Cost savings for pVAD compared to ECMO in the management of acute myocardial infarction complicated by cardiogenic shock: An episode-of-care analysis.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMICS) occurs in up to 10% of acute myocardial infarction admissions and is associated with high mortality, frequent adverse outcomes, prolonged hospitalizations, extensive medical resource utilization, and major cost. Using hospital cost data for Medicare Fee-for-Service (FFS) patients with AMICS, we sought to evaluate in hospital and 45-day outcomes and cost, comparing patients treated with percutaneous ventricular assist device (pVAD) versus extracorporeal membrane oxygenation (ECMO). The goal of this study was to better understand clinical and economic outcomes of AMICS to help clinicians and hospitals optimize outcomes most economically for AMICS patients. METHODS: A retrospective claims analysis identified patients from the full census Medicare Standard Analytic Files compiled by the Center for Medicare and Medicaid (CMS) including: Inpatient, Outpatient, Skilled Nursing Facility and Home Health files for Medicare FFS beneficiaries. Study costs were defined as the total costs incurred by providers for treating a population with AMICS. Medicare FFS beneficiaries who experienced an inpatient admission during the index period (January 1, 2015 to March 31, 2017) with a diagnosis of AMICS were eligible for study inclusion and were identified by the presence of appropriate International Classification of Diseases, Ninth and Tenth Versions (ICD-9 and ICD-10) diagnosis and procedure codes. To create a matched sample and control for any baseline differences, a 1:1 Propensity Score Matching (PSM) was performed based on criteria such as age, gender, race, geographic distribution, and 11 high-cost comorbidities (e.g., congestive HF, coronary artery disease, diabetes, etc.). Index length of stay (LOS), index costs, discharge disposition (including mortality), post-index utilization, and episode-of-care (EOC) costs were reviewed. EOC was defined as index admission for all patients plus a 45-day post index period for patients who survived the index admission. RESULTS: Each cohort included 338 patients. Index in-hospital mortality rates were 53% for pVAD versus 64% for ECMO (178 vs. 217; p = .0023), and total EOC in-hospital mortality rates were 66% for pVAD versus 74% for ECMO (222 vs. 250; p = .0160). Index LOS for pVAD was 27% lower versus ECMO (12.12 vs. 16.59; p = .0006). The index LOS for patients discharged alive was 25% lower for pVAD versus ECMO (17.73 vs. 23.62; p = .0016). For patients that experienced in-hospital mortality during their index stay, pVAD had a 44% lower LOS compared to ECMO (7.08 vs. 12.66; p < .0001). Following index hospitalization, the average cost savings with additional inpatient care was 31% lower for pVAD patients ($62,188 vs. $90,087; p = NS). During the EOC, pVAD patients incurred 32% lower costs compared to ECMO patients ($117,849 vs. $172,420; <.0001). CONCLUSIONS: This study of Medicare FFS patients demonstrates that hospitals utilizing pVAD for appropriately selected AMICS patients have reduced mortality rates and reduced index LOS with lower index facility costs and lower post index 45-day costs. The study results offer hospitals and clinicians an opportunity to improve clinical outcomes and reduce total EOC costs in treating patients with AMI complicated by CS.

Hot topics in interventional cardiology: Proceedings from the society for cardiovascular angiography and interventions (SCAI) 2021 think tank.

The Society for Cardiovascular Angiography and Interventions (SCAI) Think Tank is a collaborative venture that brings together interventional cardiologists, administrative partners, and select members of the cardiovascular industry community annually for high-level field-wide discussions. The 2021 Think Tank was organized into four parallel sessions reflective of the field of interventional cardiology: (a) coronary intervention, (b) endovascular medicine, (c) structural heart disease, and (d) congenital heart disease. Each session was moderated by a senior content expert and co-moderated by a member of SCAI's Emerging Leader Mentorship program. This document presents the proceedings to the wider cardiovascular community in order to enhance participation in this discussion, create additional dialog from a broader base, and thereby aid SCAI, the industry community and external stakeholders in developing specific action items to move these areas forward.

Balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction (BATMAN): A novel technique for patients undergoing transcatheter mitral valve replacement.

INTRODUCTION: Transcatheter mitral valve replacement (TMVR) is an option for patients at high risk for mitral valve replacement or repair via sternotomy or left thoracotomy approach. TMVR carries up to 22% risk of left ventricular outflow tract (LVOT) obstruction. Severe LVOT obstruction can have devastating hemodynamic and clinical consequences. HYPOTHESIS: We previously presented a novel technique to prevent LVOT obstruction during transapical retrograde mitral valve replacement, by penetrating and ballooning the anterior mitral leaflet (AML), resulting in creation of a "hole" and posterior translocation of AML, then deploying the valve. METHODS: Three patients underwent TMVR at Saint Louis University for severe mitral regurgitation after being deemed too high risk for surgery, and not candidates for a Mitra-clip procedure. These patients were deemed to be at risk for LVOT obstruction based on the preprocedural evaluation. Via transapical approach, a needle was advanced "through," perforating the AML and wire was placed in the left atrium. Over the wire, an 20-mm valvuloplasty balloon was positioned "within" the anterior leaflet and inflated leading to translocation of the AMVL. Then the valve was deployed. RESULTS: This novel technique has been performed on three patients at our institution. Sapien S3 transcatheter valves were used in all three patients, with 100% procedural success rate. Intraoperative TEE demonstrated no significant LVOT obstruction, cardiopulmonary bypass time was 42-44 min. CONCLUSION: The balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction technique described here may offer the option of transcatheter mitral valve implantation in patients at high risk of LVOT obstruction. A variation of this technique to allow application in cases with transseptal approach is under investigation.

Impella support and acute kidney injury during high-risk percutaneous coronary intervention: The Global cVAD Renal Protection Study.

BACKGROUND: Protection against acute kidney injury (AKI) has been reported with the use of Impella during high-risk percutaneous coronary intervention (HR-PCI). We sought to evaluate this finding by determining the occurrence of AKI during Impella-supported HR-PCI in patients from the Global cVAD Study and compare this incidence with their calculated AKI risk at baseline. METHODS AND RESULTS: In this prospective, multicenter study, we enrolled 314 consecutive patients. We included 223 patients that underwent nonemergent HR-PCI supported with Impella 2.5 or Impella CP and excluded those requiring hemodialysis prior to HR-PCI (19) and those with insufficient data (72). The primary outcome was AKI postprocedurally at 48 hr versus the predicted risk of AKI according to Mehran risk score. Logistic regression analysis determined predictors of AKI. Overall, 4.9% (11) of Impella-supported patients developed AKI (exclusively stage 1) at 48 hr versus a predicted rate of 21.9%, representing a 77.6% lower AKI rate (p < .0001). In this study, no Impella-supported patients required renal replacement therapy. Estimated glomerular filtration rate (ml/min/1.73 m2 ) alone predicted AKI (adjusted odds ratio [AOR]: 4.915; 95% confidence intervals [CI]: 1.02-23.53, p = .046), and increasing contrast had insignificant effects on AKI during high-risk PCI (AOR: 1.15; 95% CI: 0.87-1.51, p = .332). In patients not protected from AKI, the postprocedure incidence of AKI was not significantly greater and did not correlate with chronic kidney disease severity. CONCLUSION: The incidence of AKI was lower during HR-PCI than expected from current risk models. Although further exploration of this finding is warranted, these data support a new protective strategy against AKI during HR-PCI.

Carbon Dioxide Exposure Resulting From Hood Protective Equipment Used in Joint Arthroplasty Surgery.

