Effect of transitioning from conventional cardiac troponin to high-sensitivity cardiac troponin on resource utilization- a single center experience.

BACKGROUND: Compared to conventional cardiac troponin (cTn), the high-sensitivity cardiac troponin (hs-cTn) assay is associated with improved detection of myocardial infarction (MI). METHODS: We performed a descriptive retrospective analysis of resource utilization at Rush University Medical Center over the transition period (July 1, 2021) from a cTn to a hs-cTn assay. Inclusion criteria included emergency department (ED) encounters between January 1 to December 31, 2021, with chief complaints of "chest pain" or "dyspnea" with associated troponin orders. The primary endpoint was the percentage of ED discharges. Secondary endpoints included the number of cardiac studies ordered. Univariable comparisons of these endpoints were performed using Student's t-test for continuous variables and Chi-square tests for binary/categorical variables. RESULTS: A total of 5113 encounters were analyzed. Hs-cTn was associated with an overall increase in ED patient discharges with negative troponin tests (44.1% vs. 29.9%, P < 0.01). In terms of cardiac testing per encounter, hs-cTn was associated with significant increases in the number of troponin tests (1.9 vs. 1.6, P < 0.01), electrocardiograms (3.0 vs. 2.9, P = 0.01), and echocardiograms (0.5 vs. 0.4, P < 0.01). There was a significant decrease in the utilization of stress testing (0.21 vs. 0.26, P < 0.01). There was a significant increase in total coronary angiography use during the hs-cTn period compared to cTn (227/2471 (9.2%) vs. 195/2642 (7.4%), P = 0.02). CONCLUSION: Transitioning from cTn to hs-cTn was associated with significantly increased ED discharges and an increase in troponin tests, ECG, echocardiograms, and coronary angiograms. There was a decrease in the number of stress tests.

Comparison of intravascular ultrasound, optical coherence tomography, and conventional angiography-guided percutaneous coronary interventions: A systematic review, network meta-analysis, and meta-regression.

BACKGROUND: Intracoronary imaging modalities, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), provide valuable supplemental data unavailable on coronary angiography (CA) and have shown to improve clinical outcomes. We sought to compare the clinical efficacy of IVUS, OCT, and conventional CA-guided percutaneous coronary interventions (PCI). METHODS: Frequentist and Bayesian network meta-analyses of randomized clinical trials were performed to compare clinical outcomes of PCI performed with IVUS, OCT, or CA alone. RESULTS: A total of 28 trials comprising 12,895 patients were included. IVUS when compared with CA alone was associated with a significantly reduced risk of major adverse cardiovascular events (MACE) (risk ratio: [RR] 0.74, 95% confidence interval: [CI] 0.63-0.88), cardiac death (RR: 0.64, 95% CI: 0.43-0.94), target lesion revascularization (RR: 0.68, 95% CI: 0.57-0.80), and target vessel revascularization (RR: 0.64, 95% CI: 0.50-0.81). No differences in comparative clinical efficacy were found between IVUS and OCT. Rank probability analysis bestowed the highest probability to IVUS in ranking as the best imaging modality for all studied outcomes except for all-cause mortality. CONCLUSION: Compared with CA, the use of IVUS in PCI guidance provides significant benefit in reducing MACE, cardiac death, and revascularization. OCT had similar outcomes to IVUS, but more dedicated studies are needed to confirm the superiority of OCT over CA.

Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks. METHODS: We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time. RESULTS: A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement. CONCLUSIONS: TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.

Transcatheter aortic valve implantation (TAVI) was associated with increased all-cause mortality at longer periods of follow-up irrespective of surgical risk. Aortic regurgitation, paravalvular regurgitation, major vascular complications, and pacemaker placement favoured surgical aortic valve replacement (SAVR) over TAVI. TAVI remained superior to SAVR in major bleeding and renal failure events. Long-term data on newer generation valves and up-to-date implantation techniques may provide better durability and improved outcomes after TAVI.

Gender Disparities after Transcatheter Aortic Valve Replacement with Newer Generation Transcatheter Heart Valves: A Systematic Review and Meta-Analysis.

