Elective percutaneous coronary intervention performed during contrast-induced hypotension.

OBJECTIVES: To demonstrate the feasibility and safety of performing elective percutaneous coronary intervention (PCI) during contrast reaction producing severe hypotension. BACKGROUND: The development of profound hypotension due to a contrast reaction requires emergency treatment and usually signals procedure termination. METHODS AND RESULTS: We report successful completion of planned PCI with blood pressure support with vasopressors during contrast-induced hypotension in nine procedures in three patients with previously known contrast reaction causing hypotension. CONCLUSIONS: This case series provides support for the feasibility and safety of performing successful planned PCI under blood pressure support in patients with contrast reaction causing severe hypotension. A management approach for considering intervention in the setting of contrast-induced hypotension is provided.

Gender Differences and Outcomes of Hypoattenuated Leaflet Thickening (HALT) Following Transcatheter Aortic Valve Replacement: A Meta-analysis of Randomized and Cohort Studies.

Subclinical leaflet thrombosis is characterized by hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR) on computed tomography. However, given the low incidence of HALT after TAVR, the clinical significance of HALT is still being investigated. We sought to generate a more reliable estimate of the risk factors and adverse outcomes associated with HALT after TAVR by pooling data from randomized trials and cohort studies. PubMed/Medline database was systematically searched from inception until November 24, 2021, using the following terms: ("hypoattenuated leaflet thickening" and "transcatheter aortic valve replacement") and ("Subclinical leaflet thrombosis" and "transcatheter aortic valve replacement"). A random effects model meta-analysis was conducted using Mantel-Haenszel odds ratios (ORs) and the associated 95% confidence intervals (CIs), mean difference and the associated 95%. Ten studies with a total of 1462 patients were included, with follow-up ranging between 4 months and 3 years. HALT occurred in 14.4% of the patients undergoing TAVR. HALT was not associated with increased risk of stroke/TIA (OR 1.38; 95% CI [0.61-3.11]; I2=0%) or increased risk of all-cause mortality (OR 0.67; 95% CI [0.25-1.80]; I2=0). HALT was associated with a greater post-procedural mean aortic valve gradient (mean difference 2.31 mmHg; 95% CI [0.27, 4.35]; I2=71%). Interestingly, there was a trend of higher risk of HALT in men (OR 1.37; 95% CI [0.82-2.30]; I2=44%) while there was a trend towards lower risk of HALT in the presence of CKD (OR 0.76; 95% CI [0.49-1.19]; I2=0%); these trends did not reach statistical significance. This meta-analysis shows that the occurrence of HALT following TAVR is associated with a greater post-procedural mean aortic valve gradient but no excess risk of death or cerebrovascular events. The clinical significance of this higher post-procedural mean aortic valve gradient is uncertain and requires further investigations.

A Unique Case of STEMI STEALing the Flow.

We report a case of a 55-year-old woman with previous coronary artery bypass grafting. She presented with acute ST-segment elevation myocardial infarction secondary to occlusion of the proximal left subclavian artery causing reduced flow in the left internal mammary artery to left anterior descending artery graft. (Level of Difficulty: Intermediate.).

Predictors, burden and impact of cardiac arrhythmias among patients hospitalized with end-stage liver disease.

BACKGROUND: Cirrhotic cardiomyopathy, hyperammonemia, and hepatorenal syndrome predispose to cardiac arrhythmias in End-stage liver disease (ESLD). OBJECTIVES: Among ESLD hospitalizations, we evaluate the distribution and predictors of arrhythmias and their impact on hospitalization outcomes. METHODS: We selected ESLD records from the Nationwide Inpatient Sample (2007-2014), identified concomitant arrhythmias (tachyarrhythmias and bradyarrhythmias), and their demographic and comorbid characteristics, and estimated the effect of arrhythmia on outcomes (SAS 9.4). RESULTS: Of 57,119 ESLD hospitalizations, 6,615 had arrhythmias with higher odds with increasing age, males, jaundice, hepatorenal syndrome, alcohol use, and cardiopulmonary disorders. The most common arrhythmias were atrial fibrillation, cardiac arrest/asystole, and ventricular tachycardia. After propensity-matching (arrhythmia: no-arrhythmia, 6,609:6,609), arrhythmias were associated with 200% higher mortality, 1.7-days longer stay, $32,880 higher cost, and higher rates of shock, respiratory and kidney failures. CONCLUSIONS: Due to worse outcomes with arrhythmias, there is a need for better screening and follow-up of ESLD patients for dysrhythmias.

