Left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome: A review of literature on therapy, intervention, and management.

Coronary artery anomalies (CAA) are anatomical aberrations in the origin, structure, and course of the epicardial arteries. Literature has detailed common anomalies or fistulas formed because of coronary artery bypass grafting (CABG) manipulation of intrathoracic vessels. Despite the commonality of the CABG procedure, there are a few CAA and fistula findings which remain extremely rare. We present a case of left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome that presented symptomatically as a malignant arrhythmia. Following a literature review of therapy, intervention, and management we recommend a team based approach when faced with this extremely rare case presentation. The goal of management should to reduce symptoms, and ischemia, by reducing or stopping flow through the fistula and out of the coronary blood supply.

Valve in valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-Surgical aortic valve replacement (redo-SAVR): A systematic review and meta-analysis.

BACKGROUND: Bioprosthetic (BP) valves have been increasingly used for aortic valve replacement over the last decade. Due to their limited durability, patients presenting with failed BP valves are rising. Valve in Valve - Transcatheter Aortic Valve Implantation (ViV-TAVI) emerged as an alternative to the gold standard redo-Surgical Aortic Valve Replacement (redo-SAVR). However, the utility of ViV-TAVI is poorly understood. METHODS: A systematic electronic search of the scientific literature was done in PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov. Only studies which compared the safety and efficacy of ViV-TAVI and redo-SAVR head to head in failed BP valves were included. RESULTS: Six observational studies were eligible and included 594 patients, of whom 255 underwent ViV- TAVI and 339 underwent redo-SAVR. There was no significant difference between ViV-TAVI and redo- SAVR for procedural, 30 day and 1 year mortality rates. ViV-TAVI was associated with lower risk of permanent pacemaker implantation (PPI) (OR: 0.43, CI: 0.21-0.89; P = 0.02) and a trend toward increased risk of paravalvular leak (PVL) (OR: 5.45, CI: 0.94-31.58; P = 0.06). There was no significant difference for stroke, major bleeding, vascular complications and postprocedural aortic valvular gradients more than 20 mm-hg. CONCLUSION: Our results reiterate the safety and feasibility of ViV-TAVI for failed aortic BP valves in patients deemed to be at high risk for surgery. VIV-TAVI was associated with lower risk of permanent pacemaker implantation with a trend toward increased risk of paravalvular leak.

Impact of annual operator and institutional volume on percutaneous coronary intervention outcomes: a 5-year United States experience (2005-2009).

BACKGROUND: The relationship between operator or institutional volume and outcomes among patients undergoing percutaneous coronary interventions (PCI) is unclear. METHODS AND RESULTS: Cross-sectional study based on the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2005 to 2009. Subjects were identified by International Classification of Diseases, 9(th) Revision, Clinical Modification procedure code, 36.06 and 36.07. Annual operator and institutional volumes were calculated using unique identification numbers and then divided into quartiles. Three-level hierarchical multivariate mixed models were created. The primary outcome was in-hospital mortality; secondary outcome was a composite of in-hospital mortality and peri-procedural complications. A total of 457,498 PCIs were identified representing a total of 2,243,209 PCIs performed in the United States during the study period. In-hospital, all-cause mortality was 1.08%, and the overall complication rate was 7.10%. The primary and secondary outcomes of procedures performed by operators in 4(th) [annual procedural volume; primary and secondary outcomes] [>100; 0.59% and 5.51%], 3(rd) [45-100; 0.87% and 6.40%], and 2(nd) quartile [16-44; 1.15% and 7.75%] were significantly less (P<0.001) when compared with those by operators in the 1(st) quartile [≤15; 1.68% and 10.91%]. Spline analysis also showed significant operator and institutional volume outcome relationship. Similarly operators in the higher quartiles witnessed a significant reduction in length of hospital stay and cost of hospitalization (P<0.001). CONCLUSIONS: Overall in-hospital mortality after PCI was low. An increase in operator and institutional volume of PCI was found to be associated with a decrease in adverse outcomes, length of hospital stay, and cost of hospitalization.

Repeat Revascularization Post Coronary Artery Bypass Grafting: Comparing Minimally Invasive and Traditional Sternotomy Techniques in 1468 Cases.

