Post-infarction ventricular septal defect: percutaneous or surgical management in the UK national registry.

AIMS: Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken. METHODS AND RESUTS: Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar [percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18]. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older [72 (64-77) vs. 67 (61-73) years, P < 0.001] and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock [adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach [aHR 1.44 (1.01-2.05), P = 0.042], and number of vessels with coronary artery disease [aHR 1.22 (1.01-1.47), P = 0.043] were independently associated with long-term mortality. CONCLUSION: Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.

Changing trends in the incidence, management and outcomes of coronary artery perforation over an 11-year period: single-centre experience.

INTRODUCTION: Coronary artery perforation (CP) is a rare but life-threatening complication of percutaneous coronary intervention (PCI). This study aimed to assess the incidence, management and outcomes of CP over time. METHODS: A single-centre retrospective cohort study of all PCIs performed between January 2010 and December 2020. Patients with CP were divided into two cohorts (A+B), representing the two halves of the 11-year study. RESULTS: The incidence of CP was 68 of 9701 (0.7%), with an increasing trend over the two 5.5-year periods studied (24 of 4661 (0.5%) vs 44 of 5040 (0.9%); p=0.035). Factors associated with CP included chronic total occlusions (CTOs) (16 of 68 (24%) vs 993 of 9633 (10%); p<0.001), type C lesions (44 of 68 (65%) vs 4280 of 9633 (44%); p<0.001), use of intravascular ultrasound (IVUS) (12 of 68 (18%) vs 541 of 9633 (6%); p<0.001), cutting balloon angioplasty (3 of 68 (4%) vs 98 of 9633 (1%); p<0.001) and hydrophilic wires (24 of 68 (35%) vs 1454 of 9633 (15%); p<0.001). Cohorts A and B were well matched with respect to age (69±11 vs 70±12 years; p=0.843), sex (males: 13 of 24 (54%) vs 31 of 44 (70%); p=0.179) and renal function (chronic kidney disease: 1 of 24 (4%) vs 4 of 44 (9%); p=0.457). In cohort A, CP was most frequently caused by post-dilatation with non-compliant balloons (10 of 24 (42%); p=0.009); whereas in cohort B, common causes included guidewire exits (23 of 44 (52%)), followed by stent implantation (10 of 44 (23%)). The most common treatment modality in cohorts A and B was balloon inflation, which accounted for 16 of 24 (67%) and 13 of 44 (30%), respectively. The use of covered stents (16%) and coronary coils (18%) during cohort B study period did not impact all-cause mortality, which occurred in 2 of 24 (8%) and 7 of 44 (16%) (p=0.378) in cohorts A and B, respectively. CONCLUSION: The incidence of CP is increasing as more complex PCI is performed. Factors associated with perforation include CTO or type C lesions and use of IVUS, cutting balloon angioplasty or hydrophilic wires.

Proximal to Distal Y-Stent Deployment for Coronary Bifurcation Lesions: Procedure and Three-Year Clinical Outcomes.

AIMS: Percutaneous coronary intervention with Y-stenting of coronary bifurcation disease is not commonly undertaken. The procedural and medium-term clinical outcomes of coronary bifurcation lesions treated with the proximal to distal Y stent technique by a single experienced operator were reviewed. METHODS: A total of 167 consecutive procedures using either provisional Y strategies or full-coverage options performed at Auckland City Hospital, New Zealand, between January 2013 and July 2018 were included in this retrospective observational study. All medical records and coronary angiograms were reviewed. RESULTS: Three-year clinical follow-up data were available in 162 of 167 patients. The primary endpoint, defined as the composite of cardiovascular death, spontaneous myocardial infarction (MI), target-lesion revascularization (TLR), target-vessel nontarget-lesion revascularization (nontarget-lesion TVR), and stent thrombosis (ST) occurred in 25 patients (15%) at 3 years. Secondary endpoints were all-cause mortality (12%), including cardiovascular mortality (6%), noncardiovascular mortality (4%), undetermined death (2%), spontaneous MI (7%), TLR (1%), nontarget-lesion TVR (0%), and ST (0.6%). CONCLUSIONS: The proximal to distal Y-stent technique is a widely applicable approach to bifurcation lesions, with good medium-term clinical outcomes when used in a heterogeneous group of clinical and anatomical scenarios. Complications related to the stented site were infrequent. Randomized, controlled trials are needed to assess its efficacy compared with other bifurcation interventional techniques.

Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal?

Screening for occult coronary artery disease in potential kidney transplant recipients has become entrenched in current medical practice as the standard of care and is supported by national and international clinical guidelines. However, there is increasing and robust evidence that such an approach is out-dated, scientifically and conceptually flawed, ineffective, potentially directly harmful, discriminates against ethnic minorities and patients from more deprived socioeconomic backgrounds, and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. Herein we review the available evidence in the light of recently published randomized controlled trials and major observational studies. We propose ways of moving the field forward to the overall benefit of patients with advanced kidney disease.

Early Left Ventricular Thrombus Formation in a COVID-19 Patient with ST-Elevation Myocardial Infarction.

BACKGROUND: Left ventricular thrombus (LVT) is a complication of acute myocardial infarction (AMI) due to localised haemostasis. LVT is typically seen 3-12 days following AMI and is seldom seen within the first 24 hours. LVT increases the risk of mortality due to systemic thromboembolism. Patients with Coronavirus Disease-19 (COVID-19) are potentially hypercoagulable and this may promote early development of LVT. CASE: A 50-year-old man with no past medical history was admitted with a severe diabetic ketoacidosis following a 4-day history of cough and fever. The patient tested positive for COVID-19 and required intensive care treatment for ventilation and haemofiltration. After returning to ward-based care, the patient developed chest pain and electrocadiographic changes consistent with an acute anterior ST-elevation myocardial infarction. Emergency percutaneous coronary intervention was performed to the left anterior descending artery. However, the patient developed diuretic-resistant pulmonary oedema and a bedside echocardiogram revealed significant LVT despite only 4 hours of chest pain. The thrombus was associated with the anteroseptal wall of the left ventricle which was hypokinetic but not aneurysmal. An intra-aortic balloon pump (IABP) was inserted, but the patient developed ipsilateral lower limb ischaemia due to the formation of thrombus in the femoral artery and irreversible cardiogenic shock from which he ultimately succumbed. CONCLUSION: COVID-19-positive patients are potentially hypercoagulable, and MI in this population may precipitate LVT earlier than expected. Consideration should be made for routine early screening of post-MI COVID-19 patients for LVT. If detected, anticoagulation may reduce the risk of cardiovascular mortality in this high-risk group.

Occlusion of the Right Ventricular Wall Branch of a Recessive Right Coronary Artery Resulting in Ventricular Fibrillation and Anterior ST-Segment Elevation-A Case Report.

Background: Right ventricular (RV) infarction is as an extremely rare cause of isolated anterior ST-segment elevation. Occlusion of the RV branch in a recessive right coronary artery (RCA) causing isolated RV infarction and only anterior ST-elevation is extremely rare. To date, the handful of such cases reports do not describe any arrhythmia associated with this presentation. Although ventricular fibrillation (VF) has been well-documented with interruption of flow in the conus branch of the RCA, here we describe VF occurring in a patient with occlusion of the RV branch of a recessive RCA presenting with isolated anterior ST-segment elevation. Case: A 51-year-old man presented with acute chest pain and isolated anterior ST-segment elevation on electrocardiogram (ECG). The patient developed ventricular fibrillation prior to coronary angiography requiring cardiopulmonary resuscitation. Coronary angiography revealed an unobstructed left coronary system and a recessive right coronary artery with ostial occlusion of the RV branch which was treated with a drug eluting balloon, resulting in resolution of the chest pain and ECG changes. Conclusion: Isolated RV infarction due to RV branch occlusion can cause ECG changes mimic anterior left ventricular infarction. This presentation may be complicated by VF, even in the setting of a recessive RCA.

