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Papers by ray wyman

Circulation, 2021

Introduction: The use of mechanical circulatory support (MCS) in complex percutaneous coronary in... more Introduction: The use of mechanical circulatory support (MCS) in complex percutaneous coronary intervention (PCI) is the subject of ongoing investigation, but the role of MCS in chronic total occlusion (CTO) PCI is not well studied. Methods: We analyzed the patient and angiographic characteristics and procedural outcomes of 7,171 CTO PCIs performed between 2012 and June 2021 at 35 international centers. Results: Mean patient age was 64.5±10 years, mean left ventricular ejection fraction was 50 ± 13 % and 82% were men. MCS was used in 4.5% of the overall cases, MCS use was elective in 78.7% and urgent in 21.3%. The most common type of MCS was Impella CP (55.5%) followed by intra-aortic balloon pump (14.8%), Tandem Heart (10.0%) and Impella 2.5 (8.7%). Diabetes mellitus (51.0% vs. 42.4%, p=0.003), prior congestive heart failure (60.6% vs. 27.9%, p<0.001) and prior myocardial infarction (52.3% vs. 45.3%, p=0.020) were more common in MCS patients. Left ventricular ejection fraction w...

The Journal of invasive cardiology, 2019

BACKGROUND For patients needing coronary chronic total occlusion (CTO) percutaneous coronary inte... more BACKGROUND For patients needing coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI), a planned, staged intervention has been recommended by experts. Ad hoc CTO-PCI, however, occurs in practice. METHODS Observational, contemporary, multicenter, international registry. Our goals were to determine the frequency, characteristics, procedural techniques, and outcomes of patients who underwent ad hoc vs planned CTO-PCI. RESULTS Among 2282 patients who underwent CTO-PCI between 2012 and 2017, 318 (14%) were ad hoc. Patients undergoing ad hoc CTO-PCI had lower J-CTO, PROGRESS CTO, and PROGRESS Complications scores. Antegrade-wire escalation was used more often in ad hoc PCI (96% vs 81%; P<.001), whereas antegrade-dissection re-entry (22% vs 32%) and retrograde approaches (14% vs 38%) were more common in planned PCI (P<.001). There was no difference in ad hoc vs planned PCI in technical (85% vs 86%) and procedural success (84% vs 84%). In-hospital major adver...

International Journal of Cardiology, 2019

Background: During chronic total occlusion (CTO) percutaneous coronary intervention (PCI), someti... more Background: During chronic total occlusion (CTO) percutaneous coronary intervention (PCI), sometimes non-CTO lesions are also treated. Methods: We compared the clinical and procedural characteristics and outcomes of CTO PCIs with and without concomitant treatment of a non-CTO lesion in a contemporary multicenter CTO registry. Results: Of the 3598 CTO PCIs performed at 21 centers between 2012 and 2018, 814 (23%) also included PCI of at least one non-CTO lesion. Patients in whom non-CTO lesions were treated were older (65 ± 10 vs. 64 ± 10 years, p = 0.03), more likely to present with an acute coronary syndrome (32% vs. 23%, p b 0.01), and less likely to undergo PCI of a right coronary artery (RCA) CTO (46% vs. 58%, p b 0.01). The most common non-CTO lesion location was the left anterior descending artery (31%), followed by the circumflex (29%) and the RCA (25%).Combined non-CTO and CTO-PCI procedures had similar technical (88% vs. 87%, p = 0.33) and procedural (85% vs. 85%, p = 0.74) success and major in-hospital complication rates (3.4% vs. 2.7%, p = 0.23), but had longer procedure duration (131 [88, 201] vs. 117 [75, 179] minutes, p b 0.01), higher patient air kerma radiation dose (3.0 [1.9, 4.8] vs. 2.8 [1.5, 4.6] Gray, p b 0.01) and larger contrast volume (300 [220, 380] vs. 250 [180, 350] ml, p b 0.01).

