Association of mildly elevated pulmonary vascular resistance with major cardiovascular events in pulmonary hypertension and chronic kidney disease: A retrospective cohort analysis.

Pulmonary hypertension (PH) is associated with adverse outcomes in chronic kidney disease (CKD) patients. Our study suggests mildly elevated pulmonary vascular resistance ( > 2 to ≤ 3) is independently associated with major adverse cardiovascular events at 1-year follow-up. Early diagnosis of precapillary PH in CKD patients can potentially improve clinical outcomes.

Contemporary National Trends and Outcomes of Pulmonary Embolism in the United States.

Contemporary data on the national trends in pulmonary embolism (PE) admissions and outcomes are scarce. We aimed to analyze trends in mortality and different treatment methods in acute PE. We queried the Nationwide Readmissions Database (2016 to 2019) to identify hospitalizations with acute PE using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. We described the national trends in admissions, in-hospital mortality, readmissions, and different treatment methods in acute PE. We identified 1,427,491 hospitalizations with acute PE, 2.4% of them (n = 34,446) were admissions with high-risk PE. The rate of in-hospital mortality in all PE hospitalizations was 6.5%, and it remained unchanged throughout the study period. However, the rate of in-hospital mortality in high-risk PE decreased from 48.1% in the first quarter of 2016 to 38.9% in the last quarter of 2019 (p-trend <0.001). The rate of urgent 30-day readmission was 15.2% in all PE admissions and 19.1% in high-risk PE admissions. In all PE admissions, catheter-directed interventions (CDI) were used more often (2.5%) than systemic thrombolysis (ST) (2.1%). However, in admissions with high-risk PE, ST remained the most frequently used method (ST vs CDI: 11.3% vs 6.6%). In conclusion, this study showed that the rate of in-hospital mortality in high-risk PE decreased from 2016 to 2019. ST was the most frequently used method for achieving pulmonary reperfusion in high-risk PE, whereas CDI was the most frequently used method in the entire PE cohort. In-hospital death and urgent readmissions rates remain significantly high in patients with high-risk PE.

Transcatheter edge-to-edge repair of the tricuspid valve: The US experience.

OBJECTIVES: To examine the trends in utilization and outcomes of tricuspid valve (TV) transcatheter edge-to-edge repair (TEER). BACKGROUND: Surgery for isolated tricuspid regurgitation is associated with high morbidity and mortality and is rarely performed. TV TEER is an attractive alternative. METHODS: The Nationwide Readmissions Database was queried using the International Classification of Diseases, 10th Revision, procedure code for TV TEER for years 2016-2019. The main outcomes were trends in utilization and in-hospital all-cause mortality. RESULTS: We identified 918 hospitalizations for TV TEER. There was an uptrend in its utilization from 13 cases in the first quarter of 2016 to 122 cases in the last quarter of 2019 (p trend < 0.001). Concomitant mitral valve (MV) TEER was performed in 42.1% of admissions. The overall in-hospital mortality was 2.1%. Surgical TV replacement was needed in 1.1% of admissions; none of them died during the index hospitalization. Unplanned rehospitalizations were common at 30 days (15.7%); 38.2% of those were due to heart failure. There was no difference in in-hospital mortality between isolated TV TEER and combined MV and TV TEER (1.7% vs. 2.6%, p = 0.359). However, admissions receiving combined procedure had lower length of stay and urgent readmission rate. CONCLUSION: The current study showed that there was an increase in the utilization of TV TEER over 2016-2019 in the United States. TV TEER was associated with low rates of in-hospital mortality; however, the rate of urgent readmission remains high, mainly due to heart failure.

Simultaneous transcatheter tricuspid and mitral valve-in-valve replacement for the treatment of degenerated bioprosthetic valves.

Transcatheter valve-in-valve replacement has become a viable option for patients with degenerated bioprosthetic valves at high risk for redo surgery. We report a case of a patient who had degenerated mitral and tricuspid bioprosthesis causing severe tricuspid and mitral regurgitation. We performed simultaneous mitral and tricuspid valve-in-valve replacement via a transfemoral approach. Although the data on performing both valve-in-valve procedures are limited, this case demonstrated that these procedures can be safely done as a single procedure.

Failure of Complete Endothelialization of a Watchman Device 3 Years Post-Implantation.

We report an unusual case of incomplete endothelialization of the Watchman device >3 years after its implantation. Animal data suggest that device endothelialization occurs ∼45 days post-implantation; however, data on humans are lacking. Guidelines on anticoagulation are based on expectation from animal studies. (Level of Difficulty: Advanced.).

