Regional wall motion abnormalities in transthoracic echocardiography in patients with significant coronary artery disease and coronary collateral circulation in adults.

BACKGROUND: Coronary collateral circulation is a common finding in patients with chronic total occlusions (CTOs) resulting from chronic coronary artery disease (CAD). Regional wall motion abnormalities (RWMA) on transthoracic echocardiography (TTE) can be used for the diagnosis of CAD. However, little work has been done to investigate the impact of collateral vessels on the diagnostic accuracy of resting TTE for CAD. METHODS: A retrospective chart review was conducted of adults who received a resting TTE and cardiac catheterization within 30 days over a 4-year period at the Temple Baylor Scott & White echocardiography laboratory. Exclusion criteria included catheterization without coronary angiography and prior history of CAD, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). We analyzed RWMA on TTE in patients with CAD and coronary collateral circulation on cardiac catheterization to assess for correlation. RESULTS: Of the 753 patients were included in this study, 453 had CAD, 272 had both CAD and RWMA, 111 had collateral circulation, and 73 had collateral circulation and RWMA. There was no significant difference in RWMA in patients with CAD with and without collateral circulation. There was no significant difference in the sensitivity (60.0 % vs 59.2 %) and specificity (78.4 % vs 73.9 %) after collateral-adjusted interpretation of RWMA and CAD (p = 0.3). DISCUSSION: Our results suggest the average coronary collateral system is of insufficient clinical significance to prevent the development of RWMA on resting TTE.

Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease.

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

Patient characteristics associated with acute kidney injury following coronary angiography.

Objective: The objective of this study was to identify patient characteristics associated with acute kidney injury (AKI) post-coronary angiography with or without percutaneous coronary intervention. Methods: This retrospective, single-center study analyzed 350 patients from October 1, 2017 to September 30, 2018. The primary endpoint was AKI, defined as a rise in creatinine >0.3 mg/dL within 48 hours of coronary angiography. Results: AKI occurred in 41 of 350 patients (8.8%). Patients experiencing AKI had a higher incidence of hypertension (100%; P = 0.005), hyperlipidemia (98%; P = 0.001), diabetes mellitus (68%; P = 0.0005), and heart failure (37%; P = 0.0057). AKI occurred in 30 of 185 (16%) and 11 of 165 (6.7%) patients undergoing femoral and radial access, respectively. AKI incidence was not significantly affected by contrast dose (99 ± 9 vs 93 ± 3 mL; P = 0.52), fluoroscopy time (10.3 min [IQR 6.3, 17.7] vs 8.5 min [IQR 4.5, 13.9]; P = 0.2), or preprocedural computed tomography with contrast (P = 0.66). Multivariable regression showed significantly higher AKI among patients with peripheral artery disease (odds ratio [OR] = 12.4; 95% confidence interval [CI] 3.4-33.6; P = 0.0001), multivessel coronary artery disease (OR = 11.9; 95% CI 2.3-61.1; P = 0.003), and initial creatinine >1.5 mg/dL (OR = 4.4; 95% CI 1.4-13.6; P = 0.01). Conclusion: Peripheral artery disease, multivessel disease, and creatinine >1.5 mg/dL were associated with a higher risk of AKI in patients undergoing coronary angiography in this single-center retrospective cohort.

Long-term patency of rescue stenting of an anomalous left circumflex coronary artery after transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) in the setting of an anomalous left circumflex coronary artery (LCX) has had a variety of outcomes. Most commonly an anomalous LCX originates as a separate ostium arising from the right coronary sinus or is found branching off of the proximal right coronary artery. The artery courses around the aortic annulus before taking the course seen in typical anatomy. Given this deviation from typical anatomy and increased aortic annulus pressure by the replacement valve, there is an increased risk of a complication such as acute coronary artery occlusion. Special consideration and preparation are needed to prevent adverse outcomes, including death. We report a case in which intraprocedural anomalous LCX rescue stenting proved to be effective for treatment of acute coronary occlusion. Follow-up angiography provided an opportunity to demonstrate long-term patency in rescue stenting during TAVR.

Mechanical circulatory support for thyrotoxicosis-induced cardiomyopathy.

