Adoption and patterns of use of invasive physiological assessment of coronary artery disease in a large cohort of 40821 real-world procedures over a 12-year period.

INTRODUCTION AND OBJECTIVES: Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame. METHODS: We retrospectively determined the per-procedure prevalence of physiological assessment in 40821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed. RESULTS: Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages <40, 40-55 and >55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology. CONCLUSIONS: Our study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes.

Adoption and patterns of use of invasive physiological assessment of coronary artery disease in a large cohort of 40821 real-world procedures over a 12-year period.

INTRODUCTION AND OBJECTIVES: Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame. METHODS: We retrospectively determined the per-procedure prevalence of physiological assessment in 40821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed. RESULTS: Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages <40, 40-55 and >55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology. CONCLUSIONS: Our study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes.

A reversible cause of left ventricular dysfunction: Case report and brief review.

The authors describe a case of a patient admitted to the emergency department with diabetic ketoacidosis. Although there were no symptoms attributable to the cardiovascular system, lab tests revealed elevated troponin I and natriuretic peptides, coupled with repolarization abnormalities on the ECG. The transthoracic echocardiogram (TTE) showed a non-dilated left ventricle with severe left ventricular systolic dysfunction due to diffuse hypokinesia, and a concomitant diagnosis of profile L heart failure was proposed. Etiologic investigation was negative, and when a new TTE was performed seven days after the first, left ventricular function was normal. Although rarely considered, metabolic and electrolyte disorders, especially diabetic ketoacidosis, can be a cause of left ventricular systolic dysfunction, and should be considered in the differential diagnosis. This is another way diabetes can have an impact on the cardiovascular system.

Maternal ingestion of cocoa causes constriction of fetal ductus arteriosus in rats.

Maternal consumption of polyphenol-rich foods has been associated with fetal ductus arteriosus constriction (DAC), but safety of chocolate exposure in fetal life has not been studied. This experimental study tested the hypothesis that maternal cocoa consumption in late pregnancy causes fetal DAC, with possible associated antioxidant effects. Pregnant Wistar rats, at the 21st gestational day, received by orogastric tube cocoa (720 mg/Kg) for 12 h, indomethacin (10 mg/Kg), for 8 h, or only water, before cesaren section. Immediately after withdrawal, every thorax was obtained and tissues were fixed and stained for histological analysis. The ratio of the narrowest part of the pulmonary artery to the fetal ductus inner diameter and increased ductal inner wall thickness characterized ductal constriction. Substances reactive to thiobarbituric acid were quantified. Statistical analysis used ANOVA and Tukey test. Cocoa (n = 33) and indomethacin (n = 7) reduced fetal internal ductus diameter when compared to control (water, n = 25) (p < 0.001) and cocoa alone increased ductus wall thickness (p < 0.001), but no change was noted in enzymes activity. This pharmacological study shows supporting evidences that there is a cause and effect relationship between maternal consumption of cocoa and fetal ductus arteriosus constriction. Habitual widespread use of chocolate during gestation could account for undetected ductus constriction and its potentially severe consequences, such as perinatal pulmonary hypertension, cardiac failure and even death. For this reason, dietary guidance in late pregnancy to avoid high chocolate intake, to prevent fetal ductal constriction, may represent the main translational aspect of this study.

A reversible cause of left ventricular dysfunction: Case report and brief review. / Uma causa reversível de disfunção ventricular esquerda: caso clínico e breve revisão.

The authors describe a case of a patient admitted to the emergency department with diabetic ketoacidosis. Although there were no symptoms attributable to the cardiovascular system, lab tests revealed elevated troponin I and natriuretic peptides, coupled with repolarization abnormalities on the ECG. The transthoracic echocardiogram (TTE) showed a non-dilated left ventricle with severe left ventricular systolic dysfunction due to diffuse hypokinesia, and a concomitant diagnosis of profile L heart failure was proposed. Etiologic investigation was negative, and when a new TTE was performed seven days after the first, left ventricular function was normal. Although rarely considered, metabolic and electrolyte disorders, especially diabetic ketoacidosis, can be a cause of left ventricular systolic dysfunction, and should be considered in the differential diagnosis. This is another way diabetes can have an impact on the cardiovascular system.

Concomitant pulmonary embolism and aortic dissection: approach to anticoagulation. / Tromboembolismo pulmonar e disseção da aorta concomitantes: abordagem à anticoagulação.

The authors describe a case of a patient admitted with a pre-syncopal episode and precordial discomfort, and whose cardiac ultrasound performed in the Emergency Room was suggestive of Pulmonary Embolism. The patient was submitted to fibrinolytic therapy after cardiac arrest. The computerized tomography done after this episode not only confirmed the presence of pulmonary embolism but had also shown a Stanford Type B Aortic Dissection. The option was to maintain the therapeutic anticoagulation, having the patient evolved favourably.

Acute coronary syndrome of paradoxical origin.

