Catheter-directed thrombolysis versus thrombectomy for submassive and massive pulmonary embolism: A systematic review and meta-analysis.

INTRODUCTION: Controversy surrounds the optimal therapy for submassive and massive pulmonary embolism (PE). We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus surgical and catheter-based thrombectomy in patients with submassive and massive PE. METHODS: We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of CDT versus thrombectomy in submassive and massive PE. Studies were identified and data were extracted by two independent reviewers. A random effects model was used to calculate risk ratios (RRs) with 95 % confidence intervals (CIs). Outcomes included in-hospital mortality, procedural complications, hospital and intensive care unit (ICU) length of stay (LOS), 30-day readmissions, and right ventricle/left ventricle (RV/LV) ratio improvement. RESULTS: Eight observational studies with 1403 patients were included, of whom 50.0 % received CDT. Compared to thrombectomy, CDT was associated with significantly lower in-hospital mortality (RR 0.62; 95 % CI 0.43-0.89; p = 0.01) and similar rates of major bleeding (p = 0.61), blood transfusion (p = 0.41), stroke (p = 0.41), and atrial fibrillation (p = 0.71). The hospital and ICU LOS, 30-day readmissions, and degree of RV/LV ratio improvement were similar between the two strategies (all p > 0.1). In subgroup analyses, in-hospital mortality was similar between CDT and catheter-based thrombectomy (p = 0.48) but lower with CDT compared with surgical thrombectomy (p = 0.01). CONCLUSIONS: In patients with submassive and massive PE, CDT was associated with similar in-hospital mortality compared to catheter-based thrombectomy, but lower in-hospital mortality compared to surgical thrombectomy. Procedural complications, LOS, 30-day readmissions, and RV/LV ratio improvement were similar between CDT and any thrombectomy. Randomized controlled trials are indicated to confirm our findings.

Infective Endocarditis Risk with Melody versus Sapien Valves Following Transcatheter Pulmonary Valve Implantation: A Systematic Review and Meta-Analysis of Prospective Cohort Studies.

BACKGROUND: Transcatheter pulmonary valve implantation (TPVI) is an effective non-surgical treatment method for patients with right ventricle outflow tract dysfunction. The Medtronic Melody and the Edwards Sapien are the two valves approved for use in TPVI. Since TPVI patients are typically younger, even a modest annual incidence of infective endocarditis (IE) is significant. Several previous studies have shown a growing risk of IE after TPVI. There is uncertainty regarding the overall incidence of IE and differences in the risk of IE between the valves. METHODS: A systematic search was conducted in the MEDLINE, EMBASE, PubMed, and Cochrane databases from inception to 1 January 2023 using the search terms 'pulmonary valve implantation', 'TPVI', or 'PPVI'. The primary outcome was the pooled incidence of IE following TPVI in Melody and Sapien valves and the difference in incidence between Sapien and Melody valves. Fixed effect and random effect models were used depending on the valve. Meta-regression with random effects was conducted to test the difference in the incidence of IE between the two valves. RESULTS: A total of 22 studies (including 10 Melody valve studies, 8 Sapien valve studies, and 4 studies that included both valves (572 patients that used the Sapien valve and 1395 patients that used the Melody valve)) were used for the final analysis. Zero IE incidence following TPVI was reported by eight studies (66.7%) that utilized Sapien valves compared to two studies (14.3%) that utilized Melody valves. The pooled incidence of IE following TPVI with Sapien valves was 2.1% (95% CI: 0.9% to 5.13%) compared to 8.5% (95% CI: 4.8% to 15.2%) following TPVI with Melody valves. Results of meta-regression indicated that the Sapien valve had a 79.6% (95% CI: 24.2% to 94.4%, p = 0.019; R2 = 34.4) lower risk of IE incidence compared to the Melody valve. CONCLUSIONS: The risk of IE following TPVI differs significantly. A prudent valve choice in favor of Sapien valves to lower the risk of post-TPVI endocarditis may be beneficial.

Outcomes of viral myocarditis in patients with and without COVID-19: a nationwide analysis from the United States.

