Bedside veno-venous ECMO cannulation: A pertinent strategy during the COVID-19 pandemic.

BACKGROUND: Patient selection and cannulation arguably represent the key steps for the successful implementation of extracorporeal membrane oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real-time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients' critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite. AIMS: Therefore, with the objective of avoiding delay with the initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation. MATHERIAL AND METHODS: A total of 89 patients required ECMO support at Hennepin County Medical Center between March 2015 and December 2019. Twenty-eight (31%) required veno-venous support and were all cannulated at the bedside. Overall survival was 71% with no morbidity or mortality related to the cannulation procedure. CONCLUSION: In the current pandemic, the strategy of veno-venous bedside cannulation may have additional benefits for the care of patients with refractory acute respiratory distress syndrome due to coronavirus-disease-2019, decreasing the risk of exposure of health care worker or other patients to the novel severe acute respiratory syndrome coronavirus-2 occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation.

Outcomes with drug-coated balloons in small-vessel coronary artery disease.

BACKGROUND: Percutaneous coronary intervention (PCI) of small-vessel coronary artery disease (SVD) is associated with increased risk of restenosis. The use of drug-coated balloons (DCBs) in SVD has received limited study. OBJECTIVES: To assess the outcomes of DCB in the treatment of SVD compared with the standard of care. METHODS: We performed a meta-analysis of all studies published between January 2000 and September 2018 reporting the outcomes of DCB versus other modalities in the treatment of de novo SVD. RESULTS: Seven studies with 1,824 patients (1,938 lesions) were included (four randomized controlled trials and three observational studies). During a mean follow-up of 14.5 ± 10 months, DCBs were associated with a similar risk of target lesion revascularization (TLR) (OR: 0.99, 95% CI: 0.54, 1.84, P = 97) and major adverse cardiovascular events (MACE) (OR: 0.86, 95% CI: 0.51, 1.45, P = 0.57) compared with drug-eluting stents (DES). During a mean follow-up of 7 ± 1.5 months, DCBs were associated with a significantly lower risk of TLR (OR: 0.19, 95% CI 0.04-0.88, P = 0.03) and binary restenosis (OR: 0.17, 95% CI 0.08-0.37, P = <0.00001) compared with noncoated balloon angioplasty. CONCLUSION: The use of DCBs in SVD is associated with comparable outcomes when compared with DES and favorable outcomes when compared with balloon angioplasty.

Revascularization in "no option" patients with refractory angina: Frequency, etiology and outcomes.

BACKGROUND: A significant proportion of patients with complex, advanced coronary artery disease have refractory angina (RA) despite maximal pharmacological therapy and are deemed suboptimal candidates for revascularization. These patients are frequently termed "no-option" patients. However, despite this designation, many subsequently undergo coronary revascularization. We sought to determine the incidence, etiology and outcome of revascularization in "no-option" patients. METHODS AND RESULTS: We examined a comprehensive, prospective RA database to identify 342 of 1363 (25.1%) patients who subsequently underwent revascularization after a median interval of 2.2 years from the "no-option" diagnosis. Coronary revascularization was achieved by percutaneous coronary intervention (PCI) (n = 274, 20.1%), coronary bypass graft surgery (n = 44, 3.2%) or both (n = 24, 1.8%). During a median follow-up of 5.1 years, patients who underwent revascularization had lower annual mortality (2% vs. 4.4%, P < .001). Detailed paired angiographic records were available for 181 PCI patients with a combined 302 lesions. Of these interventions, 48% were for a new lesion, 31% for an existing lesion and 21% for restenosis. The location was a native vessel in 77% and a bypass graft in 23%. CONCLUSIONS: The "no-option" or non-revascularizable designation is frequently based on angiography at a single time-point. However, coronary artery disease is a progressive and dynamic process and new lesions often develop in such patients. Given the association between revascularization and better survival, careful consideration should be given to repeat revascularization in patients with refractory angina previously classified as "no-option".

