Prognostic Value of 6-Minute Walk Distance in Patients Undergoing Percutaneous Coronary Intervention: a Veterans Affairs Prospective Study.

The 6-minute walk distance (6MWD) test is a useful prognostic tool in chronic heart failure. Its usefulness after percutaneous coronary intervention is unknown. In a prospective observational study, patients underwent a 6MWD test within 2 weeks after percutaneous coronary intervention. The primary endpoint was major adverse cardiovascular events (MACE) (death, acute coronary syndrome, and heart failure admission) at one year. Receiver operating characteristic curves and area under the curve were used to determine the 6MWD test's predictive power, and the Youden index was used to measure its effectiveness. A total of 212 patients were enrolled (98% men; mean age, 65 ± 9 yr). Major comorbidities were hypertension in 187 patients (88%), dyslipidemia in 186 (88%), and diabetes mellitus in 95 (45%). Among the 176 patients (83%) who completed the 6MWD test, the incidence of MACE at one year was 22% (acute coronary syndrome in 17%; heart failure admission in 4%; and death in 3%). The area under the curve for MACE was 0.59, and 6MWD was shorter for patients with MACE than for those without (290 vs 326 m; P=0.03). For 39 patients with previous heart failure who completed the 6MWD test, the area under the curve was 0.64 for MACE and 0.78 for heart failure admission. The 6MWD test predicted reasonably well the incidence of MACE one year after percutaneous coronary intervention. In a subgroup of patients with previous heart failure, it fared even better in predicting heart failure admission. Larger studies are needed to confirm these findings.

Length of Stay After Transfemoral Transcatheter Aortic Valve Replacement: An Analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

OBJECTIVES: The goal of this study was to investigate the trends, predictors, and outcomes of delayed discharge (>72 h) after transcatheter aortic valve replacement. BACKGROUND: Length of stay post-transcatheter aortic valve replacement may have significant clinical and administrative implications. METHODS: Data from the Transcatheter Valve Therapy Registry were used to identify patients undergoing nonaborted transfemoral transcatheter aortic valve replacement who survived to discharge, and data linked from the Centers for Medicare & Medicaid Services were used to provide 1-year events. Patients were categorized to early discharge (≤72 h) versus delayed discharge (>72 h). The trends, predictors, and adjusted 1-year outcomes were compared in both groups. RESULTS: From 2011 to 2015, a total of 13,389 patients (55.1%) were discharged within 72 h, whereas 10,896 patients (44.9%) were discharged beyond 72 h. There was a significant decline in rates of delayed discharge across the study period (62% vs. 34%; p < 0.01). This remained unchanged when stratified by Transcatheter Valve Therapy risk scores. Several factors were identified as independent predictors of early and delayed discharge. After adjustment for in-hospital complications, delayed discharge was an independent predictor of 1-year all-cause mortality (hazard ratio: 1.45; 95% confidence interval: 1.30 to 1.60; p < 0.01). CONCLUSIONS: Rates of delayed discharge have declined from 2011 to 2015. Delayed discharge is associated with a significant increase in mortality even after adjusting for in-hospital complications. Further work is necessary to determine if predictors of early discharge could be used to develop length of stay scores that might be instrumental in administrative, financial, or clinical policy development.

Drug-Eluting Balloons Versus Everolimus-Eluting Stents for In-Stent Restenosis: A Meta-Analysis of Randomized Trials.

OBJECTIVES: Individual randomized trials comparing drug-eluting balloons (DEB) versus everolimus-eluting stents (EES) for in-stent restenosis (ISR) were underpowered for clinical end-points. The objective of this study was to compare the clinical outcomes of DEB versus EES for any ISR. MATERIALS & METHODS: Electronic databases were searched for randomized trials which compared DEB versus EES for any ISR (i.e., drug eluting or bare metal stents). Summary estimate risk ratios (RRs) were constructed using a DerSimonian and Laird random effects model. RESULTS: Five trials with 962 patients were included. In-segment minimum lumen diameter (MLD) was lower with DEB (standardized mean difference -0.24, 95% confidence interval [CI] -0.46 - -0.01) on angiographic follow-up at a mean of 8.6 months. There was no statistically significant difference in the risk of target vessel revascularization (TVR) at 1 year (RR 1.15, 95% CI 0.60-2.19), but TVR was increased with DEB at 3 years (RR 1.87, 95% CI 1.15-3.03). The risk of target lesion revascularization (TLR) was statistically increased with DEB (RR 2.17, 95% CI 1.13-4.19) at a mean of 24.4 months. There was no difference in the risk of MI, stent thrombosis, cardiac mortality and all-cause mortality between both groups. CONCLUSION: In patients with any type of ISR, DEB was associated a similar risk of TVR at 1-year, but increased risk of TVR and TLR at longer follow-up, as compared with EES. The quality of evidence was moderate, suggesting the need for further randomized trials with longer follow-up to confirm the role of DEB in the management of ISR.