Cardiovascular complications contribute to 40% of coronavirus disease 2019 (COVID-19) related deaths. The viral myocarditis associated with COVID-19 accounts for significant morbidity and mortality. How COVID-19 myocarditis compares to other viral myocardites is unknown. Methods: The authors conducted a retrospective cohort study using the National Inpatient Sample database to identify adult patients hospitalized for viral myocarditis in 2020 and to compare outcomes between those with and without COVID-19. The primary study outcome was in-hospital mortality. Secondary outcomes included in-hospital complications, length of stay, and total costs. Results: The study population included 15 390 patients with viral myocarditis, of whom 5540 (36%) had COVID-19. After adjustment for baseline characteristics, patients with COVID-19 had higher odds of in-hospital mortality [adjusted odds ratio (aOR) 3.46, 95% CI 2.57-4.67], cardiovascular complications (aOR 1.46, 95% CI 1.14-1.87) including cardiac arrest (aOR 2.07, 95% CI 1.36-3.14), myocardial infarction (aOR 2.97, 95% CI 2.10-4.20), venous thromboembolism (aOR 2.01, 95% CI 1.25-3.22), neurologic complications (aOR 1.82, 95% CI 1.10-2.84), renal complications (aOR 1.72, 95% CI 1.38-2.13), and hematologic complications (aOR 1.32, 95% CI 1.10-1.74), but lower odds of acute heart failure (aOR 0.60, 95% CI 0.44-0.80). The odds of pericarditis, pericardial effusion/tamponade, cardiogenic shock, and the need for vasopressors or mechanical circulatory support were similar. Patients with COVID-19 had longer length of stay (7 days vs. 4 days, P<0.01) and higher total costs ($21,308 vs. $14,089, P<0.01). Conclusions: Among patients with viral myocarditis, COVID-19 is associated with higher in-hospital mortality and cardiovascular, neurologic, renal, and hematologic complications compared to non-COVID-19 viruses.

Pulmonary Artery Catheter Use and Outcomes in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock Treated With Impella (a Nationwide Analysis from the United States).

The role of continuous hemodynamic assessment with pulmonary artery (PA) catheter placement in cardiogenic shock (CS) remains debated. We aimed to assess the association between PA catheter placement and clinical outcomes in patients with CS secondary to ST-elevation myocardial infarction (STEMI) treated with an intravascular microaxial flow pump. We identified patients hospitalized with STEMI complicated by CS on mechanical circulatory support with an intravascular microaxial flow pump (Impella, Abiomed, Danvers, Massachusetts) using the National Inpatient Sample database and compared the outcomes in those treated with and without PA catheters. The primary outcome was in-hospital mortality. The secondary outcomes included in-hospital complications, hospital length of stay, inpatient costs, and temporal trends. The total cohort included 14,635 hospitalizations for STEMI complicated by CS treated with Impella between 2016 and 2020, of whom 5,505 (37.6%) received PA catheters. Over the study period, the use of PA catheters increased significantly from 25.9% to 41.8% (ptrend <0.01). Similarly, the use of Impella increased from 9.9% to 18.9% (ptrend <0.01). After adjustment for baseline characteristics using a multivariate logistic regression analysis, PA catheter use was associated with lower in-hospital mortality (adjusted odds ratio 0.80, 95% confidence interval 0.67 to 0.96, p = 0.01) and similar cardiovascular, neurologic, renal, and hematologic complications; length of stay; and inpatient costs compared with no PA catheter use. In conclusion, PA catheter use in patients with STEMI complicated by CS treated with Impella is associated with reduced in-hospital mortality and similar complication rates. Given the mortality benefit, further research is necessary to optimize PA catheter use in patients with STEMI with CS.

Acute limb ischemia from embolization of left ventricular pseudoaneurysm thrombus: a rare case report.

