Assessment of Repeat Revascularization in Percutaneous Coronary Intervention Randomized Controlled Trials as a Surrogate for Mortality: A Meta-Regression Analysis.

The association of repeat revascularization after percutaneous coronary intervention (PCI) with mortality is uncertain. To assess the association of repeat revascularization after PCI with mortality in patients with coronary artery disease (CAD). We identified randomized controlled trials comparing PCI with coronary artery bypass graft (CABG) or optimal medical therapy (OMT) using electronic databases through January 1, 2022. We performed a random-effects meta-regression between repeat revascularization rates after PCI (absolute risk difference [%] between PCI and CABG or OMT) with the relative risks (RR) of mortality. We assessed surrogacy of repeat revascularization for mortality using the coefficient of determination (R2), with threshold of 0.80. In 33 trials (21,735 patients), at median follow-up of 4 (2-7) years, repeat revascularization was higher after PCI than CABG [RR: 2.45 (95% confidence interval, 1.99-3.03)], but lower vs OMT [RR: 0.64 (0.46-0.88)]. Overall, meta-regression showed that repeat revascularization rates after PCI had no significant association with all-cause mortality [RR: 1.01 (0.99-1.02); R2=0.10) or cardiovascular mortality [RR: 1.01 (CI: 0.99-1.03); R2=0.09]. In PCI vs CABG (R2=0.0) or PCI vs OMT trials (R2=0.28), repeat revascularization did not meet the threshold for surrogacy for all-cause or cardiovascular mortality (R2=0.0). We observed concordant results for subgroup analyses (enrollment time, follow-up, sample size, risk of bias, stent types, and coronary artery disease), and multivariable analysis adjusted for demographics, comorbidities, risk of bias, MI, and follow-up duration. In summary, this meta-regression did not establish repeat revascularization after PCI as a surrogate for all-cause or cardiovascular mortality.

Transcatheter versus surgical aortic valve replacement in patients with end stage renal disease.

OBJECTIVE: To assess contemporary national trends of comorbidities, outcomes, and health care resource utilization in patients with aortic stenosis (AS) and end-stage renal disease (ESRD) undergoing transcatheter and surgical aortic valve replacement (TAVR and SAVR). METHODS AND RESULTS: The National-Inpatient-Sample was used to study trends in patients with AS and ESRD undergoing TAVR and SAVR between January 2012 and December 2017. Of 12,550 patients, 5,735 underwent TAVR and 6,815 underwent SAVR. Over the years, the utilization of SAVR declined (from 82.0 to 37.7%); and increased for TAVR (from 18.0 to 62.3%; p < .001). Patients receiving TAVR were older (74.6 [9.1] vs. 66.8 years [9.1]), had a higher proportion of females (37.1 vs. 32.5%), Caucasians (68.7 vs. 60.9%) and Asian /Pacific Islanders (3.1 vs. 2.7%; p < .001 for all). The TAVR patients, despite having higher comorbidity burden (anemia, coronary artery disease, chronic pulmonary disease, congestive heart failure, cerebrovascular disease, and peripheral vascular disease) had lower inpatient mortality and complications (ST-elevation myocardial infarction, pneumonia, pneumothorax, pulmonary embolism, cardiogenic shock, cardiac arrest, and need for mechanical ventilators and vasopressors). The median length of stay (13.9-6.5 days; p < .001) and cost of stay ($311,538.16 to $255,693.40; p < .001) reduced with TAVR; but remained unchanged with SAVR. Higher proportion of patients was discharged home after TAVR vs. SAVR. CONCLUSION: Among patients with AS and ESRD, despite providing therapy to subjects with higher comorbidity burden, TAVR was associated with lower inpatient mortality, complications, length of stay, cost of care, and higher home disposition rates when compared with SAVR.

A Bayesian network meta-analysis of preventive strategies for contrast-induced nephropathy after cardiac catheterization.

