Transhepatic Access for Percutaneous Mitral Balloon Commissurotomy With Dextrocardia and Inferior Vena Cava Interruption.

We report a successful percutaneous mitral balloon commissurotomy via left transhepatic venous access in a 42-year-old female patient with dextrocardia, situs inversus totalis, and inferior vena cava interruption. fWe also discuss the revisions required for optimal trans-septal approach from the left transhepatic vein.

Predictive modeling for acute kidney injury after percutaneous coronary intervention in patients with acute coronary syndrome: a machine learning approach.

BACKGROUND: Acute kidney injury (AKI) is one of the preventable complications of percutaneous coronary intervention (PCI). This study aimed to develop machine learning (ML) models to predict AKI after PCI in patients with acute coronary syndrome (ACS). METHODS: This study was conducted at Tehran Heart Center from 2015 to 2020. Several variables were used to design five ML models: Naïve Bayes (NB), Logistic Regression (LR), CatBoost (CB), Multi-layer Perception (MLP), and Random Forest (RF). Feature importance was evaluated with the RF model, CB model, and LR coefficients while SHAP beeswarm plots based on the CB model were also used for deriving the importance of variables in the population using pre-procedural variables and all variables. Sensitivity, specificity, and the area under the receiver operating characteristics curve (ROC-AUC) were used as the evaluation measures. RESULTS: A total of 4592 patients were included, and 646 (14.1%) experienced AKI. The train data consisted of 3672 and the test data included 920 cases. The patient population had a mean age of 65.6 ± 11.2 years and 73.1% male predominance. Notably, left ventricular ejection fraction (LVEF) and fasting plasma glucose (FPG) had the highest feature importance when training the RF model on only pre-procedural features. SHAP plots for all features demonstrated LVEF and age as the top features. With pre-procedural variables only, CB had the highest AUC for the prediction of AKI (AUC 0.755, 95% CI 0.713 to 0.797), while RF had the highest sensitivity (75.9%) and MLP had the highest specificity (64.35%). However, when considering pre-procedural, procedural, and post-procedural features, RF outperformed other models (AUC: 0.775). In this analysis, CB achieved the highest sensitivity (82.95%) and NB had the highest specificity (82.93%). CONCLUSION: Our analyses showed that ML models can predict AKI with acceptable performance. This has potential clinical utility for assessing the individualized risk of AKI in ACS patients undergoing PCI. Additionally, the identified features in the models may aid in mitigating these risk factors.

Comparison of machine-learning models for the prediction of 1-year adverse outcomes of patients undergoing primary percutaneous coronary intervention for acute ST-elevation myocardial infarction.

BACKGROUND: Acute ST-elevation myocardial infarction (STEMI) is a leading cause of mortality and morbidity worldwide, and primary percutaneous coronary intervention (PCI) is the preferred treatment option. HYPOTHESIS: Machine learning (ML) models have the potential to predict adverse clinical outcomes in STEMI patients treated with primary PCI. However, the comparative performance of different ML models for this purpose is unclear. METHODS: This study used a retrospective registry-based design to recruit consecutive hospitalized patients diagnosed with acute STEMI and treated with primary PCI from 2011 to 2019, at Tehran Heart Center, Tehran, Iran. Four ML models, namely Gradient Boosting Machine (GBM), Distributed Random Forest (DRF), Logistic Regression (LR), and Deep Learning (DL), were used to predict major adverse cardiovascular events (MACE) during 1-year follow-up. RESULTS: A total of 4514 patients (3498 men and 1016 women) were enrolled, with MACE occurring in 610 (13.5%) subjects during follow-up. The mean age of the population was 62.1 years, and the MACE group was significantly older than the non-MACE group (66.2 vs. 61.5 years, p < .001). The learning process utilized 70% (n = 3160) of the total population, and the remaining 30% (n = 1354) served as the testing data set. DRF and GBM models demonstrated the best performance in predicting MACE, with an area under the curve of 0.92 and 0.91, respectively. CONCLUSION: ML-based models, such as DRF and GBM, can effectively identify high-risk STEMI patients for adverse events during follow-up. These models can be useful for personalized treatment strategies, ultimately improving clinical outcomes and reducing the burden of disease.

