Podcasts about Revascularization

With Justyna Sokolska, Institute of Heart Diseases, Wroclaw Medical University, Wroclaw - Poland, and Maja Cikes, University of Zagreb School of Medicine, Head at the Unit for Heart Failure and Mechanical Circulatory Support, Department of Cardiovascular Diseases, University Hospital Center, Zagreb - Croatia. In this episode of HFA CardioTalk, Justyna Sokolska interviews Maja Cikes on the challenges in management of long-term left ventricular assist device in patients with advanced heart failure. The discussion emphasizes the importance of selecting appropriate patients at the optimal time, examines the adverse events and highlights major ongoing clinical trials.  Recommended readings:  Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial, Mehra MR, et al. JAMA. 2023 Dec 12;330(22):2171-81  Trends and Outcomes of Left Ventricular Assist Device Therapy: JACC Focus Seminar, Varshney AS, et al. J Am Coll Cardiol 2022 Mar 22;79(11):1092-1107 Cardiac implantable electronic devices with a defibrillator component and all-cause mortality in left ventricular assist device carriers: results from the PCHF-VAD registry, Cikes M, et al. Eur J Heart Fail 2019 Sep;21(9):1129-41 A Fully Magnetically Levitated Left Ventricular Assist Device — Final Report, Mehra MR, et al. N Engl J Med 2019 Apr 25;380(17):1618-27 This 2025 HFA Cardio Talk podcast series is supported by Bayer AG in the form of an unrestricted financial support. The discussion has not been influenced in any way by its sponsor.

The Lancet 2002;360:743-751Background: The TACTICS-TIMI 18 trial showed that an early invasive strategy in beneficial in selected patients with unstable angina or non-ST-elevation myocardial infarction (NSTEMI). These positive findings contrasted the findings from some earlier studies.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber.The British Heart Foundation RITA 3 randomized trial sought to compare invasive vs conservative strategy in patients with unstable angina or NSTEMI, similar to the trial question of TACTICS-TIMI 18.Patients: Eligible patients had suspected cardiac chest pain at rest with at least one of the following: Evidence of ischemia on electrocardiogram (ST depression, transient ST elevation, old left bundle branch block, or T wave inversion), pathologic Q waves suggesting previous myocardial infarction, or documented coronary artery disease on prior coronary angiogram.Patients were excluded if they had evolving myocardial infarction in which reperfusion therapy was indicated. Patients were also excluded if creatine kinase or creatine kinase MB concentrations were twice the upper limit of normal before randomization, if they had myocardial infarction within a month, had percutaneous coronary intervention (PCI) in the previous 12 months, or coronary artery bypass grafting (CABG) at any time.Baseline characteristics: The trial randomized 1,810 patients – 895 randomized to the invasive strategy and 915 randomized to conservative strategy. Patients were recruited from 45 hospitals in England and Scotland.The average age of patients was 63 years and 62% were men. Approximately 35% had hypertension on drugs, 13% had diabetes and 28% had prior myocardial infarction.The majority (92%) of the patients were enrolled because they met the criteria for evidence of ischemia on electrocardiogram.Procedures: Patients were randomly assigned in a 1:1 ratio to undergo invasive vs conservative strategy.In the conservative arm, patients received aspirin and enoxaparin 1mg/kg subcutaneously twice a day for 2-8 days. Beta-blockers, other antiplatelets and glycoprotein IIb/IIIa inhibitors could also be used. Coronary angiography could be performed if patients had anginal symptoms at rest or with minimal exertion despite appropriate therapy or if they had ischemia on stress testing.Patients in the invasive strategy arm received similar medical therapy to the conservative arm. Coronary angiogram was to be performed as soon as possible after randomization and ideally within 72 hours. Revascularization was recommended for lesions of at least 70% stenosis or 50% or more if left main.Endpoints: The trial had two co-primary outcomes. The first was a composite of death from any cause, nonfatal myocardial infarction, or refractory angina at 4 months. The second was a composite of death from any cause or nonfatal myocardial infarction at 1 year.Analysis was performed based on the intention-to-treat principle. The estimated sample size to provide 80% power at 5% alpha, was 1,770 patients. This assumed that 12% of the patients in the conservative arm would experience the outcome of death or non-fatal myocardial infarction at 1-year, and that the invasive strategy would result in 33% relative risk reduction in this outcome.Results: In the invasive strategy, 97% of the patients underwent coronary angiogram at a median of 2 days after randomization, and 55.3% underwent PCI or CABG. In the conservative arm, 10.3% had revascularization during the index admission, and 17.3% had revascularization at 1-year. The median follow time was 2 years and 97% of the patients had at least 1-year of follow up.The first primary composite outcome of death from any cause, nonfatal myocardial infarction, or refractory angina at 4 months was lower with the invasive strategy (9.6% vs 14.5%, HR: 0.66, 95% CI: 0.51 – 0.85; p= 0.001). The second primary composite outcome of death from any cause or nonfatal myocardial infarction at 1 year was not significantly different between both groups (7.6% with invasive vs 8.3% with conservative, HR: 0.91, 95% CI: 0.67 – 1.25; p= 0.58). At 1-year, 4.6% patients died in the invasive arm compared to 3.9% in the conservative arm, and this was not statistically significant. Myocardial infarction at 1-year occurred in 3.8% of the patients in the invasive arm compared to 4.8% in the conservative arm, and this was not statistically significant as well.All bleeding occurred in 8.2% in the invasive arm and 3.5% in the conservative arm.Subgroup analysis showed that men benefited from an invasive strategy while women did not (p for interaction= 0.011). The endpoint of death or myocardial infarction at 1-year, in women, was 5.1% in the conservative arm and 8.6% in the invasive arm, while in men, the incidence of this endpoint was 10.1% in the conservative arm and 7.0% in the invasive arm.Conclusion: In patients with unstable angina or NSTEMI, an invasive strategy compared to conservative strategy, reduced refractory angina but not myocardial infarction or death at 1-year.The reduction in angina is a subjective endpoint, prone to bias and faith healing, as we have previously discussed in other trials of PCI. The reduction in this endpoint alone should not justify widespread adoption of invasive strategy for unstable angina or NSTEMI.A key distinction between this trial and TACTICS-TIMI 18—which demonstrated a reduction in myocardial infarction with an invasive approach—is that this study included patients with smaller myocardial infarctions. Only 41% of participants had ST depression or transient ST elevation, and patients were excluded if creatine kinase or creatine kinase MB levels were more than twice the upper limit of normal before randomization. This highlights the heterogeneity among patients with unstable angina and NSTEMI, where baseline risk and the extent of myocardial necrosis influence treatment effects. We encourage you to read again the subgroup interactions of TACTICS-TIMI 18.Additionally, in the current era, high-sensitivity troponin assays enable the detection of smaller myocardial infarctions, potentially limiting the applicability of older trial results to all present NSTEMI patients.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Get full access to Cardiology Trial's Substack at cardiologytrials.substack.com/subscribe