BACKGROUND: Traditional open sternotomy coronary artery bypass grafting (CABG) utilizes highly invasive techniques that lead to several serious complications. In response, minimally invasive cardiac surgery CABG (MICS-CABG) was developed. MICS-CABG is safe, reproducible, and with fewer complications, while allowing for better postoperative recovery periods. There is a paucity of data exploring rates of repeat revascularization in patients post MICS-CABG compared to post traditional sternotomy CABG. METHODS: This was a retrospective billing database review examining 1468 CABG patients at a large university medical center from January 2005 to December 2017. The primary objective was to compare the rate of repeat revascularization events between MICS-CABG and traditional open sternotomy CABG over an eight-year follow-up period. RESULTS: Our study population consisted of 1468 patients, of whom 513 had MICS-CABG and 955 had traditional CABG. The number of patients undergoing repeat revascularization within the eight-year surveillance was 99 for MICS-CABG and 75 for traditional CABG. The Kaplan-Meier survival probability estimates for eight years were 0.86 for MICS-CABG and 0.91 for traditional CABG. The mean time until a repeat revascularization event was 84.1 months for MICS-CABG and 88.5 months for traditional CABG. CONCLUSIONS:  Traditional CABG was found to have a statistically significantly longer time to repeat revascularization than MICS-CABG. Despite the technical challenges associated with MICS-CABG, the time to repeat revascularization was different by only about four months, which may not hold large clinical significance. This suggests that MICS-CABG may have a role to play due to previous findings showing a reduction in complications while allowing for better postoperative recovery periods.

Gender-related Disparities of Percutaneous Coronary Interventions in ST-elevation Myocardial Infarction: A Retrospective Chart Review of 500 Patients.

Door-to-balloon (DTB) time of primary percutaneous coronary intervention in ST-elevation myocardial infarction (STEMI) is a predictive indicator of outcomes and mortality. Traditional gender-related differences that existed in the provision of DTB in STEMI had been allegedly improving until recent controversial data showed re-emergence of longer DTB in females. The objective of our study was to compare circadian disparities in percutaneous coronary intervention for STEMI according to gender in our institution. We compared DTB and symptom-to-balloon (STB) as well as mortality outcomes in a registry of 514 patients. We studied 117 females and 397 males. Baseline characteristics and cardiovascular risk factors were similar among both populations. Men used more self-transportation (51% vs. 38%) compared with women. Both had similar DTB median times: males, 63 (47-79) min; and females, 61 (44-76) min. In addition, STB median times were also similar: males, 155 (116-264) min; and females, 165 (115-261) min. Mortality outcomes at 1 month were comparable at 3% in males versus 0.9% in females (P = 0.164). In a review of a tertiary care center in New York, we observed no gender differences in DTB and STB, endorsing the role of emergency medical service transportation in eliminating disparities.

Spontaneous Hemorrhagic Pericardial and Pleural Effusion in a Patient Receiving Apixaban.

Direct oral anticoagulants (DOACs) are used for many conditions where anticoagulation is needed such as non-valvular atrial fibrillation, deep vein thrombosis (DVT) and pulmonary embolism (PE). These novel agents have become popular since they do not require monitoring of therapeutic levels and there is a lower risk of certain bleeding complications when compared to warfarin. However, the efficacy and side effect profile of these agents have not been widely studied in certain patient cohorts, namely cancer patients and patients on immunomodulators or hormone analogs. We present a case of a patient with a history of malignancy and autoimmune disease who developed pericardial and pleural effusions shortly after initiating apixaban for treatment of a PE. In addition, we aim to increase awareness of the role that the newly available reversal agents for anticoagulants would offer in the acute management of hemorrhagic pericardial and pleural effusions caused by DOACs in patients with and without malignancy.

Large Left Atrial Appendage Causing Cryptogenic Stroke.

