Asymptomatic Takayasu Arteritis With Critical Multivessel Stenosis.

Takayasu arteritis is characterized by blood vessel inflammation involving the aorta and its branches. We describe a patient with Takayasu arteritis with severe multivessel involvement and classic physical examination findings but virtually no symptoms because of the presence of extensive collateral circulation seen on computed tomography angiography and magnetic resonance angiography imaging.

P2Y12 Inhibition in Patients Requiring Oral Anticoagulation After Percutaneous Coronary Intervention: The SWAP-AC-2 Study.

BACKGROUND: Among patients treated with a novel oral anticoagulant (NOAC) undergoing percutaneous coronary intervention (PCI), combination therapy with clopidogrel (ie, known as dual antithrombotic therapy [DAT]) is the treatment of choice. However, there are concerns for individuals with impaired response to clopidogrel. OBJECTIVES: The authors sought to assess the pharmacodynamic (PD) effects of clopidogrel vs low-dose ticagrelor in patients with impaired clopidogrel response assessed by the ABCD-GENE score. METHODS: This was a prospective, randomized PD study of NOAC-treated patients undergoing PCI. Patients with an ABCD-GENE score ≥10 (n = 39), defined as having impaired clopidogrel response, were randomized to low-dose ticagrelor (n = 20; 60 mg twice a day) or clopidogrel (n = 19; 75 mg once a day). Patients with an ABCD-GENE score <10 (n = 42) were treated with clopidogrel (75 mg once a day; control cohort). PD assessments at baseline and 30 days post-randomization (trough and peak) were performed to assess P2Y12 signaling (VerifyNow P2Y12 reaction units [PRU], light transmittance aggregometry, and vasodilator-stimulated phosphoprotein); makers of thrombosis not specific to P2Y12 signaling were also assessed. The primary endpoint was PRU (trough levels) at 30 days. RESULTS: At 30 days, PRU levels were reduced with ticagrelor-based DAT compared with clopidogrel-based DAT at trough (23.0 [Q1-Q3: 3.0-46.0] vs 154.5 [Q1-Q3: 77.5-183.0]; P < 0.001) and peak (6.0 [Q1-Q3: 4.0-14.0] vs 129.0 [Q1-Q3: 66.0-171.0]; P < 0.001). Trough PRU levels in the control arm (104.0 [Q1-Q3: 35.0-167.0]) were higher than ticagrelor-based DAT (P = 0.005) and numerically lower than clopidogrel-based DAT (P = 0.234). Results were consistent by light transmittance aggregometry and vasodilator-stimulated phosphoprotein. Markers measuring other pathways leading to thrombus formation were largely unaffected. CONCLUSIONS: In NOAC-treated patients undergoing PCI with an ABCD-GENE score ≥10, ticagrelor-based DAT using a 60-mg, twice-a-day regimen reduced platelet P2Y12 reactivity compared with clopidogrel-based DAT. (Tailoring P2Y12 Inhibiting Therapy in Patients Requiring Oral Anticoagulation After PCI [SWAP-AC-2]; NCT04483583).

Sex Disparities in Cardiovascular Disease.

Cardiovascular disease is the leading cause of death in women. It remains underdiagnosed, undertreated, and portends worse outcomes in women than men. Disparities exist in every stage of science, from bench research to the editorial board of major journals and in every cardiovascular subspecialty. This review summarizes differences in cardiovascular risk factors and disparities in management and outcomes of ischemic heart disease, heart failure, aortic stenosis, and atrial fibrillation. It also provides an overview of female representation as participants and leaders of clinical trials, editorial boards, and academic institutions. Strategies to overcome these disparities are proposed with examples of successful programs.

The Supportive Guidewire Paradox: How Extra Support Guidewires May Hinder Equipment Delivery Through Tortuous and Calcified Coronary Lesions.

Percutaneous coronary intervention of heavily calcified coronary vessels can be challenging due to difficult equipment delivery and suboptimal stent expansion, leading to worse clinical outcomes. Supportive guidewires are designed to facilitate equipment delivery. We present two cases of heavily calcified and tortuous coronary lesions in which use of support guidewires hindered balloon and stent delivery, possibly by increasing friction between equipment and the wall of the coronary vessel. Equipment delivery was achieved using less supportive workhorse guidewires.

An Interventional Odyssey: The Importance of Planning and Prompt Recognition and Treatment of Complications During a Complex Chronic Total Occlusion Intervention.