BACKGROUND: To protect both the surgeon and patient during procedures, hooded protection shields are used during joint arthroplasty procedures. Headache, malaise, and dizziness, consistent with increased carbon dioxide (CO2) exposure, have been anecdotally reported by surgeons using hoods. We hypothesized that increased CO2 concentrations were causing reported symptoms. METHODS: Six healthy subjects (4 men) donned hooded protection, fan at the highest setting. Arm cycle ergometry at workloads of 12 and 25 watts (W) simulated workloads encountered during arthroplasty. Inspired O2 and CO2 concentrations at the nares were continuously measured at rest, 12 W, and 25 W. At each activity level, the fan was deactivated and the times for CO2 to reach 0.5% and 1.0% were measured. RESULTS: At rest, inspired CO2 was 0.14% ± 0.04%. Exercise had significant effect on CO2 compared with rest (0.26% ± 0.08% at 12 W, P = .04; 0.31% ± 0.05% at 25 W, P = .003). Inspired CO2 concentration increased rapidly with fan deactivation, with the time for CO2 to increase to 0.5% and 1.0% after fan deactivation being rapid but variable (0.5%, 12 ± 9 seconds; 1%, 26 ± 15 seconds). Time for CO2 to return below 0.5% after fan reactivation was 20 ± 37 seconds. CONCLUSION: During simulated joint arthroplasty, CO2 remained within Occupational Safety and Health Administration (OSHA) standards with the fan at the highest setting. With fan deactivation, CO2 concentration rapidly exceeds OSHA standards.

Fresh osteochondral allograft transplantation for osteochondritis dissecans of the capitellum in baseball players.

BACKGROUND: Osteochondritis dissecans (OCD) of the capitellum is a rare yet debilitating injury seen in young athletes. This is the first report in the literature describing fresh osteochondral allograft transplantation (FOCAT) to treat OCD of the capitellum. METHODS: Nine male baseball players (mean age, 15.3; range, 14-18 years), with OCD of the capitellum were treated with FOCAT. There were 6 pitchers and 3 position players. A ligament-sparing, mini-open approach was used. A fresh femoral hemicondyle was used as a donor source. Of the 9 patients, 7 required 1 plug and 2 required 2 plugs. The average plug diameter was 11 mm (range, 8-18 mm). Five plugs were press fit, and 4 required additional fixation. Clinical outcomes were evaluated at a mean follow-up of 48.4 months (range, 11-90 months). Preoperative and postoperative outcome scores were calculated using the paired t test. RESULTS: The Mayo Elbow Performance score improved from an average 57.8 to 98.9 (P < .01). The Oxford Elbow Score improved from 22.4 to 44.8 (P < .01). The Disabilities of the Arm, Shoulder and Hand score improved from 35.2 to 5.4 (P < .01). The visual analog scale score improved from 7.8 to 0.5 (P < .01). The Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score improved from 32.6 to 82.5 (P < .01). All patients returned to throwing and were still active in their sport or played at least 2 years of baseball before leaving the sport unrelated to the elbow. CONCLUSIONS: FOCAT for OCD of the capitellum in properly selected cases is a viable treatment with significant functional improvement and pain reduction in throwers.

Modern cardiac rehabilitation: Integrating the best measures to reduce a second cardiac event.

Patients with established cardiovascular disease are at high risk for future myocardial infarction, stroke, and death. Interventions that may reduce recurrent cardiovascular events serve a critical role in improving both long-term morbidity and mortality. Cardiac rehabilitation following a cardiac event has been modernized with the integration of coronary risk factor reduction programs in addition to its traditional role of early graded mobilization of the patient and has been shown to significantly benefit men and women with coronary heart disease.

Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS: The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS: Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.

Update in the management of coronary artery disease.

We review several approaches that represent contemporary coronary disease management including noninvasive coronary imaging, selection of patients for revascularization, assessment of coronary lesions for physiologic significance and vulnerability to future ischemic events, and strategies to improve the safety of revascularization procedures. Better understanding of the pathophysiology of atherosclerosis has made secondary prevention therapies among patients with established coronary disease the highest priority, and we also discuss this evolution.