Previous studies have demonstrated gender disparities in mortality and vascular complications after transcatheter aortic valve replacement (TAVR) with early generation transcatheter heart valves (THVs). It is unclear, however, whether gender-related differences persist with the newer generation THVs. We aim to assess gender disparities after TAVR with newer generation THVs. The MEDLINE and Embase databases were thoroughly searched from inception to April 2023 to identify studies that reported gender-specific outcomes after TAVR with newer generation THVs (Sapien 3, Corevalve Evolut R, and Evolut Pro). The outcomes of interest included 30-day mortality, 1-year mortality, and vascular complications. In total, 5 studies (4 databases) with a total of 47,933 patients (21,073 females and 26,860 males) were included. Ninety-six percent received TAVR via the transfemoral approach. The females had higher 30-day mortality rates (odds ratio (OR) = 1.53, 95% confidence interval (CI) 1.31-1.79, p-value (p) < 0.001) and vascular complications (OR = 1.43, 95% CI 1.23-1.65, p < 0.001). However, one-year mortality was similar between the two groups (OR = 0.78, 95% CI 0.61-1.00, p = 0.28). The female gender continues to be associated with higher 30-day mortality rates and vascular complications after TAVR with newer generation transcatheter heart valves, while there was no difference in 1-year mortality between the genders. More data is needed to explore the causes and whether we can improve TAVR outcomes in females.

AngioVac debulking of a tricuspid valve mass following complex lead extraction in a rare case of Austrian syndrome: a case report.

Background: The European Society of Cardiology recommends surgical valvular intervention in right-sided infective endocarditis for persistent vegetations >20 mm after recurrent pulmonary emboli, infection with a difficult-to-eradicate organism with >7 days of persistent bacteraemia, or tricuspid regurgitation causing right-sided heart failure. In this case report, we discuss the role of percutaneous aspiration thrombectomy for a large tricuspid valve (TV) mass as an alternative to surgery due to poor surgical candidacy in a patient with Austrian syndrome, following a complex implantable cardioverter defibrillator (ICD) device extraction. Case summary: A 70-year-old female presented to the emergency department after being found acutely delirious at home by family. Infectious workup was notable for growth of Streptococcus pneumoniae in the blood, cerebrospinal, and pleural fluid. Transoesophageal echocardiogram was pursued in the setting of bacteraemia and revealed a mobile mass on the TV consistent with endocarditis. Given the size and embolic potential of the mass and eventual need for ICD replacement, the decision was made to pursue extraction of the valvular mass. The patient was a poor candidate for invasive surgery, so we opted to perform percutaneous aspiration thrombectomy. After the ICD device was extracted, the TV mass was successfully debulked using the AngioVac system without complication. Discussion: Percutaneous aspiration thrombectomy of right-sided valvular lesions has been introduced as a minimally invasive approach to avoid or delay valvular surgery. When intervention is indicated for TV endocarditis, AngioVac percutaneous thrombectomy may be a reasonable operative approach, particularly in patients who are at high risk for invasive surgery. We report a case of successful AngioVac debulking of a TV thrombus in a patient with Austrian syndrome.

Bacterial Culture-Negative Acute Infective Endocarditis With Vegetation in Native Bicuspid Aortic Valve.

A 51-year-old male with a past medical history of bicuspid aortic valve, hypertension, and anterior cerebral artery stroke of unclear etiology three months earlier, presented to the Emergency Department with progressive shortness of breath, hemoptysis, and night sweats. The patient's echocardiogram revealed a mobile mass greater than 1.0 cm in diameter on the bicuspid aortic valve, which was not present on the echocardiogram three months prior, during his stroke workup. Per modified Duke's criteria, this patient was found to have 'definite' infective endocarditis despite persistently negative blood cultures. The patient underwent urgent surgical aortic valve replacement and a ventricular septal defect was noted that was not seen on prior imaging. The patient was discharged on intravenous antibiotics and warfarin. The patient was able to return to his normal functional status weeks after surgery, and is continuing to exercise without limitation. This case provides an example of patients with bicuspid aortic valves having an increased propensity for developing infective endocarditis. While also highlighting the interesting intra-operative images and presentation of acute culture-negative endocarditis with vegetation, and the subsequent repair, treatment, and recovery.

Aspiration of Right Sided Intracardiac Masses in High-Risk Surgical Patients Using AngioVac: A Case Series and Review of Literature.

Management of large right heart thrombi and vegetations is challenging. Medical management may be insufficient to prevent embolization or treat infection. Surgery carries a high mortality and is often not an option for these patients with multiple comorbidities. We present a case series of four patients describing percutaneous aspiration thrombectomy with AngioVac device as a safe and effective treatment for high-risk patients with right heart thrombi or tricuspid valvular vegetations. Indexing words.

Network Meta-Analysis Comparing Angiotensin Receptor-Neprilysin Inhibitors, Angiotensin Receptor Blockers, and Angiotensin-Converting Enzyme Inhibitors in Heart Failure With Reduced Ejection Fraction.

