Transcatheter vacuum aspiration of valvular and lead related infective endocarditis.

BACKGROUND: Transcatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes. METHODS: PubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed. RESULTS: Data from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50-85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each. CONCLUSIONS: Transcatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

Coronary Bifurcation Stenting: Review of Current Techniques and Evidence.

BACKGROUND: Coronary bifurcation stenting constitutes 20% of all PCI performed. Given the extensive prevalence of bifurcation lesions, various techniques have sought to optimally stent the bifurcation to improve revascularization while also decreasing rates of stent thrombosis and lesion recurrence. Advanced techniques, such as planned two-stent approaches, have been shown to have improved outcomes but also require fluoroscopy and procedure time, posing an economic argument as well as a patient-outcome one. OBJECTIVE: Because of the many strategies posited in the literature, it becomes essential to objectively evaluate evidence from randomized controlled trials and meta-analyses to help determine the optimal stenting strategy. METHODS: We reviewed the clinical evidence on the efficacy of coronary bifurcation stenting. RESULTS: In this paper, we review the most recent randomized controlled trials and meta-analyses on the efficacy of various stenting techniques and advances in stenting technologies published to gauge the current state of understanding and chart where the field is heading. CONCLUSION: Bifurcation stenting is a maturing problem in the field of interventional cardiology that is adapting to the needs of the patients and advances in technology.

Sex difference in clinical and procedural outcomes in patients undergoing coronary atherectomy: a systematic review and meta-analysis.

BACKGROUND: Rotational and orbital coronary atherectomy (CA) are commonly utilized to treat complex calcified coronary lesions. We conducted a meta-analysis to evaluate sex differences in procedural complications and clinical outcomes after CA. METHODS: PubMed, Google Scholar, and Cochrane databases were searched for all studies comparing sex differences in procedural and clinical outcomes following CA. The outcomes of interest were procedural complications (coronary dissection, stroke, major bleeding, coronary perforation, cardiac tamponade, and slow or no flow in target vessel) and the clinical outcomes (including early mortality, mid-term all-cause mortality, stroke, myocardial infarction, and target vessel revascularization). Pooled risk ratios (RRs) with their corresponding 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel random-effects model. RESULTS: Six observational studies with 3517 patients (2420 men and 1035 women) were included in this meta-analysis. While there was no significant difference in the early mortality (RR, 1.14; 95% CI, 0.37-3.53; P = 0.83) between men and women, at a mean follow-up of 2.9 years, all-cause mortality was significantly higher in women (RR, 1.29; 95% CI, 1.11-1.49; P = 0.0009). Women had an increased risk of procedure-related stroke (RR, 3.98; 95% CI, 1.06-14.90; P = 0.04), coronary dissection (RR, 2.10; 95% CI, 1.23-3.58; P = 0.006), and bleeding (RR, 2.26; 95% CI, 1.30-3.93; P = 0.004), whereas the rates of coronary perforation, cardiac tamponade, and the risk of slow or no flow in the revascularized artery were similar in both. CONCLUSION: In our analysis, women undergoing CA are at increased risk of mid-term mortality and procedure-related complications including stroke, coronary dissection, and major bleeding.

Multivessel vs. culprit-vessel only percutaneous coronary interventions in acute myocardial infarction and cardiogenic shock: a systematic review and meta-analysis of prospective randomized and retrospective studies.