A Cardiac Computed Tomography-Based Score to Categorize Mitral Annular Calcification Severity and Predict Valve Embolization.

OBJECTIVES: This study aims to establish a computed tomography (CT)-based scoring system for grading mitral annular calcification (MAC) severity and potentially aid in predicting valve embolization during transcatheter mitral valve (MV) replacement using balloon-expandable aortic transcatheter heart valves. BACKGROUND: Transcatheter MV replacement is emerging as an alternative treatment for patients with severe MAC who are not surgical candidates. Although cardiac CT is the imaging modality of choice in the evaluation of candidates for valve-in-MAC (ViMAC), a standardized grading system to quantify MAC severity has not been established. METHODS: We performed a multicenter retrospective review of cardiac CT and clinical outcomes of patients undergoing ViMAC. A CT-based MAC score was created using the following features: average calcium thickness (mm), degrees of annulus circumference involved, calcification at one or both fibrous trigones, and calcification of one or both leaflets. Features were assigned points according to severity (total maximum score = 10) and severity grade was assigned based on total points (mild ≤3, moderate 4 to 6, and severe ≥7 points). The association between MAC score and device migration/embolization was evaluated. RESULTS: Of 117 patients in the TMVR in MAC registry, 87 had baseline cardiac CT of adequate quality. Of these, 15 were treated with transatrial access and were not included. The total cohort included 72 (trans-septal = 37, transapical = 35). Mean patient age was 74 ± 12 years, 66.7% were female, and the mean Society of Thoracic Surgery risk score was 15.4 ± 10.5%. The mean MAC score was 7.7 ± 1.4. Embolization/migration rates were lower in higher scores: Patients with a MAC score of 7 had valve embolization/migration rate of 12.5%, MAC score ≥8 had a rate of 8.7%, and a MAC score of ≥9 had zero (p = 0.023). Patients with a MAC score of ≤6 had 60% embolization/migration rate versus 9.7% in patients with a MAC score ≥7 (p < 0.001). In multivariable analysis, a MAC score ≤6 was in independent predictor of valve embolization/migration (odds ratio [OR]: 5.86 [95% CI: 1.00 to 34.26]; p = 0.049). CONCLUSIONS: This cardiac CT-based score provides a systematic method to grade MAC severity which may assist in predicting valve embolization/migration during trans-septal or transapical ViMAC procedures.

Intense exercise may not be so benign: chest pain in a young athletic woman may be spontaneous coronary artery dissection (SCAD).

We present a 26-year-old woman who came to the emergency department with chest pain of 1 hour duration that started while she was exercising on the treadmill. At presentation, ECG showed sinus bradycardia. Initial troponin level was 0.05 ng/mL and her chest pain resolved within 3 hours of onset. Troponins were trended serially, which continued to rise and peaked at 28.77 ng/mL and so heparin drip was started. On the second day of admission, a coronary angiogram was performed along with intravascular ultrasound, which revealed type 3 spontaneous coronary artery dissection. No obstructive atherosclerotic disease was noted in any of the coronary vessels. No coronary intervention was performed. Patient was started on aspirin and clopidogrel. Patient was discharged home in stable condition and was followed outpatient, where she remained in excellent health condition at her first clinic visit.

Prevalence and Clinical Correlates of Extended Mechanical Support in Patients Undergoing High-Risk Percutaneous Coronary Intervention in Current Clinical Practice: Insights from the cVAD Registry.

BACKGROUND: High-risk percutaneous coronary interventions (HR-PCI) are prone to hemodynamic instability, resulting in poor outcomes. Acute mechanical circulatory support (AMCS) devices are used during HR-PCI to improve outcomes. However, the clinical criteria for extended AMCS have not been well characterized. The aim of this study was to describe the prevalence and clinical correlates of extended AMCS in patients undergoing elective or urgent HR-PCI. METHODS: We retrospectively analyzed 507 patients enrolled in the catheter-based ventricular assist device (cVAD) registry who underwent elective or urgent HR-PCI with prophylactic use of Impella. The study population was divided into two groups: Impella support removed immediately after PCI (Group A, n = 464) and extended support after PCI (Group B, n = 43). Multivariable regression analysis was used to identify independent predictors of extended AMCS. RESULTS: Baseline characteristics were similar between the groups. Non-ST-elevation myocardial infarction in 26.3% in Group A vs 41.8% in Group B (p = 0.03). PCI of left main was common in Group A (p = 0.02), whereas the right coronary artery was common in Group B (p < 0.001). The mean duration of Impella support 1.1 ±â€¯0.6 h in Group A vs 11.4 ±â€¯16.8 h in Group B (p < 0.001). Death and vascular complications were higher with extended Impella support. Revascularization of chronic total occlusion (CTO) was an independent predictor of extended Impella support (OR 3.2, 95% CI 1.20-8.53). CONCLUSIONS: About 9% of patients enrolled in the cVAD registry undergoing elective or urgent HR-PCI received extended Impella support. In-hospital mortality was about 12% in patients requiring extended Impella support. CTO was associated with a higher likelihood of extended AMCS. The hemodynamic benefits of extended AMCS support must be weighed in terms of risk of complications.

