Diagnostic Strategies in Pulmonary Embolism.

Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.

The Pulmonary Embolism Response Team: Rationale, Operation, and Outcomes.

The pulmonary embolism response team (PERT) is an institutionally based multidisciplinary team that is able to rapidly assess and provide treatment for patients with acute pulmonary embolism (PE). Intrinsic to the team's structure is a formal mechanism to execute a full range of medical, endovascular, and surgical therapies. In addition, the PERT provides appropriate multidisciplinary follow-up of patients. In the 10 years since the PERT was first introduced, it has gained acceptance in many centers in the United States and around the world. These PERTs have joined together to form an international association, called the PERT Consortium. The mission of this consortium is to advance the diagnosis, treatment, and outcomes of patients with PE. There is considerable evidence that the PERT model improves delivery and standardization of care of PE patients, particularly those patients with massive and submassive PE. However, it is not yet clear whether PERTs improve clinical outcomes. A large prospective database is currently being compiled by the PERT Consortium. Analysis of this database will likely further delineate the role of PERTs in the management of intermediate-to-high risk PE patients and, importantly, help determine in which PE patients PERT may improve clinical outcomes.

Pathophysiology, Diagnosis, and Management of Hypertension in the Elderly.

There is a high prevalence of systemic arterial hypertension in the elderly; 70% of adults >65 years have this disease. A key mechanism in the development of hypertension in the elderly is increased arterial stiffness. This accounts for the increase in systolic blood pressure and pulse pressure and fall in diastolic blood pressure (isolated systolic hypertension) that are commonly seen in the elderly, compared with younger persons. The diagnosis of hypertension is made on the basis of in-office blood pressure measurements together with ambulatory and home blood pressure recordings. Lifestyle changes are the cornerstone of management of hypertension. Comprehensive guidelines regarding blood pressure threshold at which to start pharmacotherapy as well as target blood pressure levels have been issued by both European and American professional bodies. In recent years, there has been considerable interest in intensive lowering of blood pressure in older patients with hypertension. Several large, randomized controlled trials have suggested that a strategy of aiming for a target systolic blood pressure of <120 mm Hg (intensive treatment) rather than a target of <140 mm Hg (standard treatment) results in significant reduction in the incidence of adverse cardiovascular events and total mortality. A systolic blood pressure treatment of <130 mm Hg should be considered favorably in non-institutionalized, ambulatory, free living older patients. In contrast, in the older patient with a high burden of comorbidities and limited life expectancy, an individualized team-based approach, based on clinical judgment and patient preference should be adopted. An increasing body of evidence for older adults with hypertension suggests that intensive blood pressure lowering may prevent or at least partially prevent cognitive decline.

Therapeutic Options for Left Main, Left Main Equivalent, and Three-Vessel Disease.

Patients with left main, left main equivalent, and three-vessel coronary artery disease (CAD) represent an overlapping spectrum of patients with advanced CAD that is associated with an adverse prognosis. Guideline-directed medical therapy is a necessary but often insufficient treatment option, as such patients frequently need mechanical revascularization by either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). In patients with advanced CAD presenting with acute myocardial infarction, PCI, of course, is the preferred treatment option. For stable patients with advanced CAD, CABG surgery remains the standard of care. However, observations from the SYNergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery (SYNTAX) trial suggest that PCI may be a useful alternative in patients with three-vessel disease with a low SYNTAX score as well as in patients with left main disease and a low or intermediate SYNTAX score. In the subset of patients with diabetes mellitus, the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease trial unequivocally demonstrated the superiority of CABG surgery in improving outcomes. The findings of the recently published Everolimus-Eluting Stent System versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization and Nordic-Baltic-British Left Main Revascularization study trials point to a favorable role for PCI in certain low-to-moderate risk patients with left main stem disease.

Rupture of Papillary Muscle and Chordae Tendinae Complicating STEMI: A Call for Action.

