The 10^th Annual Update on Interventional Cardiology was held on Friday, October 29, 2021. The course offered a unique opportunity to recognize the legacy of senior members of the program, welcome new faculty, and discuss emerging topics in coronary and peripheral interventional procedures and structural heart disease.

“It is my distinct honor and pleasure together with Dr. Glen Henry to present to you the 10^th Annual Update on Interventional Cardiology,” said Carlos Mena-Hurtado, MD, an associate professor and the co-director of the conference.

“This is one of the main teaching conferences that the Section of Cardiovascular Medicine has had over the last decade, and it is a time for us as the interventional cardiology group to celebrate not only our specialty but also our team members,” Mena added.

Mena welcomed three new assistant professors Michael Nanna, MD, MHS, Jennifer Frampton, DO, MPH, and Yousif Ahmad, PhD.

“We know that interventional cardiac services are key to the advanced interventions that we provide to our patients and families,” said Francine LoRusso, RN, vice president and executive director for heart and vascular services. “Catheter based treatment has made a significant difference to how we treat our patients, and it continues to advance. We're very grateful and fortunate for the experts we have such as yourself and many of the panelists you have today.”

Eric J. Velazquez, MD, the Robert W. Berliner Professor of Medicine, noted a significant milestone in the use of endovascular therapies to treat a broad spectrum of vascular diseases and how the treatments have improved.

“We are celebrating the fifth decade of the advent of endovascular therapies for coronary artery disease and that has opened the doors to endovascular approaches to treating many vascular conditions. This wonderful work we embark on is about making the lives of the patients who we are very fortunate to serve and their families better. We only can do that if we continually push the envelope in terms of innovation, in terms of expectations around the safety and quality of the work we do and be able to establish the level of evidence that that drives population health initiatives.

I am proud of the work we are part of here at the Yale and the Yale New Haven Hospital and Health System, because we are one of those few places that can contribute across all of that not only in terms of discovery and innovation and establishing the standards that lead to patient-based clinical trials that then develop guidelines and policy beyond that, but also then educate the next group of practitioners and to do that within an infrastructure that allows us to offer the best care to patient that we can.”

Program Overview

The first speaker, Glen A. Henry, MD, FACC, FSCAI, an assistant professor and co-director of the conference, shared best practices to succeed at complex PCI or percutaneous coronary intervention. Henry defined CHIP (Complex and High-risk Coronary Intervention) as a first and foremost a team sport and included a comprehensive approach to help clinicians succeed at complex interventions.

"There is somewhat of a treatment paradox as we're focusing on higher risk patients with most to gain who are in fact, the least likely to be treated.” Henry also noted that the procedure originally had a 60% success rate, and a 6% operative emergency rate following PCI.

The lecture was grouped into three essential categories: knowledge of the field, judgment or application of knowledge, and technical skills.

Henry encouraged participants to become an expert at imaging, “Treat every patient like your mom or dad. The road to excellence is internal and requires intrinsic motivation. When you have complications, use your colleagues, and get help. Frequently fatigue evolves in complications.”

The next speaker, Elissa Altin, MD, an assistant professor, reviewed the anatomy and pathophysiology of left main disease, diagnosis, treatment options, and landmark trials comparing two revascularization procedures coronary artery bypass grafting (CABG) versus PCI.

“We can agree that impatience with syntax score less than 33, who are in the low to intermediate risk category, intermediate, complexity category. Those patients could either undergo PCI or CABG. In, the patients with the syntax score greater than 33, they will probably do better with cabbage, if their life expectancy is otherwise reasonable,” said Altin.

“Based on the early clinical trials I reviewed for you CABG has been the gold standard for over 40 years for left main disease and triple vessel disease. However, these studies compared medical therapy, from 40 years ago to cardiac surgery techniques from as long ago. Improvements in PCI have made cutaneous options safe and feasible,” she concluded.

Samit Shah, MD, PhD, an assistant professor, followed with an introductory talk on myocardial ischemia without obstructive coronary artery disease and a summary of future directions. Myocardial ischemia refers to restricted blood flow to the heart, which happens for a variety of reasons. Shah began with the historical context of interventional cardiology from the first coronary angiogram at the Cleveland Clinic to Andreas Grüntzig, MD, who performed the first coronary angioplasty in 1977 in Zurich, Switzerland.

Shah described the current approach at Yale New Haven Hospital including how to calculate the index of micro circulatory resistance and coronary flow reserve.

With funding from Women's Health Research at Yale, Shah hope to improve diagnostic testing for women.

“We're just beginning to understand the prognostic value in basic coronary physiology testing, and the role of physiologic indices in guiding patient care and future studies from our group are going to show the importance of doing this type of testing more routinely,” said Shah.

Kim Smolderen, PhD, an associate professor, provided an overview of mental health considerations in critical limb ischemia (CLI) populations that are undergoing revascularization and the implications for future research. Smolderen and Mena co-founded the Vascular Medicine Outcomes (VAMOS) research program, one of the few programs in the United States dedicated to improving patient outcomes for peripheral vascular disease.

One area of focus is interdisciplinary vascular care that includes lifestyle and behavioral care management.

“We recently updated estimates on trends for national admissions for CLI using the U.S. National Impatient Sample Database. We used ICD-9 and ICD-10 codes consistent with prior work, and the timeframe that we covered was from 2011 to 2017. What we saw that over time the risk profiles for patients with CLI admissions become extremely more complex with more hypertension, more obesity, diabetes, and a significant amount of patients presented with chronic kidney disease and a history of amputation. Surprisingly, the mean age of the cohort admitted for CLI is becoming younger over the years.”

