Platelet Reactivity Unit in Predicting Risk of Bleeding in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Bleeding is a common complication of cardiac surgery, accounting for a significant proportion of the total transfusions performed in the United States and Europe. The relationship between platelet reactivity, bleeding, and other adverse events after coronary artery bypass graft surgery (CABGS) has been incompletely characterized. This study investigated the relationship between platelet reactivity and bleeding as a clinical outcome after successful CABGS. A total of 238 patients who underwent CABGS were retrospectively followed for postoperative bleeding. Platelet reactivity unit (PRU) values for all patients were obtained preoperatively to assess the platelet reactivity. The data showed that a range of 180-200 PRU suggests the likelihood of bleeding after CABGS (P = 0.004), with a statistically significant association only for dual antiplatelet therapy with aspirin and clopidogrel. In conclusion, by using PRU values as a method to assess platelet reactivity and antiplatelet responsiveness, our findings suggest that it may be possible to stratify patients undergoing CABGS for the risk of postoperative bleeding particularly patients on dual antiplatelet therapy.

"Code STEMI" protocol helps in achieving reduced door-to-balloon times in patients presenting with acute ST-segment elevation myocardial infarction during off-hours.

BACKGROUND: Door-to-balloon (D2B) time is conceived as a crucial parameter for evaluating the quality of acute ST-segment elevation myocardial infarction (STEMI) care. Ideally, primary percutaneous intervention should be performed within 90 min of hospital arrival. OBJECTIVES: We sought to determine the impact of emergency physician-activated "Code STEMI" protocol on door-to-balloon times during off-hours. METHODS: Patients were divided into two study groups: one group consisted of 27 STEMI patients who presented during off-hours in the pre-Code STEMI period (January to December 2006) and the second group consisted of 60 STEMI patients admitted during off-hours when Code STEMI was fully operational (January 2007 to December 2008). The primary objective was to compare median D2B times in both the study groups. Secondary parameters of interest included the individual components of D2B time, peak serum troponin levels, peak creatine kinase total levels, all-cause in-hospital mortality, 6-month all-cause mortality, and 12-month all-cause mortality. RESULTS: With the implementation of "Code STEMI" protocol, the median D2B time during off-hours dropped to 77 min (interquartile range [IQR] 67-95), representing a 52-min improvement (p = 0.0001). ECG-to-catheterization laboratory time demonstrated absolute reduction of 16 min. Median peak troponin-I levels dropped from 62 ng/mL (IQR 23-142) to 25 ng/mL (IQR 7-43; p < 0.002). No statistically significant differences were perceived in all-cause mortality among the study groups. CONCLUSIONS: Implementation of "Code STEMI" protocol at our institution significantly reduced D2B times for STEMI during off-hours.

Importance of performing transesophageal echocardiography in acute stroke patients older than fifty.

BACKGROUND: The purpose of this study was to determine the value of transesophageal echocardiography (TEE) in determining the presence of cardiac manifestations that required anticoagulation in patients presenting with acute stroke. METHODS: Of 626 consecutive stroke patients who underwent TEE, 188 patients with no obvious etiology for stroke were subcategorized according to age. TEE results were analyzed for cardiac findings suggestive of a cause for embolic stroke, including complex atheromas in the arch/ascending aorta, patent foramen ovale (PFO), atrial septal aneurysm (ASA), and intracavitary thrombi. Data were analyzed using Fisher's exact test. RESULTS: Of 188 patients, 66% (125/188) were older than 50 years and 34% (63/188) were younger than 50 years. The incidence of complex atheroma was 12.8% (16/125) in patients older than 50 years as compared to 0% (0/63) in patients who were younger than 50 years (P = 0.002). In patients older than 50 years, findings that indicated a need for anticoagulation based on TEE results were found in 22.4% (28/125) (atheroma = 16, PFO = 12, ASA = 5, thrombus = 3, PFO + ASA = 1) compared to 14.3% (9/63) (atheroma = 0, PFO = 5, ASA = 2, thrombus = 2, PFO + ASA = 1) in patients younger than 50 years. CONCLUSIONS: TEE plays an important role in suspected embolic stroke patients of all age groups. Due to the higher incidence of complex atheromas in patients older than 50 years of age, TEE might be of added importance in identifying the candidates who may benefit from anticoagulation.

A Rare Case of Embolic ST-Elevation Myocardial Infarction in an Adult Patient With Repaired Hypoplastic Left Heart Syndrome.

A 24-year-old male with past medical history of hypoplastic left heart syndrome and staged reconstructive surgery in infancy culminating in the Fontan circulation presented to the hospital with a chief complaint of chest pain described as an "elephant sitting" on his chest. Initial 12-lead electrocardiogram revealed 2-mm ST segment elevation in inferior leads, 3-mm ST-segment elevation in anterolateral precordial leads V3 and V4, and 2-mm ST-segment elevation in V5 and V6, with right axis deviation. He was transported emergently to the cardiac catheterization laboratory where coronary angiography revealed complete occlusion of multiple anomalous branches of the right coronary system with hazy appearance suggesting the presence of thrombotic material. An aspiration catheter was used successfully to reestablish TIMI grade III flow. The patient was treated with aspirin, brilinta (ticagrelor), and anticoagulation with vitamin K antagonism to prevent recurrent thromboembolic complications.

