Longitudinal outcomes of final kissing balloon inflation in coronary bifurcation lesions treated with a single stent.

Background: Final kissing balloon inflation (FKBI) is a percutaneous coronary intervention (PCI) technique that is considered mandatory to improve outcomes in two-stent strategies, but its use in single-stent bifurcation PCI remains controversial. Methods: In this retrospective cohort study, we identified patients with coronary bifurcation lesions treated with one stent from January 2012 to March 2021 at a single academic medical center. Incidence rates per 1,000 patient-years (IR1000) were calculated for the outcomes of all-cause mortality, myocardial infarction (MI), stent thrombosis (ST), target lesion revascularization (TLR), coronary artery bypass graft (CABG), and cardiac readmission between patients who received FKBI and those who did not over a median follow up of 2.3 years. Studied outcomes were adjusted for all baseline clinical and procedural characteristics. Results: This study included 893 consecutive patients of which 256 received FKBI and 637 did not. The IR1000 for MI were 51.1 and 27.6 for patients who received FKBI and patients who did not, respectively (adjusted HR = 2.44, p = 0.001). The IR1000 for death were 31.2 and 52.3 for patients who received FKBI and patients who did not, respectively (adjusted HR = 0.68, p = 0.141). The incidence rates of ST, TLR, CABG, and cardiac readmissions were similar between patients who received FKBI and those who did not. Conclusions: These results suggest that performing FKBI in a one-stent technique was associated with higher rates of myocardial infarction, particularly in the first 6 months, and no difference in death, ST, TLR, CABG, and cardiac readmission rates.

Management of a patient presenting with anterior STEMI with concomitant COVID-19 infection early in the course of the U.S. pandemic.

The coronavirus disease-2019 (COVID-19) is a viral illness with heterogenous clinical manifestations, ranging from mild symptoms to severe acute respiratory distress syndrome and shock caused by the severe acute respiratory syndrome coronavirus-2. The global healthcare community is rapidly learning more about the effects of COVID-19 on the cardiovascular system, as well as the strategies for management of infected patients with cardiovascular disease. There is minimal literature available surrounding the relationship between COVID-19 infection and acute coronary syndrome. We describe the case of a woman who presented with an acute anterior ST-elevation myocardial infarction managed by primary percutaneous coronary intervention, who subsequently developed severe COVID-19 infection and ultimately succumbed to multisystem organ failure.

Sex Differences in Acute Bleeding and Vascular Complications Following Percutaneous Coronary Intervention Between 2003 and 2016: Trends From the Dartmouth Dynamic Registry.

BACKGROUND: Women undergoing percutaneous coronary intervention (PCI) are at higher risk for bleeding and vascular complications than men. Multiple approaches have been utilized to reduce bleeding in the modern era of PCI, including radial access, reduced GP IIb/IIIa inhibitor use, increased vascular closure device use, smaller sheath size and novel antithrombotic regimens. Nevertheless, few studies have assessed the impact of these techniques on the gap between men and women for such complications following PCI. We sought to quantify bleeding and vascular complications over time between men and women. METHODS: We queried The Dartmouth Dynamic Registry for consecutive PCI's performed between January 2003 and June 2016. Demographic information, procedural characteristics, and in-hospital outcomes were collected and compared between men and women over the years. RESULTS: We reviewed 15,284 PCI cases, of which 4384 (29%) were performed in women. Radial access increased from none in 2003 to nearly 40% in 2016. Use of GP IIb/IIIa and femoral access decreased substantially over the same time. Bleeding and vascular complication rates decreased significantly in women (13.2% to 3%; 6.5% to 0.8%, respectively) and men (3.5% to 0.7%, 3.4% to 0.7%, respectively). The overall bleeding and vascular complication rates decreased more for women than men, narrowing the gender gap. CONCLUSIONS: The incidence of bleeding and vascular complications fell between 2003 and 2016 in both men and women. Vascular complications have become less common over time, and based on our analysis, there was no longer any difference between the sexes for this outcome. Bleeding following PCI has decreased in both sexes over time; however, women continue to bleed more than men.

Echocardiography reporting of pulmonary hypertension and subsequent referral to a specialty clinic.

