Successful Catheter-Directed Thrombolysis of Massive Bilateral Upper Extremity DVT Presenting as Superior Vena Cava Syndrome.

Superior vena cava syndrome (SVCS) is traditionally associated with malignancy. However, approximately one-third of SVCS cases are due to intravascular devices and pacemakers. No specific guidelines exist for managing catheter-associated SVCS. We present catheter-associated SVCS resistant to anticoagulation, angioplasty, and thrombectomy but resolved with ultrasound-assisted catheter directed thrombolysis. (Level of Difficulty: Intermediate.).

Scimitar Syndrome: Late Presentation and Conservative Management.

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital malformation. The infracardiac variant with the right lobe of the lung draining to the inferior vena cava (IVC) is called Scimitar syndrome. The infantile subtype presents before one year of age and the adult variant is also usually diagnosed in childhood. A 70-year-old woman presented with worsening shortness of breath. An echocardiogram suggested severe pulmonary hypertension that was confirmed by right heart catheterization. A computed tomography (CT) without contrast revealed an anomalous vein from the right upper lobe suggestive of Scimitar syndrome. The patient did not have any other associated congenital heart defects (CHD) (incomplete Scimitar syndrome). A surgical treatment approach was avoided due to the incomplete nature of the Scimitar syndrome. Incomplete Scimitar syndrome may present later and with less severity than the typical Scimitar syndrome with left to right shunting occurring only in the lung and may be managed nonsurgically.

Periprocedural and long-term outcomes of endovascular abdominal aortic aneurysm repair in cardiology practice.

BACKGROUND: Endovascular repair of abdominal aortic aneurysm (AAA) has recently been made a class I indication in the treatment of AAA. In comparison to the conventional open surgical treatment, endovascular AAA repair (EVAR) is associated with equivalent long-term morbidity and mortality rates. Vascular surgeons perform majority of EVAR. There are no reports for the long-term results of this intervention performed by interventional cardiologists. We present one of the first reports of periprocedural and long-term outcomes of EVAR performed by interventional cardiologists. METHODS: Retrospective chart review on patients with attempted EVAR between September 2005 and January 2011 was performed. Included cases were all consecutive patients who had attempted EVAR by interventional cardiologists. RESULTS: During the study period EVAR was attempted in 170 patients, with 27% being women. The mean age was 74 years (range 52-93). The endovascular graft placement was successful in 96% (163/170) of patients. Procedure failures were more common in women (6 of 46 vs 1 of 124, P = 0.003). The 30-day mortality was 1.8 % (3 of 170). In patients with successful EVAR the mean follow-up was 30 months and mean length of hospital stay was 3.5 ± 3.2 days. Major periprocedural complications were noted in 9% patients (15 of 167). During follow-up, six patients (3.5%) required re-intervention and additional 16 patients died with no aneurysm related deaths. CONCLUSION: EVAR primarily performed by interventional cardiologists demonstrates high periprocedural and long-term success rates. A higher EVAR failure rate has been observed in women.

Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure.

Providing effective discharge instructions, appropriate dose uptitration, education regarding heart failure (HF) monitoring, and strict follow-up have all been shown to decrease readmissions for HF but are all underutilized. The authors developed and evaluated the impact of a quality-improvement HF checklist as a tool to remind physicians to improve quality of care in HF patients. The checklist was used in randomly selected patients admitted with a primary diagnosis of acute decompensated HF. It included documentation regarding medications and dose uptitration, relevant counseling, and follow-up instructions at discharge. The checklist was used in 48 patients, and this checklist group was compared with 48 patients as a randomly selected control group. Higher proportions of patients were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the checklist group compared with the control group (40 of 48 vs 23 of 48, P<.001). Compared with the controls, the rate of dose uptitration for ß-blockers and/or ACE inhibitors/ARBs was more common in the checklist group (4 of 48 vs 21 of 48, P<.001). Both 30-day (19% to 6%) and 6-month (42% to 23%) readmissions were lower in the checklist group. The use of an HF checklist was associated with better quality of care and decreased readmission rates for patients admitted with HF.

No Racial Disparities in the Treatment of ST Elevation Myocardial Infarction - A Community-based Experience.

Whether racial disparities exist in the treatment of ST elevation myocardial infarction (STEMI) is not exactly known. We report a retrospective chart review of patients with first event of STEMI, in two groups separated by one decade. Results revealed that hospital mortality in the 2007 and 1997 groups for African Americans versus Caucasians was one of 22 versus 21 of 170, 95 % confidence interval (CI) -0.178 to 0.022, p=0.48 and four of 41 versus 39 of 402, 95 % CI -0.095 to 0.096, p=1.00, respectively. The mean length of stay (LOS) for African Americans and Caucasians in the 2007 and 1997 groups was 5.7 versus 4.1 days (p=0.09) and 7.3 versus 6.6 days (p=0.42), respectively. During follow-up, a total of 40 patients needed re-intervention in the 2007 group. The re-intervention rate in African American patients being 13.6 % (three of 22) versus 21.2 % (36 of 170) in Caucasians, 95 % CI -0.231 to 0.081, with p=0.57. In conclusion, there was no evidence of racial disparity in the treatment of STEMI in terms of hospital mortality, length of hospital stay and re-intervention rate.