Despite significant progress, chronic total occlusion (CTO) percutaneous coronary interventions (PCI) are often challenging and carry increased risk of complications. We present a highly complex CTO PCI case that was successfully completed despite numerous complications (perforation, donor vessel closure, stent loss, guide extension tip fracture, access site bleeding and cardiac arrest) to highlight the importance of appropriate patient selection, pre-procedural planning, comprehensive patient-centered risk/benefit discussion, and prompt recognition and treatment of intra-procedural complications.

Retrograde approach for rewiring a jailed side branch during double kissing crush stenting.

Double kissing crush (DK crush) is one of the preferred strategies for bifurcation stenting due to the lower risk of target vessel failure but can be difficult to perform. Difficulty in wiring the jailed side branch after stenting the main vessel is not uncommon. The retrograde crossing can provide a solution in selected cases when antegrade rewiring of a jailed side branch fails during DK crush (or other bifurcation stenting techniques).

Reduction in Right Atrial Pressures Is Associated With Hemodynamic Improvements After Transcatheter Edge-to-Edge Repair of the Tricuspid Valve.

BACKGROUND: Investigational transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR) has shown promise as an alternative to surgery, but factors influencing outcomes, optimal patient selection, and procedural timing remain incompletely defined. Given the limitations of determining TR severity by conventional echocardiography, our objectives were to determine whether invasive right atrial (RA) pressures performed during the procedure are related to patient outcomes. METHODS: This study was a retrospective review of patients who underwent off-label tricuspid TEER using MitraClip (Abbott Vascular, Menlo Park, CA) for significant TR at a single institution. Intraprocedural mean RA pressure, RA peak V-wave, RA pressure nadir, and systolic increase in RA pressure (XV height) were recorded. RESULTS: Thirty-eight patients underwent tricuspid TEER; 33 underwent concomitant mitral TEER for mitral regurgitation. The study cohort was 39% female with a mean age of 78.6±14.3 years. Median follow-up was 339 days (interquartile range, 100-601). Any reduction in mean RA pressure, RA peak V-wave, RA nadir, and XV height occurred in 74%, 82%, 45%, and 87% of patients, respectively. At 1 year, event-free survival was 47%. Postprocedure XV height correlated with TR severity as determined by echocardiography (P<0.0001). The highest quartile of postprocedure XV height (>8 mm Hg) had worse event-free survival compared with those who had concluding XV height ≤8 mm Hg (P=0.02). Attainment of a concluding XV height less than or equal to median value was associated with a lower creatinine the next day (1.27±0.47 versus 1.64±0.47 mg/dL, P=0.04). CONCLUSIONS: Intraprocedural XV height correlates with TR severity after tricuspid TEER, and lower concluding pressures are associated with improved outcomes. Analysis of RA pressures may serve as a complementary tool for the evaluation of disease severity and procedural guidance.

Characteristics of Transgender Women Referred to Women's Heart Clinic.

INTRODUCTION: Transgender women have been reported to have a high burden of cardiovascular disease (CVD) and risk factors based largely on surveys. Our aim was to describe the prevalence of CVD and associated comorbidities among a cohort of older transgender women referred to cardiology as part of their gender-affirming care. METHODS: This was a retrospective, cross-sectional study of transgender women at a single institution from 2017 to 2019. RESULTS: Fifty-two consecutive patients were included. The most common reasons for referral were cardiac risk factor management (45%) and pre-operative cardiac risk stratification prior to gender-affirming surgery (35%). The mean age was 57 ± 10 years, 87% were white, and 92% had insurance coverage. Forty-eight patients (92%) were taking gender-affirming hormone therapy; 5 had undergone breast augmentation, 4 had undergone orchiectomy, and 2 had undergone vaginoplasty. The most common comorbidities were depression and/or anxiety (63%), obesity (58%), and hyperlipidemia (54%). Excluding aldosterone antagonists, 46% were on cardiac medications; changes were recommended for 25% of patients: new prescriptions in 9, dose adjustments in 5, and discontinuations in 4. According to the pooled cohort equation, the 10-year risk of atherosclerotic CVD was 9.4 ± 7.7% when the study population was calculated as male and 5.2 ± 5.1% when calculated as female (p <0.001). For patients who completed exercise testing, the functional aerobic capacity was fair (77.6 ± 21.4%) when calculated as male and average (99.5 ± 27.5%) as female (p < .0001); there was inconsistency in sex used for calculating the result on the formal report. CONCLUSIONS: Older transgender women may have an underestimated prevalence of CVD and its risk factors. More research is needed to identify cardiovascular health profiles, improve practice consistency, and establish normative values for transgender patients.