BACKGROUND: The optimal preventive strategy for contrast induced acute kidney injury (CIAKI) in patients undergoing cardiac catheterization remains uncertain. OBJECTIVE: We conducted Bayesian network meta-analysis (NMA) to compare different preventive strategies for CIAKI in these cohorts. METHODS: Forty-nine randomized controlled trials were extracted using MEDLINE, EMBASE and CENTRAL data bases (inception-1st December 2017). We calculated median of the odds ratio (OR) with the corresponding 95% credible interval (CrI). The ranking probability of each treatment was based on SUCRA (surface under the cumulative ranking curve). RESULTS: In NMA of 28,063 patients [normal saline (NS: 9716 patients), sodium bicarbonate (NaHCO3: 4484 patients), statin (2542 patients), N-acetylcysteine (NAC: 3006 patients), NAC + NaHCO3 (774 patients), NS + NAC (3807 patients), NS + NaHCO3 (135 patients) and placebo (3599 patients)], statins reduced the relative risk of CIAKI compared with NS (OR: 0.50; 95% CrI, 0.25-0.99), and placebo (OR: 0.44; 95% CrI, 0.24-0.83). Subgroup analyses showed that in patients receiving low osmolar contrast, statins reduced the relative risk of CIAKI by 58% versus NS, and 51% versus placebo. There were no significant differences across all the treatments in terms of risk of hemodialysis or all-cause mortality. Statins had the highest probability for reducing the risk of CIAKI (SUCRA, 0.86), risk of hemodialysis (SUCRA, 0.88) and all-cause mortality (SUCRA, 0.81). CONCLUSION: Statins were the superior preventive strategy for reducing the risk of CIAKI compared with NS alone and placebo.

Percutaneous Coronary Intervention Versus Surgery in Left Main Stenosis-A Meta-Analysis and Systematic Review of Randomised Controlled Trials.

OBJECTIVE: To investigate the safety and efficacy of percutaneous coronary interventions (PCI) versus coronary artery bypass graft (CABG) surgery for left main coronary artery (LMCA) disease. METHODS: Six randomised controlled trials (RCTs) were reviewed by searching PubMed/Medline, Embase and the Cochrane Library. Estimates were pooled according to random effects model. Binary outcomes were reported as risk ratio (RR) and continuous outcomes were reported as mean difference (MD) with 95% confidence interval (CI). RESULTS: 3794 patients were randomised into PCI and CABG arms. Mean age of the total population was 64.7 years, 74.4% were male and mean Logistic EURO score (LES) was 2.9. When compared with CABG, patients treated with PCI had reduced risk of major adverse cardiovascular events (MACE) at 30 days: (RR: 0.55; 95% CI, 0.41-0.75; p<0.001; I2=0) but similar risk at 1year (RR: 1.15; 95% CI, 0.92-1.45; p=0.22; I2=0). Five years MACE rates favoured CABG (RR: 1.32; 95% CI, 1.13-1.53; p<0.001; I2=0) driven by a higher rate of target vessel revascularisation (TVR) (RR: 1.71; 95%CI, 1.38-2.12; p<0.001; I2=0) and myocardial infarction (MI) (RR: 1.97; 95%CI, 1.28-3.04; p<0.001; I2=22). Percutaneous coronary intervention was comparatively a safer procedure with lower rates of periprocedural adverse events including MI, stroke, bleeding events and need for blood transfusions. CONCLUSION: Percutaneous coronary intervention reduced MACE at 30days with comparable MACE at 1year. However, CABG was a more effective modality when considering mid- to long-term outcomes. PCI is a safer procedure with regards to periprocedural adverse events.

Acute ST-elevation myocardial infarction due to septic embolism: a case report and review of management options.

Acute ST-elevation myocardial (STEMI) infarction due to septic embolism is rare and management strategies differ from those applied to atherothrombotic STEMI. A 70-year-old male with aortic valve endocarditis and persistent bacteremia developed acute inferior wall STEMI due to septic embolism. Due to inferior STEMI accompanied by hemodynamic instability, coronary angiography and primary PCI (stenting) to a totally occluded right coronary artery (RCA) was performed. Despite excellent immediate angiographic results and hemodynamic stabilization, repeat angiogram two weeks later showed mycotic aneurysms at the site of stent placement. Patient later suffered from intracranial hemorrhage and splenic infarct and had worsening aortic regurgitation, prompting surgical aortic valve replacement with bypass of the RCA. Despite aggressive medical, interventional and surgical management, he expired four weeks after the surgery. Selection of an optimal revascularization strategy in this scenario is unclear with a potential harm from standard therapies. We have reviewed prior reports and summarized results in a tabular form.

The effects of sinus membrane pathology on bone augmentation and procedural outcome using minimal invasive antral membrane balloon elevation.

