Iatrogenic Aorto-Coronary Dissection: A Rare Complication With Fatal Prognosis.

Iatrogenic aorto-coronary dissection (IACD) is a rare complication of interventional and surgical cardiac procedures, with a very high mortality burden. Here, we report the case of a 71-year-old female with a past medical history of paroxysmal atrial fibrillation, mild to moderate aortic insufficiency, hypertension, and hyperlipidemia, who presented with classic anginal symptoms and underwent a cardiac catheterization, during which she suffered Iatrogenic right coronary artery (RCA) dissection and ascending aortic dissection resulting in sudden death. IACD is a rare complication, with a fatal prognosis. Coronary angiography and percutaneous coronary intervention (PCI) are considered safe, with a low risk of major complications including coronary perforations, and a very low risk of Iatrogenic aortic dissection (IAD). The coronary injury occurs more commonly during PCI of chronic total occlusion (CTO) or RCA interventions and can extend to the aortic root. IAD is often fatal and has worse outcomes than spontaneous dissection.

Successful Transcatheter Aortic Valve Replacement in an Elderly Patient with Calcified Bicuspid Aortic Valve with Calcified Raphe: A Case Report.

At present, transcatheter aortic valve replacement (TAVR) is not only used in high-surgical-risk patients with aortic stenosis (AS), but its use has also been extended to low-risk patients, resulting in its increasing utilization in patients with bicuspid aortic valve (BAV). BAV however presents unique challenges for TAVR due to its distinct valvular anatomy, and surgical aortic valve replacement (SAVR) remains the primary recommended method of aortic valve replacement in patients with BAV. Nonetheless, observational data have been quickly accumulating regarding the successful use of TAVR in BAV. Here, we present a case of a 73-year-old female who presented with heart failure symptoms and was found to have severe AS and BAV with calcified raphe (Sievers 1a). Due to her age and complicated medical history, including coronary artery disease and chronic kidney disease, she was considered to be at intermediate surgical risk (Society of Thoracic Surgeons (STS) score 5.4%) and underwent TAVR with the successful deployment of a 29 mm Edwards SAPIEN valve (Edwards Lifesciences, California, USA). A post-procedure echocardiogram confirmed the appropriate placement of the prosthesis without any valvular or paravalvular regurgitation. This case, therefore, adds to the growing body of evidence regarding the use of TAVR in patients with BAV despite anatomical challenges.

Comparison of Hospitalization Trends and Outcomes in Acute Myocardial Infarction Patients With Versus Without Opioid Use Disorder.

Discrepancies in medical care are well known to adversely affect patients with opioid abuse disorders (OUD), including management and outcomes of acute myocardial infarction (AMI) in patients with OUD. We used the National Inpatient Sample was queried from January 2006 to September 2015 to identify all patients ≥18 years admitted with a primary diagnosis of AMI (weighted N = 13,030; unweighted N = 2,670) and concomitant OUD. Patients using other nonopiate illicit drugs were excluded. Propensity matching (1:1) yielded 2,253 well-matched pairs in which intergroup comparison of invasive revascularization strategies and cardiac outcomes were performed. The prevalence of OUD patients with AMI over the last decade has doubled, from 163 (2006) to 326 cases (2015) per 100,000 admissions for AMI. The OUD group underwent less cardiac catheterization (63.2% vs 72.2%; p <0.001), percutaneous coronary intervention (37.0% vs 48.5%; p <0.001) and drug-eluting stent placement (32.3% vs 19.5%; p <0.001) compared with non-OUD. No differences in in-hospital mortality/cardiogenic shock were noted. Among subgroup of ST-elevation myocardial infarction patients (26.2% of overall cohort), the OUD patients were less likely to receive percutaneous coronary intervention (67.9% vs 75.5%; p = 0.002), drug-eluting stent (31.4% vs 47.9%; p <0.001) with a significantly higher mortality (7.4% vs 4.3%), and cardiogenic shock (11.7% vs 7.9%). No differences in the frequency of coronary bypass grafting were noted in AMI or its subgroups. In conclusion, OUD patients presenting with AMI receive less invasive treatment compared with those without OUD. OUD patients presenting with ST-elevation myocardial infarction have worse in-hospital outcomes with increased mortality and cardiogenic shock.

Evolution of Diagnostic and Treatment Patterns of Cardiac Sarcoidosis.