Right Atrial Fibroelastoma Presenting as Typical Atrial Flutter: Rare Disease in Unusual Location.

Typical atrial flutter as initial presentation of papillary fibroelastoma involving the cavotricuspid isthmus is not described before in literature. To our knowledge only 14 cases have been reported in literature involving the right atrium. Very unusual location is at the junction between inferior vena cava (IVC) and right atria as only 1 case has been reported.

An unusual cause of postpartum heart failure.

Peripartum cardiomyopathy is a weakness of the heart muscle. It is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic dysfunction toward the end of pregnancy or in the months after delivery, in the absence of any other cause of heart failure. It is a rare condition that can carry mild or severe symptoms.

Concomitant Left Atrial Appendage Clipping During Minimally Invasive Mitral Valve Surgery: Technically Feasible and Safe.

BACKGROUND: It is believed that most of thrombi form in the left atrial appendage (LAA)before they emboli. Different surgical and percutaneouse approaches were suggested to manage the LAA. In this study we are evaluating the safety of clipping the LAA via minithoractotomy approach. METHOD: All consecutive patients who had minimally invasive mitral valve surgery with concomitant LAA clipping between December 2012 and February 2014 were included in the study. LAA exclusion was performed using AtriClip® LAA Exclusion System (Cincinnati, Ohio, AtriCure®). The patient s' clinical characteristics, intraoperative complications, and in-hospital coarse were obtained by reviewing the medical records. RESULT: Total of 22 patients(50% males) were included in the study. The median ages was 66.0 years (IQR: 50.8 to 81.3). Eight(36%) had mitral valve replacement and the rest had mitral repair surgery. Five(23%) patients needed blood product transfusion during the surgery. No clip related bleeding was observed and no perioperative mortality was recorded. CONCLUSION: During minimally invasive mitral valve surgery, Concomitant exclusion of the left atrial appendage using AtriClip® can be performed rapidly and safely.

Cardiac sequelae of human immunodeficiency virus disease.

Presently, patients with human immunodeficiency virus infection are living longer and are frequently encountered in medical practice. HIV infection is a systemic disease, which affects a wide spectrum of organs. Cardiac involvement is frequent, and the consequent clinical manifestations are a common reason to seek medical advice. In this review, we discuss the different cardiac sequelae of HIV infection.

Acute ST-segment elevation myocardial infarction in young adults: who is at risk?

OBJECTIVE: Less than 10% of patients presenting with acute myocardial infarction (AMI) are young adults. The primary objective of this study was to provide an overview of similarities and dissimilarities among younger and older patients presenting with AMI with the expectation of using the information as an aid in primary and secondary preventions in the future. METHODS: From the database of 3527 patients with AMI admitted from January 2001 to December 2008, young adults aged 21-40 years (n = 43) who were diagnosed with ST-segment elevation myocardial infarction were identified. They were then compared with their older counterparts who were admitted from January 2007 to December 2008 subdivided into age groups of 41-60 (n = 86) and 61-80 years (n = 51). Data on clinical cardiovascular risk factors, demographic features, and angiographic findings were gathered and analyzed. RESULTS: Only 2.58% of ST-segment elevation myocardial infarction patients who were admitted to our hospital over an 8-year period were less than 40 years. Young adults were found to be predominantly male patients (P = 0.04) and had positive family history for coronary artery disease (P = 0.0005). Diabetes and hypertension were less prevalent in the younger group (P = 0.048 and 0.078). Analysis of lipid profile showed comparatively higher total cholesterol, low-density lipoprotein and high-density lipoprotein values in the younger group (≤ P = 0.004). Angiographically, youngsters had propensity toward single-vessel involvement (P = 0.0001). CONCLUSION: The risk factor profile and the angiographic involvement differ considerably in the high-risk younger adults and substantiate the need for an aggressive approach directed toward primary and secondary preventions of premature cardiovascular disease.

Covered-stent treatment of coronary aneurysm after drug-eluting stent placement: case report and literature review.

Most commonly, coronary artery aneurysms are secondary to atherosclerosis, but cases have been reported in patients who have vasculitis or tissue disorders, and in patients who have undergone interventional procedures. However, over the past few years, an increasing number of cases of coronary artery aneurysms after drug-eluting stent implantation have been reported. The exact mechanism is unknown. Experimental animal studies have shown that both the active drug and the polymer coating, under certain circumstances, might cause progressive luminal dilation, positive vascular remodeling, and aneurysmal formation. Complications like rupture, thrombosis, embolization, myocardial infarction, and even sudden death have been reported. Treatment options vary from aggressive surgical ligation of the aneurysm, in union with distal bypass surgery, to percutaneous implantation of a covered stent or conservative medical management with continued antiplatelet therapy. Currently, there is no consensus on an ideal approach to treating coronary artery aneurysm after drug-eluting stent implantation. Polytetrafluoroethylene-covered stents, easy and rapid to deploy, have emerged as a newer option. We report a case of coronary artery aneurysm at the site of a previous drug-eluting stent. The lesion was successfully treated with a polytetrafluoroethylene-covered stent.

