascular disease. This study compared standard echocardiographic parameters in patients screened for the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) with healthy controls. Adolescents with type 1 diabetes (T1D) are at increased risk of early adult-onset cardiovascular disease. This study compared standard echocardiographic parameters in patients screened for the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) with healthy controls. MethodsStandard M-mode, B-mode and Doppler echocardiography was performed in all subjects. In subgroup analysis, T1D separated into tertiles according to risk of developing microalbuminuria as per the AdDIT protocol, were compared with the subgroup of healthy controls that underwent the same baseline clinical assessment including glycemic measures and serum lipids. Between groups comparisons were performed using Student’s t-tests, with p-values <0.05 considered significant. Standard M-mode, B-mode and Doppler echocardiography was performed in all subjects. In subgroup analysis, T1D separated into tertiles according to risk of developing microalbuminuria as per the AdDIT protocol, were compared with the subgroup of healthy controls that underwent the same baseline clinical assessment including glycemic measures and serum lipids. Between groups comparisons were performed using Student’s t-tests, with p-values <0.05 considered significant. ResultsWe studied 188 T1D patients (M:F 93:95; age 14.4±2.1 years; disease duration 7.0 [1.7-15.0] years) and compared to 178 controls (M:F 84:94; age 14.5±1.6 years). Sex, age and height were similar, but T1D were heavier. T1D had increased systolic (114±10 vs. 110±9 mmHg; p=0.0001) and diastolic blood pressures (62±7 vs. 58±7 mmHg; <0.0001), but decreased resting heart rates (65±9 vs. 68±12 beats per minute; p=0.0312). Left ventricular (LV) dimensions along with indexed LV mass were all similar, except for posterior wall thickness which was increased in T1D (0.66±0.11 vs. 0.64±0.11cm; p=0.0258), as has been previously reported. Systolic function indices, ejection fraction (68±5 vs. 66±5 %; p=0.0020) and mean velocity of circumferential shortening (1.18±0.18 vs. 1.14±0.16 circ/sec; p=0.0161), were increased in T1D. Diastolic function indices, mitral valve E, A and E/A were all similar, but deceleration (154±17 vs. 149±20 msec; p=0.0235) and isovolumetric relaxation times (74±17 vs. 76±8 msec; p=0.0070) were increased. In sub-group analysis, we compared 53 high-risk, 71 medium-risk and 64 low-risk T1D vs. 59 controls. As expected all the T1D sub-groups had increased fasting blood glucose and HbA1c, and also HDL cholesterol. Total and LDL cholesterol and triglycerides were similar. Only LV posterior wall thickness remained increased when comparing the T1D subgroups vs. controls (0.67±0.11 high-risk, 0.66±0.11 medium-risk, 0.67±0.13 low-risk vs. 0.62±0.10 cm controls; p=0.0172, p=0.0327, p=0.0182, respectively). We studied 188 T1D patients (M:F 93:95; age 14.4±2.1 years; disease duration 7.0 [1.7-15.0] years) and compared to 178 controls (M:F 84:94; age 14.5±1.6 years). Sex, age and height were similar, but T1D were heavier. T1D had increased systolic (114±10 vs. 110±9 mmHg; p=0.0001) and diastolic blood pressures (62±7 vs. 58±7 mmHg; <0.0001), but decreased resting heart rates (65±9 vs. 68±12 beats per minute; p=0.0312). Left ventricular (LV) dimensions along with indexed LV mass were all similar, except for posterior wall thickness which was increased in T1D (0.66±0.11 vs. 0.64±0.11cm; p=0.0258), as has been previously reported. Systolic function indices, ejection fraction (68±5 vs. 66±5 %; p=0.0020) and mean velocity of circumferential shortening (1.18±0.18 vs. 1.14±0.16 circ/sec; p=0.0161), were increased in T1D. Diastolic function indices, mitral valve E, A and E/A were all similar, but deceleration (154±17 vs. 149±20 msec; p=0.0235) and isovolumetric relaxation times (74±17 vs. 76±8 msec; p=0.0070) were increased. In sub-group analysis, we compared 53 high-risk, 71 medium-risk and 64 low-risk T1D vs. 59 controls. As expected all the T1D sub-groups had increased fasting blood glucose and HbA1c, and also HDL cholesterol. Total and LDL cholesterol and triglycerides were similar. Only LV posterior wall thickness remained increased when comparing the T1D subgroups vs. controls (0.67±0.11 high-risk, 0.66±0.11 medium-risk, 0.67±0.13 low-risk vs. 0.62±0.10 cm controls; p=0.0172, p=0.0327, p=0.0182, respectively). ConclusionAdolescent T1D of short to intermediate disease duration, have early suggestion of blood pressure, diastolic dysfunction and left ventricular geometric changes, which may contribute to increased risk of early adult-onset cardiovascular disease. Adolescent T1D of short to intermediate disease duration, have early suggestion of blood pressure, diastolic dysfunction and left ventricular geometric changes, which may contribute to increased risk of early adult-onset cardiovascular disease.

