Stealing from the Heart: A Rare Case of Chest Pain Post-Coronary Artery Bypass Grafting.

A 70-year-old veteran with prior triple vessel coronary artery bypass grafting (CABG) presented with exertional chest pain. His work-up revealed > 40 mm Hg bilateral upper extremity blood pressure difference. Chest computed tomography and invasive angiography revealed severe stenosis at the ostium of the left subclavian artery, proximal to the origin of the left internal mammary artery to left anterior descending artery graft (LIMA-LAD). A diagnosis of coronary subclavian steal syndrome (CSSS) was made, and carotid-subclavian bypass was performed. This case outlines when to suspect CSSS, an approach to its diagnosis, and the importance of its timely management.

Revascularization Options for Left Main Disease: What Clinicians Need to Know.

PURPOSE OF REVIEW: Left main disease represents the highest-risk lesion subset of coronary artery disease and is associated with adverse cardiovascular events. Accordingly, we aim to understand how the significance of left main disease is assessed by different modalities, followed by a review of management options in current era. RECENT FINDINGS: Invasive coronary angiogram remains the gold standard for assessment of left main disease, but intracoronary imaging or physiological testing is indicated for angiographically equivocal disease. Revascularization by either coronary artery bypass surgery or percutaneous coronary intervention is strongly recommended, which have been compared by six randomized trials, as well as recent meta-analyses. Surgical revascularization remains the preferred mode of revascularization, especially in patients with high lesion complexity and left ventricular dysfunction. Randomized studies are needed to understand if current-generation stents with the use of intracoronary imaging and improved medical therapy could match outcomes with surgical revascularization.

Cardiac Surgery During the Coronavirus Disease 2019 Pandemic: Perioperative Considerations and Triage Recommendations.

The coronavirus disease 2019 pandemic, caused by severe acute respiratory syndrome coronavirus-2, represents the third human affliction attributed to the highly pathogenic coronavirus in the current century. Because of its highly contagious nature and unprecedented global spread, its aggressive clinical presentation, and the lack of effective treatment, severe acute respiratory syndrome coronavirus-2 infection is causing the loss of thousands of lives and imparting unparalleled strain on healthcare systems around the world. In the current report, we discuss perioperative considerations for patients undergoing cardiac surgery and provide clinicians with recommendations to effectively triage and plan these procedures during the coronavirus disease 2019 outbreak. This will help reduce the risk of exposure to patients and healthcare workers and allocate resources appropriately to those in greatest need. We include an algorithm for preoperative testing for coronavirus disease 2019, personal protective equipment recommendations, and a classification system to categorize and prioritize common cardiac surgery procedures.

Outcomes following percutaneous coronary intervention in patients with cancer.

BACKGROUND: Randomized clinical trials demonstrated the benefits of percutaneous coronary interventions (PCI) in diverse clinical settings. Patients with cancer were not routinely included in these studies. METHODS/RESULTS: Literature search of PubMed, Cochrane, Medline, SCOPUS, EMBASE, and ClinicalTrials was conducted to identify studies that assessed one-year all-cause, cardiovascular and non-cardiovascular mortality in patients with historical or active cancer. Using the random effects model, we computed risk ratios (RRs) and standardized mean differences and their 95% confidence intervals for the dichotomous and continuous measures and outcomes, respectively. Of 171 articles evaluated in total, 5 eligible studies were included in this meta-analysis. In total, 33,175 patients receiving PCI were analyzed, of whom 3323 patients had cancer and 29,852 no cancer history. Patients in the cancer group had greater all-cause mortality [RR 2.22 (1.51-3.26; p<0.001)], including cardiovascular mortality [RR 1.34 (1.1-1.65; p=0.005)] and non-cardiovascular mortality [RR 3.42 (1.74-6.74; p≤0.001], at one-year compared to non-cancer patients. Patients in the cancer group had greater one-month all-cause mortality [RR 2.01 (1.24-3.27; p=0.005)] and greater non-cardiovascular mortality [RR 6.87 (3.10-15.21; p≤0.001)], but no difference in one-month cardiovascular mortality compared to non-cancer patients. Meta-regression analyses showed that the difference in one-year all-cause and cardiovascular mortality between both groups was not attributable to differences in baseline characteristics, index PCI characteristics, or medications prescribed at discharge. CONCLUSIONS: Patients with cancer undergoing PCI have worse mid-term outcomes compared to non-cancer patients. Cancer patients should be managed by a multi-specialist team, in an effort to close the mortality gap.

