Semiquantitative Chest CT Severity Score Predicts Failure of Noninvasive Positive-Pressure Ventilation in Patients Hospitalized for COVID-19 Pneumonia.

OBJECTIVE: Noninvasive positive-pressure ventilation (NPPV) emerged as an efficient tool for treatment of COVID-19 pneumonia. The factors influencing NPPV failure still are elusive. The aim of the study was to investigate the relationships between semiquantitative chest computed tomography (CT) scoring and NPPV failure and mortality in patients with COVID-19. DESIGN: Observational study. SETTING: Nonintensive care setting. PARTICIPANTS: A total of 112 patients consecutively admitted for COVID-19 pneumonia. INTERVENTIONS: Usual care including various degrees of respiratory support. MEASUREMENTS AND MAIN RESULTS: The semiquantitative CT score was calculated at hospital admission. Subgroups were identified according to the ventilation strategy used (oxygen delivered by Venturi mask n = 53; NPPV-responder n = 38; NPPV-failure n = 21). The study's primary endpoint was the use of NPPV. The secondary endpoints were NPPV failure and in-hospital death, respectively. CT score progressively increased among groups (six v nine v 14, p < 0.05 among all). CT score was an independent predictor of all study endpoints (primary endpoint: 1.25 [95% confidence interval {CI} 1.1-1.4], p = 0.001; NPPV failure: 1.41 [95% CI 1.18-1.69], p < 0.001; in-hospital mortality: 1.21 [95% CI 1.07-1.38], p = 0.003). According to receiver operator characteristics curve analysis, CT score was the most accurate variable for prediction of NPPV failure (area under the curve 0.862 with p < 0.001; p < 0.05 v other variables). CONCLUSIONS: The authors reported the common and effective use of NPPV in patients with COVID-19 pneumonia. In the authors' population, a semiquantitative chest CT analysis at hospital admission accurately identified those patients responding poorly to NPPV.

A clinical and angiographic study of the XIENCE V everolimus-eluting coronary stent system in the treatment of patients with multivessel coronary artery disease: the EXECUTIVE trial (EXecutive RCT: evaluating XIENCE V in a multi vessel disease).

OBJECTIVES: This study sought to investigate the efficacy and performance of the XIENCE V everolimus-eluting stent (EES) (Abbott Vascular, Santa Clara, California) in the treatment of de novo coronary lesions in patients with 2- to 3-vessel multivessel coronary artery disease (MV-CAD). BACKGROUND: Drug-eluting stents (DES) have emerged as an alternative to conventional coronary artery bypass surgery in patients with MV-CAD although first-generation DES yielded inferior efficacy and safety compared with surgery. METHODS: Prospective, randomized (1:1), multicenter feasibility trial was designed to assess angiographic efficacy of EES compared with the TAXUS paclitaxel-eluting stent (PES) in 200 patients, and a prospective, open-label, single-arm, controlled registry was designed to analyze the clinical outcome of EES at 1-year follow-up in 400 MV-CAD patients. For the randomized trial, the primary endpoint was in-stent late loss at 9 months. For the registry, the primary endpoint was a composite of all-cause death, myocardial infarction, and ischemia-driven target vessel revascularization at 12 months. RESULTS: The primary endpoint per single lesion was significantly lower in the EES group compared with the PES group (-0.03 ± 0.49 mm vs. 0.23 ± 0.51 mm, p = 0.001). Similar results were observed when analyzing all lesions (0.05 ± 0.51 mm vs. 0.24 ± 0.50 mm, p < 0.001). Clinical outcome at 1 year yielded a composite of major adverse cardiac events of 9.2% in the single-arm registry, and 11.1% and 16.5% in the EES and PES randomized groups, respectively (p = 0.30). CONCLUSIONS: The EXECUTIVE trial was a randomized pilot trial dedicated to the comparison of the efficacy of 2 different DES among patients with 2- to 3-vessel MV-CAD. The study shows lower in-stent late loss at 9 months with the EES XIENCE V compared with the PES TAXUS Libertè, and a low major adverse cardiac event rate at 1 year in patients with 2-to 3-vessel MV-CAD. (EXECUTIVE [EXecutive RCT: Evaluating XIENCE V in a Multi Vessel Disease]; NCT00531011).

Comparison of the feasibility and effectiveness of transradial coronary angiography via right versus left radial artery approaches (from the PREVAIL Study).

It remains undefined if transradial coronary angiography from a right or left radial arterial approach differs in real-world practice. To address this issue, we performed a subanalysis of the PREVAIL study. The PREVAIL study was a prospective, multicenter, observational survey of unselected consecutive patients undergoing invasive cardiovascular procedures over a 1-month observation period, specifically aimed at assessing the outcomes of radial approach in the contemporary real world. The choice of arterial approach was left to the discretion of the operator. Prespecified end points of this subanalysis were procedural characteristics. Of 1,052 patients consecutively enrolled, 509 patients underwent transradial catheterization, 304 with a right radial and 205 with a left radial approach. Procedural success rates were similar between the 2 groups. Compared to the left radial group, the right radial group had longer procedure duration (46 ± 29 vs 33 ± 24 minutes, p <0.0001) and fluoroscopy time (765 ± 787 vs 533 ± 502, p <0.0001). At multivariate analysis, including a parsimonious propensity score for the choice of left radial approach, duration of procedure (beta coefficient 11.38, p <0.001) and total dose-area product (beta coefficient 11.38, p <0.001) were independently associated with the choice of the left radial artery approach. The operator's proficiency in right/left radial approach did not influence study results. In conclusion, right and left radial approaches are feasible and effective to perform percutaneous procedures. In the contemporary real world, however, the left radial route is associated with shorter procedures and lower radiologic exposure than the right radial approach, independently of an operator's proficiency.

