State-of-the-Art Review
Drug-Coated Balloons for Coronary Artery Disease: Third Report of the International DCB Consensus Group
Raban V. Jeger, Simon Eccleshall, Wan Azman Wan Ahmad, Junbo Ge, Tudor C. Poerner, Eun-Seok Shin, Fernando Alfonso, Azeem Latib, Paul J. Ong, Tuomas T. Rissanen, Jorge Saucedo, Bruno Scheller, Franz X. Kleber, for the International DCB Consensus Group
This is the third report of the International DCB Consensus Group summarizing current recommendations on the use of drug-coated balloons (DCB). DCB are a novel treatment strategy for coronary artery disease. Their use is established for in-stent restenosis of both bare-metal and drug-eluting stents, and recent randomized clinical data demonstrate a good efficacy and safety profile in de novo small-vessel disease and high bleeding risk, besides other emerging indications such as bifurcation lesions, large-vessel disease, diabetes mellitus, and acute coronary syndromes.
Focus on Complex High-Risk Indicated PCI
Optimal Stenting Technique for Complex Coronary Lesions: Intracoronary Imaging-Guided Pre-Dilation, Stent Sizing, and Post-Dilation
Hanbit Park, Jung-Min Ahn, Do-Yoon Kang, Jung-Bok Lee, Sangwoo Park, Euihong Ko, Sang-Cheol Cho, Pil Hyung Lee, Duk-Woo Park, Soo-Jin Kang, Seung-Whan Lee, Young-Hak Kim, Cheol Whan Lee, Seong-Wook Park, Seung-Jung Park
In patients receiving drug-eluting stenting for complex coronary lesions including left main coronary artery lesion, bifurcation lesion, diffusely long lesion, and angiographically severely calcified lesion, intracoronary imaging–guided pre-dilation, stent sizing, and post-dilation was associated with a significant reduction of 3-year rates of primary composite outcome of cardiac death, target vessel myocardial infarction, or target vessel revascularization (5.6% vs. 7.9%; adjusted hazard ratio: 0.71; 95% confidence interval: 0.63 to 0.81; p < 0.001).
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EDITORIAL COMMENT Optimal Stenting Is the Gold Standard: We Have Plenty of Data and New Questions Arise
Antonio Colombo, Arif A. Khokhar, Alessandra Laricchia
Coronary Calcification and Long-Term Outcomes According to Drug-Eluting Stent Generation
Paul Guedeney, Bimmer E. Claessen, Roxana Mehran, Gary S. Mintz, Mengdan Liu, Sabato Sorrentino, Gennaro Giustino, Serdar Farhan, Martin B. Leon, Patrick W. Serruys, Pieter C. Smits, Clemens von Birgelen, Ziad A. Ali, Philippe Généreux, Björn Redfors, Mahesh V. Madhavan, Ori Ben-Yehuda, Gregg W. Stone
The authors pooled data on 19,833 patients from 18 randomized trials evaluating outcomes after percutaneous coronary intervention, categorized according to the presence of angiography core laboratory–confirmed moderate or severe coronary artery calcification in any target lesion. Coronary artery calcification was significantly associated with an increase in 5-year adverse events. Second-generation drug-eluting stents compared with first-generation drug-eluting stents were associated with significant reductions in the 5-year risks for target lesion failure and stent thrombosis in patients with target lesion moderate or severe coronary artery calcification.
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EDITORIAL COMMENT Coronary Calcifications in Patients Undergoing PCI: The Forgotten Enemy Back in the Spotlight
Mohamad Alkhouli
Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients
Giuseppe Di Gioia, Jeroen Sonck, Miroslaw Ferenc, Shao-Liang Chen, Iginio Colaiori, Emanuele Gallinoro, Takuya Mizukami, Monika Kodeboina, Sakura Nagumo, Danilo Franco, Jozef Bartunek, Marc Vanderheyden, Eric Wyffels, Bernard De Bruyne, Jens F. Lassen, Johan Bennett, Dobrin Vassilev, Patrick W. Serruys, Goran Stankovic, Yves Louvard, Emanuele Barbato, Carlos Collet
Provisional stenting has been recommended as the default technique for most coronary bifurcation lesions. The aim of this study was to compare clinical outcomes of different bifurcation percutaneous coronary intervention (PCI) techniques by means of a network meta-analysis. Twenty-one randomized controlled trials including 5,711 patients treated with 5 bifurcation PCI techniques (provisional, crush, culotte, T stenting/T and protrusion, and double-kissing crush). After a median follow-up period of 12 months (interquartile range: 9 to 36 months), the double-kissing crush technique had less occurrence of major adverse cardiovascular events (odds ratio: 0.39; 95% credible interval: 0.26 to 0.55) compared with provisional stenting. This difference was driven by a reduction in target lesion revascularization (odds ratio: 0.36; 95% credible interval: 0.22 to 0.57). No differences were found in cardiac death, myocardial infarction, and stent thrombosis among analyzed PCI techniques.