Preclinical detection of myocardial dysfunction in adolescents with type 1 diabetes (T1D) may help identify individuals at increased risk of adult-onset cardiovascular disease, who would most benefit from early intervention strategies. This study compared echocardiographic assessment of myocardial function in patients screened for the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT) with healthy controls. Myocardial function assessment included tissue Doppler, strain and strain rate imaging. In subgroup analysis, T1D separated into tertiles according to urinary albumin:creatinine ratio as per the AdDIT protocol, were compared with the subgroup of healthy controls that underwent the same baseline clinical assessment including glycemic measures and serum lipids. Between groups comparisons were performed using Student's t-tests, with p-values <0.05 considered significant. We studied 188 T1D patients (M:F 93:95; age 14.4±2.1 years; disease duration 7.0 [1.7-15.0] years) and compared to 178 controls (M:F 84:94; age 14.5±1.6 years). Sex, age and height were similar. T1D were heavier with increased systolic and diastolic blood pressures, but decreased resting heart rates. Lateral mitral valve annulus myocardial velocities, E' (17.5±2.6 vs. 18.6±2.6 cm/s; p=0.0001), A' (5.4±1.1 vs. 5.9±1.1 cm/s; p<0.0001) and S (10.5±1.8 vs. 11.1±2.0 cm/s; p=0.0017) were decreased and mitral valve E/E' (5.8±1.1 vs. 5.4±1.0; p=0.0002) increased. Global left ventricular (LV) circumferential strain (-20.4±2.3 vs. -19.5±1.7 %; p=0.0002) and longitudinal strain (-19.6±1.7 vs. -18.9±1.9 %; p=0.0003) were different, but systolic and diastolic global longitudinal strain rates were similar. Basal rotation was similar, but apical rotation (6.26±2.97 vs. 5.28±2.45 degrees; p=0.0012) and LV twist (10.35±3.58 vs. 9.33±3.05 degrees; p=0.0065) were increased. In sub-group analysis, we compared 59 controls vs. 53 high-risk, 71 medium-risk and 64 low-risk T1D. As expected all the T1D sub-groups had increased fasting blood glucose and HbA1c, and also HDL cholesterol. Total and LDL cholesterol and triglycerides were similar. Only global LV circumferential strain in the medium-risk tertile remained different when comparing the smaller T1D subgroups vs. controls (-19.4±1.6 vs. -18.8±1.7 %; p=0.0312). Significant changes in myocardial function are evident in adolescent T1D of short to intermediate disease duration, suggesting these may be clinically useful preclinical markers of deterioration in cardiac performance to guide early intervention.

