RESUMEN
A 38-year-old pregnant patient was managed by the cardio-obstetrics multidisciplinary team for severe degenerative bioprosthetic aortic valve failure. She was medically managed utilizing echocardiogram and brain natriuretic peptide until she demonstrated worsening heart failure. A valve and cardio-obstetrics team evaluation led to valve-in-valve transcatheter aortic valve replacement at 30 weeks' gestation.
RESUMEN
BACKGROUND: Coronary artery dissection is a feared and potentially life-threatening complication of percutaneous coronary intervention (PCI). METHODS: We examined the clinical, angiographic, and procedural characteristics, and outcomes of coronary dissection at a tertiary care institution. RESULTS: Between 2014 and 2019, unplanned coronary dissection occurred in 141 of 10,278 PCIs (1.4%). Median patient age was 68 (60, 78) years, 68% were men, and 83% had hypertension. The prevalence of diabetes (29%), and prior PCI (37%) was high. Most target vessels were significantly diseased: 48% had moderate/severe tortuosity and 62% had moderate/severe calcification. The most common cause of dissection was guidewire advancement (30%), followed by stenting (22%), balloon angioplasty (20%), and guide-catheter engagement (18%). TIMI flow was 0 in 33% and 1-2 in 41% of cases. Intravascular imaging was used in 17% of the cases. Stenting was used to treat the dissection in 73% of patients. There was no consequence of dissection in 43% of patients. Technical and procedural success was 65% and 55%, respectively. In-hospital major adverse cardiovascular events occurred in 23% of patients: 13 (9%) had an acute myocardial infarction (MI), 3 (2%) had emergency coronary artery bypass graft surgery, and 10 (7%) died. During a mean follow up of 1612 days, 28 (20%) patients died, and the rate of target lesion revascularization was 11.3% (n=16). CONCLUSION: Coronary artery dissection is an infrequent complication of PCI, but is associated with adverse clinical outcomes, such as death and acute MI.
Asunto(s)
Disección Aórtica , Infarto del Miocardio , Intervención Coronaria Percutánea , Masculino , Humanos , Femenino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Incidencia , Resultado del Tratamiento , Angiografía Coronaria , Infarto del Miocardio/etiologíaRESUMEN
BACKGROUND: Provisional stenting is the most commonly used coronary bifurcation stenting strategy. METHODS: We examined the clinical and angiographic characteristics, challenges encountered, and procedural outcomes with the provisional bifurcation stenting strategy in the Prospective Global Registry of Percutaneous Coronary Intervention (PCI) in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). RESULTS: Provisional stenting was used in 334 of 430 bifurcation interventions (78%). Technical success was lower (95% vs. 100%, p = 0.017) in provisional, but procedural success (90% vs. 95%, p = 0.095) and incidence of in-hospital major adverse cardiovascular events were similar (5% vs. 5%, p = 0.945) compared with two-stent strategies. Provisional was less often preferred in left main/left anterior descending involvement (47% vs. 73%, p < 0.001). Provisional stenting cases had smaller side branch (SB) diameter (2.4 ± 0.5 vs. 2.7 ± 0.6 mm, p < 0.001), shorter SB lesion length (5 [3-8] vs. 10 [5-10] mm, p < 0.001), less SB diameter stenosis (46 ± 35 vs. 81 ± 20%, p < 0.001), and were less likely to be Medina 1,1,1 (34% vs. 73%, p < 0.001). PCI challenges were less common (30% vs. 58%, p < 0.001) with provisional stenting: (1) rewiring difficulty (43%) that was overcome with use of a different wire (74%) or microcatheter (46%); (2) inability to deliver a stent (22%) or balloon (9%) that was overcome with use of a smaller balloon (88%), rewiring (25%), or increased support/microcatheter (25%). CONCLUSIONS: Provisional bifurcation stenting was more often performed in distal lesions with less SB involvement and had lower technical success, but similar procedural success and complications compared with two-stent strategies.
