The everolimus eluting Synergy MegatronTM drug-eluting stent platform: Early outcomes from the European Synergy MegatronTM Implanters' Registry.

BACKGROUND: The Synergy MegatronTM is an everolimus-drug eluting stent that may offer advantages in the treatment of aorto-ostial disease and large proximal vessels. AIMS: To report the short- to medium-term clinical outcomes from the European Synergy MegatronTM Implanters' Registry. METHODS: This registry was an investigator-initiated study conducted at 14 European centers. The primary outcome was target lesion failure (TLF), defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularisation. RESULTS: Five hundred seventy-five patients underwent PCI with MegatronTM between 2019 and 2021. Patients were 69 ± 12 years old, 26% had diabetes mellitus, 24% had moderate-severe left ventricular impairment and 59% presented with an acute coronary syndrome. 15% were deemed prohibitively high risk for surgical revascularisation. The target vessel involved the left main stem in 55%, the ostium of the RCA in 13% and was a true bifurcation (Medina 1,1,1) in 50%.  At 1 year, TLF was observed in 40 patients, with 26 (65%) occurring within the first 30 days. The cumulative incidence of TLF was 4.5% at 30 days and 8.6% (95% CI 6.3-11.7) at 1 year. The incidence of stent thrombosis was 0.5% with no late stent thromboses. By multivariate analysis, the strongest independent predictors of TLF were severe left ventricular impairment (HR 3.43, 95% CI: 1.67-6.76, p < 0.001) and a target vessel involving the left main (HR 4.00 95% CI 1.81-10.15 p = 0.001). CONCLUSIONS: Use of the Synergy MegatronTM everolimus eluting stent in a 'real-world' setting shows favorable outcomes at 30 days and 1 year.

Distal versus conventional radial access for coronary angiography and intervention: Design and rationale of DISCO RADIAL study.

BACKGROUND: Transradial access (TRA) has become the default access method for coronary diagnostic and interventional procedures. As compared to transfemoral access, TRA has been shown to be safer, cost-effective and more patient-friendly. Radial artery occlusion (RAO) represents the most frequent complication of TRA, and precludes future coronary procedures through the radial artery, the use of the radial artery as a conduit for coronary artery bypass grafting or as arteriovenous fistula for patients on hemodialysis. Recently, distal radial access (DRA) has emerged as a promising alternative to TRA, yielding potential for minimizing the risk of RAO. However, an international multicenter randomized comparison between DRA, and conventional TRA with respect to the rate of RAO is still lacking. TRIAL DESIGN: DISCO RADIAL is a prospective, multicenter, open-label, randomized, controlled, superiority trial. A total of 1300 eligible patients will be randomly allocated to undergo coronary angiography and/or percutaneous coronary intervention (PCI) through DRA or TRA using the 6 Fr Glidesheath Slender sheath introducer. Extended experience with both TRA and DRA is required for operators' eligibility and optimal evidence-based best practice to reduce RAO systematically implemented by protocol. The primary endpoint is the incidence of forearm RAO assessed by vascular ultrasound at discharge. Several important secondary endpoints will also be assessed, including access-site cross-over, hemostasis time, and access-site related complications. SUMMARY: The DISCO RADIAL trial will provide the first large-scale multicenter randomized evidence comparing DRA to TRA in patients scheduled for coronary angiography or PCI with respect to the incidence of RAO at discharge.

Cost of coronary syndrome treated with percutaneous coronary intervention and 30-day unplanned readmission in the United States.

