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.

Outcomes of Percutaneous Revascularization in Severe Ischemic Left Ventricular Dysfunction.

PURPOSE OF REVIEW: This article presents a comprehensive review of coronary revascularization versus optimal medical therapy (OMT) in patients with severe ischemic left ventricular dysfunction. RECENT FINDINGS: The REVIVED-BCIS2 trial randomized 700 patients with extensive coronary artery disease and left ventricular (LV) ejection fraction (LVEF) ≤ 35% and viability in more than four dysfunctional myocardial segments to percutaneous coronary intervention (PCI) plus OMT versus OMT alone. Over a median duration of 41 months, there was no difference in the composite of all-cause mortality, heart failure hospitalization, or improvement in LVEF with PCI plus OMT versus OMT alone at 6 and 12 months, quality of life scores at 24 months, or fatal ventricular arrhythmia. The STICH randomized trial was conducted between 2002 and 2007, involving patients with LV dysfunction and coronary artery disease. The patients were assigned to either CABG plus medical therapy or medical therapy alone. At the 5-year follow-up, the trial showed that CABG plus medical therapy reduced cardiovascular disease-related deaths and hospitalizations but no reduction in all-cause mortality. However, a 10-year follow-up showed a significant decrease in all-cause mortality with CABG. The currently available evidence showed no apparent benefit of PCI in severe ischemic cardiomyopathy as compared to OMT, but that CABG improves outcomes in this patient population. The paucity of data on the advantages of PCI in this patient population underscores the critical need for optimization of medical therapy for better survival and quality of life until further evidence from RCTs is available.

Impact of COVID-19 on Acute Myocardial Infarction Care.

The global health crisis caused by the COVID-19 pandemic has evolved rapidly to overburden health care organizations around the world and has resulted in significant morbidity and mortality. Many countries have reported a substantial and rapid reduction in hospital admissions for acute coronary syndromes and percutaneous coronary intervention. The reasons for such abrupt changes in health care delivery are multifactorial and include lockdowns, reduction in outpatient services, reluctance to seek medical attention for fear of contracting the virus, and restrictive visitation policies adopted during the pandemic. This review discusses the impact of COVID-19 on important aspects of acute MI care.

Outcomes of in-hospital cardiac arrest in COVID-19 patients: A proportional prevalence meta-analysis.

BACKGROUND: Limited epidemiological data are available on the outcomes of in-hospital cardiac arrest (CA) in COVID-19 patients. METHODS: We performed literature search of PubMed, EMBASE, Cochrane, and Ovid to identify research articles that studied outcomes of in-hospital cardiac arrest in COVID-19 patients. The primary outcome was survival at discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and types of cardiac arrest. Pooled percentages with a 95% confidence interval (CI) were calculated for the prevalence of outcomes. RESULTS: A total of 7,891 COVID patients were included in the study. There were 621 (pooled prevalence 8%, 95% CI 4-13%) cardiac arrest patients. There were 52 (pooled prevalence 3.0%; 95% CI 0.0-10.0%) patients that survived at the time of discharge. ROSC was achieved in 202 (pooled prevalence 39%;95% CI 21.0-59.0%) patients. Mean time to ROSC was 7.74 (95% CI 7.51-7.98) min. The commonest rhythm at the time of cardiac arrest was pulseless electrical activity (pooled prevalence 46%; 95% 13-80%), followed by asystole (pooled prevalence 40%; 95% CI 6-80%). Unstable ventricular arrhythmia occurred in a minority of patients (pooled prevalence 8%; 95% CI 4-13%). CONCLUSION: This pooled analysis of studies showed that the survival post in-hospital cardiac arrest in COVID patients is dismal despite adequate ROSC obtained at the time of resuscitation. Nonshockable rhythm cardiac arrest is commoner suggesting a non-cardiac cause while cardiac related etiology is uncommon. Future studies are needed to improve the survival in these patients.

Outcomes of intravascular ultrasound versus optical coherence tomography guided percutaneous coronary angiography: A meta regression-based analysis.