Case report: Thoracic endovascular aortic repair using a non-touch exclusion technique with a custom-made device for the treatment of a large patent ductus arteriosus.

Patent ductus arteriosus (PDA) is a common congenital heart disease affecting roughly one in every 2,000 term births. Although most of the patients are diagnosed and treated during childhood, few cases may persist into adulthood. We presented a 27-year-old male patient with a 20.2 mm diameter PDA who was referred to our hospital with progressive fatigue and exertional dyspnea. Given the potential complications, usual techniques such as coil occlusion and duct occluders were deemed inappropriate for this patient. Thoracic endovascular aortic repair (TEVAR) using a non-touch exclusion technique was successfully performed for this patient. The patient was discharged with no major post-surgical complications. TEVAR could be a new, safe, and effective alternative treatment to other transcatheter procedures for complicated PDAs in some patients.

Association of the high-sensitive cardiac troponin T levels and long-term mortality in patients with acute aortic dissection type A.

Introduction: Acute aortic dissection type A is a life-threatening cardiovascular emergency necessitating rapid diagnosis and treatment. We sought a new prognostic tool with cardiac biomarkers and simple inflammatory factors. Methods: from 2003 to 2014, 50 patients with documented acute aortic dissection type A were entered to this study. These patients were followed up until December 2020; within median follow up of 93.6 months. The patients were evaluated on the association of the baseline characteristics, first laboratory investigation, echocardiographic findings, surgical approach, and long-term mortality. Results: Total number of mortality during the follow up was 29 (58%) patients, which was significantly higher in medical group (89.4% vs 38.7%, P value=0.001). Multivariable analysis showed only an increase in hs-cTnT levels was suggested as a predictor of mortality (95% CI: 1.06-1.38; HR=1.21; P=0.005), so that for every 100 units increase, patients were 21% more likely to have mortality in long term. Also, performing surgical treatment for aortic dissection was determined as the independent predictor of surviving, so that death was 74.6% less than those who received medical treatment (95% CI: 0.13-0.58; HR=0.27; P=0.001). Conclusion: hs-cTnT is a potential predictor of mortality in patients with acute aortic dissection type A.

The relationship of circulating neuregulin 4 and irisin, and traditional and novel cardiometabolic risk factors with the risk and severity of coronary artery disease.

BACKGROUND AND AIMS: Neuregulin 4 (NRG4) and irisin are adipokines that have been suggested to be associated with cardiometabolic risk factors and coronary artery disease (CAD), but the data are inconclusive. This study aimed to investigate the relationship between circulating NRG4 and irisin and cardiometabolic risk factors with CAD risk and severity. METHODS AND RESULTS: In this cross-sectional study, the presence of CAD and the severity of stenosis (gensini score) were documented based on coronary angiography in 166 adults. Circulating NRG4 and irisin, glucose homeostasis markers, hs-CRP, lipid profiles, blood pressure, and anthropometric measurements were assessed as well. Age (p = 0.005), sex (p = 0.008), SBP (p = 0.033), DBP (p = 0.04), MAP (p = 0.018), FBG (p = 0.012), insulin (p = 0.039) and HOMA-IR (p = 0.01) were significantly associated with odds of having CAD. The final logistic regression model showed that age, sex, HOMA-IR, and MAP were the most important determinants of having CAD. There were no significant associations between circulating irisin and NRG4 with odds of having CAD. The final general linear model showed that being men (ß = 17.303, 95% CI: 7.086-27.52, P = 0.001), age (Aß = 0.712, 95% CI: 0.21-1.214, P = 0.006), HOMA-IR (Aß = 2.168, 95% CI: 0.256 to 4.079, P = 0.027), and NRG4 level (ß = 1.836, 95% CI: 0.119-3.553, P = 0.036) were directly associated with higher gensini score. Participants with the three-vessel disease had a mean increase of about 5 units in circulating irisin compared to those with no clinical CAD (ß = 5.221, 95% CI: 0.454-9.987, p = 0.032). CONCLUSIONS: This study showed that the adipokines NRG4 and Irisin might be associated with the severity of coronary stenosis.

Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study.

BACKGROUND: Effective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT. METHODS: We enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge. RESULTS: Twelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients. CONCLUSIONS: CDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.

Immunomodulatory potential of human clonal mesenchymal stem cells and their extracellular vesicle subpopulations in an inflammatory-mediated diabetic Rhesus monkey model.

AIMS: This study aimed to investigate the therapeutic potential of a homogenous clonal population of mesenchymal stem cells (cMSC) and their extracellular vesicles (cMSC-EV) subpopulations on isolated rat islets in vitro and in inflammatory-mediated type 1 diabetes (T1D) non-human primate models. MAIN METHODS: EV subpopulations were isolated from human bone marrow-derived cMSC supernatant by low- and high-speed ultracentrifuge (EV-20K and EV-U110K) and sucrose density gradient (EV-S110K). The EVs were characterized generally and for the level of albumin, acetylcholinesterase (AChE) activity, co-isolate apoptotic markers, and expression of CD63+/annexin V+. Rat islet-derived single cells (iSCs) proliferation was measured using a Ki-67 proliferation assay. Diabetes was induced by multiple low-dose administrations of streptozotocin in rhesus monkeys. The diabetic monkeys were divided into three groups: the cMSC group, received two injections of 1.5 × 106 cMSC/kg body weight; the EV group received two injections of EVs isolated from 1.5 × 106 cMSC/kg, and the vehicle group received phosphate-buffered saline. KEY FINDINGS: EV-S110K showed higher AChE activity, lower expression of CD63+/annexin V+, and lower apoptotic co-isolates. EV-S110K induced ß-cell proliferation in vitro in a dose-dependent manner. The administration of EV-S110K and/or cMSC in diabetic monkeys demonstrated no significant changes in general diabetic indices and ß-cell mass in the pancreas of the monkeys. Both treatments demonstrated a lowering trend in blood glucose levels and reduced pro-inflammatory cytokines. In contrast, regulatory T cells and anti-inflammatory cytokines were increased. SIGNIFICANCE: cMSC and cMSC-EV provided initial evidence to attenuate clinical symptoms in inflammatory-mediated T1D non-human primates through immunomodulation.

Edge-to-Edge Transcatheter Mitral Valve Repair Using PASCAL vs. MitraClip: A Systematic Review and Meta-Analysis.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) of the mitral valve (MV) can be performed using the PASCAL or MitraClip devices. Few studies offer a head-to-head outcome comparison of these two devices. MATERIAL AND METHODS: PubMed, EMBASE, Cochrane Library, Clinicaltrials.gov and WHO's International Clinical Trials Registry Platform, from 1 January 2000 until 1 March 2023, were searched. Study protocol details were registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42023405400). Randomized Controlled Trials and observational studies reporting head-to-head clinical comparison of PASCAL and MitraClip devices were eligible for selection. Patients with severe functional or degenerative mitral regurgitation (MR) who had undergone TEER of the MV with either PASCAL or MitraClip devices were included in the meta-analysis. Data from six studies (five observational and one randomized clinical trial) were extracted and analyzed. The main outcomes were a reduction in MR to 2+ or less, improvement of New York Heart Association (NYHA) and 30-day all-cause mortality. Peri-procedural mortality, success rate and adverse events were also compared. RESULTS: Data from 785 and 796 patients that underwent TEER using PASCAL and MitraClip, respectively, were analyzed. Thirty-day all-cause mortality (Risk ratio [RR] = 1.51, 95% CI 0.79-2.89), MR reduction to maximum 2+ (RR = 1.00, 95% CI 0.98-1.02) and NYHA improvement (RR = 0.98, 95% CI 0.84-1.15) were similar in both device groups. Both devices had high and similar success rates (96.9% and 96.7% for the PASCAL and MitraClip group, respectively, p value = 0.91). MR reduction to 1+ or less at discharge was similar in both device groups (RR = 1.06, 95% CI 0.95-1.19). Composite peri-procedural and in-hospital mortality was 0.64% and 1.66% in the PASCAL and MitraClip groups, respectively (p value = 0.094). Rates of peri-procedural cerebrovascular accidents were 0.26% in PASCAL and 1.01% in MitraClip (p value = 0.108). CONCLUSIONS: Both PASCAL and MitraClip devices have high success and low complication rates for TEER of the MV. PASCAL was not inferior to MitraClip in reducing the MR level at discharge.

