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Regional Centers of Excellence for the Care of Patients With Acute Ischemic Heart Disease

Key Points Current clinical practice guidelines for the care of patients who present with ST-segment elevation myocardial infarction (STEMI) provide a class I recommendation that “all communities should create and maintain a regional system of STEMI care that includes assessment and continuous quality improvement of emergency medical services (EMS) and hospital-based activities” (class I, level of evidence B). “Regional” care for patients with acute coronary syndromes…

Supported Percutaneous Intervention

Key Points Clinical characteristics of the elective high-risk patient include older age, history of myocardial infarction (MI), low ejection fraction, congestive heart failure (CHF), recent hemodynamic instability, renal insufficiency, and peripheral vascular disease. High-risk angiographic characteristics for the elective patient include left main coronary artery (LMCA) disease, last patent conduit, multivessel coronary artery disease, complex lesions (calcified, tortuous, bifurcation), decreased preprocedure thrombolysis in myocardial infarction (TIMI)…

Role of Adjunct Devices: Atherectomy, Cutting Balloon, and Laser

Key Points Rotational and orbital atherectomy facilitate stent implantation in undilatable, rigid, or heavily calcified lesions. Cutting or scoring balloons slip less often than conventional balloons and may be useful for treating restenotic or ostial lesions. Laser angioplasty uses a thermomechanical mechanism to prepare rigid or undilatable lesions for stent implantation. Atheroablative devices do not reduce restenosis. Atheroablative devices increase the risk of coronary perforation. The…

Restenosis

Key Points Restenosis is a pathologic response to injury that leads to narrowing of the vessel segment as a result of negative vascular remodeling and neointimal proliferation of vascular smooth muscle cells. Clinical and angiographic predictors of stent restenosis include diabetes, nonsmoking status, female sex, acute coronary syndrome, previous percutaneous coronary intervention (PCI), saphenous vein graft disease, small vessel diameter, long lesions, high angiographic complexity, ostial…

Role of the Cardiac Surgeon and the Heart Team

Key Points The role of the cardiac surgeon in the catheterization laboratory has traditionally been surgical backup for the interventional cardiologist. Such service is losing necessity as the development and mastery of new interventional procedures progress and correlate with the advancement of medical device technology. New minimally invasive interventional procedures are founded upon the historical open surgical approach and take a defined pathway from conception to…

Transradial Access for Cardiovascular Catheterization and Intervention

Key Points Access-site and nonaccess-site bleeding complications after percutaneous coronary intervention (PCI) are associated with poor outcome, including mortality. A transradial approach (TRA) for diagnostic angiography and PCI is associated with virtually no major access-site bleeding, early ambulation, and subsequent increase of net clinical benefit. After an initial short learning curve, the procedural success rates of TRA become similar to those of the transfemoral approach. TRA…

Access Management and Closure Devices

Key Points Access-site complications continue to be the most common adverse events after cardiovascular interventions, extending the patient’s hospital stay and increasing the associated procedural costs. Selection of the appropriate access site is frequently a key issue for the successful completion of coronary, peripheral vascular, or structural procedures. Selection depends on the target vessel or structural intervention, the operator’s skills, and the patient’s preferences. The ultrasound-guided…

Periprocedural Myocardial Infarction and Embolism-Protection Devices

Key Points Periprocedural myocardial necrosis remains a common complication of percutaneous coronary intervention (PCI). The 2012 Third Universal Definition document defines a myocardial infarction (MI) associated with PCI as elevation of troponin values above five times the 99th percentile of upper reference limit (URL) in patients with normal baseline values or a rise of troponin values above 20% if the baseline values are elevated and are…

Complications of Percutaneous Coronary Intervention

Key Points Although most complications are avoidable, when they occur, rapid recognition and corrective response are necessary to mitigate adverse consequences such as myocardial infarctions or death. Abrupt closure and intraprocedural stent thrombosis/acute stent thrombosis (<24 hours) are serious complications that can result in myocardial infarctions and death. Treating them requires rapid steps to restore perfusion, optimization of pharmacology, and careful evaluation to identify and treat…

The Thrombus-Containing Lesion

Key Points Thrombus plays a major role in the pathophysiology of acute and chronic ischemic coronary syndromes. Thrombus is a marker of active, unstable atherosclerotic plaques. Plaque rupture, plaque erosion, and calcified nodules are prominent histopathologic components causing coronary thrombosis. The necrotic core of the atherosclerotic plaque and its lipid content, especially the morphologic changes and dynamic movement of embedded cholesterol crystals, affect thrombus formation. The…

