Anomalous Left Circumflex Artery Originating From Right Coronary Cusp as Culprit Vessel in ST-Elevation Myocardial Infarction (STEMI).

Congenital coronary artery anomalies are rare. The most common anomalous variation is Anomalous Left Circumflex Artery (ALCx) which is a congenital anomaly. ALCx usually originates from the right sinus of Valsalva or as a proximal branching of the Right Coronary Artery (RCA). The clinical presentation has a spectrum which varies from asymptomatic presentation to angina or myocardial infarction with no atherosclerotic lesion due to kinking/compression of the vessel to ST-segment elevation myocardial infarction (STEMI) due to atherosclerotic occlusion. A 45-year-old female with a past medical history of hypertension, hyperlipidemia, type 2 diabetes, tobacco abuse, and a history of ischemic stroke, presented to the hospital due to chest pain. Electrocardiogram revealed inferior ST-elevation myocardial infarction (STEMI) and the patient was taken to the catheterization lab. Angiography revealed 90% stenotic Left Circumflex Artery (LCx) which was anomalous, arising from the right coronary cusp, whereas other coronary arteries were diffusedly atherosclerotic. A drug-eluting stent was placed in the ALCx reducing the stenosis from 90% to 0% and the patient was discharged in a stable condition on dual antiplatelet therapy and statin with plans for possible coronary artery bypass graft due to multivessel disease (severe diffuse disease of LAD, 90% mid-RCA stenosis, 80% proximal RCA stenosis). The patient was eventually lost to follow-up. Typically, anomalous LCx originating from RCA is benign, but there are many cases where there is myocardial infarction or sudden cardiac death due to acute angle take-off at the origin site. This anatomical variation is more important during cardiac surgeries because during valve replacement surgeries, there are cases of ALCx compression resulting in myocardial infarction. Our patient developed STEMI secondary to atherosclerotic stenosis in anomalous LCx. Based on her diffuse atherosclerotic disease and risk factors, it is likely that her anomalous anatomy did not cause her atherosclerotic disease. Overall, clinicians should remain vigilant for these anatomic abnormalities in their practice.

Impact of obstructive sleep apnoea on cardiovascular outcomes and mortality in young adults with congenital heart anomalies: insights from the national inpatient sample (2019).

BACKGROUND: Obstructive sleep apnoea is a common sleep disorder, and adult congenital heart disease (CHD) is also a significant burden on the population. Early diagnosis and treatment are important for improving quality of life and reducing the risk of health complications. The limited research on obstructive sleep apnoea and adult CHD highlights the need for further investigation into the relationship between these two conditions and the mechanisms underlying this relationship. METHOD: We used NIS 2019 database to identify adult CHD admissions aged 18-44 years and assess the impact of obstructive sleep apnoea on all-cause mortality, dysrhythmia, and stroke. A propensity-matched cohort of individuals with and without obstructive sleep apnoea was obtained, and the outcomes were assessed using multivariable analysis and compared in terms of resource utilisation. RESULTS: Of the 41,950 young adult CHD admissions, 6.3% (n = 2630) had obstructive sleep apnoea. The obstructive sleep apnoea+ (n = 2590) and obstructive sleep apnoea- (n = 2590) cohorts were comparable in terms of median age (35 years) and were predominantly male (63.1% versus 62.5%). The obstructive sleep apnoea+ cohort had a higher frequency of risk factors like chronic obstructive pulmonary disease, hypothyroidism, and prior venous thromboembolism than the obstructive sleep apnoea cohort. We found significant association of obstructive sleep apnoea with dysrhythmia (adjusted odds ratio 2.99, 95% confidence interval 2.13-4.19, p < 0.001), but no significant impact on the risk of all-cause mortality or stroke. The obstructive sleep apnoea+ cohort also had higher transfers to short-term facilities, prolonged stays, and higher charges (p < 0.001). CONCLUSION: Our study provides important insights into relationship between obstructive sleep apnoea and adult CHD and highlights the need for further investigation into the impact of obstructive sleep apnoea on individuals with adult CHD.

