Trends and outcomes of combined percutaneous (TAVI+PCI) and surgical approach (SAVR+CABG) for patients with aortic valve and coronary artery disease: A National Readmission Database (NRD) analysis.

BACKGROUND: In patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD), the relative merits of a combined percutaneous (transcatheter aortic valve implantation [TAVI] and percutaneous coronary intervention [PCI]] versus surgical approach (surgical aortic valve replacement [SAVR] and coronary artery bypass graft [CABG]) remain unknown. AIMS: To determine the utility of combined percutaneous versus surgical approaches in patients with severe AS and CAD. METHODS: The National Readmission Database (NRD) (2015-2019) was queried to identify all cases of TAVI+PCI and SAVR+CABG. The adjusted odds ratios (aOR) of mortality, stroke, and its composite (major adverse cardiovascular events [MACE]) were calculated using a propensity-score matched (PSM) analysis. RESULTS: A total of 89,314 (5358 TAVI+PCI, 83,956 SAVR+CABG) patients were included in the crude analysis. There was a gradual increase in the utilization of TAVI+PCI from 2016 to 2019 by 2%-4% per year. Using PSM, a subset of 11,361 (5358 TAVI+PCI, 6003 SAVR+CABG) patients with a balanced set of demographics and baseline comorbidities was selected. During index hospitalization, the adjusted odds of MACE (aOR 0.72, 95% confidence interval [CI] 0.62-0.83), and all-cause mortality (aOR 0.68, 95% CI 0.57-0.81) were significantly lower in patients undergoing TAVI+PCI compared with SAVR+CABG. However, patients undergoing TAVI+PCI had a higher incidence of MACE (aOR 1.40, 95% CI 1.05-1.87), and mortality (aOR 1.75, 95% CI 1.22-2.50) at 30-days. The risk of index-admission (aOR 0.82, 95% CI 0.62-1.09) and 30-day (aOR 0.88, 95% CI 0.51-1.51) stroke was similar between the two groups. CONCLUSION: In selected patients with severe AS and concomitant CAD, a combined percutaneous approach (TAVR+PCI) compared with SAVR+CABG may confer a lower risk of MACE and mortality during index admission but a higher incidence of 30-day complications.

Complete Horizontal Gaze Paresis Due to Medial Pontine Haemorrhage.

We report a case of bilateral horizontal conjugate gaze palsy due to a dorsal median pontine haemorrhage. The development of horizontal gaze palsy has been attributed to lesions in the pontine tegmentum, and in this case, has occurred in conjunction with other features as part of Foville's syndrome. Complete horizontal gaze palsy is a rare clinical manifestation as bilateral involvement is unusual. Our case provides further insight into the intricacies of the brainstem neuroanatomy through a description of the involved neural pathways and nuclei accounting for complex neurological manifestations in one patient.

Meta-analysis comparing valve-in-valve TAVR and redo-SAVR in patients with degenerated bioprosthetic aortic valve.

INTRODUCTION: The comparative efficacy and safety of valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) and redo-surgical AVR (redo-SAVR) in patients with degenerated bioprosthetic aortic valves remain unknown. METHOD: Digital databases were searched to identify relevant articles. Unadjusted odds ratios for dichotomous outcomes were calculated using a random effect model. A total of 11 studies comprising 8326 patients (ViV-TAVR = 4083 and redo-SAVR = 4243) were included. RESULTS: The mean age of patients undergoing ViV-TAVR was older, 76 years compared to 73 years for those undergoing SAVR. The baseline characteristics for patients in ViV-TAVR vs. redo-SAVR groups were comparable. At 30-days, the odds of all-cause mortality (OR 0.45, 95% CI 0.30-0.68, p = .0002), cardiovascular mortality (OR 0.44, 95% CI 0.26-0.73, p = .001) and major bleeding (OR 0.29, 95% CI 0.15-0.54, p = .0001) were significantly lower in patients undergoing ViV-TAVR compared to redo-SAVR. There were no significant differences in the odds of cerebrovascular accidents (OR 0.91, 95% CI 0.52-1.58, p = .74), myocardial infarction (OR 0.92, 95% CI 0.44-1.92, p = .83) and permanent pacemaker implantation (PPM) (OR 0.54, 95% CI 0.27-1.07, p = .08) between the two groups. During mid to long-term follow up (6-months to 5-years), there were no significant differences between ViV-TAVR and redo-SAVR for all-cause mortality, cardiovascular mortality and stroke. ViV-TAVR was, however, associated with higher risk of prosthesis-patient mismatch and greater transvalvular pressure gradient post-implantation. CONCLUSION: ViV-TAVR compared to redo-SAVR appears to be associated with significant improvement in short term mortality and major bleeding. For mid to long-term follow up, the outcomes were similar for both groups.