BackgroundLeft main (LM) PCI is high risk and remains controversial despite the latest ACCF/AHA/SCAI 2011 PCI guidelines that endorsed LM PCI in favorable anatomy, in poor CABG candidates, and in STEMI with LM culprit and reduced flow if access to PCI is faster than CABG (Class IIa). There are no recommendations on non-emergeny LM PCI in standalone centres.MethodsWe report our LM PCI results from an experienced standalone PCI centre, where weekly case conference was held in collaboration with the regional cardiac surgery program.ResultsOf 9,568 PCIs performed 2008-12, 99 (1.0%) were LM PCIs. Of these 42 (42.4%) had previous CABG (protected LM PCIs) and the remaining 57 (57.6%) were unprotected LM PCIs. Mean age was 69±11yrs and 29.3% were diabetic. There were 60 (60.6%) CCS Class 4 patients, of which 25 (25.2%) were Class 4C and 12 (12.1%) on intra-aortic balloon pump (IABP). All except emergency cases were peer reviewed.LM lesion was ostial in 18 (18.2%), shaft in 15 (15.2%) and distal in 66 (66.7%) cases. Stents were deployed within LM lumen in 28 (28.3%), LM into LAD in 40 (41.4%), into LCx in 17 (17.2%), into ramus in 3 (3%) and bifurcating into LAD/LCx in 9 (9.1%) of patients. Balloon only was used in 2(2%) patients.Procedural success was achieved in all patients. No patient required emergency CABG because of PCI complications. Death and revascularization rates at 30 days were 8.1% and 1%, and at 1 year 11.1% and 4%. There was no difference in outcomes between protected and unprotected LM PCI patients at 1 year (death 9.5 vs 12.3%, revascularization 4.8 vs 3.5%, P=NS). One-year death rates were significantly higher in CCS Class 4 vs Class 1-3 patients (18.3 vs 2.5%, P=.02). All but 1 of 11 patients who died were CCS Class 4 patients. Mortality rate was especially high in Class 4C patients at 29.2 & 33.3% at 30-day & 1-year vs 1.3 & 4% in the remaining patients. Neither the location of LM lesion nor the site of stent deployment alone affected death and revascularization rates. However, patients with distal LM stenosis and CCS Class 4 angina had much higher mortality rates than the remaining patients at 30 days (15.4 vs 3.3%, P=.03) and 1-year (20.5 vs 5%, P=0.02).ConclusionOur results showed that LM PCI can be performed with very high success rate in a standalone PCI centre. However, despite recent technological advances, LM PCI patients remain at high risk for major adverse events and warrant close cardiologic follow up. BackgroundLeft main (LM) PCI is high risk and remains controversial despite the latest ACCF/AHA/SCAI 2011 PCI guidelines that endorsed LM PCI in favorable anatomy, in poor CABG candidates, and in STEMI with LM culprit and reduced flow if access to PCI is faster than CABG (Class IIa). There are no recommendations on non-emergeny LM PCI in standalone centres. Left main (LM) PCI is high risk and remains controversial despite the latest ACCF/AHA/SCAI 2011 PCI guidelines that endorsed LM PCI in favorable anatomy, in poor CABG candidates, and in STEMI with LM culprit and reduced flow if access to PCI is faster than CABG (Class IIa). There are no recommendations on non-emergeny LM PCI in standalone centres. MethodsWe report our LM PCI results from an experienced standalone PCI centre, where weekly case conference was held in collaboration with the regional cardiac surgery program. We report our LM PCI results from an experienced standalone PCI centre, where weekly case conference was held in collaboration with the regional cardiac surgery program. ResultsOf 9,568 PCIs performed 2008-12, 99 (1.0%) were LM PCIs. Of these 42 (42.4%) had previous CABG (protected LM PCIs) and the remaining 57 (57.6%) were unprotected