Right Ventricular Assist Device with an Oxygenator for the Management of Combined Right Ventricular and Respiratory Failure: A Systematic Review.

BACKGROUND: Severe lung disease frequently presents with both refractory hypoxemia and right ventricular (RV) failure. OxyRVAD is an extra-corporeal membrane oxygenation (ECMO) configuration of RV bypass that also supplements gas exchange. This systematic review summarizes the available literature regarding the use of OxyRVAD in the setting of severe lung disease with associated RV failure. METHODS: PubMed, Embase, and Google Scholar were queried on September 27th, 2023, for articles describing the use of an OxyRVAD configuration. The main outcome of interest was survival to ICU discharge. Data on the duration of OxyRVAD support and device-related complications were also recorded. RESULTS: Of 475 identified articles, 33 were retained for analysis. Twenty-one articles were case reports and 12 were case series representing a total of 103 patients. No article provided a comparison group. Most patients (76.4%) were transitioned to OxyRVAD from another type of mechanical support. OxyRVAD was used as a bridge to transplant or curative surgery in 37.4% and as a bridge to recovery or decision in 62.6%. Thirty-one patients (30.1%) were managed with the dedicated single-access dual-lumen ProtekDuo cannula. Median time on OxyRVAD was twelve days (IQR 8-23) and survival to ICU discharge was 63.9%. Device-related complications were infrequently reported. CONCLUSION: OxyRVAD support is a promising alternative for RV support when gas exchange is compromised with good ICU survival in selected cases. Comparative analyses in patients with RV failure with and without severe lung disease are needed.

Prevalence of Cardiovascular Risk Factors in Women With Obstructive Coronary Disease Requiring Revascularization: A Meta-analysis.

Background: Cardiovascular disease continues to be the primary cause of premature mortality in women, who previously have been overlooked in clinical trials. Several studies showed that women undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) present more cardiovascular risk factors at baseline, develop more postprocedural complications, and have a higher mortality rate than men. The goal of this review is to analyze the difference between men and women in terms of the prevalence of individual cardiovascular risk factors. Methods: A meta-analysis was conducted of original investigations with adult subjects who underwent surgical intervention or PCIs in which cardiovascular risk factors were evaluated, using the MEDLINE, Cochrane, Evidence-Based Medicine Reviews (EBMR), Ovid Embase, Google Scholar, and PubMed databases. Results: Of the 4567 identified records found, 18 were retained for qualitative analysis. Prevalence of hypertension (CABG: 71% (95% confidence interval [CI] 64%, 78%]); PCI: (59% [95% CI 48%,70%]), and diabetes (CABG: 48% [95% CI 38%, 57%]); PCI 43% (95% CI 27%, 59%]) was high in women. Women who underwent either CABG or PCI had higher odds of having hypertension (CABG: odds ratio [OR] 1.92 [95% CI 1.47-2.50], P < 0.05); PCI: OR 1.86 [95% CI 1.76-1.97], P < 0.05]), and diabetes (CABG: OR 1.94 [95% CI 1.55-2.42], P < 0.05; PCI: OR 1.97 [95% CI 1.54-2.53], P < 0.05)). However, the prevalence of smoking among women, compared to men, was lower (CABG: 0.17 [95% CI 0.06-0.52], P < 0.05; PCI: 0.22 [95% CI 0.06-0.86], P < 0.03). Conclusion: The review shows that women who underwent either surgical or percutaneous revascularization had higher odds of hypertension and diabetes, compared to men.

