Recovery From the Impact of COVID-19 on Treatment Times and Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction: An Interim Analysis.

BACKGROUND: Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS: Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS: For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION: COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.

Outcomes of Transcatheter Aortic Valve Replacement in Patients Treated With Systemic Steroids.

BACKGROUND: Chronic steroid therapy is associated with higher vascular complication rates in patients undergoing transcatheter aortic valve replacement (TAVR). The effect of corticosteroids on aortic annular complications has not been directly assessed in this population. METHODS: A retrospective analysis of 1095 patients undergoing transfemoral TAVR was performed. Patients treated with chronic steroids at the time of the procedure (n = 99) were compared with those who received no steroids (n = 992). The primary outcome included a composite of aortic annular complications, defined as a combination of aortic annular rupture, aortic dissection/perforation, and left ventricular perforation. RESULTS: The primary outcome was significantly higher in the steroid group (4.0% vs 0.5%; P<.01). This finding was primarily driven by higher rates of acute annular rupture in the steroid group (2.0% vs 0.2%; P=.04). Steroid use was associated with higher rates of intraoperative cardiac arrest (5.1% vs 1.5%; P=.03), device capture/retrieval (4.0% vs 0.8%; P=.01), and emergent conversion to open heart surgery (4.0% vs 0.6%; P<.01). There were no differences with respect to in-hospital mortality, stroke, myocardial infarction, need for permanent pacemaker, bleeding complications, minor vascular complications, hospital length of stay, hospital 30-day readmission, or 30-day echocardiographic findings. Additionally, within the steroid group, there were no significant differences between balloon-expandable vs self-expanding TAVR prostheses with respect to composite aortic annular complications. CONCLUSION: Chronic steroid therapy increases the risk of aortic annular complications in patients undergoing TAVR, with detrimental consequences including intraoperative cardiac arrest and conversion to open heart surgery. Steroid use should be considered in patient selection and determination of procedural technique for TAVR.

Comparison of Benefit of Transcatheter Aortic Valve Implantation in Patients With Low Gradient Versus High Gradient Aortic Stenosis and Left Ventricular Dysfunction.

Patients with low gradient severe aortic stenosis (LG-AS) often exhibit significant limitations in functional status and quality of life. We aimed to evaluate the clinical effect of transcatheter aortic valve implantation (TAVI) on LG-AS patients compared to those with high transvalvular gradients and similar left ventricular dysfunction. Retrospective analysis of records for all patients with a left ventricular ejection fraction <50% who underwent TAVI at our institution was performed. Patients were grouped according to their transvalvular gradient. Data were collected from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Clinical benefit endpoints included improvements in left ventricular ejection fraction and changes in the Kansas City Cardiomyopathy Questionnaire. Additional outcomes analyzed included 1-year all-cause mortality, stroke rates, rates of rehospitalization, need for a permanent pacemaker, and hospital length of stay. Two hundred three patients met our inclusion criteria. one hundred one LG-AS patients (mean transvalvular gradient <40 mm Hg) were compared to 102 patients with high transvalvular gradients (mean transvalvular gradient >40 mm Hg). LG-AS patients yielded similar improvements in left ventricular ejection fraction (43.5% ± 63.7 vs 37.7% ± 58.7; p = 0.525) and Kansas City Cardiomyopathy Questionnaire scores (423.51% ± 1257.02 vs 266.56% ± 822.81; p = 0.352). There were no differences between the groups with respect to 1-year mortality (16.8% vs 12.7%; p = 0.412), stroke rates, hospital length of stay, need for permanent pacemaker implantation or hospital readmissions. In conclusion, we found that TAVI is associated with comparable improvement in clinical and echocardiographic outcomes in LG-AS patients as compared to those with high gradient severe aortic stenosis.

Comparative Outcomes of Balloon-Expandable S3 Versus Self-Expanding Evolut Bioprostheses for Transcatheter Aortic Valve Implantation.

