Complex percutaneous coronary intervention in patients unable to undergo coronary artery bypass grafting during the COVID-19 pandemic: insights from the UK-ReVasc Registry.

OBJECTIVES: Cardiac surgery for coronary artery disease was dramatically reduced during the first wave of the COVID-19 pandemic. Many patients with disease ordinarily treated with coronary artery bypass grafting (CABG) instead underwent percutaneous coronary intervention (PCI). We sought to describe 12-month outcomes following PCI in patients who would typically have undergone CABG. METHODS: Between March 1 and July 31, 2020, patients who received revascularization with PCI when CABG would have been the primary choice of revascularization were enrolled in the prospective, multicenter UK-ReVasc Registry. We evaluated the following major adverse cardiovascular events at 12 months: all-cause mortality, myocardial infarction, repeat revascularization, stroke, major bleeding, and stent thrombosis. RESULTS: A total of 215 patients were enrolled across 45 PCI centers in the United Kingdom. Twelve-month follow up data were obtained for 97% of the cases. There were 9 deaths (4.3%), 5 myocardial infarctions (2.4%), 12 repeat revascularizations (5.7%), 1 stroke (0.5%), 3 major bleeds (1.4%), and no cases of stent thrombosis. No difference in the primary endpoint was observed between patients who received complete vs incomplete revascularization (residual SYNTAX score £ 8 vs > 8) (P = .22). CONCLUSIONS: In patients with patterns of coronary disease in whom CABG would have been the primary therapeutic choice outside of the pandemic, PCI was associated with acceptable outcomes at 12 months of follow-up. Contemporary randomized trials that compare PCI to CABG in such patient cohorts may be warranted.

Percutaneous Coronary Intervention and Stenting for the Treatment of Myocardial Muscle Bridges: A Consecutive Case Series.

BACKGROUND: Myocardial muscle bridging is not uncommon; it is usually asymptomatic and on occasion can be associated with angina or even acute coronary syndrome. Traditionally, percutaneous intervention is not advocated and medical management or cardiac surgery, with unroofing of the bridge, is advised if troublesome symptoms occur. OBJECTIVE: To describe the experience and outcome of percutaneous intervention and stenting of symptomatic myocardial muscle bridges. METHODS: A retrospective analysis of prospectively collected data on all patients with symptomatic muscle bridge who were treated with stent insertion after physiologic and intravascular ultrasound assessment was performed. Follow-up of all patients up to 7 years was documented and repeat angiography was performed in 4 of these patients. RESULTS: Seven patients were identified with muscle bridge who were symptomatic and were managed with maximum medical therapy but remained symptomatic. They all underwent percutaneous procedure with physiologic assessment of the muscle bridge with fractional flow reserve and with intravascular ultrasound, which was also used to optimize the stent procedure. All patients remain well and asymptomatic with follow-up from 2-7 years. Two patients had atypical symptoms and had repeat angiography at 18 and 28 months, respectively, and 2 more patients had a follow-up angiography at 32 and 34 months; all showed patent stents and no evidence of any issues. CONCLUSION: Percutaneous intervention and stent for symptomatic muscle bridges performed with physiological and intracoronary imaging assessment and guidance may be an acceptable management modality for symptomatic MB patients, resulting in a good outcome and potentially sparing patients a highly invasive cardiac surgery.

Mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock.

Patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) have poor prognosis. Over the last two decades, there has been some improvement in mortality rates associated with CS. Initial measures to stabilise patients should follow a shock protocol, including therapies such as volume expansion, inotropes/vasopressors, and early coronary revascularisation. The use of mechanical circulatory support (MCS) devices demonstrated better haemodynamic and metabolic profiles for patients with CS. However, these benefits have not been consistently translated into significant reductions in cardiovascular adverse events. This review aims to discuss emerging concepts related to CS including an update on its classification and pathophysiology. The focus is on recent evidence regarding the use of MCS and the timing of initiating in patients with CS.

Coronary revascularization in patients with left ventricle systolic dysfunction, current challenges and clinical outcomes.

