Time-course of vascular dysfunction of brachial artery after transradial access for coronary angiography.

BACKGROUND: Prior studies have demonstrated endothelial and smooth muscle brachial artery dysfunction after transradial cardiac catheterization for diagnostic coronary angiography. The duration of this vascular dysfunction is unknown. OBJECTIVE: To determine the time-course of endothelial and smooth muscle cell dysfunction in the upstream brachial artery after transradial cardiac catheterization. METHODS: We studied 22 consecutive patients with suspected coronary artery disease (age 64.4 ± 7.7 years) undergoing diagnostic transradial cardiac catheterization. Using high-resolution vascular ultrasound, we measured ipsilateral brachial artery diameter changes during reactive hyperemia (endothelium-dependent dilatation) and administration of sublingual nitroglycerin (endothelium-independent dilatation). The measurements were taken at baseline (before cardiac catheterization), 6 h, 24 h, 1 week, and 1 month postprocedure. The contralateral brachial artery served as a control. RESULTS: Ipsilateral brachial artery diameter during endothelium-dependent dilatation decreased significantly compared with the contralateral diameters at 6 h and 24 h after transradial cardiac catheterization (3.22 vs. 4.11 and 3.29 vs. 4.11, respectively, P < 0.001). The administration of nitroglycerin did not affect this difference. At 1 week and 1 month postprocedure there was no significant difference in diameter of the ipsilateral versus the contralateral brachial artery. As expected the contralateral brachial artery showed no significant changes in diameter. CONCLUSION: Our results showed that transradial cardiac catheterization causes transient vascular endothelial and smooth muscle dysfunction of the ipsilateral brachial artery, which resolves within 1 week postprocedure. These findings strongly suggest the absence of systemic vascular dysfunction after transradial catheterization both immediately postprocedure as well as 1 week postprocedure. © 2015 Wiley Periodicals, Inc.

Aspiration Thrombectomy in Patients Undergoing Primary Angioplasty for ST Elevation Myocardial Infarction: An Updated Meta-Analysis.

BACKGROUND: The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI). OBJECTIVES: We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data. METHODS AND RESULTS: Clinical trials (n = 20) that randomized patients (n = 21,281) with STEMI between Routine AT (n = 10,619) and PPCI (n = 10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78-1.01, P = 0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69-1.10, P = 0.25), up to 6 months (RR: 0.91, 95%CI: 0.74-1.13, P = 0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74-1.05, P = 0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01-2.25, P = 0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83-1.06, P = 0.28) recurrent MI (RR: 0.96, 95%CI: 0.80-1.16, P = 0.68, MACE events (RR: 0.91 95%CI: 0.81-1.02, P = 0.11), early (0.59, 95%CI: 0.23-1.50, P = 0.27) and late (RR: 0.91, 95%CI: 0.69-1.18, P = 0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91-1.07, P = 0.76). CONCLUSION: Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone.

Complications and Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement With Edwards SAPIEN & SAPIEN XT Valves: A Meta-Analysis of World-Wide Studies and Registries Comparing the Transapical and Transfemoral Accesses.