With Robert M.A. van der Boon, Erasmus Medical Center, Rotterdam - The Netherlands, and Anuradha Lala, Mount Sinai Fuster Heart Hospital, New York City - USA. In this episode of HFA Cardio talk, we dive into how factors like sex, socio-economics status and ethnicity shape the way heart failure presents and progresses in different populations. We'll discuss why recognizing these differences is critical for accurate diagnosis and effective treatment and highlight practical steps clinicians can take to close the gaps in prevention and care. Papers: https://onlinelibrary.wiley.com/doi/10.1002/ejhf.2534 https://academic.oup.com/eurheartj/article/40/47/3859/5652224?login=true https://www.sciencedirect.com/science/article/pii/S1071916421004322?via%3Dihub https://www.sciencedirect.com/science/article/pii/S0002914922010074?via%3Dihub https://www.sciencedirect.com/science/article/pii/S2468266719301082?via%3Dihub https://journals.lww.com/co-cardiology/fulltext/2021/05000/racial_and_ethnic_disparities_in_heart_failure_.12.aspx https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14986   This 2025 HFA Cardio Talk podcast series is supported by Bayer AG in the form of an unrestricted financial support. The discussion has not been influenced in any way by its sponsor.

Abdullah Al-Abcha, MD, social media editor of JACC: Cardiovascular Interventions, and Matthias Götberg, MD, PhD, discuss a recently published manuscript reporting the long-term clinical outcomes after IFR vs. FFR guided coronary revascularization— Insights from SWEDEHEART.

With Henrique Arfsten, Medical University of Vienna, Vienna - Austria and Alexandre Mebazza, Hospital Lariboisiere, Paris - France.  In this episode of HFA CardioTalk, Henrike Arfsten and  Alexandre Mebazaa discuss the importance of rapid initiation and titration of guideline-directed medical heart failure therapy. A focus will be on data from the STRONG-HF trial, which demonstrated safety and efficacy of rapid up-titration following an acute heart failure event. The trial was even stopped early as the benefits of the intensive treatment strategy were overwhelming. Moreover, specific questions are raised, such as the right time to start therapy and how to deal with possible side effects. Mebazaa A, et al. Lancet 2022 Dec 3;400(10367):1938-52 Biegus J, et al. Heart Fail Rev 2024 Sep;29(5):1065-1077 McDonagh TA, et al. Eur J Heart Fail 2022 Jan;24(1):4-131 McDonagh TA, et al. Eur J Heart Fail 2024 Jan;26(1):5-17 This 2025 HFA Cardio Talk podcast series is supported by Bayer AG in the form of an unrestricted financial support. The discussion has not been influenced in any way by its sponsor.

