Mechanical circulatory support versus vasopressors alone in patients with acute myocardial infarction and cardiogenic shock undergoing percutaneous coronary intervention.

BACKGROUND: Previous studies have compared Impella use to intra-aortic balloon pump (IABP) use in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI). Our objective was to compare clinical outcomes in patients with AMI-CS undergoing PCI who received Impella (percutaneous left ventricular assist device) without vasopressors, IABP without vasopressors, and vasopressors without mechanical circulatory support (MCS). METHODS: We queried the National Inpatient Sample (NIS) using ICD-10 codes (2015-2018) to identify patients with AMI-CS undergoing PCI. We created three propensity-matched cohorts to examine clinical outcomes in patients receiving Impella versus IABP, Impella versus vasopressors without MCS, and IABP versus vasopressors without MCS. RESULTS: Among 17,762 patients, Impella use was associated with significantly higher in-hospital major bleeding (31.4% vs. 13.6%; p < 0.001) and hospital charges (p < 0.001) compared to IABP use, with no benefit in mortality (34.1% vs. 26.9%; p = 0.06). Impella use was associated with significantly higher mortality (42.3% vs. 35.7%; p = 0.02), major bleeding (33.9% vs. 22.7%; p = 0.001), and hospital charges (p < 0.001), when compared to the use of vasopressors without MCS. There were no significant differences in clinical outcomes between IABP use and the use of vasopressor without MCS. CONCLUSIONS: In this analysis of retrospective data of patients with AMI-CS undergoing PCI, Impella use was associated with higher mortality, major bleeding, and in-hospital charges when compared to vasopressor therapy without MCS. When compared to IABP use, Impella was associated with no mortality benefit, along with higher major bleeding events and in-hospital charges. A vasopressor-only strategy suggested no difference in clinical outcomes when compared to IABP. This study uses the NIS for the first time to highlight outcomes in AMI-CS patients undergoing PCI when treated with vasopressor support without MCS, compared to Impella and IABP use.

Reclassification of Treatment Strategy with Fractional Flow Reserve in Cancer Patients with Coronary Artery Disease.

Background and Objectives: Cancer and coronary artery disease (CAD) often coexist. Compared to quantitative coronary angiography (QCA), fractional flow reserve (FFR) has emerged as a more reliable method of identifying significant coronary stenoses. We aimed to assess the specific management, safety and outcomes of FFR-guided percutaneous coronary intervention (PCI) in cancer patients with stable CAD. Materials and Methods: FFR was used to assess cancer patients that underwent coronary angiography for stable CAD between September 2008 and May 2016, and were found to have ≥50% stenosis by QCA. Patients with lesions with an FFR > 0.75 received medical therapy alone, while those with FFR ≤ 0.75 were revascularized. Procedure-related complications, all-cause mortality, nonfatal myocardial infarction, or urgent revascularizations were analyzed. Results: Fifty-seven patients with stable CAD underwent FFR on 57 lesions. Out of 31 patients with ≥70% stenosis as measured by QCA, 14 (45.1%) had an FFR ≥ 0.75 and lesions were reclassified as moderate and did not receive PCI nor DAPT. Out of 26 patients with <70% stenosis as measured by QCA, 6 (23%) had an FFR < 0.75 and were reclassified as severe and were treated with PCI and associated DAPT. No periprocedural complications, urgent revascularization, acute coronary syndromes, or cardiovascular deaths were noted. There was a 22.8% mortality at 1 year, all cancer related. Patients who received a stent by FFR assessment showed a significant association with decreased risk of all-cause death (HR: 0.37, 95% CI 0.15−0.90, p = 0.03). Conclusions: Further studies are needed to define the optimal therapeutic approach for cancer patients with CAD. Using an FFR cut-off point of 0.75 to guide PCI translates into fewer interventions and can facilitate cancer care. There was an overall reduction in mortality in patients that received a stent, suggesting increased resilience to cancer therapy and progression.

Electromagnetic interference from left ventricular assist device in patients with transvenous implantable cardioverter-defibrillator.