To date, comparisons between the balloon-expandable Edwards Sapien S3 (S3) versus the self-expanding Evolut R or PRO (Evolut) valves have been limited with respect to procedural outcomes. We aim to compare the safety, efficacy, and procedural efficiency of the S3 versus the Medtronic Evolut bioprostheses in patients who underwent transcatheter aortic valve implantation for severe aortic stenosis. Retrospective analysis was performed of all consecutive transcatheter aortic valve implantation procedures performed through the transfemoral approach with either S3 or Evolut at our hospital between September 2015 and January 2019. A total of 581 patients were included. There were no significant differences between S3 (n = 452) and Evolut (n = 129) concerning in-hospital or 30-day safety outcomes. S3 was associated with significantly shorter fluoroscopy times, lower fluoroscopy Air Kerma, and higher contrast use. S3 had lower postprocedure aortic valve area (1.71 ± 0.45 vs 1.84 ± 0.50 cm2, p = 0.004), larger peak gradient at 30 days (10.7 ± 3.8 vs 7.0 ± 3.2 mm Hg, p <0.001), and lower aortic regurgitation (AR) rates postprocedure (47% vs 33%, p = 0.024) and at 30 days (50% vs 33%, p = 0.008), driven by mild AR. Device type was an independent predictor of AR postprocedure and at 30 days. Patients with ≥mild AR were more likely to have had Evolut valves (odds ratio = 2.94, p <0.001), especially in larger valves (>26 mm). Severe prosthesis-patient mismatch was higher in S3 (14.8% vs 7.9%, p <0.001). In conclusion, S3 is associated with less radiation exposure, higher contrast use, and lower incidence of AR at 30 days. Alternately, S3 has a higher transaortic gradient at 30 days, and higher levels of severe prosthesis-patient mismatch.

Propensity Matched Analysis Comparing Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Implantation.

Conscious sedation (CS) has been increasingly utilized in transcatheter aortic valve implantation (TAVI). We aim to compare safety, efficacy, efficiency, and direct cost outcomes of patients who underwent TAVI with general anesthesia (GA) to those with CS. Records for all adult patients undergoing transfemoral TAVI at our institution between February 2012 and September 2018 were retrospectively screened. Patients were grouped by anesthesia treatment (GA or CS) and propensity matched. Safety (in-hospital and 30-day mortality, in-hospital and 30-day stroke, cardiac arrest, need for permanent pacemaker, and composite bleed/vascular adverse events), efficacy (follow-up echocardiographic findings), efficiency (procedure duration, fluoroscopy time, radiation dose, intensive care unit (ICU) stay, hospital length-of-stay, and discharge to home), and direct cost outcomes were compared. A total of 589 patients met our inclusion criteria. Propensity matching yielded 154 GA patients and 154 CS patients. There were no differences in the safety outcomes of in-hospital or 30-day mortality, in-hospital or 30-day stroke, cardiac arrest, and need for permanent pacemaker between GA and CS groups. There was a significant reduction in composite bleeding/vascular events in the CS group (8.4% vs 19.5%, p < 0.01). There were no differences in the follow-up echocardiograms with respect to aortic valve area, left ventricular ejection fraction, and incidence of moderate or severe aortic regurgitation. The CS group had shorter procedural fluoroscopy times and radiation dose, shorter length-of-stay and ICU stay, with similar procedural duration. CS patients were more likely to be discharged to home (59.7% vs 74.7%, p < 0.01). Total direct costs for CS were decreased in almost every departmental category, with a mean 10.4% reduction in overall direct costs (p < 0.001). In conclusion, TAVI with CS is associated with less bleeding and vascular events, lower procedural radiation exposure, reduced length of hospitalization and ICU stay, and lower direct costs in comparison with TAVI with GA. These outcomes occur without sacrificing procedural efficacy or safety.

Dynamic LVOT Obstruction and Aortic Stenosis in the Same Patient: A Case of Challenging Doppler Hemodynamics.

