Is Concomitant Mitral Stenosis Associated With Worse Outcomes in Patients Who Underwent TAVR? Insights from a National Database.

Concomitant mitral stenosis (MS) is present in 10% to 15% of all patients who underwent transcatheter aortic valve replacement (TAVR). Our aim is to assess outcomes of TAVR in patients with MS using a national database. The Nationwide Inpatient Sample database was used to identify patients who underwent TAVR from 2015 to 2020. We created 2 groups, patients with and those without MS. We then compared baseline characteristics, demographics, and in-hospital outcomes of the groups. Primary outcomes were in-hospital mortality, acute respiratory failure, and pacemaker placement. Secondary outcomes were length of stay and in-hospital costs. Our study indicates that patients with MS had greater incidence of acute respiratory failure (8.8% vs 4.89%, p = 0.001), complete heart block (13.54% vs 9.36%, p = 0.01), and permanent pacemaker placement (8.03% vs 6.03%, p = 0.05). In-hospital mortality was greater in the MS group; however, it was not statistically significant (1.32% vs 1.53%, p = 0.679).

Impact of Frailty on Outcomes After Transcatheter Edge-to-Edge Repair With MitraClip (from the National Inpatient Sample Database).

Transcatheter edge-to-edge repair (TEER) with MitraClip (Abbott, Santa Clara, California) is a frequently chosen method for mitral valve repair for patients at high surgical risk. We investigated the impact of frailty on outcomes of patients who underwent TEER. We reviewed the National Inpatient Sample to identify patients that underwent TEER with MitraClip. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. The primary end point was in-hospital mortality. The secondary end points included blood transfusion, respiratory failure, sepsis, length of stay, and total hospitalization cost. Univariate and multivariate logistic regression analyses were performed to determine any association between frailty and primary or secondary outcomes. From January 2016 to December 2017, 10,055 patients underwent TEER in the United States, and 10.6% of them met the criteria for frailty. The frail group showed increased in-hospital mortality (7.04% vs 1.61%, p <0.001) and respiratory failure (3.75% vs 0.95%, p <0.001). Similarly, the frail group had longer lengths of stay (6 vs 2 days, p <0.001) and higher hospitalization costs ($224.8k vs $180.9k, p <0.001). After multivariable logistic regression analysis, frailty was associated with increased in-hospital mortality (odds ratio [OR] 3.70, 95% confidence interval [CI] 1.91 to 7.18, p <0.001), transfusion (OR 1.85, 95% CI 1.07 to 3.19, p = 0.029), respiratory failure (OR 3.56, 95% CI 1.48 to 8.52, p = 0.005), and sepsis (OR 4.17, 95% CI 1.84 to 9.46, p = 0.001). In conclusion, frailty was present in about 10% of patients who underwent TEER from 2016 to 2017. The presence of frailty was associated with worse in-hospital outcomes and greater resource use.

Exploring the Changes in Code Status During the COVID-19 Pandemic and the Implications for Future Pandemic Care.

Objective: We aim to explore patterns of inpatient code status during the COVID-19 pandemic compared with a similar timeframe the previous year, as well as utilization of palliative care services.Methods: This is a retrospective cohort study using data from the Montefiore Health system of all inpatient admissions between March 15-May 31, 2019 and March 15-May 31, 2020. Univariate logistic regression was performed with full code status as the outcome. All statistically significant variables were included in the multivariable logistic regression.Results: The total number of admissions declined during the pandemic (16844 vs 11637). A lower proportion of patients had full code status during the pandemic (85.1% vs 94%, P < .001) at the time of discharge/death. There was a 20% relative increase in the number of palliative care consultations during the pandemic (12.2% vs 10.5%, P < .001). Intubated patients were less often full code (66.5% vs 82.2%, P < .001) during the pandemic. Although a lower portion of COVID-19 positive patients had a full code status compared with non-COVID patients (77.6% vs 92.4%, P<.001), there was no statistically significant difference in code status at death (38.3% vs 38.3%, P = .96).Conclusions: The proportion of full code patients was significantly lower during the pandemic. Age and COVID status were the key determinants of code status during the pandemic. There was a higher demand for palliative care services during the pandemic.

Elevated red cell distribution width and cardiovascular mortality in ASCVD risk cohorts: National Health and Nutrition Examination Survey (NHANES III).