BACKGROUND: Many advanced heart failure patients have both a left ventricular assist device (LVAD) and an implantable cardioverter-defibrillator (ICD). This study examines incidence, clinical impact, and management of LVAD-related EMI. METHODS: We performed a three-center retrospective analysis of transvenous ICD implanted patients with LVAD implanted between January 1, 2005 and December 31, 2020. The primary outcome was EMI after LVAD implantation, categorized as LVAD-related noise or telemetry interference. RESULTS: The rate of LVAD-related EMI among the 737 patients (mean age 58.6 ± 12.8 years) studied was 5.0%. Telemetry interference (1.5%) compromised ICD interrogation in all patients. This was resolved successfully with use of a metal shield, encased wand, radiofrequency tower, different ICD programmer or by increasing distance between ICD programmer and LVAD (n = 6). ICD replacement was required to reestablish successful communication in three patients. LVAD-related noise (3.5%) led to oversensing (n = 4), inappropriate mode switches (n = 4), noise reversion (n = 3), inhibition of pacing (n = 2), inappropriate detection as atrial fibrillation (AF) (n = 2) and inappropriate detection as ventricular tachycardia (VT) and/or ventricular fibrillation (VF) (n = 2). This noise interference persisted (n = 3), resolved spontaneously (n = 16), resolved with programming change (n = 6) or required lead revision (n = 1). CONCLUSIONS: EMI from LVAD impacts ICD function, although, the incidence rate is low. Physicians implanting both, LVAD in patients with ICD (more common) or ICD in patients with LVAD, should be aware of possible interferences. Telemetry failure not resolved by metal shielding was overcome by ICD generator replacement to a different manufacturer. In most cases, LVAD-related noise resolves spontaneously.

Subcutaneous implantable cardioverter-defibrillator noise following left ventricular assist device implantation.

Background: The incidence and impact of noise in a subcutaneous implantable cardioverter defibrillator (S-ICD) after left ventricular assist device (LVAD) implantation is not well established. Methods: We performed a retrospective study of patients implanted with LVAD and with a pre-existing S-ICD between January 2005 and December 2020 at the three Mayo Clinic centers (Minnesota, Arizona, and Florida). Results: Of the 908 LVAD patients, a pre-existing S-ICD was present in 9 patients (mean age 49.1 ± 13.7 years, 66.7% males), 100% with Boston Scientific third-generation EMBLEM MRI S-ICD, 11% with HeartMate II (HM II), 44% with HeartMate 3 (HM 3), and 44% with HeartWare (HW) LVAD. The incidence of noise from LVAD-related electromagnetic interference (EMI) was 33% and was only seen with HM 3 LVAD. Multiple measures attempted to resolve noise, including using alternative S-ICD sensing vector, adjusting S-ICD time zone, and increasing LVAD pump speed, were unsuccessful, necessitating S-ICD device therapies to be turned off permanently. Conclusions: The incidence of LVAD-related S-ICD noise is high in patients with concomitant LVAD and S-ICD with significant impact on device function. As conservative management failed to resolve the EMI, the S-ICDs had to be programmed off to avoid inappropriate shocks. This study highlights the importance of awareness of LVAD-SICD device interference and the need to improve S-ICD detection algorithms to eliminate noise.

Abiotrophia defectiva endocarditis of bicuspid aortic valve: a case report.

Background: Patients with a bicuspid aortic valve have increased risk of infective endocarditis, but common organisms are not always the culprit. We describe a case of an otherwise healthy young gentleman with bicuspid aortic valve who experienced Abiotrophia defectiva endocarditis. The aim of this case report is to highlight an uncommon cause of endocarditis associated with significant morbidity and mortality in order to improve the care provided by trainees and clinicians. Case summary: A 37-year-old male presented with a 1-month history of fever, weight loss, myalgia, and night sweats. On transoesophageal echocardiography, he was found to have a bicuspid aortic valve with large vegetation and severe aortic insufficiency. Blood cultures were positive for A. defectiva. The endocarditis was successfully treated with surgical aortic valve replacement and 6 weeks of antibiotic therapy. Discussion: Bicuspid valves are known to have increased susceptibility to endocarditis. The difficulty of isolating A. defectiva typically leads to delayed diagnosis and significant complications. This case is a reminder to have a high degree of suspicion for organisms which are rare and difficult to isolate because prompt recognition and surgical intervention may improve the outcome of care.