AIMS: Studies comparing outcomes of multivessel (MV) vs. culprit-vessel (CV) only percutaneous coronary intervention (PCI) during index cardiac catheterization in patients presenting with acute myocardial infarction (MI) and cardiogenic shock (CS) have reported conflicting results. In this systematic review we aim to investigate outcomes with MV vs. CV-only revascularization strategies in patients with acute MI and CS. METHODS AND RESULTS: PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing MV vs. CV PCI in patients with acute MI and CS. Data were extracted and pooled by means of random effects model. Primary outcome was early all-cause mortality (up to 30 days), while the secondary outcomes included late all-cause mortality (mean, 11.4 months), stroke, new renal replacement therapy, reinfarction, repeat revascularization, and bleeding. Pooled odds ratio (OR), 95% confidence intervals (CIs), and number needed to harm (NNH) were calculated. A total of 16 studies enrolling 75 431 patients were included. The MV PCI was associated with higher risk of early mortality [OR 1.17, 95% CI (1.00-1.35); P = 0.04; NNH = 62], stroke [1.15 (1.03-1.29); P = 0.01; NNH = 351], and new renal replacement therapy [1.33 (1.06-1.67); P = 0.01; NNH = 61]; and with lower risk of repeat revascularization [0.61 (0.41-0.89); P = 0.01] when compared with CV PCI. No significant difference was observed in late-term mortality [1.02 (0.84-1.25); P = 0.84], risk of reinfarction [1.13 (0.94-1.35); P = 0.18], or bleeding [1.21 (0.94-1.55); P = 0.13] between groups. CONCLUSION: Among patients with acute MI and CS, MV PCI during index cardiac catheterization was associated with higher risk of early mortality, stroke, and renal replacement therapy.

Comparative efficacy and safety of adenosine and regadenoson for assessment of fractional flow reserve: A systematic review and meta-analysis.

BACKGROUND: Adenosine is a coronary hyperemic agent used to measure invasive fractional flow reserve (FFR) of intermediate severity coronary stenosis. AIM: To compare FFR assessment using adenosine with an alternate hyperemic agent, regadenoson. METHODS: PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing adenosine and regadenoson for assessment of FFR. Data on FFR, correlation coefficient and adverse events from the selected studies were extracted and analyzed by means of random effects model. Two tailed P-value less than 0.05 was considered significant. Heterogeneity was assessed using I 2 test. RESULTS: Five studies with 248 patients were included in the final analysis. All included patients and coronary lesions underwent FFR assessment using both adenosine and regadenoson. There was no significant mean difference between FFR measurement by the two agents [odds ratio (OR) = -0.00; 95% confidence interval (CI): (-0.02)-0.01, P = 0.88]. The cumulative correlation coefficient was 0.98 (0.96-0.99, P < 0.01). Three of five studies reported time to FFR with cumulative results favoring regadenoson (mean difference 34.31 s; 25.14-43.48 s, P < 0.01). Risk of adverse events was higher with adenosine compared to regadenoson (OR = 2.39; 95%CI: 1.22-4.67, P = 0.01), which most commonly included bradycardia and hypotension. Vast majority of the adverse events associated with both agents were transient. CONCLUSION: The performance of regadenoson in inducing maximal hyperemia was comparable to that of adenosine. There was excellent correlation between the FFR measurements by both the agents. The use of adenosine, was however associated with higher risk of adverse events and longer time to FFR compared to regadenoson.

Delayed acute myocarditis with COVID-19 infection.

Myocardial injury occurs in 20% to 30% of hospitalized patients with COVID-19 infection, and cardiovascular complications contribute to approximately 40% of all COVID-19-related deaths. Most cases of myocarditis related to COVID-19 infection occur in the acute phase of infection and are self-limited. We describe a case of delayed-onset fulminant myocarditis that developed 5 weeks after mild COVID-19 infection leading to cardiogenic shock and the need for mechanical circulatory support. Our case illustrates how myocarditis can occur as a late complication of COVID-19 infection, even in those with a mild initial course.

Ischemic and Bleeding Outcomes of Potent P2Y12 Inhibitor Antiplatelet Agents Versus Clopidogrel in Elderly Patients With Acute Coronary Syndrome: A Meta-Analysis of Randomized Trials.

