Safety of ultra-low contrast coronary angiography in patients with acute kidney injury.

BACKGROUND: Ultra-low contrast administration during coronary angiography has been previously shown to be feasible and safe among patients with stable chronic kidney disease. In the present study, we investigate the safety of ultra-low contrast coronary angiography in patients with pre-existing acute kidney injury (AKI). METHODS: The study was a retrospective single-center evaluation of hospitalized patients who had AKI and required coronary angiography. Ultra-low contrast use was defined as ≤18 mL of contrast media. RESULTS: The cohort consisted of a case series of eight inpatients with AKI who required coronary angiography. The mean age was 57 (±16) years and half were females. All patients had chronic kidney disease with a mean baseline estimated glomerular filtration rate of 34 (±17) mL/min/1.73 m2. The mean creatinine before angiography was 3 (±1) mg/dL and volume of contrast administered was 14 (±4) mL. One patient had a 0.1 mg/dL increase in creatinine during admission, and no patients had further AKI up to 1-week postprocedure. CONCLUSIONS: The current data suggest that ultra-low contrast coronary angiography can be safely performed in patients with pre-existing AKI The study should be viewed as hypothesis-generating due to its small sample size. A larger cohort is required to validate the results.

Percutaneous debulking of tricuspid valve infective endocarditis vegetations using a large bore manual aspiration device - AlphaVac.

Most infectious endocarditis patients can be managed medically. However, non-responders to antibiotics and ongoing sequelae such as septic emboli, may require mechanical interventions. AngioVac (Angiodynamics, Latham, NY, USA) is a percutaneous aspiration device used for removal of thrombi, emboli, masses, and vegetations. Main drawbacks are the requirement for a perfusionist, two large-bore accesses, and meticulous de-airing. These drawbacks make the procedure more time-consuming and possibly increase the risk of complications. AlphaVac (Angiodynamics) omits the motor element, thereby overcoming several of the limitations. In the current report, we describe two cases of percutaneous aspiration of tricuspid valve vegetations using AlphaVac. Learning objective: To consider manual percutaneous aspiration of infective valvular vegetations using the AlphaVac cannula in case of insufficient response to antibiotics or for prevention of emboli.

Incidence of acute myocardial infarction and hurricane Katrina: Fourteen years after the storm.

INTRODUCTION: Historically, natural disasters have been known to have an effect on humankind including physical and mental health. Studies dating from the early nineteen hundreds have shown repeated associations between different catastrophic natural disasters and its effects on cardiovascular (CV)health, including increased morbidity and mortality. Knowing that these effects on CV health last sometimes up to a decade, we sought to study the effects of hurricane Katrina on incidence of acute myocardial infarctions (AMI) to see if the effects perpetuated and continued or mitigated after the first decade. METHODS: Ours is a single center, retrospective observational study at TUHSC to compare the incidence of AMI, chronobiology and other demographic characteristics between the 2-year pre-Katrina and 14-year post-Katrina group. After IRB approval, patients were identified using specific ICD 9 and 10 codes. Data was collected by chart review and stored in secure password protected files. Descriptive statistics including mean, standard deviation and percentages were calculated. Statistical analysis comparing mean and standard deviations were performed using Chi-square test and t-test. RESULTS: The pre-Katrina cohort saw a 0.7% incidence of AMI, whereas the post-Katrina cohort saw 3.0% incidence of AMI (p < 0.001). The post- Katrina group was also noted to have significantly higher comorbidities including diabetes, hypertension, polysubstance abuse and coronary artery disease. CONCLUSIONS: Even 14 years after the storm, there was a four-fold increase in the incidence of AMI. Additionally, psychosocial, behavioral and traditional risk factors for CAD were significantly higher more than a decade after the natural disaster as well.

Severe but Self-Limiting Polyarthralgia with Functional Impairment Following ChAdOx1 nCov-19 Vaccination in an Elderly Recipient.

