Dynamic Invasive Hemodynamic Congestion Profile Impacts Acute Myocardial Infarction Complicated by Cardiogenic Shock Outcomes: A Real-World Single-Center Study.

BACKGROUND: Cardiogenic shock (CS) commonly complicates the management of acute myocardial infarction (AMI), and it results in high mortality rates. Pulmonary artery catheter (PAC) monitoring can be valuable for personalizing critical-care interventions. We hypothesized that patients with AMI-CS experiencing persistent congestion measures during the first 24 hours of the PAC installment would exhibit worse in-hospital survival rates. METHODS AND RESULTS: We studied 295 patients with AMI-CS between January 2006 and December 2021. The first 24-hour PAC-derived hemodynamic measures were divided by the congestion profiling and the proposed 2022 Cardiovascular Angiography and Interventions (SCAI) classification. Biventricular congestion was the most common profile and was associated with the highest patient mortality rates at all time points (mean 56.6%). A persistent congestive profile was associated with increased mortality rates (hazard ratio [HR] = 1.85; P = 0.002) compared with patients who achieved decongestive profiles. Patients with SCAI stages D/E had higher levels of right atrial pressure (RAP): 14-15 mmHg) and pulmonary capillary wedge pressure (PCWP): 18-20 mmHg) compared with stage C (RAP, 10-11 mmHg, mean difference 3-5 mmHg; P < 0.001; PCWP 14-17 mmHg; mean difference 1.56-4 mmHg; P = 0.011). In SCAI stages D/E, the pulmonary artery pulsatility index (0.8-1.19) was lower than in those with grade C (1.29-1.63; mean difference 0.21-0.73; P < 0.001). CONCLUSIONS: Continuous congestion profiling using the SCAI classification matched the grade of hemodynamic severity and the increased risk of in-hospital death. Early decongestion appears to be an important prognostic and therapeutic goal in patients with AMI-CS and warrants further study.

Patient care protocols and personal safety measures for health care professionals in cardiac catheterization rooms during the COVID-19 outbreak in the National Institute of Cardiology.

The COVID-19 was first described in late 2019 that quickly became a pandemic affecting every health system as we know it. The high transmissibility among humans represents a well-known high burden of morbidity and mortality not only for cardiovascular patients but also for a higher risk between health care professionals that must deliver high-quality care to them in any scenario, and cardiac catheterization rooms are no exception. This creates a new dilemma, minimize exposure to patients and health care professionals to COVID-19 while maintaining high quality in cardiovascular therapeutics. In order to achieve this, several international recommendations on treatment algorithms modifications and in safety measures in the catheterization room have been published, always aiming to solve this dilemma in the best possible way. Hereby, we present a summary of the most recent treatment algorithms in the most important cardiovascular interventions (acute coronary syndromes, structural and congenital heart diseases) as well as specific safety measures with a step-by-step preparedness before and after any interventional procedure during COVID-19 outbreak. The objective of this document is to inform and to train health care professionals that works in cardiac catheterization rooms on the risks as well on the plan for containment, mitigation, and response to the global situation of COVID-19 infection in order to apply this in their own local work environments.

Acute left main coronary artery thrombosis as the first manifestation of systemic lupus erythematosus and catastrophic antiphospholipid syndrome.

Most coronary events in young adults are related to atherosclerosis; however, approximately 20% of coronary heart disease in young adults is related to nonatherosclerotic factors such as coronary abnormalities, connective tissue disorders, and autoimmune diseases. Different initial manifestations of systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) have been reported. Myocardial infarction is observed in patients with SLE in all age groups; it appears during the course of the disease; and it is unusual in the APS. We present a unique case of a 28-year-old young man previously healthy who has an ST-elevation myocardial infarction by total acute thrombosis of the left main coronary artery. Laboratory studies demonstrated the presence of antibodies for SLE and APS. The patient was treated successfully with percutaneous coronary intervention. He developed catastrophic APS despite an adequate anticoagulation and was treated with intravenous steroids and plasmapheresis. Clinical evolution was satisfactory, and he discharged from the hospital. This case highlights the importance of considering in the emergency department, the prothrombotic states such as SLE and APS in young patients presenting with acute myocardial infarction caused by an unexplained intracoronary thrombosis. Early diagnosis of catastrophic APS and aggressive therapies are essential to help such patients from succumbing to this potentially fatal condition.

