Hypertrophic cardiomyopathy in pregnancy: Nationwide analysis of patients characteristics and outcomes.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) poses unique challenges in the management of pregnant patients due to the complex interplay of physiological changes of pregnancy. Despite its relatively low prevalence among pregnant women, HCM can significantly impact maternal and fetal outcomes. This study aims to enhance understanding of pregnant patients with HCM and the associated outcomes through a nationwide analysis of patient characteristics and outcomes. METHODS: A retrospective analysis was conducted using data obtained from the Agency for Healthcare Research in Quality (AHRQ) Nationwide Inpatient Sample (NIS) database from January 2016 to December 2020. 3,599,855 pregnant patients without HCM and 187 pregnant patients with HCM were identified using International Classification of Disease (ICD) codes, and baseline characteristics, medical comorbidities, and outcomes were compared between the two groups. RESULTS: Significant differences were observed in baseline characteristics, including age distribution, racial composition, and prevalence of systemic organ disease, between pregnant women with and without HCM. Women with HCM had higher odds of experiencing maternal complications, such as acute heart failure and peripartum cardiomyopathy, as well as higher rates of fetal distress and obstetric interventions, including preterm delivery and caesarean section. CONCLUSION: Comprehensive cardiovascular assessment and risk stratification are essential in pregnant women with HCM to optimize maternal and fetal outcomes. Moreover, disparities in baseline characteristics and outcomes among black pregnant women with HCM highlight the need for a multifactorial approach to addressing pregnancy-related complications.

Navigating the Unexpected: Right Aortic Arch Unveiled During Left Heart Catheterization.

A right aortic arch (RAA) is an extremely rare congenital anomaly with seven identified variants. While most variants are asymptomatic, those with a vascular ring can be associated with severe symptoms. We present an incidental RAA finding during left heart catheterization (LHC) in a 68-year-old female with multiple morbidities presented with worsening angina. Her echocardiogram was significant for inferolateral wall akinesia, prompting LHC. The procedure was challenging with an unexpected course of the guide wire distally behind the cardiac shadow. Pressure tracing confirmed arterial access and contrast injection revealed RAA. A subsequent aortic computed tomography angiography (CTA) confirmed RAA with mirror-image branching. Abnormal origin and angle of aortic arch branches pose challenges in choosing the proper access. We used the right radial artery approach, but the left radial approach may be superior in providing a more proximal access and avoiding the abnormal origin of the right subclavian artery (RSA). Choosing the appropriate angiographic view is also of utmost importance, and the right anterior oblique view provided better visualization in our case. Aortic arch anomalies are confirmed by a CTA or magnetic resonance angiography (MRA) of the aorta. This case underscores the importance of identifying the aortic arch anomalies and the imposed challenges during the LHC.

Rare Variant of Meigs Syndrome Associated With Pericardial Effusion.

Meigs syndrome is an uncommon entity associated with benign ovarian tumor, pleural effusion, and ascites. Its association with pericardial effusion is extremely rare. We report a case of Meigs syndrome associated with recurrent pericardial effusion that resolved after surgical resection of the ovarian tumor. (Level of Difficulty: Beginner.).

Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample.

Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions.

Pregnancy and Fetal Outcomes in Patients With Ehlers-Danlos Syndrome: A Nationally Representative Analysis.

Cardiovascular complications occur frequently in Ehlers-Danlos syndrome (EDS). Pregnancy outcomes, however, are not well established in patients with EDS. We conducted a population-based, retrospective, cohort study using the national inpatient sample to compare pregnancy and fetal outcomes in patients with and without EDS, delivering between 2016 and 2019. Regression analysis was performed and adjusted for maternal age and race to compare both groups. Of the total 5,887,050 births in our cohort, 1016 were to patients with EDS. The EDS cohort was more likely to be older, white and have multiple comorbidities, such as smoking, mitral valve prolapse, and chronic hypertension. When we adjusted for age and race, patients with EDS were more likely than those without EDS to require Cesarean-section, develop postpartum hemorrhage, experience intrauterine growth restriction, and deliver preterm. In this study, patients with EDS experienced higher rates of maternal complications, however, aortic aneurysmal rupture was not among them.