We present a patient with both dynamic left ventricular outflow tract obstruction and valvular aortic stenosis. The aortic valve was calcified, and velocities and gradients measured by continuous-wave Doppler met standard criteria for severe aortic stenosis. The increased subvalvular velocities invalidated assumptions of the simplified Bernoulli equation; correction using the longer form of the Bernoulli equation suggested a lower but still significant gradient. The complex shape of the subvalvular spectral Doppler envelope indicated supranormal systolic function and dynamic left ventricular outflow obstruction. Left heart catheterization with an end-hole catheter was required to determine the subvalvular and valvular components of the obstruction.

Redundant vasodilator pathways underlying radial artery flow-mediated dilation are preserved in healthy aging.

Background. Blocking nitric oxide (NO) and vasodilator prostanoids (PN) does not consistently reduce flow-mediated dilation (FMD) in young adults. The impact of aging on the contribution of NO and PG to FMD is unknown. Methods. FMD was measured in older adults (n = 10, 65 ± 3 y) after arterial infusion of saline, N(G)-monomethyl-L-arginine (L-NMMA), and ketorolac + L-NMMA. Data were compared to published data in young adults. Results. L-NMMA reduced FMD in older adults (8.9 ± 3.6 to 5.9 ± 3.7%) although this was not statistically significant (P = 0.08) and did not differ (P = 0.74) from the reduction observed in young adults (10.0 ± 3.8 to 7.6 ± 4.7%; P = 0.03). Blocking PN did not affect FMD in young or older adults. In older adults, L-NMMA reduced (n = 6; range = 36-123% decrease), augmented (n = 3; 10-122% increase), or did not change FMD (n = 1; 0.4% increase). After PN blockade, FMD responses were reduced (n = 2), augmented (n = 6), or unaffected (n = 1). Conclusions. NO or PN blockade did not consistently reduce FMD in healthy older adults, suggesting the existence of redundant vasodilator phenotypes as observed previously in young adults.

Sheath hemorrhage after percutaneous ventricular assist device implantation.

Technical advances in temporary ventricular assist devices (VADs) continue to progress, allowing for percutaneous implantation during times of hemodynamic instability. However, device delivery systems, i.e., sheaths, lag in their ability to sustain the mechanical demands of these VADs for extended periods. We propose both a novel technique and the implementation of an emergency preparedness plan to be enacted specifically during those times when delivery systems fail thereby leading to potentially catastrophic bleeding complications.

Heterogenous vasodilator pathways underlie flow-mediated dilation in men and women.

This study investigated the sex differences in the contribution of nitric oxide (NO) and prostaglandins (PGs) to flow-mediated dilation (FMD). Radial artery (RA) FMD, assessed as the dilatory response to 5-min distal cuff occlusion, was repeated after three separate brachial artery infusions of saline (SAL), N(G)-monomethyl-L-arginine (L-NMMA), and ketorolac (KETO) + L-NMMA in healthy younger men (M; n = 8) and women (W; n = 8). In eight subjects (4 M, 4W) RA FMD was reassessed on a separate day with drug order reversed (SAL, KETO, and L-NMMA + KETO). RA FMD was calculated as the peak dilatory response observed relative to baseline (%FMD) and expressed relative to the corresponding area under the curve shear stress (%FMD/AUC SS). L-NMMA reduced %FMD similarly and modestly (P = 0.68 for sex * trial interaction) in M and W (all subjects: 10.0 ± 3.8 to 7.6 ± 4.7%; P = 0.03) with no further effect of KETO (P = 0.68). However, all sex * trial and trial effects on %FMD/AUC SS for l-NMMA and KETO + l-NMMA were insignificant (all P > 0.20). There was also substantial heterogeneity of the magnitude and direction of dilator responses to blockade. After l-NMMA infusion, subjects exhibited both reduced (n = 14; range: 11 to 78% decrease) and augmented (n = 2; range: 1 to 96% increase) %FMD. Following KETO + l-NMMA, seven subjects exhibited reduced dilation (range: 10 to 115% decrease) and nine subjects exhibited augmented dilation (range: 1 to 212% increase). Reversing drug order did not change the nature of the findings. These findings suggest that RA FMD is not fully or uniformly NO dependent in either men or women, and that there is heterogeneity in the pathways underlying the conduit dilatory response to ischemia.

