Angiographic characteristics of patients with STEMI and COVID-19: Insights from NACMI registry.

BACKGROUND: To date, there has been no independent core lab angiographic analysis of patients with COVID-19 and STEMI. The study characterized the angiographic parameters of patients with COVID-19 and STEMI. METHODS: Angiograms of patients with COVID-19 and STEMI from the North American COVID-19 Myocardial Infarction (NACMI) Registry were sent to a Core Laboratory in Vancouver, Canada. Culprit lesion(s), Thrombolysis In Myocardial Infarction (TIMI) flow, Thrombus Grade Burden (TGB), and percutaneous coronary intervention (PCI) outcome were assessed. RESULTS: From 234 patients, 74% had one culprit lesion, 14% had multiple culprits and 12% had no culprit identified. Multivessel thrombotic disease and multivessel CAD were found in 27% and 53% of patients, respectively. Stent thrombosis accounted for 12% of the presentations and occurred in 55% of patients with previous coronary stents. Of the 182 who underwent PCI, 60 (33%) had unsuccessful PCI due to post-PCI TIMI flow <3 (43/60), residual high thrombus burden (41/60) and/or thrombus related complications (27/60). In-hospital mortality for successful, partially successful, and unsuccessful PCI was 14%, 13%, and 27%, respectively. Unsuccessful PCI was associated with increased risk of in-hospital mortality (risk ratio [RR] 1.96; 95% CI: 1.05-3.66, P = .03); in the adjusted model this estimate was attenuated (RR: 1.24; 95% CI: 0.65-2.34, P = .51). CONCLUSION: In patients with COVID-19 and STEMI, thrombus burden was pervasive with notable rates of multivessel thrombotic disease and stent thrombosis. Post-PCI, persistent thrombus and sub-optimal TIMI 3 flow rates led to one-third of the PCI's being unsuccessful, which decreased over time but remained an important predictor of in-hospital mortality.

Educational Experience of Interventional Cardiology Fellows in the United States and Canada.

BACKGROUND: The COVID-19 pandemic and iodinated contrast shortage may have affected interventional cardiology (IC) fellowship training. OBJECTIVES: The aim of this study was to investigate the educational experience of first-year IC fellows in the United States and Canada. METHODS: A 59-question online survey was conducted among 2021-2022 first-year IC fellows in the United States and Canada. RESULTS: Of the 360 IC fellows invited to participate, 111 (31%) responded; 95% were from the United States, and 79% were men. Participants were mostly from university programs (70%), spent 61 to 70 hours/week in the hospital, and had an annual percutaneous coronary intervention case number of <200 (5%), 200 to 249 (8%), 250 to 349 (33%), 350 to 499 (39%), 500 to 699 (12%), or ≥700 (3%). For femoral access, a micropuncture needle was used regularly by 89% and ultrasound-guided puncture by 81%, and 43% used vascular closure devices in most cases (>80%). Intravascular ultrasound was performed and interpreted very comfortably by 62% and optical coherence tomography (OCT) by 32%, and 20% did not have access to OCT. Approximately one-third felt very comfortable performing various atherectomy techniques. Covered stents, fat embolization, and coil embolization were used very comfortably by 14%, 4%, and 3%, respectively. Embolic protection devices were used very comfortably by 11% to 24% of IC fellows. Almost one-quarter of fellows (24%) were warned about their high radiation exposure. Eighty-four percent considered IC fellowship somewhat or very stressful, and 16% reported inadequate psychological support. CONCLUSIONS: This survey highlights opportunities for improvement with regard to the use of intravascular imaging, atherectomy techniques, complication prevention and management strategies, radiation awareness and mitigation, and psychological support.

Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction.

ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n = 71] COVID-19+/MCS positive [MCS+] vs 12.4% [n = 98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p = 0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p = 0.001) because of very high in-hospital mortality (59% vs 28%; p = 0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.

Peripheral arterial disease and hypertension.

PURPOSE OF REVIEW: Hypertension (HTN) is a well known risk factor for atherosclerosis and peripheral arterial disease (PAD). PAD affects more than 250 million people globally and is associated with worse clinical outcomes. Although multiple studies have been performed to evaluate treatment of HTN in patients with PAD, blood pressure management in this high-risk cohort remains poor. RECENT FINDINGS: There has been conflicting evidence regarding blood pressure goals in PAD with some recent studies showing adverse outcomes with low blood pressure in this patient population. Current guidelines, however, continue to recommend treatment goals in PAD patients similar to patients without PAD. To date, no single antihypertensive drug class has shown a clear benefit in PAD population over other antihypertensive drug classes. SUMMARY: Prospective randomized trials enrolling PAD patients are required that can shed light on optimum blood pressure target and also distinguish between different antihypertensive drugs in terms of reducing adverse outcomes.