Myocardial infarction (MI) can lead to a wide spectrum of mechanical complications. Left ventricular pseudoaneurysm (LVP) is a rare but serious complication of MI. Case presentation: A 69-year-old woman with prior coronary artery bypass grafting and a remote history of inferolateral ST-elevation MI (STEMI) with failure to revascularize the left circumflex artery presented with gangrenous right toes that appeared 2 years after her STEMI. A computed tomography angiogram of the right lower extremity showed arterial occlusion and mild atherosclerotic disease. Echocardiography revealed a pseudoaneurysm with an adherent mural thrombus as the underlying cause of acute limb ischemia. The patient was started on heparin and cardiothoracic surgery was consulted but did not operate as the risk of surgery outweighed the benefit. On hospital day 3, the patient underwent amputation of her gangrenous toes as the tissue was nonviable. The patient remained stable during her hospital stay and was discharged on day 5 on long-term anticoagulation. Clinical discussion: LVPs have a wide spectrum of presentations, from asymptomatic or nonspecific symptoms to thromboembolism with end-organ damage, such as in our case. Therefore, early diagnosis and management are of paramount importance. Our patient's prior coronary artery bypass grafting most likely helped in forming a fibrous pericardium that sealed the pseudoaneurysm and prevented its rupture. Conclusions: STEMI requires close follow-up, especially in cases where revascularization is not achievable, as the risk of mechanical complications and mortality is high. Physicians should have a high suspicion for LVP in patients with prior MI, given its wide spectrum of presentations.

Impact of sex on in-hospital mortality and 90-day readmissions in patients undergoing transcatheter mitral valve replacement (TMVR): Analysis from the nationwide readmission database.

OBJECTIVES: To evaluate sex differences in in-hospital mortality and 90-day readmission rates among patients undergoing transcatheter mitral valve replacement (TMVR) in the United States of America. BACKGROUND: Women have higher rates of mortality and rehospitalization than men following many cardiac procedures. TMVR has grown as an alternative to mitral valve surgery for patients at high surgical risk. The rates of TMVR mortality and rehospitalization by sex are unknown. METHODS: We analyzed the Nationwide Readmissions Database (NRD) from 2016 to 2019 to identify hospitalizations for TMVR. Sex differences in in-hospital mortality and 90-day readmissions were determined using logistic regression models. RESULTS: Between 2016 and 2019, 4109 hospitalizations for TMVR were identified, comprised of 1758 (42.8%) men and 2351 (57.2%) women. The median age was 74 years for both men and women. There was no significant difference in in-hospital mortality during index hospitalization (6.51% vs. 6.69%; p = 0.852) and all-cause 90-day readmission (28.19% vs. 29.59%; p = 0.563) between men and women. Across the study period, trend analysis did not reveal a significant change in in-hospital mortality (men p = 0.087, women p = 0.194) or 90-day readmission rates (men p = 0.569, women p = 0.454). CONCLUSIONS: In patients undergoing TMVR, in-hospital mortality and 90-day readmissions are similar between men and women. Between 2016 and 2019, TMVR in-hospital mortality and 90-day readmission rates remained unchanged. Further research is necessary to confirm these findings.

Meta-Analysis Comparing Valve-in-Valve Transcatheter Mitral Valve Replacement Versus Redo Surgical Mitral Valve Replacement in Degenerated Bioprosthetic Mitral Valve.

Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) and redo surgical mitral valve replacement (redo-SMVR) are 2 treatment strategies for patients with bioprosthetic mitral valve dysfunction. We conducted a systematic review and meta-analysis to compare the outcomes of ViV-TMVR versus redo-SMVR. We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of ViV-TMVR versus redo-SMVR in degenerated bioprosthetic mitral valves. We used a random-effects model to calculate odd ratios (ORs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, stroke, bleeding, acute kidney injury, arrhythmias, permanent pacemaker insertion, and hospital length of stay (LOS). A total of 6 observational studies with 707 subjects were included. The median follow-up was 2.7 years. Despite their older age and greater co-morbidity burden, patients who underwent ViV-TMVR had a similar in-hospital mortality (OR 0.52, 95% CI 0.22 to 1.23, p = 0.14), 30-day mortality (OR 0.65, 95% CI 0.36 to 1.17, p = 0.15), 1-year mortality (OR 0.97, 95% CI 0.63 to 1.49, p = 0.89), and 2-year mortality (OR 1.17, 95% CI 0.65 to 2.13, p = 0.60) compared with redo-SMVR. ViV-TMVR was associated with significantly lower periprocedural complications, including stroke, bleeding, acute kidney injury, arrhythmias, and permanent pacemaker insertion, and shorter hospital LOS than redo-SMVR. In conclusion, ViV-TMVR was associated with better outcomes than redo-SMVR in patients with degenerated bioprosthetic mitral valves, including lower complication rates and shorter hospital LOS, with no significant difference in mortality rates. Large-scale randomized trials are needed to mitigate biases and confirm our findings.