Transcatheter Mitral Valve Implantation In Patients With Chronic Kidney Disease.

There is a paucity of data regarding the outcomes of trans-septal transcatheter mitral valve implantation (TS-TMVI) in patients with chronic kidney disease (CKD). We queried the Nationwide Readmissions Database (2015 to 2018) for patients undergoing TS-TMVI. We identified patients with CKD (Stage III or higher). We conducted propensity score matching analysis to compare the outcomes in patients with CKD versus patients without CKD. The main outcomes were in-hospital mortality and 30-day nonelective readmissions. From 2015 to 2018, there were 2,017 admissions for patients receiving TS-TMVI, of whom 733 (36.34%) had CKD. In the CKD group, 76 (10.4%) required chronic dialysis. During the study years, the number of TS-TMVI procedures increased in patients with CKD (ptrend <0.001). Patients with CKD were older and less likely to be women. There was no difference in in-hospital mortality in those with versus without CKD in the matched cohorts (7.8% vs 7.3%; odds ratio 1.09; 95% confidence interval 0.64 to 1.80). Subgroup analysis showed no interaction between chronic dialysis status and in-hospital mortality after TS-TMVI. In the matched cohort, TS-TMVI in those with CKD was associated with higher rates of cardiogenic shock (12.3% vs 7.6%, p = 0.03), acute kidney injury (35.7% vs 16.7%, p <0.001), hemodialysis (5.4% vs 1.5%, p = 0.01) and longer median length of stay, (7 [12] vs 5 [8] days, p <0.001). Patients with CKD were more likely to have 30-day nonelective readmission (25.8% vs 16.5%, p = 0.01), driven by more readmissions for bleeding/anemia. In conclusion, TS-TMVI in patients with CKD is associated with increased risk for cardiogenic shock, worsening renal function requiring hemodialysis, without increased risk of mortality when compared with patients without CKD. Also, there was a higher length of stay and 30-day readmission rate in patients with CKD versus patients without CKD.

Anterior-Posterior versus anterior-lateral electrodes position for electrical cardioversion of atrial fibrillation: A meta-analysis of randomized controlled trials.

Background: The optimal electrodes position for elective direct current (DC) cardioversion of patients with atrial fibrillation (AF) remains uncertain. Methods: An electronic search of MEDLINE, EMBASE and COCHRANE databases was performed through March 2022 for randomized trials that examined the outcomes of anterior-posterior (AP) versus anterior-lateral (AL) electrodes position during cardioversion of (AF). The main outcome was the success rate of cardioversion. Data were pooled using random effects model. Results: The final analysis included 10 RCTs with a total of 1677 patients. There was no difference in the rate of successful cardioversion between the AP versus AL groups (86.6 vs 87.9 %; RR 1.00; 95 % Confidence Interval (CI) 0.95 to 1.06). Subgroup analysis by the shock waveform showed no significant interaction between monophasic and biphasic waveforms (Pintercation = 0.23). meta-regression analyses showed no effect modification of primary outcome according to body mass index (p = 0.15), left atrial diameter (p = 0.64), valvular heart disease (p = 0.34), lone AF (p = 0.58), or the duration of AF (p = 0.70). There was no significant difference between the AP and AL electrode position groups in successful cardioversion at low energy (RR 0.94; 95 % CI 0.74 to 1.19), the number of the delivered shocks (standardized mean difference [SMD] -0.03; 95 % CI -0.32 to 0.26) or the mean energy of the delivered shocks (SMD -0.11 and 95 % CI -0.30 to 0.07). There was lower transthoracic impedance with AP versus AL electrode position (SMD -0.28; 95 %CI -0.47 to -0.10). Conclusion: Meta-analysis of randomized data showed no difference between AP and AL electrode positions in the success rate of DC cardioversion of AF. Either AP or AL electrode positions should be acceptable approaches for elective DC cardioversion of patients with AF.

