TAVR in a Patient With Anomalous Origin and Course of the Left Main Coronary Artery.

In patients with anomalous coronary arteries with high-risk features, corrective cardiac surgery should be considered. We report the first case of transcatheter aortic valve replacement using a self-expanding Evolut valve, in a patient with a single coronary artery arising from the right coronary cusp and an intramural course of the left main. (Level of Difficulty: Intermediate.).

A Case of Recurrent Myocarditis After COVID-19 Vaccination, Due to Acute Myeloid Leukemia.

A 25-year-old man presented with chest pain and an elevated troponin level following COVID-19 vaccination. Despite initial response to nonsteroidal anti-inflammatory drugs, he developed a recurrent and relapsing course requiring multiple readmissions. Cardiac magnetic resonance imaging confirmed myocarditis. Due to progressing macrocytic anemia, he was eventually diagnosed with acute myeloid leukemia, thought to be the underlying driver of his recurrent and persistent myocarditis.

Nous relatons le cas d'un homme de 25 ans qui présentait une douleur thoracique et un taux élevé de troponine après avoir reçu un vaccin contre la COVID-19. Malgré la réponse initiale du patient aux anti-inflammatoires non stéroïdiens, le tableau clinique a évolué sur un mode récurrent et récidivant, et nécessité plusieurs réhospitalisations. L'imagerie par résonance magnétique cardiaque a permis de confirmer la présence d'une myocardite. Dans un contexte d'anémie macrocytaire évolutive, le patient a finalement reçu un diagnostic de leucémie myéloblastique aiguë, considérée comme le facteur sous-jacent de la myocardite récurrente et persistante dont il était atteint.

Predictors of cumulative cost for patients with severe aortic stenosis referred for surgical or transcatheter aortic valve replacement: a population-based study in Ontario, Canada.

AIMS: Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has transformed severe aortic stenosis (AS) management. Our aim was understand AS cost drivers from referral to 1-year post-procedure. METHODS AND RESULTS: We identified patients referred for either TAVR/SAVR between 1 April 2015 and 31 March 2018, with follow-up until 31 March 2019 in Ontario, Canada. We stratified costs into (i) a referral phase, (ii) a procedural phase from the procedure date to 60 days post-procedure, and (iii) post-procedure phase from 61 days to 1 year. Multivariable regression modelling using generalized linear models with a log link gamma distribution was used to identify cost drivers in each phase. The study cohort included 12 086 AS patients; 4832 were referred for TAVR and 7254 were referred for SAVR. The median cost for TAVR was higher than SAVR in the referral ($3593 vs. $2944) and post-procedural ($5938 vs. $3257) phases. In contrast, for the procedural phase, SAVR had a median cost of $29 756 vs. $27 907 for TAVR. Predictors of high cost in the referral phase were longer wait-time, and an urgent in-hospital procedure. In the procedural phase, procedural complications were the major drivers of higher cost. In the post-procedural phase, patient co-morbidities were the major drivers, specifically dialysis, liver disease, cancer, peripheral vascular disease, and diabetes mellitus. CONCLUSION: We identified distinct patterns of cost accumulation and modifiable drivers for SAVR compared with TAVR; these drivers may guide clinical and health policy decisions to make AS care more efficient.

Comparison of Cardiovascular Risk Factors and Outcomes Among Practicing Physicians vs the General Population in Ontario, Canada.