Minimally invasive retrieval of patent foramen ovale closure device after device migration to the descending aorta.

Percutaneous treatment of patent foramen ovale with a septal closure device has become a common procedure, but it is associated with various complications. Migration of the device is uncommon, and migration through the aortic valve into the aorta is rare. Managing the migration of a patent foramen ovale occluder can be challenging; it usually requires surgical retrieval of the foreign body. We report a rare case in which a patient experienced migration of a large patent foramen ovale closure device to the descending aorta. Rarer still was its successful percutaneous management.

High prevalence of obesity in young patients with ST elevation myocardial infarction.

BACKGROUND: There is growing concern about increasing rates of obesity in young people, and increasing ST elevation myocardial infarction (STEMI) at a younger age. There are only a few studies performed to study the risk factors in STEMI among young populations. METHODS: Retrospective chart reviews on all first event STEMI patients between December 2005 and July 2007 were performed. A young population was defined as: men <45 years of age and women <55 years of age. RESULTS: Among 206 patients with STEMI, 36 were young. In young patients with STEMI, 78 % were obese compared with 35 % obese, non-young (p<0.001). Also, among young patients with STEMI, family history of coronary heart disease (CHD) was positive in 39 %, compared with 19 % in non-young patients (p=0.009). This significance for obesity and family history persisted after adjusting for other risk factors using logistic regression (OR 2.96 to 17.75, 95 % CI, p<0.0001 and OR 1.36 to 7.47, 95 % CI, p=0.008, respectively). CONCLUSION: Obesity and family history of CHD were major risk factors with a higher prevalence in young patients with STEMI than non-young patients.

Endovascular abdominal aortic aneurysm repair by interventional cardiologists--a community-based experience.

INTRODUCTION: Endovascular repair of abdominal aortic aneurysm (AAA) is a relatively recent technology. In comparison to the conventional open surgical treatment for AAA, endovascular AAA repair (EVAR) combines a less-invasive approach with lower morbidity and mortality. There have been few studies regarding the performance of this procedure in a community-based setting. We report our experience of EVAR performed primarily by interventional cardiologists in a community hospital. METHODS: In our community hospital setting, between September 2005 and November 2007, we included all patients who underwent EVAR by interventional cardiologists, with available on-site vascular surgical support. Clinical and serial computed angiographic imaging outcomes were followed by a retrospective chart review. Data collection tools included demographic and clinical characteristics, anatomical aneurysm features, length of stay, peri- and postprocedural complications, and mortality. RESULTS: A total of 71 consecutive patients had EVAR attempted. The endovascular stent placement was successful in 67 (93%) patients. Thirty-day mortality in this study was 1 of 71 (1.4%). All four procedural failures and the single periprocedural mortality occurred in women. Mean follow-up was 12 months. There were a total of six mortalities and among these four were women (P ≤ 0.001); however, multivariate analysis revealed loss of significant difference in mortality (P = 0.16). Major complications following EVAR were noted in 10 of 71 (14%) patients. CONCLUSION: EVAR can be successfully performed by experienced interventional cardiologists with vascular surgical support in a community-based setting. In our experience, there is acceptable rate of complications and mortality in a carefully selected patient population.

Development of a multicenter peripheral arterial interventional database: the PVD-QI2.

BACKGROUND: The number of peripheral vascular intervention (PVI) procedures performed is steadily increasing in the United States. PVD-QI 2 is a prospective, multicenter observational study designed to improve the quality of care for patients undergoing PVI and to better understand the effectiveness and appropriateness of PVI in improving outcomes of peripheral arterial disease. The registry aims to elucidate which comorbid conditions and procedure-related variables are associated with beneficial or adverse outcomes after vascular interventions. METHODS: Five centers are currently prospectively collecting data on consecutive PVIs performed at their institutions and will include patients with both claudication and critical limb ischemia. A common data collection form and a standard set of definitions were developed during several planning meetings. Information on patient demographics, clinical history, comorbid conditions, treatment approaches, and in hospital outcomes are being collected. Patients will be followed up at 30 days, 6 months, and 1 year after each procedure to identify recurrent vascular events, medication use, lifestyle modifications (regular exercise, dietary modification), self-reported walking scores, and mortality. Data validity will be assured through review of data form accuracy by a trained nurse, by automatic database diagnostic routines, and by site visits that include review of angiography suite logs and randomly selected charts. CONCLUSIONS: The development of a quality-controlled PVI registry requires the commitment and collaboration of clinician-investigators and hospital systems devoted to understanding factors that contribute to quality outcomes. Central to achievement of this goal is the creation of a careful diagnostic and data quality assessment system. This registry will provide important clinical insights into patient demographic and clinical characteristics, procedural characteristics, and current practice patterns that foster or impede achievement of long-term quality-based clinical outcomes for patients with peripheral arterial disease.