Transradial versus transfemoral access for cardiac catheterization: a nationwide pilot study of training preferences and expertise in The United States.

BACKGROUND: The objective was to assess current training preferences, expertise, and comfort with transfemoral access (TFA) and transradial access (TRA) amongst cardiovascular training fellows and teaching faculty in the United States. As TRA continues to dominate the field of interventional cardiology, there is a concern that trainees may become less proficient with the femoral approach. METHODS: A detailed questionnaire was sent out to academic General Cardiovascular and Interventional Cardiology training programs in the United States. Responses were sought from fellows-in-training and faculty regarding preferences and practice of TFA and TRA. Answers were analyzed for significant differences between trainees and trainers. RESULTS: A total of 125 respondents (75 fellows-in-training and 50 faculty) completed and returned the survey. The average grade of comfort for TFA, on a scale of 0 to 10 (10 being most comfortable), was reported to be 6 by fellows-in-training and 10 by teaching faculty (p < 0.001). TRA was the first preference in 95% of the fellows-in-training compared to 69% of teaching faculty (p 0.001). While 62% of fellows believed that they would receive the same level of training as their trainers by the time they graduate, only 35% of their trainers believed so (p 0.004). CONCLUSION: The shift from TFA to radial first has resulted in significant concern among cardiovascular fellows-in training and the faculty regarding training in TFA. Cardiovascular training programs must be cognizant of this issue and should devise methods to assure optimal training of fellows in gaining TFA and managing femoral access-related complications.

Post thrombolytic resolution of ST elevation in STEMI patients.

OBJECTIVE: To study the effect of timing of thrombolytic therapy, cardiac risk factors and site of infarction on S.T. resolution post thrombolysis in STEMI patients. METHODS: This was a descriptive hospital based study conducted at the Hayatabad Medical Complex Peshawar. The duration of our study was 5 months from February 2015 to June 2015. Diagnosis of STEMI in symptomatic patients was based on the ECG recognized. Definition of Myocardial Infarction. Time from onset of chest pain to presentation of patients in emergency was noted through history of patients along with time of streptokinase. ECG recordings of patients were taken upon presentation in Emergency. Serial ECG monitoring was done after administration of Streptokinase (SK). ST resolution was observed in the lead with the maximum ST elevation. Data were presented as frequencies and percentages, chi square test was applied. RESULTS: Among 83 patients with STEMI 50.6% were males and 49.4% were females with the age group range of 30-83 years. Fifty nine patients (71.08%) with STEMI underwent thrombolysis within 12 hours of onset of chest pain while 24 patients (28.92%), underwent thrombolysis after 12 hours of onset of chest pain. Out of the 59 patients who received thrombolytic therapy before 12 hours, 43 (72.88%)completely resolved, while those who received thrombolytic therapy after 12 hours none of them completely resolved as per ECG findings. By applying chi-square test it gives us value of 36.470, and p-value <0.001. In our study 28 patients were diabetic and out of these six (21.43%) completely resolved as per ECG post thrombolysis, 9 (32.14%) partially resolved and 13 (46.43%) failed to resolve. On the other hand, in non-diabetics out of 55, 37 (67.27%) completely resolved, 12 (21.82%) partially resolved and 6 (10.91%) failed to resolve. Among 61 hypertensive, 26 (42.62%) had complete resolution and in 22 who were non-hypertensive, 17 (77.27%)had complete resolution on ECG. Hyperlipidemia and site of infarction didn't have statistically significant effect on the resolution of ECG post thrombolysis in STEMI patients. CONCLUSION: Patients with diabetes, hypertension and those who receive thrombolysis after 12 hours of onset of chest pain respond poorly to thrombolytic therapy as per ECG findings whereas hyperlipidemia and site of infarction don't affect the response of STEMI patients to thrombolysis.

