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The advent of excimer laser coronary atherectomy (ELCA) nearly four decades ago heralded a novel way to treat complex lesions, both coronary and peripheral, which were previously untraversable and thus untreatable. These complex lesions include heavily calcified lesions, ostial lesions, bifurcation lesions, chronic total occlusions, in-stent restenosis (including stent underexpansion), and degenerative saphenous vein grafts. We discuss the technology of ELCA, its indications, applications, and complications, and suggest the "MAXCon ELCA" technique for better outcomes without increased risk. Lastly, we present a case of MAXCon ELCA effectively treating a complex lesion.
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Aterectomia Coronária , Angiografia Coronária , Doença da Artéria Coronariana , Lasers de Excimer , Humanos , Meios de Contraste , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/diagnóstico por imagem , Lasers de Excimer/uso terapêutico , Solução Salina/administração & dosagem , Resultado do TratamentoRESUMO
OBJECTIVES: Despite the rising use of MC, the impact of preexisting AF, a common comorbidity, on short-term postprocedural outcomes is poorly defined. We sought to assess outcomes between patients with and without atrial fibrillation (AF) who underwent percutaneous mitral valve repair with MitraClip (MC). METHODS: In this retrospective cohort study, the Nationwide Readmissions Database was queried for patients who underwent MC between 2014-2017. Groups were stratified based on the presence of AF. Multivariable logistic regression analyses were performed to identify the association between AF and in-hospital stroke and mortality. RESULTS: Of the 15,570 patients who underwent MC, 7,740 (49.7%) had AF. AF patients were older (82 vs. 79 years, p < .001) and more comorbid. Patients with AF relative to without AF demonstrated increased rates of in-hospital ischemic (1.3% vs .0.7%, p < .001) and hemorrhagic stroke (0.3% vs. 0.1%, p = .007), longer duration of hospitalization (median 3 vs. 2 days, p < .001), and similar in-hospital mortality (2.8% vs. 2.6%, p = .52). After adjusting for comorbidities, age, sex, hospital procedural volume, and CHA2DS2-VASc, the presence of AF was associated with higher in-hospital stroke (OR = 2.096, 95%CI[1.503-2.921], p < .001) but not in-hospital mortality (OR = 1.012, 95%CI[0.828-1.238], p = .904). AF patients were more likely to be readmitted (16.8% vs.14.1%, p < .001) and die (1.5% vs. 0.9%, p = .005) within 30 days of discharge despite similar incidences of stroke (0.7% vs. 0.6%, p = .53). CONCLUSIONS: The increased risk of in-hospital stroke, 30-day mortality, and longer hospitalization suggest the need for increased preprocedural optimization by means of stroke prevention strategies in those with AF undergoing MC.
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Fibrilação Atrial , Procedimentos Cirúrgicos Cardíacos , Acidente Vascular Cerebral , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Resultado do TratamentoRESUMO
OBJECTIVES: To determine how self-reported level of exposure to patients with novel coronavirus 2019 (COVID-19) affected the perceived safety, training and well-being of residents and fellows. METHODS: We administered an anonymous, voluntary, web-based survey to a convenience sample of trainees worldwide. The survey was distributed by email and social media posts from April 20th to May 11th, 2020. Respondents were asked to estimate the number of patients with COVID-19 they cared for in March and April 2020 (0, 1-30, 31-60, >60). Survey questions addressed (1) safety and access to personal protective equipment (PPE), (2) training and professional development and (3) well-being and burnout. RESULTS: Surveys were completed by 1420 trainees (73% residents, 27% fellows), most commonly from the USA (n=670), China (n=150), Saudi Arabia (n=76) and Taiwan (n=75). Trainees who cared for a greater number of patients with COVID-19 were more likely to report limited access to PPE and COVID-19 testing and more likely to test positive for COVID-19. Compared with trainees who did not take care of patients with COVID-19 , those who took care of 1-30 patients (adjusted OR [AOR] 1.80, 95% CI 1.29 to 2.51), 31-60 patients (AOR 3.30, 95% CI 1.86 to 5.88) and >60 patients (AOR 4.03, 95% CI 2.12 to 7.63) were increasingly more likely to report burnout. Trainees were very concerned about the negative effects on training opportunities and professional development irrespective of the number of patients with COVID-19 they cared for. CONCLUSION: Exposure to patients with COVID-19 is significantly associated with higher burnout rates in physician trainees.
