A call to consider an aortic stenosis screening program.

Aortic stenosis (AS) is the most common age-related valvular condition with a prevalence of 13.1% in patients older than 75 years of age. Based on the severity of AS and symptoms, current guidelines recommend interval monitoring with transthoracic echocardiogram (TTE). However, no guidelines exist regarding screening asymptomatic persons for AS. Prevalence of AS is comparable to conditions such as colorectal cancer, lung cancer, breast cancer, and abdominal aortic aneurysm where dedicated screening programs are offered resulting in reduction of overall morbidity and mortality. We review recent advancements in treatment options, and we propose an AS screening program for high-risk individuals without known history of AS including all persons over age 75 and persons aged 70 years and older with dialysis dependent end-stage renal disease (ESRD).

Prognostic Value of Coronary Artery Calcification Identified by the Semi-quantitative Weston Method in the Emergency Room or Other Hospitalized Patients.

Background: Coronary artery calcification (CAC) may provide insight to the patients' coronary artery disease (CAD) risks and influence early intervention. With increasing use of non-gated CT scans in clinical practice, the visual coronary artery scoring system (Weston Method) could quickly provide clinicians with important information of CAC for patient triage and management. Methods: We retrospectively studied the available CT imaging data and estimated CAC burden using the Weston method in 493 emergency room or other hospitalized patients. The Weston scores were calculated by the sum of the score for each vessel including the left main, left anterior descending, left circumflex artery and right coronary artery (range 0-12). The primary endpoint was a composite of the major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and coronary revascularization. Results: During a median follow-up of 85 months, a total of 25 (5.1%) MACE were recorded and 57 (11.2%) patients died from any causes. Detectable CAC was most common (96%) in the left anterior descending coronary arteries. Multivariable analysis showed that CAC total scores were independent predictors for MACE and all-cause mortality. Receiver operating characteristic analysis showed that CAC total score ≥5 was the optimal cutoff value for predicting MACEs. Conclusions: In the emergency room and hospitalized patients, the semi-quantitation of CAC burden using the Weston score system was related to the long-term cardiovascular outcomes including mortality. Clinicians and radiologists should maximize the value of non-contrast chest CT images by reporting CAC details.

Ascending Aortic Stenting for Acute Supraaortic Stenosis From Graft Collapse.

A 78-year-old man with remote type-A dissection presented with acute-onset dyspnea. Twenty-two years prior, treatment for his aortic disease required replacement of ascending and arch aneurysms with a polyester graft (Dacron) using the graft inclusion technique. He presented currently in cardiogenic shock. Echocardiography demonstrated new severe hypokinesis of all apical segments. Left-heart catheterization revealed a 120 mm Hg intragraft gradient. Computed tomography arteriography was unrevealing, but intraaortic ultrasound demonstrated critical intragraft stenosis. A balloon expandable stent (Palmaz stent, Cordis, Milpitas, CA) was deployed in the stenotic region with gradient resolution. The patient later underwent aortic root replacement and ascending aneurysm repair (Bio-Bentall technique) and is doing well at 24 months.

Physiologic Guidance of Infrainguinal Vascular Interventions Using the Pressure Wire.

OBJECTIVES: To assess the relationship between the resting (RG) and hyperemic (HG) translesional peripheral gradients, with the functional and anatomic parameters before and after an infrainguinal endovascular procedure. BACKGROUND: RGs and HGs are objective tools in defining the hemodynamic significance of an arterial stenosis. METHODS: In 25 subjects with infrainguinal arterial stenosis, RG and HG were measured via a pressure wire before and after angioplasty. Before and after the procedure, all subjects had an ankle-brachial index (ABI) and Duplex ultrasound evaluation, recording prelesion and in-lesion peak systolic velocity (PSV-L), and calculating a peak systolic velocity ratio (PSV-R). A Pearson R correlation coefficient was calculated. RESULTS: The mean age was 73 ± 12 years, 70% were men, median Rutherford class 3. At baseline and after angioplasty, mean ABI was 0.78 ± 0.2 and 0.99 ± 0.1, mean PSV-L was 459 ± 110 cm/s and 126 ± 35 cm/s, and mean PSV-R was 6.7 ± 4 and 1.2 ± 0.5, respectively. RG and HG significantly improved (P<.001) from baseline to after angioplasty (28.7 ± 20.5 mm Hg to 5 ± 13 mm Hg and 40.2 ± 21.4 mm Hg to 10 ± 13 mm Hg, respectively). RG before and after the procedure correlated well with ABI (r = -0.58; r = -0.41), PSV-L (r = 0.40; r = 0.52), and PSV-R (r = 0.46; r = 0.42). An improvement of 9 mm Hg in RG predicted a change of 0.1 in ABI. CONCLUSIONS: Improvement in RG during endovascular intervention in superficial femoral artery correlates well with the improvement in ABI, PSV-L, and PSV-R. A postprocedural decrease in RG of 9 mm HG predicts an improvement in ABI of 0.1.