North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

Background: In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI. Methods: Baseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient. Results: In-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 â€‹years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P â€‹< â€‹.001), and the model demonstrated good discriminative power (c-statistic â€‹= â€‹0.81) and calibration (Hosmer-Lemeshow, P â€‹= â€‹.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high-risk score categories, respectively). Conclusions: The risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Cerebral protection during percutaneous intervention for left ventricular assist device outflow graft obstruction.

BACKGROUND: Left ventricular assist devices (LVAD) outflow graft obstruction is an uncommon complication but carries significant morbidity and mortality. Here we provide a case series of patients with LVAD intrinsic outflow graft obstruction who are deemed to be a high surgical risk for pump exchange and, therefore, underwent percutaneous intervention with the concomitant use of neuroprotective device-Sentinel cerebral protection system (CPS) (Boston Scientific) to prevent embolic stroke. METHODS: We retrospectively analyzed patients who underwent LVAD placement in our institution and developed LVAD outflow graft obstruction. The diagnosis of LVAD outflow graft obstruction was confirmed by utilizing various cardiac imaging modalities such as echocardiography and/or computed tomography angiography. All patients were treated with percutaneous intervention and a catheter-based CPS. RESULTS: From a total of 501 LVAD implants in our institute, 6 (1.2%) patients with LVAD outflow graft obstruction who underwent percutaneous treatment were included; 4 patients with HeartMate-III LVAD, 1 patient with HeartMate-II LVAD, and 1 patient with HeartWare (HVAD). The median age of patients was 56.5 years at the time of LVAD implantation. The median time from the LVAD implantation to the episode of LVAD outflow obstruction was 1343 days. Utilization of Sentinel CPS resulted in the capture and removal of thrombus/debris in all patients. CONCLUSIONS: Percutaneous intervention of LVAD outflow graft obstruction is less invasive than surgical pump exchange and an acceptable alternative in properly selected patients. In our experience, utilization of a catheter-based CPS can help in reducing the incidence of periprocedural embolic events.

Trends in Clinical Presentation, Management, and Outcomes of STEMI in Patients With COVID-19.

BACKGROUND: We previously reported high in-hospital mortality for ST-segment elevation myocardial infarction (STEMI) patients with COVID-19 treated in the early phase of the pandemic. OBJECTIVES: The purpose of this study was to describe trends of COVID-19 patients with STEMI during the course of the pandemic. METHODS: The NACMI (North American COVID-19 STEMI) registry is a prospective, investigator-initiated, multicenter, observational registry of hospitalized STEMI patients with confirmed or suspected COVID-19 infection in North America. We compared trends in clinical characteristics, management, and outcomes of patients treated in the first year of the pandemic (January 2020 to December 2020) vs those treated in the second year (January 2021 to December 2021). RESULTS: A total of 586 COVID-19-positive patients with STEMI were included in the present analysis; 227 treated in Y2020 and 359 treated in Y2021. Patients' characteristics changed over time. Relative to Y2020, the proportion of Caucasian patients was higher (58% vs 39%; P < 0.001), patients presented more frequently with typical ischemic symptoms (59% vs 51%; P = 0.04), and patients were less likely to have shock pre-PCI (13% vs 18%; P = 0.07) or pulmonary manifestations (33% vs. 47%; P = 0.001) in Y2021. In-hospital mortality decreased from 33% (Y2020) to 23% (Y2021) (P = 0.008). In Y2021, none of the 22 vaccinated patients expired in hospital, whereas in-hospital death was recorded in 37 (22%) unvaccinated patients (P = 0.009). CONCLUSIONS: Significant changes have occurred in the clinical characteristics and outcomes of STEMI patients with COVID-19 infection during the course of the pandemic.

Endovascular Management of Chronic Mesenteric Ischemia in a Patient With Left Ventricular Assist Device.

Classical symptoms of chronic mesenteric ischemia include postprandial pain referred to as "intestinal angina", food fear and weight loss. Here we present a case of chronic mesenteric ischemia treated by endovascular stenting in a patient with chronic heart failure and left ventricular assist device.

Feasibility and Safety of Coronary Angiography via Radial Approach in Cardiac Transplant Recipients: A Single Center Experience.