Prevalence, Causes, and Predictors of 30-Day Readmissions Following Hospitalization With Acute Myocardial Infarction Complicated By Cardiogenic Shock: Findings From the 2013-2014 National Readmissions Database.

BACKGROUND: Prior studies have shown that survivors of acute myocardial infarction (AMI) complicated by cardiogenic shock are likely to have increased risk of readmissions in the early post-discharge period. However, the contemporary prevalence, reasons, and predictors of 30-day readmissions are not well known. METHODS AND RESULTS: Hospitalizations for a primary diagnosis of AMI complicated by cardiogenic shock, and discharged alive, were identified in the 2013 and 2014 Nationwide Readmissions Databases. Prevalence and reasons for 30-day unplanned readmissions were investigated. A hierarchical logistic regression model was used to identify independent predictors of 30-day readmissions. Among 1 116 933 patient hospitalizations with AMI, 39 807 (3.6%) had cardiogenic shock and were discharged alive. Their 30-day readmission rate was 18.6%, with a median time for readmission 10 days post discharge. Predictors of readmission included: non-ST-segment elevation myocardial infarction, female sex, low-income status, nonprivate insurance, chronic renal failure, long-term ventricular assist device or intra-aortic balloon placement, and tachyarrhythmia. The majority of readmissions were attributable to cardiac-related causes (52%); heart failure being the most frequent cardiac cause (39% of all cardiac causes). Noncardiac-related readmissions included infections (14.9%), bleeding (5.3%), and respiratory causes (4.9%). The median cost per readmission was $9473 US dollars ($5037-20 199). CONCLUSIONS: Among survivors of AMI complicated by cardiogenic shock who were discharged from hospital, almost 1 in 5 are readmitted at 30 days, mainly because of cardiac reasons such as heart failure and new AMI. The risk of readmission was associated with certain baseline patient/hospital characteristics.

Prescription of Guideline-Based Medical Therapies at Discharge After Carotid Artery Stenting and Endarterectomy: An NCDR Analysis.

BACKGROUND AND PURPOSE: Carotid artery revascularization was previously found to incrementally reduce stroke risk among patients with carotid stenosis treated with medical therapy. However, the frequency with which optimal medical therapies are used at discharge after carotid endarterectomy (CEA) and carotid artery stenting (CAS) is not known, and the influence of patient, operator, and hospital characteristics on the likelihood of prescription is poorly understood. METHODS: In a retrospective cohort study of 23 112 patients undergoing CAS or CEA between January 2007 and June 2012 at US hospitals participating in the CARE registry (Carotid Artery Revascularization and Endarterectomy), we examined antiplatelet therapy and statin utilization at discharge. Hierarchical multivariable logistic regression was used in adjusted analyses. RESULTS: Antiplatelet agents and statins were prescribed at discharge in 99% and 78%, respectively, after CAS and 93% and 75%, respectively, after CEA. After adjustment, antiplatelet therapy was more often prescribed after CAS than CEA (odds ratio 2.4 [95% confidence interval 1.68-3.45]), but statin prescription was equally likely (odds ratio 1.11 [95% confidence interval 0.84-1.49]). Operator specialty (medical>radiology/surgery) and hospital community setting (suburban>urban>rural) independently predicted antiplatelet and statin agent use at discharge, whereas hospital geographic location (Northeast>Midwest/South>West) predicted use of statins but not antiplatelet therapy at discharge. CONCLUSIONS: US antiplatelet agent and statin discharge prescription rates were suboptimal after both CAS and CEA and varied by revascularization modality, operating physician specialty, and hospital characteristics. Improved and more uniform utilization after these procedures will be critical to the success of comprehensive stroke risk reduction efforts.

