Prospective randomized trial of antithrombotic strategies following great saphenous vein ablation using injectable polidocanol endovenous microfoam (Varithena).

OBJECTIVE: Postablation deep vein thrombosis (DVT) represents a potentially serious complication after Varithena polidocanol endovenous microfoam (PEM) ablation. The following primary outcomes were assessed: whether (1) adjunctive apixaban anticoagulation or (2) mechanical deep venous system (DVS) saline flushing could decrease saphenofemoral junction (SFJ) thrombus extension (postablation superficial thrombus extension [PASTE]) and/or DVT compared with compression alone, after great saphenous vein (GSV) PEM ablation. METHODS: Varithena 1% PEM ablation patients were randomized to (1) SFJ compression, (2) compression and DVS saline flushing, or (3) compression, DVS saline flushing, and 5 days of postprocedural 5 mg oral apixaban anticoagulation twice daily. Duplex imaging was obtained 7 to 10 days after PEM ablation and PASTE/DVT incidence (primary end point) was compared between groups at this time point. RESULTS: We treated 304 limbs in 257 patients with PEM. Overall, 103 limbs received SFJ compression (group C, 33.8%), 101 received compression and deep venous flushing (group D, 32.9%), and 100 received compression, deep flush, and anticoagulation (group A, 33.2%). Mean ultrasound follow-up time was 9.7 days (all patients) with a primary GSV closure rate of 92.4%. SFJ PASTE (II-IV) occurred in 0.9%, 1.0%, and 0% (groups C, D, and A, respectively). DVT occurred in 16.7%, 14.7%, and 1.98% (groups C, D, and A; χ2, P = .002). Patients in group A receiving apixaban anticoagulation had a significant reduction in DVT compared with patients in group C (1.98% vs 16.7%, χ2; P < .001); likewise, patients in group A had a significantly decreased DVT occurrence compared with group D (14.7% vs 1.98%; χ2, P = .00162), whereas patients in groups C and D were not statistically different (16.7% vs 14.7%; χ2, P = .60). CONCLUSIONS: (1) Neither adjunctive DVS flushing nor anticoagulation decreased clinically relevant SFJ PASTE (II-IV) incidence, which remained similarly low across all groups and ranged between 0% and 1%, regardless of adjunctive DVS flushing or anticoagulation. This rate was significantly lower than prior reports (2.3%-4.1%). (2) DVS flushing had no influence on the rate of DVT. Observed PEM-induced DVT incidence using SFJ compression alone or compression with DVS flushing (16.7% and 14.7%, respectively) was significantly higher than prior reports (2.5%-9.6%). This finding may relate to the greater extent of AK/BK GSV territory treated in the present study. (3) Five days of postprocedural oral apixaban anticoagulation, 5 mg given twice daily, significantly decreased DVT occurrence to 1.98%, compared with nonanticoagulated patients (16.7%). This finding is comparable with the DVT rates reported after endovenous thermal ablation (0.7-1.7%). (4) Postprocedural apixaban anticoagulation may have a significant preventive role in decreasing DVT occurrence after PEM ablation.

Role of Statins in the Primary Prevention of Atherosclerotic Cardiovascular Disease and Mortality in the Population with Mean Cholesterol in the Near-Optimal to Borderline High Range: A Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this meta-analysis was to analyze the benefits and harms of treating the population with statins in those having mean low-density lipoprotein cholesterol (LDL-C) in the near-optimal (100 to 129 mg/dl) to borderline high (130 to 159 mg/dl) range and free of cardiovascular disease (CVD). METHODS: We searched PubMed, PubMed Central, Cochrane Library, and Google Scholar databases for randomized controlled trials (RCTs) published between 1994 and July 2020. We included RCTs with greater than 90% of participants free of CVD. Two reviewers independently screened the articles using the Covidence software, assessed the methodological quality using the risk of bias 2 tool, and analyzed the data using the RevMan 5.4 software. RESULTS: Eleven trials were included. Statin therapy was associated with a decreased risk of myocardial infarction (RR = 0.56, 95% CI: 0.47 to 0.67), major cerebrovascular events (RR = 0.78, 95% CI: 0.63 to 0.96), major coronary events (RR = 0.67, 95% CI: 0.57 to 0.80), composite cardiovascular outcome (RR = 0.71, 95% CI: 0.62 to 0.82), revascularizations (RR = 0.65, 95% CI: 0.57 to 0.74), angina (RR = 0.76, 95% CI: 0.63 to 0.92), and hospitalization for cardiovascular causes (RR = 0.74, 95% CI: 0.64 to 0.86). There was no benefit associated with statin therapy for cardiovascular mortality and coronary heart disease mortality. All-cause mortality benefit with statin therapy was seen in the population with diabetes and increased risk of CVD. Statin therapy was associated with no significant increased risk of myalgia, creatine kinase elevation, rhabdomyolysis, myopathy, incidence of any cancer, incidence of diabetes, withdrawal of the drug due to adverse events, serious adverse events, fatal cancer, and liver enzyme abnormalities. CONCLUSION: Statin therapy was associated with a reduced risk of cardiovascular disease and procedures without increased risk of harm in populations with mean LDL-C in the near-optimal to the borderline high range and without prior atherosclerotic cardiovascular disease.