Membrane pathology tends to complicate the postprocedural course of open sinus lift by ostio-meatal complex (OMC) obstruction and consequent acute sinusitis. The objective of this study was to evaluate the outcome of subjects with considerable sinus membrane pathology undergoing maxillary sinus floor augmentation and simultaneous implant placement using the minimal invasive antral membrane balloon elevation (MIAMBE) method. This study was a retrospective chart review of MIAMBE procedures performed in the presence of significant sinus membrane pathology. Sixteen patients with maxillary sinus membrane thickening in well-ventilated OMC as determined by dental computerized tomography underwent sinus augmentation and simultaneous implant placement using the MIAMBE technique. All 16 procedures were successfully concluded without significant procedural or postprocedural complications or implant failure. Post MIAMBE membrane pathology regressed or disappeared in 8 patients (50%) or remained unchanged in 6 patients (37.5%), while in 2 patients the sinus membrane pathology was limited to evaluation by periapical X rays. Sinus augmentation using the MIAMBE technique can be performed safely in asymptomatic patients in the presence of sinus membrane pathology if the OMC is not obstructed. In a significant proportion of these cases, complete resolution of the membrane pathology after MIAMBE is observed. When compared to open sinus lift, OMC obstruction is less likely to occur when employing the MIAMBE method.

Use of antiplatelet agents in patients with atherosclerotic disease.

Platelets play a key role in the initiation of hemostatic mechanisms during vascular injury. When contemplating prescription of antiplatelet agents (APAs) for patients as primary prevention for cardiovascular events, the physician should carefully weigh the potential benefits of cardiovascular risk reduction with the likelihood of harm, related mostly to hemorrhagic complications. The role of APAs in secondary prevention of atherosclerosis and coronary artery disease is well established, however, optimal duration of therapy and intensity of patient treatment are not settled and probably need to be individualized per patient. We describe the data emerging from contemporary trials on the efficacy and safety of the use of oral APAs in various patient subpopulations. We also discuss the advantages and potential roles of new APAs during and following acute coronary syndromes, percutaneous coronary interventions, and symptomatic atherosclerosis. We propose certain strategies and directions for future research to enhance the safety and efficacy prevention by optimizing the beneficial effects of APAs along with other contemporary treatment modalities of primary and secondary prevention.

Renal artery stenosis - an update.

Renal artery stenosis (RAS) is a common form of peripheral arterial disease. The most common cause of RAS is atherosclerosis. It is predominantly unilateral. The pathophysiologic mechanism stems from renal underperfusion resulting in the activation of the renin- angiotensin-aldosterone pathway. Even though the majority of patients with RAS are asymptomatic, it can clinically present with hypertension, nephropathy and congestive heart failure. This progressive disease can lead to resistant hypertension and end stage kidney failure. Screening patients for RAS with either Doppler ultrasonography, computed tomographic angiography, or magnetic resonance angiography is preferred. Adequate blood pressure control, goal-directed lipid-lowering therapy, smoking cessation, and other preventive measures form the foundation of management of patients with RAS. Catheter-based percutaneous revascularization with angioplasty and stenting showed modest clinical benefit for patients in small retrospective studies, but data from randomized clinical trials failed to confirm these beneficial results. The current ongoing Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial may provide more concrete data regarding the role of stenting in RAS. Surgical revascularization is considered only if catheter-based revascularization is unsuitable or unsuccessful. The American College of Cardiology/American Heart Association guidelines on evaluation and management of patients with RAS provide the framework for determining individualized assessment and treatment plans for patients with RAS.

Atypical stress-induced cardiomyopathy: a case series.

Stress-induced cardiomyopathy (SIC) is characterized by reversible left ventricular (LV) systolic dysfunction, which appears to be triggered by an intense, stressful event in the absence of significant coronary artery disease. It manifests typically with transient left ventricular wall motion abnormalities (WMA) involving the apical and/or mid-ventricular myocardial segments, associated with minimal troponin rise (<5 ng/ml), and typical EGG changes. Described are 3 cases of stress-induced cardiomyopathy with atypical distribution of wall motion abnormalities. Possible contributing mechanisms to the pathogenesis and the variability in WMA are discussed.

Comparison of efficacy and safety of intracoronary sodium nitroprusside and intravenous adenosine for assessing fractional flow reserve.