INTRODUCTION: Both transfemoral (TF) and transapical (TA) routes are utilized for Transcatheter Aortic Valve Replacement (TAVR) using Edwards SAPIEN & SAPIEN XT valves. We intended to perform a meta-analysis comparing the complication rates between these two approaches in studies published before and after the standardized Valve Academic Research Consortium (VARC) definitions. METHODS: We performed a comprehensive electronic database search for studies published until January 2014 comparing TF and TA approaches using the Edwards SAPIEN/SAPIEN XT aortic valve. Studies were analyzed based on the following endpoints: 1-year mortality, 30-day mortality, stroke, new pacemaker implantation, bleeding, and acute kidney injury. RESULTS: Seventeen studies were included in the meta-analysis. Patients undergoing TA TAVR had a significantly higher logistic EuroSCORE (24.6 ± 12.9 vs. 21.3 ± 12.0; P < 0.001). The cumulative risks for 30-day mortality (RR 0.61; 95%CI 0.46-0.81; P = 0.001), 1-year mortality (RR 0.68; 95%CI 0.55-0.84; P < 0.001), and acute kidney injury (RR 0.53; 95%CI 0.38-0.73; P < 0.001) were significantly lower for patients undergoing TF as compared to TA approach. Both approaches had a similar incidence of 30-day stroke, pacemaker implantation, and major or life-threatening bleeding. Studies utilizing the VARC definitions and those pre-dating VARC yielded similar results. CONCLUSION: This meta-analysis demonstrates a decreased 30-day and 1-year mortality in TF TAVR as compared to TA TAVR. Post-procedure acute kidney injury and the need for renal replacement therapy are also significantly lower in the TF group. These differences hold true even after utilizing the standardized Valve Academic Research Consortium criteria.

Optimizing rotational atherectomy in high-risk percutaneous coronary interventions: insights from the PROTECT ΙΙ study.

OBJECTIVE: To study rotational atherectomy (RA) outcomes in patients undergoing high-risk PCI randomized to receive hemodynamic support using either IABP or Impella 2.5 in the PROTECT II trial. BACKGROUND: RA of heavily calcified lesions is often necessary for complex PCI but can be associated with slow-flow, hypotension, and higher risk of periprocedural MI. METHODS: We compared baseline, angiographic, procedural characteristics, and outcomes of patients treated with and without RA. We examined also RA technique and outcomes. RESULTS: RA was used in 52 of 448 patients (32 with Impella vs 20 with IABP, P = 0.08). RA patients were older (72 vs. 67 yo, P = 0.0009), more likely to have prior CABG (48 vs. 32%, P = 0.017), higher STS (8.1 vs. 5.7, P = 0.012) and higher SYNTAX scores (37 vs. 29, P < 0.0001). At 90 days, RA use was associated with higher incidence of MI but no mortality difference. RA was used more aggressively with Impella resulting in higher rate of periprocedural MI (P < 0.01), with no difference in mortality between groups (P = 0.78). Repeat revascularization occurred less frequently with Impella (P < 0.001). There were no differences in 90-day major adverse events between IABP and Impella in patients undergoing RA (P = 0.29). In patients not treated with RA, fewer MAEs were observed with Impella compared with IABP (P = 0.03). CONCLUSIONS: Patients who were treated with RA had more comorbidities, and more complex and extensive coronary artery disease. In patients with Impella, more aggressive RA use resulted in fewer revascularization events but higher incidence of periprocedural MI.

Cardiovascular risk stratification in diabetic patients following stress single-photon emission-computed tomography myocardial perfusion imaging: the impact of achieved exercise level.