Impact of prior coronary artery bypass grafting on periprocedural and short-term outcomes of patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis.

BACKGROUND: The effect of prior coronary artery bypass graft (CABG) on the outcomes of transcatheter aortic valve replacement (TAVR) remains incompletely characterized. In this meta-analysis, we investigated the impact of prior CABG on TAVR outcomes. METHODS: A systematic search was conducted in PubMed, Google Scholar, and Cochrane databases from inception to 24 July 2022, using the search terms 'TAVR', 'CABG', 'peri-procedural complications', and 'mortality'. The major outcomes were peri-procedural complications, intraprocedural mortality, 30-day mortality, and 30-day cardiac mortality. We used random-effects models to aggregate data and to calculate pooled incidence and risk ratios with 95% confidence intervals (CIs). RESULTS: Among 116 results from the systematic search, a total of 8 studies (5952 patients) were included. Compared to patients without previous CABG, patients with prior CABG undergoing TAVR were younger, predominantly male sex, had more comorbidities, higher rates of peri-procedural myocardial infarction (MI) [relative risk (RR) 1.93; 95% CI, 1.09-3.43; P = 0.03], but lower rates of stroke (RR 0.71; 95% CI, 0.51-0.99; P = 0.04), major vascular complications (RR 0.70; 95% CI, 0.51-0.95; P = 0.02), and major bleeding (RR 0.70; 95% CI, 0.56-0.88; P = 0.002). There were no significant differences between the two cohorts in rates of pacemaker implantation, cardiac tamponade, acute kidney injury, intra-procedural mortality, 30-day mortality, and 30-day cardiac mortality. CONCLUSION: Among patients undergoing TAVR, a history of prior CABG was not associated with an increased risk of periprocedural complications (except for acute MI) or short-term mortality compared to those without CABG.

Diagnostic Value of Cardiac Magnetic Resonance Imaging and Intracoronary Optical Coherence Tomography in Patients With a Working Diagnosis of Myocardial Infarction With Non-obstructive Coronary Arteries - A Systematic Review and Meta-analysis.

We aimed to study the efficacy of cardiac magnetic resonance imaging (CMR) and intracoronary optical coherence tomography (OCT) in detecting the etiology of myocardial infarction with non-obstructive coronary arteries (MINOCA). A systematic search was conducted in PubMed, Medline, and Cochrane databases. Search terms used: Myocardial infarction, Coronary angiography, Normal coronary arteries, CMR, and OCT. Inclusion criteria was fulfilled by 18 studies. Meta-analysis was performed with 15 studies. A total of 2697 patients were included. The mean age of all the patients was 51.5 and 56.4% were men. CMR established diagnosis in 74% of the patients; 29% had acute myocarditis, 18% had true myocardial infarction and 12% had takotsubo cardiomyopathy. Combining OCT with CMR was better at finding the etiology than either modality individually. The findings of this study conclude that CMR is integral in identifying the etiology of MINOCA. Coupling OCT and CMR is better than either technique individually at finding the cause.

A case report of ceftriaxone-induced cardiopulmonary arrest.

Introduction: and Importance: Ceftriaxone is used frequently in treating infectious diseases. While hypersensitivity skin reactions are common with the use of ceftriaxone, anaphylactic reactions are rare. Case presentation: A 66-year-old female presented to our hospital with complaints of headache and sinus congestion. Vital signs showed hypoxia, and the physical exam was unremarkable. A computed tomography scan of the chest revealed right upper lobe pneumonia, and the patient was started on ceftriaxone and azithromycin. The patient went into asystole 1 min after ceftriaxone administration. She did not require cardiopulmonary resuscitative measures as she spontaneously transitioned to normal sinus rhythm. Given the timing of the event immediately after ceftriaxone administration, we determined ceftriaxone was the likely culprit. The patient received alternative treatment for pneumonia and recovered without sequelae. We added ceftriaxone to her allergy list. Clinical discussion: This case report highlights a rare adverse event associated with ceftriaxone. After an extensive literature search, we found only four other reported cases of cardiopulmonary arrest following ceftriaxone. The exact mechanism for this adverse event has not been fully elucidated. Conclusion: Clinicians should be aware of the potential for ceftriaxone-induced asystole, perform allergy reviews and obtain informed consent before its administration.