LM PCIs. Mean age was 69±11yrs and 29.3% were diabetic. There were 60 (60.6%) CCS Class 4 patients, of which 25 (25.2%) were Class 4C and 12 (12.1%) on intra-aortic balloon pump (IABP). All except emergency cases were peer reviewed.LM lesion was ostial in 18 (18.2%), shaft in 15 (15.2%) and distal in 66 (66.7%) cases. Stents were deployed within LM lumen in 28 (28.3%), LM into LAD in 40 (41.4%), into LCx in 17 (17.2%), into ramus in 3 (3%) and bifurcating into LAD/LCx in 9 (9.1%) of patients. Balloon only was used in 2(2%) patients.Procedural success was achieved in all patients. No patient required emergency CABG because of PCI complications. Death and revascularization rates at 30 days were 8.1% and 1%, and at 1 year 11.1% and 4%. There was no difference in outcomes between protected and unprotected LM PCI patients at 1 year (death 9.5 vs 12.3%, revascularization 4.8 vs 3.5%, P=NS). One-year death rates were significantly higher in CCS Class 4 vs Class 1-3 patients (18.3 vs 2.5%, P=.02). All but 1 of 11 patients who died were CCS Class 4 patients. Mortality rate was especially high in Class 4C patients at 29.2 & 33.3% at 30-day & 1-year vs 1.3 & 4% in the remaining patients. Neither the location of LM lesion nor the site of stent deployment alone affected death and revascularization rates. However, patients with distal LM stenosis and CCS Class 4 angina had much higher mortality rates than the remaining patients at 30 days (15.4 vs 3.3%, P=.03) and 1-year (20.5 vs 5%, P=0.02). Of 9,568 PCIs performed 2008-12, 99 (1.0%) were LM PCIs. Of these 42 (42.4%) had previous CABG (protected LM PCIs) and the remaining 57 (57.6%) were unprotected LM PCIs. Mean age was 69±11yrs and 29.3% were diabetic. There were 60 (60.6%) CCS Class 4 patients, of which 25 (25.2%) were Class 4C and 12 (12.1%) on intra-aortic balloon pump (IABP). All except emergency cases were peer reviewed. LM lesion was ostial in 18 (18.2%), shaft in 15 (15.2%) and distal in 66 (66.7%) cases. Stents were deployed within LM lumen in 28 (28.3%), LM into LAD in 40 (41.4%), into LCx in 17 (17.2%), into ramus in 3 (3%) and bifurcating into LAD/LCx in 9 (9.1%) of patients. Balloon only was used in 2(2%) patients. Procedural success was achieved in all patients. No patient required emergency CABG because of PCI complications. Death and revascularization rates at 30 days were 8.1% and 1%, and at 1 year 11.1% and 4%. There was no difference in outcomes between protected and unprotected LM PCI patients at 1 year (death 9.5 vs 12.3%, revascularization 4.8 vs 3.5%, P=NS). One-year death rates were significantly higher in CCS Class 4 vs Class 1-3 patients (18.3 vs 2.5%, P=.02). All but 1 of 11 patients who died were CCS Class 4 patients. Mortality rate was especially high in Class 4C patients at 29.2 & 33.3% at 30-day & 1-year vs 1.3 & 4% in the remaining patients. Neither the location of LM lesion nor the site of stent deployment alone affected death and revascularization rates. However, patients with distal LM stenosis and CCS Class 4 angina had much higher mortality rates than the remaining patients at 30 days (15.4 vs 3.3%, P=.03) and 1-year (20.5 vs 5%, P=0.02). ConclusionOur results showed that LM PCI can be performed with very high success rate in a standalone PCI centre. However, despite recent technological advances, LM PCI patients remain at high risk for major adverse events and warrant close cardiologic follow up. Our results showed that LM PCI can be performed with very high success rate in a standalone PCI centre. However, despite recent technological advances, LM PCI patients remain at high risk for major adverse events and warrant close cardiologic follow up.

