Publications by authors named "Simon R Dixon"

99 Publications

A Novel Catheterization Laboratory Radiation Shielding System: Results of Pre-Clinical Testing.

Cardiovasc Revasc Med 2022 03 21;36:51-55. Epub 2021 May 21.

Frederik Meijer Heart & Vascular Institute, Spectrum Health, Grand Rapids, MI, United States of America.

Background: This pre-clinical study evaluated the efficacy of a novel shielding system to reduce scatter radiation in the cardiac catheterization laboratory.

Methods: Using a scatter radiation phantom in a standard cardiac catheterization laboratory, a radiation physicist recorded radiation measurements at 20 reference points on the operator side of the table. Measurements were made with fluoroscopy and cine with the C-arm in the posterior-anterior (PA) and 40 degrees left anterior oblique (LAO) orientations. Scatter radiation doses were compared with and without use of the shielding system.

Results: Use of the shielding system was associated with >94.2% reduction in scatter radiation across all reference points in the PA and LAO projections with fluoroscopy and cine. With the shielding system, dose reductions at the location of the primary operator ranged from 97.8% to 99.8%. At locations of maximum scatter radiation, use of the shielding system resulted in dose reductions ranging from 97.8% to 99.8% with fluoroscopy and from 97.9% to 99.8% with cine.

Conclusions: In this pre-clinical study, a novel radiation shielding system was observed to dramatically reduce scatter radiation doses. Based on these results, clinical testing is warranted to determine whether the shielding system will enable operators and staff to perform interventional procedures with less radiation exposure that may obviate the need to wear standard lead apparel.

Indexing Words: Radiation safety; occupational health; occupational hazard.
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http://dx.doi.org/10.1016/j.carrev.2021.05.017DOI Listing
March 2022

Comparative Safety of Bioabsorbable Polymer Everolimus-Eluting, Durable Polymer Everolimus-Eluting, and Durable Polymer Zotarolimus-Eluting Stents in Contemporary Clinical Practice.

Circ Cardiovasc Interv 2021 03 25;14(3):e009850. Epub 2021 Feb 25.

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (N.R.S., M.S., D.S., H.S.G.).

[Figure: see text].
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.009850DOI Listing
March 2021

Disparate impact of severe aortic and mitral regurgitation on left ventricular dilation.

Catheter Cardiovasc Interv 2021 05 20;97(6):1301-1308. Epub 2021 Jan 20.

Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA.

In asymptomatic severe aortic (AR) and mitral regurgitation (MR), left ventricular (LV) dimension criteria were established to guide timing of valve replacement to prevent irreversible LV dysfunction. Given both lesions are primary LV volume overload ''leaks'', it might be expected that both lesions would induce similar impact on the LV and result in equivalent dimension criteria for intervention. However, the dimension-based intervention criteria for AR versus MR (developed through natural history studies), differ markedly. The pathophysiological foundations for such discordance have neither been fully elucidated nor emphasized. This case-based treatise compares the two regurgitant lesions with respect to: (a) ''total regurgitant circuits''; (b) ''driving pressures'' resulting in LV volume overload from each respective ''leak''; and (c) volume and afterload wall stresses imposed on the LV.Key points The ''total circuits'' of volume overload differ: The AR circuit includes the LV and systemic vasculature, whereas MR includes the LV ejecting into the left atrium/pulmonary veins and systemic circulation. The ''driving pressure'' of regurgitation and afterload are high with AR and low with MR. Differing ''total circuits'' and ''driving pressures'' impose disparate wall stresses upon the LV. Parallel and serial sarcomere replication occurs in AR, while only serial replication occurs in MR. It therefore follows that for regurgitation of similar severities, AR results in greater LV dilation at the point of irreversible myocardial dysfunction compared to MR. These considerations may explain, at least in part, the disparate dimension criteria employed for valve intervention for severe AR vs MR.
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http://dx.doi.org/10.1002/ccd.29455DOI Listing
May 2021

Mechanically supported PCI for ischemic cardiomyopathy reawakening of hibernating myocardium.

Catheter Cardiovasc Interv 2020 10;96(4):771-772

Beaumont Hospital, Royal Oak, MI, USA.

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http://dx.doi.org/10.1002/ccd.29304DOI Listing
October 2020

Impact of COVID-19 pandemic on STEMI care: An expanded analysis from the United States.

Catheter Cardiovasc Interv 2021 08 7;98(2):217-222. Epub 2020 Aug 7.

The Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio.

Objective: To evaluate the impact of COVID-19 pandemic migitation measures on of ST-elevation myocardial infarction (STEMI) care.

Background: We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID-19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data.

Methods: Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019-February 2020 and March-April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC.

Results: Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18-38, p < .001), number of activations leading to angiography (34%, 95% CI: 12-50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11-27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (-0.2 to 44, p = .05).

Conclusions: The COVID-19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI.
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http://dx.doi.org/10.1002/ccd.29154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436427PMC
August 2021

SCAI shock classification in acute myocardial infarction: Insights from the National Cardiogenic Shock Initiative.

Catheter Cardiovasc Interv 2020 11 16;96(6):1137-1142. Epub 2020 Jul 16.

Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA.

Objectives: We applied the cardiovascular angiography and interventions (SCAI) shock staging system to patients presenting with acute myocardial infarction and cardiogenic shock (AMI-CS) who were enrolled in the National Cardiogenic Shock Initiative (NCSI).

Background: The SCAI shock staging system provides a framework for evaluation of patients with CS based on clinical and hemodynamic parameters, but has not been validated in patients with AMI-CS managed with a contemporary treatment algorithm that incorporates early use of Impella.

Methods: Consecutive patients enrolled in NCSI were identified, all of whom were managed with invasive hemodynamic guidance and supported with Impella. Patients were retrospectively categorized into appropriate SCAI shock stages, and outcomes were assessed accordingly.