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Atitude do Pessoal de Saúde , COVID-19/prevenção & controle , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Internato e Residência/organização & administração , Adulto , COVID-19/epidemiologia , COVID-19/transmissão , Feminino , Humanos , Controle de Infecções/organização & administração , Masculino , Equipamento de Proteção Individual , Admissão e Escalonamento de Pessoal , Segurança , Autorrelato , Inquéritos e Questionários , Telemedicina , Adulto JovemRESUMO
BACKGROUND: Transcatheter aortic valves are prone to acute recoil similar to the metal-based coronary stents. However, it is not clear if recoil remains a factor only after the initial valve deployment or also after post-dilation. METHODS: We conducted a retrospective observational study of patients who underwent transfemoral transcatheter aortic valve replacement (TAVR) with SAPIEN-3 valve. Acute recoil at the upper, central, and lower levels of the valve was calculated in both anteroposterior right anterior oblique (RAO) and lateral left anterior oblique (LAO) views after initial deployment as well as after post-dilation. The average recoil of the RAO and LAO views was also calculated and described as RAO/LAO. RESULTS: The acute recoil in the RAO/LAO views (mean ± SD) was 3.9 ± 1.1% after valve deployment in the whole study population (n = 257). Among the subset of patients who required post-dilation (n = 133), the mean acute recoil in the RAO/LAO views was found to be greater after initial valve deployment as compared with after post-dilation (3.8 ± 1.1% vs. 3.0 ± 0.9%; p < .001). Further, acute recoil was significantly greater in the RAO view than the LAO view and at the central level of the prosthesis as compared with the upper and lower levels. Those findings were consistent after initial deployment as well as after post-dilation. Clinical outcomes were similar between patients who required post-dilation compared to those who did not. In multivariable logistic regression analysis, only smaller valve cover index was found to be an independent predictor of 30-day mild or greater aortic regurgitation (OR 0.007; 95% CI 0.0001-0.707; p = .035). CONCLUSION: Acute elastic recoil of the SAPIEN-3 valve was significantly less after post-dilation as compared with after deployment. It was also greater when measured in the RAO view as compared with the LAO view. Furthermore, acute recoil was not homogenous across the height of the valve stent frame.
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Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Valvuloplastia com Balão , Cateterismo Periférico , Artéria Femoral , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter/instrumentação , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Valvuloplastia com Balão/efeitos adversos , Cateterismo Periférico/efeitos adversos , Elasticidade , Feminino , Humanos , Masculino , Desenho de Prótese , Estudos Retrospectivos , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
INTRODUCTION: Percutaneous femoral access is the preferred access route for transcatheter aortic valve replacement (TAVR). The majority of experienced TAVR centers use two 6F Perclose ProGlide™ devices to close the primary vascular access site, deployed prior to upsizing sheath size with closure completed at the end of the case (the "preclose" approach). A strategy of utilizing a single Perclose device to preclose may have advantages including fewer complications, complexity, and cost, but the safety of this is unknown. This study examines in the safety and efficacy of using a single Perclose versus double Perclose for perclosure of large bore access during TAVR. METHODS: Patients undergoing Transfemoral (TF) TAVR from January 2014 to December 2017 within the Cleveland Clinic Aortic Valve Center were identified. A retrospective review of medical charts was conducted. Vascular complications were defined according to the VARC-2 criteria. RESULTS: A total of 740 patients were included; 487 (65.8%) received a single Perclose device while 253 (34.2%) received double Perclose devices. Baseline characteristics were similar with no differences between the single versus double Perclose groups, respectively. The access sheath size was similar in both groups with (14, 16, and 18 F) being the most common sizes utilized. Of the total 487 patients with single Perclose, 75.6% needed additional closure device (AngioSeal). With double Perclose strategy, additional closure device (AngioSeal) was used in 40.3% patients with 470 (63.5%) patients being successfully perclosed. Vascular complication rates including hematoma, stenosis requiring stenting, pseudoaneurysm, and other major vascular complications were similar between both groups. CONCLUSION: Single 6F ProGlide use for preclosure is a safe strategy for TF TAVR using the S3 valve. Additional closure device was not needed in almost one-quarter of the patients. When necessary, residual bleeding can be controlled with the AngioSeal Device at the end of the procedure. This single device preclose strategy can help to reduce the cost of TAVR procedure without increasing risk.
