Orbital atherectomy safety and efficacy: A comparative analysis of ostial versus non-ostial calcified coronary lesions.

BACKGROUND: The safety and efficacy of coronary orbital atherectomy (OA) for treatment of ostial lesions are not yet fully established. We sought to evaluate (OA) treatment of severely calcified ostial and non-ostial lesions. METHODS: A retrospective analysis of subjects treated with OA for severely calcified ostial and non-ostial lesions, at the Mount Sinai Medical Center, Miami Beach, Florida (MSMCMB) from January 2014 to September 2020, was completed. Study baseline characteristics, lesion and vessel characteristics, procedural outcomes, and in-hospital major adverse cardiovascular events (MACE) were analyzed and compared. RESULTS: A total of 609 patients that underwent PCI with OA were identified. The majority of patients (81.9 %) had non-ostial lesions, while 16.6 % had ostial lesions (of which 2.8 % classified as aorto-ostial) and 1.5 % had unknown lesion anatomy. The mean age of the overall cohort was 74.0 ± 9.3 years, and 63.5 % were male. All patients received drug-eluting stent (DES) placement, and the overall freedom from MACE was 98.5 %, with no significant difference observed between the ostial and non-ostial groups. The freedom from cardiac death and MI was also similar between the two groups. There were low rates of bleeding complications and severe angiographic complications, and no persistent slow flow/no reflow was reported. CONCLUSIONS: This study demonstrated no significant differences in in-hospital MACE outcomes between patients with ostial versus non-ostial lesions, indicating that OA is a safe and effective treatment option for both lesion types, including those classified as aorto-ostial.

Beta-blockers and Ambulatory Inotropic Therapy.

BACKGROUND: Continuous infusion of ambulatory inotropic therapy (AIT) is increasingly used in patients with end-stage heart failure (HF). There is a paucity of data concerning the concomitant use of beta-blockers (BB) in these patients. METHODS: We retrospectively reviewed all patients discharged from our institution on AIT. The cohort was stratified into 2 groups based on BB use. The 2 groups were compared for differences in hospitalizations due to HF, ventricular arrhythmias and ICD therapies (shock or antitachycardia pacing). RESULTS: Between 2010 and 2017, 349 patients were discharged on AIT (95% on milrinone); 74% were males with a mean age of 61 ± 14 years. BB were used in 195 (56%) patients, whereas 154 (44%) did not receive these medications. Patients in the BB group had longer duration of AIT support compared to those in the non-BB group (141 [1-2114] vs 68 [1-690] days). After adjusting for differences in baseline characteristics and indication for AIT, patients in the BB group had significantly lower rates of hospitalizations due to HF (hazard ratio [HR] 0.61 (0.43-0.86); P = 0.005), ventricular arrhythmias (HR 0.34 [0.15-0.74]; P = 0.007) and ICD therapies (HR 0.24 [0.07-0.79]; P = 0.02). CONCLUSION: In patients with end-stage HF on AIT, the use of BB with inotropes was associated with fewer hospitalizations due to HF and fewer ventricular arrhythmias.

From Hip to Heart: A Comprehensive Evaluation of an Infiltrative Cardiomyopathy.

Infiltrative cardiomyopathies are an increasingly recognized cause of heart failure warranting systematic evaluation. Given overlap of clinical and imaging findings among etiologies of infiltrative cardiomyopathies, comprehensive evaluation, including a history and physical examination, advanced cardiac imaging, and sometimes endomyocardial biopsy, is required for diagnosis. We report a case of infiltrative cardiomyopathy in which endomyocardial biopsy confirmed diagnosis of cobalt-induced cardiomyopathy. The novel teaching points highlighted by this case report include identification of heavy-metal toxicity as a cause of infiltrative cardiomyopathy, and the outline of a diagnostic approach and management for cobalt-induced cardiomyopathy.

Le fait que les cardiomyopathies infiltrantes sont de plus en plus reconnues comme la cause de l'insuffisance cardiaque justifie une évaluation systématique. Puisque les résultats cliniques et d'imagerie se recoupent entre les étiologies des cardiomyopathies infiltrantes, l'évaluation exhaustive, y compris les antécédents et l'examen physique, les techniques avancées en imagerie cardiaque et parfois la biopsie endomyocardique, est nécessaire au diagnostic. Nous présentons un cas de cardiomyopathie infiltrante pour lequel la biopsie endomyocardique a permis de confirmer le diagnostic d'une cardiomyopathie induite par le cobalt. Parmi les points à enseigner illustrés dans cette observation, on cite la reconnaissance de la toxicité des métaux lourds comme une cause de cardiomyopathie infiltrante, et la vue d'ensemble de l'approche diagnostique et de la prise en charge de la cardiomyopathie induite par le cobalt.

