Updates on bioprosthetic valve fracture.

INTRODUCTION: Valve-in-valve (VIV) transcatheter valve replacement has emerged as a feasible and potentially safer treatment option for failed bioprosthetic surgical valves (BSVs). However, the VIV procedure carries an inherent risk of prosthesis-patient mismatch (PPM). Bioprosthetic valve fracture (BVF) and bioprosthetic valve remodeling (BVR) by either fracturing or stretching the surgical valve ring allows for a more optimal expansion of the transcatheter heart valve (THV) and beneficial effects on post-implant valve hemodynamics and perhaps long-term valve durability. AREAS COVERED: This is an expanded overview of BVF and BVR to facilitate VIV transcatheter aortic valve replacement (TAVR), with detailed discussion on lessons learned from bench testing studies and translation to procedural technique and clinical experience incorporating up-to-date evidence and experience with BVF in non-aortic positions. EXPERT OPINION: BVF and BVR improve valve hemodynamics following VIV-TAVR, with timing of BVF being an important determinant of procedure safety and efficacy; however, longer-term data are needed to determine long-term clinical outcomes including mortality, valve hemodynamics, and valve reintervention. In addition, further research will be needed to understand the safety and efficacy of these procedures in any new generation BSV or THV and to better define the role of these techniques in the pulmonic, mitral, and tricuspid positions.

Predictors of antiplatelet cessation in a real-world patient population undergoing non-cardiac surgery after PCI.

BACKGROUND: The optimal perioperative management of antiplatelet therapy (APT) therapy in patients undergoing noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) is unclear. We sought to identify predictors of APT cessation in a real-world cohort of patients undergoing NCS within 1 year of PCI. METHODS: Consecutive patients undergoing PCI at a tertiary center between 2011 and 2018 were prospectively enrolled. Perioperative interruption of APT was defined as cessation of either aspirin or P2Y12 inhibitor between 1 and 14 days prior to NCS. Predictors of APT discontinuation were identified by multivariable Cox regression with stepwise selection of candidate variables. RESULTS: A total of 1092 surgeries corresponding to 747 patients were identified. Overall, there were 487 (44.6%) preoperative antiplatelet interruptions: discontinuation of either P2Y12 inhibitors only (47.4%), aspirin only (7.9%), or both agents (44.7%). Both patient-specific risk factors (prior stroke, lower BMI, anemia, MI) and procedure specific risk factors (chronic total occlusions, multivessel disease, drug-eluting stent use) affected decisions regarding APT cessation. Likelihood of APT cessation increased in higher-risk surgeries and in patients on more potent P2Y12 inhibitors (ticagrelor/prasugrel vs clopidogrel) whereas those undergoing NCS <90 days post PCI were less likely to have cessation of APT. CONCLUSION: In this contemporary cohort of post-PCI patients undergoing NCS, patient-, angiographic- and surgery-specific factors all affected decision-making regarding APT cessation. Our findings reflective of real-world practice, highlight the importance of a multidisciplinary team approach to individualize decision making in these patients.

Mechanism and interpretation of two-for-one response to premature atrial complexes during atrioventricular node re-entry tachycardia.

AIMS: The response to premature atrial complexes (PACs) during tachycardia has been shown to differentiate atrioventricular nodal re-entrant tachycardia (AVNRT) from focal junctional tachycardia (JT). His refractory PAC (HrPACs) perturbing the next His (resetting with fusion) is diagnostic of AVNRT and such a late PAC fusing with the native beat cannot reset the focal source of JT. Early PAC advancing the immediate His with continuation of tachycardia suggests JT but can also occur in AVNRT due to simultaneous conduction through the AV nodal fast and slow pathways [two-for-one response (TFOR)]. The objective of this study was to evaluate the incidence and mechanism of TFOR after early premature atrial complexes (ePACs) during AVNRT and to differentiate it from the known response to ePACs during JT. METHODS AND RESULTS: Typical AVNRT cases were diagnosed using standard criteria. We evaluated the responses to scanning PACs delivered during tachycardia in 100 patients undergoing AV node slow pathway modification for AVNRT. The responses to HrPACs and ePACs delivered from coronary sinus os or high right atrium were retrospectively reviewed. In 10 patients, ePACs advanced the immediate His with continuation of tachycardia. In all 10 cases, HrPACs advanced the next His, confirming AVNRT as the mechanism, and indicating a TFOR. CONCLUSION: A TFOR can occur in a small number of patients during AVNRT and is therefore not diagnostic of JT. However, HrPACs always perturbed the next His in these cases, confirming the diagnosis of AVNRT and allowing for differentiation from JT.

Predictors of successful ultrasound-guided lead implantation.