Comparison of Routine Versus Selective Glycoprotein IIb/IIIa Inhibitors Usage in Primary Percutaneous Coronary Intervention (from the British Cardiovascular Interventional Society).

The role of glycoprotein IIb/IIIa inhibitors (GPI) in primary percutaneous coronary intervention (PPCI) remains uncertain. Previous analyses compare PPCI outcomes with clopidogrel plus GPI, versus without GPI. This does not reflect modern contemporary PPCI practice with ticagrelor or prasugrel. Nor does it answer the important question faced daily by PPCI operators: should GPI be used routinely or selectively? We aim to determine whether a strategy of routine use of GPI in contemporary PPCI practice is superior to selective GPI use. A total of 110,327 consecutive PPCIs performed in England were prospectively recorded in the British Cardiovascular Intervention Society Database (2009 to 2015). The cohort was divided into routine and selective GPI usage groups based on the PPCI operator's strategy, defined as GPI used in >75% and <25% PPCIs, respectively. Overall, GPI use declined from 73.1% to 43.3% of PPCIs. Routine compared with selective GPI usage was associated with lower all-cause 1-year mortality: 9.7% versus 11.0%, p < 0.001. There was a consistent survival benefit for routine GPI usage as compared with selective GPI usage: univariable analysis (hazard ratio = 0.88 [95% confidence interval 0.83 to 0.93], p < 0.001), multivariable analysis (hazard ratio = 0.82 [0.77 to 0.88], p < 0.001). For survival, there was no interaction between GPI usage and the type of P2Y12-inhibitor used. In conclusion, a strategy of routine GPI usage in patients who underwent PPCI was associated with lower all-cause mortality as compared with selective GPI usage. This benefit was maintained despite 44.3% of patients receiving prasugrel or ticagrelor.

Development of New Antithrombotic Regimens for Patients with Acute Coronary Syndrome.

Patients with acute coronary syndrome (ACS) require long-term antithrombotic intervention to reduce the risk of further ischemic events; dual antiplatelet therapy with a P2Y12 inhibitor and acetylsalicylic acid (ASA) is the current standard of care. However, pivotal clinical trials report that patients receiving this treatment have a residual risk of approximately 10% for further ischemic events. The development of non-vitamin K antagonist oral anticoagulants (NOACs) has renewed interest in a 'dual pathway' strategy, targeting both the coagulation cascade and platelet component of thrombus formation. In the phase III ATLAS ACS 2 TIMI 51 trial, a 'triple therapy' approach (NOAC plus dual antiplatelet therapy) showed reduced ischemic events with rivaroxaban 2.5 mg twice daily, albeit at an increased risk of bleeding. Two studies have investigated the role of NOACs in combination with a P2Y12 inhibitor, with or without ASA, in reducing bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention; two further studies are underway. Although these trials will help to inform optimal treatment protocols for secondary prevention of ACS, an individualized approach to treatment will be needed, taking account of the high frequency of co-morbid conditions found in this patient population.

The Influence of the Charlson Comorbidity Index on Procedural Characteristics, VARC-2 Endpoints and 30-Day Mortality Among Patients Who Undergo Transcatheter Aortic Valve Implantation.