With Novi Yanti Sari, Siloam Hospitals, Jakarta - Indonesia, and Mark Petrie, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow - UK. In this episode of the HFA podcast series, we explore the complex relationship between obesity and heart failure, discussing challenges, management strategies, and the latest therapies, while emphasising the importance of integrated care in improving clinical outcomes. This 2025 HFA Cardio Talk podcast series is supported by Bayer AG in the form of an unrestricted financial support. The discussion has not been influenced in any way by its sponsor.

The TCW Trial compared TAVI + FFR-guided PCI versus SAVR + CABG in patients with severe aortic stenosis and complex coronary artery disease. This multicenter, randomized controlled trial included 172 patients aged ≥70 years. At 1 year, the primary composite endpoint (death, MI, stroke, revascularization, valve reintervention, or major bleeding) was significantly lower in the TAVI + PCI group (4%) compared to SAVR + CABG (23%), meeting both noninferiority and superiority criteria. The study suggests TAVI + PCI as a safer, less invasive alternative with reduced mortality and bleeding risks in selected patients.

Coronary CT angiography-guided management of patients with stable chest pain: 10-year outcomes from the SCOT- HEART randomised controlled trial in Scotland Michelle C Williams, Ryan Wereski, Christopher Tuck, Philip D Adamson, Anoop S V Shah, Edwin J R van Beek, Giles Roditi, Colin Berry,Nicholas Boon, Marcus Flather, Steff Lewis, John Norrie, Adam D Timmis, Nicholas L Mills, Marc R Dweck, David E Newby, on behalf of theSCOT-HEART Investigators* Summary Background The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in management and outcomes. Methods SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from 12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18–75 years with symptoms of suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural interventions, and clinical outcomes were obtained through record linkage from national registries. The primary outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial is registered at ClinicalTrials.gov (NCT01149590) and is complete. Findings Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care alone. After a median of 10·0 years (IQR 9·3–11·0), coronary heart disease death or non-fatal myocardial infarction was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio [HR] 0·79 [95% CI 0·63–0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs 124 [6·0%]; HR 0·72 [0·55–0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%]; HR 0·80 [0·65–0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86–1·17], p=0·99) but preventive therapy prescribing remained more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio 1·17 [95% CI 1·01–1·36], p=0·034). Interpretation After 10 years, CCTA-guided management of patients with stable chest pain was associated with a sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain.

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on the Relationship Between Quantitative Ischemia, Early Revascularization, and Major Adverse Cardiovascular Events in a Multicenter Study.

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on Revascularization During Cardiac Arrest While Receiving Extracorporeal Life Support in Patients With Acute Myocardial Infarction.

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances, discusses a recently published original research paper on Revascularization During Cardiac Arrest While Receiving Extracorporeal Life Support in Patients With Acute Myocardial Infarction.

With Jasper Brugts, Erasmus Medical Center Rotterdam, Rotterdam - The Netherlands and Floran Sahiti, University Hospital Würzburg and Comprehensive Heart Failure Center Würzburg, Würzburg - Germany. In this episode of the HFA Podcast Series, we will discuss telemonitoring in general, with a main focus on invasive monitoring in heart failure, the current evidence, and the advantages and disadvantages of the systems. This 2025 HFA Cardio Talk podcast series is supported by Bayer AG in the form of unrestricted financial support. The discussion has not been influenced in any way by its sponsors.

In this episode, Dr. Valentin Fuster discusses a comprehensive network meta-analysis published in JACC, which evaluates the optimal strategy for complete revascularization in patients with STEMI and multi-vessel disease. The study concludes that both immediate and staged complete revascularization improve patient outcomes over partial revascularization, with no significant advantage between angiographic and functional guidance, suggesting that angiographic guidance alone may be sufficient in clinical practice.

FAVOR III Europe: Quantitative Flow Ratio or Fractional Flow Reserve for Guiding Coronary Revascularization

With Daniella Motta da Costa Dan, University of São Paulo - Brazil, and Marianna Adamo, University of Brescia - Italy. In this episode of HFA CardioTalk, Daniella Motta interviews Marianna Adamo on the controversies, consensus, and challenges surrounding revascularization in ischemic heart failure. The discussion highlights major clinical trials, emphasizes the importance of selecting appropriate patients, and examines the risks and benefits of revascularization in this context. Lastly, they address key updates from the latest ESC guidelines This 2024 HFA CardioTalk podcast serie is supported by Novartis in the form of an educational grant. The discussion has not been influenced in any way by its sponsor.

In the December 10, 2024 JACC issue, a study from the EXCEL trial examines the link between bleeding complications and mortality in patients with left main coronary artery disease undergoing PCI or CABG. The findings highlight that while PCI showed lower rates of bleeding, both procedures had bleeding-related mortality risks, underscoring the need for strategies to minimize bleeding during and after revascularization.