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Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Humanos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/efectos adversos , Estudios Prospectivos , Sistema de Registros , Stents , Resultado del Tratamiento , Ensayos Clínicos como AsuntoRESUMEN
OBJECTIVES: To examine the incidence, treatment and outcomes of perforation during percutaneous coronary intervention (PCI). BACKGROUND: Coronary perforation is a potentially life-threatening PCI complication. METHODS: We examined the clinical, angiographic, and procedural characteristics, management, and outcomes of coronary perforation at a tertiary care institution. RESULTS: Between 2014 and 2019, perforation occurred in 70 of 10,278 PCIs (0.7%). Patient age was 71 ± 12 years, 66% were men, and 30% had prior coronary artery bypass graft surgery. Among perforation cases, the prevalence of chronic total occlusions was 33%, moderate/severe calcification was 66% and moderate/severe tortuosity was 41%. The frequency of Ellis class 1, 2, and 3 perforations was 14%, 50%, and 36%, respectively. Most (n = 51; 73%) were large vessel perforations, 16 (23%) were distal vessel perforations and 3 (4%) were collateral vessel perforations (1 septal and 2 epicardial). Hypotension occurred in 26%, pericardial effusion in 36% and tamponade in 13%; 47% of perforations did not have clinical consequences. Perforations were most often treated with prolonged balloon inflation (63%), reversal of anticoagulation (39%), and covered stent implantation (33%). Technical and procedural success were 73% and 60%, respectively, and major periprocedural adverse cardiac events occurred in 21% of the patients. Three patients (4%) required emergent CABG surgery and four (6%) died. CONCLUSIONS: Coronary perforation is an infrequent complication of PCI. Most perforations are large vessel perforations and often require further intervention. The incidence of death or emergent cardiac surgery is low.
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Lesiones Cardíacas , Intervención Coronaria Percutánea , Lesiones del Sistema Vascular , Anciano , Anciano de 80 o más Años , Angiografía Coronaria , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Femenino , Lesiones Cardíacas/diagnóstico , Lesiones Cardíacas/epidemiología , Lesiones Cardíacas/etiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico , Lesiones del Sistema Vascular/epidemiología , Lesiones del Sistema Vascular/etiologíaRESUMEN
BACKGROUND: Percutaneous coronary interventions (PCI) with intravascular ultrasound (IVUS) guidance have been associated with better long-term outcomes, but adoption remains limited. There are limited data on the impact of IVUS on chronic total occlusion (CTO)-PCI. OBJECTIVES: To examine the impact of IVUS guidance on the outcomes of CTO-PCI. METHODS: We performed a systematic review and study-level meta-analysis of IVUS vs angiography-guided CTO-PCI. Electronic databases were systematically searched for all pertinent studies from inception through January 2021. Randomized controlled trials (RCT), registry data, and abstracts published in peer-reviewed indexed journals were included. We examined the following in-hospital and long-term outcomes: major adverse cardiac events; all-cause mortality; cardiovascular mortality; myocardial infarction (MI); target-vessel revascularization (TVR); target-lesion revascularization (TLR); and stent thrombosis (ST). We also evaluated the following procedural metrics: procedure time; fluoroscopy time; contrast volume; total stent length; and total number of stents. Random-effects models were used to pool individual study results. RESULTS: Four (2 observational, 2 randomized) studies including 1975 patients (IVUS-guided PCI, 861 patients; angiography-guided PCI, 1114 patients) were included in the analysis. IVUS-guided CTO-PCI had similar all-cause mortality, major adverse cardiac events, cardiovascular mortality, MI, TVR, and TLR compared with angiography-guided CTO-PCI, but lower risk of stent thrombosis (odds ratio, 0.24; 95% confidence interval, 0.08-0.76; P=.02; I²=0%), shorter procedure time (P<.001; I²=88%), shorter fluoroscopy time (P<.001; I²=63%), and less contrast volume use (P<.001; I²=59%). Total stent length (P<.001; I²=39%) and total number of stents (P<.001; I²=72%) were lower with IVUS-guided CTO-PCI. CONCLUSION: IVUS-guided CTO-PCI is associated with lower risk of ST.
