Congenital absence of right coronary artery: a rare coronary anomaly: case report.

Single coronary artery is a rare congenital anomaly in which a single coronary artery arises from the aortic root that supplies the entire heart. It has variable clinical presentations ranging from a completely benign course to sudden cardiac death. Identifying and categorizing to high-risk type based on clinical presentation and anatomical features can present adverse cardiac events and provides better prognosis.

Lung carcinoma paraneoplastic reactive regional pericarditis mimicking ST elevation myocardial infarct.

ST-elevation myocardial infarction (STEMI) is a cardiac emergency. However, multiple clinical disorders can cause ST-elevation ECG changes, one of which is pericarditis. Regional pericarditis is a less known clinical phenomenon that can mimic STEMI. We report a case of poorly differentiated lung carcinoma associated reactive regional pericarditis mimicking inferior STEMI.

Percutaneous Mitral Valve Technology: What Is on the Horizon?

Mitral valve disease is common, with mitral regurgitation (MR) being the most frequent pathology. The etiology of MR is diverse, but, if left untreated, MR results in left ventricular (LV) volume overload, leading to remodeling, dilation of the LV, pulmonary hypertension, heart failure, and death. Mitral regurgitation is a high-risk diagnosis, yet a minority of symptomatic patients are referred for discussion of surgical treatment options. Percutaneous repair options are under development to address this clinical need and emphasize correction of the underlying anatomical pathology to restore mitral valve coaptation. Transcatheter mitral valve replacement is in the early stages of development and may prove safe and effective in certain patient populations. Investigational devices are challenging our current thinking about the management of mitral valve disease, and it will be the task of the multidisciplinary Heart Team to determine the right device for the right pathology.

Role of Microalbuminuria in Predicting Cardiovascular Mortality in Individuals With Subclinical Hypothyroidism.

PURPOSE: Studies suggest that subclinical hypothyroidism (SCH) is related to cardiovascular mortality (CVM). We explored the role of microalbuminuria (MIA) as a predictor of long-term CVM in population with and without SCH with normal kidney function. MATERIALS AND METHODS: We examined the National Health and Nutrition Education Survey - III database (n = 6,812). Individuals younger than 40 years, thyroid-stimulating hormone levels ≥20 and ≤0.35mIU/L, estimated glomerular filtration rate <60mL/minute/1.73m2 and urine albumin-to-creatinine ratio of >250mg/g in men and >355mg/g in women were excluded. SCH was defined as thyroid-stimulating hormone levels between 5 and 19.99mIU/L and serum T4 levels between 5 and 12µg/dL. MIA was defined as urine albumin-to-creatinine ratio of 17-250mg/g in men and 25-355mg/g in women. Patients were categorized into the following 4 groups: (1) no SCH or MIA, (2) MIA, but no SCH, (3) SCH, but no MIA and (4) both SCH and MIA. RESULTS: Prevalence of MIA in the subclinical hypothyroid cohort was 21% compared to 16.4% in those without SCH (P = 0.03). SCH was a significant independent predictor of MIA (n = 6,812), after adjusting for traditional risk factors (unadjusted odds ratio = 1.75; 95% CI: 1.24-2.48; P = 0.002 and adjusted odds ratio = 1.83; 95% CI: 1.2-2.79; P = 0.006). MIA was a significant independent predictor of long-term all-cause (adjusted hazard ratio = 1.7, 95% CI: 1.24-2.33) and CVM (adjusted hazard ratio = 1.72, 95% CI: 1.07-2.76) in subclinical hypothyroid individuals. CONCLUSIONS: In a cohort of subclinical hypothyroid individuals, the presence of MIA predicts increased risk of CVM as compared to nonmicroalbuminurics with SCH. Further randomized trials are needed to assess the benefits of treating microalbuminuric subclinical hypothyroid individuals and impact on CVM.

Commotio cordis: A review.

Commotio cordis is an increasingly reported fatal mechano-electric syndrome and is the second most common cause of sudden cardiac death in young athletes. It is most commonly associated with a sports-related injury, wherein, there is a high-velocity impact between a projectile and the precordium. By virtue of this impact, malignant arrhythmias consequently develop leading to the individual's immediate demise, accompanied by a relatively normal post-mortem analysis. The importance of an autopsy remains paramount to exclude other causes of sudden death. With increasing awareness and reporting, survival rates are beginning to improve; however, prevention of the development of this condition remains the best approach for survival.

Hemodynamic Support With a Microaxial Percutaneous Left Ventricular Assist Device (Impella) Protects Against Acute Kidney Injury in Patients Undergoing High-Risk Percutaneous Coronary Intervention.

