Single versus double Perclose techniques for vascular closure during transfemoral transcatheter aortic valve replacement.

INTRODUCTION: The preferred approach for transcatheter aortic valve replacement (TAVR) is transfemoral. There has been widespread adoption of the Perclose ProglideTM device for vascular closure. Typically, two devices are deployed before upsizing the access sheath in the "preclose technique." Prior investigations have compared the use of a single device versus double device technique, but none have shown significant clinical benefit to either approach. METHODS: Five hundred and six patients underwent transfemoral TAVR (TF-TAVR) with single or double Perclose devices for vascular closure from July 2015 to February 2020. A retrospective review was conducted, and propensity-matched analyses were used to account for differences in baseline characteristics. RESULTS: In the matched analysis, there were 251 patients in the single Perclose group and 238 in the double. There was a statistically significant improvement in overall procedural success using the single closure device (94.6% vs. 88.5%, p = 0.009) This was defined as intraprocedural hemostatic control, lack of contrast extravasation, arterial dissection, occlusion, or stenosis >50% in the final crossover angiogram, as well as unimpaired limb perfusion without claudication throughout the index hospitalization. There was also a significant improvement in arterial dissection rates (0.6% vs. 4.6%, p = 0.004), stenosis >50% (1.3% vs. 4.4%, p = 0.028), and Valve Academic Research Consortium major vascular complications (1.8% vs. 4.9%, p = 0.038). CONCLUSION: A single Perclose device is a safe means of vascular closure during TF-TAVR and may have important clinical benefits compared to the commonly used two-device technique.

Cardiovascular Effects of Androgen Deprivation Therapy in Prostate Cancer.

PURPOSE OF THE REVIEW: This review paper is a comprehensive look at the cardiovascular disease (CVD) risk that is associated with the use of androgen deprivation therapy in prostate cancer. It summarizes when certain cancer therapies are indicated and should guide physicians in identifying patients at increased risk for CVD during prostate cancer therapy. RECENT FINDINGS: GnRH agonist use and maximal androgen blockade (MAB) are associated with increased CVD. This association is not observed in patients on GnRH antagonists. One example is the novel agent abiraterone, which is associated with hypertension whose mechanisms are likely driven by mineralocorticoid excess. Incidence of cardiovascular disease events is greatest when using MAB, especially in patients with pre-existing CVD. There is significant confounding that exists given patients with more aggressive cancers tend to be older and have more co-existing CVD. Given the lower CVD event rates with GnRH antagonists, future studies and strategies should focus on high-risk cancer patients with co-existing CVD receiving antagonists over agonists.

Tyrosine Kinase Inhibitor-Induced Hypertension.

PURPOSE OF REVIEW: The purpose of this paper is to identify commonly used tyrosine kinase inhibitors (TKIs) that are associated with hypertension, primarily, vascular endothelial growth factor (VEGF) signaling pathway (VSP) inhibitors. We review the incidence, mechanism, and strategies for management of TKI-induced HTN. We hope to provide clinicians with guidance on how to manage similar clinical scenarios. RECENT FINDINGS: Many of the newer VSP inhibitors are reviewed here, including cediranib, axitinib, pazopanib, and ponatinib. Trials utilizing prophylactic treatment with angiotensin system inhibitors (ASIs) are discussed as well as recent data showing an improvement in overall survival and progression-free survival in patients on ASIs and TKI-induced hypertension. The incidence of TKI-induced HTN among the VEGF inhibitors ranges from 5 to 80% and is dose dependent. Newer generation small-molecule TKIs has a lower incidence. The mechanism of action involves VSP inhibition, leading to decreased nitric oxide and increased endothelin production, which causes vasoconstriction, capillary rarefaction, and hypertension. ASIs and calcium channel blockers are first-line therapy for treatment and are associated with improved overall survival. Nitrates and beta-blockers are associated with in vitro cancer regression; however, there is a paucity of trials regarding their use as an anti-hypertensive agent in the TKI-induced HTN patient population.

The use of percutaneous left ventricular assist device in high-risk percutaneous coronary intervention and cardiogenic shock.

