Trends in the Incidence of Cardiogenic Shock, and Utilization of Mechanical Circulatory Support in Myocarditis: Insights from the National Inpatient Sample 2016 to 2019.

A subset of patients with myocarditis present with cardiogenic shock. There is a lack of contemporary data assessing the use of mechanical circulatory support (MCS) in these patients. Myocarditis hospitalizations were analyzed using the National Inpatient Sample between 2016 and 2019. Characteristics of patients with and without cardiogenic shock were assessed. Trends in mortality, MCS, right-sided cardiac catheterization (RHC) and endomyocardial biopsy were evaluated. The impact of RHC on consequent MCS and mortality was studied. A total of 38,300 hospitalizations for myocarditis were included in the study, of which 3,490 hospitalizations (9.1%) had cardiogenic shock. Patients with cardiogenic shock were older (p <0.001) and had more chronic kidney disease and atrial fibrillation. Between 2016 and 2019, there was an increase in myocarditis admissions but no difference in rates of cardiogenic shock and mortality and the use of extracorporeal membrane oxygenation, percutaneous ventricular assist devices, intra-aortic balloon pumps, left ventricular assist devices, and cardiac transplant. The most common form of MCS used in myocarditis was extracorporeal membrane oxygenation. The rates of RHC (p = 0.02) and endomyocardial biopsy (p = 0.03) increased over time. Patients who underwent RHC were more likely to receive mechanical support, and in patients with shock, RHC was associated with lower mortality (adjusted odds ratio 0.34, p <0.01). Myocarditis admissions increased over time but with no increase in the rates of cardiogenic shock and MCS. In patients with cardiogenic shock, RHC resulted in lower mortality.

A mimicker of constriction: a case report of a rare case of cardiac angiosarcoma.

Background: Cardiac angiosarcoma is an exceptionally rare primary malignant tumour with an aggressive course and typically poor prognosis. Diagnosis is difficult, and patients often present with metastatic disease. We report the rare case of a patient with cardiac angiosarcoma who presents with constrictive physiology due to tumour encasement. Case summary: A 65-year-old female with a past medical history of Hodgkin's lymphoma and limited scleroderma presented with progressive dyspnoea on exertion. Multimodality imaging and haemodynamics with echocardiography, cardiac magnetic resonance imaging (MRI), and cardiac catheterization showed findings of constrictive physiology. Cardiac MRI showed areas of pericardial enhancement, so she was initially started on colchicine, prednisone, and mycophenolate mofetil to treat pericardial inflammation. However, her symptoms progressed, and she underwent pericardiectomy with cardiac surgery. Pericardium was noted to be thickened and a mass-like substance was densely adherent and potentially invading the heart itself and could not be dissected free. Surgical pathology showed features consistent with epithelioid angiosarcoma. Patient had rapid progression of her disease and was started on chemotherapy. Her course, however, was complicated by acute gastrointestinal bleeding, atrial fibrillation with rapid rates, and persistent volume overload. She elected for comfort measures and passed away shortly after her diagnosis. Discussion: Our case shows an extremely rare diagnosis, cardiac angiosarcoma, presenting with typical findings of constrictive physiology. The case shows the typical features of constrictive physiology using multimodality imaging and haemodynamics and emphasizes the need to always think broadly in creating a differential diagnosis for constriction to ensure that rare diseases are considered.

Thirty-Day Readmission Rates after Takotsubo Syndrome with or without Malignancy: A Nationwide Readmissions Database Analysis.

