Clinical outcomes of MANTA vs suture-based vascular closure devices after transcatheter aortic valve replacement: An updated meta-analysis.

OBJECTIVE: A recently published randomized control trial showed different results with suture-based vascular closure device (VCD) than plug-based VCD in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR). The learning curve for MANTA device is steep, while the learning curve for suture based VCD is shallow as the devices are quite different. In this meta-analysis, we have compared suture-based (ProGlide and Prostar XL) vs plug-based VCDs (MANTA). METHODS: We performed a meta-analysis of all published studies (using PubMed/Medline and Cochrane databases) reporting the clinical outcome of plug-based vs suture-based VCDs in transfemoral TAVR patients. RESULTS: We included nine studies with a total of 2865 patients (plug-based n = 1631, suture-based n = 1234). There was no significant difference in primary outcome of all bleeding when using plug-based as opposed to suture-based VCDs (RR 1.14 [0.62-2.06] I2 = 72%). There was no significant difference in the incidence of secondary outcomes between two groups including major life threatening bleeding (RR 1.16 [0.38-3.58] I2 = 65%), major vascular complications (RR 0.84 [0.35-2.00] I2 = 55%), minor vascular complications (RR 1.05 [0.56-1.95] I2 = 42%), pseudo aneurysm (RR 1.84 [0.11-29.98] I2 = 44%), stenosis-dissection (RR 0.98 [0.66-1.47] I2 = 0%), VCD failure (RR 1.71 [0.96-3.04] I2 = 0%), and blood transfusion (RR 1.01 [0.38-2.71], I2 = 61%). CONCLUSION: Large bore arteriotomy closure with plug-based VCD was not superior to suture-based VCDs in this transfemoral TAVR population. There was very frequent use of secondary VCDs in suture-based VCD group which is not practical when using MANTA. Additional high-powered studies are required to determine the safety and efficacy of MANTA device.

Gadolinium-based coronary angiography in a patient with prior known anaphylaxis to iodine-based dye.

Gadodiamide is a gadolinium-based chemical element that is considered safe and well tolerated in patients without renal dysfunction and is therefore routinely used as a contrast agent in magnetic resonance imaging. Although radio-opaque, it is not frequently used for coronary angiography due to its less than optimal image quality and prohibitive cost. Our center's previous experience was less than satisfactory but the addition of a power injection system yielded good quality diagnostic images. We report a case of 63 years old male with a known history of severe, life-threatening anaphylactic reaction to previous iodinated dye presenting with persistent angina despite optimal medical therapy. Coronary and bypass graft angiography was performed using 24 cc of undiluted Gadodiamide (OMNISCAN) with a power injector (ACIST®) without any incidents or premedication with an interpretable angiogram.

COVID-19 and Diabetic Ketoacidosis: A Single Center Experience.

BACKGROUND AND OBJECTIVES:  To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetic ketoacidosis (DKA) -- a single center tertiary hospital experience. MATERIALS AND METHODS:  A retrospective study was conducted among patients admitted to our hospital in the United States between March 1st and June 15th, 2020 with DKA and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection known as COVID-19. We compared the baseline characteristics, laboratory data, and clinical course between survivors and nonsurvivors to identify the risk factors associated with mortality in the patients with DKA. RESULTS:  A total number of 43 patients were included in this study. The median age was 52 years. Thirty-three (76.7%) patients were male. Median value of initial glucose on presentation was 553 mg/dL (300.0-1927.0 mg/dL). On admission, 33 (76.7%) patients had glycated hemoglobin (HbA1c) ≥ 8% (64 mmol/mol) and HbA1c was not obtained in 10 (23.3%) patients. Acute kidney injury (AKI) was seen in 37 (86.0%) patients, 6 (14%) patients required renal replacement therapy and 22 (51.2%) required mechanical ventilation. Among the 43 patients, 25 (58.1%) died. Out of 25 patients who died 15 (60.0%) were Hispanics, 6 (24.0%) were White, 3 (12.0%) were African American, 1 (4%) was Arabic, and 1 (4%) was Asian. The patients who died were older in age than who survived (mean age 58 ± 6.13 vs 46 ± 9.39; p = 0.023). Some 95% of the patients requiring mechanical ventilation died (odds ratio [OR]: 89.25; 95% confidence interval [CI]: 9.10-874.96); p = 0.001). Compared to survivors, nonsurvivors had significantly higher d-dimer (13.00 ± 3.20 mcg/mL vs 6.15 ± 3.66 mcg/mL; p< 0.006) and peak ferritin values (2763.66 ± 1105.32 ng/mL vs 835.16 ± 257.07 ng/mL; p= 0.016).  Conclusion: Our retrospective study shows COVID-19 infection may present as DKA in patients with diabetes mellitus (DM). Older age, mechanical ventilation, elevated d-dimer, and ferritin are associated with poor prognosis in these patients. Our study shows that COVID-19 is associated with substantial mortality in DKA patients and adds to the limited literature available regarding poor risk factors associated with mortality in these patients.