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EDITORIAL COMMENT Complex Better Than Simple for Distal Left Main Bifurcation Lesions: Lots of Data But Few Crushing Operators
Manuel Pan, Soledad Ojeda
Intravascular Healing Is Not Affected by Approaches in Contemporary CTO PCI: The CONSISTENT CTO Study
Simon J. Walsh, Colm G. Hanratty, Margaret McEntegart, Julian W. Strange, Johannes Rigger, Peter A. Henriksen, Elliot J. Smith, Simon J. Wilson, Jonathan M. Hill, Zlatko Mehmedbegovic, Bernard Chevalier, Marie-Claude Morice, James C. Spratt
The adoption of dissection and re-entry techniques (DART) means that success rates of >90% are achievable for unselected coronary chronic total occlusions (CTO). The impact of DART and subintimal stenting on the durability of CTO procedures is poorly understood. A low rate of target vessel failure (composite of cardiac death, myocardial infarction related to the target vessel, or any ischemia-driven revascularization) for CTO lesions was observed at 12 and 24 months. DART did not adversely affect intravascular healing assessed using optical coherence tomography at 12 months or clinical events at 2 years.
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EDITORIAL COMMENT Back to the Future: Intravascular Imaging to Assess and Guide CTO PCI Procedures
Gary S. Mintz
Structural
Routine Ultrasound or Fluoroscopy Use and Risk of Vascular/Bleeding Complications After Transfemoral TAVR
Guy Witberg, Vasileios Tzalamouras, Heath Adams, Tiffany Patterson, Ross Roberts-Thomson, Jonathan Byrne, Rafal Dworakowski, Philip MacCarthy, Simon Redwood, Bernard Prendergast
The study compared periprocedural vascular or bleeding complications in patients undergoing transfemoral transcatheter aortic valve replacement at 2 high-volume referral centers in London, United Kingdom, during 2014 to 2018. One center routinely used 2-dimensional ultrasound (2D-US) for guiding femoral arterial puncture, whereas the used other fluoroscopy and contralateral angiography (FCA). The sample size was 1,171 patients. Rates of vascular complications, bleeding, and their composite were similar among the groups (6.7% vs. 6.8%, p = 0.63; 6.1% vs. 6.4%, p = 0.70; and 9.8% vs. 9.8%, p = 0.76, respectively). The results show that excellent outcomes can be achieved using either 2D-US or FCA in high-volume, experienced centers.
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EDITORIAL COMMENT Vascular Access Site for TAVR: Use the Approach You Master Best
Jules Mesnier, Jean Philippe Collet
Safety and Efficacy of Protamine Administration for Prevention of Bleeding Complications in Patients Undergoing TAVR
Baravan Al-Kassou, Julian Kandt, Luisa Lohde, Jasmin Shamekhi, Alexander Sedaghat, Noriaki Tabata, Marcel Weber, Atsushi Sugiura, Rolf Fimmers, Nikos Werner, Eberhard Grube, Hendrik Treede, Georg Nickenig, Jan-Malte Sinning
Bleeding complications in patients undergoing transcatheter aortic valve replacement are associated with increased mortality. The aim of this study was to evaluate whether protamine administration for heparin reversal reduces complications and affects patient outcomes. The primary endpoint, a composite of 30-day mortality and life-threatening and major bleeding, occurred less frequently in the protamine administration group (3.2%) than the control group (8.7%) (p = 0.003), driven mainly by lower rates of life-threatening (0.1% vs. 2.6%) and major (1.0% vs. 4.1%) bleeding. Protamine administration resulted in a significantly shorter hospital stay (delta 1.6 days). However, occurrence of thromboembolic events was not increased by protamine administration.
