Medical and Revascularization Management of Stable Ischemic Heart Disease: An Overview.

Stable ischemic heart disease (SIHD) affects approximately 10 million Americans with 500,000 new cases diagnosed each year. Patients with SIHD are primarily managed in the outpatient setting with aggressive cardiovascular risk factor modification via medical therapy and lifestyle changes. Currently, this approach is considered as the mainstay of treatment. The recently published ISCHEMIA trial has established the noninferiority of medical therapy in comparison to coronary revascularization in patients with moderate to severe ischemia. Percutaneous coronary intervention is currently recommended for patients with significant left main disease, large ischemic myocardial burden, and patients with severe refractory angina despite maximal medical therapy.

Long-term outcomes of sinus node modification in patients with severely symptomatic drug-refractory inappropriate sinus tachycardia: a single-center experience.

BACKGROUND: The purpose of the study was to evaluate the long-term outcomes of sinus node modification (SNM) in treating patients with severely symptomatic drug-refractory inappropriate sinus tachycardia (IST). METHODS: The study included 39 patients with symptomatic drug-refractory IST who have undergone SNM at Saint Louis University Hospital. Data was reviewed retrospectively. Recurrence of symptoms was assessed at 3-6-month follow-up intervals. RESULTS: The mean age of our cohort was 31.5 ± 11. The mean HR at diagnosis was 135 ± 25.4 beats per minute (BPM). Thirty-seven of 39 (94.8%) patients had complete resolution of symptoms. Of these 37 patients, 16 required 1 SNM, 17 patients required 2 SNM, and 4 patients required 3 SNM in order to achieve complete symptom resolution. Mean HR post-procedure was 78.6 ± 12.3 BPM. Thirteen of 39 patients required rate control medication post-procedure, all of whom were prescribed beta-blockers. Patients were followed every 3 to 6 months with a mean follow-up duration of 62.3 ± 42.9 months from the patient's last SNM procedure. Thirteen of those 37 patients (35.1%) developed intermittent symptomatic bradycardia requiring permanent pacemaker implantation. Two of the 39 patients had phrenic nerve injury, and 6 patients had post-procedure pericarditis. CONCLUSIONS: This study provides additional information to the limited dataset available in the literature and shows that SNM might provide patients with long-term symptomatic relief bearing in mind the potential increased risk for the need for permanent pacing.

Patent foramen ovale prevalence in atrial fibrillation patients and its clinical significance; A single center experience.

BACKGROUND: Patent foramen ovale (PFO) has been reported in 25-30% of the general population. The most commonly used test for detecting PFO is a contrast enhanced transesophageal echocardiography (TEE). PFO presence can be confirmed during pulmonary vein isolation (PVI) procedure by passing the transseptal catheter assembly through the foramen ovale, crossing the septum from the right to the left atrium without using a trans-septal needle for puncture. METHODS: We retrospectively reviewed data from a cohort of 178 patients with AF who underwent PVI at Saint Louis University. Pre-PVI procedure, scheduled TEE reports were reviewed to assess for the presence of PFO and the PVI procedure reports were reviewed for confirmation. RESULTS: Records of 178 patients (55.6% male, mean population age 60.4 ±â€¯11.8) were reviewed. 102 of 178 patients had a PFO detected during the PVI procedure. This translates into a 57.3% prevalence of PFO in AF patients. Out of the 178 patients, 75 patients had a pre-PVI procedure TEE for whom PFO presence was reported in 18.7%. The sensitivity and specificity of TEE in detection of PFO were 36.8% and 100%, respectively. There was no statistically significant association between stroke and PFO diagnosed during PVI (RR 1.07; 95% CI, 0.53-2.19; P = 0.805). CONCLUSIONS: Our study reports a PFO prevalence of 18.7% using a pre-procedure TEE and 56.6% during the PVI procedure in AF patients. Given that TEE is the gold standard for detection of PFO, our study suggests that the prevalence of PFO may be underestimated in our AF population.

Acute Decompensated Heart Failure Secondary to Exogenous Triiodothyronine Use in a Young Non-athlete Weightlifter.

Heart failure (HF) is a common cardiovascular disorder and is associated with increased morbidity and mortality. HF is usually detected in the elderly population, in particular, in patients with coronary artery disease, valvular disease, myocarditis, and hypertension. Acute decompensated HF in previously healthy young patients should raise suspicion for other rare etiologies. We report a case of a 28-year-old male presenting with acutely decompensated HF secondary to performance-enhancing drugs (PED). The use of non-regulated, non-approved PED has become a world-wide health problem with patients often unaware of the potentially serious and fatal side effects.

The role of precise imaging with intravascular ultrasound in coronary and peripheral interventions.

