Category: Volume 1 Number 3

Table of Contents Volume 1 Number 3

Cardiovascular Innovations and Applications (CVIA) Volume 1 Number 3 

Fractional Flow Reserve-guided Percutaneous Coronary Intervention: Standing the Test of Time 

Authors: Zimmermann, Frederik M.; van Nunen, Lokien X.

What is the Optimal Duration of Dual Antiplatelet Therapy After Stenting? 
Authors: Tantry, Udaya S.; Navarese, Eliano P.; Gurbel, Paul A.

Reports of a Possible Causal Link between Brain, Head, and Neck Tumors and Radiation Exposure during Coronary Interventional Procedures: A Sobering Look at the Data 
Authors: Reeves, Ryan R.; Mahmud, Ehtisham

Renal Denervation: Past, Present, and Future 
Authors: Pourafshar, Negiin; Karimi, Ashkan; Anderson, R. David; Alaei-Andabili, Seyed Hossein; Kandzari, David E.

Current Considerations of Thrombectomy for Acute Myocardial Infarction 
Authors: Mahmoud, Ahmed N.; Elgendy, Islam Y.; Bavry, Anthony A.

Will Transcatheter Aortic Valve Replacement (TAVR) be the Primary Therapy for Aortic Stenosis?
Authors: Condado, Jose F.; Block, Peter C.

The Future of Transcatheter Therapy for Mitral Valve Disease 
Authors: Feldman, Ted; Guerrero, Mayra

The Transradial Approach for Cardiac Catheterization and Percutaneous Coronary Intervention: A Review 
Authors: Pau, Dhaval; Patel, Nileshkumar J.; Patel, Nish; Cohen, Mauricio G.

Carotid Artery Stenting: 2016 and Beyond 
Authors: Wayangankar, Siddharth; Kapadia, Samir; Bajzer, Christopher

Coronary Artery Chronic Total Occlusion
 Authors: Choi, Calvin; Agarwal, Nayan; Park, Ki; Anderson, R. David

Cardiovascular Abnormalities Among Patients with Spontaneous Subarachnoid Hemorrhage. A Single Center Experience
Authors: Elgendy, Akram Y.; Mahmoud, Ahmed; Elgendy, Islam Y.; Mansoor, Hend; Conti, C. Richard

Identification and Management of Iatrogenic Aortocoronary Dissection
Authors: Nie, Shao-Ping; Wang, Xiao

Transient Pulmonary Atelectasis after Ketamine Sedation during Cardiac Catheterization in Spontaneously Breathing Children with Congenital Heart Disease 
Authors: Chaowu, Yan; Zhongying, Xu; Gejun, Zhang; Hong, Zheng; Jinglin, Jin; Shiguo, Li; Jianhua, Lv; Haibo, Hu; Huijun, Song; Shihua, Zhao

NSTEMI or STEMI: A Myocardial Infarction is an Infarction Regardless of the ECG Changes at Presentation
Author: Conti, C. Richard

Should Patients with Acute Myocardial Infarction Have Complete Revascularization at the Time of PCI of the Culprit Vessel?
 Author: Conti, C. Richard

Biodegradable Stents
Author: Conti, C. Richard

CVIA is available on the IngentaConnect platform and at https://dhn.zgc.mybluehostin.me/cvia/. Submissions may be made using ScholarOne Manuscripts. There are no author submission or article processing fees.

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Renal Denervation: Past, Present, and Future

Renal Denervation: Past, Present, and Future

Authors: Pourafshar, Negiin; Karimi, Ashkan; Anderson, R. David; Alaei-Andabili, Seyed Hossein; Kandzari, David E.

Over the past decade, percutaneous renal denervation has been vigorously investigated as a treatment for resistant hypertension. The SYMPLICITY radiofrequency catheter system (Medtronic CardioVascular Inc., Santa Rosa, CA, USA) is the most tested device in clinical trials. After the positive results of small phase I and II clinical trials, SYMPLICITY HTN-3 (a phase III, multi-center, blinded, sham-controlled randomized clinical trial) was completed in 2014, but did not show significant blood pressure lowering effect with renal denervation compared to medical therapy and caused the investigators and industry to revisit both the basic science elements of renal denervation as well as the design of related clinical trials. This review summarizes the SYMPLICITY trials, analyzes the SYMPLICITY HTN-3 data, and provides insights gained from this trial in the design of the most recent clinical trial, the SPYRAL HTN Global clinical trial. Other than hypertension, the role of renal denervation in the management of other disease processes such as systolic and diastolic heart failure, metabolic syndrome, arrhythmia, and obstructive sleep apnea with the common pathophysiologic pathway of sympathetic overactivity is also discussed.

