Updates on Patent Foramen Ovale (PFO) Closure.

PURPOSE OF REVIEW: Patent foramen ovale (PFO) has been previously linked to left circulation thromboembolism and stroke. This review article aims to discuss the latest evidence, updated societal guidelines, diagnostic algorithms and novel therapeutic devices for PFO closure. RECENT FINDINGS: PFO closure for cryptogenic stroke and systemic embolization is supported by a large body of evidence and has a strong societal recommendation. Limited data are available for platypnea-orthodeoxia syndrome, although closure appears to be beneficial. Current data do not support routine closure for migraines and decompression Illness. Development of heart-brain teams can improve identification of patients most likely to benefit from closure, utilizing a combination of imaging test and risk score algorithms. Multiple novel devices aiming at reducing complications and improving the long-term impact of current available devices are being evaluated. PFO closure has significantly progressed over the last years, with new data supporting its superiority in reducing risk of recurrent embolic stroke in patients with PFO-related stroke. Additional clinical data are required to provide further refinements on patient selection and guidance on treatment of specific subgroups.

Genetic diversity of the KCNE1 gene and susceptibility to postoperative atrial fibrillation.

BACKGROUND: The human KCNE1 protein forms the ß-subunit of the IKs potassium channel and is important in the regulation of the atrial action potential duration. The purpose of this study was to investigate the association between the nonsynonymous 112G>A mutation of the KCNE1 gene and postcardiac surgery atrial fibrillation (AF). METHODS AND RESULTS: A cohort of patients scheduled for cardiac surgery was prospectively recruited. The genotype of 112G>A polymorphism was determined using polymerase chain reaction/restriction fragment analysis and confirmed with direct sequencing of the polymerase chain reaction product. In total, 509 patients were recruited in the study, of whom 203 (39.9%) had at least 1 qualifying episode of postoperative AF. An increased frequency of the G allele was observed in the postoperative AF group compared with the group without postoperative AF (0.628 vs 0.552, respectively, P = .016). The individual's relative risk of postoperative AF increased as the number of G alleles increased from 1.36 (95% CI 0.89-2.08) for G allele heterozygotes to 1.62 (95% CI 1.08-2.43) for G allele homozygotes (P = .04 for trend). The multivariate analysis revealed the abnormal ejection fraction (odds ratio [OR] 1.585, 95% CI 1.076-2.331, P = .020), age (OR 1.043, 95% CI 1.022-1.064, P < .001), type of surgery (aortic valve replacement) (OR 1.869, 95% CI 1.094-3.194, P = .022), and the 112G>A genotype (OR 1.401 [in additive model], 95% CI 1.052-1.865, P = .021) to be independent predictors of postoperative AF. CONCLUSION: This study confirmed the association of the 112G>A polymorphism and postoperative AF in a cohort of patients undergoing cardiac surgery.

Advances in Management of Stable Coronary Artery Disease: the Role of Revascularization?

PURPOSE OF REVIEW: Coronary artery disease remains the most common cause of death worldwide. In patients with biomarker-positive acute coronary syndrome, the combination of guideline-directed medical therapy with routine revascularization is associated with improved outcomes. However, the role of routine revascularization in stable ischemic heart disease, in addition to medical therapy, remains a matter of debate. In this review, we aimed to describe the role of revascularization in stable ischemic heart disease. RECENT FINDINGS: Revascularization is indicated in patients with stable ischemic heart disease and progressive or refractory symptoms, despite medical management. When guided by ischemia presence, revascularization has failed to show survival benefit, compared with medical therapy alone in multiple clinical trials. On the other hand, revascularization guided by coronary lesion severity, assessed by FFR or iFR, has been shown to offer survival benefit and improvement in symptom severity. PCI-revascularization of unprotected left main disease is feasible with comparable to surgical approach outcomes. Clinical decision to perform revascularization in stable ischemic heart disease necessitates a heart team approach, and no simple algorithm can guide this process. Further studies are required to assess the benefit of routine revascularization, in combination to medical therapy, in this population.

Home Hospitalization for Acute Decompensated Heart Failure: Opportunities and Strategies for Improved Health Outcomes.

