The Benefit of Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Replacement: A Multicenter Retrospective Outcome-Based Study.

There is inadequate evidence regarding the role of percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). The current American Heart Association/American College of Cardiology guidelines are limited to class 2A recommendations for pre-TAVR revascularization in the setting of hemodynamically significant left main (LM), proximal left anterior descending (pLAD), or extensive bifurcation disease regardless of angina status. We performed a multicenter, retrospective, observational study assessing the benefit of PCI in patients with coronary artery disease who underwent transfemoral TAVR for severe symptomatic aortic stenosis. Patients were divided into 2 cohorts: (1) patients who did not undergo pre-TAVR PCI within the preceding 12 months (no-PCI group) and (2) patients who received pre-TAVR PCI within the preceding 12 months (PCI group). The primary outcome was defined as the composite end point of in-hospital and 30-day adverse events, including all-cause mortality, cardiac arrest, and myocardial infarction. Subgroup analyses were performed on patients with LM and/or pLAD disease and other high-risk features, including angina and heart failure. Comparisons were made between 1,809 consecutive patients (1,364 in the no-PCI group and 445 in the PCI group). There were no differences between the 2 cohorts regarding the primary composite outcome (2.0% vs 2.8%, p = 0.918) or individual secondary outcomes. Although LM/pLAD disease, New York Heart Association classes III to IV, and Society of Thoracic Surgeons risk score ≥8 were all independent predictors of the primary outcome, none of the subgroups demonstrated a benefit favoring PCI. In conclusion, there is no observed benefit from PCI within 12 months pre-TAVR in patients with severe aortic stenosis and concomitant coronary artery disease, including patients with LM/pLAD disease.

Intermediate Follow-Up of Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation in Patients With Small Aortic Annuli.

The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430 mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438 days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30 days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9 mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5 mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2 months (57.8 to 64.5; p = 0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5) months combining valve types (p = 0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5 months.

Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS: Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS: P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion ≥5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS: Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.

The utility of radiographic assessment of the internal mammary arteries in chest wall irradiated patients.

PURPOSE: The internal mammary arteries (IMA's) are historically recognized to be protected against atherosclerosis. Whether chest wall-irradiation for breast cancer leads to significant IMA damage remains unclear. The utility of computed tomography (CT) and mammography to detect radiation-induced damage to the IMA's and its branches is not known. The objective of this study is to assess the susceptibility of IMA's to radiation-induced atherosclerosis, and the utility of CT scan and mammography in the assessment of IMA and its branches. METHODS: A retrospective analysis of breast cancer patients who received chest wall-radiotherapy was performed. Patients with CT scans and/or mammograms ≥5 years post-radiotherapy were included. Baseline characteristics, coronary artery calcification (CAC), the presence of IMA damage assessed by CT scan, and IMA branch calcifications by mammography were recorded. RESULTS: None of the 66 patients with CT scans post-radiotherapy revealed IMA atherosclerosis. There were 28 (42.4%) patients with CAC, of which four (14.3% of CAC subgroup or 6.1% of the total cohort) had calcifications on either side on mammogram (Chi-square test, p = 0.74). Out of the 222 patients with mammograms, 36 (16.2%) had IMA branch calcifications. Two hundred and ten patients received unilateral radiotherapy, and 27 (12.9%) of these patients had calcifications on the irradiated side, and 26 patients (12.4%) had calcifications on the contralateral side (OR = 1.0). CONCLUSION: IMA's do not exhibit signs of radiation-induced atherosclerosis when evaluated by CT scan. In addition, there is no association between radiotherapy for breast cancer and the presence of IMA branch calcification on mammograms.

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.

The impact of asthma on in-hospital outcomes of COVID-19 patients.

