What Is New in Spontaneous Coronary Artery Dissection?

Spontaneous coronary artery dissection (SCAD) is a condition that leads to tearing of the coronary vessel wall in the absence of trauma, iatrogenic injury, or atherosclerosis. SCAD is an important cause of myocardial infarction in young women, leading to significant cardiovascular morbidity and mortality. Within cohorts of women aged around 50 years on average, who experience acute coronary syndrome, the prevalence of SCAD is 22.5%- 35%. Over the past decade, SCAD research has expanded rapidly, leading to improved understanding of this condition. In this review, we provide a summary of the current body of knowledge, highlight areas of ongoing research, and identify existing knowledge gaps. Specifically, we provide a focused update on the pathogenesis of SCAD, including genetic and associated conditions, clinical presentation and diagnosis, prognosis, and short-term and long-term management. Highlighted areas include the following: insights from recent genome-wide association studies; intracoronary imaging for the diagnosis of SCAD; the role of cardiac computed tomography angiography to assess for vessel healing; revascularization strategies and challenges; cardiogenic shock in SCAD; and the increasingly recognized burden of anxiety, depression, and posttraumatic stress disorder among SCAD patients.

La dissection spontanée de l'artère coronaire (DSAC) est un trouble qui survient lorsque la paroi d'un vaisseau coronarien se déchire en l'absence de traumatisme, de lésion iatrogène ou d'athérosclérose. La DSAC est une cause importante d'infarctus du myocarde chez les jeunes femmes, menant à des taux importants de morbidité et de mortalité cardiovasculaires. Dans des cohortes de femmes âgées d'environ 50 ans, en moyenne, qui ont subi un syndrome coronarien aigu, la prévalence de DSAC était de 22,5 % à 35 %. Au cours de la dernière décennie, la recherche sur la DSAC s'est accélérée, permettant de mieux comprendre cette affection. Dans cette analyse, nous présentons un résumé du corpus de connaissances actuel, mettons l'accent sur les principaux domaines de la recherche en cours et cernons les lacunes à combler. Plus particulièrement, nous présentons une mise à jour ciblée sur la pathogenèse de la DSAC, comme les causes génétiques ou autres, les manifestations et le diagnostic cliniques, le pronostic ainsi que la prise en charge à court et à long terme. Les domaines mis de l'avant sont les suivants : résultats des récentes études d'association menées sur l'ensemble du génome; imagerie intracoronarienne pour le diagnostic de DSAC; rôle de l'angiotomodensitométrie cardiaque dans l'évaluation de la guérison des vaisseaux; stratégies et difficultés de revascularisation; choc cardiogène dans la DSAC; et fardeau croissant associé à l'anxiété, la dépression et le stress post-traumatique chez les patients atteints de DSAC.

Pericardial effusion and systemic capillary leak syndrome late post-SARS-CoV-2 vaccination.

We report an interesting case of pericardial effusion associated with idiopathic systemic capillary leak syndrome (ISCLS) following administration of SARS-CoV-2 vaccine. This patient initially presented with dyspnoea and chest pain, with non-pitting oedema and clear lung fields. The diagnosis of ISCLS was made based on the clinical syndrome and laboratory evidence of polycythaemia and hypoalbuminaemia. An enlarging pericardial effusion was diagnosed on transthoracic echocardiogram. Daily point-of-care ultrasound (POCUS)-guided volume management and serial transthoracic echocardiograms contributed to avoidance of refractory shock, cardiac tamponade and critical care admission.

Valve-in-Valve Transcatheter Mitral Valve Replacement: A Large First-in-Human 13-Year Experience.

BACKGROUND: Favourable early outcomes have been reported following valve-in-valve transcatheter mitral valve replacement (TMVR). However, reports of long-term outcomes are lacking. We aimed to evaluate early and late outcomes in a large first-in-human valve-in-valve TMVR 13-year experience. METHODS: All patients undergoing valve-in-valve TMVR in our centre from 2008 to 2021 were included. Clinical and echocardiographic outcomes, defined according to the Mitral Valve Academic Research Consortium, were reported. RESULTS: A total of 119 patients were analysed: mean age 76.8 ± 10.2 years, mean Society of Thoracic Surgeons score 10.7 ± 6.8%, 55.4% female, 63.9% transapical access. Thirty-day mortality was 2.5% for the total population and 0.0% after transseptal TMVR. Maximum follow-up was 13.1 years. During a median follow-up of 3.4 years (interquartile range 1.8-5.3 years), 55 patients (46.2%) died, mainly from noncardiovascular causes. Valve hemodynamics were acceptable at 5 years, with 2.5% structural dysfunction. Patients treated from 2016 on (n = 68; 57.1%), following the advent of routine use of the Sapien 3 valve, CT screening, and transseptal access, were compared with those treated before 2016 (n = 51; 42.9%). Patients from 2016 on had a higher technical success rate (100.0% vs 94.1%; P = 0.04), shorter hospitalisation (P < 0.001), trending lower 30-day mortality (1.5% vs 3.9%; P = 0.4) and better 5-year survival (74.7% vs 41.1%; P = 0.03). CONCLUSIONS: Valve-in-valve TMVR can be performed with little morbidity and low mortality. Mid- to long-term survival remains limited owing to advanced age and comorbidities. Structural bioprosthetic valve dysfunction was rare and redo TMVR feasible in selected patients. Outcomes continue to improve, but the role for valve-in-valve TMVR in lower surgical risk patients remains unclear.

Atherosclerotic Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection is a nontraumatic, noniatrogenic intimal tearing of the coronary artery in patients without atherosclerotic coronary disease. We present 3 unique cases of patients with spontaneous coronary artery dissection and atherosclerotic coronary artery disease. (Level of Difficulty: Intermediate.).