Dengue Fever Culminating in Cardiac Arrest: A Case Report.

Infection from the dengue virus can manifest with a variety of clinical presentations. Cardiac involvement from dengue fever is a rarely reported phenomenon with significant morbidity and mortality. We illustrate the case of a 47-year-old male admitted to the hospital with fevers. The hospital course was complicated with cardiac arrest. Clinicians need to be weary of this rare occurrence particularly in areas with a known prevalence of dengue for prompt recognition and improved patient outcomes.

Systematic review and meta-analysis comparing Manta device and Perclose device for closure of large bore arterial access.

Data comparing MANTA device with Perclose device for large bore arterial access closure is limited. We performed meta-analysis to compare safety and efficacy of the two devices in large (⩾14 Fr sheath) arteriotomy closure post-TAVR. Relevant studies were identified via PubMed, Cochrane, and EMBASE databases until June, 2022. Data was analyzed using random effect model to calculate relative odds of VARC-2 defined access-site complications and short-term (in-hospital or 30-day) mortality. A total of 12 studies (2 RCT and 10 observational studies) comprising 2339 patients were included. The odds of major vascular complications (OR 0.99, 95% CI 0.51-1.92; p = 0.98); life threatening and major bleeding (OR 0.77, 95% CI 0.45-1.33; p = 0.35); minor vascular complications (OR 1.37, 95% CI 0.63-2.99; p = 0.43); minor bleeding (OR 0.94, 95% CI 0.57-1.56; p = 0.82); device failure (OR 0.74, 95% CI 0.49-1.11; p = 0.14); hematoma formation (OR 0.76, 95% CI 0.33-1.75; p = 0.52); dissection, stenosis, occlusion, or pseudoaneurysm (OR 1.08, 95% CI 0.71-1.62; p = 0.73) and short-term mortality (OR 1.01, 95% CI 0.55-1.84; p = 0.98) between both devices were similar. MANTA device has a similar efficacy and safety profile compared to Perclose device.

Distal Versus Proximal Radial Arterial Access for Percutaneous Coronary Angiography and Intervention: Updated Meta-Analysis of Randomized Controlled Trials.

Radial artery occlusion (RAO) is a major impediment to reintervention in patients who underwent proximal transradial access (p-TRA) for coronary catheterization. Distal transradial access (d-TRA) at the level of snuffbox distal to the radial artery bifurcation is a novel alternative to p-TRA. We conducted an updated meta-analysis of all available randomized controlled trials (RCTs) to compare the incidence of RAO between p-TRA and d-TRA, along with access site-related complications. PubMed, Web of Science, and Google Scholar were searched for RCTs published since 2017 to October 2023 comparing d-TRA and p-TRA for coronary angiography and/or intervention. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals were calculated using the random-effects model for procedural and clinical outcomes for the 2 approaches. A total of 18 RCTs with 8,205 patients (d-TRA n = 4,096, p-TRA n = 4,109) were included. The risk of RAO (RR 0.31, 0.21 to 0.46, p ≤0.001) and time to hemostasis (minutes) (MD -51.18, -70.62 to -31.73, p <0.001) was significantly lower in the d-TRA group. Crossover rates (RR 2.39, 1.71 to 3.32, p <0.001), access time (minutes) (MD 0.93, 0.50 to 1.37, p <0.001), procedural pain (MD 0.46, 0.13 to 0.79, p = 0.006), and multiple puncture attempts (RR 2.13, 1.10 to 4.11, p = 0.03) were significantly higher in the d-TRA group. The use of d-TRA for coronary angiography and/or intervention is associated with a lower risk of RAO at the forearm and may preserve p-TRA site for reintervention in selective patients by reducing the incidence of RAO.

