Relationship between brain natriuretic peptides and recurrence of atrial fibrillation after successful direct current cardioversion: a meta-analysis.

BACKGROUND: Atrial fibrillation (AF) recurrence is common after successful direct current cardioversion (DCCV), with a 40% rate of recurrence within the first month. Several studies have investigated the potential association between brain natriuretic peptide (BNP) or N-terminal (NT)-proBNP levels before DCCV and the risk of AF recurrence, but results have been inconsistent. We, therefore, conducted a systematic review and meta-analysis of all available data to determine whether sinus rhythm (SR) maintenance after successful DCCV may be determined by preprocedural BNP and NT-proBNP levels. METHODS: We systematically searched Scopus, the Cochrane library, EMBASE, and MEDLINE databases to identify publications evaluating BNP or NT-proBNP levels in relation to post-DCCV AF recurrence, indexed from inception to September 2013. Among the initial 1,067 citations, 18 studies fulfilled the specified criteria. The difference in BNP and NT-proBNP concentrations in the AF recurrence and the SR-maintaining group was estimated by the standardized mean difference and the estimates of the pooled outcomes were evaluated using random-effects models. RESULTS: Baseline BNP levels in the AF recurrence group were significantly higher compared to BNP levels in the SR-maintaining group (standardized mean difference [SMD] -1.51, confidence interval [CI] [-2.53, -0.48], P = 0.004). Similar results were observed for NT-proBNP levels, which were significantly higher in the AF recurrence group compared with the SR-maintaining group (SMD -0.63, CI [-1.13, -0.14], P = 0.01). CONCLUSIONS: Our analysis suggests that low preprocedural BNP/NT-proBNP levels are associated with SR maintenance. The use of BNP or NT-proBNP for prediction of long-term response to DCCV appears to be useful and should be further evaluated.

Regular tachycardia terminated by ventricular anti-tachycardia pacing in an ICD recipient. What is the mechanism?

This is the case of a misdiagnosed atrioventricular nodal reentry tachycardia (AVNRT) with occasionally 2:1 atrioventricular block terminated by delivery of an inappropriate ventricular antitachycardia pacing scheme, in an ICD recipient. The detailed analysis of stored electrograms facilitated the revelation of the arrhythmic mechanism.

Pseudo-polymorphic Ventricular Tachycardia in a 12-lead Holter Recording.

We present an image of pseudo-polymorphic ventricular tachycardia recording on a 12-lead surface ECG Holter. Although at first glance the appearance of the recording resembled polymorphic ventricular tachycardia, careful investigation revealed normal electrocardiographic findings.

Do the Kinetics of Antibody Responses Predict Clinical Outcome in Hospitalized Patients With Moderate-to-Severe COVID-19?

BACKGROUND/AIM: The relationship between the kinetics of antibody responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the severity of Coronavirus Disease 2019 (COVID-19) is poorly understood. The aim of the present study was to investigate whether serum SARS-CoV-2 antibody kinetics serve as an early predictor of clinical deterioration or recovery in hospitalized patients with COVID-19. PATIENTS AND METHODS: In this prospective observational study, 102 consecutive patients (median age: 60 years, 58% males) with symptomatic COVID-19 infection diagnosed by real-time polymerase chain reaction assay, hospitalized in two tertiary hospitals, were included. Rapid test for qualitative detection of immunoglobulin M (IgM) and immunoglobulin G (IgG) SARS-CoV-2 antibodies was performed at pre-defined time intervals during hospitalization (days: 0, 3, 7, 10, 14, 21 and 28). RESULTS: During a 3-month follow-up period after COVID-19 disease onset, a total of 87 patients were discharged, 12 patients were intubated and entered the Intensive Care Unit, and three patients died. The median time for seroconversion was 10 days for IgM and 12 days for IgG post onset of symptoms. Univariate logistic regression analysis found no associations between IgM or IgG positivity and clinical outcomes or complications during hospitalization for COVID-19 infection. Diabetes and dyslipidemia were the only clinical risk factors predictive of COVID-19-related complications during hospitalization. CONCLUSION: SARS-CoV-2 antibody responses do not predict clinical outcome in hospitalized patients with moderate-to-severe COVID-19 infection.