Circulation: Cardiovascular Interventions, 2019

Background: We examined the procedural outcomes of chronic total occlusions (CTO) percutaneous co... more Background: We examined the procedural outcomes of chronic total occlusions (CTO) percutaneous coronary interventions in patients with prior coronary artery bypass graft surgery (CABG). Methods and Results: We compared the clinical, angiographic characteristics and outcomes of 3486 CTO interventions performed in patients with (n=1101) and without (n=2317) prior CABG at 21 centers. Prior CABG patients (32% of total cohort) were older (67±9 versus 63±10 years; P <0.001) and had more comorbidities and lower left ventricular ejection fraction (50% [40–58] versus 55% [45–60]; P <0.001). The CTO target vessel in prior CABG patients was the right coronary artery (56%), circumflex (26%), and left anterior descending artery (17%). The mean J-CTO (2.9±1.2 versus 2.2±1.3; P <0.001) and PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; 1.5±1.1 versus 1.2±1.0; P <0.001) score was higher in prior CABG patients. Retrograde (53% versus 30%,...

JACC: Cardiovascular Interventions, 2019

OBJECTIVES This study examined the frequency and outcomes of radial access for chronic total occl... more OBJECTIVES This study examined the frequency and outcomes of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND Radial access improves the safety of PCI, but its role in CTO PCI remains controversial. METHODS We compared the clinical, angiographic, and procedural characteristics of 3,790 CTO interventions performed between 2012 and 2018 via radial-only access (RA) (n ¼ 747) radial-femoral access (RFA) (n ¼ 844) and femoralonly access (n ¼ 2,199) access at 23 centers in the United States, Europe, and Russia. RESULTS Patients' mean age was 65 AE 10 years, and 85% were men. Transradial access (RA and RFA) was used in 42% of CTO interventions and significantly increased over time from 11% in 2012 to 67% in 2018 (p < 0.001). RA patients were younger (age 62 AE 10 years vs. 64 AE 10 years and 65 AE 10 years; p < 0.001), less likely to have undergone prior coronary artery bypass graft surgery (18% vs. 39% and 35%; p < 0.001), and less likely to have undergone prior PCI (60% vs. 63% and 66%; p ¼ 0.005) compared with those who underwent RFA and femoral-only access PCI. RA CTO PCI lesions had lower J-CTO (Multicenter CTO Registry in Japan) (2.1 AE 1.4 vs. 2.6 AE 1.3 and 2.5 AE 1.3; p < 0.001) and PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) complication (2.3 AE 1.9 vs. 3.2 AE 2.0 and 3.2 AE 1.9; p < 0.001) scores. The mean sheath size was significantly smaller in the RA group (6.6 AE 0.7 vs. 7.0 AE 0.6 and 7.3 AE 0.8; p < 0.0001), although it increased with lesion complexity. Antegrade dissection re-entry (20% vs. 33% and 32%; p < 0.001) was less commonly used with RA, whereas use of retrograde techniques was highest with RFA (47%). The overall rates of technical success (89% vs. 88% vs. 86%; p ¼ 0.061), procedural success (86% vs. 85% vs. 85%; p ¼ 0.528), and in-hospital major complication (2.47% vs. 3.40% vs. 2.18%; p ¼ 0.830) were similar in all 3 groups, whereas major bleeding was lower in the RA group (0.55% vs. 1.94% and 0.88%; p ¼ 0.013). CONCLUSIONS Transradial access is increasingly being used for CTO PCI and is associated with similar technical and procedural success and lower major bleeding rates compared with femoral-only access interventions.

The Journal of invasive cardiology, Jan 11, 2018

The most common re-entry technique during retrograde chronic total occlusion (CTO) percutaneous c... more The most common re-entry technique during retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is reverse controlled antegrade and retrograde tracking (rCART). The use of guide-catheter extensions can facilitate rCART, but has received limited study. We compared the clinical and procedural characteristics and outcomes of traditional rCART vs guide-catheter extension rCART vs cases in which both techniques were used (combined rCART) in patients with successful retrograde CTO crossing in a contemporary multicenter CTO-PCI registry. Between 2012 and 2018, rCART was used in 467 of 1336 retrograde CTO-PCI cases. Guide-catheter extension rCART was used in 60/467 cases (13%; use increased from 0% in 2012 to 26% in 2017). The traditional rCART group, guide-catheter extension rCART group, and combined rCART group had similar target lesion J-CTO scores (3.3 ± 1.1 vs 3.2 ± 1.2 vs 3.6 ± 0.8, respectively; P=.28), technical success rates (99% vs 100% vs 96.4%, respec...