BACKGROUND: Previous studies have demonstrated that diabetic patients undergoing exercise stress single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) have significantly lower cardiac events when compared to the diabetic patients undergoing pharmacologic stress SPECT MPI across all perfusion categories. However, there are limited data on the level of exercise achieved during exercise SPECT MPI among diabetic patients and its impact on cardiovascular outcomes. METHODS: We retrospectively analyzed 14,849 consecutive patients (3,654 diabetics and 11,195 non-diabetics) undergoing exercise stress, combined exercise and pharmacologic stress, and pharmacologic stress SPECT MPI from 1996 to 2005 at a single tertiary care center. Diabetic and non-diabetic patients were categorized into 3 groups based on the metabolic equivalents (METs) achieved: ≥5 METs, <5 METs, and pharmacologic stress groups. All studies were interpreted using the 17-segment ASNC model. The presence, extent, severity of perfusion defects were calculated using the summed stress score (SSS), and patients were classified into normal (SSS < 4), mildly abnormal (SSS 4-8), and moderate-severely abnormal (SSS > 8) categories. Annualized event rates (AER) for the composite end point of non-fatal myocardial infarction and cardiac death were calculated over a mean follow-up period of 2.4 ± 1.4 years with a maximum of 6 years. RESULTS: In moderate-severe perfusion abnormality (SSS > 8) category, diabetic patients who were able to achieve ≥5 METs had significantly lower AER compared to diabetic patients who were unable to achieve ≥5 METs (3% vs 5.5%, P = .04), and non-diabetic patients unable to achieve ≥5 METs (3% vs 4.8%, P < .001). Diabetic patients who achieved a high workload of ≥10 METs had a very low AER of 0.9%. Diabetic patients, who attempted exercise but were unable to achieve ≥5 METs, still had significantly lower AER than diabetics undergoing pharmacologic stress MPI across all perfusion categories [1.5% vs 3.2%, P = .006 (SSS < 4); 2.5% vs 4.9%, P = .032 (SSS 4-8); 5.5% vs 10.3%, P = .003 (SSS > 8)]. After adjustment for cardiovascular risk factors, the percentage decrease in cardiac event rate for every 1-MET increment in exercise capacity was 10% in the overall cohort, 12% in diabetic group, and 8% in non-diabetic group. CONCLUSIONS: Despite significant perfusion defects, diabetic patients who achieve ≥5 METs during stress SPECT MPI have significantly reduced risk for future cardiac events. Diabetic patients who achieve ≥10 METs have a very low annualized event rate. These findings support that exercise capacity obtained during SPECT MPI is a surrogate for outcomes among diabetic patients undergoing nuclear stress testing.

Risk stratification among diabetic patients undergoing stress myocardial perfusion imaging.

BACKGROUND: Previous studies have suggested that diabetic patients undergoing single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) are at greater risk for cardiac events than non-diabetic patients with both normal and abnormal imaging results. However, the impact of stress modality on outcomes in this patient group has not been examined. METHODS: The data on all patients undergoing exercise stress or vasodilator stress SPECT MPI from 1996 to 2005 were reviewed. After excluding patients based on our predefined criteria, we subcategorized the study population into diabetic patients and non-diabetic patients. Among the diabetic patients, we identified patients with known coronary artery disease (CAD) and no known CAD. All studies were interpreted using the 17-segment ASNC model. The presence, extent, and severity of perfusion defects were calculated using the summed stress score (SSS), and patients were classified into normal (SSS < 4), mildly abnormal (SSS 4-8), and moderate-severely abnormal (SSS > 8) categories. The annualized cardiac event rate including cardiac death and non-fatal myocardial infarction was calculated over a mean follow-up period of 2.4 ± 1.4 years with a maximum of 6 years. RESULTS: The cardiac event rate was statistically significantly lower in diabetic patients undergoing exercise stress MPI when compared to the diabetic patients undergoing pharmacological stress MPI across all three perfusion categories (1.3% vs 3.4%, 2.3% vs 5.7%, 4.2% vs 10.7%, respectively). Diabetic patients with no known CAD, who underwent exercise stress MPI had significantly lower cardiac events across all three perfusion categories as compared to the remainder of the diabetic population. Ability to perform exercise stress test was the strongest multivariate predictor of favorable outcome, whereas ejection fraction < 50%, abnormal perfusion imaging on SPECT MPI, and increasing age stood out as independent predictors of adverse outcome in the diabetic patients. Within the abnormal perfusion category, the annualized cardiac event rate among patients undergoing exercise stress SPECT MPI was not statistically different between the diabetic and non-diabetic cohorts. CONCLUSION: Diabetic patients undergoing exercise SPECT MPI have a significantly better prognosis than those undergoing pharmacological stress, more similar to patients without diabetes. In patients with diabetes exercise stress test MPI identifies low risk patients and provides precise risk stratification.

Utilization of intravascular imaging in elective non chronic total occlusion percutaneous intervention and chronic total occlusion percutaneous intervention: Trends in utilization and impact on in-hospital mortality.