BACKGROUND: Studies comparing clinical outcomes with intravascular ultrasound (IVUS) versus optical coherence tomography (OCT) guidance for percutaneous coronary intervention (PCI) in patients presenting with coronary artery disease, including stable angina or acute coronary syndrome, are limited. METHODS: We performed a detailed search of electronic databases (PubMed, Embase, and Cochrane) for randomized controlled trials and observational studies that compared cardiovascular outcomes of IVUS versus OCT. Data were aggregated for the primary outcome measure using the random-effects model as pooled risk ratio (RR). The primary outcome of interest was major adverse cardiac events (MACE), cardiac mortality, and all-cause mortality. Secondary outcomes included myocardial infarction (MI), stent thrombosis (ST), target lesion revascularization (TLR), and stroke. RESULTS: A total of seven studies met the inclusion criteria, comprising 5917 patients (OCT n = 2075; IVUS n = 3842). OCT-PCI versus IVUS-guided PCI comparison yielded no statistically significant results for all the outcomes; MACE (RR 0.78; 95% confidence interval [CI], 0.57-1.09; p = 0.14), cardiac mortality (RR 0.97; 95% CI, 0.27-3.46; p = 0.96), all-cause mortality (RR 0.74; 95% CI, 0.39-1.39; p = 0.35), MI (RR 1.27; 95% CI, 0.52-3.07; p = 0.60), ST (RR 0.70; 95% CI, 0.13-3.61; p = 0.67), TLR (RR 1.09; 95% CI, 0.53-2.25; p = 0.81), and stroke (RR 2.32; 95% CI, 0.42-12.90; p = 0.34). Furthermore, there was no effect modification on meta-regression including demographics, comorbidities, lesion location, lesion length, and stent type. CONCLUSIONS: In this meta-analysis, OCT-guided PCI was associated with no difference in clinical outcomes compared with IVUS-guided PCI.

Safety and efficacy of drug-coated balloon for peripheral artery revascularization-A systematic review and meta-analysis.

BACKGROUND: The relative merits of the drug-coated balloon (DCB) versus uncoated balloon (UCB) angioplasty in endovascular intervention for patients with symptomatic lower extremity peripheral arterial disease (PAD) remains controversial. METHODS: Online databases were queried with various combinations of keywords to identify relevant articles. Net adverse events (NAEs) and its components were compared using a random effect model to calculate unadjusted odds ratios (ORs). RESULTS: A total of 26 studies comprising 26,845 patients (UCB: 17,770 and DCB: 9075) were included. On pooled analysis, DCB was associated with significantly lower odds of NAE (OR: 0.47, 95% confidence interval [CI]: 0.36-0.61), vessel restenosis (OR: 0.46, 95% CI: 0.37-0.57), major amputation (OR: 0.68, 95% CI: 0.47-99), need for repeat target lesion (OR: 0.38, 95% CI: 0.31-0.47) and target vessel revascularization (OR: 0.62, 95% CI: 0.47-0.81) compared with UCB. Similarly, the primary patency rate was significantly higher in patients undergoing DCB angioplasty (OR: 1.44, 95% CI: 1.19-1.75), while the odds for all-cause mortality (OR: 0.96, 95% CI: 0.85-1.09) were not significantly different between the two groups. A subgroup analysis based on follow-up duration (6 months vs. 1 vs. 2 years) followed the findings of the pooled analysis with few exceptions. CONCLUSIONS: The use of DCB in lower extremity PAD intervention is associated with higher primary patency, lower restenosis, lower amputation rate, and decreased need for repeat revascularization with similar all-cause mortality as compared to UCB.

Trends and causes of readmission following peripheral vascular intervention in patients with peripheral vascular disease.

OBJECTIVES: To study the risk factors associated with 30-readmission postperipheral vascular intervention (PVI) in peripheral artery disease (PAD). BACKGROUND: There has been a paucity of data regarding the trend and predictors of PVI readmission. METHODS: We performed an observational cohort study of patients admitted with peripheral vascular disease for PVI using the NRD for the years 2010-2014. PVI was defined as angioplasty, atherectomy, and/or stenting of lower limb vessels. RESULTS: A total of 453,278 patients (30-day readmission n = 97,235). The mean age of study population was 68.6 ± 12.2 years and included 43.8% women. The 30-day readmission post-PVI was 21.5% (p = .034). Cardiovascular causes constitute 44% of readmission. Chronic limb ischemia and intermittent claudication were two most common cardiovascular causes constituting 11.7 and 4.9% cases of readmissions. Other cardiac causes of readmissions included heart failure (4.64%), dysrhythmias (1.4%), and acute myocardial infarction (1.7%). The high-risk factors for of all-cause 30-day readmission were hypertension, CLI, diabetes, renal failure, dyslipidemia, smoking, chronic pulmonary disease, and atrial fibrillation (p < .005). Length-of-stay was greater than 5 days for 56.2 and 75.4% paid by Medicare. CONCLUSIONS: Our study shows an average yearly readmission rate of 21.5% post-PVI. Chronic comorbidities and prolonged hospitalization were associated with higher risk of readmission.

