Mitral Valve Intervention in Elderly or High-Risk Patients: A Review of Current Surgical and Interventional Management.

Mitral regurgitation is a prevalent valvular disease, and its management has gained increasing importance because of the aging population. Although traditional surgery remains the gold standard, the field of transcatheter therapies, including transcatheter edge-to-edge repair and, more recently transcatheter mitral valve replacement are advancing and are being explored as viable alternatives, particularly for patients at high surgical risk. It is essential to emphasize the necessity of a multidisciplinary team approach, involving specialized valve teams, imaging experts, cardiac anaesthesiologists, and other relevant specialists, is crucial in achieving optimal outcomes. Furthermore, proper execution of procedures, postprocedural care, and diligent follow-up for these patients are essential components for successful results. It is essential to underscore that traditional mitral valve surgery continues to play a significant role. Simultaneously, it is important to acknowledge the expanding array of transcatheter interventions available for this specific patient population.

Is Coronary Brachytherapy Staging a Comeback for the Treatment of In-Stent Restenosis?

PURPOSE OF REVIEW: The catheter-based coronary intervention has become a well-established therapeutic modality for obstructive coronary artery disease. However, in-stent restenosis remains a significant limitation of coronary intervention despite the use of newer devices. Intravascular brachytherapy was introduced to treat recurrent in-stent restenosis but only modestly adopted. This review will discuss the mechanism of intracoronary brachytherapy, available clinical evidence of brachytherapy in recurrent in-stent restenosis treatment, and the future of coronary brachytherapy in coronary intervention. RECENT FINDINGS: Drug-eluting stents have an inherent limitation as they leave a permanent metal layer inside an artery when deployed. Recently, drug-coated balloon technology has emerged to treat coronary artery disease as a combination of balloon angioplasty and local drug delivery without leaving a metal layer behind. Recent European guidelines recommended using drug-coated balloons when treating in-stent restenosis treatment, while the US guidelines have not yet addressed the use of drug-coated balloons in such cases. Coronary brachytherapy is a valuable addition to treat these challenging diseases despite several logistic issues. If there are newer technologies with easier setup, such as drug-coated balloons, coronary brachytherapy resurgence is improbable in the contemporary era, although it may not become obsolete.

Application of Genetic Testing in Unveiling the Diagnosis of Fabry Disease in a Patient with Hypertrophic Cardiomyopathy.

Fabry disease (FD) is a lysosomal storage disorder with an X-linked genetic pattern. It is caused by the genetic mutations in the galactosidase alpha gene on the long arm of the X-chromosome, resulting in the deficiency of the alpha-galactosidase A enzyme activity. This leads to an accumulation of globotriaosylceramide in a variety of cells, including cells in the heart. Left ventricular hypertrophy is one of the most common manifestations of FD involving the heart. Further cardiac disease progression portends significant morbidity and mortality. The early initiation of enzyme replacement therapy is associated with reversal or halting of the disease's progression and an improved clinical outcome. Here, we present the case of a 40-year-old male patient with left ventricular hypertrophy based on the results of a transthoracic echocardiogram and advanced cardiac imaging. He was later diagnosed with FD with the assistance of genetic testing. We also briefly outline the diagnostic challenges and treatment of FD.

CYP2C19 genotype-directed P2Y12 inhibitor antiplatelet therapy normalizes risk for major adverse cardiovascular events after percutaneous coronary intervention.

OBJECTIVE: To study the use of CYP2C19 genotyping to guide P2Y12 inhibitor selection to maximize efficacy, and attenuate risk in appropriate patients who underwent PCI for CAD. METHODS: We performed a retrospective analysis of 868 patients with CAD who received CYP2C19 genotyping after PCI and changed P2Y12 inhibitor based on the results. Patients were divided into two groups based on clopidogrel metabolizer status. Group I: Intermediate (IM) and poor metabolizers (PM). Group II: Ultra-rapid (UM), rapid (RM) and normal metabolizers (NM). Each group was then categorized to one of two treatment arms guided by CYP2C19 genotype. Category 1: IM/PM started on clopidogrel, switched to ticagrelor or prasugrel; 2:IM/PM started on ticagrelor/prasugrel, continued these medications; 3: UM/RM/NM started on ticagrelor/prasugrel, switched to clopidogrel; 4: UM/RM/NM started on clopidogrel, continued clopidogrel. Death due to cardiac causes, bleeding events, non-fatal MI, target vessel revascularization (TVR), and MACE in all four categories were considered at 1, 6 and 12 months. RESULTS: We did not observe significant difference between phenotypes for MACE at 1 (p = 0.274), 6 (p = 0.387), and 12 months (p = 0.083). Death due to cardiac causes, MI, and bleeding events were not significant at 1, 6, and 12 months. There was no significant difference in TVR at 6 (p = 0.491), and 12 months (p = 0.423) except at 1 month (p = 0.012). CONCLUSION: CYP2C19 genotype-based intervention can be implemented effectively and reliably to guide selection of P2Y12 inhibitor to optimize patient quality and safety when appropriate in post PCI patients.

