Percutaneous Left Atrial Appendage Closure for Stroke Prevention in Hypertrophic Cardiomyopathy Patients with Atrial Fibrillation.

BACKGROUND: Percutaneous left atrial appendage closure (LAAC) is an effective alternative strategy for stroke prevention in atrial fibrillation (AF) patients at high risk for bleeding with anticoagulation (AC). Efficacy of this strategy in hypertrophic cardiomyopathy (HCM) remains uncertain. OBJECTIVE: Compare risk of stroke in HCM-AF patients treated with LAAC to those treated with AC. METHODS: Using TriNetX Global Research Network, HCM-AF patients from 2015 to 2024 were categorized into those treated with LAAC vs. solely with AC, and followed for 3-years for ischemic stroke, systemic embolism, and all-cause mortality. Propensity-score matching was used to limit confounders. RESULTS: 14,867 HCM-AF patients were identified; 364 (2.5%) treated with LAAC vs. 14,503 (97.5%) treated with AC. HCM-LAAC patients were older (72 vs. 67, p<0.001), had more comorbidities, and more prior bleeding events, including higher rate of prior gastrointestinal bleeding (68% vs. 18%, p<0.001), compared to HCM patients treated solely with AC. After propensity matching, there was no baseline difference between groups including prior bleeding events (p>0.05). During follow-up, HCM patients treated with LAAC had higher rates of ischemic stroke (13% vs. 8%, HR 1.9, p=0.006) and systemic embolism (14% vs. 9%, HR 1.8, p=0.006), but no difference in mortality compared to matched HCM patients on AC. CONCLUSION: This real-world data does not support percutaneous LAAC in HCM-AF patients as the primary treatment strategy over long term AC to reduce stroke risk. However, LAAC may remain a reasonable option for HCM-AF patients who are unable to tolerate AC due to prohibitive bleeding risk.

Surgical and Transcatheter Mitral Valve Therapy: Medicare Utilization and Reimbursement.

BACKGROUND: We aimed to examine trends in the utilization and reimbursement of surgical and transcatheter mitral valve therapies and their changing relationship. METHODS: A query of administrative data on US Medicare beneficiaries undergoing mitral valve therapy was conducted from 2015 to 2020 using the Centers for Medicare and Medicaid Services Part B National Summary Data File. Inflation adjustment was to the 2020 Consumer Price Index. Trend analysis was quantified with growth rate and simple linear regression calculations. RESULTS: The annual number of all mitral valve procedures remained constant. Transcatheter mitral valve therapies increased by 313% with an increase of 1552 cases per year (P < .001), whereas surgical mitral valve therapies decreased by 31.4% with a decline of 1446 procedures per year (P = .004). As a proportion of all mitral valve therapies, surgical therapies decreased from 91.8% to 65.0%. Annual Medicare reimbursements for transcatheter and surgical mitral valve therapies mirrored the annual procedural trends. For transcatheter mitral valve therapies, per-case reimbursement decreased by 14.1% ($1283.18 to $1102.88), and for surgical mitral valve therapies, per-case reimbursement decreased by 3.8% ($1480.65 to $1424.57). CONCLUSIONS: Medicare utilization of mitral valve therapies has been stable in recent years, with growth of transcatheter volumes offset by a decrease in surgical volumes. This suggests that transcatheter therapy availability has not expanded the pool of patients with access to therapy. Nonetheless, case reimbursements decreased for both modalities.

Modification of a Transvalvular Microaxial Flow Pump for Instantaneous Determination of Native Cardiac Output and Volume.