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Cateterismo Periférico , Artéria Femoral , Hemorragia/prevenção & controle , Técnicas Hemostáticas/instrumentação , Substituição da Valva Aórtica Transcateter , Dispositivos de Oclusão Vascular , Idoso , Idoso de 80 Anos ou mais , Cateterismo Periférico/efeitos adversos , Desenho de Equipamento , Feminino , Hemorragia/etiologia , Técnicas Hemostáticas/efeitos adversos , Humanos , Masculino , Ohio , Punções , Estudos Retrospectivos , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: Despite achieving optimal levels of low-density lipoprotein cholesterol (LDL-C) with statins, the risk of atherosclerotic cardiovascular disease (ASCVD) persists. The purpose of this review is to outline the effects of icosapent ethyl (IPE), an ultra-purified eicosapentaenoic acid (EPA) on ASCVD risk assessment. RECENT FINDINGS: Many studies have shown that elevated triglycerides (TG) contribute to increased risk of ASCVD. However, the only outcomes trial to date to demonstrate a benefit in patients with elevated TG beyond its lipid-lowering properties is REDUCE-IT. Yet, despite IPE demonstrating a relatively modest reduction in TG (~ 20%), there was a 25% relative risk reduction in the primary endpoint and a 30% reduction in total events. Sub-analysis of REDUCE-IT also showed a statically significant decrease in cardiac arrest (HR 0.52 (0.31-0.86), p = 0.01) and sudden cardiac death (HR 0.69 (0.50-0.96), p = 0.03). The CVD benefits observed in REDUCE-IT coincide with on-treatment EPA levels. Icosapent ethyl's multiple bioactive properties contribute to CVD risk reduction beyond TG lowering effects. Because patients with a REDUCE-IT-like profile are highly prevalent in the USA and abroad, IPE should not be viewed as a niche drug, but rather part of a proven armamentarium that deserves widespread use in appropriate patients at elevated ASCVD risk.
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Doenças Cardiovasculares , Hipertrigliceridemia , Preparações Farmacêuticas , Doenças Cardiovasculares/prevenção & controle , Ácido Eicosapentaenoico/análogos & derivados , Ácido Eicosapentaenoico/uso terapêutico , Humanos , Fatores de Risco , TriglicerídeosRESUMO
Hypertriglyceridemia (HTG) is among the most common dyslipidemias seen in clinical practice. Studies in recent years have demonstrated a causal relationship between triglyceride-rich lipoproteins (TRL) and cardiovascular disease (CVD). This is primarily due to enhanced atherogenicity of cholesterol-enriched remnants, the metabolic byproducts of TRLs. Other factors influencing atherogenicity of TRLs include apolipoprotein CIII-directed proinflammatory signaling pathways and triglyceride enrichment of low-density lipoprotein that results in overabundance of small dense atherogenic particles within a prooxidative milieu that serves as the gateway for unregulated incorporation by vascular wall macrophages. HTG is caused by familial and metabolic disorders as well as selected medications that impair TRL hydrolysis.
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Aterosclerose , Doenças Cardiovasculares , Dislipidemias , Hipertrigliceridemia , Doenças Cardiovasculares/complicações , Humanos , Hipertrigliceridemia/tratamento farmacológico , Hipertrigliceridemia/terapia , Triglicerídeos/metabolismo , Triglicerídeos/uso terapêuticoRESUMO
Tumoral calcinosis is a rare syndrome that affects mostly soft tissues. It is characterized by calcium salt deposition in the periarticular soft tissue surrounding bony structures forming slow-growing, seldom asymptomatic masses. This case report describes a 41-year-old male with end-stage renal disease on home hemodialysis, who presented with an unusual rapidly progressive mass overlying the manubrium and suprasternal notch, following recent cardiothoracic surgery, which was initially felt to be a hematoma. The case highlights the role of spectral detector computed tomography (SDCT) in reaching the correct diagnosis of tumoral calcinosis as well as demonstrating additional changes of ectopic parathyroid hyperplasia in the anterior mediastinum.