A 67 year old woman with a history of hypertension, hyperlipidemia, diabetes, and a 25 pack year smoking history is referred your clinic and is referred for evaluation of her peripheral arterial disease. She reports pain with walking that has limited her doing some daily activities. How can you optimally manage this patient? Does she need an operation? In this episode, we will cover the basics of peripheral arterial disease, discuss the specifics of optimal medical management and dive into the nuances of when (or if) you should offer these patients an operation.  Hosts:  Dr. Bobby Beaulieu is an Assistant Professor of Vascular Surgery at the University of Michigan and the Program Director of the Integrated Vascular Surgery Residency Program as well as the Vascular Surgery Fellowship Program at the University of Michigan. Dr. Drew Braet is a PGY-5 Integrated Vascular Surgery Resident at the University of Michigan Learning Objectives - Review the definition, prevalence, and risk factors for peripheral arterial disease - Understand the specifics of optimal medical management of patients with peripheral arterial disease  - Discuss the controversy regarding operative management of patients with claudication and review indications for an operation in patients with peripheral arterial disease - Review the appropriate anti-platelet and anti-coagulation strategies after interventions in patients with peripheral arterial disease References 1.    Woo K, Siracuse JJ, Klingbeil K, Kraiss LW, Osborne NH, Singh N, Tan TW, Arya S, Banerjee S, Bonaca MP, Brothers T, Conte MS, Dawson DL, Erben Y, Lerner BM, Lin JC, Mills JL Sr, Mittleider D, Nair DG, O'Banion LA, Patterson RB, Scheidt MJ, Simons JP; Society for Vascular Surgery Appropriateness Committee. Society for Vascular Surgery appropriate use criteria for management of intermittent claudication. J Vasc Surg. 2022 Jul;76(1):3-22.e1. doi: 10.1016/j.jvs.2022.04.012. Epub 2022 Apr 22. PMID: 35470016. https://pubmed.ncbi.nlm.nih.gov/35470016/ 2.    Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W; ESVS Guidelines Committee; Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A; Document Reviewers; Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg. 2024 Jan;67(1):9-96. doi: 10.1016/j.ejvs.2023.08.067. Epub 2023 Nov 10. PMID: 37949800. https://pubmed.ncbi.nlm.nih.gov/37949800/ 3.    Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024 Jun 11;149(24):e1313-e1410. doi: 10.1161/CIR.0000000000001251. Epub 2024 May 14. PMID: 38743805. https://pubmed.ncbi.nlm.nih.gov/38743805/ 4.    Belch JJ, Dormandy J; CASPAR Writing Committee; Biasi GM, Cairols M, Diehm C, Eikelboom B, Golledge J, Jawien A, Lepäntalo M, Norgren L, Hiatt WR, Becquemin JP, Bergqvist D, Clement D, Baumgartner I, Minar E, Stonebridge P, Vermassen F, Matyas L, Leizorovicz A. Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial. J Vasc Surg. 2010 Oct;52(4):825-33, 833.e1-2. doi: 10.1016/j.jvs.2010.04.027. Epub 2010 Aug 1. Erratum in: J Vasc Surg. 2011 Feb;53(2):564. Biasi, B M [corrected to Biasi, G M]. PMID: 20678878. https://pubmed.ncbi.nlm.nih.gov/20678878/ 5.    Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, Diaz R, Alings M, Lonn EM, Anand SS, Widimsky P, Hori M, Avezum A, Piegas LS, Branch KRH, Probstfield J, Bhatt DL, Zhu J, Liang Y, Maggioni AP, Lopez-Jaramillo P, O'Donnell M, Kakkar AK, Fox KAA, Parkhomenko AN, Ertl G, Störk S, Keltai M, Ryden L, Pogosova N, Dans AL, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik TJ, Verhamme PB, Vinereanu D, Kim JH, Tonkin AM, Lewis BS, Felix C, Yusoff K, Steg PG, Metsarinne KP, Cook Bruns N, Misselwitz F, Chen E, Leong D, Yusuf S; COMPASS Investigators. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med. 2017 Oct 5;377(14):1319-1330. doi: 10.1056/NEJMoa1709118. Epub 2017 Aug 27. PMID: 28844192. https://pubmed.ncbi.nlm.nih.gov/28844192/ 6.    Bonaca MP, Bauersachs RM, Anand SS, Debus ES, Nehler MR, Patel MR, Fanelli F, Capell WH, Diao L, Jaeger N, Hess CN, Pap AF, Kittelson JM, Gudz I, Mátyás L, Krievins DK, Diaz R, Brodmann M, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR. Rivaroxaban in Peripheral Artery Disease after Revascularization. N Engl J Med. 2020 May 21;382(21):1994-2004. doi: 10.1056/NEJMoa2000052. Epub 2020 Mar 28. PMID: 32222135. https://pubmed.ncbi.nlm.nih.gov/32222135/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

In this episode, Dr. Valentin Fuster discusses a pivotal study on revascularization strategies in older patients with myocardial infarction, comparing complete versus culprit-only approaches. The findings suggest that physiology-guided complete revascularization significantly reduces adverse outcomes in both STEMI and non-STEMI patients, emphasizing its potential benefits across a diverse patient population.

