Percutaneous Coil Embolization of Coronary Artery Fistula Complicated by Refractory Ventricular Fibrillation and Cardiogenic Shock.

We present a case of a 56-year-old patient with a symptomatic right coronary artery to pulmonary artery fistula who underwent coil embolization. Post-procedure, the patient developed ventricular fibrillation that was refractory to antiarrhythmic medications and numerous attempts at defibrillation. (Level of Difficulty: Intermediate.).

Case Series of Percutaneous Mechanical Aspiration of Mitral Valve Endocarditis.

Infective endocarditis of the mitral valve that is refractory to medical therapy requires surgical debridement. However, patients who are high risk for surgery have limited options. We report 3 cases of refractory infective endocarditis involving the mitral valve that were treated with percutaneous mechanical aspiration with an embolic protection system. (Level of Difficulty: Intermediate.).

Clinical outcomes of percutaneous debulking of tricuspid valve endocarditis in intravenous drug users.

OBJECTIVES: A retrospective case series of a percutaneous approach to debulk tricuspid valve endocarditis (TVE) using an 8 French mechanical aspiration system in patients with a history of intravenous drug use (IVDU) was reported. IVDU associated TVE is increasing in the United States and is associated with high mortality despite early surgical debridement. Patients with advanced disease, shock, and respiratory failure may not be candidates for surgical debridement or replacement. These patients have recurrent events despite medical therapy METHODS: About 25 patients with IVDU associated TVE with persistent bacteremia confirmed by repeat blood cultures after 72 hr of sensitivity directed antibiotics and presence of pulmonary emboli confirmed by computed tomographic (CT) scan, who had undergone percutaneous aspiration were included. Patients were all deemed high risk for surgical debridement by a CT surgeon and evaluated by an infectious disease consultant. Procedures were performed under moderate sedation with intracardiac echo and a steerable guide with a CAT8 Penumbra aspiration catheter. RESULTS: There were no intraprocedural deaths or complications. About 36% had septic shock on presentation. Survival of index hospitalization was 88%. Repeat blood cultures showed no growth on all surviving patients. Readmission rate was 4% (n = 1) at 1 month. About 40% (n = 2) patients with septic shock survived at 1 month compared with 100% survival (n = 20) in those without shock. Presence of septic shock was associated with reduced survival at 1 month (p < .01). CONCLUSION: Percutaneous mechanical aspiration with an 8 Fr system is a feasible, minimally invasive alternative to surgical debulking. Mortality remains high in those presenting with septic shock. Further studies are needed to evaluate long-term outcomes.

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.

Percutaneous Mechanical Aspiration vs Valve Surgery for Tricuspid Valve Endocarditis in People Who Inject Drugs.

BACKGROUND: Valve surgery in tricuspid valve infective endocarditis (TVIE) is controversial in people who inject drugs (PWID) due to perceived risks of reinfection because of recidivism. The study objective was to compare outcomes of percutaneous mechanical aspiration (PMA) using the Penumbra Indigo system to valve surgery in PWID with TVIE. METHODS: Retrospective cohort of adult PWID hospitalized with definite TVIE and received PMA or valve surgery from January 2014 to April 2019. Primary endpoint was all-cause 12-month mortality; secondary endpoints included in-hospital mortality and all-cause 12-month readmission. RESULTS: In total, 85 patients were included: 42 undergoing PMA and 43 undergoing valve surgery. Baseline patient demographics were similar between groups; 62 (73%) patients were women, and the median age was 31 (interquartile range, 27-41) years. Seventy-four (86%) patients had a previous history of infective endocarditis and received long-term antibiotic therapy before surgical intervention; 33 (38%) patients presented with septic shock on admission. The most commonly organism was methicillin-resistant Staphylococcus aureus (n = 32 of 84, 38%). Five (12%) PMA patients died in hospital compared with 1 (2%) patient who received valve surgery (P = .11). All-cause 12-month mortality was 24% and 19% for the PMA and surgery groups, respectively (P = .57). When considering confounders, there was no difference in all-cause 12-month mortality between the PMA and valve surgery groups (adjusted odds ratio, 1.5; 95% confidence interval, 0.48-4.8); no significant differences in secondary outcomes were identified. CONCLUSIONS: PMA was associated with similar outcomes to valve surgery for management of TVIE in PWID. PMA may be an alternative to valve surgery as a treatment or bridging strategy to surgery while PWID undergo addiction treatment.

Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative.

BACKGROUND: The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). METHODS: Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the "SHOCK" trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS. RESULTS: A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12-24 hr reliably predicted overall mortality postindex procedure. CONCLUSION: In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.

The Mitochondrial Permeability Transition Pore Regulator Cyclophilin D Exhibits Tissue-Specific Control of Metabolic Homeostasis.

The mitochondrial permeability transition pore (mPTP) is a key regulator of mitochondrial function that has been implicated in the pathogenesis of metabolic disease. Cyclophilin D (CypD) is a critical regulator that directly binds to mPTP constituents to facilitate the pore opening. We previously found that global CypD knockout mice (KO) are protected from diet-induced glucose intolerance; however, the tissue-specific function of CypD and mPTP, particularly in the control of glucose homeostasis, has not been ascertained. To this end, we performed calcium retention capacity (CRC) assay to compare the importance of CypD in the liver versus skeletal muscle. We found that liver mitochondria are more dependent on CypD for mPTP opening than skeletal muscle mitochondria. To ascertain the tissue-specific role of CypD in metabolic homeostasis, we generated liver-specific and muscle-specific CypD knockout mice (LKO and MKO, respectively) and fed them either a chow diet or 45% high-fat diet (HFD) for 14 weeks. MKO mice displayed similar body weight gain and glucose intolerance compared with wild type littermates (WT), whereas LKO mice developed greater visceral obesity, glucose intolerance and pyruvate intolerance compared with WT mice. These findings demonstrate that loss of muscle CypD is not sufficient to alter whole body glucose metabolism, while the loss of liver CypD exacerbates obesity and whole-body metabolic dysfunction in mice fed HFD.

Distal coronary perforation in patients with prior coronary artery bypass graft surgery: The importance of early treatment.

In patients with prior coronary artery bypass graft (CABG) surgery, distal coronary perforations are commonly considered to be at low risk for causing cardiac tamponade due to a potential protective role of pericardial adhesions, which obliterate the pericardial space. Loculated effusions can however form in such patients, compressing various cardiac structures and causing hemodynamic compromise. We present two cases of distal coronary perforation in prior CABG patients undergoing chronic total occlusion percutaneous coronary intervention. In the first case a distal coronary perforation was initially observed, resulting in a loculated pericardial effusion that caused ST-segment elevation and death, despite successful sealing of the perforation. In the second case a similar perforation was immediately sealed with a covered stent, followed by uneventful patient recovery. A literature review of coronary perforation leading to hemodynamic compromise in patients with prior CABG surgery revealed high mortality (22%), suggesting that prompt sealing of the perforation is critical in these patients.

Regulation of exercise-induced fiber type transformation, mitochondrial biogenesis, and angiogenesis in skeletal muscle.

Skeletal muscle exhibits superb plasticity in response to changes in functional demands. Chronic increases of skeletal muscle contractile activity, such as endurance exercise, lead to a variety of physiological and biochemical adaptations in skeletal muscle, including mitochondrial biogenesis, angiogenesis, and fiber type transformation. These adaptive changes are the basis for the improvement of physical performance and other health benefits. This review focuses on recent findings in genetically engineered animal models designed to elucidate the mechanisms and functions of various signal transduction pathways and gene expression programs in exercise-induced skeletal muscle adaptations.