Multiple unplanned readmissions after discharge for an admission with percutaneous coronary intervention.

OBJECTIVE: This study aims to describe temporal trends, characteristics, and clinical outcomes of patients with more than one unplanned readmission within 30 and 180 days after admission with percutaneous coronary intervention (PCI). BACKGROUND: There is limited understanding of multiple readmissions after PCI. METHODS: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for unplanned readmissions at 30 and 180 days after discharge. Trends in multiple readmissions, characteristics of patients, and causes of first readmissions are described. RESULTS: A total of 2,324,194 patients were included in the analysis of 30-day unplanned readmissions and 1,327,799 patients in the analysis of 180-day unplanned readmission. The proportions of patients with a single readmission and multiple readmissions within 30 days were 8.5 and 1.0% and at 180 days were 15.4 and 9.1%, respectively. Common reasons for first readmission among patients with multiple readmissions were coronary artery disease, including angina, heart failure, and acute myocardial infarction. Factors associated with multiple readmissions were discharge against medical advice, discharge to care home, renal failure, and liver failure. The total cost of multiple readmissions is significant, with an increase from ~$20,000 for no readmission to over $60,000 at 30-day follow up and $86,000 at 180-day follow up. CONCLUSIONS: Multiple readmissions are rare within 30 days after PCI but increase to nearly 1 in 10 patients at 180 days, and 20-25% of patients who have multiple readmissions are readmitted for the same cause as for the first and second readmissions.

Trends of repeat revascularization choice in patients with prior coronary artery bypass surgery.

OBJECTIVE: To examine rates and predictors repeat revascularization strategies (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]) in patients with prior CABG. METHODS: Using the National Inpatient Sample, patients with a history of CABG hospitalized for revascularization by PCI or CABG from January 2004 to September 2015 were included. Regression analyses were performed to examine predictors of receipt of either revascularization strategy as well as in-hospital outcomes. RESULTS: The rate of redo CABG doubled between 2004 (5.3%) and 2015 (10.3%). Patients who underwent redo CABG were more comorbid and experienced significantly worse major adverse cardiovascular and cerebrovascular events (odds ratio [OR]: 5.36 95% CI 5.11-5.61), mortality (OR 2.84 95% CI 2.60,-3.11), bleeding (OR 5.97 95% CI 5.44-6.55) and stroke (OR 2.15 95% CI 1.92-2.41), but there was no difference in cardiac complications between groups. Thoracic complications were high in patients undergoing redo CABG (8%), especially in females. Factors favoring receipt of redo CABG compared to PCI included male sex, age < 80 years, and absence of diabetes and renal failure. CONCLUSION: Reoperation in patients with prior CABG has doubled in the United States over a 12-year period. Patients undergoing redo CABG are more complex and associated with worse clinical outcomes than those receiving PCI.

In-hospital outcomes of endovascular versus surgical revascularization for chronic total occlusion in peripheral artery disease.

BACKGROUND: The outcome of endovascular intervention (EVI) compared vs. surgical revascularization in patients with peripheral artery disease (PAD) due to chronic total occlusion (CTO) is unknown. METHODS: Using the National Inpatient Sample database between 2007 and 2014, we identified all PAD patients with CTO who had limb revascularization. Multivariate analysis was performed to estimate the odds of in-hospital mortality and adverse outcomes between both groups. RESULTS: A total of 168,420 patients who had peripheral CTO and underwent limb revascularization were identified. 99,279 underwent EVI, and 69,141 underwent surgical revascularization. The patients who underwent EVI were younger, more likely to be women and African American, and less likely to be white (p < 0.001 for all). EVI was associated with lower in-hospital mortality (1.2% vs 1.7%, adjusted odds ratio [aOR]: 0.54; 95% confidence interval [CI] 0.50-0.59). The EVI group had higher vascular complications, major bleeding, acute kidney injury (AKI), and major amputation compared with surgical revascularization. A subgroup analysis on patients with critical limb ischemia showed lower mortality in the EVI group (1.4% vs. 1.9, aOR 0.56; 95% CI 0.50-0.63). Although there was no difference in the incidence of AKI or major amputation between the two groups, the EVI group had higher vascular complication rates and major bleeding events. CONCLUSION: EVI in PAD with CTO is associated with lower in-hospital mortality, likely due to the procedure's less-invasive nature; however, it is associated with higher postprocedural complications likely due to the CTO's complexity.

