Left atrial appendage occlusion

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting 1.5–2% of the general population and more than 8% of those older than 80 years. Because of the progressive ageing of our population, an exponential increase in incidence is expected over the next few decades. Patients with AF have an increased mortality and morbidity, particularly owing to fatal or disabling stroke. The risk of embolic stroke is five times higher in the presence of AF, with an average annual rate around 5%, but there is a progressive increase with age and the presence of other risk factors, such as prior stroke or transient ischaemic attack, hypertension, diabetes mellitus, congestive heart failure, female sex, and vascular disease, as predicted by the CHADS2 and the CHA2DS2-VASc scores. Moreover, strokes associated with AF are more severe, with a 50% greater likelihood of becoming disabled or handicapped and more than 50% likelihood of death. Intracardiac thrombus formation due to the Virchow triad of events (endothelial or endocardial damage or dysfunction, abnormal blood stasis, and altered haemostasis, platelet function, and fibrinolysis) followed by distal embolization leads to thromboembolic events manifest as transient ischaemic attack, ischaemic stroke, and peripheral embolism in patients with AF.

No-reflow in native coronaries and vein grafts: the role of drugs and distal protection

Restoration of normal coronary bloodflow and relieving myocardial ischaemia is the main goal of percutaneous coronary intervention (PCI). However, whilst reducing an epicardial coronary stenosis by balloon dilatation may appear to be a relatively easy task, subsequent detrimental changes in bloodflow can paradoxically result in reduced/impaired myocardial perfusion. This condition of mismatch between post-PCI epicardial coronary patency and impaired myocardial reperfusion is defined as slow-flow or no-reflow. It is typically caused by and related to the presence of a damaged, dysfunctional, and/or obstructed coronary microvasculature. When no-reflow occurs, it has an adverse effect on the subsequent mid- and long-term prognosis as it is associated with a higher risk of reinfarction, arrhythmias, heart failure, and a higher in-hospital and long-term cardiac mortality. Frustratingly, nearly four decades after the first PCI, there is still uncertainty about the pathophysiology of no-reflow and a need to define successful prevention and treatment strategies.

In-stent restenosis in the drug-eluting stent era

Since the inception of percutaneous coronary intervention, restenosis has been considered a significant problem. Although drug-eluting stents (DES) have reduced rates of in-stent restenosis (ISR) compared with bare metal stents across all lesion subsets, ISR has not been abolished. DES efficacy has been limited by suboptimal polymer biocompatibility, efficacy of pharmacological agents, in vivo pharmacokinetic properties, and local drug resistance and toxicity. While the first two DES to be manufactured (sirolimus- and paclitaxel-eluting stents) have the longest clinical follow-up, extensive data are now also available on zotarolimus- and everolimus-eluting stents. The uptake of biolimus-eluting stents has recently increased in clinical practice. Although the low frequency of DES ISR makes it difficult to investigate this condition fully, many studies have examined the mechanism, incidence, predictors, and optimal treatment of DES restenosis. This review discusses the data relevant to DES restenosis and the perspective on the current treatment of this condition.

Out-of-hospital cardiac arrest: role of percutaneous coronary intervention

Out-of-hospital cardiac arrest (OHCA) remains the leading cause of death in developed countries, with an annual incidence from 36 to 81 events per 100,000. Prehospital treatment includes immediate recognition, bystander cardiopulmonary resuscitation, defibrillation, and advanced cardiac life support known as a ‘chain of survival’. Owing to improvements in the ‘chain of survival’, the proportion of patients with re-establishment of spontaneous circulation on the field may nowadays exceed 50%. This leads to increased hospital admission observed in communities with mature prehospital emergency services. According to autopsy and immediate coronary angiography (CAG), significant coronary artery disease may be documented in more than 70% of patients. Moreover, in the presence of ST-elevation myocardial infarction (STEMI) in post-resuscitation electrocardiogram, acute thrombotic lesions may be found in up to 90%. However, the absence of STEMI does not exclude obstructive or thrombotic coronary stenosis, which may be present in 25–58% of patients. Because of these findings, interventional cardiologists are increasingly alerted for immediate CAG and percutaneous coronary intervention in OHCA patients.

Chronic total occlusions

Chronic total occlusion (CTO) of a coronary artery remains one of the most challenging scenarios in cinical practice. There is much debate about whether opening a CTO is clinically indicated and the procedures are often considered too risky. As a result many patients with a clinical indication for percutaneous coronary intervention (the presence of angina despite medical therapy, with proven ischaemia and viability) are not offered treatment. This chapter will aim to demystify the procedure by explaining how pathophysiological features can help understand the anatomy and how cath lab set-up can increase procedural efficiency, safety, and overall success rates. There are four methods by which a CTO can be opened and we will describe these methods and the anatomically salient features to help select the most appropriate method with which to start.

Primary percutaneous coronary intervention for ST-elevation myocardial infarction

This chapter covers primary percutaneous coronary intervention (PPCI), with an investigation of the limitations of the competing thrombolysis procedure, optimal timing, and a discussion of the technical aspects associated with delivering PPCI. Comparing randomized trials that look at differential outcomes in both the short and long term, and covering the European Society of Cardiology guidelines for ST-elevation myocardial infarction treatment, the chapter provides an overview and analysis of the risks and benefits of PPCI.

The ‘golden rules’ of percutaneous coronary intervention

This chapter identifies general principles for the practice of interventional cardiology. The focus is on general strategic approach and the exposition of core concepts rather than details of equipment selection and manipulation. Although framed for percutaneous coronary intervention, the philosophy will translate to all forms of interventional cardiology. In contemporary activity adverse events are fortunately rare and it is very difficult for an individual operator to identify ‘best practice’ on the basis of personal experience and individual reflection. These ‘golden rules’ are based on lessons, sometimes learned at cost to patients and operators, over three decades. Knowledge of these issues and a more systematic approach may provide a framework for safe and effective practice.

Robotic percutaneous coronary intervention

Percutaneous coronary intervention (PCI) has seen steady technological progress over the past four decades. Despite improved patient safety and efficacy, modern interventionalists continue to face significant occupational hazards, including radiation exposure, cataracts, and orthopaedic injuries. Robotic remote navigation systems have been developed to address the risks and procedural challenges associated with conventional PCI. The development of novel robotic remote control navigation systems represents the dawn of a new era of interventional cardiology.

Novel device therapies for resistant hypertension

Resistant hypertension (RHTN) is defined as uncontrolled office blood pressure (>140/90 mmHg) despite treatment with maximum tolerated doses of three or more antihypertensive agents from at least three different classes, including a diuretic. The prevalence of RHTN is about 8–18% in hypertensive patients and confers greatly increased risk of cardiovascular morbidity and mortality.

Transcatheter aortic valve implantation and the management of coronary artery disease

The advent of transcatheter aortic valve implantation (TAVI) has provoked a paradigm shift in the treatment of senile calcific aortic stenosis (AS), the most common valvular disease in the developed world. Its benefits in high-risk and inoperable patients and its comparable outcomes to surgical aortic valve replacement are well established, and there is now evidence supporting use of the technique in intermediate-risk patients. AS often coexists with coronary artery disease (CAD) and, in seeking to further improve outcomes and minimize risks in the TAVI procedure, the management of concomitant CAD is an important consideration.