Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team.

BACKGROUND: Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients. METHODS: We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay. RESULTS: The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes. CONCLUSION: Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.

An algorithm for pacing and cardioverting electronic devices undergoing magnetic resonance imaging: The PACED-MRI protocol.

OBJECTIVE: Cardiac implantable electronic devices (CIEDs) have traditionally been a contraindication for magnetic resonance imaging (MRI). However, there is an increasing amount of literature to suggest that MRI can be safely performed in select patients with pacemakers and implantable cardioverter defibrillators by following a standardized protocol. We created an institutional protocol, made accessible as an online form, that is primarily technologist-driven and does not require direct electrophysiologist supervision. The purpose of this study was to evaluate the PACEDMRI protocol for screening and completing MRI in patients with MR conditional CIEDs. SUBJECTS AND METHODS: After the implementation of our standardized PACED-MRI protocol, patients with MR conditional CIEDs who were referred for MRI were included in the study. On the day of the MRI, the device company representative utilized our protocol accessed through PACEDMRI.com. If all parameters and criteria within the protocol were met, the examination proceeded. The device representative programed the CIED to the appropriate mode for MRI as instructed by the PACED-MRI protocol. CIED interrogation was performed immediately before and after MRI. The on-call electrophysiology nurse practitioner was notified only if the protocol instructed the team to not proceed with MRI. CIED programming changes, malfunctions, and intraprocedural events were documented. Additionally, any adverse outcomes were recorded including peri-MRI symptom onset, arrhythmia, and death. RESULTS: One hundred thirty-eight MRI examinations were performed on patients with MR conditional CIEDs (100 pacemakers: 38 implantable cardiac defibrillators). There was no incidence of symptom onset requiring early termination of the MRI, death, or arrhythmic events during or after MRI. No significant changes in lead parameters, including sensing amplitudes, lead thresholds, or lead impedances were noted on post-MRI device interrogation. Out of the 138 completed MRIs, the on-call electrophysiology provider was notified on one, non-urgent occasion. CONCLUSION: The implementation of the standardized, technologists-driven PACED-MRI protocol allowed for a multidisciplinary approach to MRI for patients with MR conditional CIEDs. This study demonstrates that the PACED-MRI protocol can be used for patients with MR conditional CIEDs undergoing MRI without the need for direct electrophysiologist supervision.

Hemophagocytic lymphohistiocytosis secondary to disseminated histoplasmosis, cytomegalovirus viremia, and nontuberculous mycobacteria bacteremia in a patient with recently diagnosed AIDS.

A 30-year-old Honduran male with recently diagnosed AIDS presented with a 1-month history of worsening abdominal pain, diarrhea, and fever. Initial investigations were notable for Cytomegalovirus viremia and diffuse lymphadenopathy. Axillary lymph node biopsy demonstrated necrotizing lymphadenitis with disseminated histoplasmosis. Despite aggressive antimicrobial therapy he continued to clinically deteriorate raising suspicion for hemophagocytic lymphohistiocytosis. The patient met 5 of 8 HLH-2004 diagnostic criteria and was successfully treated with dexamethasone and etoposide per the HLH-94 protocol. Despite the high mortality rates and poor clinical outcomes of hemophagocytic lymphohistiocytosis in patients living with HIV/AIDS, this case demonstrates that this high-risk patient population can be successfully treated and survive acquired hemophagocytic lymphohistiocytosis. Furthermore, our case stresses the importance of maintaining a broad differential diagnosis in patients living with HIV/AIDS who present with sepsis.

Asymptomatic Aorto-Atrial Fistula Secondary to Surgical Repair of Ascending Aortic Dissection: When to Do Nothing.

Secondary aorto-atrial fistula is a rare but potentially life-threatening complication of ascending aortic dissection surgical repair. Secondary aorto-atrial fistulas commonly lead to symptomatic heart failure requiring emergent repair. We present a rare case of secondary aorto-atrial fistula after surgical repair of aortic dissection that remained asymptomatic for a decade. (Level of Difficulty: Intermediate.).

Comparison of Tricuspid Regurgitation Severity Between Cardiac Resynchronization Therapy Versus Right Ventricular Pacing in Patients With Chronic Obstructive Pulmonary Disease.

