Renal Denervation in the Management of Resistant Hypertension: A Comprehensive Review of Literature.

Resistant hypertension is a condition in which blood pressure remains elevated despite using 3 or more antihypertensive medications. Though contemporary antihypertensive drug therapies have been essential in treating hypertension, in recent years different studies have explored renal denervation (RDN) as an adjunctive or a replacement modality. Here we summarize an open-label, Symplicity HTN 2 trial and 7 randomized, sham-controlled clinical trials: Spyral-HTN OFF MEDS (Spyral Pivotal), Spyral-HTN ON MEDS, RADIANCE-HTN SOLO, RADIANCE-HTN TRIO, RADIANCE II, SYMPLICITY-HTN 1, and SYMPLICITY-HTN 3, which evaluated safety and efficacy of multiple renal denervation systems (RDN) at lowering blood pressure from baseline, and in comparison, to control group. Prior systematic reviews and meta-analyses evinced a modest reduction of ambulatory and office blood; however, these trials and analyses were limited by short-term follow-up. In our updated comprehensive literature review we summarize the short-term, and long-term effects of RDN, based on the latest randomized clinical trials. Our conclusions based on each summary are unanimous with previous literature findings.

Cerebral Embolic Protection in Transcatheter Aortic Valve Implantation Using the Sentinel Cerebral Protection System: A Systematic Review and Meta-Analysis.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) plays a vital role in patients with symptomatic aortic stenosis. Despite the mortality benefit of TAVI, embolic stroke remains a feared complication. As a result, transcatheter cerebral embolic protection (TCEP) devices have been developed to reduce this risk. Given the ongoing debate of TCEP in TAVI, we performed a systematic review and meta-analysis of all randomized controlled trials to date to identify outcomes of periprocedural stroke using the Sentinel™ cerebral protection system (CPS). METHODS: MEDLINE, Cochrane, and Scopus databases were utilized from inception until 12/2023. PRISMA criteria was utilized. Keywords included "cerebral embolic protection", "sentinel cerebral protection system", "transcatheter aortic valve implantation", and "transcatheter aortic valve replacement". Primary outcome was periprocedural stroke. Secondary outcomes included periprocedural disabling and non-disabling stroke, all-cause mortality, transient ischemic attack, delirium, acute kidney injury, vascular complications, bleeding, and pacemaker implantation. Risk ratios (RR) were measured via Mantel-Haenszel method with fixed analysis. Heterogeneity was assessed via chi-squared and Higgin's I2 test. RESULTS: Four trials with 3528 patients were assessed. SAPIEN 3 was the most common bioprosthetic valve used. The average age was 79.4 years with 41.9% of the sample size being females. The most prevalent comorbidities were hypertension, diabetes mellitus, and coronary artery disease. There was no difference in periprocedural stroke in patients who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.75, P = 0.12). Periprocedural disabling strokes were less likely in those who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.41, P = 0.02) with a number needed to treat (NNT) of 123. All other outcomes did not reach statistical significance. CONCLUSIONS: In our analysis, there was no difference between TAVI with the Sentinel™ CPS compared to TAVI without TCEP in regard to risk of periprocedural stroke; however, it was associated with a decreased risk of periprocedural disabling stroke.

Outcomes and Readmissions after Left Atrial Appendage Occlusion in Octogenarians: A Contemporary Analysis.

INTRODUCTION AND OBJECTIVES: The outcomes of left atrial appendage occlusion (LAAO) with the Watchman device in octogenarians are unknown as this population was underrepresented in major clinical trials. This study aims at examining the causes and outcomes of readmission after LAAO. DESIGN: A retrospective cohort study based on the National Readmission Database in the United States. SETTINGS AND PARTICIPANT: Patients aged ≥80 years, admitted between January 2016 and December 2018, with the primary diagnosis of atrial fibrillation or flutter or who had LAAO were included in the study. Patients who died during index admission were excluded. METHODS: We used the National Readmission Database and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes to identify study participants. Data analysis was performed through Stata, version 17. Univariate and multivariate aggression analysis was used to adjust for confounders using Student t tests and χ2 tests. RESULTS: We identified 491,329 patients on anticoagulation (AC) and 2030 patients who underwent LAA closure. Neither group differed regarding hypertension, previous myocardial infarction, or valvular heart disease. All-cause readmissions were lower in the LAAO group at 45 days (adjusted P < .01). All-cause readmissions at 45 and 90 days were similar in both groups. There was an increase in gastrointestinal bleeding (GIB) readmissions in the LAAO at 45 (P < .01), 90 (P < .01), and 180 (P < .01) days. There was no difference in GIB readmission between the 2 groups. There was no also difference in stroke or intracranial hemorrhage rates between the 2 groups throughout the follow-up period. CONCLUSION AND IMPLICATIONS: In octogenarians who received LAAO, the rate of GIB increased during the first 6 months after the procedure; however, it was not different from that of AC after that. Special attention should be given to the antithrombotic regimens after LAAO to avoid bleeding in this vulnerable patient population.