A 79-year-old female patient with no pre-existing rheumatological conditions presented with severe functional impairment secondary to polyarthralgia, most likely an adverse reaction following her first dose of Oxford/AstraZeneca ChAdOx1 nCov-19 vaccination against SARS-CoV-2, the causative agent of Coronavirus Disease 2019 (COVID-19). The presentation mimicked clinical features of polymyalgia rheumatica and was distinctive in its pattern and delayed onset. Its severity in an elderly patient was significant against trial findings of decreasing reactogenicity of ChAdOx1 nCov-19 vaccine with increasing age, and traumatic to the patient. Acute phase reactants were elevated, consistent with recent similar reports among mostly elderly, female patients. New onset rheumatological conditions and flares of pre-existing, well-controlled conditions had been well established in COVID-19 and, to a lesser extent, post-vaccination. Viral arthralgias as a distinct clinical entity in COVID-19 is only beginning to be recognized. It could be that this case report represents a similar entity which occurs following vaccination against SARS-CoV-2. Despite this, the benefits of vaccination continue to outweigh such risks, although this case report is important for providing understanding of clinical progression when such reactions occur, aiding in patient discussions and clinical decisions to weigh up further investigations or empirical treatment against reassurance and close monitoring.

Natural disasters and acute myocardial infarction.

Natural disasters are devastating to not only our physical property but also to our health. There have been several studies over the last few decades that have correlated different types of natural disasters with acute myocardial infarctions (AMIs). Since the early 1930's singular meteorological events have been reported to have some association and effect on cardiovascular (CV) mortality and morbidity. Multiple natural disasters regardless of location have repeatedly reported a significant increase in the incidence of acute coronary syndromes (ACS). Each event was associated with similar mechanisms, which increase the overall CV mortality. The most prominent of those being neurohormonal activation, total scarcity of supplies and access to health care, poverty, stress, increased incidence of smoking and drug abuse. Increased incidence of associated infections added to the burden of ACS. We know natural disasters are inevitable; however, disaster preparedness is surely a reliable way to help curb their devastating effects on human life. In this manuscript, the authors present many forms of natural disasters and their association with acute myocardial infarction (AMI).

Stent-Only Versus Adjunctive Balloon Angioplasty Approach for Saphenous Vein Graft Percutaneous Coronary Intervention: Insights From DIVA Trial.

BACKGROUND: Direct stenting without pre-dilation or post-dilation has been advocated for saphenous vein graft percutaneous coronary intervention to decrease the incidence of distal embolization, periprocedural myocardial infarction, and target lesion revascularization. METHODS: We performed a post hoc analysis of patients enrolled in the DIVA (Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Angioplasty; NCT01121224) prospective, double-blind, randomized controlled trial. Patients were stratified into stent-only and balloon-stent groups. Primary end point was 12-month incidence of target vessel failure (defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization). Secondary end points included all-cause death, stent thrombosis, myocardial infarction, and target lesion revascularization during follow-up. RESULTS: Of the 575 patients included in this substudy, 185 (32%) patients underwent stent-only percutaneous coronary intervention. Patients in the stent-only versus balloon-stent group had similar baseline characteristics and similar incidence of target vessel failure at 12-months (15% versus 19%; hazard ratio, 1.34 [95% CI, 0.86-2.08]; P=0.19). During long-term follow-up (median of 2.7 years), the incidence of definite stent thrombosis (1% versus 5%; hazard ratio, 9.20 [95% CI, 1.23-68.92]; P=0.0085), the composite of definite or probable stent thrombosis (5% versus 11%; hazard ratio, 2.52 [95% CI, 1.23-5.18]; P=0.009), and target vessel myocardial infarction (8% versus 14%; hazard ratio, 1.92 [95% CI, 1.08-3.40]; P=0.023) was lower in the stent-only group. Multivariable analysis showed that a higher number of years since coronary artery bypass grafting and >1 target saphenous vein graft lesions were associated with increased target vessel failure during entire follow-up, while preintervention Thrombolysis in Myocardial Infarction-3 flow was protective. CONCLUSIONS: In patients undergoing percutaneous coronary intervention of de novo saphenous vein graft lesions, there was no difference in target vessel failure at 12 months and long-term follow-up in the stent-only versus the balloon-stent group; however, the incidence of stent thrombosis was lower in the stent-only group, as was target vessel myocardial infarction. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01121224.