Importance: Although cardiovascular disease is the leading cause of death in most developed countries, little is known about current physicians' cardiovascular health and outcomes. Objective: To compare cardiac risk factor burden, health services use, and major cardiovascular event incidence between physicians and the general population. Design, Setting, and Participants: This cohort study used data from practicing physicians and nonphysicians without cardiovascular disease aged 40 to 75 years in Ontario, Canada. Cohorts were assembled beginning January 1, 2008, and were followed up to December 31, 2015. Data analysis was performed between November 2017 and September 2019. Exposure: Being a practicing physician. Main Outcomes and Measures: The primary outcome was 8-year incidence of a major cardiovascular event (ie, cardiovascular death or hospitalization for myocardial infarction, stroke, heart failure, or coronary revascularization). Secondary outcomes included health services used, such as physician assessments and guideline-recommended tests. Results: The cohort comprised 17 071 physicians (mean [SD] age, 53.3 [8.8] years; 11 963 [70.1%] men) and 5 306 038 nonphysicians (mean [SD] age, 53.7 [9.5] years; 2 556 044 [48.2%] men). Physicians had significantly lower baseline rates of hypertension (16.9% vs 29.6%), diabetes (5.0% vs 11.3%), and smoking (13.1% vs 21.6%), while having better cholesterol profiles (total cholesterol levels >240 mg/dL, 13.3% vs 16.5%; low-density lipoprotein cholesterol >130 mg/dL, 33.2% vs 36.8%); age- and sex-adjusted differences were even larger. Physicians also had lower rates of periodic health examinations (58.9% [95% CI, 57.5%-60.4%] vs 67.9% [95% CI, 67.8%-67.9%]), hyperlipidemia screening (76.3% [95% CI, 74.7%-78.0%] vs 83.8% [95% CI, 83.7%-83.9%]), and diabetes screening (79.0% [95% CI, 77.3%-80.8%] vs 85.3% [95% CI, 85.2%-85.4%]), but higher rates of cardiologist consultations (25.2% [95% CI, 24.2%-26.3%] vs 19.5% [95% CI, 19.4%-19.5%]). The 8-year age- and sex-standardized primary outcome incidence was 4.4 major cardiovascular events per 1000 person-years for physicians and 7.1 major cardiovascular events per 1000 person-years for the general population. After adjusting for age, sex, socioeconomic status, and cardiac risks and comorbidities, physicians had a 22% lower hazard (hazard ratio, 0.78; 95% CI, 0.72-0.85) of experiencing the primary outcome compared with the general population. Conclusions and Relevance: Practicing physicians in Ontario had fewer cardiovascular risk factors, underwent less preventive testing, and were less likely to experience major adverse cardiovascular outcomes than the general population.

Variation in Revascularization Practice and Outcomes in Asymptomatic Stable Ischemic Heart Disease.

OBJECTIVES: The aims of this study were to assess variation in revascularization of asymptomatic patients with stable ischemic heart disease, identify the predictors of variation, and determine if it was associated with clinical outcomes. BACKGROUND: Management of stable ischemic heart disease in asymptomatic patients with obstructive coronary artery disease is controversial, potentially leading to practice variation. METHODS: A retrospective observational cohort study was performed using population-based data from Ontario, Canada, in patients with asymptomatic stable ischemic heart disease and obstructive coronary artery disease. The cohort was divided on the basis of treatment strategy: revascularization or medical therapy. Hospitals were allocated into tertiles of their revascularization ratio. Outcomes included death and nonfatal myocardial infarction. Hierarchical logistic regression was used to assess the predictors of revascularization, with median odds ratios used to quantify variation. Proportional hazards models were used to determine the association between management strategy and outcomes. RESULTS: The cohort included 9,897 patients, 47% treated with medical therapy and 53% with revascularization. Between hospitals, 2-fold variation existed in the ratio of revascularized to medically treated patients. However, the variation across hospitals was not explained by patient, physician, or hospital factors (median odds ratio in null model: 1.25; median odds ratio in full model: 1.31). Revascularization was associated with a hazard ratio of 0.81 (95% confidence interval: 0.69 to 0.96) for death and a hazard ratio of 0.58 (95% confidence interval: 0.46 to 0.73) for myocardial infarction, with this benefit consistent across tertiles of revascularization ratio. CONCLUSIONS: Wide variation was observed in revascularization practice that was not explained by known factors. Despite this variation, a clinical benefit was observed with revascularization that was consistent across hospitals.

Impact of the Publication of Appropriate Use Criteria on Utilization Rates of Myocardial Perfusion Imaging Studies in Ontario, Canada: A Population-Based Study.

BACKGROUND: Concern regarding overutilization of cardiac imaging has led to the development of appropriate use criteria (AUC). Myocardial perfusion imaging (MPI) is one of the most commonly used cardiac imaging modalities worldwide. Despite multiple iterations of AUC, there is currently no evidence regarding their real-world impact on population-based utilization rates of MPI. Our goal was to assess the impact of the AUC on rates of MPI in Ontario, Canada. We hypothesized that publication of the AUC would be associated with a significant reduction in MPI rates. METHODS AND RESULTS: We conducted a retrospective cohort study of the adult population of Ontario from January 1, 2000, to December 31, 2015. Age- and sex-standardized rates were compared from 4 different periods intersected by 3 published iterations of the AUC. Overall, 3 072 611 MPI scans were performed in Ontario during our study period. The mean monthly rate increased from 14.1/10 000 in the period from January 2000 to October 2005 to 18.2/10 000 between November 2005 and June 2009. After this point in time, there was a reduction in rates, falling to a mean monthly rate of 17.1/10 000 between March 2014 and December 2015. Time series analysis revealed that publication of the 2009 AUC was associated with a significant reduction in MPI rates (P<0.001). This translated into ≈88 849 fewer MPI scans at a cost savings of ≈72 million Canadian dollars. CONCLUSIONS: Our results reflect a potential real-world impact of the 2009 MPI AUC by demonstrating evidence of a significant effect on population-based rates of MPI.