BackgroundInterventional guidelines for the management of STEMI recommend the use of stents to reduce the risk of acute vessel closure. However, stent deployment can result in the so called no-reflow phenomenon, particularly if there was a large thrombus burden in the infarct related coronary artery. This complication has been shown to result in adverse outcomes. We evaluate a deferred stenting strategy following a period of intense antithrombotic and antiplatelet therapy as an alternative to primary stenting at the time of the initial angiogram.MethodsIn a single high volume centre study we identified all consecutive patients where a deferred stenting strategy was chosen as initial management strategy by the responsible high volume operator. Baseline characteristics and clinical outcomes as well as complications were collected from local and provincial databases. Procedural characteristics (TIMI thrombus grade scale, TIMI flow) were evaluated from detailed review of the angiograms by 2 experienced interventional cardiologists.ResultsBetween June 2011 and January 2014 38 STEMI patients were treated with a deferred stenting strategy. TIMI thrombus grade scale 4 or 5 on the initial angiogram was seen in 82% of patients. Immediate thrombectomy or balloon angioplasty was performed in 25 out of 38 patients (66%) to restore flow in the infarct related artery. Aggressive antithrombotic (86% heparin) and antiplatelet (100% Integrelin, 100% dual antiplatelet therapy) was administered for a average of 65+/- 14 hours. No emergency repeat catheterisation was required. Two patients-one with a degenerated vein graft and another with extremely ectatic coronary arteries did not undergo repeat angiography and remain well at 6 month follow up. The remaining 36 patient had a relook angiogram. TIMI 3 flow was demonstrated in 35/36 (97%) patients, only one patient had a TIMI thrombus grade of 4 or 5. No further coronary intervention was required in 12/36 (33%) of patients, 23/36 (64%) patients received at least one stent and one patient was sent for coronary artery bypass surgery. No bleeding complications requiring blood transfusion were observed in hospital. One patient treated with deferred stenting died at 2 months of follow-up from definite stent thrombosis, two patients had clinically indicated repeat cardiac catheterisation (no new problems identified and continued with medical management). No other major adverse cardiovascular events occurred.ConclusionIn our experience deferred stenting is safe and has the potential to reduce no reflow and thereby reduce infarct size. These findings need confirmation in a multicentre clinical trial. BackgroundInterventional guidelines for the management of STEMI recommend the use of stents to reduce the risk of acute vessel closure. However, stent deployment can result in the so called no-reflow phenomenon, particularly if there was a large thrombus burden in the infarct related coronary artery. This complication has been shown to result in adverse outcomes. We evaluate a deferred stenting strategy following a period of intense antithrombotic and antiplatelet therapy as an alternative to primary stenting at the time of the initial angiogram. Interventional guidelines for the management of STEMI recommend the use of stents to reduce the risk of acute vessel closure. However, stent deployment can result in the so called no-reflow phenomenon, particularly if there was a large thrombus burden in the infarct related coronary artery. This complication has been shown to result in adverse outcomes. We evaluate a deferred stenting strategy following a period of intense antithrombotic and antiplatelet therapy as an alternative to primary stenting at the time of the initial angiogram. MethodsIn a single high volume centre study we identified all consecutive patients where a deferred stenting strategy was chosen as initial management strategy by the responsible high volume operator. Baseline characteristics and clinical outcomes as well as complications were collected from local and provincial databases. Procedural characteristics (TIMI thrombus grade scale, TIMI flow) were evaluated from detailed review of the angiograms by 2 experienced interventional cardiologists. In a single high volume centre study we identified all consecutive patients where a deferred stenting strategy was chosen as initial management strategy by the responsible high volume operator. Baseline characteristics and clinical outcomes as well as complications were collected from local and provincial databases. Procedural characteristics (TIMI thrombus grade scale, TIMI flow) were evaluated from detailed review of the angiograms by 2 experienced interventional cardiologists. ResultsBetween June 2011 and January 2014 38 STEMI patients were treated with a deferred stenting strategy. TIMI thrombus grade scale 4 or 5 on the initial angiogram was seen in 82% of patients. Immediate thrombectomy or balloon angioplasty was performed in 25 out of 38 patients (66%) to restore flow in the infarct related artery. Aggressive antithrombotic (86% heparin) and antiplatelet (100% Integrelin, 100% dual antiplatelet therapy) was