Cangrelor in addition to standard therapy reduces cardiac damage and inflammatory markers in patients with ST-segment elevation myocardial infarction.

Although P2Y12 receptor blockers have become a standard, adjunctive therapy in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), the optimal regimen has not been established. We performed a prospective, open-label, randomized study to investigate the effect of cangrelor administration on platelet function and inflammation in patients with primary PCI (PPCI). Twenty-two patients were randomized to receive either cangrelor and ticagrelor or ticagrelor alone (standard group) before PPCI. Platelet reactivity was evaluated at baseline (before PCI), 10 min and the end of the procedure. At baseline, there was no significant difference in platelet reactivity between both groups, whereas platelets were significantly inhibited at 10 min after initiating cangrelor vs. standard (adenosine-diphosphate-induced aggregation 102.2 ± 24.88 vs. 333.4 ± 63.3, P < 0.05 and thrombin-receptor-activating-peptide-induced aggregation 285.8 ± 86.1 vs. 624.8 ± 106.0, P < 0.05). Lower platelet aggregation in the cangrelor group persisted but the difference was reduced by the end of the procedure. Circulating inflammatory cells, pro-inflammatory cytokines, total elastase, and surrogates of neutrophil extracellular traps (total elastase-myeloperoxidase complexes) were significantly lower in the cangrelor compared to the standard therapy group at 6 h after randomization. There was a trend towards reduction in cardiac damage in the cangrelor group as reflected by the changes in late gadolinium enhancement between 48 h and 3 months after STEMI. Early administration of cangrelor in STEMI patients was associated with more effective platelet inhibition during PPCI and significantly dampened the deleterious inflammatory response compared to standard therapy (NCT03043274).

Revascularization Strategies for Non-ST-Elevation Myocardial Infarction.

PURPOSE OF REVIEW: Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics. RECENT FINDINGS: The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.

Transradial Approach to Coronary Angiography and Percutaneous Intervention in Patients With Dextrocardia.

Patients with dextrocardia present unique challenges in the catheterization laboratory. Variable coronary artery anatomy impacts percutaneous access, catheter selection and manipulation, and image acquisition. This is a review of all published reports of radial artery access for diagnostic and/or therapeutic coronary interventions in patients with dextrocardia. We conclude that the radial approach is safe and effective in these patients and should be used without hesitation. In addition, interventionalists should consider use of multipurpose catheters and possess an understanding of how mirror-image fluoroscopy impacts catheter manipulation. Furthermore, we propose a stepwise approach to arterial access, fluoroscopy, and catheter selection for operator reference while treating dextrocardia patients.

A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support.

INTRODUCTION: While the optimal care of patients with massive pulmonary embolism (PE) is unclear, the general goal of therapy is to rapidly correct the physiologic derangements propagated by obstructive clot. Extracorporeal membrane oxygenation (ECMO) in this setting is promising, however the paucity of data limits its routine use. Our institution expanded the role of ECMO as an advanced therapy option in the initial management of massive PE. The purpose of this project was to evaluate ECMO-treated patients with massive PE at an academic medical center and report shortterm mortality outcomes. METHODS: Thirty-two patients placed on ECMO for confirmed, massive PE from January 2012 to December 2015 were retrospectively analyzed. All patients had PE confirmed by computerized tomography and/or invasive pulmonary angiography. RESULTS: In our population of patients managed with ECMO, 21 (65.6%) patients survived to decannulation and 17 (53.1%) survived index hospitalization. Baseline characteristics and clinical variables showed no difference in age, gender, right ventricular-to-left ventricular ratios, or peak troponin-T between survivors and non-survivors. Non-survivors tended to have a previous history of malignancy. Cardiac arrest prior to ECMO cannulation was associated with worse outcomes. All 5 patients who received concomitant systemic thrombolysis died, while 11 of 15 patients who received catheter-directed thrombolysis survived. A lactic acid level ≤6mmol/L had an 82.4% sensitivity and 84.6% specificity for predicting survival to discharge. CONCLUSION: The practical approach of utilizing ECMO for massive PE is to reserve it for those who would receive the greatest benefit. Patients with poor perfusion, for example from cardiac arrest, may gain less benefit from ECMO. Our findings indicate that a serum lactate >6mmol/L may be an indicator of worse prognosis. Finally, in our patient population, catheter-directed thrombolytics was effectively combined with ECMO.

A novel approach to percutaneous removal of large tricuspid valve vegetations using suction filtration and veno-venous bypass: A single center experience.

BACKGROUND: Tricuspid valve surgery has been the de facto standard treatment for tricuspid valve endocarditis (TVE) refractory to medical therapy. It is now possible to remove right-sided vegetations percutaneously using a venous drainage cannula with an extracorporeal bypass circuit. OBJECTIVES: The purpose of our study is to describe our single-center experience of percutaneous tricuspid valve vegetation removal. METHODS: We reviewed the perioperative course of 33 consecutive patients with large tricuspid valve vegetations who carried high surgical risk. RESULTS: The cohort included 12 males and 21 females over a 40-month period with an average age of 37 years. A preponderance of patients carried an admitted or confirmed diagnosis of injection drug use (72.7%). Average vegetation size was 2.1 +/- 0.7 cm prior to the procedure with a 61% reduction in size after the procedure. All patients survived the procedure and 90.9% survived the index hospitalization. Three patients proceeded to elective tricuspid valve replacement due to worsening severity of tricuspid regurgitation. CONCLUSION: Percutaneous removal of large tricuspid valve vegetations is a safe and effective alternative for patients with TVE who carry high-surgical risk. © 2017 Wiley Periodicals, Inc.