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Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Angiografía Coronaria , Humanos , Intervención Coronaria Percutánea/métodos , Ultrasonografía , Ultrasonografía Intervencional/métodosRESUMEN
BACKGROUND: Although the double kissing (DK) crush stenting technique can provide excellent outcomes in percutaneous coronary intervention (PCI) of bifurcation lesions, it can be challenging to perform. METHODS: We examined the clinical and angiographic characteristics, challenges encountered, and procedural outcomes of bifurcation PCI with DK crush in Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). RESULTS: DK crush was used in 48 of 435 bifurcation lesions (11%). Technical success was 100%, procedural success was 96%, and the incidence of in-hospital major adverse cardiovascular events was 4%. Challenges while performing DK crush were encountered in 26 lesions (54%): (1) difficulty in side branch (SB) first rewiring (38%) that was overcome with the use of a new guidewire (30%) or a microcatheter (15%); (2) inability to deliver balloon to an SB for the first kiss (54%) that was overcome with the use of a smaller balloon (86%), rewiring (29%), microcatheter (14%), and increased support 7%; (3) difficulty in SB second rewiring (19%) that was overcome with the use of a new guidewire (80%) and/or microcatheter (60%). DK crush was more often performed in left main and proximal left anterior descending artery lesions (70% vs. 50%, p = 0.014). DK crush cases required more contrast (198 ± 84 ml vs. 163 ± 70 ml, p = 0.003), fluoroscopy time (35 ± 20 min vs. 25 ± 21 min, p = 0.004), and lasted longer (137 ± 69 min vs. 99 ± 66 min, p = 0.001) compared with non-DK crush techniques. CONCLUSIONS: While challenges are common when performing DK crush bifurcation stenting, success rates are high and complication rates are low.
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Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/etiología , Enfermedad de la Arteria Coronaria/terapia , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Estudios Prospectivos , Sistema de Registros , Stents , Resultado del TratamientoRESUMEN
OBJECTIVES: The aims of this study were to describe trends and hospital variation in same-day discharge following elective percutaneous coronary intervention (PCI) and to evaluate the association between trends in same-day discharge and patient outcomes. BACKGROUND: Insights on contemporary use of same-day discharge following elective PCI are limited. METHODS: In a sequential cross-sectional analysis of 819,091 patients undergoing elective PCI at 1,716 hospitals in the National Cardiovascular Data Registry CathPCI Registry from July 1, 2009, to December 31, 2017, overall and hospital-level trends in same-day discharge were assessed. Among the 212,369 patients who linked to Centers for Medicare and Medicaid Services data, the association between same-day discharge and 30-day mortality and rehospitalization was assessed. RESULTS: A total of 114,461 patients (14.0%) were discharged the same day as PCI. The proportion of patients with same-day discharge increased from 4.5% in the third quarter of 2009 to 28.6% in the fourth quarter of 2017. From 2009 to 2017, the rate of same-day discharge increased from 4.3% to 19.5% for femoral-access PCI and from 9.9% to 39.7% for radial-access PCI. Hospital-level variation in the use of same-day discharge persisted throughout (median odds ratio adjusted for year and radial access: 4.15). Risk-adjusted 30-day mortality did not change over time, while risk-adjusted rehospitalization decreased over time and more quickly for same-day discharge (P for interaction <0.001). CONCLUSIONS: In the past decade, a large increase in the use of same-day discharge following elective PCI was not associated with worse 30-day mortality or rehospitalization. Hospital-level variation in same-day discharge may represent an opportunity to reduce costs without compromising patient outcomes.
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Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Anciano , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Estudios Transversales , Humanos , Tiempo de Internación , Medicare , Alta del Paciente , Intervención Coronaria Percutánea/efectos adversos , Sistema de Registros , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: To examine the outcomes of vascular brachytherapy (VBT) for recurrent drug-eluting stents (DES) in-stent restenosis (ISR). BACKGROUND: Recurrent DES-ISR can be challenging to treat. VBT has been used with encouraging results. METHODS: We report the long-term outcomes of patients with recurrent DES-ISR treated with VBT between January 2014 and September 2018 at a tertiary care institution. The main outcome was target lesion failure (TLF), defined as the composite of clinically driven target lesion revascularization (TLR), target lesion myocardial infarction (MI), and target lesion-related cardiac death. Cox proportional hazards analysis was performed to identify variables associated with recurrent TLF. RESULTS: During the study period, 116 patients (143 lesions) underwent VBT. Median follow-up was 24.7 (14.5-35.4) months. The incidence of TLR, target-lesion MI, and TLF was 18.9%, 5.6%,and 20.1% at 1 year, and 29.4%, 10.5%, and 32.9% at 2 years.Initial presentation with acute coronary syndrome (ACS) was independently associated with TLF (hazard ratio = 1.975, 95% CI [1.120, 3.485], p = .019). Lesions treated with intravascular ultrasound (IVUS) guidance had a lower incidence of TLR (14.3% vs. 39.6%, log-rank p = .038), and a trend toward lower incidence of TLF (19% vs. 42.6%, log-rank p = .086). CONCLUSIONS: VBT can improve the treatment of recurrent DES-ISR, but TLF occurs in approximately one in three patients at 2 years. Initial presentation with ACS was associated with higher TLF and the use of IVUS with a trend for lower incidence of TLF.