Results: A total of 300 patients were included in the analysis; 182 patients (61%) presented in Stage C shock, 25 (8%) in Stage D, and 93 (31%) in Stage E. Survival to hospital discharge was 76, 76, and 58%, respectively (p = .006). Survival was <20% among patients in Stage E at 24 hr, regardless of baseline stage. There was near perfect agreement in shock staging between two independent clinicians at baseline (kappa = 0.975, 95% CI, 0.95-1.00, p < .001) and at 24 hr (kappa = 0.985, 95% CI, 0.77-1.00, p < .001).

Conclusion: In patients with AMI-CS enrolled in NCSI, SCAI Shock classification was reproducible, and predicted survival when applied at presentation and at 24 hr.
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http://dx.doi.org/10.1002/ccd.29139DOI Listing
November 2020

One-year outcomes of supersaturated oxygen therapy in acute anterior myocardial infarction: The IC-HOT study.

Catheter Cardiovasc Interv 2021 05 10;97(6):1120-1126. Epub 2020 Jul 10.

Clinical Trials Center, Cardiovascular Research Foundation, New York.

Background: Supersaturated oxygen (SSO ) has recently been approved by the U.S. Food and Drug Administration for administration after primary percutaneous coronary intervention (pPCI) in patients with anterior ST-segment elevation myocardial infarction (STEMI) based on its demonstration of infarct size reduction in the IC-HOT study.

Objectives: To describe the 1-year clinical outcomes of intracoronary SSO treatment after pPCI in patients with anterior STEMI.

Methods: IC-HOT was a prospective, open-label, single-arm study in which 100 patients without cardiogenic shock undergoing successful pPCI of an occluded left anterior descending coronary artery were treated with a 60-min SSO infusion. One-year clinical outcomes were compared with a propensity-matched control group of similar patients with anterior STEMI enrolled in the INFUSE-AMI trial.

Results: Baseline and postprocedural characteristics were similar in the two groups except for pre-PCI thrombolysis in myocardial infarction 3 flow, which was less prevalent in patients treated with SSO (9.6% vs. 22.9%, p = .02). Treatment with SSO was associated with a lower 1-year rate of the composite endpoint of all-cause death or new-onset heart failure (HF) or hospitalization for HF (0.0% vs. 12.3%, p = .001). All-cause mortality, driven by cardiovascular mortality, and new-onset HF or HF hospitalization were each individually lower in SSO -treated patients. There were no significant differences between groups in the 1-year rates of reinfarction or clinically driven target vessel revascularization.

Conclusions: Infusion of SSO following pPCI in patients with anterior STEMI was associated with improved 1-year clinical outcomes including lower rates of death and new-onset HF or HF hospitalizations.
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http://dx.doi.org/10.1002/ccd.29090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246818PMC
May 2021

Strategic Deployment of Cardiology Fellows in Training Using the Accreditation Council for Graduate Medical Education Coronavirus Disease 2019 Framework.

J Am Heart Assoc 2020 07 1;9(14):e017443. Epub 2020 Jun 1.

Department of Cardiovascular Medicine Beaumont Hospital-Royal Oak Royal Oak MI.

Coronavirus disease 2019 is a global pandemic affecting >3 million people in >170 countries, resulting in >200 000 deaths; 35% to 40% of patients and deaths are in the United States. The coronavirus disease 2019 crisis is placing an enormous burden on health care in the United States, including residency and fellowship training programs. The balance between mitigation, training and education, and patient care is the ultimate determinant of the role of cardiology fellows in training during the coronavirus disease 2019 crisis. On March 24, 2020, the Accreditation Council for Graduate Medical Education issued a formal response to the pandemic crisis and described a framework for operation of graduate medical education programs. Guidance for deployment of cardiology fellows in training during the coronavirus disease 2019 crisis is based on the principles of a medical mission, and adherence to preparation, protection, and support of our fellows in training. The purpose of this review is to describe our departmental strategic deployment of cardiology fellows in training using the Accreditation Council for Graduate Medical Education framework for pandemic preparedness.
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http://dx.doi.org/10.1161/JAHA.120.017443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660705PMC
July 2020

Institutional Variability in Patient Radiation Doses ≥5 Gy During Percutaneous Coronary Intervention.

JACC Cardiovasc Interv 2020 04;13(7):846-856

Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan.

Objectives: The aim of this study was to evaluate institutional variability in high radiation doses during percutaneous coronary intervention (PCI).

Background: It is unknown whether radiation safety practices are optimally applied across institutions performing PCI.

Methods: Using data from a large statewide registry, PCI discharges between July 1, 2016, and March 31, 2018, with a procedural air kerma (AK) recorded were analyzed. PCI procedures were grouped by the performing hospital, and institutional frequency of procedural AK ≥5 Gy was calculated. Fitted hierarchical Bayesian modeling was performed to identify variables independently associated with an AK ≥5 Gy. The performing hospital was included as a random effect in the hierarchical model.

Results: Among 36,201 PCI procedures at 28 hospitals, procedural AK was ≥5 Gy in 1,477 cases (4.1%), ≥10 Gy in 185 (0.5%), and ≥15 Gy in 105 (0.3%). The institutional frequency of procedural AK ≥5 Gy ranged from 0.0% to 10.9%. Bayesian modeling identified body mass index, dyslipidemia, diabetes, prior coronary bypass surgery, use of mechanical circulatory support, and the performing hospital as independent predictors of an AK ≥5 Gy. The median odds ratio for the performing hospital, representing an estimate of the contribution of interhospital variability in determining the odds of having a procedural AK ≥5 Gy, was 3.08 (95% confidence interval: 3.01 to 3.16).

Conclusions: Wide variability exists in the institutional frequency of procedural AK ≥5 Gy during PCI. After accounting for patient characteristics and procedural variables, the performing hospital appears to be a major factor in determining patient radiation dose in contemporary PCI.
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http://dx.doi.org/10.1016/j.jcin.2019.11.032DOI Listing
April 2020

2-Year Outcomes After Stenting of Lipid-Rich and Nonrich Coronary Plaques.

