Modes of failure of guide catheter extensions: Insights from the MAUDE database.

OBJECTIVES: Guide catheter extensions (GCEs) are commonly used to facilitate percutaneous coronary interventions (PCIs). We investigated the incidence and modes of failure of GCEs.. METHODS: Data from the Manufacturer and User Facility Device Experience (MAUDE) database between 2012 and 2022 were used to investigate the most common modes of failure and related adverse events with the use of GCEs. We performed analysis of 4 commonly used catheters: GuideLiner (Teleflex), Guidezilla (Boston Scientific), TrapLiner (Teleflex), and Telescope (Medtronic). The first event reported for GuideLiner was in 2012, Guidezilla in 2018, TrapLiner in 2017, and Telescope in 2019. RESULTS: During the study period, a total of 651 events were reported to the database. A total of 429 true GCE device failures were identified: 59 (14%) for GuideLiner, 297 (69%) for Guidezilla, 47 (11%) TrapLiner, and 26 (6%) for Telescope. Catheter detachment or fracture was the most frequently reported device failure for all 4 GCEs; these failures included shaft fractures, tip deformations, and collar detachments. We identified 222 reported events as unspecified adverse events; these events included device-to-device incompatibility, difficulty to advance, and device fractures outside the patient body. Only 58 (8.9%) events resulted in patient complication. Of these, coronary artery dissection was the most frequently reported complication. CONCLUSIONS: Device detachment/fracture is the most common mode of device failure in all 4 GCEs, and coronary dissection is the most common patient complication.

Comparison of Figure-of-Eight Suture and Perclose ProGlide Suture-Mediated Closure in Large Bore Venous Access Hemostasis: A Randomized Controlled Trial.

Suture-mediated closure device and Figure-of-Eight suture are commonly used to achieve hemostasis after use of large bore venous access. Although both methods of closure are commonly used in clinical practice, a head-to-head comparison in a controlled setting has not been performed. Patients presenting to a single center for elective left atrial appendage occlusion or transcatheter edge-to-edge mitral valve repair were randomized to large bore venous closure using the Perclose ProGlide suture-based closure or a Figure-of-Eight suture closure. The patients were followed for 1 month after the procedure. Primary outcome, a composite of access site large ecchymosis, hematoma, infection, pain, need for unscheduled venous ultrasound and need for transfusion, was compared between the 2 arms. A total of 40 patients were randomized in a 1:1 fashion to the 2 venous closure strategies. Baseline characteristics were similar between the 2 groups. Perclose ProGlide arm required use of more devices for hemostasis (1.5 ± 0.5 vs 1 ± 0 respectively, p <0.0001), and there was a significant difference in the cost of closure device ($367.00 ± 122.00 vs $1.00 ± 0 respectively, p <0.001). At 1 month post-procedure, the primary outcome occurred in 4 patients (20%) in the Perclose arm and 7 (35%) patients in the Figure-of-Eight arm, a difference that was not statistically significant (p = 0.48). Time to hemostasis between Figure-of-Eight and Perclose arms did not reach statistical significance (2.5 ± 2.1 vs 3.7 ± 2.3, p = 0.09). In conclusion, both Perclose ProGlide suture-based device and Figure-of-Eight closure are equally feasible and safe for patients who underwent large bore venous access. Figure-of-Eight-based closure is more cost effective.

Feasibility of Transcatheter Mitral Valve Repair for Non-A2P2 Mitral Regurgitation.

