Radial versus femoral access for left main percutaneous coronary intervention: An analysis from the Veterans Affairs Clinical, Reporting, and Tracking Program.

OBJECTIVES: We aimed to compare clinical characteristics and procedural outcomes of left main percutaneous interventions (LM-PCI) by transradial (TRA) versus transfemoral (TFA) approach in the VA healthcare system. BACKGROUND: TRA for percutaneous coronary intervention (PCI) is steadily increasing. However, the frequency and efficacy of TRA for LM-PCI remain less studied. METHODS: All LM-PCIs performed in the VA healthcare system were identified for fiscal year 2008 through 2018. Patients' baseline characteristics and procedure-related variables were compared by access site. Both short- and long-term clinical outcomes were analyzed using propensity score matching. RESULTS: A total of 4004 LM-PCI were performed in the VA via either radial or femoral access from 2008 to 2018. Among these, 596 (14.9%) LM PCIs were performed via TRA. Use of TRA for LM-PCI increased from 2.2% to 31.5% over the study period. Propensity matched outcome analysis, comparing TRA versus TFA, showed a similar procedural success (98.4% for TRA vs. 97.8% for TFA; RR: 1.01 [0.98, 1.03]) and 1-year major adverse cardiovascular events (MACE) (25.9% for TRA vs. 26.8% TFA; RR: 0.96 [0.74, 1.25]). There were no statistically significant differences among secondary outcomes analyses including major bleeding. CONCLUSION: Use of TRA for LM-PCI has been steadily increasing in the VA healthcare system. These findings demonstrate similar procedural success and 1-year MACE across access strategies, suggesting an opportunity to continue increasing TRA use for LM-PCI.

Incidence and outcomes of cardiogenic shock among women with spontaneous coronary artery dissection.

BACKGROUND: There is a paucity of data on cardiogenic shock (CS) incidence and outcomes among patients with spontaneous coronary artery dissection (SCAD). METHODS: Women admitted to the hospital for acute myocardial infarction (AMI) with and without SCAD were identified from the United States National Readmission Database from October 1, 2015 to December 31, 2018. We calculated the incidence of CS among women with AMI with and without SCAD and odds for developing CS after adjusting for baseline characteristics. In addition, we report the utilization of percutaneous coronary intervention, mechanical circulatory support, severe disability surrogates, and 30-day readmission rates. RESULTS: A total of 664,292 patients admitted for AMI were eligible for analysis, including 6643 patients with SCAD and 657,649 without SCAD. Patients with SCAD were younger (57 years [interquartile range, IQR 48-68] vs. 71 years [IQR 60-81], p < 0.01) and had fewer comorbidities yet had a higher incidence of CS as compared to patients without SCAD (9% vs. 5%, p < 0.01) and remained at elevated risk after adjusting for baseline comorbidities (adjusted odds ratio 1.5 [95% confidence interval, CI 1.2-1.7]). Among patients who developed CS, those with SCAD had lower in-hospital mortality than non-SCAD (31% vs. 39%, p < 0.01), and were more likely to receive mechanical circulatory support. CONCLUSIONS: In a nationally representative sample of women admitted for AMI, we found that patients with SCAD had a higher risk of developing CS and required more frequent use of mechanical circulatory support but were more likely to survive to discharge than women suffering AMI from causes other than SCAD.

Tricuspid Valve Percutaneous Therapies.

PURPOSE OF REVIEW: In this review, we have focused on the currently available transcatheter tricuspid valve therapies, device selection, as well as role and management of tricuspid regurgitation (TR) in the setting of other transcatheter valvular procedures. RECENT FINDINGS: In this review, we have enlisted the recently finished as well as ongoing trials in the percutaneous tricuspid valve therapies. TR is highly prevalent yet remains underrecognized and is often untreated. TR has traditionally been managed conservatively with medical therapies including diuretics for volume management, whereas surgical therapies are reserved for those undergoing left-sided valvular surgery. Although the transcatheter devices for tricuspid repair and replacement are in clinical trials, the experience to date for their effectiveness and safety has been reassuring.