Safety and efficacy of the polymer-free and polymer-coated drug-eluting stents in patients undergoing percutaneous coronary intervention.

INTRODUCTION: The relative safety and efficacy of polymer-free (PF) versus polymer-coated (PC) drug-eluting stents (DES) in patients with angina or acute coronary syndrome (ACS) undergoing percutaneous coronary intervention has received limited study. METHOD: Digital databases were queried to identify relevant studies. Major adverse cardiovascular events (MACE) and secondary outcomes were compared using a random effect model to calculate unadjusted odds ratios (OR). RESULTS: A total of 28 studies consisting of 23,198 patients were included in the final analysis. On pooled analysis, there was no significant difference in the odds of MACE (OR 0.98, 95% CI 0.91-1.08) and major bleeding (OR 0.87, 95% CI 0.61-1.24) between patients undergoing PF-DES versus PC-DES. Similarly, the odds of myocardial infarction, stroke, stent thrombosis, cardiovascular mortality and need for target vessel revascularization was similar between the two groups. PF-DES was favored due to significantly lower odds of non-cardiac death (OR 0.78, 95% CI 0.68-89) and all-cause mortality (OR 0.87, 95% CI 0.80-0.95), but had a higher need for target lesion revascularization (OR 1.2, 95% CI 1.02-1.42). A subgroup analysis based on follow up duration, clinical presentation, presence of diabetes and class of eluting drugs mirrored the net estimates for all outcomes with a few exceptions. A sensitivity and meta-regression analysis showed no influence of single-study and duration of antiplatelet therapy on pooled outcomes. CONCLUSION: In patients presenting with angina or ACS, PF-DES might be favored due to lower all-cause mortality and equal risk of ischemic adverse cardiovascular and major bleeding events compared with PC-DES.

Temporal trends and outcomes in utilisation of transcatheter and surgical aortic valve therapies in aortic valve stenosis patients with heart failure.

INTRODUCTIONS & AIMS: Heart failure (HF) is a common comorbidity in patients undergoing surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). We sought to access the temporal trends and outcomes of TAVR or SAVR in HF patients. METHOD: The NIS database from 2011-2014 was queried for patients that underwent TAVR or SAVR and were subsequently diagnosed with HF. Temporal trends in the utilisation of TAVR or SAVR in HF patients were analysed. RESULTS: Among 27 982 patients who were diagnosed with HF of whom 17 681 (63.2%) had heart failure with reduced ejection fraction (HFrEF) while 10 301 (36.8%) had heart failure with preserved ejection fraction (HFpEF), 9049 (32.3%) underwent TAVR and 16 933 (76.7%) underwent SAVR. Patients with HFrEF and HFpEF had higher utilisation of TAVR compared with SAVR over the course of the study period (P trend < .001). TAVR was associated with lower mortality [2.8% in 2012 and 1.8% in 2014 (P .013)] compared with SAVR. Similarly, multiple logistic regression showed a statistically significant lower in-hospital mortality in the TAVR group compared with SAVR (aOR 0.634; CI 0.504, 0.798, P < .001). CONCLUSION: For patients with severe aortic valve stenosis and heart failure who undergo aortic valve intervention, TAVR is associated with less odds of in-hospital mortality compared with SAVR.

Outcomes of nonemergent percutaneous coronary intervention requiring mechanical circulatory support in patients without cardiogenic shock.