BACKGROUND: MitraClip is approved for treatment of both degenerative and functional mitral regurgitation (MR). The landmark trials for this device included only patients with A2P2 location of MR. Initial commercial experience showed A2P2 location was associated with higher technical success as compared with non-A2P2 location. We intended to compare technical success of A2P2 vs non-A2P2 MitraClip procedures in terms of residual MR and transmitral gradient (TMG) in the contemporary setting as the operator experience has increased. A total of 159 patients with complete data were included in the study. A total of 129 patients were in the A2P2 MitraClip group and 30 patients were in the non-A2P2 MitraClip group. Post implantation, there was a significant increase in TMG in both A2P2 and non-A2P2 groups (0.73 ± 1.42 and 0.94 ± 1.85, respectively; both P<.01). However, postimplantation TMG was not different between the 2 groups (3.6 ± 1.9 A2P2 vs 3.7 ± 1.7 non-A2P2; P=.56) and there was no difference in residual MR (P=.40). At 1-month follow-up of 82 patients (64 A2P2 and 18 non-A2P2), the results were similar; TMG (3.7 ± 1.6 A2P2 vs 3.7 ± 2.1 non-A2P2; P=.96) and residual MR (P=.41). Our data showed similar technical success of MitraClip procedures in both types of MR.

A Rare Iatrogenic Trio: Pneumopericardium, Pneumoperitoneum, and Pericarditis.

We present a rare case of iatrogenic pneumopericardium, pneumoperitoneum, and Escherichia coli pericarditis after emergency pericardiocentesis for pericardial tamponade. The patient had profound bowel distention at the time of the procedure that led to iatrogenic pericardioperitoneal fistula formation along with transverse colon perforation, which manifested later after pericardial drain removal. This condition required repeat pericardiocentesis, laparoscopic colon repair, a long course of antibiotics, and an eventual pericardial window. (Level of Difficulty: Intermediate.).

Differential effects of eplerenone versus amlodipine on muscle metaboreflex function in hypertensive humans.

Numerous studies have demonstrated that sympathetic nervous system overactivation during exercise in hypertensive rodents and humans is due, in part, to an exaggerated reflex response known as the exercise pressor reflex. Our prior studies have implicated a key role of mineralocorticoid receptor activation in mediating an augmented exercise pressor reflex in spontaneously hypertensive rats, which is mitigated by blockade with eplerenone. However, the effect of eplerenone on exercise pressor reflex has not been assessed in human hypertension. Accordingly, the authors performed a randomized crossover study to compare the effects of eplerenone to another antihypertensive drug from a different class amlodipine on sympathetic nerve activity (SNA) in 14 patients with uncomplicated hypertension. The authors found that amlodipine unexpectedly augmented the increase in SNA during the second minute of isometric handgrip, which persisted into the post-exercise circulatory arrest period (∆ SNA, from rest of 15 ± 2 vs. 9 ± 2 vs. 10 ± 2 bursts/min, amlodipine vs. baseline vs. eplerenone, respectively, p < .01), suggesting an exaggerated muscle metaboreflex function. Eplerenone did not alter sympathetic responses to exercise or post-exercise circulatory arrest in the same hypertensive individuals. In conclusions, our studies provide the first direct evidence for a potentially unfavorable potentiation of muscle metaboreflex by amlodipine during isometric handgrip exercise in hypertensive patients whereas eplerenone has no significant effect. Our study may have clinical implications in terms of selection of antihypertensive agents that have the least detrimental effects on sympathetic neural responses to isometric exercise.

Haemodynamic Interplay Between Concomitant Left Ventricular Outflow Tract Obstruction and Aortic Stenosis.

The authors describe a patient with hypertrophic cardiomyopathy with concomitant left ventricular outflow tract obstruction and aortic stenosis. Detailed haemodynamic assessment of the serial lesions was performed. Alcohol septal ablation resulted in a significant reduction of gradients across the left ventricular outflow tract.

Assessment of patient and provider attitudes towards therapeutic drug monitoring to improve medication adherence in low-income patients with hypertension: a qualitative study.

