Vertebral Artery Interventions: A Comprehensive Updated Review.

Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur, with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis are promising options widely used in clinical practice with good technical results; however, the improved clinical outcome has been examined in various clinical trials without a sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. This review aims to provide a focused update on the percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach, and advances in medical therapies.

Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review.

Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.

Laparoscopic Sleeve Gastrectomy in Patients with Obesity and Ventricular Assist Devices: a Comprehensive Outcome Analysis.

We analyzed in detail the outcomes of eight patients with ventricular assist devices (VADs) and obesity who underwent laparoscopic sleeve gastrectomy (LSG) at a single heart transplant (HT) center. This comprehensive analysis included body mass index (BMI) trends from VAD implantation to the time of LSG; BMI and percentage of excess BMI lost during follow-up; adverse outcomes; and changes in echocardiographic parameters, fasting lipids, unplanned hospitalizations, and functional status. We also identified the patients who achieved the following outcomes: listing for HT, HT, 50% excess BMI loss, and BMI < 35 kg/m2. Laparoscopic sleeve gastrectomy seems to be a reasonable and effective intervention to help patients with VADs and obesity to decrease excess BMI and become candidates for HT.

Laparoscopic sleeve gastrectomy in obese patients with ventricular assist devices: a data note.

OBJECTIVES: Patients with end-stage heart failure (ESHF) treated with ventricular assist devices (VADs) tend to gain weight after implantation, which is associated with higher complication rates and is a contraindication for heart transplantation (HT). The objective was to analyze the outcomes of obese patients with ESHF and VADs who underwent laparoscopic sleeve gastrectomy (LSG) at Ochsner Medical Center in New Orleans, which is the only program performing VADs and HT in the State of Louisiana, and also one of the largest VAD centers in the USA. DATA DESCRIPTION: This dataset contains detailed baseline, perioperative, and long-term data of patients with VADs undergoing LSG. These variables were collected retrospectively from electronic medical records. Patients who achieved ≥ 50% excess BMI loss, BMI ≤ 35 kg/m2, listing for HT, HT, or myocardial recovery were identified and the timing to each of these milestones was documented. These data can be used alone or in combination with other datasets to achieve a larger sample size with more power for further analysis of these variables, which include the most important, standard, and objective bariatric and ESHF outcomes of patients with VADs undergoing LSG. Elaboration of composite outcomes is feasible.

Progressive Left Ventricular Hypertrophy after Heart Transplantation: Insights and Mechanisms Suggested by Multimodal Images.

Immunosuppression is the typical measure to prevent rejection after heart transplantation. Although rejection is the usual cause of cardiac hypertrophy, numerous other factors warrant consideration. Calcineurin inhibitors rarely cause hypertrophic cardiomyopathy; the few relevant reports have described children after orthotopic kidney or liver transplantation. We present the case of a 73-year-old woman, an asymptomatic orthotopic heart transplantation patient, in whom chronic immunosuppression with prednisone and cyclosporine apparently caused a phenotype of hypertrophic cardiomyopathy. The natural course of her midapical hypertrophy was revealed by single-photon-emission computed tomography, positron-emission tomography, and 2-dimensional echocardiography. Clinicians and radiographers should be alert to progressive left ventricular hypertrophy and various perfusion patterns in heart transplantation patients even in the absence of underlying coronary artery disease. Toward this end, we recommend that advanced imaging methods be used to their fullest extent.

Restarting anticoagulation and outcomes after major gastrointestinal bleeding in atrial fibrillation.

Data regarding the outcomes of restarting anticoagulation in patients who develop gastrointestinal bleeding (GIB) while anticoagulated are sparse. We hypothesized that restarting anticoagulation in these patients is associated with better outcomes. This is a retrospective cohort study that enrolled subjects who developed GIB while on anticoagulation from 2005 to 2010. Atrial fibrillation was defined by history and electrocardiography on presentation. GIB was defined as a decrease in hemoglobin by 2 g, visible bleeding, or positive endoscopic evaluation. Time-to-event adjusted analyses were performed to find an association of restarting warfarin and recurrent GIB, arterial thromboembolism, and mortality. Stratified analysis by duration of interruption of warfarin was also performed. Overall, 1,329 patients (mean age 76 years, women 45%) developed major GIB. Warfarin was restarted in 653 cases (49.1%). Restarting warfarin was associated with decreased thromboembolism (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.75 to 1.84, p = 0.47) [corrected] and reduced mortality (HR 0.67, 95% CI 0.56 to 0.81, p <0.0001) but not recurrent GIB (HR 1.18, 95% CI 0.94 to 1.10, p = 0.47). When the outcomes were stratified by duration of warfarin interruption, restarting warfarin after 7 days was not associated with increased risk of GIB but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption. Decision to restart warfarin after an episode of major GIB is associated with improved survival and decreased thromboembolism without increased risk of GIB after 7 days of interruption.

Impact of restarting warfarin therapy in renal disease anticoagulated patients with gastrointestinal hemorrhage.

BACKGROUND: Atrial fibrillation (AF) is emerging as a major health problem. The prevalence is as high as 32% in patients with renal disease. Gastrointestinal bleeding (GIB) is a frequent complication. OBJECTIVE: To investigate the hazards of resumption or discontinuation of anticoagulation in renal disease patients after an episode of GIB. DESIGN, SETTINGS, PARTICIPANTS AND MEASUREMENTS: This is a multicenter retrospective cohort of patients with AF on warfarin that developed an episode of GIB. Chronic kidney disease (CKD) was defined by eGFR ≤60 mL/min and end stage renal disease (ESRD) was defined by being on hemodialysis for >3 months. Outcomes were 90-day recurrent gastrointestinal bleeding (GIB), mortality, and stroke/transient ischemic attack (TIA). RESULTS: Out of 11,513 AF patients, index GIB occurred in 96 ESRD and 159 CKD patients. Outcomes of CKD patients did not differ when compared with patients with normal kidney function. CKD patients who resumed warfarin had decreased stroke/TIA rates (p < 0.0001). There were no significant differences between CKD patients who resumed warfarin versus that did not resume warfarin (p > 0.05). ESRD patients also did not have significant differences in outcomes when compared to patients with normal kidney function restarted on warfarin. However, there was an increase in recurrent GIB and decrease in mortality as well as stroke/TIA when patients with ESRD that restarted warfarin were compared with ESRD patients who did not restart warfarin. CONCLUSION: Study suggests resuming warfarin after an episode of GIB in CKD patients but recommends considering the increased risk of recurrent GIB in ESRD patients.