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Braquiterapia , Reestenosis Coronaria , Stents Liberadores de Fármacos , Preparaciones Farmacéuticas , Braquiterapia/efectos adversos , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Reestenosis Coronaria/terapia , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND: We sought to describe changes in demographic variables, process of care measures, and outcomes of patients treated in a regional ST-segment elevation myocardial infarction (STEMI) program over the last 15 years. METHODS: We describe demographic variables, process of care measures, and outcomes of patients treated in the program in various 5-year time periods: 2003-2007 (n = 1,821), 2008-2012 (n = 1,968), and 2013-2018 (n = 2,223). The primary outcome measures were in-hospital and 30-day mortality. RESULTS: Among 6,012 STEMI patients treated from 2003 to 2018 we observed a significant increase in mean age at presentation (62 ± 14 to 64 ± 13 years) and diabetes (14-22%, p < .01). The proportion of patients with cardiogenic shock (CS) and cardiac arrest (CA) pre-PCI increased significantly from 9.5% to 11.1% and 8.5% to 12.7% (p < .05), respectively. The median door-to-balloon (D2B) times decreased from 98 to 93 min and total ischemic time decreased from 202 to 185 min (all p < .05). Despite increased patient complexity, the proportion of nontransfer and transfer patients achieving D2B times consistent with guideline recommendations remained unchanged (for nontransfer patients 79-82%, p = .45 and for transfer patients 65-64%, p = .34). Among all STEMI patients, in-hospital mortality increased during the study period from 4.9 to 6.9% (p = .007) but remained stable (<2%) when CA and CS patients were excluded. CONCLUSIONS: Over the last 15 years, short-term STEMI mortality has increased despite improvements in care delivery metrics. Patients with CA and/or CS now represent 10% of STEMI patients and are responsible for 80% of deaths. Therefore, efforts to improve STEMI mortality, and metrics for assessing STEMI programs, should focus on these patients.
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Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Intervención Coronaria Percutánea/efectos adversos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Choque Cardiogénico , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
The double kissing crush (DK crush) is the most studied two-stent coronary bifurcation stenting strategy. While published data support its use, DK crush can be challenging to perform. In this review we provide a detailed step-by-step description and troubleshooting for each stage of the DK crush technique.
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Angioplastia Coronaria con Balón , Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Stents , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Recurrent drug-eluting stents (DES) in-stent restenosis (ISR) can be challenging to treat. The combined use of excimer laser atherectomy (ELCA) and vascular brachytherapy (VBT) for this indication has received limited study. METHODS: We report the long-term outcomes of patients with recurrent DES ISR treated with combined VBT and ELCA from January 2014 to September 2018 at a single institution. Outcomes included target lesion failure (TLF), defined as the composite of clinically driven target lesion revascularization (TLR), target lesion myocardial infarction (MI), and target lesion-related cardiac death. RESULTS: During the study period, 116 patients (143 lesions) underwent VBT, of which 19 patients (19 lesions) underwent combined laser atherectomy and VBT. All procedures were successful without no-reflow or dissection. Two propensity-score matched cohorts (ELCA + VBT (n = 18) vs. VBT only (n = 18)) were compared. During a median follow-up of 25.5 (14.5-40) months, there was no difference in the incidence of TLF (38.9% vs. 38.9%, log-rank p = 0.688), target-lesion MI (5.6% vs. 5.6%, log-rank p = 0.915), or TLR (38.9% vs. 33.3%, log-rank p = 0.933) between both groups. There was no cardiac death related to the target lesion. CONCLUSIONS: When compared with VBT alone for the treatment of resistant DES ISR, combined use of ELCA and brachytherapy is associated with comparable long-term outcomes. ELCA should be considered in ISR lesions due to stent underexpansion.