Predicting the Severity and Outcome of Persistent Pulmonary Hypertension of the Newborn Using New Echocardiography Parameters.

To examine echocardiographic parameters correlation with clinical severity indices, Alveolar- arterial gradient (A-a gradient), oxygenation index and clinical outcomes in newborns with persistent pulmonary hypertension of the newborn (PPHN). Retrospective cohort study of 67 subjects, >35 weeks' gestation with the diagnosis of PPHN admitted to the University of Kentucky neonatal intensive care unit (NICU) between September 2014 and December 2016. High left ventricular end-systolic eccentricity index (EIs) correlates with the overall clinical severity of PPHN as it is associated with higher A-a gradient and oxygenation index (P = 0.0003 and P < 0.0001, respectively). Elevated EIs was also predictive for the use of inhaled nitric oxide and extracorporeal membrane oxygenation (P = 0.0004 and P < 0.0001, respectively). EIs value of >1.38 provides cutoff value as an objective marker for the need for extracorporeal membrane oxygenation. EIs can be used to assess clinical severity and outcomes and should be reported routinely. Further studies are warranted to confirm these results.

Relationship Between Body Mass Index and Outcomes in Acute Myocardial Infarction.

Background: The prevalence of obesity in the United States is high. Obesity is one of the leading risk factors in the development of acute myocardial infarction (AMI). Nevertheless, how obesity impacts AMI in-hospital outcomes remains controversial. Methods: Using National Inpatient Sample (NIS) database, we identified patients diagnosed with AMI from the year 2015 to 2018. We divided these patients into five subgroups based on their body mass index (BMI). We compared outcomes such as mortality, length of inpatient stay, and inpatient complications between our subgroups. Statistical analysis was done using the program STATA. Our nationally representative analysis included 561,535 patients who had an AMI event across various weight classes. Results: Most of our sample was obese (BMI > 30 kg/m2) and male. Obese patients were significantly younger than the rest. Length of stay (LOS) for AMI was highest for those with a BMI of less than 24 kg/m2. In-hospital mortality is highest for those with a BMI of < 30 kg/m2 and lowest for those with a BMI of 30 - 40 kg/m2. Inpatient complications are highest in the lower BMI population (BMI < 24 kg/m2). Conclusion: The current analysis of a nationally representative sample showed the clinical implications of BMI in patients with AMI. Patients with a BMI of 30 - 40 kg/m2 had more favorable LOS, inpatient complications, and in-hospital mortality when compared to those with an ideal body weight. Hence, this supports and expands on the concept of the "obesity paradox". Further studies are needed to further investigate the possible mechanism behind this.

Disparities in the Prescription of Statins in the Primary Care Setting: A Retrospective Observational Study.

Despite the high disease burden of atherosclerosis, evidence exists for the disparity in the prescription of guideline-indicated medications between genders, racial groups, socioeconomic groups, and ages. We aim to perform a retrospective study looking at the disparity in statin prescription for primary and secondary prevention in these groups. Data were collected from a single center and included patients with an LDL level >190 mg/dL, diagnosis of diabetes mellitus with LDL level >70 mg/dL, and diagnosis of cardiovascular disease regardless of LDL level. Patients older than 75 or younger than 21 were excluded from the study. Complex samples multivariable logistic and linear regression models were used to calculate the adjusted odds ratio and 95% confidence interval. The total study population was n = 56,995. Of those, 57.89% (n = 32,992) were female. Only 59.56 % of these patients for whom statin therapy was indicated received it. Most patients were White (53.21%) followed by African Americans (35.98%), Asians (2.43%), American Indian/Native Alaskans (0.40%), and Native Hawaiian/Pacific Islander (0.18%). There is a clear disparity in statin prescription favoring males, the elderly, and people of white ethnicity. Interestingly, Asians were more likely to be prescribed statins as opposed to whites. Self-pay patients were more likely to receive statins than patients on Medicare.Despite being indicated, Statins are under prescribed. Disparities based on race, gender, and insurance type mirror previous trends in the literature. Some results have shown a reversal in trends such as the higher prescription for Asian-Americans. Multiple patient-specific, provider-related, institutional factors might explain these disparities and must be investigated.