OBJECTIVES: The objectives of this retrospective study include outcomes associated with and without intravascular imaging in cases of elective single vessel (SV) CTO PCI and in non-CTO PCI. METHOD: We explored the NIS database from October 1, 2015 to December 31, 2018 to identify 317,090 adult admissions with elective SV PCI. Admissions with STEMI and NSTEMI were excluded to identify elective cases only. Using the ICD 10 diagnosis code for CTO, we identified 33,345 admissions that underwent SV CTO PCI. We classified the remaining cases as SV non-CTO PCI. RESULTS: Intravascular imaging was utilized in 2930 (8.8%) cases in CTO PCI group and 23,710 (8.3%) cases in non-CTO PCI groups. The utilization of intravascular imaging (IVUS/OCT) significantly increased in elective SV CTO PCI, 6.4%-11.2%, p-trend<0.001 and non-CTO PCI group, 7.3%-9.0%, p-trend<0.001. There was no significance difference in mortality with and without intravascular imaging (combined IVUS/OCT vs no IVUS/OCT: 1.5% vs 1.3%, p = 0.195) in the CTO PCI group. But, in non-CTO PCI admissions, there was a significantly lower in-hospital mortality when intravascular imaging was used (0.7% vs 0.8%, p = 0.003). The cost of hospitalization was significantly higher when intravascular imaging was used in elective single vessel CTO PCI admissions, combined IVUS/OCT vs no IVUS/OCT: $27,427 vs $21,452, p < 0.001 and non-CTO PCI admissions, combined IVUS/OCT vs no IVUS/OCT: $23,620 vs $20,272, p < 0.001. CONCLUSIONS: In conclusion, despite the cost, intravascular imaging use decrease mortality in non-CTO PCI groups but there is no difference in mortality in CTO PCI groups.

Mechanical circulatory device utilization in cardiac arrest: Racial and gender disparities and impact on mortality.

The objectives of this retrospective study include identifying the utilization trend of mechanical circulatory devices (MCD) such as Intra-Aortic Balloon Pump (IABP), Impella and Extracorporeal Membrane Oxygenation (ECMO) in admissions with cardiac arrest, determining whether racial or gender disparities exist in their usage, and discerning if their use is associated with a reduction in mortality. By leveraging the National Inpatient Sample, we identified 229,180 weighted adult cardiac arrest admissions between October 1, 2015 and December 31, 2018. MCD were used in 6005 admissions (2.6%). IABP had the highest utilization, representing 77.8% of all MCDs, followed by Impella at 24.8%. The utilization of IABP decreased from 90.6% to 71.6%, while the use of Impella increased from 13.5% to 29.8% in this study period; both trends were statistically significant. MCD use was found to be lower in women compared to men (1.4% vs 3.6, P < 0.001) and in the Black population compared to White (1.5% vs 2.8%, P < 0.001). There was no difference in MCD utilization between Hispanic and the White cohorts. In-hospital mortality was lower in admissions associated with MCD (31.4% vs 45.9%, P < 0.001). ECMO was associated with the lowest mortality rate at 14.3%, followed by IABP at 28.1%. The use of Impella and combination therapy were not associated with a significant decrease in mortality. In conclusion, MCD use may decrease mortality in cardiac arrest, however their utilization appears to be lower in African Americans and in women.

Appropriateness criteria are an imprecise measure for repeat echocardiograms.

