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1.
Am J Cardiol ; 214: 1-7, 2024 Mar 01.
Article in English | MEDLINE | ID: mdl-38110018

ABSTRACT

Transcatheter aortic valve replacement (TAVR) provides an option for extreme-risk patients who underwent reoperation for a failed surgical aortic bioprosthesis. Long-term data on patients who underwent TAVR within a failed surgical aortic valve (TAV-in-SAV) are limited. The CoreValve Expanded Use Study evaluated patients at extreme surgical risk who underwent TAV-in-SAV. Outcomes at 5 years were analyzed by SAV failure mode (stenosis, regurgitation, or combined). Echocardiographic outcomes are site-reported. TAV-in-SAV was attempted in 226 patients with a mean age of 76.7 ± 10.8 years; 63.3% were male, the Society of Thoracic Surgeons predicted risk of mortality score was 9.0 ± 6.7%, and 87.5% had a New York Heart Association classification III or IV symptoms. Most of the failed surgical bioprostheses were stented (81.9%), with an average implant duration of 10.2 ± 4.3 years. The 5-year all-cause mortality or major stroke rate was 47.2% in all patients; 54.4% in the stenosis, 37.6% in the regurgitation, and 38.0% in the combined groups (p = 0.046). At 5 years, all-cause mortality was higher in patients with versus without 30-day severe prosthesis-patient mismatch (51.7% vs 38.3%, p = 0.026). The overall aortic valve reintervention rate was 5.9%; highest in the regurgitation group (12.6%). The mean aortic valve gradient was 14.1 ± 9.8 mm Hg and effective orifice area was 1.57 ± 0.70 at 5 years. Few patients had >mild paravalvular regurgitation at 5 years (5.5% moderate, 0.0% severe). TAV-in-SAV with supra-annular, self-expanding TAVR continues to represent a safe and lasting intermediate option for extreme-risk patients who have appropriate sizing of the preexisting failed surgical valve. Clinical and hemodynamic outcomes were stable through 5 years.


Subject(s)
Aortic Valve Stenosis , Bioprosthesis , Heart Valve Prosthesis , Transcatheter Aortic Valve Replacement , Humans , Male , Aged , Aged, 80 and over , Female , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Follow-Up Studies , Constriction, Pathologic/etiology , Constriction, Pathologic/surgery , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/surgery , Aortic Valve Stenosis/etiology , Treatment Outcome , Transcatheter Aortic Valve Replacement/adverse effects , Surgical Instruments , Prosthesis Design , Risk Factors
2.
Case Rep Cardiol ; 2021: 6529390, 2021.
Article in English | MEDLINE | ID: mdl-34840829

ABSTRACT

Calcified aortic stenosis has become the most common form of acquired valvular heart disease in very old patients. Despite this fact, a majority of these patients were turned down by surgery owing to a risk of mortality > 10% in patients older than 90 years. In recent years, transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option for severe aortic stenosis. However, there is a paucity of data regarding the outcomes of TAVI in patients older than 100 years. We present the oldest patient who has undergone successful TAVI reported in the current literature.

4.
Catheter Cardiovasc Interv ; 85(2): 192-8, 2015 Feb 01.
Article in English | MEDLINE | ID: mdl-24585520

ABSTRACT

OBJECTIVE: This study aims to report the long-term outcomes after percutaneous coronary intervention (PCI) in human immunodeficiency virus (HIV+) patients. BACKGROUND: Sparse data exists regarding the risk of patients with HIV who undergo PCI. METHODS: Using a case-control design, we compared baseline characteristics, procedure-related outcomes, in-hospital, and 2-year clinical outcomes of 112 consecutive HIV+ patients versus 112 HIV- controls matched for age, gender, and diabetes mellitus who underwent PCI from April 2003 to September 2011. RESULTS: Baseline characteristics were generally comparable, save for more African Americans and history of chronic renal insufficiency in the HIV+ vs. HIV- group (62.5% vs. 21.4%, P < 0.001) and (27.7% vs. 9.9%, P < 0.001). There was no correlation between CD4 nadir count and extent and diffuseness of coronary artery disease. The occurrence of major adverse cardiac events at 2 years was similar in both groups. Multivariable analysis for independent correlates of major adverse cardiac events at 2 years detected patients with a history of chronic renal insufficiency (OR: 2.44, 95% confidence interval: 1.02-5.83; P = 0.04) and acute myocardial infarction (OR: 2.92, 95% confidence interval: 1.39-6.15; P = 0.005) as correlates for outcome. Post-hoc analysis showed that drug-eluting stent (DES) use in the HIV+ group was beneficial. CONCLUSION: PCI in HIV+ patients is safe, with high procedural success rates, and produces similar outcomes to those seen in HIV- patients at 2 years. HIV+ patients should be treated with DES if possible.