Contexte: Les maladies cardiovasculaires demeurent la principale cause de décès prématurés chez les femmes, qui ont antérieurement été négligées dans les essais cliniques. Or, plusieurs études ont révélé que les femmes qui subissent un pontage aortocoronarien (PAC) ou une intervention coronarienne percutanée (ICP) présentent initialement plus de facteurs de risque cardiovasculaire, connaissent plus de complications postopératoires et affichent un taux de mortalité plus élevé que les hommes. Cette analyse visait à dégager les différences entre les hommes et les femmes quant à la prévalence de chacun des facteurs de risque cardiovasculaire. Méthodologie: Une méta-analyse a été menée sur des enquêtes originales auprès d'adultes ayant subi une intervention chirurgicale ou des ICP chez qui les facteurs de risque cardiovasculaire ont été évalués. Les bases de données interrogées étaient les suivantes : MEDLINE, Cochrane, Evidence-Based Medicine Reviews (EBMR), Ovid Embase, Google Scholar et PubMed. Résultats: Parmi les 4567 dossiers recensés, 18 ont été retenus pour une analyse qualitative. La prévalence de l'hypertension (PAC : 71 % [intervalle de confiance {IC} à 95 % : 64 %; 78 %]); ICP : 59 % [IC à 95 % : 48 %; 70 %]) et du diabète (PAC : 48 % [IC à 95 % : 38 %; 57 %]); ICP : 43 % (IC à 95 % : 27 %; 59 %]) était élevée chez les femmes. Les femmes qui ont subi un PAC ou une ICP présentaient un risque accru d'hypertension (PAC : rapport de cotes [RC] de 1.92 [IC à 95 % : 1,47-2,50], p < 0,05); ICP : RC de 1,86 [IC à 95 % : 1,76-1,97], p < 0,05]) et de diabète (PAC : RC de 1,94 [IC à 95 % : 1,55-2,42], p < 0,05; ICP : RC de 1,97 [IC à 95 % : 1,54-2,53], p < 0,05). Cependant, le tabagisme était moins prévalent chez les femmes que chez les hommes (PAC : 0,17 [IC à 95 % : 0,06-0,52], p < 0,05; ICP : 0,22 [IC à 95 % : 0,06-0,86], p < 0,03). Conclusion: L'analyse révèle que, par rapport aux hommes, les femmes qui ont subi une revascularisation chirurgicale ou percutanée présentaient plus de risque d'hypertension et de diabète.

Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy.

Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.

Adherence to Cardiovascular Prevention Guidelines in an Academic Centre.

Background: Adherence to guidelines is associated with better patient outcomes. Although studies show suboptimal adherence to cardiovascular prevention guidelines among general practitioners, adherence among specialist physicians is understudied. The aim of this analysis was to identify practice gaps among cardiologists in a tertiary academic centre. Methods: We retrospectively audited cardiology outpatient clinic notes taken at the Cardiology Clinic at the Centre hospitalier de l'Université de Montréal (CHUM), from the period January 1, 2019 to February 28, 2019. Data were abstracted from hospital medical records. The primary outcome of interest was the rate of adherence to cardiovascular prevention guidelines. We compared the chart-documented practice at our centre to the Canadian hypertension, lipid, diabetes, antiplatelet, and heart failure guidelines in effect at the time of the audit. We also collected information regarding discussions of smoking, alcohol consumption, physical activity, and diet. Results: A total of 2503 patients were included, with a mean age of 65.6 ± 14.5 years. Dyslipidemia occurred in 63% of patients, hypertension in 55%, and coronary artery disease in 41%. Optimal low-density lipoprotein control was documented as having been achieved in just 39% of cases. Blood pressure control was adequate for 65% of patients, and glycemic control was achieved in 47% of patients with diabetes. Heart failure treatment was optimal in 34% of patients. Nearly all patients with coronary artery disease (95%) had appropriate antithrombotic therapy. The incidence of discussion of nonpharmacologic interventions varied, ranging from 91% (smoking) to 16% (diet). Conclusions: Primary and secondary prevention of cardiovascular events was found to be suboptimal in an academic tertiary-care outpatient cardiology clinic and may be representative of similar shortcomings nationwide. Strategies to ensure guideline adherence are needed.