Prediction of in-hospital adverse clinical outcomes in patients with pulmonary thromboembolism, machine learning based models.

Background: Pulmonary thromboembolism (PE) is the third leading cause of cardiovascular events. The conventional modeling methods and severity risk scores lack multiple laboratories, paraclinical and imaging data. Data science and machine learning (ML) based prediction models may help better predict outcomes. Materials and methods: In this retrospective registry-based design, all consecutive hospitalized patients diagnosed with pulmonary thromboembolism (based on pulmonary CT angiography) from 2011 to 2019 were recruited. ML based algorithms [Gradient Boosting (GB) and Deep Learning (DL)] were applied and compared with logistic regression (LR) to predict hemodynamic instability and/or all-cause mortality. Results: A total number of 1,017 patients were finally enrolled in the study, including 465 women and 552 men. Overall incidence of study main endpoint was 9.6%, (7.2% in men and 12.4% in women; p-value = 0.05). The overall performance of the GB model is better than the other two models (AUC: 0.94 for GB vs. 0.88 and 0.90 for DL and LR models respectively). Based on GB model, lower O2 saturation and right ventricle dilation and dysfunction were among the strongest adverse event predictors. Conclusion: ML-based models have notable prediction ability in PE patients. These algorithms may help physicians to detect high-risk patients earlier and take appropriate preventive measures.

Evaluating the role of intravenous pentoxifylline administration on primary percutaneous coronary intervention success rate in patients with ST-elevation myocardial infarction (PENTOS-PCI).

Ischemia reperfusion injury can lead to further myocardiocyte damage in patients with ST-elevation myocardial infarction (STEMI). Pentoxifylline is a methylxanthine derivative with known anti-inflammatory, antioxidant, vasodilator, and rheological properties which can be a promising agent in preventing reperfusion injury. PENTOS-PCI is a single-center, randomized, double-blind, placebo-controlled trial which evaluated the efficacy and safety of preprocedural administration of intravenous pentoxifylline in patients undergoing primary percutaneous coronary intervention (PCI). Patients with acute STEMI who were eligible for PCI were randomized to receive either 100-mg intravenous infusion of pentoxifylline or placebo, prior to transferring to catheterization laboratory. Overall, 161 patients were included in our study of whom 80 patients were assigned to pentoxifylline and 81 to the control groups. Per-protocol analysis of primary endpoint indexing PCI's success rate as measured by thrombolysis in myocardial infarction (TIMI) flow grade 3 was not significantly different between pentoxifylline and placebo (71.3% and 66.3% respectively, P = 0.40). In addition, pentoxifylline could not improve secondary angiographic endpoints including myocardial blush grade 3 (87.5% and 85.2%, P = 0.79) and corrected TIMI frame count (22.8 [± 9.0] and 24.0 [± 5.1], P = 0.33) in the intervention and placebo groups respectively. The rates of major adverse cardiac and treatment emergent adverse effects were not significantly different between the two groups. Administration of intravenous pentoxifylline before primary PCI did not improve the success rate of the procedure in patients with STEMI. Intravenous administration of pentoxifylline was well tolerated, and there were no significant differences regarding adverse drug reactions in the two groups. Panel A, background: pentoxifylline is a methylxanthine derivative with known anti-inflammatory, antioxidant, vasodilator, and rheological properties which can be a promising agent in preventing reperfusion injury. Panel B: study design and main results of the PENTOS-PCI trial. cTFC corrected TIMI frame count, ED emergency department, IRI ischemia reperfusion injury, MBG myocardial blush grade, PCI percutaneous coronary intervention, PPCI primary PCI, PTX pentoxifylline, ROS reactive oxygen species, SD standard deviation, STEMI ST-elevation myocardial infarction, TIMI thrombolysis in myocardial infarction.

Hematuria during the right heart catheterization procedure: Renal perforation as a very rare complication.