BACKGROUND: The current Impella cardiopulmonary (CP) pump, used for mechanical circulatory support in patients with cardiogenic shock (CS), cannot assess native cardiac output (CO) and left ventricular (LV) volumes. These data are valuable in facilitating device management and weaning. Admittance technology allows for accurate assessment of cardiac chamber volumes. OBJECTIVES: This study tested the ability to engineer admittance electrodes onto an existing Impella CP pump to assess total and native CO as well as LV chamber volumes in an instantaneous manner. METHODS: Impella CP pumps were fitted with 4 admittance electrodes and were placed in the LVs of adult swine (n = 9) that were subjected to 3 different hemodynamic conditions, including Impella CP speed adjustments, administration of escalating doses of dobutamine and microsphere injections into the left main artery to result in cardiac injury. CO, according to admittance electrodes, was calculated from LV volumes and heart rate. In addition, CO was calculated in each instance via thermodilution, continuous CO measurement, the Fick principle, and aortic velocity-time integral by means of echocardiography. RESULTS: Modified Impella CP pumps were placed in swine LVs successfully. CO, as determined by admittance electrodes, was similar by trend to other methods of CO assessment. It was corrected for pump speed to calculate native CO, and calculated LV chamber volumes trended as expected in each experimental protocol. CONCLUSIONS: We report, for the first time, that an Impella CP pump can be fitted with admittance electrodes and used to determine total and native CO in various hemodynamic situations. CONDENSED ABSTRACT: Transvalvular mechanical circulatory support devices such as the Impella CP do not have the ability to provide real-time information on native cardiac output (CO) and left ventricular (LV) volumes. This information is critical in device management and in weaning in patients with cardiogenic shock. We demonstrate, for the first time, that Impella CP pumps coupled with admittance electrodes are able to determine native CO and LV chamber volumes in multiple hemodynamic situations such as Impella pump speed adjustments, escalating dobutamine administration and cardiac injury from microsphere injection.

Innovative Approach to Manage Transcatheter Aortic Valve Embolization.

We describe the case of a patient with an ascending aortic aneurysm who underwent valve-in-valve transcatheter aortic valve implantation, which was complicated by valve embolization. After a multidisciplinary discussion and an innovative approach, the free-floating embolized valve was anchored securely in the aortic arch with an uncovered aortic endovascular stent. (Level of Difficulty: Intermediate.).

Derivation and validation of Pd/Pa in the assessment of residual ischemia post-intervention: A prospective all-comer registry.

BACKGROUND: Measurement of post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) demonstrates residual ischemia in a large percentage of cases deemed angiographically successful which, in turn, has been associated with worse long-term outcomes. It has recently been shown that a resting pressure index, Pd/Pa, has prognostic value post stenting, however, its diagnostic value relative to FFR post-PCI has not been evaluated. METHODS: The diagnostic accuracy of Pd/Pa in identifying ischemia (FFR≤0.80) pre- and post-PCI was evaluated. Three patient subsets were analyzed. A reference pre-PCI cohort of 1,255 patients (1,560 vessels) was used to measure the accuracy of pre-PCI Pd/Pa vs. FFR. A derivation post-PCI group of 574 patient (664 vessels) was then used to calculate the diagnostic accuracy of post-PCI Pd/Pa vs. FFR. A final prospective validation cohort of 230 patients (255 vessels) was used to test and validate the diagnostic performance of post-PCI Pd/Pa. RESULTS: Median Pd/Pa and FFR were 0.90 (IQR 0.90-0.98) and 0.80 (IQR 0.71-0.88) in the reference pre-PCI model, 0.96 (IQR 0.93-1.00) and 0.87 (IQR 0.77-0.90) in the post-PCI derivation model, and 0.94 (IQR 0.89-0.97) and 0.84 (IQR 0.77-0.90) in the post-PCI validation model respectively. There was a strong linear correlation between Pd/Pa and FFR in all three models (p < 0.0001). Using ROC analysis, the optimal Pd/Pa cutoff value to predict a FFR ≤ 0.80 was ≤0.92 (AUC 0.87) in the pre-PCI model, ≤0.93 (AUC 0.85) in the post-PCI derivation model, and ≤ 0.90 (AUC 0.91) in the post-PCI validation model. Using a hybrid strategy of post-PCI Pd/Pa and post-PCI FFR when necessary (25% patients), overall diagnostic accuracy was improved to 95%. CONCLUSIONS: Pd/Pa has excellent diagnostic accuracy for identifying ischemia post-intervention. Using a hybrid strategy of post-PCI Pd/Pa first, and FFR afterwards, if required, adenosine administration can be avoided in over 75% of physiologic assessments post intervention.