EARTH-STEMI – Complete vs. Culprit-Only Revascularization in Older STEMI Patients

N Engl J Med 2022;387:1351-1360Background: Systolic heart failure and obstructive coronary artery disease often coexist. Some patients show improvement in left ventricular systolic function after revascularization, which led to the development of the concept of myocardial hibernation. In this state, areas of the heart that are exposed to repetitive ischemia reduce their contractility to help facilitate their survival. Restoring blood flow to these hypocontractile yet viable segments could improve outcomes. Although observational studies supported this theory, large randomized trials were still lacking. Patients with severe left ventricular systolic dysfunction were generally excluded from the seminal trials of percutaneous coronary intervention (PCI) in stable coronary artery disease.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.The Revascularization for Ischemic Ventricular Dysfunction (REVIVED) trial sought to test the hypothesis that revascularization with PCI plus medical therapy is superior to medical therapy alone in patients with left ventricular systolic dysfunction, obstructive coronary artery disease and viable myocardium.Patients: Eligible patients had left ventricular ejection fraction of 35% or less, obstructive coronary artery disease, in addition to viability in at least four dysfunctional myocardial segments that are amenable to revascularization by PCI. Viability could be determined by any imaging modality and was adjudicated based on local experts.Major exclusion criteria were myocardial infarction within 4 weeks, sustained ventricular arrhythmias within 72 hours, acutely decompensated heart failure requiring inotropic support, invasive or non-invasive ventilation or mechanical circulatory support within 72 hours, glomerular filtration rate

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances discusses a recently published original research paper about mortality after multivessel revascularization in patients with diabetes and acute coronary syndromes.

N Engl J Med 1999;341:70-76Background: Percutaneous transluminal coronary angioplasty (PTCA) was widely used in the 1990s for its potential benefit in improving symptoms in patients with stable coronary artery disease, as discussed in the ACME and RITA-2 trials. However, the RITA-2 trial showed that PTCA worsened hard outcomes, and ACME was underpowered for such comparison. At the same time, trials demonstrating the ability of statin drugs to reduce cardiovascular events and improve survival had led to an increase in use of the lipid-lowering drugs. Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.The Atorvastatin versus Revascularization Treatment Investigators sought to test the unique hypothesis that atorvastatin is superior to angioplasty in reducing ischemic events in patients with stable coronary artery disease. *It is important to note that the historical trials of CABG versus medical therapy that led to the widespread adoption of coronary revascularization, in general, were completed prior to the adoption of statin therapy. Thus a weakness of the CABG literature, which we have addressed in detail in prior posts and podcasts, is that the efficacy of CABG is inconsistent at best and medical therapy, at the time, was very limited. This makes this study of atorvastatin versus angioplasty of particular interest.Patients: Eligible patients had stenosis of 50% or more in one or two coronary arteries and had been recommended for treatment with percutaneous revascularization. The patients were asymptomatic or had Canadian Cardiovascular Society (CCS) class I or II angina. LDL levels had to be least 115 mg/dL and triglyceride levels of 500 mg/dL or less.Patients were excluded if they had left main coronary artery disease, 3-vessel disease, unstable angina or myocardial infarction within the previous 2 weeks, or if the ejection fraction was

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances discusses a recently published original research paper on STEMI, revascularization, and peak troponin by adverse pregnancy outcomes in women with myocardial infarction

Abdullah Al-Abcha, MD, social media editor of JACC: Cardiovascular Interventions, and Luke Dawson, MBBS, MPH, discuss a recently published original research paper that aimed to assess the interactive effects of coronary complexity on PCI and CABG outcomes and identify the optimal threshold where PCI can be considered a reasonable option.

Dr. Valentin Fuster discusses a study on the effects of low-dose rivaroxaban combined with aspirin in fragile patients after lower extremity revascularization, focusing on the balance between efficacy and safety. It highlights that while frailty increases the risk of adverse outcomes, rivaroxaban reduces ischemic events but also raises bleeding risks, regardless of frailty status. The editorial emphasizes that frailty should not preclude the use of combined antithrombotic therapy, advocating for personalized treatment approaches.

Audio Commentary by Dr. Valentin Fuster, Emeritus Editor in Chief

Can a twice-yearly shot provide 100% protection against HIV? Find out about this and more in today's PeerDirect Medical News Podcast.

Dr. Linda Chu discusses predictors of intestinal resection-free survival in patients with acute arterial mesenteric ischemia with Dr. Lorenzo Garzelli and Dr. Maxime Ronot.   Predictors of Survival Without Intestinal Resection after First-Line Endovascular Revascularization in Patients with Acute Arterial Mesenteric Ischemia. Garzelli et al. Radiology 2024; 311(3):e230830.