The Incidence, Risk Factors, and Chronobiology of Acute Myocardial Infarction Ten Years After Hurricane Katrina.

OBJECTIVE: The purpose of this study was to investigate the 10-year impact of Hurricane Katrina on the incidence of acute myocardial infarction (AMI) along with contributing risk factors and any alteration in chronobiology of AMI. METHODS: A single-center, retrospective, comparison study of AMI incidence was performed at Tulane University Health Sciences Center from 2 years before Hurricane Katrina to 10 years after Hurricane Katrina. A 6-year, pre-Katrina and 10-year, post-Katrina cohort were also compared according to pre-specified demographic, clinical, and chronobiological data. RESULTS: AMI incidence increased from 0.7% (150/21,079) to 2.8% (2,341/84,751) post-Katrina (P<0.001). The post-Katrina cohort had higher rates of coronary artery disease (36.4% vs. 47.9%, P=0.01), diabetes mellitus (31.3% vs. 39.9%, P=0.04), hyperlipidemia (45.4% vs. 59.3%, P=0.005), smoking (34.4% vs. 53.8%, P<0.001), drug abuse (10.2% vs. 15.4%, P=0.02), psychiatric illness (6.7% vs. 14.9%, P<0.001), medication non-adherence (7.3% vs. 15.3%, P<0.001), and lack of employment (7.2% vs. 16.4%, P<0.001). The post-Katrina group had increased rates of AMI during nights (29.8% vs. 47.8%, P<0.001) and weekends (16.1% vs. 29.1%, P<0.001). CONCLUSIONS: Even 10 years after the storm, Hurricane Katrina continues to be associated with increased incidence of AMI, higher prevalence of traditional cardiovascular and psychosocial risk factors, and an altered chronobiology of AMI toward nights and weekends. (Disaster Med Public Health Preparedness. 2019;13:217-222).

Revascularization of Left Main Coronary Artery.

Left main coronary artery (LMCA) disease affect 5-7% of patient undergoing coronary angiography and is associated with multivessel CAD in 70% of the cases. Untreated significant LMCA disease is associated with significant mortality and morbidity. CABG is the traditional therapy for revascularization in LMCA disease. PCI is a reasonable alternative mainly in patients with high surgical risk or other specific factors. Drug-eluting stents, improved antiplatelet therapeutic options, atherectomy techniques, IVUS-guidance and improved operator experience have all contributed to the observed improvement in clinical outcomes. Given the large number of variables involved in deciding between PCI and CABG, a heart team should make decisions regarding revascularization of LMCA disease.

Five-Year Outcomes with PCI Guided by Fractional Flow Reserve.