The American journal of cardiology, 2018

The frequency and outcomes of patients who underwent chronic total occlusion (CTO) percutaneous c... more The frequency and outcomes of patients who underwent chronic total occlusion (CTO) percutaneous coronary intervention (PCI) of more than one CTO during the same procedure have received limited study. We compared the clinical and angiographic characteristics and procedural outcomes of patients who underwent treatment of single versus >1 CTOs during the same procedure in 20 centers from the United States, Europe, and Russia. A total of 2,955 patients were included: mean age was 65 ± 10 years and 85% were men with high prevalence of previous myocardial infarction (46%), and previous coronary artery bypass graft surgery (33%). More than one CTO lesions were attempted during the same procedure in 58 patients (2.0%) and 70% of them were located in different major epicardial arteries. Compared with patients who underwent PCI of a single CTO, those who underwent PCI of >1 CTOs during the same procedure had similar J-CTO (2.4 ± 1.3 vs 2.5 ± 1.3, p = 0.579) and Prospective Global Regist...

JACC. Cardiovascular interventions, Jan 26, 2018

The aim of this study was to determine the techniques and outcomes of hybrid chronic total occlus... more The aim of this study was to determine the techniques and outcomes of hybrid chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a diverse group of patients and operators on 2 continents. CTO PCI has been evolving with constant improvement of equipment and techniques. Contemporary outcomes of CTO PCI were examined by analyzing the clinical, angiographic, and procedural characteristics of 3,122 CTO interventions performed in 3,055 patients at 20 centers in the United States, Europe, and Russia. The mean age was 65 ± 10 years, and 85% of the patients were men, with high prevalence of diabetes (43%), prior myocardial infarction (46%), prior coronary artery bypass graft surgery (33%), and prior PCI (65%). The CTO target vessels were the right coronary artery (55%), left anterior descending coronary artery (24%), and left circumflex coronary artery (20%). The mean J-CTO (Multicenter Chronic Total Occlusion Registry of Japan) and PROGRESS CTO (Prospective Global Regi...

JACC: Cardiovascular Interventions, 2017

The aim of this study was to examine the use of saphenous vein grafts (SVGs) for retrograde cross... more The aim of this study was to examine the use of saphenous vein grafts (SVGs) for retrograde crossing during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND The use of SVGs for retrograde crossing during CTO PCI has received limited study. METHODS A total of 1,615 retrograde CTO PCIs performed between 2012 and 2019 at 25 centers were examined. Clinical, angiographic, and technical characteristics and procedural outcomes were compared among retrograde cases via SVGs (SVG group) versus other collateral vessels (non-SVG group). RESULTS Retrograde CTO PCI via SVGs was performed in 189 cases (12%). Patients in the SVG group were older (mean age 70 AE 9 years vs. 64 AE 10 years; p < 0.01) and had higher rates of prior myocardial infarction (62% vs. 51%; p < 0.01) and prior PCI (81% vs. 70%; p < 0.01). They were more likely to have moderate or severe calcification (81% vs. 65%; p < 0.01) and moderate or severe tortuosity (53% vs. 44%; p ¼ 0.02) and had similar J-CTO (Multicenter CTO Registry in Japan) scores (3.2 AE 1.0 vs. 3.1 AE 1.1; p ¼ 0.13) but higher PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores (4.7 AE 1.7 vs. 3.1 AE 1.1; p < 0.01). Technical (85% vs. 78%; p ¼ 0.04) and procedural (81% vs. 74%; p ¼ 0.04) success rates were higher in the SVG group, with no difference in in-hospital major adverse events (6.4% vs. 4.4%; p ¼ 0.22). Contrast volume was lower in the SVG group (225 ml [173 to 325 ml] vs. 292 ml [202 to 400 ml]; p < 0.01). CONCLUSIONS Use of SVGs for retrograde crossing is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with retrograde CTO PCI via other collateral vessels.

The American journal of cardiology, Jan 24, 2017

Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous co... more Coronary perforation is a potential complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,097 CTO PCIs performed in 2,049 patients from 2012 to 2017. Patient age was 65 ± 10 years, 85% were men, and 36% had prior coronary artery bypass graft surgery. Technical and procedural success were 88% and 87%, respectively. A major periprocedural adverse cardiovascular event occurred in 2.6%. Coronary perforation occurred in 85 patients (4.1%); The frequency of Ellis class 1, 2, and 3 perforations was 21%, 26%, and 52%, respectively. Perforation occurred more frequently in older patients and those with previous coronary artery bypass graft surgery (61% vs 35%, p < 0.001). Cases with perforation were angiographically more complex (Multicenter CTO Registry in Japan score 3.0 ± 1.2 vs 2.5 ± 1.3, p < 0.001). Twelve patients (14%) with perforation experienced tamponade requiring pericardiocentesis. Patient age, previous PCI, right coronary arte...