Examining the Role of Cerebral Embolic Protection Devices in Preventing Postoperative Stroke in Patients with a History of Stroke or Transient Ischemic: Insights from the National Inpatient Sample.

Cerebral embolic protection devices (CEPD) during transcatheter aortic valve replacement (TAVR) have been shown to lower the risk of stroke during the procedure. However, their long-term and clinical effects on neuro-cognition are unknown. Therefore, we hypothesized the benefit of CEPD in TAVR patients with a prior history of stroke or transient ischemic attack (TIA). National Inpatient Sample (2019) and International Classification of Diseases, 10th Revision codes were used to identify patients undergoing TAVR with prior stroke or TIA. Propensity-matched analysis was performed to adjust for baseline characteristics and comorbidities. Primary outcome measures were postoperative stroke and all-cause mortality. Length of stay and hospital cost were secondary outcomes. Of 8450 unmatched TAVR patients with prior stroke or TIA in 2019, 1095 (13%) utilized CEPD. After propensity matching previous myocardial infarction (MI), coronary artery bypass grafting, and drug abuse were higher in the TAVR-only cohort. Postoperative stroke rate (1.4% vs 2.2%; P = 0.081) and odds [adjusted odds ratio (aOR), 0.48; 95% confidence interval (CI), 0.11-2.17; P = 0.341] were lower in the CEPD group. There was no difference in all-cause in-hospital mortality between the 2 groups (0.9% vs 1.0%). Length of stay (3 vs 2 days, P <0.001) and hospital expenditure ($172,711 vs $162,284; P = 0.002) were higher for the TAVR-only cohort. CEPD in TAVR patients with prior stroke or TIA did not show statistically significant postoperative stroke benefits. However, further larger-scale prospective studies are needed to evaluate the long-term neurocognitive benefits of CEPD in these patients. As the use of TAVR continues to expand, optimizing peri-procedural strategies such as the use of CEPD remains a critical area of research to improve patient outcomes.

Chronic total occlusion rotational atherectomy (CTO RA) versus non-CTO RA in coronary artery disease: A meta-analysis of clinical outcomes and complications.

Background: Chronic total occlusion rotational atherectomy (CTO RA) is an emerging intervention in coronary artery disease (CAD), although data comparing its outcomes and complications with non-CTO RA are scarce. We sought to evaluate the outcomes of RA in CTO lesions compared to those in non-CTO lesions by performing a meta-analysis. Methods: We conducted a systematic review and meta-analysis of studies comparing the clinical outcomes and complications between CTO RA and non-CTO RA in patients with CAD. We searched PUBMED, CINAHL, EMBASE and Cochrane Central Register of Clinical Trials for any studies that compared the outcomes of RA in CTO and non-CTO lesions. The outcomes analyzed included in-hospital major adverse cardiovascular events (MACE), target vessel revascularization (TVR), angiographic success, procedural success, periprocedural complications, coronary perforation, and all-cause mortality. Results: Four studies with a total of 1868 patients were included, spanning from 2018 to 2022, from Germany, Taiwan, and Korea. The median age of included patients was 71. The rate of the pooled results indicated a moderate, non-significant increase in in-hospital MACE and TVR for CTO RA compared to non-CTO RA. There was a small, non-significant decrease in angiographic and procedural success in CTO RA compared to non-CTO RA. CTO RA was associated with a non-significant increase in periprocedural complications and a significant increase in coronary perforation compared to non-CTO RA. All-cause mortality showed a non-significant increase in the CTO RA group. Conclusion: This meta-analysis provides evidence that while CTO RA may be associated with a higher risk of coronary perforation, the risk of other outcomes including MACE, TVR, and all-cause mortality is not significantly different compared to non-CTO RA. More research is needed to further understand these relationships and to optimize treatment strategies in patients with CAD undergoing CTO RA.

Rotational Atherectomy in Acute Coronary Syndrome: A Meta-Analysis.