The association between malignancy and readmission after Takotsubo syndrome (TTS) hospitalization has not been fully described. We sought to examine the rates, cause, and cost of 30-day readmissions of TTS, with or without malignancy, by utilizing Nationwide Readmissions Databases from 2010 to 2014. We identified 61,588 index hospitalizations for TTS. TTS patients with malignancy tended to be older (70.6 ± 0.2 vs. 66.1 ± 0.1, p < 0.001), and the overall burden of comorbidities was higher than in those without malignancy. TTS patients with malignancy had significantly higher 30-day readmission rates than those without malignancy (15.9% vs. 11.0%; odds ratio (OR), 1.35; 95% confidence interval (CI), 1.18-1.56). Non-cardiac causes were the most common causes of readmission for TTS patients with malignancy versus without malignancy (75.5% vs. 68.1%, p < 0.001). The 30-day readmission rate due to recurrent TTS was very low in both groups (0.4% and 0.5%; p = 0.47). The total costs were higher by 25% (p < 0.001) in TTS patients with vs. without malignancy. In summary, among patients hospitalized with TTS, the presence of malignancy was associated with increased risk of 30-day readmission and increased costs. These findings highlight the importance of optimized management for TTS patients with malignancy.

Major aortopulmonary collateral arteries in a case of unrepaired tricuspid and pulmonary atresia with single ventricle physiology.

Tricuspid and pulmonary atresia with single ventricle physiology and major aortopulmonary collateral arteries (MAPCAs) is a complex cyanotic congenital heart disease with heterogeneous pulmonary artery morphology and arborization. The complex anatomy and physiology, coupled with a dearth of existing literature, pose imitable challenges to treatment. Although the exact surgical algorithm is still unclear, the goal is a well-developed, low-resistance pulmonary vascular bed. A precise understanding of the blood supply to each lung is a requisite for successful surgery, and a multimodality and multidisciplinary approach is compulsory. Herein, we describe a case of tricuspid and pulmonary atresia with single ventricle, MAPCAs and aortopulmonary collateral arteries.

Predictors of Late Mortality in D-Transposition of the Great Arteries After Atrial Switch Repair: Systematic Review and Meta-Analysis.

Background Existing data on predictors of late mortality and prevention of sudden cardiac death after atrial switch repair surgery for D-transposition of the great arteries (D-TGA) are heterogeneous and limited by statistical power. Methods and Results We conducted a systematic review and meta-analysis of 29 observational studies, comprising 5035 patients, that reported mortality after atrial switch repair with a minimum follow-up of 10 years. We also examined 4 additional studies comprising 105 patients who reported rates of implantable cardioverter-defibrillator therapy in this population. Average survival dropped to 65% at 40 years after atrial switch repair, with sudden cardiac death accounting for 45% of all reported deaths. Mortality was significantly lower in cohorts that were more recent and operated on younger patients. Patient-level risk factors for late mortality were history of supraventricular tachycardia (odds ratio [OR] 3.8, 95% CI 1.4-10.7), Mustard procedure compared with Senning (OR 2.9, 95% CI 1.9-4.5) and complex D-TGA compared with simple D-TGA (OR 4.4, 95% CI 2.2-8.8). Significant risk factors for sudden cardiac death were history of supraventricular tachycardia (OR 4.7, 95% CI 2.2-9.8), Mustard procedure (OR 2.2, 95% CI 1.1-4.1), and complex D-TGA (OR 5.7, 95% CI 1.8-18.0). Out of a total 124 implantable cardioverter-defibrillator discharges over 330 patient-years in patients with implantable cardioverter-defibrillators for primary prevention, only 8% were appropriate. Conclusions Patient-level risk of both mortality and sudden cardiac death after atrial switch repair are significantly increased by history of supraventricular tachycardia, Mustard procedure, and complex D-TGA. This knowledge may help refine current selection practices for primary prevention implantable cardioverter-defibrillator implantation, given disproportionately high rates of inappropriate discharges.

Myocarditis with tremelimumab plus durvalumab combination therapy for endometrial cancer: A case report.

