Your Heart, My Hands: Cardiac surgeon Arun Singh's memoir an engrossing immigrant saga of struggles, successes - in life and in the OR.

[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Direct Oral Anticoagulants (DOACs): Current Status Among Distinct Patient Subgroups.

The landscape of anticoagulant therapy for atrial fibrillation and deep-vein thrombosis has evolved considerably in the last decade with the advent of Novel or Direct-Acting Oral Antiocoagulants (DOACs). The initial phase III randomized controlled trials established the individual DOACs as viable alternatives to warfarin for thromboprophylaxis but generalizations to the larger population were limited by the small number of protocol subjects with renal insufficiency, congestive heart failure, advanced age and other comorbidities. All the DOACs have some degree of renal excretion and while safe and effective in patients with mild to moderate renal insufficiency, dose adjustment is necessary based on creatinine clearance. Subsequent data registries and real-world experience with DOACs have continued to refine their role in these particular patient subgroups. Off-label use with both under- and overdosing is not uncommon in renal failure and carries increased risk. Their increasing use among the elderly, in patients with heart failure, hepatic and renal insufficiency and among the Asian population has been shown to be relatively safe and effective compared to warfarin. Gaps in our current understanding of this new class of anticoagulants will continue to narrow as additional data becomes available through ongoing registries and real-world experience. [Full article available at http://rimed.org/rimedicaljournal-2017-05.asp].

Short-Term Effects of Tolvaptan in Patients With Acute Heart Failure and Volume Overload.

BACKGROUND: In patients with acute heart failure (AHF), dyspnea relief is the most immediate goal. Renal dysfunction, diuretic resistance, and hyponatremia represent treatment impediments. OBJECTIVES: It was hypothesized that the addition of tolvaptan to a background diuretic improved dyspnea early in patients selected for an enhanced vasopressin antagonism response. METHODS: In a double-blind trial, patients were randomized to tolvaptan 30 mg/day or placebo. Study entry required hospitalization within the previous 36 h, active dyspnea, and any of the following: 1) estimated glomerular filtration rate <60 ml/min/1.73 m2; 2) hyponatremia; or 3) diuretic resistance (urine output ≤125 ml/h following intravenous furosemide ≥40 mg). The primary endpoint was a 7-point change in self-assessed dyspnea at 8 and 16 h, using a novel standardized approach. RESULTS: We randomized 250 patients. There was no difference in the primary endpoint of day 1 dyspnea reduction, despite significantly greater weight reduction with tolvaptan (-2.4 ± 2.1 kg vs. -0.9 ± 1.8 kg; p < 0.001). At day 3, dyspnea reduction was greater with tolvaptan (p = 0.01). There were 2 significant treatment-by-subgroup interactions: patients without elevated jugular venous pressure and those without ascites showed directional favorability of tolvaptan over placebo for the primary endpoint compared with patients with these findings. CONCLUSIONS: Despite rapid and persistent weight loss with tolvaptan compared with placebo, in patients with AHF who were selected for greater potential benefit from vasopressin receptor inhibition, tolvaptan was not associated with greater early improvement in dyspnea. Apparent subsequent differences in dyspnea warrant further exploration of the temporal relationship between diuresis and dyspnea relief and a possible clinical role for tolvaptan. (Randomized, Double-Blind, Placebo Controlled Study of the Short Term Clinical Effects of Tolvaptan in Patients Hospitalized for Worsening Heart Failure With Challenging Volume Management [SECRET of CHF]; NCT01584557).

Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials.

BACKGROUND: Although transfemoral access (TFA) remains the standard of care for patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) in the USA, TRA is being increasingly used over TFA due to lower bleeding and mortality rates on the basis of meta-analyses and recently published MATRIX trial. In patients with unsuccessful ipsilateral radial access, TUA has been used as an alternative approach. The randomized controlled trials (RCTs) comparing TUA and TRA have reached mixed conclusions regarding the use of transulnar approach for coronary procedures. OBJECTIVES: To systematically review and perform a meta-analysis of published RCTs comparing the safety and efficacy of transulnar access (TUA) vs. transradial access (TRA) in patients undergoing CA or PCI. METHODS: PubMed, EMBASE, and CENTRAL databases were searched for RCTs since inception through December, 2014. Meta-analysis was performed using random-effects model. RESULTS: Five RCTs involving 2,744 total patients were included in the meta-analysis. TUA compared with TRA had similar risks of MACE [risk ratio (RR): 0.87; 95% confidence interval (CI): 0.56-1.36; P = 0.54] and access-related complications [RR: 0.92 (0.67-1.27); P = 0.62]. Higher rates of access cross-over [RR: 2.31 (1.07-4.98); P = 0.003] and number of punctures [1.57 vs. 1.4; mean difference (MD): 0.17; 95% CI: 0.08-0.26; P = 0.0002] were noted with TUA. There was no difference in arterial access time [12.8 vs. 10.9 min; MD: 1.86 (-1.35-5.7); P = 0.26], fluoroscopy time [7.6 vs. 7.2 min; MD: 0.37 (-0.39 - 1.13); P = 0.34] and contrast volume [151 vs. 153.7 ml; MD: -2.74 (-17.21 - 11.73); P = 0.71]. CONCLUSION: For patients requiring CA or PCI, TUA compared with TRA has similar efficacy and safety except for higher puncture rates and access cross-over.

Spontaneous calcific coronary embolus from a degenerative calcific aortic valve-a rare cause of acute ST segment elevation myocardial infarction.

This case report describes pathology-proven spontaneous coronary embolization from a calcific aortic valve resulting in an acute ST segment elevation myocardial infarction. It serves as an important reminder that, especially for elderly patients with coexisting aortic valvular disease, initial treatment for abrupt coronary artery occlusion with aspiration thrombectomy catheterization is standard of care.