Aortic dissection presenting as acute subtotal left main coronary artery occlusion: a case approach and review of the literature.

Aortic dissection is the most common fatal condition of the aorta, yet it is often missed on initial clinical presentation. Aortic dissection associated with acute coronary syndrome (ACS) is relatively rare, but if it occurs, it can be diagnostically challenging, and the condition can be fatal. Here we describe a case of aortic dissection presenting as ST-segment elevation myocardial infarction (STEMI) managed via the transradial approach. We describe the current literature on the subject.

Tips and tricks for antegrade recanalization of chronic total occlusions using the CrossBoss catheter.

OBJECTIVES: To provide new strategies and techniques for the successful recanalization of chronic total occlusions (CTOs) with the sole use of the CrossBoss catheter. In addition, some common CTO scenarios are illustrated in detail. BACKGROUND: CTOs are one of the most challenging complex coronary lesion subsets to intervene upon. Even with the innovation of specialized catheters, the success rate of antegrade recanalization remains low. METHODS: Between June and December 2013, a retrospective analysis of 50 consecutive patients who presented with a planned percutaneous intervention (PCI) of a CTO was performed. In all patients, the CrossBoss catheter was used. No additional reentry devices were necessary. Procedural success was defined as <20% residual stenosis and TIMI-3 distal blood flow of the treated vessel at the end of the procedure. RESULTS: The majority of the patients were male (72%), with an average age of 68 years. Thirty percent of patients presented with prior CTO-PCI failure. The average fluoroscopy time was 45.9 minutes and the average amount of contrast use was 273.8 mL. No patient suffered a coronary perforation from the CrossBoss catheter. CONCLUSIONS: With increased experience using the CrossBoss catheter, the antegrade success rate of CTOs can be improved. Some tips include identifying the likely course of the artery with the aid of retrograde injection, proper guidewire selection and manipulation, and redirecting the CrossBoss catheter if there is substantial deviation from the original path.

Outcomes of patients undergoing elective percutaneous coronary interventions in the ambulatory versus in-hospital setting.

OBJECTIVES: To compare outcomes of elective percutaneous coronary interventions (PCI) in same-day discharge and overnight hospital stays. BACKGROUND: Advances in PCI techniques and equipment have allowed same-day discharge after elective PCI. In this study, we investigated the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores. METHODS: The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. Patients were stratified into tertiles based on ACEF score: low (<1.08), mid (≥1.08 and <1.31), and high (≥1.31). The primary endpoint was 30-day major adverse cardiac events, defined as readmission, all-cause mortality, non-fatal myocardial infarction, and target lesion revascularization. Propensity score matching was done to evaluate outcomes based on similar baseline characteristics. RESULTS: There were 16,407 elective PCIs, of which 21.2% were in the ambulatory group. Patients who stayed overnight had similar 30-day composite outcomes as their same-day discharge counterparts in the high ACEF score (odds ratio [OR], 1.213; 95% confidence interval [CI], 0.625-2.355; P=.57) and mid ACEF score (OR, 0.636; 95% CI, 0.356-1.134; P=.13) comparisons, but had worse outcomes in the low ACEF score comparison (OR, 1.867; 95% CI, 1.134-3.074; P=.01). CONCLUSIONS: In this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories.

Low-density lipoprotein levels in patients with acute heart failure.

Statins do not appear to have a significant benefit in heart failure (HF) as they do in coronary artery disease (CAD). Significant evidence exists that low serum cholesterol levels may be harmful in HF. This study sought to determine the optimal low-density lipoprotein (LDL) level in patients hospitalized with acute HF. Patients were included if they presented to the hospital with acute HF and had a lipid panel drawn during admission. The primary outcome was all-cause mortality, and secondary outcomes were rates of major cardiovascular (CV) events, left ventricular assist device (LVAD) implantation, and orthotopic heart transplantation (OHT). A total of 2428 patients were followed for a mean of 2.9±2.2 years. For the entire cohort, when compared with those with LDL levels >130 mg/dL, all-cause mortality was higher in those with LDL levels <71 mg/dL (hazard ratio, 1.68; 95% confidence interval, 1.31-2.167; P<.01). Results were similar when analyzing patients with LVEF ≤40%, HF of ischemic etiology only, and in statin users. The rates of CV events, LVAD implantation, or OHT in any comparison did not differ. Low LDL levels (<71 mg/dL), similar to low total cholesterol levels, were associated with a poorer prognosis and higher overall mortality in patients with HF, regardless of etiology and systolic function.