Spontaneous coronary artery dissection: An often unrecognized cause of acute coronary syndrome.

Spontaneous coronary artery dissection (SCAD), an intramural hemorrhage leading to a separation of the layers of the coronary artery wall, is traditionally considered a rare condition associated mainly with pregnancy but is likely underdiagnosed in other settings. Its recognition by coronary angiography is key. Medical management is usually indicated, except in certain circumstances in which coronary artery bypass grafting or percutaneous coronary intervention should be considered.

From Tick Bite to Heart Failure: Ehrlichial Myocarditis.

Cardiac involvement in myocarditis induced by Human Monocytic Ehrlichiosis infection is an incredibly uncommon complication with sparsely available literature. Also, this case highlights the importance of early recognition as a first step in management.

Une atteinte cardiaque secondaire à une myocardite induite par une ehrlichiose monocytaire humaine constitue une complication extrêmement rare et très peu documentée. Le cas présenté fait ressortir l'importance d'une reconnaissance rapide du problème comme première étape de la prise en charge.

Association of Albuminuria With Major Adverse Outcomes in Adults With Congenital Heart Disease: Results From the Boston Adult Congenital Heart Biobank.

Importance: Albuminuria is associated with adverse outcomes in diverse groups of patients, but the importance of albuminuria in the emerging population of increasingly complex adults with congenital heart disease (ACHD) remains unknown. Objective: To assess the prevalence, risk factors, and prognostic implications of albuminuria in ACHD. Design, Setting, and Participants: This prospective study assessed a cohort of ambulatory patients aged 18 years and older who were examined at an ACHD referral center and enrolled in the Boston ACHD Biobank between May 17, 2012, to August 5, 2016. Albuminuria was defined as an urine albumin-to-creatinine (ACR) ratio of 30 mg/g or more. Main Outcomes and Measures: Death or nonelective cardiovascular hospitalization, defined as overnight admission for heart failure, arrhythmia, thromboembolic events, cerebral hemorrhage, and/or disease-specific events. Results: We measured the ACR of 612 adult patients with CHD (mean [SD] age, 38.6 [13.4] years; 308 [50.3%] women). Albuminuria was present in 106 people (17.3%) and was associated with older age (patients with ACR <30 mg/g: mean [SD]: 37.5 [13.2] years; vs patients with ACR ≥30 mg/g: 43.8 [13.1] years; P < .001), presence of diabetes mellitus (ACR <30 mg/g: 13 of 506 [2.6%]; vs ≥30 mg/g: 11 of 106 [10.4%]; P < .001), lower estimated glomerular filtration rate (ACR <30 mg/g: median [interquartile range (IQR)]: 103.3 [90.0-116.4] mL/min/1.73 m2; ACR ≥30 mg/g: 99.1 [78.8-108.7] mL/min/1.73 m2; P = .002), and cyanosis (ACR <30 mg/g: 23 of 506 [5.1%]; vs ACR ≥30 mg/g: 21 of 106 [22.6%]; P < .001). After a mean (SD) follow-up time of 270 (288) days, 17 patients (2.5%) died, while 68 (11.1%) either died or experienced overnight inpatient admission. Albuminuria predicted outcome, with 30 of 106 patients with albuminuria (28.3%) affected vs 38 of 506 patients without albuminuria (7.5%; hazard ratio [HR], 3.0; 95% CI, 1.9-4.9; P < .001). Albuminuria was also associated with increased mortality (11 of 106 [10.4%]; vs 6 of 506 [1.2%] in patients with and without albuminuria, respectively; HR, 6.4; 95% CI, 2.4-17.3; P < .001). Albuminuria was associated with the outcomes only in patients with a biventricular circulation (HR, 4.5; 95% CI, 2.5-8.0) and not those with single-ventricle circulation (HR, 1.0; 95% CI, 0.4-2.8; P = 0.01 compared with biventricular circulation group). Among 133 patients (21.7%) in NYHA functional class 2, albuminuria was strongly associated with death or nonelective hospitalization. Conclusions and Relevance: Albuminuria is common and is associated with increased risk for adverse outcome in patients with ACHD with biventricular circulation. Albuminuria appears especially useful in stratifying risk in patients categorized as NYHA functional class 2.