BACKGROUND: We hypothesized that fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) would be superior to medical therapy as initial treatment in patients with stable coronary artery disease. METHODS: Among 1220 patients with angiographically significant stenoses, those in whom at least one stenosis was hemodynamically significant (FFR, ≤0.80) were randomly assigned to FFR-guided PCI plus medical therapy or to medical therapy alone. Patients in whom all stenoses had an FFR of more than 0.80 received medical therapy and were entered into a registry. The primary end point was a composite of death, myocardial infarction, or urgent revascularization. RESULTS: A total of 888 patients underwent randomization (447 patients in the PCI group and 441 in the medical-therapy group). At 5 years, the rate of the primary end point was lower in the PCI group than in the medical-therapy group (13.9% vs. 27.0%; hazard ratio, 0.46; 95% confidence interval [CI], 0.34 to 0.63; P<0.001). The difference was driven by urgent revascularizations, which occurred in 6.3% of the patients in the PCI group as compared with 21.1% of those in the medical-therapy group (hazard ratio, 0.27; 95% CI, 0.18 to 0.41). There were no significant differences between the PCI group and the medical-therapy group in the rates of death (5.1% and 5.2%, respectively; hazard ratio, 0.98; 95% CI, 0.55 to 1.75) or myocardial infarction (8.1% and 12.0%; hazard ratio, 0.66; 95% CI, 0.43 to 1.00). There was no significant difference in the rate of the primary end point between the PCI group and the registry cohort (13.9% and 15.7%, respectively; hazard ratio, 0.88; 95% CI, 0.55 to 1.39). Relief from angina was more pronounced after PCI than after medical therapy. CONCLUSIONS: In patients with stable coronary artery disease, an initial FFR-guided PCI strategy was associated with a significantly lower rate of the primary composite end point of death, myocardial infarction, or urgent revascularization at 5 years than medical therapy alone. Patients without hemodynamically significant stenoses had a favorable long-term outcome with medical therapy alone. (Funded by St. Jude Medical and others; FAME 2 ClinicalTrials.gov number, NCT01132495 .).

Pooled diagnostic accuracy of resting distal to aortic coronary pressure referenced to fractional flow reserve: The importance of resting coronary physiology.

INTRODUCTION: Both resting and hyperemic physiologic methods to guide coronary revascularization improve cardiovascular outcomes compared with angiographic guidance alone. Fractional flow reserve (FFR) remains underutilized due to concerns regarding hyperemia, prompting study of resting distal to aortic coronary pressure (Pd/Pa). Pd/Pa is a vasodilator-free resting index unlike FFR. While Pd/Pa is similar to another resting index, instantaneous wave-free ratio (iFR), it is a whole-cycle measurement not limited to the wave-free diastolic period. Pd/Pa is not validated clinically although multiple accuracy studies have been performed. Our meta-analysis examines the overall diagnostic accuracy of Pd/Pa referenced to FFR, the accepted invasive standard of ischemia. METHODS: We searched PubMed, EMBASE, Central, ProQuest, and Web of Science databases for full text articles published through August 9, 2017 addressing the diagnostic accuracy of Pd/Pa referenced to FFR < 0.80. The following keywords were used: "distal coronary artery pressure" OR "Pd/Pa" AND "fractional flow reserve" OR "FFR." RESULTS: In total, 14 studies comprising 7004 lesions were identified. Pooled diagnostic accuracy estimates of Pd/Pa versus FFR < 0.80 were: sensitivity, 0.77 (95% CI, 0.75-0.78); specificity, 0.82 (0.81-0.83); positive likelihood ratio, 4.7 (3.3-6.6); negative likelihood ratio, 0.29 (0.24-0.34); diagnostic odds ratio, 18.1 (14.4-22.6); area under the summary receiver-operating characteristic curve of 0.88; and diagnostic accuracy of 0.80 (0.76-0.83). CONCLUSIONS: Pd/Pa shows adequate agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. Pd/Pa has the potential to guide coronary revascularization with easier application and availability compared with iFR and FFR.

Instantaneous wave-free ratio as an alternative to fractional flow reserve in assessment of moderate coronary stenoses: A meta-analysis of diagnostic accuracy studies.