Thyroid storm is a life-threatening condition which, in rare cases, may lead to cardiogenic shock and dysrhythmias. Mechanical circulatory support with an Impella device or extracorporeal membrane oxygenation may be used as a bridge to recovery in these cases. This case involves a patient with thyrotoxicosis and reduced ejection fraction and hemodynamic instability requiring Impella device placement. After treatment with methimazole, Lugol's iodine, and hydrocortisone, he was weaned off mechanical circulatory support and made a full recovery. Mechanical circulatory support devices can be a useful bridging tool in reversible causes of cardiogenic shock, such as thyroid storm.

Iatrogenic ventricular septal defects following transcatheter aortic valve implantation.

Ventricular septal defect (VSD) rarely occurs following transcatheter aortic valve implantation (TAVI). We report two patients who developed VSD following TAVI. One case was a Gerbode defect treated by percutaneous closure, and the second was a restrictive perimembranous VSD managed conservatively.

Large hemopericardium and pericardial tamponade from presumed erosion of a Watchman 2.5 device 1-year postimplantation.

Percutaneous left atrial appendage closure has allowed patients with atrial fibrillation who are at high risk of bleeding to safely discontinue their anticoagulant therapy shortly after device implantation. The procedure, however, comes with a small risk of complications, including pericardial effusion and tamponade. The complications pertaining to pericardial effusion occur mainly perioperatively. We present an 82-year-old man with a 24 mm Watchman 2.5 device who developed hemopericardium resulting in tamponade and shock from presumed erosion of the device into the pericardium 1 year after implantation.

Comparison of outcomes after transcatheter aortic valve implantation following home versus non-home discharge.

As more patients undergo transcatheter aortic valve implantation (TAVI), knowledge of 1-year mortality and associated factors becomes increasingly important. After other cardiac procedures, discharge location has been shown to be associated with 1-year mortality. We examined outcomes of TAVI patients discharged home vs an extended care facility (ECF). All TAVI patients from January 1, 2012, to December 31, 2017, were evaluated. Cox proportional hazard regression models with cubic splines were used to estimate the adjusted effect of discharge to ECF on 1-year mortality. A total of 957 (85.6%) patients discharged home were compared to 160 (14.3%) discharged to ECF. On univariate analysis, patients discharged home were younger and had a lower Society of Thoracic Surgeons Predicted Risk of Mortality, higher albumin, and fewer vascular complications and strokes. Patients discharged to ECF had a higher 30-day mortality (3.8% vs. 0.5%, P = 0.001) and 1-year mortality (25.7% vs. 8.3%, P < 0.001). Cox proportional hazard regression models showed increased risk of 1-year mortality for patients discharged to ECF. In conclusion, patients discharged to ECF had a higher 30-day and 1-year mortality. The strongest predictor of 1-year mortality was discharge to ECF. Society of Thoracic Surgeons Predicted Risk of Mortality score was not a predictor of 1-year mortality.

Kounis syndrome presenting as ST elevation acute myocardial infarction.

Allergic acute coronary syndrome, Kounis syndrome, is a rare cause of ST-segment elevation myocardial infarction triggered by an allergic reaction to a drug or environmental allergen, resulting in atheromatous plaque rupture or coronary artery vasospasm. We report three cases of Kounis syndrome presenting as ST-segment elevation myocardial infarction.

Occlusion following the deployment of MANTA VCD after TAVR.

BACKGROUND: We present a complication following the deployment of the MANTA vascular closure device (VCD) following a transcatheter aortic valve replacement procedure which resulted in occlusion of the common femoral artery. AIMS: To address possible complications associated with MANTA VCD. RESULTS: This was addressed by ballooning the site from the contralateral side which re-established flow. CONCLUSION: We believe this is the first report to address this kind of complication and may prove useful as more of the MANTA devices are being used in multiple procedures.

Sensitivity and specificity of the Vectraplex electrocardiogram system with a cardiac electric biomarker in the diagnosis of ST-elevation myocardial infarction.