IMPELLA VERSUS EXTRACORPOREAL MEMBRANE OXYGENATION IN CARDIOGENIC SHOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS.

ABSTRACT: Background: Cardiogenic shock (CS) carries high mortality. The roles of specific mechanical circulatory support (MCS) systems are unclear. We compared the clinical outcomes of Impella versus extracorporal membrane oxygenation (ECMO) in patients with CS. Methods: This is a systematic review and meta-analysis that was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Cochrane Central Register, Embase, Web of Science, Google Scholar, and ClinicalTrials.gov (inception through May 10, 2022) for studies comparing the outcomes of Impella versus ECMO in CS. We used random-effects models to calculate risk ratios (RRs) with 95% confidence interval (CIs). End points included in-hospital, 30-day, and 12-month all-cause mortality, successful weaning from MCS, bridge to transplant, all reported bleeding, stroke, and acute kidney injury. Results: A total of 10 studies consisting of 1,827 CS patients treated with MCS were included in the analysis. The risk of in-hospital all-cause mortality was significantly lower with Impella compared with ECMO (RR, 0.80; 95% CI, 0.65-1.00; P = 0.05), whereas there was no statistically significant difference in 30-day (RR, 0.97, 95% CI, 0.82-1.16; P = 0.77) and 12-month mortality (RR, 0.90; 95% CI, 0.74-1.11; P = 0.32). There were no significant differences between the two groups in terms of successful weaning (RR, 0.97; 95% CI, 0.81-1.15; P = 0.70) and bridging to transplant (RR, 0.88; 95% CI, 0.58-1.35; P = 0.56). There was less risk of bleeding and stroke in the Impella group compared with the ECMO group. Conclusions: In patients with CS, the use of Impella is associated with lower rates of in-hospital mortality, bleeding, and stroke than ECMO. Future randomized studies with adequate sample sizes are needed to confirm these findings.

Exercise-induced Brugada pattern and ventricular tachycardia during Capecitabine treatment.

We report the case of a 59-year-old female patient with no previous cardiovascular disease treated for Breast cancer with Capecitabine. Shortly after starting treatment, she developed recurrent angina. An exercise stress echocardiogram was performed, which induced a type 1 Brugada pattern 12 s of a non-sustained pleomorphic ventricular tachycardia ensued.

Early Outcomes of Percutaneous Coronary Intervention in Patients with Cancer: A Systematic Review and Meta-analysis.

Chemotherapeutic regimens have cardiotoxic properties and thorax irradiation is associated with accelerated coronary artery disease (CAD). There is limited data regarding the influence of cancer on outcomes after percutaneous coronary intervention (PCI), as cancer patients were not routinely included in the PCI trials. We performed a systematic review and meta-analysis to compare the early outcomes of PCI between patients with active/historical cancer and patients without a cancer history. A systematic search was made in the PubMed, Medline, and Cochrane databases using the search terms "PCI" and "Cancer". The major outcomes were in-hospital mortality, in-hospital cardiovascular mortality, 30-day mortality, and peri-procedural complications. We used random effects model to aggregate data and calculate pooled incidence and risk ratios with 95% confidence intervals (CIs). A total of 7 studies were included, out of which 4 studies reported in-hospital mortality. Compared to patients without cancer, patients with active/historical cancer undergoing PCI had higher rates of in-hospital mortality (relative risk [RR] 1.89; 95% CI 1.33-2.70; P = 0.0004), in-hospital cardiovascular mortality (RR 2.21; 95% CI 1.19-4.08; P = 0.01), 30-day mortality (RR 2.01; 95% CI 1.24-3.27; P = 0.005), and peri-procedural blood transfusion (RR 1.73; 95% CI 1.02-2.95; P = 0.04). There were no significant differences in peri-procedural myocardial re-infarction, new-onset heart failure, shock, and stroke between the two cohorts. In conclusion, Among patients undergoing PCI, active/historical cancer was associated with worse early mortality compared to patients without a history of cancer. Management of cancer patients undergoing PCI should be individualized and involve multi-specialist team discussion to narrow the mortality gap.