administered for a average of 65+/- 14 hours. No emergency repeat catheterisation was required. Two patients-one with a degenerated vein graft and another with extremely ectatic coronary arteries did not undergo repeat angiography and remain well at 6 month follow up. The remaining 36 patient had a relook angiogram. TIMI 3 flow was demonstrated in 35/36 (97%) patients, only one patient had a TIMI thrombus grade of 4 or 5. No further coronary intervention was required in 12/36 (33%) of patients, 23/36 (64%) patients received at least one stent and one patient was sent for coronary artery bypass surgery. No bleeding complications requiring blood transfusion were observed in hospital. One patient treated with deferred stenting died at 2 months of follow-up from definite stent thrombosis, two patients had clinically indicated repeat cardiac catheterisation (no new problems identified and continued with medical management). No other major adverse cardiovascular events occurred. Between June 2011 and January 2014 38 STEMI patients were treated with a deferred stenting strategy. TIMI thrombus grade scale 4 or 5 on the initial angiogram was seen in 82% of patients. Immediate thrombectomy or balloon angioplasty was performed in 25 out of 38 patients (66%) to restore flow in the infarct related artery. Aggressive antithrombotic (86% heparin) and antiplatelet (100% Integrelin, 100% dual antiplatelet therapy) was administered for a average of 65+/- 14 hours. No emergency repeat catheterisation was required. Two patients-one with a degenerated vein graft and another with extremely ectatic coronary arteries did not undergo repeat angiography and remain well at 6 month follow up. The remaining 36 patient had a relook angiogram. TIMI 3 flow was demonstrated in 35/36 (97%) patients, only one patient had a TIMI thrombus grade of 4 or 5. No further coronary intervention was required in 12/36 (33%) of patients, 23/36 (64%) patients received at least one stent and one patient was sent for coronary artery bypass surgery. No bleeding complications requiring blood transfusion were observed in hospital. One patient treated with deferred stenting died at 2 months of follow-up from definite stent thrombosis, two patients had clinically indicated repeat cardiac catheterisation (no new problems identified and continued with medical management). No other major adverse cardiovascular events occurred. ConclusionIn our experience deferred stenting is safe and has the potential to reduce no reflow and thereby reduce infarct size. These findings need confirmation in a multicentre clinical trial. In our experience deferred stenting is safe and has the potential to reduce no reflow and thereby reduce infarct size. These findings need confirmation in a multicentre clinical trial.

The safety of PCI without on-site cardiac surgery has been an ongoing debate since the early 1980’s. However, success rate has improved and acute reocclusion rate reduced since the introduction of stents and new antiplatelet therapy in the 1990s. PCI is now the predominant revascularization modality for coronary disease(CAD) worldwide and where available, primary PCI has become the standard of care for STEMI. In Ontario, 5 new standalone PCI centres have been established in the past 14 years. However, elective standalone PCI remained a Class IIb indication in the 2011 ACCF/AHA/SCAI guidelines. Nonetheless, the recent C-PORT and MASS COM trials in the US concluded that in non-emergency patients, standalone PCI is non-inferior to that performed in centres with on-site cardiac surgery. The Royal Alexandra Hospital performed the first standalone PCI in Canada in 1981 and has provided PCI services to a full spectrum of CAD patients ranging from elective, in-hospital to emergency cases with STEMI and cardiogenic shock. Surgical backup is located at the University of Alberta Hospital 6 km away. Joint case conference is conducted weekly with the cardiac surgery program. In the first 30 years, 23,261 PCIs were performed. We report our 30-year standalone experience, which we believe is the largest single centre experience in literature to date. PCI volumes, clinical and procedural characteristics, lesion success, emergency coronary bypass and mortality rates were collected and reported for the 30-year period. Results for 2006-2011, a period most relevant to current practice were compared with the most recent US PCI data. PCI volumes, CCS Class 4 patients, ad hoc, rescue and primary PCIs all increased significantly over the 30-year period. Success and emergency coronary bypass rates also improved (see Table). For 2006-11, our success, emergency CABG and 30-day mortality rates (96.5, 0.04, 1.1%) compared favorably with National Cardiovascular Data Registry (93-94, 0.3-0.4, 1.2-1.7 %*), C-PORT (93.4-94.1, 0.2, 0.8-0.9 %**) & MASS COM(95.6-97.1, 0.1-0.3, 0.3-0.7 %). PCIs can be performed safely in an experienced, high volume standalone centre with excellent success and very low complication rates. These results support the safety of establishing new standalone PCI centres to meet the growing population demand for percutaneous revascularization for coronary disease.

