Cardiac Arrest as First Presentation of Thyroid Storm.

Thyroid storm is a life-threatening condition characterized by a high level of circulating thyroid hormones and harbors high mortality and morbidity, even if diagnosed and treated early. The condition is frequently overlooked and under-recognized in emergency departments owing to its rarity. Here, we present a case of a 24-year-old male patient, previously healthy, who presented with cardiac arrest and was found to have heart failure and high thyroid hormone levels after investigations. Consequently, the presentation was attributed to thyroid storm. His clinical status and cardiac function improved after treatment of the hyperthyroidism.

Pulmonary vein stenosis presenting as massive hemoptysis, treated with pulmonary veins angioplasty.

Two patients with history of cardiac ablation presented with massive hemoptysis secondary to pulmonary vein stenosis. They underwent successful pulmonary vein angioplasty and stenting. Although the second patient ended up having a lobectomy, the successful opening of the Left Superior Pulmonary Vein helped sparing the superior lobe and lingula.

Focal Myocarditis As the First Sign in the Presentation of a COVID-19 Infection: A Case Report.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). Patients with COVID-19 typically present with symptoms and signs related to respiratory tract infection. However, a broad spectrum of cardiac manifestations including myocarditis has been reported as complications of this virus. Nevertheless, focal myocarditis as the first clinical manifestation of COVID-19 infection has not been reported before. Thus, we herein present the case of a 56-year-old male patient previously healthy and presented to the emergency department with chest pain. The clinical picture was compatible with inferior ST-elevation myocardial infarction (STEMI). Initial COVID-19 polymerase chain reaction (PCR) was negative, as well for its classic symptoms. Thereafter, further investigations suggested the diagnosis of focal myocarditis. Later on, the patient started to have a fever and repeated COVID-19 PCR that returned positive.

Update on coronary artery bioresorbable vascular scaffolds in percutaneous coronary revascularization.

Coronary angioplasty was first introduced in 1977. From plain old balloon angioplasty to the introduction of bare metal stents in 1986 and dual antiplatelet therapy in 1992 to much more later on. Due to the unacceptable rate of stent restenosis, drug eluting stents (DES) were introduced in 2000. The first generation showed an increase in late stent thrombosis which led to the introduction of the second generation DES with biocompatible or biodegradable polymers and thinner platforms. However very late stent thrombosis and late restenosis might still pose problems in the latter. Furthermore, there has been major debate regarding the impact of long-term vessel caging on normal vasomotricity and long-term positive remodeling. To resolve these issues, the bioresorbable vascular scaffolds (BVS) were launched into the real world in 2011, showing promising initial results. Multiple randomized trials, meta-analyses, and registries were performed, mainly with the Absorb Bioresorbable Vascular Scaffold System (Abbott Vascular, Chicago, IL, USA). This new technology is hindered by certain features, such as the BVS radial strength, its strut thickness, and the inflammatory process related to scaffold degradation. Moreover, there is known data indicating higher thrombosis rate with the Absorb BVS compared with the new generation of DES, despite similar cardiovascular death. In this review, we discuss the clinical procedural and technical evidence on BVS, with emphasis on their clinical impact. We finally tackle the future directions on device and procedural improvement while asking: is the bioresorbable technology still the way to the future?

Thoracic aortic disease: Can we safely cover the branches?

Thoracic aortic disease has usually been treated with surgery. Thoracic endovascular aortic repair is challenging if supra-aortic vessels are involved. In situ fenestration of the main graft from a retrograde approach while using bare-metal stents as bridge stents appears to be a safe and practical technique.

Delivery catheters: Do they truly make a difference in transcatheter pulmonary valve replacement?

Transcatheter pulmonary valve replacement (TPVR) is a safe and feasible procedure for treating pulmonary stenosis, failed right ventricular conduits, or failed bioprosthetic valves. The medtronic melody valve and the Edwards Sapien XT and S3 valves have been the main prosthetic valves used in TPVR. Using the GORE DrySeal sheath helps valve delivery and facilitates TPVR.

Myocardial fibrosis and MitraClip: Does it even matter?

Preprocedural myocardial fibrosis as identified by magnetic resonance imaging correlates with worse outcomes after MitraClip placement. Post-MitraClip mitral regurgitation gradient >2 or ischemic cardiomyopathy also correlates with worse outcomes. In the literature, other variables are mentioned (e.g., severe tricuspid regurgitation, atrial fibrillation, postoperative mitral valve area and/or gradient) that correlate with worse post-MitraClip outcomes.

Does single-valve surgery cause ischemia?

Isolated valve surgery is associated with a small incidence of postoperative PCI. PCI after single-valve surgery is associated with elevated mortality and morbidity risk. Possible mechanisms for cardiac ischemia include iatrogenic causes (such as suture-related or air embolism), intimal hyperplasia, and immunologic reaction to the valve prosthesis.

