Outcomes Following Percutaneous Coronary Intervention in Patients With Multivessel Disease Who Were Recommended for But Declined Coronary Artery Bypass Graft Surgery.

BACKGROUND: Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG. METHODS AND RESULTS: Consecutive patients with stable ischemic heart disease and unprotected left main or 3-vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI-recommended; (2) CABG-eligible but refused CABG (CABG-refusal); and (3) CABG-ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI-recommended, n=1718 [46.6%]), CABG-refusal (n=1595 [43.3%]), and CABG-ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG-ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI-recommended, CABG-refusal, and CABG-ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG-refusal (hazard ratio [HR], 1.67 [95% CI, 1.08-3.56]; P=0.02) and CABG-ineligible patients (HR, 3.26 [95% CI, 1.28-3.65]; P=0.004) groups compared with the reference PCI-recommended group, driven by increased death and stroke. CONCLUSIONS: Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real-world data to inform shared decision-making discussions.

Impact of Bleeding Risk and Inflammation on Cardiovascular Outcomes After Percutaneous Coronary Intervention.

BACKGROUND: Markers of systemic inflammation, such as high-sensitivity C-reactive protein (hsCRP), have been associated with the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) in patients undergoing percutaneous coronary intervention (PCI). Whether this risk varies according to the presence of high bleeding risk (HBR) conditions is unclear. OBJECTIVES: The aim of this study was to evaluate the impact of systemic inflammation, as measured by hsCRP levels and cardiovascular outcomes in patients stratified by HBR status following PCI. METHODS: Consecutive patients undergoing PCI between 2012 and 2019 with baseline hsCRP levels were included. High hsCRP was defined as >3 mg/L, and HBR was defined per the Academic Research Consortium HBR criteria. The primary outcome was MACCE, including all-cause death, myocardial infarction, or stroke at 1 year. All bleeding was assessed as a secondary outcome. RESULTS: A total of 15,150 patients were included, and 40.4% (n = 6,125) qualified as HBR. The adjusted risk for MACCE was consistently higher in patients with high hsCRP in both HBR (adjusted HR [aHR]: 1.49; 95% CI: 1.18-1.87) and non-HBR (aHR: 1.87; 95% CI: 1.31-2.66) subgroups, with no interaction between HBR status and hsCRP level (Pinteraction = 0.26). Conversely, although bleeding risk was higher in the HBR cohort, hsCRP did not predict the occurrence of bleeding in either the HBR (aHR: 1.04; 95% CI: 0.82-1.31) or the non-HBR (aHR: 0.99; 95% CI: 0.71-1.39) subgroup (Pinteraction = 0.539). CONCLUSIONS: Elevated hsCRP at the time of PCI is associated with a higher risk for ischemic but not bleeding events, irrespective of HBR status.

Transcatheter Aortic Valve Replacement: Current Status and Future Indications.

In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications.

Impact of Clinical Presentation on Outcomes After Rotational Atherectomy in Patients Who Underwent Percutaneous Coronary Intervention.

Rotational atherectomy (RA) is widely used in the percutaneous treatment of heavily calcified coronary artery lesions in patients with chronic coronary syndromes (CCS). However, the safety and efficacy of RA in acute coronary syndrome (ACS) is not well established and is considered a relative contraindication. Therefore, we sought to evaluate the efficacy and safety of RA in patients presenting with non-ST-elevation myocardial infarction (NSTEMI), unstable angina (UA), and CCS. Consecutive patients who underwent percutaneous coronary intervention with RA between 2012 and 2019 at a tertiary single center were included. Patients presenting with ST-elevation myocardial infarction (MI) were excluded. The primary end points of interest were procedural success and procedural complications. The secondary end point was the risk of death or MI at 1 year. A total of 2,122 patients who underwent RA were included, of whom 1,271 presented with a CCS (59.9%), 632 presented with UA (29.8%), and 219 presented with NSTEMI (10.3%). Although an increased rate of slow-flow/no-reflow was noted in the UA population (p = 0.03), no significant difference in procedural success or procedural complications, including coronary dissection, perforation, or side-branch closure, was noted (p = NS). At 1 year, there were no significant differences in death or MI between CCS and non-ST-elevation ACS (NSTE-ACS: UA + NSTEMI; adjusted hazard ratio 1.39, 95% confidence interval 0.91 to 2.12); however, patients who presented with NSTEMI had a higher risk of death or MI than CCS (adjusted hazard ratio 1.79, 95% confidence interval 1.01 to 3.17). Use of RA in NSTE-ACS was associated with similar procedural success without an increased risk of procedural complications compared with patients with CCS. Although patients presenting with NSTEMI remained at higher risk of long-term adverse events, RA appears to be safe and feasible in patients with heavily calcified coronary lesions presenting with NSTE-ACS.