BACKGROUND: Although red cell distribution width (RDW) is associated with increased cardiovascular mortality, the relationship between an elevated RDW and cardiovascular mortality among various ASCVD risk groups is unknown. METHODS: We utilized the National Health and Nutrition Examination Survey (NHANES) III, which uses a complex, multistage, clustered design to represent the civilian, community-based US population. Out of 30,818 subjects whose data were entered during the 1988-1994 period, 8884 subjects over 40 years of age, representing a weighted sample of 85,323,902 patients, were selected after excluding missing variables. The ACC/AHA pooled cohort equation (PCE) was used to calculate atherosclerotic cardiovascular disease (ASCVD) risk, and low (<7.5%), intermediate (7.5-20%), and high (>20%) risk groups were created. The primary endpoint was cardiovascular mortality. A multivariate proportional hazard regression was performed using the Fine and Gray (sub-distribution) method. Red cell distribution (RDW), C-reactive protein (CRP), age, sex, race, diabetes, smoking status, high-density lipoprotein (HDL), and chronic kidney disease (CKD) were used as covariates in each of the ACC/AHA pooled cohort risk groups. RESULTS: The adjusted hazard ratios for RDW >14 (Normal range 12.5-14.5 %) as compared to <13 were 2.79 (95% confidence intervals (95% CI) 2.77-2.81, p < 0.01), 2.02 (95% CI 2.01-2.02, p < 0.01), 1.18 (95% CI 1.18-1.18, p < 0.01) in the low, intermediate and high-risk groups respectively. The 20-year cumulative cardiovascular mortality (RDW >14 vs. <13) was 4% vs. 1.3% low, 17.7% vs. 7.7% in intermediate and 28.1% vs. 24.6% in high ASCVD risk groups respectively. CONCLUSION: Our findings support that measurement of RDW in the intermediate ASCVD group may be clinically valuable for further risk stratification and prognostication in the general population of people aged more than 40 years of age with regards to identifying those at an increased risk for cardiovascular mortality.

Statin Use in Hospitalized Patients with COVID-19: A Comprehensive Analysis of the New York City Public Hospital System.

INTRODUCTION: Statins have been commonly used for primary and secondary cardiovascular prevention. We hypothesized that statins may improve in-hospital outcomes for hospitalized patients with Coronavirus disease 2019 (COVID-19) due to its known anti-inflammatory effects. METHODS: We conducted a retrospective study at the largest municipal health care system in the United States, including adult patients who were hospitalized for COVID-19 between March 1 and December 1, 2020. The primary endpoint was in-hospital death. Propensity score matching was conducted to balance possible confounding variables between patients receiving statins during hospitalization (statin group) and those not receiving statins (non-statin group). Multivariate logistic regression was used to evaluate the association of statin use and other variables with in-hospital outcomes. RESULTS: There were 8897 patients eligible for study enrollment, with 3359 patients in the statin group and 5538 patients in the non-statin group. After propensity score matching, both the statin and non-statin groups included 2817 patients. Multivariate logistic regression analysis showed that the statin group had a significantly lower risk of in-hospital mortality (odds ratio 0.71; 95% confidence interval, 0.63-0.80; P < .001) and mechanical ventilation (OR 0.80; 95% confidence interval, 0.71-0.90; P < .001) compared with the non-statin group. CONCLUSION: Statin use was associated with lower likelihood of in-hospital mortality and invasive mechanical ventilation in hospitalized patients with COVID-19.

Diagnostic accuracy of coronary computed tomography angiography in ischemic workup of heart failure: a meta-analysis.

Aim: The role of coronary computed tomography angiography (CCTA) in evaluating the etiology of heart failure with reduced ejection fraction (HFrEF) is unclear. This is a meta-analysis assessing the pooled diagnostic accuracy of CCTA in diagnosing significant coronary artery disease in HFrEF. Materials & methods: Electronic databases were searched for studies comparing CCTA with invasive coronary angiography in HFrEF. A random-effects model meta-analysis was conducted. Results: Five studies comprising 269 patients were included. On patient-based analysis, pooled sensitivity and specificity of CCTA were 0.99 (95% CI: 0.94-1.00) and 0.94 (95% CI: 0.90-0.97), respectively. On segment-based analysis, pooled sensitivity and specificity were 0.74 (95% CI: 0.67-0.80) and 0.99 (95% CI: 0.98-0.99), respectively. Conclusion: CCTA has excellent diagnostic accuracy in diagnosing significant coronary artery disease in newly diagnosed HFrEF.