BACKGROUND/PURPOSE: Fractional flow reserve (FFR) remains underutilized due to practical concerns related to the need for hyperemic agents. These concerns have prompted the study of instantaneous wave-free ratio (iFR), a vasodilator-free index of coronary stenosis. Non-inferior cardiovascular outcomes have been demonstrated in two recent randomized clinic trials. We performed this meta-analysis to provide a necessary update of the diagnostic accuracy of iFR referenced to FFR based on the addition of eight more recent studies and 3727 more lesions. METHODS: We searched the PubMed, EMBASE, Central, ProQuest, and Web of Science databases for full text articles published through May 31, 2017 to identify studies addressing the diagnostic accuracy of iFR referenced to FFR≤0.80. The following keywords were used: "instantaneous wave-free ratio" OR "iFR" AND "fractional flow reserve" OR "FFR." RESULTS: In total, 16 studies comprising 5756 lesions were identified. Pooled diagnostic accuracy estimates of iFR versus FFR≤0.80 were: sensitivity, 0.78 (95% CI, 0.76-0.79); specificity, 0.83 (0.81-0.84); positive likelihood ratio, 4.54 (3.85-5.35); negative likelihood ratio, 0.28 (0.24-0.32); diagnostic odds ratio, 17.38 (14.16-21.34); area under the summary receiver-operating characteristic curve, 0.87; and an overall diagnostic accuracy of 0.81 (0.78-0.84). CONCLUSIONS: In conclusion, iFR showed excellent agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. When considering along with its clinical outcome data and ease of application, the diagnostic accuracy of iFR supports its use as a suitable alternative to FFR for physiology-guided revascularization of moderate coronary stenoses. SUMMARY: We performed a meta-analysis of the diagnostic accuracy of iFR referenced to FFR. iFR showed excellent agreement with FFR as a resting index of coronary stenosis severity without the undesired effects and cost of hyperemic agents. This supports its use as a suitable alternative to FFR for physiology-guided revascularization of moderate coronary stenoses.

Succesful antegrade subintimal bypass restenting of in-stent chronic total occlusion.

Coronary chronic total occlusions (CTOs) are known to cause significant patient morbidity. Over the past several years, the techniques and devices for treating these CTOs have advanced tremendously. The interventional management of CTOs within previously placed coronary stents, however, remains challenging. Here, we present a case of an in-stent restenosis of the right coronary artery CTO bypassed using a controlled subintimal dissection re-entry technique via antegrade approach creating side-by-side stents.

The broken heart syndrome: Takotsubo cardiomyopathy.

First described in 1990, Takotsubo cardiomyopathy consists of a transient systolic dysfunction of localized segments of the left ventricle. Commonly occurring in postmenopausal women, Takotsubo is often associated with intense physical and/or emotional stress. It is traditionally identified by distinctive wall motion patterns on transthoracic echocardiogram and left ventriculography. Further understanding of the disease mechanisms and recognition of at-risk populations has potentially tremendous therapeutic benefit.

Natural disasters and myocardial infarction: the six years after Hurricane Katrina.

OBJECTIVE: To determine the prolonged effect of Hurricane Katrina on the incidence and timing of acute myocardial infarction (AMI) in the city of New Orleans. PATIENTS AND METHODS: Our study population consisted of 1476 patients with AMI before (August 29, 1999, to August 28, 2005) and after (February 14, 2006, to February 13, 2012) Hurricane Katrina at Tulane University Health Sciences Center to determine post-Katrina alterations in the occurrence and timing of AMI. RESULTS: Compared with pre-Katrina values, there was a more than 3-fold increase in the percentage of admissions for AMI during the 6 years after Hurricane Katrina (P<.001). The percentage of admissions for AMI after Hurricane Katrina increased significantly on nights (P<.001) and weekends (P<.001) and decreased significantly on mornings (P<.001), Mondays (P<.001), and weekdays (P<.001). Patients with AMI after Hurricane Katrina also had significantly higher rates of psychiatric comorbidities (P=.01), smoking (P<.001), lack of health insurance (P<.05), and unemployment (P<.001). CONCLUSION: These results indicate that the effect of natural disasters on the occurrence of AMI may persist for at least a 6-year period and may be related to various factors including population shifts, alterations in the health care system, and the effects of chronic stress and associated behaviors.

OxLDL induces endothelial dysfunction and death via TRAF3IP2: inhibition by HDL3 and AMPK activators.