Coronary Microvascular Disease.

Coronary microvascular disease or dysfunction (CMVD) has been associated with adverse cardiovascular outcomes. Despite a growing prevalence, guidelines on definitive treatment are lacking. Proposed mechanisms of endothelial dysfunction and resultant inflammation have been demonstrated as the underlying cause. Imaging modalities such as echocardiography, cardiac MRI, PET, and in some instances CT, have been shown to be useful in diagnosing CMVD mainly through assessment of coronary blood flow. Invasive measurements through thermodilution and pressure sensor-guided Doppler microcatheters have also been utilized. Treatment options are directed at targeting inflammatory pathways and angina. In our review, we highlight the current literature on the background of CMVD, diagnostic modalities, and management of this disease.

Comparison of Coronary Artery Involvement and Mortality in STEMI Patients With and Without SARS-CoV-2 During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

BACKGROUND: Cardiovascular injury with SARS-CoV-2 infection is well known. Several studies have outlined baseline characteristics in patients presenting with STEMI and SARS-CoV-2. Paucity in data exists in selective coronary involvement in patients with STEMI and SARS-CoV-2 during the COVID-19 pandemic. METHODS: A systematic search and meta-analysis of studies meeting the inclusion and exclusion criteria obtained from MEDLINE, Scopus, and Cochrane databases was performed utilizing PRISMA criteria. The main outcome was likelihood of coronary artery involvement among patients with STEMI and SARS-CoV-2 versus without SARS-CoV-2. The primary adverse outcome measured was in-hospital mortality. RESULTS: The final analysis included 5 observational studies with a total of 2,266 patients. There was no statistical significance in LM (OR 1.40; 95% CI: 0.68, 2.90), LAD (OR 1.09; 95% CI 0.83, 1.43), LCX (OR 1.17; 95% CI: 0.75, 1.85), or RCA (OR 0.59; 95% CI: 0.30, 1.17) disease among the 2 groups. LAD disease was the most prevalent coronary involvement among patients with STEMI and SARS-CoV-2 (49.6%). Higher in-hospital mortality was observed in the STEMI and SARS-CoV-2 group (OR 5.24; 95% CI: 3.63, 7.56). CONCLUSIONS: Our analysis demonstrated no statistical significance in selective coronary involvement in patients with STEMI and SARS-CoV-2 during the COVID-19 pandemic. The higher mortality among patients with SARS-CoV-2 and STEMI has been noted in prior studies with concerns being late presentation due to fear of infection, delayed care time, and poor resource allocation. Focus should be placed on identifying and managing comorbidities to reduce mortality.

Percutaneous Coronary Intervention Outcomes in Patients With Prior Thoracic Radiation Therapy: A Systematic Review and Meta-Analysis.

Background: Thoracic radiation predisposes patients to accelerated coronary artery disease. There is a paucity of data in both short-term and long-term outcomes following revascularization in patients who have undergone thoracic radiation. Methods: We performed a search of the Medline, Cochrane, and Scopus databases for studies that compared outcomes in cancer patients who have undergone thoracic radiation and percutaneous coronary intervention (PCI). The primary outcome of our meta-analysis was all-cause mortality. Secondary outcomes included cardiac mortality, myocardial infarction (MI), and restenosis. Results: The analysis included four observational studies with a total of 13,941 patients for the primary outcome of all-cause mortality. There were a total of 1,322 patients analyzed for cardiac mortality, 13,103 for MI, and 10,530 for restenosis. The longest follow-up for the primary outcome was 16 years. There was statistically significant higher risk of all-cause mortality in patients who underwent thoracic radiation (risk ratio (RR): 1.29, 95% confidence interval (CI): 1.08 - 1.54, P = 0.004). There was no statistically significant difference in cardiac mortality (RR: 1.15, 95% CI: 0.83 - 1.61, P = 0.40), MI (RR: 1.01, 95% CI: 0.20 - 5.08, P = 0.99), and restenosis (RR: 1.92, 95% CI: 0.24 - 15.35, P = 0.54). Conclusion: In this meta-analysis, we found a higher risk of all-cause mortality in patients with a history of thoracic radiation undergoing PCI, likely from underlying malignancy itself.