Cardiac sarcoidosis (CS) may impart substantial morbidity and mortality, and novel imaging modalities are now available to aid in early diagnosis of this clinically silent disease. A better understanding of the clinical experience with CS is important. Twenty-eight patients were diagnosed with the aid of multimodality imaging techniques and were treated by a multidisciplinary team. Demographics, symptomatology, imaging, and therapeutic interventions were compiled from our referral center. In patients with CS, nuclear and MR techniques were often the first studies performed. Echocardiographic findings differed widely. Immunosuppressive therapy and cardiac devices were frequently used. Importantly, isolated CS was not an infrequent finding.

External Intensivists Versus In-House Intensivists: Analysis of Outcomes of Nighttime Coverage of ICUs by External On-Call and In-House On-Call Intensivists.

A 24/7 intensivist model may improve important outcomes such as mortality, length of stay, and number of ventilator days. In this retrospective, single-center study at Saint Luke's Hospital in Kansas City, Missouri, we examined patient outcomes before and after adopting a 24/7 model from 2014 to 2016. The addition of a nighttime intensivist did not lead to a statistically significant improvement in mortality (hospital and ICU) and LOS (hospital and ICU).

Trends of Incidence, Clinical Presentation, and In-Hospital Mortality Among Women With Acute Myocardial Infarction With or Without Spontaneous Coronary Artery Dissection: A Population-Based Analysis.

OBJECTIVES: The authors sought to determine the clinical characteristics and in-hospital survival of women presenting with acute myocardial infarction (AMI) and spontaneous coronary artery dissection (SCAD). BACKGROUND: The clinical presentation and in-hospital survival of women with AMI and SCAD remains unclear. METHODS: The National Inpatient Sample (2009 to 2014) was queried for all women with a primary diagnosis of AMI and concomitant SCAD. Iatrogenic coronary dissection was excluded. The main outcome was in-hospital mortality. Propensity score matching and multivariable logistic regression analyses were performed. RESULTS: Among 752,352 eligible women with AMI, 7,347 had a SCAD diagnosis. Women with SCAD were younger (61.7 vs. 67.1 years of age) with less comorbidity. SCAD was associated with higher incidence of in-hospital mortality (6.8% vs. 3.4%). In SCAD patients, a decrease in in-hospital mortality was evident with time (11.4% in 2009 vs. 5.0% in 2014) and concurred with less percutaneous coronary intervention (PCI) (82.5% vs. 69.1%). Propensity score yielded 7,332 SCAD and 14,352 patients without SCAD. The odds ratio (OR) of in-hospital mortality remained higher with SCAD after propensity matching (OR: 1.87, 95% confidence interval [CI]: 1.65 to 2.11) and on multivariable regression analyses (OR: 2.41, 95% CI: 2.07 to 2.80). PCI was associated with higher mortality in SCAD patients presenting with non-ST-segment elevation myocardial infarction (OR: 2.01; 95% CI: 1.00 to 4.47), but not with STEMI (OR: 0.62; 95% CI: 0.41 to 0.96). CONCLUSIONS: Women presenting with AMI and SCAD appear to be at higher risk of in-hospital mortality. Lower rates of PCI were associated with improved survival, with evidence of worse outcomes when PCI was performed for SCAD in the setting of non with ST-segment elevation myocardial infarction.

Comparison of the Frequency of Acute Kidney Injury in Patients With Renal Transplant Who Underwent Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery.

Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) are established modalities of coronary revascularization. Choosing between the two requires taking into consideration not only disease severity, patient characteristics, and expected outcomes but also adverse effects. One such adverse effect is acute kidney injury (AKI), especially when considering coronary revascularization in patients with renal transplant (RT). We searched the National Inpatient Sample from 2008 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for patients with RT (V42.0) who underwent PCI (00.66, 36.06, and 36.07) and CABG (36.1×, 36.2, and 36.3×). We further identified patients with AKI (584.5, 584.6, 584.7, 584.8, and 584.9) and those on dialysis (39.95). The propensity score model/method was used to form matched cohorts for PCI and CABG. We compared the incidence of AKI and AKI requiring dialysis in CABG and PCI groups. We identified 1,871 patients who underwent PCI and 1,878 patients who underwent CABG after propensity score matching. We found the incidence of both AKI (22% vs 38%, odds ratio 2.20, 95% confidence interval 1.91 to 2.54, p <0.0001) and AKI requiring dialysis (1% vs 3%, odds ratio 2.50, 95% confidence interval 1.49 to 4.19, p = 0.001) to be significantly higher in the CABG compared with the PCI cohort. In conclusion, the results of the study reflect the importance of accounting for the RT status before choosing between PCI and CABG for coronary revascularization.