Artificial Intelligence Assessment of Biological Age From Transthoracic Echocardiography: Discrepancies with Chronologic Age Predict Significant Excess Mortality.

BACKGROUND: Age and sex can be estimated using artificial intelligence on the basis of various sources. The aims of this study were to test whether convolutional neural networks could be trained to estimate age and predict sex using standard transthoracic echocardiography and to evaluate the prognostic implications. METHODS: The algorithm was trained on 76,342 patients, validated in 22,825 patients, and tested in 20,960 patients. It was then externally validated using data from a different hospital (n = 556). Finally, a prospective cohort of handheld point-of-care ultrasound devices (n = 319; ClinicalTrials.gov identifier NCT05455541) was used to confirm the findings. A multivariate Cox regression model was used to investigate the association between age estimation and chronologic age with overall survival. RESULTS: The mean absolute error in age estimation was 4.9 years, with a Pearson correlation coefficient of 0.922. The probabilistic value of sex had an overall accuracy of 96.1% and an area under the curve of 0.993. External validation and prospective study cohorts yielded consistent results. Finally, survival analysis demonstrated that age prediction ≥5 years vs chronologic age was associated with an independent 34% increased risk for death during follow-up (P < .001). CONCLUSIONS: Applying artificial intelligence to standard transthoracic echocardiography allows the prediction of sex and the estimation of age. Machine-based estimation is an independent predictor of overall survival and, with further evaluation, can be used for risk stratification and estimation of biological age.

Spontaneous Coronary Artery Dissection: Case Series and Literature Review.

Spontaneous coronary artery dissection (SCAD) is an important and rare cause of myocardial infarction (MI), particularly among young women without traditional atherosclerotic risk factors. Late pregnancy and postpartum period are associated with more risk for developing SCAD. No enough data exist regarding the ideal management of SCAD due to lack of randomized trials comparing medical therapy and revascularization strategies. We present three cases of SCAD, two of them were postpartum women while one involved an obese young woman with no identifiable risk factors. We describe the pathophysiology, types of SCAD, risk factors, clinical presentation, and management approach. This case series highlights the need to raise awareness of SCAD and to facilitate accurate diagnosis promptly.

Post-PCI outcomes in STEMI patients with coronary ectasia: meta-analysis.

BACKGROUND: Coronary ectasia (CE) is defined as dilation of the coronary artery, 1.5 times that of the surrounding vessel. Outcomes of percutaneous intervention (PCI) in patients with CE presenting as ST-elevated myocardial infarction (STEMI) remain a topic of debate. METHODS: Studies comparing outcomes of PCI in CE versus no-ectasia (NE) STEMI patients were identified. Baseline angiographic characteristics include thrombolysis in myocardial infarction (TIMI) 0-1 flow, right coronary artery (RCA) involvement, and primary outcomes including thrombus aspiration, no-reflow, mortality, and TIMI-3 post-PCI. Odds ratio (OR) and 95% confidence interval (CI) were calculated. RESULTS: Six studies (n = 5746, CE-340 and NE-5406) qualified for the analysis. RCA involvement was more common in CE than NE, OR-1.39 (95%CI1.06-1.82, p-0.02). Pre-procedure TIMI-0-1 was of comparable results between the groups (p-1.13). Higher thrombus aspiration for CE (OR 2.18, 95%CI1.44-3.32;p-<0.001). CE had higher incidence of no-reflow (OR 4.07, 95%CI2.42-6.84;p-<0.001). TIMI-3 flow post-PCI was achieved less commonly in the CE group (OR-0.64, 95%CI-0.48-0.86;p-<0.001). Mortality on follow-up was comparable (0.83, 95%CI0.39-1.78;p-0.63). Metaregression analysis did not show confounding effects from comorbidities. CONCLUSION: Coronary ectasia patients with STEMI had higher rates of PCI failure and no-reflow than NE; however, mortality during follow-up was comparable.

Deploying Mechanical Circulatory Support Via the Axillary Artery in Cardiogenic Shock and High-Risk Percutaneous Coronary Intervention.