Cryptogenic stroke is a subtype of ischemic stroke for which no identifiable cause is found after routine diagnostic evaluation. It accounts for roughly 25% of ischemic strokes. Structural cardiac abnormalities such as patent foramen ovale, atrial septal defect (ASD), and a large left atrial appendage (LAA) are commonly associated risk factors in patients with cryptogenic stroke. We report a case of a patient with a history of a surgically repaired ASD found to have a large LAA without identifiable thrombus on both transthoracic echocardiogram and transesophageal echocardiogram after presenting with an acute cryptogenic stroke in the absence of any arrhythmias. We aim to emphasize the importance of the LAA, particularly if large, in the pathogenesis and development of cryptogenic strokes. Additionally, we discuss the necessity for clearly defined guidelines on whether to start anticoagulation in these patients.

Association between coronary artery disease diagnosed by coronary angiography and breast arterial calcifications on mammography: meta-analysis of the data.

BACKGROUND: Previous studies evaluating breast arterial calcifications (BAC) as a risk marker for coronary artery disease (CAD) have been limited by sample size and have yielded mixed results. Our objective was to evaluate the association of BAC and CAD. METHODS: Data sources included Medline (1970-2010), the Cochrane Controlled Trials Register electronic database (1970-2010), and CINAHL (1970-2010). The search strategy included the keywords, breast artery calcification, vascular calcification on mammogram, coronary angiography, and meta-analysis. Eligible studies included female patients who had undergone coronary angiography, the gold standard for diagnosing CAD, and had screening mammograms that revealed the presence or absence of BAC. Information on eligibility criteria, baseline characteristics, results, and methodologic quality was extracted by two reviewers. Disagreements were resolved by consensus. RESULTS: A total of 927 patients were enrolled in the five studies. There was a 1.59 (95% confidence interval [CI] 1-21-2.09) increased odds of angiographically defined CAD in patients with BAC seen on mammography. CONCLUSIONS: The presence of BAC on mammography appears to increase the risk of having obstructive CAD on coronary angiography; thus, BAC may not be a benign finding.

Syncope, widened QRS interval, and left ventricular systolic depression: coincident with propafenone therapy for atrial fibrillation.

We report the case of a 46-year-old man who developed syncope, a widened QRS interval, and depressed left ventricular systolic function during propafenone therapy for atrial fibrillation. These acute findings may have been consequent to an increased dosage of propafenone combined with heavy alcohol consumption that led to decreased metabolism of propafenone. In addition, propafenone is known to interfere with liver function, although this patient's test results showed scant evidence of liver abnormalities. Yet another possible factor is the genetic spectrum in the metabolism of propafenone and other class I antiarrhythmic agents. When propafenone is prescribed, we recommend advising patients that alcohol consumption and interactions with other drugs can lead to increased levels of the antiarrhythmic agent, with resultant toxicity that can lead to adverse cardiovascular effects. Patients taking propafenone should also undergo periodic liver function testing. Finally, attention should be paid to voluntary or official recalls of specific antiarrhythmic medications that are of unreliable quality or potency.

Improved outcome with AngioJet thrombectomy during primary stenting in acute myocardial infarction patients with high-grade thrombus.

BACKGROUND: Primary stenting during acute myocardial infarction (MI) is often complicated by slow-flow/no-reflow due to distal embolization of intracoronary thrombus. The AngioJet thrombectomy catheter has been utilized in this setting in order to limit distal embolization and improve flow. The effect of AngioJet during primary stenting in acute MI with high-grade thrombus (greater than or equal to grade 3, as per thrombolysis in MI [TIMI] classification) is not known. METHODS: We analyzed 95 consecutive acute MI patients with thrombus grade > or = 3 who underwent primary stenting with AngioJet (n = 52) and without AngioJet (n = 43) for epicardial and microvascular flow, and followed for 30-day major adverse cardiac events (MACE) and 1-year survival. Baseline characteristics and in-hospital events were obtained from the interventional database. Two independent operators analyzed pre- and post-procedure TIMI flow rates, corrected TIMI frame count (CTFC) and TIMI myocardial perfusion grade (TMPG). RESULTS: Baseline clinical and angiographic characteristics were comparable between the two groups. AngioJet use was associated with better TIMI flow, TMP grade, CTFC and a trend towards lower 30-day and 1-year MACE. Use of AngioJet thrombectomy prior to stenting of acute MI patients with high-grade thrombus improves epicardial and microvascular flow, with a trend toward better short- and long-term outcome.