Mechanical Circulatory Support in High-Risk Percutaneous Coronary Intervention.

Due to advancing age and increasing comorbidities, the current population has a higher incidence of complex coronary artery disease, often without surgical options for revascularization. In this setting, hemodynamic support devices are an important adjunct in the interventionist's toolbox as they allow for a safer, more effective procedure. The following paper reviews the indications of various available mechanical support devices, highlights their clinical data and technical parameters, and offers a practical approach towards appropriate patient and device selection.

Utility of Glycated Hemoglobin for Assessment of Glucose Metabolism in Patients With ST-Segment Elevation Myocardial Infarction.

Glycated hemoglobin (HbA1c) is an approved and widely used laboratory investigation for diagnosis of diabetes that is not affected by acute changes in blood glucose. Our aim was to analyze the extent to which routine HbA1c measurements diagnose unknown diabetes mellitus (DM) in patients presenting with ST-segment elevation myocardial infarction (STEMI). We also compared outcomes in patients with newly diagnosed DM, previously established DM and those without DM. Consecutive patients undergoing PCI for STEMI from January 2005 to December 2012 were included and routinely performed admission HbA1c was used to identify patients with previously undiagnosed DM (HbA1c ≥6.5 and no history of DM or DM therapy) and pre-DM (HbA1c 5.7% to 6.4%). Overall 1,686 consecutive patients underwent primary percutaneous coronary intervention for STEMI during the study period and follow-up data were available for 1,566 patients (90%). A quarter of the patients (24%, n = 405) had history of DM, 7% (n = 118) had previously undiagnosed DM, and 38.7% (n = 652) had pre-DM. Mortality was comparable in patients with known DM and newly diagnosed DM both in-hospital (11.1% vs 11.9%, p = 0.87) and at 3-year follow-up (27.3% and 24%). Patients with DM, including those who were newly diagnosed, had higher mortality at 3 years (26.5%) compared to those with pre-DM (12.1%) or no dysglycemia (11.2%, p <0.01). In conclusion, a substantial number of patients with STEMI have previously undiagnosed DM (7%). These patients have similar in-hospital and long-term mortality as those with known DM, and outcomes are inferior to patients without dysglycemia.

Serial hemodynamic measurements in post-cardiac arrest cardiogenic shock treated with therapeutic hypothermia.

AIMS: Mortality from cardiogenic shock complicating acute myocardial infarction (MI) remains high despite contemporary treatment. Therapeutic Hypothermia (TH) offers cardiovascular and systemic effects that may prove beneficial in this population, however, current data are limited. This study sought to evaluate the effect of therapeutic hypothermia on serial hemodynamics obtained in subjects with post-cardiac arrest cardiogenic shock. METHODS: We analyzed serial hemodynamics of 14 consecutive patients with cardiogenic shock after cardiac arrest treated with TH. Study inclusion required baseline hemodynamics obtained prior to initiation of TH confirming cardiogenic shock defined as cardiac index ≤2.2 L/min/m(2) with a systolic blood pressure of ≤90 mmHg, a vasopressor requirement, or need for mechanical circulatory support. RESULTS: In our 14 patients, the mean age was 58 ± 13.1 years, mean ejection fraction was 21 ± 8%, six had an acute MI, 12 required vasopressors, and 10 required mechanical support prior to initiation of TH. When compared to baseline, patients had significant improvements in Fick cardiac index, mixed venous O2 saturations, and serum lactate concentrations while heart rate was reduced following initiation of TH. There was no significant change in mean arterial pressure, however vasopressor requirement was reduced. CONCLUSIONS: In patients with cardiogenic shock following cardiac arrest, initiation of TH was associated with favorable changes in invasive hemodynamics suggesting safety in this population. Given potential for favorable hemodynamic and systemic effects of TH in cardiogenic shock, further prospective study of TH as a potentially novel adjunctive therapy to early reperfusion in post-MI cardiogenic shock should be considered.

Why are we doing cardiovascular outcome trials in type 2 diabetes?

Cardiovascular disease is the leading cause of morbidity and death in people with diabetes mellitus. While worsening hyperglycemia is directly associated with poorer outcomes, studies aiming at euglycemia have failed to show an advantage over modest glucose-lowering strategies. Several diabetes drugs that were approved solely on the basis of their glucose-lowering potential were later shown to increase cardiovascular risk.

Outcomes of patients with ischemic mitral regurgitation undergoing percutaneous coronary intervention.

