Improved Screening Reduces Transesophageal Study Cancellations at a Large Tertiary Israeli Medical Center.

BACKGROUND: Cancellation of transesophageal echocardiography (TEE) tests leads to inefficient use of echocardiography laboratory (echo lab) time and wastes resources. OBJECTIVES: To identify the causes of same-day TEE cancellations in hospitalized patients, to formulate a TEE order screening protocol, and to evaluate its efficacy at implementation. METHODS: We performed a prospective analysis of inpatients referred to a single tertiary hospital echo lab for TEE study by inpatient wards. A comprehensive screening protocol emphasizing active participation of all links directly involved in the chain of inpatient TEE referral was developed and implemented. Comparison of pre- and post-implementation of the new screening protocol on two consecutive periods of 6 months on TEE cancellation rates out of total ordered TEEs stratified by cause categories was performed. RESULTS: : In total, 304 inpatient TEE procedures were ordered during the initial observation period; 54(17.8%) were canceled on the same day. The most common cancellation reasons were equally respiratory distress and patient not in fasted state (20.4% of total cancellations and 3.6% of all scheduled TEEs for each cause). Following implementation of the new screening process, total TEEs ordered (192) and cancelled (16) dropped significantly. A decrease in the rate of each cancellation category was observed, with statistical significance achieved for the overall cancellation rate (8.3% vs. 17.8%, P = 0.003), but not for the individual cancellation categories in split analysis. CONCLUSIONS: A concerted effort to implement a comprehensive screening questionnaire significantly reduced same-day cancellations of scheduled TEEs.

Temporary Trends in Fever following Transcatheter Aortic Valve Implantation.

OBJECTIVES: Fever following transcatheter aortic valve implantation (TAVI) is a common phenomenon, attributed mostly to inflammatory response which may impact outcome. Systemic inflammatory response may be triggered by multiple factors, most associated with the TAVI procedure itself. However, there are no data regarding the incidence of fever following TAVI in contemporary era with newer generation devices. Our primary objective was to measure temporal trends in fever incidence and features following TAVI. METHODS: We analyzed a retrospective cohort of 802 consecutive patients who underwent TAVI at our institution between November 2008 and February 2018. We identified and characterized all patients who developed fever (>38.0°C from any cause) within the first 72 h following the procedure and analyzed incidence and characteristics stratified into 3 time frames: 2008-2014, 2014-2016, and 2016-2018. RESULTS: Following TAVI, 190 (23.7%) patients developed fever (mean age 82.3 ± 5.2 years, 64.2% female). An infectious etiology was evident in only 32.1% of cases. The frequency decreased gradually and significantly across timeframes (32.8, 23.6, and 14.5%, respectively, p < 0.001). In a multivariate regression analysis, 1st generation CoreValve (HR 1.91; CI 95% 1.2-3.04, p = 0.006) was found to be associated with higher incidence of fever in addition to female gender, vascular complications, transfemoral access, and reduced GFR. CONCLUSIONS: Fever incidence post TAVI decreased significantly throughout the last decade. The higher rate of fever in the early years of TAVI was likely associated with first-generation devices, vascular complications, and reduced GFR.

Severe aortic stenosis echocardiographic thresholds revisited.

