Congenital Anomaly Diagnosis of Typical Cardiac Chest Pain Due to Thebesian Veins Draining Into the Left Ventricular Chamber: A Case Report and Review of Literature.

Thebesian veins are microfistulae that drain the coronary arteries directly into one or more chambers of the heart. Persistence of these anomalous connections into adulthood can lead to shunting of blood away from the myocardium causing typical chest pain symptoms with electrocardiogram changes consistent with ischemia. We describe a case of a 77-year-old female who underwent ischemic evaluation for her symptoms found to have significant Thebesian veins. We also engage in a comprehensive review of the literature finding consistencies in the way these cases are presented in the literature.

Systematic review and meta-analysis comparing Manta device and Perclose device for closure of large bore arterial access.

Data comparing MANTA device with Perclose device for large bore arterial access closure is limited. We performed meta-analysis to compare safety and efficacy of the two devices in large (⩾14 Fr sheath) arteriotomy closure post-TAVR. Relevant studies were identified via PubMed, Cochrane, and EMBASE databases until June, 2022. Data was analyzed using random effect model to calculate relative odds of VARC-2 defined access-site complications and short-term (in-hospital or 30-day) mortality. A total of 12 studies (2 RCT and 10 observational studies) comprising 2339 patients were included. The odds of major vascular complications (OR 0.99, 95% CI 0.51-1.92; p = 0.98); life threatening and major bleeding (OR 0.77, 95% CI 0.45-1.33; p = 0.35); minor vascular complications (OR 1.37, 95% CI 0.63-2.99; p = 0.43); minor bleeding (OR 0.94, 95% CI 0.57-1.56; p = 0.82); device failure (OR 0.74, 95% CI 0.49-1.11; p = 0.14); hematoma formation (OR 0.76, 95% CI 0.33-1.75; p = 0.52); dissection, stenosis, occlusion, or pseudoaneurysm (OR 1.08, 95% CI 0.71-1.62; p = 0.73) and short-term mortality (OR 1.01, 95% CI 0.55-1.84; p = 0.98) between both devices were similar. MANTA device has a similar efficacy and safety profile compared to Perclose device.

A Case of Cardiac Arrest Due to Transcatheter Aortic Valve Infolding.

Prosthetic valvular infolding during transcatheter aortic valve implantation (TAVI) is an under-recognized yet significant complication that can occur. Here, we describe the case of a 61-year-old male with a history of heart failure with reduced ejection fraction (HFrEF) and low-flow, low-gradient severe aortic valve stenosis of a bicuspid aortic valve who presented to undergo TAVI. During the procedure, repositioning of the valve resulted in prosthetic valvular infolding and resultant severe aortic regurgitation (AR), culminating in cardiac arrest. Swift balloon valvuloplasty corrected the valve geometry and eliminated any AR, allowing hemodynamic recovery and completion of the procedure. Our case and review highlight methods, both angiographic and echocardiographic, to recognize prosthetic valvular infolding the moment it presents, as well as strategies to correct the infolding with minimal detriment to the patient.

Angiographic-only or intravascular ultrasound-guided approach for left-main coronary artery intervention: a systematic review and meta-analysis.

INTRODUCTION: The use of intravascular ultrasound (IVUS) in percutaneous revascularization of left-main coronary artery disease (LMCAD) warrants further exploration. We aimed to collate all available data on the merits of IVUS in LMCAD to help decision-making. METHODS: The MEDLINE, Embase, and Cochrane databases were queried for relevant randomized controlled trials (RCTs) and observational cohort studies (OCS). The data were analyzed using random-effects model to calculate unadjusted odds ratio (OR) between IVUS-guided and angiography-only LMCA revascularization. RESULTS: A total of 14 studies (2 RCTs and 12 OCS), comprising 18944 patients, were included. The pooled odds of all-cause mortality (OR 0.57, 95%CI 0.46-0.70, p = <0.00001), cardiovascular mortality (OR 0.37, 95%CI 0.26-0.54, p = <0.00001), left-main revascularization (OR 0.63, 95%CI 0.45-0.89, p = 0.009) and myocardial infarction (OR 0.80, 95% CI 0.66-0.97, p = 0.02) were significantly lower with IVUS-guidance. There was no difference observed in the odds of the stent thrombosis (OR 0.57, 95% CI 0.31-1.05, p = 0.07) and stroke (OR 1.7, 95%CI 0.56-5.14, p = 0.35) between the two groups. A subgroup analysis based on the study design and follow-up duration mirrored the pooled estimates. CONCLUSION: IVUS-guided LMCA intervention is associated with overall improved cardiovascular outcomes than the angiography-only approach. This needs to be tested in a large randomized controlled trial.

Meta-analysis comparing valve-in-valve TAVR and redo-SAVR in patients with degenerated bioprosthetic aortic valve.