BACKGROUND: Fulminant myocarditis has been reported in patients treated with immune checkpoint inhibitors. We present the first described case of acute immune-mediated myocarditis and myositis associated with durvalumab plus tremelimumab combination therapy. The patient was undergoing treatment for advanced endometrial cancer. CASE PRESENTATION: A 75-year-old Caucasian female presented with difficulty ambulating due to neck protraction, imbalance, and increased shortness of breath with exertion 3 weeks after her first durvalumab and tremelimumab administration for advanced endometrial cancer. While the patient's initial laboratory data showed an acute transaminitis and elevated creatine phosphokinase (CPK), consistent with myositis, she developed complete heart block and ventricular dysfunction, with elevated troponins. Endomyocardial biopsy confirmed a diagnosis of immune-mediated myocarditis. She was treated with high-dose steroids and mycophenolate mofetil, which led to eventual native conduction and left ventricular ejection fraction recovery. Upon discharge, she was titrated off of steroids over 8 weeks and her mycophenolate was subsequently stopped. A follow-up computed tomography scan revealed progression of metastatic disease. The patient remains alive using supplemental oxygen 3 months after admission. CONCLUSIONS: Durvalumab plus tremelimumab combination therapy can lead to fulminant immune-mediated myocarditis. This patient's myocarditis was amenable to treatment with high-dose intravenous steroids and mycophenolate.

Long-term Management of the Arterial Switch Patient.

PURPOSE OF REVIEW: This review paper describes the management of patients with dextro-transposition of the great arteries (D-TGA) with a focus on the complications seen and the appropriate care required to identify and prevent adverse events. RECENT FINDINGS: D-TGA is a form of cyanotic congenital heart disease (CHD) representing ~ 3% of all CHD and almost 20% of all cyanotic CHD. Since the late 1980s, standard of care is to repair these patients with an arterial switch operation (ASO) as opposed to a Mustard/Senning operation. The long-term survival and complication rates are superior in the ASO. Long-term follow-up is recommended for all D-TGA patients and includes management with adult congenital heart disease specialists and the use of echocardiography and advanced imaging with CT or MRI. The most common complications seen are pulmonary stenosis, coronary artery stenosis, and neo-aortic regurgitation. Careful evaluation of new symptoms or declining function is essential in preventing and treating these long-term sequelae.

Gender Differences in In-Hospital Outcomes After Coronary Artery Bypass Grafting.

Women historically have a greater risk of operative mortality than men after coronary artery bypass grafting (CABG). There is paucity of contemporary data in gender outcomes of surgical revascularization and understanding modifiable factors that contribute to gender differences are critical for quality improvement and practice change. We, therefore, sought to examine whether the gender gap in CABG outcomes is closing in the contemporary era by conducting a retrospective analysis from the Nationwide Inpatient Sample database from 2003 to 2012. We included all patients who underwent isolated CABG surgery (n = 2,272,998; female n = 623,423 [27.4%]; male n = 1,649,575 [72.6%]). The annual rate of CABG surgeries decreased by 53.7% in men and 57.8% in women over the 10-year study period. Although internal mammary artery use in women was less frequent than in men in 2003 (77.4% vs 81.9%, p <0.001), a significant uptrend closed this gap by 2012 (86.2% vs 87.0%, ptrend 0.003). Overall, unadjusted in-hospital mortality was greater in women (3.2% vs 1.8%, p <0.001). Female gender remained an independent predictor of mortality after multivariate adjustment (odds ratio 1.40, 95% CI 1.36 to 1.43, p <0.001) across all age groups. However, in-hospital mortality decreased at a faster rate in women (3.8% to 2.7%, RR -29.1%, ptrend 0.002) than in men (2.2% to 1.6%, RR -25.7%, ptrend <0.001) from 2003 to 2012. In conclusion, CABG rates in the United States are decreasing over time, yet in-hospital mortality continues to improve. Women have worse in-hospital outcomes than men; however, the gender gap is slowly closing.

Characteristics of Patients Undergoing Cardiac Catheterization Before Noncardiac Surgery: A Report From the National Cardiovascular Data Registry CathPCI Registry.