Remdesivir-induced Bradycardia is not Associated with Worse Outcome in Patients with COVID-19: A Retrospective Analysis.

BACKGROUND: COVID-19, is primarily a respiratory illness but is known to cause extrapulmonary manifestations, especially on the cardiovascular system. Bradycardia is commonly reported in COVID-19 patients despite no prior history of occurrence, and many studies have shown an association with increased mortality. Multiple case reports have been published showcasing remdesivir potentially causing bradycardia. Our aim was to investigate the incidence of bradycardia in patients receiving remdesivir and examine the association with disease severity and survival outcomes. METHODS: A retrospective study was performed including 160 COVID-19 patients receiving remdesivir for 5 days. Patients' demographics, comorbidities, medication, vital signs, laboratory tests and outcome were recorded. Bradycardia was defined as a heart rate < 60 beats/min and severe bradycardia < 50 beats/min. RESULTS: One hundred eighteen (73.8%) patients experienced at least one episode of bradycardia during hospitalisation. Bradycardia was present in 12 (7.5%) patients before treatment with remdesivir. The rate of bradycardia increased up to the 6th day of hospitalisation (40.6%) and subsequently diminished and normalised within 5 days after the last remdesivir dose (5% at Day 10). Severe bradycardia was observed in 13 (7.5%) patients. No difference was observed in ICU admission between groups (bradycardia vs no bradycardia). When we stratified patients according to the outcome of hospitalisation, no significant difference was observed in the occurrence of bradycardia between groups (alive vs dead) [p = 0.853]. CONCLUSIONS: Treatment with remdesivir may be associated with new-onset bradycardia in hospitalised patients with COVID-19. However, bradycardia is transient and is not associated with ICU admission and mortality.

Chronic skeletal muscle ischemia preserves coronary flow in the ischemic rat heart.

Chronic skeletal muscle ischemia confers cytoprotection to the ventricular myocardium during infarction, but the underlying mechanisms remain unclear. Although neovascularization in the left ventricular myocardium has been proposed as a possible mechanism, the functional capacity of such vessels has not been studied. We examined the effects of chronic limb ischemia on infarct size, coronary blood flow, and left ventricular function after ischemia-reperfusion. Hindlimb ischemia was induced in 65 Wistar rats by excision of the left femoral artery, whereas 65 rats were sham operated. After 4 wk, myocardial infarction was generated by permanent coronary artery ligation. Infarct size was measured 24 h postligation. Left ventricular function was evaluated in isolated hearts after ischemia-reperfusion, 4 wk after limb ischemia. Neovascularization was assessed by immunohistochemistry, and coronary flow was measured under maximum vasodilatation at different perfusion pressures before and after coronary ligation. Infarct size was smaller after limb ischemia compared with controls (24.4 ± 8.1% vs. 46.2 ± 9.5% of the ventricle and 47.6 ± 8.7% vs. 80.1 ± 9.3% of the ischemic area, respectively). Indexes of left ventricular function at the end of reperfusion (divided by baseline values) were improved after limb ischemia (developed pressure: 0.68 ± 0.06 vs. 0.59 ± 0.05, P = 0.008; maximum +dP/dt: 0.70 ± 0.08 vs. 0.59 ± 0.04, P = 0.004; and maximum -dP/dt: 0.86 ± 0.14 vs. 0.72 ± 0.10, P = 0.041). Coronary vessel density was markedly higher (P = 0.00021) in limb ischemic rats. In contrast to controls (F = 5.65, P = 0.00182), where coronary flow decreased, it remained unchanged (F = 1.36, P = 0.28) after ligation in limb ischemic rats. In conclusion, chronic hindlimb ischemia decreases infarct size and attenuates left ventricular dysfunction by increasing coronary collateral vessel density and blood flow.

Distal Radial Access: A Review Article.