BACKGROUND: Aortic stenosis (AS) is a common valvular abnormality and transcatheter aortic valve implantation (TAVI) is being increasingly used to treat patients considered too high risk for conventional surgery. We aimed to assess the prevalence of comorbid conditions in patients undergoing TAVI using the Charlson Comorbidity Index (CCI) and to assess their impact on clinical and procedural outcomes. METHODS: We analysed 158 patients who underwent a TAVI at our institution between June 2009 and September 2015 to define their co-morbid burden as measured with CCI, and study its impact on procedural characteristics and mortality at 30 days. RESULTS: One hundred fifty-eight (158) patients with a mean age of 82±8years and a mean CCI score of 2.67 underwent a TAVI. Only 12/158 patients had a CCI of 0. The commonest cardiovascular comorbidities were previous myocardial infarction (24%), congestive heart failure (15%) and diabetes mellitus (23%) whilst the commonest non-cardiovascular comorbidities were renal disease (46%) and chronic obstructive pulmonary disease (COPD) (29%). After multivariable adjustment, CCI was not independently associated with adverse clinical outcomes. The addition of CCI to scoring systems such as Logistic EuroScore (LES) and Society of Thoracic Surgeons (STS) risk models improved the area under the curve from 0.75 (95%CI: 0.44-1.00) and 0.83 (95%CI: 0.64-1.00) to 0.78 (95%CI: 0.53-1.00) and 0.89 (95%CI: 0.78-1.00) respectively. CONCLUSIONS: The burden of comorbid conditions in patients undergoing TAVI is significant. The CCI score was not independently associated with a higher risk of death but can be useful in addition to LES and STS risk models in informing decision making on the selection of patients for TAVI.

Association of comorbid burden with clinical outcomes after transcatheter aortic valve implantation.

OBJECTIVES: To investigate the association of the CharlsonComorbidity Index (CCI) with clinical outcomes after transcatheter aortic valve implantation (TAVI). BACKGROUND: Patients undergoing TAVI have high comorbid burden; however, there is limited evidence of its impact on clinical outcomes. METHODS: Data from 1887 patients from the UK, Canada, Spain, Switzerland and Italy were collected between 2007 and 2016. The association of CCI with 30-day mortality, Valve Academic Research Consortium-2 (VARC-2) composite early safety, long-term survival and length of stay (LoS) was calculated using logistic regression and Cox proportional hazard models, as a whole cohort and at a country level, through a two-stage individual participant data (IPD) random effect meta-analysis. RESULTS: Most (60%) of patients had a CCI ≥3. A weak correlation was found between the total CCI and four different preoperative risks scores (ρ=0.16 to 0.29), and approximately 50% of patients classed as low risk from four risk prediction models still presented with a CCI ≥3. Per-unit increases in total CCI were not associated with increased odds of 30-day mortality (OR 1.09, 95% CI 0.96 to 1.24) or VARC-2 early safety (OR 1.04, 95% CI 0.96 to 1.14) but were associated with increased hazard of long-term mortality (HR 1.10, 95% CI 1.05 to 1.16). The two-stage IPD meta-analysis indicated that CCI was not associated with LoS (HR 0.97, 95% CI 0.93 to 1.02). CONCLUSION: In this multicentre international study, patients undergoing TAVI had significant comorbid burden. We found a weak correlation between the CCI and well-established preoperative risks scores. The CCI had a moderate association with long-term mortality up to 5 years post-TAVI.

The effect of pre-procedure sublingual nitroglycerin on radial artery diameter and Allen's test outcome - Relevance to transradial catheterization.

BACKGROUND: The radial artery is increasingly used for cardiac procedures, but is a relatively small vessel that is prone to spasm when instrumented. Intra-arterial nitroglycerine has been shown to reduce radial spasm but first requires arterial access. We investigated the effect of pre-procedure sublingual nitroglycerin (NTG) on the diameter of the radial artery in a large cohort of patients. METHODS: 305 subjects underwent ultrasound measurement of their radial and ulnar arteries in both arms before and after the administration of 800µg of sublingual NTG. The Allen's test was also performed in the subjects prior to and after NTG. RESULTS: Radial artery diameter in this Caucasian study group is larger than that reported for other populations. The administration of sublingual NTG significantly increased the size of the right radial artery from 2.88±0.36mm to 3.36±0.40mm in men and from 2.23±0.37 up to 2.74±0.36mm in women. There were also significant increases in left radial, right and left ulnar artery diameters in males and females with NTG. There was no significant effect of NTG on blood pressure. In all patients with an unfavourable Allen's test, retesting following sublingual NTG resulted in transition to a favourable Allen's. CONCLUSION: Caucasian populations have larger calibre radial arteries compared to other geographic areas. Sublingual NTG is effective at dilating the radial artery in both men and women. This may make radial artery puncture and cannulation less challenging and should be considered in all patients in the absence of contraindications. The results of Allen's testing are dynamic and its usefulness for screening prior to transradial access is undetermined.