INTRODUCTION: Echocardiography is commonly performed in the evaluation of patients with pulmonary hypertension (PH). The report summary often serves to guide the future evaluation of these patients. Our aim was to explore the relationship between the echocardiography reports of patients with PH and referral to a PH specialty clinic. METHODS: A random sample of 500 echocardiographic reports of patients with an estimated right ventricular systolic pressure (RVSP) greater than 40 mm Hg between 2006 and 2014 was selected from the institutional database of a single academic center. Referral to the PH clinic was determined by evaluating the electronic medical record. Univariate and multivariate logistic regression analyses were performed to identify characteristics associated with referral. RESULTS: Pulmonary hypertension was mentioned in 31% of the report summaries, and only 4.6% were referred to the PH clinic. Variables associated with referral were younger age, indication for echocardiography, higher right atrial and ventricular (RV) systolic pressures, RV dilatation, mention of PH in the summary, and higher left ventricular ejection fraction. Mention of PH in the summary was the variable most strongly associated with referral (adjusted odds ratio 4.6, 95% CI 1.5-14.2). CONCLUSION: Pulmonary hypertension was infrequently mentioned in the summary of echocardiography reports of patients with RVSP >40 mm Hg. Referral to the PH clinic was rare but occurred more often following the mention of PH in the summary. Explicit mention of the presence of PH in the echocardiography report summary may facilitate referral to a specialty clinic and allow more comprehensive evaluation of PH.

Patterns of in-hospital mortality and bleeding complications following PCI for very elderly patients: insights from the Dartmouth Dynamic Registry.

BACKGROUND: Very elderly patients (age ≥ 85 years) are a rapidly increasing segment of the population. As a group, they experience high rates of in-hospital mortality and bleeding complications following percutaneous coronary intervention (PCI). However, the relationship between bleeding and mortality in the very elderly is unknown. METHODS: Retrospective review was performed on 17,378 consecutive PCI procedures from 2000 to 2015 at Dartmouth-Hitchcock Medical Center. Incidence of bleeding during the index PCI admission (bleeding requiring transfusion, access site hematoma > 5 cm, pseudoaneurysm, and retroperitoneal bleed) and in-hospital mortality were reported for four age groups (< 65 years, 65-74 years, 75-84 years, and ≥ 85 years). The mortality of patients who suffered bleeding complications and those who did not was calculated and multivariate analysis was performed for in-hospital mortality. Lastly, known predictors of bleeding were compared between patients age < 85 years and age ≥ 85 years. RESULTS: Of 17,378 patients studied, 1019 (5.9%) experienced bleeding and 369 (2.1%) died in-hospital following PCI. Incidence of bleeding and in-hospital mortality increased monotonically with increasing age (mortality: 0.94%, 2.27%, 4.24% and 4.58%; bleeding: 3.96%, 6.62%, 10.68% and 13.99% for ages < 65, 65-74, 75-84 and ≥ 85 years, respectively). On multivariate analysis, bleeding was associated with increased mortality for all age groups except patients age ≥ 85 years [odds ratio (95% CI): age < 65 years, 3.65 (1.99-6.74); age 65-74 years, 2.83 (1.62-4.94); age 75-84 years, 3.86 (2.56-5.82), age ≥ 85 years: 1.39 (0.49-3.95)]. CONCLUSIONS: Bleeding and mortality following PCI increase with increasing age. For the very elderly, despite high rates of bleeding, bleeding is no longer predictive of in-hospital mortality following PCI.

Bivalirudin versus heparin, without glycoprotein inhibition, in percutaneous coronary intervention: A comparison of ischemic and hemorrhagic outcomes over 10years.

OBJECTIVE: The choice of antithrombotic agent used during percutaneous coronary intervention (PCI) is controversial. While earlier studies suggested a reduction in bleeding events with bivalirudin, these studies were confounded by the concomitant use of glycoprotein IIbIIIa inhibitors (GPI) in the heparin group. More recent studies have challenged the superiority of bivalirudin, pointing to an increased risk of stent thrombosis. Real-world data remains limited. METHODS: We queried our institutional catheterization laboratory database for all PCI cases performed between January 2003 and December 2012 using only heparin or only bivalirudin (no use of GPI). We collected data on relevant patient and procedural characteristics and compared both efficacy and safety outcomes. We adjusted for baseline differences using coarsened exacting matching. RESULTS: 8061 cases met our inclusion criteria. Of these, 34.9% were performed with heparin alone and 65.1% with bivalirudin. After adjusting for baseline differences, we found that those patients receiving heparin had a slightly lower risk of post-procedural abrupt vessel closure (0.1% vs 0.5%). All other outcomes favored bivalirudin including procedural success (97.2% vs 95.5%), transfusion within 72h (2.2% vs 4.8%), retroperitoneal bleeding (0.1% vs 0.8%), and all-cause mortality (0.9% vs 1.9%). Subgroup analysis suggested that outcomes were different only in non-elective cases and non STEMI cases. CONCLUSION: Heparin appears to offer the advantage of slightly reduced risk of abrupt vessel closure post-procedure but at the cost of increased hemorrhagic complications and all-cause mortality. This difference in outcomes may be limited to non-elective and non STEMI cases with femoral access.