We sought to study the feasibility of axillary artery as alternative access for mechanical circulatory support (MCS) in cardiogenic shock and high-risk percutaneous coronary intervention (HR-PCI) patients with severe occlusive peripheral artery disease (PAD). In patients with severe PAD, the iliofemoral artery may be so diseased preventing deployment of MCS, precluding the use of lifesaving therapy. In such circumstances, the axillary artery may be a viable access site. Records of all patients presenting with cardiogenic shock or HR-PCI requiring MCS through axillary artery access at our institution from January 2016 to September 2018 were examined. Demographics, clinical, procedural, and outcomes data were collected on all patients. A total of 48 patients presented with cardiogenic shock (60%) or HR-PCI (40%) requiring MCS via axillary artery due to prohibitive PAD (mean age 66 ± 11 years). Admission diagnoses were non-ST segment elevation myocardial infarction (38%), unstable angina (23%), ST segment elevation myocardial infarction (19%), and cardiac arrest (21%). Time from axillary access to activation of Impella was 11.9 ± 4 minutes. Four patients required concomitant Impella RP for right ventricular support due to biventricular cardiogenic shock. Twenty-two patients died before Impella was explanted due to multiorgan failure, stroke, and infection. None of the patients who died had vascular complications related to axillary access. Axillary artery appears to be a viable alternative access for large bore devices in patients with prohibitive PAD. As experience of the field with this approach grows, it may be the default access for deployment of large bore sheaths in the future.

MitraClip to Treat Severe Ischemic Mitral Regurgitation During Impella CP Support in a 70-Year-Old Woman.

Acute mitral regurgitation is a life-threatening complication of acute myocardial infarction. We present the case of a 70-year-old woman who had acute myocardial infarction complicated by severe mitral regurgitation and cardiogenic shock. Although current guidelines recommend mitral valve surgery for such patients, surgery often carries prohibitive risk of morbidity and mortality. Thus, in certain patients, percutaneous repair may be the only viable treatment option. In this case, we used a 3-step percutaneous approach involving coronary artery revascularization with a drug-eluting stent in the left circumflex coronary artery, mechanical circulatory support with an Impella CP pump for cardiogenic shock, and mitral valve repair with the MitraClip system for severe mitral regurgitation. After successful intervention, our patient regained hemodynamic stability and showed clinical improvement at one-month follow-up.

Sex-related difference in the use of percutaneous left ventricular assist device in patients undergoing complex high-risk percutaneous coronary intervention: Insight from the cVAD registry.

OBJECTIVE: To assess the in-hospital and short-term outcome differences between males and females who underwent high-risk PCI with mechanical circulatory support (MCS). BACKGROUND: Sex differences have been noted in several percutaneous coronary intervention (PCI) series with females less likely to be referred for PCI due increased risk of adverse events. However, data on sex differences in utilization and outcomes of high-risk PCI with MCS is scarce. METHODS: Using the cVAD Registry, we identified 1,053 high-risk patients who underwent PCI with MCS using Impella 2.5 or Impella CP. Patients with cardiogenic shock were excluded. A total of 792 (75.21%) males and 261 (24.79%) females were included in the analysis with median follow-up of 81.5 days. RESULTS: Females were more likely to be African American, older (72.05 ± 11.66 vs. 68.87 ± 11.17, p < .001), have a higher prevalence of diabetes (59.30 vs. 49.04%, p = .005), renal insufficiency (35.41 vs. 27.39%, p = .018), and peripheral vascular disease (31.89 vs. 25.39%, p of .05). Women had a higher mean STS score (8.21 ± 8.21 vs. 5.04 ± 5.97, p < .001) and lower cardiac output on presentation (3.64 ± 1.30 vs. 4.63 ± 1.49, p < .001). Although women had more comorbidities, there was no difference in in-hospital mortality, stroke, MI or need for recurrent revascularization compared to males. Females were more likely to have multivessel revascularization than males. Ejection fraction improved in both males and females at the time of discharge (26.59 to 31.40% and 30.75 to 36.05%, respectively, p < .0001). However, females had higher rate of bleeding requiring transfusion compared with males (9.58 vs. 5.30%, p = .019). CONCLUSION: Female patients undergoing high PCI were older and had more comorbidities but had similar outcomes compared to males.

Treatment of a Child With Submassive Pulmonary Embolism Associated With Hereditary Spherocytosis Using Ultrasound-Assisted Catheter-Directed Thrombolysis.

Background: The clinical presentation of hereditary spherocytosis varies from no symptoms to severe hemolytic anemia requiring splenectomy. Splenectomy imposes the risk of hypercoagulability and acute pulmonary embolism. Catheter-directed thrombolysis is an established treatment for submassive pulmonary embolism in adults. However, the literature regarding its use in children is limited. Case Report: We present the case of a 12-year-old male with hereditary spherocytosis who was diagnosed with pulmonary embolism and successfully treated with catheter-directed thrombolysis. The patient was initially treated with 10.5 mg of recombinant tissue plasminogen activator (r-tPA) delivered over 8 hours. However, because of minimal clinical and hemodynamic improvement, a second course of thrombolytic was administered for an additional 24 hours (25 mg of r-tPA), and the treatment resulted in marked clinical and hemodynamic improvement. Clot resolution was confirmed via angiography. The patient was discharged on enoxaparin and with regular follow-up. One year later, the patient was asymptomatic on enoxaparin. Conclusion: This case demonstrates that catheter-based treatment of submassive pulmonary embolism restores hemodynamic stability and thus is an alternative to surgery or systemic thrombolysis, even in the pediatric setting. While catheter-directed thrombolysis is a safe and effective alternative to systemic thrombolysis, further research is needed to establish appropriate dosing and indications in the adolescent population.

Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative.

BACKGROUND: The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). METHODS: Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the "SHOCK" trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS. RESULTS: A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12-24 hr reliably predicted overall mortality postindex procedure. CONCLUSION: In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.

Axillary Artery Access for Mechanical Circulatory Support Devices in Patients With Prohibitive Peripheral Arterial Disease Presenting With Cardiogenic Shock.

In patients with severe peripheral vascular disease, the common femoral artery may be so diseased as to not allow for deployment of mechanical circulatory support (MCS) such as in the setting of cardiogenic shock (CS). We sought to study the feasibility of axillary artery as alternative access for MCS in CS patients with severe occlusive peripheral artery disease (PAD). Records of all patients who presented with CS requiring MCS through axillary artery access from January 2016 to October 2017 were examined. Demographics, clinical, procedural, and outcomes data were collected on all patients. A total of 17 patients (mean age 68 ± 14years, 95% men) were identified. This was due to severe PAD in the iliac and/or common femoral arteries prohibiting large bore sheath access in allcases. Of the 17 patients, 9 required percutaneous coronary intervention. Time from axillary access to activation of Impella was 14.8 ± 4 minutes. Three patients required concomitant Impella RP for right ventricular support due to biventricular CS. Twelve patients died before Impella was explanted due to multiorgan failure, stroke, and infection. None of the patients who died had vascular complications related to axillary access. All 5 patients who survived to Impella explant were discharged from the hospital without major complication. Axillary artery is a safe and feasible alternative access for large bore devices in patients with prohibitive PAD. The meticulous technique described assures a very low rate of access related complications.

Large bore occlusive sheath management.

The field of interventional cardiology has evolved in its ability to carry out complex procedures. Procedures such as transcatheter aortic valve replacement (TAVR), endovascular aneurysm repair (EVAR), and mechanical circulatory support (MCS) devices require large bore access for successful deployment. With the use of large bore-access, comes with it an increased risk for vascular complications, such as thrombosis and limb ischemia. It is paramount for the interventional cardiologist to know how to manage such complications. In this manuscript, we describe our strategies for the management of occlusive sheaths increasingly encountered with large bore accesses in the upper and lower extremities. Strategies such as peeling away of the introducer sheath and the creation of internal and external bypass circuits are described. By using the described techniques, one can provide prolonged hemodynamic support and maintain large bore sheath access, without jeopardizing perfusion to the extremity.

Access and closure management of large bore femoral arterial access.

Femoral and radial artery access continue to be the standard of care for percutaneous coronary interventions. Cardiac catheterization has progressed to encompass a wide range of diagnostic and interventional procedures including coronary, peripheral, endovascular, and structural heart disease interventions. Despite advanced technology to make these procedures safe, bleeding, and vascular complications continue to be a substantial source of morbidity, especially in patients undergoing large-bore access procedures. New variations of percutaneous devices have reduced complications associated with these procedures. However, safe vascular access with effective hemostasis requires special techniques which have not been well described in the literature. Large-bore femoral artery access is feasible, safe, and associated with low complication rates when a protocol is implemented. Wayne State University, Detroit Medical Center Heart Hospital is a tertiary care, high-volume center for endovascular, structural heart and complex high risk indicated procedures with more 150 procedures involving mechanical circulatory support (MCS) devices per year. In this manuscript, we describe our approach to femoral artery large-bore sheath insertion and management. Our protocol includes proper identification of the puncture site, device selection, insertion, assessment of limb perfusion while on prolong MCS support, and hemostasis techniques after sheath removal.

Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism.

BACKGROUND: Right ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown. METHODS: We included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP. RESULTS: Total of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m2, (0.88-2.15 L/min/m2 ), to 2.5 L/min/m2 (range 1.88-3.4), after 24 h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79-105), and mean systolic blood pressure increased to 140 mmHg (115-179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3 g/dL but did not require blood transfusion. All patients survived to discharge. CONCLUSION: In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge.

Pre-close technique of percutaneous closure for delayed hemostasis of large-bore femoral sheaths.