Association Between Diastolic Dysfunction and Health Status Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement.

OBJECTIVES: The aim of this study was to assess the association of baseline left ventricular diastolic dysfunction (LVDD) with health status outcomes of patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND: Although LVDD in patients with aortic stenosis is associated with higher mortality after TAVR, it is unknown if it is also associated with health status recovery. METHODS: In a cohort of 304 patients with interpretable echocardiograms, undergoing TAVR, LVDD was categorized at baseline as absent (grade 0), mild (grade 1), moderate (grade 2), or severe (grade 3). Disease-specific health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) at baseline and at 1-month and 12-month follow-up. Association of baseline LVDD with health status at baseline and follow-up after TAVR was assessed using a linear trend test, and association with health status recovery (change in KCCQ-OS) was examined using a linear mixed model adjusting for baseline KCCQ-OS. RESULTS: Twenty-four (7.9%), 54 (17.8%), 186 (61.2%), and 40 (13.2%) patients had LVDD grades of 0, 1, 2, and 3, respectively. Baseline KCCQ-OS was 61.3 ± 22.7, 51.0 ± 26.1, 44.7 ± 25.7, and 44.4 ± 21.9 (p = 0.004) in patients with LVDD grades of 0, 1,2 and 3. At 1 and 12 months after TAVR, LVDD was not associated with KCCQ-OS. Recovery in KCCQ-OS after TAVR was substantial and similar in patients across all severities of LVDD. CONCLUSIONS: Although LVDD is associated with health status prior to TAVR, patients across all severities of LVDD have similar recovery in health status after TAVR.

Evaluating Equivocal Left Main Stenosis with Fractional Flow Reserve - Not all Daughter Vessels are Created Equally.

Fractional flow reserve (FFR) evaluation of intermediate left main coronary artery (LMCA) stenosis has been validated in clinical decision-making. However, the size of the daughter vessel, in which the FFR transducer is placed and the amount of myocardium it subtends, has received less attention. We present a case that demonstrates the importance of transducer location, size of the daughter vessel and the amount of subtended myocardium in evaluation of LMCA stenosis, pointing out potential pitfalls.

Outcomes of Fractional Flow Reserve-Based Deferral in Saphenous Vein Graft Narrowing.

Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries of patients with stable coronary disease. However, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the prognostic value of deferring intervention in lesions with FFR >0.8 in SVG lesions. Clinical, angiographic, and hemodynamic variables and long-term outcomes were recorded in consecutive patients in whom percutaneous coronary intervention was deferred based on an FFR >0.8 for intermediate native coronary artery or SVG stenosis. Thirty-three patients underwent FFR of SVG lesions and were compared with 532 patients who underwent native vessel FFR during the same period. There were no differences in age (66.6 [interquartile range, IQR 63 to 76] vs 65 years [IQR 61 to 70]; p = 0.12), diabetes (41% vs 50%; p = 0.35), or hypertension (94% vs 97%; p = 0.71). During a median follow-up of 3.2 years (IQR 1.7 to 4.6 years) major adverse cardiac event was significantly higher in SVG group (36% vs 21%; log rank p = 0.01). Similarly, the rate of target vessel failure was significantly higher in the SVG group (27% vs 14%; p = 0.01). Deferred SVG lesions had the worst survival free of target vessel failure compared with deferred native lesions in both patients with and without previous CABG. An SVG lesion was an independent predictor of major adverse cardiac events on Cox proportional hazards analysis (hazard ratio 2.26; confidence interval 1.19, 4.28; p = 0.01). In conclusion, nonischemic FFR carries a significantly worse prognosis in SVG compared with non-SVG lesions. Caution is warranted in utilizing FFR for clinical decision-making in SVG lesions.

Long Term Risk of Recurrent Atrial Fibrillation and Ischemic Stroke after Post-Operative Atrial Fibrillation Complicating Cardiac and Non-Cardiac Surgeries.