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OBJECTIVE: Calcium metabolism has long been implicated in aortic stenosis (AS). Studies assessing the long-term safety of oral calcium and/or vitamin D in AS are scarce yet imperative given the rising use among an elderly population prone to deficiency. We sought to identify the associations between supplemental calcium and vitamin D with mortality and progression of AS. METHODS: In this retrospective longitudinal study, patients aged ≥60 years with mild-moderate native AS were selected from the Cleveland Clinic Echocardiography Database from 2008 to 2016 and followed until 2018. Groups were stratified into no supplementation, supplementation with vitamin D alone and supplementation with calcium±vitamin D. The primary outcomes were mortality (all-cause, cardiovascular (CV) and non-CV) and aortic valve replacement (AVR), and the secondary outcome was AS progression by aortic valve area and peak/mean gradients. RESULTS: Of 2657 patients (mean age 74 years, 42% women) followed over a median duration of 69 months, 1292 (49%) did not supplement, 332 (12%) took vitamin D alone and 1033 (39%) supplemented with calcium±vitamin D. Calcium±vitamin D supplementation was associated with a significantly higher risk of all-cause mortality (absolute rate (AR)=43.0/1000 person-years; HR=1.31, 95% CI (1.07 to 1.62); p=0.009), CV mortality (AR=13.7/1000 person-years; HR=2.0, 95% CI (1.31 to 3.07); p=0.001) and AVR (AR=88.2/1000 person-years; HR=1.48, 95% CI (1.24 to 1.78); p<0.001). Any supplementation was not associated with longitudinal change in AS parameters in a linear mixed-effects model. CONCLUSIONS: Supplemental calcium with or without vitamin D is associated with lower survival and greater AVR in elderly patients with mild-moderate AS.
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Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Cálcio , Feminino , Humanos , Estudos Longitudinais , Masculino , Estudos Retrospectivos , Índice de Gravidade de Doença , Vitamina D , VitaminasRESUMO
Background: Coronary obstruction during transcatheter aortic valve replacement (TAVR) is a rare, yet life-threatening, complication. The routine use of left main (LM) protection with or without stent placement in high-risk patients remains controversial. The aim of this study was to evaluate the outcomes of LM protection during TAVR and identify anatomic factors associated with need for stent placement. Methods: We retrospectively reviewed all TAVR cases (native and valve-in-valve) performed in our institution between 2014 and 2019 and identified patients who underwent LM protection with a coronary wire, balloon, and/or stent during the procedure. We compared the pre-TAVR computed tomography aortic root characteristics, procedural data, short-, and long-term outcomes among the patients who eventually received an LM stent and those who did not. Results: Among 1925 TAVR patients, 41 (2.1%) underwent LM protection, and 10 of them (25%) had eventually a stent placed in the LM for threatened obstruction after valve deployment. In the native TAVR group (n = 35), 8 patients underwent LM stenting. A larger TAVR prosthesis, larger annular circumference (83.8 vs 76.1 âmm; P = .038), lower ratio of sinotubular junction diameter to prosthesis size (1.02 vs 1.11; P = .032), and longer left coronary cusp (15.1 vs 13.9 âmm; P = .18) were associated with higher incidence of LM stenting. In the valve-in-valve TAVR group (n = 6), 5 patients had a valve-to-coronary distance of less than 4 âmm, and 2 of them received an LM stent. Both stent and nonstent groups had excellent outcomes with no major adverse cardiovascular events or coronary obstruction at 30 âdays. After a median follow-up of 351 âdays, 4 patients died (9.7%) (1 in the stent and 3 in the nonstent group), without any cases of late coronary obstruction or percutaneous coronary intervention in either group. Conclusions: LM protection with a coronary guidewire, balloon, or stent is a safe and effective method of coronary protection during TAVR in appropriately selected high-risk patients. Annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and ratio of sinotubular junction to prosthesis size are important predictors of stent deployment.
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Transcatheter aortic valve replacement (TAVR) is a safe and feasible alternative to surgery in patients with symptomatic severe aortic stenosis regardless of the surgical risk. Conduction abnormalities requiring permanent pacemaker (PPM) implantation remain a common finding after TAVR due to the close proximity of the atrioventricular conduction system to the aortic root. High-grade atrioventricular block and new onset left bundle branch block (LBBB) are the most commonly reported conduction abnormalities after TAVR. The overall rate of PPM implantation after TAVR varies and is related to pre-procedural and intraprocedural factors. The available literature regarding the impact of conduction abnormalities and PPM requirement on morbidity and mortality is still conflicting. Pre-procedural conduction abnormalities such as right bundle branch block and LBBB have been linked with increased PPM implantation and mortality after TAVR. When screening patients for TAVR, heart teams should be aware of various anatomical and pathophysiological conditions that make patients more susceptible to increased risk of conduction abnormalities and PPM requirement after the procedure. This is particularly important as TAVR has been recently approved for patients with low surgical risk. The purpose of this review is to discuss the incidence, predictors, impact, and management of the various conduction abnormalities requiring PPM implantation in patients undergoing TAVR.
