Cardiogenic Shock Complicating Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention Supported by Impella: Implications of Advanced Age and Refractory Shock on Outcomes.

With percutaneous left ventricular mechanical circulatory support devices becoming increasingly available for patients with cardiogenic shock due to acute myocardial infarction and the lack of a clear mortality benefit to date, identifying optimal candidates for this technology is crucial. We studied the effectiveness of Impella Cardiac Pow (Abiomed, Danvers, MA) in various stages of cardiogenic shock and elderly cohorts. DESIGN: Retrospective review. SETTING: Data were collected for patients at a single community hospital between January 1, 2018, and December 31, 2019. SUBJECTS: Thirty-one consecutive adult patients with cardiogenic shock due to acute myocardial infarction who received Impella Cardiac Pow support. Shock stages were defined by the Society for Cardiovascular Angiography and Intervention (Stages A-E). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital death across Society for Cardiovascular Angiography and Intervention cardiogenic shock stages and in patients greater than or equal to 80 and less than 80 years old. Secondary outcomes were Valve Academic Research Consortium-2 vascular and bleeding complications, stroke, and renal failure requiring dialysis. The median age of the study population was 64 years, with seven patients (23%) being greater than or equal to 80 years old. No patients were in Society for Cardiovascular Angiography and Intervention Stage A, whereas there were seven in B, eight in C, six in D, and 10 (32%) in E. Overall in-hospital mortality occurred in 61% of patients. All 10 patients in Stage E died before hospital discharge. Mortality occurred in 54% of patients (13/24) age less than 80 years compared with 86% of those 80 years or older (6/7). A total of 38.7% of patients (12/31) and 32.3% of patients (10/31) experienced Valve Academic Research Consortium-2 bleeding and vascular events, which were evenly distributed across Society for Cardiovascular Angiography and Intervention cardiogenic shock Stages. CONCLUSIONS: In conclusion, patients with shock in extremis and those 80 years old and older may have a prohibitively high mortality despite Impella use. These findings merit further prospective investigation in a larger number of patients to evaluate the effectiveness of Impella (and other left ventricular mechanical circulatory devices) and the inherent resource utilization in advanced cardiogenic shock and the elderly.

Early Versus Delayed Use of Ultrasound-Assisted Catheter-Directed Thrombolysis in Patients With Acute Submassive Pulmonary Embolism.

OBJECTIVES: The effect of early vs delayed use of ultrasound-assisted catheter-directed thrombolysis (USAT) on invasive hemodynamics and in-hospital outcomes in patients with acute submassive pulmonary embolism (PE) is not well known. METHODS: We evaluated 41 patients with submassive PE to study the association of early USAT (≤24 hours; n = 21) vs delayed USAT (>24 hours; n = 20) with change in invasive hemodynamic measures from pre USAT to post USAT. RESULTS: Significantly greater improvement was observed in the early USAT group compared to the delayed group for median cardiac index (0.6 L/min/m² [IQR, 0.4-1.1 L/min/ m²] vs 0.4 L/min/m² [IQR, 0.1-0.6 L/min/m²]; P=.03), median pulmonary vascular resistance (3.4 Wood units [IQR, 2.5-4.1 Wood units] vs 0.5 Wood units [IQR, 0.2-1.3 Wood units]; P<.001), and mean right ventricular stroke work index (3.5 ± 2.0 g-m/m²/beat vs 2.3 ± 1.6 g-m/m2/beat; P=.04). Although not statistically significant, a trend in favor of early treatment was found for improvement in mean right ventricle to left ventricle diameter ratio (0.38 ± 0.17 vs 0.33 ± 0.21; P=.40), mean pulmonary artery pressure (8.4 ± 7.1 mm Hg vs 5.3 ± 5.2 mm Hg; P=.13), and median pulmonary artery pulsatility index (1.14 [IQR, 2.01-0.45] vs 0.65 [IQR, 0.22-1.78]; P=.49). The mean postprocedural length of stay was significantly lower in the early-USAT group (6.0 ± 2.7 days vs 10.1 ± 7.0 days; P=.02). Three patients experienced moderate bleeding (2 patients in the early-USAT group and 1 patient in the delayed-USAT group) and no major bleeds or in-hospital mortality occurred. CONCLUSION: Early USAT was associated with greater improvement in pulmonary hemodynamics and shorter postprocedural length of stay compared with delayed USAT in patients with acute submassive PE.