OBJECTIVE: The impact of asthma as a possible risk factor for adverse clinical outcomes in patients diagnosed with COVID-19 remains controversial. The purpose of this study was to examine the impact of asthma on adverse clinical outcomes in a COVID-19 hospitalized cohort. METHODS: Retrospective, propensity-matched observational study of consecutive COVID-19-positive patients between February 24, 2020, and November 3, 2020 at a single health care system. RESULTS: In the initial population of 1925 patients, 4.4% presented with asthma. Propensity score matching reduced the total sample to n = 1045: 88 (8.4%) with asthma and n = 957 without asthma. A total of 164 (15.7%) patients died during the hospitalization, including 7 (8.0%) in the asthma group and 157 (16.4%), p = .037, in the non-asthmatic cohort. There was no difference between these groups in need for mechanical ventilation, length of stay on a ventilator, or hospital length of stay.Logistic regression analysis demonstrated that asthma was an independent predictor of lower mortality, while older age, BMI > 30 kg/m2, heart failure, chronic kidney disease, and admission National Early Warning Score (NEWS) were significantly associated with an increased risk of in-hospital death. There were no significant differences between asthmatic and non-asthmatic cohorts with respect to need for mechanical ventilation, length of mechanical ventilation, serum markers of severe COVID-19 disease, or overall length of hospital stay. CONCLUSION: We conclude that asthma in hospitalized COVID-19 patients is associated with a lower risk of mortality and no increase in disease severity in hospitalized COVID-19 patients.

Benefit of Transcatheter Aortic Valve Replacement in Patients With Paradoxical Low-Flow Low-Gradient Versus High-Gradient Aortic Stenosis and Preserved Left Ventricular Function.

[Figure: see text].

Outcomes of Percutaneous and Surgical Pulmonary Valve Implantation.

BACKGROUND: The objective of this study is to describe the recent trends and in-hospital outcomes with percutaneous pulmonic valve implantation (PPVI) and surgical pulmonic valve replacement (SPVR) in adult hospitals in the US after the availability of both the Melody valve (Medtronic Inc., Minneapolis, Minnesota) and the Sapien XT valve (Edwards Lifesciences, Irvine, CA). METHODS: We queried the National Inpatient Sample database (NIS) from January 2016 to December 2017 to identify hospitalizations for PPVI and SPVR. RESULTS: We identified 5455 weighted discharges with PPVI and SPVR (PPVI=1140, SPVR=4305). PPVI procedures had increased in number over 2016 and 2017 (115 procedure at the first quarter of 2016, 195 procedures in the final quarter of 2017, P-trend=0.086), while SPVR volume remained constant. The incidence of in-hospital mortality was low with both procedures (SPRV: 1.6% vs. PPVI: 0.9%, p=0.071). SPVR had worse in-hospital outcomes, was associated with a longer length of stay [5 days vs. 1 day, p<0.001], and comparable cost of index hospitalization [$51,657 vs. $51,193] compared with PPVI. CONCLUSION: After approval of the Sapien valve for commercial use in 2016, PPVI procedures have increased in frequency. PPVI is associated with lower procedural complications than SPVR, however, both carry a low risk of mortality. Despite the higher cost of the valves and delivery systems, PPVI is associated with a slightly lower cost of index hospitalization compared with SPVR, likely due to the higher in-hospital complications and LOS of the latter.

Outcomes of Transcarotid Versus Trans-Subclavian Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

OBJECTIVES: This study aimed to perform the first meta-analysis of studies comparing transcarotid (TC) and trans-subclavian (TSc) transcatheter aortic valve replacement (TAVR). BACKGROUND: The safety and feasibility of a TC and a TSc approach for performing TAVR in patients with prohibitive femoral anatomy have been well described. The potential advantage of one approach over the other is yet to be ascertained. METHODS: A computerized literature search of key medical databases through September 2020 was performed. Randomized controlled trials (RCTs) and observational studies comparing TC and TSc TAVR with reported 30-day outcomes were considered. The primary endpoint was a composite of all-cause mortality, stroke, life-threatening, and/or major bleeding or major vascular complications. Statistical analysis using random-effects models to report the odds ratio (OR) with 95% confidence interval (CI) was performed. RESULTS: A total of 5 observational studies inclusive of 4164 patients (TC = 1788 and TSc = 2376) met the eligibility criteria. The average age of patients was 81.1 years. There was no difference in the occurrence of the composite endpoint between the groups at 30-days. A statistically insignificant trend towards higher rates of major vascular complications (OR 1.65; 95% CI 0.94-2.89; P = 0.08; I2 = 0%) and the need for permanent pacemaker placement was observed with the TSc approach. CONCLUSIONS: This meta-analysis of studies comparing TC and TSc TAVR showed similar 30-day outcomes between the 2 approaches. A notable trend towards higher rates of major vascular complications and the need for permanent pacemaker placement was observed with the TSc approach.

