Impact of right ventricular function on outcome of severe aortic stenosis patients undergoing transcatheter aortic valve replacement.

BACKGROUND: Right ventricular (RV) dysfunction was shown to be associated with adverse outcomes in a variety of cardiac patients and is considered a risk factor for adverse outcome according to the updated Valve Academic Research Consortium criteria. OBJECTIVE: Our goal was to assess the impact of RV function at baseline on 1-year mortality among patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). METHODS: All patients with severe AS treated with TAVR from May 2007 to March 2015 at our center were included in the present study, and baseline and procedural characteristics were recorded for each patient. The patients were categorized according to RV function at baseline as assessed by current guidelines, and a comparison of mortality rates up to 1 year was performed. RESULTS: Among 650 patients, 606 had adequate echocardiogram quality and 146 (24%) had RV dysfunction. There were significant differences between the 2 groups, as patients with RV dysfunction were younger (81±9 vs 84±7 years, P=.01) and were more likely to be male (65% vs 42%, P<.001). In addition, patients with RV dysfunction had higher rates of prior myocardial infarction (26% vs 16%, P=.02) and atrial fibrillation (51% vs 39%, P=.02). Echocardiographic parameters demonstrated higher rates of left ventricular ejection fraction <40% (40% vs 18%, P<.001), tricuspid regurgitation above moderate (16% vs 9%, P=.04), and higher pulmonary artery systolic pressure (50±17 vs 44±16 mm Hg, P<.001) among patients with severe AS and RV dysfunction compared with patients with normal RV function. Despite the unfavorable cardiac function, patients with severe AS undergoing TAVR have similar functional class (P=.22) and mortality rates at 1year (27% vs 23%, log-rank P=.45). CONCLUSIONS: Patients with severe AS and RV dysfunction have similar 1-year mortality and functional class after TAVR to patients with normal RV function. The presence of RV dysfunction does not correlate with outcome in patients with severe AS.

Comparison of transradial and transfemoral access in patients undergoing percutaneous coronary intervention for complex coronary lesions.

OBJECTIVE: Comparison of transradial versus transfemoral access for complex percutaneous coronary intervention (PCI) with regard to both complications and long-term outcomes. BACKGROUND: Radial access has been shown to confer superior results in patients undergoing PCI, especially in patients with acute coronary syndromes. However, radial access has limitations of sheath and device size, which may increase procedure time and result in inferior outcomes. METHODS: Patients undergoing PCI for complex lesions, defined as type C according the ACC/AHA classification system, were included in this study. Propensity matching was performed to adjust for differences in baseline characteristics. Transradial patients were then compared to transfemoral patients in regard to procedural, in-hospital, and 6-month outcomes. RESULTS: Among 2142 patients with 2591 lesions treated, 1876 had femoral access and 267 had radial access. Radial access patients were more likely to be male (75% vs. 66%, P = 0.003) and less likely to present with acute myocardial infarction (27% vs. 42%, P < 0.001). Procedural characteristics demonstrated lower use of heparin in the femoral group (17% vs. 73%, P < 0.001) with similarly low use of glycoprotein inhibitors (5.6% vs. 3.4%, P = 0.14). Patients in the femoral group had higher rates of transfusions (3.7% vs. 0%, P = 0.004) and vascular complications (1.7% vs. 0%, P = 0.03). Following propensity matching, there was no difference in mid-term outcomes between radial and femoral groups. CONCLUSIONS: In patients with complex coronary lesions undergoing PCI, the radial approach demonstrates similar mid-term outcomes as the femoral approach with a potentially lower rate of complications. © 2016 Wiley Periodicals, Inc.

Use of mechanical circulatory support in patients undergoing percutaneous coronary intervention: insights from the National Cardiovascular Data Registry.