Subject(s)
Coronary Artery Disease/therapy , HIV Infections/complications , Percutaneous Coronary Intervention , Aged , Chi-Square Distribution , Coronary Artery Disease/complications , Coronary Artery Disease/diagnosis , Coronary Artery Disease/mortality , Databases, Factual , Drug-Eluting Stents , Female , HIV Infections/diagnosis , HIV Infections/mortality , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Multivariate Analysis , Myocardial Infarction/etiology , Odds Ratio , Patient Selection , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/instrumentation , Percutaneous Coronary Intervention/mortality , Proportional Hazards Models , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome
5.
Cardiovasc Revasc Med ; 15(4): 195-9, 2014 Jun.
Article in English | MEDLINE | ID: mdl-24746598

ABSTRACT

OBJECTIVES: Our study aimed to assess the characteristics and outcomes of transfemoral approach (TFA) versus the initial steps of a transradial approach (TRA) program and to assess the learning curve of TRA in contemporary, US practice. BACKGROUND: When compared to TFA, TRA has been shown to lower bleeding and vascular complications during percutaneous coronary intervention (PCI). However, use of TRA is still low. There are limited data regarding the characteristics of TRA learning curve, especially in an era with designated TRA equipment. METHODS: Consecutive patients undergoing PCI in a single US center were divided into two cohorts according to vascular access approach: the last 250 TFA patients prior to the establishment of a TRA program and the initial 239 TRA patients following the establishment of a TRA program. Subgroup analysis of the TRA group, which was divided into five sequential case groups of 50 cases per group, was performed in order to assess TRA learning curve. RESULTS: Overall, the baseline characteristics of TFA vs. TRA groups were comparable. Fluoroscopy time was significantly longer during TRA procedures (18±11 vs. 15±8min, respectively, p=0.002); however, contrast use was lower during TRA procedures (161±72 vs. 180±63ml, respectively, p=0.002). In-hospital outcomes were similar between the two groups, with low frequencies of mortality, myocardial infarction, and stent thrombosis. Subanalysis of TRA group for learning curve assessment showed no major differences in patient demographics among the five subgroups. In the initial cases, more PCI was performed among non-acute cases (62% in patients 1-50 vs. 8-27% in patients 51-239, p<0.001). Despite these differences, characteristics of the treated vessels were similar between groups. There was no significant change in fluoroscopy time or in the amount of iodinated contrast volume delivered. Similarly, no differences in procedural, in-hospital, and long-term outcomes were documented. CONCLUSIONS: Adopting TRA as a default is feasible for high-volume operators without significant learning curve effects.


Subject(s)
Cardiac Catheterization/methods , Catheterization, Peripheral/methods , Clinical Competence , Coronary Artery Disease/therapy , Femoral Artery , Learning Curve , Percutaneous Coronary Intervention/methods , Radial Artery , Aged , Cardiac Catheterization/adverse effects , Catheterization, Peripheral/adverse effects , Contrast Media , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/mortality , Coronary Thrombosis/etiology , Coronary Thrombosis/mortality , District of Columbia , Feasibility Studies , Female , Hospitals, High-Volume , Humans , Male , Middle Aged , Myocardial Infarction/etiology , Myocardial Infarction/mortality , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/instrumentation , Program Development , Radiography, Interventional , Stents , Time Factors , Treatment Outcome
6.
J Invasive Cardiol ; 26(4): 154-60, 2014 Apr.
Article in English | MEDLINE | ID: mdl-24717271

ABSTRACT

OBJECTIVE: This study aimed to assess the long-term safety and clinical effectiveness of the Xience V everolimus-eluting stent (EES) compared to both Taxus paclitaxel-eluting stent (PES) and Cypher sirolimus-eluting stent (SES) in an unselected patient population. BACKGROUND: There are limited long-term data comparing Xience V EES vs the first-generation Cypher SES. METHODS: This retrospective analysis included 6069 patients treated with Cypher SES, Taxus PES, or Xience V EES from 2003-2009 at our institution. Patients were followed by telephone contact or office visit up to 2 years after the index procedure. RESULTS: Baseline characteristics were generally comparable, with the exception of a significantly higher prevalence of diabetes mellitus, systemic hypertension, history of angioplasty, and coronary bypass surgery among Xience V EES patients. At 2 years, the incidence of major adverse cardiovascular events was 13.3% (Xience V EES) vs 17.8% (Cypher SES) vs 22% (Taxus PES) (P<.001). The main drivers for the differences in event rates were lower mortality, the need for target vessel revascularization, and Q-wave myocardial infarction. Stent thrombosis was lowest in Xience V EES patients (0.2% vs 1.2% SES vs 0.7% PES, respectively; P=.01). A landmark analysis after 1 year showed that the benefits of Xience V EES continued in long-term follow-up. CONCLUSIONS: In a contemporary clinical United States practice with an unselected patient population, Xience V EES use was associated with improved safety profile and reduction of all-cause mortality and stent thrombosis when compared to both first-generation drug-eluting stents. This superiority continues to widen from 1 to 2 years.