OBJECTIVES: This study aimed to examine the cost of coronary syndrome treated with percutaneous coronary intervention (PCI) and 30-day unplanned readmissions. BACKGROUND: There is limited understanding of the hospital cost of index PCI and 30-day unplanned readmissions. METHODS: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were included. The primary outcome was total cost defined by cost of index PCI and first unplanned readmission within 30 days. RESULTS: This analysis included 2,294,244 patients who underwent PCI, and the mean cost was $23,541 ± $20,730 (~$10.8 billion/year). There was a modest increase in cost over the study years of 17.5%. Of the 9.4% with an unplanned readmission within 30 days, the mean total cost was $35,333 ± 24,230 versus $22,323 ± 19,941 for those not readmitted. The variables most strongly associated with the highest quartile of cost were heart failure (adjusted odds ratio (aOR) 25.60 [95% CI 21.59-30.35]), need for circulatory support (aOR 11.62 [10.13-13.32]), periprocedural coronary artery bypass graft (CABG, aOR 585.08 [357.85-956.58]), and readmission within 30 days (aOR 24.49 [22.40-26.77]). An acute kidney injury (AKI; 8.5%), major bleed (0.8%), vascular injury (0.8%), or need for periprodedural CABG (1.4%) had an average increased cost of $21,935; $30,898; $27,875; and $43,005, respectively, compared to PCI without adverse outcome. CONCLUSIONS: The annual 30-day hospital cost of PCI is approximately $10.8 billion, and the costs associated with in-hospital adverse events, particularly the need for AKI and periprocedural CABG, were significant.

Rates, predictors and the impact of cannabis misuse on in-hospital outcomes among patients undergoing percutaneous coronary intervention (from the National Inpatient Sample).

BACKGROUND: Whether cannabis use worsens outcomes in coronary heart disease is unknown and no previous study has evaluated the outcomes for patients who undergo percutaneous coronary intervention (PCI) according to cannabis use. METHODS: We analysed patients in the National Inpatient Sample between 2004 and 2014 who underwent PCI and evaluated rates, predictors and outcomes of patients according to cannabis misuse defined by cannabis abuse or dependence. RESULTS: A total of 7 306 012 patients were included and 32 765 cannabis misusers (0.4%). Cannabis misusers were younger (49.5 vs 64.6 years, P < .001) and were more likely to be male (82.7% vs 66.3%, P < .001). There was also a greater proportion of patients who were of black ethnicity in the cannabis misuse group (27.7% vs 7.9%, P < .001) and fewer elective admissions (7.8% vs 27.6%, P < .001). There was no difference in in-hospital mortality (OR 1.06 95% CI 0.80-1.40, P = .67), bleeding (OR 0.94 95% CI 0.77-1.15, P = .55) and stroke/transient ischaemic attack (OR 1.19 95% CI 0.98-1.45, P = .084) compared with non-cannabis misusers. Cannabis misusers had significantly lower odds of in-hospital vascular complications (OR 0.73 95% CI 0.58-0.90, P = .004). CONCLUSIONS: Our results suggest that cannabis misusers are more likely to be male, of black ethnicity and from the lowest quartile of income, but there was no evidence that cannabis misuse is associated with worse periprocedural outcomes following PCI when controlling for key proxies of health status.

The Influence of the Charlson Comorbidity Index on Procedural Characteristics, VARC-2 Endpoints and 30-Day Mortality Among Patients Who Undergo Transcatheter Aortic Valve Implantation.

BACKGROUND: Aortic stenosis (AS) is a common valvular abnormality and transcatheter aortic valve implantation (TAVI) is being increasingly used to treat patients considered too high risk for conventional surgery. We aimed to assess the prevalence of comorbid conditions in patients undergoing TAVI using the Charlson Comorbidity Index (CCI) and to assess their impact on clinical and procedural outcomes. METHODS: We analysed 158 patients who underwent a TAVI at our institution between June 2009 and September 2015 to define their co-morbid burden as measured with CCI, and study its impact on procedural characteristics and mortality at 30 days. RESULTS: One hundred fifty-eight (158) patients with a mean age of 82±8years and a mean CCI score of 2.67 underwent a TAVI. Only 12/158 patients had a CCI of 0. The commonest cardiovascular comorbidities were previous myocardial infarction (24%), congestive heart failure (15%) and diabetes mellitus (23%) whilst the commonest non-cardiovascular comorbidities were renal disease (46%) and chronic obstructive pulmonary disease (COPD) (29%). After multivariable adjustment, CCI was not independently associated with adverse clinical outcomes. The addition of CCI to scoring systems such as Logistic EuroScore (LES) and Society of Thoracic Surgeons (STS) risk models improved the area under the curve from 0.75 (95%CI: 0.44-1.00) and 0.83 (95%CI: 0.64-1.00) to 0.78 (95%CI: 0.53-1.00) and 0.89 (95%CI: 0.78-1.00) respectively. CONCLUSIONS: The burden of comorbid conditions in patients undergoing TAVI is significant. The CCI score was not independently associated with a higher risk of death but can be useful in addition to LES and STS risk models in informing decision making on the selection of patients for TAVI.