COVID-19 Infection and Arterial Thrombosis: Report of Three Cases.

Thrombotic complications associated with coronavirus disease 2019 (COVID-19) have been described; these have mainly included venous thromboembolic events. Limited literature is available regarding arterial thrombosis. Acute limb ischemia is associated with severe complications that can result in significant morbidity and mortality. Herein, we report 3 cases of COVID-19 infection complicated by arterial thrombosis in the form of acute limb ischemia. Our case series adds to the limited literature regarding arterial thrombosis.

Acute Intestinal Ischemia in a Patient with COVID-19 Infection.

The World Health Organization has declared novel coronavirus disease 2019 (COVID-19) a global public health emergency. Although respiratory symptoms predominate in COVID-19, thrombosis can occur in patients with COVID-19. This paper reports a case of an 82-year-old female with a prior medical history of hypertension, diabetes presenting with fever and cough, and was diagnosed with COVID-19. The patient subsequently developed progressively worsening of abdominal distention, tenderness, and underwent emergent laparotomy. She was found to have a gangrenous colon. This case adds to the limited literature regarding the extrapulmonary complications of COVID-19.

The utility of bedside echocardiography in critically ill COVID-19 patients: Early observational findings from three Northern New Jersey hospitals.

INTRODUCTION: Cardiovascular complications related to coronavirus disease 2019 (COVID-19) have led to the need for echocardiographic services during the pandemic. The present study aimed to identify the echocardiographic findings in hospitalized COVID-19 patients and their utility in disease management. METHODS: We included patients who were diagnosed with COVID-19 using polymerase chain reaction and those who underwent echocardiographic examination during their hospitalization. RESULTS: Altogether, 45 patients were evaluated. The mean age was 61.4 ± 12.2 years. Hypertension (n = 29, 64%) and diabetes mellitus (n = 25, 55%) were the most common comorbidities followed by congestive heart failure (n = 11, 24%), coronary artery disease (n = 9, 20%), and valvular heart disease (n = 3, 7%). Eight patients (18%) showed evidence of myocardial injury, as suggested by elevated troponin levels. Brain natriuretic peptide was elevated in 14 patients (36%), and 14 patients had left ventricular dysfunction in the form of reduced ejection fraction (31%). Right ventricular (RV) dilatation was observed in six patients, and five patients had reduced RV ejection fraction. RV pressure and volume overload were observed in three patients. RV thrombus was observed in one patient. Pulmonary pressure was elevated in 10 patients (24%). CONCLUSION: Two-dimensional echocardiography can be an important bedside tool for the assessment of cardiovascular abnormalities and hemodynamic status of COVID-19 patients.

Coronary vasospasm complicating atrial fibrillation ablation: a case report and review of the literature.

Radiofrequency ablation is one of the alternative treatment strategies in patients with atrial fibrillation. With the increasing number of such ablation procedures being performed it is important for the physicians to be aware of the associated complications. We present a very rare case of severe triple coronary vessel spasm during radiofrequency catheter ablation. The procedure was complicated by cardiac arrest secondary to ventricular fibrillation and cardiogenic shock requiring subsequent management with a temporary mechanical circulatory support device. Multi-vessel spasm is a rare and life-threatening complication leading to ventricular fibrillation and cardiac arrest. One should be extra vigilant in monitoring patients during extensive ablations and the procedure should be terminated at the earliest signs of ischemia in order to prevent this rare but fatal complication.

COVID-19 and Influenza Co-Infection: Report of Three Cases.