BACKGROUND: New onset post-operative atrial fibrillation (POAF) can complicate both non-cardiac(NCS) and cardiac(CS) surgeries. Long term differences in recurrence of atrial fibrillation (AF) and incidence of ischemic stroke/transient ischemic attack(CVA)between these types of POAFare lacking. OBJECTIVE: To compare thelong term recurrence rate of AF and incidence of CVAin patients withnew onset POAF after CS and NCS. METHODS: All patients who developed POAF between May 2010 and April 2014 were included in this single-center, retrospective study Exclusion criteria included a prior history of atrial tachyarrhythmias and pre-operative use of anti-arrhythmic drugs. Recurrence of atrial fibrillation and CVA was identified by review of medical records, electrocardiogram and Holter monitor. RESULTS: patients identified by the ICD9 code=523, 112 patients (61 cardiac; 51 non-cardiac) met inclusion criteria. Mean follow up was 943 days (range 32-2052 days).AF recurrence rate within 30 days after hospital discharge was higher in CS compared with NCS(10% vs 0%, p =0.03). Kaplan Meier analysis showed a trend towards higher recurrence in NCS compared with CS(HR 2.8; 95% CI 0.78-10.6, log rank p =0.03).In long term follow-up, CVA was numerically more common in patients with POAF after CS compared withNCS(10% vs 2%) though this difference was non-significant(HR 3.1; 95% CI 0.72-13.3; log rank p =0.26). CONCLUSION: The risk of recurrent AF and ischemic stroke is not different between POAF after CS or NCS. The overall high rate of AF recurrence and risk of ischemic stroke mandate careful long term follow-up.

Correlation between Echocardiographic Pulmonary Artery Pressure Estimates and Right Heart Catheterization Measurement in Liver Transplant Candidates.

BACKGROUND: Patients undergoing liver transplant have worse outcomes in the presence of pulmonary hypertension. Correlation between echocardiography and catheterization derived pressures in this population is not well studied. Our study's aim is to show the relationship between pulmonary artery systolic pressure derived from transthoracic echo (ePASP) with pulmonary artery systolic pressure measured during right heart catheterization (cPASP). METHODS: Single center retrospective study, patients being evaluated for liver transplant (n = 31) who had an interpretable Doppler signal for ePASP and had right heart catheterization (RHC) measurements within 3 months constituted the study group. Control group (n = 49) consisted of patients who did not have liver disease. RESULTS: There was modest correlation between ePASP and cPASP (R = 0.58, p < 0.001) in LT candidates (n = 31) compared with the control group (R = 0.74, p < 0.001, n = 49). The 95% limits of agreement by Bland-Altman analysis ranged from +33.6 mmHg to -21.7 mmHg. Using receiver operating characteristic analysis, ePASP cut-off > 47 mmHg was 59% sensitive and 78% specific to diagnose pulmonary artery (PA) hypertension (mean PA pressure > 25 mmHg) in the LT candidates, while a similar cutoff performed well in the control group (cutoff > 43 mmHg, n = 47, 91% sensitive, 100% specific). CONCLUSIONS: Compared with other disease states, ePASP correlates modestly with cPASP in patients with advanced liver disease. A higher ePASP cutoff should be used to screen for pulmonary hypertension. A multi-center prospective study with simultaneous transthoracic echocardiography and RHC measurements is required to determine the best cut-off in this population.

Long-Term Outcomes With Transcatheter Aortic Valve Replacement in Women Compared With Men: Evidence From a Meta-Analysis.