IMPORTANCE: Many patients undergo cardiac catheterization and/or percutaneous coronary intervention (PCI) before noncardiac surgery even though these procedures are not routinely indicated. Data on this cohort of patients are limited. OBJECTIVE: To describe the characteristics, angiographic findings, and treatment patterns of clinically stable patients undergoing cardiac catheterization and/or PCI before noncardiac surgery in a large national registry. DESIGN, SETTING, AND PARTICIPANTS: This study is a retrospective, descriptive analysis of National Cardiac Data Registry CathPCI Registry diagnostic catheterization and PCI data from July 1, 2009, through December 31, 2014. Data analysis was performed from April 21, 2015, to January 4, 2016. The study included 194 444 patients from 1046 sites who underwent coronary angiography before noncardiac surgery. Patients with acute coronary syndrome, cardiogenic shock, cardiac arrest, or emergency catheterization were excluded. MAIN OUTCOMES AND MEASURES: Demographic characteristics, preprocedure noninvasive testing results, angiographic findings, and treatment recommendations are summarized. Among the 27 838 patients who underwent PCI, procedural details, inpatient outcomes, and discharge medications are reported. RESULTS: Of the 194 444 included patients, 113 590 (58.4%) were male, the median age was 65 years (interquartile range, 57-73 years), and 162 532 (83.6%) were white. Most were overweight or obese (152 849 [78.6%]), and 78 847 (40.6%) had diabetes mellitus. Most patients were asymptomatic (117 821 [60.6%]), although 112 302 (57.8%) had been taking antianginal medications within 2 weeks of the procedure. Prior noninvasive stress testing was reported in 126 766 (65.2%), and results were positive in 109 458 (86.3%) of those with stress data. Obstructive disease was present in 93 447 (48.1%). After diagnostic angiography, revascularization with PCI or bypass surgery was recommended in 46 380 patients (23.8%) in the overall cohort, 27 191 asymptomatic patients (23.1%), and 45 083 patients with obstructive disease (48.3%). In the 27 191 patients undergoing PCI, 367 treated lesions (1.3%) were in the left main artery and 3831 (13.8%) in the proximal left anterior descending artery. A total of 11 366 patients (40.8%) received drug-eluting stents. Complications occurred in a few patients, with a catheterization-related mortality rate of 0.05%. CONCLUSIONS AND RELEVANCE: In the largest contemporary US cohort reported to date, most patients undergoing diagnostic catheterization before noncardiac surgery are asymptomatic. The discovery of obstructive coronary artery disease is common, and although randomized clinical trials have found no benefit in outcomes, revascularization is recommended in nearly half of these patients. The overall findings highlight management patterns in this population and the need for greater evidence-based guidelines and practices.

Impact of Chronic Statin Therapy on Postprocedural Contrast-Induced Nephropathy in Patients Undergoing Non-Emergent Percutaneous Coronary Intervention.

BACKGROUND: Following percutaneous coronary intervention (PCI), elevations in serum creatinine level and declines in glomerular filtration rate are common. Prior studies have demonstrated benefit of chronic statin therapy in the prevention of contrast-induced nephropathy (CIN); however, it is unknown whether chronic statin therapy reduces the incidence of CIN in the non-emergent PCI setting. METHODS: Using the 2004-2005 Cornell Angioplasty Registry, a total of 1171 consecutive patients were selected for analysis. The population was divided into two groups: (1) patients on chronic (≥30 days) statin therapy prior to PCI (n = 874); and (2) patients not on chronic statin therapy (n = 297). RESULTS: Patients taking chronic statin therapy were more likely to have diabetes mellitus (35.7% vs 22.6%; P<.001), previous myocardial infarction (36.3% vs 20.5%; P<.001), previous PCI (38.9% vs 16.2%; P<.001), and previous coronary artery bypass graft surgery (19.5% vs 11.4%; P=.01). Statin users were also more likely to be taking long-term aspirin (77.8% vs 59.6%; P<.001) and clopidogrel therapy (29.9% vs 14.1%; P<.001). Baseline serum creatinine levels were comparable between the two groups, as were procedural characteristics. The incidence of CIN following PCI was not significantly different between patients on chronic statin therapy versus those not on chronic statin therapy (4.2% vs 5.4%; P=.42). However, after multivariate adjustment, chronic statin therapy was associated with a lower incidence of CIN (odds ratio [OR], 0.21; 95% confidence interval [CI], 0.05-0.94; P=.04). Acute heart failure on admission and the urgency of the procedure (urgent vs elective PCI) were also independent predictors for developing CIN (OR, 3.04; 95% CI, 1.45-6.66 [P=.01] and OR, 2.80; 95% CI, 1.42-5.55 [P=.01], respectively). Long-term mortality rates were similar between those on chronic statin therapy and those not on statins. CONCLUSION: CIN occurred in 4.5% of patients following non-emergent PCI. Multivariate analysis demonstrated that chronic statin therapy decreased the odds of developing CIN in patients undergoing PCI.

