Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review.

The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.

Dilated Cardiomyopathy With Multiple Left Ventricular Thrombi and Embolic Stroke After Mild COVID-19.

COVID-19 is a novel disease with multisystem involvement, but most patients have pulmonary and cardiovascular involvement in the acute stages. The cardiovascular impact of acute COVID-19 is well recognized and ranges from myocarditis, arrhythmias, and thrombotic occlusion of coronary arteries to spontaneous coronary artery dissection and microthrombi in small coronary vessels on autopsy. We report a case of a 37-year-old man who recovered from mild COVID-19 only to present a few weeks later with devastating cardiovascular involvement that included severe left ventricular impairment resulting from nonischemic cardiomyopathy, multiple left ventricular thrombi, and embolic stroke.

Coronary thrombo-embolic events after Covid-19 vaccination- a single centre study.

Thrombo-embolic complications after Corona virus disease-19 (COVID-19) vaccination have been previously reported. We aimed to study the coronary thrombo-embolic complications (CTE) after COVID-19 vaccination in a single centre during the initial 3 months of vaccination drive in India. All patients admitted to our hospital between 1st March 2021 and 31st May 2021 with Acute coronary syndrome (ACS) were included. Of the 89 patients [Age 55 (47-64)y, 13f] with ACS and angiographic evidence of coronary thrombus, 37 (42%) had prior vaccination history. The timing from last vaccination dose to index event was <1, 1-2, 2-4 and >4 weeks in 9(24%), 4(11%), 15(41%) and 9 (24%) respectively. ChAdOx1 nCoV-19/AZD1222 (Covishield) was the most used vaccine- 28 (76%), while 9 (24%) had BBV152 (Covaxin). Baseline characteristics were similar in both vaccinated (VG) and non-vaccinated group (NVG), except for symptom to door time [8.5 (5.75-14) vs 14.5 (7.25-24) hrs, p = 0.003]. Thrombocytopenia was not noted in any of the VG patients, while 2 (3.8%) of NVG patient had thrombocytopenia (p = 0.51). The pre- Percutaneous Coronary Intervention (PCI) Thrombolysis in Myocardial Infarction (TIMI) flow was significantly lower [1 (0-3) vs2 (1-3), p = 0.03) and thrombus grade were significantly higher [4 (2.5-5) vs 2 (1-3), p = 0.0005] in VG. The in-hospital (2.7% vs 1.9%, p = 1.0) and 30-day mortality were also similar (5.4% vs 5.8%, p = 1.0). This is the first report of CTE after COVID-19 vaccination during the first 3 months of vaccination drive in India. We need further reports to identify the incidence of this rare but serious adverse events following COVID-19 vaccination.

Unanticipated complication of transcatheter correction of superior sinus venosus atrial septal defect.

Transcatheter correction of superior sinus venosus atrial septal defect (SVASD) is being considered as an alternative to surgery in selected patients. We present the case of a 42-year-old woman with SVASD and partial anomalous venous connection of the right upper pulmonary vein (RUPV), who underwent transcatheter correction with self-expanding aortic stent graft, following feasibility assessment by balloon occlusion. Hemodynamic parameters and angiography demonstrated successful closure of the SVASD without any residual shunt and unobstructed return of RUPV to the left atrium. She developed cardiac tamponade after a few hours despite pericardial drain and underwent emergency exploratory thoracotomy. This revealed leak from a small rent in the ascending aortic wall adjacent to superior vena cava (SVC) caused by barbs of the stent protruding from SVC, without any leak in SVC. This was repaired with suture and further Teflon was placed around the barbs in SVC to prevent further injury. We also discuss the possible reason for this complication, considering our successful previous two cases with the same stents. This case highlights the importance of assessing the relationship between SVC and aorta to decide about the cranial placement of the aortic stent either by computed tomography prior or by contrast aortogram during the procedure. .

Thrombolysis in Acute Pulmonary Embolism: Are we overdoing it?