BACKGROUND: The utilization of mechanical circulatory support (MCS) for percutaneous coronary intervention (PCI) using percutaneous ventricular assist device (PVAD) or intra-aortic balloon pump (IABP) has been increasing. We sought to evaluate the outcome of coronary intervention using PVAD compared with IABP in noncardiogenic shock and nonacute myocardial infarction patients. METHOD: Using the National Inpatient Sampling (NIS) database from 2005 to 2014, we identified patients who underwent PCI using ICD 9 codes. Patients with cardiogenic shock, acute coronary syndrome, or acute myocardial infarction were excluded. Patient was stratified based on the MCS used, either to PVAD or IABP. Univariate and multivariate logistic regression were performed to study PCI outcome using PVAD compared with IABP. RESULTS: Out of 21,848 patients who underwent PCI requiring MCS, 17,270 (79.0%) patients received IABP and 4,578 (21%) patients received PVAD. PVAD patients were older (69 vs. 67, p < .001), were less likely to be women (23.3% vs. 33.3%, p < .001), and had higher rates of hypertension, diabetes, hyperlipidemia prior PCI, prior coronary artery bypass graft surgery, anemia, chronic lung disease, liver disease, renal failure, and peripheral vascular disease compared with IABP group (p ≤ .007). Using Multivariate logistic regression, PVAD patients had lower in-hospital mortality (6.1% vs. 8.8%, adjusted odds ratio [aOR] 0.62; 95% CI 0.51, 0.77, p < .001), vascular complications (4.3% vs. 7.5%, aOR 0.78; 95% CI 0.62, 0.99, p = .046), cardiac complications (5.6% vs. 14.5%, aOR 0.29; 95% CI 0.24, 0.36, p < .001), and respiratory complications (3.8% vs. 9.8%, aOR 0.37; 95% CI 0.28, 0.48, p < .001) compared with patients who received IABP. CONCLUSION: Despite higher comorbidities, nonemergent PCI procedures using PVAD were associated with lower mortality compared with IABP.

In-hospital outcome of peripheral vascular intervention in dialysis-dependent end-stage renal disease patients.

BACKGROUND: The impact of end-stage renal disease (ESRD) on peripheral vascular intervention (PVI) outcome remains incompletely elucidated. OBJECTIVES: We sought to compare the outcome of PVI in dialysis patients with those with normal kidney function. METHODS: Using weighted data from the National Inpatient Sample database between 2002 and 2014, we identified all peripheral artery disease (PAD) patients aged ≥18 years that underwent PVI. Multivariate logistic regression analysis was performed to examine in-hospital outcomes. RESULTS: Of 1,186,192 patients who underwent PVI, 1,066,830 had normal kidney function (89.9%) and 119,362 had ESRD requiring dialysis (10.1%). Critical limb ischemia was more prevalent in dialysis patients (63.2 vs. 34.0%, p < .001). Compared with normal kidney function group, ESRD requiring dialysis was associated with higher in-hospital mortality (1.5 vs. 4.2%, adjusted OR: 2.13 [95% CI: 2.04-2.23]) and longer length of hospital stay (median 3 days, Interquartile range [IQR] (0-6) vs. 7 days, IQR (4-18); p < .001). Dialysis patients had higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke; 14.3 vs. 9.8%, p < .001) and net adverse cardiovascular events (composite of MACE, major bleeding, or vascular complications; 40.8 vs. 29.1%, p < .001). ESRD patients less frequently underwent open bypass (5.6 vs. 8.5%, p < .001) and more frequently had major amputation (10.3 vs. 3.0%, p < .001) compared with normal kidney function group. CONCLUSION: PAD patients on dialysis who underwent PVI have higher rates of mortality and adverse outcomes as compared to those with normal kidney function.

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.

Percutaneous Intervention or Bypass Graft for Left Main Coronary Artery Disease? A Systematic Review and Meta-Analysis.

BACKGROUND: The safety and efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for stable left main coronary artery disease (LMCAD) remains controversial. METHODS: Digital databases were searched to compare the major adverse cardiovascular and cerebrovascular events (MACCE) and its components. A random effect model was used to compute an unadjusted odds ratio (OR). RESULTS: A total of 43 studies (37 observational and 6 RCTs) consisting of 29,187 patients (PCI 13,709 and CABG 15,478) were identified. The 30-day rate of MACCE (OR, 0.56; 95% CI, 0.42-0.76; p = 0.0002) and all-cause mortality (OR, 0.52; 95% CI, 0.30-0.91; p = 0.02) was significantly lower in the PCI group. There was no significant difference in the rate of myocardial infarction (MI) (p = 0.17) and revascularization (p = 0.12). At 5 years, CABG was favored due to a significantly lower rate of MACCE (OR, 1.67; 95% CI, 1.18-2.36; p = <0.04), MI (OR, 1.67; 95% CI, 1.35-2.06; p = <0.00001), and revascularization (OR, 2.80; 95% CI, 2.18-3.60; p = <0.00001), respectively. PCI was associated with a lower overall rate of a stroke, while the risk of all-cause mortality was not significantly different between the two groups at 1- (p = 0.75), 5- (p = 0.72), and 10-years (p = 0.20). The Kaplan-Meier curve reconstruction revealed substantial variations over time; the 5-year incidence of MACCE was 38% with CABG, significantly lower than 45% with PCI (p = <0.00001). CONCLUSION: PCI might offer early safety advantages, while CABG provides greater durability in terms of lower long-term risk of ischemic events. There appears to be an equivalent risk for all-cause mortality.