BACKGROUND: In view of inconsistencies in threshold values of severe aortic stenosis (AS) hemodynamic indices, it is unclear what is the relative contribution of each variable in a binary classification of AS based on aortic valve replacement (AVR) indication. We aimed to assess relative discriminative value and optimal threshold of each constituent hemodynamic parameter for this classification and confirm additional prognostic value. METHODS: Echocardiography studies of 168 patients with ≥ moderate AS were included. AS types were dichotomized into Group-A, comprising moderate and Normal-Flow Low-Gradient (NFLG), and Group-B, comprising High-Gradient(HG), Low Ejection Fraction Low-Flow Low-Gradient(Low EF-LFLG), and Paradoxical Low-Flow Low-Gradient(PLFLG) AS. Aortic valve area (AVA), Doppler velocity index (DVI), peak aortic velocity, mean gradient, stroke volume index and transaortic flow rate(TFR) were assessed for A/B Group discrimination value and optimal thresholds were determined. Dichotomized values were assessed for predictive value for AVR or death. RESULTS: C-statistic values for binary AS classification was .74-.9 for the tested variables. AVA and DVI featured the highest score, and SVI the lowest one. AVA≤.81 cm2 and DVI≤.249 had 87.6% and 86% respective sensitivity for Group B patients, and a similar specificity of 80.9%. During a mean follow-up of 9.1±10.1 months, each of the tested dichotomized variables except for SVI predicted AVR or death on multivariate analysis. CONCLUSION: An AVA value ≤.81 cm2 or a DVI ≤ .249 threshold carry the highest discriminative value for severe AS in patients with aortic stenosis, translating into an independent prognostic value, and can be helpful in making clinical decisions.

Long-term Israeli Single-Center Experience with the Percutaneous MitraClip Procedure.

BACKGROUND: The MitraClip procedure is becoming an acceptable alternative for high-risk patients with mitral regurgitation (MR) due to functional (FMR) or degenerative (DMR) disease and suitable mitral anatomy. OBJECTIVES: To evaluate the results of MitraClip at our institute in carefully selected patients. METHODS: We conducted a retrospective analysis of medical records and echocardiography data from January 2012 to December 2017. RESULTS: A total of 39 MitraClip procedures in 37 patients (aged 75 ± 12 years, 9 women) was performed. Twenty-four patients presented with FMR, 12 with DMR, and 1 with combined pathology. One-day post-procedure MR was moderate to low in 86.1% of patients, with immediate device success in 88.8%. MR at 1 year was moderate to low in 79% at 1 year. Survival at 1 year was 86% and at 2 years 69.4%. Peri-procedural (< 1 week) death and MitraClip failure occurred in one and three patients, respectively. New York Heart Association score improved to class 1 or 2 in 37% of patients at 1 year vs. one patient at baseline. Post-procedural systolic pulmonary pressure was reduced from 53 (range 48-65) to 43 (range 36-52) mmHg at 1 month with a subsequent plateau at follow-up, to 41 (34-57) mmHg at 6 months, and to 47 (38-50) at 12 months. CONCLUSIONS: MitraClip in severe MR resulted in modest improvement in functional status and pulmonary pressure with a small risk of immediate procedural complications. Outcomes are encouraging considering the natural course of MR and the risks of surgical intervention.

Case records of the Massachusetts General Hospital: Case 5-2014: 2014: A 59-year-old man with fever, confusion, thrombocytopenia, rash, and renal failure.

A 59-year-old man was admitted to this hospital because of fever, confusion, rash, thrombocytopenia, and renal failure, 10 days after a hunting trip in the Nevada valley. Diagnostic procedures were performed, and diagnostic test results were received from another hospital.

Incremental Value of Transesophageal Echocardiography Integrated with Transthoracic Echocardiography in the Assessment of Aortic Stenosis Severity.

BACKGROUND: Transthoracic echocardiography (TTE) is the standard method for evaluating the severity of aortic stenosis (AS), while transesophageal echocardiography (TEE) is useful for morphologic characterization. The study aim was to assess the impact of complementary TEE to TTE in refining hemodynamic assessment of AS severity. METHODS: A retrospective analysis was conducted of sequential TTE and TEE studies performed in 100 patients with moderate or severe AS confirmed on prior TTE. The left ventricular outflow tract (LVOT) velocity-time-integral (VTI1) and the aortic valve velocity-time integral (VTI2) were measured for both modalities. The highest values of VTI1 and VTI2 and mean gradients and peak velocities were selected from the sequential TTE/TEE study for indexed aortic valve area (AVAi) calculation and AS severity determination through an integrated assessment. RESULTS: AVAi determined by TTE was not significantly different from that determined by TEE (mean difference -0.008 cm2; p = 0.38). The dimensionless velocity index (DVI) was higher when assessed by TTE than by TEE (mean difference 0.0126 ± 0.04; p = 0.003). Using the integrated AS assessment, six of 13 patients with a TTE-based diagnosis of moderate AS were re-classified as severe AS. A slight lowering of the recommended TTE-derived DVI threshold for severe AS, from 0.25 to 0.24, improved the ability to discriminate moderate versus severe AS, as determined by the integrated assessment. CONCLUSIONS: TEE integrated with TTE may improve the detection of severe AS, particularly in patients with moderate AS criteria assessed by TTE, but with a DVI ratio ≤0.24.

