Hybrid approach of percutaneous coronary intervention followed by minimally invasive mitral valve surgery: a 5-year single-center experience.

BACKGROUND: The current study evaluated the safety and feasibility of staged ("hybrid") percutaneous coronary intervention (PCI) followed by isolated minimally invasive mitral valve (MV) surgery [PCI + minimally invasive mitral valve surgery (MIMVS)], for patients with concomitant coronary artery and MV disease. METHODS: A total of 93 patients who underwent PCI + MIMVS for coronary artery and MV disease between February 2009 and April 2014 were retrospectively analyzed. RESULTS: There were 54 (58.1%) men and 39 (41.9%) women. The mean age was 73±8 years, and all patients had severe mitral regurgitation. PCI was performed for single-vessel coronary artery disease in 40 (43%) patients, two-vessel in 49 (52.7%), and three-vessel in 4 (4.3%). Within a median of 48 days (IQR, 18-71) after PCI, 78 (83.9%) patients underwent primary valve surgery, and 15 (16.1%) underwent re-operative valve surgery, with 56 (60.2%) having MV replacement, and 37 (39.8%) having MV repair. Sixty-five (69.9%) patients were being treated with dual anti-platelet therapy at the time of surgery. The median number of transfused intra-operative red blood cell units was 1 (IQR, 0-2), and the intensive care unit and hospital lengths of stay were 46 hours (IQR, 27-76) and 8 days (IQR, 5-11), respectively. Post-operatively, there was 1 (1.1%) cerebrovascular accident, 2 (2.2%) patients developed acute kidney injury, and 4 (4.3%) required a re-operation for bleeding. Thirty-day mortality occurred in 4 (4.3%) patients. At a mean follow-up of 15.3±13.2 months, 3 (3.4%) patients required target-vessel revascularization. The survival rate was 89% and 85% at 1 and 3 years, respectively. CONCLUSIONS: In patients with concomitant coronary artery and MV disease, PCI + MIMVS can be safely performed and is associated with good short-term and follow-up outcomes.

Same-day discharge or overnight stay after percutaneous coronary intervention: comparison of net adverse cardiovascular events.

BACKGROUND: Same-day discharge after percutaneous coronary intervention (PCI), if achieved with acceptable safety, could result in greater patient satisfaction and potential cost savings. Comparative analyses reporting the safety outcomes of same-day discharge vs overnight stay after elective PCI are lacking. METHODS: Data of same-day discharge and overnight-stay patients undergoing elective PCI in a high-volume center were compared. We specifically evaluated the incidence of net adverse cardiovascular events (NACE; i.e., death, myocardial infarction, stroke, target vessel revascularization, vascular complication, and major bleeding) within 48 hours post index procedure among both groups and at 30 days. RESULTS: A total of 188 cases were evaluated, with 93 discharged the same day and 95 after overnight stay following elective PCI. Baseline characteristics were similar, except for older age (73.0 ± 7 years vs. 64.0 ± 12 years; P<.001), more prior PCI (49.5% vs. 34.7%; P<.001), and prior coronary artery bypass graft surgery (16.1% vs. 11.6%; P=.01) in the same-day discharge group. Procedural characteristics were similar in both groups. No significant difference in the NACE rate was found between the groups at 48 hours (0 [0%] vs. 2 [2.1%]; P=.25) or at 30 days (3 [3.2%] vs. 6 [6.3%]; P=.26). CONCLUSION: In the population studied, same-day discharge after PCI is safe and feasible. Adequately powered randomized prospective studies are necessary to confirm these results.

The use of nitrates in the prevention of contrast-induced nephropathy in patients hospitalized after undergoing percutaneous coronary intervention.