Anaemia and mortality in patients with transcatheter aortic valve replacement: a systematic review and meta-analysis.

Objective: This study was done to determine the relationship between pre-procedural anaemia and mortality post transcatheter aortic valve replacement (TAVR). Introduction: TAVR is now a treatment option for patients with severe aortic stenosis (AS) with high surgical risk. Anaemia is a common comorbidity in the TAVR population. Small studies have suggested that anaemia is associated with worse short-term and long-term mortality in patients who underwent TAVR. However, there are no meta-analyses to further assess this association. Method: Studies were systematically searched from electronic databases (EMBASE and MEDLINE). Inclusion criteria were adult population with aortic stenosis who underwent TAVR, and number of patients with pre-procedural anaemia reported. Outcomes were short-term mortality or long-term mortality. Pooled effect size was calculated with a random-effect model, weighted for the inverse of variance. Heterogeneity was assessed with I2. Results: Six studies were included in the final analysis. Of these, pooled analysis of four studies examining association between anaemia and 30-day mortality did not show a statistically significant relationship. A pooled analysis of four studies examining the association of anaemia and long-term mortality after TAVR showed pooled adjusted risk ratio (RR) of 1.43, 95% CI 1.22-1.67 with low heterogeneity (I2 = 33%). Subgroup analysis after exclusion of one smaller study showed that the association remained significant (RR 1.41, 95% CI 1.27-1.56) with decreased heterogeneity (I2 = 0%). Conclusion: This systematic review and meta-analysis found an association between pre-procedural anaemia and increased long-term but not short-term mortality after TAVR. Further study of the pathophysiology underlying this association is needed.

Unloading the Left Ventricle Before Reperfusion in Patients With Anterior ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: In ST-segment-elevation myocardial infarction (STEMI), infarct size correlates directly with heart failure and mortality. Preclinical testing has shown that, in comparison with reperfusion alone, mechanically unloading the left ventricle (LV) before reperfusion reduces infarct size and that 30 minutes of unloading activates a cardioprotective program that limits reperfusion injury. The DTU-STEMI pilot trial (Door-To-Unload in STEMI Pilot Trial) represents the first exploratory study testing whether LV unloading and delayed reperfusion in patients with STEMI without cardiogenic shock is safe and feasible. METHODS: In a multicenter, prospective, randomized exploratory safety and feasibility trial, we assigned 50 patients with anterior STEMI to LV unloading by using the Impella CP followed by immediate reperfusion (U-IR) versus delayed reperfusion after 30 minutes of unloading (U-DR). The primary safety outcome was a composite of major adverse cardiovascular and cerebrovascular events at 30 days. Efficacy parameters included the assessment of infarct size by using cardiac magnetic resonance imaging. RESULTS: All patients completed the U-IR (n=25) or U-DR (n=25) protocols with respective mean door-to-balloon times of 72 versus 97 minutes. Major adverse cardiovascular and cerebrovascular event rates were not statistically different between the U-IR versus U-DR groups (8% versus 12%, respectively, P=0.99). In comparison with the U-IR group, delaying reperfusion in the U-DR group did not affect 30-day mean infarct size measured as a percentage of LV mass (15±12% versus 13±11%, U-IR versus U-DR, P=0.53). CONCLUSIONS: We report that LV unloading using the Impella CP device with a 30-minute delay before reperfusion is feasible within a relatively short time period in anterior STEMI. The DTU-STEMI pilot trial did not identify prohibitive safety signals that would preclude proceeding to a larger pivotal study of LV unloading before reperfusion. An appropriately powered pivotal trial comparing LV unloading before reperfusion to the current standard of care is required. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03000270.

The Effects of Geography on Outcomes of Routine Early Versus Selective Late Revascularization Strategy in the Treatment of Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: A Meta-Analysis of Transatlantic Randomized Controlled Trials.

