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.

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement.

BACKGROUND: The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR). METHOD: Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in-hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility. RESULTS: A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in-hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392-0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group. CONCLUSION: In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

National outcomes of urgent vs. non-urgent percutaneous edge-to-edge transcatheter mitral valve repair.

Background: The current data regarding outcomes of transcatheter edge-to-edge mitral valve repair with the MitraClip system in the urgent setting has not been well described. Therefore, we sought to evaluate the outcomes of urgent MitraClip procedures compared with non-urgent ones. Method: The Nationwide Inpatient Sample database years 2011-2017 was used to identify hospitalizations for MitraClip in the urgent setting. Propensity score matching was used to compare the patients who underwent MitraClip in urgent versus non-urgent settings. Results: A total of 15,993 patients underwent the MitraClip procedures from 2011 to 2017. 3,929 (24.6%) were urgent and 12,064 (75.4%) were non-urgent. Patients in the urgent group were younger (75.08 vs 77.46) and more likely to be African American (p < 0.001). The urgent group had a higher burden of comorbidities such as diabetes, atrial fibrillation, renal failure and pulmonary circulatory disorders. Using multivariable logistic regression, there was no statistically significant difference in mortality between urgent and non-urgent groups (4.2% vs 1.8%, OR 0.64; 95% CI 0.41-1.00, p = 0.051). Using propensity score matching, there was no statistically significant difference in the in-hospital mortality between urgent and non-urgent groups (4.4% vs 2.8%, OR: 1.60, 95% CI: 0.71-3.63, p = 0.254). The risks of acute kidney injury and discharge to an outside facility were higher in the urgent group (p < 0.001). Conclusion: No significant in-hospital mortality for patients who underwent urgent versus non-urgent MitraClip procedures. Therefore, urgent MitraClip procedure might be an acceptable option when indicated.

Risk of Left Atrial Enlargement in Obese Patients With Obesity-Induced Hypoventilation Syndrome vs Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is a known risk factor for atrial fibrillation (AF) that is principally driven by left atrial enlargement. The impact of hypoventilation caused by obesity-induced hypoventilation syndrome (OHS) on left atrial diameter has not been examined. We investigated the association between OHS and left atrial diameter in obese patients. METHODS: We performed a retrospective review of 210 consecutive medical records of patients diagnosed as obese (body mass index [BMI] >30 kg/m2) and as having OHS and OSA for the period January 2010 through December 2016 at St. Vincent Charity Medical Center in Cleveland, OH. Logistic regression analysis was performed for left atrial diameter ≥4 cm in 2 groups of patients: those with OHS+OSA and those with OSA alone. RESULTS: A total of 104 obese patients with OHS+OSA and 106 obese patients with OSA alone were identified. Statistically significant differences were found in 6 demographic and baseline characteristics: median BMI, median left atrial diameter, history of type 2 diabetes mellitus, history of stroke, history of coronary artery disease, and history of congestive heart failure. The median left atrial diameter for the OHS+OSA and OSA alone groups was 4.45 cm and 4.20 cm, respectively (P = 0.014). Left ventricular ejection fraction <50% was found in 22% of the patients with OHS+OSA and in 21% of the patients with OSA alone (P = 0.777). Multivariate logistic regression analysis showed that patients in the OHS+OSA group had 2 times higher odds (odds ratio 2.151, 95% confidence interval 1.016-4.550, P = 0.045) of exhibiting a larger left atrial diameter vs patients in the OSA alone group. CONCLUSION: The results of this study indicate that OHS may be an independent risk factor for left atrial enlargement and may possibly contribute to AF development irrespective of left ventricular function.

AF Detected on Implanted Cardiac Implantable Electronic Devices: Is There a Threshold for Thromboembolic Risk?

OPINION STATEMENT: Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with elevated thromboembolism risk caused by multiple pathophysiologies, including a hypercoagulable state, structural heart changes, left atrial appendage stasis, inflammation, and endothelial dysfunction. With the exception of lone AF, most other categories of AF, whether paroxysmal or persistent, have been shown to share a high thromboembolism risk. Risk stratification schemes such as CHADS2 and CHA2DS2-VASc scores help to identify the level at which anticoagulation may mitigate thromboembolism risk. AF may be episodic and asymptomatic; therefore, AF diagnosis that depends entirely on office electrocardiogram (ECG) may be easily missed. With the increasing use of pacemakers, implantable cardioverter defibrillators (ICDs), and insertable loop recorders (ILRs) for diagnosis and treatment of arrhythmias, AF has been incidentally detected with increasing frequency. However, the sensitivity and specificity for detection of AF, especially brief episodes, vary from one type of device to another, and rhythm confirmation should be considered. Several recent studies have examined device-detected AF and have tried to follow associated clinical outcomes. In this paper, we review studies that have addressed device-detected AF and associated thromboembolism risk to try to identify the burden of AF that is associated with an elevated risk of thromboembolism and may therefore warrant anticoagulation therapy.

Acute myocardial infarction due to coronary thrombosis caused by blunt chest trauma.

A 65-year-old man presented to the emergency department following an anterior chest trauma. He had significant chest pain and chest X-ray was significant for revealed multiple rib fractures and negative. CT scan of the chest ruled out pulmonary embolism or aortic dissection. However, few hours later he developed hypotension requiring admission to medical intensive care unit and intravenous vasopressors. Further workup showed ST elevation myocardial infarction involving the anterior ECG leads. Emergent coronary angiography was performed with intervention to the mid-left anterior descending occlusion. Cardiogenic shock resolved and patient was discharged few days later. One-year follow-up with echocardiogram showed stable ischaemic cardiomyopathy with improved left ventricular ejection fraction to 50%.