Contexte: Le respect des lignes directrices est associé à de meilleurs résultats pour les patients. Bien que les études montrent que les omnipraticiens adhèrent de façon sous-optimale aux lignes directrices en matière de prévention des événements cardiovasculaires, l'observance chez les médecins spécialistes n'a pas été assez étudiée. Notre analyse a pour objectif de déceler les lacunes dans la pratique des cardiologues exerçant dans des centres universitaires de soins tertiaires. Méthodologie: Nous avons examiné de manière rétrospective les notes cliniques consignées au dossier des patients du Centre cardiovasculaire du Centre hospitalier de l'Université de Montréal (CHUM) et résumé les données issues des consultations ayant eu lieu du 1er janvier au 28 février 2019. Le principal résultat d'intérêt était le taux d'adhésion aux lignes directrices en matière de prévention des événements cardiovasculaires. Nous avons comparé les pratiques enregistrées dans les dossiers de notre centre aux lignes directrices canadiennes sur la prise en charge de l'hypertension, de la lipidémie, du diabète, du traitement antiplaquettaire et de l'insuffisance cardiaque en place au moment de l'évaluation. Nous avons aussi recueilli de l'information sur les discussions entourant le tabagisme, la consommation d'alcool, l'activité physique et l'alimentation. Résultats: Les données de 2 503 patients, âgés en moyenne de 65,6 ± 14,5 ans, ont été retenues. De ces patients, 63 % présentaient une dyslipidémie, 55 %, une hypertension et 41 %, une maladie coronarienne. Le taux de lipoprotéines de basse densité n'était maîtrisé de façon optimale que dans 39 % des cas. La normalisation de la pression artérielle était adéquate chez 65 % des patients, et 47 % des patients diabétiques atteignaient les cibles glycémiques. L'insuffisance cardiaque était optimalement traitée chez 34 % des patients. Presque tous les patients atteints de maladie coronarienne (95 %) recevaient un traitement antithrombotique approprié. La fréquence des discussions sur les interventions non pharmacologiques variait, allant de 91 % dans le cas du tabagisme à 16 % dans celui de l'alimentation. Conclusions: La prévention primaire et secondaire des événements cardiovasculaires s'est révélée sous-optimale dans une clinique externe de cardiologie d'un hôpital universitaire et pourrait être représentative de lacunes similaires dans l'ensemble du pays. Des stratégies visant à assurer le respect des lignes directrices sont nécessaires.

Toward a Cardio-Environmental Risk Model: Environmental Determinants of Cardiovascular Disease.

It is increasingly recognized that strong geographic variations in cardiovascular risk cannot be explained using traditional cardiovascular risk factors alone. Indeed, it is highly unlikely that heredity and classic risk factors such as hypertension, diabetes, dyslipidemia, and tobacco use can explain the tenfold variation observed in cardiovascular mortality among men in Russia and those in Switzerland. Since the advent of industrialization and resultant changes to our climate, it is now clear that environmental stressors also influence cardiovascular health and our thinking around cardiovascular risk prediction is in need of a paradigm shift. Herein, we review the basis for this shift in our understanding of the interplay of environmental factors with cardiovascular health. We illustrate how air pollution, hyperprocessed foods, the amount of green space, and population activity levels are now considered the 4 major environmental determinants of cardiovascular health and provide a framework for how these considerations might be incorporated into clinical risk assessment. We also outline the clinical and socioeconomic effects of the environment on cardiovascular health and review key recommendations from major medical societies.

Multisystem inflammatory syndrome in adults: Comparison with other inflammatory conditions during the Covid-19 pandemic.

BACKGROUND: Multisystem inflammatory syndrome in adults (MIS-A) is an increasingly recognized complication of Covid-19. We assessed risk factors, clinical characteristics, and outcomes of patients with MIS-A compared with other inflammatory conditions. METHODS: We analyzed a cohort of patients ≥21 years hospitalized with MIS-A in Quebec, Canada between February 2020 and March 2021. We included comparison groups that share symptomatology or pathophysiology with MIS-A, including Kawasaki disease, toxic shock syndrome, and other Covid-19 complications. We examined characteristics of men and women at admission, and identified preexisting factors associated with MIS-A through odds ratios (OR) and 95% confidence intervals (CI) from adjusted logistic regression models. RESULTS: Among 22,251 patients in this study, 52 had MIS-A, 90 Kawasaki disease, 500 toxic shock syndrome, and 21,609 other Covid-19 complications. MIS-A was associated with an elevated risk of respiratory failure compared with Kawasaki disease (OR 7.22, 95% CI 1.26-41.24), toxic shock syndrome (OR 4.41, 95% CI 1.73-11.23), and other Covid-19 complications (OR 3.03, 95% CI 1.67-5.50). Patients with MIS-A had a greater risk of cardiac involvement, renal failure, and mortality. The data pointed towards sex-specific differences in presentation, with more respiratory involvement in women and cardiac involvement in men compared with patients that had other Covid-19 complications. Except for allergic disorders and cancer, prior medical risk factors were not associated with a greater likelihood of MIS-A. CONCLUSIONS: Patients with MIS-A have an elevated risk of mortality compared with other inflammatory conditions, with women having a predominance of respiratory complications and men cardiovascular complications.

Association of first trimester anaesthesia with risk of congenital heart defects in offspring.