Diabetes is an independent predictor of right ventricular dysfunction post ST-elevation myocardial infarction.

BACKGROUND: Diabetes mellitus (DM) is estimated to become the 7th leading cause of death by 2030. Right ventricular dysfunction (RVD) complicating ST elevation myocardial infarction (STEMI) is independently associated with a higher mortality; however the relationship between DM and RVD is currently unknown. The purpose of this study was to determine whether DM is an independent predictor for the presence of right ventricular dysfunction (RVD) post STEMI. METHODS: 106 patients post primary PCI for STEMI were enrolled in the study. Cardiac MRI was performed within 48-72 h after admission in order to assess ventricular function. Statistical analysis consisted initially of descriptive statistics including Chi square, Fisher's exact, or the Wilcoxon rank sum as appropriate. Subsequently, logistic regression analysis was performed to determine independent predictors of RVD. RESULTS: The median age in the study was 58 years (IQR 53, 67). 30 % of the patients had diabetes. Of 99 patients for which RV data was available, 40 had RVD and 59 did not. Patients with DM were significantly more likely to have RVD when compared to those without diabetes (45 vs 22 %, p = 0.03). There was no significant difference in age, hypertension, smoking status, dyslipidemia, serum creatinine or peak CK levels between the two groups. After adjusting for other factors, presence of DM remained an independent predictor for the presence of RV dysfunction (OR 2.78, 95 % CI 1.12, 6.87, p = 0.03). Amongst diabetic patients, those with HbA1C ≥ 7 % had greater odds of having RVD vs those with HbA1C < 7 % (OR 5.58 (1.20, 25.78), p = 0.02). CONCLUSIONS: The presence of DM conferred an approximately threefold greater odds of being associated with RVD post STEMI. No other major cardiovascular risk factors were independently associated with the presence of RVD.

Advanced MRI for carotid plaque imaging.

Atherosclerosis is the ubiquitous underling pathological process that manifests in heart attack and stroke, cumulating in the death of one in three North American adults. High-resolution magnetic resonance imaging (MRI) is able to delineate atherosclerotic plaque components and total plaque burden within the carotid arteries. Using dedicated hardware, high resolution images can be obtained. Combining pre- and post-contrast T1, T2, proton-density, and magnetization-prepared rapid acquisition gradient echo weighted fat-saturation imaging, plaque components can be defined. Post-processing software allows for semi- and fully automated quantitative analysis. Imaging correlation with surgical specimens suggests that this technique accurately differentiates plaque features. Total plaque burden and specific plaque components such as a thin fibrous cap, large fatty or necrotic core and intraplaque hemorrhage are accepted markers of neuroischemic events. Given the systemic nature of atherosclerosis, emerging science suggests that the presence of carotid plaque is also an indicator of coronary artery plaque burden, although the preliminary data primarily involves patients with stable coronary disease. While the availability and cost-effectiveness of MRI will ultimately be important determinants of whether carotid MRI is adopted clinically in cardiovascular risk assessment, the high accuracy and reliability of this technique suggests that it has potential as an imaging biomarker of future risk.

Role of vascular function in predicting arteriovenous fistula outcomes: an observational pilot study.

BACKGROUND: Many arteriovenous fistula (AVF) fail prior to use due to lack of maturation or thrombosis. Determining vascular function prior to surgery may be helpful to predict subsequent AVF success. This is a feasibility study to describe the vascular function in a cohort of chronic kidney disease (CKD) patients who are awaiting AVF creation. METHODS: A prospective cohort of 28 CKD patients expected to progress to HD underwent arterial stiffness (pulse wave velocity, PWV) and endothelial function testing (flow mediated dilation FMD, and peripheral arterial tonometry, PAT) one week prior to AVF creation. AVF success was defined as maintaining patency and achieving maturation. Post operative fistula assessment at 8 weeks evaluated maturation (clinical assessment of adequate fistula flowand ultrasound diameter ≥ 0.5 cm). RESULTS: The median age 72 years (62 - 78), 75% males, eGFR 15 ml/min/1.73 m(2) (12 - 18). 20 (71%) patients had successful AVF surgery with a mature AVF at 8 weeks. Patients with AVF success had higher mean PAT values 1.87 ± 0.52 than those with failed AVF 1.41 ± 0.24 p = 0.03. CONCLUSIONS: Microvascular endothelial function as measured using PAT may be useful as a predictor of AVF maturation and function. This simple non invasive marker of vascular function may be a useful tool to predict AVF outcomes.