Transradial approach (TRA) for coronary angiography and interventions has been increasingly used over the last decades and has become the default strategy in the majority of catheterization laboratories worldwide. Recently, a novel transradial access site, the distal radial access (DRA), has been proposed as an alternative to traditional TRA. Several case reports and case series have been published on this new approach over the last year showing overall good success rates. Aim of this review is to present the possible benefits and drawbacks of DRA and offer guidance on its successful use.

Optimal Treatment Strategy for Coronary Artery Stenoses with Grey Zone Fractional Flow Reserve Values. A Systematic Review and Meta-Analysis.

OBJECTIVES: We conducted a review and meta-analysis of published data to compare revascularization to deferral strategy for coronary lesions with grey zone fractional flow reserve (FFR). BACKGROUND: Optimal treatment for coronary stenoses with FFR values between 0.75 and 0.80, the so-called grey zone, remains a matter of debate. METHODS: We included all studies evaluating revascularization versus deferral for lesions with grey zone FFR. The primary outcome was study-defined major adverse cardiac events (MACE). Secondary outcomes were the composite of death or MI and target vessel revascularization (TVR). A total of 2362 patients were included, of whom 1181 underwent revascularization (revascularization group) and 1181 received medical treatment only (deferral group). RESULTS: After a mean follow-up period of 2.4 years, no difference was found for the primary outcome of the study-defined MACE between the two groups [RR = 1.33 (0.73-2.44), p = 0.35]. In addition, there was no difference for the secondary outcomes of death or MI and TVR between the two groups [RR = 1.39 (0.56-3.47), p = 0.48 and RR = 1.49 (0.89-2.51), p = 0.13, respectively]. CONCLUSIONS: In this meta-analysis revascularization of coronary stenoses with grey zone FFR showed no advantage over a deferral strategy in terms of study-defined MACE. Case by case judgment should be implemented to guide treatment in this special subset of patients.

Distal Versus Traditional Radial Approach for Coronary Angiography.

PURPOSE: The aim of this study was to evaluate the efficacy and safety of distal radial (DR) versus traditional radial (TR) approach during coronary angiography. METHODS: Two hundred patients scheduled to undergo transradial coronary angiography were randomized between the two approaches. Primary endpoint of the study was switching to another access site due to inability of successful target artery cannulation. Secondary endpoints were time to cannulation, total procedure duration, number of attempts, number of skin punctures and duration of manual hemostasis. Secondary safety endpoints were the rate of moderate or severe spasm, arm hematoma EASY class III or more and radial artery occlusion at discharge. Quality of life endpoint was the patient's preference of cannulation method at 30 days. RESULTS: The primary endpoint was met in 30 patients (30%) from the DR group and 2 patients (2%) from the TR group (p < 0.001). The time of cannulation was longer in the DR group compared to the TR group (269 ±â€¯251 s vs 140 ±â€¯161 s, p < 0.001), but this did not affect the total procedural duration (925 ±â€¯896 s vs 831 ±â€¯424 s, p = 0.494). The number of attempts and the number of skin punctures were more in the DR group compared to the TR group (6.8 ±â€¯6.2 vs 3.4 ±â€¯4.5, p < 0.001 and 2.4 ±â€¯1.7 vs 1.6 ±â€¯1.2, p < 0.001, respectively). However, DR treated patients had faster manual hemostasis time compared to TR treated patients (568 ±â€¯462 s vs 841 ±â€¯574 s, p = 0.002). There were no differences recorded in the safety endpoints of moderate or severe spasm, EASY grade III or more radial hematomas or the incidence of radial artery occlusion after the procedure. Patients' preference to the randomized puncture sites was the same (79% vs 85%, p = 0.358). CONCLUSION: Distal radial approach is associated with lower successful cannulation rates and shorter manual hemostasis time compared to the traditional radial approach.

Forearm Versus Femoral Approach for Cardiac Catheterization in End-Stage Renal Disease Patients.