Angiography remains a widely utilized imaging modality during vascular procedures. Angiography, however, has its limitations by underestimating the true vessel size, plaque morphology, presence of calcium and thrombus, plaque vulnerability, true lesion length, stent expansion and apposition, residual narrowing post intervention and the presence or absence of dissections. Intravascular ultrasound (IVUS) has emerged as an important adjunctive modality to angiography. IVUS offers precise imaging of the vessel size, plaque morphology and the presence of dissections and guides interventional procedures including stent sizing, assessing residual narrowing and stent apposition and expansion. IVUS-guided treatment has shown to yield superior outcomes when compared to angiography-only guided therapy. The cost-effectiveness of the routine use of IVUS during vascular procedures needs to be further studied.

Post-surgical Euglycemic Diabetic Ketoacidosis in a Patient on Empagliflozin in the Intensive Care Unit.

Euglycemic diabetic ketoacidosis (EDKA) is a rare variant of diabetic ketoacidosis which has been recently reported in association with sodium-glucose cotransporter 2 (SGLT-2) inhibitors. Empagliflozin, an agent belonging to this therapeutic class, was approved by the U.S. Food and Drug Administration (FDA) in 2014 for management of type 2 diabetes. Since then, sparse reports of its association with EDKA are emerging, similarly to its predecessors in the class. We report the case of a 58-year-old female who developed EDKA in the intensive care unit (ICU) 48 hours after her last intake of empagliflozin and a day after neurosurgery. Though expected to improve in the post-operative period, she developed a rapidly worsening and unexplained anion gap metabolic acidosis. She was eventually diagnosed with EDKA which was successfully treated with intravenous insulin infusion, dextrose-containing fluids and discontinuation of the offending drug. Metabolic abnormalities improved in less than 24 hours and patient recovered without complications. This report highlights the importance of recognizing EDKA as a complication of oral anti-diabetics and discontinuing SGLT-2 inhibitors days prior to surgery and ICU admission. Care should be applied to providing patient with low-dose ketogenesis-inhibiting basal insulin and close observation of laboratory values in order to minimize delays in diagnosis, prolonged hospital stays and complications of EDKA.

Predicting Iliac Vein Compression With Computed Tomography Angiography and Venography: Correlation With Intravascular Ultrasound.

BACKGROUND: Intravascular ultrasound (IVUS) is considered the gold standard in diagnosing common iliac vein (CIV) compression. The presence of >50% surface area reduction by IVUS is considered significant compression by most operators. Thus, we evaluated the role of computed tomography angiography (CTA) and venography in diagnosing CIV compression when compared to IVUS. METHODS: All patients who underwent CTA of the pelvis with venous filling phase, IVUS, and venography within a few weeks apart to evaluate for symptomatic CIV compression from one cardiovascular practice were retrospectively reviewed. Quantitative vascular analysis was performed on all images obtained to determine (1) percent stenosis (PS) by venogram; and (2) minimal lumen area (MLA) and PS by CTA and IVUS at the compression site (using ipsilateral distal CIV as reference area). Spearman's rank correlation, paired t-tests, or signed rank tests were performed as appropriate to compare between values of MLA and PS among the three different imaging modalities. RESULTS: A total of 96 patients were included (62.5% females; mean age, 62.3 ± 14.8 years). A significant correlation was found between MLA-CTA and MLA-IVUS (Spearman's rho, 0.27; P=.01) and PS-CTA and PS-IVUS (Spearman's rho, 0.327; P<.01). A significant correlation was also found between PS-venogram and PS-IVUS (Spearman's rho, 0.471; P<.001). MLA-CTA and MLA-IVUS had a median difference of +41 mm² (95% CI, 25.0-57.5; P<.001) whereas PS-CTA and PS-IVUS were not statistically different (median difference, -5.6 mm²; 95% CI, -12.2 to 0.7). Furthermore, PS-IVUS and PS-venogram had a median difference of +15.2% (95% CI, 10.4-20.1; P<.001). CONCLUSION: PS-venogram correlates with PS-IVUS, but venogram underestimates the PS by an average of 15.2%. In contrast, PS-CTA and PS-IVUS are not statistically different despite an over-estimation of MLA by CTA when compared to IVUS. Therefore, we conclude that PS-CTA and not PS-venogram can be used to predict PS on IVUS.

Long-term outcomes with Jetstream atherectomy with or without drug coated balloons in treating femoropopliteal arteries: A single center experience (JET-SCE).