BACKGROUND: A substantial number of pregnant women require anaesthesia for non-obstetric surgery, but the risk to fetal heart development is unknown. We assessed the relationship between first trimester anaesthesia and risk of congenital heart defects in offspring. METHODS: We conducted a longitudinal cohort study of 2 095 300 pregnancies resulting in live births in hospitals of Quebec, Canada, between 1990 and 2016. We identified women who received general or local/regional anaesthesia in the first trimester, including anaesthesia between 3 and 8 weeks post-conception, the critical weeks of fetal cardiogenesis. The main outcome measures were critical and non-critical heart defects in offspring. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association of first trimester anaesthesia with congenital heart defects, using log-binomial regression models adjusted for maternal characteristics. RESULTS: There were 107.3 congenital heart defects per 10 000 infants exposed to anaesthesia, compared with 87.2 per 10 000 unexposed infants. Anaesthesia between 3 and 8 weeks post-conception was associated with 1.50 times the risk of congenital heart defects (95% CI 1.11-2.03), compared with no anaesthesia. Anaesthesia between 5 and 6 weeks post-conception was associated with 1.84 times the risk (95% CI 1.10-3.08). Associations were driven mostly by general anaesthesia, which was associated with 2.49 times the risk between weeks 5 and 6 post-conception (95% CI 1.40-4.44). CONCLUSIONS: General anaesthesia during critical periods of fetal heart development may increase the risk of congenital heart defects. Further research is needed to confirm that anaesthetic agents are cardiac teratogens.

Iatrogenic Superior Vena Cava Syndrome: A Rare Cause of Hemodynamic Compromise After Cardiac Surgery.

Given the broad array of potential complications following cardiac surgery, specialized care is critical to ensuring good patient outcomes. Herein, we present a rare case of severe hemodynamic compromise, following cardiac surgery, found to be due to iatrogenic superior vena cava syndrome in the setting of baseline biventricular dysfunction. Hemodynamics improved immediately upon addressing the syndrome, highlighting the importance of multidisciplinary collaboration in the postoperative care of cardiac surgery patients.

Compte tenu du large éventail de complications potentielles après une chirurgie cardiaque, des soins spécialisés sont indispensables afin de garantir de bons résultats pour les patients. Nous présentons ici un cas rare de compromis hémodynamique grave à la suite d'une chirurgie cardiaque, causé par un syndrome iatrogène de compression de la veine cave supérieure dans un contexte de dysfonction biventriculaire existante. Le compromis hémodynamique s'est immédiatement amélioré après la prise en charge du syndrome, ce qui souligne l'importance de la collaboration multidisciplinaire dans les soins postopératoires des patients en chirurgie cardiaque.

Cardiovascular disease and cancer in women with accreta and retained placenta: a longitudinal cohort study.

PURPOSE: The association between placental detachment disorders and risk of chronic disease is unclear. We determined the association of placenta accreta and retained placenta with risk of future maternal cardiovascular disease and cancer. METHODS: We tracked a longitudinal cohort of 541,051 pregnant women over a period of 13 years (2006-2019) in Quebec, Canada. The main exposure measures were placenta accreta and retained placenta in any pregnancy. Outcomes included future hospitalizations for cardiovascular disease and cancer. Using Cox regression models adjusted for maternal characteristics, we estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association of accreta and retained placenta with cardiovascular disease and cancer at 13 years. RESULTS: The incidence of cardiovascular hospitalization was 21.2 per 10,000 person-years for accreta and 23.4 per 10,000 for retained placenta with postpartum hemorrhage, compared with 20.3 per 10,000 for neither placental disorder. Cancer incidence followed a similar pattern, with rates highest for retained placenta with hemorrhage. Retained placenta with hemorrhage was associated with 1.19 times the risk of cardiovascular disease (95% CI 1.03-1.38) and 1.27 times the risk of cancer (95% CI 1.06-1.53). Retained placenta with hemorrhage was associated with heart failure (HR 1.84, 95% CI 1.04-3.27), cardiomyopathy (HR 1.88, 95% CI 1.03-3.43), and cervical cancer (HR 2.03, 95% CI 1.17-3.52). Accreta and retained placenta without hemorrhage were not associated with these outcomes. CONCLUSION: Retained placenta with hemorrhage may be a risk marker for cardiovascular disease and certain cancers later in life.