The effects of coronary revascularization in patients with left ventricle systolic dysfunction (LVSD) are not well studied. The decision about revascularization and its timing remain challenging, not only related to procedural risk, but also linked to other several limitations including assessment of ischemia, viability, and ability to predict LV recovery. The role of viability as a prognostic marker for patients with LVSD and its use as a therapeutic target remains debatable. In this article, we will review the role of LVSD in patients undergoing coronary revascularization alongside the role of ischemia and viability assessment. We will provide a review of the literature on the outcomes of coronary revascularization, both surgically and percutaneously, in patients with LVSD.

Serratus Anterior Plane Block in Pediatric Patients Undergoing Thoracic Surgeries: A Randomized Controlled Trial.

OBJECTIVE(S): This study was designed to evaluate the efficacy and safety of serratus anterior plane block (SAPB) as an analgesic technique for thoracotomies in pediatric patients. DESIGN: Double-blinded randomized controlled trial. SETTING: A single-center study at Aboelrish Pediatric Hospital, one tertiary hospital of Cairo University Hospitals. PARTICIPANTS: Seventy pediatric patients aged six months-to-three years scheduled for thoracotomies. INTERVENTIONS: Patients were randomized into two groups, group SF and group F. Group SF received an ultrasound-guided SAPB (n = 35), whereas group F (n = 35) did not. All groups received an intraoperative fentanyl infusion (at 0.5 µg/kg /h). MEASUREMENTS: The primary outcome was the total dose of postoperatively administrated fentanyl in the first 24 hours. The secondary outcomes included the total dose of intraoperative additional fentanyl boluses; time of the first postoperative rescue analgesia; and postoperative Face, Legs, Activity, Cry, Consolability scale (FLACC) score values. MAIN RESULTS: The main results of this study showed that the administrated fentanyl in the 24 hours postoperatively was significantly lower in SF group than in F group (p value ˂ 0.001). In addition, significant decreases of the postoperative FLACC pain score (p value ˂ 0.001), reduction of intraoperative fentanyl consumption (p value ˂ 0.001), and delay of the first rescue analgesia (p value ˂ 0.001) were recorded in SF group in relation to F group without significant complications in both groups. CONCLUSIONS: Serratus anterior plane block can provide a safe, effective, and easy-to-perform regional technique for children undergoing thoracotomies.

Intensive lipid-lowering therapy, time to think beyond low-density lipoprotein cholesterol.

Statins have been shown to be effective in reducing cardiovascular events. Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol (LDL-c). Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes. Unselective application of these treatments is undesirable and unaffordable and, therefore, has been guided by LDL-c level. Nonetheless, the residual risk in the post-statin era is markedly heterogeneous, including thrombosis and inflammation risks. Moreover, the lipo-protein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a). Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease, post coronary artery bypass graft and diabetes. Notably, these clinical entities share similar phenotype of large burden of atherosclerotic plaques. Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites. Those patients may be suitable candidates for intensive lipid lowering treatment.

Novel economic treatment for coronary wire perforation: A case report.

BACKGROUND: Coronary artery perforation is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with embolization of coils, fat, thrombin, or collagen. We describe a novel and cost-effective method of embolisation using a cut remnant of a used angioplasty balloon that was successful in sealing a distal wire perforation. we advocate this method as a simple method of managing distal vessel perforation. CASE SUMMARY: A 73-year-old male with previous coronary Bypass graft operation and recurrent angina on minimal exertion had undergone rotablation and PCI to his dominant left circumflex. At the end of the procedure there was evidence of wire perforation at the distal branch and despite prolonged balloon tamponade there continued to be extravasation and the decision was made to seal this perforation. A cut piece of an angioplasty balloon was used and delivered on the original angioplasty wire to before the perforation area and released which resulted in sealing of the perforation with no unwanted clinical consequences. CONCLUSION: The use of a balloon remnant for embolization in coronary perforation presents a simple, efficient and cost-effective method for managing coronary perforations and may be an alternative for achieving hemostasis and preventing poor outcome. Prevention remains the most important part with meticulous attention to the distal wire position, particularly with hydrophilic wires.

Management of Coronary Artery Perforation.

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors for CAP include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. There are 3 major types of CAP depending on location: (a) large vessel perforation, (b) distal vessel perforation, and (c) collateral perforation. Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with coil or fat embolization. In this article we provide a state-of-the-art overview of the contemporary management of CAP.