The Journal of invasive cardiology, Jan 15, 2017

We sought to determine the effect of age and sex on procedural outcomes and efficiency of chronic... more We sought to determine the effect of age and sex on procedural outcomes and efficiency of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the clinical and angiographic characteristics and outcomes of 1675 CTO-PCIs performed in 1644 patients between 2012 and 2016 at 15 United States centers. Mean age was 65.3 ± 10 years and 1408 (86%) were men. Overall technical and procedural success rates were 88% and 87%, respectively. Increasing age was associated with more comorbidities (dyslipidemia, hypertension, prior coronary artery bypass graft surgery, prior stroke, peripheral arterial disease, and chronic lung disease) and more lesion calcification. As compared with the reference age of <65 years, age >75 years was independently associated with technical failure (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.20-4.28). Increasing age was also independently associated with the incidence of major adverse cardiovascular events (MACEs; OR, 2.9...

International journal of cardiology, Jan 23, 2016

Various scoring systems have been developed to predict the technical outcome and procedural effic... more Various scoring systems have been developed to predict the technical outcome and procedural efficiency of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the predictive capacity of 3 CTO PCI scores (Clinical and Lesion-related [CL], Multicenter CTO registry in Japan [J-CTO] and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention [PROGRESS CTO] scores) in 664 CTO PCIs performed between 2012 and 2016 at 13 US centers. Technical success was 88% and the retrograde approach was utilized in 41%. Mean CL, J-CTO and PROGRESS CTO scores were 3.9±1.9, 2.6±1.2 and 1.4±1.0, respectively. All scores were inversely associated with technical success (p<0.001 for all) and had moderate discriminatory capacity (area under the curve 0.691 for the CL score, 0.682 for the J-CTO score and 0.647 for the PROGRESS CTO score [p=non-significant for pairwise comparisons]). The difference in technical success between the minimum and maximum CL...

The Journal of invasive cardiology, 2016

Administration of a large amount of contrast volume during chronic total occlusion (CTO) percutan... more Administration of a large amount of contrast volume during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) may lead to contrast-induced nephropathy. We examined the association of clinical, angiographic and procedural variables with contrast volume administered during 1330 CTO-PCI procedures performed at 12 experienced United States centers. Technical and procedural success was 90% and 88%, respectively, and mean contrast volume was 289 ± 138 mL. Approximately 33% of patients received >320 mL of contrast (high contrast utilization group). On univariable analysis, male gender (P=.01), smoking (P=.01), prior coronary artery bypass graft surgery (P=.04), moderate or severe calcification (P=.01), moderate or severe tortuosity (P=.04), proximal cap ambiguity (P=.01), distal cap at a bifurcation (P<.001), side branch at the proximal cap (P<.001), blunt/no stump (P=.01), occlusion length (P<.001), higher J-CTO score (P=.02), use of antegrade dissection an...

International Journal of Cardiology, 2015

Journal of the American College of Cardiology, 2015

background: We sought to validate the clinical utility of the J-CTO score in chronic total occlus... more background: We sought to validate the clinical utility of the J-CTO score in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). methods: The records of 650 patients who underwent CTO PCI using the "hybrid" approach at six experienced CTO PCI centers were reviewed. Baseline characteristics and procedural outcomes were compared in patients with high (≥3) and low (<3) J-CTO scores. Multivariable logistic regression was performed to evaluate the score's ability to predict technical success. The model goodness-of-fit was examined using receiver operator curves. results: Most patients (374 of 650, 58%) had a J-CTO score of ≥3. Patients with high J-CTO scores had higher frequency of dyslipidemia (97% vs. 92%, p=0.04), prior PCI (70% vs. 61%, p=0.015), and prior coronary artery bypass graft surgery (45% vs. 24%, p<0.001). The incidence of technical success, procedural success and major adverse cardiac events (MACE) were significantly lower in patients with J-CTO scores ≥3 (technical success 89.9% vs. 97.1%; procedural success 88.2% vs. 96.0%, MACE 2.1% vs. 1.1%, p<0.001). A high J-CTO score was associated with higher procedure times (123 [92-183] vs. 82 [55-129] minutes, p<0.001) and increased air-kerma radiation dose (4.4 [2.7-6.2] vs. 2.7 [1.7-5.1] Gray, p<0.001). The J-CTO score demonstrated good discrimination (c statistic=0.862) Conclusion: J-CTO score is a very useful tool for predicting the technical and procedural success and efficiency of CTO PCI, supporting its expanded use.