Influenza and coronavirus disease 2019 (COVID-19) are both contagious respiratory illnesses, but they are caused by different viruses. COVID-19 pandemic is caused by a novel virus - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Influenza is an infectious respiratory disease, caused by influenza A and influenza B viruses. We describe the three cases of influenza and COVID-19 co-infection.

Should Bangladeshi Race Be Considered as an Independent Risk Factor for Multi Vessel Coronary Artery Disease?

INTRODUCTION: Coronary Artery Disease (CAD) continues to be on the rise not only in the Western developed world but also affecting the South Asian race, particularly Bangladeshis. The objectives of this study were as follows: To determine whether or not risk factors of Bangladeshis differ from non-Bangladeshis, whether there is any difference in the extent of CAD for both groups, and if there are risk factors that can significantly affect the extent of CAD. METHODS: All patients with a diagnosis of CAD admitted to our 800-bed tertiary care hospital between January 2001 and December 2015 were retrospectively analyzed. We reviewed the age, sex, body-mass index (BMI), cardiac risk factors such as family history of CAD, dyslipidemia, hypertension, diabetes and smoking. We also reviewed coronary angiographic findings of these consecutive 150 Bangladeshis and a randomly selected group of 193 non-Bangladeshis. RESULTS: A total of 343 medical records were evaluated, this included two groups: 193 non-Bangladeshis and 150 Bangladeshi subjects. The Bangladeshi group was older than the non-Bangladeshi group (63.49 vs 59.22, p-value=0.001), and included a larger proportion of males than the non-Bangladeshi group (28.7% vs 15.68%, p-value=0.0116). Bangladeshi subjects are more likely to be smokers than non-Bangladeshi (11.75% vs 6.67%, χ2=12.7, p-value=0.0004). Non-obstructive, 1-vessel, 2-vessel and 3-vessel accounts for 13.33%, 36.67%, 22%, and 28% for Bangladeshis, and 16.39%, 20.77% 34.43% and 28.42% for non-Bangladeshis, respectively. The difference of extent of CAD is significant between two groups (χ2 =12.397, p-value=0.0061). The findings suggest that Bangladeshi ethnicity has almost 2 times the likelihood of having 1-vessel CAD at coronary angiography (OR=2.361, 95% CI 1.452-3.839, p=0.0005). CONCLUSION: This study is a pivotal starting point for further evaluating the link between Bangladeshis and CAD. In our study we found that being Bangladeshi increases the risk of having CAD and may be an independent risk factor for multi-vessel CAD.

Conquering the pneumococcal nemesis with oral antibiotics.

Introduction: Streptococcus pneumoniae endocarditis (SPE) occurs in <3% of all EI cases due to the evolution of penicillin and vaccination. However, immunocompromised and unvaccinated patients are still at grave risk. Case: A 58-year-old African American male who used alcohol and intravenous (IV) drugs presented with confusion, fever, and hemoptysis. He had coarse rhonchi with a grade 2/5 holosystolic apical murmur. CT chest showed diffuse bilateral infiltrates. Blood cultures were positive for pansensitive Streptococcus pneumoniae. Echocardiogram demonstrated large vegetations on the anterior and posterior leaflets of the mitral valve with flail leaflet and severe eccentric mitral regurgitation. Patient was started on IV ceftriaxone, but after 3 weeks of therapy, he wished to leave against medical advice. He was discharged on combination oral therapy with successful resolution of SPE on follow-up. Discussion: Invasive pneumococcus is highly virulent causing irreversible valvular destruction or death. IV beta-lactams are first-line treatment, but there are currently no guideline-recommended alternatives for oral therapy. Recent data suggest partial oral therapy may be noninferior to IV only therapy. Conclusion: Switching to oral combination antibiotics after at least 2 weeks of IV therapy is an acceptable alternative to treat SPE.

Bivalirudin Versus Heparin During Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction.

