Background: Physiological assessment with pressure wire pullback can characterize coronary artery disease (CAD) with a focal or diffuse pattern. However, the clinical relevance of this distinction is unknown. We use data from the ORBITA trial (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) to test if the pattern of CAD predicts the placebo-controlled efficacy of percutaneous coronary intervention (PCI) on stress echocardiography ischemia and symptom end points. Methods: One hundred sixty-four patients in ORBITA underwent blinded instantaneous wave-free ratio (iFR) pullback assessment before randomization. Focal disease was defined as a ≥0.03 iFR unit drop within 15 mm, rather than over a longer distance. Analyses were performed using regression modeling. Results: In the PCI arm (n=85), 48 were focal and 37 were diffuse. In the placebo arm (n=79), 35 were focal and 44 were diffuse. Focal stenoses were associated with significantly lower fractional flow reserve (FFR) and iFR values than diffusely diseased vessels (mean FFR and iFR, focal 0.60±0.15 and 0.65±0.24, diffuse 0.78±0.10 and 0.88±0.08, respectively, P <0.0001). With adjustment for this difference, PCI for focal stenoses resulted in significantly greater reduction in stress echo ischemia than PCI for diffuse disease ( P <0.05). The effect of PCI on between-arm pre-randomization adjusted exercise time was 9.32 seconds (95% CI, −17.1 to 35.7 seconds; P =0.487). When stratified for pattern of disease, there was no detectable difference between focal and diffuse CAD ( P interaction=0.700). PCI improved Seattle Angina Questionnaire angina frequency score and freedom from angina more than placebo ( P =0.034; P =0.0035). However, there was no evidence of interaction between the physiological pattern of CAD and these effects ( P interaction=0.436; P interaction=0.908). Conclusions: PCI achieved significantly greater reduction of stress echocardiography ischemia in focal compared with diffuse CAD. However, for symptom end points, no such difference was observed. Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT02062593.

Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective treatment for severe aortic stenosis across the spectrum of surgical risk cohorts. Subsequently, the dramatic increase in procedural volume worldwide has placed significant financial and logistical pressures on healthcare institutions, particularly regarding hospital length of stay (LOS), which can adversely affect patient flow. In this review article, we discuss different peri-procedural strategies developed to reduce LOS and facilitate early discharge after TAVI.

Background/Objectives: Acute ischemic stroke is an uncommon but potentially devastating complication of Transcatheter Aortic Valve Implantation (TAVI). Despite improvements in device technology and procedural techniques, stroke rates have remained stable, with cerebral embolic protection devices demonstrating only limited efficacy to date. Therefore, the management of acute ischemic stroke complicating TAVI (AISCT) remains a key priority. We conducted a systematic review of the management of AISCT and provided multidisciplinary consensus recommendations for optimal management. Methods: PubMed, Google Scholar, and Cochrane databases were searched from inception to October 2023. All the original studies focusing on the treatment of AISCT were included. Non-English language studies, review articles, and studies in pediatric populations were excluded. Consensus recommendations were made by a working group comprising experts in stroke medicine and structural interventional cardiology. Results: A total of 18 studies met the inclusion criteria, including 14 case reports/series and 4 observational studies. No clinical trials were identified. The included case reports and series suggest that tissue-type plasminogen activator (tPA) and mechanical thrombectomy (MT) might be effective strategies for managing AISCT. However, significant bleeding complications were reported in two out of the four patients receiving tPA. Four observational studies also suggest an association between tPA and/or MT and improved functional outcomes and survival compared to conservative management. Higher bleeding rates were reported following tPA. Observational data suggest that there is currently little real-world utilization of either reperfusion strategy. Conclusions: There is an absence of high-quality randomized data to guide clinical decision making in this important area. Observational data suggest reperfusion strategies are associated with improved clinical outcomes once important confounders such as stroke severity have been accounted for. While MT can be recommended as the standard of care in appropriately selected patients, significantly increased rates of bleeding with tPA following large-bore arterial access raise important safety concerns. We present simple clinical guidance for AISCT based on the limited available data. Close multidisciplinary work and patient-specific consideration of ischemic and bleeding risk is essential.

Transfemoral transcatheter aortic valve replacement is an effective treatment for severe aortic stenosis with a high rate of procedural success with the current devices. However, anatomic factors and device limitations may increase technical difficulty. We describe the balloon nudge technique, a novel technique that improves coaxial alignment while crossing the aortic valve. (Level of Difficulty: Advanced.)

Background. Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period, in part given its reliance on echocardiography for diagnosis and management and the associated virus transmission risks to patients and healthcare workers. This study assesses utilisation of the endocarditis team (ET) in limiting routine echocardiography, especially transoesophageal echocardiography (TOE), in patients with suspected IE, and explores the effect on clinical outcomes. Methods. All patients discussed at the ET meeting at Imperial College Healthcare NHS Trust during the first lockdown in the UK (23 March to 8 July 2020) were prospectively included and analysed in this observational study. Results. In total, 38 patients were referred for ET review (71% male, median age 54 [interquartile range 48, 65.5] years). At the time of ET discussion, 21% had no echo imaging, 16% had point-of-care ultrasound only, and 63% had formal TTE. In total, only 16% underwent TOE. The ability of echocardiography, in those where it was performed, to affect IE diagnosis according to the Modified Duke Criteria was significant ( ); however, sensitivity was not affected. All-cause mortality was 17% at 30 days and 25% at 12 months from ET discussion in those with confirmed IE. Conclusion. Limiting echocardiography in patients with a low pretest probability (not probable or definite IE according to the Modified Duke Criteria) did not affect the diagnostic ability of the Modified Duke Criteria to rule out IE in this small study. Moreover, restricting nonessential echocardiography, and importantly TOE, in patients with suspected IE through use of the ET did not impact all-cause mortality.