Subject(s)
Coronary Artery Disease/therapy , Drug-Eluting Stents , Percutaneous Coronary Intervention/instrumentation , Percutaneous Coronary Intervention/methods , Postoperative Complications/epidemiology , Sirolimus/analogs & derivatives , Aged , Coronary Stenosis/epidemiology , Coronary Stenosis/etiology , Drug-Eluting Stents/adverse effects , Everolimus , Female , Follow-Up Studies , Humans , Incidence , Longitudinal Studies , Male , Middle Aged , Myocardial Infarction/epidemiology , Myocardial Infarction/etiology , Paclitaxel , Postoperative Complications/etiology , Retrospective Studies , Treatment Outcome
7.
Eur Heart J ; 35(38): 2663-71, 2014 Oct 07.
Article in English | MEDLINE | ID: mdl-24598983

ABSTRACT

AIMS: This study aimed to evaluate incidence and correlates for low platelet count after transcatheter aortic valve replacement (TAVR) and to determine a possible association between acquired thrombocytopenia and clinical outcomes. METHODS AND RESULTS: Patients undergoing TAVR from two medical centres were included in the study. They were stratified according to nadir platelet count post procedure: no/mild thrombocytopenia, ≥100 × 10(9)/L; moderate, 50-99 × 10(9)/L; and severe, <50 × 10(9)/L. A total of 488 patients composed of the study population (age 84.7 ± 7.5 years). At a median time of 2 days after TAVR, 176 patients (36.1%) developed significant thrombocytopenia: 149 (30.5%) moderate; 27 patients (5.5%) severe. Upon discharge, the vast majority of patients (90.2%) had no/mild thrombocytopenia. Nadir platelet count <50 × 10(9)/L was highly specific (96.3%), and a count <150 × 10(9)/L highly sensitive (91.2%), for predicting 30-day death (C-statistic 0.76). Patients with severe acquired thrombocytopenia had a significantly higher mortality rate at 1 year (66.7% for severe vs. 16.0% for no/mild vs. 20.1% for moderate; P < 0.001). In multivariate logistic regression, severe thrombocytopenia was independently associated with 1-year mortality (hazard ratio 3.44, CI: 1.02-11.6; P = 0.046). CONCLUSIONS: Acquired thrombocytopenia was common after TAVR and was mostly resolved at patient discharge. The severity of thrombocytopenia after TAVR could be used as an excellent, easily obtainable, marker for worse short- and long-term outcomes after the procedure.


Subject(s)
Aortic Valve Stenosis/surgery , Thrombocytopenia/etiology , Transcatheter Aortic Valve Replacement/adverse effects , Aged, 80 and over , Female , Humans , Length of Stay , Male , Platelet Count , Treatment Outcome
8.
J Interv Cardiol ; 27(2): 212-6, 2014 Apr.
Article in English | MEDLINE | ID: mdl-24447166

ABSTRACT

OBJECTIVE: We aimed to identify the correlates in the development of post-percutaneous coronary intervention (PCI) iatrogenic femoral pseudoaneurysm (IFP). BACKGROUND: IFP is one of the more common vascular complications of PCI. METHODS: From February 2008 to June 2012, 10,169 consecutive patients who underwent PCI were retrospectively studied. Patients who developed postprocedural IFP were identified at a single, large tertiary PCI center. RESULTS: One hundred thirty-nine patients developed IFP (1.38%) and were compared to the cohort that did not. Baseline characteristics were comparable, although patients in the IFP group were older and had a higher incidence of insulin-requiring diabetes mellitus and chronic renal insufficiency (68.4 ± 12.9 vs. 65.4 ± 12.3 years, P = 0.004; 23.9% vs. 14.6%, P = 0.002; and 26.6% vs. 17.3%, P = 0.004, respectively). The non-IFP group had more men and a higher use of vascular closure devices, respectively (64.7% vs. 49.6%, P < 0.001; and 54.1% vs. 26.5%, P < 0.001). There was no significant difference in the use of dual antiplatelet or anticoagulation therapies between the 2 cohorts. Univariable correlates for the development of IFP were female gender, insulin-requiring diabetes mellitus, chronic renal insufficiency, and use of manual compression to achieve hemostasis. On multivariable analysis, the successful deployment of vascular closure device for hemostasis reduced the occurrence of IFP (odds ratio 0.31, 95% confidence interval 0.21-0.46, P < 0.0001). CONCLUSION: The development of IFP following PCI is not uncommon and the appropriate use of vascular closure devices to achieve hemostasis should be encouraged to minimize this vascular complication.


Subject(s)
Aneurysm, False/etiology , Femoral Artery , Iatrogenic Disease , Percutaneous Coronary Intervention , Aged , Aneurysm, False/epidemiology , Diabetes Mellitus, Type 1/complications , Female , Hemostasis , Humans , Iatrogenic Disease/epidemiology , Male , Percutaneous Coronary Intervention/methods , Postoperative Complications , Renal Insufficiency, Chronic/complications
9.
Catheter Cardiovasc Interv ; 83(1): E61-3, 2014 Jan 01.
Article in English | MEDLINE | ID: mdl-23592591

ABSTRACT

Implantation of coronary stents should be performed with high precision to ensure optimal clinical results. In some clinical conditions, during the cardiac cycle, significant movement of the predeployed stent may impact its implantation accuracy. We describe a case in which a patient had a short ostial left anterior descending artery stenosis and hyperkinetic left ventricle, resulting in significant movement of the stent inside the vessel lumen during the cardiac cycle. Intracoronary adenosine was used to create temporary heart block to enable accurate stent implantation.


