Management of Patients With Giant Cell Myocarditis: JACC Review Topic of the Week.

Giant cell myocarditis is a rare, often rapidly progressive and potentially fatal, disease due to T-cell lymphocyte-mediated inflammation of the myocardium that typically affects young and middle-aged adults. Frequently, the disease course is marked by acute heart failure, cardiogenic shock, intractable ventricular arrhythmias, and/or heart block. Diagnosis is often difficult due to its varied clinical presentation and overlap with other cardiovascular conditions. Although cardiac biomarkers and multimodality imaging are often used as initial diagnostic tests, endomyocardial biopsy is required for definitive diagnosis. Combination immunosuppressive therapy, along with guideline-directed medical therapy, has led to a paradigm shift in the management of giant cell myocarditis resulting in an improvement in overall and transplant-free survival. Early diagnosis and prompt management can decrease the risk of transplantation or death, which remain common in patients who present with cardiogenic shock.

Prosthetic mitral valve paravalvular leak: A problem that requires dexterity.

Prosthetic valve paravalvular leak (PVL) is a known and relatively common complication of surgical valve replacement, which may lead to significant morbidity. Patients with significant mitral valve replacement (MVR) PVL typically present with symptoms of heart failure and elevated filling pressures or with hemolytic anemia. Percutaneous closure of these leaks has become the preferred therapy. Percutaneous closure of MVR PVL can be technically challenging, given the anatomy of the approach (trans-septal, trans-apical), the level of associated comorbidities and the geographic location of the paravalvular defect. Steerable catheters offer a unique ability to position themselves coaxial to the PVL. The Dexterity catheter (Spirus Medical LLC, Bridgewater, MA, USA) is a semi-rigid steerable catheter used in our lab with the ability to articulate at two separate points on the distal tip and flex greater than 360 degrees. We present cases of surgical valves that developed PVL which underwent successful repair with a Dexterity catheter.

Endovascular Removal of Intracardiac Thrombus Prior to Radical Nephrectomy and Inferior Vena Cava Thrombectomy.

We report a case of a 54-year-old patient with a T3c renal mass with intracardiac extension of the thrombus to the level of the pulmonary valve. The patient was not a candidate for cardiopulmonary bypass due to recent pulmonary embolism. Under transesophageal echocardiogram guidance, the intracardiac thrombus was removed percutaneously via transvenous mechanical thrombectomy. The patient was effectively downstaged to T3b and underwent successful radical nephrectomy and inferior vena cava thrombectomy without the use of cardiopulmonary bypass.

Mitral valve regurgitation and left ventricular dysfunction treatment with an intravalvular spacer.

Attempts at transcatheter treatment of mitral valve regurgitation have generally been modeled on proven surgical procedures such as leaflet repair, annuloplasty, or prosthetic valve implantation. We introduce a novel approach to directly reducing the regurgitant orifice: the mitral valve spacer, a balloon that attempts to reduce the regurgitant orifice.

The data extraction and longitudinal trend analysis network study of distributed automated postmarket cardiovascular device safety surveillance.

BACKGROUND: Current approaches for postmarket medical device safety surveillance are limited in their ability to produce timely and accurate assessments of adverse event rates. METHODS AND RESULTS: The Data Extraction and Longitudinal Trend Analysis (DELTA) network study was a multicenter prospective observational study designed to evaluate the safety of devices used during percutaneous coronary interventions. All adult patients undergoing percutaneous coronary intervention from January 2008 to December 2012 at 5 participating Massachusetts sites were included. A safety alert was triggered if the cumulative observed adverse event rates for the study device exceeded the upper 95% confidence interval of the event rates of propensity-matched control cohort. Prespecified sensitivity analyses were developed to validate any identified safety signal. A total of 23,805 consecutive percutaneous coronary intervention procedures were evaluated. Two of 24 safety analyses triggered safety alerts. Patients receiving Perclose vascular closure device experienced an increased risk of minor vascular complications (relative risk, 4.14; P<0.01) and any vascular complication (relative risk, 2.06; P=0.01) when compared with propensity-matched patients receiving alternative vascular closure device, a result primarily driven by relatively high event rates at 1 participating center. Sensitivity analyses based on alternative risk adjustment methods confirmed a pattern of increased rate of complications at 1 of the 5 participating sites in their use of Perclose vascular closure device. CONCLUSIONS: The DELTA network study demonstrates that distributed automated prospective safety surveillance has the potential of providing near real-time assessment of safety risks of newly approved medical devices.

Right heart catheterization using antecubital venous access: feasibility, safety and adoption rate in a tertiary center.