Orbital Atherectomy and Heavily Calcified Saphenous Vein Graft Intervention.

Percutaneous coronary intervention in the diseased saphenous vein graft differs significantly from that in the diseased native coronary artery. After being exposed to arterial pressures over time, vein grafts have substantially different plaque characteristics, with more inflammatory cells, more diffuse disease, and less calcification. Severe calcification of saphenous vein grafts, although uncommon, poses a high risk of stent underexpansion. Orbital atherectomy for treatment of de novo calcified coronary lesions has been associated with better outcomes at 5-year follow-up. However, there are no published data on the use of orbital atherectomy to treat severely calcified saphenous vein graft lesions. We present the case of a 77-year-old woman with non-ST-segment-elevation myocardial infarction who underwent successful orbital atherectomy to prepare a severely calcified saphenous vein graft lesion for stent implantation.

A prospective study of contrast preservation using ultra-low contrast delivery technique versus standard automated contrast injector system in coronary procedures.

BACKGROUND: We aimed to assess the decrease in contrast media volume (CMV) with ultra-low contrast delivery technique (ULCD) developed at our institution versus the usual automated contrast injector system (ACIS) contrast delivery in coronary procedures. METHODS: We analyzed the amount of contrast given in the consecutive 204 patients of the operators who use ULCD technique versus consecutive 200 patients of the other operators who use ACIS without ULCD technique for coronary angiograms and/or percutaneous coronary interventions (PCIs) from May 2017 to July 2018 at our center. We calculated the mean CMV between these groups. RESULTS: We observed a significant reduction in mean CMV with ULCD technique versus standard ACIS, respectively: angiogram 24.8 ± 15.8 mL (n = 194) vs 42.3 ± 25.1 mL (n = 200) (p < 0.0001); PCI 23.5 ± 19.7 mL (n = 52) vs 48.2 ± 30.8 mL (n = 16) (p < 0.0070); angiogram with ad hoc PCI 53.4 ± 32.1 mL (n = 23) vs 89.7 ± 35.6 mL (n = 16) (p < 0.0024); and overall angiogram and PCI 27.4 ± 20.5 mL (n = 204) vs 44.9 ± 28.0 mL (n = 181) (p < 0.0001). CONCLUSION: Our study showed a highly significant reduction in CMV using ULCD technique compared to standard ACIS contrast delivery in coronary invasive procedures. Even in the standard ACIS arm, CMV was significantly lower than values reported in literature, possibly due to operators' bias toward contrast preservation.

Outcomes and Safety of Transcatheter Aortic Valve Implantation With and Without Routine Use of Transesophageal Echocardiography.

Transesophageal echocardiography (TEE) has been extensively used historically for Transcatheter aortic valve implantation (TAVI) but focus is shifting from routine use of TEE and general anesthesia to "as needed" use. We evaluated patients who had TAVI in our institution from September 2012 to February 2017. Decision for implantation and use of TEE during procedure was made by the structural heart team on a case-to-case basis, based on FDA approved indications. Data including procedural details, length of stay and rehospitalizations were obtained from all patients. TAVI was performed on 178 patients during the study period of which 104 of 178 had TEE during TAVI. Baseline characteristics were fairly comparable in both groups. Similar proportion of self-expanding and balloon expanding valves were deployed. Patients in TEE group had longer overall procedure time (107 minute vs 83 minute, p = 0.0002) and longer length of stay (5.01days vs 2.49days, p < 0.0001). Echocardiographic study postprocedure showed similar incidence of paravalvular leak and similar gradients and velocities across aortic valve. Rates of 30-day readmissions were similar in both groups. In conclusion, in this single-center retrospective analysis-TAVI without the 'routine use' of TEE was comparable with those done with TEE guidance in terms of periprocedural complications and 30-day readmissions. Overall procedure length and length of stay was predictably higher in the TEE group.