OBJECTIVES: The purpose of this study was to compare the efficacy and safety of intracoronary (IC) nitroprusside and intravenous adenosine (IVA) for assessing fractional flow reserve (FFR). BACKGROUND: IV infusion of adenosine is a standard method to achieve a coronary hyperemia for FFR measurement. However, adenosine is expensive, causes multiple side effects, and is contraindicated in patients with reactive airway disease. Sodium nitroprusside (NTP) is a strong coronary vasodilator but its efficacy and safety for assessing FFR is not well established. METHODS: We compared FFR response and side effects profile of IC NTP and IVA. Bolus of NTP at a dose of 100 µg and IVA (140 µg/kg/min) were used to achieve coronary hyperemia. RESULTS: We evaluated 75 lesions in 53 patients (60% male) mean age 61.6 ± 13.9 years. Mean FFR after NTP was similar to FFR after adenosine (0.836 ± 0.107 vs. 0.856 ± 0.106; P = 0.26; r = 0.91, P < 0.001). NTP induced maximal stable hyperemia within 10 sec (mean: 6.4 ± 1) which lasted consistently between 38 and 60 sec (mean 51 ± 7.5). NTP caused significant (14%), but asymptomatic decrease in mean blood pressure which returned to baseline within 60 sec. Adenosine caused shortness of breath in 26%, headache and flushing in 19%, and transient second degree heart block in 6% of patients. No adverse symptoms were reported after NTP. CONCLUSIONS: IC NTP is as effective as IVA for measuring FFR. NTP is better tolerated by patients. Since NTP is inexpensive, readily available, well tolerated, and safe, it may be a better choice for FFR assessment.

Extensive myocardial iron deposition in a patient with hepatitis C.

During a cardiac evaluation prior to liver transplantation, a 51-year-old man with hepatitis C and cirrhosis was found to have nonischemic cardiomyopathy-a condition that would have made him ineligible for liver transplantation. Right ventricular biopsy revealed extensive cardiac hemosiderosis. Despite the elevated levels of serum ferritin, the patient had no history of multiple red blood cell transfusions; moreover, genetic testing for hereditary hemochromatosis was negative for the HFE mutations C282Y and H63D. Chelation therapy was considered for this patient, to reduce the cardiac iron deposits. However, before a course of treatment was established, the patient's clinical condition worsened, and chelation therapy was no longer feasible. He was referred for combined heart and liver transplantation. Cardiac iron deposition can be diagnosed readily using right ventricular biopsy or T2* magnetic resonance imaging. Early detection may allow time for intensive chelation therapy, which might, in turn, reverse the myopathic process. Improved cardiac function should improve cirrhosis patients' chances to be placed on the liver transplant waiting list and ultimately optimize transplantation outcomes.

Minimally invasive subnasal elevation and antral membrane balloon elevation along with bone augmentation and implants placement.

Atrophic edentulous anterior maxilla is a challenging site for implant placement and has been successfully treated surgically by anterior maxillary osteoplasty. This procedure is associated with considerable discomfort, morbidity, and cost-and consequently reduced patient acceptance. The efficacy and safety of minimally invasive bone augmentation of the posterior maxilla has not been extended thus far to the anterior subnasal maxilla. We present 2 representative cases in which minimally invasive subnasal floor elevation was performed along with minimally invasive antral membrane balloon elevation. Both segments underwent bone grafting and implant placement during the same sitting. Minimally invasive anterior maxilla bone augmentation appears to be feasible. Designated instruments for alveolar ridge splitting and nasal mucosa elevation are likely to further enhance this initial favorable experience.

Neurohormonal activation in acute heart failure: results from VERITAS.

OBJECTIVES: Recent heart failure studies have suggested that inflammatory and immune system activation are associated with increased levels of cytokines, chemokines and inflammatory proteins during acutely decompensated heart failure. The objectives of this substudy were to evaluate the role of neurohormonal and inflammatory activation in the pathogenesis and outcome of acute heart failure (AHF) and the correlation between biomarker levels and clinical outcomes. METHODS: Serum levels of B-type natriuretic peptide-32 (BNP-32), endothelin-1 (ET-1), norepinephrine, troponins I and T, C-reactive protein (CRP), von Willebrand factor, plasminogen activator inhibitor-1, interleukin-6 (IL-6) and tissue plasminogen activator (TPA) were measured at baseline, 24 and 48 h and 7 and 30 days in 112 patients with AHF recruited to the Value of Endothelin Receptor Inhibition with Tezosentan in Acute Heart Failure Study neurohormonal substudy. RESULTS: On univariable analysis, CRP, BNP and ET-1 were predictive of worsening heart failure by day 30; when considered together, only CRP and BNP were significantly associated with this outcome. On adjustment for age, baseline blood pressure, serum sodium and serum creatinine, only age and BNP remained significant. CRP, IL-6 and TPA levels were significantly correlated with 180-day mortality on univariable analysis. CONCLUSION: Circulating markers of inflammation may be useful in gauging prognosis in patients with AHF.

Minimally invasive antral membrane balloon elevation for single-tooth implant placement.