OBJECTIVES: To determine feasibility, safety, and adoption rates of right heart catheterization (RHC) using antecubital venous access (AVA) as compared to using the traditional approach of proximal venous access (PVA). BACKGROUND: RHC via PVA (i.e., internal jugular, femoral or subclavian) is generally a low risk procedure; however, complications may occur and are usually access site related. RHC via an antecubital approach has regained attention given the increase in transradial left heart catheterizations. METHODS: Patients undergoing RHC for any indication at a single large academic medical center were identified over a 5-year period (January 2008 to December 2012) from a database. Medical records were retrospectively analyzed for demographic, procedural and outcomes data. RESULTS: Two hundred seventy-two RHC procedures were included (106 AVA, 166 PVA). The adoption rate of AVA for RHC increased rapidly since its introduction in our laboratory in 2010 (100% PVA in 2008 and 2009, 85% AVA in 2012). All procedures were successful; however, 6% of procedures required additional, alternate access to the original site. Initial success rates were similar in the two groups (91 vs. 96% for AVA and PVA respectively, P = 0.12). Fluoroscopy time was shorter in the group of patients who underwent the procedure via AVA. The complication rate was 0% in the AVA group compared with 3% in the PVA group (P = 0.16). CONCLUSION: RHC via the AVA is a feasible and safe alternative to PVA. Our experience and rapid adoption support the use AVA as the access site of choice for RHC in uncomplicated patients.

Risk-treatment paradox in the selection of transradial access for percutaneous coronary intervention.

BACKGROUND: Access site complications contribute to morbidity and mortality during percutaneous coronary intervention (PCI). Transradial arterial access significantly lowers the risk of access site complications compared to transfemoral arteriotomy. We sought to develop a prediction model for access site complications in patients undergoing PCI with femoral arteriotomy, and assess whether transradial access was selectively used in patients at high risk for complications. METHODS AND RESULTS: We analyzed 17 509 patients who underwent PCI without circulatory support from 2008 to 2011 at 5 institutions. Transradial arterial access was used in 17.8% of patients. In those who underwent transfemoral access, 177 (1.2%) patients had access site complications. Using preprocedural clinical and demographic data, a prediction model for femoral arteriotomy complications was generated. The variables retained in the model included: elevated age (P<0.001), female gender (P<0.001), elevated troponin (P<0.001), decreased renal function or dialysis (P=0.002), emergent PCI (P=0.01), prior PCI (P=0.005), diabetes (P=0.008), and peripheral artery disease (P=0.003). The model showed moderate discrimination (optimism-adjusted c-statistic=0.72) and was internally validated via bootstrap resampling. Patients with higher predicted risk of complications via transfemoral access were less likely to receive transradial access (P<0.001). Similar results were seen in patients presenting with and without ST-segment myocardial infarction and when adjusting for individual physician operator. CONCLUSIONS: We generated and validated a model for transfemoral access site complications during PCI. Paradoxically, patients most likely to develop access site complications from transfemoral access, and therefore benefit from transradial access, were the least likely to receive transradial access.

Improvement in mortality risk prediction after percutaneous coronary intervention through the addition of a "compassionate use" variable to the National Cardiovascular Data Registry CathPCI dataset: a study from the Massachusetts Angioplasty Registry.

OBJECTIVES: This study investigated the impact of adding novel elements to models predicting in-hospital mortality after percutaneous coronary interventions (PCIs). BACKGROUND: Massachusetts mandated public reporting of hospital-specific PCI mortality in 2003. In 2006, a physician advisory group recommended adding to the prediction models 3 attributes not collected by the National Cardiovascular Data Registry instrument. These "compassionate use" (CU) features included coma on presentation, active hemodynamic support during PCI, and cardiopulmonary resuscitation at PCI initiation. METHODS: From October 2005 through September 2007, PCI was performed during 29,784 admissions in Massachusetts nonfederal hospitals. Of these, 5,588 involved patients with ST-segment elevation myocardial infarction or cardiogenic shock. Cases with CU criteria identified were adjudicated by trained physician reviewers. Regression models with and without the CU composite variable (presence of any of the 3 features) were compared using areas under the receiver-operator characteristic curves. RESULTS: Unadjusted mortality in this high-risk subset was 5.7%. Among these admissions, 96 (1.7%) had at least 1 CU feature, with 69.8% mortality. The adjusted odds ratio for in-hospital death for CU PCIs (vs. no CU criteria) was 27.3 (95% confidence interval: 14.5 to 47.6). Discrimination of the model improved after including CU, with areas under the receiver-operating characteristic curves increasing from 0.87 to 0.90 (p < 0.01), while goodness of fit was preserved. CONCLUSIONS: A small proportion of patients at extreme risk of post-PCI mortality can be identified using pre-procedural factors not routinely collected, but that heighten predictive accuracy. Such improvements in model performance may result in greater confidence in reporting of risk-adjusted PCI outcomes.

