Iatrogenic Aorto-Coronary Dissection: A Rare Complication With Fatal Prognosis.

Iatrogenic aorto-coronary dissection (IACD) is a rare complication of interventional and surgical cardiac procedures, with a very high mortality burden. Here, we report the case of a 71-year-old female with a past medical history of paroxysmal atrial fibrillation, mild to moderate aortic insufficiency, hypertension, and hyperlipidemia, who presented with classic anginal symptoms and underwent a cardiac catheterization, during which she suffered Iatrogenic right coronary artery (RCA) dissection and ascending aortic dissection resulting in sudden death. IACD is a rare complication, with a fatal prognosis. Coronary angiography and percutaneous coronary intervention (PCI) are considered safe, with a low risk of major complications including coronary perforations, and a very low risk of Iatrogenic aortic dissection (IAD). The coronary injury occurs more commonly during PCI of chronic total occlusion (CTO) or RCA interventions and can extend to the aortic root. IAD is often fatal and has worse outcomes than spontaneous dissection.

Comprehensive review of statin-intolerance and the practical application of Bempedoic Acid.

Statin-intolerance (SI) has prevalence between 8.0 % and 10 %, and muscular complaints are the most common reason for discontinuation. Bempedoic acid (BA), an ATP citrate lyase inhibitor, decreases hepatic generation of cholesterol, upregulates low-density lipoprotein (LDL) receptor expression in the liver, and eventually clears circulating LDL-cholesterol from the blood. Multiple randomized clinical trials studying BA demonstrate a reduction in LDL levels by 17-28 % in SI. The CLEAR OUTCOME trial established significant cardiovascular benefits with BA. A dose of 180 mg/day of BA showed promising results. BA alone or in combination with ezetimibe is US Food and Drug Administration-approved for use in adults with heterozygous familial hypercholesterolemia and/or established atherosclerotic cardiovascular disease. BA reduced HbA1c by 0.12 % (p < 0.0001) in patients with diabetes. Adverse events of BA include myalgia (4.7 %), anemia (3.4 %), and increased aminotransferases (0.3 %). BA can cause up to four times higher risk of gout in those with a previous gout diagnosis or high serum uric acid levels. Reports of increased blood urea nitrogen and serum creatinine were noted. Current evidence does not demonstrate a reduction in deaths from cardiovascular causes. More studies that include a diverse population and patients with both high and low LDL levels should be conducted. We recommend that providers consider BA as an adjunct to statin therapy in patients with a maximally tolerated dosage to specifically target LDL levels.

Successful Transcatheter Aortic Valve Replacement in an Elderly Patient with Calcified Bicuspid Aortic Valve with Calcified Raphe: A Case Report.

At present, transcatheter aortic valve replacement (TAVR) is not only used in high-surgical-risk patients with aortic stenosis (AS), but its use has also been extended to low-risk patients, resulting in its increasing utilization in patients with bicuspid aortic valve (BAV). BAV however presents unique challenges for TAVR due to its distinct valvular anatomy, and surgical aortic valve replacement (SAVR) remains the primary recommended method of aortic valve replacement in patients with BAV. Nonetheless, observational data have been quickly accumulating regarding the successful use of TAVR in BAV. Here, we present a case of a 73-year-old female who presented with heart failure symptoms and was found to have severe AS and BAV with calcified raphe (Sievers 1a). Due to her age and complicated medical history, including coronary artery disease and chronic kidney disease, she was considered to be at intermediate surgical risk (Society of Thoracic Surgeons (STS) score 5.4%) and underwent TAVR with the successful deployment of a 29 mm Edwards SAPIEN valve (Edwards Lifesciences, California, USA). A post-procedure echocardiogram confirmed the appropriate placement of the prosthesis without any valvular or paravalvular regurgitation. This case, therefore, adds to the growing body of evidence regarding the use of TAVR in patients with BAV despite anatomical challenges.

QIPS CURE: Implementing a Quality Improvement and Patient Safety Curriculum and Resident Experience.