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Estenose da Valva Aórtica , Marca-Passo Artificial , Substituição da Valva Aórtica Transcateter , Valva Aórtica , Estenose da Valva Aórtica/cirurgia , Eletrocardiografia , Humanos , Incidência , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVES: This study sought to evaluate and assess the extent of serial coronary artery calcification in response to oral calcium supplementation. BACKGROUND: Oral calcium supplements are frequently used despite their cardiovascular safety remaining controversial. Their effects on serial coronary calcification are not well established. METHODS: In a post hoc patient-level analysis of 9 prospective randomized trials using serial coronary intravascular ultrasound, changes in serial percentage of atheroma volume (PAV) and calcium indices (CaI) were compared in matched segments of patients coronary artery disease who were receiving concomitant calcium supplements (n = 447) and in those who did not receive supplements (n = 4,700) during an 18- to 24-month trial period. RESULTS: Patients (mean age 58 ± 9 years; 73% were men; 43% received concomitant high-intensity statins) demonstrated overall annualized changes in PAV and CaI with a mean of -0.02 ± 1.9% (p = 0.44) and a median of 0.02 (interquartile range: 0.00 to 0.06) (p < 0.001) from baseline, respectively. Following propensity-weighted mixed modeling adjusting for treatment and a range of demographic, clinical, ultrasonic, and laboratory parameters (including but not limited to sex, race, baseline, and annualized change in PAV, baseline CaI, concomitant high-intensity statins, diabetes mellitus, renal function), there were no significant between-group differences in annualized changes in PAV (least-squares mean: 0.09; 95% confidence interval [CI]: -0.20 to 0.37 vs. 0.01; 95% CI: -0.27 to 0.29; p = 0.092) according to calcium supplement intake. Per a multivariable logistic regression model accounting for the range of covariates described, calcium supplementation independently associated with an increase in annualized CaI (odds ratio: 1.15; 95% CI: 1.05 to 1.26; p = 0.004). CONCLUSIONS: Oral calcium supplementation may increase calcium deposition in the coronary vasculature independent of changes in atheroma volume. The impact of these changes on plaque stability and cardiovascular outcomes requires further investigation.
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Doença da Artéria Coronariana , Idoso , Cálcio , Vasos Coronários/diagnóstico por imagem , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica , Valor Preditivo dos Testes , Estudos Prospectivos , Ultrassonografia de Intervenção , Calcificação VascularRESUMO
[Figure: see text].
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Fibrilação Atrial/psicologia , Ablação por Cateter/métodos , Medidas de Resultados Relatados pelo Paciente , Veias Pulmonares/cirurgia , Qualidade de Vida , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Icosapent ethyl (IPE) is a highly purified (>96%) form of eicosapentanoic acid, a marine-derived omega-3 fatty acid known to reduce serum triglyceride (TG) levels. In the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT), the addition of 4 g IPE daily resulted in a 25% reduction in cardiovascular events beyond statins and other standard of care therapies. IPE is now the only therapy currently approved by the Food and Drug Administration to treat patients with elevated TGs (150-499 mg/dL) with cardiovascular disease (CVD) or Type 2 diabetes mellitus and two or more CVD risk factors.Areas covered: IPE is a highly purified form of eicosapentanoic acid for patients with elevated TGs as monotherapy or combined with statins and/or other lipid lowering therapies.The REDUCE-IT Study demonstrated a 25% reduction in the primary outcome measure and 30% reduction in total CVD events in high-risk patients with elevated TGs (135-499 mg/dL) assigned to IPE (4 g daily).Side effects included a statistically significant increased risk of atrial fibrillation and bleeding, although the risk of stroke was reduced and there were no cases of fatal bleeding.The FDA recently approved IPE for treatment of patients with TG levels of 150-499 mg/dL and preexisting CVD or Type 2 diabetes mellitus with two or more risk factors.Expert opinion:IPE has proven to be superior to other forms of omega 3 fatty acid in reducing CVD risk in patients with elevated TG. This could be attributed to multiple factors including the use of highly purified eicosapentaenoic acid ethyl esters without docosahexaenoic acid (DHA), thus preventing the increase in low-density lipoprotein cholesterol associated with DHA especially at high TG levels, reduction in atherogenic TG-rich particles, antioxidant and anti-inflammatory properties, improvement in endothelial function, and stabilization of atherosclerotic plaque.