Trend, predictors, and outcomes of combined mitral valve replacement and coronary artery bypass graft in patients with concomitant mitral valve and coronary artery disease: a National Inpatient Sample database analysis.

Aims: Combined mitral valve replacement (MVR) and coronary artery bypass graft (CABG) procedures have been the norm for patients with concomitant mitral valve disease (MVD) and coronary artery disease (CAD) with no large-scale data on their safety and efficacy. Methods and results: The National Inpatient Sample database (2002-18) was queried to identify patients undergoing MVR and CABG. The major adverse cardiovascular events (MACE) and its components were compared using a propensity score-matched (PSM) analysis to calculate adjusted odds ratios (OR). A total of 6 145 694 patients (CABG only 3 971 045, MVR only 1 933 459, MVR + CABG 241 190) were included in crude analysis, while a matched cohort of 724 237 (CABG only 241 436, MVR only 241 611 vs. MVR + CABG 241 190) was selected in PSM analysis. The combined MVR + CABG procedure had significantly higher adjusted odds of MACE [OR 1.13, 95% confidence interval (CI) 1.11-1.14 and OR 1.96, 95% CI 1.93-1.99] and in-hospital mortality (OR 1.29, 95% CI 1.27-1.31 and OR 2.1, 95% CI 2.05-2.14) compared with CABG alone and MVR alone, respectively. Similarly, the risk of post-procedure bleeding, major bleeding, acute kidney injury, cardiogenic shock, sepsis, need for intra-aortic balloon pump, mean length of stay, and total charges per hospitalization were significantly higher for patients undergoing the combined procedure. These findings remained consistent on yearly trend analysis favouring the isolated CABG and MVR groups. Conclusion: Combined procedure (MVR + CABG) in patients with MVD and CAD appears to be associated with worse in-hospital outcomes, increased mortality, and higher resource utilization compared with isolated CABG and MVR procedures. Randomized controlled trials are needed to determine the relative safety of these procedures in the full spectrum of baseline valvular and angiographic characteristics.

A Diagnostic Dilemma of White Matter Lesions and Cerebral Oedema without Identifiable Cause-A Neurological Conundrum.

INTRODUCTION: This paper describes a case of bi-frontal vasogenic oedema associated with bilateral frontal lobe and left parietal lobe white matter lesions where extensive investigations, including brain biopsy, failed to establish a diagnosis. CASE REPORT: A 67-year-old female presented with three weeks' history of memory loss, fatigue, insomnia, nausea, and occasional dysphasia. Physical examination was unremarkable, yet cerebral CT and MRI showed bilateral frontal lobe vasogenic oedema. Extensive investigations, including: biochemical; radiological; immunological; microbiological; haematological; histopathological; and cytological, failed to establish a confirmed diagnosis. A multidisciplinary team could not achieve a consensus for this atypical presentation. Brain biopsy was unusual, showing destructive inflammatory and subtly granulomatous disease, but an exhaustive list of auxiliary tests could not confirm a cause, and consensus favoured glial fibrillary acidic protein (GFAP) autoimmune encephalopathy. DISCUSSION: A definitive diagnosis could not be established for this patient despite a gamut of investigations. Although some of the presenting features were consistent with GFAP astrocytopathy, initial staining of the patient's CSF for neuronal antibodies was negative. Her symptoms and radiological changes of brain imaging improved without any corticosteroid therapy. CONCLUSIONS: Through this case report, the aim is to add to the repository of neurological sciences in the hope that future similar presentations could potentially lead to discovery of a new aetiology or contribute towards better understanding of an existing disease process.