IMPORTANCE: Heart failure (HF) is the leading cause of hospitalization among patients over the age of 65 in the United States and developed countries, posing a significant economic burden to the health care systems. More than half of the patients with HF will be readmitted to the hospital within 6 months from discharge, leading not only to increased health care related expenses but also functional decline, iatrogenic injuries and in-hospital infections. With the increasing prevalence of HF, there is a substantial need for innovative delivery care models that can provide hospital level of care at a patient's home. OBSERVATIONS: Home hospitalization was originally used to safely manage chronically ill patients with general medical (stroke, chronic obstructive pulmonary disease, deep vein thrombosis, community acquired pneumonia) and surgical conditions and was associated with improved patient satisfaction and improvement in activity of daily living status. This had no clear effect on readmission or cost. When hospital at home care model was applied to HF patients it demonstrated increased time to readmission, reduced index costs and improved health related quality of life, with no significant differences in adverse events. Eligible patients should be selected based on multiple factors taking into consideration applicable limitations and comorbidities. CONCLUSIONS AND RELEVANCE: Providing in-hospital level care to the patient's house presents a reliable alternative, yielding multiple benefits both for the patient, as well as the health care system. Formulating a well-defined model is necessary before wide implementation.

Timing and Outcomes of PCI in the TAVR Era.

PURPOSE OF REVIEW: Transcatheter aortic valve replacement (TAVR) has become an established therapy for patients with symptomatic severe aortic stenosis (AS). As the number of patients referred for TAVR increases, so does the prevalence of untreated obstructive coronary artery disease (CAD) in the population under evaluation. Despite the high prevalence of CAD in patients treated with TAVR, the management strategy of concomitant CAD in these patients remains an area of considerable uncertainty. RECENT FINDINGS: Percutaneous coronary intervention (PCI) in patients with CAD and severe AS has been shown to be feasible and safe. Whether revascularization before, during, or after TAVR is optimal remains a subject of debate. All three approaches represent valid strategies with advantages and disadvantages that need to be carefully weighed on an individual basis. Current expert opinions recommend that PCI should be performed before or at the time of TAVR as long as the risk of the procedure does not outweigh the potential benefits. The results of large clinical trials evaluating the optimal revascularization time are closely awaited.

Medicolegal implications of radial and femoral access for coronary angiography and intervention in 2016: Focus on retroperitoneal hemorrhage.

BACKGROUND AND OBJECTIVES: Retroperitoneal hemorrhage is a rare but serious complication of transfemoral approach (TFA) and TFA percutaneous coronary intervention (PCI). Radial approach for coronary angiography and intervention (transradial approach, TRA) is associated with lower access site complications and reduced blood transfusion rates. Retroperitoneal bleeding has not been described with TRA. This study sought to evaluate the relationship between femoral access for coronary angiography (TFA) and PCI-induced retroperitoneal hemorrhage and the resulting medical litigation in the United States. METHODS: From 342 lawsuit claim records identified in LexisNexis database search, 17 cases of TFA and TFAPCI-related retroperitoneal hemorrhage decided between 1995 and 2015 were included in the study. Claims were thoroughly reviewed and information about the date the case was decided, patient outcome, the plaintiff, the defendant, the claim, and the trial outcome were extracted. RESULTS: The most common filled claim was medical malpractice (53% of the cases), followed by wrongful death (18%) and review of the Commissioner's decision to deny the application for supplemental security income (12%). Forty-seven percent of the cases were won by the defense, 29% by the plaintiff, and 24% were remanded for a new trial. In 82% of the cases, physicians were sued, but only 14% of the cases were won by the plaintiff. In 59% of the claims, the patient died; however, 70% of those cases were decided in favor of the defending physician and hospital. CONCLUSION: Retroperitoneal hemorrhage is an uncommon complication of TFA and TFA PCI and is associated with high mortality rates. Physicians should able to identify this complication early and address it in a timely manner based on the applicable standard of care. TRA and TRA PCI is a reliable alternative and may potentially reduce medicolegal liability related to access site choice.

Radial Interventions: Present and Future Indications.

OPINION STATEMENT: Since its first introduction, radial access for diagnostic and interventional cardiovascular procedures has progressively evolved with advances in understanding, capabilities, and ease of operation. Numerous studies have demonstrated its safety, efficacy, and cost-effectiveness. Overall, radial catheterization is a valid alternative to the femoral approach with additional benefits of shorter length of hospital stay and reduced patient costs when performed by experienced interventionists. Moreover, with reduced rates of access site complications and enhanced patient satisfaction, the transradial approach has emerged as the preferred vascular access route for most coronary interventions, even in cases of acute myocardial infarction.