BACKGROUND: The role of P2Y12 inhibition in acute coronary syndrome (ACS) has been well described in literature. However, the agent of choice is less clear among elderly patients (>65 years) who are at increased risk of bleeding. This meta-analysis was designed to investigate the efficacy and safety of potent P2Y12 inhibitors vs. clopidogrel in this population. METHODS AND RESULTS: PubMed, Cochrane Central Register of Clinical Trials, EMBASE, and ClinicalTrial.gov (inception through February 25, 2021) were searched for randomized studies comparing potent oral P2Y12 inhibitors to clopidogrel in elderly population presenting with ACS. Study endpoints included major adverse cardiac events (MACE), major bleeding, all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed and p<0.05 was considered significant. Eight randomized studies with a total 10,081 patients were included in the final analysis. At mean follow up of 26 months, there were no significant differences between potent oral P2Y12 inhibitors and clopidogrel in MACE (HR 0.97, 95% CI [0.82-1.15]; p=0.73), all-cause mortality (HR 0.91, 95% CI [0.75-1.10]; p=1.00), MI (HR 0.95, 95% CI [0.78-1.17]; p=0.64), and stroke (HR 1.24, 95% CI [0.82-1.86]; p=0.31). However, potent oral P2Y12 inhibitors were associated with a reduction in cardiovascular mortality (HR 0.82, 95% CI [0.68-0.98]; p=0.03), and an increase in major bleeding events (HR 1.32, 95% CI [1.09-1.59]; p<0.01). CONCLUSION: In comparison with clopidogrel, the use of potent oral P2Y12 inhibitors in elderly patients with ACS, is associated with a reduction in the risk of cardiovascular mortality with increased risk of bleeding events and no significant change in MACE outcomes.

Aspiration thrombectomy in ST-Elevation myocardial infarction: Further insights from a network meta-analysis of randomized trials.

BACKGROUND: The initial enthusiasm for thrombectomy during percutaneous coronary intervention (PCI) of ST-elevation myocardial infarction (STEMI) patients has given way to restraint. There has been some limited interest whether it is beneficial in a few selected subgroups. Hence, we performed a network meta-analysis to compare conventional PCI (cPCI), Aspiration or manual thrombectomy (AT) and Mechanical thrombectomy (McT) for clarification. METHODS: Electronic databases were searched for randomized studies that compared AT, McT, or cPCI. A network meta-analysis was performed and odd's ratio (OR) with 95% confidence intervals was generated for major adverse cardiac events (MACE), mortality, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), stroke, left ventricular ejection fraction (LVEF), myocardial blush grade (MBG) and ST segment resolution (STR). RESULTS: A total of 43 randomized trials (n = 26,682) were included. The risk of MACE (OR 0.86 95% CI 0.73-1.00), Mortality (OR 0.85 95% CI 0.73-0.99), MI (OR 0.65, 95% CI: 0.44-0.95) and TVR (OR 0.86, 95% CI: 0.74-1.00) were lower with AT compared to cPCI. The risk of ST and stroke was no different with the use of adjunctive AT. MBG, STR, and LVEF improved with the use of AT while the infarct size was no different in the two groups. CONCLUSIONS: Our comprehensive network meta-analysis suggests conflicting outcomes with AT. While Mortality, MACE, MI seem better, there is a suggestion that, Stroke and ST might be worse. Whether AT can still be pursued in any select cases should be further scrutinized.

Valve-in-valve transcatheter aortic valve replacement versus redo surgical valve replacement for degenerated bioprosthetic aortic valve: An updated meta-analysis comparing midterm outcomes.

BACKGROUND: Redo surgical aortic valve replacement (redo SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR) are the two treatment strategies available for patients with severe symptomatic bioprosthetic aortic valve dysfunction. Herein, we performed a systematic review and meta-analysis comparing both early and mid-term outcomes of ViV TAVR versus redo SAVR in patients with bioprosthetic aortic valve disease. METHODS: PubMed, Cochrane reviews, and Google scholar electronic databases were searched and studies comparing ViV TAVR versus redo SAVR were included. The primary outcome of interest was mid-term (1-5 years) and 1-year all-cause mortality. Secondary outcomes included were 30-day all-cause mortality, myocardial infarction, pacemaker implantation, stroke, acute kidney injury, major or life-threatening bleeding, and postprocedural aortic valve gradients. Pooled risk ratios (RR) with their corresponding 95% confidence intervals (CIs) were calculated for all outcomes using the DerSimonian-Laird random-effects model. RESULTS: Nine observational studies with a total of 2,891 individuals and mean follow-up of 26 months met the inclusion criteria. There is no significant difference in mid-term and 1-year mortality between ViV-TAVR and redo SAVR groups with RR of 1.15 (95% CI 0.99-1.32; p = .06) and 1.06 (95% CI 0.69-1.61; p = .8). 30-day mortality rate was significantly lower in ViV-TAVR group with RR of 0.65 (95% CI 0.45-0.93; p = .02). ViV-TAVR group had lower 30-day bleeding, length of stay, and higher postoperative gradients. CONCLUSION: Our study demonstrates a lower 30-day mortality and similar 1-year and mid-term mortality for ViV TAVR compared to redo SAVR despite a higher baseline risk. Given these findings and the ongoing advances in the transcatheter therapeutics, VIV TAVR should be preferred over redo SAVR particularly in those at intermediate-high surgical risk.