Contrast-induced nephropathy (CIN) is a significant cause of morbidity and mortality and effective strategies for its prevention are greatly needed. The purpose of this retrospective, single-center study was to investigate whether nitrate use during percutaneous coronary artery intervention reduces the incidence of CIN. Chart review of all individuals who underwent percutaneous coronary intervention (PCI) from April 2010 to March 2011 was done. Included in the study were patients who were admitted to the hospital after percutaneous coronary artery intervention and had baseline and follow-up creatinine measured. Patients with end-stage renal disease requiring dialysis and those patients with insufficient information to calculate Mehran score were excluded. There were 199 patients who met the eligibility criteria for inclusion in this study. In the identified population, postprocedure renal function was compared between 112 patients who received nitrates prior to coronary intervention and 87 who did not. Baseline characteristics were similar between the 2 groups. Contrast-induced nephropathy was defined as either a 25% or a 0.5 mg/dL, or greater, increase in serum creatinine during the first 48 to 72 hours after contrast exposure. Overall, 43 (21.6%) patients developed CIN post-PCI. Of the patients who received nitrates, 15.2% developed renal impairment when compared to 29.9% in those who did not (odds ratio [OR] = 0.42, 95% confidence interval [CI] 0.21-0.84, P = .014). Multivariate logistic regression analysis demonstrated that nitrate use was independently correlated with a reduction in the development of contrast nephropathy (OR = 0.334, 95% CI 0.157-0.709, P = .004). Additionally, of the various methods of nitrate administration, intravenous infusion was shown to be the most efficacious route in preventing renal impairment (OR = 0.42, 95% CI 0.20-0.90, P = .03). In conclusion, the use of nitrates prior to PCI, particularly intravenous nitroglycerin infusion, may be associated with a decreased incidence of CIN.

Usefulness of the troponin-ejection fraction product to differentiate stress cardiomyopathy from ST-segment elevation myocardial infarction.

The presentation of stress cardiomyopathy (SC) with nonobstructive coronary artery disease mimics that of ST-segment elevation myocardial infarction (STEMI) due to coronary occlusion. No single parameter has been successful in differentiating the 2 entities. We thus sought to develop a noninvasive clinical tool to discriminate between these 2 conditions. We retrospectively reviewed 59 consecutive cases of SC at our institution from July 2005 through June 2011 and compared those with 60 consecutives cases of angiographically confirmed STEMI treated with primary percutaneous coronary intervention in the same period. All patients underwent acute echocardiography, and the peak troponin I level was determined. The troponin-ejection fraction product (TEFP) was derived by multiplying the peak troponin I level and the echocardiographically derived left ventricular ejection fraction. Comparing the SC and STEMI groups, the mean left ventricular ejection fraction at the time of presentation was 30 ± 9% versus 44 ± 11%, respectively (p <0.001), and the peak troponin I was 7.6 ± 18 versus 102.2 ± 110.3 ng/dl, respectively (p <0.001). The mean TEFP was thus 182 ± 380 and 4,088 ± 4,244 for the SC and STEMI groups, respectively (p <0.001). Receiver operating characteristic curve analysis showed that a TEFP value ≥250 had a sensitivity of 95%, a specificity of 87%, a negative predictive value of 94%, a positive predictive value of 88%, and an overall accuracy of 91% to differentiate a true STEMI from SC (C-statistic 0.91 ± 0.02, p <0.001). In conclusion, for patients not undergoing emergent angiography, the TEFP may be used with high accuracy to differentiate SC with nonobstructive coronary artery disease from true STEMI due to coronary occlusion.

Incidence of postoperative acute kidney injury in patients with chronic kidney disease undergoing minimally invasive valve surgery.

BACKGROUND: We hypothesize that minimally invasive valve surgery in patients with chronic kidney disease (CKD) is superior to a conventional median sternotomy. METHODS: We retrospectively analyzed 1945 consecutive patients who underwent isolated valve surgery. Included were patients with CKD stages 2 to 5. In-hospital mortality, composite complication rates, and intensive care unit and total hospital lengths of stay of those who underwent a minimally invasive approach were compared with those who underwent a standard median sternotomy. Resource use was approximated based on intensive care unit and total hospital lengths of stay. RESULTS: There were 688 patients identified; 510 (74%) underwent minimally invasive surgery, and 178 (26%) underwent a median sternotomy. There was no significant difference in mortality. Minimally invasive surgery was associated with fewer composite complications (33.1% vs 49.4%; odds ratio, 0.5; P ≤ .001), shorter intensive care unit (48 [interquartile range {IQR}, 33-74] hours vs 71 [IQR, 42-96] hours; P < .01), and hospital (8 [IQR, 6-9] days vs 10 [IQR, 8-15] days; P < .001) lengths of stay, and a lower incidence of acute kidney injury (8% vs 14.7%; odds ratio, 0.5; P = .01), compared with median sternotomy. In a multivariable analysis, minimally invasive surgery was associated with a 60% reduction in the risk of development of postoperative acute kidney injury. CONCLUSIONS: In patients with CKD undergoing isolated valve surgery, minimally invasive valve surgery is associated with reduced postoperative complications and lower resource use.