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Braquiterapia , Reestenosis Coronaria , Stents Liberadores de Fármacos , Aterectomía , Braquiterapia/efectos adversos , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Reestenosis Coronaria/terapia , Humanos , Rayos Láser , Stents , Resultado del TratamientoRESUMEN
OBJECTIVE: To examine the outcomes with intravascular brachytherapy (IVBT) in recurrent in-stent restenosis (ISR). BACKGROUND: Recurrent ISR can be challenging to treat and IVBT can be used for recurrent ISR but has received limited study. METHODS: We performed a systematic review and meta-analysis of five observational studies, including 917 patients (1014 lesions) with recurrent ISR, defined as having at least two prior ISR episodes with previous treatment with a stent, who underwent treatment with IVBT. Outcomes of interest included target vessel revascularization (TVR), myocardial infarction (MI), and all-cause mortality. RESULTS: During a mean follow-up of 24 ± 7 months, the incidence of TVR was 29.2% (95% CI 18.0-40.4%). The incidence of MI and all-cause mortality were 4.3% (95% CI 1.7%-6.9%) and 7.3% (95% CI 3.2-11.5%), respectively. At one- and two-years after PCI the incidence of TVR was 17.5% (95% CI 13.6%-21.4%) and 26.7% (95% CI 16.6%-36.9%), respectively and the incidence of MI was 3.1% (95% CI 2-4.2%) and 3.9% (95% CI 1-6.8%), respectively. CONCLUSION: Intravascular brachytherapy can be used to treat recurrent ISR, although TVR is needed in approximately one of four patients at two years.
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Braquiterapia , Reestenosis Coronaria , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Braquiterapia/efectos adversos , Angiografía Coronaria , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Reestenosis Coronaria/terapia , Humanos , Intervención Coronaria Percutánea/efectos adversos , Resultado del TratamientoRESUMEN
INTRODUCTION: The effect of x-ray system optimization on patient radiation dose has received limited study. METHODS: We analyzed patient radiation dose in 1786 cardiac catheterization procedures (diagnostic coronary angiography and/or percutaneous coronary intervention [PCI]) performed at a single tertiary-care center before and after x-ray system optimization. RESULTS: After optimization, cineangiography dose-area product (DAP) dose was lower in the overall group of patients who underwent diagnostic angiography and/or PCI (1347 µGyâ¢m² [IQR, 645-2345 µGyâ¢m²] vs 1658 µGyâ¢m² [IQR, 640- 2757 µGyâ¢m²]; P=.03), as well as in the diagnostic angiography group (1795 µGyâ¢m² [IQR, 1140-2994 µGyâ¢m²] vs 2356 µGyâ¢m² [IQR, 311-3576 µGyâ¢m²]; P<.01) and PCI group (2152 µGyâ¢m² [IQR, 1338-3477 µGyâ¢m²] vs 2562 µGyâ¢m² [IQR, 1681-3859 µGyâ¢m²]; P=.02). Cineangiography DAP per exposure was also lower in the overall group (143 µGyâ¢m² [IQR, 91-212 µGyâ¢m²] vs 164 µGyâ¢m² [IQR, 106-233 µGyâ¢m²] per exposure; P<.01) and in the diagnostic angiography group (158 µGyâ¢m² [IQR, 102-225 µGyâ¢m²] vs 184 µGyâ¢m² [IQR, 125-271 µGyâ¢m²] per exposure; P<.01). After optimization, cineangiography air kerma (AK) dose (319 mGy [IQR, 197-531 mGy] vs 421 mGy [IQR, 241-600 mGy]; P=.01) and cineangiography AK per exposure (20.7 mGy [IQR, 12.9-29.0 mGy] vs 23.6 mGy [IQR, 14.1-32.9 mGy] per exposure; P=.03) were also lower in the PCI group. There was no significant change in fluoroscopy AK dose after optimization (20.7 mGy [IQR, 12.7-30.1 mGy] vs 20.4 mGy [IQR, 12.8-31.3 mGy] per minute; P=.71) and fluoroscopy DAP dose (156 µGyâ¢m² [IQR, 101-242 µGyâ¢m²] vs 156 µGyâ¢m² [IQR, 102-236 µGyâ¢m²] per minute; P=.91). CONCLUSION: X-ray system optimization was associated with lower cineangiography DAP, but similar fluoroscopy radiation dose.