SCAD: a rare case of cardiac arrest in a young female.

A 43-year-old caucasian female without prior history or family history of cardiac disease presented to a community hospital with severe chest pain and electrocardiographic evidence of an acute left anterior descending (LAD) territory infarction. Duringtransferto ourtertiaryfacility, the patient had a cardiac arrest and was cardioverted in the ambulance. After arrival, the patient suffered a second cardiac arrest, was given CPR, cardioverted, intubated and given volume resuscitation. The patient was stabilized with vasopressors and was taken to the cardiac catherization (cath) lab where an intra-aortic balloon pump (IABP) was inserted. At catherization, the patient was found to have an acute left main coronary artery dissection and had evidence of cardiogenic shock. Prompt treatment including multiple stents, hypothermia protocol (HP), left ventricular assist device (LVAD) and multiple inotropic agents resulted in complete clinical recovery.

Determinants and clinical significance of persistent residual shunting in patients with percutaneous patent foramen ovale closure devices.

BACKGROUND: Percutaneous patent foramen closure has emerged as a dynamic therapy for stroke prevention secondary to paradoxical embolism. Recent reports, however, have documented uncertain clinical efficacy and patients with incomplete PFO closure may remain at risk of recurrent events. We sought to identify echocardiographic determinants and the clinical significance of persistent residual shunting after percutaneous PFO closure. METHODS: From 2002 to 2008, 51 consecutive patients with recurrent stroke (n=46) or transient ischemic attack (TIA) (n=5) underwent percutaneous PFO closure at a tertiary care hospital. PFO size, degree of shunt, tunnel length, and atrial septal aneurysm geometry were documented at the time of device implantation. All patients received follow-up with transesophageal (n=43) or transthoracic (n=8) echocardiography 6.7+/-2 months post procedure and presence of residual shunting and recurrent stroke/TIA were recorded. RESULTS: All patients underwent percutaneous PFO closure without complication. Ten patients (20%) demonstrated residual right-to-left shunting at the time of follow-up: color Doppler (2), mild (n=3), moderate (n=2) and severe (n=3). Univariate analysis revealed larger PFO size (F=4.71, p=0.036) as the only independent predictor of residual shunting after PFO closure. Ninety six percent of patients remained stroke and TIA free 3 years+/-8 months post closure, with no clinical differences between the two groups. CONCLUSIONS: In patients undergoing percutaneous PFO closure for stroke or TIA, a larger PFO size predisposes to residual shunting approximately 6 months post PFO closure, but with no short term increased risk of recurrent thromboembolic events.

Use of prehospital electrocardiograms for the treatment of patients with ST-segment elevation myocardial infarction.

Use of prehospital electrocardiograms (ECG) by emergency medical personnel may reduce door-to-balloon (DTB) time in patients with ST-segment elevation myocardial infarction (STEMI) referred for urgent percutaneous coronary intervention (PCI). A 79-year-old female awoke from sleep with severe substernal chest pain and called 911 for assistance. The patient was initially evaluated by advanced life support paramedics who performed a 12-lead ECG at the patient's home. The ECG, which demonstrated an acute inferior STEMI, was transferred using a novel, web-based system to Hartford Hospital's Emergency Department. As a result of prehospital communication, the on-call catheterization team was mobilized prior to the patient's arrival. The patient underwent successful PCI of an occluded right coronary artery with a DTB time of 67 minutes and was subsequently discharged four days later. Use of prehospital electrocardiography combined with early catheterization laboratory mobilization allowed for timely STEMI reperfusion according to national guidelines, despite "off-hour" presentation.