DOI: http://dx.doi.org/10.15212/CVIA.2016.0016

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Link between tumors and radiation exposure

Reports of a Possible Causal Link between Brain, Head, and Neck Tumors and Radiation Exposure during Coronary Interventional Procedures: A Sobering Look at the Data

Authors: Reeves, Ryan R.; Mahmud, Ehtisham

Radiation exposure is a hazard for patients and physicians during fluoroscopically-guided procedures. Invasive cardiologists are exposed to high levels of scatter radiation and both increasing procedural complexity and higher operator volumes contribute to exposure above recommended thresholds. Standard shielding does not offer sufficient protection to the head and neck region and the potential for negative biological, subclinical, and clinical effects exists. Large population studies suggest that cranial exposure to low dose radiation increases the risks of tumor development. In addition, modest doses of therapeutic cranial radiation have been linked with the development of brain cancer. Although a causal association between scatter radiation in the cath lab and brain cancer does not currently exist, given the known detrimental effects of radiation exposure to the head and neck region support a focus on potential methods of protection for both the patient and the operator.

http://dx.doi.org/10.15212/CVIA.2016.0014

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NSTEMI or STEMI

NSTEMI or STEMI: A Myocardial Infarction is an Infarction Regardless of the ECG Changes at Presentation

Author: C. Richard Conti, MD, MACC, Department of Medicine, University of Florida, Gainesville, FL 32610, USA

ST segment elevation is considered by most as a sign of an occluded coronary artery and myocardial ischemia. Coronary artery occlusion usually is the cause of the acute infarction in the patient with that type of ECG. Patients with acute myocardial infarction who do not show ST segment elevation yet leak troponin, still have a myocardial infarction.

Since patients with ST segment elevation or non ST segment elevation have had an acute myocardial infarction, why should we assume that the patient without ST segment elevation did not occlude an epicardial artery?

Despite the absence of ST segment elevation, these patients still may have a coronary occlusion associated with collateral blood flow to the distal circulation of the infarct related artery. Alternatively the patient could have embolized to the microcirculation from a disrupted plaque or a plaque that had occlusive thrombus attached.

It is also possible that the NSTEMI patient, who is now leaking troponin, may be doing so after spontaneous opening of the epicardial artery in question, secondary to their own Tissue Plasminogen activator. Some of these patients will be left with a high grade stenosis of the infarct related coronary artery.

In patients presenting with NSTEMI, it should be considered a possibility that the epicardial artery in question could have been occluded prior to the first ECG taken. Thus, the patient might have demonstrated ST segment elevation had the patient been evaluated with ECG at an earlier time. This patient could now be categorized as a MSTEMI (missed STEMI).

Some will argue that if the epicardial vessel is patent there is no need for emergent PCI. I will accept that argument but only if the vessel is widely patent as it would be after PCI/stent (that can only be determined at coronary angiography). I will not accept the argument about patency, if the vessel (probably with plaque disruption) remains patent but nearly occluded.

Another clinical issue that must be considered by first responders, relates to an area of the heart that is infarcting but may not demonstrate changes on the first 12 lead ECG (even if vessels are occluded). This is the lateral wall of the left ventricle, which usually is supplied by the obtuse marginal branches of the Circumflex coronary artery. In this instance the initial 12 lead ECG may be normal despite a good story and Troponin elevation. ECG leads, V7-9 may be required to detect any ECG abnormalities, such as ST segment elevation.
I am of the opinion that all patients with acute myocardial infarction (with or without ST segment elevation) are at higher risk than those without an acute myocardial infarction. I believe that all patients with acute myocardial infarction should be considered for urgent coronary angiography. If the vessel in question (infarct related artery) is widely patent, leave it alone and consider microcirculatory dysfunction. If it is not widely patent, make it so with PCI/Stent.
Finally, it is common practice to emergently take patients with recent onset LBBB, Troponin leak and good story to the cardiac catherization laboratory for coronary angiography and possible PCI/Stent. This is done because new onset of LBBB in this setting is considered a “STEMI Equivalent”. This is done despite not having a clue as to the coronary pathology. Why not do the same for patients with a good story for a myocardial infarction and troponin leak, not related to CKD or some other reason, who do not have ST elevation on the ECG?

Some have the impression that NSTEMI is benign compared to STEMI and thus need not be considered for urgent revascularization.

The message I am getting from the literature is that there is insufficient evidence to accept or reject the emergent use of Coronary angiography and subsequent PCI/Stent in the NSTEMI patient. I guess my message is that if we do no harm, (with urgent coronary angiography) why not find out what is going on in the coronary circulation? We might be surprised in patients in whom the diagnosis of vessel occlusion was missed.

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