[Evolution of endovascular treatment compared with medical and surgical treatment in patients with aortic syndrome type B]. / Evolución del tratamiento endovascular comparado con el tratamiento médico y el quirúrgico en pacientes con síndrome aórtico agudo de tipo B.

INTRODUCTION: Surgical treatment is accepted as conventional treatment of patients with acute aortic syndrome associated to ischemic complications. Promising results of thoracic endovascular aortic repair (TEVAR) has expanded its indication to a variety of thoracic aorta pathologies. OBJECTIVES: The objective of this study was to evaluate the safety and efficacy of TEVAR during the in-hospital period and at mid-term follow-up, and compare with medical and surgical treatment in patients who presented with acute aortic syndrome (AAS) type B. MATERIAL AND METHODS: Of 113 patients that fulfilled the inclusion criteria, 58 underwent endovascular treatment (Group 1), 34 had medical treatment (Group 2), and 21 had surgical treatment (Group 3). RESULTS: Global and cardiovascular in-hospital mortality was superior in Group 3 (p = 0.0001). Mean follow-up was 30.4 ± 12.2 months. The survival rate free from cardiovascular death was 92.5, 60.5, and 42.9, in Group 1, 2, and 3, respectively, at 36 months. CONCLUSIONS: Our results suggest that endovascular treatment is feasible, safe, and associated with a reduction of in-hospital and mid-term major adverse cardiovascular events, and superior survival rate compared with surgical and medical treatment.

Endovascular treatment of type B dissection in patients with Marfan syndrome: mid-term outcomes and aortic remodeling.

OBJECTIVES: To evaluate the mid-term outcomes, and the aortic remodeling in Marfan syndrome (MFS) patients with type B dissection that were treated with endovascular repair. BACKGROUND: MFS is a relative contraindication to thoracic endovascular aortic repair (TEVAR). Mid-term aortic outcomes data in MFS after TEVAR are limited, and the occurrence of late events remains unclear. METHODS: Of 89 patients that underwent TEVAR between September 2002 and February 2011, 10 patients with mid-term follow-up fulfilled the Ghent criteria for MFS and complicated type B dissection. High risk for open surgery was documented in 90%. RESULTS: The mean age was 35.1 ± 9.4 years and all patients presented with acute aortic syndrome complicating a chronic type B dissection (DeBakey type IIIb). Five patients underwent a Bentall surgical procedure previous to endovascular repair, and in four patients initial TEVAR was followed by surgery of the ascending aorta. Treatment was limited to endovascular repair in only one patient. In-hospital mortality was 10%. At a mean follow-up of 59.6 ± 38.9 months, the cumulated mortality was of 20% and late mortality 11.1%. The rate of secondary endoleak was 44.4%, and late reintervention of 33.3%. Survival freedom from cardiovascular death at 8 years was 80.0%, and positive remodeling was documented in 37.5% of patients. CONCLUSIONS: Our results suggest that TEVAR is feasible, safe, and associated with a high reintervention rate and reduced rate of positive aortic remodeling in patients with Marfan syndrome. Survival at 8 years was comparable to contemporary series of open repair.

Left atrial veno-arterial extracorporeal membrane oxygenation in post-myocardial infarction ventricular septal defect with cardiogenic shock: a case report.