Comparison of abciximab versus eptifibatide during percutaneous coronary intervention in ST-segment elevation myocardial infarction (from the HORIZONS-AMI trial).

There are limited safety and effectiveness data comparing glycoprotein IIb/IIIa inhibitors in the setting of primary percutaneous coronary intervention. In this substudy of the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, the clinical and bleeding outcomes of eptifibatide versus abciximab were evaluated in patients with ST-segment elevation myocardial infarction who underwent percutaneous coronary intervention. Three-year clinical outcomes of patients in the heparin plus glycoprotein IIb/IIIa inhibitor arm were compared according to treatment with abciximab (n = 907) versus eptifibatide (n = 803). Adjudicated end points included major adverse cardiovascular events (MACEs; mortality, reinfarction, ischemia-driven target vessel revascularization, or stroke), major bleeding, and net adverse clinical events (MACEs or major bleeding). Propensity score matching was used to identify 1,342 matched cases (671 each in the abciximab and eptifibatide groups). Multivariate analysis was performed in the entire cohort and the propensity-matched groups. At 3-year follow-up, eptifibatide and abciximab resulted in nonsignificantly different rates of MACEs (18.3% vs 19.6%, hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.74 to 1.16, p = 0.51), major bleeding (10.7% vs 11.9%, HR 0.90, 95% CI 0.67 to 1.19, p = 0.44), and net adverse clinical events (24.5% vs 25.5%, HR 0.96, 95% CI 0.79 to 1.17, p = 0.69). Similarly, at 3 years by multivariate analysis, there was no statistically significant difference between abciximab and eptifibatide for net adverse clinical events (HR 0.89, 95% CI 0.73 to 1.09, p = 0.27), MACEs (HR 0.96, 95% CI 0.77 to 1.20, p = 0.73), and major bleeding (HR 1.05, 95% CI 0.78 to 1.41, p = 0.75). The propensity-matched groups also had similar outcomes. In conclusion, abciximab and eptifibatide have comparable bleeding risks and clinical efficacy in primary percutaneous coronary intervention.

Future horizons for catheter-based interventions in adult congenital and structural heart disease.

In recent decades, there has been an exponential growth in both the number and range of catheter-based interventions for adult congenital and structural heart disease. In this article, we discuss the rationale for the ongoing development of minimally invasive multidisciplinary interventions; the required training elements necessary to achieve expertise in the field; the cardiac team needed to best perform these interventions; and the currently available and up and coming technologies for performing transcatheter valve therapies.

Relation of clinical success in coronary brachytherapy to dose.

Intravascular brachytherapy is the primary treatment for coronary in-stent restenosis. Variations in dose in the treated artery may represent a potential cause of treatment failure. We compared dose distributions in patients who had developed recurrent restenosis (treatment failure) with those in patients who remained event free at 9 months (treatment success). We followed 140 patients who were receiving brachytherapy for in-stent restenosis with 4 radiation delivery devices to identify treatment failures and successes. Through a nested case-control construct, treatment failures (n = 14) were compared 1:2 with treatment successes (n = 28) matched by radiation delivery system and in-stent restenosis lesion pattern. The dose absorbed by 90% of the artery encompassed by the external elastic membrane (D(90)EEM) was calculated by applying intravascular ultrasound at 2-mm intervals along the treated lesion. Dose calculations were performed using dose kernel integration techniques generated from Monte Carlo simulations. The mean minimum D(90)EEM in treatment failures was 7.46 +/- 1.98 Gy, and that in treatment successes was 8.87 +/- 1.13 Gy (p = 0.007). Using a minimum dose threshold of 8.4 Gy, a minimum D(90)EEM

Brachytherapy for in-stent restenosis in general interventional practice: a single institution's experience using four radiation devices.