Subject(s)
Adenosine/administration & dosage , Coronary Stenosis/therapy , Heart Block , Percutaneous Coronary Intervention/instrumentation , Stents , Ventricular Function, Left/drug effects , Adult , Coronary Angiography , Coronary Stenosis/diagnosis , Coronary Stenosis/physiopathology , Electrocardiography , Female , Humans , Injections , Treatment Outcome , Ultrasonography, Interventional
10.
Catheter Cardiovasc Interv ; 84(3): 397-405, 2014 Sep 01.
Article in English | MEDLINE | ID: mdl-24227477

ABSTRACT

OBJECTIVE: To evaluate the axial integrity of different coronary stents using intravascular ultrasound (IVUS). BACKGROUND: Longitudinal stent deformation was recently reported. METHODS: Consecutive patients who underwent IVUS analysis after drug-eluting stent (DES) implantation for de novo coronary lesions were evaluated. Stent length was compared with label length for calculation of absolute change and relative difference (absolute change divided by label length). RESULTS: A total of 233 DES utilizing five different platforms were included. The median absolute change in stent length was 0.90 mm (interquartile range [IQR] 0.48-1.39) and the relative difference was 5.24% (IQR 2.55-8.29). There was no significant difference among the groups in median absolute or relative change: Cypher 0.89 mm/3.89%, Taxus 0.88 mm/5.39%, Endeavor 1.16 mm/6.77%, Xience V 0.86 mm/5.80%, and PROMUS Element 0.79 mm/5.34% (P = 0.085, P = 0.072, respectively). Multivariate logistic regression revealed that the Cypher stent was independently correlated with a lower change in length, whereas stent label length and deployment pressure were correlated with higher absolute change. CONCLUSION: The axial integrity of DES platforms examined in vivo was high, with only mild changes in stent length after implantation. While there are differences between first- and second-generation DES, axial integrity among second-generation DES was similar.


Subject(s)
Coronary Artery Disease/surgery , Coronary Vessels/diagnostic imaging , Percutaneous Coronary Intervention/methods , Stents , Ultrasonography, Interventional/methods , Aged , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Coronary Vessels/surgery , Female , Follow-Up Studies , Humans , Male , Middle Aged , Prosthesis Design , Prosthesis Failure
11.
Int J Cardiol ; 170(1): 43-8, 2013 Dec 05.
Article in English | MEDLINE | ID: mdl-24169532

ABSTRACT

BACKGROUND: Drug-eluting stents (DES) are routinely used in complex patients, but the impact of 1st- versus 2nd-generation DES on clinical outcomes has not been well described. This study aimed to assess the efficacy and safety of 2nd-generation (everolimus-eluting) DES compared to 1st-generation (sirolimus- and paclitaxel-eluting) DES in a selected, higher-risk population with complex clinical and angiographic features. METHODS: The study included 5693 consecutive patients with the presence of ≥ 1 predefined complex clinical and angiographic characteristic treated with either generation DES. Using propensity score matching, the clinical outcomes of 1076 patients treated with 2nd-generation DES were compared with the outcomes of a matched population treated with 1st-generation DES over 1-year follow-up. RESULTS: After matching, baseline clinical and angiographic characteristics were similar between groups. At 1-year follow-up, the rate of major adverse cardiac events was 9.4% with 2nd-generation DES and 11.3% with 1st-generation DES (p=0.16). There were no significant differences in the rates of death (3.2 vs. 4.0%, p=0.30), myocardial infarction (1.6 vs. 1.3%, p=0.57), target vessel revascularization (5.9 vs. 7.3%, p=0.17) or target lesion revascularization (4.4 vs. 5.0%, p=0.50). Definite stent thrombosis was less frequent with 2nd-generation DES (0.1 vs. 0.8%, p=0.011), as was definite or probable stent thrombosis (0.7 vs. 1.6%, p=0.040). CONCLUSION: In this propensity score matched patient population with complex features undergoing percutaneous coronary intervention, the use of 2nd-generation DES was associated with lower rates of stent thrombosis, and similar 1-year major adverse cardiac events compared to 1st-generation DES.