In the J–CTO model, angiographic variables of blunt entry, calcification, lesion length >20mm, angle>45o and previous PCI attempt are independent predictors of CTO PCI failure. While the use of bilateral injections and retrograde approach during CTO PCI remain operator dependent, these strategies

While non emergent percutaneous coronary intervention (PCI) can be safely and effectively be carried out in high volume stand alone centres, there is limited data examining the feasibility of performing PCI to chronic total occlusions (CTO-PCI) because of the relatively high CTO-PCI failure rates. With the development of retrograde and contemporary anterograde approaches the success rates of CTO PCI continues to improve. The CK Hui Heart Centre at the Royal Alexandra Hospital has been performing PCI without on site surgery over the last 30 years. We identified all patients undergoing CTO PCI between January 2010 and March 2013 and examined the outcomes of CTO-PCI procedures over 4 separate time frames: Jan 2010 - Dec 2010, Jan 2011-Dec 2011, Jan 2012 - Dec 2012 and Jan 2013 - Apr 2013.

OBJECTIVE: The GuideLiner (R) five-in-six catheter (Vascular Solutions, USA) is a commercially available delivery catheter recently approved by Health Canada and the Food and Drug Administration based on the mother-and-child principle. The purpose of the present study is to report the authors' initial experience with this novel device. METHODS: In a single centre, all cases in which the GuideLiner was to be used were prospectively identified. Use of the device was left at the operator's discretion, but it was suggested that conventional techniques, such as buddy wires or deep intubation of the guide catheter, be attempted first. All patient, procedural and outcome characteristics were recorded in a dedicated database. RESULTS: From September 2010 through May 2011, five interventional cardiologists treated 34 consecutive patients using the new device. All lesions were American Heart Association/American College of Cardiology class B2 or C, and problems with stent delivery were due to tortuosity of the proximal vessel (present in 82% of cases), excessive calcification (44%) and poor guide catheter support (18%). The mean age of the patients was 64.7 years and 18% of the patients were women. Radial access was used in 79% of cases. Introduction of the GuideLiner device resulted in successful stent delivery in 82%. Two device-related coronary artery dissections were observed. CONCLUSIONS: The GuideLiner catheter is a novel and effective tool that facilitates stent delivery in challenging lesions when conventional techniques have failed. The major complication appears to be device-related coronary artery dissections.

The Transradial route (TR) has been shown less bleeding and vascular complications in primary PCI. Its technique however remains generally underutilised in the elderly (> 80 years) population because of concerns of high cross over rates, longer catheter lab to balloon and fluoroscopy times. We aim to report the safety, efficacy and limitations of performing primary PCI in octogenarians via the TR at the CK Hui Heart Centre which has been carrying out PCI via the TR route since 2001.

