Exposure to glucocorticoids prior to transcatheter aortic valve replacement is associated with reduced incidence of high-degree AV block and pacemaker.

BACKGROUND: Tissue edema and inflammation, which occur at the device landing zone during valve deployment, may contribute to the pathophysiology of conduction abnormalities after transcatheter aortic valve replacement (TAVR). We hypothesized that exposure to glucocorticoids prior to TAVR will reduce the incidence of conduction abnormalities requiring PPM implantation after TAVR. METHODS: We included 167 consecutive patients treated with TAVR at the Minneapolis VA Medical Center and University of Minnesota. Exposure to glucocorticoids was assessed by linking electronic medical and pharmacy records. The primary outcome was a new PPM within 30 days of the index TAVR procedure. RESULTS: Of the 167 patients included, 16 (9.5%) were exposed to glucocorticoids prior to TAVR. No differences in age, STS score, pre-existing right bundle branch block, implantation depth or valve type were seen among patients exposed to glucocorticoids versus those who were unexposed. Patients exposed to glucocorticoids were more likely to have moderate/severe COPD (43% versus 18%, p < 0.01). The cumulative incidence of PPM implantation at 30-days after TAVR was 18%. None of the patients exposed to glucocorticoids required a PPM while 30 (19%) of the unexposed patients did (p = 0.04). CONCLUSIONS: Exposure to glucocorticoids prior to TAVR may be associated with reduced incidence of PPM requirement though larger studies are needed to support these findings. Tissue edema and inflammation may be significant contributors to the pathophysiology of conduction abnormalities after TAVR and could represent a therapeutic target.

Avoiding the Learning Curve for Transcatheter Aortic Valve Replacement.

Objectives. To evaluate whether collaboration between existing and new transcatheter aortic valve replacement (TAVR) programs could help reduce the number of cases needed to achieve optimal efficiency. Background. There is a well-documented learning curve for achieving procedural efficiency and safety in TAVR procedures. Methods. A multidisciplinary collaboration was established between the Minneapolis VA Medical Center (new program) and the University of Minnesota (established program since 2012, n = 219) 1 year prior to launching the new program. Results. 269 patients treated with TAVR (50 treated in the first year at the new program). Mean age was 76 (±18) years and STS score was 6.8 (±6). Access included transfemoral (n = 35, 70%), transapical (n = 8, 16%), transaortic (n = 2, 4%), and subclavian (n = 5, 10%) types. Procedural efficiency (procedural time 158 ± 59 versus 148 ± 62, p = 0.27), device success (96% versus 87%, p = 0.08), length of stay (5 ± 3 versus 6 ± 7 days, p = 0.10), and safety (in hospital mortality 4% versus 6%, p = 0.75) were similar between programs. We found no difference in outcome measures between the first and last 25 patients treated during the first year of the new program. Conclusions. Establishing a partnership with an established program can help mitigate the learning curve associated with these complex procedures.

Acute coronary thrombosis in a patient with septic shock without any evidence of disseminated intravascular coagulation.

The case report describes an interesting and unusual finding of acute coronary artery thrombosis in a patient presenting with septic shock without any clinical and laboratory evidence of disseminated intravascular coagulation (DIC). The patient presented with leucocytosis and refractory hypotension requiring pressor support and found to have anterior and inferior ST-elevation in 12-lead electrocardiogram. Coronary angiogram revealed acute thrombotic occlusions in the proximal right coronary artery and the proximal left anterior descending coronary artery. There was no occlusive atherosclerotic coronary artery disease. The patient underwent mechanical thrombectomy. Haemodynamic parameters obtained from right heart catheterisation confirmed sepsis as the aetiology of hypotension. The patient was treated successfully with broad spectrum antibiotics, pressors and intravenous fluid.Acute myocardial infarctions as a complication secondary to disseminated intravascular coagulation in patients with sepsis and septic shock have been described in the literature. To our knowledge, this is the first reported case of acute coronary artery thrombosis in patient with septic shock without DIC and without any underlying occlusive coronary artery disease.

