Aortic valve disorders and left ventricular assist devices.

Aortic valve disorders are important considerations in advanced heart failure patients being evaluated for left ventricular assist devices (LVAD) and those on LVAD support. Aortic insufficiency (AI) can be present prior to LVAD implantation or develop de novo during LVAD support. It is usually a progressive disorder and can lead to impaired LVAD effectiveness and heart failure symptoms. Severe AI is associated with worsening hemodynamics, increased hospitalizations, and decreased survival in LVAD patients. Diagnosis is made with echocardiographic, device assessment, and/or catheterization studies. Standard echocardiographic criteria for AI are insufficient for accurate diagnosis of AI severity. Management of pre-existing AI includes aortic repair or replacement at the time of LVAD implant. Management of de novo AI on LVAD support is challenging with increased risks of repeat surgical intervention, and percutaneous techniques including transcatheter aortic valve replacement are assuming greater importance. In this manuscript, we provide a comprehensive approach to contemporary diagnosis and management of aortic valve disorders in the setting of LVAD therapy.

Exercise-Induced Left Atrial Hypertension in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: Many patients with heart failure and preserved ejection fraction have no overt volume overload and normal resting left atrial (LA) pressure. OBJECTIVES: This study sought to characterize patients with normal resting LA pressure (pulmonary capillary wedge pressure [PCWP] <15 mm Hg) but exercise-induced left atrial hypertension (EILAH). METHODS: The REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure) trial randomized 626 patients with ejection fraction ≥40% and exercise PCWP ≥25 mm Hg to atrial shunt or sham procedure. The primary trial outcome, a hierarchical composite of death, heart failure hospitalization, intensification of diuretics, and change in health status was compared between patients with EILAH and those with heart failure and resting left atrial hypertension (RELAH). RESULTS: Patients with EILAH (29%) had similar symptom severity, but lower natriuretic peptide levels, higher 6-minute walk distance, less atrial fibrillation, lower left ventricular mass, smaller LA volumes, lower E/e', and better LA strain. PCWP was lower at rest, but had a larger increase with exercise in EILAH. Neither group as a whole had a significant effect from shunt therapy vs sham. Patients with EILAH were more likely to have characteristics associated with atrial shunt responsiveness (peak exercise pulmonary vascular resistance <1.74 WU) and no pacemaker (63% vs 46%; P < 0.001). The win ratio for the primary outcome was 1.56 (P = 0.08) in patients with EILAH and 1.51 (P = 0.04) in those with RELAH when responder characteristics were present. CONCLUSIONS: Patients with EILAH had similar symptom severity but less advanced myocardial and pulmonary vascular disease. This important subgroup may be difficult to diagnose without invasive exercise hemodynamics, but it has characteristics associated with favorable response to atrial shunt therapy. (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure [REDUCE LAP-HF TRIAL II]; NCT03088033).

Transcatheter Closure of Complex Left Circumflex to Coronary Sinus Fistula.

Coronary artery fistulae connecting the left circumflex to the coronary sinus are rare. Surgical closure of coronary sinus connections is technically challenging because of the location, especially in high-risk surgical patients. We used multimodality imaging to delineate the drainage site and successfully closed a left circumflex to coronary sinus fistula using a transcatheter closure technique. (Level of Difficulty: Advanced.).

Symptomatic Supraventricular Tachycardia Resistant to Adenosine Therapy in a Patient with Chronic Theophylline Use.

Theophylline is a potent adenosine receptor antagonist with indirect adrenergic effects that can lead to arrhythmias and metabolic abnormalities such as hypokalemia. Therapeutic toxicity cases have declined over the years mainly due to decreased recommended therapeutic doses and overall decreased usage of this medication due to newer available COPD treatment options. We present a clinical case of symptomatic supraventricular tachycardia resistant to adenosine therapy in a patient with theophylline use. This case highlights the importance of comprehensive medication review in acute settings to aid in identifying the underlying etiologies and initiating prompt treatments. It also signifies the importance of reviewing chronic medications in each outpatient visits to ensure continued indication for their use and be able to change them to newer agents per guidelines whenever possible.

Percutaneous Axillary Access for Placement of Microaxial Ventricular Support Devices: The Axillary Access Registry to Monitor Safety (ARMS).