Effect of access site, gender, and indication on clinical outcomes after percutaneous coronary intervention: Insights from the British Cardiovascular Intervention Society (BCIS).

BACKGROUND: Gender is a strong predictor of periprocedural major bleeding complications after percutaneous coronary intervention (PCI). The access site represents an important site of such bleeding complications, which has driven adoption of the transradial access (TRA) use during PCI, although female gender is an independent predictor of transradial PCI failure. This study sought to define gender differences in access site practice and study associations between access site choice and clinical outcomes for PCI over a 6-year period, through the analysis of the British Cardiovascular Intervention Society observational database. METHODS AND RESULTS: In-hospital major adverse cardiovascular events (a composite of in-hospital mortality and in-hospital myocardial reinfarction and target vessel revascularization), in-hospital bleeding complications, and 30-day mortality were studied based on gender and access site choice (transfemoral access, TRA) in 412,122 patients who underwent PCI between 2007 and 2012 in the United Kingdom. Use of TRA increased in both genders over time, although this lagged behind in women (21% in 2007 to 58% in 2012) compared with men (24% in 2007 to 64% in 2012). In both men and women, TRA was independently associated with a lower in-hospital major adverse cardiovascular event (odds ratio [OR] 0.82, 95% CI 0.76-0.90; OR 0.75, 95% CI 0.66-0.84), in-hospital major bleeding (OR 0.54, 95% CI 0.44-0.66; OR 0.26, 95% CI 0.20-0.33), and 30-day mortality (OR 0.80, 95% CI 0.73-0.89; OR 0.82, 95% CI 0.71-0.94), respectively. CONCLUSIONS: Where possible, TRA should be considered as the preferred access site choice for PCI, particularly in women in whom the greatest reductions bleeding end points were observed across all indications.

Impact of age on access site-related outcomes in 469,983 percutaneous coronary intervention procedures: Insights from the British Cardiovascular Intervention Society.

We investigate adoption of the TRA in different age groups and study the relationship between age and access site related outcomes in a national cohort of patients undergoing PCI in the UK. Previous studies have reported conflicting data on radial access site adoption between different age groups, with age an independent predictor of failure of procedures undertaken through the radial approach. Age and access site related outcomes (based on transradial (TRA) and transfemoral (TFA) access) were studied in 469,983 PCI procedures undertaken in the UK from 2006 to 2012 in the age groups; <60, 60-<70, 70-<80, and ≥80 in the British Cardiovascular Intervention Society database. We studied access site practice in 469,983 patients who underwent PCI procedures in the United Kingdom. TRA utilization increased from 17.5% to 65.6% in the age group <60, and 16.6% to 54.5% in the age group ≥80 between 2006 and 2012. TRA was independently associated with decreased 30-day mortality in all age groups (<60: OR 0.64; 95% CI 0.54-0.74, P < 0.0001; 60-<70: OR 0.65; 95% CI 0.57-75, P < 0.0001, 70-<80: OR 0.58 (0.52-0.65, P < 0.0001 and ≥80: OR 0.65 (0.57-0.73, P < 0.0001). Adoption of the TRA for PCI has occurred least in older patients in the UK despite similar associations between TRA use and decreased 30-day mortality observed in all age groups.

Arterial access site utilization in cardiogenic shock in the United Kingdom: is radial access feasible?