OBJECTIVES: This study sought to examine long-term outcomes with transcatheter aortic valve replacement (TAVR) in women versus men. BACKGROUND: TAVR is commonly performed in women. Previous studies have shown conflicting results with respect to sex differences in outcomes with TAVR. In addition, short-term outcomes have primarily been reported. METHODS: Electronic search was performed until March 2017 for studies reporting outcomes with TAVR in women versus men. Random effects DerSimonian-Laird risk ratios were calculated. Outcomes included all-cause mortality and major cardiovascular events at short- (30 days) and long-term (>1 year) follow-up. RESULTS: Seventeen studies (8 TAVR registries; 47,188 patients; 49.4% women) were analyzed. Women were older but exhibited fewer comorbidities. At 30 days, women had more bleeding (p < 0.001), vascular complications (p < 0.001), and stroke/transient ischemic attack (p = 0.02), without difference in all-cause (p = 0.19) or cardiovascular mortality (p = 0.91) compared with men. However, female sex was associated with lower all-cause mortality at 1 year (risk ratio: 0.85; 95% confidence interval: 0.79 to 0.91; p < 0.001), and longest available follow-up (mean 3.28 ± 1.04 years; risk ratio: 0.86; 95% confidence interval: 0.81 to 0.92; p < 0.001), potentially caused by less moderate/severe aortic insufficiency (p = 0.001), and lower cardiovascular mortality (p = 0.009). The female survival advantage remained consistent across multiple secondary analyses. The risk of stroke, moderate/severe aortic insufficiency, and all-cause mortality seemed to vary based on the type of valve used; however, without significant subgroup interactions. CONCLUSIONS: Despite a higher upfront risk of complications, women derive a better long-term survival after TAVR compared with men.

Comparison of the prognostic value of non-ischaemic fractional flow reserve using intracoronary versus intravenous adenosine.

AIMS: Intracoronary adenosine (ICA) yields similar fractional flow reserve (FFR) results to the "gold standard" of intravenous adenosine (IVA). Whether they have similar prognostic significance is unknown. We therefore sought to study the prognostic value of the route of adenosine administration for the measurement of FFR in deferred coronary lesions in a large, real-world cohort. METHODS AND RESULTS: Five hundred and seventy-six patients with 787 lesions in whom PCI was deferred based on FFR >0.75 were studied. The primary outcome was the first major adverse cardiovascular event (MACE; defined as death, myocardial infarction [MI], or target vessel revascularisation [TVR]), and the secondary outcome was a composite of MI and target vessel failure (TVF). FFR was measured with ICA in 426 lesions and IVA in 361 lesions. Median follow-up duration was 3.2 years (interquartile range: 1.7- 4.6). Propensity-matched cohorts of ICA and IVA were well matched for baseline clinical, angiographic and haemodynamic characteristics. In the propensity-matched cohort, MACE occurred in 23.5% of the ICA group and in 22.3% of the IVA group (p=0.29). On multivariate analysis, acute coronary syndrome, FFR and prior MI/revascularisation were independent predictors of MACE and MI/TVF. The route of adenosine administration was not predictive of MACE or MI/TVF. CONCLUSIONS: ICA and IVA yield similar FFR values and show comparable long-term prognostic utility in a deferred population. These findings provide confirmation that non-ischaemic FFR using a simpler ICA protocol provides prognostic data similar to the gold standard IVA.

Role of fractional flow reserve in the evaluation and management of patients with acute coronary syndrome.

PURPOSE OF REVIEW: The aim of this review is to appraise the clinical and prognostic value and pitfalls of FFR across different spectra of ACS presentations and lesion subsets. RECENT FINDINGS: Preponderance of evidence on this subject is from observational nonrandomized studies with conflicting results and short-term outcomes. Multiple recent studies evaluating the role of FFR-based deferral in non-STE ACS from a potentially culprit lesion have demonstrated poor long-term prognosis as related to future risk of target vessel failure (myocardial infarction/revascularization). The prognostic power of nonischemic FFR seems favorable in clear nonculprit ACS lesions. SUMMARY: Fractional flow reserve evaluation can be helpful in clinical decision-making for certain subsets of ACS patients and lesions. Definite ACS-producing lesions should not be evaluated using FFR due to altered pathophysiology and distinct mechanisms underlying the disease process. In uncertain culprit lesions, FFR may be useful with complementary intracoronary imaging.

Clinical Decision-Making for the Hemodynamic "Gray Zone" (FFR 0.75-0.80) and Long-Term Outcomes.