Transfemoral aortic valve replacement in a nonagenarian with aortic stenosis and cardiac amyloidosis: case report.

BACKGROUND: Cardiac amyloidosis (CA) is diagnosed with increasing frequency in the elderly population with severe aortic stenosis (AS), especially with the low-flow, low- gradient phenotype. Prognosis is poor with no treatment. CASE PRESENTATION: The patient is a 94-year-old active male who presented with a stroke that fully resolved. He was found to have low-flow, low-gradient severe AS, along with concomitant CA. Gradients across the aortic valve worsened with the dobutamine challenge test. He underwent successful transfemoral aortic valve replacement (TAVR) and did well postoperatively, where he remained in the hospital for only one day. Treatment of his CA with Tafamidis was recommended; however, the patient declined due to its cost and personal preference. CONCLUSION: To our knowledge, we report on one of the oldest patients to undergo TAVR for low-flow, low-gradient AS with concurrent CA (AS-CA). It might be prudent to screen elderly patients with AS for CA, as prognosis is worse with medical management alone. TAVR has overall improved survival in patients with AS-CA and is considered the procedure of choice, as these patients are typically older and at higher risk for surgical intervention.

Exhaustion of coronary vasodilatory reserve in the resting state: Clinical characteristics and long-term outcomes after intervention.

OBJECTIVES/BACKGROUND: Resting coronary blood flow approximates flow with maximal vasodilation in very severe coronary stenosis. We studied the incidence of exhausted vasodilatory reserve by FFR, its clinical characteristics and long-term prognosis after FFR guided percutaneous coronary intervention (PCI). METHODS: Consecutive patients undergoing FFR-guided PCI for coronary stenosis with reduced resting blood flow (baseline Pd/Pa < 0.8) were included. Basal maximal vasodilation (BMV) was defined as less than 5% difference between resting Pd/Pa and FFR, that is, FFR-baseline Pd/Pa < 0.05. RESULTS: Of 658 vessels that underwent FFR-guided PCI in 602 patients, 151 vessels had resting blood flow in the ischemic range (baseline Pd/Pa ≤ 0.8) and were included in the analysis. Of these, 28 lesions in 28 patients met criteria for BMV (4.25% of the entire registry and 18.5% of those with the reduced basal coronary flow). Stenosis severity was a significant predictor of the presence of BMV. In long term follow-up (median 106 ± 3.6 months), BMV was not associated with increased target vessel revascularization (TVR) or major adverse cardiac event compared to non-BMV(OR 1.9, 95% CI 0.7-4.8, p-value 0.2 and OR 1.3, 95% CI 0.75-2.5, p = 0.3, respectively). CONCLUSION: Low baseline Pd/Pa that approximates fractional flow reserve (exhausted vasodilatory reserve) defines a subgroup of patients with severe coronary artery stenosis. Prognosis, when treated with PCI along with medical therapy, appears similar to those with intact vasodilatory reserve.

Role of Vasodilator Therapy in Acute Heart Failure.

Over the past decade, several trials have questioned the efficacy of vasodilator therapy in acute heart failure (AHF) in the absence of uncontrolled hypertension. In this article, we provide a unique review of the most valuable four trials that present the role of vasodilator therapy in the management of patients with AHF. These four trials have evaluated the efficacy of different types of vasodilators such as nesiritide, ulatritide, and serelaxin in the setting of AHF. Also, we compared comprehensive vasodilator therapy versus standard therapy to see if there is any effect on mortality and re-hospitalization.