AIM AND METHODS: We aimed to study the clinical data and outcome of patients admitted in our center with acute pulmonary embolism (PE) over a 5-year period from May 2013 to April 2018. The main outcome data included were: in - hospital bleeding, in - hospital right ventricular (RV) function improvement, pulmonary arterial hypertension improvement, duration of hospital stay, and 30- and 90-day mortality. RESULTS: A total of 114 (69 m, 55 f) patients with the mean age of 55 ± 15 years were included. Patients who had involvement of central pulmonary trunk called as "Central PE" group (n = 82) and others as "Peripheral PE" group (n = 32). There were more women in the peripheral PE group (53.1% vs. 34.1%, P = 0.05), while RBBB (22% vs. 3.1%, P = 0.02) and RV dysfunction (59.8% vs. 25%, P = 0.002) were noted more in the central PE group. Systemic thrombolysis was done in 53 patients (49 central, 4 peripheral), of which only 3 had hypotension and 28 patients were in the Intermediate-high risk group. The overall inhospital, 30-day, and 90-day mortalities were 3.6, 13.2, and 22.8%, respectively. Bleeding was significantly higher in the thrombolysis group compared to the nonthrombolysis group (18.9% vs. 0, P = 0.0003). However, improvement in pulmonary hypertension was noted more in thrombolysis group compared to nonthrombolytic group (49% vs. 21.2%, P = 0.01). CONCLUSION: This retrospective data from a tertiary center in South India showed that short- and mid-term mortality of patients with PE still remains high. The high nonguideline use of thrombolysis has been reflected in the increased bleeding noted in our study.

Acute Coronary Syndrome admissions and outcome during COVID-19 Pandemic-Report from large tertiary centre in India.

Few studies from various countries have reported decline in Acute Coronary Syndrome (ACS) admissions to hospital during COVID-19 pandemic. We studied the impact of COVID-19 strict lockdown on ACS admission in a tertiary referral hospital in India. This showed 43% decline in admissions (n = 104 vs mean n = 183) and even in those who got admitted, there was a delay in presentation compared to previous year, which was reflected in the outcome of patients. Government and health organizations should educate the public early-on during the pandemic about the consequences of ignoring other acute medical problems such as ACS.

Early discharge of patients (within 24 h) after percutaneous coronary intervention is feasible and safe in Indian setup.

Percutaneous coronary intervention (PCI) is the commonest cardiac procedure in most centres in India. Unlike in most western countries, patients who undergo PCI in India are discharged after a few days. We undertook an observational study of 100 consecutive patients to evaluate the outcome of early discharge (within 24 h) after uncomplicated elective PCI. This showed that early discharge is feasible and safe; and most patients felt comfortable with early discharge. It is the responsibility of the interventional cardiologist to educate and reassure these uncomplicated PCI patients about the safety of this approach.

Cardiac Intensive Care Unit Admissions during COVID-19 Pandemic-A Single Center Experience.

AIM: The impact of coronavirus disease 2019 (COVID-19) lockdown on cardiac emergency admissions to hospitals has been reported previously. We aimed to study the emergency room (ER) admissions to cardiac intensive care unit (CICU) at a tertiary care center during that period and compare this with admissions during the same time frame in the previous years. MATERIALS AND METHODS: This is a retrospective observational study of patients admitted to the CICU during the pandemic period from March 22 to August 1 (inclusive) of 2020 and compared this with CICU admissions in the same time frame in the previous 2 years (2018 and 2019). RESULTS: During the study period in 2020, a total of 216 patients (age 59 ± 14 years) were admitted via ER, which is a 33% and 30% decline in admissions compared to 2019 (n = 322, age 63 ± 12 years) and 2018 (n = 307, age 62 ± 13), respectively. The decline in admissions with the primary diagnosis of acute coronary syndrome (ACS), acute decompensated heart failure, arrhythmia, and other diagnoses during the study period in 2020 were 27%, 38%, 62%, and 59%, respectively, while there was a 50% increase in acute pulmonary embolism admission compared to the mean admission in 2018 and 2019. Weekly admission rates gradually increased from less than 10 per week in the first 3 weeks to >15 by eighth week of the study period in 2020, while the trend was same throughout the study period in the previous 2 years. The CICU mortality rate in 2020 study period was 4.6% compared to 3.9% in 2018 (p = 0.83) and 5.6% in 2019 (p = 0.70). The in-hospital mortality of these patients was also similar in all 3 years (6.5%, 7.8%, and 7.9% in 2018, 2019, and 2020, respectively; p = 0.61). CONCLUSION: Our study showed that CICU admissions during COVID-19 lockdown had declined compared to the previous years in a large tertiary center in India. Government and health organizations should educate the public early on during the pandemic about the consequences of ignoring other acute medical problems such as ACS, provide various measures for them to reach hospital early, and give reassurance with the best practices adopted in hospitals to avoid contracting the virus from the hospital environment. HOW TO CITE THIS ARTICLE: Yalamanchi R, Dasari BC, Narra L, Oomman A, Kumar P, Nayak R, et al. Cardiac Intensive Care Unit Admissions during COVID-19 Pandemic-A Single Center Experience. Indian J Crit Care Med 2020;24(11):1103-1105.