BACKGROUND: The use of rotational atherectomy (RA) in percutaneous coronary intervention (PCI) of acute coronary syndrome (ACS) is considered relatively contraindicated. There have been several observational studies showing RA use in ACS, however, no systemic studies have been undertaken. We sought to evaluate the feasibility and outcomes of RA PCI in ACS by performing a meta-analysis. METHODS: We searched PUBMED, EMBASE, CINAHL, and Cochrane Central Register of Clinical Trials for any studies that evaluated the role of RA PCI in ACS. The outcomes analyzed were all-cause mortality, cardiac mortality, short and long-term major adverse cardiac events (MACE), procedural complications and cardiac perforations. RESULTS: There was a total of 8 retrospective studies with a total population of 1237 with a median follow up of 23 months. The median age of the included patient was 73. Angiographic success rate was 97.4%. The rate of all-cause mortality and cardiac mortality were 5% (range 1-12%, p < 0.001, I2 = 92%) and 2% (range 0-5%, P = 0.03, I2 = 58%) respectively. In-hospital MACE and long-term MACE were 7% (range 3-13%, p < 0.001, I2 = 87%) and 29% (range 21-37%, p = 0.21, I2 = 34%) respectively. The incidence of total procedural complications was noted to be 7% (range 2-14%, p < 0.001, I2 = 90%). Rate of perforation was 1% (range 0-1%, p = 0.9, I2 = 0%). CONCLUSION: Our results show that RA PCI is feasible in ACS with comparable procedural complications and short-term MACE, but with a higher long-term MACE rate compared to RA PCI in routine cases.

Improving Outcomes in Cardiovascular Diseases: A Review on Vorapaxar.

Antiplatelet agents are the standard of practice in the management of atherosclerosis and acute coronary syndrome. In contrast to the available antiplatelet agents, vorapaxar represents a novel mechanism of action. It is an antagonist of the platelet protease-activated receptor-1 and inhibits thrombin-induced and thrombin receptor agonist peptide-induced platelet aggregation. The Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events-Thrombolysis in Myocardial Infarction 50 (TRA 2°P-TIMI 50) trial led to the approval of vorapaxar by the Food and Drug Administration and European Medicines Agency for the reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI) or peripheral arterial disease. TRA 2°P-TIMI 50 trial showed that the use of vorapaxar (2.5 mg once/daily) in addition to standard dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor was effective in the secondary prevention of recurrent thrombotic events among patients with previous atherothrombosis, particularly in patients with prior MI; at the expense of an increase in major bleeding. Another recently published Vorapaxar Therapy in Patients With Prior Myocardial Infarction Treated With Newer Generation P2Y12 Receptor Inhibitors Prasugrel and Ticagrelor (VORA-PRATIC) study showed that among post-MI patients treated with potent P2Y12 inhibitors (prasugrel or ticagrelor), vorapaxar reduced platelet-driven global thrombogenicity, an effect that persisted, albeit attenuated, in the absence of aspirin. The current review summarizes an up-to-date literature on pharmacokinetics, pharmacodynamics, and clinical efficacy of vorapaxar and proposes future directions of research.

Thromboinflammatory Biomarkers in COVID-19: Systematic Review and Meta-analysis of 17,052 Patients.