Meta-Analysis Comparing Catheter-Directed Thrombolysis Versus Systemic Anticoagulation Alone for Submassive Pulmonary Embolism.

The optimal therapy for submassive pulmonary embolism (sPE), defined by right ventricular dysfunction without hemodynamic instability, is uncertain. We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus systemic anticoagulation (SA) alone in patients with sPE. We searched PubMed, EMBASE, Cochrane, ClinicalTrials.gov, and Google Scholar (from inception through May 2022) for studies comparing outcomes of CDT versus SA in sPE. Studies were identified, and data were extracted by 2 independent reviewers. We used a random-effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 90-day, and 1-year mortality, major and minor bleeding, and need for blood transfusion. A total of 12 studies (1 randomized, 11 observational) with 9,789 patients were included. Compared with SA, CDT was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.00001), 30-day mortality (RR 0.37, 95% CI 0.18 to 0.73, p = 0.004), 90-day mortality (RR 0.36, 95% CI 0.17 to 0.72, p = 0.004), and a tendency toward lower 1-year mortality (RR 0.56, 95% CI 0.29 to 1.05, p = 0.07). The risks of major bleeding (RR 1.31, 95% CI 0.57 to 3.01, p = 0.53), minor bleeding (RR 1.67, 95% CI 0.77 to 3.63, p = 0.20), and the rates of blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08) were similar between the 2 strategies. In conclusion, in patients with sPE, CDT is associated with significantly lower in-hospital, 30-day, and 90-day mortality and a tendency toward lower 1-year mortality with similar bleeding rates compared with SA. This study expands the evidence supporting CDT as first-line therapy for sPE, and randomized controlled trials are indicated to confirm our findings.

Atrial invasion from primary lung adenocarcinoma extension via the pulmonary vein.

Intravascular extension of lung adenocarcinoma is one of the four defined routes of metastasis to the heart but is rarely described in the literature. This is a rare case of primary lung adenocarcinoma with intravenous extension to the left atrium via the pulmonary vein. A 56-year-old female presented to the hospital with chest tightness and dyspnea. Chest computed tomography revealed a right hilar mass extending through the right superior pulmonary vein into the left atrium. Transthoracic echocardiography revealed a large, partially mobile left atrial mass occupying the entire atrial cavity and affecting mitral valve closure. Endobronchial ultrasound with transbronchial biopsy of the right middle lobe of the lung histologically showed a poorly differentiated adenocarcinoma compatible with the primary lung cancer. The patient was deemed a poor surgical candidate by cardiothoracic surgery due to the extent of metastasis and was started on chemoradiation. The patient's left atrial tumor mass started shrinking in size after starting the treatment. This unique case displaying intravascular extension of lung cancer to the left atrium has rarely been described in the literature.

Left main coronary artery vasospasm: A case report of misdiagnosed severe coronary artery disease.

Introduction and importance: Left main coronary artery (LMCA) vasospasm is rare and can cause demand-supply mismatch that can mimic coronary artery disease (CAD). This could lead to misdiagnosis and inappropriate referral for surgical intervention. Case presentation: A 55-year-old woman with no cardiac risk factors presented with anginal chest pain. Vital signs were stable and physical exam was unremarkable. Chest x-ray was normal and electrocardiography (ECG) revealed sinus bradycardia with nonspecific ST-segment and T-wave changes in the inferolateral leads present on prior ECGs. Echocardiography revealed a left ventricular ejection fraction of 60-65% without regional wall motion abnormalities and cardiac troponin was within normal limits. Nuclear stress test was unsuccessful due to severe reaction to regadenoson. Subsequent invasive coronary angiography revealed an isolated 70% stenosis of the LMCA. Patient was referred for surgery, however, coronary computed tomography angiography (CCTA) prior to surgery unmasked spasm and prevented unnecessary surgery. Clinical discussion: Coronary spasm is diagnosed clinically based on typical symptoms, transient ECG changes, and a negative stress test with no regional wall motion abnormalities on echocardiography. During episodes of spasm, coronary angiography would reveal an area of stenosis in the affected coronary segment. This could lead to a misdiagnosis of CAD and, in cases of LMCA stenosis, inappropriate referral for surgical intervention. Conclusion: LMCA spasm is rare but can mimic CAD leading to misdiagnosis and unnecessary surgery. Physicians should have a high suspicion for spasm especially in patients with anginal chest pain who lack CAD risk factors. CCTA can unmask spasm and prevent unnecessary interventions.