Utility of Coronary Artery Calcium Scores in Predicting Risk of Subclinical Cardiovascular Atherosclerotic Disease: An Analysis of Limitations to its Adoption With Policy Recommendations.

This survey-based analysis aims to highlight key limitations to a wider adoption of coronary artery calcium (CAC) scoring as a means of screening asymptomatic individuals for atherosclerotic cardiovascular disease. The need for a screening tool that adds objective anatomical information to historically established risk scores in the aforementioned population has been met by this imaging modality. Despite that, there has been a hesitance towards frequent usage of these scans. Within the pre-set sampling frame of the University of Toledo, a convenience sampling technique was used to reach out to 60 health care providers. The resultant responses were analyzed and discussed. In addition to identifying patients who need to be worked up further, CAC scans can also help re-stratify patients within-risk groups and inform decision-making regarding the use of lipid-lowering therapies. The public health impact of a greater but appropriate utilization of this diagnostic tool will be impactful. This analysis seeks to better understand real-life obstacles to a wider adoption of these scans and attempts to lay out policy recommendations to address these issues.

Meta-Analysis Comparing Culprit-Only Versus Complete Multivessel Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction.

ST-segment elevation myocardial infarction (STEMI) in patients with concomitant multivessel coronary artery disease is associated with poor prognosis. We sought to determine the merits of percutaneous coronary intervention of the culprit-only revascularization (COR) compared with multivessel revascularization (MVR) approach. Multiple databases were queried to identify relevant articles. Data were analyzed using a random-effect model to calculate unadjusted odds ratio (OR) and relative risk. A total of 28 studies comprising 26,892 patients, 18,377 in the COR and 8,515 in the MVR group were included. The mean age of patients was 63 years, comprising 72% of male patients. The baseline characteristics of the 2 treatment groups were comparable. On a median follow-up of 1-year, COR was associated with a significantly higher odds of major adverse cardiovascular events (MACE; OR 1.36, 95% confidence interval [CI] 1.10 to 1.70, p = 0.005), angina (OR 2.28, 95% CI 1.83 to 2.85, p ≤ 0.00001) and revascularization (OR 1.76, 95% CI 1.22 to 2.54, p = 0.002) compared with patients undergoing MVR for STEMI. The all-cause mortality (OR 1.18, 95% CI 0.91 to 1.53, p = 0.22), cardiovascular mortality (OR 1.30, 95% CI 0.98 to 1.72, p = 0.07), rate of heart failure (OR 1.17, 95% CI 0.86 to 1.59, p = 0.31), need for coronary artery bypass graft (CABG) (OR 1.47, 95% CI 0.82 to 2.64, p = 0.19), repeat myocardial infarction (MI) events (OR 1.23, 95% CI 0.93 to 1.64, p = 0.15) and risk of stroke (OR 1.27 95% CI 0.68 to 2.34, p = 0.45%) were similar between the two groups. A subgroup analysis based on follow-up duration and study design mostly followed the results of the pooled analysis except that the risk of repeat MI events were significantly lower in the MVR group across RCTs (OR 1.46, 95% CI 1.10 to 1.94, p = 0.009). In contrast to the culprit-only approach, MVR in patients with STEMI is associated with a significant reduction in MACE, angina and need for revascularization.

Angiographic-only or intravascular ultrasound-guided approach for left-main coronary artery intervention: a systematic review and meta-analysis.