INTRODUCTION: The comparative efficacy and safety of valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) and redo-surgical AVR (redo-SAVR) in patients with degenerated bioprosthetic aortic valves remain unknown. METHOD: Digital databases were searched to identify relevant articles. Unadjusted odds ratios for dichotomous outcomes were calculated using a random effect model. A total of 11 studies comprising 8326 patients (ViV-TAVR = 4083 and redo-SAVR = 4243) were included. RESULTS: The mean age of patients undergoing ViV-TAVR was older, 76 years compared to 73 years for those undergoing SAVR. The baseline characteristics for patients in ViV-TAVR vs. redo-SAVR groups were comparable. At 30-days, the odds of all-cause mortality (OR 0.45, 95% CI 0.30-0.68, p = .0002), cardiovascular mortality (OR 0.44, 95% CI 0.26-0.73, p = .001) and major bleeding (OR 0.29, 95% CI 0.15-0.54, p = .0001) were significantly lower in patients undergoing ViV-TAVR compared to redo-SAVR. There were no significant differences in the odds of cerebrovascular accidents (OR 0.91, 95% CI 0.52-1.58, p = .74), myocardial infarction (OR 0.92, 95% CI 0.44-1.92, p = .83) and permanent pacemaker implantation (PPM) (OR 0.54, 95% CI 0.27-1.07, p = .08) between the two groups. During mid to long-term follow up (6-months to 5-years), there were no significant differences between ViV-TAVR and redo-SAVR for all-cause mortality, cardiovascular mortality and stroke. ViV-TAVR was, however, associated with higher risk of prosthesis-patient mismatch and greater transvalvular pressure gradient post-implantation. CONCLUSION: ViV-TAVR compared to redo-SAVR appears to be associated with significant improvement in short term mortality and major bleeding. For mid to long-term follow up, the outcomes were similar for both groups.

Impact of Age in Acute Myocardial Infarction Cardiogenic Shock: Insights From the National Cardiogenic Shock Initiative.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with high mortality. Patients ≥75 years old represent an increasing proportion of those who present with AMICS and are at high risk for adverse outcomes. METHODS: The National Cardiogenic Shock Initiative includes patients with AMICS treated using a standard shock protocol with early invasive hemodynamic monitoring, mechanical circulatory support (MCS), and percutaneous coronary intervention (PCI). We evaluated the outcomes of patients based on their age group, dividing them into <75 and ≥75 years old. RESULTS: We included 300 consecutive patients: 238 were <75 years old (79.3%) and 62 patients ≥75 years old. There were significant differences in survival; patients <75 years old had a 75.6% survival, while those ≥75 years old had a 50% survival (adjusted OR: 10.4, P = 0.001). SCAI shock classification impacted survival as well; those <75 years old with class C or D shock had a survival of 84%, compared with 57% in those ≥75 years old. Patients ≥75 years old requiring 1 or 2 vasopressors had significantly lower survival rates (36% and 25%, respectively) when compared with patients <75 years old (76.7% with 1 and 60.5% with >1 vasopressor). CONCLUSIONS: Age is inversely proportional to survival; patients <75 years old have high rates of survival if treated using best practices with invasive hemodynamic monitoring, early MCS, and PCI. However, using a standardized protocol can improve survival in the elderly; therefore, age on its own should not be a reason to withhold PCI or MCS use.

The impact of fractional flow reserve measurement on clinical outcomes after transradial coronary stenting.

AIMS: Fractional flow reserve (FFR) ≥0.96 after stenting correlates well with an optimal stent expansion, but outcomes based on FFR after drug eluting stents (DES) have not been studied. This study sought to investigate the proportion of patients in whom an FFR ≥0.96 can be achieved after transradial stenting using primarily DES and to determine outcomes based on a post-stent FFR ≥0.96 vs. an FFR<0.96. METHODS AND RESULTS: A total of 66 patients with single-vessel disease and FFR<0.75 underwent transradial stenting. After stenting, FFR was <0.96 in 34 patients and there was a hyperaemic trans-stent gradient across the edges of stent in five patients; after high-pressure balloon inflation, FFR increased to ≥0.96 in three patients and an FFR ≥0.96 was achieved in 35 patients (53%, group 1), but FFR remained <0.96 in 31 patients (47%, group 2). There was no correlation between FFR and minimum lumen diameter in group 1 or group 2 (r=0.03; p=0.72 and r=0.02; p=0.22, respectively). The 24-month event-free survival estimate defined as freedom from death, MI, and target vessel revascularisation (PCI or CABG) was significantly greater in group 1 than in group 2 (94% versus 72%, respectively; p=0.02). CONCLUSIONS: After transradial stenting with predominately DES, an FFR ≥0.96 was achieved in only 53% of patients and event rates among patients with a post-stent FFR ≥0.96 were significantly lower than those with an FFR<0.96.

Does left atrial volume affect exercise capacity of heart transplant recipients?

BACKGROUND: Heart transplant (HT) recipients demonstrate limited exercise capacity compared to normal patients, very likely for multiple reasons. In this study we hypothesized that left atrial volume (LAV), which is known to predict exercise capacity in patients with various cardiac pathologies including heart failure and hypertrophic cardiomyopathy is associated with limited exercise capacity of HT recipients. METHODS: We analyzed 50 patients [age 57 ±2 (SEM), 12 females] who had a post-HT echocardiography and cardiopulmonary exercise test (CPX) within 9 weeks time at clinic follow up. The change in LAV (ΔLAV) was also computed as the difference in LAV from the preceding one-year to the study echocardiogram. Correlations among the measured parameters were assessed with a Pearson's correlation analysis. RESULTS: LAV (n = 50) and ΔLAV (n = 40) indexed to body surface area were 40.6 ± 11.5 ml·m-2 and 1.9 ± 8.5 ml·m-2·year-1, data are mean ± SD, respectively. Indexed LAV and ΔLAV were both significantly correlated with the ventilatory efficiency, assessed by the VE/VCO2 slope (r = 0.300, p = 0.038; r = 0.484, p = 0.002, respectively). LAV showed a significant correlation with peak oxygen consumption (r = -0.328, p = 0.020). CONCLUSIONS: Although our study is limited by a retrospective study design and relatively small number of patients, our findings suggest that enlarged LAV and increasing change in LAV is associated with the diminished exercise capacity in HT recipients and warrants further investigation to better elucidate this relationship.