[AORTIC DISSECTION DIAGNOSED BY THE SUPRASTERNAL ECHOCARDIOGRAPHIC VIEW].

INTRODUCTION: Patients with suspected dissection of the thoracic aorta require immediate diagnostic evaluation so that urgent therapeutic interventions can begin. We present a case of aortic dissection with an atypical initial presentation mimicking acute pericarditis, in which the correct diagnosis was made on the basis of the suprasternal view of transthoracic echocardiography.

Aortic Valve Gradient and Clinical Outcome in Patients Undergoing Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis.

OBJECTIVES: To explore the relation between the baseline aortic valve gradient (AVG) as a continuous variable and clinical outcomes following transcatheter aortic valve implantation (TAVI) in general and specifically in patients with high-gradient aortic stenosis (AS). METHODS: We reviewed 317 consecutive patients who underwent TAVI at our institution. We investigated the relation between AVG as a continuous/categorical variable and outcome among all patients and in patients without low-flow low-gradient AS, using the Cox proportional hazard model adjusting for multiple prognostic variables. RESULTS: Patients had a peak AVG of 79.9 ± 22.8 mm Hg (mean 50.5 ±15.7). During a mean follow-up of 2.7 years, AVG was inversely associated with mortality and mortality or cardiac hospitalization. Every 10-mm-Hg increase in peak AVG was associated with 18% reduction in mortality (p = 0.003) and 19% reduction in mortality/cardiac hospitalization (p < 0.001). Every 10-mm-Hg increase in mean AVG was associated with a 24% reduction in both outcomes (p = 0.005 and p < 0.001). Subgroup analysis of patients with left-ventricular ejection fraction >40% or peak AVG >64 mm Hg yielded similar results. CONCLUSIONS: Mean and peak baseline AVGs are directly associated with improved outcomes after TAVI; AVG can be used to select the patients most likely to benefit from TAVI.

Mechanical heart valve thrombosis in pregnancy.

Effective anticoagulation is critical in patients with mechanical prosthetic heart valve (MPHV), but remains challenging in pregnancy because both oral anticoagulation and heparins are associated with important fetal and maternal risks. A 33-year-old high-risk pregnant woman presented with MPHV thrombosis during early pregnancy. Resolution of the thrombus and eventual resumption of normal prosthetic mitral valve function was obtained through treatment with low-molecular weight heparin (LMWH). This case of early pregnancy MPHV thrombosis emphasized the importance of adequate initial coagulation prior to pregnancy and the potential need to extend measurements to both peak and trough levels to assure an adequate level of anticoagulation in women with MPHV treated with LMWH during pregnancy.

Low circulating monocyte count is associated with severe aortic valve stenosis.