BACKGROUND: Fractional flow reserve (FFR) value between 0.75 and 0.80 is considered the "gray zone" and outcomes data relative to treatment strategy (revascularization vs medical therapy alone [deferral]) are limited for this group. METHODS AND RESULTS: A total of 238 patients (64.3 ± 8.6 years; 97% male; 45% diabetic) with gray-zone FFR were followed for the primary endpoint of major adverse cardiovascular event (MACE), defined as a composite of death, myocardial infarction (MI), and target-vessel revascularization. Mean follow-up duration was 30 ± 17 months. Deferred patients (n = 48 [20%]) had a higher prevalence of smoking and chronic kidney disease compared with the percutaneous coronary intervention (PCI) group (n = 190 [80%]; P<.05). Patients who underwent PCI had significantly lower MACE compared with the deferred patients (16% vs 40%; log rank P<.01). While there was a trend toward a decrease in all-cause mortality (8% vs 19%; log rank P=.06), the composite of death or MI was significantly lower in the PCI group (9% vs 27%; P<.01). On multivariate Cox proportional hazards regression analysis, PCI was associated with lower MACE (hazard ratio, 0.5; 95% confidence interval, 0.27-0.95; P=.03). CONCLUSION: Revascularization for patients with gray-zone FFR was associated with a significantly reduced risk of MACE compared with medical therapy alone.

Chronic lead malposition diagnosis and management: discussion of two cases and literature review.

Management of lead malposition is crucial to avoid complications and is carried out on case-by-case bases. The 12-lead ECG during pacing and chest X-ray are essential during initial workup and recommended for new patients to the device clinic. Echocardiography and CT scan are important to confirm the location and plan appropriate therapy.

Clinical and angiographic predictors of persistently ischemic fractional flow reserve after percutaneous revascularization.

AIMS: Despite optimal angiographic results after percutaneous coronary intervention (PCI), some lesions may continue to produce ischemia under maximal hyperemia. We evaluated the factors associated with persistently ischemic fractional flow reserve (FFR) after angiographically successful PCI. METHODS AND RESULTS: A total of 574 consecutive patients with 664 lesions undergoing PCI who had FFR pre- and post-PCI were analyzed. Percutaneous coronary intervention led to effective ischemia reduction from pre-FFR (0.65±0.14) to post-FFR (0.87±0.08; ∆FFR 0.22±0.16, P<.001). There were 63 (9.5%) lesions with a persistently ischemic FFR of ≤0.80 despite optimal angiographic PCI results. Multivariate analysis revealed the presence of diffuse disease (odds ratio [OR] 3.54, 95% CI 1.80-6.94, P<.01), left anterior descending artery PCI (OR 8.35, 95% CI 3.82-18.27, P<.01), use of intravenous adenosine for inducing hyperemia (OR 3.95, 95% CI 2.0-7.84, P<.01), and pre-PCI FFR (OR 0.03, 95% CI 0.004-0.23, P<.01) as independent predictors of persistently ischemic FFR (≤0.80) after PCI. The predictive accuracy of this model was robust, with an area under the curve of 0.85 (95% CI 0.82-0.88). CONCLUSION: Multiple factors are associated with persistently ischemic FFR after angiographically optimal PCI. It is recommended that in lesions with the above-identified factors, FFR should be remeasured after PCI, and if abnormal, further measures should be undertaken for functional optimization.

Long-Term Prognosis of Deferred Acute Coronary Syndrome Lesions Based on Nonischemic Fractional Flow Reserve.