BACKGROUND: Cardiogenic shock (CS) remains the leading cause of mortality in patients hospitalized with acute myocardial infarction (AMI). The transradial access site (TRA) has become increasingly adopted as a default access site for percutaneous coronary intervention (PCI); however, even in experienced centers that favor the radial artery as the primary access site during PCI, patients presenting in CS are often treated via the transfemoral access site (TFA); and commentators have suggested that CS remains the final frontier that has given even experienced radial operators pause. We studied the use of TRA in patients presenting in CS in a nonselected high-risk cohort from the British Cardiovascular Intervention database over a 7-year period (2006-2012). METHODS: Mortality (30-day) and major adverse cardiac and cerebrovascular events (a composite of in-hospital mortality, in-hospital myocardial reinfarction, target vessel revascularization, and cerebrovascular events) were studied based on TFA and TRA utilization in CS patients. The influence of access site selection was studied in 7,231 CS patients; TFA was used in 5,354 and TRA in 1,877 patients. RESULTS: Transradial access site was independently associated with a lower 30-day mortality (hazard ratio [HR] 0.56, 95% CI 0.46-0.69, P = 0 < .001), in-hospital major adverse cardiac and cerebrovascular events (HR 0.64, 95% CI 0.53-0.76, P < .0001) and major bleeding (HR 0.37, 95% CI 0.18-0.73, P = .004). CONCLUSIONS: Although the majority of PCI cases performed in patients with cardiogenic shock in the United Kingdom are performed through the TFA, the radial artery represents an alternative viable access site in this high-risk cohort of patients in experienced centers.

Influence of access site choice on incidence of neurologic complications after percutaneous coronary intervention.

BACKGROUND: Neurologic complications (NCs) are a rare but potentially devastating complication that may follow percutaneous coronary intervention (PCI). In recent years, there has been an increase in use of transradial access, driven by a developing body of evidence that favors its use over femoral access. Concerns have been raised, however, that transradial access may increase the risk of NC compared with transfemoral access. We aimed to investigate the influence of access site selection on the occurrence of NCs through a period of transition during which transradial access became the dominant route for PCI procedures performed in the United Kingdom. METHODS: We performed a retrospective analysis of the British Cardiovascular Intervention Society database between January 2006 and December 2010. The data were split into 2 cohorts based on access site. An NC was defined as a periprocedural ischemic stroke, hemorrhagic stroke, or transient ischemic attack occurring before hospital discharge. Binary logistic multivariate analysis was used to investigate the influence of access site utilization on NCs and adjust for measured confounding factors. RESULTS: Between 2006 and 2010, the use of radial access increased from 17.2% to 50.8% of all PCI procedures. A total of 124,616 radial procedures and 223,476 femoral procedures were studied with a NC rate of 0.11% in each cohort. In univariate (odds ratio 1.01, 95% CI 0.82-1.24, P = .93) and multivariate analysis (odds ratio 0.99, 95% CI 0.79-1.23, P = .91), there was no significant association between the use of radial access and the occurrence of NCs. CONCLUSION: These results suggest that radial access is not associated with an increased risk of clinically detected NCs, even during a period when there was a rapid evolution in the preferred access site for PCI in the United Kingdom. These are reassuring results, particularly for operators embarking on a change to radial access for PCI.

Impact of access site selection and operator expertise on radiation exposure; a controlled prospective study.

BACKGROUND: Published data relating to arterial access site selection and radiation exposure during coronary procedures suggest radial access may lead to increased radiation exposure, but this is based on poorly controlled studies. We sought to measure radiation exposure to patients and operators during elective coronary angiography (CA) according to access site, with other procedure related variables controlled for. We also investigated the specific effect of operator expertise in relation to radiation exposure. METHODS: 100 consecutive patients undergoing first time elective CA were recruited prospectively. An expert transradial (TR) and an expert transfemoral (TF) operator performed 25 cases each via their default route. A trainee cardiologist with intermediate experience in both access sites performed 25 cases via each route. Angiographic projections were standardised and optimised radiation protection was utilised for all procedures. The primary endpoints were operator and patient exposure, quantified by effective dose (ED) and dose area product (DAP) respectively. Secondary endpoints included fluoroscopy time (FT) and time to patient ambulation. RESULTS: The trainee operator recorded higher values for radiation exposure in radial and femoral cases when compared to the expert operators. There were no significant differences in radiation exposure during CA to operator or patient according to access site when standardised by operator experience. For the trainee, ED for TR and TF procedures was 8.8 ± 4.3 µSv and 8.5 ± 6.5 µSv (P = .86) and DAP was 25.4 ± 4.8 Gycm(2) vs 25.2 ± 8.3 Gycm(2) (P = .9). For the expert TR and TF operators, ED was 6.4 ± 4.7 µSv vs 6.1 ± 5.6 µSv (P = .85) and DAP was 21.7 ± 6.5 Gycm(2) vs 22.4 ± 8.0 Gycm(2), (P = .74). There was no significant difference in FT in relation to access site. Time to ambulation was significantly longer with TF access. CONCLUSION: The use of TR access has no adverse effect on radiation exposure or FT for diagnostic CA, but does allow for quicker ambulation compared to TF access. The magnitude of radiation exposure is related to operator expertise for both access sites. The results of previous studies reflect the effect of uncontrolled patient and operator variables and not access site selection.