A Dynamic Systems Approach for Detecting and Localizing of Infarct-Related Artery in Acute Myocardial Infarction Using Compressed Paper-Based Electrocardiogram (ECG).

Timely evaluation and reperfusion have improved the myocardial salvage and the subsequent recovery rate of the patients hospitalized with acute myocardial infarction (MI). Long waiting time and time-consuming procedures of in-hospital diagnostic testing severely affect the timeliness. We present a Poincare pattern ensemble-based method with the consideration of multi-correlated non-stationary stochastic system dynamics to localize the infarct-related artery (IRA) in acute MI by fully harnessing information from paper-based Electrocardiogram (ECG). The vectorcardiogram (VCG) diagnostic features extracted from only 2.5-s long paper ECG recordings were used to hierarchically localize the IRA-not mere localization of the infarcted cardiac tissues-in acute MI. Paper ECG records and angiograms of 106 acute MI patients collected at the Heart Artery and Vein Center at Fresno California and the 12-lead ECG signals from the Physionet PTB online database were employed to validate the proposed approach. We reported the overall accuracies of 97.41% for healthy control (HC) vs. MI, 89.41 ± 9.89 for left and right culprit arteries vs. others, 88.2 ± 11.6 for left main arteries vs. right-coronary-ascending (RCA) and 93.67 ± 4.89 for left-anterior-descending (LAD) vs. left-circumflex (LCX). The IRA localization from paper ECG can be used to timely triage the patients with acute coronary syndromes to the percutaneous coronary intervention facilities.

Comparison of hand-held acoustic Doppler with point-of-care portable color Doppler ultrasound in the assessment of venous reflux disease.

OBJECTIVE: Diagnostic-quality portable color Doppler ultrasound (PCD) offers convenient point-of-care venous reflux disease (VRD) diagnosis. Philips Lumify (Philips N.V., Best, The Netherlands), a high-fidelity broadband linear array transducer (4-12 MHz frequency), connects through a web-enabled smartphone or tablet to cloud software and offers B-mode and color Doppler imaging without pulsed wave Doppler capability. The aims of the study were to compare hand-held acoustic Doppler (HHD) vs PCD diagnostic performance using conventional duplex ultrasound (DUP) as the "gold standard" for VRD assessment, to assess effects of body mass index (BMI) and disease severity on diagnostic performance of HHD and PCD, and to determine whether PCD offers any diagnostic improvement over HHD in VRD assessment. METHODS: There were 241 patients (65 male, 176 female; mean age, 55.5 ± 15.5 years; mean BMI, 32.2 ± 7.9 kg/m2). DUP (447 legs), PCD (262 legs), and HHD (217 legs) studied the great saphenous vein at above-knee (AK) and below-knee (BK) levels. A phlebologist performed HHD, whereas PCD and DUP were performed sequentially (PCD first) by an experienced technologist and interpreted independently. PCD was done blinded to DUP results. DUP findings were analyzed blinded to HHD and PCD results. Venous reflux was dichotomously assessed as <2 seconds and >2 seconds. RESULTS: HHD improves from moderate to good sensitivity from AK level (68%) to BK level (94%) but suffers poor specificity that declines significantly from AK level (50%) to BK level (12%; P < .05). HHD positive predictive value exceeds its negative predictive value (NPV) and remains unchanged from AK level (71%) to BK level (72%). HHD NPV remains consistently poor at AK (48%) and BK (42%) levels. PCD has similar sensitivity from AK level (69%) to BK level (74%), better AK level (79%) vs BK level (58%) specificity (P < .05), similar positive predictive value for AK (76%) and BK levels (78%), and better NPV for AK level (72%) vs BK level (53%; P < .05). BMI range (<30 kg/m2 vs ≥ 30 kg/m2) did not influence diagnostic performance of HHD and PCD significantly. HHD and PCD specificity was higher for Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class <4 compared with CEAP class ≥4 (P < .05). CONCLUSIONS: The relative diagnostic performance of HHD and PCD is highly dependent on insonation level. PCD advantages compared with HHD are marginally greater specificity at AK and BK levels and better NPV at AK level. Compared with HHD, PCD's disadvantage is lower sensitivity at BK level. Both HHD and PCD have higher specificity at AK level than at BK level. Overall, PCD offers only moderate sensitivity and specificity, making it inadequate for exclusion of significant venous reflux. Neither obesity nor CEAP class significantly influenced the general diagnostic performance of PCD or HHD.