BACKGROUND: End-stage renal disease (ESRD) is considered a relative contraindication for forearm (radial or ulnar) cardiac catheterization. However, in everyday practice, many ESRD patients are catheterized from the forearm. The aim of this study was to compare femoral and forearm approach for cardiac catheterization in ESRD patients. METHODS: All cardiac catheterization procedures performed in ESRD patients in three Greek hospitals in a 2-year period (2014-2015) were retrospectively evaluated. The primary endpoint of the study was major access-site complication, defined as any Blood Academic Research Consortium class ≥3 bleeding or limb ischemia requiring intervention or prolonging hospitalization. RESULTS: During the study period, a total of 124 procedures were performed in 109 ESRD patients: 44 procedures (35.5%) were performed transfemorally and 80 procedures (64.5%) were performed from the forearm approach (77 transradial [96.3%] and 3 transulnar [3.7%]). Forearm access was always performed from the contralateral arm of a functional hemodialysis access site. Sixty-one procedures (49.6%) were diagnostic coronary artery angiographies (CAAs) and 63 procedures (50.4%) were percutaneous coronary interventions with or without CAA. Two deaths and 1 procedure-related myocardial infarction were recorded during hospitalization. Five patients suffered major access-site complications, all from the femoral group (5/44 vs 0/80; P<.01). Three transradial patients had asymptomatic radial artery occlusion after a diagnostic procedure. Five patients (4.0%) had problems with their hemodialysis access site during long-term follow-up, and required a new access site. CONCLUSION: Forearm approach for cardiac catheterization is feasible and safe in ESRD patients. All measures to preserve radial patency should be taken in this high-risk patient group, where a possible forearm artery occlusion might have serious consequences.

The Rise and Fall of Anticoagulation with Bivalirudin During Percutaneous Coronary Interventions: A Review Article.

Bivalirudin is a direct thrombin inhibitor used during percutaneous coronary intervention (PCI). Treatment with bivalirudin compared to heparin plus glycoprotein IIb/IIIa inhibitors (GPI) reduced bleeding complications, but resulted in higher rates of ischemic events, including acute stent thrombosis in ST segment elevation myocardial infarction (STEMI) patients. Thus, it may be considered a reasonable alternative antithrombotic agent in patients at high risk of bleeding undergoing PCI. However its superiority over heparin alone is questioned particularly in the era of novel antiplatelet agents and transradial PCI.

Undilatable Stent Neoatherosclerosis Treated with Ad Hoc Rotational Atherectomy.

A middle age woman with known ischemic heart disease and old stents in proximal left anterior descending coronary artery (LAD) was admitted to Coronary Care Unit with acute coronary syndrome. The coronary angiography showed one vessel disease with significant restenosis within the previously implanted stents. The lesion was tough and remained undilatable despite high pressure balloon inflation. Eventually, the balloon ruptured creating a massive dissection of the LAD beginning immediately after the distal part of the undilatable lesion. We proceeded with a challenging ad hoc rotational atherectomy of the lesion and finally stenting of the lesion. In-stent restenosis many years after stent implantation is considered to be mainly due to neoatheromatosis compared to intimal hyperplasia, making lesion treatment more difficult and unpredictable.

Transulnar approach for coronary catheterization in patients with a harvested ipsilateral radial artery: A case series.

Forearm approach for coronary catheterization is associated with better outcomes, compared to the femoral approach. However, the possibility of post catheterization forearm artery occlusion is a medical concern, which leads many patients to be treated transfemorally. We present a case series of patients who had a harvested radial artery and were successfully catheterized from ipsilateral ulnar artery without any complications recorded.

Guide extension catheter stepwise advancement facilitated by repeated distal balloon anchoring.

Coronary stent delivery can be extremely challenging in tortuous and calcified lesions especially when radial approach is chosen. Guide extension catheter is a useful tool for overcoming the inherent difficulties arising by the use of radial access in complex percutaneous interventions. We describe a technique for guide extension catheter system advancement by presenting two cases. This was performed stepwise by repeated distal balloon anchoring in the coronary artery of interest.

