Multidisciplinary Approach to Pulmonary Embolism and the Role of the Pulmonary Embolism Response Team.

PURPOSE OF REVIEW: Acute pulmonary embolism (PE) is a leading cause of cardiovascular death and morbidity, and presents a major burden to healthcare systems. The field has seen rapid growth with development of innovative clot reduction technologies, as well as ongoing multicenter trials that may completely revolutionize care of PE patients. However, current paucity of robust clinical trials and guidelines often leave individual physicians managing patients with acute PE in a dilemma. RECENT FINDINGS: The pulmonary embolism response team (PERT) was developed as a platform to rapidly engage multiple specialists to deliver evidence-based, organized and efficient care and help address some of the gaps in knowledge. Several centers investigating outcomes following implementation of PERT have demonstrated shorter hospital and intensive-care unit stays, lower use of inferior vena cava filters, and in some instances improved mortality. Since the advent of PERT, early findings demonstrate promise with improved outcomes after implementation of PERT. Incorporation of artificial intelligence (AI) into PERT has also shown promise with more streamlined care and reducing response times. Further clinical trials are needed to examine the impact of PERT model on care delivery and clinical outcomes.

Cerebral Embolic Protection in Transcatheter Aortic Valve Implantation Using the Sentinel Cerebral Protection System: A Systematic Review and Meta-Analysis.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) plays a vital role in patients with symptomatic aortic stenosis. Despite the mortality benefit of TAVI, embolic stroke remains a feared complication. As a result, transcatheter cerebral embolic protection (TCEP) devices have been developed to reduce this risk. Given the ongoing debate of TCEP in TAVI, we performed a systematic review and meta-analysis of all randomized controlled trials to date to identify outcomes of periprocedural stroke using the Sentinel™ cerebral protection system (CPS). METHODS: MEDLINE, Cochrane, and Scopus databases were utilized from inception until 12/2023. PRISMA criteria was utilized. Keywords included "cerebral embolic protection", "sentinel cerebral protection system", "transcatheter aortic valve implantation", and "transcatheter aortic valve replacement". Primary outcome was periprocedural stroke. Secondary outcomes included periprocedural disabling and non-disabling stroke, all-cause mortality, transient ischemic attack, delirium, acute kidney injury, vascular complications, bleeding, and pacemaker implantation. Risk ratios (RR) were measured via Mantel-Haenszel method with fixed analysis. Heterogeneity was assessed via chi-squared and Higgin's I2 test. RESULTS: Four trials with 3528 patients were assessed. SAPIEN 3 was the most common bioprosthetic valve used. The average age was 79.4 years with 41.9% of the sample size being females. The most prevalent comorbidities were hypertension, diabetes mellitus, and coronary artery disease. There was no difference in periprocedural stroke in patients who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.75, P = 0.12). Periprocedural disabling strokes were less likely in those who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.41, P = 0.02) with a number needed to treat (NNT) of 123. All other outcomes did not reach statistical significance. CONCLUSIONS: In our analysis, there was no difference between TAVI with the Sentinel™ CPS compared to TAVI without TCEP in regard to risk of periprocedural stroke; however, it was associated with a decreased risk of periprocedural disabling stroke.

Comparison of In-Hospital Outcomes between Early and Late Catheter-Directed Thrombolysis in Acute Pulmonary Embolism: A Retrospective Observational Study.

The purpose of this study is to evaluate whether early initiation of catheter-directed thrombolysis (CDT) in patients presenting with acute pulmonary embolism is associated with improved in-hospital outcomes. A retrospective cohort was extracted from the 2016-2019 National Inpatient Sample database, consisting of 21,730 weighted admissions undergoing CDT acute PE. From the time of admission, the sample was divided into early (<48 h) and late interventions (>48 h). Outcomes were measured using regression analysis and propensity score matching. No significant differences in mortality, cardiac arrest, cardiogenic shock, or intracranial hemorrhage (p > 0.05) were found between the early and late CDT groups. Late CDT patients had a higher likelihood of receiving systemic thrombolysis (3.21 [2.18-4.74], p < 0.01), blood transfusion (1.84 [1.41-2.40], p < 0.01), intubation (1.33 [1.05-1.70], p = 0.02), discharge disposition to care facilities (1.32 [1.14-1.53], p < 0.01). and having acute kidney injury (1.42 [1.25-1.61], p < 0.01). Predictors of late intervention were older age, female sex, non-white ethnicity, non-teaching hospital admission, hospitals with higher bed sizes, and weekend admission (p < 0.01). This study represents a comprehensive evaluation of outcomes associated with the time interval for initiating CDT, revealing reduced morbidity with early intervention. Additionally, it identifies predictors associated with delayed CDT initiation. The broader ramifications of these findings, particularly in relation to hospital resource utilization and health disparities, warrant further exploration.

