Intravascular Ultrasound-Guided versus Angiography-Guided Percutaneous Coronary Intervention for Stent Thrombosis Elevation Myocardial Infarction: An Updated Systematic Review and Meta-Analysis.

INTRODUCTION: Intravascular ultrasound (IVUS) provides intra-procedural guidance in optimizing percutaneous coronary interventions (PCI) and has been shown to improve clinical outcomes in stent implantation. However, current data on the benefit of IVUS during PCI in ST-elevation myocardial infarction (STEMI) patients is mixed. We performed meta-analysis pooling available data assessing IVUS-guided versus angiography-guided PCI in STEMI patients. METHODS: We conducted a systematic search on PubMed and Embase for studies comparing IVUS versus angiography-guided PCI in STEMI. Mantel-Haenszel random effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs) for outcomes of major adverse cardiovascular events (MACEs), death, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST) and in-hospital mortality. RESULTS: A total of 8 studies including 336,649 individuals presenting with STEMI were included for the meta-analysis. Follow-up ranged from 11 to 60 months. We found significant association between IVUS-guided PCI with lower risk for MACE (RR 0.82, 95% CI 0.76-0.90) compared with angiography-guided PCI. We also found significant association between IVUS-guided PCI with lower risk for death, MI, TVR, and in-hospital mortality but not ST. CONCLUSION: In our meta-analysis, IVUS-guided compared with angiography-guided PCI was associated with improved long-term and short-term clinical outcomes in STEMI patients.

Revascularization Options for Left Main Disease: What Clinicians Need to Know.

PURPOSE OF REVIEW: Left main disease represents the highest-risk lesion subset of coronary artery disease and is associated with adverse cardiovascular events. Accordingly, we aim to understand how the significance of left main disease is assessed by different modalities, followed by a review of management options in current era. RECENT FINDINGS: Invasive coronary angiogram remains the gold standard for assessment of left main disease, but intracoronary imaging or physiological testing is indicated for angiographically equivocal disease. Revascularization by either coronary artery bypass surgery or percutaneous coronary intervention is strongly recommended, which have been compared by six randomized trials, as well as recent meta-analyses. Surgical revascularization remains the preferred mode of revascularization, especially in patients with high lesion complexity and left ventricular dysfunction. Randomized studies are needed to understand if current-generation stents with the use of intracoronary imaging and improved medical therapy could match outcomes with surgical revascularization.

Coronavirus disease-19 and cardiovascular disease: A risk factor or a risk marker?

Severe acute respiratory syndrome coronavirus-2 causes the clinical syndrome of coronavirus disease of 2019 (COVID-19) which has become a global pandemic resulting in significant morbidity and mortality. While the virus primarily affects the respiratory system, it also causes a wide variety of complex cardiac manifestations such as acute myopericarditis, acute coronary syndrome, congested heart failure, cardiogenic shock and cardiac arrhythmias. There are numerous proposed mechanisms of cardiac injury, including direct cellular injury, pro-inflammatory cytokine storm, myocardial oxygen-demand mismatch, and systemic inflammation causing multi-organ failure. Additionally, medications commonly used to treat COVID-19 patients have various cardiovascular side effects. We aim to provide a succinct review about the pathophysiology and cardiac manifestations of COVID-19, as well as treatment considerations and the various adaptations made to the current healthcare structure as a result of the pandemic.

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients with Left Ventricular Systolic Dysfunction.