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Doenças Cardiovasculares/tratamento farmacológico , LDL-Colesterol/sangue , Ácido Eicosapentaenoico/análogos & derivados , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Aterosclerose/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Ácido Eicosapentaenoico/administração & dosagem , Humanos , Hipertrigliceridemia/tratamento farmacológico , Fatores de Risco , Triglicerídeos/sangueRESUMO
Benign metastasizing leiomyoma is a rare condition usually affecting women of reproductive age with a history of uterine leiomyoma and characterized by soft tissue masses in various extrauterine sites. We report a case of a 46-year-old woman with previously resected uterine leiomyoma with subsequent pulmonary and tricuspid valve lesions. (Level of Difficulty: Intermediate.).
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The influence of age on outcomes of patients selected for transcatheter mitral valve repair (TMVR) remains largely unknown in the United States. This study sought to assess the outcomes of TMVR in highly aged patients (≥80 years). We queried the National Readmission Database from January 2014 to December 2016 for elective TMVR hospitalizations. Propensity-score matching was used to compare in-hospital and 30-day outcomes between highly aged patients and those less than 80 years. Of 6,025 (weighted national estimate) hospitalizations for TMVR, total of 3,368 included highly aged patients (mean age 85.3) and 2,657 included patients less than 80 years (mean age 69). In the Propensity-score matched cohort (age≥ 80, nâ¯=â¯2,185; age <80, nâ¯=â¯2,197), highly aged patients had similar rates of in-hospital mortality (2.2% vs 1.6%; pâ¯=â¯0.22), ischemic stroke (0.5% vs 0.5%; pâ¯=â¯0.83), cardiac tamponade (0.2% vs 0.4%; pâ¯=â¯0.58), cardiogenic shock (1.2% vs 1.7%; pâ¯=â¯0.25), and acute myocardial infarction (0.6% vs 0.4%; pâ¯=â¯0.30), but higher rates of discharge to skilled nursing facility(9.7% vs 4.5%; p <0.001), all-cause 30-day readmissions (14.2% vs 10.5%; p <0.001), and heart failure-related 30-day readmissions (4.7% vs 3.0%; pâ¯=â¯0.006), compared with those less than 80 years. TMVR therapy is safe and is associated with low rates of in-hospital adverse events but higher rate of 30-day readmissions in highly aged patients compared with patients less than 80 years. Evidence-based interventions proven to be effective in reducing the burden of heart failure readmissions should be utilized in these patients to further improve outcomes.
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Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Insuficiência da Valva Mitral/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Insuficiência da Valva Mitral/mortalidade , Pontuação de Propensão , Desenho de Prótese , Fatores de Risco , Estados UnidosRESUMO
OBJECTIVES: The aim of this study was to investigate the impact of spontaneous coronary artery dissection (SCAD) on 30-day readmission rates following hospitalization with acute myocardial infarction (AMI) using a national database. BACKGROUND: AMI in the setting of SCAD represents an uncommon type of myocardial infarction with limited data on short-term outcomes. METHODS: All hospitalizations with primary or index diagnoses of AMI from 2010 to 2015 in the Nationwide Readmissions Database were queried. The primary outcome was overall 30-day readmission rates in both SCAD and non-SCAD cohorts. Propensity score matching (1:2) was conducted. RESULTS: A total of 2,654,087 patients with AMI were included in the final analysis, of whom 1,386 (0.052%) were diagnosed with SCAD. SCAD was associated with a higher readmission rate in the SCAD cohort (12.3% vs. 9.9%; p = 0.022). The main causes of readmissions in the SCAD cohort were cardiac causes (80.6%), and AMI was the most common cardiac cause (44.8%), followed by chest pain (20.1%) and arrhythmia (12.7%). Among the SCAD readmissions, 50.6% patients were readmitted in the first week post-discharge, with 54.5% of AMI readmissions occurring in the first 2 days post-discharge. CONCLUSIONS: The incidence of 30-day readmission following AMI and SCAD is nontrivial and occurs early post-discharge. Most readmissions are due to cardiac causes, especially AMI. Targeted management approaches are needed to diminish the high rates of readmission and early recurrent AMI.