Valve in valve implantation to prevent acute prosthetic valve migration in Transcatheter Aortic Valve Implantation (TAVI).

This case demonstrates the importance of accurate sizing of aortic annulus prior to TAVI. There was migration of first valve after deployment and therefore to prevent further migration to the left ventricle, a new TAVI valve was deployed jailing the first valve.

"Incidental findings" during TAVI work-up: more than just an inconvenience.

AIMS: To characterise the clinical course of patients who had incidental findings on the CT aortogram (CTA) done as a transcatheter aortic valve implantation (TAVI) work-up investigation. METHODS AND RESULTS: All patients who underwent CTA as a work-up investigation for TAVI were retrospectively recruited (n=295, 83±6.7 years) to identify those with an incidental finding. A total of 323 incidental findings were identified in 201 (68.1%) patients. Of those with incidental findings, 87 (43.3%) had at least one of immediate clinical significance. Within this group, fewer (52.9%) eventually had TAVI compared to those without incidental findings (63%). In patients going on to have TAVI, the time between CTA and TAVI was longer in those with incidental findings (median 96 vs. 81 days). At follow-up, overall mortality in those with incidental findings was higher than in those without (49.4% vs. 37.5%). In patients who underwent TAVI, there was a trend to increased mortality in those with incidental findings (34.8% vs. 21.4%, p=0.07). CONCLUSIONS: Incidental findings were associated with a longer time to TAVI procedure, lower chance of eventually receiving TAVI as definitive therapy and a worse overall outcome. Such findings are clearly important and should be taken into account when delivering a contemporary TAVI service.

Should primary percutaneous coronary intervention be the routine reperfusion strategy in octogenarians presenting with ST elevation myocardial infarction?

AIM: Very few randomized trials have analysed the outcome of primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) in very elderly patients (≥80 years). An observational study was performed to evaluate the outcome of PPCI in patients of at least 80 years of age who were admitted to our unit. METHODS: We included all patients undergoing PPCI in our unit from September 2009 to November 2011. RESULTS: Of the 1471 patients who underwent PPCI during the study period, 236 (16%) were at least 80 years of age. The mean age was 85 ±â€Š4 years (range 80-99 years, median 85 years). There was a significant difference in in-hospital mortality [14.4 vs. 2.9%, odds ratio (OR) 5.6, 95% confidence interval (CI) 3.4-9.2, P <0.0001], 30-day mortality (20.3 vs. 4%, OR 6.2, 95% CI 4.0-9.5, P <0.0001), 1-year mortality (28.8 vs. 6.2%, OR 6.1, 95% CI 4.2-8.8, P <0.0001), 30-day stent thrombosis (1.7 vs. 0.4%, OR 4.2, 95% CI 1.1-15.9, P = 0.04) and non-coronary artery bypass grafting major bleed (5.9 vs. 3%, OR 2, 95% CI 1.1-3.8, P = 0.03) between patients aged at least 80 years and those less than 80 years. CONCLUSION: The mortality in our patients of at least 80 years was similar to the previously published data, despite the advances in PPCI procedures. Considering the increasing number of octogenarian patients with STEMI at the present time, there is a need for a randomized trial to compare the different treatment strategies for STEMI.

Typical takotsubo cardiomyopathy in suspected ST elevation myocardial infarction patients admitted for primary percutaneous coronary intervention.