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention: The DISCO RADIAL Trial.

BACKGROUND: Currently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking. OBJECTIVES: The aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO. METHODS: DISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site-related complications. RESULTS: Overall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P < 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups. CONCLUSIONS: With the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time.

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance.

BACKGROUND: Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT). METHODS: 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR). RESULTS: Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group. CONCLUSIONS: Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.

Fluoroscopic left ventricular lead position and the long-term clinical outcome of cardiac resynchronization therapy.

BACKGROUND: To determine the effects of left ventricular (LV) lead tip position on the long-term outcome of cardiac resynchronization therapy (CRT). SETTING: Cardiac device therapy center. PATIENTS: Five hundred and fifty-six patients (age 70.4 ± 10.7 years [mean ± standard deviation]). INTERVENTIONS: CRT-pacing or CRT-defibrillation device implantation. MAIN OUTCOME MEASURES: Cardiovascular mortality and events over a maximum follow-up period of 9.1 years. RESULTS: Hazard ratios (HRs [95% 785]797) for cardiovascular mortality, adjusted for age, gender, QRS duration, heart failure etiology, New York Heart Association class, and presence of diabetes and atrial fibrillation, were derived for LV lead tip positions in terms of veins, circumferential, and longitudinal positions with respect to the LV chamber. For vein position, these were 1.07 (0.74-1.56) for anterolateral vein position and 1.24 (0.79-1.95) for the middle cardiac vein, compared with a posterolateral vein. For circumferential lead tip position, HRs were 1.56 (0.73-3.34) for anterolateral and 1.57 (0.76-3.25) for lateral, compared with posterior positions. For longitudinal lead tip positions, HRs were 1.02 (0.72-1.46) for basal and 1.21 (0.68-2.17) for apical, compared with mid-ventricular positions. The risk of meeting the composite endpoints of cardiovascular death or hospitalizations for heart failure and death from any cause or hospitalizations for major adverse cardiovascular events was similar among the various LV lead tip positions. CONCLUSIONS: The position of the LV lead over the LV free wall, assessed by fluoroscopy, has no influence over the long-term outcome of CRT.

Intravascular imaging-guided intracoronary lithotripsy: First real-world experience.

BACKGROUND AND AIMS: Coronary calcification remains a significant challenge for the contemporary interventional cardiologist. We aim to describe the use of intravascular lithotripsy (IVL) in a range of real-world settings. METHODS: A retrospective two-center analysis of patients treated with IVL between June 2018 and November 2019. Technical and procedural success, as well as procedural complications and 30-day outcomes (death, myocardial infarction, or repeat target vessel revascularization), was recorded. RESULTS: Sixty-five patients underwent IVL: 80% were male and the mean age was 70.1 ± 12.0 years. 54% of patients presented with acute coronary syndrome (ACS) and 68% of patients had intracoronary imaging. Twelve patients required IVL within pre-existing stents, and 12 underwent IVL in the left main stem. All balloons were successfully delivered with 98.5% procedural success. There was a significant gain in MLA post PCI of 261.9 ± 100% following IVL. There were two procedural complications. At 30-day follow-up, there was one death, and one patient required a repeat procedure due to stent underexpansion. CONCLUSIONS: In this largest real-world series of imaging-guided IVL for calcified lesions to date, we demonstrate that IVL is deliverable, safe, and effective at calcium modification especially when intracoronary imaging is used.