INTRODUCTION: The use of intravascular ultrasound (IVUS) in percutaneous revascularization of left-main coronary artery disease (LMCAD) warrants further exploration. We aimed to collate all available data on the merits of IVUS in LMCAD to help decision-making. METHODS: The MEDLINE, Embase, and Cochrane databases were queried for relevant randomized controlled trials (RCTs) and observational cohort studies (OCS). The data were analyzed using random-effects model to calculate unadjusted odds ratio (OR) between IVUS-guided and angiography-only LMCA revascularization. RESULTS: A total of 14 studies (2 RCTs and 12 OCS), comprising 18944 patients, were included. The pooled odds of all-cause mortality (OR 0.57, 95%CI 0.46-0.70, p = <0.00001), cardiovascular mortality (OR 0.37, 95%CI 0.26-0.54, p = <0.00001), left-main revascularization (OR 0.63, 95%CI 0.45-0.89, p = 0.009) and myocardial infarction (OR 0.80, 95% CI 0.66-0.97, p = 0.02) were significantly lower with IVUS-guidance. There was no difference observed in the odds of the stent thrombosis (OR 0.57, 95% CI 0.31-1.05, p = 0.07) and stroke (OR 1.7, 95%CI 0.56-5.14, p = 0.35) between the two groups. A subgroup analysis based on the study design and follow-up duration mirrored the pooled estimates. CONCLUSION: IVUS-guided LMCA intervention is associated with overall improved cardiovascular outcomes than the angiography-only approach. This needs to be tested in a large randomized controlled trial.

Clinical outcomes of patients with diabetes mellitus and acute ST-elevation myocardial infarction following fibrinolytic therapy: a nationwide inpatient sample (NIS) database analysis.

The impact of diabetes mellitus (DM) on clinical outcomes of acute ST-segment elevation myocardial infarction (STEMI) following fibrinolytic therapy remains uncertain. We queried the National Inpatient Sample (NIS) for STEMI patients who received fibrinolytic therapy. Categorical and continuous variables were compared using the unadjusted odds ratio (uOR) and t-test analysis, respectively. A binary logistic regression model was used to control the outcomes for patient demographics, procedural characteristics, and baseline comorbidities. A total of 111,155 (no-DM 84,146, DM 27,009) were included. The unadjusted odds of in-hospital mortality (8.4% vs. 6.8%, uOR 1.25, 95% CI 1.19-1.31, P = <0.0001) and cardiogenic shock (7.7% vs. 6.2%, uOR 1.26, 95% CI 1.20-1.33, P = <0.0001) were significantly higher in patients with DM compared to those with no DM, respectively. The odds for major bleeding and cardiopulmonary arrest were significantly lower for in diabetes. The adjusted pooled estimates mirrored the unadjusted findings. Diabetic patients receiving fibrinolytic therapy for STEMI might have higher odds of all-cause mortality and cardiogenic shock compared to non-diabetic patients.

Safety and Efficacy of Colchicine in Patients with Stable CAD and ACS: A Systematic Review and Meta-analysis.

BACKGROUND: Evidence from recent trials has shown conflicting results in terms of the utility of colchicine in patients with coronary artery disease (CAD). METHODS: Multiple databases were queried to identify all randomized controlled trials (RCTs) comparing the merits of colchicine in patients with acute coronary syndrome (ACS) or stable CAD. The pooled relative risk ratio (RR) of major adverse cardiovascular events (MACE), its components, and gastrointestinal (GI) adverse events were computed using a random-effect model. RESULTS: Ten RCTs comprising a total of 12,761 patients were identified. At a median follow-up of 12 months, there was a significantly lower risk of MACE [RR 0.66, 95% confidence interval (CI) 0.45-96], ACS (RR 0.66, 95% CI 0.45-0.96), ischemic stroke (RR 0.42, 95% CI 0.22-0.81), and need for revascularization (RR 0.61, 95% CI 0.42-90) in patients receiving colchicine compared with placebo. A subgroup analysis based on the clinical presentation showed that the significantly lower incidence of MACE and stroke were driven by the patients presenting with ACS. The use of colchicine in patients with stable CAD did not reduce the incidence of MACE (RR 0.55, 95% CI 0.28-1.09), ACS (RR 0.52, 95% CI 0.25-1.08), or stroke (RR 0.61, 95% CI 0.33-1.13). There was no significant difference in the relative risk of cardiac arrest, ACS, cardiovascular mortality, and all-cause mortality between the two groups in both ACS and stable CAD populations. The risk of GI adverse events was significantly higher in patients receiving colchicine (RR 2.10, 95% CI 1.12-3.95). CONCLUSION: In patients presenting with ACS, low-dose colchicine might reduce the incidence of MACE, stroke, and the need for revascularization at long follow-up durations. Colchicine might offer no benefits in reducing the risk of ischemic events in patients with stable angina.