Radiation Exposures Associated With Radial and Femoral Coronary Interventions.

OPINION STATEMENT: The volume of cardiac diagnostic procedures involving the use of ionizing radiation has increased rapidly in recent years, and the radiation exposure experienced by patients undergoing any medical imaging procedure has recently obtained a growing attention. Transradial (TR) access is being increasingly used worldwide for diagnostic coronary angiography (CA), and percutaneous coronary interventions, since it offers several benefits as compared to transfemoral (TF) access, such as by reducing hemostasis time and vascular complications, increased patient comfort, reduced hospital stay, and lower cost. In contrast, TR CA is thought to be associated with increased radiation exposure parameters compared with the traditional TF access. Although experienced operators may almost counterbalance this shortcoming, the increase in radiation exposure associated with TR approach seems not to be present in most clinical settings.

Transapical transcatheter aortic valve replacement in patients with or without prior coronary artery bypass graft operation.

BACKGROUND: Transapical approach (TA) is an established access alternative to the transfemoral technique in patients undergoing transcatheter aortic valve replacement (TAVR) for treatment of symptomatic aortic valve stenosis. The impact of prior coronary artery bypass grafting (CABG) on clinical outcomes in patients undergoing TA-TAVR is not well defined. METHODS: A single center retrospective cohort analysis of 126 patients (male 41%, mean age 85.8 ± 6.1 years) who underwent TA balloon expandable TAVR (Edwards SAPIEN, SAPIEN XT or SAPIEN 3) was performed. Patients were classified as having prior CABG (n = 45) or no prior CABG (n = 81). Baseline clinical characteristics, in-hospital, 30-day, 6 months and one-year clinical outcomes were compared. RESULTS: Compared to patients without prior CABG, CABG patients were more likely to be male (62.2 vs. 29.6%, p < 0.001) with a higher STS score (11.66 ± 5.47 vs. 8.99 ± 4.19, p = 0.003), history of myocardial infarction (55 vs. 21.1%, p < 0.001), implantable cardioverter defibrillator (17.8 vs. 3.7%, p = 0.017), left main coronary artery disease (42.2 vs. 4.9%, p < 0.001), and proximal left anterior descending coronary artery stenosis (57.8 vs. 16%, p < 0.001). They also presented with a lower left ventricular ejection fraction (%) (42.3 ± 15.3 vs. 54.3 ± 11.6, p < 0.01) and a larger effective valve orifice area (0.75 ± 0.20 cm2 vs. 0.67 ± 0.14 cm2, p = 0.025). There were no intra-procedural deaths, no differences in stroke (0 vs. 1.2%, p = 1.0), procedure time in hours (3.50 ± 0.80 vs. 3.26 ± 0.86, p = 0.127), re-intubation rate (8.9 vs. 8.6% p = 1.0), and renal function (highest creatinine value 1.73 ± 0.71 mg/ml vs.1.88 ± 1.15 mg/ml, p = 0.43). All-cause mortality at 6 months was similar in both groups (11.4, vs. 17.3% p = 0.44), and one-year survival was 81.8 and 77.8% respectively (p = 0.51). On multivariate analysis, the only factor significantly associated with one-year mortality was prior history of stroke (HR, 2.76; 95% CI, 1.06-7.17, p = 0.037). CONCLUSION: Despite the higher baseline clinical risk profile, patients with history of prior CABG undergoing TA-TAVR had comparable in-hospital, 6 months and one-year clinical outcomes to those without prior CABG.

Novel Inflammatory Biomarkers in Coronary Artery Disease: Potential Therapeutic Approaches.

Coronary artery disease constitutes the leading cause of mortality and morbidity in the modern world. Inflammation has been implicated to play a key role in the initiation and promotion of atherosclerosis, and the induction of plaque instability, possibly leading to acute coronary syndrome (ACS). This review aims to assess the clinical utility of well established (CRP) and novel inflammatory biomarkers (Homocyesteine, SAA, sCD40L, sLOX-1, IMA, MPO, PAPP-A and MMPs) in the diagnosis and outcome prediction of patients with ACS. The PubMed database was searched for reports using the terms "biomarkers", "acute coronary syndrome", "infarction", "markers" and only original articles written in English were included. The diversity of novel biomarkers for coronary artery disease provides an insight of the varied pathophysiology of this disease. A better understanding of their properties and assimilation in daily clinical use is essential for optimal management and patient care in the future.