The absence of evidence is not the evidence of absence: A case report on the challenges in diagnosing ostial left main stenosis.

Because left main (LM) coronary artery stenosis is known to have higher mortality and morbidity compared to lesions in other territories, an early diagnosis and management are crucial to prevent worse outcomes. Due to limitations of coronary angiography (CA), the diagnosis of ostial LM stenosis solely based on CA may result in underdiagnosis of such lesions. Therefore, additional testing is often needed either by pressure wire or intravascular ultrasound (IVUS) to make appropriate diagnosis. We, hereby, present a case of left main ostial stenosis in a 56-year-old male that was missed on multiple coronary angiograms, and highlights many of the considerations in the diagnosis of LM disease.

Endotheliitis and Endothelial Dysfunction in Patients with COVID-19: Its Role in Thrombosis and Adverse Outcomes.

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), emerging in Wuhan, China and developing into a pandemic with rapidly emerging cardiovascular manifestations [...].

Cushing syndrome cardiomyopathy: an unusual manifestation of small-cell lung cancer.

Cushing syndrome is a rare cause of dilated cardiomyopathy and heart failure with reduced ejection fraction. Cases describing this association are scarce. We describe a patient presenting with acute heart failure, new cardiomyopathy, refractory hypokalaemia, severe hyperglycaemia, and uncontrolled hypertension who was found to have hypercortisolism secondary to an ectopic adrenocorticotropic hormone-secreting primary lung neoplasm. This case highlights the effects of hypercortisolism on the myocardium. The finding of a non-dilated cardiomyopathy in this case is unique because the majority of previously reported Cushing syndrome cardiomyopathy cases have described left ventricular dilatation or significant left ventricular hypertrophy. In addition, small-cell lung cancer with adrenocorticotropic hormone production causing Cushing syndrome cardiomyopathy is rare.

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.

NOAC-Based Sual Therapy Versus Warfarin-Based Triple Therapy After Percutaneous Coronary Intervention or Acute Coronary Syndrome in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: Several randomized clinical trials (RCTs) have compared the use of dual therapy (DT), or one of the non-vitamin K antagonist oral anticoagulants (NOAC) with a P2Y12 agent, versus triple therapy (TT), consisting of a vitamin-K antagonist (VKA) along with dual antiplatelet therapy, in patients with concomitant atrial fibrillation after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS). We performed a meta-analysis and systematic review of RCTs to evaluate the safety and efficacy of NOAC-based DT in such patients. METHODS: The major efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of mortality, myocardial infarction, stroke, stent thrombosis (ST), and urgent revascularization. The International Society on Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNM) was the major primary safety outcome. RESULTS: A total of 4 RCTs were included in the meta-analysis with 7942 total patients for analysis (DT: 4377 & TT: 3565). Compared to TT, DT resulted in similar risk of MACCE (OR: 1.12; 95% CI: 0.94-1.34; P = 0.20) and other efficacy endpoints with a trend in increased risk of ST in the DT group (1.55; 0.99-2.44; P = 0.06). DT resulted in lower risk of ISTH major or CRNM bleeding (0.56; 0.41-0.76; P < 0.01), and all other bleeding outcomes except for a trend of reduced risk of TIMI minor bleeding. CONCLUSION: In conclusion, patients with atrial fibrillation who undergo PCI or develop ACS, NOAC-based dual therapy reduces bleeding outcomes without significantly increasing ischemic outcomes. Future trials should explore the possible differences in stent thrombosis.

Comparative Outcomes of Transcarotid and Transsubclavian Transcatheter Aortic Valve Replacement.