ST-elevation myocardial infarction (STEMI) is a clinical diagnosis based on a compatible history and characteristic electrocardiographic changes. In the current era, STEMI is treated emergently with angiography, leading to percutaneous coronary intervention. However, false-positive electrocardiograms (ECGs) occur, resulting in unnecessary emergent catheterizations. We hypothesized that the Vectraplex cardiac electrical biomarker (CEB) would increase the specificity for the diagnosis of STEMI. We studied 50 patients who were identified by standard of care (clinical history, physical exam, and 12-lead ECG) as suspected to have STEMI and tested the sensitivity and specificity of the Vectraplex ECG system. Using the final clinical diagnosis (based on history, ECGs, troponin values, and angiographic findings) as the gold standard, we found the CEB value to be quite dynamic, with a reasonable sensitivity and a good positive predictive value but generally poor specificity and negative predictive value. It offered only a 20% improvement compared to 50-50 performance on receiver operator curves.

Adjunctive use of Angio-Seal closure device following transcatheter aortic valve implantation via percutaneous transfemoral approach with incomplete hemostasis after modified Perclose ProGlide preclosure technique.

Adequate and reliable hemostasis following transcatheter aortic valve implantation (TAVI) is crucial. Closure devices have improved the amount of time required to achieve hemostasis following these procedures. We retrospectively looked at TAVI procedures that achieved adequate hemostasis after use of the Angio-Seal as an adjunctive measure following use of the Perclose ProGlide system. Sixteen cases (age range, 56-91 years) were identified between January 2016 and February 2018. Half had undergone transfemoral diagnostic angiography in the same vessel used for the TAVI delivery system within the prior 1 to 63 days. Five were receiving oral anticoagulants; six, aspirin; and two, dual-antiplatelet therapy. All had undergone computed tomography angiography for sizing of iliofemoral arteries, aorta, and the aortic valve prior to TAVI. No patient experienced any significant access site-related complications or ischemic leg symptoms, and there were no reports of late vascular or access site complications. Our case series suggests that adjunctive Angio-Seal systems may be a reliable alternative for incomplete hemostasis following Perclose ProGlide systems and can serve as a "bailout" procedure for incomplete postprocedural hemostasis.

Management of bioprosthetic cardiac valve thrombosis.

Valvular thrombosis is a known complication of bioprosthetic valve replacement that usually occurs within a year of implantation. Four-dimensional computed tomography is quickly becoming the gold standard to directly visualize thrombus. Current guidelines for prophylaxis include aspirin for all bioprosthetic valve replacements, dual antiplatelet therapy for aortic valves, and anticoagulation for mitral valves. However, new trials have suggested single-agent antiplatelet therapy or anticoagulation for treatment of bioprosthetic valve thrombosis. Three cases are presented that illustrate the use of anticoagulants and new techniques for detecting thrombosis on imaging.

Rupture of a left internal mammary artery during cardiopulmonary resuscitation.

We present a rare case of a left internal mammary artery rupture during cardiopulmonary resuscitation (CPR). This case demonstrates that intrinsic cardiac/vascular injuries can occur even with manual CPR, and each patient should be monitored closely, considering the very subtle signs that can clue the physicians into the diagnosis.

Pulmonary artery catheter-induced perforation treated with coil embolization.

The past 40 years have taught us much about the use of pulmonary artery catheters and their complications. Pulmonary artery rupture carries high morbidity and mortality, and therefore a high index of suspicion and timely management are key to the survival of patients who suffer from this rare complication. While surgical therapy has been considered the mainstay of treatment, endovascular therapy is feasible when surgery is not possible or desirable, as demonstrated in our patient. It is unknown which approach is optimal.

Ventricular tachycardic storm with a chronic total coronary artery occlusion treated with percutaneous coronary intervention.

A 66-year-old man with a history of coronary artery disease was evaluated due to ventricular tachycardic (VT) storm. The patient continued to have frequent recurrences of VT despite treatment with amiodarone and lidocaine. Since the ventricular arrhythmia could be related to myocardial ischemia related to a chronic total occlusion (CTO) of the right coronary artery, the patient underwent successful percutaneous coronary intervention of the CTO, followed by implantable cardioverter defibrillator implantation. He had no further episodes of VT during his hospital stay. After 9 months of follow-up, he had no further chest pain or clinically apparent recurrent ischemia. Interrogation of his defibrillator has shown brief nonsustained episodes of ventricular tachycardia, but the patient has not required delivery of a shock. The temporal association between treatment of the CTO and resolution of the VT, as well as the lack of recurrence of sustained VT, suggest a causative link between underlying ischemia produced by a chronically occluded coronary artery and provocation of VT and lend supportive evidence to this treatment approach.