BACKGROUND: Previous studies have reported that most transthoracic echocardiograms meet current ACC/ASE appropriateness criteria, but efficacy of appropriateness criteria for repeat echocardiograms has not been investigated. We sought to prospectively determine whether current appropriateness criteria accurately assess the need for repeat echocardiograms in a consecutive series of inpatients in a tertiary care community teaching hospital. METHODS AND RESULTS: Appropriateness criteria were assessed for consecutive echocardiograms ordered over 30 days. Ordering clinician specialty and level of training were recorded. For repeat echocardiograms, change in clinical status between first and second echocardiogram and any change in echocardiographic findings were documented. Out of 574 echocardiograms analyzed, 143 repeat studies were performed in 104 patients. Level of appropriateness for first time studies was estimated at 84.6% and for repeat studies at 73.4% (x(2) = 7.71, P = 0.005). Of those patients receiving at least 1 repeat echocardiogram 42 patients (40%) experienced no detectable change in clinical status or other reason that would justify a repeat study. New echocardiographic findings were found in slightly more than half (52%) of patients receiving repeat studies. CONCLUSIONS: Inappropriate repeat echocardiograms are ordered more frequently than first time studies. A significant proportion of repeat echocardiograms do not appear to be justified, and often yield no new echocardiographic findings. Our data suggest that current appropriateness criteria might benefit from further revision with particular regard to justification for repeat studies.

Fistula Between the First Obtuse Marginal Branch of the Left Circumflex and the Left Ventricular Cavity: A Rare Anomaly.

Coronary-cameral fistulae (CCF) are rare, frequently incidental findings uncommonly noted during routine coronary angiography. They are nearly always congenital and are sometimes associated with other cardiac malformations. They can also be acquired due to trauma or chronic inflammation. These fistulae most commonly originate from the right coronary artery. The site of termination is usually the right ventricle (RV) and rarely the left ventricle (LV). Though nearly always asymptomatic and clinically insignificant, depending on their size and pressure gradient between communicating sites and terminating area, CCF can lead to pulmonary hypertension, LV dysfunction, and myocardial infarction. We describe the case of a 55-year-old woman who presented with worsening dyspnea and lower extremity edema. Transthoracic echocardiography demonstrated an ejection fraction of 55% with an RV systolic pressure of 67 mmHg. Right heart catheterization was performed to formally diagnose pulmonary hypertension and left heart catheterization was performed concurrently. This demonstrated a fistula between the first obtuse marginal branch of the left circumflex artery to the LV cavity. In this report, the authors provide a brief review of the presentation, diagnosis, complications, and management of CCF.

Intravenous magnesium sulfate enhances the ability of dofetilide to successfully cardiovert atrial fibrillation or flutter: results of the Dofetilide and Intravenous Magnesium Evaluation.

AIMS: A previous study found that the adjunctive use of intravenous magnesium sulfate with ibutilide could increase the odds of a patient chemically cardioverting from atrial fibrillation (AF) or flutter (AFL) to normal sinus rhythm (NSR) by 78%. Whether or not intravenous magnesium has the same effect on dofetilide's ability to chemically cardiovert patients from AF/AFL to NSR is not known. METHODS AND RESULTS: This was a retrospective cohort evaluation of consecutive eligible patients receiving dofetilide for chemical cardioversion of AF or AFL at a single institution. All AF or AFL patients received dofetilide according to the institution's standard protocol, which required patients to remain as an inpatient for a minimum of 3 days or 6 doses after the initiation of dofetilide therapy. Patients receiving any dose of intravenous magnesium starting on the same day as dofetilide constituted the treatment group. Controls received dofetilide, but no intravenous magnesium any time prior to chemical cardioversion. Patients underwent continuous electrocardiographic monitoring throughout their hospital admission. Multivariable logistic regression analysis was used to determine the impact of intravenous magnesium on dofetilide's efficacy. A total of 160 patients in persistent AF or AFL (mean age 66.6 +/- 11.0 years, 70.0% male, 30.0% in AF or AFL >15 days, 54.4% hypertension, 37.5% heart failure, 16.3% valvular disease, 16.3% previous myocardial infarction, and baseline serum magnesium levels 2.1 +/- 0.26 mg/dL) and receiving dofetilide (mean dose 428 +/- 118 microg/dose) were included in this analysis. The overall chemical cardioversion rate with dofetilide irrespective of adjunctive intravenous magnesium utilization was 41.9%. The concurrent administration of intravenous magnesium (n = 50) was associated with a 107% increased odds of successful chemical cardioversion [adjusted odds ratio: 2.07 (95% confidence intervals: 1.00-4.33)] compared with those who did not receive magnesium (n = 110). Only one case of torsade de pointes occurred in the no magnesium group during the index hospital admission. CONCLUSION: Concurrent use of intravenous magnesium is associated with an enhanced ability of dofetilide to successfully convert AF or AFL.