In-Hospital Outcomes of Chronic Total Occlusion Percutaneous Coronary Interventions in Heart failure patients.

In-hospital outcomes of chronic total occlusion Percutaneous Coronary Interventions (CTO PCI) in heart failure patients has not been evaluated on a national base and was the focus of this investigation. We used the Nationwide Inpatient Sample database from 2008 to 2014 to identify adults with single vessel CTO PCI for stable ischemic heart disease (SIHD). Patients were divided into 3 groups: patients without heart failure, heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple logistic regression models were performed to assess in-hospital mortality, acute renal failure, and the use of mechanical support devices. Of 112,061 inpatients with SIHD from 2008 to 2014 undergoing CTO PCI, 21,185 (19%) had HFrEF and 3309 (3%) had HFpEF. Compared to patients without heart failure, HFrEF and HFpEF patients were older (mean age 69.2 vs 66.3, 70.3 vs 66.3 respectively, P < 0.001), had more comorbidities and higher acute in-hospital complications. HFrEF patients had higher adjusted in-hospital mortality [AOR 1.73, 95% CI (1.21-2.48)], acute renal failure [AOR 2.68, 95% CI (2.34-3.06)], and need for mechanical support [AOR 2.76, 95% CI (2.17-3.51)]. Compared to patients without heart failure, HFpEF patients had similar mortality and need for mechanical support, but higher incidence of acute renal failure. Older age was significantly associated with increased in-hospital mortality. chronic total occlusion PCI in patients with heart failure is associated with higher in-hospital morbidity and mortality and warrants further investigation to optimize health care delivery.

Percutaneous Repair of Mitral Regurgitation: A Comprehensive Review of Literature.

Mitral regurgitation is the most common valvular disease in the US and the second most common worldwide. Left untreated, it can lead to the development of heart failure, giving rise to increased mortality rates. Mitral valve intervention is usually indicated in severe mitral regurgitation at the onset of symptoms, even if the function of the left ventricle is preserved. A surgical approach is generally favored according to current guidelines, with excellent clinical outcomes. However, the emergence of novel data from contemporary trials indicates that percutaneous, catheter-based approach may have similar improvements in mortality outcomes while maintaining a superior safety profile when compared to the surgical approach. Here, we discuss transcatheter mitral valve repair as a treatment option for mitral regurgitation and summarize the major clinical trials which were recently conducted on transcatheter repair.

Coronary Artery Disease and Aspirin Intolerance: Background and Insights on Current Management.

Aspirin is one of the most widely used medications across the global healthcare system and is the foundation in treating ischemic heart disease, as well as secondary prevention for ischemic and valvular heart disease. Challenges arise in treating patients with cardiovascular disease who have concomitant aspirin intolerance. Through an extensive review of the literature, we provide a comprehensive background on the pharmacology of aspirin, the mechanisms behind aspirin intolerance, the importance of aspirin in cardiovascular disease, and the management of aspirin intolerance in both acute coronary syndrome and stable coronary artery disease. Our review includes a multidisciplinary approach from the internist, allergist/immunologist, and cardiologist when evaluating this important patient population.

Coronary Microvascular Disease.