Subject(s)
Drug-Eluting Stents/standards , Myocardial Infarction/surgery , Population Surveillance/methods , Propensity Score , Thrombosis/prevention & control , Aged , Female , Follow-Up Studies , Humans , Male , Middle Aged , Myocardial Infarction/diagnosis , Myocardial Infarction/epidemiology , Percutaneous Coronary Intervention/standards , Prospective Studies , Thrombosis/epidemiology , Treatment Outcome
12.
J Interv Cardiol ; 26(6): 561-9, 2013 Dec.
Article in English | MEDLINE | ID: mdl-24028183

ABSTRACT

OBJECTIVE: This study aimed to compare the safety and efficacy of everolimus-eluting stents (EES) to first-generation drug-eluting stents (DES) in multivessel disease (MVD). BACKGROUND: Second-generation EES have demonstrated superiority over first-generation DES for single-vessel disease, although the merits of EES in MVD are less established. METHODS: A cohort of 1,285 patients (3,124 lesions) with ≥ 2 diseased vessels were treated with either first-generation DES (n = 1,002) or EES (n = 283). The rates of death, myocardial infarction, target lesion revascularization, target vessel revascularization, definite stent thrombosis, and major adverse cardiac events (MACE), defined as the combined incidence of target vessel revascularization, death, and non-fatal myocardial infarction, were compared at 1 year. RESULTS: Baseline characteristics were similar except for a lower left ventricular ejection fraction and a lower incidence of stable angina pectoris in the first-generation DES group (P = 0.001 and 0.013, respectively). At 1 year, the MACE rate was lower in the EES group (9.5P% vs. 15.7%; P = 0.01). Multivariable analysis demonstrated that EES use predicted a higher chance of freedom from MACE at 1 year (hazard ratio 0.58 [0.38-0.87]; P = 0.009; 95% confidence interval). CONCLUSIONS: The use of EES in patients with MVD is safe with signals for improved effectiveness compared to first-generation DES. Randomized trials comparing new-generation DES to coronary artery bypass grafting surgery are warranted.


Subject(s)
Coronary Disease/therapy , Drug-Eluting Stents , Sirolimus/analogs & derivatives , Aged , Coronary Angiography , Coronary Disease/complications , Everolimus , Female , Humans , Male , Sirolimus/administration & dosage , Treatment Outcome
13.
Am J Cardiol ; 112(8): 1093-8, 2013 Oct 15.
Article in English | MEDLINE | ID: mdl-23827397

ABSTRACT

The safety and efficacy outcomes of stent overlap with second-generation drug-eluting stents (DES) have not been well established. This study aimed to compare the 1-year clinical outcomes of overlapping everolimus-eluting stents (EES) with those of overlapping first-generation DES. This retrospective analysis included 350 patients treated with overlapping EES (169 patients with 237 lesions), sirolimus-eluting stents (SES, 102 patients with 252 lesions), or paclitaxel-eluting stents (PES, 79 patients with 182 lesions). End points were major adverse cardiovascular events (MACE: defined as the composite of death, myocardial infarction, or target lesion revascularization), target vessel revascularization, and definite stent thrombosis at 1 year. During a follow-up of 1 year, overall MACE occurred in 6.5% of EES-, 16.8% of SES-, and 10.1% of PES-treated patients (p = 0.026). Myocardial infarction was lowest in the EES group versus SES and PES groups (0 vs 1.0% vs 2.5%, respectively; p = 0.080), and mortality was similar (3.6% vs 9.0% vs 5.1%, p = 0.162). The EES patients showed a trend toward lower rates of 1-year target lesion revascularization (3.1% vs 8.2% vs 6.5%, p = 0.181) and target vessel revascularization (3.7% vs 9.1% vs 11.7%, p = 0.051) compared with the SES- and PES-treated patients. The cumulative incidence of definite stent thrombosis was lowest in the EES group (0 for EES vs 3.9% for SES vs 2.5% for PES, p = 0.014). In conclusion, stent overlap with EES versus first-generation DES was associated with lower rates of MACE and stent thrombosis. Our results suggest that the use of EES when deploying overlapping stents is effective and safe.


Subject(s)
Coronary Artery Disease/surgery , Drug-Eluting Stents , Immunosuppressive Agents/pharmacology , Paclitaxel/pharmacology , Sirolimus/analogs & derivatives , Aged , Antineoplastic Agents, Phytogenic/pharmacology , District of Columbia/epidemiology , Everolimus , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Postoperative Complications/epidemiology , Prosthesis Design , Retrospective Studies , Sirolimus/pharmacology , Treatment Outcome
14.
Am Heart J ; 166(1): 104-9, 2013 Jul.
Article in English | MEDLINE | ID: mdl-23816028