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Intervención Coronaria Percutánea , Exposición a la Radiación , Cateterismo Cardíaco , Cineangiografía , Angiografía Coronaria , Fluoroscopía , Humanos , Dosis de Radiación , Rayos XRESUMEN
New-onset left bundle branch block (N-LBBB) after transcatheter aortic valve replacement (TAVR) is a challenging clinical dilemma. In our single-center study, 60 out of 172 patients who underwent permanent pacemaker implantation (PPM) after TAVR had N-LBBB (34.9%). At a median follow-up duration of 357 days (IQR, 178; 560 days), two patients (3.5%) were completely pacemaker-dependent, and four others (7%) were partially dependent. Twelve patients (24%) recovered conduction in their left bundle at a median follow-up duration of 5 weeks (IQR, 4; 14 weeks). Due to the lack of clinical predictors of pacemaker dependency, active surveillance is warranted and may be an alternative to permanent pacemaker implantation.
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Bloqueo de Rama/terapia , Marcapaso Artificial , Complicaciones Posoperatorias/terapia , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Anciano , Anciano de 80 o más Años , Bloqueo de Rama/etiología , Bloqueo de Rama/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Marcapaso Artificial/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Implantación de Prótesis/estadística & datos numéricos , Recuperación de la Función , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/estadística & datos numéricos , Resultado del TratamientoRESUMEN
BACKGROUND: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) often requires administration of large contrast volume. The DyeVert system (Osprey Medical) is a disposable, Food and Drug Administration (FDA)-approved device that interfaces with standard manifold systems to reduce the amount of contrast used in cardiac catheterization. METHODS: We compared the procedural outcomes of patients in whom the DyeVert system was used vs those in whom it was not used during CTO-PCI at a single center between 2017 and 2018. RESULTS: The DyeVert system was used in 39 of 134 CTO-PCIs performed in 130 patients (30%). Most patients (79%) were men and the mean age was 66.6 ± 10.9 years. The most common target vessel was the right coronary artery (54.5%), followed by the left anterior descending artery (26.1%), and circumflex artery (15.7%). The median contrast volume used in DyeVert patients was significantly lower (200 mL [interquartile range, 153-256 mL] vs 250 mL [interquartile range, 170-303 mL]; P=.04). There were no in-hospital major complications with the DyeVert system, nor device-related procedural complications. One patient in the DyeVert group had contrast-induced nephropathy following CTO-PCI that did not require dialysis. CONCLUSION: Use of the DyeVert system is feasible during CTO-PCI and may reduce the contrast volume administered to the patient. Additional larger studies with a primary clinical endpoint are needed to confirm these findings.
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Oclusión Coronaria/cirugía , Vasos Coronarios/cirugía , Intervención Coronaria Percutánea/instrumentación , Sistema de Registros , Anciano , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The burden and impact of sleep deprivation in cardiology has received limited study. METHODS: A multidisciplinary, online survey on sleep health patterns and sleep deprivation involving 44 closed-ended questions was distributed via email list to cardiovascular workers. RESULTS: The survey was circulated among 6683 individuals, of whom 481 (7.2%) completed the survey; 80% of the respondents were men and 70% were interventional cardiologists. Nearly all (91%) had call responsibilities, with 43% doing ≥7 call-nights per month. Sleep disorders were reported in 25%, with 25% using sleep-inducing medications (8.4% at least once per week). The main factors diminishing the quality and/or quantity of sleep were related to work (66%), family and/or personal activities (56%), and staying up late at night writing or studying (48%). Sleep deprivation was associated with difficulty concentrating (58%), lack of motivation (56%), and irritability (68%). Work performance was felt to be hindered by 46% of participants and 8.6% reported an adverse event such as a complication and/ or negative patient outcome likely related to sleep deprivation. Many (56.5%) felt burnout and 85% opined that policies should exist allowing sleep-deprived individuals to go home early post call. CONCLUSIONS: Our survey provides insights into sleep health patterns among cardiovascular workers and potential factors contributing to sleep deprivation. Sleep deprivation may impact performance, with 8.6% of respondents describing sleep-deprivation related adverse events. Further study is required to both identify measures to attenuate the burden and better understand the impact of sleep deprivation on both health-care personnel and patient outcomes.