A feasibility study of transaxillary TAVI with the lotus valve.

OBJECTIVES: To assess the feasibility of axillary transcatheter aortic valve implantation (TAVI) using the Lotus valve. BACKGROUND: TAVI is used to treat patients with severe aortic stenosis, with transfemoral (TF) access being the safest and most widely used route. In patients unsuitable for this, there are reports that the axillary artery may be safest alternative access route. The Lotus device is a fully retrievable 2nd generation transcatheter heart valve which is licensed for femoral and transaortic access. There are limited data on the suitability of this valve for axillary access. METHODS: We assessed the feasibility of transaxillary TAVI with the Lotus valve in patients unsuitable for TF TAVI. Between January and October 2016, we identified 10 patients who underwent transaxillary TAVI with the Lotus valve. This cohort was compared with 347 (85%) patients who underwent TF TAVI, 45 (11%) patients who underwent and trans-apical or direct-aortic TAVI and the total group of 16 (4%) patients who underwent axillary TAVI. RESULTS: Ten patients aged 75 years (69-83) underwent attempted TAVI with the Lotus via axillary access. Device success was 100%. In-hospital and 30-day mortality was zero. There were no neurological events, no major vascular complications and no myocardial infarctions. Four of 10 patients required a pacemaker post-TAVI. No patient was left with moderate or greater aortic regurgitation. Median length of stay was 3 days CONCLUSIONS: TAVI with the Lotus valve is feasible via the axillary artery and appears safe in our small cohort of patients.

Transcatheter Aortic Valve Implantation With or Without Percutaneous Coronary Artery Revascularization Strategy: A Systematic Review and Meta-Analysis.

BACKGROUND: Recent recommendations suggest that in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and coexistent significant coronary artery disease, the latter should be treated before the index procedure; however, the evidence basis for such an approach remains limited. We performed a systematic review and meta-analysis to study the clinical outcomes of patients with coronary artery disease who did or did not undergo revascularization prior to transcatheter aortic valve implantation. METHODS AND RESULTS: We conducted a search of Medline and Embase to identify studies evaluating patients who underwent transcatheter aortic valve implantation with or without percutaneous coronary intervention. Random-effects meta-analyses with the inverse variance method were used to estimate the rate and risk of adverse outcomes. Nine studies involving 3858 participants were included in the meta-analysis. Patients who underwent revascularization with percutaneous coronary intervention had a higher rate of major vascular complications (odd ratio [OR]: 1.86; 95% confidence interval [CI], 1.33-2.60; P=0.0003) and higher 30-day mortality (OR: 1.42; 95% CI, 1.08-1.87; P=0.01). There were no differences in effect estimates for 30-day cardiovascular mortality (OR: 1.03; 95% CI, 0.35-2.99), myocardial infarction (OR: 0.86; 95% CI, 0.14-5.28), acute kidney injury (OR: 0.89; 95% CI, 0.42-1.88), stroke (OR: 1.07; 95% CI, 0.38-2.97), or 1-year mortality (OR: 1.05; 95% CI, 0.71-1.56). The timing of percutaneous coronary intervention (same setting versus a priori) did not negatively influence outcomes. CONCLUSIONS: Our analysis suggests that revascularization before transcatheter aortic valve implantation confers no clinical advantage with respect to several patient-important clinical outcomes and may be associated with an increased risk of major vascular complications and 30-day mortality. In the absence of definitive evidence, careful evaluation of patients on an individual basis is of paramount importance to identify patients who might benefit from elective revascularization.

5-Fr sheathless transradial cardiac catheterization using conventional catheters and balloon assisted tracking; a new approach to downsizing.