RATIONALE: Acute kidney injury (AKI) is common during high-risk percutaneous coronary intervention (PCI), particularly in those with severely reduced left ventricular ejection fraction. The impact of partial hemodynamic support with a microaxial percutaneous left ventricular assist device (pLVAD) on renal function after high-risk PCI remains unknown. OBJECTIVE: We tested the hypothesis that partial hemodynamic support with the Impella 2.5 microaxial pLVAD during high-risk PCI protected against AKI. METHODS AND RESULTS: In this retrospective, single-center study, we analyzed data from 230 patients (115 consecutive pLVAD-supported and 115 unsupported matched-controls) undergoing high-risk PCI with ejection fraction ≤35%. The primary outcome was incidence of in-hospital AKI according to AKI network criteria. Logistic regression analysis determined the predictors of AKI. Overall, 5.2% (6) of pLVAD-supported patients versus 27.8% (32) of unsupported control patients developed AKI (P<0.001). Similarly, 0.9% (1) versus 6.1% (7) required postprocedural hemodialysis (P<0.05). Microaxial pLVAD support during high-risk PCI was independently associated with a significant reduction in AKI (adjusted odds ratio, 0.13; 95% confidence intervals, 0.09-0.31; P<0.001). Despite preexisting CKD or a lower ejection fraction, pLVAD support protection against AKI persisted (adjusted odds ratio, 0.63; 95% confidence intervals, 0.25-0.83; P=0.04 and adjusted odds ratio, 0.16; 95% confidence intervals, 0.12-0.28; P<0.001, respectively). CONCLUSIONS: Impella 2.5 (pLVAD) support protected against AKI during high-risk PCI. This renal protective effect persisted despite the presence of underlying CKD and decreasing ejection fraction.

Red cell distribution width and risk of cardiovascular mortality: Insights from National Health and Nutrition Examination Survey (NHANES)-III.

INTRODUCTION: Red cell distribution width (RDW) has been linked to cardiovascular disease. We sought to determine whether addition of RDW improved the Framingham risk score (FRS) model to predict cardiovascular mortality in a healthy US cohort. METHODS: We performed a post-hoc analysis of the National Health and Nutritional Examination Survey-III (1988-94) cohort, including non-anemic subjects aged 30-79years. Primary endpoint was death from coronary heart disease (CHD). We divided the cohort into three risk categories: <6%, 6-20% and >20%. RDW>14.5 was considered high. Kaplan-Meier survival curves and Cox proportional hazards models were created. Discrimination, calibration and reclassification were used to assess the value of addition of RDW to the FRS model. RESULTS: We included 7005 subjects with a mean follow up of 14.1years. Overall, there were 233 (3.3%) CHD deaths; 27 (8.2%) in subjects with RDW>14.5 compared to 206 (3.1%) in subjects with RDW≤14.5 (p<0.001). Adjusted hazard ratio of RDW in predicting CHD mortality was 2.02 (1.04-3.94, p=0.039). Addition of RDW to FRS model showed significant improvement in C-statistic (0.8784 vs. 0.8751, p=0.032) and area under curve (0.8565 vs. 0.8544, p=0.05). There was significant reclassification of FRS with a net reclassification index (NRI) of 5.6% (p=0.017), and an intermediate-risk NRI of 9.6% (p=0.011). Absolute integrated discrimination index (IDI) was 0.004 (p=0.02), with relative IDI of 10.4%. CONCLUSIONS: Our study demonstrates that RDW is a promising biomarker which improves prediction of cardiovascular mortality over and above traditional cardiovascular risk factors.

Heparin Versus Bivalirudin in ST-Segment Elevation Myocardial Infarction: A SCAI-Based National Survey From US Interventional Cardiologists.

BACKGROUND: The use of antithrombotic therapy (ATT) (bivalirudin or unfractionated heparin) is a class I recommendation for patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). This survey was conducted to better understand current United States (US) practices in terms of preferences regarding the selection of ATT in STEMI-PPCI, particularly in light of recent clinical trials. METHODS: An electronic survey consisting of 9 focused questions was forwarded to 2676 US interventional cardiologists who were members of the Society for Cardiovascular Angiography and Interventions (SCAI). RESULTS: Among 390 responders (14.5%), bivalirudin with bail-out glycoprotein IIb/IIIa inhibitor (GPI) was the predominant strategy for 53% of operators, whereas 32% preferred heparin with bail-out GPI and 15% preferred heparin with more routine GPI. The duration of bivalirudin infusion varied widely among operators, and significant variability existed in the bolus dose of heparin that was preferred by operators. About 49% of respondents stated that the choice of ATT was not affected by the bleeding risk of the patient, although access site did appear to affect the choice of ATT for some operators. Notably, 43% of operators reported to have changed their practice regarding ATT in light of recent trial results. CONCLUSION: There is marked variability in self-reported ATT use in STEMI-PPCI among US interventional cardiologists. Given the patient-related variability in bleeding risk and mixed clinical trial results between the two predominant ATT agents, bivalirudin and unfractionated heparin, more data are needed in order to further inform and potentially unify clinical practice in STEMI-PPCI.