The prognostic significance of repeated prehospital shocks for out-of-hospital cardiac arrest survival.

OBJECTIVES: Patients suffering from an out-of-hospital cardiac arrest (OHCA) associated with an initial shockable rhythm have a better prognosis than their counterparts. The implications of recurrent or refractory malignant arrhythmia in such context remain unclear. The objective of this study is to evaluate the association between the number of prehospital shocks delivered and survival to hospital discharge among patients in OHCA. METHODS: This cohort study included adult patients with an initial shockable rhythm over a 5-year period from a registry of OHCA in Montreal, Canada. The relationship between the number of prehospital shocks delivered and survival to discharge was described using dynamic probabilities. The association between the number of prehospital shocks delivered and survival to discharge was assessed using multivariable logistic regression. RESULTS: A total of 1,788 patients (78% male with a mean age of 64 years) were included in this analysis, of whom 536 (30%) received treatments from an advanced care paramedic. A third of the cohort (583 patients, 33%) survived to hospital discharge. The probability of survival was highest with the first shock (33% [95% confidence interval 30%-35%]), but decreased to 8% (95% confidence interval 4%-13%) following nine shocks. A higher number of prehospital shocks was independently associated with lower odds of survival (adjusted odds ratio=0.88 [95% confidence interval 0.85-0.92], p < 0.001). CONCLUSION: Survival remains possible even after a high number of shocks for patients suffering from an OHCA with an initial shockable rhythm. However, requiring more shocks is independently associated with worse survival.

Incremental cost and length of stay associated with postprocedure delirium in transcatheter and surgical aortic valve replacement patients in the United States.

OBJECTIVES: To explore the impact of post-procedure delirium on resource utilization following transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively). BACKGROUND: Postprocedure delirium is associated with worse long-term survival after TAVR and SAVR. However, its effect on resource utilization has been understudied. METHODS: Using the 2015 Medicare Provider Analysis and Review File (MedPAR), we retrospectively analyzed elderly (≥80 years) Medicare beneficiaries receiving either SAVR or endovascular TAVR in the United States. Multivariate regression models estimating hospitalization cost and length of stay (LoS) were adjusted for patient demographics, comorbidities, and nondelirium complications. RESULTS: A total of 21,088 discharges were available for analysis (12,114 TAVR and 8,974 SAVR). TAVR patients were older (87 ± 3.8 vs. 84 ± 2.7 years; P < 0.001) with a higher comorbidity burden (Charlson index 3.0 ± 1.8 vs. 2.1 ± 1.7; P < 0.0001). Despite this, fewer TAVR patients (1.6%) experienced postoperative delirium during the index hospitalization compared to surgical patients (3.6%; P < 0.0001). Delirium was associated with a 4.16 [3.51-4.81] day longer hospital LoS and $15,592 ($12,849-$18,334) higher incremental hospitalization cost. When stratified by treatment approach, the adjusted incremental cost of delirium was +$13,862 ($9,431-$18,292) with TAVR and +$16,656 ($13,177-$20,136) with SAVR with an additional hospital LoS of +3.39 (2.34-4.43) days and +4.63 (3.81-5.45) days for TAVR and SAVR, respectively. CONCLUSIONS: Postprocedure delirium is associated with significantly increased hospitalization costs and LoS following AVR. TAVR was associated with a lower postoperative delirium rate compared to SAVR. Post-TAVR delirium may be associated with less resource consumption than post-SAVR delirium.

Longer Inflation Duration and Predilation-Sizing-Postdilation Improve Bioresorbable Scaffold Outcomes in a Long-term All-Comers Canadian Registry.