Background: Right ventricular (RV) lead placement can worsen tricuspid regurgitation (TR). TR is known to be associated with lower survival irrespective of left ventricular ejection fraction (LVEF) or pulmonary hypertension (PH). Patients with chronic obstructive pulmonary disease (COPD) often have PH and pre-existent TR with higher morbidity and mortality from worsening TR. Prior studies are lacking to indicate if cardiac resynchronization therapy (CRT) may be more beneficial in lessening TR in COPD patients. Therefore, we sought to study if patients with COPD will have less TR with CRT versus non-CRT devices. Methods: We performed a retrospective, single-center analysis on 154 COPD patients (mean age = 71.69 ± 10.58, males = 54.14%) that required single-chamber (n = 27), dual-chamber (n = 90), or CRT (n = 37) devices. TR severity, LVEF and right ventricular systolic pressure (RVSP) were evaluated by two cardiologists in a blinded fashion. Analysis of variance (ANOVA) and Chi-square tests were applied for continuous and categorical variables respectively. The primary endpoint was a change in the severity of TR comparing pre-device versus post-device echocardiogram. Secondary endpoints included changes in LVEF and RVSP. Results: COPD patients, who underwent a CRT device had a significantly lower incidence of worsening TR (16%) when compared to single- (37%) (P = 0.001) and dual-chamber devices (30%) (P = 0.02). The increase in RVSP was similar between the groups. There was an expected improvement in LVEF in the CRT group. Conclusions: COPD patients receiving a CRT device were least likely to have worsening TR, compared to single- or dual-chamber devices. Since both COPD and progression in TR may result in poor outcomes, our study may suggest that an upfront strategy of CRT rather than a single- or dual-chamber device may be more beneficial in COPD patients, especially with pre-existent TR.

Takotsubo Cardiomyopathy Secondary to Cryptococcal Meningoencephalitis in a Patient With Multiple Sclerosis.

Takotsubo or stress-induced cardiomyopathy is described as reversible left ventricular dysfunction that develops following a stressful emotional or physical event primarily occurring in postmenopausal females. Many physiologic triggers have been identified in the pathogenesis of Takotsubo cardiomyopathy, including diseases which affect the central nervous system such as traumatic brain injuries, hemorrhagic and ischemic strokes, epilepsy, and central nervous system infections, including meningitis and encephalitis; however, there are very few published case reports of Takotsubo cardiomyopathy in the setting of fungal meningoencephalitis. We present a unique case of Takotsubo cardiomyopathy secondary to Cryptococcus neoformans meningoencephalitis in a middle-aged female with a history of multiple sclerosis who was taking immunosuppressive therapy.

Prevotella bivia cardiac implantable electronic device related endocarditis.

Cases of Gram-negative, anaerobic rod bacteremia and endocarditis have been increasingly recognized in recent years. This increase has been primarily observed in patients at risk for polymicrobial infections, such as those who use injection drugs and patients with diabetes mellitus. Despite a growing incidence, there are few published case reports of cardiac implantable electronic device related endocarditis secondary to Gram negative, anaerobic organisms. We present a unique case of Prevotella bivia cardiac implantable electronic device related endocarditis in a middle-aged woman with no history of injection drug use. This case highlights the increasing incidence of polymicrobial infections and anaerobic endocarditis. Additionally, it demonstrates how Prevotella bivia has the potential to cause native valve infective endocarditis as well as cardiac implantable electronic device related endocarditis.

Pathophysiological factors contributing to fractional flow reserve and instantaneous wave-free ratio discordance.

The diagnostic accuracy and clinical benefits of instantaneous wave-free ratio (iFR) compared to fractional flow reserve (FFR) have been well-established in the literature. Despite the advantages of non-hyperemic pressure indices, approximately 20% of iFR and FFR measurements are discordant. Efforts have been made to establish the mechanisms as well as identify causative factors that lead to such a discordance. Recent studies have identified many factors of discordance including sex differences, age differences, bradycardia, coronary artery stenosis location, elevated left ventricular end-diastolic pressure, and diastolic dysfunction. Additionally, discordance secondary to coronary artery microcirculation dysfunction, as seen in diabetics and patients on hemodialysis, has sparked interest amongst experts. As more interventional cardiologists are utilizing iFR independent of FFR to guide percutaneous coronary intervention an emphasis has been placed on identifying factors leading to discordance. The aim of this review is to outline recent studies that have identified factors of FFR and iFR discordance.

Inferior Myocardial Infarction Secondary to Coronary Artery Vasospasm Following Regadenoson Stress Imaging.

Coronary artery vasospasm is a rare condition that is caused by hyperactive arterial smooth muscle vasoconstriction leading to reversible coronary artery occlusion. Patients that suffer from coronary artery vasospasm have the potential to develop life-threatening conditions such as myocardial infarction and fatal arrhythmias. ST-elevations are a rare complication that can occur in people with coronary vasospasm, and to the best of our knowledge there are no documented cases of ST-elevation myocardial infarction occurring in patients undergoing regadenoson stress test. We present a unique case of a patient with known coronary artery disease and catheter-induced coronary artery vasospasm who developed ST-segment elevations and typical angina immediately following the administration of regadenoson during an elective myocardial stress test.