The cycloxygenase 2 (COX-2) story: it's time to explain, not inflame.

Despite initial promising reports that anti-inflammatory properties of cycloxygenase-2 (COX-2) inhibitors may confer anti-atherosclerosis effects and stabilize the atherosclerotic plaque, subsequent data from long-term clinical trials have shown that selective COX-2 inhibitors are associated with increased risk of cardiovascular events. The commonly cited explanation is that selective inhibition of COX-2 leads to depletion of prostacyclin, whereas the production of pro-thrombotic thromboxane by means of cycloxygenase-1 (COX-1) is unopposed. This hypothesis seems unlikely as the overall explanation, because low-dose aspirin does not decrease the increased risk associated with COX-2 inhibitors. Moreover, the risk associated with nonselective COX inhibitors may be similar to selective COX-2 inhibitors. Alternative hypotheses include (1) elevated blood pressure, (2) abnormal vascular remodeling, (3) inhibition of protective mechanisms against ischemia-reperfusion injury, and (4) inhibition of 15-epi-lipoxin production. Varying results in different experimental models may be related to the fact that COX-2 is involved in numerous cellular functions. Inhibiting COX-2 in inflammatory cells may have favorable effects, whereas in organs such as the heart and brain and/or blood vessels may have deleterious effects. Currently, the "selective COX-2 inhibitors" are not selective in the sense that they inhibit COX-2 in all tissues without predilection to inflammatory cells and, as a result, may summate to increase the risk of cardiovascular events.

Grade 3 ischemia on admission electrocardiogram and chest pain duration predict failure of ST-segment resolution after primary percutaneous coronary intervention for acute myocardial infarction.

OBJECTIVES: ST resolution (STR) is a surrogate marker of myocardial tissue reperfusion and a predictor of outcome after primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI). Terminal QRS distortion (grade 3 ischemia) has been shown to predict failure of STR after thrombolysis for STEMI, but the ability of grade 3 ischemia to predict STR with pPCI is unclear. METHODS: We retrospectively analyzed 155 patients who underwent pPCI and compared grade 2 ischemia (ST elevation without terminal QRS distortion; n = 89) to grade 3 ischemia (n = 66) on admission for baseline characteristics, in-hospital course, and STR immediately after pPCI and at 18 to 24 hours. RESULTS: Patients with grade 3 ischemia were older (60 +/- 12 vs 56 +/- 11 years; P = .018), had more anterior STEMI (42% vs 17%; P = .0004), and were less often smokers (41% vs 90%; P = .004). The grade 3 ischemic group had significantly less complete STR (35% vs 75% [P < .00001] immediately after pPCI and 33% vs 79% [P < .00001] 18-24 hours after pPCI), a longer hospital stay (6.4 +/- 4.1 vs 4.9 +/- 1.9 days; P = .008), and higher peak CKMB (292 +/- 231 vs 195 +/- 176 ng/mL; P = .0005). Duration of symptoms before pPCI (odds ratio [OR], 0.838; 95% confidence interval [CI], 0.724-0.969; P = .017) and grade 3 ischemia (OR, 0.181; 95% CI, 0.068-0.480; P < .001) were negative predictors of complete STR, whereas nonanterior STEMI (OR, 5.95; 95% CI, 2.154-16.436; P < .001) and initial sum of ST elevation (OR, 3.132; 95% CI, 1.140-8.605; P = .027) were positive predictors. CONCLUSION: Grade 3 ischemia on presentation of STEMI and duration of chest pain are strong independent predictors of failure to achieve complete STR after pPCI.

Chronic pseudoaneurysm and coarctation of the aorta: a rare delayed complication of trauma.

We report an unusual case of pseudoaneurysm and coarctation of the descending thoracic aorta after trauma. The coarctation of aorta resulted in hypertension, severe left ventricular dysfunction, and symptoms of congestive heart failure. Surgical bypass resulted in control of blood pressure and improvement of heart failure symptoms. The mechanism of aortic injury leading to the development of this rare combination is discussed.

Successful closure of coronary artery perforation using non-conventional embolic material.