Audio Commentary by Dr. Valentin Fuster, Emeritus Editor in Chief

Audio Commentary by Dr. Valentin Fuster, Emeritus Editor in Chief

This week on The Beat, Editor in Chief Joel Dunning discusses upcoming interviews to be published on CTSNet. In addition, Joel discusses heart transplantation in adults with congenital heart disease, a commentary on revascularization, and gender representation among speaking and leader roles at CT surgery meetings. He also talks about a video demonstrating TAVR explantation, pulmonary stenosis correction after TAPVR correction, and a LAD to RCA anastomosis from Dr. Tristan Yan. Before saying goodbye, Joel discusses upcoming events in CT surgery. JANS Items Mentioned Trends and Outcomes of Heart Transplantation in Adults With Congenital Heart Disease  Commentary: What Matters More—Method of Revascularization or Completeness?  Gender Representation Among Speaking and Leader Roles at European Cardiothoracic Surgical Annual Meetings CTSNet Content Mentioned TAVR Explantation: A Necessary Skill Set in the Contemporary Cardiac Surgery's Armamentarium  Redo Pulmonary Vein Stenosis Correction After TAPVR Correction  Deep Dive Into Total Arterial Anaortic Off-Pump Coronary Artery Bypass Grafting: Dual Inflow BIMA In Situ to LAD and RCA  Other Items Mentioned CTSNet Events Calendar Disclaimer The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.

The Association Between Diagnosis-to-limb Revascularization Time And Clinical Outcomes In Outpatients With Chronic Limb-threatening Ischemia

N Engl J Med 2008; 358:2218-2230Background The use of percutaneous coronary intervention (PCI) is associated with improved outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Nonetheless, there was a need to further improve survival rates. As seen in OASIS-6, the 30-day mortality in the control arm was still high at 8.9%. Glycoprotein IIb/IIIa inhibitors emerged as a potential solution. US clinicians widely adopted these agents; their use soared to over 90% of STEMI cases undergoing primary PCI. But IIb/IIIa inhibitors increase the risk of bleeding and thrombocytopenia.Cardiology Trial's Substack is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.Bivalirudin, a direct thrombin inhibitor, has been shown to reduce bleeding when used instead of heparin plus glycoprotein IIb/IIIa inhibitors in patients with ACS without ST segment elevation. The Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial sought to test the hypothesis that bivalirudin is superior to the combination of heparin plus glycoprotein IIb/IIIa inhibitors in patients with STEMI who were undergoing primary PCI.Patients Patients were enrolled if they were within 12 hours from the onset of symptoms and had ST-segment elevation of 1 mm or more in two or more contiguous leads, new left bundle-branch block or had posterior myocardial infarction. There were numerous exclusion criteria including bleeding diathesis, coagulopathy, intracerebral mass, prior hemorrhagic stroke, platelet count< 100,000 cells/ ml, hemoglobin< 10 g/dl plus many more.Baseline characteristics The trial enrolled 3,602 patients. The average age of patients was 60 years and 77% were men. About 53% had hypertension, 43% had hyperlipidemia, 16% had diabetes, 11% had prior myocardial infarction and 46% were current smokers. The majority of patients were stable, with 91.5% classified as Killip class I. Primary PCI was performed in about 93% of the patients and coronary artery bypass graft surgery in 1.7%.Heparin before coronary angiography was administrated in 76.3% in the heparin plus glycoprotein IIb/IIIa inhibitor arm and 65.8% in the bivalirudin arm. During coronary angiography heparin was administered in 98.9% patients in the heparin plus a glycoprotein IIb/IIIa inhibitor arm and 2.6% in the bivalirudin arm. Glycoprotein IIb/IIIa inhibitors were given to 94.5% patient in the heparin plus glycoprotein IIb/IIIa inhibitors arm and 7.2% in the bivalirudin arm.Procedures The trial was open-label and patients were randomly assigned 1:1 to receive unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor or bivalirudin alone. Heparin was administered to keep activated clotting time of 200 to 250 seconds. An initial intravenous bolus of 60 IU/ kg was given followed by boluses as needed. Bivalirudin was administered intravenously with an initial bolus of 0.75 mg/kg followed by an infusion of 1.75 mg/kg/hour. A glycoprotein IIb/IIIa inhibitor was administered before PCI in all the patients in the heparin group. It was also administered in selected patients in the bivalirudin group if there was no reflow or there was a large thrombus after PCI. The main glycoprotein IIb/IIIa inhibitors used were abciximab or eptifibatide.Endpoints The study had two primary endpoints at 30-days. The first endpoint was major bleeding not related to coronary artery bypass graft surgery. The second endpoint was a composite endpoint of major bleeding, all-cause death, reinfarction, target-vessel revascularization for ischemia or stroke.Analysis was performed based on the intention-to-treat principle. Assuming a 30-day event rate of 9% for the first endpoint and 12% for the second endpoint in the heparin plus glycoprotein IIb/IIIa inhibitor group and 6% for the first endpoint and 9% for the second endpoint in the bivalirudin group, a sample size of 1,700 patients in each group would have 99% power to show superiority of bivalirudin for the first endpoint and 80% power for the second endpoint.Results The study randomized 1,802 patients to the heparin plus glycoprotein IIb/IIIa inhibitor group and 1,800 patients to the bivalirudin group.The first primary endpoint was significantly lower with bivalirudin (4.9% vs 8.3%, RR: 0.60, 95% CI: 0.46 - 0.77; p

