Completion peripheral angiography in single-access, Impella-assisted, high-risk PCI: Using a buddy microcatheter sheath after MANTA closure for imaging and potential bailout.

High-risk percutaneous coronary intervention (HR-PCI) is increasingly performed, often with mechanical circulatory support (MCS) provided by devices like the Impella CP. Bleeding and vascular complications remain concerns for HR-PCI, leading to significantly higher in-hospital mortality, duration of stay, and cost, which are important considerations in the decisions surrounding MCS support for HR-PCI. Newly introduced, single-catheter techniques for Impella-supported HR-PCI, along with recent approvals of dedicated large-bore closure devices (MANTA®-Vascular Closure Device) may reduce bleeding and vascular complications, but have limitations with regard to completion of peripheral angiography and/or postclosure percutaneous bailout options. The present technique offers a potential solution to these limitations, and describes a buddy microcatheter approach to postclosure management of HR-PCI with MCS, which was highly successful in a consecutive series of patients at our institution.

Prosthetic Valve Endocarditis After TAVR and SAVR: Insights From the PARTNER Trials.

BACKGROUND: Prosthetic valve endocarditis (PVE) is a rare but critical mechanism of valve failure and death after transcatheter and surgical aortic valve replacement (TAVR, SAVR) warranting further analysis in modern aortic valve replacement experience. We characterize the incidence, risk factors, microbiological profile and outcomes of PVE from the PARTNER trials and registries (Placement of Aortic Transcatheter Valve). METHODS: We analyzed a pooled cohort of all patients in PARTNER 1 and PARTNER 2 trials and registries. Patients had severe aortic stenosis, were treated with TAVR or SAVR, and were analyzed with respect to development of PVE. PVE adjudication by a clinical events committee was based on modified Duke Criteria. The incidence, infection timing, organism, and association between PVE and all-cause mortality were analyzed. RESULTS: 8530 patients were included. PVE occurred in 107 cases (5.06 PVE events per 1000 person-years over a mean follow-up of 2.69±1.55 years [95% CI, 4.19-6.12]). The incidence of TAVR-PVE (5.21 PVE per 1000 person-years [95% CI, 4.26-6.38]) was not significantly different from SAVR-PVE (4.10 per 1000 person-years [95% CI, 2.33-7.22]; incident rate ratio, 1.27 [95% CI, 0.70-2.32]; P=0.44). Temporal risk of PVE was similar for TAVR and SAVR, even after adjusting for competing risk of death (hazard ratio, 1.15 [95% CI, 0.58-2.28]; P=0.69). Through multivariable analysis, PVE was associated with baseline cirrhosis (incident rate ratio, 2.86 [95% CI, 1.33-6.16]; P=0.007), pulmonary disease (incident rate ratio, 1.70 [95% CI, 1.16-2.48]; P=0.006), and renal insufficiency (incident rate ratio, 1.71 [95% CI, 1.03-2.83]; P=0.04). Timing of PVE was similar between TAVR and SAVR (<30 days: 4.2% vs 8.3%; 31 days to 1 year: 52.6% vs 66.7%; >1 year: 43.2% vs 25.0%; P=0.28). Staphylococcus occurred more commonly after SAVR (58.3% vs 28.4% in TAVR; P=0.04). PVE was strongly associated with all-cause mortality after endocarditis diagnosis (hazard ratio, 4.4 [95% CI, 3.42-5.72]; P<0.0001). CONCLUSIONS: The widespread adoption of TAVR and application to lower-risk patients makes understanding mechanisms of valve failure increasingly important. PVE is an established mechanism of prosthetic valve failure post-SAVR and TAVR with unclear differences between approaches. We herein demonstrate in the largest trials and registries of TAVR that PVE remains rare, but often fatal, in modern AVR experience and that there is no difference in incidence, predictors, or risk of PVE between TAVR and SAVR. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov. Unique identifiers: NCT00530894 (PARTNER 1), NCT01314313 (PARTNER 1IA), NCT02184442 (PARTNER 1IB), NCT03222141 (PII S3HR), NCT03222128 (PII S3i).

Emergency valve-in-valve transcatheter aortic valve replacement in a patient with degenerated bioprosthetic aortic stenosis and cardiogenic shock on veno-arterial extracorporeal membrane oxygenation.

