Angiographic Characteristics and Clinical Outcomes in Patients With Chronic Kidney Disease Undergoing Impella-Supported High-Risk Percutaneous Coronary Intervention: Insights From the cVAD PROTECT III Study.

BACKGROUND: Prior studies have found that patients with chronic kidney disease (CKD) have worse outcomes following percutaneous coronary intervention (PCI). There are no data about patients with advanced CKD undergoing Impella-supported high-risk PCI. We, therefore, aimed to evaluate angiographic characteristics and clinical outcomes in patients with CKD who received Impella-supported high-risk PCI as part of the catheter-based ventricular assist device PROTECT III study (A Prospective, Multi-Center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump [IABP] in Patients Undergoing Non Emergent High Risk PCI). METHODS: Patients enrolled in the PROTECT III study were analyzed according to their baseline estimated glomerular filtration rate (eGFR). The primary outcome was 90-day major adverse cardiovascular and cerebrovascular events (the composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization). RESULTS: Of 1237 enrolled patients, 1052 patients with complete eGFR baseline assessment were evaluated: 586 with eGFR ≥60 mL/min per 1.73 m2, 190 with eGFR ≥45 to <60, 105 with eGFR ≥30 to <45, and 171 with eGFR <30 or on dialysis. Patients with lower eGFR (all groups with eGFR <60) were more frequently females and had a higher prevalence of hypertension, diabetes, anemia, and peripheral artery disease. The baseline Synergy Between PCI With Taxus and Cardiac Surgery score was similar between groups (28.2±12.6 for all groups). Patients with lower eGFR were more likely to have severe coronary calcifications and higher usage of atherectomy. There were no differences in individual PCI-related coronary complications between groups, but the rates of overall PCI complications were less frequent among patients with lower eGFR. Major adverse cardiovascular and cerebrovascular events at 90 days and 1-year mortality were significantly higher among patients with eGFR <30 mL/min per 1.73 m2 or on dialysis. CONCLUSIONS: Patients with advanced CKD undergoing Impella-assisted high-risk PCI tend to have higher baseline comorbidities, severe coronary calcification, and higher atherectomy usage, yet CKD was not associated with a higher rate of immediate PCI-related complications. However, 90-day major adverse cardiovascular and cerebrovascular events and 1-year mortality were significantly higher among patients with eGFR<30 mL/min per 1.73 m2 or on dialysis. Future studies of strategies to improve intermediate and long-term outcomes of these high-risk patients are warranted. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04136392.

Acute coronary syndromes in patients with cancer: Recent advances.

Coronary artery disease is presently one of the leading causes of death among cancer survivors. Due to the number of cancer survivors projected to reach 26 million by 2040 managing coronary disease in this population presents a unique challenge. Cancer patients face an elevated risk of atherosclerotic disease due to shared cardiovascular risk factors and the cardiotoxic effects of cancer therapies, predisposing them to acute coronary syndromes. Challenges in treating cancer patients presenting with acute coronary syndromes include atypical presentations, obscured symptoms, and the impact of cancer-related processes on traditional biomarkers. This review explores the complexities of acute coronary syndrome management in cancer patients, addressing challenges involved, recent advances in percutaneous strategies, pharmacology, and considerations for these high-risk individuals. This review discusses a balance between invasive vs. medical strategy, technical advances in multimodal imaging, intravascular physiology, intracoronary imaging, and evolving stent options, highlighting the need for tailored approaches in this complex patient population.

Clinical characteristics and outcomes of patients requiring prolonged mechanical circulatory support after high-risk percutaneous coronary intervention.