Commentary by Dr. Valentin Fuster

Authors:  Sebouh Bazikian - MS4 at Keck School of Medicine of University of Southern California Gowri Gowda - PGY1 at the University of California Davis Integrated Vascular Surgery Program Steven Maximus- Vascular surgery attending at the University of California Davis, Director of the Aortic Center   Resources:  Rutherford's 10th Edition Chapters: 88, 89, and 91 The North American Symptomatic Carotid Endarterectomy Asymptomatic Carotid Atherosclerosis Study Audible Bleeding's eBook chapter on cerebrovascular disease Houston Methodist CEA Dissection Video: Part 1: https://www.youtube.com/watch?v=wZ8PzhwmSXQ Part 2: https://www.youtube.com/watch?v=E_wWpRKBy4w   Outline:  1. Etiology of Carotid Artery Stenosis Risk factors: advanced age, tobacco use, hypertension, diabetes. Atherosclerosis as the primary cause. Development of Atherosclerotic Disease and Plaque Formation LDL accumulation in arterial walls initiating plaque formation. Inflammatory response, macrophage transformation, smooth muscle cell proliferation. Role of turbulent blood flow at carotid bifurcation in plaque development. Clinical Features of Carotid Artery Stenosis Asymptomatic nature in many patients. Symptomatic presentation: Transient ischemic attacks, amaurosis fugax, contralateral weakness/sensory deficit. Carotid bruit as a physical finding, limitations in diagnosis. Importance of Evaluating CAS Assessing stenosis severity and stroke risk. Revascularization benefits dependent on stenosis severity. Classification of Stenosis Levels Clinically significant stenosis: ≥ 50% narrowing. Moderate stenosis: 50%–69% narrowing. Severe stenosis: 70%–99% narrowing. Stroke Risk Associated with Carotid Stenosis Annual stroke rate: ~1% for 50-69% stenosis, 2-3% for 70-99% stenosis. Diagnosis and Screening No population-level screening recommendation. Screening for high-risk individuals as per SVS guidelines. Carotid Duplex Ultrasound as primary diagnostic tool. Additional tools: CT angiography, Magnetic Resonance Angiography. Handling of 100 cm/sec, Internal/Common Carotid peak systolic velocity Ratio > 4. Revascularization Criteria Symptomatic Patients: 50-69% or 70-99% stenosis, life expectancy at least three or two years, respectively. Asymptomatic Patients: 70% stenosis, considering life expectancy. Surgical Indications and Contraindications Indications: symptomatic patients, life expectancy considerations. Contraindications: Stenosis

Welcome to the MassDevice Fast Five medtech news podcast, the show that keeps you up-to-date on the latest breakthroughs in medical technology. Here's what you need to know for today, February 9, 2024. Check out the show notes for links to the stories we discussed today at MassDevice.com/podcast. Baxter beat The Street in its fourth-quarter results as its kidney care spinoff progresses. Fast Five hosts Sean Whooley and Danielle Kirsh talk about the company's financial performance and how the spinoff is going. The FDA has cleared Fresenius Medical Care's 5008X hemodialysis system. Hear more about the hemodialysis system and what makes it different. CMR Surgical has enhanced its surgical robot with new imaging technology. Whooley explains the new imaging technology and how it helps doctors. Biosense Webster supports a duo of new studies using Varipulse pulsed field ablation technology. Learn what the studies will evaluate in today's episode. J&J's Cerenovus has launched a next-generation stroke revascularization catheter. The Fast Five hosts explain what the catheter is designed for, some of its features and what executives are saying.