J Am Coll Cardiol 2020 03;75(12):1371-1382

Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Montefiore Medical Center, Bronx, New York.

Background: Autopsy studies suggest that implanting stents in lipid-rich plaque (LRP) may be associated with adverse outcomes.

Objectives: The purpose of this study was to evaluate the association between LRP detected by near-infrared spectroscopy (NIRS) and clinical outcomes in patients with coronary artery disease treated with contemporary drug-eluting stents.

Methods: In this prospective, multicenter registry, NIRS was performed in patients undergoing coronary angiography and possible percutaneous coronary intervention (PCI). Lipid core burden index (LCBI) was calculated as the fraction of pixels with the probability of LRP >0.6 within a region of interest. MaxLCBI was defined as the maximum LCBI within any 4-mm-long segment. Major adverse cardiac events (MACE) included cardiac death, myocardial infarction, definite or probable stent thrombosis, or unplanned revascularization or rehospitalization for progressive angina or unstable angina. Events were subcategorized as culprit (treated) lesion-related, nonculprit (untreated) lesion-related, or indeterminate.

Results: Among 1,999 patients who were enrolled in the COLOR (Chemometric Observations of Lipid Core Plaques of Interest in Native Coronary Arteries Registry), PCI was performed in 1,621 patients and MACE occurred in 18.0% of patients, of which 8.3% were culprit lesion-related, 10.7% were nonculprit lesion-related, and 3.1% were indeterminate during 2-year follow-up. Complications from NIRS imaging occurred in 9 patients (0.45%), which resulted in 1 peri-procedural myocardial infarction and 1 emergent coronary bypass. Pre-PCI NIRS imaging was obtained in 1,189 patients, and the 2-year rate of culprit lesion-related MACE was not significantly associated with maxLCBI (hazard ratio of maxLCBI per 100: 1.06; 95% confidence interval: 0.96 to 1.17; p = 0.28) after adjusting clinical and procedural factors.

Conclusions: Following PCI with contemporary drug-eluting stents, stent implantation in NIRS-defined LRPs was not associated with increased periprocedural or late adverse outcomes compared with those without significant lipid.
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http://dx.doi.org/10.1016/j.jacc.2020.01.044DOI Listing
March 2020

Relationship Between Troponin on Presentation and In-Hospital Mortality in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

J Am Heart Assoc 2019 10 24;8(19):e013551. Epub 2019 Sep 24.

Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Ann Arbor MI.

Background Troponin release in ST-segment-elevation myocardial infarction (STEMI) has predictable kinetics with early levels reflective of ischemia duration. Little research has examined the value of admission troponin levels in STEMI patients undergoing primary percutaneous coronary intervention. We investigated the relationship between troponin on presentation and mortality in a large, real-world cohort of STEMI patients undergoing primary percutaneous coronary intervention. Methods and Results We used multivariable adaptive regression modeling to examine the association between admission troponin levels and in-hospital mortality for patients who underwent primary percutaneous coronary intervention for STEMI. We adjusted for known clinical risk factors using a validated mortality risk model derived from the NCDR (National Cardiovascular Data Registry) CathPCI database, and this same model was used to calculate patients' predicted mortality based on clinical and demographic factors. Patients were then stratified by troponin groups to compare predicted versus observed mortality. Of the 14 061 patients included in the cohort, 47.2% had initial troponin levels that were undetectable or within the reference range. Admission troponin was an independent predictor of in-hospital mortality, and any value above the reference range was associated with increased mortality (1.8% versus 5.1%, [standardized difference, 18.2%]). Patients with the highest predicted risk for mortality (13% predicted) in the highest admission troponin grouping experienced an observed mortality of 19.5%. Patients in low troponin groupings consistently demonstrated lower than predicted mortality based on their clinical and demographic risk profile. Conclusions Nearly half of patients undergoing primary percutaneous coronary intervention had normal troponin on presentation and had a relatively good outcome. Mortality increases with elevated admission troponin levels, regardless of baseline clinical risk. The substantial number of patients who present with markedly elevated troponin and their relatively worse outcomes highlights the need for continued improvement in prehospital STEMI detection and care.
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http://dx.doi.org/10.1161/JAHA.119.013551DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806038PMC
October 2019

Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department.

JACC Cardiovasc Imaging 2020 02 17;13(2 Pt 1):452-461. Epub 2019 Jul 17.

Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan.

Objectives: This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFR) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program.

Background: FFR is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied.

Methods: ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFR were studied. FFR ≤0.80 was considered positive for hemodynamically significant stenosis.

Results: Among 555 patients, 297 underwent coronary CTA and FFR (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFR was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFR groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFR results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFR when revascularization was deferred. Negative FFR was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFR (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFR groups ($8,582 vs. $8,048; p = 0.550).

Conclusions: In ACP, FFR is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFR, which is associated with higher nonobstructive disease on invasive angiography.
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http://dx.doi.org/10.1016/j.jcmg.2019.05.025DOI Listing
February 2020

Cardiac Rehabilitation Use After Percutaneous Coronary Intervention.

J Am Coll Cardiol 2019 06;73(24):3148-3152

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Division of Cardiology, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.

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http://dx.doi.org/10.1016/j.jacc.2019.03.515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6857732PMC
June 2019

Disparate Impact of Ischemic Injury on Regional Wall Dysfunction in Acute Anterior vs Inferior Myocardial Infarction.

Cardiovasc Revasc Med 2019 11 21;20(11):965-972. Epub 2018 Dec 21.

Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, MI, USA.

Background: Acute transmural ischemia should induce similar magnitude of wall motion abnormality (WMA) in both anterior myocardial infarction (AMI) and inferior (IMI). However, patients with AMI generally suffer more severe hemodynamic compromise.

Methods: This retrospective study compared WMA's in ST segment elevation MI patients undergoing primary reperfusion and subsequent cardiac MRI. Regional systolic wall motion and thickening were assessed in all segments throughout the left ventricle (LV).