BACKGROUND: There are limited data on the clinical characteristics and outcomes of patients who require prolonged mechanical circulatory support (MCS) after Impella-supported high-risk percutaneous coronary intervention (HR-PCI). AIMS: The aim of this study is to describe the contemporary clinical characteristics, outcomes, and predictors associated with prolonged MCS support after assisted HR-PCI. METHODS: Patients enrolled in the prospective, multicentre, clinical endpoint-adjudicated PROTECT III study who had undergone HR-PCI using Impella were evaluated. Patient and procedural characteristics and outcomes for those who received prolonged MCS beyond the duration of their index procedure were compared to those in whom MCS was successfully weaned and explanted at the conclusion of the index PCI. RESULTS: Among 1,155 patients who underwent HR-PCI with Impella between 2017 and 2020 and had sufficient data to confirm the duration of Impella support, 16.5% received prolonged MCS (mean duration 25.2±31.1 hours compared with 1.8±5.8 hours for those who only received intraprocedural MCS). Patients receiving prolonged support presented with more urgent indications (e.g., acute coronary syndromes [ACS], lower ejection fraction [EF], elevated baseline heart rate and lower systolic blood pressure). Use of the Impella CP, intraprocedural complications, periprocedural complications and in-hospital mortality were all more common amongst the prolonged MCS group. Prolonged MCS was associated with increased rates of major adverse cardiovascular and cerebrovascular events, cardiovascular death, and all-cause mortality at 90-day follow-up. CONCLUSIONS: Patients receiving prolonged MCS after Impella-supported HR-PCI presented with more ACS, reduced EF and less favourable haemodynamics. Additionally, they were more likely to experience intraprocedural and periprocedural complications as well as increased in-hospital and post-discharge mortality.

Influence of left ventricular ejection fraction in patients undergoing contemporary pLVAD-supported high-risk PCI.

BACKGROUND: Left ventricular (LV) systolic dysfunction worsens outcomes in patients undergoing percutaneous coronary intervention (PCI). The objective of this study, therefore, was to evaluate outcomes of pLVAD-supported high-risk PCI (HRPCI) patients according to LV ejection fraction (LVEF). METHODS: Patients from the PROTECT III study undergoing pLVAD-supported HRPCI were stratified according to baseline LVEF: severe LV dysfunction (LVEF <30%), mild and moderate LV dysfunction (LVEF ≥30% to <50%), or preserved LV function (LVEF ≥50%). Major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization), and PCI-related complications were assessed at 90 days and mortality was assessed at 1-year. RESULTS: From March 2017 to March 2020, 940 patients had evaluable baseline LVEF recorded in the study database. Patients with preserved LV function were older, more frequently presented with myocardial infarction, and underwent more left main PCI and atherectomy. Immediate PCI-related coronary complications were infrequent (2.7%, overall), similar between groups (P = 0.98), and not associated with LVEF. Unadjusted 90-day MACCE rates were similar among LVEF groups; however, as a continuous variable, LVEF was associated with both 90-day MACCE (adj.HR per 5% 0.89, 95% CI [0.80, 0.98], P = 0.018) and 1-year mortality (adj.HR per 5% 0.84 [0.78, 0.90], P <0.0001). CONCLUSIONS: Patients who underwent pLVAD-supported HRPCI exhibited low incidence of PCI-related complications, regardless of baseline LVEF. However, LVEF was associated with 90-day MACCE and 1-year mortality.

Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS: The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS: Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.

Prevalence and outcomes of type 2 myocardial infarction in patients with cancer: A retrospective analysis from the National Inpatient Sample dataset.

BACKGROUND: This study aimed to investigate the prevalence, clinical characteristics and outcomes of type 2 myocardial infarction (T2AMI) in patients with versus without cancer. METHODS: All hospitalizations with a primary discharge diagnosis of T2AMI were stratified according to cancer status (secondary diagnosis of any-cancer vs cancer-free) using data from the US National Inpatient Sample (2016-2019). The primary outcome was in-hospital all-cause mortality while secondary outcomes were in-hospital major adverse cardiovascular and cerebrovascular events (MACCE). RESULTS: Among 61,305 included hospitalizations with primary diagnosis of T2AMI, 3745 (6.1%) were associated with a diagnosis of cancer. Patients with T2AMI and cancer presented more frequently with acute respiratory failure (23.2% vs 18.1%), acute pulmonary embolism (3.7% v 1.3%), major bleeding (6.8% vs 4.1%) and renal failure (51.0% vs 46.8%), compared to patients without. On adjusted analysis, diagnosis of cancer was associated with lower odds of invasive coronary angiography (aOR 0.75, 95% CI 0.60 to 0.93, p = 0.009) but greater odds of mortality (aOR 1.95, 95% C.I. 1.26-2.99 p = 0.002). Among the different types of cancer, adjusted risk of all-cause mortality was higher in patients with colorectal (aOR 4.17 95% CI 1.68-10.32, p = 0.002), lung (aOR 3.63, 95% CI 1.83-7.18, p < 0.001) and haematologic (aOR 2.48, 95% CI 1.22-5.05, p = 0.001) cancer. CONCLUSIONS: Patients with cancer presenting with T2AMI have lower odds of management with invasive diagnostic coronary angiography and have higher rates of in-hospital all-cause death. Further studies are warranted to improve overall care and outcomes of cancer patients and cardiovascular diseases.