Validation of UK-BCIS CHIP Score to Predict 1-Year Outcomes in a Contemporary United States Population.

BACKGROUND: A complex high-risk indicated percutaneous coronary intervention (CHIP) score was recently developed from the British Cardiovascular Intervention Society (BCIS) database to define CHIP cases and their risk of in-hospital major adverse cardiac or cerebrovascular events (MACCE). OBJECTIVES: The authors sought to apply this score to a contemporary U.S. population for the prediction of adverse events at 1 year following percutaneous coronary intervention (PCI). METHODS: Consecutive patients undergoing PCI at a large tertiary care center between 2011 and 2020 were considered for inclusion. Patients were categorized into 4 groups based on their BCIS-CHIP score (0, 1-2, 3-4, ≥5). In each category, we assessed the 1-year risk of MACCE, a composite of all-cause death, myocardial infarction, and stroke. Secondary outcomes were the individual components of MACCE, and major bleeding at 1 year. RESULTS: Among 20,799 patients included, MACCE at 1 year occurred in 1.7% patients with score 0 (reference), 3.0% with score 1 or 2 (HR: 1.72; 95% CI: 1.32-2.24), 6.1% with score 3 or 4 (HR: 3.60; 95% CI: 2.78-4.66), and 12.0% with score ≥5 (HR: 7.40; 95% CI: 5.75-9.51). Each point increase of the BCIS-CHIP score conferred a 28.0% increase of MACCE risk. The BCIS-CHIP score demonstrated good discrimination for the prediction of 1-year MACCE (C-index 0.70). The risk of secondary outcomes also progressively increased with higher score values. CONCLUSIONS: In a large PCI registry, the BCIS-CHIP score had a good predictive value for MACCE at 1 year. The utilization of this score can facilitate an accurate risk stratification of patients undergoing PCI.

Efficacy and Safety of an Upfront RotaTripsy Strategy in the Treatment of De Novo and In-Stent Restenosis Cases.

BACKGROUND: Use of both rotational atherectomy (RA) and intravascular lithotripsy (IVL)-the "RotaTripsy" technique-offers a potentially synergistic calcium-modification strategy that can treat both luminal and abluminal calcification. An upfront RotaTripsy strategy using an undersized burr in large-caliber coronaries also offers the advantage of facilitating IVL catheter passage while being able to undertake the procedure with a 6-Fr system. METHODS: Consecutive patients with heavily calcified lesions on angiographic or intravascular imaging and large target-vessel caliber (≥3 mm) who underwent an upfront RA followed by IVL between July 2021 and January 2022 were included in this study. Study aims were to evaluate periprocedural efficacy and safety. RESULTS: Of the 21 patients included, RotaTripsy was used for treatment of de novo lesions in 12 patients (57%) and for in-stent-restenosis in 9 patients (43%). Seven cases of in-stent restenosis (ISR) involved 2 layers of stents. Mean reference vessel diameter was 3.67 ± 0.46 mm and baseline diameter stenosis was 77.4 ± 11.3%. Average RA burr-to-artery ratio was 0.43 ± 0.05 and IVL balloon-to-artery ratio was 0.93 ± 0.06, with IVL balloon crossing the lesion in all cases following RA. Procedural success was attained in 20 of 21 cases; 1 periprocedural complication (a death related to coronary perforation following stent postdilation) was recorded. CONCLUSIONS: An upfront RotaTripsy strategy is associated with a high degree of procedural success in de novo lesions and ISR cases by facilitating the use of a smaller burr-to-artery ratio and smaller-bore vascular access. Larger studies are required to further evaluate the potential benefits of an upfront RotaTripsy strategy from a safety and cost-benefit perspective.

Coronary artery intramural hematoma, a rare complication of percutaneous coronary intervention.

