Race and outcomes after percutaneous coronary intervention: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium.

BACKGROUND: Current studies show similar in-hospital outcomes following percutaneous coronary intervention (PCI) between Black and White patients. Long-term outcomes and the role of individual and community-level socioeconomic factors in differential risk are less understood. METHODS: We linked clinical registry data from PCIs performed between January, 2013 and March, 2018 at 48 Michigan hospitals to Medicare Fee-for-service claims. We analyzed patients of Black and White race. We used propensity score matching and logistic regression models to estimate the odds of 90-day readmission and Cox regression to evaluate the risk of postdischarge mortality. We used mediation analysis to evaluate the proportion of association mediated by socioeconomic factors. RESULTS: Of the 29,317 patients included in this study, 10.28% were Black and 89.72% were White. There were minimal differences between groups regarding post-PCI in-hospital outcomes. Compared with White patients, Black patients were more likely to be readmitted within 90-days of discharge (adjusted OR 1.62, 95% CI [1.32-2.00]) and had significantly higher risk of all-cause mortality (adjusted HR 1.45, 95% CI 1.30-1.61) when adjusting for age and gender. These associations were significantly mediated by dual eligibility (proportion mediated [PM] for readmission: 11.0%; mortality: 21.1%); dual eligibility and economic well-being of the patient's community (PM for readmission: 22.3%; mortality: 43.0%); and dual eligibility, economic well-being of the community, and baseline clinical characteristics (PM for readmission: 45.0%; mortality: 87.8%). CONCLUSIONS: Black patients had a higher risk of 90-day readmission and cumulative mortality following PCI compared with White patients. Associations were mediated by dual eligibility, community economic well-being, and traditional cardiovascular risk factors. Our study highlights the need for improved upstream care and streamlined postdischarge care pathways as potential strategies to improve health care disparities in cardiovascular disease.

Balloon Expandable Transcatheter Aortic Valve Implantation in Failing Self-Expandable Transcatheter Valve in Degenerated Surgical Bioprosthesis: Valve-in-Valve-in-Valve Implantation for the Treatment of Early Degenerative Prosthetic Insufficiency.

Background: Transcatheter aortic valve implantation (TAVI) has emerged as the standard of care for patients with severe aortic stenosis who are at high surgical risk. However, transcatheter valves can degenerate, and redo TAVI has been reported after surgical aortic valve implantation and post initial TAVI. Case Report: We describe the case of a 70-year-old male who presented with decompensated heart failure secondary to severe prosthetic valve insufficiency. The patient had a history of distant triple coronary artery bypass surgery in 2004, surgical ascending aortic aneurysm repair and stentless aortic valve replacement in 2012, and transcatheter CoreValve (Medtronic) implantation in 2015 for the failing stentless aortic valve. In 2019, the patient presented with heart failure symptoms. A 29-mm SAPIEN 3 valve (Edwards Lifesciences) was implanted for the third time (valve-in-valve-in-valve) with excellent clinical and echocardiographic results and no evidence of coronary obstruction. Conclusion: Early (<5 years) bioprosthetic valve insufficiency after initial valve-in-valve implantation can be successfully treated with a second TAVI.

Safety and Efficacy of Renin-Angiotensin-Aldosterone System Inhibitors in COVID-19 Population.

INTRODUCTION: The safety of renin-angiotensin-aldosterone system inhibitors (RAASi) among COVID-19 patients has been controversial since the onset of the pandemic. METHODS: Digital databases were queried to study the safety of RAASi in COVID-19. The primary outcome of interest was mortality. The secondary outcome was seropositivity improvement/viral clearance, clinical manifestation progression, and progression to intensive care units. A random-effect model was used to compute an unadjusted odds ratio (OR). RESULTS: A total of 49 observational studies were included in the analysis consisting of 83,269 COVID-19 patients (RAASi n = 34,691; non-RAASi n = 48,578). The mean age of the sample was 64, and 56% were males. We found that RAASi was associated with similar mortality outcomes as compared to non-RAASi groups (OR 1.07; 95% CI 0.99-1.15; p > 0.05). RAASi was associated with seropositivity improvement including negative RT-PCR or antibodies, (OR 0.96; 95% CI 0.93-0.99; p < 0.05). There was no association between RAASi versus control with progression to ICU admission (OR 0.99; 95% CI 0.79-1.23; p > 0.05) or higher odds of worsening of clinical manifestations (OR 1.04; 95% CI 0.97-1.11; p > 0.05). Metaregression analysis did not change our outcomes for effect modifiers including age, sex, comorbidities, RAASi type, or study type on outcomes. CONCLUSIONS: COVID-19 is not a contraindication to hold or discontinue RAASi as they are not associated with higher mortality or worsening symptoms. Continuation of RAASi might be associated with favorable outcomes in COVID-19, including seropositivity/viral clearance.

