Comparison of rotational and orbital atherectomy for the treatment of calcific coronary lesions: Insights from the VA clinical assessment reporting and tracking (CART) program.

BACKGROUND: Previous studies suggested that pre-treatment of coronary artery calcification (CAC) with rotational atherectomy (RA) prior to stent deployment improved procedural success but was not associated with a concomitant improvement in clinical outcomes. Orbital atherectomy (OA) has demonstrated similar benefits, though there are few data comparing the safety and efficacy of the two modalities. METHODS: Patients who underwent PCI of a native coronary lesion with RA or OA from 2014 to 2018 within the Veterans Affairs Healthcare System were identified. Propensity matched cohorts were generated to compare the clinical and safety outcomes following either RA or OA. The primary endpoint was the rate of 30-day major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause mortality, repeat myocardial infarction, target vessel revascularization, and stroke. RESULTS: We identified 1,091 patients that underwent atherectomy during the study period, 640 (59%) treated with RA and 451 (41%) treated with OA. Among a propensity-matched cohort consisting of 950 patients, there was no significant difference in MACCE for patients who underwent RA or OA (7.1 vs. 8.2%, p = .36). Components of the primary outcome including 30-day mortality, myocardial infarction, target vessel revascularization, and stroke were also similar in the matched cohort. Additionally, procedural complications including perforation, no-reflow, dissection, and in-stent thrombosis were comparable across both treatment strategies. CONCLUSIONS: Both rotational and orbital atherectomy are safe and effective strategies for the treatment of calcified coronary plaque prior to stent deployment, with similarly low rates of peri-procedural adverse events.

Preadmission Oral Corticosteroids Are Associated With Reduced Risk of Acute Respiratory Distress Syndrome in Critically Ill Adults With Sepsis.

OBJECTIVES: To determine the association between preadmission oral corticosteroid receipt and the development of acute respiratory distress syndrome in critically ill patients with sepsis. DESIGN: Retrospective observational study. SETTING: Medical, surgical, trauma, and cardiovascular ICUs of an academic medical center. PATIENTS: A total of 1,080 critically ill patients with sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The unadjusted occurrence rate of acute respiratory distress syndrome within 96 hours of ICU admission was 35% among patients who had received oral corticosteroids compared with 42% among those who had not (p = 0.107). In a multivariable analysis controlling for prespecified confounders, preadmission oral corticosteroids were associated with a lower incidence of acute respiratory distress syndrome in the 96 hours after ICU admission (odds ratio, 0.53; 95% CI, 0.33-0.84; p = 0.008), a finding that persisted in multiple sensitivity analyses. The median daily dose of oral corticosteroids among the 165 patients receiving oral corticosteroids, in prednisone equivalents, was 10 mg (interquartile range, 5-30 mg). Higher doses of preadmission oral corticosteroids were associated with a lower incidence of acute respiratory distress syndrome (odds ratio for 30 mg of prednisone compared with 5 mg 0.53; 95% CI, 0.32-0.86). In multivariable analyses, preadmission oral corticosteroids were not associated with in-hospital mortality (odds ratio, 1.41; 95% CI, 0.87-2.28; p = 0.164), ICU length of stay (odds ratio, 0.90; 95% CI, 0.63-1.30; p = 0.585), or ventilator-free days (odds ratio, 1.06; 95% CI, 0.71-1.57; p = 0.783). CONCLUSIONS: Among ICU patients with sepsis, preadmission oral corticosteroids were independently associated with a lower incidence of early acute respiratory distress syndrome.

Aortic valve chordae tendineae: A rare cause of aortic stenosis.

We describe a rare case of severe low-flow, low-gradient aortic stenosis due to a calcified aortic valve chordae tendineae. The chordae was captured on cardiac computed tomography (CT) using advanced 3-dimensional image reconstruction to reveal the fibrous strand tethering the non-coronary cusp to the left ventricular outflow tract, rendering it functionally immobile. This is one of the first reported cases of severe aortic stenosis from an aortic valve chordae tendineae which highlights the utility of advanced image processing techniques in cardiac CT.

Association of Ischemic Evaluation and Clinical Outcomes Among Patients Admitted With New-Onset Heart Failure.

Background The significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause. We thus sought to evaluate the proportion of patients who received an ischemic evaluation after a hospitalization for new-onset systolic heart failure. Methods and Results Patients admitted with a new diagnosis of heart failure and a reduction in left ventricular ejection fraction (≤40%) were identified in the VA Healthcare System from January 2006 to August 2017. Among those who survived 90 days without a readmission, we evaluated the proportion of patients who underwent an ischemic evaluation. We identified 9625 patients who were admitted with a new diagnosis of systolic heart failure with a concomitant reduction in ejection fraction. A minority of patients (3859, 40%) underwent an ischemic evaluation, with significant variation across high-performing (90th percentile) and low-performing (10th percentile) sites (odds ratio, 3.79; 95% CI, 2.90-4.31). Patients who underwent an evaluation were more likely to be treated with angiotensin-converting enzyme inhibitors (75% versus 64%, P<0.001) or beta blockers (92% versus 82%, P<0.001) and subsequently undergo percutaneous (8% versus 0%, P<0.001) or surgical (2% versus 0%, P<0.001) revascularization. Patients with an ischemic evaluation also had a significantly lower adjusted hazard of all-cause mortality (hazard ratio, 0.54; 95% CI, 0.47-0.61) compared with those without an evaluation. Conclusions Ischemic evaluations are underutilized in patients admitted with heart failure and a new reduction in left ventricular systolic function. A focused intervention to increase guideline-concordant care could lead to an improvement in clinical outcomes.