We describe a rare case of acute myocardial infarction secondary to paradoxical embolism complicating acute pulmonary embolism. A 44-year-old woman presented to the emergency department with chest pain. The physical examination was unremarkable except for oxygen saturation of 75%, and the electrocardiogram showed ST-segment elevation in the inferior leads. Urgent coronary angiography showed a distal occlusion of the right coronary artery and multiple thrombi were aspirated. Despite relief of chest pain and electrocardiogram normalization, her oxygen saturation remained low (90%) with high-flow oxygen by mask. The transthoracic echocardiogram showed a mass in the left atrium and dilatation of the right chambers, while the transesophageal echocardiogram showed a thrombus attached to the interatrial septum in the region of the foramen ovale. Color flow imaging was consistent with a patent foramen ovale. Thoracic computed tomography angiography documented thrombi in both branches of the pulmonary trunk. After five days on anticoagulation, the patient underwent surgical foramen ovale closure.

[A rare form of acute pulmonary edema: case report]. / Forma rara de edema pulmonar agudo: a propósito de um caso clínico.

We report the case of a 21-year-old man who underwent appendectomy under general anesthesia and developed acute pulmonary edema immediately after extubation. We then review the literature, focusing on the pathophysiology and the most important aspects of diagnosis and treatment of post-extubation pulmonary edema.

Applications of computed tomography and magnetic resonance imaging in percutaneous ablation therapy for atrial fibrillation.

Percutaneous catheter ablation is an established therapy for symptomatic drug-refractory atrial fibrillation (AF). Accurate delineation of relevant anatomy is critical but often challenging and limited in traditional technologies such as intra-procedural fluoroscopy. There has been an increased interest in non-invasive three-dimensional imaging technologies, especially computed tomography (CT) and magnetic resonance imaging (MRI), as useful tools for patients undergoing AF ablation. Here, we review applications of CT and MRI before, during, and after AF ablation and highlight areas for future research.

Combined myocardial infarction: two case reports.

Combined myocardial infarction is defined as a current of injury on the electrocardiogram in both inferior and anterior leads. From a pathophysiological standpoint, this indicates simultaneous acute transmural ischemia of contralateral vascular territories. The authors present the cases of two patients admitted with this rare type of infarction, followed by a discussion of the relationship between electrocardiographic and angiographic findings and their value for assessing prognosis in this clinical entity.

Left ventricular noncompaction: case report and literature review.

Isolated left ventricular noncompaction (ILVNC) is a rare cause of dilated cardiomyopathy. It is morphologically characterized by a spongy left ventricle with prominent myocardial trabeculations. Although not proven, it is nowadays widely accepted that ILVNC results from arrest of the normal myocardial compaction process during early embryonic life. ILVNC can occur in a familial form and certain genes coding proteins linking the extracellular matrix and the cytoskeleton have been related to this disorder. Clinically, the disease courses with heart failure, embolic and arrhythmic events being a common cause of morbidity and mortality. Current diagnostic criteria for ILVNC are based on clinical and echocardiographic data. Therapy is based on current heart failure guidelines, with particular emphasis on anticoagulation and prevention of fatal arrhythmias. The authors describe the case of a 29-year-old man admitted to the Cardiology Department with decompensated heart failure (NYHA IV), a dilated left ventricle with severe systolic dysfunction, an apical thrombus and highly trabeculated walls. Clinical evolution was favorable after standard pharmacologic therapy for heart failure and levosimendan, the patient being discharged in NYHA class I-II. Eighteen months later, despite partial recovery of left ventricular systolic function, the patient suffered sudden death. A review and discussion of the literature presented regarding etiopathogenesis, diagnostic criteria and therapeutic options.

Ischemic stroke complicating cardiac catherization: case report.

Ischemic stroke occurs in 0.2-0.4% of patients undergoing left heart catheterization, and is responsible for 5-10% of the mortality associated with the procedure. The main predisposing factors for this complication are female gender, complex atherosclerotic plaques in the ascending aorta, and peripheral arterial disease. The possibility of timely intervention with reperfusion therapy supports close clinical monitoring during the immediate post-catheterization period. The cardiologist should be familiar with the various types of stroke reperfusion therapy and its indications according to the time interval between catheterization and the stroke. The decision should be discussed with neurology and neuroradiology.

Intraventricular thrombi with systemic embolization: two clinical cases.

Ventricular thrombi are a frequent complication of dilated cardiomyopathy and acute myocardial infarction, with variable risk of embolization according to the clinical setting and thrombus morphology. The authors report two cases of patients admitted on the same day for acute myocardial infarction and dilated cardiomyopathy respectively, with high embolic risk left ventricular thrombi that embolized to the lower limbs after admission. Echocardiography, considered the gold standard diagnostic tool for intraventricular thrombi, is also the mainstay of embolic risk evaluation, for characterizing their size, mobility and echostructure. In the absence of evidence-based guidelines, management options--anticoagulation therapy, thrombolysis or thrombectomy--must be decided according to each specific case, taking account of embolic, bleeding and surgical risk.