Temporal Trends and Outcomes of Patients Undergoing Percutaneous Coronary Interventions for Cardiogenic Shock in the Setting of Acute Myocardial Infarction: A Report From the CathPCI Registry.

OBJECTIVES: The purpose of this study was to examine the temporal trends in demographics, clinical characteristics, management strategies, and in-hospital outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS-AMI) who underwent percutaneous coronary intervention (PCI) from the Cath-PCI Registry (2005 to 2013). BACKGROUND: The authors examined contemporary use and outcomes of PCI in patients with CS-AMI. METHODS: The authors used the Cath-PCI Registry to evaluate 56,497 patients (January 2005 to December 2013) undergoing PCI for CS-AMI. Temporal trends in clinical variables and outcomes were assessed. RESULTS: Compared with cases performed from 2005 to 2006, CS-AMI patients receiving PCI from 2011 to 2013 were more likely to have diabetes, hypertension, dyslipidemia, previous PCI, dialysis, but less likely to have chronic lung disease, peripheral vascular disease, or heart failure within 2 weeks (p < 0.01). Between 2005 and 2006 to 2011 and 2013, intra-aortic balloon pump use decreased (49.5% to 44.9%; p < 0.01), drug-eluting stent use declined (65% to 46%; p < 0.01), and the use of bivalirudin increased (12.6% to 45.6%). Adjusted in-hospital mortality; increased (27.6% in 2005 to 2006 vs. 30.6% in 2011 to 2013, adjusted odds ratio: 1.09, 95% confidence interval: 1.005 to .173; p = 0.04) for patients who were managed with an early invasive strategy (<24 h from symptoms). CONCLUSIONS: Our study shows that despite the evolution of medical technology and use of contemporary therapeutic measures, in-hospital mortality in CS-AMI patients who are managed invasively continues to rise. Additional research and targeted efforts are indicated to improve outcomes in this high-risk cohort.

SCAI/SVM expert consensus statement on carotid stenting: Training and credentialing for carotid stenting.

Carotid artery stenting (CAS) has become an integral part of the therapeutic armamentarium offered by cardiovascular medicine programs for the prevention of stroke. The purpose of this expert consensus statement is to provide physician training and credentialing guidance to facilitate the safe and effective incorporation of CAS into clinical practice within these programs. Since publication of the 2005 Clinical Competence Statement on Carotid Stenting, there has been substantial device innovation, publication of numerous clinical trials and observational studies, accumulation of extensive real-world clinical experience and widespread participation in robust national quality improvement initiatives [5]. Collectively, these advances have led to substantial evolution in the selection of appropriate patients, as well as in the cognitive, technical and clinical skills required to perform safe and effective CAS. Herein, we summarize published guidelines, describe training pathways, outline elements of competency, offer strategies for tracking outcomes, specify facility, equipment and personnel requirements, and propose criteria for maintenance of CAS competency.

Bioresorbable Stents: Is This Where We Are Headed?

Current drug-eluting stents (DES) have shown excellent safety and efficacy in various clinical settings. However, the presence of a permanent metallic scaffold remains an Achilles heel, with concerns for late stent thrombosis and the need for prolonged dual anti-platelet therapy. The bioresorbable vascular scaffold (BRS) has been termed the fourth revolution in interventional cardiology, with an ability to not only treat the coronary lesion, but also restore endothelial function after complete absorption. The absence of a permanent scaffold after months of implantation has the potential to overcome the shortcomings of current metallic DES and markedly impact interventional cardiology practice around the world. This review article focuses on the history, development and clinical studies on various BRS and attempts to predict how this technology could impact future cardiology practice.

Racial/Ethnic variation in carotid artery revascularization utilization and outcomes: analysis from the National Cardiovascular Data Registry.