BACKGROUND: The pathophysiology of aortic stenosis (AS) involves inflammatory features including infiltration of the aortic valve (AV) by activated macrophages and T cells, deposition of lipids, and heterotopic calcification. OBJECTIVES: To evaluate the correlation between white blood cell (WBC) differential count and the occurrence and progression of AS. METHODS: We identified in our institutional registry 150 patients with AS who underwent two repeated echo studies at least 6 months apart. We evaluated the association between the average of repeated WBC differential counts sampled during the previous 3 years and subsequent echocardiographic AS indices. RESULTS: There was no significant difference in total WBC, lymphocyte or eosinophil count among mild, moderate or severe AS groups. There was a progressive decrease in monocyte count with increasing AS severity (P = 0.046), more prominent when comparing the mild and severe groups. There was a negative correlation between AV peak velocity or peak or mean gradient and monocyte count in the entire group (r = -0.31, -0.24, and -0.25 respectively, all P < 0.01). Similar partial correlations controlling for age, gender, hypertension, smoking, dyslipidemia and ejection fraction remained significant. The median changes over time in peak velocity and peak gradients in AS patients were 0.44 (0-1.3) m/sec/ year and 12 (0-39) mmHg/year, respectively. There was no correlation between any of the WBC differential counts and the change in peak velocity or peak gradient per year. CONCLUSIONS: Severe AS is associated with decreased total monocyte count. These findings may provide further clues to the mechanism underlying the pathogenesis of aortic stenosis.

Primary cardiac mesothelioma presenting with fulminant recurrent pericarditis: a case report.

Background: Primary pericardial mesothelioma is an extremely rare disease. Prognosis is poor, with little effects of chemo- or radio-therapy. The majority of cases is diagnosed at autopsy. Case summary: A 22-year-old man, who presented with recurrent pericarditis and large pericardial effusion 2 months after a second BNT162b2 COVID-19 vaccine, underwent pericardiocentesis and pericardial window. Pathology specimen of pericardium revealed benign mesothelial inflammation, consistent with acute pericarditis. Four months later, he presented with a large pericardial mass manifesting in heart failure and underwent urgent pericardiectomy. A new pathology specimen immunostaining and fluorescence in situ hybridization analysis revealed pericardial mesothelioma. Despite intensive care, the patient died 3 weeks later. Discussion: Primary pericardial mesothelial should be considered in the differential diagnosis of refractory recurrent pericarditis, even with prior biopsy-proven pericarditis or when a putative trigger (COVID-19 mRNA prior vaccination) is suspected, as was the case in this patient. Tumour diagnosis and identification consist of multimodal imaging and laboratory tests. A multidisciplinary, individualized care approach should be performed.

Progression of Non-Significant Mitral and Tricuspid Regurgitation after Surgical Aortic Valve Replacement for Aortic Regurgitation.

Little is known about the natural history of non-significant mitral and tricuspid regurgitation (MR and TR) following surgical aortic valve replacement (SAVR) for aortic regurgitation (AR). We retrospectively analyzed 184 patients (median age 64 (IQR, 55-74) years, 76.6% males) who underwent SAVR for AR. Subjects with significant non-aortic valvulopathies, prior/concomitant valvular interventions, or congenital heart disease were excluded. The cohort was evaluated for MR/TR progression and, based on the latter's occurrence, for echocardiographic and clinical indices of heart failure and mortality. By 5.8 (IQR, 2.8-11.0) years post-intervention, moderate or severe MR occurred in 20 (10.9%) patients, moderate or severe TR in 25 (13.5%), and either of the two in 36 (19.6%). Patients who developed moderate or severe MR/TR displayed greater biventricular disfunction and functional limitation and were less likely to be alive at 7.0 (IQR, 3.4-12.1) years compared to those who did not (47.2 vs. 79.7%, p < 0.001). The emergence of significant MR/TR was associated with preoperative atrial fibrillation/flutter, symptomatic heart failure, and above-mild MR/TR as well as concomitant composite graft use, but not with baseline echocardiographic measures of biventricular function and dimensions, aortic valve morphology, or procedural aspects. In conclusion, among patients undergoing SAVR for AR, significant MR/TR developed in one fifth by six years, correlated with more adverse course, and was anticipated by baseline clinical and echocardiographic variables.

Acute Reduction in Left Ventricular Function Following Transcatheter Mitral Edge-to-Edge Repair.

