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.

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.

Reduction in Contrast Nephropathy From Coronary Angiography and Percutaneous Coronary Intervention With Ultra-Low Contrast Delivery Using an Automated Contrast Injector System.

OBJECTIVE: To evaluate the incidence of contrast-induced nephropathy (CIN) following coronary angiography and percutaneous coronary intervention (PCI) utilizing a novel ultra-low contrast delivery (ULCD) technique. BACKGROUND: Current techniques for reducing contrast volumes during angiographic and PCI procedures require the use of advanced coronary imaging methods, such as intravascular ultrasound and coronary flow wires. We propose the use of an automated contrast injector system (ACIS) with a novel programming technique that significantly reduces contrast volumes and CIN development. METHODS: From 2013 to 2014, a total of 123 patients with stage III or higher chronic kidney disease (CKD) underwent coronary angiography, PCI, or a combined procedure using the ULCD technique. A retrospective analysis was conducted to evaluate contrast volumes and rate of CIN development. Patients developing CIN were compared using tests of proportions. RESULTS: The median contrast volume was 17.9 mL (n = 123). The study cohorts comprised diagnostic (15.2 mL; n = 72), PCI (17.1 mL; n = 30), and PCI + diagnostic groups (27.9 mL; n = 21). The incidence of CIN observed in the entire cohort through day 7 was 3.3% (4/123). Seventy-five percent of the CIN cases occurred following diagnostic angiography alone. Longitudinal follow-up at 21 days identified an additional 5 cases of CIN. Compared to literature data, the ULCD technique delivers less contrast per case. CONCLUSION: The adaptation of the ULCD technique for coronary procedures significantly reduces contrast volume delivery when compared with conventional practice or previously described low-contrast techniques. The ULCD appears to be an efficacious method of limiting CIN development in a susceptible population with CKD.

A rare large right atrial myxoma with rapid growth rate.

Atrial myxomas are the most common benign intracavitary cardiac neoplasms. They most frequently occur in the left atrium. Right atrial tumors are rare, comprising 20 percent of myxomas achieving an incidence of 0.02 percent. Due to their rarity, right atrial tumor development and associated clinical symptoms has not been well described. The classical clinical triad for the presentation of left atrial myxomas--heart failure, embolic events, and constitutional symptoms--may not be applicable to right sided tumors. Also, natural development of myxoma is not well described, as surgical resection is the common practice. Previously ascribed growth rates of myxomas refer mostly to left atrial ones, as right atrial tumors are rare. We present a case of right atrial myxoma with growth rates exceeding those previously described.

Stenting of the unprotected left main coronary artery in a nonagenarian presenting with recurrent non-ST elevation myocardial infarction.

Coronary artery disease (CAD) involving the left main (LM) artery has traditionally been considered an indication for coronary artery bypass surgery (CABG). With recent advances in the field of percutaneous coronary interventions (PCI), angioplasty and stenting of the unprotected' LM has been performed in patients at high surgical risk. This is a challenging intervention as a large area of myocardium is at risk during the procedure. Features that make it especially high risk are distal stenosis of this vessel and presence of coronary disease in other territories. Left ventricular assist devices need to be considered in these situations so as to minimize the risk involved. We present a case of a 90-year-old female with myocardial infarction who underwent complex angioplasty involving the distal LM and proximal left anterior descending (LAD) coronary artery, without left ventricular assist device or balloon pump support.