Guillain-Barré Syndrome Induced Dysautonomia Resulting in Cardiac Arrest.

Life-threatening cardiovascular complications can occur as a result of Guillain-Barré Syndrome (GBS) induced autonomic dysfunction necessitating the need for early recognition and potential cardiac pacing. We present the case of a 69-year-old female who was admitted to the hospital for worsening fatigue, bilateral lower extremity weakness and inability to ambulate for two days. Five days later, she experienced large fluctuations in blood pressure, appeared diaphoretic, and had spells of bradycardia. This was soon followed by an episode of unresponsive and cardiac arrest with rhythm strip consistent with asystole. Cardiopulmonary resuscitation (CPR) was initiated with a return of spontaneous circulation (ROSC) after 6 minutes. The patient was intubated and transferred to the intensive care unit (ICU). Reassessment of the patient revealed a new bilateral symmetric upper extremity weakness. Respiratory failure with ascending symmetric paralysis warranted a lumbar puncture which revealed albuminocytologic dissociation-ultimately leading to the diagnosis of GBS.

Interarterial course of anomalous right coronary artery: role of symptoms and surgical outcomes.

Anomalous origin of right coronary artery with interarterial course (ARCA-IA) is a risk factor for sudden death and other cardiac complications. Surgical correction remains its gold standard treatment. We describe clinical characteristics, workup, surgical techniques and outcomes of ARCA-IA at our center. A retrospective analysis of cardiovascular database was performed. From March 2005 through January 2011, 11 patients with mean age of 53 ± 18 years were diagnosed with ARCA-IA. Reported symptoms included chest pain (64%), arrhythmia [27%; i.e. atrial flutter (9%), recurrent supraventricular tachycardia (9%), ventricular tachycardia (9%)], syncope (18%), dyspnea (9%) and aborted sudden cardiac death (9%). Chest pain (n = 7) was episodic and lasted longer than 6 months before diagnosis. Initial diagnosis was made at coronary computed tomography in two patients and at cardiac catheterization in nine patients. Four patients had positive stress test and were subsequently found to have ARCA-IA at cardiac catheterization. There was no operative mortality. Surgery (bypass with ligation of native vessel or translocation and reimplantation) was performed in seven patients. Three patients refused surgery, and in one patient, surgery was not considered due to comorbidities. Symptom relief was noted in all surgical patients. At mean follow-up of 36 months, two patients had noncardiac-related deaths whereas nine were asymptomatic. There were no deaths reported in patients treated surgically. Definitive surgery is indicated in symptomatic ARCA-IA and is associated with excellent long-term outcome. RCA dominance in ARCA-IA is an adverse marker with increased symptoms; this hypothesis should be tested in larger studies.

Comparative accuracy of non-invasive imaging versus right heart catheterization for the diagnosis of pulmonary hypertension: A systematic review and meta-analysis.