BACKGROUND: The optimal timing of revascularization in unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI) remains uncertain. We compared routine early revascularization (REV) versus selective late revascularization (SLR) strategies and divergence in the approach of cardiologists in the United States and Europe. METHODS: Seventeen randomized controlled trials (RCTs) (15,812 patients) were extracted from PubMed, Cochrane Library, EMBASE and Web of Science databases. The data were pooled using the Der Simonian and Laird random-effect models and expressed as pooled risk ratios (RR) with 95% confidence intervals (95% CIs). RESULTS: Overall, there was no difference in all-cause mortality (RR: 1.01, 95% CI: 0.95 - 1.08, P = 0.7), myocardial infarction (MI) (RR: 0.98, 95% CI: 0.79 - 1.22, P = 0.85) or coronary artery bypass grafting (CABG) (RR: 1.33, 95% CI: 0.92 - 1.91, P = 0.12) between REV and SLR strategy. There were trends of decreased incidence of MI in REV, 13.3% (1,029/7,704) vs. 15.1% (1,108/7,314) in SLR (P = 0.007), and rate of CABG was higher in REV, 4.9% (140/2,831) vs. 3.7% (105/2,819) in SLR (P = 0.031). There were trends of lower all-cause mortality in the combined US/international trials in both REV 8.4% (390/4,624) vs. 22.8% (908/3,975) (P < 0.001) and SLR 8% (359/4,421) vs. 24% (910/3,808) (P < 0.001) compared to the European trials. There were also trends of lower rates of MI in the European trials in the REV group 20% (623/3,080) vs. 25% (712/2,893) in SLR (P = 0.001) and higher rates of CABG in REV 8.3% (96/1,144) vs. 5.7% (67/1,165) in SLR (P = 0.02); however, there were no significant effects in the pooled RR ratios even after subgroup analysis between US/international trials and European trials. CONCLUSIONS: Despite having contemporary differences in the management approach towards UA/NSTEMI patients, no significant differences in trends were observed with REV strategy in US/international trials vs. European trials.

Pericardium: The Forgotten Space During Acute Myocardial Infarction.

BACKGROUND: Acute pericardial pathologies, such as pericardial effusion, pericarditis, and cardiac tamponade, have been reported rarely in patients presenting as ST-elevation myocardial infarction (STEMI). We present a series of 3 patients with STEMI, where an undiagnosed pericardial effusion led to pericardial tamponade and subsequent cardiocirculatory collapse. CASE REPORTS: This is a case series of 3 patients, all women, aged 72, 64, and 54 years who presented to the emergency department with chest pain or syncope and were found to have STEMI with hemodynamic instability. They were taken to the catheterization laboratory for urgent coronary revascularization requiring mechanical circulatory support (intra-aortic balloon pump or impella). During catheterization, all 3 patients were diagnosed with large pericardial effusion using hemodynamic parameters and bedside transesophageal echocardiogram. Commonly ignored, pericardial tamponade and acute large pericardial effusion can be the cause of cardiocirculatory collapse. Two of the 3 patients survived with aggressive interventions requiring pericardial drains, long-term mechanical circulatory support, and effective postoperative rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important for treating clinicians, including emergency physicians, intensivist, and cardiologist, to consider the differential of a cardiac tamponade due to a pericardial effusion as a potential cause for hypotension in patients with an acute STEMI.

Trends, etiologies, and predictors of 90-day readmission after percutaneous ventricular assist device implantation: A national population-based cohort study.

Percutaneous ventricular assist devices (pVADs) are indicated to provide hemodynamic support in high-risk percutaneous interventions and cardiogenic shock. However, there is a paucity of published data regarding the etiologies and predictors of 90-day readmissions following pVAD use. We studied the data from the US Nationwide Readmissions Database (NRD) for the years 2013 and 2014. Patients with a primary discharge diagnosis of pVAD use were collected by searching the database for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedural code 37.68 (Impella and TandemHeart devices). Amongst this group, we examined 90-day readmission rates. Comorbidities as identified by "CM_" variables provided by the NRD were also extracted. The Charlson Comorbidity Index was calculated using appropriate ICD-9-CM codes, as a secondary diagnosis. A 2-level hierarchical logistic regression model was then used to identify predictors of 90-day readmission following pVAD use. Records from 7074 patients requiring pVAD support during hospitalization showed that 1562 (22%) patients were readmitted within 90 days. Acute decompensated heart failure (22.6%) and acute coronary syndromes (11.2%) were the most common etiologies and heart failure (odds ratio [OR]: 1.39, 95% confidence interval [CI]: 1.17-1.67), chronic obstructive pulmonary disease (OR: 1.26, 95% CI: 1.07-1.49), peripheral vascular disease (OR: 1.305, 95% CI: 1.09-1.56), and discharge into short- or long-term facility (OR: 1.28, 95% CI: 1.08-1.51) were independently associated with an increased risk of 90-day readmission following pVAD use. This study identifies important etiologies and predictors of short-term readmission in this high-risk patient group that can be used for risk stratification, optimizing discharge, and healthcare transition decisions.