Rupture of sinus of Valsalva aneurysm: Two case reports and a concise review of the literature.

BACKGROUND: The rupture of sinus of Valsalva aneurysm (RSoVA) is a rare disorder that affects the integrity of the cardiovascular system, disrupting its dynamics and resulting in a variety of manifestations. In this report, we discuss two cases of RSoVA that we encountered and review similar cases reported in the literature. METHODS: literature review of reported cases of RSoVA in PubMed and Google Scholar. RESULTS: A total of 223 cases were found and the final analysis included 225 cases, of which 69% occurred in males and the mean age was 38.9 years. Dyspnea was the most common presenting symptom and 76% of the cases described continuous murmur on examination. The right sinus was affected in 61% of the cases and the fistula connected to the right chambers of the heart 73% of the time. CONCLUSION: RSoVA is a rare condition that is difficult to diagnose, it should be considered in the right context, particularly in young patients with symptoms of heart failure and the presence of continuous murmur on cardiac examination.

Caught in Time: When IVC Filters Save Lives.

Inferior vena cava filters are indicated in patients with venous thromboembolic disease in whom anticoagulation is a contraindication. This case highlights the importance of inferior vena cava filter placement in patients with extensive proximal deep vein thromboses in order to prevent massive pulmonary emboli, possibly associated with sudden cardiac death.

Painless Aortic Dissection.

Painless aortic dissection (PAoD) has been previously linked to poor outcomes. We recently encountered a case of a patient with PAoD presenting with dyspnea; the clue to diagnosis was the presence of a loud aortic diastolic murmur. A systematic review of the literature revealed 86 other cases, 62% of which occurred in men with a mean age of 65 years. Left-sided neurologic deficits were the most common presentation, followed by dyspnea and bilateral lower extremity deficits. Pulse asymmetry was found in 53% of patients, as 29% had right-left asymmetry and 24% had upper-lower asymmetry. Cumulatively, 88% of the cases were type A dissection and 51% of the patients died. Erroneous application of fibrinolysis and anticoagulation occurred in multiple instances. PAoD is rare but potentially fatal; a high index of suspicion and a thorough cardiovascular examination are needed to establish the diagnosis before applying possible harmful interventions such as fibrinolysis, vasodilation or anticoagulation.

Novel CenterCross and MultiCross devices for the treatment of infrainguinal chronic total occlusions: initial single-centre experience.

AIMS: Our aim was to evaluate the effectiveness and safety of CenterCross/MultiCross devices to facilitate the crossing of chronic total occlusions in peripheral arteries. METHODS AND RESULTS: This was a single-centre study in which 53 consecutive patients who were not amenable to initial attempts at crossing using standard guidewires underwent an attempt to recanalise chronically occluded infrainguinal peripheral arteries with MultiCross/CenterCross devices. The primary endpoint of interest was the ability to advance the guidewire beyond the chronic total occlusion (CTO) lesions with the use of these devices. Safety endpoints were freedom from bleeding, distal embolisation and vessel perforation, dissection or need for emergent surgical intervention. Popliteal artery and below lesions were the most commonly treated, comprising 89% of the total. The CTO lesions were crossed successfully in 92.4% of the cases within a relatively short time (5.5±3.5 minutes). There was no bleeding, dissection or need for emergent surgery and 98.1% and 96.2% of the patients were free from distal embolisation and perforations, respectively. CONCLUSIONS: Our study demonstrated that MultiCross and CenterCross were effective and safe for recanalisation of peripheral CTO lesions which were not amenable to conventional guidewires. Further study is required to define the role of these novel devices in the treatment of complex lesions, particularly CTOs in patients with peripheral arterial disease.