BACKGROUND: Little is known about the contemporary use of intra-aortic balloon pump (IABP) and other mechanical circulatory support (O-MCS) devices in patients undergoing percutaneous coronary intervention (PCI) in the setting of cardiogenic shock. METHODS AND RESULTS: We identified 76 474 patients who underwent PCI in the setting of cardiogenic shock at one of 1429 National Cardiovascular Data Registry CathPCI participating hospitals from 2009 to 2013. Temporal trends and hospital-level variation in the use of IABP and O-MCS were evaluated. No mechanical circulatory support was used in 41 286 (54%) patients, 29 730 (39%) received IABP only, 2711 (3.5%) received O-MCS only, and 2747 (3.6%) received both IABP and O-MCS. At the start of the study period, 45% of patients undergoing PCI in the setting of cardiogenic shock received an IABP and 6.7% received O-MCS. The proportion of patients receiving IABP declined at an average rate of 0.3% per quarter, whereas the rate of O-MCS use was unchanged over the study period. The predicted probability of IABP use varied significantly by site (hospital median 42%, interquartile range 33% to 51%, range 8% to 85%). The probability of O-MCS use was <5% for half of hospitals and >20% in less than one-tenth of hospitals. CONCLUSIONS: In this large national registry, the use of IABP in the setting of PCI for cardiogenic shock decreased over time without a concurrent increase in O-MCS use. The probability of IABP and O-MCS use varied across hospitals, and the use of O-MCS was clustered at a small number of hospitals.

Cerebrovascular accidents after percutaneous coronary interventions from 2002 to 2014: Incidence, outcomes, and associated variables.

BACKGROUND: Cerebrovascular accident (CVA) and transient ischemic attack (TIA) related to percutaneous coronary intervention (PCI) are relatively rare complications, but they are associated with high morbidity and mortality. Given the evolution of both CVA risk and PCI techniques over time, this study was conducted to evaluate trends in CVA and TIA associated with PCI and to identify variables associated with neurologic events. METHODS: Consecutive patients undergoing PCI at the Washington Hospital Center between January 2002 and June 2015 were included. Prespecified data were prospectively collected, including baseline and procedural characteristics, in-hospital outcomes, and 1-year mortality. The subjects who had a CVA or TIA during or immediately after PCI were compared with those without procedure-associated CVA or TIA. RESULTS: Overall, 25,626 patients were included in the study. The mean age was 65.0 ± 12.4 years, 16,949 (65.2%) were male, and 7,436 (28.6%) were African American. From 2002 to 2015, 110 neurologic events post-PCI were diagnosed (0.43%); this included 86 CVAs (0.34%) and 24 TIAs (0.09%). The annual rate of postprocedural neurologic events was 0.42% ± 0.12%. There were significant changes in baseline risk factors over time, with increasing age, incidence of insulin-dependent diabetes, and chronic kidney disease. Patients with neurologic events were more often African American (43.6% vs 28.6%, P < .001) with prior history of CVA (24.5% vs 7.8%, P < .001), chronic renal insufficiency (26.6% vs 15.2%, P < .001), and insulin-dependent diabetes (19.1% vs 12.4%, P = .03). Acute myocardial infarction (56% vs 30.4%, P < .001) and cardiogenic shock (20.2% vs 3%, P < .001) were also more common among patients with neurologic events post-PCI. After multivariable adjustment, use of an intraaortic balloon pump was strongly associated with neurologic events (odds ratio [OR] 4.9, 95% CI 2.7-8.8, P < .001), as was prior CVA (OR 2.4, 95% CI 1.4-4.4, P = .002) and African American race (OR 2.4, 95% CI 1.5-3.9, P < .001); there was a borderline association with the use of a thrombus extraction device (OR 1.7, 95% CI 0.9-3.2, P = .09). In-hospital mortality (20.0% vs 1.5%, P < .001) and 1-year mortality (45.0% vs 7.3%, P < .001) were also much higher in patients with neurologic events. CONCLUSION: Neurologic events post-PCI are associated with markedly worse in-hospital outcomes. The incidence of CVA and TIA post-PCI, however, remained stable over the last 12 years despite an increase in risk factors for CVA.