The use of transcatheter aortic valve replacement (TAVR) as an acute treatment in severe decompensated bioprosthetic aortic valve disease is not well documented. We describe herein a unique case in which valve-in-valve (ViV) TAVR was successfully used as both an emergency salvage therapy and a bridge to definitive fourth reoperative aortic valve replacement (AVR) in a young patient with cardiogenic shock secondary to bioprosthetic aortic valve stenosis who was dependent on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). © 2017 Wiley Periodicals, Inc.

Exercise N-13 cardiac positron emission tomography myocardial perfusion imaging detecting ischemia in an adult patient with anomalous aortic origin of the left main coronary artery from the right coronary sinus.

Anomalous aortic origin of a coronary artery is a rare congenital condition that has variable presentations from atypical chest pain to syncope and cardiac arrest. Commonly used myocardial perfusion imaging techniques, stress agents, and perfusion agents may have limited ability to detect inducible ischemia in this rare patient group. We herein describe a unique case of anomalous left main coronary artery from a common right coronary sinus ostium with a subpulmonic and intramyocardial course. This patient had multiple atypical chest pain presentations and multiple-negative pharmacologic single-photon emission-computed tomography stress tests performed. Significant ischemia was detected via N-13 exercise cardiac positron emission tomography and with surgical intervention she had resolution of her symptoms.

Appropriateness of percutaneous coronary intervention: a review.

The appropriateness of coronary revascularization for various clinical scenarios has been reviewed formally by several specialty and subspecialty societies resulting in the formulation of scored appropriateness criteria. The goal of the appropriateness criteria is to guide physician decision-making and future research as well as to label coronary revascularization more clearly for patients and payors in regards to its expected benefits in certain situations. The appropriateness criteria were formulated from a standardized process and are intended to be updated at regular intervals as new data further elucidates the clinical roles of revascularization. Since its last iteration in early 2012, several studies have been published that may further expand scenarios or impact the appropriateness of revascularization in already-established scenarios. The differentiation of appropriateness with particular forms of revascularization has been reserved for specific clinical scenarios where revascularization is generally considered necessary and appropriate. The goals of this review are 1) to highlight aspects of the methodology and development of the coronary revascularization appropriateness criteria, and 2) to focus on the role established specifically for percutaneous coronary intervention within the criteria. Important data published in 2012 that further evaluates the role of percutaneous coronary intervention will also be reviewed with a focus on its potential impact on future iterations of the appropriateness criteria.

Takotsubo cardiomyopathy: definition and clinical profile.

Takotsubo cardiomyopathy (TTC) is an increasingly recognized, reversible cardiomyopathy with a clinical presentation that mimics an acute coronary syndrome but without evidence of obstructive coronary lesions. Typical presentation involves chest pain and/or dyspnea, transient ST-segment elevation on the electrocardiogram, and a modest increase in cardiac troponin. Cardiac imaging demonstrates wall-motion abnormalities that extend beyond the territory of a single epicardial coronary artery, and the absence of obstructive coronary lesions. Supportive treatment leads to spontaneous, rapid recovery of ventricular function, but about 10% of patients have recurrent events. This article reviews the defining features and clinical profile of TTC.

Coincidence of apical ballooning syndrome (tako-tsubo/stress cardiomyopathy) and posterior reversible encephalopathy syndrome: potential common substrate and pathophysiology?

BACKGROUND: Apical ballooning syndrome (ABS) and posterior reversible encephalopathy syndrome (PRES) are recently described, seemingly unrelated, reversible conditions. The precise pathophysiology of these syndromes remains unknown. The aim of this study was to describe the clinical characteristics and outcomes of a unique series of patients with both ABS and PRES. METHODS AND RESULTS: In a retrospective study of 224 consecutive patients diagnosed with ABS between 2002 and 2010, 6 (2.7%) were also diagnosed with PRES. All were female with a mean age of 63.7 ± 12.5 years. All patients had preceding medical comorbidities and physical stress triggers that precipitated ABS and PRES. Mean peak troponin T levels and left ventricular ejection fraction at presentation were 0.47 ± 0.48 mg/dL and 31.5 ± 8.2%, respectively. Characteristic left ventricular wall motion abnormalities (regional wall motion score index 2.22 ± 0.37) were noted in all patients, and magnetic resonance imaging of the brain was significant for vasogenic edema, predominantly in the posterior circulation. All patients recovered left ventricular (ejection fraction at follow-up 60.2 ± 6.0%) and neurologic function with supportive management. Two patients had recurrence of ABS and 1 of PRES during follow-up. CONCLUSIONS: ABS and PRES can occur simultaneously during an acute illness. Patients with ABS who develop neurologic dysfunction should be evaluated for PRES and vice versa. Because transient sympathetic overactivity and microvascular dysfunction have been observed in both reversible syndromes, we speculate that they may represent the shared pathophysiologic mechanism.