Oxidized low-density lipoprotein (oxLDL) induces endothelial cell death through the activation of NF-κB and AP-1 pathways. TRAF3IP2 is a redox-sensitive cytoplasmic adapter protein and an upstream regulator of IKK/NF-κB and JNK/AP-1. Here we show that oxLDL-induced death in human primary coronary artery endothelial cells (ECs) was markedly attenuated by the knockdown of TRAF3IP2 or the lectin-like oxLDL receptor 1 (LOX-1). Further, oxLDL induced Nox2/superoxide-dependent TRAF3IP2 expression, IKK/p65 and JNK/c-Jun activation, and LOX-1 upregulation, suggesting a reinforcing mechanism. Similarly, the lysolipids present in oxLDL (16:0-LPC and 18:0-LPC) and minimally modified LDL also upregulated TRAF3IP2 expression. Notably, whereas native HDL3 reversed oxLDL-induced TRAF3IP2 expression and cell death, 15-lipoxygenase-modified HDL3 potentiated its proapoptotic effects. The activators of the AMPK/Akt pathway, adiponectin, AICAR, and metformin, attenuated superoxide generation, TRAF3IP2 expression, and oxLDL/TRAF3IP2-mediated EC death. Further, both HDL3 and adiponectin reversed oxLDL/TRAF3IP2-dependent monocyte adhesion to endothelial cells in vitro. Importantly, TRAF3IP2 gene deletion and the AMPK activators reversed oxLDL-induced impaired vasorelaxation ex vivo. These results indicate that oxLDL-induced endothelial cell death and dysfunction are mediated via TRAF3IP2 and that native HDL3 and the AMPK activators inhibit this response. Targeting TRAF3IP2 could potentially inhibit progression of atherosclerotic vascular diseases.

Coronary angiographic significance of hyperacute ST-T changes associated with regadenoson stress.

An abnormal electrocardiographic stress test is typically characterized by ST segment depression. In rare cases, ST segment elevation is observed, which, in the absence of diagnostic Q waves, has anatomic specificity for localized myocardial ischemia. Most instances of ST elevation occurring during cardiac stress testing have been observed with exercise, with only six cases reported with pharmacologic stress. Despite different physiologic mechanisms for inducing myocardial ischemia, development of ST segment elevation during pharmacologic stress, as illustrated by the present case, may also be indicative of critical coronary stenoses, warranting urgent coronary arteriography.

Primary Streptococcus pneumoniae pericarditis.

Although commonly fatal, bacterial pericarditis is often not diagnosed antemortem due to its infrequent occurrence and fulminant course. Historically, Streptococcus pneumoniae has been the most common cause of bacterial pericarditis. Over the past 70 years, however, it has become largely eliminated and now occurs almost exclusively in immunocompromised individuals with a preceding primary site of infection. Herein, we present a case of primary S. pneumoniae pericarditis that developed over the course of 3 to 4 weeks in an immunocompetent 45-year-old man. The patient, who developed cardiac tamponade shortly after admission, experienced a rapid resolution of symptoms following pericardial drainage and initiation of antibiotics.

Effect of Hurricane Katrina on chronobiology at onset of acute myocardial infarction during the subsequent three years.

The onset of acute myocardial infarction (AMI) has been shown to occur in a nonrandom pattern, with peaks in midmorning and on weekdays (especially Monday). The incidence of AMI has been shown to increase locally after natural disasters, but the effect of catastrophic events on AMI biorhythms is largely unknown. To assess the differences in the chronobiology of AMI in residents of New Orleans before and after Hurricane Katrina, the onset of AMI in patients at Tulane University Health Sciences Center in the 6 years before and the 3 years after Hurricane Katrina was retrospectively examined. Compared to the pre-Katrina group, the post-Katrina cohort demonstrated significant decreases in the onset of AMI during mornings (p = 0.002), Mondays (p <0.0001), and weekdays (p <0.0001) and significant increases in onset during weekends (p <0.0001) and nights (p <0.0001). These changes persisted during all 3 years after the storm. In conclusion, the normal pattern of AMI onset was altered after Hurricane Katrina, and expected morning, weekday, and Monday peaks were eliminated.