Meta-analysis of the impact of successful chronic total occlusion percutaneous coronary intervention on left ventricular systolic function and reverse remodeling.

BACKGROUND: We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on left ventricular (LV) function. METHODS: We performed a systematic review and meta-analysis of studies published between January 1980 and November 2017 on the impact of successful CTO PCI on LV function. RESULTS: A total of 34 observational studies including 2735 patients were included in the meta-analysis. Over a weighted mean follow-up of 7.9 months, successful CTO PCI was associated with an increase in LV ejection fraction by 3.8% (95%CI 3.0-4.7, P < 0.0001, I2 = 45%). In secondary analysis of 15 studies (1248 patients) that defined CTOs as occlusions of at least 3-month duration and reported follow-up of at least 3-months after the procedure, successful CTO PCI was associated with improvement in LV ejection fraction by 4.3% (95%CI [3.1, 5.6], P < 0.0001). In the 10 studies (502 patients) that reported LV end-systolic volume, successful CTO PCI was associated with a decrease in LV end-systolic volume by 4 mL, (95%CI -6.0 to -2.1, P < 0.0001, I2 = 0%). LV end-diastolic volume was reported in 9 studies with 403 patients and did not significantly change after successful CTO PCI (-2.3 mL, 95%CI -5.7 to 1.2 mL, P = 0.19, I2 = 0%). CONCLUSIONS: Successful CTO PCI is associated with a statistically significant improvement in LV ejection fraction and decrease in LV end-systolic volume, that may reflect a beneficial effect of CTO recanalization on LV remodeling. The clinical implications of these findings warrant further investigation.

Comparison of visual assessment of coronary stenosis with independent quantitative coronary angiography: Findings from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial.

BACKGROUND: The outcomes in patients by visual assessment and quantitative coronary angiography (QCA) for obstructive coronary artery disease (CAD) are not known. Our objectives were to compare visual and QCA estimates of obstructive CAD and to assess their relationship to outcomes in stable patients with symptoms of CAD. METHODS: The PROMISE trial randomized 10,003 patients with CAD symptoms to anatomical or functional testing. Site reports of invasive angiography detailing visual stenosis and independent, blinded QCA were performed for obstructive CAD (≥50% stenosis). Disagreement between methods was determined and compared with outcomes (death, myocardial infarction, unstable angina hospitalization, or major procedural complications). RESULTS: Of 929 patients (9.3% of PROMISE cohort) with angiograms assessed by sites and QCA, 593 (64%) had obstructive CAD per site reports, whereas 428 (46%) had stenosis ≥50% per QCA. Results differed in 177 patients (disagreement rate 19.1%, κ=0.63), of whom 171 had CAD per sites but not per QCA. One-year unadjusted Kaplan-Meier event rates were highest (5.1%) when QCA and visual assessment agreed for CAD, lowest (0.9%) when the 2 agreed for no obstructive CAD, and intermediate (3.1%) for patients who had CAD per visual assessment but not per QCA. CONCLUSIONS: Visual estimation of angiograms results in more frequent diagnosis of obstructive CAD as compared with QCA. Concordance of results for presence or absence of obstructive CAD was associated with high and low event rates, respectively. Disagreement was associated with intermediate event rates, suggesting that cardiologists integrated clinical information into routine visual assessment of angiograms.

Clinical characteristics and outcomes after unplanned intraaortic balloon counterpulsation in the Counterpulsation to Reduce Infarct Size Pre-PCI Acute Myocardial Infarction trial.