BACKGROUND: Real-world long-term safety and efficacy of the ABSORB (Abbott Vascular, Santa Clara, CA) bioresorbable vascular scaffold has not been well characterized in the literature, particularly in the setting of acute coronary syndromes (ACS). Herein, we report outcomes up to 4 years in such a high-risk cohort, with identification of parameters associated with better outcomes. METHODS: ReABSORB is a Canadian dual-centre, prospective, nonrandomized, all-comers registry consisting of 125 consecutively enrolled nontrial patients between October 2012 and December 2016. Angiographic and clinical follow-up is now available up to 4 years. RESULTS: Average age was 59 ± 11 years and 69% were male. Most (70.4%) presented with ACS and the median available follow-up was 1330 days (interquartile range, 1035-1483). Treated lesions (n = 163) were type A in 23%, type B (1 or 2) in 64%, and type C in 13%. Procedural success and device success were 98.2% and 98.8%, respectively. Using Kaplan-Meier methods, major adverse cardiac event-free survival (EFS) up to 4 years of clinical follow-up was 90.7% overall. However, use of a predilation-sizing-postdilation (PSP) technique was associated with an EFS rate of 95.8% vs 74.0% without PSP (P = 0.001). No significant differences in major adverse cardiac EFS rates were found between patients with or without ACS (92.7% vs 86.0%, respectively, P = 0.239). Use of PSP as well as inflation time ≥ 60 seconds were independent predictors of EFS at 2 years. CONCLUSIONS: In this prospective, real-world registry with mostly ACS patients, use of the recommended PSP implantation technique and longer inflations times were associated with significantly higher EFS.

Impact of Paclitaxel-Eluting Balloons Compared to Second-Generation Drug-Eluting Stents for of In-Stent Restenosis in a Primarily Acute Coronary Syndrome Population / Impacto dos Balões de Eluição de Paclitaxel Comparados a Stents Farmacológicos de Segunda Geração para Reestenose Intra-Stent em uma População com Síndrome Coronária Aguda Primária

Abstract Background: The place of drug-eluting balloons (DEB) in the treatment of in-stent restenosis (ISR) is not well-defined, particularly in a population of all-comers with acute coronary syndromes (ACS). Objective: Compare the clinical outcomes of DEB with second-generation drug-eluting stents (DES) for the treatment of ISR in a real-world population with a high proportion of ACS. Methods: A retrospective analysis of consecutive patients with ISR treated with a DEB compared to patients treated with a second-generation DES was performed. The primary endpoint was a composite of major adverse cardiovascular events (MACE: all-cause death, non-fatal myocardial infarction, and target lesion revascularization). Comparisons were performed using Cox proportional hazards multivariate adjustment and Kaplan-Meier analysis with log-rank. Results: The cohort included 91 patients treated with a DEB and 89 patients treated with a DES (74% ACS). Median follow-up was 26 months. MACE occurred in 33 patients (36%) in the DEB group, compared to 17 patients (19%) in the DES group (p log-rank = 0.02). After multivariate adjustment, there was no significant difference between the groups (HR for DEB = 1.45 [95%CI: 0.75-2.83]; p = 0.27). Mortality rates at 1 year were 11% with DEB, and 3% with DES (p = 0.04; adjusted HR = 2.85 [95%CI: 0.98-8.32]; p = 0.06). Conclusion: In a population with a high proportion of ACS, a non-significant numerical signal towards increased rates of MACE with DEB compared to second-generation DES for the treatment of ISR was observed, mainly driven by a higher mortality rate. An adequately-powered randomized controlled trial is necessary to confirm these findings.

Resumo Fundamento: O papel de balões farmacológicos (BFs) no tratamento de reestenose intra-stent (RIS) não está bem definido, particularmente em na síndrome coronária aguda (SCA). Objetivo: Comparar desfechos clínicos do uso de BF com stents farmacológicos (SFs) de segunda geração no tratamento de RIS em uma população real com alta prevalência de SCA. Métodos: Foi realizada uma análise retrospectiva de pacientes consecutivos com RIS tratados com um BF comparados a pacientes tratados com SF de segunda geração. O desfecho primário incluiu eventos cardiovasculares adversos importantes (morte por todas as causas, infarto do miocárdio não fatal, e revascularização da lesão alvo). As comparações foram realizadas pelo modelo proporcional de riscos de Cox ajustado e análise de Kaplan-Meier com log-rank. Resultados: A coorte incluiu 91 pacientes tratados com BF e 89 pacientes tratados com um SF (75% com SCA). O tempo mediano de acompanhamento foi de 26 meses. Eventos cardiovasculares adversos importantes ocorreram em 33 pacientes (36%) no grupo BF, e em 17 (19%) no grupo SF (p log-rank = 0,02). Após ajuste multivariado, não houve diferença significativa entre os grupos (HR para BF = 1,45 [IC95%: 0,75-2,83]; p = 0,27). As taxas de mortalidade de 1 ano foram 11% com BF, e 3% com SF (p = 0,04; HR ajustado = 2,85 [IC95%: 0,98-8,32; p = 0,06). Conclusão: Em uma população com alta prevalência de SCA, observou-se um aumento não significativo nas taxas de eventos cardiovasculares adversos importantes com o uso de BF comparado ao uso de SF de segunda geração para o tratamento de RIS, principalmente pelo aumento na taxa de mortalidade. É necessário um ensaio clínico controlado, randomizado, com poder estatístico adequado para confirmar esses achados.