Development and validation of a predictive model for bleeding after peripheral vascular intervention: A report from the National Cardiovascular Data Registry Peripheral Vascular Interventions Registry.

OBJECTIVES: To develop a model to predict risk of in-hospital bleeding following endovascular peripheral vascular intervention. BACKGROUND: Peri-procedural bleeding is a common, potentially preventable complication of catheter-based peripheral vascular procedures and is associated with increased mortality. We used the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Interventions (PVI) Registry to develop a novel risk-prediction model to identify patients who may derive the greatest benefit from application of strategies to prevent bleeding. METHODS: We examined all patients undergoing lower extremity PVI at 76 NCDR PVI hospitals from 2014 to 2017. Patients with acute limb ischemia (n = 1600) were excluded. Major bleeding was defined as overt bleeding with a hemoglobin (Hb) drop of ≥ 3 g/dl, any Hb decline of ≥ 4 g/dl, or a blood transfusion in patients with pre-procedure Hb ≥ 8 g/dl. Hierarchical multivariable logistic regression was used to develop a risk model to predict major bleeding. Model validation was performed using 1000 bootstrapped replicates of the population after sampling with replacement. RESULTS: Among 25,382 eligible patients, 1017 (4.0%) developed major bleeding. Predictors of bleeding included age, female sex, critical limb ischemia, non-femoral access, prior heart failure, and pre-procedure hemoglobin. The model demonstrated good discrimination (optimism corrected c-statistic = 0.67), calibration (corrected slope = 0.98, intercept of -0.04) and range of predicted risk (1%-18%). CONCLUSIONS: Post-procedural PVI bleeding risk can be predicted based upon pre- and peri-procedural patient characteristics. Further studies are needed to determine whether this model can be utilized to improve procedural safety through developing and targeting bleeding avoidance strategies.

Outcomes of transcatheter aortic valve replacement for patients with severe aortic stenosis and concomitant aortic insufficiency: Insights from the TVT Registry.

AIMS: Data regarding outcomes for patients with severe aortic stenosis (AS) with concomitant aortic insufficiency (AI), undergoing transcatheter aortic valve replacement (TAVR) are limited. This study aimed to analyze the prevalence of severe AS with concomitant AI among patients undergoing TAVR and outcomes of TAVR in this patient group. METHODS AND RESULTS: Using data from the STS/ACC-TVT Registry, we identified patients with severe AS with or without concomitant AI who underwent TAVR between 2011 and 2016. Patients were categorized based on the severity of pre-procedural AI. Multivariable proportional hazards regression models were used to examine all-cause mortality and heart failure (HF) hospitalization at 1-year. Among 54,535 patients undergoing TAVR, 42,568 (78.1%) had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001). CONCLUSIONS: Severe AS with concomitant AI is common among patients undergoing TAVR, and is associated with lower 1 year mortality and HF hospitalization. Future studies are warranted to better understand the mechanisms underlying this benefit. SHORT ABSTRACT: In this nationally representative analysis from the United States, 78.1% of patients undergoing TAVR had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001).

Evolution of Diagnostic and Treatment Patterns of Cardiac Sarcoidosis.

Cardiac sarcoidosis (CS) may impart substantial morbidity and mortality, and novel imaging modalities are now available to aid in early diagnosis of this clinically silent disease. A better understanding of the clinical experience with CS is important. Twenty-eight patients were diagnosed with the aid of multimodality imaging techniques and were treated by a multidisciplinary team. Demographics, symptomatology, imaging, and therapeutic interventions were compiled from our referral center. In patients with CS, nuclear and MR techniques were often the first studies performed. Echocardiographic findings differed widely. Immunosuppressive therapy and cardiac devices were frequently used. Importantly, isolated CS was not an infrequent finding.

Temporal trends of survival and utilization of mechanical circulatory support devices in patients with in-hospital cardiac arrest secondary to ventricular tachycardia/ventricular fibrillation.