Comparison of outcomes and safety of "facilitated" versus primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction.

Recent studies have documented that use of "facilitated" percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) may be harmful. In-hospital outcomes in 1,553 consecutive patients with STEMI without cardiogenic shock who underwent PCI at a single tertiary center within 6 hours of presentation were analyzed. The study group included 767 patients who underwent primary PCI who initially presented to the tertiary center and were triaged for emergent PCI and 786 patients who underwent facilitated PCI who were pretreated at a community hospital with a glycoprotein IIb/IIIa platelet inhibitor and/or intravenous thrombolytic therapy before transfer for catheter-based therapy. Compared with patients who underwent primary PCI, the facilitated PCI group had longer door-to-balloon times (162 +/- 57 vs 113 +/- 61 minutes), higher baseline infarct-vessel TIMI 3 flow rates (52.8% vs 25.4%; p <0.001), and no increase in major adverse in-hospital outcomes. In patients treated with door-to-balloon times >90 and < or =150 minutes, patients who underwent facilitated PCI had fewer composite major adverse clinical events (combined mortality, recurrent myocardial infarction, emergent repeated PCI, hemorrhagic and nonhemorrhagic stroke, and nonintracranial TIMI major bleeding) compared with patients who underwent primary PCI (relative risk 0.50, 95% confidence interval 0.26 to 0.96, p = 0.034). In conclusion, facilitated PCI can be safely used to increase pharmacologic reperfusion before catheter-based therapy in patients with STEMI without an increase in clinical hazard and with fewer major adverse clinical events in patients treated with door-to-balloon times >90 and < or =150 minutes.

Long-term efficacy and safety of sirolimus-eluting vs bare-metal stents.

BACKGROUND: Although previous studies have documented persistent clinical benefit of sirolimus-eluting stents (SES)in reducing the need for target vessel revascularization without an increase in myocardial infarction (MI) or mortality, the long-term safety and efficacy of CYPHER stent use in routine clinical practice, including off-label stent implantation, remains uncertain. METHODS: We compared long-term clinical outcomes in 2,550 patients treated with one or more SES with 1,022 patients treated with one or more bare metal or heparin-coated stents (BMS). The study groups included 1,058 SES patients (41.5%) and 488 BMS patients (47.7%) with off-label indications. A propensity-score method was utilized to adjust for differences in baseline characteristics. Patients were followed for up to five years for the occurrence of all-cause mortality, MI and repeat target vessel revascularization. RESULTS: Compared to BMS patients, SES patients demonstrated significantly improved event-free survival with respect to all-cause mortality (RR, 1.39; 95% CI, 1.07 to 1.80, P = 0.014) and repeat target vessel revascularization (RR, 2.72; 95% CI, 1.99 to 3.73, P < 0.001), with no significant difference in the incidence of cumulative MI. A landmark analysis, examining composite adverse events occurring six months after stent implantation in the two study groups, demonstrated no increased late hazard associated with SES use (relative risk, 1.08; 95% CI, 0.80 to 1.46). CONCLUSIONS: Use of SES in routine clinical practice, including off-label indications, is associated with improved long-term mortality, reduced need for repeat target vessel revascularization and no increase in MI compared to BMS.

Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events.

