Recurrence of eosinophilic granulomatosis with polyangitis after orthotopic heart transplant.

Eosinophilic granulomatosis with polyangitis (EGPA), previously referred to as Churg-Strauss syndrome, is a necrotizing small vessel vasculitis associated with eosinophilic infiltrates and extravascular granulomas. We report a case of a Caucasian woman successfully bridged to heart transplantation with a continuous flow left ventricular assist device (LVAD) who survived recurrence of EGPA in the allograft.

Current periprocedural anticoagulation in transcatheter aortic valve replacement: could bivalirudin be an option? Rationale and design of the BRAVO 2/3 studies.

Transcatheter aortic valve replacement (TAVR) is considered an important option in the management of patients with critical aortic valve stenosis that are either inoperable or have a high surgical risk. Despite continued advances in the procedural aspects of TAVR and decreasing complications rates, the risks of major vascular complications and stroke remain significant, which may in turn confer worse clinical outcomes and impact morbidity and mortality. In this review, we outline certain limitations of the currently recommended periprocedural anticoagulation in TAVR, namely unfractionated heparin that is guided by activated clotting times and protamine use if the bleeding risk is high. We will explore the potential for bivalirudin in this setting, which has become a frontrunner in acute coronary syndrome management because of favorable pharmacokinetics and lower bleeding complications. Finally, we will describe an ongoing large multicenter multinational trial that compares intravenous bivalirudin to unfractionated heparin during TAVR procedures using standardized clinical endpoints.

Meta-analysis: impact of drug class on adherence to antihypertensives.

BACKGROUND: Observational studies suggest that there are differences in adherence to antihypertensive medications in different classes. Our objective was to quantify the association between antihypertensive drug class and adherence in clinical settings. METHODS AND RESULTS: Studies were identified through a systematic search of English-language articles published from the inception of computerized databases until February 1, 2009. Studies were included if they measured adherence to antihypertensives using medication refill data and contained sufficient data to calculate a measure of relative risk of adherence and its variance. An inverse-variance-weighted random-effects model was used to pool results. Hazard ratios (HRs) and odds ratios were pooled separately, and HRs were selected as the primary outcome. Seventeen studies met inclusion criteria. The pooled mean adherence by drug class ranged from 28% for ß-blockers to 65% for angiotensin II receptor blockers. There was better adherence to angiotensin II receptor blockers compared with angiotensin-converting enzyme inhibitors (HR, 1.33; 95% confidence interval, 1.13 to 1.57), calcium channel blockers (HR, 1.57; 95% confidence interval, 1.38 to 1.79), diuretics (HR, 1.95; 95% confidence interval, 1.73 to 2.20), and ß-blockers (HR, 2.09; 95% confidence interval, 1.14 to 3.85). Conversely, there was lower adherence to diuretics compared with the other drug classes. The same pattern was present when studies that used odds ratios were pooled. After publication bias was accounted for, there were no longer significant differences in adherence between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors or between diuretics and ß-blockers. CONCLUSION: In clinical settings, there are important differences in adherence to antihypertensives in separate classes, with lowest adherence to diuretics and ß-blockers and highest adherence to angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors. However, adherence was suboptimal regardless of drug class.

What is the optimal antithrombotic strategy in primary percutaneous coronary intervention?

PURPOSE OF REVIEW: Major bleeding in the setting of acute coronary syndromes and percutaneous coronary intervention has been associated with increased short-term and long-term risk for adverse cardiac events and mortality. Recent studies on antithrombotic agents in this setting have highlighted their differential impact on ischemic and hemorrhagic complications. RECENT FINDINGS: To measure bleeding events consistently, an updated standardized definition has been developed by the Bleeding Academic Research Consortium (BARC) representatives. Additionally, the antithrombin agent bivalirudin has emerged as a frontrunner in the invasive management of acute coronary syndromes because of fewer bleeding complications, lower long-term mortality, and similar efficacy compared with heparin plus a glycoprotein IIb/IIIa inhibitor. The mortality benefit with bivalirudin is most likely correlated with reductions in major bleeding, including in-hospital, access-site, and nonaccess site bleeding, and despite the use of preprocedural unfractionated heparin. SUMMARY: The BARC definition is an improved version of prior bleeding classifications, and will likely play a significant role in comparing different anticoagulation strategies in future clinical trials and registry analyses. Bivalirudin has been shown to reduce bleeding events in a multitude of diverse clinical settings and bleeding definitions, and has become the preferred antithrombotic agent in the setting of acute coronary syndromes.

Impact of in-hospital major bleeding on outcomes in acute coronary syndromes.

