Transcatheter PFO closure for cryptogenic stroke: current approaches and future considerations.

Patent Foramen Ovale (PFO) is a common congenital atrial septal defect present in 20%-35% of the general population. Although generally considered a benign anatomic variant, a PFO may facilitate passage of a thrombus from the venous to arterial circulation, thereby resulting in cryptogenic stroke or systemic embolization. A PFO is detected in nearly one half of patients presenting with cryptogenic stroke and often considered the most likely etiology when other causes have been excluded. In this review, we discuss the contemporary role of transcatheter closure of PFO in the treatment of cryptogenic stroke, including devices currently available for commercial use in the United States (Amplatzer PFOTM Occluder and GoreTM Cardioform Septal Occluder) and a novel suture-mediated device (NobleStitchTM EL) under clinical investigation. To provide the best care for cryptogenic stroke patients, practitioners should be familiar with the indications for PFO closure and corresponding treatment options.

A Randomized Comparison of Radial Artery Intimal Hyperplasia Following Distal Versus Proximal Transradial Access for Coronary Angiography: PRESERVE RADIAL.

BACKGROUND: Distal transradial access (dTRA) is an alternative to conventional forearm transradial access (fTRA) for coronary angiography (CAG). Differences in healing of the radial artery (RA) in the forearm have not been evaluated between these 2 access strategies. We sought to compare the mean difference in forearm RA intimal-medial thickening (IMT) in patients randomized to dTRA versus fTRA. METHODS AND RESULTS: In this single-center randomized clinical trial, 64 patients undergoing nonemergent CAG were randomized (1:1) to dTRA versus fTRA. Ultra-high-resolution (55-MHz) vascular ultrasound of the forearm and distal RA was performed pre-CAG and at 90 days. The primary end point was the mean change in forearm RA IMT. Secondary end points included procedural characteristics, vascular injury, RA occlusion, and ipsilateral hand pain and function. Baseline demographics and clinical characteristics, mean forearm RA IMT, and procedural specifics were similar between the dTRA and fTRA cohorts. There was no difference in mean change in forearm RA IMT between the 2 cohorts (0.07 versus 0.07 mm; P=0.37). No RA occlusions or signs of major vascular injury were observed at 90 days. Ipsilateral hand pain and function (Borg pain scale score: 12 versus 11; P=0.24; Disabilities of the Arm, Shoulders, and Hand scale score: 6 versus 8; P=0.46) were comparable. CONCLUSIONS: Following CAG, dTRA was associated with no differences in mean change of forearm RA IMT, hand pain, and function versus fTRA for CAG. Further investigation is warranted to elucidate mechanisms and predictors of RA healing and identify effective strategies to preserving RA integrity for repeated procedures. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04801901.

A Randomized Comparison of Radial Artery Intimal Hyperplasia Following Distal vs. Proximal Transradial Access for Coronary Angiography: PRESERVE RADIAL Trial.

Background: Distal transradial access (dTRA) is an alternative to conventional forearm transradial access (fTRA) for coronary angiography (CAG). Differences in healing of the radial artery in the forearm (FRA) have not been evaluated between these 2 access strategies. We sought to compare FRA intimal-medial thickening (IMT) in patients randomized to dTRA vs. fTRA for CAG. Methods and Results: Sixty-four consecutive patients undergoing non-emergent CAG were randomized (1:1) to dTRA vs. fTRA. Ultrahigh resolution (55 MHz) vascular ultrasound) of the FRA and distal RA was performed pre-CAG and at 90 days. Primary endpoint was 90-day FRA IMT. Secondary endpoints included procedural characteristics, vascular injury, RA occlusion and ipsilateral hand pain and function. Baseline demographics and clinical characteristics, mean FRA IMT, time to RA access, procedure time, and radiation exposure were similar between the dTRA and fTRA cohorts. There were no between group differences in 90-day FRA IMT (0.37 mm vs 0.38 mm, respectively; p =0.73). No RA occlusions or signs of major vascular injury were observed at 90 days. Ipsilateral hand pain and function (Borg pain scale:12 vs 11, p =0.24; DASH scores: 6 vs 8, p =0.46) were comparable. Conclusions: In this single center randomized clinical trial, similar patterns of FRA vascular healing at 90 days, procedural results as well as hand pain and function were observed following dTRA vs. fTRA for CAG. Further investigation is warranted to better understand the mechanistics and predictors of RA healing and to identify strategies aimed at preserving RA integrity for future procedures. What is New?: DTRA has been proposed as an alternative to traditional fTRA in the wrist for CAG and PCI because of ergonomic and post-procedural recovery benefits to the patient, as well as potential reductions in occlusion of the FRA.There are gaps in knowledge, however, regarding potential differences in remodeling of the FRA in patients undergoing dTRA versus fTRA.In this randomized clinical trial, there were no differences in IMT and patterns of vascular injury and healing, using ultrahigh resolution (55 MHz) ultrasound, at 90 days in patients randomized to dTRA or FTRA for elective and non-emergent CAG and PCI. What Are the Clinical Implications: Our findings highlight the need for further inquiry through large multicenter randomized clinical trials to better the understand the mechanistics and predictors of IMT and to identify strategies to mitigate the adverse effects of vessel remodeling in patients undergoing TRA across the entire severity spectrum of cardiovascular disease.

