A multidisciplinary approach for a patient with cardiogenic shock from pulmonary embolism with concomitant impending clot in transit trapped in PFO.

Impending paradoxical embolism (IPDE) is a right heart thrombus (RHT), in times of elevated pulmonary arterial pressure, that is trapped in a patent foramen ovale (PFO) Myers et al. (2010) (3). We present a case that highlights our multidisciplinary approach in a patient with IPDE with cardiogenic shock from pulmonary embolism (PE).

Initial Findings From the North American COVID-19 Myocardial Infarction Registry.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI). OBJECTIVES: The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI. METHODS: A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. RESULTS: As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients). CONCLUSIONS: COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.

Machine-Learning-Based In-Hospital Mortality Prediction for Transcatheter Mitral Valve Repair in the United States.

BACKGROUND: Transcatheter mitral valve repair (TMVR) utilization has increased significantly in the United States over the last years. Yet, a risk-prediction tool for adverse events has not been developed. We aimed to generate a machine-learning-based algorithm to predict in-hospital mortality after TMVR. METHODS: Patients who underwent TMVR from 2012 through 2015 were identified using the National Inpatient Sample database. The study population was randomly divided into a training set (n = 636) and a testing set (n = 213). Prediction models for in-hospital mortality were obtained using five supervised machine-learning classifiers. RESULTS: A total of 849 TMVRs were analyzed in our study. The overall in-hospital mortality was 3.1%. A naïve Bayes (NB) model had the best discrimination for fifteen variables, with an area under the receiver-operating curve (AUC) of 0.83 (95% CI, 0.80-0.87), compared to 0.77 for logistic regression (95% CI, 0.58-0.95), 0.73 for an artificial neural network (95% CI, 0.55-0.91), and 0.67 for both a random forest and a support-vector machine (95% CI, 0.47-0.87). History of coronary artery disease, of chronic kidney disease, and smoking were the three most significant predictors of in-hospital mortality. CONCLUSIONS: We developed a robust machine-learning-derived model to predict in-hospital mortality in patients undergoing TMVR. This model is promising for decision-making and deserves further clinical validation.

Sudden cardiac arrest as the initial presentation for left ventricular noncompaction cardiomyopathy.

A 37-year-old man without a significant medical history had an out-of-hospital sudden cardiac arrest. A bystander started cardiopulmonary resuscitation, and emergency medical services arrived promptly, confirmed ventricular fibrillation, and restored sinus rhythm. An emergent coronary arteriogram was normal. Transthoracic echocardiography revealed a severely reduced left ventricular ejection fraction and suggested left ventricular noncompaction. The patient's heart failure with reduced ejection fraction was treated with carvedilol, lisinopril, and spironolactone, and after he was weaned from the ventilator he received an implantable cardioverter-defibrillator. The patient's identical twin was treated in the same fashion for a sudden cardiac arrest. Although many experts think that left ventricular noncompaction cardiomyopathy is a distinct nosological entity, others think that it is simply a dilated cardiomyopathy with unusually prominent left ventricular trabeculae.

Machine Learning Prediction Models for In-Hospital Mortality After Transcatheter Aortic Valve Replacement.

OBJECTIVES: This study sought to develop and compare an array of machine learning methods to predict in-hospital mortality after transcatheter aortic valve replacement (TAVR) in the United States. BACKGROUND: Existing risk prediction tools for in-hospital complications in patients undergoing TAVR have been designed using statistical modeling approaches and have certain limitations. METHODS: Patient data were obtained from the National Inpatient Sample database from 2012 to 2015. The data were randomly divided into a development cohort (n = 7,615) and a validation cohort (n = 3,268). Logistic regression, artificial neural network, naive Bayes, and random forest machine learning algorithms were applied to obtain in-hospital mortality prediction models. RESULTS: A total of 10,883 TAVRs were analyzed in our study. The overall in-hospital mortality was 3.6%. Overall, prediction models' performance measured by area under the curve were good (>0.80). The best model was obtained by logistic regression (area under the curve: 0.92; 95% confidence interval: 0.89 to 0.95). Most obtained models plateaued after introducing 10 variables. Acute kidney injury was the main predictor of in-hospital mortality ranked with the highest mean importance in all the models. The National Inpatient Sample TAVR score showed the best discrimination among available TAVR prediction scores. CONCLUSIONS: Machine learning methods can generate robust models to predict in-hospital mortality for TAVR. The National Inpatient Sample TAVR score should be considered for prognosis and shared decision making in TAVR patients.

Racial/Ethnic Disparities in Patients Undergoing Transcatheter Aortic Valve Replacement: Insights from the Healthcare Cost and Utilization Project's National Inpatient Sample.