Late enhancement detected by cardiac magnetic resonance imaging in acute myocarditis mimicking acute myocardial infarction: location patterns and lack of correlation with systolic function.

OBJECTIVE: Clinical recognition of acute myocarditis is difficult. Late enhancement (LE) detected by magnetic resonance imaging appears to be a valuable tool for evaluating and monitoring inflammatory myocardial diseases. However, patterns of myocardial enhancement and its correlation with systolic function are not yet well defined. The aim of this study was to assess the extent and location of LE during the acute phase of active myocarditis mimicking acute myocardial infarction and at follow-up, in order to correlate LE with systolic function and to monitor disease progression. METHODS: Magnetic resonance imaging was performed in 13 patients with clinical symptoms and signs of acute myocarditis. RESULTS: All patients showed LE, which was located in the lateral free wall in 11 (85%) patients, at the basal level in eight (61%), at the mid level in nine (69%), and at the distal level in 10 (77%). Moreover, six (46%) patients showed LE in the posterior and inferior wall (P = 0.099 versus lateral wall), four (31%) patients in the septum and inferior wall (P = 0.017 versus lateral wall) and three (23%) patients in the anterior wall (P = 0.006 versus lateral wall). Left ventricular ejection fraction was 0.50 +/- 10 and it was severely reduced only in one patient (0.20). Conversely, in the remaining patients, left ventricular ejection fraction was preserved (> or =0.45) (P < 0.001). Multifocal LE was detected in eight (61%) patients, whereas pericardial effusion was observed only in two (15%) patients (P = 0.002). Twelve patients showed ST-segment elevation and chest pain, as it occurs in acute myocardial infarction, whereas one patient showed non-ST-segment elevation with dyspnoea, as it occurs in non-ST-elevation myocardial infarction. The mean follow-up duration was 4 +/- 12 months, and follow-up was complete for all but one patient who died. LE extent decreased in 11 (92%) patients, whereas new areas of LE were detected in one (8%) patient (P < 0.001). CONCLUSIONS: Contrast enhancement is a frequent finding in the clinical setting of suspected myocarditis and is associated with active and/or persistent myocardial inflammation. Myocarditis detected by magnetic resonance imaging predominantly occurs in the lateral free wall and very rarely affects systolic function.

Effects of reperfusion obtained two to six months after acute myocardial infarction on myocardial electrical stabilization in patients with an occluded infarct-related coronary artery.

To assess the changes in electrical stability markers in patients with previous myocardial infarction after very late reopening of the infarct-related artery, we studied QT dispersion, corrected-QT dispersion, and late potentials before and 1, 3, and 6 months after an attempt at late percutaneous coronary intervention (PCI) in 31 consecutive patients with single-vessel disease (infarct-related artery occlusion or subocclusion) diagnosed > or = 4 weeks after the ST-elevation myocardial infarction. Patients underwent PCI 3.9 +/- 2 months after ST-elevation myocardial infarction. PCI was successful in 24 patients (group A) and unsuccessful in 7 (group B). The 2 groups were similar in clinical and angiographic characteristics, as well as the prevalence of basal late potentials, average QT dispersion, and corrected-QT dispersion. One month after PCI, the successful reperfusion group had a significant 67% decrease in the prevalence of late potentials and average QT dispersion and corrected QT dispersion (51 +/- 9 vs 72 +/- 11 ms, p <0.00001, and 51 +/- 10 vs 76 +/- 15 ms, p <0.00001, respectively). These benefits remained stable at 3 and 6 months after PCI. Conversely, the unsuccessful group did not show any improvement in electrical stability markers after PCI failed. Thus, reperfusion obtained very late after ST-elevation myocardial infarction confers significant electrical stabilization that may contribute to a better outcome in patients with patent infarct-related arteries.

Effects of the nitric oxide donor nitroprusside on no-reflow phenomenon during coronary interventions for acute myocardial infarction.

We tested the effects of the nitric oxide donor nitroprusside as treatment for no reflow in 23 consecutive patients who underwent coronary angioplasty for acute myocardial infarction. No reflow was defined as a decrease of >/=1 Thrombolysis In Myocardial Infarction (TIMI) trial flow grade occurring after successful initial coronary recanalization. Nitroprusside induced a significant improvement in coronary flow, with an increase in TIMI flow grade from 1.5 +/- 0.8 to 2.9 +/- 0.3 (p <0.0001) and in TIMI frame count from 46 +/- 25 to 16 +/- 5 (p <0.0001). There were no significant adverse effects apart from transient hypotension. Intracoronary nitroprusside should be considered as a treatment of no reflow occurring in acute myocardial infarction.

A uncommon cause of angina during upper limb exercise.

Subclavian artery stenosis or occlusion may be a cause of myocardial ischemia in patients treated using an internal mammary artery graft. Subclavian stenosis may cause myocardial ischemia during arm exercise by a coronary-subclavian steal phenomenon, with flow inversion in the graft from the coronary tree to the left subclavian artery. We here describe a case of a patient developing left subclavian occlusion after coronary artery bypass grafting with the left internal mammary artery. The lesion was successfully treated with a carotid-subclavian bypass. The article underscores the importance of an early diagnosis (possibly before bypass surgery) and discusses possible treatments. Percutaneous interventions with stent implantation appear the treatment of choice, but surgery has an important role in case of total occlusion.