Multi-organ system failure secondary to difluoroethane toxicity in a patient "huffing" air duster: a case report.

Inhalant misuse is a growing concern among Americans. According to recent reports by the National Institutes of Health and the Substance Abuse and Mental Health Services Administration, the prevalence of teenage inhalant misuse is increasing. Of the many household items that are "huffed", refrigerant-based propellant cleaners or air dusters, are one of the most misused. Although commonly referred to as "compressed air", refrigerant-based propellant cleaners contain harmful fluorinated hydrocarbons, such as 1,1-difluoroethane, that have significant toxic effects when inhaled. While the central nervous system is primarily affected, there are case reports of cardiovascular, renal, hepatic, and musculoskeletal injury secondary to 1,1-difluoroethane toxicity. However, there are few cases that have presented 1,1-difluoroethane toxicity leading to multi-organ system failure in adults with a long history of inhalant misuse. We present a unique case of multi-system organ failure secondary to 1,1-difluoroethane toxicity in a middle-aged female that was "huffing" a refrigerant-based propellant aerosol duster for more than three months. This case stresses the importance of obtaining a detailed social history to identify inhalant misuse in patients that present with acute illness of unknown etiology. This case also highlights the importance of early communication with toxicology professionals for treatment and supportive care recommendations in patients presenting the life-threatening 1,1-difluoroethane toxicity. Furthermore, this case demonstrates that 1,1-difluoroethane toxicity in the setting of "huffing" air duster has the potential to cause multi-organ system failure.

Use of the CHA2DS2-VASc Score in Assessing Transradial Approach Failure.

BACKGROUND: Radial access is now considered the preferred approach for coronary angiography and percutaneous coronary intervention because of the low risk of vascular complications. However, radial access failure is not uncommon, leading to crossover to a different access site. The CHA2DS2-VASc score is used to estimate stroke risk in patients with atrial fibrillation. Our study aimed to assess the CHA2DS2-VASc score in predicting failure of the transradial approach, resulting in crossover to transfemoral access (TFA) for coronary angiography. METHODS: We performed a single-center, non-randomized, retrospective study. The study included 1775 patients who underwent coronary angiography with or without subsequent percutaneous intervention between July 2018 and October 2019. The study population was divided into three groups based on the CHA2DS2-VASc score: low (≤2), intermediate (3-4), and high score (≥5) groups. The association between the CHA2DS2-VASc score and radial access failure was evaluated and compared between the groups. RESULTS: A total of 197 patients (11.1%) had crossover to the femoral artery. A large percentage of patients (19.2%) had radial access failure in the high CHA2DS2-VASc score group (≥5) compared with 12.5% in the intermediate score group (3-4) and only 6.3% in the low score group (≤2). The highest crossover rate (42.9%) was observed in patients with a CHA2DS2-VASc score of 8. Higher CHA2DS2-VASc scores were also associated with increased fluoroscopy time, contrast administration, and radiation exposure. CONCLUSION: The CHA2DS2-VASc score can predict failure of the transradial approach, with a score of ≥5 having the highest correlation of failure requiring crossover to TFA.

Comparison of Transcatheter Aortic Valve Implantation Outcomes Between Normal-Flow, Low-Gradient Severe Aortic Stenosis and Normal-Flow, High-Gradient Severe Aortic Stenosis.

BACKGROUND: Normal flow low gradient severe aortic stenosis (NFLG-AS) with preserved ejection fraction is the most prevalent form of low gradient severe aortic stenosis. Despite the increased prevalence, the clinical outcomes and management strategy of NFLG-AS remain controversial. Therefore, our study aimed to evaluate transcatheter aortic valve implantation (TAVI) outcomes of patients with NFLG-AS compared with normal flow high gradient severe aortic stenosis (NFHG-AS). METHODS: We performed a retrospective analysis of 394 patients who underwent TAVI between January 2011 to September 2020. Among 394 patients, 232 patients had NFLG-AS, and 162 patients had NFHG-AS. The primary outcomes included all-cause mortality and cardiovascular mortality. In addition, multiple secondary outcomes were evaluated, including stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, symptom improvement, and repeat hospitalizations due to any cardiac disease. RESULTS: The cumulative six months incidence of all-cause mortality and cardiovascular mortality were similar between and NFLG-AS and NFHG-AS (4.32% vs. 5.17%, P = 0.71 and 2.47% vs. 2.59%, P = 0.94 respectively). There was no difference in the rates of stroke, myocardial infarction, duration of hospital stay, new-onset atrial fibrillation, temporary or permanent pacemaker requirement, major bleeding, blood transfusion, vascular complications, acute kidney injury, hemodialysis requirement, and symptom improvement between the two groups. However, patients with NFLG-AS compared to NFHG-AS had more frequent cardiac-related repeat hospitalizations (19.14% vs. 11.64%, P = 0.04%). CONCLUSION: There was no significant difference in all-cause mortality and cardiovascular mortality between NFLG-AS and NGHG-AS six months post-TAVI. However, patients undergoing TAVI with NFLG-AS had significantly higher rates of cardiac-related repeat hospitalizations.