A systematic review on the safety of Prostar XL versus ProGlide after TAVR and EVAR.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) and transfemoral transcatheter aortic valve replacement (TAVR) are widely spreading minimally invasive procedures performed mainly through the femoral artery. Prostar XL and ProGlide vascular closure devices are used in clinical practice for the hemostasis in these procedures and they have been shown to be safe and effective. PURPOSE: The aim of our systematic review is to compare the safety of these two devices for percutaneous closure of large arteriotomies in patients undergoing TAVR and EVAR. METHODS: We searched PubMed, EMBASE, Google Scholar and the Cochrane Central Register of Controlled Trials for all randomized and observational published studies that compared Prostar XL vs. ProGlide. Relative risk was calculated by random-effects model. Review Manager 5.1 was used for statistical analysis. RESULTS: A total number of 2909 patients were included in our analysis. The rate of overall vascular complications did not differ between Prostar XL and ProGlide {RR 1.35 (0.80-2.29), p=0.27}. In contrary, the risk ratio of all bleeding complications with Prostar XL compared to ProGlide was 1.82 (1.47-2.24, p<0.001) and for major and life-threatening bleeding complications was 2.48 (1.65-3.73, p<0001, suggesting a lower bleeding risk with ProGlide). No statistical difference was found between groups for end-stage acute kidney injury (AKI), with a risk ratio of 2.14 (0.81-5.66), p=0.05. Finally, there were no differences in in-hospital and 30-days mortality rate between the two groups (1.41, 0.56-3.54, p=0.46 and 1.43, 0.55-3.73, p=0.47, respectively). CONCLUSIONS: Prostar XL is associated with greater risk of any bleeding as well as life threatening bleeding compared to the ProGlide device. However, no significant differences were observed in the rate of overall vascular complications, end stage AKI and in-hospital and 30-days mortality.

Feasibility and safety of same-day discharge after complex percutaneous coronary intervention using forearm approach.

OBJECTIVES: We sought to assess the feasibility and safety of same-day discharge (SDD) after complex percutaneous coronary intervention (PCI) using a forearm approach. BACKGROUND: SDD has been shown to be safe after elective, low-risk PCI. However, the feasibility and safety of SDD in more complex patients and lesions has received limited study. METHODS: We retrospectively reviewed 1190 elective PCIs that were performed between January 2013 and December 2015 at the Red Cross General Hospital. RESULTS: Of the 1190 PCIs, 166 (13.9%) were complex (bifurcations, vein and arterial grafts, unprotected left main, last remaining vessel, chronic total occlusions, or with utilization of rotational atherectomy or hemodynamic support). As compared with non-complex cases, complex cases were associated with older age, male gender, higher prevalence of diabetes mellitus and prior coronary artery bypass graft surgery, lower prevalence of smoking, higher utilization of femoral access and 7F guiding catheters, higher contrast utilization and fluoroscopy dose, longer fluoroscopy time, more stents per lesion, more frequent single vessel treatment and non-complete revascularization, and treatment with ticagrelor and bivalirudin. Among the patients who underwent complex PCI (n=166), twenty eight (16.9%) were discharged the same day. SDD after complex PCI was associated with younger age and more frequent use of forearm access. The 30-day incidence of major adverse cardiac events after complex PCI was 0% vs 3.6% (p=0.59) in patients with SDD vs. overnight hospitalization. CONCLUSIONS: SDD is feasible and safe in selected patients undergoing elective complex PCI using the forearm approach.

Predictors of same day discharge after percutaneous coronary interventions.