BACKGROUND AND PURPOSE: It is not known whether racial or ethnic disparities observed with other revascularization procedures are also seen with carotid artery stenting (CAS) and endarterectomy (CEA). METHODS: We compared the utilization and outcomes of CAS and CEA across racial/ethnic groups within the CARE Registry between May 2007 and December 2012. RESULTS: Between 2007 and 2012, of the 13 129 patients who underwent CAS, majority were non-Hispanic whites (89.3%), followed by blacks (4.4%), Hispanics (4.3%), and other groups (2.0%). A similar distribution was observed among the 10 953 patients undergoing CEA (non-Hispanic whites, 92.6%; blacks, 3.5%; Hispanics, 2.8%; and other groups, 1.1%). During this time period, a trend toward proportionate increase in CAS utilization was observed in non-Hispanic whites and other groups, whereas the opposite was observed among Hispanics and blacks. This trend persisted even when hospitals performing both CAS and CEA were exclusively analyzed. Adherence to antiplatelet and statin therapy was significantly lower among blacks post CEA. In-hospital major adverse cardiac and cerebrovascular events remained comparable across groups post CAS and CEA. At 30 days, the incidence of stroke (7.2%) and major adverse cardiac and cerebrovascular events (8.8%) was higher among blacks post CEA (P<0.05), after risk adjustment. CONCLUSION: During the study period, utilization of CAS and CEA was highest among non-Hispanic whites. There was a trend toward increased CAS utilization over time among non-Hispanic whites and other groups, and a trend toward increased CEA utilization among Hispanics and blacks. In-hospital major adverse cardiac and cerebrovascular events remained comparable between groups, whereas 30-day major adverse cardiac and cerebrovascular events were significantly higher in blacks.

Transcatheter coiling of saphenous vein graft to coronary sinus after coronary artery bypass surgery: a case report.

Unintended graft anastamosis to coronary veins after coronary artery bypass surgery is an extraordinarily rare complication. The following case report involves the unintended grafting of a saphenous vein to the coronary sinus rather than the intended arterial target during coronary artery bypass surgery, and the subsequent physiologic consequences and clinical management.

High-dose cytosine arabinoside-induced symptomatic bradycardia.

Cardiac complications of high-dose cytosine arabinoside (HiDAC), although rare, predominantly include pericarditis, pericardial effusion and cardiomyopathy (with concurrent use of cyclophosphamide). Clinically significant arrhythmias associated with HiDAC, although reported in the literature, are rare. The following case report has for the first time used the Naranjo Scale to document a high-probability association (definite adverse drug reaction) of cytarabine with symptomatic sinus bradycardia.

Carotid Artery Stenting: Operator and Institutional Learning Curves.

Despite rapid growth in the frequency that carotid artery stenting (CAS) is performed, there remain concerns regarding the steep learning curve associated with this procedure. This article reviews the evidence base supporting operator and institutional CAS learning curves and discusses their implications for the establishment and maintenance of competencies. Attempts are made to delineate minimum volume thresholds to attain these goals and means to enhance procedural safety without compromising patient access.

Hemorrhagic and ischemic outcomes after bivalirudin versus unfractionated heparin during carotid artery stenting: a propensity score analysis from the NCDR.

BACKGROUND: The direct thrombin inhibitor, bivalirudin, is associated with similar efficacy and superior safety in patients undergoing percutaneous coronary intervention. However, the role of direct thrombin inhibitors in carotid artery stenting is not well defined. The objective of this study was to compare the safety and effectiveness of bivalirudin and unfractionated heparin (UFH) for carotid artery stenting. We hypothesized that bivalirudin would be associated with less in-hospital postprocedure bleeding than UFH but similar rates of in-hospital and 30-day ischemic outcomes. METHODS AND RESULTS: We compared the incidence of in-hospital hemorrhagic and in-hospital/30-day ischemic outcomes among patients in the CARE Registry who underwent carotid artery stenting between May 2005 and March 2012 using bivalirudin or UFH. Propensity score matching was used to obtain a balanced cohort of 3555 patients in each treatment group. Patients treated with bivalirudin had a significantly lower incidence of bleeding or hematoma requiring red blood cell transfusions (0.9% versus 1.5%; odds ratio, 0.57 [0.36-0.89]; P=0.01) when compared with UFH-treated patients. The incidence of in-hospital and 30-day ischemic outcomes, including death, myocardial infarction, stroke, transient ischemic attack, and the composite outcome, death/myocardial infarction/stroke, did not differ significantly between groups. CONCLUSIONS: Bivalirudin was associated with lower rates of hemorrhagic outcomes compared with UFH during the index hospitalization for carotid artery stenting. In-hospital and 30-day ischemic events were similar between the 2 groups. Randomized comparisons of these agents are needed to confirm these findings.