Pulmonary artery catheterization in acute myocardial infarction complicated by cardiogenic shock: A review of contemporary literature.

Acute myocardial infarction (AMI) with left ventricular (LV) dysfunction patients, the most common cause of cardiogenic shock (CS), have acutely deteriorating hemodynamic status. The frequent use of vasopressor and inotropic pharmacologic interventions along with mechanical circulatory support (MCS) in these patients necessitates invasive hemodynamic monitoring. After the pivotal Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial failed to show a significant improvement in clinical outcomes in shock patients managed with a pulmonary artery catheter (PAC), the use of PAC has become less popular in clinical practice. In this review, we summarize currently available literature to summarize the indications, clinical relevance, and recommendations for use of PAC in the setting of AMI-CS.

Access to smart devices and utilization of online health resources among older cardiac rehabilitation participants.

BACKGROUND: Newer models of cardiac rehabilitation (CR) delivery are promising but depend upon patient participation and ability to use technological media including Internet and smart devices. AIM: To explore the availability of smart devices, current utilization and proficiency of use among older CR program attendees. METHODS: Study participants were enrolled from four CR programs in Omaha, Nebraska United States and completed a questionnaire of 28 items. RESULTS: Of 376 participants approached, 169 responded (45%). Mean age was 71.1 (SD ± 10) years. Demographics were 73.5% males, 89.7% Caucasians, 52% with college degree and 56.9%, with income of 40K$ or more. Smart device ownership was 84.5%; desktop computer was the most preferred device. Average Internet use was 1.9 h/d (SD ± 1.7); 54.3% of participants indicating for general usage but only 18.4% pursued health-related purposes. Utilization of other health information modalities was low, 29.8% used mobile health applications and 12.5% used wearable devices. Of all participants, 72% reported no barriers to using Internet. Education and income were associated positively with measures of utilization and with less perceived barriers. CONCLUSION: Among an older group of subjects attending CR, most have access to smart devices and do not perceive significant barriers to Internet use. Nonetheless, there was low utilization of health-related resources suggesting a need for targeted education in this patient population.

Comparison of Computed Tomography derived Fractional Flow Reserve to invasive Fractional Flow Reserve in Diagnosis of Functional Coronary Stenosis: A Meta-Analysis.

Computed Tomography derived Fractional Flow Reserve (CTFFR) is an emerging non-invasive imaging modality to assess functional significance of coronary stenosis. We performed a meta-analysis to compare the diagnostic performance of CTFFR to invasive Fractional Flow reserve (FFR). Electronic search was performed to identify relevant articles. Pooled Estimates of sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (DOR) with corresponding 95% confidence intervals (CI) were calculated at the patient level as well as the individual vessel level using hierarchical logistic regression, summary receiver operating characteristic (SROC) curve and area under the curve were estimated. Our search yielded 559 articles and of these 17 studies was included in the analysis. A total of 2,191 vessels in 1294 patients were analyzed. Pooled estimates of sensitivity, specificity, LR+, LR- and DOR with corresponding 95% CI at per-patient level were 83% (79-87), 72% (68-76), 3.0 (2.6-3.5), 0.23 (0.18-0.29) and 13 (9-18) respectively. Pooled estimates of sensitivity, specificity, LR+, LR- and DOR with corresponding 95% CI at per-vessel level were 85% (83-88), 76% (74-79), 3.6 (3.3-4.0), 0.19 (0.16-0.22) and 19 (15-24). The area under the SROC curve was 0.89 for both per patient level and at the per vessel level. In our meta-analysis, CTFFR demonstrated good diagnostic performance in identifying functionally significant coronary artery stenosis compared to the FFR.