BACKGROUND: The effectiveness of brachytherapy for the treatment of in-stent restenosis (ISR) has been established in a number of large randomized controlled trials. Efficacy of this therapy in general population is less well established. METHODS AND MATERIALS: We report our experience of 207 patients, 236 coronary lesions, treated with brachytherapy between November 2000 and November 2002. All commercially available brachytherapy devices, as well as one investigational device, were utilized. This cohort was followed over 9 months and clinical outcomes were obtained with subsequent analysis of patient and lesion-specific characteristics. RESULTS: Average treatment age was 62.5 years; 73% were male and the most frequent presentation was unstable angina (74%). All patients had successful delivery of radiation, with no in-hospital deaths. Novoste BetaCath device was used for 163 (65%) lesions, Cordis Checkmate for 56 (24%) lesions, Interventional Therapies device in 13 (8%) lesions, and Guidant Galileo in 4 lesions (3%). At a mean follow-up of 9.1 months, 78.7% were free of major adverse cardiac event (MACE). Twenty-one patients required repeat PTCA (10.1%), 19 had CABG (9.2%), 3 had MI (1.4%), and there was 1 death (0.5%). Unadjusted MACE rates for each device were 21% for Novoste, 28% for Checkmate, 8% for Interventional Therapies, and 50% for Galileo. Lesion length, minimal lumen diameter, renal failure, diabetes, and smoking did not predict treatment failure; only age was inversely correlated with MACE (P=.002). CONCLUSION: When applied across a spectrum of patients, lesions, and devices, brachytherapy retains its effectiveness with outcomes similar to those reported in randomized clinical trials.

Midterm follow-up of penetrating ulcer and intramural hematoma of the aorta.

OBJECTIVE: Most studies on variant forms of aortic dissection--penetrating ulcer and intramural hematoma--have focused on the initial presenting episode, with scant follow-up. This investigation provides midterm follow-up of penetrating ulcer and intramural hematoma to determine whether the aorta shows healing according to radiography, goes on to dilate, or tends to rupture during later follow-up. METHODS: Forty-five patients with penetrating ulcers (n = 26) or intramural hematomas (n = 19) were treated at our institution. Ten patients with penetrating ulcers were male and 16 were female, and their ages ranged from 54 to 87 years (mean 72 years). Eight patients with intramural hematomas were male and 11 were female, and their ages ranged from 54 to 88 years (mean 74 years). These patients all had symptoms of aortic disease. Patients with incidental imaging findings were not considered. RESULTS: In the group with penetrating ulcers, rupture occurred during the initial admission in 10 (38%) cases, 17 patients (65%) underwent surgery, and 22 patients (85%) survived to hospital discharge. Among those with intramural hematomas, rupture occurred during the initial admission in 5 cases (26%), 7 patients (37%) underwent surgery, and 16 patients (84%) survived to hospital discharge. Follow-up ranged from 1 month to 12.5 years (mean 3.4 years). No ischemic vascular complications occurred. Imaging follow-up was available for 26 of the 45 patients. Of these, 19% of lesions showed resolution, 23% had worsened, 39% had progressed to typical dissection, and 19% were unchanged. Six late deaths were known to be caused by rupture. In the group with penetrating ulcers, aortic diameter increased from 4.8 to 5.1 cm during the course of 14 months. In the group with intramural hematomas, aortic diameter increased from 5.3 to 5.9 cm during the course of 21 months. Overall survivals were 80% at 1 year, 73% at 3 years, and 66% at 5 years. CONCLUSIONS: Intramural hematoma and penetrating ulcer are lesions associated with advanced age. Women predominate. Penetrating ulcer and intramural hematoma rupture both early and late. Radiographically documented worsening, improvement, or frank dissection may occur with time. Aortic growth does occur (0.2 cm per year for penetrating ulcer and 0.4 cm per year for intramural hematoma). Vascular ischemic complications do not occur. Because of the high early rupture rate, the frequency of radiographic worsening, and the documented occurrence of late rupture, we now recommend surgical replacement of the aorta for these virulent vascular lesions as long as the patient's comorbidities do not preclude surgical intervention.