Endovascular repair of traumatic aortic injury: a novel arena in interventional cardiology.

OBJECTIVE: To assess the feasibility of endovascular repair of traumatic aortic injuries performed by interventional cardiologists in collaboration with cardiothoracic surgeons. BACKGROUND: Traumatic aortic injury (TAI) represents a significant cause of mortality in trauma patients. Endovascular techniques have recently come into play for the management of TAI and are usually performed by a multidisciplinary team consisting of a thoracic or vascular surgeon and/or interventional radiology. With extensive expertise in catheter-based interventions, interventional cardiologists may have a pivotal role in this important procedure. METHODS: From January 2009 to July 2011, we reviewed the TAI endovascular repair outcomes performed by a team of interventional cardiologists in collaboration with cardiothoracic surgery at our institution. The charts of these patients were reviewed to collect desired data, which included preoperative, procedural, and follow-up details. RESULTS: Twenty patients were identified in our series. Most of these patients developed TAI from motor vehicle accidents. Technical success for endovascular repair of TAI was achieved in all patients. Two patients developed endoleak, of which one patient required subsequent open repair. Two patients expired in the hospital from coexistent injuries. CONCLUSIONS: Our series of endovascular repair for TAI performed by interventional cardiologists with the collaboration of cardiothoracic surgeons showed excellent outcomes. Our experience may give further insight in the collaborative role of interventional cardiology and cardiothoracic surgery for endovascular repair of TAI.

Primary retroperitoneal abscess caused by Candida glabrata.

Clinically, retroperitoneal abscesses present insidiously and the diagnosis may be delayed. This, with inadequate drainage, may result in increased morbidity and mortality. Most cases result from a renal or gastrointestinal process, but in a small number of patients there is no identifiable source and the abscess is designated as "primary." Most retroperitoneal abscesses are polymicrobial, and cultures often reveal organisms such as Proteus mirabilis, Staphylococcus species, Peptostreptococcus, Enterococcus, Enterobacter, Escherichia coli and Bacteroides species. Fungal causes appear to be very rare, and in this study, a case of a patient with primary Candida glabrata retroperitoneal abscess is reported.

Clinical safety of bivalirudin in patients undergoing carotid stenting.

BACKGROUND: Prior to June 2011, carotid artery stenting (CAS) had been limited to patients deemed high risk for surgical revascularization due to medical or anatomic reasons. Intraprocedural anticoagulation for CAS has traditionally been carried out with unfractionated heparin (UFH). The direct thrombin inhibitor bivalirudin has emerged as a possible alternative choice for anticoagulation in this patient population. In patients undergoing coronary interventions, bivalirudin has been shown in large prospective analysis to reduce major adverse events and hemorrhagic complications (TIMI major bleeding rates, 0.6%-3.1%; TIMI minor bleeding rates, 1.3%-3.7%). As of now, the safety and efficacy of bivalirudin for use during carotid stenting has not been rigorously evaluated. To date, the published evidence in favor of bivalirudin for CAS exists in small retrospective analyses and two prospective studies. METHODS: We present a retrospective analysis of 331 patients with a total of 365 carotid artery lesions undergoing CAS between February 2007 and September 2010. The procedures were performed by five experienced operators from four separate sites within the same metropolitan area. Patients were included who received bivalirudin as the anticoagulation strategy and underwent CAS. The primary endpoints of the study were 30-day incidence of death, stroke, TIMI major bleeding (defined as ≥5 g/dL Hgb drop or intracranial hemorrhage), TIMI minor bleeding (defined as ≥3 g/dL Hgb drop), and blood transfusion. All data were collected by retrospective chart review. RESULTS: A total of 365 CAS procedures were performed. There were no deaths, strokes, or TIMI major bleeds. There was a 2.19% incidence of TIMI minor bleeding (8/365) and a 1.64% rate of blood transfusion (6/365). CONCLUSIONS: In our patient population, the major endpoints of stroke, death, MI, major and minor bleeding rates were well within those previously reported overall for carotid artery revascularization. Hence, we conclude that bivalirudin may be safe for use in CAS procedures with a safety profile similar to that validated in percutaneous coronary interventions.