BACKGROUND: Deferring percutaneous coronary intervention in nonischemic lesions by fractional flow reserve (FFR) is associated with excellent long-term prognosis in patients with stable ischemic heart disease (SIHD). Although FFR is increasingly used for clinical decision making in acute coronary syndrome (ACS) patients with intermediate lesions, its effect on long-term prognosis has not been well established. OBJECTIVES: This study investigated the clinical and prognostic utility of FFR in ACS patients with percutaneous coronary intervention deferred on the basis of nonischemic FFR. METHODS: We studied 206 consecutive ACS patients with 262 intermediate lesions and 370 patients with SIHD (528 lesions) in whom revascularization was deferred on the basis of a nonischemic FFR (>0.75). The primary outcome measure was a composite of myocardial infarction and target vessel failure (major adverse cardiovascular events [MACE]). RESULTS: In the entire cohort, the long-term (3.4 ± 1.6 years) MACE rate was higher in the ACS group than in the SIHD group (23% vs. 11%, p < 0.0001). After propensity score matching (200 patients/group), MACE remained significantly higher (ACS 25% vs. SIHD 12%; p < 0.0001). On Cox proportional hazards analysis for MACE, ACS had a hazard ratio of 2.8 (95% confidence interval: 1.9 to 4.0; p < 0.0001). In both the matched and unmatched cohorts, across all FFR categories, ACS patients had a significantly higher annualized myocardial infarction/target vessel revascularization rate compared with SIHD (p < 0.05). Receiver-operating characteristic analysis identified FFR cutoffs (best predictive accuracy for MACE) of <0.84 for ACS (MACE 21% vs. 36%; p = 0.007) and <0.81 for SIHD (MACE 17% vs. 9%; p = 0.01). CONCLUSIONS: Deferring percutaneous coronary intervention on the basis of nonischemic FFR in patients with an initial presentation of ACS is associated with significantly worse outcomes than SIHD. Caution is warranted in using FFR values derived from patients with SIHD for clinical decision making in ACS patients.

Spontaneous Coronary Artery Dissection: One Disease, Variable Presentations, and Different Management Approaches.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. It occurs predominantly among younger females, typically in the absence of atherosclerotic coronary artery disease. Presentations vary greatly and this condition can be fatal. Given its rarity, there are no management guidelines. We present six patients with SCAD with different presentations and treatment approaches as examples in our literature review. Two patients presented with ST elevation myocardial infarction (STEMI), two with non-STEMI (NSTEMI), and two with cardiac arrest. Patients were treated according to the presentation, clinical stability, and extension and distribution of the dissection. Four patients underwent emergent percutaneous coronary intervention (PCI) and one was clinically stable and treated medically initially and underwent an elective PCI after 4 weeks when coronary angiogram showed persistent dissection. Another patient was treated medically as he was hemodynamically stable and the dissection affected a small branch. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used for diagnosis confirmation as well as during and after PCI to assure good stent apposition. All patients had excellent outcome. SCAD is a rare cause of acute coronary syndrome and a high index of suspicion is crucial for early diagnosis. In patients with early presentation, limited disease, and ongoing symptoms, emergent cardiac catheterization with PCI has excellent outcome. However, in stable patients, medical management and elective PCI in few weeks if the dissection persists is a more reasonable approach. IVUS and OCT are invaluable especially in ambiguous cases.

Perioperative Heparin Bridging in Atrial Fibrillation Patients Requiring Temporary Interruption of Anticoagulation: Evidence from Meta-analysis.

BACKGROUND: Patients with atrial fibrillation (AF) often require temporary interruption of warfarin for an elective operation or invasive procedure. However, the safety and efficacy of periprocedural bridging anticoagulation with unfractionated heparin (UH) or low-molecular-weight heparin (LMWH) are still unclear. We evaluated the safety of periprocedural heparin bridging in AF patients requiring temporary interruption of oral anticoagulation. METHODS: We searched the literature for trials that compared heparin bridging with no bridging in AF patients for whom warfarin was temporarily interrupted. The incidence of all-cause mortality, thromboembolism, and major and all bleeding was included, and meta-analysis was performed. RESULTS: A total of 13,808 patients with AF were included in 4 observational studies, 1 randomized trial, and 1 subgroup analysis of a randomized trial. The mean CHADS2 score for the no heparin bridging group was 2.49 and that for the heparin bridging group was 2.34. At 30 days and up to 3 months, when compared to the heparin bridging group, the no bridging group did not have any significant difference in mortality (odds ratio [OR], 1.29; 95% confidence interval [CI], .15-11.52; P = .82) or cerebrovascular accidents (OR, .93; 95% CI, .34-2.51; P = .88), but the no bridging group had significantly less major bleeding (OR, .41; 95% CI, .24-.68; P = .0006). CONCLUSION: Among AF patients with intermediate CHADS2 scores who are anticoagulated with warfarin and who required temporary interruption of warfarin for an elective surgery or procedure, periprocedural bridging with UH or LMWH was associated with a higher rate of major bleeding with no significant difference in mortality or CVA.