OBJECTIVES: The aim of this study was to determine correlates of acute/subacute coronary stent thrombosis among unselected patients treated in the era of routine dual antiplatelet therapy and specifically to investigate the influence of prophylactic administration of glycoprotein IIb/IIIa (GpIIb-IIIa) inhibitors and use of clopidogrel versus ticlopidine on the development of coronary stent thrombosis (ST). BACKGROUND: Because of a relative infrequency of ST events and relatively uniform practice patterns within randomized trials, previous studies have had a limited ability to address whether the use of different antiplatelet regimens at the time of coronary stenting is associated with differences in ST. METHODS: We performed a multicenter, case-control study to evaluate clinical, angiographic, and pharmacologic/procedural correlates of ST. Between 1996 and 2000, all cases of angiographically-confirmed ST (n = 145) among patients receiving dual antiplatelet therapy were identified from 10 participating clinical sites and were matched with a control without ST randomly selected from the same institution. RESULTS: Multivariable conditional logistic regression identified higher pre-procedure platelet count, stenting for acute myocardial infarction, use of a coil or self-expanding stent, and overt angiographic thrombus prior to the procedure, as independent predictors of ST (all P < .05). After adjusting for these factors, the use of clopidogrel (vs ticlopidine) was independently associated with an increased risk of ST (OR 2.1, 95% CI 1.0-4.1, P = .04). The use of prophylactic glycoprotein IIb/IIIa inhibitors was not associated with reduced ST in the overall analysis, but appeared to confer some protection against ST within the first 24 hours post procedure (OR 0.5 [95% CI 0.2-1.1] for ST during first day, OR 1.7 [95% CI 0.7-4.3] for ST on subsequent days). CONCLUSION: Both biologic and pharmacologic factors are independently associated with acute/subacute ST. The association between clopidogrel use (vs ticlopidine) and increased ST in this analysis requires confirmation in adequately powered clinical trials and suggests a potential role for newer and more potent antiplatelet agents.

Drug-eluting stent implantation results in effective treatment of small coronary artery disease (DESIRE Small CAD).

OBJECTIVE: Sirolimus-eluting stents (SES) have been shown to significantly reduce restenosis in the treatment of lesions in large coronary arteries. We assessed and compared the in-hospital and long-term outcomes of patients treated with SES and bare-metal stents (BMS) for small coronary artery disease. METHODS: We compared 448 patients who underwent SES implantation in small coronary arteries (<2.5mm) with patients who received conventional BMS (n=124). In-hospital and nine-month events were evaluated. RESULTS: The rate of angiographic restenosis at nine months was significantly lower in the SES group (1.6% vs 9.9%, P<0.001) than in the BMS group. The overall rate of MACE was 4.3% in SES and 13.9% in BMS groups (P<0.001). CONCLUSIONS: As compared with BMS, SES placement in small coronary arteries is effective and associated with a marked reduction in restenosis rate and the subsequent need for target lesion revascularization at nine months.

Comparison of results of percutaneous coronary intervention for non-ST-elevation acute myocardial infarction or unstable angina pectoris in men versus women.

Previous randomized trials have addressed the impact of gender on outcomes, showing worse results in women assigned to invasive strategies compared with men with non-ST-elevation (NSTE) acute coronary syndrome (ACS). However, there is still a significant amount of controversy on strategies of treatment on the basis of gender. This study evaluated the impact of gender on treatment strategies and outcomes in patients with NSTE ACS in a high-volume, single-site tertiary center. We identified 1,197 consecutive patients with NSTE ACS (381 women, 816 men) who underwent percutaneous coronary intervention during their index hospitalizations. Patients were stratified by gender and baseline clinical and angiographic characteristics, and in-hospital and 9-month clinical outcomes were compared between the 2 groups. There were clear differences in baseline characteristics between men and women with ACS at presentation. Women were, on average, slightly older than men, with more hypertension and morbid obesity, but there were no differences in racial backgrounds or the prevalence of diabetes or dyslipidemia, nor were there treatment disparities in pharmacologic interventions. Women and men with ACS had similar rates of percutaneous coronary intervention on index admission. Women had a greater incidence of bleeding complications requiring blood transfusions. Overall, in-hospital and 9-month event-free survival were equivalent for the 2 genders. In conclusion, in this single-site observational study, patients with NSTE ACS who underwent angiography followed by percutaneous coronary intervention demonstrated no significant gender differences in treatment or in-hospital or 9-month event-free survival. From these results, interventional strategies should not be based on gender.