Role of Invasive Functional Assessment in Surgical Revascularization of Coronary Artery Disease.

In patients with stable coronary artery disease, percutaneous coronary intervention is associated with improved outcomes if the lesion is deemed significant by invasive functional assessment using fractional flow reserve. Recent studies have shown that a revascularization strategy using instantaneous wave-free ratio is noninferior to fractional flow reserve in patients with intermediate-grade stenoses. The decision to perform coronary artery bypass grafting surgery is usually based on anatomic assessment of stenosis severity by coronary angiography. The data on the role of invasive functional assessment in guiding surgical revascularization are limited. In this review, we discuss the diagnostic and prognostic significance of invasive functional assessment in patients considered for coronary artery bypass grafting. In addition, we critically discuss ongoing and future clinical trials on the role of invasive functional assessment in surgical revascularization.

Prosthetic Aortic Valve Endocarditis Following Transcatheter Aortic Valve Implantation.

Infective endocarditis after transcatheter aortic valve implantation is a life-threating complication, resulting in high in-hospital and one-year mortality. With the ongoing evolution of transcatheter aortic interventions, the proportion of endocarditis cases encountered by health care providers will continue to rise. Early diagnosis of infective endocarditis is of paramount importance to institute appropriate treatment with antibiotics and/or surgery to avoid negative clinical outcomes. In this review, we outline our experience with two cases of infective endocarditis following transcatheter aortic valve implantation and briefly review the literature on the incidence, microbiology, diagnosis, and management of this condition.

A Fish Mouth Appearing Perforation of the Native Aortic Valve Due to Streptococcus infantarius subspecies coli.

Infective endocarditis due to Streptococcus infantarius with the subspecies (subsp.) coli is infrequently encountered in healthy humans. This entity is associated with hepatobiliary malignancies and colorectal neoplasia. Here, we report on a unique case of endocarditis associated with S. infantarius subsp. coli in an 80-year-old male with no known risk factors of the infective endocarditis.

Pressure-Guided cryoablation of pulmonary veins in atrial fibrillation: A fast and effective strategy.

BACKGROUND: Cryoballoon ablation of atrial fibrillation (AF) involves successful electrical pulmonary vein isolation (PVI). Pulmonary vein (PV) ostial occlusion with cryoballoon is classically assessed using PV angiography. A pressure-guided technique to assess ostial occlusion has been evaluated in small cohorts with mixed results. We evaluated the efficacy of this pressure-guided PVI technique and its impact on reducing contrast and fluoroscopy time as compared to the traditional approach. METHODS: We evaluated patients with paroxysmal AF, who underwent cryoballoon PVI. Patients prior to January 20th, 2013 underwent confirmation of PV occlusion by angiography only. Patients ablated after this time had PV occlusion initially determined by pressure monitoring and further confirmed by contrast injection into the PV in most cases (Pressure-guided PVI). Differences in the volume of contrast used and fluoroscopy time were evaluated. RESULTS: 46 patients had pressure-guided PVI and29 patients had occlusion of PV confirmed by angiography alone. Pressure-guided PVI was 99.5% successful in ablating AF, which was non-inferior to traditional method of PV isolation. This technique used an average of 8cc of contrast and 21.5min of fluoroscopy time, which was significantly less than the contrast amount used, and fluoroscopy time with angiographic isolation of PV. CONCLUSION: Pressure-guided PVI is an effective method for cryoablation of AF. This method not only significantly reduces the volume of contrast used but also decreases the fluoroscopy without compromising the success of PVI.

Pregnancy-Related Spontaneous Coronary Artery Dissection: A Case Series and Literature Review.