BACKGROUND: The aim of the study was to compare the efficacy and safety of bivalirudin versus unfractionated heparin (UFH) in patients with acute myocardial infarction who undergo percutaneous coronary intervention (PCI). Earlier trials comparing bivalirudin and UFH during PCI demonstrated that bivalirudin caused less bleeding with more stent thrombosis. Since then, adjunct antiplatelet strategies have evolved. Improved upstream platelet inhibition with potent P2Y12 inhibitors decreased the need for routine glycoprotein IIb/IIIa inhibitor (GPI), resulting in similar outcomes among UFH and bivalirudin. Therefore, the role of bivalirudin in modern PCI practices is questionable. METHODS: We utilized Cochrane Review Manager (RevMan) 5.3 to perform a meta-analysis of seven randomized controlled trials (RCTs) with 22,844 patients to compare bivalirudin to UFH in patients with acute myocardial infarction requiring revascularization. RESULTS: There was no difference between bivalirudin and UFH regarding major adverse cardiac events (MACE), risk ratio (RR) 0.99, 95% confidence interval (CI) 0.87 - 1.12; P = 0.83) or cardiovascular mortality (RR 0.87, 95% CI 0.71 - 1.07; P = 0.18). Bivalirudin increased acute stent thrombosis (RR 2.77, 95% CI 1.49 - 5.13; P = 0.001), which was only significant among ST-elevation myocardial infarction (STEMI) only trials. Bivalirudin caused less major bleeding (RR 0.66, 95% CI 0.49 - 0.90; P = 0.007), which was negated when GPI was used provisionally (RR 0.93, 95% CI 0.64 - 1.33; P = 0.67). CONCLUSIONS: Among patients with acute myocardial infarction who underwent PCI, bivalirudin and UFH demonstrated similar MACE and cardiovascular mortality. Bivalirudin increased acute stent thrombosis, which was more remarkable among STEMI. Bivalirudin decreased major bleeding, but this benefit was negated when GPI was used provisionally.

Brugada syndrome & AKAP9: Reconciling clinical findings with diagnostic uncertainty.

INTRODUCTION: Brugada Syndrome typically presents with sudden nocturnal arrhythmias. Diagnosis may be challenging due to variable and transient electrocardiogram patterns and nondiagnostic provocation studies. Genetic testing can establish the etiology, but results may be inconclusive with variants of uncertain significance. CASE: A 24-year-old male with family history of sudden cardiac death was found unresponsive due to seizure. He was hemodynamically stable. ECG showed saddle-back ST elevations in V1 and V2. Procainamide challenge was negative. We subsequently performed genetic testing, which demonstrated AKAP9 variant. DISCUSSION: AKAP9 is a scaffolding protein that facilitates phosphorylation of delayed-rectifier potassium channels. The AKAP9 variant alters potassium current causing disordered repolarization and ventricular reentry. It has been previously linked to other channelopathies, but its pathogenicity is fully undetermined. CONCLUSION: Genetic testing is a useful tool to determine the origin of channelopathy, but inconclusive results with variants of uncertain significance should be clinically correlated.

Meta-Analysis Comparing Usefulness of Beta Blockers to Preserve Left Ventricular Function During Anthracycline Therapy.

The purpose of this analysis was to evaluate the cardioprotective benefit of ß blockers in preventing anthracycline-induced cardiotoxicity (AIC) in breast cancer patients. Anthracyclines are the cornerstone treatment for breast cancer. Yet, their use has declined in the last decade due to associated AIC. Although ß blockers may protect left ventricular (LV) function, previous trials were underpowered with equivocal results. The authors systematically searched online databases through August 2018 for studies evaluating effectiveness of ß blockers in preventing AIC in breast cancer patients. We analyzed 9 studies including 771 patients. Data on converting-enzyme inhibitors, trastuzumab, or other malignancies were excluded. The primary outcome was comparison of postchemotherapy LV ejection fraction (LVEF) between ß blocker and placebo. Secondary outcomes were changes in global longitudinal strain, LV end-diastolic diameter (LVEDD), and diastolic function parameters, as assessed by 2D echocardiogram and MRI. The mean pre-chemotherapy LVEF was >60% in all studies. Our pooled analysis demonstrated significantly higher LVEF postchemotherapy in the ß blocker group in comparison to placebo: mean difference -3.84 with 95% confidence interval [-(6.19 to 1.48) p = 0.001]. The absolute change in EF also favored ß blockers: mean difference -3.66 with 95% confidence interval [-(6.20 to 1.12) p = 0.005]. Diastolic function, global longitudinal strain, and LVEDD were also preserved by ß blockers, but only LVEDD reached statistical significance. In conclusion, this study suggests that ß blockers during anthracycline chemotherapy may prevent cardiotoxicity by preserving LV function.