Percutaneous Coronary Intervention in Patients With End-Stage Liver Disease.

The objective of our study was to assess patients with end-stage liver disease undergoing percutaneous coronary intervention (PCI) and determine the rates and trend of complications and in-hospital outcomes. Data were obtained from the Nationwide Inpatient Sample 2005 to 2012. We identified all PCIs performed in patients with diagnosis of cirrhosis during the study period by the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Preventable procedural complications were identified by Patient Safety Indicators. Propensity scoring method was used to establish matched cohorts to control for imbalances and account for differences that may have influenced treatment outcomes. A total of 1,051,242 PCIs were performed during the study period, of these, 122,342 were done on subjects with a formal diagnosis of cirrhosis. Bare-metal stents (BMS) were more likely to be used in patients who presented with ST-elevation myocardial infarction (19.73 vs 13.58, p <0.001), in cardiogenic shock (5.58, vs 2.81, p <0.001), or required intraaortic balloon pump (4.73 vs 2.38, p <0.001). The overall rate of complications was 7.1%, whereas the overall mortality rate over these years was 3.63%. On a propensity-matched analysis the mortality rate was 2 times higher for BMS (5.18 vs 2.35, p <0.001) compared with drug-eluting stents. PCI remains a safe and plausible option for patients with cirrhosis albeit riskier than for the general population. The use of BMS is associated with increased mortality and bleeding complications compared with drug-eluting stents which likely is representative of preferential use of BMS in patients with more advanced end-stage liver disease who are also likely to experience higher postprocedural complications.

Comparison of Outcomes of Transcatheter Aortic Valve Replacement Plus Percutaneous Coronary Intervention Versus Transcatheter Aortic Valve Replacement Alone in the United States.

Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) has emerged as a less-invasive therapeutic option for high surgical risk patients with aortic stenosis and coronary artery disease. The aim of this study was to determine the outcomes of TAVR when performed with PCI during the same hospitalization. We identified patients using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes from the Nationwide Inpatient Sample between the years 2011 and 2013. A total of 22,344 TAVRs were performed between 2011 and 2013. Of these, 21,736 (97.3%) were performed without PCI (TAVR group) while 608 (2.7%) along with PCI (TAVR + PCI group). Among the TAVR + PCI group, 69.7% of the patients had single-vessel, 22.2% had 2-vessel, and 1.6% had 3-vessel PCI. Drug-eluting stents were more commonly used than bare-metal stents (72% vs 28%). TAVR + PCI group witnessed significantly higher rates of mortality (10.7% vs 4.6%) and complications: vascular injury requiring surgery (8.2% vs 4.2%), cardiac (25.4% vs 18.6%), respiratory (24.6% vs 16.1%), and infectious (10.7% vs 3.3%), p <0.001% for all, compared with the TAVR group. The mean length of hospital stay and cost of hospitalization were also significantly higher in the TAVR + PCI group. The propensity score-matched analysis yielded similar results. In conclusion, performing PCI along with TAVR during the same hospital admission is associated with higher mortality, complications, and cost compared with TAVR alone. Patients would perhaps be better served by staged PCI before TAVR.

In-Hospital Outcomes of Atherectomy During Endovascular Lower Extremity Revascularization.