Coronary perforation during percutaneous coronary interventions is a rare but dreadful complication. While coronary perforation involving large vessels are managed successfully by covered stents, small distal vessel perforation is usually managed by prolonged balloon inflation or embolization of gel foam/thrombogenic metallic coils. We describe a case, where perforation of a small ventricular branch of the right coronary artery was successfully occluded by packing it with pieces of thrombogenic floppy tips of used coronary angioplasty guidewires instead of conventional metallic coils.

Percutaneous transseptal myocardial ablation with wire (PTSAW): a new technique.

Alcohol septal ablation has recently been described as a safe alternative to surgical myectomy for treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy. We describe a case where percutaneous myectomy was performed by mechanically occluding the septal artery using thrombogenic floppy tips of used PTCA wires instead of alcohol, as the anatomy of the septal artery was not suitable for alcohol ablation.

Stenting of a large thrombus-containing subclavian artery stenosis using a distal protection device.

Atheromatous obstructive lesions of the arch vessels that contain thrombi are at high risk for distal embolization during angioplasty. This can lead to catastrophic neurological complications. We report a case of acute-on-chronic ischemia of the left upper limb due to thrombus-containing subclavian artery stenosis. After placement of an intravascular filter device, angioplasty and stent implantation successfully relieved the stenosis without any complications.

Transcatheter closure of perimembranous ventricular septal defect in a patient with situs inversus and dextrocardia.

Successful transcatheter closure of a perimembranous ventricular septal defect with an Amplatzer device has been reported in patients with levocardia. We report a case in which the device could be deployed successfully in a child with isolated perimembranous ventricular septal defect with situs inversus and dextrocardia.

Focal extra strength of a stent causing instent hourglass stenosis: an unusual complication.

We report an unusual complication of a 25 mm long stent, which did not expand at all for 1 mm in its proximal segment, while rest of the 24 mm length of the stent got fully expanded. Repeated attempts to expand the extremely focal unexpanded part of the stent at high pressure led to rupture of the stent balloon and its entrapment. We failed to retrieve the balloon using various techniques and the patient had to be sent for coronary artery bypass graft surgery.

Stenting of a septal perforator for post-myocardial infarction angina.

Occlusion of a septal perforator branch alone, without the involvement of the left anterior descending coronary artery, leading to acute myocardial infarction is unusual. We report a case in which an isolated severely stenotic thrombus-containing first septal artery causing intractable post-myocardial infarction angina was successfully dilated and stented.

Post-stenotic dilatation: challenge in renal ostial stenting--a simple solution.

Stenting is the treatment of choice for treating stenotic renal ostial lesions. During the stenting of an ostial lesion in a renal artery with post-stenotic dilatation, we were faced with the problems of unavailability of a balloon of appropriate length and diameter, and determining the real reference vessel diameter. The problem was solved by a simple technique.

Transcatheter closure of coronary artery fistulas.

BACKGROUND: Transcatheter closure of coronary artery fistulas has emerged as a successful alternative to surgery. We describe various techniques and short-term findings in 15 patients who were taken up for transcatheter closure of these fistulas. METHODS AND RESULTS: Fifteen patients (aged 2-55 years; 12 males) with coronary artery fistulas underwent percutaneous transcatheter closure between June 1997 and December 2002. Site of origin of these fistulas were: right coronary artery in 7, left anterior descending coronary artery in 4, left main coronary artery in 2 and left circumflex coronary artery in 2 patients. Drainage site of these fistulas were: right ventricle in 9, right atrium in 4 and pulmonary artery in 2 patients. Out of these 15 fistulas, 14 were congenital and one was iatrogenically produced following inadvertent cutting balloon angioplasty of a septal perforator in a patient with chronic total occlusion of left anterior descending coronary artery. Various occlusion devices used to close these fistulas were: conventional metallic coils in 10, floppy tips of coronary angioplasty guidewires in 2, Amplatzer duct occluder in 1 and Amplatzer septal occluder in 2 patients. One of our patients had a coronary artery fistula draining by two openings into the right atrium, both of which were successfully closed using 2 Amplatzer duct occluders. Check angiogram after the procedure revealed complete occlusion in 13 (86.6%) and small residual flow in 2 patients. Follow-up studies at 3-55 months (mean 18 months) showed complete abolition of shunt in all patients with no evidence of recanalization leading to recurrence of shunt. CONCLUSION: Transcatheter closure of coronary artery fistulas is feasible and safe in the anatomically suitable vessels. Use of floppy tips of coronary angioplasty guidewires reduces the cost of the procedure significantly. which is an important consideration in developing countries like India.