Comparison of Outcomes of Coronary Revascularization for Acute Myocardial Infarction in Men Versus Women.

This study sought to examine the differences in the characteristics and outcomes between men and women who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) in contemporary US practice. The Nationwide Inpatient Sample was used to identify patients who underwent revascularization for AMI between January 1, 2003 and December 31, 2016. The primary outcome was in-hospital mortality. Propensity score matching was utilized to account for differences in baseline characteristics. In total, 3,603,142 patients were included, of whom only 1,180,436 (33%) were women. Compared with men, women were older and had higher prevalence of key co-morbidities including diabetes, hypertension, congestive heart failure, and chronic kidney and lung disease (p <0.001). In the PCI cohort, women were significantly less likely to undergo multivessel PCI, to receive mechanical circulatory support, or to undergo atherectomy. In the CABG group, women were more likely to have concomitant valve surgery. In the propensity-matched cohorts, in-hospital mortality was higher for women than men regardless of revascularization strategy: 7.6% versus 6.6% for PCI in ST-elevation myocardial infarction, 2.0% versus 1.9% for PCI in non-ST-elevation myocardial infarction, and 5.7% versus 4.3% for CABG in any AMI (p <0.001). Women also had higher rates of major complications, longer hospitalizations, higher costs, and were less likely to be discharged home (vs nursing facility). These sex-based differences persisted over the study 14-year period. In conclusion, in a contemporary nationwide analysis of propensity score-matched patients, women who undergo revascularization for AMI have worse in-hospital outcomes than men regardless of revascularization mode.

Institutional learning experience for combined edge-to-edge tricuspid and mitral valve repair.

BACKGROUND: Transcatheter edge-to-edge repair with MitraClip is only approved for treatment of mitral regurgitation but is increasingly used to treat concomitant tricuspid regurgitation (TR) due to its common coexistence and association with poor outcomes. This study aimed to describe the learning curve associated with the challenge of off-label treatment of concomitant TR. METHODS: This is a retrospective review of initial and consecutive patients who underwent combined edge-to-edge repair of mitral and tricuspid valves (TVs) at our institution from August 2017 to October 2019. RESULTS: Repair of both valves with MitraClip was performed in 22 patients (median age 81.5 years, 32% female). Mean procedure time was 176 ± 47 min; mean fluoroscopy time was 65 ± 24 min. Procedure duration in the first tertile was significantly longer (223 ± 13 min) than in the third tertile (143 ± 23 min, p = .0003). Median number of total clips placed per case was 3; in 15 patients (68%), the anterior and septal leaflets of the TV were clipped. The average changes in mean right atrial (RA) and left atrial (LA) pressures were -1.7 ± 2.5 mmHg (p = .0080) and -3.2 ± 4.6 mmHg (p = .0045), respectively. The average changes in RA and LA V-wave heights were -3.3 ± 4.0 mmHg (p = .0009) and -8.1 ± 9.9 mmHg (p = .038), respectively. There was a significant trend toward decreasing residual TR over the course of the series (p = .046). At 30 days, survival was 100% and mean NYHA class decreased from 2.8 to 1.8 (p < .0001). CONCLUSIONS: Combined edge-to-edge tricuspid and mitral valve repair is safe and feasible. With experience, procedure duration and residual TR decreased.

Recurrent pulmonary vein stenosis after successful intervention: Prognosis and management of restenosis.

OBJECTIVES: The aim of this study was to describe management of recurrent pulmonary vein stenosis (PVS) and determine if stenting is superior to balloon angioplasty (BA) in preventing subsequent restenosis. BACKGROUND: PVS is a serious complication of atrial fibrillation ablation. BA and stenting are effective therapies; however, restenosis frequently occurs. Here we report management of recurrent stenosis. METHODS: This was a prospective observational study performed from 2000 to 2014. RESULTS: One hundred and thirteen patients with severe PVS underwent intervention in 88 veins treated with BA and 81 treated with stenting. Forty-two patients experienced restenosis. Restenosis was more common in veins treated with BA (RRR 53% [95% CI 32-70%, p = .008]). A second intervention was performed in 41 patients. In the 34 vessels treated with initial BA, 24 were treated for restenosis with a stent and 10 were treated with a second BA. The recurrence rate was 46% in those treated with BA followed by stenting and 50% in those treated with two BA procedures. In the 22 veins treated with initial stenting, 9 were treated with another stent and 13 were treated with BA. The recurrence rate was 44% in those treated with a second stent and 46% for those treated with a stent followed by BA. The risk of a third stenosis was the same among all groups (Analysis of variance [ANOVA] p = .99). Limited sample size precluded analysis of outcome by stent size. CONCLUSIONS: Restenosis occurred in 44% of patients overall. Management is challenging; stenting does not appear to be superior to BA.