Ticagrelor Use in Acute Myocardial Infarction: Insights From the National Cardiovascular Data Registry.

BACKGROUND: Ticagrelor is a P2Y12 receptor inhibitor with superior clinical efficacy compared with clopidogrel. However, it is associated with reduced efficacy when combined with a high-dose aspirin. METHODS AND RESULTS: Patients in the acute coronary treatment and intervention outcomes network (ACTION) Registry-Get With The Guidelines (GWTG) with acute myocardial infarction from October 2013 through December 2014 were included in the study (167 455 patients; 622 sites). We evaluated temporal trends in the prescription of P2Y12 inhibitors, and identified factors associated with ticagrelor use at discharge. Among patients discharged on ticagrelor and aspirin (21 262 patients), we evaluated the temporal trends and independent factors associated with high-dose aspirin prescription at discharge. Ticagrelor prescription at discharge increased significantly from 12% to 16.7% (P<0.0001). Decreases in prasugrel and clopidogrel use at discharge (15.7%-13.9% and 54.2%-51.1%, respectively, P<0.0001) were also observed. Independent factors associated with preferential ticagrelor prescription at discharge over clopidogrel included younger age, white race, home ticagrelor use, invasive management, and in-hospital re-infarction and stroke (P<0.0001 for all), whereas older age, female sex, prior stroke, home ticagrelor use, and in-hospital stroke (P<0.0001 for all) were associated with preferential ticagrelor prescription at discharge over prasugrel. High-dose aspirin was used in 3.1% of patients discharged on ticagrelor. Independent factors associated with high-dose aspirin prescription at discharge included home aspirin use, diabetes mellitus, previous myocardial infarction, previous coronary artery bypass graft, ST-segment-elevation myocardial infarction, cardiogenic shock, and geographic region (P=0.01). CONCLUSIONS: Our contemporary analysis shows a modest but significant increase in the use of ticagrelor and a high rate of adherence to the use of low-dose aspirin at discharge.

Suspected coronary fat embolism after liposuction.

A 38-year-old female presented with chest pain and ST elevation on electrocardiogram after an outpatient liposuction procedure. Emergent coronary angiography revealed complete occlusion of multiple coronary arteries, with fat embolism as the suspected etiology. Attempts to restore distal coronary flow with balloon dilatation, aspiration with Pronto catheter, and distal adenosine administration resulted in minimal improvement in flow. The material aspirated was consistent with fat. With supportive therapy, including Impella CP support, the patient's clinical condition improved. To our knowledge, this is the first reported case of multiple coronary occlusion after liposuction.

Coronary Physiology Assessment for the Diagnosis and Treatment of Stable Ischemic Heart Disease.

Coronary artery disease is the most prevalent cardiovascular disease in the USA. In the majority of settings, percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) reduces angina and improves quality of life; however, it does not improve survival and is associated with infrequent but serious complications. Selection of appropriate patients and coronary lesions for revascularization with PCI is crucial to maximize the benefit-to-risk ratio. The assessment of the hemodynamic significance of intermediate coronary lesions has been shown to improve outcomes and reduce healthcare costs. The current review summarizes the existing evidence regarding the physiological assessment of coronary lesions, with emphasis on fractional flow reserve, the most common invasive hemodynamic assessment modality.

Comparison of the use of hemodynamic support in patients ≥80 years versus patients <80 years during high-risk percutaneous coronary interventions (from the Multicenter PROTECT II Randomized Study).