Coronary microvascular disease or dysfunction (CMVD) has been associated with adverse cardiovascular outcomes. Despite a growing prevalence, guidelines on definitive treatment are lacking. Proposed mechanisms of endothelial dysfunction and resultant inflammation have been demonstrated as the underlying cause. Imaging modalities such as echocardiography, cardiac MRI, PET, and in some instances CT, have been shown to be useful in diagnosing CMVD mainly through assessment of coronary blood flow. Invasive measurements through thermodilution and pressure sensor-guided Doppler microcatheters have also been utilized. Treatment options are directed at targeting inflammatory pathways and angina. In our review, we highlight the current literature on the background of CMVD, diagnostic modalities, and management of this disease.

Use of Coronary Intravascular Lithotripsy: A Comprehensive Review of Literature.

Severe coronary artery calcification (CAC) is associated with high rate of procedural complications. The current techniques that facilitate percutaneous coronary interventions in moderate to severe CAC have significant risk of complications, including periprocedural myocardial infarction , dissection, perforation and transient atrioventricular block. Coronary Intravascular lithotripsy (IVL) is a novel technology for the treatment of moderate to severe calcified lesions. IVL uses sonic pressure waves to break down the calcium deposits with no to minimal impact on the blood vessel tissues, which makes IVL a safe option with high procedural success and minimal complications. Here, we discuss coronary IVL as a treatment option for CAC and summarize the major clinical trials performed evaluating the safety and outcome of IVL.

Percutaneous Coronary Intervention Outcomes in Patients With Prior Thoracic Radiation Therapy: A Systematic Review and Meta-Analysis.

Background: Thoracic radiation predisposes patients to accelerated coronary artery disease. There is a paucity of data in both short-term and long-term outcomes following revascularization in patients who have undergone thoracic radiation. Methods: We performed a search of the Medline, Cochrane, and Scopus databases for studies that compared outcomes in cancer patients who have undergone thoracic radiation and percutaneous coronary intervention (PCI). The primary outcome of our meta-analysis was all-cause mortality. Secondary outcomes included cardiac mortality, myocardial infarction (MI), and restenosis. Results: The analysis included four observational studies with a total of 13,941 patients for the primary outcome of all-cause mortality. There were a total of 1,322 patients analyzed for cardiac mortality, 13,103 for MI, and 10,530 for restenosis. The longest follow-up for the primary outcome was 16 years. There was statistically significant higher risk of all-cause mortality in patients who underwent thoracic radiation (risk ratio (RR): 1.29, 95% confidence interval (CI): 1.08 - 1.54, P = 0.004). There was no statistically significant difference in cardiac mortality (RR: 1.15, 95% CI: 0.83 - 1.61, P = 0.40), MI (RR: 1.01, 95% CI: 0.20 - 5.08, P = 0.99), and restenosis (RR: 1.92, 95% CI: 0.24 - 15.35, P = 0.54). Conclusion: In this meta-analysis, we found a higher risk of all-cause mortality in patients with a history of thoracic radiation undergoing PCI, likely from underlying malignancy itself.

Novel use of fused cardiac computed tomography and transesophageal echocardiography for left atrial appendage closure.

The use of the Watchman left atrial appendage occlusion device (Boston Scientific Inc.) is becoming increasingly frequent in patients with atrial fibrillation. Cardiac computed tomography (CT) for device sizing pre-procedure can help facilitate more accurate device selection compared with transesophageal echo (TEE) alone. CT can also help identify minor lobes and trabeculations that may not be apparent on TEE. We report a series of three cases to highlight the utility of a novel application of CT-TEE fusion imaging to provide procedural guidance during Watchman implant and to assess for peri-device leak post-implant.

Strengthening the feedback culture in a postgraduate residency program.

Background: Feedback is defined as specific information presented to a learner that facilitates professional development through the process of reflection. Timely provision of constructive feedback to learner is important in optimizing the learning curve. The aim of the current study was to see the effectiveness of various interventions on feedback practices of faculty members. Methods: This is a quasi-experimental study (pre- and postdesign). It was conducted from November 2009 to March 2011 at The Aga Khan University, Pakistan. Faculty development workshops, allotment of specified feedback time, and restructuring of residency feedback forms were done as interventions. Data collection was done pre- and postintervention. Resident's and faculty satisfaction regarding the feedback process were evaluated using a prepiloted questionnaire. Paired t-test was applied to assess the effect of interventions on faculty and resident's satisfaction. Results: The mean satisfaction scores of residents were significantly improved (P < 0.05). Pre- and postintervention faculty satisfaction score also demonstrated significant difference in overall satisfaction level, from 47.88 ± 13.92 to 63.40 ± 8.72 (P < 0.05). Discussion: This study showed improved faculty engagement and satisfaction for the provision of feedback to the trainee resident. Strengthening this, culture requires continuous reinforcement, individualized feedback to the faculty members regarding their feedback practices, and continuing faculty development initiatives.