Impact of Human Immunodeficiency Virus Infection on Takotsubo Cardiomyopathy Outcomes in a Large Nationwide Sample.

BACKGROUND/PURPOSE: Takotsubo cardiomyopathy (TCM) or stress-induced cardiomyopathy is characterized by transient wall-motion abnormalities often preceded by physical or emotional stress. Various baseline medical comorbidities were associated with worse outcomes, theoretically due to their effect on chronic stress exposure. The effect of concurrent human immunodeficiency virus (HIV) infection on outcomes of TCM has not been well-established. METHODS/MATERIAL: We conducted a US-wide analysis of TCM hospitalizations from 2006 to 2014 by querying the National Inpatient Sample database for the International Classification of Diseases, Ninth Revision TCM code, baseline characteristics, and inpatient outcomes. TCM patients with HIV were compared to TCM patients without HIV. Multivariate regression models were constructed to account for potential confounders. RESULTS: We identified 123,050 patients hospitalized with TCM; of those patients, 304 had positive HIV status. In an unadjusted analysis, in-hospital outcomes were worse in TCM patients with HIV infection in terms of development of acute kidney injury (16.8% vs 33.3%, P-value 0.002), use of invasive mechanical ventilation (18.3% vs 34.5%, P-value 0.003), and mortality (5.3% vs 17.1%, P-value <0.0001). After adjusting for age, gender, and comorbidities, there was no significant difference in the captured outcomes. CONCLUSION: TCM patients with concurrent HIV had numerically worse outcomes. After adjusting for potential confounders, the statistical significance no longer existed, suggesting that statistical difference was primarily driven by difference in baseline sociodemographic parameters and coexisting comorbidities.

In-Depth Analysis of a Case of Persistent Severe Chronic Thromboembolic Pulmonary Hypertension.

Pulmonary hypertension (PH) is a disease characterized by an increase in the pulmonary vascular resistance that typically progresses to right heart failure and death. It is classified into five groups. Management depends on the group classification. Group four PH, chronic thromboembolic pulmonary hypertension (CTEPH) is thought to be a result of acute pulmonary emboli that cause fibrosis and scarring of the pulmonary arteries with consequent obstruction. The diagnosis of CTEPH is made by identifying perfusion abnormalities on ventilation/perfusion (V/Q) scan. Other studies required for the diagnostic evaluation include transthoracic echocardiogram, right heart catheterization, NT pro-B-type natriuretic peptide and thrombophilia evaluation. Several other tests needed to exclude other causes of pulmonary hypertension include high-resolution computed tomography (HRCT), connective tissue disease evaluation, thyroid function testing, human immunodeficiency virus testing, and liver ultrasonography to exclude portal hypertension. The treatment for CTEPH is surgical pulmonary endarterectomy (PEA). In patients who are not candidates or decline PEA, pulmonary balloon angioplasty may be useful, however, further studies are required. Several pulmonary artery hypertension medications have been studied in the management of inoperable CTEPH or persistent PH following PEA including bosentan (improves hemodynamics but not exercise capacity), macitentan (improves both hemodynamics and clinical parameters), and riociguat (improves both hemodynamics and exercise capacity). However, only riociguat is approved by the Food and Drug Administration for this indication.

Uncommon Anatomic Predisposition to Myocardial Infarction: A Case of Coronary Artery Ectasia.

Coronary artery ectasia (CAE) is a recognized cause of acute coronary syndrome (ACS), and can be associated with life-threatening complications, including thrombus formation with consequent distal coronary artery embolization. Several studies have demonstrated a higher incidence of cardiovascular adverse events and cardiac death in patients with CAE or coronary artery aneurysms compared to those without such abnormalities. Management of symptomatic CAE is similar to coronary artery disease (CAD), where guideline-directed medical therapy is indicated due to coexistence of CAD with acquired CAE. Percutaneous coronary intervention can be attempted; however, it is challenging, as it is associated with lower procedural success, higher rates of stent thrombosis, and repeat revascularization.

Optimizing Computed Tomography for Detection of Pulmonary Thromboembolism in Patients With Fontan Circulation.