ABSTRACT

BACKGROUND: Red cell distribution width (RDW), a measure of variability in the size of circulating erythrocytes, is an independent predictor of mortality in cardiovascular disease and in patients undergoing percutaneous coronary intervention (PCI). We set out to determine if RDW is a prognostic marker of major bleeding post-PCI. METHODS: The study population included 6,689 patients who were subjected to PCI. The RDW was derived from a complete blood count drawn before PCI. Major inhospital bleeding was defined as a hematocrit decrease ≥12%, hemoglobin drop of ≥4, transfusion of ≥2 units of packed red blood cells, retroperitoneal, or gastrointestinal or intracranial bleeding. Multivariable logistic analysis of major inhospital bleeding was performed using a logistic regression model that comprised the National Cardiovascular Data Registry (NCDR) risk score model as a single variable. RESULTS: Major bleeding (P < .001), vascular complications (P = .005), and transfusions (P < .001) were significantly higher in patients with higher baseline RDW values. After adjustment for known bleeding correlates, RDW was a significant predictor for major bleeding (odds ratio 1.12, 95% CI 1.06-1.19, P < .001). Although the c statistic of the NCDR risk prediction model changed from 0.730 to 0.737 (P = .032), the net reclassification improvement increased significantly after the addition of RDW as a continuous variable (17.3% CI 6.7%-28%, P = .002). CONCLUSIONS: Red cell distribution width, an easily obtainable marker, has an independent, linear relationship with major bleeding post-PCI and incrementally improves the well-validated NCDR risk prediction model. These data suggest that further investigation is necessary to determine the relationship of RDW and post-PCI bleeding.


Subject(s)
Coronary Artery Disease/surgery , Erythrocytes , Percutaneous Coronary Intervention , Postoperative Care/methods , Postoperative Hemorrhage/blood , Aged , Coronary Artery Disease/blood , Erythrocyte Count , Female , Follow-Up Studies , Humans , Male , Middle Aged , Postoperative Hemorrhage/diagnosis , Predictive Value of Tests , Prognosis , Retrospective Studies , Risk Factors , Stents
15.
J Interv Cardiol ; 26(4): 366-71, 2013 Aug.
Article in English | MEDLINE | ID: mdl-23795684

ABSTRACT

OBJECTIVE: To determine the best revascularization strategy when treating distal anastomotic lesions. BACKGROUND: Distal anastomotic lesions are the most common reason for venous graft failure especially early after bypass surgery. However, the best percutaneous method for treating these lesions is still controversial. METHODS: All patients from 2/2000 to 1/2011 who underwent percutaneous coronary intervention of bypass graft distal anastomotic lesions were retrospectively enrolled. Among the 139 patients included, 26 (18.7%) were treated with plain old balloon angioplasty (POBA), 68 (48.9%) with bare metal stents (BMS), and 45 (32.4%) with drug-eluting stents (DES). RESULTS: Baseline characteristics were generally comparable among the 3 groups. At 6 months' follow-up, the highest rate of target lesion revascularization-major adverse cardiac events (TLR-MACE) was seen in the BMS group compared to the DES and POBA groups (16.2 vs. 2.2 vs. 3.8%, respectively, P=0.03), which was driven mainly by the highest rates of death and TLR in the BMS group (11.8 and 4.7%, respectively). At 1-year follow-up, a higher rate of TLR-MACE was seen in the BMS group compared to the DES and POBA groups (20.6 vs. 11.1 vs. 7.7%, respectively, P=0.19). After adjustment, on Cox regression analysis for hazard ratios, no significant differences were found among the 3 groups at 1-year follow-up of TLR-MACE. CONCLUSIONS: When selecting the treatment modality for saphenous vein graft distal anastomotic lesions, BMS implantation should be discouraged while POBA and DES implantation can be performed with favorable long-term outcomes. The optimal treatment approach should be evaluated in large, randomized clinical trials.


Subject(s)
Coronary Artery Bypass/adverse effects , Coronary Restenosis/therapy , Graft Occlusion, Vascular/therapy , Percutaneous Coronary Intervention , Aged , Aged, 80 and over , Angioplasty, Balloon, Coronary , Coronary Artery Bypass/methods , Drug-Eluting Stents , Female , Humans , Male , Middle Aged , Reoperation , Retrospective Studies , Saphenous Vein/transplantation , Stents , Treatment Outcome , Vascular Patency
16.
Cardiovasc Revasc Med ; 14(3): 174-81, 2013.
Article in English | MEDLINE | ID: mdl-23773501

ABSTRACT

Paravalvular regurgitation is a common, potentially life-threatening complication of transcatheter aortic valve replacement. Previous studies report a 65%-94% rate of paravalvular leakage after transcatheter implantation, mostly of mild degree. The rate of significant (≥ +2) paravalvular regurgitation varies in large clinical trials, and is associated with worse clinical outcome. There is less agreement regarding the significance of mild regurgitation (grade 1+). There are anatomical and procedural correlates for paravalvular leak-most importantly, severe valve calcification, patient prosthetic mismatch, and device malposition. The following review details the current knowledge on paravalvular regurgitation after transcatheter aortic valve replacement, including diagnosis, correlates, clinical outcome, preventive and therapeutic strategies related to this complication.