The role of 'CAT scan,' a computerized series of x-rays, in determining the cause of heart failure with low pumping capacity of the heart is unclear. We conducted a study to assess the accuracy of CAT scan in diagnosing significant blockage of blood vessels supplying the heart muscle. We searched electronic databases for studies comparing the accuracy of CAT scan with another procedure that injects a special dye into blood vessels to visualize blockage of the blood vessels supplying the heart muscle, specifically in patients with heart failure. On statistically analysis, CAT scan was found to be highly accurate in diagnosing significant blockage of these blood vessels in patients with heart failure.

Day-to-day variation in sleep duration is associated with increased all-cause mortality.

STUDY OBJECTIVES: There is a paucity of data on the association between day-to-day variation in sleep pattern and all-cause mortality. We aimed to investigate whether day-to-day variation in sleep duration and onset of sleep are associated with cardiovascular and all-cause mortality. METHODS: We used data belonging to 388 unique patients from the Midlife in the United States 2 Biomarker study (2004-2009). Information on sleep onset, duration, and sleep-wake cycles was collected for 7 consecutive days using the Actiwatch device. Sleep irregularity was assessed using mean and standard deviations in sleep duration and time of onset of sleep over 7 days. Cox proportional regression analysis and the Fine and Gray subdistribution method were used with all-cause and cardiovascular mortality, respectively. RESULTS: Over a median of 8.6 years of follow-up, 37 patients died, including 10 deaths resulting from cardiovascular causes. There was no statistically significant increase in cardiovascular mortality with variation in sleep duration in the highest vs the lowest tertile (hazard ratio, 4.00; 0.45-35.48; P = .21). However, increased all-cause mortality was seen in the highest vs the lowest tertile (hazard ratio, 3.99; 1.33-11.94; P = .01). Multivariable model adjusting for confounders had higher all-cause mortality with increased sleep duration variation in the highest vs the lowest tertile: hazard ratio, 4.85; 1.52-15.49; P < .01). CONCLUSIONS: Day-to-day variation in sleep duration is associated with increased all-cause mortality but not cardiovascular mortality after adjusting for mean sleep duration, inflammation, diabetes, age, body mass index, renal function, and blood pressure. Irregularity in the onset of sleep is not associated with all-cause mortality or cardiovascular mortality. CITATION: Katamreddy A, Uppal D, Ramani G, et al. Day-to-day variation in sleep duration is associated with increased all-cause mortality. J Clin Sleep Med. 2022;18(3):921-926.

Sodium-Glucose Cotransporter-2 Inhibitor Use is Associated with a Reduced Risk of Heart Failure Hospitalization in Patients with Heart Failure with Preserved Ejection Fraction and Type 2 Diabetes Mellitus: A Real-World Study on a Diverse Urban Population.

BACKGROUND: Limited evidence-based therapies exist for the management of heart failure with preserved ejection fraction (HFpEF). Sodium-glucose cotransporter-2 inhibitor (SGLT2i) use in patients with systolic heart failure (HFrEF) and type-2-diabetes mellitus (T2DM) is associated with improved cardiovascular (CV) and renal outcomes. OBJECTIVE: We sought to examine whether there is an association of SGLT2i use with improved CV outcomes in patients with HFpEF. PATIENTS AND METHODS: We conducted a single-center, retrospective review of patients with HFpEF and T2DM. The cohort was divided into two groups based on prescription of a SGLT2i or sitagliptin. The primary outcome was heart failure hospitalization (HFH); secondary outcomes were all-cause hospitalization and acute kidney injury (AKI). RESULTS: After propensity score matching, there were 250 patients (89 in the SGLT2i group, 161 in the sitagliptin group), with a mean follow-up of 295 days. Univariate Cox regression analysis showed that the SGLT2i group had a reduced risk of HFH versus the sitagliptin group (hazard ratio (HR) 0.13; 95% confidence interval (CI) (0.05-0.36); p < 0.001). The SGLT2i group had a decreased risk of all-cause hospitalization (HR 0.48; 95% CI (0.33-0.70); p < 0.001) and SGLT2i had a lower risk of AKI (HR 0.39; 95% CI (0.20-0.74); p = 0.004). CONCLUSIONS: The use of SGLT2is is associated with a reduced incidence of HFH and AKI in patients with HFpEF and T2DM.

DNR Code Status Is Not Associated with Under-Utilization of Inpatient Transthoracic Echocardiograms.