A single missing tooth in the posterior atrophic maxillary segment poses a therapeutic challenge. Open sinus lift is not often performed because of anatomical restrictions and the need for specific surgical skills. The osteotome approach has considerable efficacy and safety limitations. In many cases, the clinician elects to treat with a three-unit partial denture or discard any rehabilitation plans. Two cases in which minimal invasive antral membrane balloon elevation was performed for single-tooth replacement are presented. This procedure appears to be a relatively simple, highly effective, and safe solution for single-tooth, implant-supported restorations of the posterior atrophic maxilla.

Coronary stenting with MGuard: extended follow-up of first human trial.

OBJECTIVES: To evaluate feasibility and safety of MGuard based percutaneous coronary interventions (PCI) in vein grafts (VG) and native coronaries (NC). BACKGROUND: Distal embolization is a frequent complication of PCI of VG and NC during acute coronary syndromes (ACS). MGuard was a stent designed to reduce embolization. METHODS: Prospective, single arm, two-center trial assessing the feasibility and safety of MGuard-based PCI with post-PCI clinical and laboratory monitoring including: cardiac biomarkers, ECG and 6-month angiography. RESULTS: Forty-one patients with mean age of 68.2±10.1 years were enrolled. Mean VG age (n=23) was 14.4±4.3 years. All patients received heparin, clopidogrel and aspirin; while none received glycoprotein IIb/IIIa inhibitors, or embolic protection device (EPD). Device and procedural success were 100% and 95.1% respectively. Two patients (4.9%) experienced procedure-related creatinine phosphokinase rise. At 6 months one patient had myocardial infarction and 19.5% had target vessel revascularization (TLR). Late follow up (12-27 months) revealed one additional TLR. CONCLUSION: MGuard based PCI of NC and VG appears encouraging especially in view of unfavorable patient and lesion characteristics. Efficacy needs to be further established in larger randomized trials.

Intra-aortic balloon pump prior to noncardiac surgery: a forgotten remedy?

High-risk cardiac patients, especially those with severe coronary artery disease, are prone to ischemic, arrhythmic and heart failure complications during urgent or emergent noncardiac surgery. The American and European guidelines endorse selective revascularization by either coronary artery bypass grafting or percutaneous coronary intervention in symptomatic ischemic patients prior to major elective surgery. However, conventional revascularization may not be suitable for certain patients requiring emergent or urgent surgery. Reported are two representative cases in which severely ischemic patients were bridged uneventfully through moderate-risk surgery by using prophylactic intra-aortic balloon pump (IABP). Prophylactic IABP should be considered for the support of ischemic patients who are severely symptomatic or hemodynamically unstable undergoing moderate-high risk surgery, who are not suitable for preoperative revascularization. This therapeutic option should be acknowledged in the relevant guidelines.

Right coronary artery anatomical variants: where and how?

BACKGROUND: Ectopic origin of the right coronary artery (RCA) occurs in approximately 1.0% of studied populations. We investigated the prevalence and location of ectopic RCAs among patients undergoing coronary angiography (CA) and assessed its effects on resource utilization. METHODS: Cases of ectopic RCAs were prospectively collected over 21 months among patients undergoing cardiac catheterization at a University Hospital. "Ectopic RCA" was defined as a RCA originating outside the posterior two-thirds of the right coronary sinus. RESULTS: The study population included 2,120 patients, of which 23 (1.1%) had ectopic RCAs. Of these, 15 (65%) originated from the anterior third of the right sinus, while 8 (35%) originated from the anterior half of the left sinus. Mean procedure and fluoroscopy times were 60 +/- 33 and 15 +/- 12 minutes (min) for the former, and 78 +/- 35 and 31 +/- 20 min for the latter, while mean contrast volume for CA was 112 +/- 62 ml and 192 +/- 85 ml, respectively. 26% required a second CA or a second intervention to image the RCA. CONCLUSION: Ectopic RCAs pose a clinical problem, consuming time and resources. The search for an ectopic RCA should have < 90 degree boundaries limited to the anterior third of the right sinus and anterior half of the left sinus.

Acute eosinophilic myocarditis: diagnosis and treatment.

Hypereosinophilic syndrome (HES) is a rare disorder of unregulated eosinophilia, which if untreated, may lead to systemic tissue infiltration and inflammation. Cardiac involvement is a common and serious associated complication. We describe a case of HES associated myocarditis mimicking a non-ST elevation MI (NSTEMI). Unlike myocarditis in general, our patient responded well to high dose methylprednisone, the standard of care in HES. We review the clinical presentation, pathophysiology, pathology and treatment of eosinophilic myocarditis related to HES.