BACKGROUND: Technical advances have improved the safety of cardiac implantable electronic device (CIED) insertion, but periprocedural complications persist. Despite ultrasound (US) guidance for vascular access being feasible and exhibiting shorter fluoroscopy times, it is not widely adopted for insertion of CIEDs. Thus, we studied the use of US for CIED insertion to (1) quantify the success rate of venous cannulation, (2) identify predictors of failed cannulation, and (3) quantify the rate of complications using US guidance. METHODS: We studied 166 consecutive patients who underwent US-guided CIED implantation. Anatomic parameters of the axillary vein were measured. The primary outcome was success (group 1) or failure (group 2) to obtain vascular access utilizing US guidance. Secondary outcomes included pneumothorax and hematoma. RESULTS: Successful US-guided cannulation occurred in 154 of 166 patients (93%). No patient had a pneumothorax. Hematoma occurred in 1 of 166 patients (0.01%). Group 2 exhibited higher male proportion at 11 of 12 (92%) compared with 94 of 154 (61%) in group 1 (P = .03), increased vein depth at 3.84 versus 2.85 cm (P = .003), more right-sided implants (P = .03), higher weight at 104.6 versus 85.3 kg (P = .017), higher body mass index at 35.6 versus 29.2 kg/m2 (P = .049), and higher body surface area at 2.24 versus 1.99 m2 (P = .013). Other parameters were statistically nonsignificant. In multivariate analysis, vein depth remained significantly associated with failure. CONCLUSION: Using US guidance for CIED implantation is successful in the vast majority (93%) of patients. Rare cases of unsuccessful cannulation were associated with right-sided implants and increased venous depth.

Troubleshooting electromagnetic interference in a patient with centrifugal flow left ventricular assist device and subcutaneous implantable cardioverter defibrillator.

A 25-year-old man with severe nonischemic dilated cardiomyopathy underwent subcutaneous implantable cardioverter defibrillator (S-ICD) implant and subsequently underwent HeartWare ventricular assist device (HVAD) placement. Postoperative interrogation revealed both primary and secondary S-ICD vectors inappropriately regarded sinus rhythm as "noise," and the alternate vector significantly undersensed sinus rhythm. The S-ICD was reinterrogated using high-resolution capture to visually confirm EMI with a dominant frequency in both the primary and secondary vectors of 46.67 Hz that fell within the S-ICD operational range of 9-60 Hz. The 46.67 Hz frequency correlated with the HVAD operational speed of 2,800 RPM. The HVAD pump speed was increased from 2,800 to 3,000 RPM, resulting in a dominant frequency of 50 Hz. The notch filter is nonprogrammable in S-ICDs. However, the built-in filter is 50 Hz for countries in European time zones as opposed to 60 Hz in US time zones due to differences in the anticipated noise from electrical sources within each continent. Thus, the S-ICD time zone was reprogrammed from EST to GMT, which reduced the notch filter from 60  to 50 Hz, resulting in S-ICD successfully eliminating EMI when the patient was in a supine position. The EMI interference was still intermittently present in the upright patient position. This case demonstrates the utility of high-resolution electrogram capture to identify the source and frequency of EMI in S-ICD and offers a potential avenue to troubleshoot dominant frequency oversensing by changing the device time zone.

Electrocardiographic Abnormalities, Malignant Ventricular Arrhythmias, and Cardiomyopathy Associated With Loperamide Abuse.

A 20-year-old man presented with recurrent syncope and abnormal electrocardiogram (ECG). His evaluation revealed a prolonged QT interval >600 milliseconds, witnessed torsades de pointes (TdP), and dilated cardiomyopathy. At his initial admission, an ICD was implanted and atrial pacing at 80 beats per minute suppressed ventricular arrhythmias. The patient was readmitted with device infection and recurrent TdP leading to intubation. This led to the discovery of a hitherto unrevealed loperamide abuse and his cardiac arrhythmias and LV dysfunction were determined to be related to large doses of loperamide. Following abstinence, his ejection fraction and ECG returned to normal.

Phenomenology of delirium among patients admitted to a coronary care unit.

AIM: To study the phenomenology and motor sub-types of delirium in patients admitted in a Coronary Care Unit (CCU). METHODS: Three hundred and nine consecutive patients were screened for delirium, and those found positive for the same were evaluated by a psychiatrist on DSM-IVTR criteria to confirm the diagnosis. Those with a diagnosis of delirium were evaluated on the DRS-R-98 to study the phenomenology and on the amended Delirium Motor Symptom Scale (DMSS) to study the motor sub-types. RESULTS: Eighty-one patients were found to have delirium. Commonly seen symptoms of delirium included: disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Very few patients had delusions. More than half of the participants were categorized as having hyperactive (n = 46; 56.8%) followed by hypoactive sub-type (n = 21; 26%) and mixed sub-type (n = 9; 11.1%) of delirium. There were minor differences in the frequency and severity of symptoms of delirium between incidence and prevalence cases of delirium and those with different motoric sub-types. CONCLUSION: Delirium in CCU set-up is characterized by the symptoms of disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Hyperactive delirium is more common than hypoactive delirium.