OBJECTIVES: Previous studies have implicated therapeutic drug monitoring (TDM), by measuring serum or urine drug levels, as a highly reliable technique for detecting medication non-adherence but the attitudes of patients and physicians toward TDM have not been evaluated previously. Accordingly, we solicited input from patients with uncontrolled hypertension and their physicians about their views on TDM. DESIGN: Prospective analysis of responses to a set of questions during semistructured interviews. SETTING: Outpatient clinics in an integrated health system which provides care for a low-income, uninsured population. PARTICIPANTS: Patients with uncontrolled hypertension with either systolic blood pressure of at least 130 mm Hg or diastolic blood pressure of at least 80 mm Hg despite antihypertensive drugs and providers in the general cardiology and internal medicine clinics. PRIMARY AND SECONDARY OUTCOME MEASURES: Attitudes towards TDM and the potential impact on physician-patient relationship. RESULTS: We interviewed 11 patients and 10 providers and discussed the findings with 13 community advisory panel (CAP) members. Of the patients interviewed, 91% (10 of 11) and all 10 providers thought TDM was a good idea and should be used regularly to better understand the reasons for poorly controlled hypertension. However, 63% (7 of 11) of patients and 20% of providers expressed reservations that TDM could negatively impact the physician-patient relationship. Despite some concerns, the majority of patients, providers and CAP members believed that if test results are communicated without blaming patients, the potential benefits of TDM in identifying suboptimal adherence and eliciting barriers to adherence outweighed the risks. CONCLUSION: The idea of TDM is well accepted by patients and their providers. TDM information if delivered in a non-judgmental manner, to encourage an honest conversation between patients and physicians, has the potential to reduce patient-physician communication obstacles and to identify barriers to adherence which, when overcome, can improve health outcomes.

Quality of Life Outcomes After Transcatheter Aortic Valve Replacement in Nonagenarians.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) is an increasingly prevalent treatment in patients who are intermediate or high risk for surgical intervention. In nonagenarian patients undergoing TAVR, symptomatic relief and quality of life (QoL) outcomes have not been well established. This study explores these outcomes in this patient population that has been underrepresented in landmark clinical trials. METHODS: All patients who underwent TAVR between January 1, 2015 and December 31, 2018 at Delray Medical Center were included. The 12-item Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) score was used to assess QoL prior to and 30 days following TAVR in two patient groups: the nonagenarian group (patients ≥90 years old) and the younger group (patients <90 years old). KCCQ-OS scores were compared between these two groups. Frailty assessment included grip strength, gait speed, and activities of daily living. Unadjusted and adjusted analyses (baseline KCCQ-OS score, frailty, and Society of Thoracic Surgery perioperative risk of mortality [STS-PROM] score) were performed to assess the impact of age on QoL outcomes in both groups. RESULTS: Of the total 223 patients included in this study, a total of 46 (20.6%) were nonagenarians and 118 (52.7%) were men. KCCQ-OS scores were lower at baseline and 30-day follow-up in nonagenarians compared with the younger group (P=.70). Age was a significant predictor of 30- day KCCQ-OS in unadjusted and adjusted analyses (adjusted for baseline KCCQ-OS, frailty, and STS-PROM score). Nonagenarians had an average 6.45 points lower 30-day KCCQ-OS scores than the younger patients in adjusted analysis. However, there was a significant clinical improvement in the 30-day KCCQ-OS score in both groups (P<.001). CONCLUSIONS: Our data suggest that with appropriate patient selection, a significant clinical improvement may be expected with TAVR in nonagenarians.

Transcatheter Closure of Persistent Left Superior Vena Cava Draining to Pulmonary Vein: A Rare Entity.

We describe a patient with recurrent embolic strokes who was found to have a persistent left superior vena cava draining into a pulmonary vein. Transcatheter placement of a vascular plug resulted in successful occlusion of the superior vena cava. Repeat bubble study on follow-up imaging was negative for a right-to-left shunt. (Level of Difficulty: Advanced.).

Usefulness of Blood Pressure Variability Indices Derived From 24-Hour Ambulatory Blood Pressure Monitoring in Detecting Autonomic Failure.