Coronary steal due to bilateral internal mammary artery--pulmonary artery fistulas: a rare cause of chest pain after coronary artery bypass grafting.

A 54-year-old man with a history of coronary artery bypass grafting (CABG) presented with chest pain and was found to have non-ST-segment elevation myocardial infarction. Left heart catheterization with coronary angiography demonstrated 100% occlusion of the right internal mammary artery (IMA) to the right coronary artery graft in its midsegment and a patent left IMA to the left anterior descending graft. An unusually large extensive fistulous collateral formation was observed between the right IMA and the left IMA to the pulmonary arterial system, causing left to right shunting. His angina was attributed to substantial coronary steal caused by the shunt. The patient refused any further intervention or surgery and opted for medical treatment. As a complication of CABG, IMA to pulmonary artery (PA) fistulas are rare. Thus far, more than 20 cases have been reported; most have been unilateral. This is the second reported case to date of bilateral IMA-PA fistula formation after CABG. An IMA-PA fistula should be considered in the differential diagnosis of patients presenting with chest pain after CABG and can be diagnosed by selective angiography of IMA grafts.

Treatment of an Angio-Seal-related vascular complication using the SilverHawk plaque excision system: a case report.

The Angio-Seal is a user-friendly and safe arterial closure device increasingly used after percutaneous diagnostic and interventional procedures. Although it achieves rapid hemostasis and facilitates early patient mobilization, its use can be associated with vascular complications. A specific problem related to the device is protrusion of the collagen plug into the artery, causing either acute occlusion or symptomatic stenosis. When this occurs, treatment with balloon angioplasty alone is usually suboptimal, while stenting of the common femoral artery may be undesirable. In this report we describe a novel application of the SiverHawk plaque excision system to treat a highly eccentric stenosis at the site of a previously deployed Angio-Seal. Since the device allows preferential cutting in the direction of the lesion and collagen plug debulking, it may be ideally suited to treat this complication without the need for stenting of the common femoral artery.

Classic intermittent claudication is an uncommon manifestation of lower extremity peripheral arterial disease in hospitalized patients with coronary artery disease.

Synchronous peripheral arterial disease (PAD) and coronary artery disease (CAD) is common. Standardized questionnaires such as the Rose/WHO questionnaire and later the Edinburgh modification of this questionnaire were developed to screen for PAD. Little data are available on the sensitivity of these questionnaires in hospitalized patients with CAD. The aim of this study was to determine the accuracy of these questionnaires and the prevalence of classic intermittent claudication in hospitalized patients with CAD. Medically stable patients with CAD were invited to participate before hospital discharge. The patients answered both the Rose/WHO and Edinburgh modification claudication questionnaires and had an ankle-brachial index (ABI) measured. An ABI less than or equal to 0.9 was considered to be indicative of significant PAD. Patients who had undergone previous lower extremity revascularization for PAD and had a corrected ABI greater than 0.9 were excluded. Ninety-five patients (66 men) were recruited. By measuring the ABI, 35 patients (25 men) were found to have significant PAD. An additional 3 patients who had an ABI corrected by lower extremity revascularization were excluded from the analysis. The Rose/WHO questionnaire had a sensitivity, specificity, and overall accuracy (95% CI) of 14.3% (2.7-25.9%), 96.7% (92.1-100%), and 66.3% (56.8-75.8%), respectively. The Edinburgh modification of the Rose/WHO questionnaire had a sensitivity, specificity, and overall accuracy (95% CI) of 28.6% (13.6-43.5%), 90.0% (82.4-97.6%), 67.4% (57.9-76.8%), respectively. Despite the high incidence of synchronous PAD in hospitalized patients with CAD, traditional claudication questionnaires are insensitive to PAD detection. Classic claudication is an uncommon manifestation of PAD in hospitalized patients with CAD.