Percutaneous balloon mitral valvuloplasty under neuroprotection: Too Early for Knighthood.

The case describes the successful percutaneous balloon mitral valvuloplasty under neuroprotection in a patient with severe symptomatic mitral stenosis and persistent left atrial appendage thrombus despite chronic warfarin therapy. Although the procedure was uneventful for any systemic embolism, the limitations of this approach are highlighted with authors still advocating that surgery remains the benchmark treatment for these patients. © 2014 Wiley Periodicals, Inc.

Use of electroconvulsive therapy in an elderly after 5 weeks of myocardial infraction with 30% cardiac output.

There is limited literature on the use of electroconvulsive therapy (ECT) in patients with recent myocardial infarction and in those with reduced cardiac output. In this report, we describe the safe use of ECT in a 70-year-male suffering from severe depressive episode with psychotic symptoms. He had a history of poor response to adequate pharmacotherapy and had suffered from myocardial infraction (MI), about 3 weeks prior to admission to the psychiatric unit. In view of severe depression associated with marked anxiety, agitation, psychotic symptoms, and poor food intake he was started on ECT after 5 weeks of MI when his cardiac output was only 30%. He received nine sessions of ECT without any cardiac complications and his depression remitted with ECT.

Transcatheter therapy for Lutembacher's syndrome: The road less travelled.

An 18-year-old male with Lutembacher's syndrome underwent balloon mitral valvotomy (BMV) and device closure of the atrial septal defect (ASD). BMV necessitated technical modification of taking the Inoue balloon over the wire (OTW) into the left ventricle (LV). The procedure was complicated by slippage of ASD device into the right atrium, which was managed successfully by percutaneous retrieval, and deployment of a larger device. The case highlights the challenges associated with the seemingly easy transcatheter therapy for this disease entity.

Delirium in patients admitted to a cardiac intensive care unit with cardiac emergencies in a developing country: incidence, prevalence, risk factor and outcome.

AIM: To assess the incidence, prevalence, risk factors and outcome of delirium in patients admitted to a cardiac intensive care unit (ICU) of a tertiary care hospital. METHODS: Three hundred nine consecutive patients admitted to a 22-bed coronary care unit were screened for presence of delirium by using Confusion Assessment Method for Intensive Care Unit (CAM-ICU), and those found positive on CAM-ICU were further evaluated by a psychiatrist to confirm the diagnosis of delirium as per DSM-IV-TR criteria. Patients were also evaluated for the risk factors for delirium and outcome of delirium. RESULTS: Incidence rate of delirium was 9.27%, and prevalence rate was 18.77%. The risk factors identified for delirium in binary logistic regression analysis were hypokalemia, Sequential Organ Failure Assessment score, presence of cognitive deficits, receiving more than three medications, sepsis, hyponatremia, presence of cardiogenic shock, having undergone coronary artery bypass grafting, left ventricular ejection fraction <30, currently receiving opioids, age more than 65 years, presence of diabetes mellitus, presence of uncontrolled diabetes mellitus, history of seizures, presence of congestive cardiac failure, having undergone angioplasty, presence of atrial fibrillation, ongoing depression, currently receiving/taking benzodiazepines, warfarin, ranitidine, steroids, non-steroidal anti-inflammatory drugs, higher total number of medications, presence of raised creatinine, anaemia, hypoglycemia, Acute Physiology and Chronic Health Evaluation II score and Charlson Comorbidity Index score. About one fourth (n=22; 27%) of the patients who developed delirium died during the hospital stay in contrast to 1% mortality in the non-delirious group. Those with delirium also had longer stay in the ICU. CONCLUSIONS: Delirium is highly prevalent in the cardiac ICU setting and is associated with presence of many modifiable risk factors. Development of delirium increases the mortality risk and is associated with longer cardiac ICU stay.

Is endovascular therapy the right choice for treatment of functional compression of anomalous right coronary artery arising from left coronary sinus with interarterial course?

We report a case of successful percutaneous coronary intervention (PCI) for reversible ischaemia owing to an anomalous right coronary artery arising from the left coronary sinus with malignant interarterial course and not associated with obstructive coronary artery disease (CAD). PCI for treatment of functional compression of the ostioproximal intramural segment of the anomalous vessel, though described in the literature, is technically challenging, requiring appropriate hardware selection; the peculiar anatomical milieu, in the absence of atherosclerotic CAD, lends itself to an uncertain long-term outcome following endovascular therapy with stenting.