Spontaneous Coronary Artery Dissection: Latest Developments and New Frontiers.

PURPOSE OF REVIEW: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized entity leading to myocardial infarction especially in women. Multiple observational studies have been published in the recent years. This review summarizes the current body of knowledge and recent developments in SCAD epidemiology, presentation, diagnosis, and management. RECENT FINDINGS: Contemporary series have estimated the incidence of SCAD to be up to ~ 4% of all patients presenting with acute coronary syndrome (ACS). Fibromuscular dysplasia, hormonal therapy, multiparity, connective tissue disorders, and systemic inflammatory diseases have been identified as predisposing factors for SCAD. Although SCAD typically presents as ACS, emerging evidence shows that cardiogenic shock, ventricular arrhythmia, and cardiac arrest are not uncommon, with higher incidence of complication among peripartum women. Advances in SCAD diagnosis include a novel angiographic classification of SCAD and the use of optical coherence tomography and intravascular ultrasound to aid in diagnosis. Management depends on clinical stability and the presence of high-risk features. Beta-blockers are the mainstay of medical therapy long term and was shown to reduce recurrent SCAD. The largest study to date including 750 patients across 22 North American centers showed that the majority of patients was managed conservatively and that the technical success rates of percutaneous coronary intervention were low. Following discharge, SCAD-specific cardiac rehabilitation had been shown to have long-term cardiovascular benefits. The recent years have seen a surge in SCAD awareness and publication. Centralized patient networks as well as core lab interpretation of diagnostic data have contributed significantly to the growing body of knowledge. Current efforts to delineate the pathogenesis of SCAD; improve medical and revascularization therapy; and understand complications such as cardiogenic shock and cardiac arrest will serve as foundational building blocks for future research and innovation.

Pooled Nucleic Acid Amplification Test for Screening of Stool Specimens for Shiga Toxin-Producing Escherichia coli.

Shiga toxin-producing Escherichia coli (STEC)-associated enteric illness is attributed to O157 and non-O157 serotypes; however, traditional culture-based methods underdetect non-O157 STEC. Labor and cost of consumables are major barriers to implementation of the CDC recommendation to test all stools for both O157 and non-O157 serotypes. We evaluated the feasibility of a pooled nucleic acid amplification test (NAAT) as an approach for screening stool specimens for STEC. For retrospective evaluation, 300 stool specimens were used to create pools of 10 samples each. The sensitivity was 83% for the preenrichment pooling strategy and 100% for the postenrichment pooling strategy compared with those for individual NAAT results. The difference in cycle threshold (CT) between individual and pooled NAAT results for specimens was significantly lower and more consistent for postenrichment pooling (stx1 mean = 3.90, stx2 mean = 4.28) than those for preenrichment pooling (excluding undetected specimens; stx1 mean = 9.34, stx2 mean = 8.96) (P ≤ 0.0013). Cost of consumables and labor time savings of 48 to 81% and 6 to 66%, respectively, were estimated for the testing of 90 specimens by the postenrichment pooled NAAT strategy on the basis of an expected 1 to 2% positivity rate. A 30-day prospective head-to-head clinical trial involving 512 specimens confirmed the sensitivity and labor savings associated with the postenrichment pooled NAAT strategy. The postenrichment pooled NAAT strategy described here is suitable for efficient large-scale surveillance of all STEC serotypes. Comprehensive detection of STEC will result in accurate estimation of STEC burden and, consequently, appropriate public health interventions.

A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia.

OBJECTIVE: Access-related hand ischemia (ARHI) is a potentially limb-threatening complication of arteriovenous access for dialysis. The distal revascularization-interval ligation (DRIL) and revision using distal inflow (RUDI) procedures both allow treatment of ischemic symptoms while maintaining fistula patency. Although outcomes with the DRIL are well established, experience with the RUDI for ARHI remains preliminary. We compared outcomes in these procedures with respect to cumulative patency, resolution of symptoms, and patient survival. METHODS: A large, prospectively maintained database was used to identify all patients after autogenous arteriovenous fistula construction at two hospitals between 2005 and 2015. Patients with severe Society for Vascular Surgery grade 3 ARHI were included for analysis. RESULTS: A total of 2035 autogenous accesses were created during the study period, and 58 (3%) developed grade 3 ARHI. Of this cohort, RUDI was performed in 20 and DRIL in 21. The indication for intervention was tissue loss (61%) or ischemic rest pain (39%). Mean age was 57.5 years, and 54% of patients were female. Most patients had diabetes (86%) and symptomatic peripheral arterial disease (63%). The mean preoperative digital-brachial index was 0.25 ± 0.12. There were no preoperative differences in patient comorbidities between the RUDI and DRIL cohorts. Primary patency between the RUDI and DRIL cohorts at 12 months (58% ± 11% vs 55% ± 12%) and 36 months (51% ± 12% vs 41% ± 12%) were similar (P = .841). Cumulative secondary patency at 12 months (84% ± 8% vs 94% ± 6%) and 36 months (78% ± 9% vs 86% ± 9%) showed no significant difference (P = .398). Resolution of ischemic symptoms, including resolution or improvement in pain or healing of ischemic ulcers or amputations, occurred in 90% with RUDI and in 81% with DRIL (P = .131). Survival for patients who underwent RUDI or DRIL procedures at 1 and 3 years was 85% vs 86% (P = .948) and 55% vs 49% (P = .278). CONCLUSIONS: In this preliminary study, the RUDI demonstrated similar patency, symptom resolution, and survival compared with the DRIL for patients with severe ARHI. All-cause mortality after any procedure for severe steal syndrome is high, and the particular intervention for management of steal must account for anatomic-, patient-, and disease-related considerations.