1-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Mitral Annular Calcification.

BACKGROUND: The risk of surgical mitral valve replacement in patients with severe mitral annular calcification (MAC) is high. Several patients worldwide with severe MAC have been treated successfully with transcatheter mitral valve replacement (TMVR) using balloon-expandable aortic transcatheter valves. The TMVR in MAC Global Registry is a multicenter registry that collects data on outcomes of these procedures. OBJECTIVES: The goal of this study was to evaluate 1-year outcomes in this registry. METHODS: This study was a multicenter retrospective review of clinical outcomes. RESULTS: A total of 116 extreme surgical risk patients with severe MAC underwent TMVR; 106 had a procedure date >1 year before data-lock and were included in the analysis. Their mean age was 73 ± 12 years, and 68% were female. The mean Society of Thoracic Surgeons score was 15.3 ± 11.6%, and 90% were in New York Heart Association functional class III or IV. Thirty-day and 1-year all-cause mortality was 25% and 53.7%, respectively. Most patients who survived 30 days were alive at 1 year (49 of 77 [63.6%]), and the majority (71.8%) were in New York Heart Association functional class I or II. Echocardiography data at 1 year were available in 34 patients. Mean left ventricular ejection fraction was 58.6 ± 11.2%, mean mitral valve area was 1.9 ± 0.5 cm2, mean mitral gradient was 5.8 ± 2.2 mm Hg, and 75% had zero or trace mitral regurgitation. CONCLUSIONS: TMVR with balloon-expandable aortic valves in extreme surgical risk patients with severe MAC is feasible but associated with high 30-day and 1-year mortality. Most patients who survive the 30-day post-procedural period are alive at 1 year and have sustained improvement of symptoms and transcatheter valve performance. The role of TMVR in patients with MAC requires further evaluation in clinical trials.

Cholesterol embolization syndrome: An under-recognized entity in cardiovascular interventions.

Cholesterol embolization syndrome (CES) is a multi-systemic disease caused by embolization of atherosclerotic plaque contents from proximal large-caliber artery to distal small to medium arteries, occurring spontaneously or more commonly after vascular intervention. This report is a comprehensive review of the reported cases of CES found in our literature search. We discuss the risk factors, clinical manifestations, management, and prognosis of CES. The major predisposing factors for CES include older age, male sex, atherosclerotic cardiovascular risk factors, anticoagulation, and femoral access route. The composite incidence of atheroembolic renal disease was 92% and mortality 63%. Our review highlights the importance to recognize this disease entity for the cardiologist and nephrologist.

Effects of staged versus ad hoc percutaneous coronary interventions on renal function-Is there a benefit to staging?

AIM: The purpose of this study is to determine whether ad hoc (same session) percutaneous coronary intervention, and staged (multiple session) percutaneous coronary intervention (PCI) have different renal outcomes. METHODS AND RESULTS: This is a retrospective cohort study that compares the maximal decline in glomerular filtration rate (GFR) at various times points (3-6days, 1-4weeks, 4-12weeks) after either ad hoc or staged PCI. 115 patients undergoing staged PCI and 115 matched ad hoc PCI controls were included in the study. They were equivalent in baseline GFR, left ventricular ejection fraction and intra-procedural volume status based on LVEDP. The group undergoing staged PCI had greater cumulative fluoroscopy time, SYNTAX score and number of stents placed. Staged PCIs used less contrast per catheterization (155.0±5.6mL) but higher cumulative contrast dose (326.6±14.0mL) compared to ad hoc PCIs (193.4±7.2mL). Following intervention, there was a progressive decline in renal function that did not significantly differ between the ad hoc and staged groups. In the subgroup of patients with initial GFR ≤60cm3/min, staged PCI was associated with 2.6-fold greater decline in renal function 4-12weeks after the procedure compared to ad hoc. A propensity match analysis performed in patients with GFR ≤60cm3/min confirmed worse renal function in the staged group at 4-12weeks. CONCLUSIONS: Staged PCI exposes patients to greater cumulative contrast agent loads. The decline in renal function observed in both groups did not differ significantly, however worse renal outcomes were observed in the staged PCI group with baseline GFR ≤60cm3/min.