Background Little is known about the impact of transcatheter mitral valve edge-to-edge repair on changes in left ventricular ejection fraction (LVEF) and the effect of an acute reduction in LVEF on prognosis. We aimed to assess changes in LVEF after transcatheter mitral valve edge-to-edge repair for both primary and secondary mitral regurgitation (PMR and SMR, respectively), identify rates and predictors of LVEF reduction, and estimate its impact on prognosis. Methods and Results In this international multicenter registry, patients with both PMR and SMR undergoing transcatheter mitral valve edge-to-edge repair were included. We assessed rates of acute LVEF reduction (LVEFR), defined as an acute relative decrease of >15% in LVEF, its impact on all-cause mortality, major adverse cardiac event (composite end point of all-cause death, mitral valve surgery, and residual mitral regurgitation grade ≥2), and LVEF at 12 months, as well as predictors for LVEFR. Of 2534 patients included (727 with PMR, and 1807 with SMR), 469 (18.5%) developed LVEFR. Patients with PMR were older (79.0±9.2 versus 71.8±8.9 years; P<0.001) and had higher mean LVEF (54.8±14.0% versus 32.7±10.4%; P<0.001) at baseline. After 6 to 12 months (median, 9.9 months; interquartile range, 7.8-11.9 months), LVEF was significantly lower in patients with PMR (53.0% versus 56.0%; P<0.001) but not in patients with SMR. The 1-year mortality was higher in patients with PMR with LVEFR (16.9% versus 9.7%; P<0.001) but not in those with SMR (P=0.236). LVEF at baseline (odds ratio, 1.03 [95% CI, 1.01-1.05]; P=0.002) was predictive of LVEFR for patients with PMR, but not those with SMR (P=0.092). Conclusions Reduction in LVEF is not uncommon after transcatheter mitral valve edge-to-edge repair and is correlated with worsened prognosis in patients with PMR but not patients with SMR. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05311163.

The "obesity paradox": does it persist among Israeli patients with decompensated heart failure? A subanalysis of the Heart Failure Survey in Israel (HFSIS).

BACKGROUND: Earlier studies among heart failure (HF) patients reported a paradox of reduced mortality rates in those with increased body mass index (BMI). Recently, however, it has been shown that obesity was not associated with better prognosis in certain groups. The aim of this study was to evaluate the "obesity paradox" among patients included in the Heart Failure Survey in Israel (HFSIS). METHODS AND RESULTS: Clinical, demographic, and laboratory characteristics of 2,323 patients hospitalized with a diagnosis of acute or decompensated chronic HF in 25 public Israeli hospitals between March 1 and April 30, 2003, were categorized by BMI as: normal weight (18.5-24.9 kg/m(2); n = 837), overweight (25.0-29.9 kg/m(2); n = 877), or obese (≥30.0 kg/m(2); n = 574), excluding 35 patients with BMI <18.5 kg/m(2). Survival over 15 months was inversely related to BMI category. Age-adjusted mortality hazard ratio (HR) was 0.95 (95% confidence interval [CI] 0.79-1.14) for overweight patients and 0.70 (95% CI 0.55-0.88) for obese patients compared with normal-weight patients. After further adjustment for gender, ejection fraction, New York Heart Association functional class, ischemic heart disease, diabetes, hypertension, dyslipidemia, renal function, and medications (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, ß-blocker, spironolactone), obesity was associated with a nonsignificant HR of 0.79 (95% CI 0.59-1.05). Hypertension and dyslipidemia were also paradoxically associated with better survival in our model (HR 0.74, CI 0.59-0.92; and HR 0.77, CI 0.63-0.94; respectively; both P < .05). CONCLUSIONS: Our study falls in line with the obesity paradox observation (in obese but not overweight patients) in a large survey of HF patients, although this finding was not statistically significant on multivariate adjustment analysis.

Comparison of Simultaneous Transthoracic Versus Transesophageal Echocardiography for Assessment of Aortic Stenosis.

