Narrow Escape: A Novel Approach to the Endovascular Treatment of Superior Vena Cava Syndrome Secondary to Pacemaker Leads with Excellent Long-term Outcomes.

Pacemaker or defibrillator placement is a common procedure done in more and more patients due to increased longevity and the prominence of cardiac disease. With more indications for cardiac implantable electrode devices, the devices themselves have evolved into more complex structures with more leads. The mechanical stress, risk of infection, and decreased blood flow through the superior vena cava (SVC) put patients at risk for SVC obstruction. Herein, we present a rare case of complete SVC obstruction secondary to fibrosis due to pacemaker leads which was treated with venoplasty and showed excellent long-term results. We also review the current literature on different approaches to treating SVC obstruction in this group of patients.

A Novel Case of Spontaneous Coronary Artery Dissection During Cabergoline Therapy for Prolactinoma.

We present a case of spontaneous coronary artery dissection associated with cabergoline treatment for prolactinoma. A 31-year-old woman with history of hypertension and prolactinoma, treated with cabergoline, presented with chest pain. She had non-ST-segment elevation myocardial infarction with double vessel coronary artery dissection and was treated with coronary artery bypass grafting. (Level of Difficulty: Beginner.).

Predictors of Access Site Crossover in Patients Who Underwent Transradial Coronary Angiography.

Despite increasing use of the transradial approach (TRA) for coronary angiography, TRA failure and subsequent access site crossover remain a barrier to TRA adoption. The aim of this study was to elucidate patient and procedural characteristics associated with TRA to transfemoral approach (TFA) crossover and examine TRA to TFA crossover by operator experience over time. This retrospective analysis identified 1,600 patients who underwent coronary angiography with possible percutaneous coronary intervention through TRA by operators with varied TRA experience in an urban tertiary care center from October 2010 to August 2013. Univariate and multivariable logistic regression were used to identify independent predictors of access site crossover, from TRA to TFA, and strength of association is presented as odds ratio (OR, 95% confidence interval [CI]). Access site crossover was noted in 166 patients (10.4%). Multivariable predictors of access site crossover included age >75 years (OR 1.90, 95% CI 1.23 to 2.91, p = 0.004) and operator experience (OR 2.98, 95% CI 1.96 to 4.52, p <0.0001). Less experienced operators (≤5 years TRA experience) had a decrease in access site crossover over time (quartile 1: 8.9%, quartile 2: 18.8%, quartile 3: 16.4%, and quartile 4: 8.6%, p <0.001), which paralleled an increase in the proportion of procedures using initial TRA over time (quartile 1: 38.0%, quartile 2: 53.7%, quartile 3: 54.8%, and quartile 4: 70.3%, p <0.001). Experienced operators (>5 years TRA experience) had no significant change in proportion of access site crossover over time (quartile 1: 2.8%, quartile 2: 6.4%, quartile 3: 5.6%, quartile 4: 5.8%, p = 0.54). In conclusion, rate of access site crossover in the contemporary era is relatively low and can be mitigated with operator experience.

A pilot randomized controlled trial comparing CABG surgery performed with total arterial grafts or without.

OBJECTIVE: To date only a few randomized controlled studies have compared grafting strategies in patients with multi-vessel coronary disease. This study represents a pilot RCT designed to test the feasibility of a trial comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) and CABG performed with total arterial grafting (TAG). METHODS: Consenting patients undergoing non-redo isolated CABG surgery at a single institution were randomized to TAG or LIMA+SVG groups. Exclusion criteria included prior CABG, emergent procedure, concomitant procedure, varicose veins and renal dysfunction. The primary endpoints were: enrolment >20% and completion of CT coronary angiography at 6 months >80%. Statistical investigation was performed on an intention to treat analysis. RESULTS: Of 421 eligible patients, 60 were enrolled and 2 withdrew (n = 30 in TAG, n = 28 LIMA+SVG) for 14% enrolment rate. Patient characteristics were similar in each group. No patients died in hospital and adverse events such as MI, stroke and deep sternal wound infection were not significantly different between groups. Clinical follow-up was complete in 100% of patients, with 44/58 (76%) undergoing CT coronary angio at 6 months. Graft occlusion occurred in 2 patients in each group for patency rates of 89% (TAG) and 91% (LIMA+SVG). CONCLUSIONS: We provide evidence that an RCT comparing grafting strategy is possible but also show that achieving recruitment or follow-up CT may be difficult. Given the excellent patency results and little difference between groups, our findings suggest that the sample size required may make it infeasible to compare graft patency at 6 months as a study end-point. TRIAL REGISTRATION: Randomized Controlled Trial number: ISRCTN80270323 . Few RCT's exist comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) compared to CABG performed with total arterial grafting (TAG). This study is a pilot RCT designed to test the feasibility of such a trial and identify pitfalls.