Mental Stress in Anesthesia and Intensive Care Physicians During COVID-19 Outbreak.

BACKGROUND: Since the announcement of the World Health Organization of COVID-19 as a global pandemic, the probability of experiencing psychological disturbances and mental health problems among the frontline doctors who deal early with the suspected or confirmed patients is expected to increase, especially among anesthesia and ICU physicians. OBJECTIVES: The objective of this study was to assess the magnitude of mental stress among anesthesia and ICU physicians in Cairo university hospitals, Egypt, treating patients exposed to COVID-19. METHODS: This cross-sectional, survey-based study collected the demographic and mental health data from anesthesia and ICU physicians working in Cairo university hospitals from March 15 to April 15, 2020, in Egypt. The level of stress was assessed by the perceived stress scale (PSS-10). RESULTS: A total of 193 out of 315 contacted physicians completed the survey. A significant proportion of participants (65%) experienced high levels of psychological distress during this acute situation, with the PSS-10 median score of 21 in the registrar group and 18 in the consultant group; the difference was statistically significant (P = 0.03). The most common causes of stress among the participants were the fears that they might transmit the disease to their loved people and the lack of a clear protocol on how to deal with COVID-19 cases, either suspected or confirmed. CONCLUSIONS: In this survey study, anesthesia and ICU physicians responding to the spread of COVID-19 reported high rates of symptoms of mental stress.

Delayed fistulization from esophageal replacement surgery.

We present two patients who developed delayed fistulization following esophageal replacement surgery. The first is a 13-year-old child who, at the age of 3 years, underwent a trans-mediastinal colonic esophageal replacement for a refractory corrosive injury followed by a retrosternal reverse gastric tube after an early catastrophic leak. Ten years later, he presented with a history of intermittent chest pain for 6 months. He developed a tension pneumo-pericardial tamponade caused by a fistula between gastric tube and pericardium. He recovered after sternotomy. The second was born prematurely with type C esophageal atresia and other malformations. After esophageal anastomosis, he developed a refractory stricture that was resected at 10 months. Despite a fundoplication at 4 years, the recurrent esophageal stricture required resection at 14 years, accomplished by mobilizing the stomach into the chest through a left thoracoabdominal incision. The postoperative course was complicated by a gastric leak in the chest with empyema, but the patient recovered and was able to eat. Five years later, he underwent an anterior spinal fusion to correct a worsening kyphoscoliosis. Postoperatively, he developed an ARDS picture, leakage of air through the gastrostomy, and a fatal pulmonary hemorrhage secondary to a gastro-bronchial fistula. Fistulization from esophageal replacement surgery represents a rare long-term complication that pediatric surgeons need to be aware of.

Outcomes of pyloroplasty and pyloric dilatation in children diagnosed with nonobstructive delayed gastric emptying.

BACKGROUND: Pyloroplasty and pyloric dilatation are methods used to ameliorate the symptoms of nonobstructive delayed gastric emptying in children. Our purpose was to review the results of these methods with respect to symptomatic improvements. METHODS: We retrospectively reviewed the records of children who, exclusive of fundoplications, in the 11-year period before December 31, 2005, had undergone at our institution a Heineke-Mikulicz pyloroplasty (HMP) and/or a fluoroscopically guided balloon pyloric dilatation (FGBD). We recorded evidence of either short- or long-term subjective improvement of symptoms. RESULTS: Twenty-three children underwent HMP. Five had no prior medical treatment. Of the 23, 3 had no subjective improvement in symptoms. Of the 20 who had subjective evidence of improvement recorded, 13 (56.5%) proved to be long-term and 7 short-term improvement. Eight children had FGBD. All 8 had prior medical treatment that had failed. There were 3 who displayed no subjective evidence of improvement, whereas 5 had subjective evidence of improvement-3 (37.5%) long term and 2 short term. CONCLUSIONS: Heineke-Mikulicz pyloroplasty and FGBD in this study demonstrated only in limited numbers long-term improvement of symptoms. Efforts to understand more fully gastric emptying and to define those children who should undergo FGBD or HMP are needed.