Papillary muscle rupture (PMR) or chordae tendinae rupture (CTR) is a rare but lethal complication after ST elevation myocardial infarction (STEMI). Due to the rarity of this condition, there are limited studies defining its epidemiology and outcomes. This is a retrospective study from Nationwide Inpatient Sample database from 2002 to 2014 of patients with STEMI and PMR/CTR. Outcomes of interest were incidence of in-hospital mortality, cardiogenic shock (CS), utilization of mechanical circulatory support (MCS) devices and mitral valve procedures (MVPs) among patients with and without rupture. We also performed simulation using the cardiovascular model to better understand the hemodynamics of severe mitral regurgitation and effects of different medications and device therapy. We identified 1,888 patients with STEMI complicated with PMR/CTR. Most of the patients were >65 years of age (65.3%), male (63.6%), and white (82.3%). They had significantly higher incidence of CS, cardiac arrest, and utilization of MCS devices. In-hospital mortality was higher in patients with rupture (41% vs. 7.40%, p < 0.001) which remained unchanged over the study period. Hospitalization cost and length of stay was also higher in them. MVP and revascularization led to better survival rates (27.9% vs. 60.6%, adjusted OR: 0.14; 95% CI: 0.10-0.19; p < 0.001). Despite significant advancement in the revascularization strategy, PMR/CTR after STEMI continues to portend poor prognosis with high inpatient mortality. Cardiogenic shock is a common presentation and is associated with significantly inpatient mortality. Future studies are needed determine the best strategies to improve outcomes in patients with STEMI with PMR/CTR and CS.

The efficacy and safety of transradial and transfemoral approach in treatment of coronary chronic total occlusion: a systematic review and meta-analysis.

BACKGROUND: The clinical efficacy and safety of transradial (TR) percutaneous coronary intervention (PCI) in comparison to transfemoral (TF) for chronic total occlusion (CTO) is not well studied in literature. Objectives: We sought to study the outcome and complications associated with TR compared with TF for CTO interventions. METHODS: After a systematic literature search was done in PubMed and EMBASE, we performed a meta-analysis of studies comparing TF and TR for CTO PCI. Results: Twelve studies with 19,309 patients were included. Compared to those who has TF access, individuals who were treated via TR approach had statistically significant lower access complication rates [odds ratio (OR): 0.33; 95% confidence interval (CI): 0.22 to 0.49; p < 0.0001]. The procedural success was in the favor of TR method (OR: 1.4; 95% CI: 1.31-1. 51; p < 0.0001). The incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and contrast-induced nephropathy were similar in both groups. CONCLUSION: When compared with TF access interventions in CTO PCI; the TR approach appears to be associated with far less access-site complications, higher procedural success, and comparable MACCE.

Transcatheter Versus Surgical Aortic Valve Replacement in Renal Transplant Patients: A Meta-Analysis.

BACKGROUND: The outcome of transcutaneous aortic valve replacement (TAVR) in patients with kidney transplant is unknown, as majority of these patients were excluded from the major TAVR clinical trials. We sought to compare patients with severe aortic stenosis who underwent TAVR versus surgical aortic valve replacement (SAVR) with a history of kidney transplant. METHODS: PubMed, Google Scholar and Cochrane databases were searched to identify relevant articles. The incidence of all-cause mortality and acute kidney injury (AKI) was calculated using relative risk on a random effect model. RESULTS: A total of 1,538 patients (TAVR 328, SAVR 1,210) were included in the study. TAVR was associated with lower mortality as compared with SAVR at 30 days from the index procedure (odds ratio (OR) 0.48, 95% confidence interval (CI): 0.25 - 0.93; P = 0.03). One-year mortality was studied in three studies and showed comparable mortality in patients undergoing TAVR and SAVR (OR: 0.76, 95% CI: 0.10 - 5.51; P = 0.78). Compared to SAVR, TAVR carries an identical risk of AKI (OR: 0.44, 95% CI: 0.10 - 1.90; P = 0.27). A sensitivity analysis performed by exclusion of Voudris et al study showed a non-significant difference in the mortality incidence of two groups at 30 days (OR: 0.72, 95% CI: 0.27 - 1.91; P = 0.51). CONCLUSIONS: In patients with a history of kidney transplant, TAVR was associated with a comparable risk of mortality and AKI compared to SAVR.