In the strictest sense, do-not-resuscitate (DNR) status means that cardiopulmonary resuscitation should not be performed after death has occurred; all other medical interventions in line with a patient's goals of care should be implemented. The use of transthoracic echocardiography (TTE) in patients with DNR status is unknown. Therefore, we aim to evaluate the utilization of TTE among patients with DNR status using this retrospective data analysis. A total of 16,546 patient admissions were included in the final study. A total of 4370 (26.4%) of the patients had a TTE during hospitalization; among full code patients, 3976 (25.7%) underwent TTE, whereas TTEs were performed in 394 (37.4%) of DNR patients. On univariate logistic regression analysis, full code status had OR (95% confidence interval, CI) 0.57 (0.51-0.66), p < 0.01 compared with DNR status for the performance of inpatient TTE. In the final multivariate model adjusted for age, sex, race, and clinical comorbidities, the full code patients had OR (95% CI) 0.91 (0.79-1.05), p = 0.22 compared with DNR patients for the performance of inpatient TTE. DNR status is not associated with a decrease in inpatient transthoracic echocardiography performance.

A Case-Control Study Evaluating the Impact of Dedicated Palliative Care Training on Critical Care Interventions at the end of Life.

Many patients admitted to intensive care units (ICUs) are at high risk of dying. We hypothesize that focused training sessions for ICU providers by palliative care (PC) certified experts will decrease aggressive medical interventions at the end of life. We designed and implemented a 6-session PC training program in communication skills and goals of care (GOC) meetings for ICU teams, including house staff, critical care fellows, and attendings. We then reviewed charts of ICU patients treated before and after the intervention. Forty-nine of 177 (28%) and 63 of 173 (38%) patients were identified to be at high risk of death in the pre- and postintervention periods, respectively, and were included based on the study criteria. Inpatient mortality (45% vs 33%; P = .24) and need for mechanical ventilation (59% vs 44%, P = .13) were slightly higher in the preintervention population, but the difference was not statistically significant. The proportion of patients in whom the decision not to initiate renal replacement therapy was made because of poor prognosis was significantly higher in the postintervention population (14% vs 67%, P = .05). There was a nonstatistically significant trend toward earlier GOC discussions (median time from ICU admission to GOC 4 vs 3 days) and fewer critical care interventions such as tracheostomies (17% vs 4%, P = .19). Our study demonstrates that directed PC training of ICU teams has a potential to reduce end of life critical care interventions in patients with a poor prognosis.

Sepsis-induced cardiomyopathy is associated with higher mortality rates in patients with sepsis.

BACKGROUND: Patients with sepsis are at risk for developing sepsis-induced cardiomyopathy (SIC). Previous studies offer inconsistent results regarding the association of SIC and mortality. This study sought to assess whether SIC is linked to mortality in patients with sepsis and to evaluate predictors of the development of SIC. METHODS: In this retrospective study, patients admitted to the medical intensive care unit with a diagnosis of sepsis in the absence of acute coronary syndrome were included. SIC was identified using transthoracic echo and was defined by a new onset decline in left ventricular ejection fraction (LVEF) ≤50%, or ≥10% decline in LVEF compared to baseline in patients with a history of heart failure with reduced ejection fraction. Multivariable logistic regression analysis was performed using the R software program. RESULTS: Of the 359 patients in the final analysis, 19 (5.3%) had SIC. Eight (42.1%) of the 19 patients in the SIC group and 60 (17.6%) of the 340 patients in the non-SIC group died during hospitalization. SIC was associated with an increased risk for all-cause in-hospital mortality (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.15-18.69; P=0.03). Independent predictors for the development of SIC were albumin level (OR, 0.47; 95% CI, 0.23-0.93; P=0.03) and culture positivity (OR, 8.47; 95% CI, 2.24-55.61; P=0.006). Concomitant right ventricular hypokinesis was noted in 13 (68.4%) of the 19 SIC patients. CONCLUSIONS: SIC was associated with an increased risk for all-cause in-hospital mortality. Low albumin level and culture positivity were independent predictors of SIC.

Diagnostic accuracy of cardiac testing for coronary artery disease in potential liver transplant recipients: A systematic review and meta-analysis.