Association of Diabetes Mellitus and Its Types with In-Hospital Management and Outcomes of Patients with Acute Myocardial Infarction.

BACKGROUND: Diabetes mellitus (DM) is an important risk factor for adverse outcomes following acute myocardial infarction (AMI), but large-scale studies investigating the differential impact of Type 1 DM (T1DM) and Type 2 DM (T2DM) on AMI outcomes are lacking. METHODS: All adult discharges for AMI in the National Inpatient Sample (October 2015 to December 2018) were included and stratified into T1DM, T2DM and non-DM (NDM) groups. Outcomes of interests were all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and acute ischemic stroke, as well as invasive management. Binomial hierarchical multilevel multivariable logistic regression with adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) was used to investigate the association between DM and its subtypes with the AMI outcomes. RESULTS: Out of 2,587,615 patients, there were 29,250 (1.1 %) T1DM and 1,032,925 (39.9 %) T2DM patients. After multivariable adjustment, patients with T1DM had increased odds of MACCE (aOR 1.20, 95 % CI 1.09-1.31), all-cause mortality (aOR 1.20, 95 % CI 1.08-1.33) and major bleeding (aOR 1.28, 95 % CI 1.13-1.44), whilst T2DM patients had increased odds of MACCE (aOR 1.03, 95 % CI 1.01-1.05) and ischemic stroke (aOR 1.09, 95 % CI 1.05-1.13), compared to NDM patients. The adjusted odds of receiving percutaneous coronary intervention were lower in both T1DM and T2DM patients (aOR 0.70, 95 % CI 0.66-0.75 and aOR 0.95, 95 % CI 0.94-0.96, respectively), but T2DM patients showed higher utilization of composite percutaneous and surgical revascularization (aOR 1.03, 95 % CI 1.03-1.04) compared to NDM patients. CONCLUSIONS: DM patients presenting with AMI have worse in-hospital clinical outcomes compared to NDM patients. There are important DM type-related differences with T1DM patients having overall worse outcomes and receiving less overall revascularization.

Outcomes with catheter-directed thrombolysis vs. catheter-directed embolectomy among patients with high-risk pulmonary embolism: a nationwide analysis.

AIMS: To examine the shot-term outcomes with catheter-directed thrombolysis (CDT) vs. catheter-directed embolectomy (CDE) for high-risk pulmonary embolism (PE). METHODS AND RESULTS: The Nationwide Readmissions Database was utilized to identify hospitalizations with high-risk PE undergoing CDE or CDT from 2016 to 2019. The main outcome was all-cause in-hospital mortality. Propensity score matching was used to compare the outcomes in both groups. Among 3216 high-risk PE hospitalizations undergoing catheter-directed interventions, 868 (27%) received CDE, 1864 (58%) received CDT, and 484 (15%) received both procedures. In the unadjusted analysis, the rate of all-cause in-hospital mortality was not different between CDE and CDT (39.6% vs. 34.2%, P = 0.07). After propensity score matching, there was no difference in the incidence of in-hospital mortality [adjusted odds ratio (aOR): 1.28, 95% confidence interval (CI): 0.95, 1.72, P = 0.10], intracranial haemorrhage (ICH) (adjusted OR 1.57, 95% CI: 0.75, 3.29, P = 0.23), or non-ICH bleeding (aOR: 1.17, 95% CI: 0.85, 1.62, P = 0.33). There were no differences in the length of stay, cost, and 30-day unplanned readmissions between both groups. CONCLUSION: In this contemporary observational analysis of patients admitted with high-risk PE undergoing CDT or CDE, the rates of in-hospital mortality, ICH, and non-ICH bleeding events were not different.

Invasive Management and In-Hospital Outcomes of Myocardial Infarction Patients in United States Safety-Net Hospitals.