Prognostic value of frontal QRS-T angle in predicting survival after primary percutaneous coronary revascularization/coronary artery bypass grafting for ST-elevation myocardial infarction.

BACKGROUND: Frontal QRS-T angle (FQRST) has previously been correlated with mortality in patients with stable coronary artery disease, but its role as survival predictor after ST-elevation myocardial infarction (STEMI) remains unknown. METHODS: We evaluated 267 consecutive patients with STEMI undergoing reperfusion or coronary artery bypass grafting. Data assessed included demographics, clinical presentation, electrocardiograms, medical therapy, and one-year mortality. RESULTS: Of 267 patients, 187 (70%) were males and most (49.4%) patients were Caucasian. All-cause mortality was significantly higher among patients with the highest (101-180°) FQRST [28% vs. 15%, p = 0.02]. Patients with FQRST 1-50° had higher survival (85.6%) compared with FQRST = 51-100° (72.3%) and FQRST = 101-180° (67.9%), [log rank, p = 0.01]. Adjusting for significant variables identified during univariate analysis, FQRST (OR = 2.04 [95% CI: 1.31-13.50]) remained an independent predictor of one-year mortality. FQRST-based risk score (1-50° = 0 points, 51-100° = 2 points, 101-180° = 5 points) had excellent discriminatory ability for one-year mortality when combined with Mayo Clinic Risk Score (C statistic = 0.875 [95%CI: 0.813-0.937]. A high (>4 points) FQRST risk score was associated with greater mortality (32% vs. 19%, p = 0.02) and longer length of stay (6 vs. 2 days, p < 0.001). CONCLUSION: FQRST represents a novel independent predictor of one-year mortality in patients with STEMI undergoing reperfusion. A high FQRST-based risk score was associated with greater mortality and longer length of stay and, after combining with Mayo Clinic Risk Score, improved discriminatory ability for one-year mortality.

The relative roles of power, linear endovenous energy density, and pullback velocity in determining short-term success after endovenous laser ablation of the truncal saphenous veins.

OBJECTIVE: The objective of this study was to describe the relative contributions of power output, linear endovenous energy density (LEED), and pullback rate (PBR) in determining successful long-term occlusion of the truncal saphenous veins after endovenous laser ablation (EVLA). METHODS: A consecutive 203 patients (336 ablated veins) with reflux of the great saphenous vein or small saphenous vein (Clinical, Etiology, Anatomy, and Pathophysiology class C2-C6) defined by duplex ultrasound and clinical criteria were treated with 1470-nm EVLA at a power of 6 to 12 W. Prospective outcomes were evaluated in serial clinical and duplex ultrasound follow-up. Univariate logistic regression (ULR) and multivariable logistic regression modeling assessed LEED, power output, and PBR as success predictors and optimal settings for sustained closure. RESULTS: Higher power outputs (8-12 W) were significantly better than lower outputs (6-7 W) for successful closure. ULR suggested a ≥90% probability of success for power output >10.34 W (P < .001) and LEED >26.56 J/cm (P = .001). Power output was foremost (P < .001) and LEED second (P < .001), and PBR was insignificant overall (P = .38), becoming significant only at LEED values >26 J/cm (P < .001). Multivariable logistic regression confirmed both power (P < .040) and LEED (P < .008) but not PBR (P = .69) as significant determinants. Clinical side effects were not associated by ULR with power output (P = .14), LEED (P = .71), or PBR (P = .39). CONCLUSIONS: Power and LEED are separate but important determinants of short-term EVLA success. Threshold-dependent effects are observed for PBR (LEED ≤26 J/cm or ≥26 J/cm), with significant PBR correlation seen only at higher LEED values. Whereas ideal values for power and LEED differ according to the clinical scenario, our findings suggest that use of higher power outputs and greater LEED values (≥90% success probability achieved with power >10.34 W or LEED >26.56 J/cm) may yield optimal results.

Finding the sweet spot for non-apical RV pacing - "love's labor's lost or much ado about nothing:" a new angiographic technique to accomplish accurate physiological RV septal pacing in under 5 minutes from venous cannulation (or bust).