Background Increased blood pressure ( BP ) variability and nondipping status seen on 24-hour ambulatory BP monitoring are often observed in autonomic failure ( ATF ). Methods and Results We assessed BP variability and nocturnal BP dipping in 273 patients undergoing ambulatory BP monitoring at Southwestern Medical Center between 2010 and 2017. SD , average real variability, and variation independent of mean were calculated from ambulatory BP monitoring. Patients were divided into a discovery cohort (n=201) and a validation cohort (n=72). ATF was confirmed by formal autonomic function test. In the discovery cohort, 24-hour and nighttime average real variability, SD , and variation independent of mean did not differ significantly between ATF (n=25) and controls (n=176, all P>0.05). However, daytime SD, daytime coefficient of variation, and daytime variation independent of mean of systolic BP ( SBP ) were all significantly higher in patients with ATF than in controls in both discovery and validation cohorts. Nocturnal BP dipping was more blunted in ATF patients than controls in both cohorts (both P<0.01). Using the threshold of 16 mm Hg, daytime SD SBP yielded a sensitivity of 77% and specificity of 82% in detecting ATF in the validation cohort, whereas nondipping status had a sensitivity of 80% and specificity of 44%. The area under the receiver operator characteristic of daytime SD SBP was greater than the area under the receiver operator characteristic of nocturnal SBP dipping (0.79 [0.66-0.91] versus 0.73 [0.58-0.87], respectively). Conclusions Daytime SD of SBP is a better screening tool than nondipping status in detecting autonomic dysfunction.

Diagnostic Thresholds for Blood Pressure Measured at Home in the Context of the 2017 Hypertension Guideline.

Most guidelines have recommended lower home blood pressure (BP) threshold when clinic BP threshold of 140/90 mm Hg is used for diagnosis of hypertension. However, home BP thresholds to define hypertension have never been determined in the general population in the United States. We identified home BP thresholds for stage 1 (BP ≥130/80 mm Hg) hypertension using a regression-based approach in the DHS (Dallas Heart Study; n=5768) and the NCMH study (North Carolina Masked Hypertension; n=420). Home BP thresholds were also assessed using outcome-derived approach based on the composite of all-cause mortality or cardiovascular events in the DHS cohort. For this approach, BP thresholds were identified only for systolic BP because diastolic BP was not associated with the outcome. Among untreated participants, the regression-derived thresholds for home BP corresponding to clinic BP for stage 1 hypertension were 129/80 mm Hg in blacks, 130/80 mm Hg in whites, and 126/78 mm Hg in Hispanics, respectively. The results are similar in the North Carolina cohort. The 11-year composite cardiovascular and mortality events corresponding to clinic systolic BP >130 mm Hg were higher in blacks than in whites and Hispanics (13.3% versus 5.98% versus 5.52%, respectively). Using a race/ethnicity-specific composite outcome in the untreated DHS participants, the outcome-derived home systolic BP thresholds corresponding to stage 1 hypertension were 130 mm Hg in blacks, 129 mm Hg in whites, and 131 mm Hg in Hispanics, respectively. Our data based on both regression-derived and outcome approach support home BP threshold of 130/80 mm Hg for diagnosis of hypertension in blacks, whites, and Hispanics.

Is the Pulmonary Embolism Severity Index Being Routinely Used in Clinical Practice?

Background. The Pulmonary Embolism Severity Index (PESI) score can risk-stratify patients with PE but its widespread use is uncertain. With the PESI, we compared length of hospital stay between low, moderate, and high risk PE patients and determined the number of low risk PE patients who were discharged early. Methods. PE patients admitted to St. Joseph Mercy Oakland Hospital from January 2005 to August 2010 were screened. PESI score stratified acute PE patients into low (<85), moderate (86-105), and high (>105) risk categories and their length of hospital stay was compared. Patients with low risk PE discharged early (≤3 days) were calculated. Results. Among 315 PE patients, 51.7% were at low risk. No significant difference in hospital stay between low (7.11 ± 3 d) and moderate (6.88 ± 2.9 d) risk, p > 0.05, as well as low and high risk (7.28 ± 3.0 d), p > 0.05, was found. 9% of low risk patients were discharged ≤ 3 days. Conclusions. There was no significant difference in length of hospital stay between low and high risk groups and only a small number of low risk patients were discharged from the hospital early suggesting that risk tools like PESI may not have a widespread use.