Case Series: Spontaneous Relapse After Recovery From Peripartum Cardiomyopathy.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a distinct type of heart failure with reduced ejection fraction (EF) with variable outcomes. Rates of recovery range from 29% to 72% and mortality rates range from 0% to 25%. In studies, outcomes are often determined at 6 to 12 months following diagnosis, and many of those who recover stop following with cardiology and are lost to follow-up. CASE REPORT: Patient 1 was a 25-year-old G2P1 who was diagnosed with PPCM 5 days after childbirth with an EF of 25%. Initially, her EF improved and first normalized at 4.1 years after diagnosis. It subsequently dropped to 30% without clear heart failure symptoms or identifiable trigger and 1 year later normalized again to an EF of 60%. Patient 2 was a 36-year-old G6P3 who was diagnosed with PPCM 6 weeks after the birth of her third child when echocardiogram revealed an EF of 10%. Time to EF normalization was 3.0 years after diagnosis when her EF was measured at 55%. She remained without symptoms of heart failure for the first 8 years after diagnosis when she developed dyspnea on exertion and lower extremity edema; EF at that time declined to a nadir of 42.5% without apparent cause. CONCLUSIONS: Women with PPCM can have an unpredictable course, and those who appear to have recovered may have unrecognized subclinical dysfunction that places them at risk for future injury or deterioration.

Characterizing the Burden of Hepatitis C Infection Among Entrants to Pennsylvania State Prisons, 2004 to 2012.

Although hepatitis C (HCV) infection is common among prisoners, relatively few undergo evaluation for treatment. This study reports the prevalence of chronic infection and the genotype distribution among an incarcerated population. HCV antibody testing was provided to adults entering Pennsylvania prisons; confirmatory and genotype testing were offered to those eligible for treatment. Antibody prevalence among 101,727 individuals was 18.1%. Among 7,633 individuals who underwent confirmatory testing, 69.3% had detectable RNA. Among 3,247 individuals who underwent genotype testing, genotype 1 was the most common (76.6%). The rate of chronic infection after HCV exposure is similar to that reported in the community, as is genotype distribution. Correctional facilities provide access to a population with a high disease burden, creating a public health opportunity for evaluation and treatment.

Long-term survival after pneumonectomy for primary pulmonary malignant melanoma.

As few as 30 cases of primary malignant melanoma of the lung have been reported in the literature. Many patients die within months of diagnosis; few published cases describe patients who survive long-term after treatment. We report a case of primary pulmonary malignant melanoma in a patient who remains disease-free 60 months after pneumonectomy.

Epidemiology of hepatitis C virus in Pennsylvania state prisons, 2004-2012: limitations of 1945-1965 birth cohort screening in correctional settings.

OBJECTIVES: We described hepatitis C virus antibody (anti-HCV) prevalence in a state prison system and retrospectively evaluated the case-finding performance of targeted testing of the 1945 to 1965 birth cohort in this population. METHODS: We used observational data from universal testing of Pennsylvania state prison entrants (June 2004-December 2012) to determine anti-HCV prevalence by birth cohort. We compared anti-HCV prevalence and the burden of anti-HCV in the 1945 to 1965 birth cohort with that in all other birth years. RESULTS: Anti-HCV prevalence among 101,727 adults entering prison was 18.1%. Prevalence was highest among those born from 1945 to 1965, but most anti-HCV cases were in people born after 1965. Targeted testing of the 1945 to 1965 birth cohort would have identified a decreasing proportion of cases with time. CONCLUSIONS: HCV is endemic in correctional populations. Targeted testing of the 1945 to 1965 birth cohort would produce a high yield of positive test results but would identify only a minority of cases. We recommend universal anti-HCV screening in correctional settings to allow for maximum case identification, secondary prevention, and treatment of affected prisoners.