OBJECTIVES: The aim of this study is to identify possible predictors for same day discharge (SDD) after percutaneous coronary interventions (PCI). BACKGROUND: Same day discharge after PCI is becoming more and more appealing and patient's selection criteria are being formulated. METHODS: A retrospective analysis was performed in all PCI procedures from January 2013 until December 2015. Patients were discharged the same day (SDD group) or had at least one overnight stay (non-SDD group). The decision of SDD or not was on treating physician discretion. We evaluated predictors of SDD decision by a logistic regression analysis. RESULTS: One thousand one hundred sixty eight procedures were performed from our department during the study period: 308 patients (26.4%) were discharged the same day (SDD group) and the rest 860 procedures (73.6%) had at least one overnight stay (non-SDD group). Multivariate analysis revealed that forearm approach (OR=5.498, CI: 2.067-14.629; p=<0.001), patient's residency proximal to the hospital (OR=4.543, CI: 2.406-8.580; p<0.001), completion of the procedure before 13,00p.m. (OR=3.437, CI: 1.789-0.6.601; p<0.001) and the success of the performed procedure (OR=1.125, CI 1.043-2.135; p=0.044) were positive predictors of SDD, while presentation with non-ST elevation myocardial infarction or unstable angina (OR=0.542, CI: 0.268-0.872; p<0.010) and amount of contrast used (OR=0.910, CI: 0.852-0.969; p<0.030) were negative predictors of SDD. CONCLUSION: In retrospect, both procedural and demographic details play a crucial role in patient selection for same day discharge post coronary percutaneous intervention.

Needle versus cannula over needle for radial artery cannulation during transradial coronary angiography and interventions.

PURPOSE: To evaluate the efficacy of radial artery cannulation with needle versus cannula over needle during transradial coronary angiography and intervention. METHODS: Five hundred patients scheduled to undergo transradial catheterization were randomized between the two methods. Primary endpoint of the study was the combined endpoint of switching to another access site due to inability of successful sheath insertion or switching to another method of cannulation (from needle to cannula over needle and vice versa). RESULTS: The primary end point was met in 12 patients (4.8%) from the needle group and 14 patients (5.6%) from the cannula over needle group (p=0.695). There were no differences in switching of cannulation method [10 (4.0%)% versus 11 (4.4%), p=0.831], switching of access site [6 (2.8%) versus 9 (3.6%), p=0.441), time for artery cannulation [1.20 (0.80-2.20) min versus 1.26 (1.01-2.39) min, p=0.152], total procedure time [15.05 (9.47-29.03) min versus 19.14 (10.13-32.02) min, p=0.112] number of attempts [2 (1-4) versus 2 (1-5), p=0.244] and number of skin punctures [1 (1-2) versus 1 (1-2), p=0.399] before successful radial artery cannulation. There were no differences recorded in the safety endpoints of EASY grade III or more radial hematomas [2 (0.8%) versus 1 (0.4%), p=1.000] or the incidence of radial artery occlusion after the procedure [9 (3.6% versus 16 (6.8%), p=0.358]. CONCLUSION: Radial artery cannulation with needle and cannula over needle seems to be equal in terms of efficacy and safety.

ULnar Artery Transient Compression Facilitating Radial Artery Patent Hemostasis (ULTRA): A Novel Technique to Reduce Radial Artery Occlusion After Transradial Coronary Catheterization.

AIMS: To evaluate the safety and efficacy of a novel technique with simultaneous compression of the ulnar artery in order to reduce the incidence of radial artery occlusion (RAO) after transradial cardiac catheterizations. METHODS AND RESULTS: Ipsilateral ulnar artery transient compression for 1 hour facilitating radial artery patent hemostasis (ULTRA) was performed in all patients treated transradially in October 2015 and was compared with patients treated with conventional patent hemostasis in September 2015. The primary endpoint of the study was to evaluate the incidence of RAO within 1 hour after removing the closure device, confirmed by the absence of palpation and the consecutive absence of flow signal with Doppler examination. A total of 119 patients were treated with the ULTRA method and 121 patients with conventional patent hemostasis. None of the patients treated with ULTRA had RAO compared with 6 patients (5%) of those treated with conventional patent hemostasis (P=.01). No hematomas EASY class ≥3, nerve injury, or ischemic pain complications were recorded in either group. CONCLUSION: The ULTRA technique may reduce the incidence of RAO in patients treated with the radial approach compared with conventional patent hemostasis.