Association of cardiac troponin T and growth differentiation factor 15 with replacement and interstitial cardiac fibrosis in community dwelling adults: The multi-ethnic study of atherosclerosis.

Background: Subclinical abnormalities in myocardial structure (stage B heart failure) may be identified by cardiac and non-organ specific biomarkers. The associations of high-sensitivity cardiac troponin T (hs-cTnT) and growth differentiation factor-15 (GDF-15) with cardiac magnetic resonance imaging (CMR) interstitial fibrosis (extracellular volume [ECV]) is unknown and for GDF-15 the association with replacement (late gadolinium enhancement [LGE]) is also unknown. GDF-15 is a systemic biomarker also released by myocytes associated with fibrosis and inflammation. We sought to define the associations of hs-cTnT and GDF-15 with these CMR fibrosis measures in the MESA cohort. Methods: We measured hs-cTnT and GDF-15 in MESA participants free of cardiovascular disease at exam 5. CMR measurements were complete in 1737 for LGE and 1258 for ECV assessment. We estimated the association of each biomarker with LGE and increased ECV (4th quartile) using logistic regression, adjusted for demographics and risk factors. Results: Mean age of the participants was 68 ± 9 years. Unadjusted, both biomarkers were associated with LGE, but after adjustment only hs-cTnT concentrations remained significant (4th vs. 1st quartile OR] 7.5, 95% CI: 2.1, 26.6). For interstitial fibrosis both biomarkers were associated with 4th quartile ECV, but the association was attenuated compared to replacement fibrosis. After adjustment, only hs-cTnT concentrations remained significant (1st to 4th quartile OR 1.7, 95%CI: 1.1, 2.8). Conclusion: Our findings identify that both interstitial and replacement fibrosis are associated with myocyte cell death/injury, but GDF-15 a non-organ specific biomarker prognostic for incident cardiovascular disease is not associated with preclinical evidence of cardiac fibrosis.

Indispensable Role of Multimodality Imaging in Diagnosis and Management of Coronary Arteriovenous Fistulas.

We describe a patient with right coronary artery to coronary sinus fistula requiring surgical elimination. The decision process in managing fistulas depends on the size, site of origin, and symptoms caused by the fistula. We highlight the pivotal role of multimodality cardiovascular imaging in the diagnosis and management of coronary fistulas. (Level of Difficulty: Intermediate.).

Peripartum Cardiomyopathy Presenting With Incessant Ventricular Arrhythmias.

Sudden cardiac death is hypothesized to be one of the leading causes of mortality in peripartum cardiomyopathy. This case illustrates a patient who presented with cardiac arrest, and it discusses the importance of considering multiple causes of fulminant ventricular arrhythmias in the setting of decreased left ventricular function during the peripartum period. (Level of Difficulty: Advanced.).

Acute Perimyocarditis Unmasking Anomalous Coronary Artery: Is Treating the Inflammation Enough? Does Surgery Fix All?

We report the case of a patient with anomalous right coronary artery (RCA) unmasked by acute perimyocarditis who continued to have ischemic symptoms despite total resolution of perimyocarditis and required surgical intervention of the anomalous RCA. This case was further complicated by ventricular arrhythmia after surgical repair. Collaboration among different cardiac specialists was essential in this case. (Level of Difficulty: Advanced.).

Concurrent Waldenstrom Macroglobulinemia and Mutant Transthyretin Cardiac Amyloidosis.

Cardiac amyloidosis is caused by abnormal deposit of amyloid in the myocardium and can be divided into light chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis. ATTR amyloidosis can be further divided into wild-type and mutant type based on genetic mutation. Differentiation between AL, wild-type, and mutant type ATTR amyloidosis has significant prognostic and therapeutic implications.

'Routine' versus 'Smart Phone Application Based - Intense' follow up of patients with acute coronary syndrome undergoing percutaneous coronary intervention: Impact on clinical outcomes and patient satisfaction.