Background: Ventricular septal defect (VSD) complicating acute myocardial infarction (MI) represents a life-threatening condition and has a mortality of >90% if left untreated. Case summary: A 53-year-old man with a prior medical history of diabetes and hypertension presented with cardiogenic shock secondary to VSD as a mechanical complication of non-reperfused inferior MI. Discussion: The choice of mechanical support can be difficult in this type of patient. Given the risk of an increased shunt because of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and the increase in left ventricle (LV) afterload, several measures were taken to plan the best ECMO configuration. Given the absence of any real improvement in the LV and an elevated residual ratio between pulmonary and systemic flow (Qp/Qs), the final decision was to switch to left atrial VA-ECMO (LAVA-ECMO). The use of LAVA-ECMO improved the patient's haemodynamics and allowed his condition to stabilize; LAVA-ECMO is feasible and may be effective as a mechanical circulatory support (MCS) strategy for patients in cardiogenic shock due to VSD as a mechanical complication of acute MI.

Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach.

Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.

Left circumflex artery injury occurring during mitral valve surgery treated successfully with percutaneous intervention in a high surgical and bleeding risk patient.

Perioperative myocardial infarction is a complication of cardiac surgery, and the cause can be multifactorial. Injury of the left circumflex coronary artery has been described, particularly after mitral valve replacement. We present the case of a 72-year-old woman who underwent mitral valve replacement but developed a lesion in the proximal circumflex coronary artery related to partial mechanical kinking caused by a suture. The therapeutic options are surgical or percutaneous. In this patient, the percutaneous strategy was successful. Learning objective: • Percutaneous coronary intervention is an option in cases involving kinking of the left circumflex coronary artery after mitral valve replacement.• If unable to cross the lesion with a workhorse guide wire, one alternative is to use wires with good support properties and avoid very high tip loads to reduce the risk of perforation.In patients at high risk of bleeding, use of a drug-eluting stent and short-duration dual antiplatelet therapy is recommended.

[Acute myocardial infarction patients without COVID-19 manifestations in the pandemic may have high thrombus burden]. / Pacientes con infarto agudo de miocardio sin manifestaciones de COVID-19 pueden tener alta carga de trombo.

Objective: The objective of the study is to identify clinical and angiographic characteristics of patients with ST-segment elevation myocardial infarction (STEMI) but without clinical manifestations of COVID-19 infection during the pandemic, compared with patients 1 year before the pandemic. Methods: Observational study that included 138 consecutive patients hospitalized with STEMI who underwent primary percutaneous coronary intervention (PCI) without COVID-19 infection during the 2020 pandemic. A group of 175 STEMI patients treated with PCI in the year before the pandemic served as the control group. Results: During the periods analyzed, compared with the control group, patients admitted during the pandemic without clinical manifestations of COVID-19 did not have significant differences in demographic characteristics, comorbidities, or delayed time and location of the acute myocardial infarction. Furthermore, there were no differences between the two groups concerning levels of CK-MB and NT-proBNP, or in inflammation markers and left ventricular ejection fraction. In patients without COVID-19 during the pandemic compared with control, we found a higher intracoronary thrombus burden (thrombus grade 5; 78.3% vs. 62.9%, respectively. p = 0.002). Accordingly, the use of glycoprotein IIB/IIIa inhibitors (37.7% vs. 26.3%, p = 0.03) was higher in these patients. Conclusions: This study demonstrates an increased thrombus burden in STEMI patients without clinical manifestation of COVID-19 during the pandemic compared with the same time period in the previous year.

Objetivo: Identificar las características clínicas y angiográficas de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) sin manifestaciones clínicas de COVID-19 durante la pandemia y compararlos con los pacientes en el año previo. Métodos: Estudio observacional que incluyó 138 pacientes consecutivos que fueron hospitalizados por IAMCEST y que fueron tratados con angioplastía primaria (ACTP) sin manifestaciones clínicas de COVID-19 durante la pandemia de 2020. Se seleccionó a un grupo control de 175 pacientes con IAMCEST tratados con ACTP en el año previo a la pandemia. Resultados: Los pacientes atendidos durante la pandemia no tuvieron diferencias significativas en cuanto a las características clínicas, demográficas, comorbilidades, tiempo de retraso y localización del infarto. Además, no hubo diferencias entre ambos grupos en los niveles de CK-MB, NT-proBNP, marcadores de inflamación ni en la fracción de eyección del ventrículo izquierdo. En los pacientes sin COVID-19 tratados durante la pandemia encontramos mayor carga trombótica intracoronaria (trombo grado 5; 78.3% vs. 62.9%, respectivamente. p = 0.002). De igual manera, el uso de inhibidores de la glucoproteina IIB/IIIa (37.7% vs. 26.3%, p = 0.03) fue mayor. Conclusiones: Este studio demostró un aumento en la carga trombótica en los pacientes con IAMCEST sin manifestaciones clínicas de COVID-19 durante la pandemia al compararlos con los pacientes tratados por la misma patología en el año previo.