Comparing Optical Coherence Tomography and Intravascular Ultrasound Guidance for Percutaneous Coronary Intervention: Trends and Outcomes 2010-2019.

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) optimize percutaneous coronary intervention (PCI) by characterizing lesion morphology, accurately measuring vessel dimensions, and optimizing stent characteristics. We sought to compare the utilization of OCT and IVUS to guide inpatient PCI and their relative association with in-hospital mortality and readmission rates. We queried the National Readmission Database to identify patients undergoing intracoronary imaging-guided PCI from 2010 to 2019 and compared outcomes and readmission rates between patients undergoing OCT-guided PCI and IVUS-guided PCI. Multivariable logistic regression was performed to generate adjusted odds ratios (aOR) of adverse outcomes between the 2 groups. Of 3,71,450 intracoronary imaging-guided PCI admissions, OCT (n = 12,808) was used less frequently than IVUS (n = 358,642). The use of OCT-guided PCI increased from 0.1% in 2010 to 0.6% in 2019 while the rate of IVUS-guided PCI increased from 7.2% in 2010 to 9.4% in 2019 (both ptrend <0.001). Patients undergoing OCT compared to IVUS had lower in-hospital mortality (aOR 0.69, P = 0.015) and 30-day readmission rate (aOR 0.91, P = 0.040) with no statistical difference in 90-day readmission rate (aOR 0.93, P = 0.065). Heart failure was the most common cause of 30-day and 90-day readmissions in both cohorts. There was no difference in the rate of acute kidney injury between the 2 modalities. In this in-patient admission database of intracoronary imaging-guided PCI, OCT-guided PCI during index hospitalization appears to be associated with lower in-hospital mortality and 30-day readmission rates compared to IVUS-guided PCI with no difference in terms of the 90-day readmission rates.

In-hospital mortality and readmission after ST-elevation myocardial infarction in nonagenarians: A nationwide analysis from the United States.

OBJECTIVES: To assess readmission rates in nonagenarians (age ≥ 90 years) with ST-elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) versus no pPCI. BACKGROUND: There are limited data exploring readmissions following STEMI in nonagenarians undergoing pPCI versus no pPCI. METHODS: We retrospectively analyzed the Nationwide Readmissions Database to identify nonagenarians hospitalized with STEMI. We divided the cohort into two groups based on pPCI status. We compared mortality during index hospitalization and during 30-day readmission, readmission rates, and causes of readmissions. RESULTS: We identified 58,231 nonagenarian STEMI hospitalizations between 2010 and 2018, of which 18,809 (32.3%) included pPCI, and 39,422 (67.7%) had no pPCI. Unadjusted unplanned 30-day readmission was higher in pPCI cohort (21.0% vs. 15.4%, p < 0.001). However, mortality during index hospitalization and during 30-day readmission were significantly lower in pPCI cohort (15.8% vs. 32.2%, p < 0.001; 7.4% vs. 14.2%, p < 0.001, respectively). After adjusting for baseline characteristics, hospitalizations that included pPCI had 25% greater odds of unplanned 30-day readmission (adjusted odds ratio [aOR]: 1.25, 95% confidence interval [CI]: 1.12-1.39, p < 0.001) and 49% lower odds of in-hospital mortality during index hospitalization (aOR: 0.51, 95% CI: 0.46-0.56, p < 0.001). Heart failure was the most common cause of readmission in both cohorts followed by myocardial infarction. CONCLUSIONS: In nonagenarians with STEMI, pPCI is associated with slightly higher 30-day readmission but significantly lower mortality during index hospitalization and during 30-day readmission than no pPCI. Given the overwhelming mortality benefit with pPCI, further research is necessary to optimize the utilization of pPCI while reducing readmissions following STEMI in nonagenarians.