Incremental prognostic value of spect over CCTA.

BACKGROUND: Coronary computed tomographic angiography (CCTA) and Single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) provide comprehensive anatomic and functional assessment of the coronary arteries useful in the diagnosis and prognosis of patients with coronary artery disease (CAD). We aimed to assess the incremental prognostic role of SPECT physiologic assessment to CCTA in patients with suspected CAD. METHODS: Consecutive patients with suspected CAD undergoing clinically indicated CCTA within 180 days of undergoing SPECT were included. Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting 90-days after imaging test.) RESULTS: The cohort consisted of 956 patients (mean age 61.1 ± 14.2 years, 54% men, 89% hypertension, 81% diabetes, 84% dyslipidemia). Obstructive stenosis was found in 14% of patients, while scar (fixed perfusion defect), ischemia and left ventricular ejection fraction <40% were found in 17, 14 and 9% of patients, respectively. In nested multivariable cox regression models, perfusion and left ventricular function when added to a model with CCTA obstructive stenosis significantly improved model risk prediction (Harrell's C = 0.73, p = 0.037) and risk reclassification on a continuous scale (P < 0.001). CONCLUSION: We have shown that a combined assessment of perfusion burden and left ventricular function added incremental value over and above a CCTA based anatomic assessment in patients with suspected CAD.

Artificial intelligence-augmented analysis of contemporary procedural, mortality, and cost trends in carcinoid heart disease in a large national cohort with a focus on the "forgotten pulmonic valve".

Background: Carcinoid heart disease is increasingly recognized and challenging to manage due to limited outcomes data. This is the largest known cohort study of valvular pathology, treatment (including pulmonary and tricuspid valve replacements [PVR and TVR]), dispairties, mortality, and cost in patients with malignant carcinoid tumor (MCT). Methods: Machine learning-augmented propensity score-adjusted multivariable regression was conducted for clincal outcomes in the 2016-2018 U.S. National Inpatient Sample (NIS). Regression models were weighted by the complex survey design and adjusted for known confounders and the likelihood of undergoing valvular procedures. Results: Among 101,521,656 hospitalizations, 55,910 (0.06%) had MCT. Patients with MCT vs. those without had significantly higher inpatient mortality (2.93 vs. 2.04%, p = 0.002), longer mean length of stay (12.20 vs. 4.62, p < 0.001), and increased mean total cost of stay ($70,252.18 vs. 51,092.01, p < 0.001). There was a step-wise increased rate of TVR and PVR with each subsequent year, with significantly more TV (0.16% vs. 0.01, p < 0.001) and PV (0.03 vs. 0.00, p = 0.040) diagnosed with vs. without MCT for 2016, with comparable trends in 2017 and 2018. There were no significant procedural disparities among patients with MCT for sex, race, income, urban density, or geographic region, except in 2017, when the highest prevalence of PV procedures were performed in the Western North at 50.00% (p = 0.034). In machine learning and propensity score augmented multivariable regression, MCT did not significantly increase the likelihood of TVR or PVR. In sub-group analysis restricted to MCT, neither TVR nor PVR significantly increased mortality, though it did increase cost (respectively, $141,082.30, p = 0.015; $355,356.40, p = 0.012). Conclusion: This analysis reflects a favorable trend in recognizing the need for TVR and PVR in patients with MCT, with associated increased cost but not mortality. Our study also suggests that pulmonic valve pathology is increasingly recognized in MCT as reflected by the upward trend in PVRs. Further research and updated societal guidelines may need to focus on the "forgotten pulmonic valve" to improve outcomes and disparities in this understudied patient population.

The Effects of Warfarin and Direct Oral Anticoagulants on Systemic Vascular Calcification: A Review.

