David A. McNamara

Background: A multidisciplinary heart team (HT) approach to patients with complex coronary artery disease has a class IB recommendation, yet there are limited data on adherence to HT treatment recommendations and long‐term clinical follow‐up. The objective of this study was to assess adherence rates to HT recommendations and assess long‐term mortality rates among patients with complex CAD. Methods and Results: Six hundred eighty‐four sequential HT cases for complex coronary artery disease from January 2015 to May 2017 were reviewed. After excluding cases with significant comorbid valve disease, baseline characteristics were compared based on HT treatment recommendations: optimal medical therapy, percutaneous coronary intervention, and coronary artery bypass grafting. Adherence rates were manually extracted, and 5‐year mortality rates were obtained from the Michigan Death Registry. Seventy‐two percent of 405 included patients were men (mean age 66±11 years), with high rates of medical comorbidities. Estimated surgical risk scores were lowest in the coronary artery bypass grafting group. Optimal medical therapy was recommended in 138 patients (34%), percutaneous coronary intervention in 95 (23%), and coronary artery bypass grafting in 172 (42%). Adherence to HT recommendations across groups was high (96%) and did not differ between treatment groups. Over 5 years of follow‐up, there were 119 deaths, resulting in a cumulative mortality rate of 29%. Conclusions: In the largest HT cohort in the United States to date, high rates of adherence to HT recommendations were observed among high‐risk patients with coronary artery disease. High rates of adherence to HT recommendations were observed irrespective of treatment group recommendation, suggesting that HT recommendations were individualized and acceptable to both patients and physicians alike.

During the past decade, percutaneous procedures to treat structural heart disease have rapidly expanded. Among structural heart interventions, left atrial appendage occlusion (LAAO) and transcatheter edge-to-edge mitral valve repair (TEER) are now performed routinely at many centers and are increasing rapidly.^1,2 Both LAAO and TEER are typically performed under the guidance of fluoroscopy and transesophageal echocardiography (TEE), which has resulted in the addition of an interventional echocardiographer as an integral member of the structural heart team.

Objective: This study was performed to investigate the efficacy and safety of robotic diagnostic coronary angiography.Background: Robotic percutaneous coronary intervention is associated with marked reductions in physician radiation exposure. Development of robotic diagnostic coronary angiography might similarly impact occupational safety.Methods: Stable patients referred for coronary angiography were prospectively enrolled. After obtaining vascular access, diagnostic catheters were manually advanced over a wire to the ascending aorta. All subsequent catheter movements were performed robotically. The primary endpoint was procedural success, defined as robotic completion of coronary angiography without conversion to a manual procedure and the absence of procedural major adverse cardiovascular events (MACE—cardiac death, cardiac arrest, or stroke) and major angiographic complications (coronary/aortic dissection or embolization). The primary hypothesis was that the observed rate of the primary endpoint, evaluated at the completion of coronary angiography, would meet a pre‐specified performance goal of 74.5%.Results: Among 46 consecutive patients (age 67 ± 12 years; 69.6% male), diagnostic coronary angiography was completed robotically in all cases without the need for manual conversion and without any MACE or major angiographic complications. Thus, procedural success was 100%, which was significantly higher than the pre‐specified performance goal (p < 0.001). Robotic coronary angiography was completed using 2 [2, 3] catheters per case with a median procedural time of 15 [11, 20] minutes.Conclusions: Robotic diagnostic coronary angiography was performed with 100% procedural success and no observed complications. These results support the performance of future studies to further explore robotic coronary angiography.

A woman in her 50s with discoid lupus in remission and recent adult-onset asthma presented to the emergency department with 2 weeks of dyspnea on exertion associated with substernal chest pain radiating to her jaw. She noted a 5-kg weight loss in the preceding 3 months. Examination revealed nonreproducible chest tenderness, bibasilar crackles, and no extra heart sounds. A 12-lead electrocardiogram is shown in Figure 1A. Testing revealed leukocytosis (white blood cell count, 16 900 cells/μL [to convert to × 10⁹ cells/L, multiply by 0.001]) with a differential of 6% neutrophils and 59% eosinophils, an elevated N-terminal pro B-type natriuretic peptide of 3963 pg/mL (reference level, <900 pg/mL [to convert to ng/L, multiply by 1.0]), and an elevated initial troponin T of 0.36 ng/mL, which later peaked at 0.41 ng/mL (to convert to micrograms per liter, multiply by 1.0). Her C-reactive protein level was 3.09 mg/dL (normal, <0.5 mg/dL [to convert to milligrams per liter, multiply by 10]). Subsequent plasma flow cytometry demonstrated 65% eosinophils, and a bone marrow biopsy with immunohistochemistry showed eosinophilia without evidence of clonal expansion. Cardiac magnetic resonance imaging was performed (Figure 1B; Video).