Right ventricular septal pacing has been long touted as a more physiologic alternative to right ventricular apical pacing. This article reviews the physiologic and clinical evidence for right ventricular septal versus apical pacing, and presents a novel angiographic technique for efficient attainment of the optimal septal pacing site. The reasons for equivocal clinical findings in septal versus apical pacing studies are discussed, and a new strategy for non-apical pacing clinical trial design utilizing comparative anatomic assessment of septal pacing site versus clinical outcome is proposed.

Neutrophil to lymphocyte ratio predicts short- and long-term mortality following revascularization therapy for ST elevation myocardial infarction.

BACKGROUND: Several inflammation biomarkers have been implicated in the pathogenesis and prognosis of acute coronary syndromes. However, the prognostic role of the neutrophil-lymphocyte white cell interactive response to myocardial injury in predicting short- and long-term mortality after ST elevation myocardial infarction (STEMI) remains poorly defined. METHODS: We evaluated 250 consecutive STEMI patients presenting acutely for revascularization to our tertiary care center over 1 year. Patients with acute sepsis, trauma, recent surgery, autoimmune diseases, or underlying malignancy were excluded. Data gathered included demographics, clinical presentation, leukocyte markers, electrocardiograms, evaluations, therapy,major adverse cardiac events, and all-cause mortality. RESULTS: Mean age was 62 ± 15 years, 70.4% of subjects were males while majority (49.4%) were Caucasians. Mean duration of follow-up was 571 ± 291 days (median 730 days). Univariate analysis of several inflammatory biomarkers including C-reactive protein, revealed white cell count (OR = 1.09, p < 0.001) and neutrophil to lymphocyte ratio (NLR) (OR = 1.05, p = 0.011) as predictors of short- and long-term mortality; but not mean neutrophil count (OR = 1.04, p = 0.055) or lymphocyte count alone (OR = 0.96, p = 0.551). Multivariate analysis using backward stepwise regression revealed NLR (OR = 2.64, p = 0.026), female gender (OR = 5.35, p < 0.001), cerebrovascular accident history (OR = 3.36, p = 0.023), low glomerular filtration rate (OR = 0.98, p = 0.012) and cardiac arrest on admission (OR = 17.43, p < 0.001) as robust independent predictors of long-term mortality. NLR was divided into two sub-groups based on an optimal cut off value of 7.4. This provided the best discriminatory cut off point for predicting adverse mortality outcome. Both short-term (≤ 30 days) and long-term (≤ 2 years) mortality were predicted with Kaplan-Meier survival curve separation best stratified by a NLR cut off value of 7.4. CONCLUSIONS: NLR based on an optimal cut off value of 7.4, was an excellent predictor of short- and long-term survival in patients with revascularized STEMI and warrants larger scale multi-center prospective evaluation, as a prognostic indicator. NLR offers improved prognostic capacity when combined with conventional clinical scoring systems, such as the Thrombolysis In Myocardial Infarction risk score.

Multimodality imaging of right-sided (tricuspid valve) papillary fibroelastoma: recognition of a surgically remediable disease.

Presentation of an increasingly recognized right-sided primary valve tumor of clinical importance: the tricuspid valve papillary fibroelastoma (PF). Early recognition and surgical intervention is emphasized for valvular PF, which carries a significant risk of morbidity and mortality. Newer imaging techniques, including CT and MRI, assist in localizing and differentiating PF from alternative cardiac pathology.

Alcaligenes xylosoxidans endocarditis of a prosthetic valve and pacemaker in a 62-year-old woman.

The bacterium Alcaligenes xylosoxidans is known to cause several nosocomial infections; however, it rarely causes endocarditis, which has a very high mortality rate. Early isolation of the infection source and prompt identification of the patient's antibiotic sensitivities are paramount if the infection is to be treated adequately. We present what is apparently only the second documented case of the successful eradication of bioprosthetic valve endocarditis that was caused by pacemaker lead infection with Alcaligenes xylosoxidans. A 62-year-old woman with multiple comorbidities presented with endocarditis of a recently placed bioprosthetic aortic valve. The infection was secondary to pacemaker lead infection. She underwent antibiotic therapy, but an unusual pattern of antibiotic resistance developed. Despite initially adequate therapy, the infection recurred because of virulence induced by antibiotic resistance. Emergent, high-risk surgical treatment involved excising the infected valve and removing the source of the infection (the pacemaker leads). The patient eventually recovered after prolonged antibiotic therapy and close vigilance for recurrent infection. In addition to the patient's case, we discuss the features of this bacteremia and the challenges in its diagnosis.