New England Journal of Medicine, 1988

Between October 1, 1985, and April 1, 1988, we performed balloon aortic valvuloplasty in 170 pati... more Between October 1, 1985, and April 1, 1988, we performed balloon aortic valvuloplasty in 170 patients (mean age [+/- SD], 77 +/- 5 years) who had symptomatic aortic stenosis. The procedure was completed successfully in 168 patients and resulted in significant increases in the mean (+/- SD) aortic-valve area (from 0.6 +/- 0.2 to 0.9 +/- 0.3 cm2) and cardiac output (from 4.6 +/- 3.4 to 4.8 +/- 1.4 liters per minute) and decreases in the peak aortic-valve pressure gradient (from 71 +/- 20 to 36 +/- 14 mm Hg) (P less than 0.01 for all three comparisons). There were six in-hospital deaths, and five patients required early aortic-valve replacement. Follow-up data were available for all patients, for a period averaging 9.1 months. In addition to the 6 patients who died in the hospital, 25 patients died an average of 6.4 +/- 5.3 months after discharge. Symptoms recurred in 44 patients; they were managed by repeat valvuloplasty in 16 patients, by aortic-valve replacement in 17, and by medical therapy in 11. At the most recent follow-up examination, the symptoms of 103 patients had improved after valvuloplasty; this number includes 15 patients with restenosis who successfully underwent redilation. Life-table analysis indicates that the probability of survival 12 months after the procedure was 74 percent. We conclude that balloon aortic valvuloplasty is an effective palliative therapy for some elderly patients with symptomatic aortic stenosis. Symptoms improve in the majority of patients; although restenosis is common, it can be managed in some patients by repeat balloon dilation.

Journal of the American College of Cardiology, 1991

Journal of the American College of Cardiology, 1988

Data from 2,883 cardiac catheterizations performed during an 18 month period (from July 1986 thro... more Data from 2,883 cardiac catheterizations performed during an 18 month period (from July 1986 through December 1987) were analyzed to assess the current complication profile of diagnostic and therapeutic procedures. Procedures performed during the study period included 1,609 diagnostic catheterizations, 933 percutaneous transluminal coronary angioplasties and 199 percutaneous balloon valvuloplasties. Overall, the mortality rate was 0.28% but ranged from 0.12% for diagnostic catheterizations to 0.3% for coronary angioplasty and 1.5% for balloon valvuloplasty. Emergency cardiac surgery was required in 12 angioplasty patients (1.2 %). Cardiac perforation occurred in seven patients (0.2%), of whom six were undergoing valvulo-From the Charles A.

Circulation, 1989

Percutaneous mitral valvuloplasty has been proposed as a nonsurgical technique for treating high-... more Percutaneous mitral valvuloplasty has been proposed as a nonsurgical technique for treating high-risk patients with mitral stenosis who are deferred from mitral valve replacement. The effect of this technique on patients with pulmonary hypertension, however, has not been fully evaluated. Accordingly, serial assessment of pulmonary vascular resistance was made in 14 patients with critical mitral stenosis and pulmonary hypertension (pulmonary vascular resistance greater than 250 dynes.sec/cm5 or mean pulmonary artery pressure greater than 40 mm Hg or both) who underwent percutaneous balloon dilatation of the mitral valve. Balloon valvuloplasty was performed with either one (n = 10) or two (n = 4) balloons through the transseptal approach, and it resulted in significant improvement in mean mitral gradient (from 18 +/- 4 to 9 +/- 4 mm Hg, p less than 0.001), systemic blood flow (from 3.7 +/- 1.2 to 5.0 +/- 2.2 l/min, p less than 0.001), and calculated mitral valve area (from 0.7 +/- 0.2...

The American Journal of Cardiology, 1988