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Anomalias dos Vasos Coronários/terapia , Infarto do Miocárdio/terapia , Admissão do Paciente , Readmissão do Paciente , Doenças Vasculares/congênito , Idoso , Anomalias dos Vasos Coronários/diagnóstico por imagem , Anomalias dos Vasos Coronários/mortalidade , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Recidiva , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/mortalidade , Doenças Vasculares/terapiaRESUMO
OBJECTIVES: The aim of this study was to determine the utility of rapid atrial pacing immediately after transcatheter aortic valve replacement (TAVR) to predict the need for permanent pacemaker implantation (PPI). BACKGROUND: Risk stratification for patients without high-grade atrioventricular block (AVB) after TAVR is imprecise and based on anatomic considerations, electrocardiographic characteristics, and clinical suspicion. A more reliable assessment is necessary to minimize inpatient rhythm monitoring and/or reduce unnecessary PPI. METHODS: Consecutive patients undergoing TAVR at 2 centers were included. After valve implantation in patients without pacemakers who did not have complete heart block or atrial fibrillation, the temporary pacemaker was withdrawn from the right ventricle and placed in the right atrium. Rapid atrial pacing was performed from 70 to 120 beats/min, and patients were assessed for the development of Wenckebach AVB. Patients were then followed for clinical outcomes, including PPI. RESULTS: A total of 284 patients were included. Of these, 130 (45.8%) developed Wenckebach AVB. There was a higher rate of PPI within 30 days of TAVR among the patients who developed Wenckebach AVB (13.1% vs. 1.3%; p < 0.001), with a negative predictive value for PPI in the group without Wenckebach AVB of 98.7%. A greater percentage of patients receiving self-expanding valves required PPI than those receiving a balloon-expandable valves (15.9% vs. 3.7%; p = 0.001), though these rates were still relatively low among patients who did not develop Wenckebach AVB (2.9% and 0.8%). CONCLUSIONS: Atrial pacing post-TAVR is easily performed and can help identify patients who may benefit from extended rhythm monitoring. Patients who did not develop pacing-induced Wenckebach AVB demonstrated an extremely low likelihood of PPI.
Assuntos
Estenose da Valva Aórtica/cirurgia , Bloqueio Atrioventricular/diagnóstico , Técnicas Eletrofisiológicas Cardíacas , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Bloqueio Atrioventricular/etiologia , Bloqueio Atrioventricular/fisiopatologia , Bloqueio Atrioventricular/terapia , Estimulação Cardíaca Artificial , Tomada de Decisão Clínica , Feminino , Humanos , Itália , Masculino , Ohio , Marca-Passo Artificial , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Procedimentos DesnecessáriosRESUMO
BACKGROUND: The utilization of monoclonal antibodies has become more widespread over the past decade. However, the development of non-caseating granulomas with the use of monoclonal antibodies, such as ustekinumab, is not widely reported in the literature. CASE PRESENTATION: We report a case of a 50-year-old Caucasian male who presented complaining of weight loss and shortness of breath. He was receiving ustekinumab for refractory psoriasis but had no other significant medical comorbidities. On physical examination, reduced breath sounds on the right side were noted. Blood cultures were drawn on presentation and came back negative in 48 hours. A chest computed tomography scan revealed a large right lung mass in addition to right-sided pleural effusion. Therapeutic thoracocentesis was done; fluid cytology and analysis were negative for malignancy, acid-fast bacilli, or fungal infections. A positron emission tomography scan showed multifocal radiotracer uptake including within right lung mass, multiple bones, lymph nodes, liver and spleen. Biopsies showed hyalinized non-necrotizing granulomas. Immunohistochemical stains for AE1/AE3, cytokeratin 7 and 20, and thyroid transcription factor 1, were all negative. He was started on steroid therapy, and ustekinumab was discontinued and the follow-up computed tomography after a few months showed substantial improvement. However, over the course of next 4 months patient developed hepatic dysfunction and recurrent ascites and ultimately underwent transjugular intrahepatic portosystemic shunt placement. Furthermore, he was started on azathioprine and steroids were tapered. He improved clinically and was discharged from our hospital within a week. CONCLUSIONS: This case highlights the need for careful consideration of patient medication history while evaluating the possible differential diagnoses that may contribute to a patient's presentation.