BACKGROUND: Previous reports described successful use of transcarotid and transsubclavian approaches for the performance of transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis who cannot be treated with transfemoral access. The purpose of the present study was to compare these two alternative approaches with respect to safety, efficacy, and procedural efficiency. METHODS: A retrospective analysis of all TAVR procedures performed through either a transcarotid or a transsubclavian approach at a single tertiary care medical center between January 2016 and October 2018 was performed. Outcomes are reported in accordance with the Valve Academic Research Consortium definitions. RESULTS: During the study period, 33 patients had transcarotid TAVR and 38 patients had transsubclavian TAVR. Transcarotid patients were older (mean age, 82.9 ± 7.2 vs 78.1 ± 8.2 years; P = .012), but otherwise the two groups were not significantly different with respect to preoperative characteristics. Valve deployment was similar between the groups (100% vs 97%; P = .348). Procedure time was shorter with the transcarotid approach (110 ± 32 vs 134 ± 45 minutes; P = .014). There was a lower mean fluoroscopy air kerma in the transcarotid group (682.82 ± 713.48 mGy vs 2141 ± 2055 mGy; P < .001), although fluoroscopy dose-area product did not differ between the groups. There was no difference between the groups with respect to in-hospital or 30-day mortality (0% vs 3%; P = .355), stroke (3% vs 8%; P = .393), or vascular complication (3% vs 4%; P = .840). CONCLUSIONS: The transcarotid and the transsubclavian approaches have similar safety and efficacy outcomes. The transcarotid approach had a shorter procedure duration and a trend toward lower fluoroscopy duration and radiation exposure.

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.

Evaluation of YouTube as a reliable source for patient education on aortic valve stenosis.

BACKGROUND: Aortic stenosis (AS) is a prevalent disease in the elderly population and has been a public health concern for decades. YouTube is currently being used for obtaining healthcare related information. We evaluated the quality of information about AS on YouTube for patient education. METHODS: YouTube was queried for the search phrases "aortic valve stenosis", "aortic valve replacement", "transcatheter aortic valve replacement" and "TAVR". Videos were assessed for their reliability and content with two five-point scales. They were categorized into groups according to usefulness and uploader source. All videos were assessed for audience interaction. Videos were viewed and analyzed by 2 independent investigators. Conflicts were resolved by a third investigator. RESULTS: Search phrases yielded 69,300 videos, among which, 120 videos were evaluated and 85 videos were included in the final analysis. Of the 85 videos, only 45 videos (53%) were found to be useful while 40 videos (47%) were found to be non-useful. The majority (98%) of the useful videos were uploaded by professional sources. Overall, videos uploaded by non-professional sources had higher number of views (23,553 vs. 11,110, P≤0.001) despite of being less useful (14% vs. 67%, P<0.001) when compared to videos uploaded by professional sources. CONCLUSIONS: There is a potential to increase public awareness about aortic valve stenosis and the available treatment options by utilizing YouTube. Professional societies are encouraged to provide more useful material that can deliver comprehensive and reliable information in an entertaining and intuitive manner to the public.

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.

Mesalamine-induced Myocarditis in a Young Athlete: Can He Run Again?

Mesalamine is often used in the treatment of inflammatory bowel disease (IBD). Mesalamine-induced cardiotoxicity has been reported in the literature and is a rare entity. The mechanism of cardiotoxicity remains unclear, however, it is believed to be due to a humoral-mediated hypersensitivity reaction. Patients with mesalamine-induced cardiotoxicity could present with a wide range of cardiovascular symptoms ranging from mild chest pain and shortness of breath (SOB) to cardiogenic shock secondary to left ventricular systolic dysfunction. Symptoms could be associated with elevation in cardiac biomarkers and electrocardiogram (EKG) changes including ST-segment or T-wave abnormalities. We report a case of mesalamine-induced myocarditis in a young athlete presenting with chest pain 10 days after mesalamine therapy was initiated for recently diagnosed Crohn's disease. Workup was significant for elevated cardiac biomarkers. The diagnosis was confirmed with cardiovascular magnetic resonance imaging (CMR). Immediate cessation of the medication resulted in resolution of symptomatology and normalization of cardiac biomarkers over a 48-hour period. Mesalamine-induced cardiotoxicity is a rare, yet serious side effect that necessitates medical community awareness. CMR is the confirmatory diagnostic modality of choice.