AIM: Takotsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography is much quicker than before. We aimed to analyse the prevalence of typical TCM in patients admitted for primary percutaneous coronary intervention (PPCI) with suspected ST elevation myocardial infarction (STEMI) to a single tertiary centre in United Kingdom. METHODS: All patients admitted to our unit with suspected STEMI from September 2009 to November 2011 were included for analysis. RESULTS: Of the 1875 patients admitted, 17 patients (all female) with mean age of 69±11.9 yrs were identified to have clinical features of typical TCM, thus giving an overall prevalence of 0.9% in PPCI admissions (3.2% prevalence in women). The admission ECG showed ST elevation in 14 patients (82%) and 3 had LBBB (18%). In the 16 patients who had raised hs Troponin (normal range <14), the mean level was 921±668 (median 778, range 110 to 2550) ng/L. Two patients survived cardiac arrest and one had apical thrombus on presentation. Left ventricular function was severely impaired (EF ≤30%) in 2 patients, whilst it was moderately impaired (EF 31-50%) in others. During a mean follow-up period of 22±7 months (range 8-36 months), there was no mortality or recurrence. CONCLUSION: This is the first observational study to report the prevalence of typical TCM in patients admitted for PPCI in "real-world" practice. Though this condition is not benign during the acute episode, there is a good survival outcome if managed appropriately during the acute phase.

Comparison of bivalirudin with heparin versus abciximab with heparin for primary percutaneous coronary intervention in "Real World" practice.

OBJECTIVE: We aimed to carry out a "real world" comparison of bivalirudin plus unfractionated heparin (UFH) versus abciximab plus UFH in patients undergoing primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI). METHODS: We included patients who had abciximab or bivalirudin during their PPCI in our unit between Sept 2009 and Nov 2011. RESULTS: The study included 516 and 484 patients in the bivalirudin and abciximab group respectively. There were more women in the bivalirudin group (29% vs 20%, p 0.001), while cardiogenic shock (6.4% vs 10.1%, p 0.04) and thrombectomy device use (76.6% vs 82%, p 0.04) were lower in the bivalirudin group. The primary composite end point of 30-day mortality, 30-day definite stent thrombosis or non-CABG major bleeding was similar between the bivalirudin and abciximab groups (7.8% vs 9.5%, OR 0.8, 95% CI 0.5 to 1.2, p 0.4). There was also no difference in in-hospital mortality (4.1% vs 4.3%, p 0.9), 30-day mortality (5.2% vs 6.4%, p 0.5), 1-year mortality (9.1% vs 9.9%, p 0.7), 30-day stent thrombosis (1% vs 0.4%, p 0.5) and non-CABG bleeding (2.7 vs 3.7%, p 0.4) between the bivalirudin and abciximab group respectively. On Cox proportional hazard analysis after adjusting for all the co-variates, the use of bivalirudin was not a predictor of 30-day mortality (HR 1.13, 95% CI 0.7-1.9, p 0.7). CONCLUSION: In this "real-world" observational study, there was no significant difference in the clinical outcome of PPCI for patients who had abciximab or bivalirudin after initial pre-treatment with UFH.

The advantages of a consultant led primary percutaneous coronary intervention service on patient outcome.

BACKGROUND: Mortality among emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends. AIM: We studied the outcome of ST elevation myocardial infarction (STEMI) patients presenting at different times to our centre with 24/7 primary percutaneous coronary intervention (PPCI) service. METHODS: We divided all patients who underwent PPCI between September 2009 and November 2011 into three groups according to the time of admission as group 1: in-hours (0800-1800 h weekdays), group 2: out-of-hours (1800- 0800 h weekdays) and group 3: weekends (Sat to Mon 0800-0800 h). RESULTS: A total of 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3, respectively. Apart from cardiogenic shock (8.9%, 5.5% and 7.7%, P = 0.05) and door to balloon time (median 29, 33 and 36 min, P < 0.0001), there was no significant difference noted in the baseline and procedural characteristics between the groups. In-hospital mortality (4.6%, 4.3% and 5.3%, P = 0.5), 30-day mortality (6.4%, 6.3% and 7%, P = 0.7), 30-day stent thrombosis (0.8%, 0.8% and 0.2%, P = 0.1) and 1-year mortality (10.7%, 10.8% and 9.8%, P = 0.7) were no difference between the groups. On logistic regression analysis, out-of-hours and weekend admissions were not found to be a predictor of both 30-day and 1-year mortality. CONCLUSION: In this consecutive series of patients admitted to a high volume PPCI centre, there was no difference in mortality when patients were admitted at different times. The involvement of senior medical staff early in the patients' admission may have contributed to these consistent outcomes.