Subject(s)
Aortic Valve Insufficiency/etiology , Aortic Valve Stenosis/therapy , Aortic Valve/physiopathology , Cardiac Catheterization/adverse effects , Heart Valve Prosthesis Implantation/adverse effects , Hemodynamics , Aortic Valve Insufficiency/diagnosis , Aortic Valve Insufficiency/physiopathology , Aortic Valve Insufficiency/prevention & control , Aortic Valve Insufficiency/therapy , Aortic Valve Stenosis/physiopathology , Cardiac Catheterization/instrumentation , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/methods , Humans , Prosthesis Design , Severity of Illness Index , Time Factors , Treatment Outcome
17.
Cardiovasc Revasc Med ; 14(3): 128-33, 2013.
Article in English | MEDLINE | ID: mdl-23642502

ABSTRACT

BACKGROUND: Drug-eluting stents have shown promising clinical results in the treatment of acute coronary syndrome (ACS) patients. We aimed to evaluate the long-term outcome of Endeavor zotarolimus-eluting stent (EZES) implantation in an ACS population and to compare these results with those obtained in patients treated with sirolimus-eluting (SES) and paclitaxel-eluting stents (PES). METHODS: This prospective study included 1481 consecutive ACS patients (72% myocardial infarction, age 65 ± 13 years, 62% male) treated with a drug-eluting stent: (SES, n=925; PES, n=417; EZES, n=139). The primary end point was major adverse cardiac events (MACE) at 2 years, defined as the composite of death, myocardial infarction, and target vessel revascularization. Two-year follow-up was obtained in all patients. RESULTS: Baseline clinical and angiographic characteristics were mostly similar. Unadjusted 2-year MACE and death rates were lower in the EZES group than in the SES and PES groups (MACE: 18.7% vs. 25.3% vs. 30.2%, p=0.02; death: 10.1% vs. 16.4% vs. 22.2%, p=0.002, respectively). The rate of definite stent thrombosis at 2 years was lower in the EZES group without statistically significant difference (0.7% vs. 2.9% SES vs. 1.7% PES, p=0.16). After adjusting for differences in baseline characteristics, EZES use was an independent correlate for 2-year MACE (vs. SES, hazard ratio 0.65, p=0.049; vs. PES, hazard ratio 0.57, p=0.01). CONCLUSION: In an ACS patient population, a lower long-term MACE rate was observed in patients treated with an EZES when compared to treatment with first-generation drug-eluting stents. The use of EZES in contemporary practice has excellent long-term outcome in terms of low rates of revascularization and clinical events.


Subject(s)
Acute Coronary Syndrome/therapy , Cardiovascular Agents/administration & dosage , Drug-Eluting Stents , Myocardial Infarction/therapy , Paclitaxel/administration & dosage , Percutaneous Coronary Intervention/instrumentation , Sirolimus/analogs & derivatives , Acute Coronary Syndrome/diagnosis , Acute Coronary Syndrome/mortality , Aged , Coronary Angiography , Disease-Free Survival , District of Columbia , Female , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Multivariate Analysis , Myocardial Infarction/diagnosis , Myocardial Infarction/mortality , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/mortality , Prospective Studies , Prosthesis Design , Registries , Risk Factors , Sirolimus/administration & dosage , Time Factors , Treatment Outcome
18.
Am J Cardiol ; 112(1): 61-7, 2013 Jul 01.
Article in English | MEDLINE | ID: mdl-23561590

ABSTRACT

Second-generation everolimus-eluting stents (EESs) have demonstrated superiority in efficacy and safety compared with first-generation drug-eluting stents (DESs) in the treatment of native coronary artery lesions. The present study evaluated and compared the safety and efficacy of EESs and first-generation DESs in saphenous vein graft lesions. The EES group consisted of 88 patients with 96 lesions, and the first-generation DES group consisted of 243 patients with 317 lesions (sirolimus-eluting stents, n = 212; paclitaxel-eluting stents, n = 105). The end points included target lesion revascularization, target vessel revascularization, major adverse cardiovascular events (composite of all-cause death, myocardial infarction, and target vessel revascularization), and definite stent thrombosis at 2 years. The groups had similar baseline characteristics and graft ages (128.1 ± 77.5 vs 132.4 ± 90.8 months, p = 0.686). The EES group had more type C lesions and less embolic protection device use. The peak postprocedure values of creatinine kinase-MB and troponin I were similar between the 2 groups. Overall, major adverse cardiovascular events occurred in 18.2% of EES patients and 35.0% of first-generation DES patients (p = 0.003), mainly driven by a lower target vessel revascularization rate (6.8% vs 24.5%, p <0.001). The target lesion revascularization rate was lower in the EES group (1.1% vs 11.6%, p = 0.005). Stent thrombosis was low and similar between the 2 groups (0% vs 0.8%, p = 1.000). On multivariate analysis, the type of DES implanted and graft age were the only independent predictors of major adverse cardiovascular events. In conclusion, the superiority of EESs compared with first-generation DESs shown in native artery lesions has been extended to saphenous vein graft lesions and should be considered as the DES of choice for this lesion type.