BACKGROUND: The incidence of coronary artery disease (CAD) in Liver transplant (LT) patients is much higher than prior estimates and the morbidity and mortality are significant in this group of patients. Coronary angiography is the gold standard for detection of CAD, a non-invasive test that allows appropriate risk stratification would be preferred. In this systematic review and meta-analysis, we sought to assess the pooled diagnostic accuracy of various noninvasive cardiac imaging tests in detecting CAD in patients listed for LT. METHODS: We performed a systematic review and meta-analysis of studies comparing sensitivity and specificity of non-invasive tests to that of coronary angiography in diagnosing coronary artery disease in patients undergoing liver transplantation. RESULTS: Five studies (616 participants) evaluated myocardial perfusion imaging (MPI); five studies (1243 participants) dobutamine stress echocardiography (DSE); and three (87 participants), other tests. MPI had a pooled sensitivity of 0.62 (95% CI 0.37, 0.83), specificity of 0.60 (95% CI 0.39, 0.79), diagnostic odds ratio (DOR) of 2.5 (95% CI 1.7, 5.64) and Area under the curve (AUC) 0.649. DSE had a pooled sensitivity of 0.25 (95%CI 0.09, 0.51), specificity of 0.68 (95% CI 0.44, 0.84) and DOR of 0.7 (95% CI 0.12, 3.84). CONCLUSIONS: Our results show that both MPI and DSE are not effective screening tools for detecting CAD in patients with end-stage liver disease (ESLD). Future studies are needed to evaluate the role of real-time myocardial contrast echocardiography (RTMCE) and coronary artery calcium score (CAC) with coronary CT angiography in patients with ESLD.

Risk Models and Scores in Patients with Peripheral Artery Disease and Chronic Limb-threatening Ischemia: A Comprehensive Review.

Peripheral artery disease (PAD) affects more than 200 million patients worldwide and chronic limbthreatening ischemia (CLTI) is the most advanced stage of PAD with very high morbidity and mortality rates. Cardiovascular medicine is trending towards a more personalized approach where each individual patient will be managed according to specific risk factors, disease characteristics, expectations related to their disease and individualized assessment of potential outcomes. For this reason, a number of risk models and scores have been developed during the last few years. Our aim in this comprehensive review article is to provide an overview of selected risk models and scores for patients with PAD and CLTI. Given that some of the published scores were of low quality (minimal discriminatory ability), we included scores that were already externally validated or scores that had promising initial findings. Available scoring systems were grouped in the five following categories according to their utility: i) scores that can detect asymptomatic patients who should be screened for PAD, ii) scores for assessment of functional status and quality of life in patients with PAD, iii) scores assessing risk for amputation and other major adverse limb events among patients with CLTI, iv) scores for the optimal revascularization strategy in each patient and scores predicting successful procedural outcomes; v) scores predicting short or long-term cardiovascular and limb related outcomes after either revascularization or at least angiographic assessment. Limitations of available scoring systems include development and validation in specific populations, lack of external validation (for some of them) and also lack of synchrony with current era endovascular technology. However, with further optimization of current scores and the development of new scores, the field of PAD and CLI can be transitioned to a personalized medicine approach.

Elevated red cell distribution width is associated with negative P wave amplitude in lead V1: national health and nutrition examination survey (NHANES III).

INTRODUCTION: Red cell distribution (RDW) is associated with atrial fibrillation (AF) incidence. However, its relationship with precursors of AF has not been established. We aim to investigate if association exists between RDW and negative P wave amplitude in V1, a marker of left atrial abnormality. METHODS: NHANES III is a complex, multistage, clustered design survey of noninstitutionalized United States population between 1988-94. A Sample of 6403 individuals was extracted after excluding missing demographic, laboratory, anthropometric and ECG data and major ECG abnormalities. Variables were selected and univariate analysis was done first with a level of significance at P<0.01 (99% confidence). All the significant variables were included in a multivariate linear regression model. RESULTS: 53.58% of subjects were female. Racial distribution was caucasian 50.2%, hispanic 23.9% and african american 21.7%. Age, PR interval, heart rate, systolic blood pressure, red cell distribution width, glycated hemoglobin, serum cholesterol, serum ferritin, and body mass index showed a significant correlation with negative P wave amplitude in V1 (P<0.001). After including all these variables in a multivariate regression model, only age, body mass index, systolic blood pressure, PR interval, heart rate and red cell distribution width had a P≤0.001. CONCLUSIONS: Increased RDW is independently associated with negative P wave amplitude in V1 after correcting for other cardiovascular risk factors. Further studies are required to analyze the reason for this correlation.

Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic: A Single-Center Experience From a New York City Public Hospital.

BACKGROUND: Patients hospitalized for severe coronavirus disease 2019 (COVID-19) infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared with a pre-COVID-19 period. METHODS: All patients who experienced an IHCA at our hospital from March 1, 2020 through May 15, 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1, 2019 to December 31, 2019 were identified. All patient data were extracted from our hospital's Get With The Guidelines-Resuscitation registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions, and overall outcomes of IHCAs during the COVID-19 pandemic were compared with IHCAs in 2019, before the COVID-19 pandemic. RESULTS: There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared with 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% versus 33%; 19% versus 60% in 2019; P<0.001), were overall shorter in duration (median time of 11 minutes [8.5-26.5] versus 15 minutes [7.0-20.0], P=0.001), led to fewer endotracheal intubations (52% versus 85%, P<0.001), and had overall worse survival rates (3% versus 13%; P=0.007) compared with IHCAs before the COVID-19 pandemic. CONCLUSIONS: Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared with those who had an IHCA before the COVID-19 pandemic. Our findings highlight important differences between these 2 time periods. Further study is needed on cardiac arrest care in patients with COVID-19.

Use, Safety and Effectiveness of Subintimal Angioplasty and Re-Entry Devices for the Treatment of Iliac Artery Chronic Total Occlusions: A Systematic Review of 30 Studies and 1112 Lesions.

BACKGROUND: Management of iliac artery occlusive disease has changed dramatically over the past few decades. Secondary to advancement in endovascular technologies and techniques, percutaneous interventions have gradually replaced open surgical approaches even for the most difficult cases. In difficult to cross chronic total occlusions (CTO) of the iliac artery, subintimal angioplasty (SIA) with or without the use of re-entry devices (RED) offers a valuable alternative to intra-luminal crossing. OBJECTIVE: To systematically review the literature for studies reporting procedural or short- and long-term clinical outcomes after the use of SIA, with or without RED use for iliac CTOs. METHODS: PRISMA guidelines were followed. Literature search (PubMed, Cochrane CENTRAL and EMBASE) and data extraction were performed by two independent researchers. Quantitative synthesis of the reported outcomes was applied when possible. RESULTS: Thirty studies met the inclusion criteria and were selected as eligible for this systematic review, with a total of 1002 patients (61.3% males) and 1112 lesions treated with SIA. RED were used in 21.9% of the lesions. Critical limb ischemia was the indication in 51.4%. The overall procedural success rates were 85.8% for SIA and 88.5% for RED. The complication rate ranged from 0 to 10% among different series, but overall it was similar among the two groups (6.9% in the RED group and 6.7% among the SIA group). One year primary patency rates were around 60% in the RED. In the SIA only arm, there was a large heterogeneity, with patency rates ranging from 51.7% to 96.8%. CONCLUSION: SIA with or without RED use is a safe and effective treatment for the treatment of iliac artery CTOs. Future studies are needed to delineate whether intraluminal crossing or SIA is more effective for endovascular treatment of iliac CTOs.

Atrial Septostomy as a Bridge to Replace a Thrombosed Mechanical Aortic Valve Requiring Extracorporeal Membrane Oxygenation.

Atrial septostomy is an infrequently used percutaneous technique to decompress either side of the heart. Here, a case is reported of atrial septostomy performed as an emergency 'bridge' procedure in a hemodynamically unstable 62-year-old man with acute mechanical prosthetic aortic valve thrombosis requiring peripheral venoarterial (VA) extracorporeal membrane oxygenation (ECMO). ECMO was placed emergently as the patient suffered cardiac arrest during anesthesia induction for surgical replacement of the thrombosed prosthetic aortic valve. The increased afterload as a result of ECMO, in the setting of severe prosthetic valve dysfunction, led to a marked elevation of the left heart pressures, pulmonary edema and multiorgan dysfunction. A percutaneous atrial septostomy led to a rapid decompression of the left heart by shunting blood to the right atrium, allowing for a marked improvement in the patient's clinical condition. This facilitated the performance of re-do surgery to replace the dysfunctional thrombosed aortic prosthetic valve. Postoperatively, the pulmonary edema resolved completely and the patient achieved full recovery with no residual cardiac symptoms at three months. Video: Gated cardiac CT angiography demonstrating a large thrombus present between the St. Jude Medical mechanical aortic prosthetic leaflets, resulting in severe restriction of leaflet motion.