OBJECTIVE: To evaluate differences in thromboinflammatory biomarkers between patients with severe coronavirus disease 2019 (COVID-19) infection/death and mild infection. PATIENTS AND METHODS: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, EBSCO, Web of Science, and CINAHL databases were searched for studies comparing thromboinflammatory biomarkers in COVID-19 among patients with severe COVID-19 disease or death (severe/nonsurvivors) and those with nonsevere disease or survivors (nonsevere/survivors) from January 1, 2020, through July 11, 2020. Inclusion criteria were (1) hospitalized patients 18 years or older comparing severe/nonsurvivors vs nonsevere/survivors and (2) biomarkers of inflammation and/or thrombosis. A random-effects model was used to estimate the weighted mean difference (WMD) between the 2 groups of COVID-19 severity. RESULTS: We included 75 studies with 17,052 patients. The severe/nonsurvivor group was older, had a greater proportion of men, and had a higher prevalence of hypertension, diabetes, cardiac or cerebrovascular disease, chronic kidney disease, malignancy, and chronic obstructive pulmonary disease. Thromboinflammatory biomarkers were significantly higher in patients with severe disease, including D-dimer (WMD, 0.60; 95% CI, 0.49 to 0.71; I 2 =83.85%), fibrinogen (WMD, 0.42; 95% CI, 0.18 to 0.67; I 2 =61.88%; P<.001), C-reactive protein (CRP) (WMD, 35.74; 95% CI, 30.16 to 41.31; I 2 =85.27%), high-sensitivity CRP (WMD, 62.68; 95% CI, 45.27 to 80.09; I 2 =0%), interleukin 6 (WMD, 22.81; 95% CI, 17.90 to 27.72; I 2 =90.42%), and ferritin (WMD, 506.15; 95% CI, 356.24 to 656.06; I 2 =52.02%). Moderate to significant heterogeneity was observed for all parameters (I 2 > 25%). Subanalysis based on disease severity, mortality, and geographic region of the studies revealed similar inferences. CONCLUSION: Thromboinflammatory biomarkers (D-dimer, fibrinogen, CRP, high-sensitivity CRP, ferritin, and interleukin 6) and marker of end-organ damage (high-sensitivity troponin I) are associated with increased severity and mortality in COVID-19 infection.

Carotid access for transcatheter aortic valve replacement: A meta-analysis.

OBJECTIVE: We sought to evaluate the feasibility and safety of carotid access transcatheter aortic valve replacement (TAVR) by performing a meta-analysis of published cases. BACKGROUND: Several case series and regional data have provided initial basis for carotid access TAVR in patients with prohibitive femoral approach. We performed this meta-analysis to provide further evidence of feasibility and safety of carotid TAVR. METHODS: We searched PubMed, EMBASE, CINAHL, and Cochrane CENTRAL for any study on carotid access TAVR involving ⩾5 patients since inception till March 1, 2020. Random-effects model was used to compute overall effects. The outcomes analyzed were all-cause mortality, Transient ischemic attack (TIA)/stroke, need for permanent pacemaker (PPM) implantation, pericardial tamponade, access site complications, major bleeding, and length of stay. RESULTS: There was a total of 17 retrospective studies (n = 2082) with a median follow-up of 1 month. Mean age of the patient was 80 years. Mean Euroscore and STS scores were 15 ± 6.2 and 7.9 ± 3.3, respectively. The procedural success rate was 99%. The rate of all-cause mortality was 6.7% (range 4.6-9.7%, p < .001, I2 = 67%). Incidence of TIA/stroke was 3.9% (range 3.1-4.8%, p < .001, I2 = 0%) and PPM implantation was 16.7% (range 12.5-21.9%, p < .001, I2 = 56%). Rate of pericardial tamponade, vascular complication, and major bleeding were 1.7, 2.5, and 7%, respectively. Average length of hospital stay was 7.7 days. CONCLUSION: Our results show that transcarotid approach is a feasible option in patients with prohibitive femoral access for TAVR.

Six sigma approach to reduce door-to-balloon time for patients with STEMI.

Specific measures using a Six Sigma approach led to sustained reduction of door-to-balloon times among patients with ST-segment elevation myocardial infarction (STEMI) in a community setting.

Baseline thrombocytopenia in women with coronary heart disease increases incident acute coronary syndrome: insights from national inpatient database.