The prevalence and predictors of an abnormal ankle-brachial index in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial.

OBJECTIVE: To examine ankle-brachial index (ABI) abnormalities in patients with type 2 diabetes and coronary artery disease (CAD). RESEARCH DESIGN AND METHODS: An ABI was obtained in 2,240 patients in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) Trial. ABIs were classified as: normal, 0.91-1.3; low, ≤ 0.9; high, >1.3; or noncompressible artery (NC). Baseline characteristics were examined according to ABI and by multivariate analysis. RESULTS ABI was normal in 66%, low in 19%, and high in 8% of patients, and 6% of patients had NC. Of the low ABI patients, 68% were asymptomatic. Using normal ABI as referent, low ABI was independently associated with smoking, female sex, black race, hypertension, age, C-reactive protein, diabetes duration, and lower BMI. High ABI was associated with male sex, nonblack race, and higher BMI; and NC artery was associated with diabetes duration, higher BMI, and hypertension. CONCLUSIONS: ABI abnormalities are common and often asymptomatic in patients with type 2 diabetes and CAD.

Clinical characteristics of tako-tsubo cardiomyopathy.

Tako-tsubo cardiomyopathy (TTC) is increasingly diagnosed in the United States, especially in the Caucasian population. To evaluate the clinical features and outcome of patients with TTC, we evaluated 34 patients (32 women and 2 men) 22 to 88 years of age (mean 66 +/- 14) who fulfilled the following criteria: (1) akinesia or dyskinesia of the apical and/or midventricular segments of the left ventricle with regional wall motion abnormalities that extended beyond the distribution of a single epicardial vessel and (2) absence of obstructive coronary artery disease. Twenty-five patients (74%) presented with chest pain, 20 patients (59%) presented with dyspnea, and 8 patients (24%) presented with cardiogenic shock. Twenty-two patients (65%) had ST-segment elevation and 14 patients (41%) had T-wave inversion on presentation. Twenty-five patients (74%) reported a preceding stressful event. Cardiac biomarkers were often mildly increased, with a mean troponin I (peak) of 13.9 +/- 24. Mean +/- SD left ventricular ejection fractions were 28 +/- 10% at time of presentation and 51 +/- 14 at time of follow-up (p <0.0001). Two patients (6%) died during the hospital stay. Average duration of hospital stay was 6.6 +/- 6.2 days. In conclusion, TTC is common in postmenopausal women with preceding physical or emotional stress. It predominantly involves the apical portion of the left ventricle and patients with this condition have a favorable outcome with appropriate medical management. The precise cause remains unclear.

Prevalence of metabolic syndrome in patients < or =45 years of age with acute myocardial infarction having percutaneous coronary intervention.

The prevalence of metabolic syndrome (MS) was determined in patients aged < or =45 years who presented with acute myocardial infarction and underwent primary percutaneous coronary intervention. Two hundred twenty-three consecutive patients aged 18 to 45 years who underwent cardiac catheterization for acute myocardial infarction from June 2001 to December 2004 were reviewed. MS was diagnosed by National Cholesterol Education Program Adult Treatment Panel III guidelines (modified by substituting body mass index > or =28.8 kg/m2 for waist circumference). One hundred sixty-one patients met all 5 criteria for MS available for evaluation. Seventy-six of these patients (47%) met > or =3 of the 5 criteria for MS. Sixteen patients with MS (21%) and 5 patients without MS (6%) had diabetes mellitus. The prevalence of each criterion was significantly higher (p <0.05) in the MS group. Average Framingham risk scores were 7.0 and 4.5 for patients with and without MS, respectively. The prevalence of smoking, male gender, and family history of premature coronary artery disease were the same for the 2 groups. In conclusion, MS was highly prevalent in this population of young patients with acute myocardial infarction.

Stroke complicating percutaneous coronary intervention in patients with acute myocardial infarction.

BACKGROUND: Stroke associated with percutaneous coronary intervention (PCI) is a tragic complication. Despite advances in the practice of PCI, the incidence of stroke complicating PCI has not changed over the decades. The objective of the present study was to evaluate incidence and correlates of stroke occurring in patients with myocardial infarction (MI) undergoing PCI. METHODS AND RESULTS: Stroke was defined as the presence of any new focal neurological deficit lasting > or =24 h that occurred anytime during or after PCI until discharge. In 2,281 consecutive patients with PCIs for non-ST-elevation MI, or ST-elevation MI (STEMI), 20 strokes were identified (0.88%). Strokes were ischemic in 95%. On multivariate analyses, ejection fraction < or =30% (odds ratio =4.3, p=0.003) was the only independent predictor for stroke. In patients who developed stroke within 24 h of PCI, PCI of vein grafts was more frequent, and use of glycoprotein IIb/IIIa inhibitor was less frequent. Those patients tended to present late in the course of MI. Stroke found more than 24 h after PCI was related to diabetes, higher serum creatinine, lower ejection fraction, anterior wall STEMI and emergency use of intra-aortic balloon pumps. CONCLUSIONS: Low ejection fraction was the only independent predictor for stroke, but risk factors for periprocedural stroke are different from those of stroke occurring more than 24 h after PCI. Upstream use of glycoprotein IIb/IIIa inhibitor might decrease the risk of periprocedural stroke.