AIM: Safety-net hospitals (SNHs) look after a higher proportion of uninsured patients and are often located in deprived areas. This study aimed to determine whether there are differences in the clinical characteristics, treatments and outcomes of patients presenting with acute myocardial infarction (AMI) in SNHs versus non-SNHs (N-SNHs). METHODS: All hospitalizations with a principal diagnosis of AMI in the United States' National Inpatient Sample between 2016 and 2019 were stratified by safety-net hospital status. Multivariable logistic regression with adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) was conducted to investigate invasive management and clinical outcomes. RESULTS: A total of 2,544,009 weighted discharge records were analyzed, including 601,719 records from SNHs (23.7 %). Compared with N-SNHs, SNH AMI patients were younger (median 66 years vs. 67 years, p < 0.001), and had a higher proportion in the lowest quartile of median household income (37.3 % vs. 28.5 %, p < 0.001). Patients from SNHs were less likely to receive coronary angiography (aOR 0.92, 95 % CI 0.91-0.93, p < 0.001), percutaneous coronary intervention (aOR 0.94, 95 % CI 0.93-0.95, p < 0.001), and coronary artery bypass grafting (aOR 0.93, 95 % CI 0.92-0.94, p < 0.001). In addition, they had increased all-cause mortality (aOR 1.11, 95 % CI 1.09-1.12, p < 0.001), major adverse cardiovascular/cerebrovascular events (composite of mortality, stroke and reinfarction) (aOR 1.11, 95 % CI 1.09-1.12, p < 0.001), and stroke (aOR 1.11, 95 % CI 1.08-1.14, p < 0.001), while there was no difference in major bleeding (aOR 1.02, 95 % CI 1.00-1.04, p = 0.107). CONCLUSION: Among AMI patients, treatment in SNHs was associated with lower utilization of coronary angiography and revascularization and worse clinical outcomes.

Utilization of Non-Drug-Eluting Devices for Inpatient Percutaneous Coronary Intervention in the United States.

There is a paucity of data on the contemporary use of non-drug-eluting devices (balloon angioplasty or bare-metal stents) in contemporary percutaneous coronary intervention (PCI) in the United States. We utilized the Nationwide Readmissions Database to identify patients hospitalized to undergo PCI with non-drug-eluting devices from 2016 to 2019. The main outcome of interest was the trends in utilization over the study years. Among 1,870,262 PCI procedures, 127,810 (6.8%) were performed with non-drug-eluting devices; 72% of these were in the setting of acute myocardial infarction (MI). The use of non-drug-eluting devices decreased throughout the study period from 12.9% of all PCI in the first quarter of 2016 to 3.4% in the last quarter of 2019 (p <0.001). Factors associated with their use included advanced age and high bleeding risk. Only a small percentage were used as a bridge to coronary artery bypass graft surgery (2%) and for treatment of in-stent restenosis (3%). The in-hospital mortality was 5.8% for the entire cohort and 6.6% when the indication for use was an acute MI. In patients presenting with an acute MI, reinfarction within 30 days was common and occurred in 18% of the patients. In conclusion, the use of non-drug-eluting devices in PCI in the United States decreased from 2016 to 2019. Factors associated with their use included old age and high bleeding risk. Due to suboptimal outcomes in patients currently being treated with non-drug-eluting devices, there remains an unmet clinical need for alternative treatment options.

Saphenous Vein Graft Intervention.

Even though saphenous vein grafts (SVGs) are the most commonly used surgical conduits, their long-term patency is limited by accelerated atherosclerosis often resulting in acute coronary syndrome or asymptomatic occlusion. SVG intervention is associated with 2 significant challenges: a significant risk of distal embolization with resultant periprocedural myocardial infarction in the short-term and restenosis in the long-term. Several individual trials have compared bare metal stents with drug-eluting stents for SVG intervention. This review article discusses the pathophysiology of SVG lesions, indications for SVG intervention, and the challenges encountered, and also technical considerations for SVG intervention and the supporting evidence.

Contemporary Management of Severely Calcified Coronary Lesions.

Coronary artery calcification is increasingly prevalent in our patient population. It significantly limits the procedural success of percutaneous coronary intervention and is associated with a higher risk of adverse cardiovascular events both in the short-term and long-term. There are several modalities for modifying calcified plaque, such as balloon angioplasty (including specialty balloons), coronary atheroablative therapy (rotational, orbital, and laser atherectomy), and intravascular lithotripsy. We discuss each modality's relative advantages and disadvantages and the data supporting their use. This review also highlights the importance of intravascular imaging to characterize coronary calcification and presents an algorithm to tailor the calcium modification therapy based on specific coronary lesion characteristics.