Transthoracic echocardiography (TTE) is the gold standard for aortic stenosis (AS) assessment. Transesophageal echocardiography (TEE) provides better resolution, but its effect on AS assessment is unclear. To answer this question, we studied 56 patients with ≥moderate AS. Initial TTE (TTE1) was followed by conscious sedation with simultaneous TEE and TTE2. Based on conservative versus actionable implication, AS types were dichotomized into group A, comprising moderate and normal-flow low-gradient, and group B, comprising high gradient, low ejection fraction low-flow low-gradient, and paradoxical low-flow low-gradient AS. Paired analysis of echocardiographic variables and AS types measured by TEE versus TTE2 and by TEE versus TTE1 was performed. TEE versus simultaneous TTE2 comparison demonstrated higher mean gradients (31.7 ± 10.5 vs 27.4 ± 10.5 mm Hg) and velocities (359 ± 60.6 vs 332 ± 63.1 cm/s) with TEE, but lower left ventricular outflow velocity-time-integral (VTI1) (18.6 ± 5.1 vs 20.2 ± 6.1 cm), all p <0.001. This resulted in a lower aortic valve area (0.8 ± 0.21 vs 0.87 ± 0.28 cm2), p <0.001, and a net relative risk of 1.86 of group A to B upgrade. TEE versus (awake state) TTE1 comparison revealed a larger decrease in VTI1 because of a higher initial awake state VTI1 (22 ± 5.6 cm), resulting in similar Doppler-velocity-index and aortic valve area decrease with TEE, despite a slight increase in mean gradients of 0.8 mm Hg (confidence interval -1.44 to 3.04) and velocities of 10 cm/s (confidence interval -1.5 to 23.4). This translated into a net relative risk of 1.92 of group A to B upgrade versus TTE1. In conclusion, TEE under conscious sedation overestimates AS severity compared with both awake state TTE and simultaneous sedation state TTE, accounted for by different Doppler insonation angles obtained in transapical versus transgastric position.

Increased risk of non-hematological cancer in young patients with aortic stenosis: a retrospective cohort study.

BACKGROUND: We have previously reported an increased risk for non-hematological malignancies in young patients with moderate or severe aortic stenosis (AS). These findings were the result of a post-hoc analysis from a large echocardiography database and needed verification. Our aim was to determine, using a different study population, whether young patients with AS are at increased risk for cancer. METHODS: A large echocardiographic database was used to identify patients (age ≥ 20 years) with moderate or severe AS (study group) and patients without aortic stenosis (comparative group). The new occurrence of non-hematological malignancies was determined after the index date (first echo with moderate or severe AS or first recorded echo in the control group). RESULTS: The final study group included 7013 patients with AS and 98,884 without AS. During a median follow-up of 6.9 years (3.0-11.1) there were 10,705 new cases of non-hematological cancer. The crude incidence rate of cancer was higher in AS compared to non-AS patients (22.3 vs. 13.7 per 1000 patient-year, crude HR 1.58 (95%CI 1.46-1.71). After adjustment for relevant covariates, there was no difference between groups (HR 0.93, 95% CI 0.86-1.01). Only patients in the lowest age quartile (20-49.7 years), had an increased adjusted risk of cancer (HR 1.91, 95%CI 1.08-3.39). The HR for the risk of cancer associated with AS was inversely proportional to age (P < 0.001 for the interaction between AS and age). CONCLUSIONS: Young patients with moderate or severe AS may have an increased risk for cancer. Cancer surveillance should be considered for young patients with AS.

Effect of Transcatheter Aortic Valve Replacement on Concomitant Mitral Regurgitation and Its Impact on Mortality.