BACKGROUND: Pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) is the initial rhythm in a third of in-hospital cardiac arrest patients. Mechanical circulatory support (MCS) device use remains poorly understood in this population. METHODS: We conducted an observational analysis of temporal trends in the utilization of MCS in VT/VF IHCA between January 2008 and December 2014 utilizing the Nationwide Inpatient Sample (NIS) database. Using multivariable analysis, we assessed factors associated with MCS use and survival to discharge. RESULTS: Among 151,628 hospitalizations with VT/VF IHCA, 14,981 (9.9%) received MCS. Intra-aortic balloon pump (IABP) was the most commonly used MCS (9.1%). From 2008 to 2014, there was significant increase in the utilization of MCS (8.7-11%; ptrend < 0.0001). On multivariable analysis, there was 12-fold increase and three-fold increase in the utilization of PVAD and ECMO respectively; however, there was no significant change in the use of IABP. Over the seven-year sample period, there was significant increase in the overall survival to hospital discharge (35.4-43.5%; ptrend < 0.0001). Survival to hospital discharge increased in both MCS and non-MCS groups. CONCLUSION: There was significant increase in utilization of MCS after VT/VF IHCA during the study period. IABP was the most commonly utilized MCS. The survival to hospital discharge increased in the overall study population including both MCS and non-MCS groups. Future studies are needed to identify patient population most likely to benefit from the use of MCS after VT/VF IHCA.

Multimodality detection of multiple left ventricular diverticula: A case report and brief review of the literature.

Left ventricular diverticula (LVD) are rare congenital anomalies usually detected incidentally in the adult population. Most commonly, they are found as a single left ventricular diverticulum in association with other congenital abnormalities but multiple LVD are exceedingly rare. We are describing a patient who was found to have multiple LVD on multimodality imaging studies. He had presented with a sudden cardiac arrest attributed to a combination of alcohol intoxication and QT interval prolongation from hypokalemia and antidepressant medications. The patient was managed conservatively and discharged with an implantable loop recorder for detecting any occult arrhythmias.

Spectral Analysis of Baseline Electrocardiogram During Atrial Fibrillation Predicts Response to Antiarrhythmic Drug Therapy in Patients With Persistent Atrial Fibrillation.

BACKGROUND: We evaluated the ability of spectral analysis of the baseline ECG during atrial fibrillation (AF) to predict the response of persistent AF to antiarrhythmic drug therapy. METHODS: Patients with persistent AF who were admitted for dofetilide loading were prospectively enrolled in the study. Atrial activity was extracted from the ECG using an Independent Component Analysis method and then subjected to a Modified Periodogram. The regularity index was computed as the ratio of the power in the dominant frequency and all its harmonics to the total power in the spectrum. Patients were followed at 1 month, 3 months and every 3 months thereafter. RESULTS: Of 28 patients enrolled in the study, 14 (50%) converted acutely to sinus rhythm during the 3-day hospital loading period. The clinical and echocardiographic characteristics of patients with and without acute pharmacologic conversion were similar. The regularity index was significantly higher in those who converted to sinus rhythm compared to those who did not (0.71 ± 0.20 vs. 0.38 ± 0.13, respectively; P < 0.0001). A regularity index ≥0.44 had a 79% sensitivity and 93% specificity to predict acute conversion and was associated with a nearly 5-fold increase in the acute conversion rate (odds ratio = 4.89; 95% confidence interval 1.74-13.75; P = 0.003). The regularity index was the only independent predictor of acute conversion. Neither acute conversion, nor the regularity index predicted sinus rhythm maintenance, after a median follow-up of 10 months. CONCLUSION: Increased regularity index predicts acute conversion of persistent AF during dofetilide loading, but does not predict long-term sinus rhythm maintenance.

An Unusual Presentation of Native Valve Endocarditis Caused by Staphylococcus warneri.