Coronary artery intramural hematoma is a rare complication of percutaneous coronary intervention which develops from intimal tear of coronary artery and propagates by blood accumulation along the medial surface of adjacent segment. Fifty-three-year-old male presented with nonexertional chest pain; he was referred after a positive stress test with+ moderate lateral wall ischemia. Coronary angiography showed 80% lesion in mid-left anterior descending artery (mLAD). Angiogram after angioplasty with 2.0 mm × 15 mm balloon and 3.0 mm × 15 mm drug-eluting-stent demonstrated a new stenotic lesion distal to stented mLAD segment. Subsequently, an overlapping 3.0 mm × 30 mm stent was placed with effective restoration of blood flow through LAD. During percutaneous coronary intervention (PCI), balloon predilatation can result in plaque fracture and stent deployment may cause intimal tear forming intramural hematoma which can lead to post-PCI myocardial infarction necessitating prompt detection by intravascular imaging with intravascular ultrasound and optical coherence tomography. Management is based on individual patient's characteristics and includes medical therapy, angiographic surveillance or repeat PCI.

A Rarely Reported Case of Enterococcus faecalis Bacteremia Causing Infective Endocarditis and Osteomyelitis.

Infective endocarditis (IE) is an infection of the heart valves or endocardium, usually due to the spread of infection through the blood. It can cause a varied range of symptoms, from being asymptomatic to reduced heart function, valvular abnormalities, embolization, or death. Enterococci are usually present as normal gut flora but can also cause bacteremia, urinary tract infections, or IE, especially in the elderly population. The source of enterococcal spread in most of the cases is unidentifiable and sometimes associated with the genitourinary tract or damage to the gut mucosa due to trauma, malignancy, and infection, among others. Very few cases have been reported so far on Enterococcus faecalis (E. faecalis) endocarditis and even rarer for such cases complicated by osteomyelitis. Here, we describe the case of a 63-year-old male patient with a recent history of cardiac arrest, a percutaneous endoscopic gastrostomy tube placement, and endotracheal tube placement. He presented with back pain and was found to have osteomyelitis on magnetic resonance imaging and aortic valve vegetations on transthoracic echocardiography (TTE). His blood cultures were positive for E. faecalis. Repeat TTE showed growth in the vegetation, and the patient underwent bioprosthetic aortic valve replacement.

A Rare Case Report of ST-Segment Elevation Myocardial Infarction and Recurrent Chest Pain in Polyarteritis Nodosa.

Polyarteritis nodosa (PAN) is a type of vasculitis that mainly affects small and medium-sized blood vessels. The clinical presentation can be nonspecific as weight loss, abdominal pain, and hypertension, or fatal as myocardial infarction (MI) and bowel perforation depending upon the organ involved. Cardiac involvement of PAN usually manifests as congestive heart failure, aneurysms, or MIs and is mostly identified during postmortem studies of autopsied patients. Here, we report a case of anterior MI as a sequela of PAN in a 40-year-old female who was diagnosed with PAN two weeks before her MI. She presented with intermittent chest pain for one day. At the time of admission, an electrocardiogram revealed anterior MI, and she was subsequently found to have 95-99% stenosis of the proximal left anterior descending artery during cardiac catheterization. The patient was successfully treated with percutaneous coronary intervention and was started on dual antiplatelet therapy. Her treatment was continued with steroids and cyclophosphamide. The case illustrates the importance of recognizing MI as a sequela of PAN as timely treatment could be lifesaving.

Thrombus in Transit: Extract or Dissolve?

Thrombus in transit (TIT) remains an uncommon diagnosis. However, it is often found in patients diagnosed with acute pulmonary embolism (PE). While thrombolytics are mainly used in life-threatening presentations, their role in stable patients with a known history of intracranial hemorrhage (ICH) is unclear.

Stress-Induced Cardiomyopathy: As a Diagnosis That Is Time Sensitive and Anticipative in Certain Individuals.

Stress-induced cardiomyopathy, also known as Takotsubo cardiomyopathy, presents as an acute coronary syndrome. However, the physiology and pathogenesis are different. It is imperative to treat stress-induced cardiomyopathy as an acute coronary syndrome, and once diagnosed, it is imperative to assess and treat heart failure and wait for the impaired myocardial energetics to resolve. At times, the myocardial recuperation is quick that we miss the diagnosis of Takotsubo cardiomyopathy.