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.

Successful Treatment of Left Ventricular Perforation Occurring After Insertion of an Impella Device.

The Impella device is a miniaturized ventricular assist device that is being increasingly used to increase the safety and efficacy of high-risk coronary interventions and to treat patients with acute myocardial infarction complicated by cardiogenic shock. The device has a miniaturized rotary pump mounted on a 9F catheter with a pigtail conformation. The pump draws blood from the left ventricular cavity and expels it into the ascending aorta and systemic circulation. We report a patient who, following insertion of an Impella device, developed angiographically documented left ventricular perforation with marked hemodynamic instability. Our successful management of this patient is described and potential mechanisms responsible for the perforation are discussed.

Comparison of In-Hospital Outcomes in Patients Having Limb-Revascularization With Versus Without Atrial Fibrillation.

The impact of atrial fibrillation (AF) on clinical outcomes among patients with peripheral artery disease (PAD) who undergo limb revascularization procedures is not well understood. We aim to compare in-hospital outcomes for patients with and without AF who underwent limb revascularization. We identified patients with PAD aged ≥18 years that underwent limb revascularization using endovascular or surgical approaches in the National Inpatient Sample between 2002 and 2014. Multivariate logistic regression analysis was performed to examine in-hospital outcomes. A total of 2,283,568 patients underwent limb revascularization during the study duration and 294,469 (12.9%) had AF. Patients with AF were older (mean age 76.1 ± 10.0 years), more likely to be women and white, compared with non-AF group. Among patients who had surgical revascularization, AF was associated with a higher rates of in-hospital mortality (6.4% vs 2.5%, adjusted odds ratio [aOR]: 1.09 [95% confidence interval {CI}: 1.05 to 1.12]) and major amputation (5.2% vs 3.8%, aOR: 1.05 [95% CI: 1.02 to 1.08]), compared with non-AF group. Among patients who had endovascular intervention (EVI), AF was associated with a higher rates of in-hospital mortality (3.8% vs 1.6%, aOR: 1.29 [95% CI: 1.24 to 1.33]) and major amputation (5.2% vs 3.9%, aOR: 1.07 [95% CI: 1.04 to 1.10]), compared with non-AF group. Within study period, EVI utilization increased in patients with and without AF (Ptrend <0.001); whereas, surgical revascularization utilization decreased in patients with and without AF (Ptrend <0.001). In conclusion, among patients with PAD who undergo limb revascularization, AF appears to be associated with poor in-hospital outcomes.

Comparison of Outcomes After Percutaneous Coronary Interventions in Patients of Eighty Years and Above Compared With Those Less Than 80 Years.

Life expectancy in the United States has increased due to advances in health care. Despite increased utilization of percutaneous coronary intervention (PCI), octogenarian patients are less likely to be referred to the catheterization laboratory for coronary interventions. This is in part due to multiple patient co-morbidities and lack of established guidelines. We examined in-hospital clinical outcomes of octogenarian and nonoctogenarian patients who underwent PCI in the United States. Using the National Inpatient Sampling database, we identified all adult patients who are older than 18 years and underwent PCI. Patient were stratified by age into 2 groups, ≥80 years old and <80 years old and in-hospital adverse outcome rates were determined. A total of 11,056,559 patients underwent PCI between the years of 2002 and 2014 and 1,544,563 patients were ≥80 years old (14%). After multivariable adjustment, patients who are ≥80 years old had higher in-hospital mortality (3.3% vs 1.3%, adjusted Odds Ratio, 1.624; 95% confidence interval, 1.602 to 1.647, p <0.0001) and longer length of stay (median length of stay days 3, range 2 to 8 days vs median 2 days, range 1 to 4 days) (p <0.0001). Patients ≥80 years old had a higher rate of cardiopulmonary complications, postprocedural stroke, acute kidney injury, postprocedural thromboembolic complications, and hemorrhage requiring transfusion. There was no difference in vascular complications between the 2 groups. In conclusion, octogenarians who underwent PCI were at increased risk for in-hospital mortality and morbidity compared with nonoctogenarians. The decision to proceed with PCI in this patient population should be individualized, taking into consideration known risk factors and patient's wishes.