BACKGROUND: Cardiac emergencies during pregnancy are rare but have significant associated morbidity and mortality when they do occur. The emergency physician must not only be aware of potentially life-threatening conditions in the pregnant woman, but also know the emergent management and treatment of these conditions to avoid worsening of the underlying condition. Pregnancy-related spontaneous coronary artery dissection has been described in the cardiology literature, but is not well-known in emergency medicine literature. CASE SERIES: We present a case series of six previously healthy women ages 27 to 39 years who presented 1 to 75 days after delivery with spontaneous coronary artery dissection. The left main coronary was involved in 5 of 6 cases. One patient died, 5 survived. Two survivors maintained significant long-term disability. The patient that died had the diagnosis made on autopsy, the others were diagnosed with coronary angiography. Two patients were treated with stents, 2 with coronary artery bypass surgery, and 2 with medical management. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergent coronary catheterization is indicated if this diagnosis is suspected. However, emergency care teams must also understand how and why management including coronary artery catheterization can exacerbate the underlying condition. The role of coronary artery computed tomography remains unknown, although it exposes the fetus to significant radiation if the woman is still pregnant at presentation. Medical management is indicated with diffuse or distal disease as pregnancy-related coronary artery dissections often resolve with time. Localized discrete lesions may be stented. Coronary artery bypass graft surgery may be considered if the left main artery is involved or there are multiple proximal lesions. Cardiac transplantation is indicated rarely.

A Case of Hepatotoxicity Related to Kombucha Tea Consumption.

The use of herbal and dietary supplements (HDSs) is widespread and growing due to the popular notion that these products are of natural origins and safe. Kombucha (or "mushroom") tea is one HDS that is consumed by people for various perceived health benefits. Kombucha tea is a well-known health beverage made by fermenting sweet black tea with a round, flat, gray fungus for a week or longer. There is concern, however, from the evidence of a few case reports currently available, that it may pose life-threatening and/or adverse effects for users.

An Unusual Presentation of an Unusual Disease: Spontaneous Pneumomediastinum.

We report a case of spontaneous pneumomediastinum with unusual clinical presentation. The most common symptoms of spontaneous mediastinum are chest pain and shortness of breath. Our patient presented with neck swelling and change in voice, an unusual presentation for spontaneous pneumothorax. A 30-year-old previously healthy man presented with complaints of neck swelling and hoarseness of voice beginning after an intense coughing spell. He had no other complaints. He denied any trauma to the chest, nausea, vomiting, recent air travel, scuba diving or recreational drug use. His vital signs were stable with an O2 saturation of 97 percent on room air. Chest examination was remarkable for palpable crepitus over lower neck as well as bilateral upper and mid anterior chest. Chest radiograph as well as chest computed tomography (CT) demonstarted a massive pneumomediastinum with free air dissecting throughout the soft tissues of the neck. The patient was admitted for observation. Neck swelling and hoarseness of voice resolved in less than 24 hours with conservative management of cough. He was discharged without incident. Spontaneous pneumomediastinum is an uncommon, self-limiting condition in which air is present in the mediastinum with no obvious precipitating factor. Cough, inhaled drugs, physical exercise, labor, and diabetic ketoacidosis have been reported to trigger spontaneous pneumomediastinum. Our patient developed the condition after an intense coughing spell following smoking cessation. CT scan is considered gold standard for the diagnosis. Spontaneous pneumomediastinum is characterized by spontaneous recovery and can be treated with short period of observation and symptomatic management.

Current Guidelines on Syncope.

Syncope is a very commonly encountered clinical problem in general practice and in the emergency department. In the evaluation of syncope, it is important to identify the specific cause to determine the treatment, to estimate the precise risk to a patient, and to reduce recurrence. Sometimes, making a diagnosis of syncope is difficult, as different mechanisms may often coexist. Syncope causes a significant impact on quality of life due to associated risk of physical injury. In particular, syncope can be a precursor to sudden cardiac death in patients with underlying cardiac disease. It is crucial to identify patients at increased risk of death, such as those with myocardial ischemia and/or potentially life-threatening genetic diseases (e.g., Long-QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and arrhythmogenic right ventricular dysplasia). After these conditions have been excluded, other benign conditions that cause syncope must be identified, and efforts should be made to improve quality of life. The lack of a gold-standard clinical tool to aid in diagnosing syncope as well as improper use of various diagnostic tests, are leading to high economic burdens in this area.