National trends of acute pericarditis post-atrial fibrillation ablation.

BACKGROUND: Atrial fibrillation ablation increased over the last two decades by its high success rate. However, the trend of inpatient adverse outcomes is limited. The aim of this study to examine the frequency and predictors of acute pericarditis resulting from catheter ablation. METHODS: Using the National Inpatient Sample, we identified all patients who underwent AF ablation. Univariate and multivariate logistic regressions were performed for the primary outcome of in-hospital acute pericarditis post-AF ablation. Variance-weighted regression has been used to test for linear and curvilinear trends in disease characteristics and outcomes over time. RESULTS: From 2002 to 2014, our study included 122,993 patients, acute pericarditis was found in 984 (0.8%) patients who underwent AF ablation. The trend of acute pericarditis showed inconsistent fluctuation leaning towards reduction over the years. Multivariate analysis showed that patients of female gender are at a 40% higher risk of acute pericarditis post-ablation compared with males. Additionally, obese patients have a 40% higher risk of developing acute pericarditis compared with patients who have BMI < 30. Furthermore, anaemia and rheumatoid arthritis have the odds ratio (OR: 2.63; 95% [CI] 2.04-3.39) and (OR: 1.64; 95% [CI] 1.08-2.48). CONCLUSION: Post-AF ablation, in-hospital acute pericarditis showed inconsistent fluctuation leaning towards reduction. Female gender and obesity are at higher risk for developing acute pericarditis post-AF ablations. Proper evaluation might alter those complications.

Rates, predictors and the impact of cannabis misuse on in-hospital outcomes among patients undergoing percutaneous coronary intervention (from the National Inpatient Sample).

BACKGROUND: Whether cannabis use worsens outcomes in coronary heart disease is unknown and no previous study has evaluated the outcomes for patients who undergo percutaneous coronary intervention (PCI) according to cannabis use. METHODS: We analysed patients in the National Inpatient Sample between 2004 and 2014 who underwent PCI and evaluated rates, predictors and outcomes of patients according to cannabis misuse defined by cannabis abuse or dependence. RESULTS: A total of 7 306 012 patients were included and 32 765 cannabis misusers (0.4%). Cannabis misusers were younger (49.5 vs 64.6 years, P < .001) and were more likely to be male (82.7% vs 66.3%, P < .001). There was also a greater proportion of patients who were of black ethnicity in the cannabis misuse group (27.7% vs 7.9%, P < .001) and fewer elective admissions (7.8% vs 27.6%, P < .001). There was no difference in in-hospital mortality (OR 1.06 95% CI 0.80-1.40, P = .67), bleeding (OR 0.94 95% CI 0.77-1.15, P = .55) and stroke/transient ischaemic attack (OR 1.19 95% CI 0.98-1.45, P = .084) compared with non-cannabis misusers. Cannabis misusers had significantly lower odds of in-hospital vascular complications (OR 0.73 95% CI 0.58-0.90, P = .004). CONCLUSIONS: Our results suggest that cannabis misusers are more likely to be male, of black ethnicity and from the lowest quartile of income, but there was no evidence that cannabis misuse is associated with worse periprocedural outcomes following PCI when controlling for key proxies of health status.

Ex-vivo percutaneous bypass: Limb perfusion in the setting of occlusive large bore sheath.

Successful cardiac catheterization procedure begins with safe vascular access and ends with effective hemostasis after equipment removal. These new and advanced technologies in the cath lab require large-bore arterial accesses. Large-bore sheaths are associated with blood flow obstruction resulting in limb ischemia. In this case we present a 48-year-old woman was admitted NSTEMI and cardiogenic shock requiring mechanical circulatory support. Selective left common iliac angiography demonstrated obstructive flow at the level of the left CFA (access site). Therefore, ipsilateral bypass circuit was done. The current case illustrates the utility of a temporary ex-vivo bypass circuit to preserve limb perfusion in the presence of an occlusive large bore sheath. The technique permits sufficient hemodynamic support while maintaining limb perfusion and can be used for any occlusive large bore sheath.

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.