PURPOSE: There is a paucity of comparative data examining the optimal revascularization strategy in patients with left ventricular systolic dysfunction (LVD). METHODS: We performed an aggregate data meta-analysis of clinical outcomes comparing percutaneous coronary intervention (PCI) versus coronary artery bypass (CABG) in patients with LVD (left ventricle ejection fraction (LVEF) of ≤ 40%), using the random effects model. Effects size is reported as odds ratio (OR) and a 95% confidence interval. Outcomes included all-cause mortality, myocardial infarction, stroke, repeat revascularization, and a composite of major adverse cardiac and cerebrovascular events (MACCE) at 30-day, 3-year, and long-term (6.3 ± 0.9 years) follow-ups. Seventeen studies (16 observational, 1 randomized) and 18,599 patients (CABG 9651; PCI 8948) were included. RESULTS: PCI and CABG had comparable all-cause mortality at 30 days (OR 0.78, 95% CI 0.49-1.23) and 3 years (OR 1.05, 95% CI 0.91-1.21); however, PCI was associated with increased long-term morality after a mean follow-up of 6.3 ± 0.9 years (31.6% vs. 24.3%, OR 1.41, 95% CI 1.21-1.64). A similar mortality trend was observed in the subgroup of patients with EF ≤ 35%. PCI had a higher rate of repeat revascularization at 3-year and long-term follow-ups. The long-term rates of stroke and MI were comparable. PCI, on the other hand, had lower rates of stroke at 30-day and 3-year follow-ups. CONCLUSION: CABG was associated with lower rates of long-term mortality and revascularization but higher rate of upfront stroke in patients with LVD. However, the data included consisted predominantly of observational studies, highlighting the paucity and need for randomized trials.

Ischemia-Guided Approach Versus Early Invasive Approach for NSTE-ACS: How Early Is Early?

PURPOSE OF REVIEW: Non-ST segment elevation acute coronary syndromes (NSTE-ACS) account for 70% of the patients with ACS. Most NSTE-ACS patients receive invasive therapies. Despite improvements in the systems of care and interventional techniques, the mortality of NSTE-ACS patients remains high, and delays in the treatment of NSTE-ACS patients continue to be a problem. This paper aims to discuss the importance of timeliness of invasive strategy in the treatment of NSTE-ACS as well as the state-of-the-art approach to this critical health problem. RECENT FINDINGS: The relatively recent guidelines and meta-analyses on the subject try to shed light on the issue of timing. The picture is now a little clearer, but still much remains to be answered. We know that the early invasive strategy at least is safe and improves recurrent ischemia and refractory angina as well as the length of stay, lowering the cost. In higher-risk patients, there is a benefit for a more aggressive approach. The definition of "early" in the early invasive strategy has evolved over the past decade and currently pertains to an invasive strategy performed within 12-24 h of presentation.

Temporal trends, outcomes, and predictors of mortality after pericardiocentesis in the United States.

BACKGROUND: Data regarding the temporal trends, outcomes, and predictors of in-hospital mortality after pericardiocentesis are limited. METHODS: The National Inpatient Sample database was used to extract hospitalizations of patients who underwent pericardiocentesis from January 2007 to September 2015. We examined the rates of in-hospital mortality, its predictors, and the temporal trends of pericardiocentesis utilization in the United States during the study period. We also examined trends and outcomes of pericardiocentesis associated with different cardiovascular procedures. RESULTS: A total of 96,377 hospitalizations with pericardiocentesis were examined. The number of pericardiocentesis procedures performed trended up significantly between 2007 and 2015 (p trend <.001), and this increase was observed predominantly in patients with unstable conditions. In-hospital mortality after pericardiocentesis decreased over time (14.6% in 2007 vs. 12.0% in 2015, p trend <.001), but remained higher than that after surgical pericardial intervention (13.1 vs. 8.9%, p value <.0001), predominantly attributable to a higher patient risk profile. Rates of in-hospital mortality were not statistically different between the procedural cohort and the nonprocedural cohort, 13.5 versus 13.0%, p value = .051. After multivariable adjustment, structural heart interventions (odds ratio [OR] 2.86; 95% confidence interval [CI] 2.35-3.49), bacterial and/or infective endocarditis (OR 2.09; 95% CI 1.72-2.54) and active neoplasms (OR 1.72; 95% CI 1.6-1.85) were independently associated with increased in-hospital mortality in pericardiocentesis patients. CONCLUSION: In this nationwide analysis, the number of pericardiocentesis procedures increased significantly over time. Structural interventions, endocarditis, and active neoplasms were associated with increased in-hospital mortality after pericardiocentesis.