BACKGROUND: There has been increasing utilization of short-term mechanical circulatory support devices for a variety of clinical indications. Many patients have suboptimal iliofemoral access options or reasons why early mobilization is desirable. Axillary artery access is an option for these patients, but little is known about the utility of this approach to facilitate short-term use for circulatory support with microaxial pump devices. METHODS: The Axillary Access Registry to Monitor Safety (ARMS) was a prospective, observational multicenter registry to study the feasibility and acute safety of mechanical circulatory support via percutaneous upper-extremity access. RESULTS: One hundred and two patients were collected from 10 participating centers. Successful device implantation was 98% (100 of 102). Devices were implanted for a median of 2 days (interquartile range, 0-5 days; range, 0-35 days). Procedural complications included 10 bleeding events and 1 stroke. There were 3 patients with brachial plexus-related symptoms all consisting of C8 tingling and all arising after multiple days of support. Postprocedural access site hematoma or bleeding was noted in 9 patients. Device explantation utilized closure devices alone in 61%, stent grafts in 17%, balloon tamponade facilitated closure in 15%, and planned surgical explant in 5%. Duration of support appeared to be independently associated with a 1.1% increased odds of vascular complication per day ([95% CI, 0.0%-2.3%] P=0.05). CONCLUSIONS: Percutaneous axillary access for use with microaxial support pumps appears feasible with acceptable rates of bleeding despite early experience. Larger studies are necessary to confirm the pilot data presented here.

Histologic grading of the tumor/tissue interface to predict lymph node metastasis in squamous cell carcinoma of the tongue.

BACKGROUND: The invasive front is presumed to contain the most aggressive subpopulation of tumor cells that ultimately invade, spread locally and metastasize. Studying the histopathological grading of the tumor/ tissue interface at the invasive front may help in developing the treatment plan. OBJECTIVES: The aim of this study was to check the reliability of the tumor/tissue interface in predicting lymph node metastasis in oral squamous cell carcinoma (OSCC) of the tongue by evaluating the following: the histopathological grading of hematoxylin and eosin (H&E)-stained excision biopsy specimens according to the modified version of Broder's classification system; and the invasive tumor front (ITF) with the modified version of Bryne's grading system. The study also aimed at studying the lymph nodes for metastases and comparing these histopathological grading systems and lymph node metastases. MATERIAL AND METHODS: All retrospective and prospective cases from the archives of the Department of Oral Pathology and Microbiology of the A.B. Shetty Memorial Institute of Dental Sciences (ABSMIDS), NITTE University in Mangalore, India, collected during the period from 2012 to 2014 were considered for histopathological grading. RESULTS: This study found a significant association between the modified version of Bryne's ITF grading system and lymph node metastases whereas the widely used modified version of Broder's classification failed to show any statistical significance. Only the multifactorial malignancy grading of the deep invasive margins of OSCC proved to be of high prognostic value. CONCLUSIONS: The study found that the degree of keratinization, nuclear polymorphism, the pattern of invasion, and the host response showed significant variation at the invasive front of the tumor as compared to superficial parts, which makes Bryne's grading system more reliable than Broder's grading system.

Arrhythmias in Relation to Mortality After Transcatheter Aortic Valve Replacement.

BACKGROUND: The purpose of this study was to identify predictors of mortality and potentially modifiable factors related to arrhythmias in patients that undergo transcatheter aortic valve replacement (TAVR). Patients that undergo TAVR are at risk for complete heart block requiring pacemaker implant. Additionally, other arrhythmias, specifically atrial fibrillation (AF), are common in this population. It is unclear how arrhythmias and their management contribute to mortality risk. METHODS: The study analyzed 176 patients who underwent TAVR at a single center. Factors associated with pacemaker implantation within 30 days were analyzed by logistic regression. Factors associated with mortality were analyzed by Kaplan-Meier and Cox regression analyses. RESULTS: Mean age was 80 ± 8.5 years. AF was present in 69 patients, and 39 received anticoagulation. Post-TAVR, a pacemaker was implanted in 25 patients within 30 days. Over a follow up of 566 ± 496 days, 49 patients died. In multivariable analysis, right bundle branch block remained significant (odds ratio 4.212, P = 0.012) for pacemaker implant within 30 days. The AF (hazard ratio [HR] 3.905, P = 0.001), albumin level (HR 0.316, P = 0.034), and diabetes (HR 2.323, P = 0.027) were predictors of death in a multivariate analysis, while pacemaker implant within 30 days was not. Patients with AF who were anticoagulated had improved survival in a stratified Kaplan-Meier analysis compared with those who were not anticoagulated (P = 0.0001). CONCLUSION: AF, diabetes, and low albumin levels are independently associated with mortality after TAVR. In particular, patients with AF who are not anticoagulated are at highest risk for death. Efforts to identify AF and consider anticoagulation should be emphasized.

Degenerated TAVR Within Degenerated Surgical Bioprosthetic Valve Treated With Second TAVR.

Transcatheter aortic valve replacement within a degenerated surgical bioprosthetic aortic valve is increasing in frequency. We present a rare case of a patient requiring a second TAVR placed within a previous placed degenerated transcatheter aortic valve, which was implanted in a degenerated surgical bioprosthetic aortic valve. (Level of Difficulty: Advanced.).

aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion.