Results: We analyzed 37 patients (AMI = 24 vs IMI = 13). Reperfusion success was achieved in all and there were no differences between groups in door-to-balloon time (AMI median 77 vs IMI 119 min, p = 0.085). Compared to IMI, in AMI LV ejection fraction was more depressed (37 ± 7.6% vs 51 ± 10.3%, P = 0.0006) and regional WMA more severe (total regional WMA score = 2.63 ± 0.53 vs IMI = 2.1 ± 0.52, P = 0.007). Regional dyskinesis was commonly observed in AMI patients but was rare in IMI (79% vs 7% of cases). Similarly, AMI manifested systolic thinning, whereas thickening was depressed but still present in IMI patients. Strikingly, WMA severity differed downstream relative to the origin of the infarct artery: In all AMI cases, WMA worsened from proximal anterior toward the distal apical zone; in IMI the pattern was reverse, with WMA consistently most severe in the basal segment of the inferior-posterior wall with preservation toward the apical distribution of the infarct vessel.

Conclusion: These results demonstrate a disparate impact of ischemic injury on mechanical performance of the anterior vs inferior-posterior walls. These findings may be attributable to differences between the walls in architecture, mechanics and coronary blood flow. These observations may have implications for myocardial salvage, remodeling and prognosis.
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http://dx.doi.org/10.1016/j.carrev.2018.12.016DOI Listing
November 2019

Long-term outcome of brachytherapy treatment for coronary in-stent restenosis: Ten-year follow-up.

Catheter Cardiovasc Interv 2019 03 2;93(4):E211-E216. Epub 2018 Oct 2.

Beaumont Hospital Royal Oak, Royal Oak, Michigan.

Objectives: The objective of this study was to determine the long-term major adverse cardiac events (MACE) in patients treated with intracoronary brachytherapy (ICBT) for coronary in-stent restenosis (ISR).

Background: ICBT was commonly used to treat coronary ISR prior to the availability of drug-eluting stents (DES). The long-term outcomes of ICBT for ISR remain unknown.

Methods: Six hundred and eighty consecutive patients who underwent ICBT treated for ISR between September 1998 and April 2005 were included in the study. Clinical and angiographic data were collected and the long-term MACE were measured for all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR) at 10-year follow-up.

Results: Patients were 63 ± 11 years old (66% male). The majority of patients were treated with a bare metal stent 670/680 (99%) prior to ICBT. Significant baseline clinical findings include high incidence of smokers 479/680 (70%), hyperlipidemia 638/680 (94%), and multivessel disease 526/680 (77%). The majority of target lesions were diffuse 407/680 (60%), and either in the left anterior descending 258/680 (38%) or right coronary artery 215/680 (32%). At 10-year follow-up, the rate of death was 25%, MI was 22.4%, and TVR was 48%.

Conclusion: MACE at 10-year follow-up following ICBT for ISR indicates steady rate of death and MI and declining rate of TVR after 5 years.
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http://dx.doi.org/10.1002/ccd.27866DOI Listing
March 2019

Evaluation of intracoronary hyperoxemic oxygen therapy in acute anterior myocardial infarction: The IC-HOT study.

Catheter Cardiovasc Interv 2019 04 28;93(5):882-890. Epub 2018 Sep 28.

Cardiovascular Research Foundation, New York, New York.

Background: In the randomized AMIHOT-II trial, supersaturated oxygen [SSO ] delivered into the left anterior descending (LAD) artery via an indwelling intracoronary infusion catheter following primary percutaneous coronary intervention (PCI) significantly reduced infarct size in patients with anterior ST-segment elevation myocardial infarction (STEMI) but resulted in a numerically higher incidence of safety events.

Objectives: The IC-HOT study evaluated the safety of SSO therapy selectively delivered to the left main coronary artery (LMCA) for 60 minutes after PCI in patients with anterior STEMI.

Methods: SSO therapy was administered to the LMCA after stent implantation in 100 patients with anterior STEMI and proximal or mid-LAD occlusion presenting within 6 hours of symptom onset. The primary endpoint was the 30-day composite rate of net adverse clinical events (NACE) (death, reinfarction, clinically driven target vessel revascularization, stent thrombosis, severe heart failure, or TIMI major/minor bleeding) compared against an objective performance goal of 10.7%. Cardiac magnetic resonance imaging was performed at 4 and 30 days to assess infarct size.

Results: SSO delivery was successful in 98% of patients. NACE at 30 days occurred 7.1% of patients (meeting the primary safety endpoint of the study); there were no deaths, only one stent thrombosis and one case of severe heart failure. Median [interquartile range] infarct size was 24.1% [14.4%, 31.6%] at 4 days and 19.4% [8.8%, 28.9%] at 30 days.

Conclusion: Following primary PCI in acute anterior STEMI, infusion of SSO via the LMCA was feasible and was associated with a favorable early safety profile.
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http://dx.doi.org/10.1002/ccd.27905DOI Listing
April 2019

Contemporary use of and outcomes associated with ultra-low contrast volume in patients undergoing percutaneous coronary interventions.

Catheter Cardiovasc Interv 2019 02 25;93(2):222-230. Epub 2018 Aug 25.

Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan.

Background: The risk of contrast-induced acute kidney injury (CI-AKI) increases in a nonlinear fashion with increasing volume of contrast media. Prior studies recommend limiting contrast volume to less than three times the estimated creatinine clearance (CC). Recently, a number of operators have reported successful percutaneous coronary intervention (PCI) using even lower volumes of contrast.

Objectives: To evaluate the prevalence and outcomes associated with ultra-low contrast volume among patients undergoing PCI.

Methods: We assessed the prevalence and outcomes associated with use of ultra-low contrast volume among 75 393 patients undergoing PCI in Michigan between July 2014 and June 2017 in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry. Ultra-low contrast volume was defined as contrast volume less than or equal to the patient's estimated CC. Patients receiving dialysis at the time of the procedure were excluded.