Congenital heart disease (CHD) patients who have undergone the Fontan procedure or one of its variants usually have altered vascular anatomy. Consequently, this poses a challenge when diagnosing pulmonary thromboembolism (PTE) with computed tomography (CT). Detailed review of the type of surgery performed and the person's individual anatomy beforehand can help in choosing the appropriate diagnostic CT modality and technique. It would also help reduce false-positive and false-negative test results that would otherwise result in unnecessary anticoagulation, as well as avoid needless radiation exposure and additional cost, respectively.

Crossing Boundaries: A Rare Case of Cardiac Dysfunction.

Cardiac tumors are relatively rare. Secondary cardiac tumors are by far more common than primary cardiac tumors. Cardiac involvement may occur secondary to hematogenous metastases, direct invasion, or tumor growth into the venous system and extension into the right atrium. Patients can present with a spectrum of conditions, including embolization, obstruction of ventricular outflow tracts, direct invasion of myocardium causing impaired myocardial function, invasion of surrounding tissue, interference with valvular function causing valvular regurgitation, or constitutional non-specific signs and symptoms. Imaging modalities are essential for diagnosis. Management is mostly surgical, but can include other medical strategies as well. We present a case of a 65-year-old male with hepatocellular carcinoma with direct invasion to the heart through the venous system.

Rapidly Developing Methicillin-Resistant Staphylococcus Aureus Pericarditis and Pericardial Tamponade.

Methicillin-resistant staphylococcus aureus (MRSA) pericarditis is a rare life-threatening infection. A 46-year-old female with hypertension, acquired immunodeficiency syndrome (AIDS) and recurrent neck abscesses, presented with a neck abscess and sepsis. Bloody purulent drainage from the abscess was found and antibiotics were started. Drainage was positive for MRSA. Four days after, course was complicated by acute pericarditis and pericardial tamponade; pericardial fluid was drained and was positive for MRSA. Vancomycin was continued, and aspirin and colchicine were started. Two days later, there was a recurrent pericardial fluid collection with loculation. Surgery was thought to be dangerous in the setting of CD4 count of 12. She was managed conservatively thereafter, with vancomycin, aspirin and colchicine, and was successfully discharged from the hospital.

Embolic ST-elevation Myocardial Infarction from Candida Endocarditis.

Infective endocarditis in intravenous drug users is uncommon in left-sided native valves. Adding to the rarity, in this case, is endocarditis from Candida species complicated by ST-elevation myocardial infarction. Embolic myocardial infarction has worse outcomes as compared to other etiologies, and the management of septic embolic myocardial infarction is rather challenging. The management of embolic myocardial infarction from Candida endocarditis vegetation includes antifungal therapy. The use of anti-thrombotic therapy and anticoagulation carries a significant risk of fatal neurologic complications and has been controversial, with limited observational data available. Among percutaneous coronary interventions, balloon angioplasty and stenting have been associated with multiple complications while aspiration embolectomy appears to be a safer option. Surgical management is considered if medical and interventional therapies fail or if there is an indication for valve replacement.

Plaque Rupture-Induced Myocardial Infarction and Mechanical Circulatory Support in Alpha-Gal Allergy.

Alpha-gal (AG) allergy is an IgE-mediated allergic reaction to galactose-alpha-1,3-galactose found in mammalian meat. Heparin, being derived from porcine intestinal tissue, may have a degree of cross-reactivity with AG antigen and thus place patients at risk for allergic and even anaphylactic reactions. This is especially important in patients with myocardial infarction (MI) and mechanical circulatory support, such as a left ventricular assist device (LVAD), since anticoagulation is immediately required. Therefore, individualized assessment and preoperative planning is needed regarding the use of heparin vs. nonheparinoid products in such a population.

Retained Coronary Guidewire Extending to the Right Axillary Artery.

This is a case of a 56-year-old female who presented with inferior ST segment elevation myocardial infarction (STEMI), treated with percutaneous intervention (PCI), which was complicated by a retained guidewire extending from left circumflex artery (at location of obtuse marginal (OM) stent) through the ascending aorta, the right brachiocephalic artery and into the right axillary artery. Patient underwent cardiac CT, with maximum intensity projection image showing the course of the retained guidewire. Percutaneous retrieval was deferred due to risk of damaging the stent, and the patient initially deferred coronary artery bypass (CABG) and surgical retrieval as. She was discharged on triple therapy with Aspirin, Clopidogril and Apixaban for 3 months with no bleeding or thromboembolic complications on a 3-month follow up with cardiology clinic, during which rediscussion of risks and benefits of CABG and surgical retrieval or retained wire took place with the patient. Patient agreed to undergo the procedure and guidewire was retrieved surgically and CABG was done.