BACKGROUND: Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression. METHODS: STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression. RESULTS: Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001). CONCLUSIONS: STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

Prophylactic Left Ventricular Outflow Tract Septal Ablation Before Transcatheter Mitral Valve Replacement.

An 82-year-old woman with severe respiratory distress and limitations in functional status was found to have severe mitral valve stenosis with annular calcification and referred for transcatheter mitral valve replacement. Prophylactic alcohol septal ablation was used pre-procedurally to minimize mortality risk due to obstruction of the left ventricular outflow tract. (Level of Difficulty: Intermediate.).

Targeted Temperature Management; Review of Literature and Guidelines; A Cardiologist's Perspective.

BACKGROUND: Out of Hospital Cardiac Arrest (OHCA) remains not an uncommon occurrence in USA and the rest of the world. However, the survival to discharge following an episode of OHCA in adults is still very disappointing at around 10%. Several areas of improvement including education of general public in early Cardio Pulmonary Resuscitation (CPR) by bystander, chest compression first, and improvement of Emergency Medical response time have had a positive effect on the outcomes and survival but still much needs to be done. Recently, new data has emerged with regards to post resuscitation care and mild induced hypothermia (now preferably called; Targeted Temperature Management {TTM}) and several advances have been made. CONCLUSION: The purpose of this review is to summarize and compare the most recent guidelines and also provide a practical approach to TTM especially with regards to the field of cardiology.

Insertion of the Impella via the axillary artery for high-risk percutaneous coronary intervention.

Hemodynamic support with the Impella device is an important tool during high risk percutaneous coronary intervention. This device is usually inserted via the femoral artery. However, some patients have severe peripheral artery disease precluding the use of the femoral artery for this purpose. The axillary artery is a viable alternative in these cases. We reviewed the two access techniques for inserting the Impella via the axillary artery and also described 6 cases of successful implantation.

PCR-based evidence showing the presence of Vibrio vulnificus in wound infection cases in Mangaluru, India.

Vibrio vulnificus is a Gram-negative, opportunistic human pathogen capable of causing life-threatening septicaemia, wound infections, and gastroenteritis, especially in immunocompromised individuals. Two cases of V. vulnificus-associated wound infection occurring in diabetic patients are reported here. The pathogen was detected by PCR targeting species-specific marker gyrB and virulence markers, including repeats in toxin (rtxA) and hemolysin (vvhA), but the causative agent could not be cultured. Genotyping based on the virulence-correlated gene revealed that the V. vulnificus detected in this study belonged to the vcg-C type, which is commonly associated with clinical cases. This report highlights the clinical applicability of PCR-based methods in the detection of V. vulnificus in culture-negative cases. Such methods may add a very useful clinical dimension to currently used diagnostic practices.

Meta-analysis of revascularization versus medical therapy for atherosclerotic renal artery stenosis.

The aim of the study was to compare the efficacy of revascularization versus medical therapy in patients with atherosclerotic renal artery stenosis (ARAS). ARAS is the most common cause of secondary hypertension and is associated with several complications, such as renal failure, coronary artery disease, cardiac destabilization, and stroke. Medical therapy is the cornerstone for management of ARAS; however, numerous trials have compared medical therapy with revascularization in the form of percutaneous renal artery angioplasty (PTRA) or percutaneous renal artery angioplasty with stent placement (PTRAS). Medline (PubMed and Ovid SP), Embase, Cochrane Central Register of Controlled Clinical Trials (CENTRAL), and Cochrane Database of Systematic Review (CDSR) were searched till present (November 2013) to identify clinical trials where medical therapy was compared with revascularization (PTRA or PTRAS). We performed a meta-analysis using a random effects model. The heterogeneity was assessed using I2 values. The initial database search identified 540 studies and 7 randomized controlled trials, and 2,139 patients were included in the final analysis. Angioplasty with or without stenting was not superior to medical therapy with respect to any outcome. The incidence of nonfatal myocardial infarction was 6.74% in both the stenting and medical therapy group (odds ratio=0.998, 95% confidence interval 0.698 to 1.427, p=0.992), and incidence of renal events in stenting population was found to be 19.58% versus 20.53% in medical therapy (odds ratio=0.945, 95% confidence interval 0.755 to 1.182, p=0.620). In conclusion, PTRA or PTRAS does not improve outcomes compared with medical therapy in patients with ARAS. Future studies should investigate to identify patient subgroups that may benefit from such an intervention.

Contemporary antiplatelet therapy in patients undergoing percutaneous coronary intervention.