The superiority of angiotensin receptor-neprilysin inhibitor (ARNI) over angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) has not been reassessed after the publication of recent trials that did not find clinical benefits. Therefore, we performed an updated network meta-analysis comparing the efficacy and safety of ARNI, ACE-I, ARB, and placebo in heart failure with reduced ejection fraction. We included randomized clinical trials that compared ARNI, ARB, ACE-I, and placebo in heart failure with reduced ejection fraction. We extracted prespecified efficacy end points and produced network estimates, p scores, and surface under the cumulative ranking curve scores using frequentist and Bayesian network meta-analysis approaches. A total of 28 randomized controlled trials including 47,407 patients were included. ARNI was associated with lower risk of all-cause mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68 to 0.96), cardiac death (RR 0.79, 95% CI 0.64 to 0.99), and major adverse cardiac events (MACEs; RR 0.83, 95% CI 0.72 to 0.97) but higher risk of hypotension (RR 1.46, 95% CI 1.02 to 2.10) than ARB. ARNI was associated with lower risk of MACE (RR 0.85, 95% CI 0.74 to 0.97), but higher risk of hypotension (RR 1.69, 95% CI 1.27 to 2.24) compared with ACE-I. P scores and surface under the cumulative ranking curve scores demonstrated superiority of ARNI over ARB and ACE-I in all-cause mortality, cardiac death, MACE, and hospitalization for heart failure. In conclusion, ARNI was associated with improved clinical outcomes, except for higher risk of hypotension, compared with ARB and ACE-I.

Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention.

Background Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive. Methods and Results Extensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta-analysis produced pooled relative risk (RR) and 95% CI of 2-stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta-analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta-analysis showed no significant differences in all-cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2-stent techniques and provisional stenting. Frequentist network meta-analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38-0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39-0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39-0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28-0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2-stent techniques, including T-stent or T and protrusion, dedicated bifurcation stent, and culotte. Conclusions Double kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2-stent techniques. Superiority of 2-stent strategy over provisional stenting was observed in subgroup meta-analysis stratified to side branch lesion length ≥10 mm.

Concise Review of the Rationale for Pulmonary Embolism Treatment and Endovascular Device Therapies.

In the ever-changing landscape of device therapy for pulmonary embolism, it is important to understand the rationale behind the ongoing explosion in the development of new device therapies. There needs to be an in-depth understanding of risk stratification in pulmonary embolism and indications for therapy. Selecting the ideal device for a particular pulmonary embolism subset remains elusive and poorly defined. Knowledge of the risks, benefits, capabilities, and potential limitations of each device is crucial.

Thrombolysis for Cardiogenic Shock Secondary to Aortic Bioprosthetic Valve-in-Valve Thrombosis.

Valvular obstruction and thromboembolism are feared complications of bioprosthetic valve thrombosis. We describe the case of an 81-year-old man with a prior aortic valve-in-valve bioprosthesis who presented in cardiogenic shock, requiring mechanical circulatory support. He was found to have acute bioprosthetic valve thrombosis and was treated with systemic thrombolysis. This case highlights the overall uncertainty regarding the optimal treatment of acute bioprosthetic valve thrombosis. Society guidelines and the current evidence behind prophylaxis and treatment are reviewed. Although the data remain sparse, systemic thrombolysis may be an effective strategy in critically ill patients who are poor surgical candidates.

The clot thickens: role of mechanical thrombectomy in intermediate to high-risk pulmonary embolism in the peri-operative setting-a case report.

BACKGROUND: European Society of Cardiology (ESC) recommends catheter-directed thrombectomy for management of high-risk pulmonary embolism (PE) with contraindications to thrombolytics or in patients that have failed thrombolytic therapy, as well as intermediate-risk PE with haemodynamic deterioration. In this case report, the role of catheter-directed mechanical thrombectomy is highlighted in the urgent peri-operative setting. CASE SUMMARY: A 71-year-old female presented with 10 days of progressive lower extremity weakness and was found to have malignant cord compression along with incidental saddle, intermediate-high-risk PE that extended to all lobes on chest computed tomography. Given the intermediate to high-risk PE with acute cor pulmonale, urgent need for surgery, and risk of haemodynamic collapse upon induction of general anaesthesia, the decision was made to proceed with urgent percutaneous treatment of the PE. Percutaneous catheter-directed thrombectomy was successfully performed. The patient returned to the intensive care unit in stable condition and was able to then receive urgent cord decompression and further treatment for malignancy with no complication. DISCUSSION: In this case, single-session thrombectomy resulted in rapid reduction of pre-operative cardiopulmonary risk by alleviating the right ventricular strain, allowing urgent cord decompression surgery to proceed with optimized haemodynamics, no bleeding events, and no further oxygen requirements. While peri-operative risk stratification for cardiovascular outcomes is well established in current guidelines, there are no clear guidelines for peri-operative risk stratification in the setting of pulmonary embolism. The importance of the multidisciplinary PE Response Team is thus emphasized, as well as the importance of continuous evaluation of clinical decompensation in PE.

