The Imaging Toolbox to Assess Patients with Suspected Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease (MINOCA).

PURPOSE OF REVIEW: This paper will review myocardial infarction with non-obstructive coronary arteries (MINOCAs) briefly, and then focus on the imaging tools that should be employed when caring for patients with suspected MINOCA. RECENT FINDINGS: Diagnostic imaging has a critical role in assessing patients with suspected or confirmed MINOCA. The extent at which these diagnostic tests are used in any given patient will depend on the clinical acumen for the underlying condition, as well as the available resources. There are myriad conditions that can lead to MINOCA; further testing to exclude other underlying causes of myocardial injury is crucial. Cardiovascular imaging may assist in identifying the etiological cause in cases where MINOCA remains the most likely diagnosis. A systematic approach to the diagnostic assessment will help to uncover the underlying diagnosis, guide therapy, and provide the patient and their families with appropriate feedback.

Meta-analysis of randomized controlled trials comparing percutaneous coronary intervention with aspiration thrombectomy Vs. Conventional percutaneous coronary intervention during ST-segment elevation myocardial infarction.

OBJECTIVES: Evaluate the impact of aspiration thrombectomy (AT) during primary coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) on clinical outcomes. BACKGROUND: AT during PCI for STEMI may improve microvascular reperfusion, but its impact on clinical outcomes has remained controversial. METHODS: We searched Pubmed, EMBASE, Medline, Scopus, CENTRAL, andClinicalTrials.gov databases on March 31, 2015 for randomized controlled trials that evaluated the use of AT with PCI compared with PCI alone for STEMI. The primary end point was all-cause mortality. Secondary end points included major adverse cardiac events (MACE, consisting of death, myocardial infarction, and target-vessel revascularization), recurrent myocardial infarction (MI), target-vessel revascularization (TVR), stent thrombosis and stroke. RESULTS: Eighteen randomized controlled trials (n = 21,501) fulfilled the inclusion criteria. A total of 10,544 patients were treated with AT and PCI, compared to 10,957 control patients. The use of AT was not associated with a significant decrease in all-cause mortality (RR 0.88; 95% CI 0.78-1.01; P = 0.07), MACE (RR 0.93; 95% CI 0.86-1.00; P = 0.06), recurrent MI (RR 0.97: 95% CI 0.81-1.17; P = 0.77), TVR (RR 0.93; 95% CI 0.82-1.05; P = 0.23), stent thrombosis (RR 0.84; 95% CI 0.66-1.07; P = 0.17), or stroke (RR 1.35; 95% CI 0.86-2.11; P = 0.19). CONCLUSIONS: Using the totality of evidence available through 2015, this meta-analysis failed to show that the routine use of aspiration thrombectomy in patients with ST-elevation myocardial infarction significantly reduces all-cause mortality, MACE, recurrent MI, TVR, or stent thrombosis. The role of aspiration thrombectomy in selected patients with angiographic evidence of large thrombus burden requires further clinical investigation. © 2015 Wiley Periodicals, Inc.

Role of Cerebral Embolic Protection Devices in Patients Undergoing Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis.

BACKGROUND: Cerebral embolic protection devices (CEPD) capture embolic material in an attempt to reduce ischemic brain injury during transcatheter aortic valve replacement. Prior reports have indicated mixed results regarding the benefits of these devices. With new data emerging, we performed an updated meta-analysis examining the effect of CEPD during transcatheter aortic valve replacement on various clinical, neurological, and safety parameters. METHODS AND RESULTS: A comprehensive review of electronic databases was performed comparing CEPD and no-CEPD in transcatheter aortic valve replacement. Primary clinical outcome was all-cause stroke. Secondary clinical outcomes were disabling stroke and all-cause mortality. Neurological outcomes included worsening of the National Institutes of Health Stroke Scale score, Montreal Cognitive Assessment score from baseline at discharge, presence of new ischemic lesions, and total lesion volume on neuroimaging. Safety outcomes included major or minor vascular complications and stage 2 or 3 acute kidney injury. Seven randomized controlled trials with 4016 patients met the inclusion criteria. There was no statistically significant difference in the primary clinical outcome of all-cause stroke; secondary clinical outcomes of disabling stroke, all-cause mortality, neurological outcomes of National Institutes of Health Stroke Scale score worsening, Montreal Cognitive Assessment worsening, presence of new ischemic lesions, or total lesion volume on diffusion-weighted magnetic resonance imaging between CEPD versus control groups. There was no statistically significant difference in major or minor vascular complications or stage 2 or 3 acute kidney injury between the groups. CONCLUSIONS: The use of CEPD in transcatheter aortic valve replacement was not associated with a statistically significant reduction in the risk of clinical, neurological, and safety outcomes.

Left Ventricular Unloading With Impella Versus IABP in Patients With VA-ECMO: A Systematic Review and Meta-Analysis.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2 = 71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2 = 82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2 = 66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.