One-Year Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement for Stenotic Bicuspid versus Tricuspid Aortic Valves: A Meta-Analysis and Meta-Regression.

OBJECTIVE: To assess 1-year mortality after transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (AS). BACKGROUND: Clinical trials have proven the beneficial effect of TAVR on mortality in patients with tricuspid AS. Individuals with bicuspid AS were excluded from these trials. METHODS: A meta-analysis using literature search from the Cochrane, PubMed, ClinicalTrials, SCOPUS, and EMBASE databases was conducted to determine the effect of TAVR on 1-year mortality in patients with bicuspid AS. Short-term outcomes that could potentially impact one-year mortality were analyzed. RESULTS: After evaluating 380 potential articles, 5 observational studies were selected. A total of 3890 patients treated with TAVR were included: 721 had bicuspid and 3,169 had tricuspid AS. No statistically significant difference between the baseline characteristics of the two groups of patients was seen outside of mean aortic gradient. Our primary endpoint of one-year all-cause mortality revealed 85 deaths in 719 patients (11.82%) with bicuspid AS compared to 467 deaths in 3100 patients (15.06%) with tricuspid AS, with no difference between both groups [relative risk (RR) 1.03; 95% CI 0.70-1.51]. Patients with bicuspid AS were associated with a decrease in device success (RR 0.62; 95% CI 0.45-0.84) and an increase in moderate-to-severe prosthetic valve regurgitation (RR 1.55; 95% CI 1.07-2.22) after TAVR compared to patients with tricuspid AS. The effect of meta-regression coefficients on one-year all-cause mortality was not statistically significant for any patient baseline characteristics. CONCLUSION: When comparing TAVR procedure in tricuspid AS versus bicuspid AS, there was no difference noted in one-year all-cause mortality.

Suspected coronary fat embolism after liposuction.

A 38-year-old female presented with chest pain and ST elevation on electrocardiogram after an outpatient liposuction procedure. Emergent coronary angiography revealed complete occlusion of multiple coronary arteries, with fat embolism as the suspected etiology. Attempts to restore distal coronary flow with balloon dilatation, aspiration with Pronto catheter, and distal adenosine administration resulted in minimal improvement in flow. The material aspirated was consistent with fat. With supportive therapy, including Impella CP support, the patient's clinical condition improved. To our knowledge, this is the first reported case of multiple coronary occlusion after liposuction.

Coronary Physiology Assessment for the Diagnosis and Treatment of Stable Ischemic Heart Disease.

Coronary artery disease is the most prevalent cardiovascular disease in the USA. In the majority of settings, percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) reduces angina and improves quality of life; however, it does not improve survival and is associated with infrequent but serious complications. Selection of appropriate patients and coronary lesions for revascularization with PCI is crucial to maximize the benefit-to-risk ratio. The assessment of the hemodynamic significance of intermediate coronary lesions has been shown to improve outcomes and reduce healthcare costs. The current review summarizes the existing evidence regarding the physiological assessment of coronary lesions, with emphasis on fractional flow reserve, the most common invasive hemodynamic assessment modality.

Safety and efficacy of coil embolization of the septal perforator for septal ablation in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVE: The objective of this study was to evaluate safety, efficacy, and durability of coil embolization of the major septal perforator of the left anterior descending coronary artery in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: The long-term effect of coil embolization therapy in HOCM patients is not well defined. METHODS: We evaluated 24 symptomatic HOCM patients in a single center who underwent coil embolization of the septal perforator artery(ies). RESULTS: Twenty-four patients on optimal medical therapy presented with NYHA functional class III (75%) or IV (25%) underwent the procedure. The procedure was successful in 22 patients, with significant reduction in left ventricular outflow tract (LVOT) gradient. The functional class significantly improved to class I (54.2%) or II (41.7%) (P < = 0.01). The LVOT gradient was significantly lower during follow up echocardiography (21.3 ± 19 vs. 81.3 ± 41 mm Hg; P < = 0.01). Interventricular septal thickness decreased over time (16.3 ± 3 vs. 18.5 ± 2 mm, P< = 0.01). The procedure was aborted in one of the patients after the third coil prolapsed from the septal perforator in to the left anterior descending artery. The coil was effectively snared out. Three patients required additional coil placement in the second major septal perforator. New permanent pacemaker placement was required in one patient. However, three patients underwent ICD implantation at follow up due to ventricular arrhythmias. CONCLUSIONS: The results of this study suggest that the use of coil embolization for septal ablation is safe, effective, and durable in patients with symptomatic HOCM. © 2016 Wiley Periodicals, Inc.