Impact of baseline mitral regurgitation on short- and long-term outcomes following transcatheter aortic valve replacement.

BACKGROUND: The prevalence of concomitant significant mitral regurgitation (MR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) ranges from 2% to 33%. The impact of significant MR on post-TAVR outcomes remains controversial. METHODS: The data from a cohort of patients with symptomatic severe AS undergoing TAVR at out institution were retrospectively analyzed. The last transthoracic echocardiogram (TTE) before the index TAVR procedure was selected as the baseline assessment of the degree of MR. The total study cohort (N = 589) was divided into 2 groups: significant ≥moderate MR (n = 68) versus nonsignificant

Body mass index association with survival in severe aortic stenosis patients undergoing transcatheter aortic valve replacement.

BACKGROUND: Conflicting results have been reported regarding impact of body mass index (BMI) on outcome of transcatheter aortic valve replacement (TAVR) patients. This study evaluates the impact of BMI on 1 year mortality in patients undergoing TAVR via the transfemoral (TF) access. METHODS: Aortic stenosis (AS) patients undergoing TAVR via a TF access between May 2007 and December 2014 were categorized to 4 groups by BMI: low (<20), normal (20-24.9), overweight (25-30), and obese (>30). Baseline parameters were compared, and multivariate Cox proportional hazard regression models were generated to assess outcome differences. RESULTS: Among 491 severe AS TAVR patients, 43 had low BMI, 148 had normal BMI, 162 were overweight, and 138 were obese. Obese patients were younger with lower Society of Thoracic Surgeons scores and higher rates of preserved ejection fraction and diabetes. There was a higher rate of women in the BMI extremes. Aortic valve area was higher among obese patients; however, the indexed area was inversely correlated with BMI. Vascular complications and transfusions were more common in the low-BMI group, while acute kidney injury was more common in obese patients. All-cause mortality at 1 year was higher in the low-BMI group (log-rank p = 0.003) with no significant difference among normal and above-normal BMI patients. In a multivariate model, BMI <20 kg/m(2) was an independent predictor of mortality (HR = 2.45, p = 0.01). CONCLUSIONS: BMI <20 kg/m(2) should be considered a frailty marker during the screening process of severe AS TAVR patients as it is associated with higher mortality, while obesity confers similar mortality risk as normal weight. © 2015 Wiley Periodicals, Inc.

Active Versus Passive Anchoring Vascular Closure Devices Following Percutaneous Coronary Intervention: A Safety and Efficacy Comparative Analysis.

OBJECTIVE: We evaluate the prevalence of complications and failure rates between the most commonly used "active" anchoring vascular closure device (VCD), AngioSeal™ and the "passive" anchoring VCD, Mynx™, in all-comers undergoing percutaneous coronary intervention (PCI). METHODS: A total of 4,074 patients between 2008 and 2014, representing an era when both devices were available, were included. Thirty-two percent were acute coronary syndromes (37% STEMI). VCD choice was at the operator's discretion and included AngioSeal (n = 2,910) or Mynx (1,164). Cardiogenic shock or patients receiving intra-aortic balloon pumps were excluded. Safety was assessed by vascular complications defined as either vascular injury (perforation, dissection, acute limb ischemia, arteriovenous fistula, pseudoaneurysm with thrombin injection, or surgical repair) or access-site bleed (hemoglobin droP >3 g/dL requiring transfusion, retroperitoneal bleed, or hematoma >5 cm, or the composite of both. Efficacy was evaluated by device failure and defined as inability to achieve immediate hemostasis or use of additional hemostatic mechanisms. Outcomes at 30-days were evaluated. RESULTS: Groups (AngioSeal vs Mynx) were fairly balanced with regards to bleeding risk factors of gender (male, 65% vs 66%), body mass index (30 ± 6 vs 30 ± 7), heart failure class III/IV (5% vs 6%), chronic kidney disease (15% vs 17%), use of glycoprotein IIb/IIIa inhibitor (5% vs 4%), or bivalirudin (86% vs 88%), all P >0.5. The AngioSeal group was slightly younger (64 ± 12 vs 65 ± 12, P < 0.001) with less peripheral arterial disease (11.3% vs 13.9%, P = 0.03), and increased 7F sheath use compared with Mynx (59% vs 22%, P < 0.001). Safety and efficacy outcomes were similar between groups. CONCLUSIONS: AngioSeal and Mynx appear to be equally safe and efficacious VCDs following PCI. The passive anchoring system may prove desirable as no intra-arterial anchor remains upon device removal.