The occurrence of hematuria during a right heart catheterization can be a sign of renal perforation, a rare but life-threatening complication that could be developed due to the misdirection of wire into the abdominopelvic venous plexus. We showed this complication could be managed with venoplasty of the common iliac vein.

Effects of opium use on one-year major adverse cardiovascular events (MACE) in the patients with ST-segment elevation MI undergoing primary PCI: a propensity score matched - machine learning based study.

BACKGROUND: Considerable number of people still use opium worldwide and many believe in opium's health benefits. However, several studies proved the detrimental effects of opium on the body, especially the cardiovascular system. Herein, we aimed to provide the first evidence regarding the effects of opium use on one-year major adverse cardiovascular events (MACE) in the patients with ST-elevation MI (STEMI) who underwent primary PCI. METHODS: We performed a propensity score matching of 2:1 (controls: opium users) that yielded 518 opium users and 1036 controls. Then, we performed conventional statistical and machine learning analyses on these matched cohorts. Regarding the conventional analysis, we performed multivariate analysis for hazard ratio (HR) of different variables and MACE and plotted Kaplan Meier curves. In the machine learning section, we used two tree-based ensemble algorithms, Survival Random Forest and XGboost for survival analysis. Variable importance (VIMP), tree minimal depth, and variable hunting were used to identify the importance of opium among other variables. RESULTS: Opium users experienced more one-year MACE than their counterparts, although it did not reach statistical significance (Opium: 72/518 (13.9%), Control: 112/1036 (10.8%), HR: 1.27 (95% CI: 0.94-1.71), adjusted p-value = 0.136). Survival random forest algorithm ranked opium use as 13th, 13th, and 12th among 26 variables, in variable importance, minimal depth, and variable hunting, respectively. XGboost revealed opium use as the 12th important variable. Partial dependence plot demonstrated that opium users had more one-year MACE compared to non-opium-users. CONCLUSIONS: Opium had no protective effects on one-year MACE after primary PCI on patients with STEMI. Machine learning and one-year MACE analysis revealed some evidence of its possible detrimental effects, although the evidence was not strong and significant. As we observed no strong evidence on protective or detrimental effects of opium, future STEMI guidelines may provide similar strategies for opium and non-opium users, pending the results of forthcoming studies. Governments should increase the public awareness regarding the evidence for non-beneficial or detrimental effects of opium on various diseases, including the outcomes of primary PCI, to dissuade many users from relying on false beliefs about opium's benefits to continue its consumption.

In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis.

Aim: A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established. Methods: This retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions. Results: Approximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99-12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91-2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92-6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women. Conclusions: Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality.

Percutaneous stent implantation for occluded central shunts in adults: A case report and review of current evidence.

Background: Patients with cyanotic complex congenital heart defects (CHDs) commonly undergo palliation with interposition of systemic-to-pulmonary shunts (SPSs). These palliative shunts are rarely found in adults with CHDs and can be complicated with progressive obstruction or total occlusion during follow-up. The best treatment option for shunt re-permeabilization is challenging and case-oriented because most patients are high risk candidates for redo surgeries. We aimed to review the current evidence on percutaneous stent implantation to treat failed SPSs. Methods: We performed a comprehensive literature review on percutaneous stent implantation to treat failed and occluded SPSs. We also reported the case of a 33-year-old man with cyanotic CHD and a occluded central aorto-pulmonary shunt, who was successfully treated with percutaneous balloon dilatation and subsequently stent implantation at our institution. Result: We identified and included 31 articles reporting on 150 patients and 165 stent implantations in failed SPSs. The age of patients at the time of stent implantation ranged from 6 days to 47 years. The time between the surgical shunt creation and transcatheter intervention ranged from 1 day to 17 years. Overall, 161/165 (97.5%) stent implantations were successful. The most common clinical presentation was cyanosis and decreased atrial oxygen saturations and the indication for stent implantation was shunt obstruction and stenosis. Conclusion: This review highlights the benefits of endovascular stenting to permeabilize failed SPSs in children and adults with complex CHD who are classified as poor candidates for re-surgical repair.

Predictors and mortality of patients with delayed pulmonary embolism diagnosis: A cohort study.