Patients with high-risk coronary lesions may be denied coronary artery bypass grafting due to excessive comorbidities. Percutaneous coronary intervention (PCI) may be a feasible revascularization strategy in high-risk patients who present with ST-elevation myocardial infarction and cardiogenic shock. Historically, the use if intra-aortic balloon pump (IABP) has been used in high-risk PCI and cardiogenic shock. However, recent data has shown that elective IABP insertion did not reduce the incidence of major cardiovascular events following PCI. The use of a left ventricular assist device is a reasonable and safe alternative compared with IABP counterpulsation, giving greater cardiac output and hemodynamic support in patients undergoing high-risk PCI and in those with severe cardiogenic shock. This review outlines a case of severe cardiogenic shock and hemodynamic instability where high-risk PCI is a reasonable option.

The association of patent foramen ovale morphology and stroke size in patients with paradoxical embolism.

BACKGROUND: Patent foramen ovale (PFO) has been implicated in the pathogenesis of cryptogenic stroke through paradoxical embolization to the cerebral circulation. This study evaluated the relationship between the morphological and functional size of the PFO by echocardiography compared with cerebral infarct volume identified on MRI. METHODS AND RESULTS: Patients who were referred to interventional cardiology with the diagnosis of cryptogenic stroke were included and had either a transesophageal echocardiogram or an intracardiac echo and a brain MRI at the time of stroke. Transesophageal echocardiogram or intracardiac echo was used to obtain PFO measurements. MRI of the brain with 3 sequences (T2, diffusion-weighted imaging, and fluid-attenuated inversion recovery) was used to diagnose acute stroke and measure the infarct volume. In the 72 patients studied, the median measured stroke volume was 4.3 cm(3) on diffusion-weighted imaging, 4.1 cm(3) on T2, and 3.5 cm(3) on fluid-attenuated inversion recovery. There was no significant correlation between the PFO height, length, septum secundum thickness, or echo bubble grade and the infarct volume measured from the 3 MRI sequences. There was a significant correlation between septal excursion distance and infarct volume (r=0.35; P=0.005), but the 12 patients with atrial septal aneurysm did not have the largest strokes. CONCLUSIONS: This analysis revealed that septal excursion distance correlates with stroke size by MRI. However, smaller PFO size without the presence of atrial septal aneurysm may still be associated with significant strokes. There was no significant association between PFO height, length by echo, or shunt grade by transcranial Doppler study and brain infarct volume. Therefore, PFO size or morphology should not be the only criteria to decide whether a PFO should be closed.

White coat hypertension: relevance to clinical and emergency medical services personnel.

CONTEXT: White-coat hypertension (WCHT) is a relatively unexplored cause of elevated blood pressure readings in the clinic and in prehospital emergency medical services (EMS) settings. OBJECTIVE: The purpose is to summarize WCHT in the clinical office setting and speculate on its relevance in the prehospital setting. This review emphasizes the etiology, diagnosis, prognosis, and application of WCHT in both the clinical and prehospital settings. DATA SOURCES: A systematic literature review was undertaken with the Medline PubMed database, UpToDate, and Web of Science. The following search queries were used: "prehospital WCHT, " " prehospital white coat hypertension, " "EMS WCHT, " " emergency medical services white coat hypertension, " " ambulatory WCHT, " " ambulatory white coat hypertension, " " labile HTN, " " labile hypertension, " " variable HTN, " and " variable hypertension " limited to 1980-July 2006. Only human studies published in English were included. STUDY SELECTION: The reviews yielded 233 articles initially, which were narrowed down to those mentioned herein by direct relevance to either the observed WCHT effect in the clinic or the prehospital setting. DATA SYNTHESIS: WCHT has not been applied or explored in the prehospital setting as of yet, and thus all data were shown to be related to clinical WCHT. It was found that WCHT may not be simply a benign entity but rather part of a continuum in the development of true essential hypertension. It was found that WCHT patients, when followed, had higher morbidity than non-WCHT patients but less morbidity than established essential hypertensive patients. CONCLUSIONS: WCHT may be a significant step toward the evolution into full-blown hypertension. For many populations, routine access to a healthcare provider is not possible, and thus their only interaction with healthcare providers may be in the prehospital EMS setting. On the basis of findings of true organic morbidity in WCHT, it comes to reason that contact with patients in the setting should be thorough--including urging follow-up for those whose blood pressure is found to be elevated in the presence of healthcare professionals.