Karthik Murugiah MBBS, FACC, FSCAI, an instructor in medicine, highlighted balloon pulmonary angioplasty and its role for chronic thromboembolic pulmonary hypertension (CTEPH).

“There is a wide range and estimates that are seen in various studies. This is because there are several challenges that exist in its assessment and diagnosis. Referral bias, there is often a paucity of early symptoms, there's different as difficulty in differentiating acute PE from symptoms of pre-existing CTEPH. Overall CTEPH is likely underdiagnosed the entire population, but likely over diagnosed in patients post PE.”

Murugiah added that the testing patterns of CTEPH suggested that most patients are not getting the necessary testing that could potentially diagnose CTEPH.

“There is an important advancement that has happened in this procedure that has made it much safer,” said Murugiah. “The use of imaging technology such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and pressure wire or pressure catheter has been a radical improvement in this procedure.”

Sameer Nagpal, MD, an assistant professor, discussed carotid artery interventions. The talk included two categories: symptomatic carotid artery disease patients, those who had experienced a stroke or transient ischemic attack (TIA) within the last six months prior to diagnosis and asymptomatic patients, those who haven't had any event in the last six months to one year.

“There's a debate about what's the appropriate treatment modality for these patients. Life expectancy, goals of care, and other comorbidities come into the picture as with any of the variety of cardiovascular diseases that we treat, but particularly in asymptomatic patients, perioperative risk with the procedures or surgeries that they may undergo for their carotid artery disease becomes of significant importance. The challenge for us as clinicians is to identify those asymptomatic people who have never had a problem from their carotid disease to find out who is at higher risk and who may benefit from an invasive intervention.”

Jeptha Curtis, MD, an associate professor, spoke about stroke prevention in atrial fibrillation with a focus on left atrial appendage occlusion.

"Atrial fibrillation is increasingly important public health issue where the proportion and number of patients in the United States with atrial fibrillation has continued to rise. In 1995 it was estimated that about 2 million patients were living with atrial fibrillation. Now that number is more than 3 million and climbing yearly,” said Curtis.

These patients have at least a five-fold increased risk stroke, compared with patients without atrial fibrillation.

“Until recently, the WATCHMAN was the only commercially available method for performing left atrial appendage occlusions. The goal of this device is to eliminate the communication between the left atrial appendage and the remainder of the circulation, so we're inserting a vascular plug. We're hoping that it forms a scar on top of it that prevents communication, and the theory is that if blood can't get in, it can't form a clot. If it can't form a clot, it can’t cause a stroke,” said Curtis.

He also added that when used appropriately and in the correct population, the WATCHMAN device can reach patients who might not otherwise receive or be eligible for anticoagulant therapy.

Curtis is a principal investigator for the CHAMPION-AF Clinical Trial, to determine whether left atrial appendage closure with the WATCHMAN FLX device could be a safe and reasonable alternative to oral anticoagulants in patients with non-valvular atrial fibrillation.

“The watchman device is a very effective, niche product for that 30% of patients who can't or won't take anticoagulation. The big question is what's going to happen over time. And is this going to be a therapy that should and can be offered to all patients with atrial fibrillation, or increased risk of stroke,” he added.

In closing, Vratika Agarwal, MD, an assistant professor, and Ryan Kaple MD, FACC, FSCAI, an assistant professor, presented a combined lecture on mitral and tricuspid valve therapies.

“We as a community should work harder for early identification and referral of patients with significant vital regurgitation. Surgery continues to be the gold standard, but transcatheter options should also be considered for patients who are deemed as high surgical risk, and who cannot be sent for surgery. Patient and pathology catered device selection is the future of treatment and management of mitral valve regurgitation,” said Agarwal.

Kaple added that tricuspid regurgitation (TR) is a disease that is under treated and under recognized.

“There are roughly 1.6 million patients the United States with moderate, severe or severe TR, and the only about half a percent of those are treated.”

Current treatment options are no ideal. Surgery presents a high risk with limited clinical evidence. Kaple advised that transcatheter devices for percutaneous or minimally invasive treatment, offer a better alternative.

“There's limited clinical evidence in the early to late survival after isolated tricuspid regurgitation is not ideal. After 10 years the survival is about 60%, whether it's repair or replacement. This is due to the effects of cardiopulmonary bypass on the right ventricle among other reasons.”

Kaple is the principle investigator of the TRILUMINATE Pivotal Trial, which aims to evaluate the clinical outcomes of TriClip, the first non-surgical minimally invasive tricuspid valve repair device.

“As we evolve and bring new technologies to the forefront, it will require us to even be more diligent in terms of our approach,” Kaple added.

In closing, Yousif Ahmad, MD, PhD, an assistant professor, provided an overview of the current landscape of transcatheter aortic valve interventions including recent advances in reducing pacemaker rates, cerebral embolic protection, and reducing paravalvular aortic regurgitation.

Ahmad commented on the latest iterations of TAVR valve systems such as the Evolut PRO therapeutic device, which provides advanced sealing and less aortic regurgitation.

“These advances have helped us eliminate moderate paravalvular regurgitation,” he said.

“Another recent advance where we've been trying to get results comparable to surgery and the results of rates of pacemakers after TAVI or TAVR. As the field has progressed, we began to pay more attention to this. There was initially a feeling the pacemakers after TAVR had no negative prognosis and that may have been true when we were treating 85- and 90-year-olds, but as we're treating younger and lower risk patients, I think everyone agrees that we want to avoid the potentially deleterious effects of long-term RV pacing for these patients. The aim should be to get an equivalent to what we see in the surgical data, which is around 5%.”

“TAVR is being increasingly performed at a number of programs. Case complexity at larger programs. The assessment and treatment of these patients is really challenging, and it does need an expert multidisciplinary heart team approach.”