CONTEXTE: On attribue l'échec précoce de plusieurs fistules artérioveineuses (FAV) à un manque de maturation ou à une thrombose précoce. Une évaluation de la fonction vasculaire en phase préopératoire pourrait aider à prédire l'issue d'une FAV prochaine. Ceci est une étude de faisabilité de l'évaluation de la fonction vasculaire d'une cohorte de patients atteints d'insuffisance rénale chronique (IRC) en attente de confection de FAV. MÉTHODE: L'étude de cohorte prospective comprenait 28 patients atteints d'une IRC évoluant vers des traitements d'hémodialyse. Une semaine avant la confection de la FAV, les participants ont subi des évaluations de la rigidité artérielle (analyse de l'onde de pouls) et de la fonction endothéliale (mesure de la vasodilatation médiée par le flux [flow-mediated dilatation ou FMD] et tonométrie artérielle périphérique ou EndoPAT) une semaine avant la confection de la FAV. Nous définissons le succès de la FAV comme le maintien de la perméabilité et l'atteinte de sa maturité. L'examen postopératoire de la fistule, 8 semaines après l'intervention, évaluait sa maturation (examen clinique du débit adéquat de la fistule, et évaluation du diamètre par ultrasons, soit ≥ 0,5 cm.). RÉSULTATS: L'âge moyen des participants était de 72 ans (62 ­ 78); 75% des participants étaient de sexe masculin. Le DFG estimé était de 15 ml/min/1,73 m2 (12 ­ 18). Le succès de la confection et la maturation de la FAV à 8 semaines ont été évalués auprès de 20 patients (71%). Les valeurs moyennes de l'EndoPAT étaient plus élevées chez les FAV complétées avec succès (1,87 ± 0,52), que chez les FAV en échec précoce (1,41 ± 0,24 p = 0,03). Après redressement de l'échantillon pour l'âge, le sexe et le DFG, l'EndoPAT était lié au succès de la FAV (pour chaque augmentation à l'EndoPAT, le taux de succès de la FAV était multiplié par 1,75; p = 0,02). CONCLUSIONS: La fonction microvasculaire endothéliale évaluée par EndoPAT pourrait être utilisée pour prédire la maturation et le fonctionnement d'une FAV. Cet indicateur simple et non invasif de la fonction vasculaire pourrait être également un outil pratique pour prédire le résultat de la confection d'une FAV.

Inflammatory bowel disease cause-specific mortality: a primer for clinicians.

BACKGROUND: Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC) is perceived to harbor significant morbidity but limited excess mortality, thought to be driven by colon cancer, compared with the general population. Recent studies suggest mortality rates seem higher than previously understood, and there are emerging threats to mortality. Clinicians must be up to date and able to clearly convey the causes of mortality to arm individual patients with information to meaningfully participate in decisions regarding IBD treatment and maintenance of health. METHODS: A MEDLINE search was conducted to capture all relevant articles. Keyword search included: "inflammatory bowel disease," "Crohn's disease," "ulcerative colitis," and "mortality." RESULTS: CD and UC have slightly different causes of mortality; however, malignancy and colorectal cancer-associated mortality remains controversial in IBD. CD mortality seems to be driven by gastrointestinal disease, infection, and respiratory diseases. UC mortality was primarily attributable to gastrointestinal disease and infection. Clostridium difficile infection is an emerging cause of mortality in IBD. UC and CD patients have a marked increase in risk of thromboembolic disease. With advances in medical and surgical interventions, the exploration of treatment-associated mortality must continue to be evaluated. CONCLUSIONS: Clinicians should be aware that conventional causes of death such as malignancy do not seem to be as significant a burden as originally perceived. However, emerging threats such as infection including C. difficile are noteworthy. Although CD and UC share similar causes of death, there seems to be some differences in cause-specific mortality.