The ARF GAPs ELMOD1 and ELMOD3 act at the Golgi and cilia to regulate ciliogenesis and ciliary protein traffic.

ELMODs are a family of three mammalian paralogues that display GTPase-activating protein (GAP) activity toward a uniquely broad array of ADP-ribosylation factor (ARF) family GTPases that includes ARF-like (ARL) proteins. ELMODs are ubiquitously expressed in mammalian tissues, highly conserved across eukaryotes, and ancient in origin, being present in the last eukaryotic common ancestor. We described functions of ELMOD2 in immortalized mouse embryonic fibroblasts (MEFs) in the regulation of cell division, microtubules, ciliogenesis, and mitochondrial fusion. Here, using similar strategies with the paralogues ELMOD1 and ELMOD3, we identify novel functions and locations of these cell regulators and compare them to those of ELMOD2, allowing the determination of functional redundancy among the family members. We found strong similarities in phenotypes resulting from deletion of either Elmod1 or Elmod3 and marked differences from those arising in Elmod2 deletion lines. Deletion of either Elmod1 or Elmod3 results in the decreased ability of cells to form primary cilia, loss of a subset of proteins from cilia, and accumulation of some ciliary proteins at the Golgi, predicted to result from compromised traffic from the Golgi to cilia. These phenotypes are reversed upon activating mutant expression of either ARL3 or ARL16, linking their roles to ELMOD1/3 actions.

Basic surface electrocardiogram interpretation for the pharmacist.

PURPOSE: The electrocardiogram (ECG) is an invaluable tool for clinicians that provides important information about a patient's heart. As clinical pharmacists play an ever-increasing role in cardiovascular care, ECG interpretation is an important skill with which to become familiar. SUMMARY: The ECG provides information on both electrical and biomechanical aspects of the heart. Electrical information such as the rhythm, rate, and axis of the electrical activity can all be provided by the ECG. Biomechanical information about the heart, such as the presence of ventricular hypertrophy and repolarization changes that may be associated with ischemia or myocardial injury, can also easily be gleaned from the ECG. Furthermore, the ECG plays a central role in both the diagnosis and treatment of common clinical conditions such as atrial fibrillation, ischemic heart disease, and QT interval prolongation. CONCLUSION: The ECG is one of the most commonly performed diagnostic tests, and clinicians should become familiar with its basic interpretation.

Leadless solution for arrhythmia-related sudden unexpected death in epilepsy.

A leadless pacemaker is a recently approved pacing technology that helps mitigate lead-related complications, but it has several limitations. Careful candidate selection is needed. Here, we demonstrate leadless pacing as the solution for prolonged postictal bradycardia/asystole; there is no consensus regarding pacemaker implantation for seizure patients with such a risk of sudden cardiac death.

Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology.

With advances in technology, the physiological assessment of coronary artery disease in patients in the catheterization laboratory has become increasingly important in both clinical and research applications, but this assessment has evolved without standard nomenclature or techniques of data acquisition and measurement. Some questions regarding the interpretation, application, and outcome related to the results also remain unanswered. Accordingly, this consensus statement was designed to provide the background and evidence about physiological measurements and to describe standard methods for data acquisition and interpretation. The most common uses and support data from numerous clinical studies for the physiological assessment of coronary artery disease in the cardiac catheterization laboratory are reviewed. The goal of this statement is to provide a logical approach to the use of coronary physiological measurements in the catheterization lab to assist both clinicians and investigators in improving patient care.

Coronary pathophysiology in the cardiac catheterization laboratory.

While Coronary angiography remains the standard for the diagnosis and treatment of coronary artery disease within the cardiac catheterization lab, many lesion subsets require further investigation to determine their overall significance in causing symptoms. Direct measurement coronary flow and subsequently the ability to measure coronary pressure changes at maximal hyperemia have been developed to provide physiologic data to the catheterization operator which reveal the significance of coronary artery lesions in question and guide treatment. These measures, coronary flow reserve (CFR) and fractional flow reserve (FFR) have been validated against non-invasive tests for myocardial ischemia. Furthermore, FFR has also been studied in its ability to guide percutaneous coronary interventions in single vessel disease, multi-vessel disease, ostial side-branch lesions, and left main lesions.