Commentary by Dr. Valentin Fuster

CardioNerds (Drs. Amit Goyal, Jason Feinman, and Tiffany Dong) discuss Beyond the Boards: Diseases of the Peripheral Arteries with Dr. Amy Pollak. We review common presentations of peripheral vascular disease, ranging from aortic disease to the more distal vessels in an engaging case-based discussion. Dr. Pollack talks us through these cases, including the diagnosis and management of peripheral vascular diseases. Show notes were drafted by Dr. Matt Delfiner and episode audio was edited by student doctor Tina Reddy. The CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen. CardioNerds Beyond the Boards SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Disease of the Peripheral Arteries Risk factors for abdominal aortic aneurysm include traditional atherosclerotic risk factors such as age, hypertension, hyperlipidemia, and tobacco use. Screening for AAA should be for men over the age of 65 years with a history of tobacco use. If present, medical management includes blood pressure and lipid lowering therapies to decrease the risk of expansion. Decision for surgical intervention relies on size and rate of growth of AAA, with clear indications if it grows> 10 mm in a year or diameter of 5.5 cm in men and 5.0 cm in women. When diagnosis of PAD is not straightforward (presence of symptoms but ABI is normal), an exercise ankle-brachial index (ABI) test can be useful. An exercise-induced decrease in ABI by 20% or in ankle pressure by 30 mmHg is consistent with PAD. For PAD, treatment with low dose rivaroxaban and aspirin yields lower event rates than with antiplatelet therapy alone. This in combination with lifestyle therapies (diet + exercise) and risk factor management (hypertension and hyperlipidemia) are the cornerstones of therapy. Revascularization is indicated for continued PAD symptoms despite conservative therapy. Acute limb ischemia is an “acute leg attack” and is a life-threatening emergency. Common symptoms include pain, pallor, pulselesess, parasthesias, cold temperature (poikilothermia), and paralysis. Restoration of blood flow is paramount, and emergent or urgent revascularization is the first line therapy for those with symptoms < 2 weeks. Notes - Disease of the Peripheral Arteries Learning Objectives: Describe screening and therapeutic strategy for AAA management. Understand the risk factors and diagnosis of peripheral arterial disease. Compare different management approaches for PAD. Be able to recognize acute limb ischemia. Describe the overall treatment strategy for acute limb ischemia. Abdominal Aortic Aneurysms Abdominal aortic aneurysms are a source of high morbidity and mortality. The US Preventative Services Task Force recommends one time screening ultrasound for AAA in men older than 65 years of age with a tobacco use history. Risk factors include age, hypertension, hyperlipidemia, and tobacco use. Patients with AAA between 3-3.9 mm should be monitored every 2-3 years. Sizes 4-5 cm should be re-imaged every 6-12 months.  Additional screening can be done for individuals < 65 years who have a first degree relative with AAA. Women are more likely to have aortic dissection at smaller diameters than men, which is why intervention (open vs endovascular repair) is recommended at 5 cm diameter for women versus at 5.5 cm for men. Additionally, repair is also warranted if a AAA grows more than 5 mm in 6 months or 10 mm in one year. Risk factor management is key with AAA, including blood pressure, glucose, and lipid targeting.  The presence of an AAA should be treated as secondary ASCVD prevention like coronary a...

King and I Ep.6 | Multivessel Immediate Versus Staged Revascularization STEMI

Interview with Divaka Perera, MA, MD, author of Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction: A Prespecified Secondary Analysis of the REVIVED-BCIS2 Trial, and Julio A. Panza, MD, author of Assessment of Myocardial Viability in Ischemic Cardiomyopathy—Scarred by the Data but Still Alive. Hosted by James E. Udelson, MD. Related Content: Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction Assessment of Myocardial Viability in Ischemic Cardiomyopathy—Scarred by the Data but Still Alive

Interview with Divaka Perera, MA, MD, author of Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction: A Prespecified Secondary Analysis of the REVIVED-BCIS2 Trial, and Julio A. Panza, MD, author of Assessment of Myocardial Viability in Ischemic Cardiomyopathy—Scarred by the Data but Still Alive. Hosted by James E. Udelson, MD. Related Content: Viability and Outcomes With Revascularization or Medical Therapy in Ischemic Ventricular Dysfunction Assessment of Myocardial Viability in Ischemic Cardiomyopathy—Scarred by the Data but Still Alive

Commentary by Dr. Valentin Fuster

Commentary by Dr. Valentin Fuster

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Commentary by Dr. Valentin Fuster

Audible Bleeding editors Matt (@chia_md) and Wen (@WenKawaji) are joined by JVS-CIT assistant editor Dr. Bernardo Mendes (@drbermendes) and JVS Editor-in-chief Dr. Thomas Forbes (@TL_Forbes) , to discuss two great articles in the JVS family of journals.  They're joined by Dr. Powell, Dr. Corriere and Dr. Cooper, the authors of each of the papers discussing patient reported outcomes in claudication and gut microbiome in chronic mesenteric ischemia.   Articles: “Characterizing patient-reported claudication treatment goals to support patient-centered treatment selection and measurement strategies” by Powell et al. “Chronic Mesenteric Ischemia Intestinal Dysbiosis Resolves after Revascularization” by Cooper et al. Show Guests: Dr. Chloe Powell: PGY-V vascular surgery resident at University of Michigan Dr. Matthew Corriere (@MCorriereMD): Associate professor in the department of vascular surgery at University of Michigan.  Dr. Michol Cooper (@CooperMichol): Assistant professor in the division of vascular surgery and endovascular therapy at the University of Florida College of Medicine.  Follow us @AudibleBleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.