Operator Experience and Outcomes After Left Main Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: This review was performed with the goal of summarizing the role of operator experience in the treatment of severe left main stenosis by percutaneous intervention techniques. RECENT FINDINGS: The Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial demonstrated that percutaneous coronary intervention and coronary artery bypass grafting had similar clinical outcomes for severe left main disease. However, PCI of the left main coronary stenosis is considered to be a high-risk intervention because of the large area of myocardium at jeopardy that can quickly cause hemodynamic compromise. Operator experience and familiarity with the use of hemodynamic support devices, plaque modification techniques, and intravascular imaging tools is associated with better clinical outcomes. In patients with severe left main stenosis undergoing percutaneous coronary intervention by high-volume operators, the clinical outcomes are superior.

Mechanical function of the left atrium is improved with epicardial ligation of the left atrial appendage: Insights from the LAFIT-LARIAT Registry.

BACKGROUND: Left atrial (LA) strain (ε) and ε rate (SR) analysis by 2-dimensional speckle tracking echocardiography is a novel method for functional assessment of the LA. OBJECTIVE: The purpose of this study was to determine the impact of left atrial appendage (LAA) exclusion by Lariat epicardial ligation on mechanical function of the LA by performing ε and SR analysis before and after the procedure. METHODS: A total of 66 patients who underwent successful LAA exclusion were included in the study. Of these 66 patients, 32 had adequate paired data for ε and SR analysis. SR during ventricular systole (LA-SRs) represents LA reservoir function, and SR during early ventricular diastole (LA-SRe) represents LA conduit function. ε and SR were determined from apical 4- and 2-chamber views using the electrocardiographic QRS as a reference point. LA volume index as surrogate for LA remodeling was measured from apical views. RESULTS: Mean patient age was 70 ± 9.2 years. LAA ligation resulted in improved reservoir function (LA-SRs: pre 0.72, confidence interval [CI] 0.63-0.83 vs post 0.81, CI 0.73-0.98; P = .043) and conduit function (LA-SRe: pre 0.74, CI 0.67-0.99 vs post 0.89, CI 0.82-1.07; P = .025). LA volume index improved significantly with the Lariat (pre 35.4, CI 29.4-37.2 vs post 29.2, CI 28.2-35.9; P <.023). CONCLUSION: LAA exclusion seems to improve mechanical function of the LA and results in reverse LA remodeling.

Role of B-Type Natriuretic Peptide in Predicting In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Preserved Left Ventricular Function: A 5-Year Retrospective Analysis.

BACKGROUND: The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). METHODS: This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. RESULTS: Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. CONCLUSION: Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.

Treatment Patterns and Outcomes in Early-stage Hodgkin Lymphoma in the Elderly: A National Cancer Database Analysis.

BACKGROUND: The outcome for early-stage (I/II) Hodgkin lymphoma (HL) has improved significantly during the past few decades. However, older age (≥ 60 years) has continued to be associated with poor outcomes, and a paucity of data is available defining the optimal treatment regimens. In the present study, we sought to identify the practice patterns and outcomes in elderly patients with early-stage HL using the National Cancer Database. MATERIALS AND METHODS: We performed a retrospective study of patients aged 60 years with early-stage classic HL diagnosed from 2004 to 2012. The overall survival (OS) of patients undergoing chemotherapy (CT), radiation therapy (RT), or CT plus RT were compared. Kaplan-Meier curves of OS for individual therapy were constructed and compared using the log-rank test. Multivariate analysis for predictors of mortality was conducted using the Cox proportional hazard method. RESULTS: A total of 3795 patients were included in the analysis. At baseline, 41% patients had stage I disease. Of the 3795 patients, 51% underwent CT, 16% underwent RT, and 33% underwent CT plus RT. With a median follow-up duration of 40.4 months, the unadjusted OS rates for patients receiving CT, RT, or CT plus RT were 58.1%, 54%, and 77.7%, respectively (P < .0001). On multivariate analysis, CT plus RT improved OS compared with monotherapy. CONCLUSION: In older patients (age ≥ 60 years) with stage I/II HL, the combination of CT plus consolidative RT resulted in improved OS compared with monotherapy. However, the use of combination therapy in this age group seems suboptimal. This could be, in part, secondary to comorbidities limiting the use of CT plus RT in the elderly.