Technical success and long-term outcomes after anomalous right coronary artery stenting with cardiac computed tomography angiography correlation.

INTRODUCTION: Anomalous origin of coronary arteries has been observed in about 0.35-2.10% of the population. Patients with anomalous right coronary artery (ARCA) may present with significant symptoms, arrhythmias or ACS, and at times sudden death. Traditionally, surgical correction has been the recommended treatment. However, these may be technically challenging, and bypass grafting for such anomalies has the potential for graft failure because of competitive flow. We sought to determine the intermediate and long-term outcomes of drug-eluting stent placement for patients with symptomatic ARCA. We also looked at angiographic findings suggestive of interarterial course as confirmed by subsequent computed tomography (CT) findings. METHODS: Between January 2005 and December 2012, we enrolled 11 patients for elective percutaneous coronary intervention (PCI) of ARCA in a single center, prospective, nonrandomized fashion. Patients were followed up in clinic at 1 week, 3 months, 6 months, and 1 year, and then annually or more frequently if needed. All patients underwent a cardiac CT, as well as functional stress testing when needed to assess for recurrence of disease. RESULTS: All 11 of our patients, who presented with significant symptomatic stenosis with an ARCA, were successfully treated with PCI. Mean follow-up duration was 8.5 years. The only two deaths during follow-up were related to noncardiac causes (sepsis), with a mortality rate of 18.2%. Two patients had a positive functional study and on subsequent coronary angiography, one of them had significant in-stent restenosis (target lesion revascularization of 9.1%) and one distal to the stent (target vessel revascularization 9.1%). We found the observation of a "slit-like lesion" on angiography to have a sensitivity of 100% and specificity of 86% for the diagnosis of interarterial course of the anomalous vessel seen on subsequent CT. CONCLUSIONS: Our study results suggest that PCI of ARCA is an effective and low-risk alternative to surgical correction, with good procedural success and long-term outcomes. It can provide symptomatic relief in such patients and may reduce the risk of sudden death in younger patients, without the inherent risks associated with surgical repair.

Optimum number of procedures required to achieve procedural skills competency in internal medicine residents.

BACKGROUND: Procedural skills training forms an essential, yet difficult to assess, component of an Internal Medicine Residency Program. We report the development of process of documentation and assessment of procedural skills training. METHOD: An explanatory sequential mixed methods design was adopted where both quantitative and qualitative information was collected sequentially. A survey was conducted within the Department of Internal Medicine at The Aga Khan University Hospital, Karachi, Pakistan to determine the optimum number of procedures needed to be performed by residents at each year of residency. Respondents included both faculty and the residents in the Department. Thereafter, all responses were compiled and later scrutinized by a focus group comprising of a mix of faculty from various subspecialties and resident representatives. RESULTS: A total of 64 responses were obtained. A significant difference was found in eight procedural skills' status between residents and faculty, though none of these were significant after accounting for multiple consecutive testing. However, the results were reviewed and a consensus for the procedures needed was developed through a focus group. A finalized procedural list was generated to determine: (a) the minimum number of times each procedure needed to be performed by the resident before deemed competent; (b) the level of competency for each procedure for respective year of residency. CONCLUSION: We conclude that the opinion of both the residents and the faculty as key stakeholders is vital to determine the number of procedures to be performed during an Internal Medicine Residency. Documentation of procedural competency development during the training would make the system more objective and hence reproducible. A log book was designed consisting of minimum number of procedures to be performed before attaining competency.

Challenges of providing timely feedback to residents: Faculty perspectives.