The outcomes of hemodynamic support during high-risk percutaneous coronary intervention in the very elderly are unknown. We sought to compare outcomes between the patients ≥80 years versus patients <80 years enrolled in the PROTECT II (Prospective Randomized Clinical Trial of Hemodynamic Support with the Impella 2.5 versus Intra-Aortic Balloon Pump in Patients undergoing High Risk Percutaneous Coronary Intervention) randomized trial. Patients who underwent high-risk percutaneous coronary intervention with an unprotected left main or last patent conduit and a left ventricular ejection fraction ≤35% or with 3-vessel disease and a left ventricular ejection fraction ≤30% were randomized to receive an intra-aortic balloon pump or the Impella 2.5; 90-day (or the longest follow-up) outcomes were compared between patients ≥80 years (n = 59) and patients <80 years (n = 368). At 90 days, the composite end point of major adverse events and major adverse cerebral and cardiac events were similar between patients ≥80 and <80 years (45.6% vs 44.1%, p = 0.823, and 23.7% vs 26.8%, p = 0.622, respectively). There were no differences in death, stroke, or myocardial infarction rates between the 2 groups, but fewer repeat revascularization procedures were required in patients ≥80 years (1.7% vs 10.4%, p = 0.032). Bleeding and vascular complication rates were low and comparable between the 2 age groups (3.4% vs 2.4%, p = 0.671, and 6.8% vs 5.4%, p = 0.677, respectively). Multivariate analysis confirmed that age was not an independent predictor of major adverse events (odds ratio = 1.031, 95% confidence interval 0.459-2.315, p = 0.941), whereas Impella 2.5 was an independent predictor for improved outcomes irrespective of age (odds ratio = 0.601, 95% confidence interval 0.391-0.923, p = 0.020). In conclusion, the use of percutaneous circulatory support is reasonable and feasible in a selected octogenarian population with similar outcomes as those of younger selected patients. Irrespective of age, the use of Impella 2.5 was an independent predictor of favorable outcomes.

A randomized, double-blind, placebo-controlled, dose-escalation study of intravenous adult human mesenchymal stem cells (prochymal) after acute myocardial infarction.

OBJECTIVES: Our aim was to investigate the safety and efficacy of intravenous allogeneic human mesenchymal stem cells (hMSCs) in patients with myocardial infarction (MI). BACKGROUND: Bone marrow-derived hMSCs may ameliorate consequences of MI, and have the advantages of preparation ease, allogeneic use due to immunoprivilege, capacity to home to injured tissue, and extensive pre-clinical support. METHODS: We performed a double-blind, placebo-controlled, dose-ranging (0.5, 1.6, and 5 million cells/kg) safety trial of intravenous allogeneic hMSCs (Prochymal, Osiris Therapeutics, Inc., Baltimore, Maryland) in reperfused MI patients (n=53). The primary end point was incidence of treatment-emergent adverse events within 6 months. Ejection fraction and left ventricular volumes determined by echocardiography and magnetic resonance imaging were exploratory efficacy end points. RESULTS: Adverse event rates were similar between the hMSC-treated (5.3 per patient) and placebo-treated (7.0 per patient) groups, and renal, hepatic, and hematologic laboratory indexes were not different. Ambulatory electrocardiogram monitoring demonstrated reduced ventricular tachycardia episodes (p=0.025), and pulmonary function testing demonstrated improved forced expiratory volume in 1 s (p=0.003) in the hMSC-treated patients. Global symptom score in all patients (p=0.027) and ejection fraction in the important subset of anterior MI patients were both significantly better in hMSCs versus placebo subjects. In the cardiac magnetic resonance imaging substudy, hMSC treatment, but not placebo, increased left ventricular ejection fraction and led to reverse remodeling. CONCLUSIONS: Intravenous allogeneic hMSCs are safe in patients after acute MI. This trial provides pivotal safety and provisional efficacy data for an allogeneic bone marrow-derived stem cell in post-infarction patients. (Safety Study of Adult Mesenchymal Stem Cells [MSC] to Treat Acute Myocardial Infarction; NCT00114452).