The proper use of antiplatelet agents in the cardiac catheterization laboratory is important for ensuring optimal results in patients undergoing percutaneous revascularization. Understanding the mechanisms by which these drugs exerts their effects is important for both interventional and non-interventional cardiologists. The effects of these agents on platelet function can be assessed and monitored using a variety of commercially available laboratory assays but so far these tests have not been adopted in routine clinical practice. Currently, aspirin, thienopyridines and glycoprotein IIb/IIIa inhibitors are the primary types of antiplatelet drugs being utilized. The use of these drugs and of several newer antiplatelet drugs in the treatment of patients undergoing percutaneous revascularization in the cardiac catheterization laboratory will be discussed, especially in the light of the recently published guidelines.

Contemporary anticoagulation therapy in patients undergoing percutaneous intervention.

The proper use of anticoagulants is crucial for ensuring optimal patient outcomes post percutaneous interventions in the cardiac catheterization laboratory. Anticoagulant agents such as unfractionated heparin, a thrombin inhibitor; low-molecular weight heparins, predominantly Factor Xa inhibitors; fondaparinux, a Factor Xa inhibitor and bivalirudin, a direct thrombin inhibitor have been developed to target various steps in the coagulation cascade to prevent formation of thrombin. Optimal anticoagulation achieves the correct balance between thrombosis and bleeding and is related to optimal outcomes with minimal complications. This review will discuss the mechanisms and appropriate use of current and emerging anticoagulant therapies used during percutaneous interventions.

Treatment of an iatrogenic femoral artery pseudoaneurysm with concomitant arteriovenous fistula with percutaneous implantation of an Amplatzer vascular plug.

Iatrogenic pseudoaneurysms can occur following percutaneous cardiac and peripheral procedures. There are multiple modalities available for the treatment of pseudoaneurysms including ultrasound guided compression repair, ultrasound guided thrombin injection, or endovascular repair with covered stent placement. If these methods are not indicated or unsuccessful, patients typically require open surgical repair. We report a case of a woman with a post-procedural pseudoaneurysm with concomitant arteriovenous fistula who was treated percutaneously with the implantation of an Amplatzer vascular plug. This novel technique was safe and effective and allowed our patient to avoid the morbidity and mortality associated with surgical repair.

Percutaneous catheter-based left atrial appendage ligation and management of periprocedural left atrial appendage perforation with the LARIAT suture delivery system.

We report an 88-year-old male with coronary artery disease, previously placed left main coronary artery drug-eluting stent, and atrial fibrillation unable to tolerate anticoagulation with warfarin in addition to dual antiplatelet therapy who underwent percutaneous catheter-based ligation of the left atrial appendage. During the procedure, left atrial appendage perforation occurred with resultant pericardial effusion. The novel LARIAT suture delivery system (SentreHEART) allowed immediate and definitive management of this complication and effective ligation of the left atrial appendage. Prospective studies are needed to determine whether this is a safe and effective method for thromboembolism prophylaxis in patients with atrial fibrillation, but its novel design incorporates an immediate resolution to the most-feared complication of catheter-based left atrial appendage manipulation while effectively excluding the left atrial appendage via suture ligation.

Atherosclerotic inferior mesenteric artery stenosis resulting in large intestinal hypoperfusion: a paradigm shift in the diagnosis and management of symptomatic chronic mesenteric ischemia.

Symptomatic chronic mesenteric ischemia results from intestinal hypoperfusion and is classically thought to result from involvement of two or more mesenteric arteries. The celiac artery and superior mesenteric artery are most frequently implicated in this disease process, and their involvement usually results in symptoms of small intestinal ischemia. Symptomatic chronic mesenteric ischemia resulting predominantly from inferior mesenteric artery involvement has largely been overlooked but does gives rise to its own, unique clinical presentation with symptoms resulting from large intestinal ischemia. We present four patients with atherosclerotic inferior mesenteric artery stenosis with symptomatic chronic mesenteric ischemia that have unique clinical presentations consistent with large intestinal ischemia that resolved following percutaneous endovascular treatment of the inferior mesenteric artery stenosis. These cases represent a novel approach to the diagnosis and management of this disease process and may warrant a further subclassification of chronic mesenteric ischemia into chronic small intestinal ischemia and chronic large intestinal ischemia.

Percutaneous left axillary artery approach for Impella 2.5 liter circulatory support for patients with severe aortoiliac arterial disease undergoing high-risk percutaneous coronary intervention.

The use of the Impella 2.5 liter (L) device for hemodynamic support has been well described. The typical access site for the Impella 2.5 L device is the femoral artery. The use of the axillary and subclavian artery has been described via surgical cut down for the Impella 5 L device when femoral artery access is not possible. In patients with severe aortoiliac disease and difficult anatomy the femoral artery access for the Impella 2.5 L device is not feasible. We describe the successful percutaneous use of the Impella 2.5 L device for hemodynamic support via the left axillary artery in 2 patients undergoing high-risk PCI with concomitant severe aortoiliac disease.