BACKGROUND: Despite advances in primary percutaneous coronary intervention (pPCI) and regional systems of care, the development of cardiogenic shock is associated with poor clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). We sought to better characterize the baseline characteristics and clinical outcomes of patients who underwent crossover to intraaortic balloon counterpulsation (IABC) in the CRISP AMI trial. METHODS: Patients with anterior STEMI were randomized to IABC before pPCI or pPCI alone. Infarct size and 6-month clinical outcomes were evaluated in patients both in the pPCI-alone group who did undergo crossover to IABC and those who did not undergo crossover to IABC. RESULTS: Among 176 patients randomized to pPCI alone, 161 patients did not later receive IABC during the index hospitalization, and 15 patients (8.5%) underwent crossover and did receive unplanned IABC. Hypotension and/or cardiogenic shock precipitated crossover to IABC in 12 patients (80%). Patients who underwent crossover to IABC demonstrated lower systolic and diastolic blood pressures on admission. At 6 months, rates of death (26.7% vs 3.1%, P = .003), readmission for severe hypotension (53.3% vs 3.7%, P < .001), resuscitated cardiac arrest, and ventricular arrhythmia were higher in the group that did crossover to IABC. Crossover to IABC was not associated with increased infarct size. CONCLUSIONS: The most significant predictor of crossover to IABC in the setting of anterior STEMI was relative hypotension at the time of hospital admission, and crossover to IABC in CRISP AMI was associated with significantly worse clinical outcomes.

Implementation of Extracorporeal Membrane Oxygenation Without On-Site Cardiac Surgery or Perfusion Support: A Tale of Two County Hospitals.

Patients with refractory respiratory and cardiac failure may present to noncardiac surgery centers. Prior studies have demonstrated that acute care surgeons, intensivists, and emergency medicine physicians can safely cannulate and manage patients receiving extracorporeal membrane oxygenation (ECMO). Harborview Medical Center (Harborview) and Hennepin County Medical Center (Hennepin) are both urban, county-owned, level 1 trauma centers that implemented ECMO without direct, on-site cardiac surgery or perfusion support. Both centers 1) use an ECMO specialist model staffed by specially trained nurses and respiratory therapists and 2) developed comparable training curricula for ECMO specialists, intensivists, surgeons, and trainees. Each program began with venovenous ECMO to provide support for refractory hypoxemic respiratory failure and subsequently expanded to venoarterial ECMO support. The coronavirus disease 2019 (COVID-19) pandemic created an impetus for restructuring, with each program creating a consulting service to facilitate ECMO delivery across multiple intensive care units (ICUs) and to promote fellow and resident training and experience. Both Harborview and Hennepin, urban county hospitals 1,700 miles apart in the United States, independently implemented and operate adult ECMO programs without involvement from cardiovascular surgery or perfusion services. This experience further supports the role of ECMO specialists in the delivery of extracorporeal life support.

Educational Experience of Interventional Cardiology Fellows in the United States and Canada.

BACKGROUND: The COVID-19 pandemic and iodinated contrast shortage may have affected interventional cardiology (IC) fellowship training. OBJECTIVES: The aim of this study was to investigate the educational experience of first-year IC fellows in the United States and Canada. METHODS: A 59-question online survey was conducted among 2021-2022 first-year IC fellows in the United States and Canada. RESULTS: Of the 360 IC fellows invited to participate, 111 (31%) responded; 95% were from the United States, and 79% were men. Participants were mostly from university programs (70%), spent 61 to 70 hours/week in the hospital, and had an annual percutaneous coronary intervention case number of <200 (5%), 200 to 249 (8%), 250 to 349 (33%), 350 to 499 (39%), 500 to 699 (12%), or ≥700 (3%). For femoral access, a micropuncture needle was used regularly by 89% and ultrasound-guided puncture by 81%, and 43% used vascular closure devices in most cases (>80%). Intravascular ultrasound was performed and interpreted very comfortably by 62% and optical coherence tomography (OCT) by 32%, and 20% did not have access to OCT. Approximately one-third felt very comfortable performing various atherectomy techniques. Covered stents, fat embolization, and coil embolization were used very comfortably by 14%, 4%, and 3%, respectively. Embolic protection devices were used very comfortably by 11% to 24% of IC fellows. Almost one-quarter of fellows (24%) were warned about their high radiation exposure. Eighty-four percent considered IC fellowship somewhat or very stressful, and 16% reported inadequate psychological support. CONCLUSIONS: This survey highlights opportunities for improvement with regard to the use of intravascular imaging, atherectomy techniques, complication prevention and management strategies, radiation awareness and mitigation, and psychological support.