There are paucity of data on gender-based differences in the effect of thrombocytopenia and coronary heart disease (CHD) towards development of acute coronary syndrome (ACS). We used National Inpatient Sample (NIS) database of the United States to assess the gender-based differences in the association of thrombocytopenia with CHD and the impact of thrombocytopenia on mortality, length of stay and hospitalization costs on ACS subgroup of CHD. Our analysis found that thrombocytopenia was associated with increased odds of CHD on univariate (odds ratio [OR] 1.31 (95% CI 1.30-1.32) p < 0.001) and multivariate (OR 1.36 (95% CI 1.34-1.38) p < 0.001) analyses. Thrombocytopenic CHD patients had increased odds of developing ACS only in women (OR 1.15, 95% CI 1.12-1.17, p < 0.001). Thrombocytopenia was found to be associated with poor short-term outcome in ACS subgroup of CHD with higher in-hospital mortality (OR 1.64, CI 1.58 to 1.71, p < 0.001), length of stay (3.4 days, CI 3.30-3.52, p < 0.001), and cost of hospitalization ($55,652, CI 53,717-57,587, p < 0.001). Thrombocytopenic women with ACS have greater odds of mortality compared to men. Our study suggests that thrombocytopenia among women with CHD is associated with increased odds of developing ACS. Women with ACS have greater mortality compared to men. Thrombocytopenic ACS patients have worse in-hospital outcome compared to patients with normal platelet count. We demonstrated association only and is not possible to establish causality with our study.

Is paroxysmal supraventricular tachycardia truly benign? Insightful association between PSVT and stroke from a National Inpatient Database Study.

BACKGROUND: Atrial fibrillation and flutter are well-known causes of stroke. Whether other atrial arrhythmias categorized as paroxysmal supraventricular tachycardia (PSVT) are associated with stroke is less clear. We aimed to evaluate the association of PSVT with ischemic and embolic stroke and its impact on short-term outcomes in hospitalized stroke patients. METHODS: National Inpatient Sample database of the USA was used to assess the association of PSVT with ischemic stroke. Atrial fibrillation and flutter were excluded to minimize the confounding effects. The association of PSVT with stroke was evaluated using univariate and multivariate analysis. Subgroup analyses by gender, age, and stroke type were also performed. RESULTS: PSVT was associated with increased odds of overall ischemic stroke in univariate [OR 1.18 (95% CI 1.09-1.27) p < 0.001] analysis. No such association was observed in multivariate analysis (OR 1.06 (95% CI 0.98-1.14) p = 0.1) or with subgroup analysis by gender and age. However, PSVT was associated with embolic stroke in both univariate (OR 2.01 (95%CI 1.67-2.43, p < 0.001) and multivariate analysis (OR 1.7 (95%CI 1.4-2.14) p < 0.001) as well as in subgroup analyses by gender and age. Furthermore, the presence of PSVT was associated with increased mortality in embolic stroke (OR 4.11, CI 2.29 to 7.39, p < 0.001) and increased total hospital cost and length of hospital stay in all stroke types. CONCLUSIONS: PSVT is independently associated with higher prevalence of embolic stroke but not with overall ischemic stroke. Patients with embolic stroke in the presence of PSVT have worse in-hospital outcomes with increased mortality.

Oral Anticoagulants With Dual Antiplatelet Therapy Versus Clopidogrel in Patients After Percutaneous Coronary Intervention: A Meta-Analysis.

BACKGROUND: In patients on oral anticoagulation (OAC), dual antiplatelet therapy (DAPT) is often indicated after percutaneous coronary intervention (PCI). AREAS OF UNCERTAINTY: We sought to investigate the effects of triple antithrombotic therapy (TT) versus dual therapy (DT) with OAC and clopidogrel on all-cause mortality, cardiovascular death, major bleeding, myocardial infarction (MI), stroke, and stent thrombosis. DATA SOURCES: We systematically searched on MEDLINE, EMBASE, and CENTRAL for randomized controlled or cohort studies, which investigated the comparative effects of TT versus DT. We performed a meta-analysis of 6 studies (1 randomized control study and 5 cohort studies). RESULTS: The included studies enrolled 7259 patients; 4630 (63.8%) were on TT and 2629 (36.2%) were on DT. The average follow-up time was 1.4 years. No significant differences were found between TT and DT in all-cause mortality (P = 0.70; I = 64%), stent thrombosis (P = 0.41), myocardial infarction (P = 0.43; I = 0%), stroke (P = 0.36; I = 0%), and major bleeding (P = 0.43; I = 0%). CONCLUSIONS: In patients who are on OAC with vitamin K antagonist and underwent percutaneous coronary intervention, no significant differences were found in mortality, ischemic, and hemorrhagic complications between the patients treated with TT and DT. Thus, tailored treatment based on individual thromboembolic and bleeding risk might be the most reasonable approach in these patients.