Subject(s)
Coronary Stenosis/drug therapy , Drug-Eluting Stents , Graft Occlusion, Vascular/drug therapy , Immunosuppressive Agents/therapeutic use , Saphenous Vein/transplantation , Sirolimus/analogs & derivatives , Sirolimus/therapeutic use , Aged , Biomarkers/blood , Electrocardiography , Everolimus , Female , Follow-Up Studies , Humans , Male , Percutaneous Coronary Intervention , Proportional Hazards Models , Retrospective Studies , Treatment Outcome
19.
Am J Cardiol ; 111(9): 1337-43, 2013 May 01.
Article in English | MEDLINE | ID: mdl-23415511

ABSTRACT

The incidence and prognostic implication of myocardial injury after transcatheter aortic valve replacement (TAVR) have not been consistently studied. We aimed to assess the incidence and extent of myocardial injury after TAVR performed using transfemoral and transapical approaches. The clinical data from patients with aortic stenosis who underwent TAVR were retrospectively analyzed. The myocardial necrosis markers cardiac troponin I and creatine kinase (CK)-MB were assessed during hospitalization. Of the 150 TAVR patients, 95% and 50% had an abnormally elevated cardiac troponin I and CK-MB level, respectively. The transapical patients had significantly greater elevations of both cardiac troponin I (13.8 ± 14.0 vs 2.5 ± 5.8 ng/ml, p <0.001) and CK-MB (28.4 ± 24.2 vs 7.4 ± 8.6 ng/ml, p ≤0.001). On receiver operating curve analysis, postprocedural CK-MB (twofold increase) had high predictive power for 30-day mortality (area under the curve 0.85, p <0.001). Patients with high CK-MB levels had greater rates of postprocedural kidney injury (22% vs 6%, p = 0.026), in-hospital (22% vs 0%, p <0.001), 30-day (27% vs 1.5%, p <0.001), and 1-year mortality (41% vs 18%, p = 0.01). Baseline renal failure and no ß-blocker treatment on admission were independent predictors of an elevated postprocedural CK-MB level. In conclusion, a cardiac biomarker increase after TAVR was common and more frequent among transapical access patients. A twofold increase (>7 ng/ml) in CK-MB after transfemoral TAVR was a surrogate for poor long-term outcomes.


Subject(s)
Aortic Valve Stenosis/surgery , Heart Injuries/epidemiology , Heart Valve Prosthesis , Intraoperative Complications , Aged, 80 and over , Aortic Valve Stenosis/mortality , Biomarkers/blood , Creatine Kinase/blood , Creatine Kinase, MB Form/blood , District of Columbia/epidemiology , Female , Follow-Up Studies , Heart Injuries/diagnosis , Heart Injuries/etiology , Humans , Male , Myocardium/metabolism , Prevalence , Prognosis , Retrospective Studies , Severity of Illness Index , Survival Rate/trends , Troponin/blood
20.
Am J Cardiol ; 111(8): 1092-8, 2013 Apr 15.
Article in English | MEDLINE | ID: mdl-23352262

ABSTRACT

Previous studies have shown a relation between female gender and adverse outcomes after percutaneous coronary intervention (PCI). The aim of this study was to determine whether there are differences in correlates between genders for these long-term adverse outcomes in patients with acute coronary syndromes. Gender differences were evaluated in the clinical outcomes of 6,929 consecutive patients with acute coronary syndromes from a large, contemporary PCI registry. Rates of major adverse cardiovascular events, defined as all-cause mortality, myocardial infarction, and target lesion revascularization at 1-year follow-up, are reported. Independent correlates of adverse outcomes were identified using multivariate proportional-hazards regression analysis. Women were older (p <0.001); had a higher prevalence of diabetes mellitus (p <0.001), systemic hypertension (p <0.001), chronic renal insufficiency (p = 0.02), peripheral arterial disease (p <0.001), and congestive heart failure (p <0.001); had lower body surface areas (p <0.001); and had higher body mass indexes (p <0.001). Acute coronary syndrome presentation in women tended to be unstable angina pectoris with Canadian Cardiovascular Society class III and IV symptoms, whereas men had more acute myocardial infarctions. At 1 year, the unadjusted rates of all-cause mortality (10.7% vs 7.5%, p <0.001) and major adverse cardiovascular events (16.4% vs 12.7%, p <0.001) were higher in women. There was a stark difference between the genders in independent correlates of mortality and major adverse cardiovascular events at 1 year. Moreover, the traditional correlates did not have the same impact in women as in men. In conclusion, although there are differences in clinical outcomes after PCI for women compared with men, there are different correlates for these adverse outcomes. These gender-based differences should be taken into account when women undergo contemporary PCI.


Subject(s)
Acute Coronary Syndrome/surgery , Percutaneous Coronary Intervention , Postoperative Complications/epidemiology , Acute Coronary Syndrome/mortality , Aged , Body Mass Index , Cause of Death , Chi-Square Distribution , Diabetes Mellitus/epidemiology , District of Columbia/epidemiology , Electrocardiography , Female , Heart Failure/epidemiology , Humans , Hypertension/epidemiology , Male , Middle Aged , Proportional Hazards Models , Registries , Retrospective Studies , Risk Factors , Sex Factors , Treatment Outcome
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