Coronary angiography remains the gold standard post-transplant screening test for cardiac allograft vasculopathy. This procedure has traditionally been performed via femoral approach. Data on safety and efficacy of radial approach in cardiac transplant patients remains scarce. Single center retrospective study including all cardiac transplant patients who underwent coronary angiography via transradial approach (TRA) or transfemoral approach (TFA). Safety and efficacy outcomes were compared between the 2 groups. Primary end points included major bleeding, vascular complications, crossover to femoral approach, contrast use and radiation exposure. A total of 201 patients were included. 96 patients (47.8%) underwent angiography via TRA. At baseline, no significant differences with regards to age, gender, or traditional risk factors such as HTN, DM, hyperlipidemia were noted between the 2 groups. Most patients underwent intravascular ultrasound (n = 179, 89%) with no statistically significant differences between the 2 groups (TRA: 90.6% vs TFA: 87.6%, P = 0.5). Additionally, there were no statistically significant differences in radiation exposure, amount of contrast use and fluoroscopy time between the 2 groups. Although there were trends toward increased bleeding among TFA group, these were not statistically significant and were mostly driven by access site hematomas. Use of TRA increased over time and Conversion from TRA to TFA was low (n = 4, 4.2%). Coronary angiography via the radial approach in cardiac transplant recipients is feasible, safe and is associated with low a risk of bleeding with no significant increase in radiation exposure when compared to the traditional femoral approach.

Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists.

Brachiocephalic and subclavian artery stenoses are less common manifestations of peripheral arterial disease (PAD) compared to lower extremity PAD. However, even among asymptomatic patients, a diagnosis of PAD portends worse long-term mortality. Symptoms may include subclavian steal syndrome and arm claudication. Among patients with internal mammary coronary bypass grafts, symptoms may include those of myocardial ischemia. Symptomatic subclavian stenosis can be readily treated using endovascular techniques with durable outcomes.

SCAI publications committee manual of standard operating procedures.

Evidence-based recommendations for clinical practice are intended to help health care providers and patients make decisions, minimize inappropriate practice variation, promote effective resource use, improve clinical outcomes, and direct future research. The Society for Cardiovascular Angiography and Interventions (SCAI) has been engaged in the creation and dissemination of clinical guidance documents since the 1990s. These documents are a cornerstone of the society's education, advocacy, and quality improvement initiatives. The publications committee is charged with oversight of SCAI's clinical documents program and has created this manual of standard operating procedures to ensure consistency, methodological rigor, and transparency in the development and endorsement of the society's documents. The manual is intended for use by the publications committee, document writing groups, external collaborators, SCAI representatives, peer reviewers, and anyone seeking information about the SCAI documents program.

The Medical and Endovascular Treatment of PAD: A Review of the Guidelines and Pivotal Clinical Trials.

Peripheral arterial disease (PAD) is a global health problem. The risk factors for developing PAD have been clearly described in the literature, as have the medical therapies and preventative strategies for the prevention and treatment of PAD. Unfortunately, PAD patients remain undertreated with regard to guideline-directed medical therapy. During the last 2 decades, endovascular therapies for PAD have evolved such that randomized controlled trial level data are available for the treatment of lower extremity PAD at every major anatomic segment. Furthermore, endovascular therapy has evolved to the point that among experienced operators, an endovascular first strategy is reasonable for the treatment of most patients with intermittent claudication or critical limb ischemia.

Metaanalysis of Multivessel vs Culprit Artery Only Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction.

Background: Primary percutaneous coronary intervention (PCI) is the most frequently used treatment modality for patients presenting with ST elevation myocardial infarction (STEMI). Current professional society guidelines recommend culprit artery only PCI. Recent evidence suggests the potential benefit of multivessel PCI among patients with STEMI that is not complicated by cardiogenic shock. Methods: We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for clinical studies of patients with STEMI, not complicated by cardiogenic shock, who underwent primary PCI between January 1966 and January 2018. We evaluated all-cause and cardiovascular mortality, reinfarction, and repeat revascularization among patients randomized to a multivessel PCI strategy compared to a culprit artery only PCI strategy. Results: Four randomized clinical trials with a total of 1,044 patients met the inclusion criteria. Five hundred and sixty-six patients underwent multivessel PCI, and 478 patients underwent culprit artery only PCI. Multivessel PCI reduced all the studied endpoints: total death, cardiac death, reinfarction, and repeat revascularization (all P values <0.05). Conclusion: To our knowledge, this is the largest metaanalysis of randomized controlled trials studying multivessel PCI vs culprit artery only PCI in STEMI patients without shock, among whom lesion severity was graded by angiography alone. We found that compared to culprit artery only PCI, the multivessel PCI strategy was beneficial in reducing all-cause and cardiovascular mortality, reinfarction, and the need for repeat revascularization.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis.

PURPOSE OF REVIEW: This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials. RECENT FINDINGS: In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13-2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups. A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.

Neuroprotection in the Treatment of Acute Ischemic Stroke.

Neuroprotection remains one of the holy grails of acute ischemic stroke therapy. The ability to protect the ischemic brain from injury until reperfusion and then to protect the brain from reperfusion injury could theoretically improve freedom from disability among stroke survivors. This manuscript reviews the molecular and cellular pathophysiology of stroke and summarizes pharmacologic and other therapies that showed promise in pre-clinical testing as neuroprotection agents. However to date, no compelling efficacy data have been published regarding any pharmacologic or other therapies. Nonetheless the search for effective neuroprotection continues at stroke centers throughout the world.