QT prolongation is associated with increased mortality in end stage liver disease.

AIM: To determine the prevalence of QT prolongation in a large series of end stage liver disease (ESLD) patients and its association to clinical variables and mortality. METHODS: The QT interval was measured and corrected for heart rate for each patient, with a prolonged QT cutoff defined as QT > 450 ms for males and QT > 470 ms for females. Multiple clinical variables were evaluated including sex, age, serum sodium, international normalized ratio, creatinine, total bilirubin, beta-blocker use, Model for End-Stage Liver Disease (MELD), MELD-Na, and etiology of liver disease. RESULTS: Among 406 ESLD patients analyzed, 207 (51.0%) had QT prolongation. The only clinical variable associated with QT prolongation was male gender (OR = 3.04, 95%CI: 2.01-4.60, P < 0.001). During the study period, 187 patients (46.1%) died. QT prolongation was a significant independent predictor of mortality (OR = 1.69, 95%CI: 1.03-2.77, P = 0.039). In addition, mortality was also associated with viral etiology of ESLD, elevated MELD score and its components (P < 0.05 for all). No significant reversibility in the QT interval was seen after liver transplantation. CONCLUSION: QT prolongation was commonly encountered in an ESLD population, especially in males, and served as a strong independent marker for increased mortality in ESLD patients.

Chronologic Changes and Correlates of Loop Diuretic Dose in Patients with Left Ventricular Assist Device.

No study has systematically evaluated the prevalence and dosages of diuretic use for patients after left ventricular assist device (LVAD) implantation. The primary objective was to characterize chronologic change in prevalence and doses of loop diuretics after LVAD placement. The secondary objective was to identify correlates of actual doses of loop diuretics. We retrospectively reviewed medical records of adult patients with LVAD implantation at the University of Kentucky. Prevalence of diuretic use and furosemide equivalent dose were assessed before LVAD implantation and at seven time points thereafter: 1 week, 1 month, 3 months, 6 months, 1 year, 18 months, and 2 years. Correlation analyses and linear mixed modeling were used to identify correlates of diuretic dose before and after LVAD implantation. Eighty-two consecutive eligible patients were reviewed. The prevalence of loop diuretic use was 95% at baseline but significantly lower than that at all subsequent time points (p < 0.048 for all). Nevertheless, more than half of patients on whom we had such follow-up data were on loop diuretics 2 years after LVAD implantation. Average furosemide equivalent dose was significantly lower at every time point after implantation compared with baseline (p < 0.006 for all). Blood urine nitrogen (BUN) was the most robust predictor of dose after LVAD implant. The prevalence and average furosemide equivalent dose were significantly reduced after LVAD implantation, but the use of loop diuretic remained more than 50% for up to 2 years. Consistent association with BUN may indirectly indicate overuse of diuretics post-LVAD implant.

Fibrillary glomerulonephritis masquerading as rapidly progressive glomerulonephritis with pseudo-linear glomerular basement membrane staining.

Fibrillary glomerulonephritis (FGN) is a rare disorder with poor renal prognosis. It is a heterogeneous disease associated with significant risk of end-stage renal disease (ESRD). Its etiology and pathogenesis have not been clearly identified. We report a case of a patient presenting with hypertensive crisis, nephrotic range proteinuria, and rapidly progressive glomerulonephritis (RPGN). The kidney biopsy demonstrates crescentic GN on light microscopy (LM) and strong pseudo-linear/globular glomerular basement membrane (GBM) staining for immunoglobulin G on immunofluorescence (IF), suggestive of anti-GBM disease. However, circulating anti-GBM antibodies were negative. Electron microscopy (EM) revealed fibrillary deposits in the GBM, confirming the diagnosis of FGN. Review of the literature revealed very few reported similar cases. It appears that severe hypertension and heavy proteinuria, while uncommon in anti-GBM disease, are consistent findings in RPGN form of FGN.

A retrospective analysis of catheter-based thrombolytic therapy for acute submassive and massive pulmonary embolism.

Catheter-based thrombolysis (CBT) is emerging as an option for acute pulmonary embolism (PE). Although prior studies have demonstrated improvement in right ventricular function, little data is available regarding clinical patient outcomes. Our institution adopted CBT as an option for patients with submassive and massive PE and we evaluated its effect on patient outcomes. Two hundred and twenty-one patients who presented to our institution with submassive and massive PE were analyzed over three years by time period; 102 prior to the use of CBT and 119 during the time CBT was performed. The primary outcome was in-hospital major adverse clinical events (a composite of death, recurrent embolism, major bleeding, or stroke). Secondary outcomes were overall and ICU length of stay and individual components of the composite outcome. Mean age was 56.3±16 years with high rates of central PE (57.9%), RV dysfunction (37%), and myocardial necrosis (26%). Mean RV/LV ratio was 1.2. Thirty-two patients were treated with CBT. The composite endpoint occurred more frequently in the CBT era vs the pre-CBT era (21.0% vs 14.7%, p=0.23). After multivariate adjustment, CBT treatment demonstrated no effect on major adverse clinical events (OR 0.84, CI 0.22-3.22, p=0.80). CBT era patients had an unadjusted 37% increase in ICU days and 54% increase in total length of stay (p<0.001). Within the CBT era, CBT treatment resulted in an adjusted 190% increase in overall length of stay (p<0.001). CBT did not demonstrate improvement in hospital outcomes, despite adjustments of PE severity, and was associated with a significant increase in overall and ICU length of stay.