Iatrogenic Arteriovenous Fistula Secondary to Coronary Artery Dissection Caused by Contrast Injection Into a Chronically Occluded Right Coronary Artery.

Coronary arteriovenous fistulas and coronary cameral fistulas are rare anomalies that involve the abnormal communication between a coronary artery and a venous structure, such as a coronary vein or a right-sided cardiac chamber. Iatrogenic coronary arteriovenous fistulas and coronary cameral fistulas can be uncommon complications of coronary artery angiography and intervention. Acquired coronary arteriovenous fistulas that develop during percutaneous coronary intervention of chronic total occlusions have been previously reported in the literature. However, a coronary arteriovenous fistula resulting from contrast injection into a chronically and totally occluded right coronary artery during diagnostic coronary angiography is very rare. We present a unique case of a contrast-induced iatrogenic right coronary dissection leading to a coronary arteriovenous fistula communicating to the right atrium through the middle cardiac vein.

Association of Echocardiographic Diastolic Dysfunction with Discordance of Invasive Intracoronary Pressure Indices.

Instantaneous wave-free ratio (iFR)-guided coronary revascularization has similar clinical outcomes compared to fractional flow reserve (FFR)-guided revascularization strategy. However, some studies have shown a discordance of around 20% between iFR and FFR. Although various factors have been reported in the literature to affect pressure indices and lead to such discordance, there is a paucity of data regarding the effect of diastolic dysfunction on functional assessment of coronary arteries. Our study aimed to investigate whether there was an association between echocardiographic left ventricular diastolic dysfunction and iFR/FFR discordance. This retrospective observational study evaluated 100 patients with angiographically intermediate coronary stenosis (50-70%) who underwent physiological testing with iFR and FFR. Transthoracic echocardiograms were reviewed to assess echocardiographic indices of diastolic function. The study population was divided into two groups based on diastolic function. iFR and FFR discordance was measured in each group and compared to evaluate the statistical difference. The mean age of the study population was 66.22 ± 10.02 years. Discordance between iFR and FFR was seen in 45.16% of patients with diastolic dysfunction compared to 24.64% of patients with normal diastolic function (p = 0.04). Multivariable logistic regression analysis indicated that echocardiographic E/e' was independently associated with iFR/FFR discordance (p = 0.02). Left ventricular diastolic dysfunction is a significant factor that can lead to discordance between iFR and FFR and should be taken into account during coronary physiological testing.

Effect of Elevated Left Ventricular End Diastolic Pressure on Instantaneous Wave-Free Ratio and Fractional Flow Reserve Discordance.

BACKGROUND: Instantaneous wave-free ratio (iFR)-guided physiological assessment has been shown to be non-inferior to fractional flow reserve (FFR)-guided assessment for deciding best treatment strategy for angiographically intermediate stenosis. The diagnostic accuracy of iFR compared to FFR reported in various studies is around 80%. Many factors can lead to iFR/FFR discordance, though underlying physiological mechanism of discordance and its associated factors have not been fully evaluated. The effect of left ventricle end diastolic pressure (LVEDP) on iFR/FFR discordance is unknown and needs further evaluation. METHODS: We performed a single center, non-randomized, both retrospective and prospective study. A total of 65 patients with intermediate coronary stenosis undergoing physiological assessment were included in the study. Patients were assigned to two groups (normal LVEDP and high LVEDP group) based on LVEDP cutoff of 15 mm Hg. iFR and FFR were measured for each patient and iFR/FFR results were compared between the two groups. RESULTS: A significantly large number of patients in elevated LVEDP group had iFR/FFR discordance compared to normal LVEDP group (42.8% vs. 6.7%, P = 0.001). More patients with acute coronary syndrome (ACS) had discordance compared to stale coronary artery disease (CAD) patients (53% vs. 15%, P = 0.003). CONCLUSIONS: Elevated LVEDP can affect iFR and FFR measurements and can lead to discordance. Further studies are required to determine effect of elevated LVEDP on iFR/FFR discordance and whether such discordance is clinically relevant. "Normal range" iFR results should be cautiously interpreted in patients with elevated LVEDP, especially those with ACS.