Relation of timing of cardiac catheterization to outcomes in patients with non-ST-segment elevation myocardial infarction or unstable angina pectoris enrolled in the multinational global registry of acute coronary events.

We assessed whether timing of catheterization is associated with the type of non-ST-segment elevation acute coronary syndrome and/or outcome in patients who were enrolled in the Global Registry of Acute Coronary Events. Overall, 8,853 patients who had unstable angina pectoris or non-ST-elevation myocardial infarction were categorized according to timing of catheterization: expeditive (<24 hours), early (24 to 48 hours), and delayed (>48 hours). Patients in the delayed group were older, more frequently had previous myocardial infarction or stroke, and had a higher risk score compared with those in the expeditive and early groups (all p < or =0.001). Killip class IV at admission, non-ST-elevation myocardial infarction, and Q waves after the index electrocardiogram were more common in the expeditive group (all p <0.0001). Patients in the expeditive and early groups were treated more aggressively with medications than were those in the delayed group. The in-hospital composite end point (death, stroke, or major bleed) occurred most frequently in the expeditive group (expeditive 6.6%, early 3.9%, delayed 5.1%, p = 0.0005), as did in-hospital death (expeditive 3.5%, early 1.4%, delayed 2.0%, p <0.0001). The highest incidence of death during follow-up occurred in the delayed group (3.8% delayed vs 2.8% expeditive/early, p = 0.0210). Multivariate regression analysis suggested that expeditive catheterization was related to in-hospital death and death from time of catheterization to 6 months. We conclude that expeditive catheterization is associated with unstable presenting features that contribute significantly to the higher risk of death and death or myocardial infarction in hospital compared with patients who undergo later catheterization.

Treating patients with acute coronary syndromes with aggressive antiplatelet therapy (from the Global Registry of Acute Coronary Events).

Few data exist on the use of aggressive combination therapy with thienopyridines and glycoprotein IIb/IIIa inhibitors in higher risk patients with an acute coronary syndrome (ACS). The aim of this study was to characterize the combined use of these agents and the associated hospital outcomes in patients with ACS enrolled in the multinational Global Registry of Acute Coronary Events. Data from 8,081 patients with non-ST-segment elevation myocardial infarction or unstable angina were analyzed. Of these patients, 5,070 (62.7%) received aspirin and a thienopyridine, and the remainder received aspirin, a thienopyridine, and a glycoprotein IIb/IIIa blocker. The presence of a non-ST-segment elevation myocardial infarction; a history of diabetes or coronary artery bypass surgery; performance of in-hospital catheterization, percutaneous coronary intervention, or coronary artery bypass grafting; and in-hospital use of heparin were independent predictors of the use of triple antiplatelet therapy with aspirin, thienopyridines, and glycoprotein IIb/IIIa blockers. Increased diastolic blood pressure and increased serum creatinine were associated with a failure to prescribe triple therapy. An increased risk of major bleeding during hospitalization was associated with the use of triple antiplatelet therapy (odds ratio 1.6, 95% confidence interval 1.2 to 2.2). Aggressive antiplatelet therapy was used in approximately 2 of every 5 patients presenting with an ACS. Triple therapy was associated with the performance of catheterization and/or percutaneous coronary intervention, as well as high-risk patient features. Although no differences in hospital death rates were evident in patients receiving triple therapy, this population was at significantly increased risk of major bleeding episodes during hospitalization.

Myofibroblastic sarcoma of mitral valve: a case report.

We report a patient with symptoms of congestive heart failure whose workup revealed a myofibroblastic sarcoma of mitral valve.