Multidisciplinary Approach to Hemodynamic Management During High-Risk Ventricular Tachycardia Ablation.

Percutaneous ventricular assist devices have been used for high-risk ventricular tachycardia ablation when hemodynamic decompensation is expected. Utilizing a case example, we present our experience with development of a coordinated, team-based approach focused on periprocedural management of patients with high-risk ventricular tachycardia. (Level of Difficulty: Advanced.).

Relation of Extracardiac Vascular Disease and Outcomes in Patients With Diabetes (1.1 Million) Hospitalized for Acute Myocardial Infarction.

The association between vascular disease and outcomes of patients with acute myocardial infarction (AMI) has not been well-defined in the diabetes mellitus (DM) population. All patients with DM presenting with AMI between October 2015 and December 2018 in the National Inpatient Sample database were stratified by number and site of extracardiac vascular comorbidity (cerebrovascular [CVD], renovascular, neural, retinal and peripheral [PAD] diseases). Multivariable logistic regression was used to determine the adjusted odds ratios (aORs) of in-hospital adverse outcomes and procedures. Of 1,116,670 patients with DM who were hospitalized for AMI, 366,165 had ≥1 extracardiac vascular comorbidity (32.8%). Patients with vascular disease had an increased aOR for mortality (aOR 1.05, 95% confidence interval [CI] 1.04 to 1.07), major adverse cardiovascular and cerebrovascular events (MACCEs) (aOR 1.19, 95% CI 1.18 to 1.21), stroke (aOR 1.72, 95% CI 1.68 to 1.76), and major bleeding (aOR 1.11, 95% CI 1.09 to 1.13) and had lower odds of receiving coronary angiography (CA) (aOR 0.90, 95% CI 0.90 to 0.91) and percutaneous coronary intervention (PCI) (aOR 0.82, 95% CI 0.82 to 0.83) than patients without extracardiac vascular disease. Patients with PAD had the highest odds of mortality (aOR 1.29, 95% CI 1.27 to 1.32), whereas patients with CVD had the greatest odds of MACCEs, stroke, and major bleeding (aOR 1.82, 95% CI 1.78 to 1.87, aOR 4.25, 95% CI 4.10 to 4.40, and aOR 1.51, 95% CI 1.45 to 1.57, respectively). Patients with DM presenting with AMI and concomitant extracardiac vascular disease were more likely to develop clinical outcomes and less likely to undergo CA or PCI. Patients with PAD had the highest risk of mortality, whereas patients with CVD had the greatest risk of MACCEs, stroke, and major bleeding.

Echocardiographic Parameters and Outcomes in Methamphetamine-Associated Heart Failure: A Propensity Score-Weighted Analysis.

Background: Methamphetamines are a common cause of systolic heart failure (HF). There are limited data on the prognosis associated with hospitalizations for decompensated HF in the setting of methamphetamine use. We aimed to evaluate patient characteristics and outcomes among patients admitted with decompensated HF who had positive drug screens for amphetamines as well as to determine whether any parameters from transthoracic echocardiogram (TTE) can predict outcomes in this population. Methods: This was a retrospective cohort study of consecutive adult patients admitted to the Loma Linda Medical Center who had an active hospital problem of acute on chronic systolic (or systolic and diastolic) HF from 2013 to 2018. Electronic medical records were mined for relevant patient data. Methamphetamine-associated heart failure (MethHF) group was defined as those with an admission urine drug screen (UDS) that was positive for methamphetamines, whereas non-MethHF was defined by patients with negative methamphetamine on UDS or UDS was not done on physician's discretion. The primary outcomes of the study were 30-day composite outcome (defined as combined all-cause readmission and all-cause mortality), 365-day all-cause mortality, and length of stay (LOS). Propensity score weighting for these outcomes was performed using demographics, laboratory and clinical variables, and left ventricular ejection fraction (LVEF) as covariates. TTE parameters from presentation were also evaluated to determine if any had prognostic implications. Results: A total of 1,655 patients were included (101 patients with positive urine methamphetamine and 1,554 patients without). Patients with MethHF were younger, more likely to be male, had fewer comorbidities, had lower LVEF, and were more likely to have right ventricular systolic dysfunction. In propensity-weighted analyses, there were no significant differences in LOS, 30-day composite outcome, or 365-day mortality between the MethHF and non-MethHF group in (P > 0.05 for all). Presence of at least moderate tricuspid valve regurgitation (TR) was the only TTE predictor of 30-day composite outcome (odds ratio (OR) = 4.67, 95% confidence interval (CI): 1.5 - 14.50, P < 0.01) and 365-day mortality (OR = 4.67, 95% CI: 1.5 - 14.50, P < 0.01) in the MethHF group. Conclusion: Patients with MethHF admitted for decompensated HF had similar outcomes compared to non-MethHF after adjusting for baseline characteristics. TR is the only TTE value to predict outcomes in this population.