EDITORIAL COMMENT Protamine in Patients Undergoing Transcatheter Aortic Valve Replacement: Why Not?
Jurrien M. ten Berg, Jorn Brouwer
Viewpoint
Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the COVID-19 Pandemic: An ACC/SCAI Position Statement
Pinak B. Shah, Frederick G.P. Welt, Ehtisham Mahmud, Alistair Phillips, Neal S. Kleiman, Michael N. Young, Matthew Sherwood, Wayne Batchelor, Dee Dee Wang, Laura Davidson, Janet Wyman, Sabeeda Kadavath, Molly Szerlip, James Hermiller, David Fullerton, Saif Anwaruddin, on behalf of American College of Cardiology and the Society for Cardiovascular Angiography and Interventions
The coronavirus disease-2019 (COVID-19) pandemic has strained health care resources around the world, causing many institutions to curtail or stop elective procedures. This has resulted in an inability to care for patients with valvular and structural heart disease in a timely fashion, potentially placing these patients at increased risk for adverse cardiovascular complications, including CHF and death. The effective triage of these patients has become challenging in the current environment as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment during the COVID-19 pandemic against the risk of delaying a needed procedure. In this document, the authors suggest guidelines for how to triage patients in need of structural heart disease interventions and provide a framework for how to decide when it may be appropriate to proceed with intervention despite the ongoing pandemic. In particular, the authors address the triage of patients in need of transcatheter aortic valve replacement and percutaneous mitral valve repair. The authors also address procedural issues and considerations for the function of structural heart disease teams during the COVID-19 pandemic.
Images in Intervention
Angiographic Findings of the Development of a Reverse Blood Supply After Percutaneous Deep Venous Arterialization
Tatsuya Nakama, Kotaro Obunai, Shunsuke Kojima, Makio Muraishi, Hiroyuki Watanabe
Should We Protect the Coronary Artery During Transcatheter Aortic Valve Replacement in Quadricuspid Valve Patients?
Masao Takahashi, Kei Aizawa, Yusuke Oba, Hiroshi Funayama, Koji Kawahito, Kazuomi Kario
ONLINE FEATURE Spontaneous Coronary Artery Dissection in a Patient With COVID-19
Pierre-Yves Courand, Brahim Harbaoui, Marc Bonnet, Pierre Lantelme
ONLINE FEATURE Successful Repeat Transcatheter Mitral Valve Replacement After Late Prosthesis Failure 
Philipp Moritz Rumpf, Anna Lena Lahmann, Michael Joner, Erion Xhepa
ONLINE FEATURE Electro-Cut Assisted Crossing Technique for Noncrossable Extreme Aortic Coarctation: First-in-Man
Julio I. Farjat Pasos, Heriberto Ontiveros Mercado, Luis A. Marroquín Donday, Gian M. Jiménez Rodríguez, Moises Jiménez Santos, Eduardo A. Arias Sánchez, Felix Damas de los Santos
ONLINE FEATURE THESE ARTICLES DO NOT APPEAR IN THE PRINTED ISSUE. THEY ARE AVAILABLE IN THE ONLINE VERSION OF THIS ISSUE.
Letters
To the Editor Subclassification of CYP2C19 Genotyping for Better-Adjusted Thienopyridine Treatment
Jung-Joon Cha, Do-Sun Lim
Reply
Jean-Sébastien Hulot, Gilles Montalescot
To the Editor A Claim for Consensus
Alessandra Laricchia, Antonio Mangieri, Francesco Giannini, Antonio Colombo, Arif A. Khokhar
Reply
Kerstin Piayda, Shazia Afzal, Verena Veulemans, Horst Sievert, Sameer Gafoor, Malte Kelm, Tobias Zeus
Research Correspondence A Novel Method to Quantify Leaflet Insertion During Transcatheter Mitral Valve Repair With the MitraClip
Gilbert H.L. Tang, Richard J. Ro, Aditya Sengupta, Sahil Khera, Samin K. Sharma, Annapoorna Kini, Stamatios Lerakis
Research Correspondence Evolving Technique for SAPIEN Pulmonary Valve Implantation: A Single-Center Experience
Alessia Faccini, Luca Giugno, Luciane Piazza, Angelo F. d’Aiello, Francesca R. Pluchinotta, Massimo Chessa, Mario Carminati