Retrieval of ruptured valves and their accessories during transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is a safe alternative to surgery in patients with severe aortic stenosis. We report a case of balloon rupture during TAVR with successful retrieval of its remnant and review this complication and its management.

The role of carotid intimal thickness and plaque imaging in risk stratification for coronary heart disease.

Improving the 10-year coronary heart disease (CHD) risk prediction beyond its current state is important as the current risk prediction schemes classify the majority of individuals who experience an incident CHD event as low or intermediate in risk. B-mode ultrasound-based carotid intima-media thickness (CIMT) measurement and carotid plaque detection is one of the surrogate markers of atherosclerosis that has shown value in CHD risk prediction. It has been shown that adding either CIMT, plaque, or both to traditional risk prediction models improves CHD risk prediction. Carotid ultrasound-based CIMT measurement and plaque identification is noninvasive, safe, and relatively inexpensive. Recent guidelines have given CIMT and plaque-based risk prediction a class II A recommendation. This article reviews the available data related to the use of CIMT and plaque information in CHD risk prediction.

Temporal Association Between the COVID-19 Ad26.COV2.S Vaccine and Acute Myocarditis: A Case Report and Literature Review.

With the recent approval and widespread administration of the Pfizer-BioNTech, Moderna, and Janssen vaccines worldwide, incidence of severe Coronavirus Disease 2019 (COVID-19) infection has significantly decreased. In spite of their undisputed role in reducing the severity of the disease and reduction of the disease burden in the community, there have been case reports of serious side effects with these vaccines. We aim to describe a case report of myocarditis following administration of the Janssen vaccine in a healthy, young male and review the available literature on COVID-19 vaccine related myocarditis and its possible pathogenesis. This case and literature review notes a temporal association between COVID-19 vaccination and myocarditis. Despite these observations, the benefits of the vaccines far outweigh the risks of possible myocarditis.

Large blood transfusion as a rare cause of ventricular fibrillation.

Large blood transfusions are common in clinical practice. Though several complications have been described with this procedure, cardiac arrhythmias occur uncommonly in this setting. We describe a case of a previously healthy 17-year-old girl who developed wide-complex ventricular tachycardia rapidly culminating in a ventricular fibrillation cardiac arrest several hours following an uneventful large-volume blood transfusion. Hypomagnesemia was detected on postcardiac arrest investigations. A review of this life-threatening complication and discussion on the ways to prevent it are presented.

What should a fellow-in-training expect at national cardiovascular conferences? The interventional cardiology fellows' perspective.