Contemporary data on clinical outcomes after utilization of atherectomy in lower extremity endovascular revascularization are sparse. The study cohort was derived from Healthcare Cost and Utilization Project nationwide inpatient sample database from the year 2012. Peripheral endovascular interventions including atherectomy were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes. The subjects were divided and compared in 2 groups: atherectomy versus no atherectomy. Two-level hierarchical multivariate mixed models were created. The coprimary outcomes were in-hospital mortality and amputation; secondary outcome was a composite of in-hospital mortality and periprocedural complications. Hospitalization costs were also assessed. Atherectomy utilization (odds ratio, 95% CI, p value) was independently predictive of lower in-hospital mortality (0.46, 0.28 to 0.75, 0.002) and lower amputation rates (0.83, 0.71 to 0.97, 0.020). Atherectomy use was also predictive of significantly lower secondary composite outcome of in-hospital mortality and complications (0.79, 0.69 to 0.90, 0.001). In the propensity-matched cohort, atherectomy utilization was again associated with a lower rate of amputation (11.18% vs 12.92%, p = 0.029), in-hospital mortality (0.71% vs 1.53%, p 0.001), and any complication (13.24% vs 16.09%, p 0.001). However, atherectomy use was also associated with higher costs ($24,790 ± 397 vs $22635 ± 251, p <0.001). Atherectomy use in conjunction with angioplasty (with or without stenting) was associated with improved in-hospital outcomes in terms of lower amputation rates, mortality, and postprocedural complications.

Management of pseudoaneurysm of internal maxillary artery resulting from trauma.

Pseudoaneurysm of internal maxillary artery following trauma is a rare clinical entity. A rapidly growing swelling in the facial region following fracture of the mandibular subcondylar region is an indication of a developing aneurysm. A case of pseudoaneurysm of the internal maxillary artery following condylar fracture of mandible is reported. The case was treated successfully by surgery.

Acute pulmonary embolism masquerading as acute myocardial infarction.

Pulmonary embolism can be extremely difficult to diagnose based on clinical presentation. Many studies have demonstrated certain electrocardiographic patterns commonly seen in pulmonary embolism, but few have described changes consistent with ST segment elevation myocardial infarction. In this report, we describe a patient who presented to the emergency department with electrocardiographic findings consistent with an anteroseptal myocardial infarction and his subsequent clinical course.

The story of the lost needle: Foreign body embolization to the heart.

A 61-year-old female was evaluated because of severe symptomatic mitral regurgitation. She was found to have a foreign body in the heart by cardiac catheterization. Through a retrospective review of serial imaging studies, we found that a hypodermic needle had been retained in the body from a prior abdominal wall surgery and had subsequently migrated to the heart. During surgical mitral valve replacement the needle was identified and removed. We demonstrate the trajectory of this foreign body from the abdominal wall into the heart. .

Comparison of Inhospital Outcomes of Surgical Aortic Valve Replacement in Hospitals With and Without Availability of a Transcatheter Aortic Valve Implantation Program (from a Nationally Representative Database).

We hypothesized that the availability of a transcatheter aortic valve implantation (TAVI) program in hospitals impacts the overall management of patients with aortic valve disease and hence may also improve postprocedural outcomes of conventional surgical aortic valve replacement (SAVR). The aim of the present study was to compare the inhospital outcomes of SAVR in centers with versus without availability of a TAVI program in an unrestricted large nationwide patient population >50 years of age. SAVRs performed on patients aged >50 years were identified from the Nationwide Inpatient Sample (NIS) for the years 2011 and 2012 using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. SAVR cases were divided into 2 categories: those performed at hospitals with a TAVI program (SAVR-TAVI) and those without (SAVR-non-TAVI). A total of 9,674 SAVR procedures were identified: 4,526 (46.79%) in the SAVR-TAVI group and 5,148 (53.21%) in SAVR-non-TAVI group. The mean age of the study population was 70.2 ± 0.1 years with majority (53%) of the patients aged >70 years. The mean Charlson's co-morbidity score for patients in SAVR-TAVI group was greater (greater percentage of patients were aged >80 years, had hypertension, congestive heart failure, renal failure, and peripheral arterial disease) than that of patients in SAVR-non-TAVI group (1.6 vs 1.4, p <0.001). The propensity score matching analysis showed a statistically significant lower inhospital mortality (1.25% vs 1.72%, p = 0.001) and complications rate (35.6% vs 37.3%, p = 0.004) in SAVR-TAVI group compared to SAVR-non-TAVI group. The mean length of hospital stay was similar in the 2 groups the cost of hospitalization was higher in the SAVR-TAVI group ($43,894 ± 483 vs $41,032 ± 473, p <0.0001). Having a TAVI program was a significant predictor of reduced mortality and complications rate after SAVR in multivariate analysis. In conclusion, this largest direct comparative analysis demonstrates that SAVRs performed in centers with a TAVI program are associated with significantly lower mortality and complications rates compared to those performed in centers without a TAVI program.