Utility of a real-time appropriate use criteria decision support application for percutaneous coronary interventions in non-acute coronary syndrome.

OBJECTIVES: The aim of this study was to test the feasibility and value of a real-time online appropriate use criteria (AUC) application for percutaneous coronary intervention (PCI) in patients without acute coronary syndrome. BACKGROUND: High rates of non-appropriate elective PCI in the National Cardiovascular Data Registry (NCDR) CathPCI Registry have created interest in integrating decision support tools into routine clinical care to improve the frequency of appropriate PCIs. METHODS: Patients undergoing diagnostic coronary angiography and subsequent PCI for non-ACS indications at a single center were scored using a real-time AUC application pre-procedure. Blinded angiographic review was performed subsequently for each case. Rates of appropriate, inappropriate, uncertain and not rated PCIs were tabulated according to specific clinical scenarios using information available both before and after the angiographic audit. RESULTS: Of 308 PCIs in 272 patients, 196 (63.6%) were deemed appropriate, 79 (25.6%) uncertain, and two (0.6%) inappropriate; 31 (10.1%) scenarios could not be rated. With angiographic audit, inappropriate PCIs increased to 9.7%. There was a significant improvement in the rate of appropriate PCI using the real-time AUC application compared with retrospective data collection for NCDR reporting (64% vs. 53%, P = 0.01). CONCLUSIONS: Use of a real-time AUC application together with angiographic audit may improve the accuracy of reporting PCI appropriateness. © 2015 Wiley Periodicals, Inc.

Effect of aspirin and warfarin therapy on thromboembolic events in patients with univentricular hearts and Fontan palliation.

BACKGROUND: Patients with univentricular hearts and Fontan palliation are at risk for thromboembolic complications. While aspirin and warfarin therapies are currently the mainstay of prophylaxis, controversy exists as to the optimal prevention strategy. METHODS: A cohort study was conducted on the New England registry of patients born in 1985 or earlier with Fontan surgery at Boston Children's Hospital, in order to assess and compare the effect of prophylactic aspirin and warfarin on incident thromboembolic events. RESULTS: A total of 210 qualifying patients (49% male) underwent Fontan surgery at a median age of 8.5 years: 48.6% had a right atrium to pulmonary artery anastomosis, 11% a right atrium to right ventricle conduit, 38.6% a lateral tunnel, and 1.9% an extracardiac conduit. No thromboembolic prophylaxis was prescribed to 50.0%, whereas 24.3% received aspirin, and 25.7% warfarin. In multivariate analyses, lack of aspirin or warfarin was associated with a significantly higher thromboembolic event rate when compared to therapy with either [hazard ratio 8.5, 95% confidence interval (3.6-19.9), P < 0.001], with no difference between the two treatment strategies (P = 0.768). Twenty-year freedom from thromboemboli was 86% versus 52% in patients with and without thromboprophylaxis, respectively. Other factors independently associated with thromboemboli were a low post-operative cardiac index [hazard ratio 2.6, 95% confidence interval (1.2, 5.9)] and atrial fibrillation or flutter [hazard ratio 3.1, 95% confidence interval (1.2, 8.0)]. CONCLUSIONS: Prophylaxis with either aspirin or warfarin was associated with a significantly lower rate of incident thromboembolic events following Fontan palliation, with no difference between the two therapies.

Cardiac output responses in a flow-driven protocol of resuscitation following cardiac surgery.