Intravascular Lithotripsy for Stent Underexpansion Despite Utilization of Rotational Atherectomy for Plaque Modification.

Percutaneous coronary intervention (PCI) in the context of heavily calcified coronary arteries can be challenging. Intravascular lithotripsy (IVL) has been suggested as an alternative to rotational atherectomy (RA). We report a case of stent under expansion, despite plaque modification using rotational atherectomy that was successfully managed with intravascular lithotripsy.

Idiopathic eosinophilic myocarditis presenting with features of an acute coronary syndrome.

SUMMARY: A 62-year-old female was admitted with severe left-sided chest pain, nausea and pre-syncope. She had widespread T wave inversion on ECG and elevated troponins and was suspected to have an acute coronary syndrome event. Invasive coronary angiogram revealed normal coronary anatomy with no flow-limiting lesions. Echocardiography and cardiac MRI revealed impaired left ventricular (LV) systolic impairment, a mobile LV apical thrombus and a moderate global pericardial effusion with no significant compromise. Full blood count analysis indicated the patient to have significant eosinophilia, and the patient was diagnosed with idiopathic eosinophilic myocarditis. She was commenced on Prednisolone and Apixaban, and eosinophil levels returned to normal after 10 days of steroids. Over the course of 3 months, the patient had a complete recovery of her LV function and resolution of the LV thrombus. This case highlights a rare, reversible case of idiopathic eosinophilic myocarditis which may present similar to acute coronary syndrome. LEARNING POINTS: Eosinophilic myocarditis (EM) is a rare disease that can exhibit symptoms similar to acute coronary syndrome events.The diagnosis of EM should be considered in patients with chest pain, normal coronary angiogram and pronounced eosinophilia levels.Endomyocardial biopsy is the gold standard diagnostic tool; however, it has a low sensitivity detection rate and its use is not indicated in some patients.Echocardiography is useful in the initial detection of cardiac involvement and complications. However, echocardiography lacks diagnostic specificity for all forms of myocarditis including EM.Cardiac magnetic resonance is a useful method and may add in diagnosing all forms of myocarditis including EM.Patients with EM should be identified promptly and treated with high doses of oral glucocorticoid to reduce the risk of permanent cardiac dysfunction.

Clinical Characteristics and Outcomes From Percutaneous Coronary Intervention of Last Remaining Coronary Artery: An Analysis From the British Cardiovascular Intervention Society Database.

BACKGROUND: Patients with complex high-risk coronary anatomy, such as those with a last remaining patent vessel (LRPV), are increasingly revascularized with percutaneous coronary intervention (PCI) in contemporary practice. There are limited data on the outcomes of these high-risk procedures. METHODS: We analyzed a large longitudinal PCI cohort (2007-2014, n=501 841) from the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing patients into 2 groups; LRPV group (n=2432) and all other PCI groups (n=506 691). RESULTS: Patients in the LRPV PCI group were older, had more comorbidities, and higher prevalence of moderate-severe left ventricular systolic dysfunction. Mortality was higher in the LRPV PCI group during hospital admission (12 % versus 1.5 %, P<0.001), at 30 days (15% versus 2%, P<0.001), and at one-year (24% versus 5%, P<0.001). In a propensity score matching analysis the adjusted risk of mortality during index admission (odds ratio, 2.05 [95% CI, 1.65-2.44], P<0.001), at 30 days (odds ratio, 2.13 [95% CI, 1.78-2.5], P<0.001), at 1 year (odds ratio, 1.81 [95% CI, 1.59-2.03], P<0.001), and in-hospital major adverse cardiovascular events (odds ratio, 1.8 [95% CI, 1.42-2.19], P<0.001) were higher in LRPV PCI group as compared to control group. In sensitivity analyses, similar clinical outcomes were observed irrespective of which major epicardial coronary artery was treated. CONCLUSIONS: In this contemporary cohort, patients who had PCI to their LRPV had a higher-risk profile and more adverse clinical outcomes, irrespective of the vessel treated.

Edwards SAPIEN 3 Transcatheter Heart Valve Implantation in a Native Bicuspid Aortic Regurgitation.