Retroperitoneal hemorrhage from inferior epigastric artery: value of femoral angiography for detection and management.

Laceration of the inferior epigastric artery during cardiac catheterization is under-reported in the literature, but it is a serious complication leading to retroperitoneal hemorrhage and even death. We report on two cases of retroperitoneal bleeding from unintentional puncture of the inferior epigastric artery during cardiac catheterization. Femoral angiography is a valuable tool to promptly recognize this complication.

Myocardial infarction as a presentation of clinical in-stent restenosis.

BACKGROUND: In-stent restenosis is considered to be a gradual and progressive condition and there is scant data on myocardial infarction (MI) as a clinical presentation. METHODS AND RESULTS: Of 2,462 consecutive patients who underwent percutaneous coronary intervention between June 2001 and December 2002, clinical in-stent restenosis occurred in 212 (8.6%), who were classified into 3 groups: ST elevation MI (STEMI), non-ST elevation MI (NSTEMI) and non-MI. Of the 212 patients presenting with clinical in-stent restenosis, 22 (10.4%) had MI (creatine kinase (CK)>or=2xbaseline with elevated CKMB). The remaining 190 (89.6%) patients had stable angina or evidence of ischemia by stress test without elevation of cardiac enzymes. Median interval between previous intervention and presentation for clinical in-stent restenosis was shorter for patients with MI than for non-MI patients (STEMI, 90 days; NSTEMI, 79 days; non-MI, 125 days; p=0.07). Diffuse in-stent restenosis was more frequent in MI patients than in non-MI patients (72.7% vs 56.3%; p<0.005). Renal failure was more prevalent in patients with MI than in those without MI (31.8% vs 6.3%, p=0.001). Compared with the non-MI group, patients with MI were more likely to have acute coronary syndromes at the time of index procedure (81.8% vs 56.8%, p=0.02). CONCLUSION: Clinical in-stent restenosis can frequently present as MI and such patients are more likely to have an aggressive angiographic pattern of restenosis. Renal failure and acute coronary syndromes at the initial procedure are associated with MI.

Impact of gender on in-hospital outcomes following contemporary percutaneous intervention for peripheral arterial disease.

BACKGROUND: Percutaneous peripheral arterial intervention (PPAI) has emerged as an effective and less invasive alternative to surgery for peripheral arterial disease (PAD), however, data on gender differences in outcome of PPAI, especially in the stent era, are limited. The purpose of this study was to assess the gender differences on in-hospital outcomes of patients undergoing PPAI. METHODS: We analyzed data on 268 consecutive patients (women: 122; men: 146) who underwent PPAI for PAD between October 2001 and January 2004. A total of 405 lesions (women: 184; men: 221) were treated. RESULTS: Background characteristics were similar except for less prevalent prior coronary intervention in women (18.0% versus 28.8%; p = 0.04), and more prevalent current smokers in women (22.1% versus 12.3%; p = 0.03). Upper extremities interventions were performed more often in women (9.2% versus 3.2%; p = 0.01). Procedure success was achieved in 89.3% of women and 89.7% of men (p = NS). In-hospital mortality was similar between women and men (1.6% versus 0.7%; p = NS). However, hemorrhagic complications occurred more frequently in women (7.4% versus 0.7%; p = 0.006). The blood transfusion rate was significantly higher in women (6.6% versus 0.7%; p = 0.013). Female gender was the only independent predictor of hemorrhagic complications (OR = 12.2; 95% CI = 1.39-111.1; p = 0.024). CONCLUSIONS: Percutaneous intervention for PAD can be performed in women with similar success rates as in men, albeit with a greater than 10-fold higher risk of hemorrhagic complications.

Nonmalignant superior vena cava syndrome: pathophysiology and management.

Superior vena cava (SVC) syndrome occurs following obstruction either from external compression or internal thrombosis or scarring. In the past, treatment was limited to medical therapy or surgical bypass but now percutaneous revascularization presents a viable therapeutic option. We present our experience in the percutaneous therapy of patients with nonmalignant SVC syndrome and review the condition with regard to its pathophysiology and management.