Ulcerative cutaneous lesions synchronously present with the diagnosis of primary lung cancer.

The percentage of patients with lung cancer that develop skin metastases is low. The diagnosis is usually made using clinical information and skin biopsy in patients with suspicious skin lesions and history of smoking or lung cancer. The prognosis for patients having lung cancer with skin metastasis is very poor. We describe findings in a 70-year-old man with lung cancer with skin metastases. Interestingly, multiple skin lesions were the first manifestation of the underlying lung cancer. The prognosis for patients having lung cancer with skin metastasis is thus very poor.

Hyponatremia associated with unilateral hand weakness and numbness: a case report.

CONTEXT: The key clinical features in this case are to make the diagnosis apical lung cancer (Pancoast tumor) in a patient with brachial plexopathy and to recognize the association between syndrome of inappropriate secretion of antidiuretic hormone (SIADH) as a paraneoplastic syndrome and non-small cell lung cancer (NSCLC). CASE REPORT: We herein describe a rare case of NSCLC presented as pancoast tumor complicated by brachial plexopathy and associated with SIADH as a paraneoplastic phenomena. There were no renal insufficiency, congestive cardiac failure, liver insufficiency, volume depletion, diuretic use, hypoadrenalism, and hypothyroidism in our patient. Furthermore, the findings of serum hyponatraemia and hypo-osmolality associated with an inappropriate high urinary osmolality indicate that the SIADH was present in our patient due to the NSCLC. CONCLUSION: Our case also emphasizes that early recognition and appropriate applied management may significantly improve symptoms and prevent complications of hyponatremia which may enhance quality of life in patients with paraneoplastic SIADH.

Brugada pattern electrocardiogram unmasked with cocaine ingestion.

Cocaine is considered a leading cause of drug-related deaths. This is usually sudden, unwitnessed, and without prodromal features. It has been reported that in-hospital mortality is close to 2%. Cocaine has powerful central nervous system effects(1) and acute cocaine overdose has been associated with hyperthermia, agitation, paranoid ideation, status epilepticus, ventricular fibrillation, ventricular tachycardia, and myocardial infarction (MI). The mechanisms of cocaine-related death remain poorly understood. We report a patient who survived massive cocaine ingestion with psychomotor agitation and generalized seizures followed by asystolic cardiac arrest and transient Brugada pattern on electrocardiogram (ECG).

Menthol toxicity: an unusual cause of coma.

The US Food and Drug Administration (FDA) consider menthol an effective substance, which help in common cold symptoms and labeled to have low toxicity profile. Direct exposure to high menthol amount has been reported in animal; but no studies have been done to show the effect of menthol on long-term use in humans. Up to our knowledge we are reporting a rare case of chronic exposure to significant amount of menthol associated with cutaneous, gastrointestinal and neurological manifestations.

Optical coherence tomography endpoints in stent clinical investigations: strut coverage.

Late stent thrombosis (LST) and very LST (VLST) are infrequent complications after drug-eluting stent (DES) implantation, but they carry a significant risk for patients. Delayed healing, which may be represented by incomplete stent coverage, has been observed in necropsy vessel specimens treated with DES. As a result, in vivo assessment of stent coverage, as well as stent apposition using optical coherence tomography (OCT), have been recently used as surrogate safety endpoints in clinical trials testing DES platforms. By adopting strut coverage assessed by OCT, one can assess the safety profile of the new generation of DES in preregistration studies. This article focuses on stent strut coverage as a central predictor of late DES thrombosis from the histopathological point of view, discusses the limitations of the current imaging modalities and presents the technical characteristics of OCT for the detection of neointimal coverage after stent implantation. We also review the preclinical and clinical investigations using this novel imaging modality.

In vitro validation of new Fourier-domain optical coherence tomography.

AIMS: To validate the accuracy and evaluate the intra- and inter-observer variability of vascular measurements using novel Fourier-domain optical coherence tomography (FD-OCT) versus intravascular ultrasound (IVUS) in a coronary phantom model. METHODS AND RESULTS: A dedicated cylindrical phantom comprised of four sections with differing dimensions was used to compare images generated by five FD-OCT and five IVUS catheters. Each FD-OCT catheter was tested using three different consoles, generating 15 imaging pullbacks. Two independent experts, blinded to the phantom data, performed measurements. There were 180 FD-OCT and 60 IVUS cross-sectional measurements of mean lumen diameter (MeanLD), minimal lumen diameter (MLD), maximum lumen diameter (MaxLD) and lumen area (LA) at three points in each section. FD-OCT measurements had excellent correlations with IVUS (concordance correlation coefficient [CCC]: ≥0.9769 for MeanLD, LA or longitudinal length [LL]) and phantom dimensions (CCCs for FD-OCT: ≥0.9958 for MeanLD, LA or LL). FD-OCT measurements were larger than IVUS (p<0.0001), but showed less measurement errors compared to IVUS (p<0.0001). Moreover, FD-OCT caused less discrepancy between MaxLD and MLD versus IVUS (p<0.0001). Intra- and inter-observer variability was low for both FD-OCT (CCCs for MeanLD, LA and LL ≥0.9996) and IVUS (≥0.9935). Image catheter position did not influence FD-OCT measurements. CONCLUSIONS: FD-OCT was more accurate than IVUS and had similar high reproducibility to determine vascular dimensions in vitro. These results support the use of FD-OCT in the clinical setting.