OBJECTIVES: The purpose of this study was to examine the impact of residual mitral regurgitation (MR) on mortality in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND: MR is common in patients undergoing TAVR. Data on optimal management of patients with significant MR after TAVR are limited. METHODS: The registry consisted of 16 TAVR centers (n = 7,303). Outcomes of patients with ≥ moderate versus lesser grade MR after TAVR were compared. RESULTS: In 1,983 (27.2%) patients, baseline MR grade was ≥ moderate. MR regressed in 874 (44.1%) patients and persisted in 1,109 (55.9%) after TAVR. Four-year mortality was higher for those with MR persistence, but not for those with MR regression after TAVR, compared with nonsignificant baseline MR (43.8% vs. 35.1% vs. 32.4%; hazard ratio [HR]: 1.38; p = 0.008; HR: 1.02; p = 0.383, respectively). New York Heart Association functional class III to IV after TAVR was more common in those with MR persistence vs. regression (14.4% vs. 3.9%; p < 0.001). In a propensity score-matched cohort (91 patients' pairs), with significant residual MR after TAVR who did or did not undergo staged mitral intervention, staged intervention was associated with a better functional class through 1 year of follow-up (82.4% vs. 33.3% New York Heart Association functional class I or II; p < 0.001), and a numerically lower 4-year mortality, which was not statistically significant (64.6% vs. 37.5%; HR: 1.66; p = 0.097). CONCLUSIONS: Risk stratification based on improvement in MR and symptoms after TAVR can identify patients at increased mortality risk after TAVR. These patients may benefit from a staged transcatheter mitral intervention, but this requires further proof from future studies. (Transcatheter Treatment for Combined Aortic and Mitral Valve Disease. The Aortic+Mitral TRAnsCatheter [AMTRAC] Valve Registry [AMTRAC]; NCT04031274).

Cardiac tamponade or normal respiratory variation? An illustrative case of septal ablation for obstructive hypertrophic cardiomyopathy.

Cardiac tamponade can be a lethal complication in the cardiac catheterization laboratory. Patients with obstructive hypertrophic cardiomyopathy are particularly vulnerable to the hemodynamic effects of tamponade because of their heightened sensitivity to ventricular load in the generation of forward stroke volume. Cardiac tamponade should be distinguished from the normal effects of respiration on dynamic outflow tract obstruction in these patients. This recognition not only ensures an accurate hemodynamic diagnosis, but it also will expedite timely therapy for patients in need.

Comparative efficacy analysis of an aspiration device before primary angioplasty in patients with acute myocardial infarction: a single-center experience.

BACKGROUND: ST-elevation myocardial infarction is caused by occlusive coronary thrombosis where antecedent plaque disruption occurs. When treating STEMI the main goal is to achieve prompt reperfusion of the infarction area. Several studies have demonstrated the efficacy of an aspiration device before percutaneous coronary intervention in patients with acute myocardial infarction. OBJECTIVES: To determine the added value of thrombus aspiration prior to primary PCI by comparing AMI patients with totally occluded infarct-related artery treated with routine primary PCI to those treated with extraction device prior to primary PCI. METHODS: The study group comprised 122 consecutive patients with AMI and a totally occluded infarct artery (TIMI flow 0) who underwent primary PCI. The patients were divided into two groups: 68 who underwent primary PCI only (control group) and 54 who underwent primary thrombus extraction with an extraction device before PCI (extraction group). Baseline clinical and lesion characteristics were similar in both groups. Final TIMI grade flow and myocardial blush as well as 1 year mortality, target lesion revascularization, recurrent myocardial infarction, unstable angina and stroke were compared between the two groups. RESULTS: Primary angiographic results were better for the extraction group versus the control group: final grade 3 TIMI flow was 100% vs. 95.6% (P= 0.03) and final grade 3 myocardial blush grade 50% vs. 41.18% (although Pwas not significant). Long-term follow-up total MACE showed a nonsignificant positive trend in the extraction group (12.96% vs. 24.71%, P= 0.26). CONCLUSIONS: The use of extraction devices for intracoronary thrombectomy during primary PCI in patients with totally occluded infarct artery significantly improved epicardial reperfusion in the infarct-related vessel and showed a trend for more favorable long-term outcome.