Does more than a single chest tube for mediastinal drainage affect outcomes after cardiac surgery?

BACKGROUND: The use of 1 or more mediastinal chest tubes has traditionally been routine for all cardiac surgery procedures to deal with bleeding. However, it remains unproven whether multiple chest tubes offer a benefit over a single chest tube. METHODS: All consecutive patients undergoing cardiac surgery (2005-2010) received at least 1 chest tube at the time of surgery based on surgeon preference. Patients were grouped into those receiving a single chest tube (SCT) and those receiving multiple chest tubes (MCT). The primary outcome was return to the operating room for bleeding or tamponade. RESULTS: A total of 5698 consecutive patients were assigned to 2 groups: 3045 to the SCT and 2653 to the MCT group. Patients in the SCT group were older, more often female and less likely to undergo isolated coronary artery bypass graft than those in the MCT group. Unadjusted outcomes for SCT and MCT, respectively, were return to the operating room for bleeding or tamponade (4.7% v. 5.0%; p = 0.50), intensive care unit stay longer than 48 hours (25.5% v. 27.9%; p = 0.041, postoperative stay > 9 days (31.5% v. 33.1%; p = 0.20) and mortality (3.8% v. 4.6%; p = 0.16). Logistic regression analysis, adjusted for clinical differences between groups, showed that the number of chest tubes was not associated with return to the operating room for bleeding or tamponade. CONCLUSION: The use of multiple mediastinal chest tubes after cardiac surgery confers no advantage over a single chest tube in preventing return to the operating room for bleeding or tamponade.

Relationship between renal dysfunction and outcomes in emergency department patients with potential acute coronary syndromes.

OBJECTIVES: To determine whether patients with elevated creatinine who present to the emergency department (ED) with potential acute coronary syndrome (ACS) are at an increased risk of acute myocardial infarction (AMI) or 30-day cardiovascular (CV) events. METHODS: A secondary analysis of a cohort study of patients presenting to the ED with potential ACS with serum creatinine measurements. Research assistants collected demographics, history, symptoms, hospital course and 30-day follow-up. Outcomes measured were in-hospital AMI and 30-day CV events (death, nonfatal AMI, revascularisation). Prespecified multivariable models included age, gender, race and cardiac risk factors and presenting electrocardiogram (ECG). We used a creatinine cut-off point of 132.6 mmol/l. Data are presented as OR and 95% CI. RESULTS: 3451 patients were enrolled (age, 52.9±13.2; 55% female patients; 64% black patients). There were 120 AMI during initial visit and 232 patients had 30-day CV events (43 deaths, 128 AMI, 120 revascularisations). Creatinine values were normal in 3086 (89.4%) and abnormal in 365 (10.5%) patients. In multivariable models the adjusted OR (95% CI) for the association between abnormal creatinine and AMI was 1.43 (0.88 to 2.30) and 30-day CV events was 1.57 (1.10 to 2.25). The odds of 30-day CV events were increased for patients who were older, male subjects, white, had hyperlipidaemia, hypertension or a history of CAD, or presented with an abnormal ECG. CONCLUSION: In patients with potential ACS in the ED, renal dysfunction predicts a higher likelihood of 30-day CV events, but not an independent predictor after controlling for other risk factors. It appears to be a marker of other CV risks.

Lack of sex disparity in cardiovascular testing after coronary computerized tomographic angiography.

OBJECTIVES: The authors assessed whether there was a sex disparity in testing of patients after coronary computerized tomographic angiography (CTA) was performed for emergency department (ED) patients with potential acute coronary syndromes (ACS). In theory, once coronary anatomy has been determined, any disparity in subsequent workup should not be the result of differences in presentation. METHODS: This was a prospective cohort study of ED patients who presented with potential ACS and received coronary CTAs at a university hospital. Demographics, history, cardiac risk factors, follow-up testing, and procedures were recorded. Follow-up at 30 days was obtained by structured record review and telephone contact. Patients were stratified by sex and coronary CTA results (max stenosis: none, 1% to 24%, 25% to 49%, 50% to 69%, and ≥70%). Main outcome was the relative risk (RR) of a male receiving a stress test or catheterization within 30 days, stratified by categories of percent maximal stenosis. RESULTS: A total of 1,144 patients received coronary CTAs (mean ± SD age = 47.8 ± 8.7 years), 55% were female, and 64% were black or African American. Overall, 161 patients received follow-up testing within 30 days, 113 during their index visit. Men were more likely to receive further testing (RR = 1.51; 95% confidence interval [CI] = 1.14 to 1.99) compared to women. However, when stratified by percentage of stenosis, men were not more likely to receive further testing within 30 days after coronary CTA compared to women (RR = 1.14; 95% CI = 0.68 to 1.91). In multivariable modeling for risk of further testing, stenosis remained significant (adjusted relative risk [aRR] = 1.51; 95% CI = 1.19 to 1.91), while male sex, age, race, and Thrombolysis in Myocardial Infarction (TIMI) risk score were not. CONCLUSIONS: Male patients with potential ACS who receive a coronary CTA as a part of their ED evaluation were no more likely than female patients to receive further testing within 30 days.