Transcatheter aortic valve replacement over the last few years has revolutionized the way severe aortic stenosis patients are being managed [1-4]. Randomized clinical trials commonly excluded bicuspid aortic valves and pure native severe aortic regurgitation [2,4]. We present a case with severe acute aortic regurgitation complicated by refractory pulmonary oedema successfully managed by transfemoral transcatheter aortic valve replacement using a Sapien 3 valve.

Transcatheter aortic valve replacement outcomes in bicuspid compared to trileaflet aortic valves.

AIM: TAVR in patients with bicuspid aortic valves (BAV) is more challenging compared to individuals with trileaflet aortic valves (TAV). BAV have been excluded from the large randomized clinical trials assessing transcatheter aortic valve replacements (TAVR) and has been considered as a relative contraindication to TAVR. To report the outcomes of TAVR in BAV and compare them to TAV in the National Inpatient Sample (NIS). METHODS AND RESULTS: TAVR procedures were identified between 2011 and 2014 in the NIS dataset. Endpoints assessed included in-hospital mortality, periprocedural complications, length of stay and cost. Of 40,604 identified TAVR procedures, 407 (1%) were BAV and the 40,197 (99%) were TAV. Patients with BAV were younger and had a lower comorbidity burden. In hospital mortality (4.89% vs 4.17%, OR: 1.71, 95%CI: 0.57-5.12, P = 0.21), AMI (3.49% vs 3.58%, OR: 1.12, 95%CI: 0.36-3.54, P = 0.85), stroke and TIA (2.49% vs 3.55%, OR: 0.75, 95%CI: 0.18-3.16, P = 0.70), vascular complications (2.39% vs 5.58%, OR:0.47, 95%CI: 0.11-1.93, P = 0.29), major bleeding (16.96% vs 23.50%, OR: 0.63, 95%CI: 0.34-1.17, P = 0.15) and rates of permanent pacemaker (PPM) (9.88% vs 10.88%, OR: 1.19, 95%CI: 0.57-2.51, P = 0.64) were similar in both cohorts. CONCLUSIONS: With multimodality imaging and further improvement in technology, our study demonstrates off-label TAVR should not be considered prohibitive and can be successfully performed for BAV with similar peri-procedural outcomes compared to those with TAV. However, there is a need for robust large prospective studies.

Accelerated patent hemostasis using a procoagulant disk; a protocol designed to minimize the risk of radial artery occlusion following cardiac catheterization.

PURPOSE: Radial artery occlusion flowing cardiac catheterisation has been linked to flow reduction and prolonged compression. We investigate whether these factors can be optimised following transradial cardiac catheterisation by using an accelerated band removal protocol facilitated by a haemostasis promoting pad, in combination with a patent haemostasis technique. METHODS: In this single centre prospective study, 389 consecutive patients undergoing TRA for coronary angiography or angioplasty were randomised to two haemostasis protocols: use of a Helix™ compression device alone (HC) or in combination with a haemostatic pad (StatSeal® disc) and an accelerated haemostasis protocol (AC). A patent haemostasis technique was employed in both study arms. The primary efficacy endpoint was the time to haemostasis and the secondary safety outcome was access site related complications: re-bleeding, haematoma and radial artery patency assessed within 24 h using reverse Barbeau's Test (BT). RESULTS: Between May and Nov 2017, 191 patients were randomised to receive HC and 198 patients to AC. Compression time was significantly higher with HC as compared to AC (165.8 ±â€¯63.1 versus 79.7 ±â€¯41.2 min, p < 0.001). There were no significant differences in re-bleeding and RAO between groups (3.7% versus 5.6%, p = 0.37 and 6.3% versus 4.1%, p = 0.33) respectively. Incidence of haematoma was higher in AC group (4.7% versus 12.1%, p = 0.009). CONCLUSION: A reduction in radial artery compression time can be achieved by using Statseal in association with an accelerated haemostasis protocol without increasing the risk of access site bleeding and RAO. The combination of reduced compression time combined with maintained radial flow via patent haemostasis has the potential to reduce the risk of radial occlusion after transradial catheterisation.