Refining Telemedicine: A Plea From Healthcare Workers During a Pandemic.

Telemedicine has been in existence for decades with little traction for global mainstream medicine. However, COVID-19 has exposed the importance of providing continued care for patients while minimizing the risk of exposure during pandemics. There has been robust growth in the use of telemedicine since the pandemic began, rendering safety in care provided by minimizing exposure to patients and healthcare workers. There has been tremendous growth and innovation in various digital applications that facilitate telehealth as the platforms continue to improve. Even in the absence of a pandemic, telemedicine allows for care of patients who may live in remote areas or have issues with transportation and comorbidities prohibiting ambulation. This study is based on a questionnaire for healthcare providers who have been exposed to telemedicine during COVID-19. A survey was shared in social media forums involving groups of physicians and nurse practitioners who were willing to take the survey. Telemedicine is one of the best approaches to handling situations like pandemics or disease surges. In these circumstances, a virtual visit is beneficial for social distancing if a laptop, smartphone, or tablet is available, along with internet or cellular coverage. This survey was conducted among healthcare workers of various specialties and it was found out that there was a considerable impetus for the continued benefit from telemedicine as an alternative to in-person visits for selected patients. Ongoing improvements in the quality of applications/tools, education, and cost are essential to maintain telemedicine. There is also a constant necessity for vast improvements in healthcare policies and reimbursements to allow for telemedicine to evolve.

How the COVID-19 Pandemic Has Affected Cardiology Fellow Training.

With the advent of the COVID-19 pandemic in the United States, resources have been reallocated and elective cases have been deferred to minimize the spread of the disease, altering the workflow of cardiac catheterization laboratories across the country. This has in turn affected the training experience of cardiology fellows, including diminished procedure numbers and a narrow breadth of cases as they approach the end of their training before joining independent practice. It has also taken a toll on the emotional well-being of fellows as they see their colleagues, loved ones, patients or even themselves struggling with COVID-19, with some succumbing to it. The aim of this opinion piece is to focus attention on the impact of the COVID-19 pandemic on fellows and their training, challenges faced as they transition to practicing in the real world in the near future and share the lessons learned thus far. We believe that this is an important contribution and would be of interest not only to cardiology fellows-in-training and cardiologists but also trainees in other procedural specialties.

Aortofemoral Bypass Graft Access for Impella Placement.

Left ventricular support with Impella requires a large-bore sheath. Alternate access sites have often been required in patients with severe peripheral artery disease. This paper reports the first case in which an aortofemoral bypass graft for Impella access was used in a patient without other alternatives and the method of access closure. (Level of Difficulty: Advanced.).

Retrograde recanalization of a nonchronic total occlusion lesion.

The use of the retrograde approach to treat chronic total occlusion (CTO) has improved overall success rate in this lesion subgroup. Its use to treat complex non-CTO lesions unable to be revascularized by an antegrade approach has not been described. We report a case of the use of the retrograde approach to recanalize a non-CTO lesion under Impella support in a patient with critical stenosis and poor left ventricular function. The retrograde approach may be an alternate pathway in selected non-CTO lesions where the antegrade has been unsuccessful.

Cardiac drug therapy-considerations in the elderly.

Elderly individuals constitute a majority of patients encountered in current cardiovascular clinical practice. Management of these patients is a clinical challenge owing to a multitude of factors. Although medications such as statins have been shown to reduce cardiovascular mortality in the general population, evidence supporting the use of these drugs in patients greater than 75 years of age is sparse. Furthermore, aging associated changes in organ function and associated comorbidities influence the pharmacokinetics of multiple medications and can potentiate drug toxicity. In this article, we review the evidence behind the use of common cardiovascular medications in elderly patients and discuss pertinent clinical challenges.