Treatment and Outcomes of Acute Myocardial Infarction in Patients With Polymyalgia Rheumatica With and Without Giant Cell Arteritis.

This study analyzed the characteristics, management, and outcomes of patients with polymyalgia rheumatica (PMR) hospitalized with acute myocardial infarction (AMI), including sensitivity analysis for presence of giant cell arteritis (GCA). Using the National Inpatient Sample (January 2004 to September 2015) and International Classification of Diseases, Ninth Revision, all AMI hospitalizations were stratified into main groups: PMR and no-PMR; and subsequently, PMR, PMR with GCA, and GCA and no-PMR. Outcomes were all-cause mortality, major adverse cardiovascular/cerebrovascular events (MACCEs), major bleeding, and ischemic stroke as well as coronary angiography (CA) and percutaneous coronary intervention (PCI). Multivariable logistic regression was used to determine adjusted odds ratios with 95% confidence interval (95% CI). A total of 7,622,043 AMI hospitalizations were identified, including 22,597 patients with PMR (0.3%) and 5,405 patients with GCA (0.1%). Patients with PMR had higher rates of mortality (5.8% vs 5.4%, p = 0.013), MACCEs (10.2% vs 9.2%, p <0.001), and stroke (4.6% vs 3.5%, p <0.001) and lower receipt of CA (48.9% vs 62.6%, p <0.001) and PCI (30.6% vs 41.0%, p <0.001) than the no-PMR group. After multivariable adjustment, patients with PMR had decreased odds of mortality (0.75, 95% CI 0.71 to 0.80), MACCEs (0.78, 95% CI 0.74 to 0.81), bleeding (0.79, 95% CI 0.73 to 0.86), and stroke (0.88, 95% CI 0.83 to 0.93); no difference in use of CA (1.01, 95% CI 0.98 to 1.04) and increased odds of PCI (1.07 95% CI 1.03 to 1.10) compared with the no-PMR group. Similar results were observed for patients with concomitant PMR and GCA, whereas patients with GCA only showed increased odds of bleeding (1.51 95% CI 1.32 to 1.72) and stroke (1.31 95% CI 1.16 to 1.47). In conclusion, patients with AMI with PMR have an increased incidence of crude adverse in-hospital outcomes than those without PMR; however, these differences do not persist after adjusting for age and comorbidities.

Hemorrhagic pericardial effusion resulting in constriction in hereditary hemorrhagic telangiectasia.

BACKGROUND: We report the first ante-mortem diagnosis of hemorrhagic pericardial effusion in hereditary hemorrhagic telangiectasia resulting in constriction; the case also demonstrates the unusual but well-described complication of right-sided heart failure requiring extracorporeal membrane oxygenation (ECMO) support after pericardiectomy. CASE PRESENTATION: A previously healthy 48 year old man with a strong family history of Osler-Weber-Rendu disease presented to our institution with signs and symptoms of advance heart failure. His workup demonstrated a thickened pericardium and constrictive physiology. He was brought to the operating room where old clot and inflamed tissue were appreciated in the pericardial space and he underwent complete pericardiectomy under cardiopulmonary bypass. Separation from bypass, hampered by the development of right ventricular dysfunction and profound vasoplegia, required significant pressor and inotropic support. The right heart dysfunction and vasoplegia worsened in the early postoperative period requiring a week of ECMO after which his right ventricle recovered and he was successfully de-cannulated. CONCLUSION: Given the poor outcome of severe postoperative right ventricular failure after pericardiectomy, with high central venous pressure, a low gradient between central venous and pulmonary artery pressures and high vasopressor requirements, ECMO should be instituted promptly.