[Successful endovascular treatment of nutcracker's syndrome with self-expanding stent]. / Tratamiento endovascular exitoso del síndrome de cascanueces con stent autoexpandible.

Nutcracker's syndrome is caused by compression of the left renal vein between aorta and superior mesenteric artery, causing extrinsic compression generated functional stenosis. This causes congestion and hypertension of the left renal vein resulting in insufficiency and left gonadal vein varicose, unilateral hematuria and left flank pain, diagnosis is rarely identified by their low frequency and difficulty of suspecting, treatment of nutcracker's syndrome include renal autotransplantation, transposition of superior mesenteric artery revascularization and recently stenting in renal vein, we present the case of a patient, who showed this pathology by diagnostic support by image studies, was performed successfully implant a self-expanding stent with immediate success criteria by angiography, collateral reduction and by disappearance of cava/renal gradient.

[Renal sympathetic denervation (RSD): a new, non-pharmacologic therapeutic strategy for treatment-resistant hypertension (TRH). Report of the first procedure in Mexico]. / Denervación simpática renal (DSR): una nueva terapéutica no farmacológica para la hipertensión arterial (HTA) resistente. Informe del primer procedimiento en México.

A patient with resistant hypertension successfully treated with sympathetic renal denervation (SRD) is reported. This novel therapy is based on the partial ablation of the renal nerves by applying radiofrequency to the luminal surface of the renal arteries using vascular catheterization techniques. This first case performed in Mexico has two particular features: (i) an electrophysiology ablation catheter was employed due to the unavailability of the system specifically designed for SDR, and (ii) under current denervation protocols, the anatomical complexity of the targeted renal arteries would have excluded our patient from this procedure and thus deprived her of the benefit provided.

Prevention of Radial Artery Occlusion of 3 Hemostatic Methods in Transradial Intervention for Coronary Angiography.

OBJECTIVES: The main objective of this study was to compare the efficacy of 3 hemostatic methods for the prevention of early radial artery occlusion (RAO): standard patent hemostasis, patent hemostasis with ulnar compression or the ulnar artery transient compression facilitating radial artery patent hemostasis (ULTRA) method, and facilitated hemostasis with a hemostatic disc. BACKGROUND: There are no prospective randomized studies that compare early RAO rates with the 3 most used nonocclusive hemostatic methods. METHODS: This was a prospective, longitudinal, comparative, and randomized study. The final population analyzed was 1,469, and they were randomized into 3 groups: 491 patients in group 1 with standard patent hemostasis, 490 patients in group 2 with the ULTRA method, and 488 patients in group 3 with facilitated hemostasis with a hemostatic disc. RESULTS: The RAO rate at 24 hours of the total population analyzed was 4.6%. By hemostasis groups, it was 3.6% for patent hemostasis, 5.5% for the ULTRA method, and 4.7% for facilitated hemostasis with a hemostatic disc, with no statistical difference among the 3 groups (P = 0.387). At 30 days, the overall rate of RAO was 1.8%, and by groups, it was 1.4% for the patent hemostasis group, 1.8% for the ULTRA method group, and 2.2% for the facilitated hemostasis with a hemostatic disc group, respectively (P = 0.185). CONCLUSIONS: The rates of RAO at 24 hours evaluated by plethysmography oximetry and confirmed by ultrasound among 3 current radial hemostasis methods (ie, patent hemostasis, the ULTRA method, and facilitated hemostasis with a hemostatic disc) are not different.