Advancement of coronary interventions and portable hemodynamic device requires placement of large bore sheaths. Access for large caliber sheaths, its placement, maintenance, and hemostasis is very challenging and one of the key ailments for successful procedures. Traditional hemostasis method is manual compression, which is unattractive due to its own limitations and subsequent complications. Single closure device for sheath size larger than 8 French (Fr) is not available. We performed retrospective analysis of large cohort of patients with 13, 14 Fr sheaths (Impella device [ABIOMED]) percutaneous closure with the use of two Perclose devices. Two perclose devices were placed in a "Preclose" fashion and hemostasis was obtained few days later once hemodynamic support was weaned off by deployment of perclose sutures.

Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: The Detroit cardiogenic shock initiative.

OBJECTIVE: The 'Detroit Cardiogenic Shock Initiative' is a single-arm, multicenter study to assess the feasibility of early mechanical circulatory support (MCS) in patients who present with acute myocardial infarction complicated by cardiogenic shock (AMICS) who undergo percutaneous coronary intervention. METHODS: Between July 2016 and February 2017, 4 metro Detroit sites participated in the study. The centers agreed to treat patients with AMICS using a mutually agreed-upon protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those from the 'SHOCK' trial with an additional exclusion criteria being use of intra-aortic balloon pump counter pulsation prior to MCS. RESULTS: A total of 41 consecutive patients were included. Patients had an average age of 65 ± 14 years, 71% were male and 59% of patients were admitted to the hospital in cardiogenic shock. Prior to receiving MCS, 93% of patients were on vasopressors or inotropes, 15% of patients had a witnessed out of hospital cardiac arrest, 27% of patients had an in-hospital cardiac arrest, and 17% were under active cardiopulmonary resuscitation while MCS was being implanted. In accordance to the protocol recommendation, 66% of patients had a MCS device inserted prior to PCI. Right heart catheterization and hemodynamic monitoring was performed in 83% of patients. Door to support times averaged 83 ± 58 minutes and 71% of patients were able to reduce the levels of inotropes and vasopressors within the first 24-hours of their index procedure. Pre-procedure cardiac power output (CPO) was 0.57 W and post-procedure CPO was 0.95 W, a 67% increase (p < 0.001). Survival to explant for the entire cohort was 85% a significant improvement from institutional historical controls (85% vs 51% p < 0.001) and survival to discharge was 76%. CONCLUSION: Centers who adopted a regional shock protocol emphasizing the delivery of early MCS with invasive hemodynamic monitoring can achieve rapid door to support times and can improve survival in patients who present with AMICS. Larger national studies will be needed to further validate this pilot feasibility study.

Mechanical Circulatory Support for High-Risk Pulmonary Embolism.

Temporary mechanical circulatory support (MCS) devices have a role in treating high-risk patients with pulmonary embolism with cardiogenic shock. Mechanical circulatory device selection should be made based on center experience and device-specific features. All current devices are effective in decreasing right arterial pressure and providing circulatory support of 4 to 5 L/min. The pulmonary artery pulsatility index may prove to be an unreliable method to assess right ventricular function. Careful clinical evaluation on an individual patient basis should determine the need for MCS.

Real-world supported unprotected left main percutaneous coronary intervention with impella device; data from the USpella registry.

BACKGROUND: Patients with left main (LM) coronary artery disease are increasingly being treated with percutaneous revascularization (PCI). The safety, feasibility, and efficacy of unprotected LM intervention (ULMI) with hemodynamic support by Impella device have not been evaluated previously. OBJECTIVE: Using a large retrospective single center database from the USpella registry, we evaluated the safety, feasibility, and potential benefits of periprocedural left ventricular assist with axial flow Impella 2.5 and Impella CP (Abiomed Inc. Danvers, Mass) during ULMI. METHODS: We analyzed a total of 127 consecutive patients who received hemodynamic support with Impella (2.5 or CP) for ULMI from August 2008 to July 2015. Safety, feasibility and efficacy end points included procedural success rates, in-hospital and 30-day major adverse cardiovascular event (MACE) rates. RESULTS: Among 127 patients who received hemodynamic support for ULMI (mean age 69.98 ± 10.7 years, 71% men, and mean left ventricular ejection fraction 28.74 ± 15.55%, Society of Thoracic Surgeons' mortality/morbidity 4/23%) the in-hospital and 30 days mortality rates were 1.43% (2/140) and 2.1% (3/141), respectively. The average baseline and post PCI (residual) syntax scores were 31.4 and 7.86, respectively, (P < 0.001). Only one patient (0.8%) had vascular complication that required surgery; 2.36% (3/127) had hematoma and 3.9% (5/127) had bleeding that required transfusion. CONCLUSION: This large singe center retrospective evaluation of USpella registry substantiates and strongly supports the feasibility, safety, and hemodynamic usefulness of Impella device for ULMI with acceptable in-hospital and 30-day MACE rates. © 2017 Wiley Periodicals, Inc.