PURPOSE OF REVIEW: To describe the hazard of in-hospital major bleeding after acute coronary syndromes. RECENT FINDINGS: Long-term complications of early bleeding can extend to over 3 years beyond the index event. Nonaccess-site bleeding accounts for much of the higher risk associated with major in-hospital bleeding. SUMMARY: Bleeding complications after percutaneous coronary intervention are a consistent and independent predictor of adverse clinical outcomes. The majority of complications associated with major bleeding are attributable to in-hospital early bleeds. Whether the link between bleeding and increased mortality is causal has not been established. Bleeding may simply be a marker of higher comorbidity. When possible, bleeding should be avoided, and strategies such as use of risk scores, bivalirudin, vascular closure devices and radial access may decrease major bleeding. In the highest-risk patients, however, bleeding avoidance strategies may not be effective.

Is there attenuation of benefit of invasive therapy in patients with chronic kidney disease? Results from randomized trials and registry data.

Chronic kidney disease (CKD) is not only a common comorbidity among patients presenting with acute coronary syndrome (ACS), it is also an entity that portends worse short- and long-term prognosis. Differences in the pathophysiology of arterial atherosclerosis and calcification, chronic inflammation, platelet reactivity, and thrombogenicity in patients with and without CKD underpin the increased vulnerability of CKD patients with ACS to subsequent ischemic and bleeding complications. These differences, as well as the frequent exclusion of CKD patients from randomized control trials, create uncertainty regarding the benefit of invasive treatment for ACS in patients with CKD. The limited evidence from randomized trials suggests a benefit with invasive treatment in CKD patients with ACS. However, some data from registry studies suggest no benefit or even harm with invasive therapy. Thus, the optimal management of ACS in patients with CKD, in particular end-stage CKD, remains uncertain. In this article we review the characteristics of coronary artery disease in patients with CKD, the available evidence pertaining to the outcomes of CKD patients with ACS with invasive versus conservative therapy, and potential areas for reducing complications of invasive therapy in this high-risk subset of patients.

A model to provide comprehensive testing for HIV, viral hepatitis, and sexually transmitted infections at a short-term drug treatment center.

Substance users are at high risk for blood-borne infections as well as those that are transmitted sexually. Substance abuse treatment centers present an opportunity to offer comprehensive counseling and testing (CCT) for HIV, viral hepatitis, and sexually transmitted infections (STIs) to this high-risk population. We examined the feasibility and acceptability of one model of CCT among substance users. CCT was offered to 145 consecutive inpatients; study participants completed a risk factor questionnaire and selected from a menu of testing options. Thirty-six percent of those approached agreed to participate and accepted at least one biologic test. Sixty-two percent of participants accepted all tests that were offered. While beneficial to those who accept testing, the described model of CCT is feasible in a drug treatment center, but acceptable to only a minority of inpatients.

Impact of bivalirudin and paclitaxel-eluting stents on outcomes in patients undergoing primary percutaneous coronary intervention of the left anterior descending artery.

Patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) of the left anterior descending artery (LAD) are at increased risk for cardiovascular events compared with patients undergoing non-LAD PCI. We assessed the impact of bivalirudin and paclitaxel-eluting stenting (PES) in patients with STEMI who underwent LAD PCI. In the HORIZONS-AMI trial, 1,445 patients had LAD PCI and 1,884 patients had non-LAD PCI. The 3-year composite rates of death, reinfarction, stroke, or ischemia-driven target vessel revascularization were significantly higher in patients who underwent LAD PCI compared with non-LAD PCI (24.0% vs 20.6%, hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.04 to 1.39, p = 0.013), driven by a statistically significant increase in cardiac death (5.4% vs 2.7%, HR 2.00, 95% CI 1.40 to 2.86, p = 0.001). For patients who underwent LAD PCI, treatment with bivalirudin resulted in significantly lower rates of cardiac death (3.8% vs 6.8%, HR 0.55, 95% CI 0.34 to 0.89, p = 0.01), reinfarction (5.3% vs 9.5%, HR 0.55, 95% CI 0.37 to 0.83, p = 0.004), and major bleeding events (7.3% vs 11.8%, HR 0.60, 95% CI 0.43 to 0.86, p = 0.004) compared with unfractionated heparin plus glycoprotein IIb/IIIa inhibitor. Randomization to PES compared with bare-metal stenting resulted in a significant lower rate of target vessel revascularization (13.2% vs 19.8%, HR 0.64, 95% CI 0.47 to 0.86, p = 0.003) with no significant differences in stent thrombosis, reinfarction, or death. In conclusion, in patients with STEMI who underwent primary PCI of LAD, the use of bivalirudin was associated with a reduction in mortality and bleeding rates at 3 years. PES reduced revascularization rates in this population but did not have a significant impact on mortality.