OBJECTIVE: To explore faculty's perceptions of challenges in providing verbal feedback to the Residents and suggest ways to overcome the barriers. METHODS: As part of a larger study on feedback assessment, five focus group discussions were conducted at the Department of Medicine, Aga Khan University Hospital, Karachi, during faculty development workshops held from January to June 2010. Qualitative grounded theory was used to explore faculty perceptions of challenges in providing verbal feedback to the Residents. RESULTS: Of the 54 faculty members, 49(91%) participated. Four themes that emerged were 'time constraint' indicating high patient load; 'faculty related issues' indicating faculty's apprehension about its own evaluation by Residents; 'educational issues' indicating that the importance of feedback was not emphasised; and 'system and logistic issues' indicating that the assessment form used for assessing Residents was ambiguous. CONCLUSIONS: Work load of the faculty and the expectations with respect to patient care responsibilities may have an impact on the quality, timing, content and delivery of the feedback provided to the Residents.

A 360-degree evaluation of the communication and interpersonal skills of medicine resident physicians in Pakistan.

BACKGROUND: To provide high-quality patient care, effective communication and interpersonal skills are necessary for physicians. A 360-degree evaluation of residents in the department of medicine was conducted to assess their interpersonal and communication skills. The measurement properties and utility of the multi-source ratings were investigated. METHODS: A cross-sectional assessment of a cohort of Internal Medicine residents was conducted at the Aga Khan Medical University in Pakistan. Every resident (n = 49) was evaluated by eight raters, including physicians, nurses and unit staff. Each resident also completed a self-evaluation. Evidence to support the validity of the ratings was gathered by exploring performance differences amongst more- and less-experienced providers. Analysis of variance (ANOVA) was employed to test for differences in mean scores, both for rater type and experience (residency year). Generalizability theory was employed to estimate the reliability of the ratings. RESULTS: We received 367/441 (83.2%) completed forms. There was a significant effect attributable to rater source (F = 5.2, P < 0.01). There were no significant differences in mean scores for residents at different levels of training. The mean resident self-assessment scores were significantly lower than those provided by faculty (P < 0.01). Based on eight raters, the reliability of the ratings was moderate (ρ2 = 0.39). DISCUSSION: The 360-degree evaluation technique can be used to measure the communication and interpersonal skills of residents. It can also provide important data to guide resident feedback. Health care providers and staff who interact with residents on regular basis can, as a group provide moderately consistent judgments of their abilities.

The learners' perspective on internal medicine ward rounds: a cross-sectional study.

BACKGROUND: Ward rounds form an integral part of Internal Medicine teaching. This study aimed to determine the trainees' opinions regarding various aspects of their ward rounds, including how well they cover their learning needs, how they would like the rounds to be conducted, and differences of opinion between medical students and postgraduates. METHODS: A cross-sectional study was conducted on a total of 134 trainees in Internal Medicine, comprising medical students, interns, residents and fellows, who were asked to fill in a structured, self-designed questionnaire. Most of the responses required a rating on a scale of 1-5 (1 being highly unsatisfactory and 5 being highly satisfactory). RESULTS: Teaching of clinical skills and bedside teaching received the lowest overall mean score (Mean +/- SD 2.48 +/- 1.02 and 2.49 +/- 1.12 respectively). They were rated much lower by postgraduates as compared to students (p < 0.001). All respondents felt that management of patients was the aspect best covered by the current ward rounds (Mean +/- SD 3.71 +/- 0.72). For their desired ward rounds, management of patients received the highest score (Mean +/- SD 4.64 +/- 0.55), followed by bedside examinations (Mean +/- SD 4.60 +/- 0.61) and clinical skills teaching (Mean +/- SD 4.50 +/- 0.68). The postgraduates desired a lot more focus on communication skills, counselling and medical ethics as compared to students, whose primary focus was teaching of bedside examination and management. A majority of the respondents (87%) preferred bedside rounds over conference room rounds. Even though the duration of rounds was found to be adequate, a majority of the trainees (68%) felt there was a lack of individual attention during ward rounds. CONCLUSIONS: This study highlights important areas where ward rounds need improvement in order to maximize their benefit to the learners. There is a need to modify the current state of ward rounds in order to address the needs and expectations of trainees.