Pericardial Decompression Syndrome: A Comprehensive Review of a Controversial Entity.

Pericardial decompression syndrome is an ambiguous clinical entity which has generated controversy regarding its existence. Following pericardial decompression, patients experienced clinical deterioration ranging in complications from pulmonary edema to death that could not be attributed to any other distinct clinical pathology. Multiple theories have suggested the pathophysiology behind pericardial decompression syndrome is related to preload-afterload mismatch following pericardial decompression, coronary microvascular ischemia, and stress from high adrenergic state. Our review aims to describe this syndrome by analyzing demographics, etiology of pericardial effusion, method of drainage, volume of pericardial fluid removed, time to decompensation, and clinical outcomes. A systematic review of MEDLINE/PubMed and Google Scholar literature databases were queried for case reports, case series, review articles, and abstracts published in English journals between 1983 and December 2022. Each author's interpretation of echocardiographic and/or pulmonary arterial catheterization data provided in the case reports was used to characterize ventricular dysfunction. Based on our inclusion criteria, 72 cases of pericardial decompression syndrome were included in our review. Our results showed that phenotypic heterogeneity was present based on echocardiographic findings of right/left or biventricular failure with similar proportions in each type of ventricular dysfunction. Time to decompensation was similar between immediate, subacute, and acute cases with presentation varying between hypoxic respiratory failure and shock. This review article highlights theories behind the pathophysiology, clinical outcomes, and therapeutic options in this high mortality condition.

Transcatheter Aortic Valve Replacement: Current Status and Future Indications.

In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications.

Risk Factors for 30-day Hospital Readmissions After Peripheral Vascular Interventions in Peripheral Artery Disease Patients at the US-Mexico Border.

Peripheral artery disease (PAD) is associated with high rates of readmission following endovascular interventions and contributes to a significant hospital readmission burden. Quality metrics like hospital readmissions affect hospital performance, but must adjust to local trends. Our primary goal was to evaluate risk factors and readmission rates post-percutaneous peripheral intervention in a US-Mexico border city, at a single tertiary university hospital. We performed a retrospective review of patients with PAD undergoing first time peripheral intervention from July 2015 to June 2020. Among 212 patients, 58% were readmitted with median 235-day follow-up (inter-quartile range (IQR) 42-924); 35.3% of readmissions occurred within 30 days, and 30.2% of those were within 7 days. Median time to readmission was 62 days. Active smokers had 84% higher risk of readmission (hazard ratio (HR) 1.84, 95% CI 1.23-2.74, P < .01). Other significant factors noted were insurance status-Medicaid or uninsured (HR 1.94, 95% CI 1.22-3.09), prior amputation (HR 1.69, 95% CI 1.13-2.54), heart failure, both preserved (HR 4.35, 95% CI 2.07-9.16) and reduced ejection fraction (HR 1.88, 95% CI 1.14-3.10). Below the knee, interventions were less likely to be readmitted (adjusted HR .64, 95% CI 0.42-.96). Readmission rates were unrelated to medication adherence.

The Clot Thickens: COVID-19-Related ST-Elevation Myocardial Infarction in the Setting of Recent Boosters.

The coronavirus disease of 2019 (COVID-19) has an array of pathological effects that continue to be discovered. Vaccines against COVID-19 have quickly emerged as our main tool. However, the thrombotic risk of both the virus and the vaccine is yet to be established, let alone together. In this case report, we present a case involving a recently diagnosed COVID-19 patient who developed an ST-elevated myocardial infarction (STEMI) after receiving his booster shot. Our aim is to highlight the standard of treatment outcomes in COVID-19-associated clots, familiarize ourselves with the complexity of the clot burden in a COVID-19-associated STEMI, and illustrate the potential role of the cumulative pro-thrombotic effects of a recent COVID-19 booster with a concomitant symptomatic COVID-19 infection.

PCI or CABG for Left Main Disease: Does Disease Location Matter?

PURPOSE OF REVIEW: This review attempts to specifically assess impact of disease location in left main artery on mortality and cardiovascular outcomes in patients treated with percutaneous coronary intervention versus coronary artery bypass surgery. RECENT FINDINGS: The management of left main disease, once thought to be the sole province of cardiothoracic surgeon, has recently undergone a reappraisal by the cardiovascular medicine community. For many years, societal guideline recommendations advised bypass surgery as the "de rigeur" method of revascularization for unprotected left main disease. However, recent studies suggest that coronary intervention, especially with advances in drug-eluting stent technology, has mounted a serious challenge to surgical bypass in treatment of this disease. Although overall mortality rates are comparable for percutaneous coronary intervention and bypass surgery, left main disease location does influence long-term outcomes for percutaneous coronary intervention more than bypass surgery. A patient- and lesion-centered approach to treatment of this disease may provide optimal outcomes.

Nonbacterial Thrombotic Endocarditis: Presentation, Pathophysiology, Diagnosis and Management.

Initially described in 1936, non-bacterial thrombotic endocarditis (NBTE) is a rare entity involving sterile vegetations on cardiac valves. These vegetations are usually small and friable, typically associated with hypercoagulable states of malignancy and inflammatory diseases such as systemic lupus erythematosus. Diagnosis remains challenging and is commonly made post-mortem although standard clinical methods such as echocardiography (transthoracic and transesophageal) and magnetic resonance imaging may yield the clinical diagnosis. Prognosis of NBTE is poor with very high morbidity and mortality usually related to the serious underlying conditions and high rates of systemic embolization. Therapeutic anticoagulation with unfractionated heparin has been described as useful for short term prevention of recurrent embolic events in patients with NBTE but there are no guidelines for management of this disease.