Delayed spontaneous recanalization of chronic total occlusion of left anterior descending artery after attempted but failed revascularization during percutaneous coronary intervention.

Chronic total occlusion (CTO) of coronary artery remains the Achilles heel of the interventional cardiologist and is present in a significant proportion of referrals for coronary artery bypass graft surgery (CABG); however, with the development and standardization of modern CTO recanalization techniques, it has been able to achieve excellent success while coping with lesions of increasing complexity. Nevertheless, failure to recanalize despite the development of new techniques still remains one of the challenges in the field of interventional cardiology. Spontaneous recanalization has been described in nonocclusive coronary artery dissections in detail; none has addressed the possibility of spontaneous recanalization after failed percutaneous coronary intervention (PCI). We report a case of spontaneous but delayed recanalization of CTO of left anterior descending artery 3 years after attempted but failed revascularization during PCI.

The obesity paradox: the protective effect of obesity on right ventricular function using echocardiographic strain imaging in patients with pulmonary hypertension.

BACKGROUND: Obesity is associated with right ventricular (RV) dysfunction, but its effect on RV remodeling in patients with pulmonary hypertension (PHTN) has not been studied. We evaluated the effect of obesity, and its interplay with diabetes, in patients with PHTN using RV echocardiographic strain imaging. METHODS: One hundred eighty-five patients underwent echocardiographic imaging and pulmonary artery pressure was calculated using tricuspid regurgitation jet velocity. From focused RV apical-four-chamber view, global and mid peak systolic RV free wall longitudinal strain (FWLS) was calculated using speckle-tracking software. RESULTS: Global and mid RV FWLS in patients with PHTN (N.=84) was lower (-16.8±7 vs. 18.9±6.3, P=0.035 and -11.2±12.8 vs. -18.9±9.2, P=0.002 respectively) compared with patients without PHTN (N.=101). Among patients without PHTN, obese patients (BMI>30) had lower global and mid RV FWLS (-17.2±6.2 vs. -20.3±5.7, P=0.012 and -17.6±7.2 vs. -21.9±7.3, P=0.004), even after excluding diabetic patients (Mid RV FWLS -18.2±6.8 vs. -22.1±8, P=0.032). Among patients with PHTN, obese patients had similar RV FWLS compared with non-obese patients (P=0.46). However, on excluding diabetic patients from PHTN group, obese patients with PHTN had higher global and mid RV FWLS (-21.7±5.7 vs. -16.1±8, P=0.017 and 23.8±4.8 vs. -17±9.4, P=0.009 respectively) compared to non-obese patients which suggests a protective effect of obesity on RV function in patients with PHTN. CONCLUSIONS: Obesity is associated with subclinical RV dysfunction as assessed by RV strain imaging, but paradoxically it may confer a protective effect on RV function once the patient develops PHTN. Future studies should evaluate the clinical impact of this paradox.

Medical cost of type 2 diabetes attributable to physical inactivity in the United States in 2012.

AIMS: Type 2 diabetes has grown to epidemic proportions in the U.S. and physical activity levels in the population continues to remain low, although it is one of the primary preventive strategies for diabetes. The objectives of this study were to estimate the direct medical costs of type 2 diabetes attributable to not meeting physical activity Guidelines and to physical inactivity in the U.S. in 2012. METHODS: This was a cross sectional study that used physical activity prevalence data from the Behavioral Risk Factor Surveillance System to estimate the population attributable risk percentage for type 2 diabetes. These data were combined with the prevalence and cost data of type 2 diabetes to estimate the cost of type 2 diabetes attributable to not meeting physical activity Guidelines and to inactivity in 2012. RESULTS: The cost of type 2 diabetes in the U.S. in 2012, attributable to not meeting physical activity guidelines was estimated to be $18.3 billion, and that attributable to physical inactivity was estimated to be $4.65 billion. Based on sensitivity analyses, these estimates ranged from $10.19 billion to $27.43 billion for not meeting physical activity guidelines and $2.59 billion-$6.98 billion for physical inactivity in the year 2012. CONCLUSIONS: This study shows that billions of dollars could be saved annually just in terms of type 2 diabetes cost in the U.S., if the entire adult population met physical activity guidelines. Physical activity promotion, particularly at the environmental and policy level should be a priority in the population.