Acute coronary syndrome may occur with in-stent restenosis and is associated with adverse outcomes (the PRESTO trial).

Patients with de novo acute coronary syndromes (ACSs) have a higher rate of adverse cardiac events and recurrent revascularization after percutaneous coronary interventions compared with patients who have stable angina. However, it is not known if an ACS presentation in patients with in-stent restenosis (ISR) is associated with a worse prognosis. Using the large PRESTO database of patients with ISR, we compared outcomes after successful percutaneous coronary intervention in 824 patients who presented with ACS with 617 patients who had stable angina. In-hospital and 9-month follow-up for myocardial infarction, target vessel revascularization, death, and a combined outcome of major adverse cardiac events (MACEs) were obtained. Follow-up angiographic results were also compared in those patients included in the angiographic substudy (140 patients with ACS and 99 with stable angina). Patients with ISR who presented with ACS were older and less often men, with higher incidences of diabetes, hypertension, tobacco use, previous coronary artery bypass graft surgery, and congestive heart failure. In-hospital complications were rare and similar in the 2 groups. At follow-up, patients with ACS had higher incidences of target vessel revascularization (33% vs 21%, p <0.001), MACEs (35% vs 22%, p <0.001), and angiographic restenosis (> or =50% narrowing, 56% vs 42%, p = 0.043). In multivariate analysis, after adjusting for baseline differences, an ACS presentation was associated with a higher incidence of long-term MACEs (odds ratio 1.66, 95% confidence interval 1.27 to 2.18, p <0.001). In conclusion, an ACS presentation in patients with ISR is associated with a higher incidence of recurrent adverse cardiovascular events and angiographic restenosis.

Cutting balloon angioplasty vs. conventional balloon angioplasty in patients receiving intracoronary brachytherapy for the treatment of in-stent restenosis.

The objective of this study was to evaluate the safety and efficacy of cutting balloon angioplasty (CBA) for the treatment of in-stent restenosis prior to intracoronary brachytherapy (ICB). Cutting balloon angioplasty may reduce the incidence of uncontrolled dissection requiring adjunctive stenting and may limit "melon seeding" and geographic miss in patients with in-stent restenosis who are subsequently treated with ICB. We performed a retrospective case-control analysis of 134 consecutive patients with in-stent restenosis who were treated with ICB preceded by either CBA or conventional balloon angioplasty. We identified 44 patients who underwent CBA and ICB, and 90 control patients who underwent conventional percutaneous transluminal coronary angioplasty (PTCA) and ICB for the treatment of in-stent restenosis. Adjunctive coronary stenting was performed in 13 patients (29.5%) in the CBA/ICB group and 41 patients (45.6%; P < 0.001) in the PTCA/ICB group. There was no difference in the injury length or active treatment (ICB) length. The procedural and angiographic success rates were similar in both groups. There were no statistically significant differences in the incidence of death, myocardial infarction, recurrent angina pectoris, subsequent target lumen revascularization, or the composite endpoint of all four clinical outcomes (P > 0.05). Despite sound theoretical reasons why CBA may be better than conventional balloon angioplasty for treatment of in-stent restenosis with ICB, and despite a reduction in the need for adjunctive coronary stenting, we were unable to identify differences in clinical outcome.

Comparison of combination therapy of adenosine and nitroprusside with adenosine alone in the treatment of angiographic no-reflow phenomenon.

We sought to compare the combination therapy of adenosine and nitroprusside in no-reflow phenomenon during percutaneous coronary intervention. Improvement in coronary flow from no-reflow to postdrug state was evaluated. Patients who received adenosine (n = 21) were compared to ones who received the combination of adenosine and nitroprusside (n = 20) for treatment. Improvement of TIMI flow grades was higher in the group that received combined therapy (1.5 +/- 1.0 vs. 0.8 +/- 0.6; P < 0.05). Combination therapy of adenosine and nitroprusside is safe and provides better improvement in coronary flow compared to intracoronary adenosine alone in case of impaired flow during coronary interventions.