Warfarin for stroke prevention following anterior ST-elevation myocardial infarction.

OBJECTIVES: To assess the benefit of vitamin K antagonist (VKA) therapy for prevention of ischemic stroke following anterior ST-elevation myocardial infarction (STEMI) in patients with reduced ejection fraction. METHODS: A prospective institutional-based registry was used to identify survivors of anterior STEMI with a post-STEMI ejection fraction of 40% or less over a 10-year period. Clinical and procedural characteristics were collected from medical records and vital status from the Social Security Death Index. Outcomes were compared on the basis of VKA use. The primary outcome was a composite of ischemic stroke, death, and clinically relevant bleeding. A secondary analysis examined the effects of low-molecular-weight heparin bridging therapy. RESULTS: The primary outcome occurred in 24.7% (40/162) of VKA patients and 20.5% (22/107) of non-VKA patients [adjusted hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.71-2.31]. Ischemic stroke occurred in 2.5 and 0.9% of VKA patients and non-VKA patients, respectively (adjusted HR, 2.81; 95% CI, 0.31-25.1). There was no significant difference in the rate of bleeding or death between groups. The addition of a low-molecular-weight heparin bridge to VKA therapy was associated with increased bleeding events (adjusted HR, 2.55; 95% CI, 1.04-6.24). CONCLUSION: Ischemic stroke was infrequent in the 6 months following anterior STEMI irrespective of VKA treatment status. The routine use of anticoagulation for prevention of stroke following anterior STEMI may not be warranted.

Obesity and pulmonary hypertension: a review of pathophysiologic mechanisms.

Pulmonary hypertension (PH) is a potentially life-threatening condition arising from a wide variety of pathophysiologic mechanisms. Effective treatment requires a systematic diagnostic approach to identify all reversible mechanisms. Many of these mechanisms are relevant to those afflicted with obesity. The unique mechanisms of PH in the obese include obstructive sleep apnea, obesity hypoventilation syndrome, anorexigen use, cardiomyopathy of obesity, and pulmonary thromboembolic disease. Novel mechanisms of PH in the obese include endothelial dysfunction and hyperuricemia. A wide range of effective therapies exist to mitigate the disability of PH in the obese.

Medicare services provided by cardiologists in the United States: 1999-2008.

BACKGROUND: Services provided by cardiologists represent a major portion of Medicare expenditures for specialist physicians. The absolute growth and distribution of these services over the past decade have not been well described. METHODS AND RESULTS: We analyzed fee-for-service Medicare Part B claims for each year from 1999-2008 and selected claims from physicians whose specialty code was cardiology. We then grouped approximately 1000 CPT-9 codes into 45 specific service groups that were then further aggregated into 3 broad service categories: evaluation and management, noninvasive procedures, and invasive procedures. Our main outcome measures were services and allowed charges per 1000 beneficiaries. Sample size ranged from 30.9 million beneficiaries in 1999 to 31.7 million in 2008. During this 10-year period, the number of claims from cardiologists increased 44% (from 2082-2997 per 1000 beneficiaries) while the allowed charges increased 28% after adjusting for inflation (in 2008 dollars, from $181,397-231,728 per 1000 beneficiaries). Evaluation and management services and invasive procedures contributed relatively little to this growth. Instead, most of the growth involved noninvasive procedures--with a 70% increase in claims. Although the most dramatic increases in noninvasive procedures involved emerging imaging technologies (cardiac CT, MRI, and PET scanning), the bulk of the growth occurred in two established technologies: resting echocardiograms and stress tests with nuclear imaging. CONCLUSIONS: Most of the growth in services provided by cardiologists over the past decade is the result of increased noninvasive imaging.

Prevalence and risk factors of pulmonary hypertension in patients with elevated pulmonary venous pressure and preserved ejection fraction.