Staphylococcus warneri is a coagulase-negative staphylococcal (CoNS) bacterium. It is a common saprophyte on human skin, present in approximately 50% of the healthy adult population; it has emerged as a cause of serious infection in the past two decades. In most cases, there is a predisposing condition, such as a new implant or surgical procedure, before the identification of S warneri as the pathogen. It is believed that CoNS are mostly associated with prosthetic valve infections. S warneri can lead to a slow growing and an indolent course and late diagnosis. Cases of CoNS infective endocarditis are less likely to have a vascular or immunologic phenomenon and can lead to large vegetations requiring valve replacement if not detected in time. There are currently only two cases of native valve endocarditis from community-acquired S warneri in the literature. We report a case of native valve endocarditis in an immunocompetent patient without any of the usual predisposing risk factors. Our case illustrates the importance of CoNS bacteremia and the implications of delayed diagnosis of CoNS endocarditis in clinical practice.

Nonbacterial thrombotic endocarditis involving both the tricuspid and aortic valves.

A 71-year-old male presented after sudden onset of confusion and expressive aphasia. MRI head revealed multiple ischemic lesions consistent with cardio-embolic pathophysiology. A computed tomography angiography of lung showed peripheral pulmonary emboli. He underwent a transesophageal echocardiogram as a part of the stroke workup and was found to have vegetations on both aortic and tricuspid valves. The blood cultures did not show any growth, and the patient remained afebrile during the course of hospitalization. A diagnosis of nonbacterial thrombotic embolism was made, and he was discharged on anticoagulation therapy with subcutaneous low molecular heparin.

Death by Carbs: Added Sugars and Refined Carbohydrates Cause Diabetes and Cardiovascular Disease in Asian Indians.

By the year 2030, India will supplant China as the world's most populous nation. Rapid urbanization and an increasingly Westernized diet and lifestyle, in a population with genetic predisposition to insulin resistance is fueling a rising epidemic of non-communicable diseases in India. A diet that is high in processed foods, added sugars and other refined carbohydrates is a principle factor driving the growing epidemics of type 2 diabetes (T2D), hypertension (HTN), and cardiovascular (CV) disease (CVD). Immediate postprandial spikes in the blood levels of glucose and triglycerides cause immediate parallel rises in oxidative stress, inflammation, and endothelial dysfunction; eventually leading to T2D, and CVD. Furthermore the Asian Indian population is particularly susceptible to exaggerated rises in postprandial glucose and triglycerides because they are genetically predisposed to metabolic syndrome (MetSyn), insulin resistance, and T2D. A diet restricting the consumption of refined carbohydrates and limiting added sugars to not more than 5 grams/day should be adopted by Asian Indians to reduce risk of T2D, HTN, coronary disease, and stroke.

Wide complex tachycardia in the presence of class I antiarrhythmic agents: a diagnostic challenge.

We present two patients with paroxysmal atrial fibrillation on class 1C antiarrhythmic drugs without concomitant atrioventricular (AV) nodal blocking agents who developed atrial flutter with 1:1 AV conduction. Their electrocardiogram revealed wide complex tachycardia with rates >200/minute. Atrial flutter with 1:1 conduction in the presence of class IC antiarrhythmic drugs may present a diagnostic challenge. These cases illustrate the importance of coadministering an AV nodal blocking agent with class IC antiarrhythmic agents in patients with atrial fibrillation. The differential diagnosis of wide complex tachycardia in patients taking class IC agents should include atrial flutter with 1:1 AV conduction.

An unusual case of pulmonary coccidioidomycosis presenting as pneumothorax.

Coccidioidomycosis, although endemic to southwest regions of United States, has sporadic cases which can be encountered outside of the endemic areas. Clinicians must be aware of usual and unusual presentations of this disease entity and should keep a high level of suspicion for the diagnosis. We discuss an uncommon presentation for pulmonary coccidioidomycosis in a patient with a history of HIV/AIDS, who presented with pneumothorax due to a ruptured coccidioidal cavity. This report also illustrates the high importance of travel history in investigating rare disease presentations.

Giant high-pressure pulmonary artery aneurysm (PAA) in a patient with COPD and chronic pulmonary embolism (PE).