Culprit versus multivessel coronary intervention in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials.

BACKGROUND: The 2015 American College of Cardiology/American Heart Association update on primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) recommended PCI of the non-infarct-related artery at the time of primary PCI (class IIb recommendation). Despite evidence supporting complete revascularization in STEMI, its benefit on mortality rates is uncertain. METHODS: We searched all available databases for randomized controlled trials comparing complete multivessel percutaneous coronary intervention (CMV PCI) with infarct-artery-only revascularization in patients with STEMI. Summary risk ratios and 95% confidence intervals (CIs) were calculated for both the efficacy and safety outcomes. RESULTS: Nine randomized controlled trials fulfilled the inclusion criteria, yielding 2991 patients. Follow-up periods ranged from 6 to 36 months. Compared with infarct-related artery-only PCI, CMV PCI was associated with significantly lower rates of major adverse cardiac events [relative risk (RR)=0.54, 95% CI=0.41-0.71; P<0.00001], cardiovascular mortality (RR=0.48, 95% CI=0.28-0.80; P=0.005), and repeat revascularization (RR=0.38, 95% CI=0.30-0.47; P<0.00001). Although, contrast-induced nephropathy and major bleed rates were comparable between both groups, CMV PCI failed to show any reduction in all-cause mortality (RR=0.75, 95% CI=0.53-1.07; P=0.11) and nonfatal myocardial infarction (RR=0.69, 95% CI=0.43-1.10; P=0.12). CONCLUSION: Our results suggest that in patients with STEMI and multivessel disease, complete revascularization is safe, and is associated with reduced risks of major adverse cardiac events and cardiac death along with a reduced need for repeat revascularization. However, it showed no beneficial effect on all-cause mortality and nonfatal myocardial infarction.

The State of the Absorb Bioresorbable Scaffold: Consensus From an Expert Panel.

Significant progress has been made in the percutaneous coronary intervention technique from the days of balloon angioplasty to modern-day metallic drug-eluting stents (DES). Although metallic stents solve a temporary problem of acute recoil following balloon angioplasty, they leave behind a permanent problem implicated in very late events (in addition to neoatherosclerosis). BRS were developed as a potential solution to this permanent problem, but the promise of these devices has been tempered by clinical trials showing increased risk of safety outcomes, both early and late. This is not too dissimilar to the challenges seen with first-generation DES in which refinement of deployment technique, prolongation of dual antiplatelet therapy, and technical iteration mitigated excess risk of very late stent thrombosis, making DES the treatment of choice for coronary artery disease. This white paper discusses the factors potentially implicated in the excess risks, including the scaffold consideration and deployment technique, and outlines patient and lesion selection, implantation technique, and dual antiplatelet therapy considerations to potentially mitigate this excess risk with the first-generation thick strut Absorb scaffold (Abbott Vascular, Abbott Park, Illinois). It remains to be seen whether these considerations together with technical iterations will ultimately close the gap between scaffolds and metal stents for short-term events while at the same time preserving options for future revascularization once the scaffold bioresorbs.

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.

Dexamethasone Associated ST Elevation Myocardial Infarction Four Days after an Unremarkable Coronary Angiogram-Another Reason for Cautious Use of Steroids: A Case Report and Review of the Literature.

Drug induced myocardial infarction is a known entity with different forms of steroids linked to coronary artery disease (CAD) either through promoting its traditional risk factors, inducing coronary spasm, or by other unidentified mechanisms. Dexamethasone is known to promote an atherogenic and hypercoagulable state. We report a case of a 75-year-old woman who had ST elevation myocardial infarction (STEMI) associated with dexamethasone use just 4 days following an angiogram showing minor luminal irregularities.

Meta-Analysis of Usefulness of Percutaneous Left Ventricular Assist Devices for High-Risk Percutaneous Coronary Interventions.