Pulmonary hypertension (PH) is a well-recognized complication of left-sided heart failure with preserved left ventricular systolic function that portends a worse prognosis. The identification of risk factors may provide insight into possible mechanisms for the development of PH in this population. Targeting these risk factors could possibly attenuate the development of PH. The limited data available regarding the prevalence of PH and its risk factors in patients with heart failure with preserved left ventricular systolic function are based on echocardiography. To further study this, an institutional database was searched for all patients who underwent right-sided and left-sided cardiac catheterization with ventriculography from October 1996 to September 2007 who met the following criteria: left ventricular end-diastolic pressure (LVEDP) >15 mm Hg, a left ventricular ejection fraction > or =50%, and no significant left-sided cardiac valvular disease. The demographic, clinical, and hemodynamic data of these patients were then analyzed. Of 455 patients who met these criteria, 239 (52.5%) had PH, defined as mean pulmonary artery pressure >25 mm Hg. Using multivariate logistic regression, PH was strongly and independently associated with LVEDP > or =25 mm Hg (odds ratio 4.3), morbid obesity (odds ratio 3.4), and atrial arrhythmias (odds ratio 3.1). Other significant associations were age > or =80 years, chronic obstructive pulmonary disease, and dyspnea on exertion. In conclusion, PH is a frequent finding in patients with elevated LVEDPs and preserved left ventricular systolic function. Factors associated with its development are LVEDP > or =25 mm Hg, morbid obesity, atrial arrhythmias, age > or =80 years, chronic obstructive pulmonary disease, and dyspnea on exertion.

Percutaneous and surgical treatment of aortic stenosis.

Aortic stenosis due to calcific degeneration is the most common valvular disorder among the elderly. With the growing elderly population, the prevalence of this disease will continue to increase. Based on converging lines of evidence linking calcific aortic stenosis with atherosclerosis, there has been interest in drug therapy to slow the progression of aortic stenosis. Unfortunately, recently completed prospective trials have been disappointing. Mechanical measures remain the principal form of therapy. Among percutaneous techniques, aortic valvuloplasty provides only transient and modest benefit at a significant risk of stroke and vascular injury. However, aortic valvuloplasty can play a useful role in stabilizing patients who require additional attention prior to definitive surgery. Building on this foundation, a bold new technique of percutaneously implanting a balloon-mounted valve has been developed. Although promising, there have been relatively few patients treated in this fashion (at a single center) and with only limited follow-up. Surgical treatment, specifically valve replacement, is still the definitive treatment of choice for patients with symptomatic aortic stenosis. Surgeons and patients must choose between a variety of models of both tissue and mechanical valves and a variety of surgical approaches. Recent trends include the use of tissue valves in increasingly younger patients and continued interest in alternatives to full median sternotomy in approaching the valve.

Stability of ascending aortic dilatation following aortic valve replacement.

BACKGROUND: Replacement of the ascending aorta (Asc Ao) at the time of aortic valve replacement (AVR) is controversial because the risk of progressive dilatation following valve replacement is uncertain. Our aim was to determine the natural history of ascending aortic dilatation following AVR. METHODS AND RESULTS: We studied 185 patients undergoing AVR at our institution between 1992 and 1999. Clinical and echocardiographic data were obtained by merging our institutional echocardiographic database with the DHMC component of the Northern New England Cardiovascular Disease Study Group database. Baseline Asc Ao measurements obtained from intraoperative transesophageal echocardiograms or early (<8 weeks) postoperative transthoracic echocardiograms were compared with late follow-up measurements (mean follow-up 30.0+/-23.4 months). During follow-up, there was no increase in the mean Asc Ao diameter (3.6+/-0.6 cm versus 3.6+/-0.6 cm, p=NS). Progressive aortic dilatation, defined as an increase in diameter >0.3 cm, occurred in 27/185 patients (15%). Baseline Asc Ao dilatation (>or=3.5 cm) was present in 107/185 patients (58%). In this subset of patients, there was no increase in mean Asc Ao diameter (4.0+/-0.4 versus 3.9+/-0.6 cm, p=NS) and progressive aortic dilatation occurred in only 10 patients (9.3%). No patients with baseline aortic dilatation (range, 3.5 to 5.3 cm) dilated beyond 5.5 cm on follow-up (range, 2.4 to 5.5 cm). There were no clinical or valvular characteristics that predicted progressive Asc Ao dilatation. CONCLUSIONS: An increase in Asc Ao dilatation occurs infrequently following AVR and therefore, argues against routine Asc Ao replacement at the time of AVR.