Stress testing in young low-risk patients with potential acute coronary syndromes.

OBJECTIVE: Young patients are at low risk for an acute coronary syndrome (ACS); however, many of these patients still enter a "rule-out ACS" pathway and receive stress testing. We hypothesized that stress testing in patients younger than 40 years without known coronary disease will not identify patients at high risk for 30-day adverse cardiovascular events. METHODS: We conducted a cohort study of patients younger than 40 years evaluated in the emergency department for potential ACS. Patients were excluded if they used cocaine, had known cardiac disease, or had an abnormal electrocardiogram. Patients were followed up in-house; follow-up was performed by direct telephone contact and medical record review. The main outcome was a composite of death, acute myocardial infarction (AMI), and revascularization at 30 days. Comparisons between patients with and without stress testing were done using χ2 or t test, as appropriate; 95% confidence intervals were reported for the main outcomes. RESULTS: Of 8816 patient visits, 1144 patients met inclusion criteria. Within 30 days, 82 patients (7.2%) received stress testing, 2 of whom led to cardiac catheterization. Death (n=2), AMI (n=3), and revascularization (n=1) were not different between patients who did and did not receive stress testing (2.4% [0.2%-8.5%] vs 0.4% [0.1%-1.0%]). CONCLUSION: The 30-day cardiovascular complication rate is not different between young patients without known heart disease who do and do not receive stress testing when they present with symptoms of a potential ACS. Testing of young patients at low risk for disease should be reconsidered.

Does coronary artery calcium scoring add to the predictive value of coronary computed tomography angiography for adverse cardiovascular events in low-risk chest pain patients?

OBJECTIVES: Coronary angiography calcium score (CACS) is included for patients who receive coronary computed tomography angiography (CTA) as part of diagnostic testing for low-risk chest pain. Both tests add radiation exposure, and it is unclear whether the combination provides more information than either test alone. The objective was to asses if CACS = 0 determines freedom from coronary artery disease (CAD) and whether the addition of CACS to coronary CT angiography provides additional risk stratification information or helps predict 30-day cardiovascular outcomes. METHODS: This was a secondary analysis of a prospective cohort study at an urban university hospital emergency department (ED), of patients with symptoms suggestive of potential acute coronary syndrome (ACS) and low Thrombolysis in Myocardial Infarction (TIMI) risk scores who received coronary CTA. Data collected included demographics and medical history. The main outcome was CAD, defined as the presence of a maximal stenosis >50% on coronary CTA, stratified by CACS results. The secondary outcome was cardiovascular events including death, myocardial infarction, or revascularization at 30 days. Data were analyzed with standard descriptive techniques and relative risks (RR) with 95% confidence intervals (CIs). RESULTS: A total of 1,049 patients were enrolled (median age = 48.1 years; interquartile range [IQR] = 42.4 to 53.3 years); 55% were female, and 63% were black or African American. Of these, 17 of 795 (2.1%) with CACS of 0 had CAD, 16 of 169 patients (9.5%) with CACS of 0.1 to 99 had CAD, 53.3% (32 of 60) with CACS between 100 and 399 had CAD, and 10 of 23 (43.5%) with CACS ≥ 400 had CAD. There was a higher likelihood of significant CAD with increased CACS. Patients who had a calcium score of 0 but still had CAD were more likely to be young (50 years old or less; RR = 1.73, 95% CI = 1.01 to 2.96). For the secondary outcome, there were 15 cardiovascular events within 30 days: one patient with CACS = 0 and no CAD (1 of 733; 0.1%), one patient with CACS > 0 and no CAD (1 of 182; 0.5%), four patients with CACS = 0 and CAD (4 of 17; 23.5%), and nine patients with CACS > 0 and CAD (9 of 58; 15.5%), with a net reclassification index of -0.001 (p = 0.32). CONCLUSIONS: In the study sample, elevated CACS was associated with a higher likelihood of underlying CAD on coronary CTA, but the addition of CACS to coronary CTA did not help predict 30-day cardiovascular events.