Warfarin has been utilized for decades as an effective anticoagulant in patients with a history of strong risk factors for venous thromboembolism (VTE). Established adverse effects include bleeding, skin necrosis, teratogenicity during pregnancy, cholesterol embolization, and nephropathy. One of the lesser-known long-term side effects of warfarin is an increase in systemic arterial calcification. This is significant due to the association between vascular calcification and cardiovascular morbidity and mortality. Direct oral anticoagulants (DOACs) have gained prominence in recent years, as they require less frequent monitoring and have a superior side effect profile to warfarin, specifically in relation to major bleeding. The cost and lack of data for DOACs in some disease processes have precluded universal use. Within the last four years, retrospective cohort studies, observational studies, and randomized trials have shown, through different imaging modalities, that multiple DOACs are associated with slower progression of vascular calcification than warfarin. This review highlights the pathophysiology and mechanisms behind vascular calcification due to warfarin and compares the effect of warfarin and DOACs on systemic vasculature.

Noninvasive Imaging for Patients with COVID-19 and Acute Chest Pain.

Acute chest pain is a common presentation in patients with COVID-19. Although noninvasive cardiac imaging modalities continue to be important cornerstones of management, the pandemic has brought forth difficult and unprecedented challenges in the provision of timely care while ensuring the safety of patients and providers. Clinical practice has adapted to these challenges, with several recommendations and societal guidelines emerging on the appropriate use of imaging modalities. In this review, we summarize the current evidence base on the use of noninvasive cardiac imaging modalities in COVID-19 patients with acute chest pain, with a focus on acute coronary syndromes.

Stress cardiomyopathy in hospitalized patients with cancer: machine learning analysis by primary malignancy type.

AIMS: Previous studies have shown that patients with stress (Takotsubo) cardiomyopathy (SC) and cancer have higher in-hospital mortality than patients with SC alone. No studies have examined outcomes in patients with active cancer and SC compared to patients with active cancer without SC. We aimed to assess the potential association between primary malignancy type and SC and their shared interaction with inpatient mortality. METHODS AND RESULTS: We analysed SC by primary malignancy type with propensity score adjusted multivariable regression and machine learning analysis using the 2016 United States National Inpatient Sample. Of 30 195 722 adult hospitalized patients, 4 719 591 had active cancer, of whom 568 239 had SC. The mean age of patients with cancer and SC was 69.1, of which 74.7% were women. Among patients with cancer, those with SC were more likely to be female and have white race, Medicare insurance, hypertension, heart failure with reduced ejection fraction, obesity, cerebrovascular disease, anaemia, and chronic obstructive pulmonary disease (P < 0.003 for all). In machine learning-augmented, propensity score multivariable regression adjusted for age, race, and income, only lung cancer [OR 1.25; 95% CI: 1.08-1.46; P = 0.003] and breast cancer [OR 1.81; 95% CI: 1.62-2.02; P < 0.001] were associated with a significantly increased likelihood of SC. Neither SC alone nor having both SC and cancer was significantly associated with in-hospital mortality. The presence of concomitant SC and breast cancer was significantly associated with reduced mortality (OR 0.48; 95% CI: 0.25-0.94; P = 0.032). CONCLUSIONS: This analysis demonstrates that primary malignancy type influences the likelihood of developing SC. Further studies will be necessary to delineate characteristics in patients with lung cancer and breast cancer which contribute to development of SC. Additional investigation should confirm lower mortality in patients with SC and breast cancer and determine possible explanations and protective factors.

Percutaneous Coronary Intervention in Patients With Gynecological Cancer: Machine Learning-Augmented Propensity Score Mortality and Cost Analysis for 383,760 Patients.