The efficacy and safety of transradial and transfemoral approach in treatment of coronary chronic total occlusion: a systematic review and meta-analysis.

BACKGROUND: The clinical efficacy and safety of transradial (TR) percutaneous coronary intervention (PCI) in comparison to transfemoral (TF) for chronic total occlusion (CTO) is not well studied in literature. Objectives: We sought to study the outcome and complications associated with TR compared with TF for CTO interventions. METHODS: After a systematic literature search was done in PubMed and EMBASE, we performed a meta-analysis of studies comparing TF and TR for CTO PCI. Results: Twelve studies with 19,309 patients were included. Compared to those who has TF access, individuals who were treated via TR approach had statistically significant lower access complication rates [odds ratio (OR): 0.33; 95% confidence interval (CI): 0.22 to 0.49; p < 0.0001]. The procedural success was in the favor of TR method (OR: 1.4; 95% CI: 1.31-1. 51; p < 0.0001). The incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and contrast-induced nephropathy were similar in both groups. CONCLUSION: When compared with TF access interventions in CTO PCI; the TR approach appears to be associated with far less access-site complications, higher procedural success, and comparable MACCE.

Percutaneous coronary intervention following Fontan procedure.

Fontan procedure is known to increase the risk of thromboembolic events. However, coronary artery thrombotic occlusion is rarely reported in patients with Fontan procedure. We present a case of a 10-year-old boy with hypoplastic left heart syndrome palliated with a Fontan procedure who presented with myocardial infarction secondary to thrombotic occlusion of the left circumflex coronary artery. He underwent successful percutaneous coronary intervention with thrombus aspiration, balloon angioplasty, and stent placement, highlighting the necessity of collaboration between congenital and adult cardiologists to treat acute coronary syndrome among this challenging young population.

Remote monitoring of implantable cardiac devices in heart failure patients: a systematic review and meta-analysis of randomized controlled trials.

This study aims to determine whether the use of remote monitoring (RM) in implantable cardiac devices decreases all-cause mortality and heart failure (HF)-related hospitalization. We sought to conduct a systematic review and a meta-analysis of published randomized controlled studies. The population is adult patients with a diagnosis of HF with implantable devices. The intervention is RM using implantable cardiac devices whether added or used alone compared to standard of care. The outcomes are HF-related hospitalization and all-cause mortality. Risk of bias was assessed using the criteria defined in the Revised Cochrane Collaboration's tool for assessment of risk of bias. Data were extracted and validity was assessed independently by two reviewers. Electronic databases EMBASE and MEDLINE (Ovid) were searched up to 14th of October 2019, supplemented by a second search in CENTRAL (Cochrane Central Register of Controlled Trials) and clinicaltrials.gov. Only randomized controlled studies published in peer-reviewed journals with full format text in English of adult HF patients with a minimum follow-up of 6 months reporting mortality and/or hospitalization. Observational studies and studies that did not meet inclusion criteria were excluded. Thirteen randomized controlled studies that enrolled a total of 7015 patients were identified, 7 of which reported on all-cause mortality only and included 4460 patients. Compared with standard of care, the pooled relative risk (RR) of all-cause mortality and HF-related hospitalization in patients with RM compared to those receiving standard of care was 0.88 (95% confidence interval (CI) 0.69 to 1.11) and 0.95 (95% CI 0.78-1.16), respectively. In the subgroup analysis, using pulmonary pressure for RM was associated with a decrease in HF-related hospitalization (RR 0.73; 95% CI 0.60-0.88). RM showed benefit in reducing HF-related hospitalization when compared to standard of care only when using pulmonary pressure monitoring.