Ischemic mitral regurgitation (IMR) is associated with poor outcomes in patients with coronary artery disease. The impact of percutaneous coronary intervention (PCI) on patients with IMR is not well elucidated. We sought to determine the outcomes of patients with severe IMR who underwent PCI. Patients with severe (≥3+) IMR who underwent PCI from 1998 to 2010 were identified. Improvement in IMR was defined as reduction in severity from ≥3+ to ≤2+ without any other invasive intervention beyond PCI. Outcomes were compared between patients with and without improvement in IMR after PCI. One hundred thirty-seven patients with severe IMR were included in our study. After PCI, 50 patients (36.5%) had improvement in IMR with PCI alone and 24 patients (18.5%) required another intervention. Left atrial size was a significant predictor of improvement in IMR (odds ratio 0.39, 95% confidence interval 0.2 to 0.8). Left ventricular size decreased (systolic diameter 3.9±0.3 vs 4.6±0.2 cm, p=0.0008 and diastolic diameter 5.2±0.2 vs 5.7±0.2 cm, p=0.002) and ejection fraction increased (39.1±4.0% vs 33.1±1.9%, p=0.002) significantly after PCI in the patients with improvement in IMR compared with patients without improvement. Patients with improvement in IMR had numerically better survival; however, it was not statistically significant (p log-rank=0.2). In conclusion, 1/3 of the patients with IMR had improvement in severity of IMR with PCI alone. Improvement in IMR was associated with left ventricular reverse remodeling. Left atrial size was an important predictor of improvement in IMR after PCI.

The FREEDOM trial: in appropriate patients with diabetes and multivessel coronary artery disease, CABG beats PCI.

The Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial (N Engl J Med 2012; 367:2375-2384) was designed to resolve the long-standing debate over the optimal revascularization strategy in patients with diabetes mellitus and multivessel coronary artery disease. At a median follow-up of 3.8 years, the incidence of the primary outcome (a composite of death, myocardial infarction, and stroke) was significantly lower with bypass surgery than with percutaneous intervention.

Cause of death within 30 days of percutaneous coronary intervention in an era of mandatory outcome reporting.

OBJECTIVES: This study sought to ascertain causes of death and the incidence of percutaneous coronary intervention (PCI)-related mortality within 30 days. BACKGROUND: Public reporting of 30-day mortality after PCI without clearly identifying the cause may result in operator risk avoidance and affect hospital reputation and reimbursements. Death certificates, utilized by previous reports, have poor correlation with actual cause of death and may be inadequate for public reporting. METHODS: All patients who died within 30 days of a PCI from January 2009 to April 2011 at a tertiary care center were included. Causes of death were identified through detailed chart review using Academic Research Consortium consensus guidelines and compared with reported death certificates. The causes of death were divided into cardiac and noncardiac and PCI and non-PCI-related categories. RESULTS: Of the 4,078 PCI, 81 deaths (2%) occurred within 30 days. Of these, 58% died of cardiac and 42% of noncardiac causes. However, only 42% of 30-day deaths were attributed to PCI-related complications. Patients with non-PCI-related, compared with PCI-related, death presented with a higher incidence of cardiogenic shock (15 of 47 [32%] vs. 2 of 34 [6%]; p < 0.01) and cardiac arrest (19 of 47 [40%] vs. 1 of 34 [3%]; p < 0.01). Death certificates had only 58% accuracy (95% confidence interval: 45% to 72%) for classifying patients as experiencing cardiac versus noncardiac death. CONCLUSIONS: Less than one-half of 30-day deaths are attributed to a PCI-related complication. Death certificates are inaccurate and do not report PCI-related deaths, which may represent a better marker of PCI quality.

Transfer of patients with suspected acute aortic syndrome.

Patients with acute aortic syndrome (AAS) often require emergent transfer for definitive therapy. The aim of this study was to evaluate the safety of transfer and the ability to optimize hemodynamics in subjects with AAS transported by an aortic network. A total of 263 consecutive patients with suspected AAS transferred to a coronary care unit from March 2010 to June 2012 were included. Transfers were accomplished by the institutional critical care transfer system using ground ambulance (n = 47), helicopter (n = 196), or fixed-wing jet (n = 20) from referring centers directly to the coronary care unit, bypassing the emergency department. The transfer mortality rate was 0%, and the in-hospital mortality rate was 9% (n = 23). Initial systolic blood pressure and heart rate at the time of arrival of the transfer team to the referring hospital were compared with those on arrival to the coronary care unit. The median transfer distance was 66 km (interquartile range 24 to 119), and the median transfer time was 87 minutes (interquartile range 67 to 114). The transfer team achieved significant reductions in systolic blood pressure (from 142 ± 29 to 132 ± 23 mm Hg) (mean difference in systolic blood pressure 10 mm Hg, 95% confidence interval 7 to 14, p <0.0001) and heart rate (from 78 ± 16 to 75 ± 16 beats/min) (mean difference in heart rate 3 beats/min, 95% confidence interval 1 to 4, p <0.0001). In conclusion, these results indicate that patients with AAS can be safely transferred to specialized centers for definitive treatment, and a well-trained critical care transfer team can actively continue to optimize medical management during transit.