BACKGROUND: While the uptake of transradial access site is growing, there are concerns about associated radial injury. We report a feasibility study of a technique that enables both 5Fr diagnostic and PCI cases to be undertaken without an arterial sheath using conventional diagnostic and guide catheters with a modified balloon assisted tracking (BAT) technique. METHODS: We performed a prospective single center pilot study to assess the feasibility and effectiveness of sheathless radial artery access and BAT to perform coronary angiography and angioplasty using conventional 5 Fr diagnostic and guide catheters. We assessed for successful acquisition of good quality angiogram, completion of the angioplasty and access site complications. RESULTS: 5 Fr sheathless cardiac catheterization was undertaken in diagnostic (55%) and PCI cases (45%, all indications) in 60 consecutive patients (mean age 62.8±11.4years) using conventional catheters. The procedure was successfully performed via the radial artery using a sheathless technique with BAT in 93.3% of patients. All patients had a patent radial artery following removal of the Helix device and there were no recorded access site complications. CONCLUSIONS: Trans-radial cardiac catheterisation for diagnostic and PCI cases using 5F Sheathless catheters (whose outer diameter is smaller than a 3Fr introducer sheath) with BAT appears feasible and allows both cardiac catheterization for diagnostic and PCI indications to be undertaken safely using conventional catheters through the radial route, with high success rates.

Radial artery perforation treated with balloon tracking and guide catheter tamponade - A case series.

A 78year old woman was admitted with an acute coronary syndrome. She underwent coronary angiography via the left radial artery which was complicated by a guide catheter induced radial artery perforation confirmed by extravasation of contrast into the forearm. We used balloon assisted tracking and guide catheter tamponade to complete the angioplasty procedure via the radial artery and successfully seal the radial artery perforation. We describe a series of 7 cases where this technique was used to both treat radial artery perforation and to complete the angioplasty via the radial approach.

Ischaemic heart disease - a selected review of recent developments.

PURPOSE OF REVIEW: The purpose of this review is to highlight important and interesting advances in the field of ischaemic heart disease that have occurred over the last 18 months. It is focused on research that is likely to lead to changes in clinical practice. RECENT FINDINGS: There is new evidence on appropriate pharmacotherapy during angioplasty in both stable and unstable patients. The use of pressure wire assessment has been shown to improve patient outcome. The management of patients with ST elevation myocardial infarction (STEMI) is likely to change with a reduction in the use of manual thrombectomy and an increase in the treatment of nonculprit disease. SUMMARY: The optimal duration of dual antiplatelet therapy in percutaneous coronary intervention remains an intensely debated topic with contradictory results from major trials. Pressure wire guided coronary intervention reduces the need for urgent revascularization. The use of fractional flow reserve computed tomography has the potential to revolutionize functional testing. The treatment of patients presenting with ST elevation myocardial infarction is likely to change dramatically. Heparin with bailout glycoprotein IIbIIIa-inhibitor (GPIIbIIIa-I) appears superior to bivalirudin alone, although there is no longer a role for routine manual thrombectomy. Multivessel PCI to establish complete revascularization may become the gold standard in patients presenting with STEMI, although larger trials are needed. Novel therapies are being devised for the treatment of patients with intractable angina, but further work is required in this area.

Guidewire-induced coronary perforation successfully treated with subcutaneous fat embolisation: A simple technique available to all.

A 62-year-old man presented with an anterior ST elevation myocardial infarction and underwent primary percutaneous coronary intervention to an occluded diagonal artery. Following stenting, a type III distal guidewire-induced coronary perforation of the diagonal branch was recognized with extravasation of contrast into the pericardial space. Prolonged balloon inflations proximal to the site of the perforation were unsuccessful. Subcutaneous fat was therefore harvested from the patients upper thigh under local anesthetic and embolized through an Export catheter into the distal diagonal vessel, resulting in the immediate cessation of leak through the site of perforation. We discuss the technical aspects of this technique as well as alternative methods of distal embolization and the potential complications that must be considered.