A woman in her 60s with a history of known severe chronic obstructive pulmonary disease (COPD), former smoker of 50 pack-years and small patent foramen ovale (PFO) without significant shunt was admitted for acute on chronic hypoxic respiratory failure. Diagnostic workup showed severe dilatation of main pulmonary artery (MPA) (75.5 mm axial view and 86.6 mm sagittal view) and left and right PAs measuring 40 mm and 34 mm, respectively, on CT angiography of the chest. Right heart catheterisation showed severe pulmonary hypertension (PH). A diagnosis of giant high-pressure pulmonary arterial aneurysm (PAA) secondary to PH, induced by COPD, and chronic pulmonary embolism was made. Despite aggressive medical management, she passed away on comfort care. Giant high-pressure PAAs are rarely reported. This is a unique case that demonstrates this very rare condition in a living patient. The management of giant PAA is controversial. Experts recommend medical management or aneurysmectomy for sizes of >55-60 mm. Death could have been prevented if our patient was screened earlier and received appropriate medical care.

Haemolysis resolution after transcatheter valve in valve within a prior mitral annuloplasty ring: a case report.

Background: Transcatheter mitral valve in ring procedure has emerged as a minimally invasive alternative to re-do surgery among patients with failed mitral annuloplasty rings. Uncommonly, haemolysis presents as a complication after the percutaneous valvular procedures and often require aggressive measures to correct paravalvular leaks and mechanical collision. Case summary: We report a case of an 82-year-old female who underwent a transcatheter valve in ring procedure (Edwards Sapien S3, Edwards Lifesciences) for symptomatic severe mitral regurgitation from a bioprosthetic annuloplasty ring failure complicated by acute haemolytic anaemia a week after the procedure manifesting as dark coloured urine, profound icterus, and acute renal injury. She was treated with a post-dilation balloon valvuloplasty leading to reduction in haemolysis, but the patient was readmitted with acute haemolysis episode again. At this time, a decision was made to perform a repeat valve in valve TMVR with a 29 mm S3 Edwards Sapien valve which led to a resolution of haemolysis. Discussion: In this case, the leaflets of previously placed S3 valve sealed the blood flow through the valve frame thus diverting the blood flow away from the area of collision leading to resolution of haemolysis.

Clinical Impact of Tricuspid Regurgitation on Transcatheter Edge-to-Edge Mitral Valve Repair for Mitral Regurgitation.

OBJECTIVES: This study aimed to evaluate whether baseline tricuspid regurgitation (TR) impacted clinical outcomes after mitral valve transcatheter edge-to-edge repair (M-TEER) for severe secondary mitral regurgitation (MR). BACKGROUND: Baseline TR is common among patients undergoing M-TEER for secondary MR, although its impact on clinical outcomes is unclear. METHODS: The Cochrane Library, PubMed/MEDLINE, and Google Scholar were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from January 1, 2011 through January 31, 2021. Randomized controlled trials and nonrandomized prospective studies that evaluated baseline TR by echocardiography before M-TEER for MR were included. The primary outcome was a composite of mortality and heart failure hospitalization (HFH) at 1-year. RESULTS: A total of 5 studies (n = 1395 patients) were included in the primary analysis. Concurrent moderate/severe TR was associated with a worse 1 year composite of all-cause mortality and HFH (OR: 2.13; 95% CI: 1.12-4.05; p = 0.02) after M-TEER for severe MR. In studies that reported TR grade pre- and post-M-TEER for severe MR, 32% of patients with moderate-to-severe baseline TR had a reduction in TR severity after the intervention. CONCLUSIONS: Baseline moderate-to-severe TR was associated with increased 1-year mortality and heart failure hospitalizations among patients undergoing M-TEER. Further randomized studies are needed to assess the interaction of TR among patients undergoing M-TEER.

Association Between Early Left Ventricular Ejection Fraction Improvement After Transcatheter Aortic Valve Replacement and 5-Year Clinical Outcomes.