Chest Pain: Who Needs Additional Testing Beyond ECG and Troponin?

In the first case, we describe a 45-year-old man who presented to the emergency department for evaluation of chest pain. He reported having chest discomfort 5 days prior that lasted a few minutes after an altercation with his coworker. In the second case, we describe a 54-year-old woman with history of well-controlled diabetes mellitus, hypertension, and dyslipidemia who presented to the ED with a 10-day history of intermittent sharp and burning chest pain in the substernal region, 5/10 intensity, lasting 15-20 minutes, associated with exertion. (Level of Difficulty: Intermediate.).

Management of Stent Thrombosis Post-Percutaneous Coronary Intervention and Associated Rare Complications.

Stent thrombosis is a devastating complication of percutaneous coronary intervention (PCI) associated with significant morbidity and mortality. Progressive technical advancements from balloon angioplasty to bare-metal stent and drug-eluting stent placement have reduced the incidence of stent thrombosis. Definitive management and preventive methods are still negligible. Here, we describe two cases of definite subacute stent thrombosis of the right coronary complicated by pericarditis and very late left anterior descending stent thrombosis after the intervention in the right coronary artery. In both cases, antiplatelet treatment with clopidogrel showed excellent compliance. Therefore, after successful PCI, we switched both cases from clopidogrel to potentially more potent antiplatelet treatment, such as ticagrelor, to reduce the occurrence of stent thrombosis in the future.

Endovascular Therapies for Type B Aortic Dissection.

Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, Type B Aortic Dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as a primary strategy is favored. However, there has been a recent paradigm shift in the management of TBAD due to late aneurysmal degeneration of TBAD, increasing morbidity and mortality in the long term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.

Posterior Wall Isolation for Atrial Fibrillation: Effects on Echocardiographic Parameters of cardiac function.

BACKGROUND: Posterior wall isolation (PWI) in addition to circumferential pulmonary vein isolation (CPVA) requires more ablation of left atrial tissue. We compared the effect of PWI versus non-PWI methods (CPVA + linear lesions) on echocardiographic parameters of left atrial and left ventricular function. METHODS: We selected patients who had pre and post ablation echocardiogram at our institution. Parameters assessed were: Left ventricular outflow tract velocity time integral (VTI), left ventricular ejection fraction (LVEF), atrial Doppler velocity across mitral valve (A), E/E', and deceleration time. RESULTS: Of the 72 patients studied, 32.5% had PWA in addition to CPVA. The mean duration between echocardiograms was 650 + 542 days. PWA group had an average postoperative VTI 0.21 + 0.05 vs 0.21 + 0.05 in the non-PWA (p=0.61) group. Average improvement compared to pre ablation parameters: VTI was 0.03 + 0.06 vs 0.008 + 0.05 (p=0.17), postoperative A was 0.49 + 0.19 vs 0.57 + 0.19 (p=0.16), postoperative LVEF was 57.5 + 9.9% vs 57.8 + 10.8 % (p=0.89), with average change in LVEF 1.5 ± 7.8 vs 0.86 ± 9.7 (p=0.78) in PWA and non-PWA groups respectively. There was no significant difference in change in deceleration time or E/E' when comparing the two groups. CONCLUSIONS: PWA did not adversely affect echocardiographic parameters of left atrial function or left ventricular systolic or diastolic function when compared to other types of ablation.

Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation.

OBJECTIVES: In an effort to define the gold standard for annular sizing for transcatheter aortic valve replacement (TAVR), we sought to critically analyze and compare the predictive value of multiple measures of the aortic annulus for post-TAVR paravalvular (PV) regurgitation and then assess the impact of a novel cross-sectional computed tomographic (CT) approach to annular sizing. BACKGROUND: Recent studies have shown clear discrepancies between conventional 2-dimensional (2D) echocardiographic and CT measurements. In terms of aortic annular measurement for TAVR, such findings have lacked the outcome analysis required to inform clinical practice. METHODS: The discriminatory value of multiple CT annular measures for post-TAVR PV aortic regurgitation was compared with 2D echocardiographic measures. TAVR outcomes with device selection according to aortic annular sizing using a traditional 2D transesophageal echocardiography-guided or a novel CT-guided approach were also studied. RESULTS: In receiver-operating characteristic models, cross-sectional CT parameters had the highest discriminatory value for post-TAVR PV regurgitation: This was with the area under the curve for [maximal cross-sectional diameter minus prosthesis size] of 0.82 (95% confidence interval: 0.69 to 0.94; p < 0.001) and that for [circumference-derived cross-sectional diameter minus prosthesis size] of 0.81 (95% confidence interval: 0.7 to 0.94; p < 0.001). In contrast, traditional echocardiographic measures were nondiscriminatory in relation to post-TAVR PV aortic regurgitation. The prospective application of a CT-guided annular sizing approach resulted in less PV aortic regurgitation of grade worse than mild after TAVR (7.5% vs. 21.9%; p = 0.045). CONCLUSIONS: Our data lend strong support to 3-dimensional cross-sectional measures, using CT as the new gold standard for aortic annular evaluation for TAVR with the Edwards SAPIEN device.