Cardiothoracic surgery and peripheral endovascular intervention in cardiovascular damage from a cohort of orphan rheumatological diseases-epidemiological and survival analysis.

Background: Aortic diseases in some orphan rheumatological diseases require medical, surgical or peripheral endovascular intervention because they can be catastrophic. Objectives: to analyze the main clinical and epidemiological characteristics of patients with Takayasu arteritis (TA), Marfan syndrome (MS) and similar conditions that were treated with cardiothoracic surgery and peripheral endovascular intervention. Methods: Retrospective and descriptive cohort study that included patients of any age and gender with TA (as per the criteria of the American College of Rheumatology and EULAR/PRINTO), MS (according to Ghent criteria), and similar conditions who underwent cardiothoracic surgery or peripheral endovascular intervention. Data were collected from electronic charts. Results: A total of 77 patients with TA and 135 patients with MS and similar conditions were included. The frequency of surgical or interventional requirements in patients with TA and MS/similar conditions was 77/364 (21.2%) and 135/300 (45%), respectively; such patients were followed for a median of 6 [2-12] and 3.29 (0.42-6.62) years, with (maximum follow-up range of 47 and 21.37 years, respectively). Aneurysms were present in 11 (14.3%) and 66 (48.9%) in patients with TA and MS/similar conditions, respectively. Aortic, mitral and tricuspid valve damage occurred in 8 (10.4%) patients, 4 (5.2%) patients and 1 (1.3%) patient with TA, respectively; corresponding frequencies in patients with MS/similar conditions were 98 (72.6%), 50 (37.0%) and 20 (14.8%). We identified that 20% of patients with TA died after 5.08 years (95% CI: 0.23-25.42 years) and 20 % of the patients with MS and other similar conditions died after 7.52 years (95% CI: 1.10-9.02 years). Conclusions: The frequency of surgical intervention was low in this study. Long-term prognosis is good if surgery is performed in a timely manner. Epidemiological studies provide relevant information for public health decisions related to the management of orphan rheumatological diseases.

Bioprosthetic valve failure. Comparative trial of two balloon-expandable transcatheter heart valve systems in intermediate-risk patients: a propensity score analysis.

BACKGROUND: The comparative mid and long-term durability, including the rates of bioprosthetic valve failure (BVF) of the Sapien XT® and Sapien 3® transcatheter heart valve (THV) in patients with intermediate surgical risk has not been reported. METHODS: Consecutive intermediate-risk patients with severe aortic stenosis from the Mexican registry of transcatheter aortic valve replacement (TAVR) with Sapien® THVs were included. The primary endpoint was to compare the BVF rate between THVs at 2 years of follow-up. Secondary endpoints were comparisons of the composite of global mortality, cardiovascular mortality, and neurological events at 30 d and 24 months of follow-up. RESULTS: During 2014-2019, 115 (60 Sapien XT® and 55 Sapien 3®) patients met the inclusion criteria in five medical centres. The mean age was 77.3 ± 8.4 years. The average Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was 5.6 ± 2.9. There was no statistically significant difference between the groups in BVF rate. At 30 d, overall, cardiovascular and non-cardiovascular mortality was 4.3%, 2.6%, and 1.7%, respectively. Neurological events rate was 1.73%. The mean long-term follow-up was 25.3 ± 14.2 months with an overall mortality of 9.56% but lower for the Sapien 3® group (15% vs. 3.6%, p=.037). The only independent predictor of composite mortality and neurological events that occurred in the long term was using a Sapien XT® [OR 1.6, CI 95%, 1.0-24.9; p=.049]. CONCLUSIONS: The BVF rate at 25 months of follow-up was similar with the XT and S3 systems. During this follow-up period, the major composite events of death from any cause and neurological events were significantly lower with the S3 system.