Drug-eluting stent thrombosis 1,659 days after stent deployment: case report and literature review.

Drug-eluting stents are considered to be superior to bare-metal stents in reducing restenosis rates at 6 months. However, drug-eluting stents appear to be subject to stent thrombosis, a concern that has been reported more frequently in recent times. In November 2003, a 64-year-old man with a medical history of hypertension, type 2 diabetes mellitus, and coronary artery disease underwent percutaneous coronary intervention for the deployment of a sirolimus-eluting stent in the left anterior descending coronary artery. He experienced no complications. More than 4 years later, at age 69, he underwent neurosurgical treatment for a subdural hematoma that resulted from a fall, and he was advised to stop taking aspirin and clopidogrel. Thirty-three days later--1,659 days after stent deployment--he presented with a clinical event that was associated with very late stent thrombosis. After undergoing emergent coronary angiography and the placement of 2 bare-metal stents, he resumed antiplatelet therapy, recovered uneventfully, and was discharged from the hospital in stable condition. To the best of our knowledge, 1,659 days is the longest reported interval between the deployment of a drug-eluting stent and the occurrence of a clinical event that was associated with very late stent thrombosis. Herein, we discuss the case of our patient, review the pertinent medical literature, reinforce the importance of continuous and uninterrupted antiplatelet therapy in drug-eluting stent recipients, and offer considerations regarding the use of drug-eluting stents.

Percutaneous coronary interventions in nonagenarians: in-hospital mortality and outcome at one year follow-up.

BACKGROUND: Limited information is available regarding outcome of very elderly patients referred for percutaneous coronary intervention (PCI). PURPOSE: This study aimed to assess acute and intermediate term clinical outcomes among nonagenarians. METHODS: The study included 32 consecutive nonagenarian patients undergoing PCI between January 2001 to August 2006. There were 6 (19%) patients admitted with acute ST-segment elevation myocardial infarction (STEMI), 10 (31%) patients with non-STEMI, and 16 (50%) patients with unstable angina pectoris. Receiver-operator characteristic curve (ROC) analysis was done to define the relationship between heart rate, blood pressure, left ventricle ejection fraction, serum creatinine level, and mortality. RESULTS: Results: Immediate procedure success was achieved in 28 (88%) patients. Cumulative mortality at hospital discharge was 3(9%), at 6 months it was 6 (19%) and remained 6(19%) at 1 year follow-up. CONCLUSION: Hypotension and low ejection fraction correlated with in-hospital mortality and worst clinical outcome. Procedural success does not appear to decline in nonagenarians.

Ethnic minorities exhibit reduction in door-to-balloon time comparable to whites with a newly-implemented emergency physician activation protocol (Code-STEMI).

BACKGROUND: Studies have shown significant differences in door-to-balloon times (D2B) for ethnic minority patients (minorities) undergoing angioplasty for ST-elevation myocardial infarction (STEMI) compared to white patients (white). In this study, we evaluated the D2B for these groups before and after modification of the emergency protocol for STEMI. METHODS: We compared D2B for 51 consecutive STEMIs during 2006, (serial activation protocol, SAP) with D2B times for 72 consecutive STEMI patients during 2007 when a "Code STEMI" (concurrent activation) protocol was instituted. Outcomes were D2B times in whites versus minorities, pre- and post-Code-STEMI, length of stay (LOS) and peak troponin I levels. RESULTS: The median D2B time in the SAP group was 113 (whites) vs. 122 (minorities) minutes (p = 0.324), as compared to 74 (whites) vs. 78 (minorities) minutes (p = 0.324) in the Code STEMI group. The D2B for both groups was significantly reduced (p < 0.0001) with the use of Code STEMI. The median peak troponin I in the SAP group was 97 ng/mL (whites) vs. 78 ng/mL (minorities) (p = 0.084), as compared to 54 ng/mL (whites) vs. 29 ng/mL (minorities) (p = 0.084) for the Code STEMI group. LOS was 4.88 days (whites) vs. 4.39 days (minorities) (p = 0.84) in the SAP group, as compared to 3.7 days (whites) vs. 3.4 days (minorities) (p = 0.84) for the Code STEMI group, a significant change (p = 0.012) for both groups. CONCLUSION: No ethnic disparity was observed in the mean D2B time, LOS and peak troponin I levels between whites and minorities; both groups demonstrated comparable improvement in all outcomes evaluated.