PURPOSE: To identify racial/ethnic disparities in utilization rates, in-hospital outcomes and health care resource use among Non-Hispanic Whites (NHW), African Americans (AA) and Hispanics undergoing transcatheter aortic valve replacement (TAVR) in the United States (US). METHODS AND RESULTS: The National Inpatient Sample database was queried for patients ≥18 years of age who underwent TAVR from 2012 to 2014. The primary outcome was all-cause in hospital mortality. A total of 36,270 individuals were included in the study. The number of TAVR performed per million population increased in all study groups over the three years [38.8 to 103.8 (NHW); 9.1 to 26.4 (AA) and 9.4 to 18.2 (Hispanics)]. The overall in-hospital mortality was 4.2% for the entire cohort. Race/ethnicity showed no association with in-hospital mortality (P > .05). Though no significant difference were found between AA and NHW in any secondary outcome, being Hispanic was associated with higher incidence of acute myocardial infarction (aOR = 2.02; 95% CI, 1.06-3.85; P = .03), stroke/transient ischemic attack (aOR = 1.81; 95% CI, 1.04-3.14; P = .04), acute kidney injury (aOR = 1.65; 95% CI, 1.23-2.21; P < .01), prolonged length of stay (aOR = 1.18; 95% CI, 1.08-1.29; P < .01) and higher hospital costs (aOR = 1.27; 95% CI, 1.18-1.36; P < .01). CONCLUSION: There are significant racial disparities in patients undergoing TAVR in the US. Though in-hospital mortality was not associated with race/ethnicity, Hispanic patients had less TAVR utilization, higher in-hospital complications, prolonged length of stay and increased hospital costs.

Crushed Prasugrel Tablets in Patients With STEMI Undergoing Primary Percutaneous Coronary Intervention: The CRUSH Study.

BACKGROUND: Platelet inhibitory effects induced by oral P2Y12 receptor antagonists are delayed in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI), which may be attributed to impaired absorption affecting drug pharmacokinetics (PK) and pharmacodynamics (PD). Crushing tablets has been suggested to lead to more favorable PK/PD profiles. To date, no studies have investigated the PK/PD effects of crushing prasugrel. OBJECTIVES: This study sought to determine whether crushing prasugrel is associated with more favorable drug bioavailability and platelet inhibitory effects compared with whole tablets in STEMI patients undergoing PPCI. METHODS: Our prospective, randomized, open-label study assessed STEMI patients undergoing PPCI (n = 52) who were treated with a prasugrel 60-mg loading dose (LD) either as whole or crushed tablets. PK/PD analyses were performed at 7 time points. PD effects were measured as P2Y12 reaction units and platelet reactivity index, and PK by plasma levels of prasugrel's active metabolite. RESULTS: Compared with whole tablets, crushed prasugrel led to reduced P2Y12 reaction units by 30 min post-LD, which persisted at 1, 2 (164 vs. 95; least square mean difference = 68; 95% confidence interval: 10 to 126; primary endpoint), and 4 h post-LD. Significant differences were no longer present at 6 h post-LD. Parallel findings were shown with platelet reactivity index. Accordingly, high on-treatment platelet reactivity rates were reduced with crushed prasugrel. PK analyses showed a >3-fold faster absorption with crushed compared with whole prasugrel. CONCLUSIONS: In STEMI patients undergoing PPCI, crushed prasugrel leads to faster drug absorption, and consequently, more prompt and potent antiplatelet effects compared with whole tablet ingestion. (Pharmacological Effects of Crushing Prasugrel in STEMI Patients; NCT02212028).

Experience with Percutaneous Transcatheter Closure of Interatrial Communications at the Cardiovascular Center of Puerto Rico and the Caribbean.

OBJECTIVE: The annual rate of percutaneous transcatheter closure of atrial septal defects (ASDs) and patent foramen ovales (PFO) has markedly increased in the United States over the past decade. This technique has been used at the Cardiovascular Center for Puerto Rico and the Caribbean since 2005. We report on the clinical characteristics and the immediate and short-term follow-up of adult patients who underwent this procedure at this center from 2008 to 2012. METHODS: One hundred and two consecutive medical records of adult Hispanic patients who underwent this procedure at our center from 2008 to 2012 were identified. A retrospective analysis of the clinical characteristics and the immediate and short-term clinical and echocardiographic follow-up of those patients was performed. RESULTS: The study population comprised 70 women and 32 men, with a mean age of 51 years (age range: 19 to 80 years). Of those, 43 (42%) underwent ASD closure and 60 (59%), closure of a PFO. A 99% procedural success rate was achieved. There were only 3 procedural complications, including the failure of the initial implantation of 1 device, which required the endovascular removal of that device and the implantation of another, a hematoma at the vascular access site, and 1 brief episode of atrial fibrillation. CONCLUSION: Based on our review of the available records, we were able to determine that the percutaneous transcatheter closure of interatrial communications proved to be, at our institution, a safe procedure with a high success rate and a low incidence of in-hospital complications. To our knowledge, this is the first report on the utilization of this interventional procedure in Puerto Rico.