BACKGROUND: The long-term outcome of Jetstream atherectomy (JA) with or without adjunctive drug coated balloons (DCB) in a real-world setting remains unknown. We report 16-month target lesion revascularization (TLR) rates on patients treated for femoropopliteal (FP) artery disease with JA in a single center by one operator. METHODS: From 1/1/12 to 8/24/16 a total of 311 procedures were performed with atherectomy by a single operator at a single center. Of these procedures, 75 met inclusion and exclusion criteria. This report evaluates the outcomes of these 75 patients treated at index and who were followed up to 16 months. The primary endpoint of the study was clinically driven TLR. Patients were stratified by the use of DCB (vs angioplasty (PTA)) post-JA. TLR was calculated by excluding bailout stenting as TLR. Survival analysis for TLR over time was plotted. RESULTS: 75 patients (49.3% male, mean age 68.0 years, 54.7% diabetes) with de novo or restenotic FP lesions whose symptoms were classified as Rutherford category I-V were enrolled. Adjunctive PTA was performed on 50 patients (26 de novo, 13 in-stent restenosis, 3 non-stent restenosis, 8 mixed lesions) and adjunctive DCB (LUTONIX® 24, IN.PACT® 1) on 25 patients (21 de novo, 1 in-stent restenosis, 2 non-stent restenosis, 1 mixed lesion) (p = 0.0249). There was no difference in the median treated length between the adjunctive PTA (15 cm) and DCB (10 cm) groups (p = 0.0530). The estimated freedom from TLR (fTLR) was significantly higher with atherectomy and adjunctive DCB compared to atherectomy with adjunctive PTA at 12 months (94.7% vs 68.0%, p = 0.002) and 16 months (94.4% vs 54%; p = 0.002). CONCLUSIONS: In a single center cohort of JA reflecting real-world practice, JA with DCB had a superior TLR rate up to 16-month follow-up when compared to JA with PTA in treating all comers FP arterial disease.

Complete Resolution of a Large Bicuspid Aortic Valve Thrombus with Anticoagulation in Primary Antiphospholipid Syndrome.

Native aortic valve thrombosis in primary antiphospholipid syndrome (APLS) is a rare entity. We describe a 38-year-old man who presented with neurological symptoms and a cardiac murmur. Transthoracic echocardiography detected a large bicuspid aortic valve thrombus. Laboratory evaluation showed the presence of antiphospholipid antibodies. Anticoagulation was started, and serial echocardiographic studies showed complete resolution of the aortic valve vegetation after 4 months. The patient improved clinically and had no residual symptoms. This report and review of the literature suggests that vegetations in APLS can be treated successfully with conservative treatment, regardless of their size.

Recanalization of Total Occlusion of the Superficial Femoral Artery and Profunda Femoris Using the Transcollateral Approach.

Chronic total occlusions (CTOs) are seen in 30%-40% of symptomatic superficial femoral artery (SFA) disease. Despite advances in revascularization techniques, 10%-20% of these occlusions cannot be crossed. We report 1 case and review the literature on transcollateral retrograde crossing of the SFA from the profunda femoris. The procedural steps and devices (wires and crossing catheters) utilized by various operators are outlined. Based on an overview of current cases in the literature (19 cases, 21 CTOs), success rate was 95.2% with no complications reported. We conclude that transcollateral recanalization of chronically occluded SFA appears to be a viable technique when antegrade access is not feasible.

Predictors of common femoral artery access site complications in patients on oral anticoagulants and undergoing a coronary procedure.

BACKGROUND: It is unclear whether patients on oral anticoagulants (OAC) undergoing a procedure using common femoral artery access have higher adverse events when compared to patients who are not anticoagulated at the time of the procedure. METHODS: We retrospectively reviewed data from consecutive patients who underwent a cardiac procedure at a tertiary medical center. Patients were considered (group A) fully or partially anticoagulated if they had an international normalized ratio (INR) ≥1.6 on the day of the procedure or were on warfarin or new OAC within 48 h and 24 h of the procedure, respectively. The nonanticoagulated group (group B) had an INR <1.6 or had stopped their warfarin and new OAC >48 h and >24 h preprocedure, respectively. The index primary end point of the study was defined as the composite end point of major bleeding, vascular complications, or cardiovascular-related death during index hospitalization. The 30-day primary end point was defined as the occurrence of the index primary end point and up to 30 days postprocedure. RESULTS: A total of 779 patients were included in this study. Of these patients, 27 (3.5%) patients were in group A. The index primary end point was met in 11/779 (1.4%) patients. The 30-day primary composite end point was met in 18/779 (2.3%) patients. There was no difference in the primary end point at index between group A (1/27 [3.7%]) and group B (10/752 [1.3%]; P=0.3155) and no difference in the 30-day primary composite end point between group A (2/27 [7.4%]) and group B (16/752 [2.1%]; P=0.1313). Multivariable analysis showed that a low creatinine clearance (odds ratio [OR] =0.56; P=0.0200) and underweight patients (<60 kg; OR =3.94; P=0.0300) were independent predictors of the 30-day primary composite end point but not oral anticoagulation (P=0.1500). CONCLUSION: Patients on OAC did not have higher 30-day major adverse events than those who were not anticoagulated at index procedure.

Double Inferior Vena Cava and its Implications During Endovascular and Surgical Interventions: A Word of Caution.

Double inferior vena cava (DIVC) is present in 0.2%-3.0% of the general population. Its presence can be detected by computed tomographic angiography or magnetic resonance imaging. Identifying the presence of DIVC is important to define its relationship with the renal vein, its size when IVC filters are planned, the location of the left renal vein in relationship to the aorta, and for planning of IVC filter placement in the setting of deep vein thrombosis and pulmonary embolism. Finally, this entity should not be mistaken for lymphadenopathy and its course should be well understood before abdominal and pelvic/retroperitoneal surgical interventions.