BACKGROUND: It has become challenging for cardiovascular fellows-in-training (FIT) to determine which national cardiovascular conference (NCC) to attend given the broad range of meetings and the breadth of information offered. The aim of this study was to report our own experiences of the utility and individual strengths of the NCCs and to further understand the interventional cardiology (IC) FITs' viewpoint regarding the benefits of the individual NCCs. METHODS: A survey was formulated with questions and scenarios regarding topics deemed to be of highest importance for an IC-FIT. The survey emphasized experiences regarding the utility and benefits of the NCCs, time management, optimization of acquired education, and specific interests in clinical and research topics. The completely anonymous survey was sent via an email format to a total of 234, majority of IC (fourth and fifth years) and a minority of general (third year), FITs. RESULTS: A completed survey response was received from 131 of the fellows (56%). The results demonstrated that the IC-FITs endorsed that the small, focused sub-specialty interventional meetings vs. the large society general meetings were more beneficial in regard to the didactic education offered. In addition, the IC-FITs indicated that pre-planning for the meetings is the most beneficial approach in optimizing one's education and that the caliber of expert faculty, case-based and live-case presentations are among the most important aspects of the meetings. CONCLUSIONS: Interventional cardiology FITs prefer the small sub-specialty interventional meetings over the large society general NCCs in regard to the benefits of didactic learning.

Pericardial disease: a clinical review.

Pericardial disease is infrequently encountered in cardiovascular practice, but can lead to significant morbidity and mortality. Clinical data and practice guidelines are relatively sparse. Early recognition and prompt treatment of pericardial diseases are critical to optimize patient outcomes. In this review we provide a concise summary of acute pericarditis, constrictive pericarditis and pericardial effusion/tamponade.

The impact of prior stroke on the outcome of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.

AIMS: The present study aimed to evaluate the impact of prior cardiovascular events (CVE) on outcome in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: Patients with severe AS undergoing TAVR between May 2007 and March 2015 were included and categorized to patients with and without prior stroke, defined as embolic, hemorrhagic stroke and transit ischemic attack. Baseline, procedural characteristics, in-hospital outcomes, and 1-month and 1-year mortality were compared in accordance with the Valve Academic Research Consortium-2 consensus. A cohort of 662 consecutive patients with severe AS undergoing TAVR were included in the analysis. Of these, 120 patients had prior stroke, and 542 without. Transfemoral access was used in 78% (571), and pre-TAVR balloon aortic valvuloplasty was performed in 87% (574). Patients with prior stroke had a higher mean Society of Thoracic score compared to those without (10.1% versus 8.8%, respectively; p=0.006) and higher rates of atherosclerotic disease involving the coronary, peripheral, and carotid arteries. Patients with prior stroke also had more occurrence of in-hospital minor stroke (3.3% versus 0.7%; p=0.04). Nevertheless, similar mortality rates were recorded at 1, 6, and 12months, and there were no significant differences in major stroke, bleeding, or post-procedure hospital stay between both groups. CONCLUSION: Prior history of stroke infers a higher risk for in-hospital minor stroke, yet no impact on other outcomes post TAVR. Therefore, history of prior stroke should not be considered an exclusion criterion for TAVR in patients with severe AS.

Intracoronary Brachytherapy for Recurrent Drug-Eluting Stent Failure.

OBJECTIVES: The study sought to report safety and long-term clinical efficacy of intravascular brachytherapy (VBT) for recurrent drug-eluting stent in-stent restenosis (DES-ISR). BACKGROUND: Recurrent DES-ISR remains a therapeutic challenge, and VBT has been used selectively in recurrent DES failure. METHODS: Patients undergoing VBT for recurrent DES-ISR were enrolled from a percutaneous coronary intervention registry. Clinical, procedural, VBT, and outcome data were collected for DES-ISR treated with radiation. Follow-up was obtained by phone call and clinic visits. RESULTS: A total of 186 patients (283 lesions) were included. Mean age was 65 ± 11 years, and 115 (61.8%) were men. Mean time to failure from last failed DES implantation was 450.65 ± 50 days. Majority (95%) had >2 episodes of target lesion revascularization (TLR). Commonest presentation of DES-ISR was unstable angina (68, 30%). All lesions were treated with balloon angioplasty followed by VBT using Beta-Cath system (Best Vascular Inc., Springfield, Virginia) with a dose of 23 to 25 Gy at 2 mm from source center. Radiation was delivered to site of ISR, without procedural adverse events, in 99% cases. Incidence of TLR was 3.3% at 6 months, 12.1% at 1 year, 19.1% at 2 years, and 20.7% at 3 years. No subacute thrombosis event was noted. One patient had late thrombosis during a 3-year follow-up. CONCLUSIONS: VBT for recurrent DES-ISR is safe, with low recurrence rates at 12 months post-procedure, and can be safely used as an effective short-term strategy. Overtime, there is a gradual attrition in patency requiring repeat intervention.