Results: Ultra-low contrast volume was used in 13% of procedures with the majority of these patients being at low risk of renal complications. Compared with patients who received a contrast volume between one and three times the CC, use of ultra-low volume of contrast was associated with a significantly lower incidence of AKI (aOR 0.682, 95% CI 0.566-0.821, P < 0.001) and a lower incidence of need for dialysis (aOR = 0.341, 95% CI 0.165-0.704, P = 0.003). These benefits were most evident in the patients with a high baseline predicted risk of AKI.

Conclusions: A small but clinically significant number of patients are treated with ultra-low contrast volume. Ultra-low contrast volume use is associated with a significant reduction in the incidence of AKI or need for dialysis. It may be prudent to consider this new threshold when performing PCI on patients who are at an increased risk of AKI.
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http://dx.doi.org/10.1002/ccd.27819DOI Listing
February 2019

Outcomes After Percutaneous Coronary Intervention in Patients With a History of Cerebrovascular Disease: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

Circ Cardiovasc Interv 2018 06;11(6):e006400

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (D.S., M.S., H.S.G.).

Background: Because of shared risk factors between coronary artery disease and cerebrovascular disease, patients with a history of transient ischemic attack (TIA) or stroke are at greater risk of developing coronary artery disease, which may require percutaneous coronary intervention (PCI). However, there remains a paucity of research examining outcomes after PCI in these patients.

Methods And Results: We analyzed consecutive patients who underwent PCI between January 1, 2013, and March 31, 2016, at 47 Michigan hospitals and identified those with a history of TIA/stroke. We used propensity score matching to adjust for differences in baseline characteristics and compared in-hospital outcomes between patients with and without a history of TIA/stroke. We compared rates of 90-day readmission and long-term mortality in a subset of patients. Among 98 730 patients who underwent PCI, 10 915 had a history of TIA/stroke. After matching (n=10 618 per group), a history of TIA/stroke was associated with an increased risk of in-hospital stroke (adjusted odds ratio, 2.04; 95% confidence interval, 1.41-2.96; <0.001). There were no differences in the risks of other in-hospital outcomes. In a subset of patients with postdischarge data, a history of TIA/stroke was associated with increased risks of 90-day readmission (adjusted odds ratio, 1.22; 95% confidence interval, 1.09-1.38; <0.001) and long-term mortality (hazard ratio, 1.23; 95% confidence interval, 1.07-1.43; =0.005).

Conclusions: A history of TIA/stroke was common in patients who underwent PCI and was associated with increased risks of in-hospital stroke, 90-day readmission, and long-term mortality. Given the devastating consequences of post-PCI stroke, patients with a history of TIA/stroke should be counseled on this increased risk before undergoing PCI.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.118.006400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873702PMC
June 2018

Analysis of outcomes for 15,259 US patients with acute myocardial infarction cardiogenic shock (AMICS) supported with the Impella device.

Am Heart J 2018 08 7;202:33-38. Epub 2018 Apr 7.

Duke Clinical Research Institute, Duke University Medical Center, Durham, NC. Electronic address:

Background: The Impella percutaneous ventricular assist device (PVAD) rapidly deploys mechanical circulatory support (MCS) in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS). We present findings from a quality improvement (IQ) registry for US patients with AMICS who received Impella devices.

Methods And Results: From January 2009 to December 2016, 46,949 patients from 1010US hospitals were entered into the IQ registry; of these, 15,259 had AMICS. Limited de-identified patient information, product performance, and survival to explantation were recorded. Of those with AMICS, 51% survived to explantation of PVAD. There was a significant difference between survival at explantation with quintile volume at hospitals (range: 0-100%; 30% survival rate in lowest quintile vs. 76% in top quintile; P<.0001). Use of the Impella device as first-line treatment pre-PCI was associated with a 59% survival rate, compared with 52% when used as a salvage strategy (P<.001). The survival rate among those who received hemodynamic monitoring with pulmonary artery catheters was 63% as compared with 49% in those who did not (P<.0001). Overall institutional Impella volume was related to survival (56% survival at sites with >7/year vs. 51% at sites with ≤1; P<.001).

Conclusions: In this early clinical experience with Impella support for AMICS, wide variation in outcomes existed across centers. Survival was higher when Impella was used as first support strategy, when invasive hemodynamic monitoring was used, and at centers with higher Impella implantation volume.
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http://dx.doi.org/10.1016/j.ahj.2018.03.024DOI Listing
August 2018

The cVAD registry for percutaneous temporary hemodynamic support: A prospective registry of Impella mechanical circulatory support use in high-risk PCI, cardiogenic shock, and decompensated heart failure.

Am Heart J 2018 05 28;199:115-121. Epub 2017 Sep 28.

Henry Ford Hospital/Wayne State University, Detroit, MI. Electronic address:

Management of patients requiring temporary, mechanical hemodynamic support during high- risk percutaneous coronary intervention (PCI) or in cardiogenic shock is rapidly evolving. With the availability of the Impella 2.5, CP, 5.0, LD, and RP percutaneous mechanical circulatory support devices, there is a need for continued surveillance of outcomes. Three factors underline the importance of a registry for these populations. First, large randomized trials of hemodynamic support, involving cardiogenic shock, are challenging to conduct. Second, there is increasing interest in the use of registries to provide "real-world" experience and to allow the flexibility to evaluate individual patient uses and outcomes. Third, current, large databases have not captured the specific impact of mechanical support treatment of cardiogenic shock. The predecessor to the catheter-based ventricular assist devices registry, known as USpella, began in 2009 with paper data acquisition but beginning in 2011 transferred to electronic data capture, enrolling 3,339 patients through 2016. Throughout, registry data have been used to assess the outcomes of Impella therapy, leading to 8 publications and 4 Food and Drug Administration premarket approvals covering multiple indications and Impella devices. Going forward, the registry will continue to assess not only in-hospital outcomes but long-term follow-up to 1 year. In addition, data management will be enhanced to assess quality and clinical experiences. The registry will also provide a mechanism for postmarketing surveillance. This manuscript reviews the ongoing catheter-based ventricular assist devices registry design, management, and contributions of the registry data. The upgraded registry will provide a more robust opportunity to assess acute and late outcomes of current and future device use worldwide.