The impact of drug shortages on the pharmacy, nursing, and medical staff's ability to effectively care for critically ill patients.

Managing drug shortages has become a daily requirement for health care providers in the critical care environment. Drug shortages impact the practice of different disciplines in various ways, and the perceptions of the underlying causes and appropriate management of drug shortages vary among physicians, nurses, and pharmacists as well. Frequently, these differences can lead to tension between disciplines and feelings of frustration, anger, and helplessness. Understanding the reasons behind drug shortages, the role each discipline has in managing shortages, and establishment of an effective method of communication between disciplines is key to reducing the tension and frustration that can be associated with drug shortages.

Stealing from the Heart: A Rare Case of Chest Pain Post-Coronary Artery Bypass Grafting.

A 70-year-old veteran with prior triple vessel coronary artery bypass grafting (CABG) presented with exertional chest pain. His work-up revealed > 40 mm Hg bilateral upper extremity blood pressure difference. Chest computed tomography and invasive angiography revealed severe stenosis at the ostium of the left subclavian artery, proximal to the origin of the left internal mammary artery to left anterior descending artery graft (LIMA-LAD). A diagnosis of coronary subclavian steal syndrome (CSSS) was made, and carotid-subclavian bypass was performed. This case outlines when to suspect CSSS, an approach to its diagnosis, and the importance of its timely management.

Trends and Outcomes in Patients With Coronary Artery Disease Undergoing TAVR: Insights From VA CART.

Background: Obstructive coronary artery disease (CAD) is common in patients with severe symptomatic aortic stenosis. The management and impact of obstructive CAD in patients undergoing transcatheter aortic valve replacement (TAVR) have not been fully evaluated. We aimed to determine the patient characteristics and clinical outcomes among veterans undergoing TAVR with and without obstructive CAD and to determine temporal trends and association of pre-TAVR percutaneous coronary intervention (PCI) with clinical outcomes. Methods: We identified all patients who underwent TAVR from 2012 to 2021 in the VA Health Care System. The sample population was divided into patients with and without obstructive CAD and further stratified by coronary intervention status 1 year prior to TAVR. The primary outcome was 1-year all-cause mortality, and the secondary outcome was major bleeding. Results: During the study period, 759 patients underwent TAVR, and 282 (37%) had obstructive CAD. Obstructive CAD was associated with higher 1-year mortality (15.6% vs 7.1%; P < .01) after TAVR. The rate of PCI prior to TAVR increased from 2012 until 2016, after which it steadily declined such that 144 patients (51%) underwent PCI pre-TAVR during the entire study period. There was no difference in 1-year mortality (16.0% vs 15.2%; P = .89) or bleeding (16.7% vs 12.3%; P = .33) between patients who underwent or did not undergo pre-TAVR PCI. Conclusions: Among veterans undergoing TAVR, the presence of obstructive CAD is associated with higher mortality though pre-TAVR coronary intervention is not associated with improved outcomes. Further studies could identify a subset of patients who may benefit from coronary revascularization prior to TAVR.

Readmission in patients undergoing percutaneous patent foramen ovale closure in the United States.

Current estimates suggest that a patent foramen ovale (PFO) may exist in up to 25% of the general population and is a potential risk factor for embolic, ischemic stroke. PFO closure complications include bleeding, need for procedure-related surgical intervention, pulmonary emboli, device malpositioning, new onset atrial arrhythmias, and transient atrioventricular block. Rates of PFO closure complications at a national level in the Unites States remain unknown. To address this, we performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database (NRD) to identify patterns of readmissions after percutaneous PFO closure. In conclusion, our study showed that following PFO closure, the most common complications were atrial fibrillation/atrial flutter followed by acute heart failure syndrome, supraventricular tachycardia and acute myocardial infarction.