Myocardial ischaemia in patients with coronary endothelial dysfunction: insights from body surface ECG mapping and implications for invasive evaluation of chronic chest pain.

AIMS: Coronary endothelial dysfunction (ED), by predisposing to abnormal vasomotion, may cause chest pain in individuals with non-obstructed coronary arteries. The aim of this study was to correlate the magnitude of coronary ED with the presence and extent of inducible myocardial ischaemia using body surface electrocardiogram (ECG) mapping in symptomatic patients. METHODS AND RESULTS: In 30 patients with chest pain and angiographically normal coronary arteries or mild atherosclerosis, we studied endothelium-dependent responses with acetylcholine (ACH) and endothelium-independent function with nitroglycerin and adenosine in the left anterior descending artery. Eighty-lead body surface ECG maps were collected at baseline and after each dose of ACH. There was a significant correlation between the maximal change in epicardial diameter with ACH and the magnitude of ST-segment shift [r = -0.44 (95% CI: -0.097 to -0.69), P = 0.015]. Patients with ≥ 0.05 mV ST-segment shift/lead had greater epicardial vasoconstriction (31.6 vs. 15.6%, P = 0.019), and lower coronary flow reserve (2.9 vs. 3.6, P = 0.047) compared with those with ST-segment shift <0.05 mV. Four patients had inducible ischaemia with ACH in the absence of abnormal epicardial or global microvascular vasomotion (>20% decrease in diameter or <50% increase in blood flow). CONCLUSIONS: This study demonstrates that abnormal vasomotion due to coronary ED is associated with myocardial ischaemia in patients with chest pain. The magnitude of ischaemia correlates with the extent of ED. A small subset of patients develop myocardial ischaemia during ACH infusion without significant abnormalities in epicardial or global microvascular endothelium-dependent blood flow responses.

Importance of the C2, N7, and C8 positions to the mutagenic potential of 8-Oxo-2'-deoxyguanosine with two A family polymerases.

8-Oxo-2'-deoxyguanosine (OdG) is a prominent DNA lesion produced from the reaction of 2'-deoxyguanosine (dG) with reactive oxygen species. While dG directs the insertion of only dCTP during replication, OdG can direct the insertion of either dCTP or dATP, allowing for the production of dG → dT transversions. When replicated by Klenow fragment-exo (KF-exo), OdG preferentially directs the incorporation of dCTP over dATP, thus decreasing its mutagenic potential. However, when replicated by a highly related polymerase, the large fragment of polymerase I from Bacillus stearothermophilus (BF), dATP incorporation is preferred, and a higher mutagenic potential results. To gain insight into the reasons for this opposite preference and the effects of the C2, N7, and C8 positions on OdG mutagenicity, single-nucleotide insertions of dCTP and/or dATP opposite dG, OdG, and seven of their analogues were examined by steady state kinetics with both KF-exo and BF. Results from these studies suggest that the two enzymes behave similarly and are both sensitive not only to steric and electronic changes within the imidazole ring during both dCTP and dATP incorporation but also to the presence of the C2-exocyclic amine during dATP incorporation. The difference in incorporation preference opposite OdG appears to be due to a somewhat increased sensitivity to structural perturbations during dCTP incorporation with BF. Single-nucleotide extensions past the resulting base pairs were also studied and were not only similar between the two enzymes but also consistent with published ternary crystallographic studies with BF. These results are analyzed in the context of previous biochemical and structural studies, as well as stability studies with the resulting base pairs.