Aortic Perforation and Ascending Dissection Due to Intra-Aortic Balloon Counterpulsation Implantation in Cardiac Surgery.

The intra-aortic balloon pump continues to be a useful ventricular assist device in cardiac surgery. Complications are estimated to be 7% to 40%, significantly high to catastrophic. We describe an aortic injury associated with the use of the device and an interdisciplinary management for the diagnostic and therapeutic approach. (Level of Difficulty: Intermediate.).

Application of the SCAI classification to admission of patients with cardiogenic shock: Analysis of a tertiary care center in a middle-income country.

AIMS: The Society of Cardiovascular Angiography and Interventions (SCAI) shock stages have been applied and validated in high-income countries with access to advanced therapies. We applied the SCAI scheme at the time of admission in order to improve the risk stratification for 30-day mortality in a retrospective cohort of patients with STEMI in a middle-income country hospital at admission. METHODS: This is a retrospective cohort study, we analyzed 7,143 ST-segment elevation myocardial infarction (STEMI) patients. At admission, patients were stratified by the SCAI shock stages. Multivariate analysis was used to assess the association between SCAI shock stages to 30-day mortality. RESULTS: The distribution of the patients across SCAI shock stages was 82.2%, 9.3%, 1.2%, 1.5%, and 0.8% to A, B, C, D, and E, respectively. Patients with SCAI stages C, D, and E were more likely to have high-risk features. There was a stepwise significant increase in unadjusted 30-day mortality across the SCAI shock stages (6.3%, 8.4%, 62.4%, 75.2% and 88.3% for A, B, C, D and E, respectively; P < 0.0001, C-statistic, 0.64). A trend toward a lower 30-day survival probability was observed in the patients with advanced CS (30.3, 15.4%, and 8.3%, SCAI shock stages C, D, and E, respectively, Log-rank P-value <0.0001). After multivariable adjustment, SCAI shock stages C, D, and E were independently associated with an increased risk of 30-day death (hazard ratio 1.42 [P = 0.02], 2.30 [P<0.0001], and 3.44 [P<0.0001], respectively). CONCLUSION: The SCAI shock stages applied in patients con STEMI at the time of admission, is a useful tool for risk stratification in patients across the full spectrum of CS and is a predictor of 30-day mortality.

Distal Radial Artery Approach to Prevent Radial Artery Occlusion Trial.

OBJECTIVES: The aim of this study was to compare the rate of proximal radial artery occlusion (RAO) with Doppler ultrasound between distal and conventional radial access 24 h and 30 days after a transradial coronary procedure. BACKGROUND: The use of distal radial access to prevent proximal RAO (PRAO) in the proximal segment at 24 h and 30 days after a procedure, compared with conventional radial access, is unknown. METHODS: This was a prospective, comparative, longitudinal, randomized study. A total of 282 patients were randomized to either proximal radial access (n = 142) or distal radial access (n = 140) to evaluate the superiority of the distal approach in the prevention of PRAO with Doppler ultrasound 24 h and 30 days after a transradial coronary procedure. RESULTS: In the per protocol analysis, the rates of PRAO at 24 h and 30 days were 8.4% and 5.6% in the proximal group and 0.7% and 0.7% in the distal group, respectively (24 h: odds ratio [OR]: 12.8; 95% confidence interval [CI]: 1.6 to 100.0; p = 0.002; 30 days: OR: 8.2; 95% CI: 1.0 to 67.2; p = 0.019). In an intention-to-treat analysis, the 24-h and 30-day rates of PRAO were 8.8% and 6.4% for proximal radial access and 1.2% and 0.6% in the distal radial access group (24 h: OR: 7.4; 95% CI: 1.6 to 34.3; p = 0.003; 30 days: OR: 10.6; 95% CI: 1.3 to 86.4; p = 0.007). CONCLUSIONS: Distal radial access prevents RAO in the proximal segment at 24 h and 30 days after the procedure compared with conventional radial access.