Percutaneous aortic balloon valvotomy in the United States: a 13-year perspective.

BACKGROUND: We determined the contemporary trends of percutaneous aortic balloon valvotomy and its outcomes using the nation's largest hospitalization database. There has been a resurgence in the use of percutaneous aortic balloon valvotomy in patients at high surgical risk because of the development of less-invasive endovascular therapies. METHODS: This is a cross-sectional study with time trends using the Nationwide Inpatient Sample database between the years 1998 and 2010. We identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for valvotomy. Only patients aged more than 60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications and length of hospital stay. RESULTS: A total of 2127 percutaneous aortic balloon valvotomies (weighted n = 10,640) were analyzed. The use rate of percutaneous aortic balloon valvotomy increased by 158% from 12 percutaneous aortic balloon valvotomies per million elderly patients in 1998-1999 to 31 percutaneous aortic balloon valvotomies per million elderly patients in 2009-2010 in the United States (P < .001). The hospital mortality decreased by 23% from 11.5% in 1998-1999 to 8.8% in 2009-2010 (P < .001). Significant predictors of in-hospital mortality were the presence of increasing comorbidities (P = .03), unstable patient (P < .001), any complication (P < .001), and weekend admission (P = .008), whereas increasing operator volume was associated with significantly reduced mortality (P = .03). Patients who were admitted to hospitals with the highest procedure volume and the highest volume operators had a 51% reduced likelihood (P = .05) of in-hospital mortality when compared with those in hospitals with the lowest procedure volume and lowest volume operators. CONCLUSION: This study comprehensively evaluates trends for percutaneous aortic balloon valvotomy in the United States and demonstrates the significance of operator and hospital volume on outcomes.

Balloon mitral valvuloplasty in the United States: a 13-year perspective.

BACKGROUND: Incidence and prevalence of mitral stenosis is declining in the US. We performed this study to determine recent trends in utilization, complications, mortality, length of stay, and cost associated with balloon mitral valvuloplasty. METHODS: Utilizing the nationwide inpatient sample database from 1998 to 2010, we identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for "percutaneous valvuloplasty." Patients ≥18 years of age with mitral stenosis were included. Patients with concomitant aortic, tricuspid, or pulmonic stenosis were excluded. Primary outcome included death and procedural complications. RESULTS: A total of 1308 balloon mitral valvuloplasties (weighted n = 6540) were analyzed. There was a 7.5% decrease in utilization of the procedure from 24.6 procedures/10 million population in 1998-2001 to 22.7 procedures/10 million population in 2008-2010 (P for trend = .098). We observed a 15.9% overall procedural complication rate and 1.7% mortality rate. The procedural complication rates have increased in recent years (P = .001), corresponding to increasing age and burden of comorbidities in patients. The mean cost per admission for balloon mitral valvuloplasty has gone up significantly over the 10 years, from $11,668 ± 1046 in 2001 to $23,651 ± 301 in 2010 (P <.001). CONCLUSIONS: In a large cross-sectional study of balloon mitral valvuloplasty in the US, we have reported trends of decreasing overall utilization and increasing procedural complication rates and cost over a period of 13 years.