Infants commonly suffer from low cardiac output (CO) after surgical repair of congenital heart disease (CHD). Low-cardiac output syndrome can lead to post-operative morbidity and mortality. Therefore monitoring CO early after surgery is important, but is difficult due to difficulty in measuring oxygen consumption. Echo can measure CO and is widely available, but its accuracy for CO measurement in the critical early post-operative period has not been well studied in this group. The aim of this study was to compare CO measured by echo with a gold standard method in infants early after surgical repair of biventricular CHD. We prospectively recruited infants < 4 months of age with biventricular CHD undergoing reparative surgery on CPB. Reference CO was calculated using the Fick method with oxygen consumption measured by respiratory mass spectrometry. Superior caval vein saturation was used as the 'mixed' venous saturation. Echo CO was measured by 2 different methods: 1. difference in LV end-diastolic and end-systolic volume (Simpson's biplane) x heart rate (2D) 2. Velocity time integral of aortic outflow pulse Doppler x the aortic outflow tract area x heart rate (Doppler). For each infant, CO measurements by Fick and echo were simultaneously taken at baseline (arrival in ICU) and at 48 hrs or prior to extubation if sooner. Echo derived absolute CO values by 2D and Doppler were compared to the reference method using Bland-Altman analysis and Pearson's correlation. In addition, change in CO between baseline and study end were compared between the methods. 39 infants were studied (mean±SD age 29±31 days; weight 3.7±0.9 kg), yielding 78 CO measurements by each method. Half the infants had transposition of the great arteries. Mean ± SD CO by Fick was 0.49±0.27 l/min. Echo measured CO correlated poorly with Fick CO with significant bias and wide limits of agreement (Figure). While both echo methods performed poorly, Doppler was slightly better than 2-D. The percentage change in CO from baseline to study end by echo correlated poorly with that derived from Fick (r=0.2). Echo, either 2D or Doppler, is inadequate to measure CO in infants in the 1st 48 hours after surgical repair of biventricular CHD. Echo performed poorly both for measurement of absolute CO values and CO change over time.

There is limited data on the long term outcomes of coronary bifurcation lesions treated with drug eluting stents (DES). We studied the outcomes of patients with coronary bifurcation lesions who were treated with both first and second generation DES between 2002 and 2011. Clinical outcomes of target lesion revascularization (TLR) and all cause mortality were collected from the APPROACH database and review of patients' medical records. Outcomes for first generation DES (sirolimus - SES; paclitaxel - PES) and second generation DES (everolimus - EES) were compared over 2 years while the first generation DES were compared over an 8 year period. A multivariate analysis regression model was used to identify the independent predictors of TLR. 829 consecutive patients (79% males; mean 62.21±0.44 years) underwent coronary stenting for 940 bifurcation lesions of which 66% of lesions had side branch disease. Stent usage was 43% SES, 29% PES, 25% EES and 3% zotarolimus. 32.21% of bifurcation lesions with side branch disease required side branch stenting. At 2 years the TVR rate in the total cohort was 5.51%. SES had lower TVR rates when compared to PES (3.8% vs 7.9%, log rank p = 0.0036) and EES (3.8% vs 5.5%, log rank p = 0.015). Survival rate in the three groups were similar; SES 96.9%, PES 94.5%, EES 97.4%, log rank p=0.298. Patients with side branch disease undergoing side branch stenting had a significantly higher TVR rate than those who did not receive a side branch stent (9.11 vs 5.09% log rank p = 0.044). Side branch stenting was an independent predictor of TVR at 2 years (HR 17.46, 6.62 - 46.06 [95% CI], p<0.00001). Over 8 years there was no difference in survival between the first generation DES; (SES vs PES; 97.0% vs 94.6% log rank p=0.408). CABG rate in the total cohort was SES 2.5%, PES 2.3%, EES 0.8%, p=0.32. Definite stent thrombosis occurred in 0.74% of lesions treated over the eight year period. Both first and second generation DES are effective in the treatment of bifurcation lesions with overall low rates of TVR beyond 2 years. SES appears to have better long term outcome compared to PES and EES in bifurcation lesions. A single stent approach gives better long term outcomes compared to additional side branch stenting.