Background: Some earlier studies demonstrated an increased mortality risk attributed to delayed pulmonary embolism (PE) diagnosis. Therefore, we mainly aimed to determine the predictors of diagnostic delays and the effect of delayed diagnosis on mortality. Methods: We prospectively studied 756 consecutive patients admitted with PE between March 2007 and September 2017. The delayed diagnosis was defined as (1) patient presenting > 7 days after onset of symptoms, (2) diagnosis takes > 24 hours upon arriving in the ED, or (3) undergoing coronary angiography before establishing PE diagnosis. Results: A total of 127 (16.7%) patients met the delayed group's criteria. Heart failure (OR= 2.257, 95% CI: 1.130-4.508, P= 0.021), diabetes mellitus (OR= 1.568, 95% CI: 0.996-2.469, P= 0.052), and precordial T wave inversions (OR=2.559, 95% CI: 1.649-3.970, P< 0.001) were linked to higher rates of delayed diagnosis, while hemoptysis (OR=0.254, 95% CI: 0.059-1.087, P= 0.065) and hemodynamic instability (OR= 0.434, 95% CI: 0.168-1.123, P= 0.085) negatively correlated with it. Delayed PE diagnosis did not significantly impact the overall survival during the follow-up. The unadjusted and adjusted mortality hazard ratio for delayed diagnosis were 1.198 (95% CI: 0.758- 1.894, P= 0.439) and 1.215 (95% CI: 0.762- 1.939, P=0.413), respectively. Older age, heart failure, and hemodynamic instability increased the risk of death (p<0.001). Conclusion: Hemoptysis, hemodynamic instability, diabetes mellitus, heart failure, and T wave inversions in precordial leads were the independent predictors of delayed diagnosis. Delayed PE diagnosis did not increase the patients' mortality rates.

Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial.

Importance: The optimal treatment of intermediate-high-risk pulmonary embolism (PE) remains unknown. Objective: To assess the effect of conventional catheter-directed thrombolysis (cCDT) plus anticoagulation vs anticoagulation monotherapy in improving echocardiographic measures of right ventricle (RV) to left ventricle (LV) ratio in acute intermediate-high-risk PE. Design, Setting, and Participants: The Catheter-Directed Thrombolysis vs Anticoagulation in Patients with Acute Intermediate-High-Risk Pulmonary Embolism (CANARY) trial was an open-label, randomized clinical trial of patients with intermediate-high-risk PE, conducted in 2 large cardiovascular centers in Tehran, Iran, between December 22, 2018, through February 2, 2020. Interventions: Patients were randomly assigned to cCDT (alteplase, 0.5 mg/catheter/h for 24 hours) plus heparin vs anticoagulation monotherapy. Main Outcomes and Measures: The proportion of patients with a 3-month echocardiographic RV/LV ratio greater than 0.9, assessed by a core laboratory, was the primary outcome. The proportion of patients with an RV/LV ratio greater than 0.9 at 72 hours after randomization and the 3-month all-cause mortality were among secondary outcomes. Major bleeding (Bleeding Academic Research Consortium type 3 or 5) was the main safety outcome. A clinical events committee, masked to the treatment assignment, adjudicated clinical outcomes. Results: The study was prematurely stopped due to the COVID-19 pandemic after recruiting 94 patients (mean [SD] age, 58.4 [2.5] years; 27 women [29%]), of whom 85 patients completed the 3-month echocardiographic follow-up. Overall, 2 of 46 patients (4.3%) in the cCDT group and 5 of 39 patients (12.8%) in the anticoagulation monotherapy group met the primary outcome (odds ratio [OR], 0.31; 95% CI, 0.06-1.69; P = .24). The median (IQR) 3-month RV/LV ratio was significantly lower with cCDT (0.7 [0.6-0.7]) than with anticoagulation (0.8 [0.7-0.9); P = .01). An RV/LV ratio greater than 0.9 at 72 hours after randomization was observed in fewer patients treated with cCDT (13 of 48 [27.0%]) than anticoagulation (24 of 46 [52.1%]; OR, 0.34; 95% CI, 0.14-0.80; P = .01). Fewer patients assigned to cCDT experienced a 3-month composite of death or RV/LV greater than 0.9 (2 of 48 [4.3%] vs 8 of 46 [17.3%]; OR, 0.20; 95% CI, 0.04-1.03; P = .048). One case of nonfatal major gastrointestinal bleeding occurred in the cCDT group. Conclusions and Relevance: This prematurely terminated randomized clinical trial of patients with intermediate-high-risk PE was hypothesis-generating for improvement in some efficacy outcomes and acceptable rate of major bleeding for cCDT compared with anticoagulation monotherapy and provided support for a definitive clinical outcomes trial. Trial Registration: ClinicalTrials.gov Identifier: NCT05172115.