Condensed Abstract: The current catheter-based ventricular assist devices registry is an international database documenting outcomes with temporary Impella hemodynamic support. The registry has supported 8 publications and 4 Food and Drug Administration premarket approvals since its inception in 2009. The current registry is more robust containing outcomes up to 1 year postprocedure.
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http://dx.doi.org/10.1016/j.ahj.2017.09.007DOI Listing
May 2018

Ninety-Day Readmission and Long-Term Mortality in Medicare Patients (≥65 Years) Treated With Ticagrelor Versus Prasugrel After Percutaneous Coronary Intervention (from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium).

Am J Cardiol 2017 Dec 30;120(11):1926-1932. Epub 2017 Aug 30.

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Division of Cardiology, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.

Ticagrelor and prasugrel were found to be superior to clopidogrel for the treatment of acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI); however, the comparative effectiveness of these 2 drugs remains unknown. We compared postdischarge outcomes among older patients treated with ticagrelor versus prasugrel after PCI for ACS. We linked clinical data from PCIs performed in older patients (age ≥65) for ACS at 47 Michigan hospitals to Medicare fee-for-service claims from January 1, 2013, to December 31, 2014, to ascertain rates of 90-day readmission and long-term mortality. We used propensity score matching to adjust for the nonrandom use of ticagrelor and prasugrel at discharge. Logistic regression and Cox proportional hazards models were used to compare rates of 90-day readmission and long-term mortality, respectively. Patients discharged on ticagrelor (n = 1,243) were more frequently older, female, had a history of cerebrovascular disease, and presented with ST- or non-ST-elevation myocardial infarction compared with prasugrel (n = 1,014). After matching (n = 756 per group), there were no significant differences in the rates of 90-day readmission (16.7% ticagrelor vs 14.6% prasugrel; adjusted odds ratio 1.15, 95% confidence interval 0.86 to 1.55, p = 0.35) or 1-year mortality (5.4% ticagrelor vs 3.7% prasugrel; hazard ratio 1.3, 95% confidence interval 0.8 to 2.2, p = 0.31). In conclusion, we found no significant differences in the rates of 90-day readmission or long-term mortality between older patients treated with ticagrelor and patients treated with prasugrel after PCI for ACS. In the absence of randomized data to the contrary, these 2 treatments appear similarly effective.
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http://dx.doi.org/10.1016/j.amjcard.2017.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850017PMC
December 2017

Maintenance of valvular integrity with Impella left heart support: Results from the multicenter PROTECT II randomized study.

Catheter Cardiovasc Interv 2018 10 8;92(4):813-817. Epub 2017 Oct 8.

Henry Ford Hospital, Detroit, Michigan.

Background: The Impella 2.5 axial flow pump, which is positioned across the aortic valve, is widely employed for hemodynamic support. The present study compared structural and functional integrity of the left heart valves in patients undergoing Impella vs intra-aortic balloon pump in the randomized PROTECT II trial.

Methods And Results: Transthoracic echocardiograms were performed at baseline, 1 and 3 months in 445 patients in the PROTECT II trial. Serial studies were analyzed by an independent echocardiography core laboratory for aortic and mitral valve structure and function, and left ventricular ejection fraction (LVEF). During Impella support there was no appreciable change in the degree of baseline valvular regurgitation. There were no cases of structural derangement of the mitral or aortic valve after use of the Impella device. At 90-day follow-up, there was an average 22% relative increase in LVEF from baseline (27% ± 9 vs. 33% ± 11, P < 0.001).

Conclusions: The present echocardiographic analysis of the PROTECT II study confirms prior observations regarding the safety of the Impella 2.5 device with respect to mitral and aortic valve function.
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http://dx.doi.org/10.1002/ccd.27242DOI Listing
October 2018

Contemporary Trends and Outcomes Associated With the Preprocedural Use of Oral P2Y12 Inhibitors in Patients Undergoing Percutaneous Coronary Intervention: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

J Invasive Cardiol 2017 Oct 15;29(10):340-351. Epub 2017 Apr 15.

University of Michigan Cardiovascular Center, 2A 394, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5853 USA.

Objectives: We sought to describe trends in the use of preprocedural P2Y12 inhibitors and their clinical impact in patients undergoing percutaneous coronary intervention (PCI).

Background: Oral P2Y12 inhibitors are ubiquitously used medications; however, the specific timing of initial P2Y12 inhibitor administration remains intensely debated.

Methods: Our study population comprised 74,053 consecutive patients undergoing PCI at 47 hospitals in Michigan from January 2013 through June 2015. In-hospital outcomes included stent thrombosis, bleeding, need for transfusion, and death. Hierarchical logistic regression, propensity matching, and targeted maximum likelihood estimation were used to adjust for baseline patient differences and clustering, and to minimize bias.

Results: Of 24,733 patients who received a preprocedural P2Y12 inhibitor, 82% received clopidogrel, 8% prasugrel, and 10% ticagrelor. Preprocedural administration of P2Y12 inhibitors declined during the study (49.3% to 24.8%; P<.001), and varied greatly across hospitals (14.5%-95.9%). No significant differences in outcomes were observed between patients receiving preprocedural clopidogrel and a matched cohort of those not receiving any preprocedural P2Y12 inhibitor (stent thrombosis: adjusted odds ratio [OR], 1.55; 95% confidence interval [CI], 0.30-7.84; bleeding: OR, 0.96; 95% CI, 0.63-1.46; transfusion: OR, 1.03; 95% CI, 0.69-1.55; and death: OR, 0.95; 95% CI, 0.38-2.37). Similar findings were demonstrated for preprocedural ticagrelor and prasugrel. Results from a subgroup analysis of patients with non-ST segment elevation acute coronary syndrome (n = 28,072) were consistent with the overall findings.