BACKGROUND: Resident participation in quality improvement and patient safety (QIPS) programs is an essential training experience and Accreditation Council for Graduate Medical Education requirement. However, the most effective approach to achieve this is unclear. OBJECTIVE: We developed an experiential Quality Improvement and Patient Safety Curriculum and Resident Experience (QIPS CURE) program, which provides internal medicine (IM) residents with foundational QIPS knowledge, and evaluated its effectiveness. METHODS: After reviewing IM residency QIPS curricula and obtaining input from institutional stakeholders in 2013-2014, we launched a longitudinal QIPS curriculum for all 66 postgraduate year 1-3 IM residents in July 2014. The QIPS CURE included 2 major elements: didactics, delivered through a variety of sources, including online modules and workshops, and hands-on projects. We delivered this curriculum annually from 2014 to 2018. We used project completion and an attitude survey of participants to evaluate it. RESULTS: Six projects were completed in 2014-2015, and 10 projects completed yearly for the next 3 academic years. Residents presented all projects at regional meetings. Surveyed residents reported improvement in understanding (M = 5.71, SD = 1.07 pre- to M = 6.38, SD = 0.49 post-curriculum, P = .013) and competence (M = 3.31, SD = 1.18 pre- to M = 6.08, SD = 0.77, post-curriculum, P < .001) when comparing graduates of the curriculum with incoming interns. Qualitative analysis revealed perceived acquisition of skills needed to carry out successful QIPS projects. CONCLUSIONS: This QIPS program was sustainable over 4 years and generally well-received by residents, with many projects completed each year.

National Trends and Procedural Complications from Endomyocardial Biopsy: Results from the National Inpatient Sample, 2007-2014.

AIM: The aim of this study is to report recent trends in the performance of endomyocardial biopsy (EMB) and its in-hospital complications (and their predictors) in the United States (US). METHOD: We analyzed Nationwide Inpatient Sample (NIS) database from years 2007 through 2014 to identify patients who underwent EMB. Once identified, the patients were subdivided into those with no history of heart transplant (HT) (cohort 1) and those with history of HT (cohort 2). We then studied the major complication of pericardial effusion, hemopericardium or/and cardiac tamponade that required a pericardiocentesis or a pericardial window (CTRPD) following the EMB procedure. RESULTS: We observed a steady increase in the in-patient EMB procedures, with more EMB procedures being performed in males and in Caucasians. In cohort 1, the CTRPD was higher (0.70%) as compared to cohort 2 (0.19; p = 0.01). CTRPD in women was higher compared to men (0.94 vs. 0.53% p = 0.022). Most of the EMB procedures are performed in teaching hospitals. The CTRPD rate was significantly higher in the nonteaching hospitals when compared to teaching hospitals in both cohort 1 and cohort 2 (3.4 vs. 0.53% and 1 vs.0.18%, respectively; p = 0.01 and < 0.001, respectively). The overall mortality in cohort 1 was 4.3% as compared to 2.5% in cohort 2; p = 0.01. In cohort 1, the mortality was significantly higher in the group that had EMB-related complications versus the group without the complications (20 vs. 2.5%; p < 0.001). CONCLUSION: There has been an increase in the number of EMB procedures in the US in recent years. Though the overall risk of CTRPD is very low, the risk is significantly higher in cohort 1, women, and in nonteaching hospitals. The study results provide data benchmarks for assessing EMB outcomes in the US.

State Of The Art In Left Atrial Appendage Ligation - The Lariat.

Percutaneous left atrial appendage ligation (LAA) techniques have come to the forefront of management of atrial fibrillation (AF) patients who are at high risk of stroke and are unsuitable for oral anticoagulation therapy. LARIAT is a novel percutaneous endo-epicardial ligation technique for LAA exclusion. This technique is increasingly becoming popular for LAA exclusion in AF patients. A few studies have validated the efficacy of LARIAT in mitigating stroke risk in AF patients with contraindications to anticoagulation. Additionally a few studies have suggested that AF burden decreases after the LARIAT procedure. In this review paper we discuss the indications, technique and the latest advances in the LAA exclusion using the LARIAT system.

Remote Magnetic Navigation System Guided Radiofrequency Ablation of Intra Atrial Reentrant Tachycardia in Corrected Transposition of Great Arteries.

Atrial arrhythmias are delayed manifestations after atrial switch procedures for d-transposition of the great arteries. Often times, these arrhythmias are intraatrial reentry tachycardias that arise in the pulmonary venous neo-atrium. Access and ablation in the pulmonary venous neo-atrium may require baffle puncture, risking damage to the baffle. We describe a case of neoatrial arrhythmia ablation in d-transposition of the great arteries using remote magnetic guided catheter navigation system using a retrograde approach without doing a baffle puncture.