BACKGROUND: Right heart catheterization (RHC) is the gold-standard in the diagnosis of pulmonary hypertension (PH) but at the cost of procedure-related complications. We sought to determine the comparative accuracy of RHC versus non-invasive imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and transthoracic echocardiography (TTE). METHODS: Pulmonary hypertension was defined as a mean pulmonary artery pressure (mPAP) of>20 mmHg. Multiple databases were queried for relevant articles. Raw data were pooled using a bivariate model to calculate the measures of diagnostic accuracy and to estimate Hierarchical Summary Receiver Operating Characteristic (HSROC) on Stata 13. RESULTS: A total of 51 studies with a total patient population of 3947 were selected. The pooled sensitivity and specificity of MRI for diagnosing PH was 0.92(95% confidence interval (CI) 0.88-0.96) and 0.86 (95% CI, 0.77-0.95), respectively. The net sensitivities for CT scan and TTE were 0.79 (95% CI 0.72-0.89) and 0.85 (95% CI 0.83-0.91), respectively. The overall specificity was 0.82 (0.76-0.92) for the CT scan and 0.71 (95% CI 0.61-0.84) for TTE. The diagnostic odds ratio (DOR) for MRI was 124 (95% CI 36-433) compared to 30 (95% CI 11-78) and 24 (95% 11-38) for CT scan and TTE, respectively. Chi-squared (x2) test showed moderate heterogeneity on the test for equality of sensitivities and specificities. CONCLUSIONS: MRI has the highest sensitivity and specificity compared to CT and TTE. MRI can potentially serve as a surrogate technique to RHC for the diagnosis of PH.

Meta-Analysis Comparing Transcatheter Aortic Valve Implantation to Surgical Aortic Valve Replacement in Low Surgical Risk Patients.

Transcatheter aortic valve implantation (TAVI) is recommended for inoperable and high risk surgical patients with severe aortic stenosis. It is noninferior to surgical aortic valve replacement (SAVR) in intermediate risk candidates. TAVI is currently being assessed for low surgical risk individuals. We performed a meta-analysis of randomized controlled trials (RCTs) and matched observational studies between TAVI and SAVR in low surgical risk patients. The primary outcomes were short-term and mid-term mortality and neurologic events. Secondary outcomes were other periprocedure complications. A total of 8 studies (3 RCTs and 5 matched observational studies) totaling 6,686 patients were included. No difference was seen in short-term mortality and neurologic events (risk ratio [RR] 0.68, 95% confidence interval [CI] 0.45 to 1.03, p 0.07 and RR 0.76, 95% CI 0.52 to 1.13, p 0.18) as well as mid-term mortality and neurologic events (RR 0.89, 95% CI 0.54 to 1.47, p 0.65 and RR 1.04, 95% CI 0.55 to 1.97, p 0.9) between the 2 groups. Reduced risk of new onset atrial fibrillation (RR 0.14, 95% CI 0.08 to 0.25, p <0.00001), acute kidney injury (RR 0.43, 95 CI 0.23 to 0.82, p 0.01), and bleeding (RR 0.43, 95% CI 0.27 to 0.69, p 0.0005) whereas increased risk of ≥ moderate aortic regurgitation (RR 6.53, 95% CI 3.48 to 12.24, p <0.00001), pacemaker or defibrillator implantation (RR 3.11, 95% CI 1.96 to 4.94, p <0.00001) and vascular complications (RR 5.29, 95% CI 1.58 to 17.70, p 0.007) was noted in TAVI arm. In conclusion, TAVI is comparable to SAVR in terms of short-term and mid-term mortality and neurologic events in low surgical risk patients. The risk of periprocedure events is variable.

Thyrotoxicosis factitia: a rare cause of junctional rhythm and cardiac arrest.

Thyrotoxicosis factitia is a hyperthyroid state due to the accidental or deliberate thyroxine ingestion. It can have many complications depending upon the organ involved. We present a case of a heavy built athlete presenting with cardiac arrest, who was found to be abused the thyroxine hormone for bodybuilding. Electrocardiogram (EKG) was significant for junctional arrhythmias along with interval supraventricular tachycardia (SVT) and bradycardia. The patient ultimately expired due to a failed resuscitation. To our knowledge, this is the first reported case of junctional arrhythmias caused by exogenous thyroxine.