Conclusions: There was a substantial decline in the rate of preprocedural P2Y12 inhibitor administration during the study. Furthermore, there were no significant differences in outcomes between patients treated with preprocedural P2Y12 inhibitors and those who were not.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699908PMC
October 2017

Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock.

Am J Cardiol 2017 Mar 18;119(6):845-851. Epub 2016 Dec 18.

Division of Cardiology, Henry Ford Hospital/Wayne State University, Detroit, Michigan. Electronic address:

The role and timing of percutaneous mechanical circulatory support (MCS) devices in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS) are not well understood. We sought to evaluate patient characteristics and predictors of outcomes in patients presenting with AMICS supported with an axial flow percutaneous MCS device; 287 consecutive unselected patients enrolled in the catheter-based ventricular assist device registry presenting with AMICS who underwent percutaneous coronary intervention (PCI) were included in this analysis. All patients were supported with either the Impella 2.5 or Impella CP. Mean patient age was 66 ± 12.5 years, 76% were men, and mean left ventricular ejection fraction was 25 ± 12%. Before receiving MCS, 80% of patients required inotropes or vasopressors and 40% were supported with intra-aortic balloon pump; 9% of patients were under active cardiopulmonary resuscitation at the time of MCS implantation. Survival to discharge was 44%. In a multivariate analysis, early implantation of a MCS device before PCI (p = 0.04) and before requiring inotropes and vasopressors (p = 0.05) was associated with increased survival. Survival was 66% when MCS was initiated <1.25 hours from shock onset, 37% when initiated within 1.25 to 4.25 hours, and 26% when initiated after 4.25 hours (p = 0.017). Survival was 68%, 46%, 35%, 35%, and 26% for patients requiring 0, 1, 2, 3, and ≥4 inotropes before MCS support, respectively (p <0.001). In conclusion, MCS implantation early after shock onset, before initiation of inotropes or vasopressors and before PCI, is independently associated with improved survival in patients presenting with AMICS.
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http://dx.doi.org/10.1016/j.amjcard.2016.11.037DOI Listing
March 2017

Clinical outcomes of percutaneous coronary intervention in patients turned down for surgical revascularization.

Catheter Cardiovasc Interv 2017 Jul 21;90(1):94-101. Epub 2016 Sep 21.

Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan.

Objectives: We examined clinical outcomes following percutaneous coronary intervention (PCI) in patients turned down for surgical revascularization across a broad population.

Background: Prior studies suggest that surgical ineligibility is associated with increased mortality in patients with unprotected left main or multivessel coronary artery disease undergoing PCI.

Methods: This study included consecutive patients who underwent PCI in a multicenter registry in Michigan from January 2010 to December 2014. Surgical ineligibility required documentation indicating that a cardiac surgeon deemed the patient ineligible for surgery. In-hospital outcomes included mortality (primary outcome), cardiogenic shock, cerebrovascular accident, contrast-induced nephropathy (CIN), and a new requirement for dialysis (NRD).

Results: Of 99,370 patients at 33 hospitals with on-site surgical backup, 1,922 (1.9%) were surgically ineligible. The rate of ineligibility did not vary by hospital (range: 1.5-2.5%; P = 0.79). Overall, there were no major differences in baseline characteristics or outcomes between surgically ineligible patients and the rest (i.e., nonineligible patients): mortality (0.52% vs. 0.52%; P > 0.5), cardiogenic shock (0.68% vs. 0.73%; P > 0.5), cerebrovascular accident (0.05% vs. 0.19%; P = 0.28), NRD (0.16% vs. 0.19%; P > 0.5), CIN (2.7% vs. 2.3%; P = 0.27). Among 1,074 patients who underwent unprotected left main PCI, 20 (1.9%) were surgically ineligible and experienced increased rates of mortality (20.0% vs. 5.3%; P = 0.022; adjusted OR = 7.38; P < 0.001) and other complications as compared to the remainder.

Conclusions: PCI in a broad population of surgically ineligible patients is generally safe. However, among patients who underwent unprotected left main PCI, those deemed surgically ineligible experienced significantly worse outcomes as compared to the rest. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ccd.26781DOI Listing
July 2017

Left ventricular systolic dysfunction is associated with adverse outcomes in acute right ventricular infarction.

Coron Artery Dis 2016 Jun;27(4):277-86

aDepartment of Cardiovascular Medicine, Beaumont Health System, Royal Oak bHurley Medical System, Flint, Michigan, USA.

Background: In patients with acute right ventricular infarction (RVI), global right ventricular (RV) performance is dependent on compensatory left ventricular (LV)-septal contractile contributions. This study was designed to assess the influence of depressed left ventricular ejection fraction (LVEF) on hemodynamics and clinical outcomes in patients with RVI.

Methods And Results: We retrospectively identified 338 patients with acute inferior ST elevation myocardial infarction (STEMI) undergoing a primary percutaneous coronary intervention. RVI was determined echocardiographically by right ventricular free wall motion abnormalities and depressed global RV performance (fractional area change); LV function was similarly calculated. RVI was documented in 185 (55%) cases. Compared with those with inferior myocardial infarction alone, patients with RVI suffered more hemodynamic compromise (need for inotropes or vasopressors 39 vs. 15%, P<0.0001, and intra-aortic balloon pump 32 vs. 13%, P<0.0001) and higher in-hospital mortality (14 vs. 3%, P=0.0006). In cases without RVI, the status of LV function did not influence in-hospital mortality (ejection fraction≤40%=7.3% vs. ejection fraction>40%=1.8, P=0.12). In contrast, in patients with RVI, LVEF was an important determinant of outcome: those with LVEF ≤ 40% suffered more hemodynamic compromise (need for inotropes or vasopressors 63 vs. 30%, P<0.0001, and intra-aortic balloon pump 59 vs. 22%, P<0.0001) and had markedly higher in-hospital mortality (33 vs. 7%, P<0.0001).