BACKGROUND: Despite the growing number of patients with both coronary artery disease and gynecological cancer, there are no nationally representative studies of mortality and cost effectiveness for percutaneous coronary interventions (PCI) and this cancer type. METHODS: Backward propagation neural network machine learning supported and propensity score adjusted multivariable regression was conducted for the above outcomes in this case-control study of the 2016 National Inpatient Sample (NIS), the United States' largest all-payer hospitalized dataset. Regression models were fully adjusted for age, race, income, geographic region, cancer metastases, mortality risk, and the likelihood of undergoing PCI (and also with length of stay [LOS] for cost). Analyses were also adjusted for the complex survey design to produce nationally representative estimates. Centers for Disease Control and Prevention (CDC)-based cost effectiveness ratio (CER) analysis was performed. RESULTS: Of the 30,195,722 hospitalized patients meeting criteria, 1.27% had gynecological cancer of whom 0.02% underwent PCI including 0.04% with metastases. In propensity score adjusted regression among all patients, the interaction of PCI and gynecological cancer (vs. not having PCI) significantly reduced mortality (OR 0.53, 95%CI 0.36-0.77; p = 0.001) while increasing LOS (Beta 1.16 days, 95%CI 0.57-1.75; p < 0.001) and total cost (Beta $31,035.46, 95%CI 26758.86-35312.06; p < 0.001). Among gynecological cancer patients, mortality was significantly reduced by PCI (OR 0.58, 95%CI 0.39-0.85; p = 0.006) and being in East North Central, West North Central, South Atlantic, and Mountain regions (all p < 0.03) compared to New England. PCI reduced mortality but not significantly for metastatic patients (OR 0.74, 95%CI 0.32-1.71; p = 0.481). Eighteen extra gynecological cancer patients' lives were saved with PCI for a net national cost of $3.18 billion and a CER of $176.50 million per averted death. CONCLUSION: This large propensity score analysis suggests that PCI may cost inefficiently reduce mortality for gynecological cancer patients, amid income and geographic disparities in outcomes.

Three-valve endocarditis in a patient with bioprosthetic aortic valve replacement and intravenous drug use: a case report.

BACKGROUND: Here, we outline the case of a US Veteran's Health Administration (VA) patient with a history of recent bioprosthetic aortic valve replacement (AVR) and recent intravenous drug use (IVDU) who was found to have three-valve infective endocarditis (IE) resulting in septic shock. We highlight this case because it represents an uncommon case of three-valve IE in the setting of recent bioprosthetic valve replacement and IVDU, and it raises the need for continued awareness of mental health and drug rehabilitation in the US military veteran population. CASE SUMMARY: A 62-year-old gentleman with recent bioprosthetic AVR presented with dyspnoea and lower extremity oedema and was found to have a heart failure exacerbation. He developed sepsis and was found to have three-valve endocarditis, as well as aortic root abscess and pacemaker lead infection. He was treated with broad-spectrum antibiotics and evaluated for surgical intervention. After discussion with the surgical team, the patient decided not to pursue surgery due to prohibitively high perioperative mortality risk. The patient was transferred to hospice and expired within 2 weeks. DISCUSSION: Three-valve IE is sparingly documented in published literature and can be difficult to treat. Providers must be cognizant of prosthetic valve endocarditis as an uncommon but known complication of valve replacement surgery. Intravenous drug use is a common risk factor for endocarditis and is prevalent in the US military veteran population. Prosthetic valve endocarditis should be treated with broad-spectrum antibiotics, and in general, if it leads to new significant valvular abnormalities, the valve should be replaced.

Internal Carotid Artery Stenosis Presenting with Limb Shaking TIA.

Internal carotid artery (ICA) stenosis may lead to a wide range of clinical symptoms. We describe the case of a 66-year-old female who experienced a transient ischemic attack (TIA) with episodes of limb shaking caused by ICA stenosis. After epilepsy had been suspected and ruled out, studies of her left ICA showed extensive blockage as a result of atherosclerosis. Magnetic resonance angiography (MRA) revealed total occlusion of the left ICA and the patient was eventually medically managed due to the strong possibility of surgical complications. We reported this patient's clinical course to shed light on a rare manifestation of carotid stenosis that may be confused with other diagnoses if not closely scrutinized.