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Agotamiento Profesional/epidemiología , Cardiología , Competencia Clínica , Privación de Sueño/epidemiología , Sueño/fisiología , Encuestas y Cuestionarios , Adulto , Agotamiento Profesional/complicaciones , Agotamiento Profesional/fisiopatología , Femenino , Humanos , Incidencia , Masculino , Estudios Retrospectivos , Privación de Sueño/etiología , Privación de Sueño/fisiopatología , Estados Unidos/epidemiologíaRESUMEN
Cardiogenic shock develops in up to 10% of patients with acute myocardial infarction and continues to have high mortality. Early invasive treatment is the default therapeutic approach in these patients. On the basis of the results of the CULPRIT-SHOCK trial, culprit-only revascularization during the acute phase is preferred over multivessel revascularization. Routine use of intra-aortic balloon pump (IABP) is not recommended; however, the use of mechanical circulatory support has been increasing despite limited observational data to support its use. Several studies support multivessel revascularization in patients with uncomplicated ST-segment elevation acute myocardial infarction and simple nonculprit lesions to improve subsequent clinical outcomes.
Asunto(s)
Síndrome Coronario Agudo/terapia , Hemodinámica/fisiología , Contrapulsador Intraaórtico , Revascularización Miocárdica/métodos , Choque Cardiogénico/prevención & control , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/fisiopatología , Humanos , Choque Cardiogénico/etiologíaRESUMEN
BACKGROUND/PURPOSE: Patients and lesions at a higher procedural risk for percutaneous coronary intervention (PCI) are an understudied population. We examined the frequency, clinical characteristics, and outcomes of higher risk and non-higher risk PCIs at a large tertiary center. METHODS/MATERIALS: The following procedures were considered higher risk: unprotected left main PCI, chronic total occlusion PCI, PCI requiring atherectomy, multivessel PCI, bifurcation PCI, PCI in prior coronary artery bypass graft surgery (CABG) patients, pre-PCI left ventricular ejection fraction ≤30%, or use of hemodynamic support. RESULTS: Of the 1975 PCIs performed from 6/29/09 to 12/30/2016 in patients without acute coronary syndromes, 1230 (62%) were higher risk. Patients undergoing higher risk PCI were more likely to have a history of CABG, myocardial infarction, PCI, cerebrovascular disease, peripheral arterial disease, or congestive heart failure. Higher risk PCIs required more stents (2.0 vs. 1.0, pâ¯<â¯0.001), and had longer median fluoroscopy times (17.3 vs. 8.5â¯min, pâ¯<â¯0.001) and higher median contrast doses (160 vs. 120â¯mL, pâ¯<â¯0.001). In higher risk PCIs, the risks for technical failure and periprocedural complications were 2.9 (95% CI 1.2-7.4) times and 2.2 (95% CI 0.9-5.4) times higher as compared with non-higher risk PCI procedures. CONCLUSIONS: In summary, over half of the PCIs performed in non-acute coronary syndrome patients were higher risk and were associated with lower odds of technical success and higher periprocedural complication rates as compared with non-higher risk PCIs. SUMMARY: We examined the frequency, clinical characteristics, and outcomes of higher risk and non-higher risk PCIs at a large tertiary center. Higher risk PCI was associated with lower odds of technical and procedural success and higher odds of procedural complications as compared with non-higher risk PCI. However, the risk/benefit ratio may still be favorable for many of these higher-risk patients and should be estimated on a case by case basis.
Asunto(s)
Síndrome Coronario Agudo/terapia , Intervención Coronaria Percutánea/tendencias , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/mortalidad , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Prevalencia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Centros de Atención Terciaria/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is most commonly used in patients with cardiac arrest and cardiogenic shock. There are limited data on the use of VA-ECMO for elective, high-risk percutaneous coronary intervention (PCI). We examined the in-hospital and mid-term clinical outcomes in patients undergoing complex, high-risk PCI with VA-ECMO support. METHODS: . We conducted a retrospective review of ECMO-supported elective high-risk PCIs performed at our institution between May 2012 and May 2017. The electronic medical records and angiograms were individually reviewed. We assessed the in-hospital and mid-term major adverse cardiovascular and cerebrovascular event (MACCE) rates, and reviewed bleeding and vascular complications. RESULTS: Five patients underwent elective high-risk PCI with ECMO support. Mean age was 66.8 ± 8.6 years and all patients were men. The mean ejection fraction was 26.6 ± 18.0%. Most procedures were unprotected left main PCIs. All PCIs were successful; 1 patient required femoral artery surgical repair. The mean hospital stay post procedure was 6.4 ± 2.0 days. ECMO was successfully weaned in all cases, and the duration of ECMO was <24 hours in 4 cases. There was no occurrence of in-hospital and 1-year MACCE. CONCLUSION: ECMO can be successfully used for hemodynamic support during elective high-risk PCI.