Catheter-Directed Thrombectomy for Pulmonary Embolism in the Setting of Acute Stroke.

A 79-year-old male presented with an acute stroke and was treated with tissue plasminogen activator (tPA). His neurological symptoms improved, but he subsequently developed hemodynamic instability requiring intubation and vasopressors. Imaging studies revealed a massive pulmonary embolism as the cause of his worsening clinical picture. Mechanical thrombectomy using traditional devices was deemed too risky as the patient could not safely tolerate the usual anticoagulation dosage these devices require. The Penumbra Indigo® system (Alameda, CA, USA) was thus chosen for its ability to achieve thrombus aspiration within a lower therapeutic heparin range. Pulmonary artery aspiration thrombectomy was done using the device, and three days after the procedure, he was extubated and weaned completely off vasopressors. The therapy's efficacy despite the patient's unique life-threatening conditions demonstrates a novel application of the state-of-the-art pulmonary embolism treatment currently in research.

Therapeutic angiogenesis for the management of refractory angina: current concepts.

The optimal treatment of coronary artery disease (CAD) involves reducing the ischemic burden, lowering the risk of future adverse cardiac events, and relieving symptoms of angina pectoris. Medical and mechanical therapies have played a major role in reducing the morbidity and mortality associated with ischemic heart disease. Despite the success of these conventional therapies, there are patients with CAD who continue to experience angina despite maximal medical and revascularization therapy. Therapeutic angiogenesis represents a novel treatment option for these "no-option" patients with refractory ischemic coronary disease. A growing body of evidence has demonstrated the therapeutic potential of therapeutic angiogenesis with gene, protein, or cell-based therapies. The goal of therapeutic angiogenesis is to induce the formation of new vessels that can enhance blood flow to areas that no longer have adequate blood supply. While the existing data are not definitive, there is reason to be optimistic, as several studies have suggested a clinical benefit. This review focuses on the current state of therapeutic angiogenesis in the management of the "no-option" patient with refractory angina.

The effect of ethnicity on the relationship between premature coronary artery disease and traditional cardiac risk factors among uninsured young adults.

Prior studies of premature coronary artery disease (CAD) in young adults did not address the association of race/ethnicity and risk factors. Therefore, the authors conducted a study of 400 patients 40 years and older undergoing coronary angiography at a large, urban public hospital that serves predominantly minority, uninsured populations. The prevalence of risk factors and their association with premature CAD varied markedly by ethnic group. Among blacks, dyslipidemia, diabetes, and smoking were independently associated with premature CAD. Among Hispanics, dyslipidemia, male sex, and family history of CAD were independently associated with premature CAD. Smoking was the only risk factor in whites, and no independent risk factor was identified in Asian Indians. Whites and Asian Indians had a higher prevalence of disease than blacks or Hispanics--before and after adjusting for risk factor imbalances across ethnic groups. In this ethnically diverse population, the authors' findings underscore the importance of identifying distinctive risk factors in various ethnic groups.

Therapeutic angiogenesis in the management of critical limb ischemia: current concepts and review.

Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease. Manifestations of CLI include rest pain, ischemic ulcers, and/or gangrene. The presence of CLI frequently leads to amputation, and furthermore, patients with CLI are at an increased risk of cardiovascular events including death. Treatment options for CLI when revascularization is not possible are extremely limited. Therapeutic angiogenesis is a promising new tool in the management of CLI. There is a growing body of evidence demonstrating the safety and efficacy of therapeutic angiogenesis with gene and cell therapy. Many factors must be considered in formulating clinically efficacious gene and/or cell therapies. The dosing regimen, route of delivery, and choice of growth factor or cell population must be decided. Although the optimal regimen of therapeutic angiogenesis has yet to be identified, building on the knowledge gained from the early pioneering studies may help to identify the best combination.

Erosion of an extrapericardial implantable cardioverter defibrillator patch through the gastric fundus with fistulous tract formation.

Until as recently as the mid-1990s, implantable cardioverter defibrillator (ICD) leads were placed through thoracotomy as anterior and/or posterolateral patches. The defibrillator patches have reportedly been associated with a number of relatively common mechanical complications as well as less common complications, including patch migration or erosion into contiguous structures. We report a previously unreported late complication of epicardial defibrillator patch placement in which patch migration and erosion through the gastric fundus resulted in fistulous tract formation from the mediastinum to the lumen of the stomach. Although surgically implanted epicardial patch defibrillator systems are relatively uncommon in current U.S. practice, these devices are still used when specific anatomic or electrophysiological considerations preclude the use of more common endocardial lead systems. Several thousand patients with epicardial patch leads in place are still believed to be alive in the United States. In these patients, continued vigilance for lead-related complications is appropriate. Prompt surgical intervention is usually warranted when patch migration or complications such as the one described occur.