The Use of Bivalirudin in ST-Segment Elevation Myocardial Infarction: Advantages and Limitations.

The incidence of ST-segment elevation myocardial infarction (STEMI) is a common, albeit declining, manifestation of coronary heart disease. Significant improvements in cardiovascular outcomes and mortality in STEMI patients have occurred in recent years, reflecting evolution in the understanding of the pathophysiological mechanisms and therapeutic targets of this disease. Nonetheless, the risks of recurrent ischemia and bleeding complications in this population remain substantial. This review focuses on the adjunctive anticoagulant agents used in the management of STEMI. Major insights from the HORIZONS-AMI trial regarding the impact of bivalirudin on both hemorrhagic and ischemic outcomes in STEMI patients are discussed.

Treatment of unresectable hepatocellular carcinoma with use of 90Y microspheres (TheraSphere): safety, tumor response, and survival.

PURPOSE: To present safety and efficacy results obtained in treatment of a cohort of patients with unresectable hepatocellular carcinoma (HCC) with use of 90Y microspheres (TheraSphere). PATIENTS AND METHODS: Forty-three consecutive patients with HCC were treated with 90Y microspheres over a 4-year period. Patients were treated by liver segment or lobe on one or more occasions based on tumor distribution, liver function, and vascular flow dynamics. Patients were followed for adverse events, objective tumor response, and survival. Patients were stratified into three risk groups according to method of treatment and risk stratification (group 0, segmental; group 1, lobar low-risk; group 2, lobar high-risk) and Okuda and Child-Pugh scoring systems. RESULTS: Based on follow-up data from 43 treated patients, 20 patients (47%) had an objective tumor response based on percent reduction in tumor size and 34 patients (79%) had a tumor response when percent reduction and/or tumor necrosis were used as a composite measure of tumor response. There was no statistical difference among the three risk groups with respect to tumor response. Survival times from date of diagnosis were different among the risk groups (P < .0001). Median survival times were 46.5 months, 16.9 months, and 11.1 months for groups 0, 1, and 2, respectively. Median survival times of 24.4 months and 12.5 months by Okuda scores of I and II, respectively, were achieved (mean, 25.8 months vs 13.1). Patients had median survival times of 20.5 months and 13.8 months according to Child class A and class B/C disease, respectively (mean, 22.7 months vs 13.6 months). Patients classified as having diffuse disease exhibited decreased survival and reduced tumor response. There were no life-threatening adverse events related to treatment. CONCLUSIONS: Use of 90Y microspheres (TheraSpheres) provides a safe and effective method of treatment for a broad spectrum of patients presenting with unresectable HCC. Further investigation is warranted.

Angiographic considerations in patients undergoing liver-directed therapy.

The rapid evolution and increasing complexity of liver-directed therapies has forced the medical community to further advance its understanding of hepatic arterial anatomy. The anatomy of the mesenteric system, and particularly the hepatic arterial bed, has been demonstrated to have a high degree of variation. This is important when considering presurgical planning, catheterization, and transarterial hepatic therapies. Although anatomic variants have been well described, the characterization and understanding of regional hepatic perfusion is also required to optimize endovascular therapy and intervention. Although this is true for patients undergoing bland embolization or chemoembolization, drug delivery, and hepatic infusional pump therapy, it is particularly true for intraarterial brachytherapy. The purpose of this review is to provide historical perspective in angiographic aspects of liver-directed therapy, as well as a discussion of normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors. Methods of optimizing the safety and efficacy of liver-directed therapies with use of percutaneous techniques will be discussed. This review is based on the experience gained in treating more than 500 patients with transarterial liver-directed therapies. Although the principles described in this article apply to all liver-directed therapies such as chemoembolization and administration of drug-coated microspheres, they apply particularly to intraarterial brachytherapy.

Closure of a ureterocutaneous fistula with a covered stent-graft.

A 74-year-old woman developed retroperitoneal fibrosis after aortic surgery for a left common iliac artery aneurysm. On the 5th day after repair, a left groin ureterocutaneous fistula developed. Because of the presence of a hostile surgical bed, the fistula was treated with percutaneous nephrotomy and double J stent insertion. Despite proximal control for more than 1 year, the fistula persisted. She was referred to the interventional radiology department for exchange to a nephrostomy with ureteral embolization. Rather than perform embolization of the ureter, we successfully repaired the fistula with a covered stent-graft. The patient was seen again 1 year after stent-graft placement. Output continues to fluctuate but never exceeds 5 mL per day.