Invasive Coronary Physiology Assessment for Patients With Stable Coronary Disease.

Visual assessment of coronary stenosis severity using conventional coronary angiography is associated with wide interoperator variability and a weak relationship with hemodynamics. Invasive coronary physiology assessment using fractional flow reserve (FFR) has been shown to be safe and beneficial. Large multicenter randomized trials have demonstrated the superiority of FFR-guided percutaneous coronary intervention in reducing the risk of major cardiac adverse events, number of stents used, and total cost in patients with multivessel coronary disease. FFR requires vasodilatory agents for the microvasculature to induce maximal hyperemia, which carry a slight risk, cost, and effort. Nonhyperemic pressure ratios provide a physiologic metric without vasodilator medications but with more limited clinical outcomes data. The transition from anatomy to physiology for coronary artery disease decision-making represents a cultural sea change in the cardiac catheterization laboratory that requires time and retooling.

Decongestion Models and Metrics in Acute Heart Failure: ESCAPE Data in the Age of the Implantable Cardiac Pressure Monitor.

The United States Food and Drug Administration restricts the use of implantable cardiac pressure monitors to patients with New York Heart Association (NYHA) class III heart failure (HF). We investigated whether single-pressure monitoring could predict survival in HF patients as part of a model constructed using data from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial. We validated survival models in 204 patients, using all-cause 180-day mortality. Two levels of model complexity were tested: 1) a simplified 1-pressure model based on pulmonary artery mean pressure ([PAM]1P) (information obtainable from an implanted intracardiac monitor alone), and 2) a pair of 5-variable risk score models based on right atrial pressure (RAP) + pulmonary capillary wedge pressure (PCWP) ([RAP+PCWP]5V) and on RAP + PAM ([RAP+PAM]5V). The more complex models used 5 dichotomous variables: a congestion index above a certain threshold value, baseline systolic blood pressure of <100 mmHg, baseline blood urea nitrogen level of ≥ 34 mg/dL, need for cardiopulmonary resuscitation or mechanical ventilation, and posttreatment NYHA class IV status. The congestion index was defined as posttreatment RAP+PCWP or posttreatment RAP+PAM, with congestion thresholds of 34 and 42 mmHg, respectively (median pulmonary catheter indwelling time, 1.9 d). The 5-variable models predicted survival with areas under the curve of 0.868 for the (RAP+PCWP)5V model and 0.827 for the (RAP+PAM)5V model, whereas the 1-pressure model predicted survival with an area under the curve of 0.718. We conclude that decongestion as determined by hemodynamic assessment predicts survival in HF patients and that it may be the final pathway for treatment benefit despite improvements in pharmacologic intervention since the ESCAPE trial.

Targeted Hypothermia vs Targeted Normothermia in Survivors of Cardiac Arrest: A Systematic Review and Meta-Analysis of Randomized Trials.

BACKGROUND: The role of targeted hypothermia in patients with coma after cardiac arrest has been challenged in a recent randomized clinical trial. METHODS: We performed a computerized search of MEDLINE, EMBASE, and Cochrane databases through July 2021 for randomized trials evaluating the outcomes of targeted hypothermia vs normothermia in patients with coma after cardiac arrest with shockable or non-shockable rhythm. The main study outcome was mortality at the longest reported follow-up. RESULTS: The final analysis included 8 randomized studies with a total of 2927 patients, with a weighted follow-up period of 4.9 months. The average targeted temperature in the hypothermia arm in the included trials varied from 31.7°C to 34°C. There was no difference in long-term mortality between the hypothermia and normothermia groups (56.2% vs 56.9%, risk ratio [RR] 0.96; 95% confidence interval [CI], 0.87-1.06). There was no significant difference between hypothermia and normothermia groups in rates of favorable neurological outcome (37.9% vs 34.2%, RR 1.31; 95% CI, 0.99-1.73), in-hospital mortality (RR 0.88; 95% CI, 0.77-1.01), bleeding, sepsis, or pneumonia. Ventricular arrhythmias were more common among the hypothermia vs normothermia groups (RR 1.36; 95% CI, 1.17-1.58; P = .42). Sensitivity analysis, excluding the Targeted Hypothermia vs Targeted Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial, showed favorable neurological outcome with hypothermia vs normothermia (RR 1.45; 95% CI, 1.17-1.79). CONCLUSION: Targeted temperature management was not associated with improved survival or neurological outcomes compared with normothermia in comatose patients after cardiac arrest. Further studies are warranted to further clarify the value of targeted hypothermia compared with targeted normothermia.