Current diagnosis and management of left main coronary disease.

Left main coronary artery (LMCA) disease remains an important risk factor for increased mortality and morbidity at all stages of diagnosis and treatment of coronary artery disease. Left main stem pathology is often silent, with unpredictable presentation: as such it poses diagnostic and management challenges. This article reviews the anatomy, epidemiology and diagnosis of left main stem disease, as well as advances in multidisciplinary concepts of diagnosis and management, and summarises the outcomes of recent prospective studies comparing percutaneous and surgical revascularisation in LMCA disease.

Accuracy of low-dose prospectively gated axial coronary CT angiography for the assessment of coronary artery stenosis in patients with stable heart rate.

BACKGROUND: Desirable methods for cardiac CT angiography would both reduce radiation exposure from cardiac CT angiography and preserve accuracy. OBJECTIVES: We assessed image quality, radiation dose, and diagnostic accuracy of a low-dose, prospectively gated axial cardiac CT angiography protocol for the evaluation of patients with suspected coronary artery disease (CAD). METHODS: Fifty consecutive patients referred for diagnostic invasive coronary angiography (ICA) and with a stable heart rate < 60 beats/min after beta-blocker administration were prospectively enrolled in a single center study. Subjects underwent CT angiography with a 64-row multidetector CT scanner with a prospectively gated axial imaging protocol. If the examination was determined to be nondiagnostic, then a retrospectively gated helical scan was performed. Two reviewers independently assessed image quality and the presence of significant coronary artery stenosis (>50%). RESULTS: Prospectively gated CT angiography was successfully performed in 46 of 50 patients. Of 794 coronary segments, 777 were determined to be of diagnostic image quality. The overall patient-based sensitivity (95% CI), specificity, positive predictive value, negative predictive value, and accuracy for the diagnosis of significant coronary stenosis were 100% (87%-100%), 75% (53%-90%), 81% (64%-93%), 100% (81%-100%), and 88% (81%-95%), respectively. The mean effective radiation dose for CT angiography and ICA were 3.4 +/- 0.4 mSv and 6.9 +/- 0.8 mSv, respectively. CONCLUSIONS: Cardiac CT angiography performed in a prospectively gated axial mode with 64-row multidetector CT provides an accurate, low-dose alternative for the detection of CAD.

Initial experience of removal of 10-French sheaths using the 8-French Angio-Seal vascular closure device.

OBJECTIVES: We studied the use of 8 Fr Angio-Seal in closure of access sites up to 10 Fr. BACKGROUND: The use of larger French catheters for procedures such as valvuloplasty and percutaneous valve replacement has required the use of better methods for arterial closure. The use of 6 and 8 Fr Angio-Seal hemostatic devices (St. Jude Medical, St. Paul, Minnesota) has been well described and are routinely used for diagnostic and interventional procedures up to 8 Fr in size. However, no data are available for the use of an 8 Fr Angio-Seal device in the closure of access sites up to 10 Fr. METHODS: In our center, we evaluate the incidence of vascular complications following the use of an 8 Fr Angio-Seal device with 10 Fr sheaths in patients undergoing aortic valvuloplasty. RESULTS: Of 53 procedures, there was only 1 vascular complication, a ruptured pseudoaneurysm, which required vascular repair. CONCLUSIONS: Our data suggest that an 8 Fr Angio-Seal device can be utilized effectively and safely in procedures requiring larger access sites up to 10 Fr.

Structural model of the amino propeptide of collagen XI alpha1 chain with similarity to the LNS domains.

Fibrillar collagens are the principal structural molecules of connective tissues. The assembly of collagen fibrils is regulated by quantitatively minor fibrillar collagens, types V and XI. A unique amino-terminal propeptide domain of these collagens has been attributed this regulatory role. The structure of the amino terminal propeptide has yet to be determined. Low sequence similarity necessitated a secondary structure-based method to carry out homology modeling based upon the determined structure of LNS family members, named for a common structure in the laminin LG5 domain, the neurexin 1B domain and the sex hormone binding globulin. Distribution of amino acids within the model suggested glycosaminoglycan interaction and calcium binding. These activities were tested experimentally. Sequence analyses of existing genes for collagens indicate that 16 known collagen alpha chains may contain an LNS domain. A similar approach may prove useful for structure/function studies of similar domains in other collagens with similar domains. This will provide mechanistic details of the organization and assembly of the extracellular matrix and the underlying basis of structural integrity in connective tissues. The absolute requirement for collagen XI in skeletal growth is indicated by collagen XI deficiencies such as chondrodystrophies found in the cho/cho mouse and in humans with Stickler syndrome.