TAVI: How to best predict postprocedural outcomes?

Baseline risk scores for TAVI patients, including STS and EuroSCORE, might not predict long-term outcomes. Including postprocedural data might improve risk stratification. The ACEF-7 risk score includes the lowest creatinine clearance in the first 7 postprocedural days and appears to be a good predictor of worse long-term outcomes.

Plug vs. suture: Who wins in large bore access closure?

Large Bore Access in increasingly common and surgical closure used to be the gold standard for closure. Novel less invasive closure devices such as the suture based vascular devices offer a safe alternative to surgery. Recent developments provide us with MANTA (Essential Medical Inc., Malvern, Pennsylvania) a vascular closure device that seems to be as safe and associated with less bleeding. Certain genetic polymorphisms might account for HoTPR.

Aortic dissection: Is the false lumen really important?

Aortic dissection is associated with a high mortality rate and has been increasingly treated with endovascular therapy. False lumen (FL) patency has been shown to be associated with worse outcomes. FL interventions that incorporate the FLIRT (FL intervention to promote remodeling and thrombosis) concept have been associated with improved aortic remodeling that may confer favorable long-term outcomes.

Bleeding in patients receiving non-vitamin K oral anticoagulants: clinical trial evidence.

In optimizing anticoagulation therapy, it is essential to balance treatment efficacy with the major adverse effect of anticoagulant treatment, bleeding risk. This narrative review examines the efficacy and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban compared with standard anticoagulation or placebo. NOAC therapies provide equivalent to superior protection versus standard therapy, with similar or superior safety, and potential benefits in convenience. We will review the phase III evidence for each of the available NOACs in different antithrombotic indications, including atrial fibrillation (in the absence of significant mitral stenosis or mechanical heart valves); prophylaxis of venous thromboembolism (VTE) in patients undergoing orthopedic surgery; and acute and long-term treatment of VTE. Further, we will illustrate scenarios in which the evidence is stronger for a particular agent in the context of the overall positive safety and efficacy profile of NOACs in general. Limitations of the factor Xa inhibitors include the lack of a specific antidote in case of a bleeding emergency (an approved agent is available for reversing the effect of the direct thrombin inhibitor). We discuss the options for mitigating bleeding and describe the ongoing developments towards specific reversal agents. In conclusion, the available data for efficacy and safety, together with reliable pharmacokinetics obviating the need for regular monitoring, indicate that NOACs may offer substantial benefits for patients with nonvalvular atrial fibrillation or VTE.

Use of an AFX aortic cuff in the endovascular treatment of aortocaval fistula secondary to abdominal aortic pseudoaneurysm.

Aortocaval fistula (ACF) is rare and lethal and can be either primary (due to an enlarged abdominal aortic aneurysm) or secondary (iatrogenic or secondary to abdominal surgery) in origin. We describe a case of an ACF secondary to a ruptured abdominal aortic pseudoaneurysm that we successfully treated with a planned endovascular approach using an AFX aortic cuff on both the arterial and venous sides.

Peripheral artery disease: How do genes and pharmacology interplay?

In patients with peripheral artery disease, high on-treatment platelet reactivity (HoTPR) might be associated with worse outcomes for those taking clopidogrel, but not for those taking aspirin. Certain genetic polymorphisms might account for HoTPR. Current literature supports the importance of antiplatelet therapy in treating patients with PAD with clopidogrel, aspirin, or both.

Chronic total occlusion: Does anti-platelet choice impact outcomes?

Chronic total occlusion (CTO) is associated with worse outcomes compared to non CTO percutaneous coronary intervention (PCI). CTO might be associated with vasomotor dysfunction Ticagrelor is a novel P2Y12 inhibitor that increases local adenosine The TIGER-BVS trial plans to assess the impact of using ticagrelor vs. clopidogrel on vasomotor activity and outcomes after successful CTO PCI.

A cardiologist's nightmare: Coronary obstruction during transcatheter aortic valve implantation: How to identify patients at highest risk for this complication.

Transcatheter aortic valve implantation (TAVI) is associated with several complications including coronary obstruction (CO) CO occurs in ∼1% of patients and mostly in patients receiving the SAPIEN XT valve Possible predictors of CO include coronary height <10 mm and aortic sinus diameter of <30 mm.

"To close or not to close?" When should vascular closure devices be used after cardiac catheterization procedures?

Vascular closure devices (VCD) appear to be safe when compared to manual compression or surgical closure. VCDs' main advantage seems to stem from lower time to hemostasis (TTH) and time to mobilization. In anticoagulated patients with 6-Fr femoral sheaths, the new Celt ACT VCD, which uses a stainless-steel permanent implant, seems to be safe and decreases TTH when compared to manual pressure.