Bypass Graft Intervention

Key Points Early postoperative ischemia (<30 days) is frequently due to graft occlusion or stenosis, and percutaneous coronary intervention (PCI) is often feasible. Unstable angina or ST–segment–elevation myocardial infarction (STEMI) years after coronary artery bypass grafting (CABG) is most often due to a saphenous vein graft (SVG) lesion; in such cases, native vessel PCI is preferred whenever possible. Embolic protection reduces the risk of atheroembolic myocardial…

Intervention for Coronary Chronic Total Occlusions

Key Points Chronic total occlusion (CTO) is a common feature in patients with coronary artery disease (CAD) and is a frequent reason for not proceeding with percutaneous coronary intervention (PCI). Observational data suggests that ischemic reduction from successful CTO PCI improves symptoms, ejection fraction (EF), and long-term clinical survival compared with failure of CTO PCI. Available randomized trial data are limited and have several limitations. Clinically,…

Complex and Multivessel Percutaneous Coronary Intervention

Key Points Myocardial revascularization, which aims to relieve the negative prognostic impact of coronary artery disease left untreated, has emerged as a strategy to improve prognosis and quality of life in patients with multivessel disease (MVD). Over the past four decades, percutaneous coronary intervention (PCI) has evolved into a safe and reproducible procedure that, using an armamentarium of cutting-edge devices, has extended the possibility of noninvasive…

Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis

Key Points Coronary angiography has limitations in assessing left main coronary artery (LMCA) disease and guiding treatment. The complementary use of coronary physiology and imaging modalities is helpful to improve outcomes following LMCA stenting. Long-term prognosis following ostial or shaft LMCA stenting is excellent. When treating the distal LMCA bifurcation, the interventionalist should understand the advantage and disadvantage of each stenting strategy. Whatever percutaneous coronary intervention…

Bifurcations and Branch Vessel Stenting

Key Points Always consider an ostial lesion as a possible bifurcation lesion, except in cases of aortoostial location. A 6-Fr guiding catheter is appropriate most of the time; when in doubt, use 7- or 8-Fr. Do not risk losing the side branch (SB); when in doubt, always protect it with a wire. If there are difficulties wiring the SB, consider dilating the main branch first. Provisional…

Interventions in Cardiogenic Shock

Key Points Cardiogenic shock (CS) remains the leading cause of death among patients hospitalized with acute myocardial infarction (AMI). Left ventricular (LV) dysfunction accounts for most CS in AMI patients. Early restoration of perfusion to the territory supplied by the infarct-related artery is of paramount importance in preventing CS and changing outcomes once it has developed. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock…

Post-Percutaneous Coronary Intervention Hospitalization, Length of Stay, and Discharge Planning

Key Points Comprehensive post-percutaneous coronary intervention (PCI) discharge management is an integral aspect of postprocedure care and includes direct patient communication, monitoring for procedural or vascular complications, and clear discharge instructions with a specific follow-up plan. Medication reconciliation, especially regarding dual antiplatelet therapy (DAPT) post-PCI, is critical for aggressive secondary prevention and to prevent late complications. Evaluation of cardiac biomarkers post-PCI is controversial. Although it is…

Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction

Key Points Catheter-based primary percutaneous coronary intervention (PPCI) has become the mainstay of reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI). PPCI is superior to thrombolytic therapy in reducing death, reinfarction, intracranial bleeding, reocclusion of the infarct-related artery, and myocardial ischemia in patients with STEMI irrespective of the patient’s risk or whether interhospital transfer for PCI is required. Regional systems of care coordinating hospitals and…

Intervention for Non–ST-Segment Elevation Acute Coronary Syndromes

Key Points All patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) need to undergo risk stratification at the time of diagnosis. Risk stratification provides prognostic value and helps guide the therapeutic decision-making process. Immediate angiography within 2 hours is recommended for NSTE-ACS patients who present with either hemodynamic instability or life-threatening arrhythmias or mechanical complications of myocardial infarction. Compared with ischemia-guided management, an early invasive strategy…

Elective Intervention for Stable Angina or Silent Ischemia

Key Points Chronic angina is a growing worldwide problem with significant economic and societal costs. By reducing the ischemic burden, percutaneous coronary revascularization provides important clinical benefit in patients with established obstructive coronary artery disease (CAD). The foremost effect is prompt symptom control and improved exercise tolerance. Direct evidence for improvement in survival or definitive reduction of major cardiovascular events is lacking in the broad population…