Contemporary Use of Veno-Arterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Acute Coronary Syndrome.

BACKGROUND: Refractory cardiogenic shock (RCS) in acute myocardial infarction (AMI) is associated with high rates of mortality. Smaller ventricular assist devices, such as the intraaortic balloon pump, provide limited support. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) offers more robust mechanical ventricular support, but is not widely utilized by interventional cardiologists. This study aimed to evaluate the patient characteristics and outcomes of VA-ECMO with RCS in the setting of AMI. METHODS AND RESULTS: A retrospective chart review of all VA-ECMO cannulations between 2009 and 2014 was performed, and patients with an indication of RCS in AMI were identified. A total of 15 patients underwent VA-ECMO placement for AMI with RCS. One-third of these patients presented with out-of-hospital cardiac arrest, and 60% had ST-elevation myocardial infarction. The Intraaortic balloon pump was placed in addition to VA-ECMO in 60% of patients. Median duration of VA-ECMO support was 45 hours. Successful wean off VA-ECMO was obtained in 50% of the patients, and vascular complications occurred in 53% of patients. The survival rate at discharge was 47%, and all survivors were alive at 30 days post discharge. CONCLUSION: VA-ECMO is infrequently used in patients for cardiopulmonary resuscitation in the AMI setting. When used judiciously, it has good clinical outcomes in this group of patients. However, use of VA-ECMO should be individualized based on vascular anatomy for best results. Close cooperation among interventional cardiologists, cardiovascular surgeons, cardiologists, cardiac intensivists, and perfusionists is essential for success of this therapy for RCS in AMI.

How should we manage thrombosis of Viabahn stent-graft? A case report focused on catheter-directed thrombolysis.

PURPOSE: To report a case of a thrombosed GORE® VIABAHN® endoprosthesis stent-graft in the femoral artery (SFA) and popliteal artery managed using the pulse-spray technique and complicated by compartment syndrome of the lower leg of the affected limb. CASE REPORT: A 61-year-old woman with three Viabahn stent grafts relining seven bare-metal stents in her right SFA and popliteal artery visited our hospital with complaint of recurrent lifestyle-limiting claudication of right leg. Angiography and intravascular ultrasound showed complete intra-stent obstruction by thrombus from the proximal right SFA to the proximal popliteal artery. Catheter-directed thrombolysis using pulse-spray technique followed by mechanical thrombectomy was performed. Despite successful recanalization, unfortunately, compartment syndrome developed on her right leg on the following day and fasciotomy was performed. CONCLUSION: The larger thrombus burden in Viabahn stent-grafts and its unique physicochemical properties increases the risk for distal embolic complications and potential poor clinical outcomes.

Vascular access in critical limb ischemia.

Currently, percutaneous endovascular intervention is considered a first line of therapy for treating patients with critical limb ischemia. As the result of remarkable development of techniques and technologies, percutaneous endovascular intervention has led to rates of limb salvage comparable to those achieved with bypass surgery, with fewer complications, even in the presence of lower rates of long-term patency. Currently, interventionalists have a multiplicity of access routes including smaller arteries, with both antegrade and retrograde approaches. Therefore, the choice of the optimal access site has become an integral part of the success of the percutaneous intervention. By understanding the technical aspects, as well as the advantages and limitations of each approach, the interventionalists can improve clinical outcomes in patients with severe peripheral arterial disease. This article reviews the access routes in critical limb ischemia, their advantages and disadvantages, and the clinical outcomes of each.