High-risk percutaneous coronary intervention (PCI) is often offered to patients with extensive coronary artery disease, decreased left ventricular function, and co-morbid conditions that increase surgical risk. In these settings, percutaneous left ventricular assist devices (PVADs) can be used for hemodynamic support. To assess the effects of PVAD use on mortality, myocardial infarction, and complication rates in patients undergoing high-risk PCI, we systematically searched the electronic databases, MEDLINE, PUBMED, EMBASE, and Cochrane for prospective controlled trials and cohort studies of patients that received hemodynamic support with PVADs for high-risk PCI. The primary outcome measures were 30-day all-cause mortality, 30-day myocardial infarction rates, periprocedural major bleeding, and vascular complications. We included 12 studies with 1,346 participants who underwent Impella 2.5 L device placement and 8 cohort studies with 205 patients that received TandemHeart device for high-risk PCI. Short-term mortality rates were 3.5% and 8% and major bleeding rates were 7.1% and 3.6% with Impella and TandemHeart, respectively. Both devices are associated with comparable periprocedural outcomes in patients undergoing high-risk PCI.

Transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with previous coronary artery bypass surgery: A systematic review and meta-analysis.

BACKGROUND: Patients with severe aortic stenosis (AS) and previous coronary artery bypass graft (CABG) surgery have increased risk for aortic valve replacement. Whether surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) offers better outcomes in this population is unclear. We aimed to assess outcomes of TAVR and SAVR in patients with previous CABG. METHODS: A systematic literature search of Medline, EMBASE and Cochrane library was conducted. Studies that reported clinical outcomes (perioperative or mid-term all-cause-mortality, cardiovascular mortality, pacemaker implantation, hospital duration and stroke) were included. Random-effect modeling was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Five cohort studies including a total of 872 patients (423 in TAVR, 449 in SAVR) were analyzed. STS scores were comparable between the two groups. No difference in all-cause-mortality, cardiovascular mortality and stroke at 30days, 1year and total follow-up period was seen between the two groups. TAVR patients had higher pacemaker implantation rates (OR 3.41, 95% CI 1.66-6.38, p<0.001, I(2)=21%) and shorter hospital stay (-2.63days, 95% CI -5.20 to -0.04, p=0.05, I(2)=43%). CONCLUSIONS: Patients with previous CABG who underwent TAVR had similar perioperative and long-term survival while experiencing more pacemaker implantations and shorter hospital stay compared to those who had SAVR making TAVR a safe and efficacious alternative to SAVR.

In-Hospital Outcomes of Atherectomy During Endovascular Lower Extremity Revascularization.

Contemporary data on clinical outcomes after utilization of atherectomy in lower extremity endovascular revascularization are sparse. The study cohort was derived from Healthcare Cost and Utilization Project nationwide inpatient sample database from the year 2012. Peripheral endovascular interventions including atherectomy were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. The subjects were divided and compared in 2 groups: atherectomy versus no atherectomy. Two-level hierarchical multivariate mixed models were created. The coprimary outcomes were in-hospital mortality and amputation; secondary outcome was a composite of in-hospital mortality and periprocedural complications. Hospitalization costs were also assessed. Atherectomy utilization (odds ratio, 95% CI, p value) was independently predictive of lower in-hospital mortality (0.46, 0.28 to 0.75, 0.002) and lower amputation rates (0.83, 0.71 to 0.97, 0.020). Atherectomy use was also predictive of significantly lower secondary composite outcome of in-hospital mortality and complications (0.79, 0.69 to 0.90, 0.001). In the propensity-matched cohort, atherectomy utilization was again associated with a lower rate of amputation (11.18% vs 12.92%, p = 0.029), in-hospital mortality (0.71% vs 1.53%, p 0.001), and any complication (13.24% vs 16.09%, p 0.001). However, atherectomy use was also associated with higher costs ($24,790 ± 397 vs $22635 ± 251, p <0.001). Atherectomy use in conjunction with angioplasty (with or without stenting) was associated with improved in-hospital outcomes in terms of lower amputation rates, mortality, and postprocedural complications.