BACKGROUND: Acute coronary syndrome (ACS) refers to the spectrum of clinical presentation of coronary artery disease (CAD). As a routine practice at our institute, following PCI, ACS patients are called for the first follow up after two weeks. This period of two weeks can be full of anxieties, concerns and medical issues. In this study, we planned to assess the feasibility/acceptability of smart phone application (app) based system for patient follow-up and its comparison to routine practice among patients with ACS who have undergone a PCI. METHODS: A randomized controlled trial (RCT) was conducted over a period of one year from January to December 2017. After the PCI was deemed successful, patients were recruited and enrolled based on the understanding of basic English language and operation of a smart phone. Those who consented to be part of study were then randomly allocated either the conventional follow up group or the intense follow up (routine + smart phone app based follow up) group. First co- primary outcome was composite of clinical outcomes (mortality, myocardial infarction, stroke, target vessel revascularisation, heart failure admission and emergency visit). Second co- primary outcome was patient satisfaction. The overall patient satisfaction was assessed by the patients using a five-point patient satisfaction survey instrument containing five questions with 5 marks each, in which higher scores meant more satisfaction. Secondary outcome was controlled hypertension in hypertensive patients. It was defined as systolic BP less than 130 and diastolic BP less than 80 mmHg. RESULTS: A cohort of 228 patients (109 in intense app-based arm; 119 in routine follow up arm) were analyzed. The result showed significant improvement in blood pressure control in hypertensive population in intense app based follow up group (76.2%) when compared to routine follow up group (45%) with p value 0.0062. The satisfaction score was significantly higher in the intense app based follow up (20.7 ± 1.29) as compared to routine follow up (16.5 ± 2.68); p value 0.0001. In the intense app based follow up 72.5% patient felt it was excellent tool (score 21-25) while 27.5% categorized it as good (score 16-20). While the routine follows up was perceived as good by most (91.6%) of the patients. Only 4.2% graded it as excellent and an equal number (4.2%) graded it as a poor way of follow up. CONCLUSIONS: App based system shows higher satisfaction rate and comparable clinical outcome when compared to traditional hospital based follow up protocol alone. It has a high acceptance rate and thus this system should be explored further to optimize long term patient care.

Ventricular septal rupture and cardiogenic shock complicating STEMI during COVID-19 pandemic: An old foe re-emerges.

The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant.

Combined Venoarterial ECMO and Impella-CP Circulatory Support for Cardiogenic Shock Due to Papillary Muscle Rupture.

Papillary muscle rupture (PMR) is a catastrophic complication of acute myocardial infarction (AMI). We report on 3 consecutive patients with AMI cardiogenic shock due to PMR, treated with combined venoarterial extracorporeal membrane oxygenation and Impella-CP axial flow circulatory support as a bridge to definitive surgery. (Level of Difficulty: Intermediate.).

Impact of preoperative imaging on surgical approach for primary hyperparathyroidism: Data from single institution in India.

CONTEXT: Preoperative localization of parathyroid adenoma is essential in deciding the surgical approach of parathyroidectomy. AIM: To describe clinical and biochemical profile, evaluate preoperative imaging modalities and surgical approach in patients with primary hyperparathyroidism (PHPT). METHODOLOGY: This was a retrospective study conducted at the single institution. All patients who underwent evaluation and surgery for PHPT from 2011 to 2015 were included in the study. RESULTS: A total of 100 patients underwent surgery for PHPT. Mean (standard deviation) age was 51.6 (15.9) years with female to male ratio of 1.7:1. Forty patients had severe symptoms, and sixty had mild to moderate symptoms. The sensitivity of technetium-99m hexakis (2-methoxyisobutylisonitrile) (MIBI) scan and ultrasonography (USG) neck in identifying abnormal parathyroid gland was 93% (93/100) and 98% (98/100), respectively. The MIBI scan results of 90/93 (96.7%) patients corresponded with their surgical findings whereas preoperative USG findings of 96/98 patients (98%) showed correlation with operative findings. Intraoperative intact parathyroid hormone (IOPTH) levels at 10 min postexcision were measured in forty patients (minimally invasive parathyroidectomy = 38, bilateral neck exploration = 1, and unilateral neck exploration = 1). All patients except two had <50% fall in IOPTH. Adenoma weight was positively correlated with preoperative intact PTH. CONCLUSION: We found that USG has higher sensitivity (98%) than MIBI scan (93%) in localizing abnormal parathyroid gland. Moreover, USG had a higher preoperative localization accuracy (93%) than MIBI scan (90%), allowing to choose an appropriate surgical approach. A higher proportion of patients (60%) had mild/asymptomatic form of PHPT.