Prevalence and factors associated with false positive suspicion of acute aortic syndrome: experience in a patient population transferred to a specialized aortic treatment center.

STUDY OBJECTIVE: Acute aortic syndrome (AAS) is a medical emergency that requires prompt diagnosis and treatment at specialized centers. We sought to determine the frequency and etiology of false positive activation of a regional AAS network in a patient population emergently transferred for suspected AAS. METHODS: We evaluated 150 consecutive patients transferred from community emergency departments directly to our Cardiac Intensive Care Unit (CICU) with a diagnosis of suspected AAS between March, 2010 and August, 2011. A final diagnosis of confirmed acute Type A, acute Type B dissection, and false positive suspicion of dissection was made in 63 (42%), 70 (46.7%) and 17 (11.3%) patients respectively. RESULTS: Of the 17 false positive transfers, ten (58.8%) were suspected Type A dissection and seven (41.2%) were suspected Type B dissection. The initial hospital diagnosis in 15 (88.2%) patients was made by a computed tomography (CT) scan and 10 (66.6%) of these patients required repeat imaging with an ECG-synchronized CT to definitively rule out AAS. Five (29.4%) patients had prior history of open or endovascular aortic repair. Overall in-hospital mortality was 9.3%. CONCLUSIONS: The diagnosis of AAS is confirmed in most patients emergently transferred for suspected AAS. False positive activation in this setting is driven primarily by uncertainty secondary to motion-artifact of the ascending aorta and the presence of complex anatomy following prior aortic intervention. Network-wide standardization of imaging strategies, and improved sharing of imaging may further improve triage of this complex patient population.

Recent advances in treatment of acute coronary syndromes.

In this manuscript we highlight recent advances in the management of acute coronary syndromes. Efforts to minimize myocardial ischemia time through improved health care systems have resulted in significant success. In addition, new evidence in the areas of reperfusion therapy and pharmacological intervention has emerged. Percutaneous coronary intervention continues to evolve and new data concerning the superiority of the radial route, the use of improved stents and adjunctive therapy will be presented. We will highlight the changes that were made in international guidelines (from the American College of Cardiology/American Heart Association and the European Society of Cardiology) in the last 18 months in order to incorporate the latest evidence. Although significant advancements have been made in the management of acute coronary syndromes, the morbidity and mortality associated with this condition remains high, necessitating continued research in this field of cardiovascular medicine.

Depth of tumor invasion better predicts prognosis than the current American Joint Committee on Cancer T classification for distal bile duct carcinoma.

BACKGROUND: The American Joint Committee on Cancer (AJCC) T classification system for cholangiocarcinoma does not take into account the unique pathologic features of the bile duct. As such, the current AJCC T classification for distal cholangiocarcinoma may be inaccurate. METHODS: A total of 147 patients with distal cholangiocarcinoma were identified from a single institution database. The prognostic importance of depth of tumor invasion relative to the AJCC T classification system was assessed. RESULTS: The AJCC T classification was T1 (n = 11, 7.5%), T2 (n = 6, 4.1%), T3 (n = 73, 49.7%), or T4 (n = 57, 38.8%). When cases were analyzed according to depth of tumor invasion, most lesions were > or =5 mm (<5 mm, 9.5%; range, 5-12, 51.0%; >12 mm, 39.5%). The AJCC T classification was not associated with survival outcome (median survival, T1, 40.1 months; T2, 14.8 months; T3, 16.5 months; T4, 20.2 months; P = .17). In contrast, depth of tumor invasion was associated with a worse outcome as tumor depth increased (median survival, <5 mm, not reached; range, 5-12, 28.9 months; >12 mm, 12.9 months; P = .001). On multivariate analyses, tumor depth remained the factor most associated with outcome (<5 mm; hazard ratio [HR] = referent vs 5-12 mm; HR = 3.8 vs >12 mm; HR = 6.7 mm; P = .001). CONCLUSION: The AJCC T classification for distal cholangiocarcinoma does not accurately predict prognosis. Depth of the bile duct carcinoma invasion is a better alternative method to determine prognosis and should be incorporated into the pathologic assessment of resected distal cholangiocarcinoma.

Giant cystic lymphangioma of the middle mediastinum.

A middle-aged male presenting with complaint of progressively increasing dysphagia was found to have a large cystic mass lesion in the middle mediastinum on evaluation. A diagnosis of an endo-duplication cyst was considered after exploration, in view of infiltration of the muscular layer of the lower thoracic esophagus, presence of multiple hyperemic nodular lesions on its inner surface and its location in the middle mediastinum. However, the histopathology revealed the lesion to be a cystic lymphangioma.