Conclusion: In patients with acute inferior myocardial infarction complicated by RVI, depressed LVEF is associated with greater hemodynamic compromise and higher in-hospital mortality. These findings may have clinical implications for supportive efforts in such cases.
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http://dx.doi.org/10.1097/MCA.0000000000000358DOI Listing
June 2016

Using simulation for teaching femoral arterial access: A multicentric collaboration.

Catheter Cardiovasc Interv 2016 Feb 22;87(3):376-80. Epub 2015 Oct 22.

Department of Mechanical Engineering, Wu Manufacturing Research Center University of Michigan, Ann Arbor, Michigan.

Objective: To assess the impact of simulation training on complications associated with femoral arterial access obtained by first year cardiology fellows.

Background: Prior studies demonstrate a higher incidence of arterial access related complications among patients undergoing invasive cardiac procedures.

Methods: First year cardiology fellows at four teaching hospitals in Michigan tracked their femoral access experience and any associated complications between July 2011 and June 2013. Fellows starting their academic training in July 2012 were first trained on a specially developed simulator before starting their rotation in the catheterization laboratory. The primary outcome was access proficiency, defined as five successful femoral access attempts without any complication or need to seek help from a more experienced team member.

Results: A total of 1,278 femoral access attempts were made by 21 fellows in 2011-2012 compared with 869 femoral access attempts made by 21 fellows in 2012-2013. There was a lower rate of access related complications in patients undergoing access attempts by first year fellows in year 2 compared with year 1 (2.1% versus 4.5%, P = 0.003). The number of procedures to achieve procedural proficiency was significantly higher in year 1 compared with year 2 (median 20 versus 10, P = 0.007).

Conclusions: Incorporation of simulation in the training of first year fellows was associated with an improvement in proficiency and a clinically meaningful reduction in vascular complications.
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http://dx.doi.org/10.1002/ccd.26256DOI Listing
February 2016

Radial PCI and the obesity paradox: Insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

Catheter Cardiovasc Interv 2016 Feb 22;87(2):211-9. Epub 2015 May 22.

Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, Michigan.

Objective: To examine if transradial approach (TRA) negates the increased risk associated with femoral access in lean and morbidly obese patients undergoing percutaneous coronary intervention (PCI).

Background: Patients at extremes of body mass are at increased risk of bleeding after PCI. TRA has been associated with lower overall rates of bleeding compared to femoral approach.

Methods And Results: We studied patients undergoing emergent and elective PCI from 2010 to 2012 across 47 hospitals in Michigan who participate in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PCI registry. The primary outcomes were the incidences of bleeding and postprocedure transfusion. Propensity matching (PM) was used to adjust for nonrandomized use of TRA. TRA was used in 10,235 procedures. In PM analyses, use of TRA was associated with a reduction in bleeding (0.80 vs. 1.9%, odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.32-0.54, P < 0.001) and need for transfusion (1.4 vs. 2.5%, OR = 0.56, 95% CI = 0.45-0.69, P < 0.001) compared with femoral access. The absolute difference in bleeding and transfusion associated with TRA was largest in patients with lean body mass (BMI < 25 kg/m(2)) and morbid obesity (BMI ≥ 40 kg/m(2)): Lean patients undergoing TRA had a rate of bleeding of 1.2 versus 2.8% for femoral access (OR = 0.43, 95% CI = 0.24-0.77, P = 0.002); and rate of transfusion of 2.4 versus 3.9% (OR = 0.61, 95% CI = 0.40-0.94, P = 0.019). The morbidly obese had a rate of bleeding of 0.8% for TRA versus 2.4% for femoral access (OR = 0.33, 95% CI = 0.44-0.72, P = 0.004); and rate of transfusion of 1.7 versus 3.0%, (OR = 0.55, 95% CI = 0.30-1.0, P = 0.051).

Conclusions: Compared with the femoral approach, TRA is associated with a reduction in bleeding across all patients undergoing PCI and the absolute benefit was greatest in those with extremely low or high BMI.
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http://dx.doi.org/10.1002/ccd.26015DOI Listing
February 2016

Comparison of coronary artery lesion length by NIRS-IVUS versus angiography alone.

Coron Artery Dis 2015 Sep;26(6):484-9

aBeaumont Health System, Royal Oak, Michigan bColumbia University Medical Center and the Cardiovascular Research Foundation, New York, New York, USA.

Background: Intravascular ultrasound (IVUS) studies analyzing target lesion plaque burden (PB) have established that invasive coronary angiography commonly underestimates lesion length, predisposing to 'geographic miss' during a percutaneous coronary intervention, which has been associated with adverse outcomes. Plaque composition may also influence stent outcome. The present study used near-infrared spectroscopy and IVUS (NIRS-IVUS) to assess the prevalence of PB and lipid-core plaque (LCP) extending beyond angiographic borders of target lesions.

Methods: Fifty-eight patients (58 lesions) undergoing NIRS-IVUS were identified. By invasive coronary angiography, target lesion length and minimum lumen diameter were measured. Plaque, defined as NIRS-IVUS atheroma (either PB>40% or LCP), was identified adjacent to the angiographic-defined lesion margins.

Results: By NIRS-IVUS, atheroma (either PB>40% or LCP) was identified beyond angiographic lesion margins in 52/58 (90%) lesions. The mean lesion length was 13.4±5.9 mm by angiography and 19.8±7.0 mm (P<0.0001) by NIRS-IVUS. LCP extending beyond the angiographic border was observed in 30/58 (52%) lesions.

Conclusion: NIRS-IVUS imaging shows that target lesion length is commonly underestimated by angiography alone. This finding may have implications for stent length selection and avoidance of geographic miss.
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http://dx.doi.org/10.1097/MCA.0000000000000263DOI Listing
September 2015
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