The Impella Device: Historical Background, Clinical Applications and Future Directions.

The Impella device is a catheter-based miniaturized ventricular assist device. Using a retrograde femoral artery access, it is placed in the left ventricle across the aortic valve. The device pumps blood from left ventricle into ascending aorta and helps to maintain a systemic circulation at an upper rate between 2.5 and 5.0 L/min. This results in almost immediate and sustained unloading of the left ventricle, while increasing overall systemic cardiac output. The most common indications for using the Impella device are in the treatment of acute myocardial infarction complicated by cardiogenic shock and to facilitate high risk coronary angioplasty. Other indications include the treatment of cardiomyopathy with acute decompensation, postcardiotomy shock, and off-pump coronary bypass surgery. A growing body of observational and registry data suggest a potentially valuable role for the Impella system in reducing the mortality associated with cardiogenic shock. However, there are, as of yet, no randomized controlled trial data supporting this observation.

The Outcomes of Pulmonary Hypertension Patients With Severe Aortic Stenosis Who Underwent Surgical Aortic Valve Replacement or Transcatheter Aortic Valve Implantation.

The outcomes for patients who undergo transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) with pulmonary hypertension (PH) is not well understood. We sought to evaluate the outcomes of patients with PH who underwent TAVI compared with SAVR. We identified patients who were diagnosed with PH and underwent TAVI SAVR for aortic valve stenosis in the National Inpatient Sample database who were admitted from 2011 to 2014. Propensity score matching was used to generate 2 matched cohorts for TAVI and SAVR and outcomes were compared using logistic regressions. A total of 36,786 patients were diagnosed with PH and had an intervention for aortic valve stenosis. Twenty six percent underwent TAVI (n = 9,560) and 74% underwent SAVR (n = 27,225). Patients in the TAVI group were older (81.0 vs 68.5, p <0.001) had more women (53.2% vs 45.4%) and less African-American patients (4.6% vs 8.3%; p <0.001 for both). Although both groups had comparable co-morbidities, the TAVI group had higher prevalence of congestive heart failure, chronic pulmonary disease, renal failure, peripheral vascular disease, coronary artery disease, and previous stroke compared with the SAVR group (p ≤0.002). After propensity-score-matching, patients with PH had no statistically significant difference in in-hospital mortality between for TAVI or SAVR procedures (5.6% vs 4.6%, odds ratio [OR] 1.23, confidence interval [CI] 0.92 to 1.66, p = 0.165). However, TAVI patients were less likely to have cardiac complications (15.4% vs 19.9%, OR 0.73, CI 0.61 to 0.87, p = 0.001) and respiratory complications (12.4% vs 25.1%, OR 0.42, CI 0.35 to 0.51, p <0.001). In conclusion, whereas patient with PH who underwent TAVI and SAVR had similar in-hospital mortality, TAVI was associated with lower cardiac, respiratory and bleeding complications compared with SAVR.

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.

Successful Treatment of Occlusive Left Main Coronary Artery Dissection by Impella-Supported Stenting.

We report successful treatment of a patient, who, during diagnostic angiography, developed an ostial left main coronary artery dissection with stump occlusion of the vessel. First, mechanical circulatory support with an Impella CP device was established. Then, patency of the left coronary system was achieved by placement of stents in the left anterior descending, left circumflex, and left main coronary arteries. On completion of the procedure, left ventricular systolic function, as assessed by echocardiography, was normal. At 24-month clinical follow-up, the patient remains angina-free and well. This is the first reported case of the use of an Impella device to support treatment of iatrogenic left main coronary artery dissection.