M. Nicholas Burke

The use of ionizing radiation during cardiac catheterization procedures poses risks to patients and medical staff, both directly and indirectly through orthopedic injuries caused by lead aprons. In this review, we summarize recent advances in radiation protection in the cardiac catheterization laboratory and discuss the effectiveness of traditional and novel radiation protection strategies and equipment.

Background: Death is a rare but devastating complication of chronic total occlusion (CTO) percutaneous coronary intervention.Methods: We examined the clinical characteristics and procedural outcomes of patients who died periprocedurally in the Prospective Global Registry for the Study of CTO Interventions (PROGRESS-CTO).Results: Of the 12 928 patients who underwent CTO percutaneous coronary intervention between 2012 and 2022, 52 (0.4%) died during the index hospitalization. Patients who died were more likely to have a history of heart failure (43% versus 28%;P=0.023). The J-CTO ([Multicenter CTO Registry of Japan]; 2.8±1.1 versus 2.4±1.3;P=0.019), PROGRESS-CTO mortality (2.6±0.9 versus 1.6±1.1;PPPP<0.001). The cause of death was cardiac in 43 patients (83%) and noncardiac in 9 patients (17%). Complications leading to cardiac death were: tamponade in 30 patients (58%), acute myocardial infarction in 9 (17.3%), and cardiac arrest/shock in 4 (7.7%). Noncardiac causes of death were: stroke in 3 (5.8%), renal failure in 2 (3.8%), respiratory distress in 2 (3.8%), and hemorrhagic shock in 2 (3.8%).Conclusions: Approximately 0.4% of patients who underwent CTO percutaneous coronary intervention died during the index hospitalization. The main cause of death was tamponade in 58%. PROGRESS-CTO complication scores might help in risk stratification and procedural planning in patients undergoing CTO percutaneous coronary intervention.Registration: URL:https://www.clinicaltrials.gov; Unique Identifier: NCT02061436.

Background Estimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods We analyzed 2,784 CTO PCIs performed between 2012 and 2021 at 12 centers. The variable importance was estimated by a bootstrap applying a random forest algorithm to a propensity-matched sample (a ratio of 1:5 matching cases with controls on center). The identified variables were used to predict the risk of urgent MCS. The performance of the risk model was assessed in-sample as well as on 2411 out-of-sample procedures who did not require urgent MCS. Results Urgent MCS was used in 62 (2.2%) of cases. Patients who required urgent MCS were older (70 [63, 77] vs. 66 [58, 73] years, p=0.003) compared with those who did not require urgent MCS. Technical (68% vs. 87%, pConclusion The PROGRESS CTO MCS score can help estimate the risk of urgent MCS use during CTO PCI. What Is Known? Estimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). What the Study Adds? We developed a risk model for urgent MCS use during CTO PCI using retrograde crossing strategy, left ventricular ejection fraction, and lesion length. Use of the PROGRESS CTO urgent MCS score may facilitate patient selection for prophylactic hemodynamic support optimizing the risk benefit ratio of the procedure.

Saphenous vein grafts (SVGs) remain the most frequently used conduits in coronary artery bypass graft surgery (CABG). Despite advances in surgical techniques and pharmacotherapy, SVG failure rates remain high, often leading to repeat coronary revascularization. The no-touch SVG harvesting technique (minimal graft manipulation with preservation of vasa vasorum and nerves) reduces the risk of SVG failure, whereas the effect of the off-pump technique on SVG patency remains unclear. Use of buffered storage solutions, intraoperative graft flow measurement, careful selection of the target vessels, and physiological assessment of the native coronary circulation before CABG may also reduce the incidence of SVG failure. Perioperative aspirin and high-intensity statin administration are the cornerstones of secondary prevention after CABG. Dual antiplatelet therapy is recommended for off-pump CABG and in patients with a recent acute coronary syndrome. Intermediate (30%–60%) SVG stenoses often progress rapidly. Stenting of intermediate SVG stenoses failed to improve outcomes; hence, treatment focuses on strict control of coronary artery disease risk factors. Redo CABG is associated with higher perioperative mortality compared with percutaneous coronary intervention (PCI); hence, the latter is preferred for most patients requiring repeat revascularization after CABG. SVG PCI is limited by high rates of no-reflow and a high incidence of restenosis during follow-up. Drug-eluting and bare metal stents provide similar long-term outcomes in SVG PCI. Embolic protection devices reduce no-reflow and should be used when feasible. PCI of the corresponding native coronary artery is associated with better short- and long-term outcomes and is preferred over SVG PCI, if technically feasible.

Objective: The outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in octogenarians and nonagenarians have received limited study. Methods: We compared in‐hospital outcomes of CTO PCI between patients ≥80 vs. p < 0.0001) and more likely to have atrial fibrillation (27% vs. 12%, p < 0.0001) and prior coronary artery bypass graft surgery (CABG) (43% vs. 29%, p < 0.0001). They were more likely to have CTOs with moderate/severe calcification (71% vs. 46%, p < 0.0001), but had similar mean J‐CTO scores (2.5 ± 1.3 vs. 2.4 ± 1.3, p = 0.08). They had lower technical and procedural success (82.2% vs. 86.3%, p = 0.0201; 80.3% vs. 84.8%, p = 0.016, respectively) and higher incidence of in‐hospital major adverse cardiovascular events (3.4% vs. 1.8%, p = 0.021). On multivariable analysis PCI in octo‐ and nonagenarians was not independently associated with technical and procedural success or with in‐hospital MACE. Conclusion: CTO PCI is feasible in octo‐ and nonagenarians, although success rates are lower, and the risk of complications is higher compared with younger patients, likely related to more comorbidities and higher coronary lesion complexity.

A letter to the editor regarding coronary chronic total occlusion in patients with prior MI. from Journal of Invasive Cardiology.