Left Ventricle Mass Regression After Surgical or Transcatheter Aortic Valve Replacement in Veterans.

BACKGROUND: Differences in left ventricular mass regression (LVMR) between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have not been studied. We present clinical and echocardiographic data from veterans who underwent TAVR and SAVR, evaluating the degree of LVMR and its association with survival. METHODS: We retrospectively reviewed TAVR (n = 194) and SAVR (n = 365) procedures performed in veterans from 2011 to 2019. After 1:1 propensity matching, we evaluated mortality and secondary outcomes. Echocardiographic data (median follow-up 957 days, interquartile range 483-1652 days) were used to evaluate LVMR, its association with survival, and predictors of LVMR. RESULTS: There was no difference between SAVR and TAVR patients in mortality (for up to 8 years), stroke at 30 days, myocardial infarction, renal failure, prolonged ventilation, reoperation, or structural valve deterioration. SAVR patients (67.3% [101 of 150]) were more likely to have LVMR than TAVR patients (55.7% [44 of 79], P = .11). The magnitude of LVMR was greater for the SAVR patients (median, -23.3%) than for the TAVR patients (median, -17.8%, P = .062). SAVR patients with LVMR had a survival advantage over SAVR patients without LVMR (P = .016). However, LVMR was not associated with greater survival in TAVR patients (P = .248). CONCLUSIONS: SAVR patients were more likely to have LVMR and had a greater magnitude of LVMR than TAVR patients. LVMR was associated with better survival in SAVR patients, but not in TAVR patients.

Long-Term Outcomes of Veteran Patients After Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become a mainstay treatment for severe aortic stenosis and is increasingly used for veterans, producing excellent short-term outcomes. There is a paucity of long-term outcome data after TAVR in the veteran population. METHODS: We examined consecutive patients who underwent TAVR at a single Veterans Affairs medical center through 2019. Baseline characteristics, echocardiographic and angiographic variables, and clinical outcomes were abstracted. All-cause mortality was the primary outcome of interest. Factors associated with all-cause mortality and cardiac-specific mortality, including the presence of significant non-revascularized coronary artery disease (CAD), were assessed with multivariable regression and competing-risk analyses. RESULTS: The 189 consecutive patients enrolled (mean age, 76.6 ± 8.4 years) had a median Society of Thoracic Surgeons (STS) score of 6.0 (interquartile range [IQR], 4.0-8.5). After a maximum follow-up of 7.5 years, 71 (37.6%) deaths occurred, of which 76% had a cardiac cause. Median overall survival was 3.55 years (95% confidence interval [CI], 3.21-5.30); significant graded differences were observed across STS risk subgroups (P<.001). After multivariable adjustment, CAD was significantly associated with cardiac mortality (hazard ratio [HR], 2.6; 95% CI, 1.3-5.3) and all-cause mortality (HR, 2.2; 95% CI, 1.1-4.3). Other independent variables associated with all-cause mortality included age (P=.01), baseline creatinine (P<.01), and chronic obstructive pulmonary disease (P=.03). Baseline ejection fraction (P=.04), age (P<.01), creatinine (P=.02), and vascular disease (P=.04) were independently associated with cardiac-specific mortality. CONCLUSION: Long-term survival of veterans after TAVR is comparable to that of their non-veteran counterparts. Significant CAD, along with age and select comorbidities, was associated with poorer survival.