HIV infection is associated with decreased thrombin generation.

BACKGROUND: Excess risk of cardiovascular disease occurs in effectively treated individuals with human immunodeficiency virus (HIV) infection. Although elevated plasma D-dimer levels are associated with increased morbidity and mortality, the impact of HIV infection on coagulation in vivo has not been well studied. METHODS: We measured D-dimers, antithrombin, endogenous thrombin potential (ETP; a functional measure of thrombin generation in vitro), thrombin/antithrombin complexes (TAT; a measure of thrombin generation in vivo), tissue factor, prothrombin fragment 1 + 2 (F1+2), and normalized APC sensitivity ratio (nAPCsr) in 199 HIV-positive men who were receiving antiretroviral therapy and had an undetectable HIV RNA level, in 79 HIV-positive untreated men, and in 39 uninfected controls. RESULTS: Median antithrombin levels were higher while the ETP was lower among HIV-infected adults (treated and untreated), compared with controls. There were few differences between coagulation markers in the 2 HIV groups. Compared with controls, the nAPCsr was lower in treated men and the TAT level was lower in untreated individuals. We observed little difference among measured levels of D-dimer, tissue factor, or F1+2 between HIV-infected individuals and controls. Antiretroviral therapy exposure was associated with a lower antithrombin level, a lower nAPCsr, and a lower ETP, while history of opportunistic infection was associated with a higher nAPCsr. CONCLUSIONS: HIV infection is associated with decreased thrombin generation, as measured by the ETP, and an increased antithrombin level. These data suggest that HIV infection may not be associated with increased propensity toward clotting, as has been suggested on the basis of isolated measures of D-dimer levels.

Comparison of Outcomes in DeBakey Type AI Versus AII Aortic Dissection.

The DeBakey classification divides type A acute aortic dissection (AAD) into type I and type II; the latter limited to the ascending aorta. We endeavored to examine differences in DeBakey groups in a contemporary registry. We divided 1,872 patients with noniatrogenic AAD from the International Registry of Acute Aortic Dissection into type I (n = 1691, 90.3%) and type II (n = 181, 9.7%). Patients with type II AAD were older. On presentation, patients with type I AAD reported more back and abdominal pain and were more likely to have pulse deficit. Intramural hematoma was more frequent in type II AAD. Most patients with both types were treated surgically. Lower rates of renal failure, coma, mesenteric and limb ischemia were noted in those with type II AAD. In-hospital death was less frequent (16.6% vs 22.5%) after type II AAD, a trend that did not reach significance. There was no difference in the incidence of new dissection, rapid aortic growth, late aortic intervention or survival at 5 years. In conclusion, AAD limited to the ascending aorta (DeBakey type II) appears to be associated with improved clinical outcomes compared with dissection that extend to the aortic arch or beyond. Although fewer dissection-related complications were noted in patients presenting with type II AAD, as was a trend toward reduced in-hospital mortality, 5-year survival and descending aortic sequelae are not reduced in this contemporary report from International Registry of Acute Aortic Dissection.

Insertion of the beta Geo promoter trap into the Fem1c gene of ROSA3 mice.