Transcatheter Aortic Valve Replacement Complication Rates in Teaching Vs Non-Teaching Centers in the United States.

OBJECTIVE: The objective of our study is to compare transcatheter aortic valve replacement (TAVR) complication rates among teaching vs non-teaching centers in the United States. METHODS: Using National Inpatient Sample (NIS) data, the largest all-payer database of hospital inpatient stay available in the United States, we identified patients (age ≥18 years) who underwent TAVR from January-December 2012. We constructed multivariable models to determine independent predictors (age, sex, race, Charlson's comorbidity index, hospital size, hospital location, and TAVR approach) of TAVR-associated complications. RESULTS: We identified 7405 TAVR procedures performed in the United States in 2012. In all, 88% of TAVRs were performed in teaching centers. There was no difference in mortality following TAVR between teaching and non-teaching centers. In-hospital complication rate was lower in teaching centers vs non-teaching centers (42% vs. 50%, respectively; P<.001). In adjusted analysis, hemorrhage requiring transfusion (13.2% vs. 20.8%; P<.001), renal complications requiring dialysis (1.2% vs. 2.3%; P<.01), respiratory complications (7.5% vs. 11%; P<.001), and complications requiring open-heart surgery (2% vs. 4.6%; P<.001) were lower in teaching centers vs non-teaching centers. Vascular access-site, pacemaker insertion, pericardial, and neurological complications were similar between teaching and non-teaching centers. CONCLUSION: Institutional design impacts TAVR complications, albeit with no difference in mortality. In general, complication rates are lower in teaching centers compared with non-teaching centers.

Impact of Hospital Volume on Outcomes of Endovascular Stenting for Adult Aortic Coarctation.

Use of transcatheter endovascular stenting has been increasing in the treatment of coarctation of aorta (CoA). The present study was undertaken on adults with CoA who underwent stent placement from 2000 to 2011 to analyze the relation of hospital volumes to the outcomes of stenting in adults with CoA. It was a retrospective study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2000 to 2011 and identified subjects using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code of 747.10 (CoA). Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the Nationwide Inpatient Sample were used to generate national estimates. A total of 105 (weighted 521) subjects were identified with International Classification of Diseases, Ninth Revision, code of 39.90 (Endovascular stent). Hospital volumes were divided into tertiles. We compared the highest tertile (≥3 procedures annually) with other tertiles (<3 procedure annually). The composite outcomes of the analysis were procedure-related complications, length of stay (LOS), and cost in relation to the hospital volume. No inhospital death was reported in either group. Hospitals with ≥3 procedures annually had significantly lower incidence of complications (9.5% vs 23.0%) compared to the hospitals with <3 procedures annually (p-value 0.002). Similar results were obtained after multivariate regression analysis in relation to hospital volume. Shorter LOS and lower cost were observed with annual hospital volume of ≥3 procedures. In conclusion, stenting adults for CoA is remarkably safe, and the outcomes of the procedure have improved in centers with annual hospital volume of ≥3 procedures. There is also decreasing trend of procedure-related complications, shorter LOS, and lower costs compared to centers with annual volume <3 procedures.

Variation in utilization of multivessel percutaneous coronary intervention: influence of hospital volume.

BACKGROUND: The purpose of this study was to investigate the contemporary trends in the utilization of multivessel percutaneous coronary interventions (MVPCIs) in the USA. METHODS: We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample between 2006 and 2011 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes 00.40 (single stent), 00.46, 00.47, and 00.48 (single vessel and multiple stents) and 00.41, 00.42 and 00.43 (MVPCI). We built a hierarchical three-level model adjusted for multiple confounding factors. RESULTS: A total of 543 434 (weighted: 2 683 206) procedures were identified. Independent predictors of increased MVPCI utilization (odds ratio, 95% confidence interval, P-value) were found to be age (1.05, 1.04-1.07, P<0.001) and comorbid conditions on using Deyo's modification of Charlson's comorbidity index of at least 2 (1.13, 1.09-1.16, P<0.001). Female sex (0.88, 0.87-0.90, P<0.001), myocardial infarction (0.86, 0.83-0.89, P<0.001), weekend admissions (0.94, 0.91-0.96, P<0.001), and urgent admissions (0.88, 0.83-0.93, P<0.001) predicted decreased utilization. Highest quartile of hospital (1.34, 1.16-1.54, P<0.001) predicted higher utilization. Between-hospital variation of 7.7% (interclass correlation coefficient) was observed, which was minimally affected by patient or hospital mix. A randomly selected patient was ∼1.6 (median odds ratio) times more likely to receive an MVPCI from a given hospital compared with another identical patient being treated at a different random hospital. CONCLUSION: The utilization rate of MVPCI varied considerably among hospitals. Higher annual hospital volume was associated with a higher utilization rate of MVPCI.