OBJECTIVE: Determine the role of cardiac output and central venous pressure (CVP) measurements in the clinical decisions that were based on the algorithm used in a randomized trial that compared a colloid to a crystalloid solution in the management of patients early after cardiac surgery (FACS trial, NCT00337805, Crit Care Med 2010; 38:2117). METHODS: We analyzed the changes in CVP and cardiac index (CI) in 729 fluid challenges from the FACS trial in which 119 patients were randomized to colloid and 118 to crystalloid boluses in a flow-based protocol. A fluid challenge was defined as being positive if CI increased by ≥ 0.3 L/min(-1)m(-2) and negative if CI increased by <0.3 L/min(-1)m(-2) but CVP increased by ≥ 2 mmHg. RESULTS: As defined in the protocol, 26% of boluses were given for a low CI (<2.2 L/min(-1)m(-2)). CI did not increase in 20% of boluses despite an adequate increase in CVP; in the protocol this meant that further volume boluses were not given. In another 34% of boluses in which CI did not increase, CVP increased by < 2 mmHg, which meant that volume responsiveness could not be ruled out and another bolus was indicated. 43% of the boluses were given for hypotension, but surprisingly in 90% of these instances, CI was in the acceptable range indicating that the low arterial pressure was due to decreased systemic vascular resistance. CONCLUSION: Measurement of cardiac output and CVP significantly influenced clinical decisions in the FACS algorithm.

Hemodynamic and clinical benefits associated with chronic sildenafil therapy in advanced heart failure: experience of the Montréal Heart Institute.

BACKGROUND: Pulmonary hypertension is highly prevalent in advanced heart failure (HF) despite optimal medical and device therapies. The objective of this investigation was to report on a single centre's experience of open-label chronic sildenafil therapy in patients with advanced HF. METHODS: We conducted a retrospective systematic medical record review of all patients evaluated at our institution for heart transplantation who had also been treated with chronic sildenafil therapy. Baseline demographics, comorbidities, and concomitant medications, as well as the results of laboratory investigations and physiological testing, were abstracted from patient medical records. Change in systolic and mean pulmonary artery pressure (PAP), transpulmonary gradient, cardiac output and cardiac index, and selected laboratory parameters was analyzed by means of the Wilcoxon rank sum test. Outcomes of interest included New York Heart Association (NYHA) functional class after 6 months of therapy and adverse effects attributable to sildenafil. RESULTS: The 16 patients undergoing evaluation for cardiac transplantation combined for 4166 patient-days on sildenafil, with a mean dose of 102.5 ± 54.0 mg/d. None discontinued because of side effects. At 6 months, there was an improvement in the cardiac index (P = 0.014) and systolic PAP (P = 0.049) without any significant change in other hemodynamic parameters. Ten patients (62.5%) experienced an improvement in their NYHA functional class, 8 (50%) received a heart transplantation, and 2 (12.5%) improved sufficiently to be removed from the transplant list. CONCLUSION: Chronic sildenafil therapy was well tolerated and associated with improved functional capacity and decreased systolic PAP. Properly controlled randomized studies of the long-term usefulness of sildenafil therapy in advanced HF populations are warranted.

Fluids after cardiac surgery: a pilot study of the use of colloids versus crystalloids.

OBJECTIVES: To determine whether a starch solution for volume resuscitation in a flow-based protocol improves circulatory status better than a crystalloid solution, as defined by the need for catecholamines in patients the morning after cardiac surgery, and whether this can be performed without increased morbidity. DESIGN: Concealed, randomized, double-blind, controlled trial. PARTICIPANTS: Two hundred sixty-two patients who underwent cardiac surgery at a tertiary care hospital. INTERVENTIONS: Based on predefined criteria indicating a need for fluids, and a nurse-delivered algorithm that used central venous pressure and cardiac index obtained from a pulmonary artery catheter, patients were allocated to receive 250-mL boluses of 0.9% saline or a 250-molecular weight 10% solution of pentastarch. RESULTS: Two hundred thirty-seven patients received volume boluses: 119 hydroxyethyl starches and 118 saline. Between 8:00 am and 9:00 am the morning after surgery, 13 (10.9%) of hydroxyethyl starch patients and 34 (28.8%) saline patients were using catecholamines (p = .001). Hydroxyethyl starch patients had less pneumonia and mediastinal infections (p = .03) and less cardiac pacing (p = .03). There were two deaths in each group. There was no difference in the daily creatinine, development of RIFLE risk criteria during hospital stay, or new dialysis. The numbers and volumes of packed red blood cells were similar in the two groups, but more hydroxyethyl starch patients received plasma transfusions (p = .05). CONCLUSIONS: Use of a colloid solution for volume resuscitation in a nurse-delivered flow-based algorithm, which included a pulmonary artery catheter, significantly improved hemodynamic status, an important factor for readiness for discharge from the intensive care unit.