Comparison of Angiographic and Clinical Outcomes After Primary Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction Between Patients With and Without Concomitant COVID-19 Infection.

OBJECTIVE: COVID-19 infection can involve the cardiovascular system and worsen the prognosis of the patients. This study aimed to investigate the adverse effects of COVID-19 on angiographic and clinical outcomes of primary percutaneous coronary intervention (PCI) in patients with acute ST-elevation MI and compare results with those patients without COVID-19 disease. METHODS: The study was a retrospective observational cohort, in which patients presented with ST-elevation MI from February 2020 to April 2021, treated with primary PCI were divided into 2 groups based on the COVID-19 infection. Then, the procedural and angiographic indices and also clinical outcomes were compared between the 2 groups. RESULTS: A total of 1150 patients were enrolled in the study. Those with established COVID-19 infection had worse baseline thrombolysis in myocardial infarction flow grade and also were at higher risk for worse procedural outcomes such as lower thrombolysis in myocardial infarction frame count, myocardial blush grade, and slow-flow coronary disease, after the primary PCI. Additionally, the presence of COVID-19 at the time of primary PCI was related to a significantly higher duration of hospitalization and in-hospital mortality. Given the potential impact of other factors on outcomes, analysis for all of the primary endpoints was done again after adjustment of these factors and the results were the same as before, suggesting the independent effect of COVID-19 infection. CONCLUSIONS: The concomitant COVID-19 infection in the patients undergoing primary PCI is associated with significantly worse angiographic, procedural and clinical outcomes. Surprisingly, this finding is regardless of patients' baseline risk factors and demographical characteristics.

Impact of Baseline Estimated Glomerular Filtration Rate Using CKD-EPI Equation on Long-term Prognosis of STEMI Patients: A Matter of Small Increments!

BACKGROUND: Baseline biomarkers including glomerular filtration rate (GFR) guide the management of patients with ST-segment elevation myocardial infarction (STEMI). GFR is a tool for prediction of adverse outcomes in these patients. OBJECTIVES: We aimed to determine the prognostic utility of estimated GFR using Chronic Kidney Disease Epidemiology Collaboration in a cohort of STEMI patients. METHODS: A retrospective cohort was designed among 5953 patients with STEMI. Primary endpoint of the study was major adverse cardiovascular events. GFR was classified into 3 categories delineated as C1 (<60 mL/min), C2 (60-90), and C3 (≥ 90). RESULTS: Mean age of the patients was 60.38 ± 5.54 years and men constituted 78.8% of the study participants. After a median of 22 months, Multivariate Cox-regression demonstrated that hazards of major averse cardiovascular event, all-cause mortality, cardiovascular mortality, and nonfatal myocardial infarction were significantly lower for subjects in C3 as compared with those in C1. Corresponding hazard ratios (HRs) for mentioned outcomes regarding C3 versus C1 were (95% confidence interval) were (HR = 0.852 [0.656-0.975]; P = 0.035), (HR = 0.425 [0.250-0.725]; P = 0.002), (HR = 0.425 [0.242-0.749]; P = 0.003), and (0.885 [0.742-0.949]; P = 0.003), respectively. Normal GFR was also associated with declined in-hospital mortality with HR of C3 versus C1: 0.299 (0.178-0.504; P < 0.0001). CONCLUSIONS: Baseline GFR via Chronic Kidney Disease Epidemiology Collaboration is associated with long-term cardiovascular outcomes following STEMI.