Importance: In patients with severe aortic stenosis and left ventricular ejection fraction (LVEF) less than 50%, early LVEF improvement after transcatheter aortic valve replacement (TAVR) is associated with improved 1-year mortality; however, its association with long-term clinical outcomes is not known. Objective: To examine the association between early LVEF improvement after TAVR and 5-year outcomes. Design, Setting, and Participants: This cohort study analyzed patients enrolled in the Placement of Aortic Transcatheter Valves (PARTNER) 1, 2, and S3 trials and registries between July 2007 and April 2015. High- and intermediate-risk patients with baseline LVEF less than 50% who underwent transfemoral TAVR were included in the current study. Data were analyzed from August 2020 to May 2021. Exposures: Early LVEF improvement, defined as increase of 10 percentage points or more at 30 days and also as a continuous variable (ΔLVEF between baseline and 30 days). Main Outcomes and Measures: All-cause death at 5 years. Results: Among 659 included patients with LVEF less than 50%, 468 (71.0%) were male, and the mean (SD) age was 82.4 (7.7) years. LVEF improvement within 30 days following transfemoral TAVR occurred in 216 patients (32.8%) (mean [SD] ΔLVEF, 16.4 [5.7%]). Prior myocardial infarction, diabetes, cancer, higher baseline LVEF, larger left ventricular end-diastolic diameter, and larger aortic valve area were independently associated with lower likelihood of LVEF improvement. Patients with vs without early LVEF improvement after TAVR had lower 5-year all-cause death (102 [50.0%; 95% CI, 43.3-57.1] vs 246 [58.4%; 95% CI, 53.6-63.2]; P = .04) and cardiac death (52 [29.5%; 95% CI, 23.2-37.1] vs 135 [38.1%; 95% CI, 33.1-43.6]; P = .05). In multivariable analyses, early improvement in LVEF (modeled as a continuous variable) was associated with lower 5-year all-cause death (adjusted hazard ratio per 5% increase in LVEF, 0.94 [95% CI, 0.88-1.00]; P = .04) and cardiac death (adjusted hazard ratio per 5% increase in LVEF, 0.90 [95% CI, 0.82-0.98]; P = .02) after TAVR. Restricted cubic spline analysis demonstrated a visual inflection point at ΔLVEF of 10% beyond which there was a steep decline in all-cause mortality with increasing degree of LVEF improvement. There were no statistically significant differences in rehospitalization, New York Heart Association functional class, or Kansas City Cardiomyopathy Questionnaire Overall Summary score at 5 years in patients with vs without early LVEF improvement. In subgroup analysis, the association between early LVEF improvement and 5-year all-cause death was consistent regardless of the presence or absence of coronary artery disease or prior myocardial infarction. Conclusions and Relevance: In patients with severe aortic stenosis and LVEF less than 50%, 1 in 3 experience LVEF improvement within 1 month after TAVR. Early LVEF improvement is associated with lower 5-year all-cause and cardiac death.

Anemia Among Patients Undergoing Transcatheter Mitral Valve Repair: From the National Inpatient Sample in the United States.

Background The prevalence and impact of anemia on the outcomes of transcatheter mitral valve repair (TMVr) have not been well-studied. Anemia is a commonly encountered comorbidity among patients with cardiovascular disorders and is frequently under-recognized. The study aimed to analyze the prevalence of anemia and its impact on post-TMVr in-hospital outcomes. Methods The National Inpatient Sample (NIS) was queried to identify all patients who underwent TMVr from 2011-2015 in the United States by utilizing suitable International Classification of Diseases, Ninth Revision (ICD-9) codes. The baseline characteristics and in-hospital outcomes were compared among patients with and without anemia. Results A total of 4,382 patients were identified. Out of these, 978 (22.3%) patients had baseline anemia. Anemic patients were noted to have a higher burden of co-morbidities, including chronic kidney disease, hypertension, and diabetes mellitus. The in-hospital mortality was higher but not statistically significant between anemic and non-anemic patients (3.6% vs 2.6%; odds ratio (OR): 1.44; confidence interval (CI): 0.85-2.46, p=0.179). The other adverse outcomes, including the length of stay, the requirement for blood transfusions, the incidence of post-implant acute kidney injury, hemodialysis, and the cost of hospitalization, were higher in anemic patients. Conclusion Anemia was present in one out of five patients undergoing TMVr in this nationally representative cohort. Baseline anemia showed numerically higher but not statistically significant in-hospital mortality and was associated with other in-hospital adverse outcomes. Further larger studies are needed to highlight the importance of anemia in the TMVr procedure.