ROSA3 mice were developed by retroviral insertion of the beta Geo gene trap vector. Adult ROSA3 mice exhibit widespread expression of the trap gene in epithelial cells found in most organs. In the central nervous system the highest expression of beta Geo is found in CA1 pyramidal cells of the hippocampus, Purkinje cells of the cerebellum, and ganglion cells of the retina. Characterization of the genomic insertion site for beta Geo in ROSA3 mice shows that the trap vector is located in the first intron of Fem1c, a gene homologous to the sex-determining gene fem-1 of Caenorhabditis elegans. Transcription of the Rosa3 allele (R3) yields a spliced message that includes the first exon of Fem1c and the beta Geo coding region. Although normal processing of the Fem1c transcript is disrupted in homozygous Rosa3 (Fem1c(R3/R3)) mice, some tissues show low levels of a partially processed transcript containing exons 2 and 3. Since the entire coding region of Fem1c is located in these two exons, Fem1c(R3/R3) mice may still be able to express a putative FEM1C protein. To this extent, Fem1c(R3/R3) mice show no adverse effects in their sexual development or fertility or in the attenuation of neuronal cell death, another function that has been attributed to both fem-1 and a second mouse homolog, Fem1b. Examination of beta Geo expression in ganglion cells after exposure to damaging stimuli indicates that protein levels are rapidly depleted prior to cell death, making the beta Geo reporter gene a potentially useful marker to study early molecular events in damaged neurons.

Low pO2 Contributes to Potential Error in Oxygen Saturation Calculations Using a Point-of-Care Assay.

OBJECTIVES: The present study addressed the accuracy of calculated oxygen saturation (sO2) using point-of-care (POC) testing compared with measured values on a blood gas analyzer. METHODS: In total, 3,323 sO2 values were measured in 1,180 patients using a CO-oximeter (ABL 800 Flex; Radiometer, Copenhagen, Denmark). Measured parameters were then used to calculate an expected sO2 for the POC method (Abbott i-STAT; Abbott POC, Princeton, NJ). Cases in which calculated sO2 differed from measured sO2 by 10% or more were analyzed. RESULTS: Of the 3,323 comparisons performed, 260 (8%) showed discrepancies (± ≥10%) between measured and calculated sO2 values. Ninety-four of discrepant measurements (245 of 260) occurred when pO2 was less than 50 mm Hg. pH and bicarbonate distributions shifted to lower values in discrepant vs nondiscrepant cases. CONCLUSIONS: Our results suggest that the likelihood of discrepant sO2 is 27% among patients with pO2 less than 50 mm Hg. Direct measurement of sO2 by CO-oximetry is strongly suggested in this clinical scenario.

Outcomes of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients with previous coronary bypass surgery.

OBJECTIVES: This study sought to determine the contemporary clinical characteristics and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and previous coronary artery bypass graft (CABG), including those with a saphenous vein graft culprit lesion. BACKGROUND: The outcome of STEMI patients with previous CABG is reported to be inferior to those without previous CABG, but limited data is available from the primary percutaneous coronary intervention era. METHODS: Data was extracted from a large, regional STEMI system's prospective database, which contained 3,542 unique STEMI episodes from March 4, 2003 through April 22, 2012. RESULTS: Previous CABG was present in 249 patients (7%). Despite higher comorbidity, patients with versus those without previous CABG had similar in-hospital (4.8% vs. 5.2%; p = 0.82) and 1-year (10.8% vs. 9.1%; p = 0.36) mortality, but 5-year (24.9% vs. 14.2%; p < 0.001) mortality was higher. Patients with previous CABG have similar door-to-balloon times. The culprit vessel was the saphenous vein graft in 84 patients (34%), a native vessel in 104 (42%), with no clear culprit in 59 (24%). The left internal mammary artery graft was not a culprit in any patient. Mortality at 30 days (8.3% vs. 3.9% vs. 1.7%, p = 0.19) and 1 year (14.3% vs. 9.0% vs. 6.8%; p = 0.35) was higher (but not statistically) with a saphenous vein graft culprit and was equivalent at 5 years (25.0% vs. 26.0% vs. 20.3%; p = 0.71). CONCLUSIONS: Patients with previous CABG treated in a regional STEMI system have similar outcomes as patients without previous CABG, although 5-year mortality is higher. The most common culprit location was a native vessel (42%). Outcomes have improved significantly compared with historical reports.