Transcatheter closure of a large coronary cameral fistula presenting as a calcified cystic right atrial mass.

A 51-year-old patient with progressive right heart dysfunction was found to have a large calcified right atrial mass on echocardiography. As part of the work up for an intracardiac mass he had a cardiac computed tomogram which detailed a large coronary cameral fistula from the circumflex coronary artery to the right atrium associated with a spherical calcific pseudo-aneurysmal sac. Transcatheter occlusion of the exit point into the atrium with a vascular plug was performed directly from a right atrial approach without the need for an arteriovenous wire loop. This case details a unique presentation of a coronary cameral fistula to an unusual position within the right atrium which facilitated the rare ability to occlude the fistula from a venous approach without creating an arteriovenous wire rail.

Utilization of Cardiac Rehabilitation Among Cardiac Intensive Care Unit Survivors.

Cardiac rehabilitation (CR) is associated with decreased mortality and rehospitalization rates for patients with a variety of cardiac conditions. Although CR referral rates for STEMI patients have improved, rates for heart failure have remained low. Many of these patients are admitted to the cardiac intensive care unit (CICU). However, it is unknown how often CICU survivors qualify for cardiac rehabilitation, how often they are referred, and why eligible patients are not referred. This is a retrospective single-center study of 417 consecutive patients admitted to CICU for >48 hours from March 30, 2016 to March 30, 2017. We excluded patients with in-hospital mortality or those discharged AMA, to hospice or transferred. Chart abstraction was used to determine CR indications based on known American College of Cardiology/American Heart Association guidelines. If CR was indicated, medical records through September 2017 were reviewed to determine both referral and participation rates. In the absence of a referral, medical records were reviewed for potential barriers. A total of 296 CICU survivors were identified upon discharge with 185 (63%) having guideline-directed indications for CR referral. The most common indications were heart failure with reduced ejection fraction (HFrEF, 38%), cardiothoracic surgery (26%), and STEMI (23%). Upon discharge, only 30% of patients were referred to CR. The referral rate increased by 33% to 63% by 18 months postdischarge. CR referrals were most frequently placed following STEMI (91%), NSTEMI (80%), and postpercutaneous coronary intervention (80%). Only 35% of HFrEF discharges were referred to CR. Of patients not referred to CR, no explanation for a lack of referral was documented 87% of the time. In conclusion, nearly 2 of 3 patients discharged from the CICU had CR indications, most commonly HFrEF. CR referrals are frequently not placed and reason for nonreferral is rarely documented. CICU admission may provide a defined event to prompt referral.

Doxorubicin Exposure Causes Subacute Cardiac Atrophy Dependent on the Striated Muscle-Specific Ubiquitin Ligase MuRF1.

Background Anthracycline chemotherapeutics, such as doxorubicin, are used widely in the treatment of numerous malignancies. The primary dose-limiting adverse effect of anthracyclines is cardiotoxicity that often presents as heart failure due to dilated cardiomyopathy years after anthracycline exposure. Recent data from animal studies indicate that anthracyclines cause cardiac atrophy. The timing of onset and underlying mechanisms are not well defined, and the relevance of these findings to human disease is unclear. Methods and Results Wild-type mice were sacrificed 1 week after intraperitoneal administration of doxorubicin (1-25 mg/kg), revealing a dose-dependent decrease in cardiac mass ( R2=0.64; P<0.0001) and a significant decrease in cardiomyocyte cross-sectional area (336±29 versus 188±14 µm2; P<0.0001). Myocardial tissue analysis identified a dose-dependent upregulation of the ubiquitin ligase, MuRF1 (muscle ring finger-1; R2=0.91; P=0.003) and a molecular profile of muscle atrophy. To investigate the determinants of doxorubicin-induced cardiac atrophy, we administered doxorubicin 20 mg/kg to mice lacking MuRF1 (MuRF1-/-) and wild-type littermates. MuRF1-/- mice were protected from cardiac atrophy and exhibited no reduction in contractile function. To explore the clinical relevance of these findings, we analyzed cardiac magnetic resonance imaging data from 70 patients in the DETECT-1 cohort and found that anthracycline exposure was associated with decreased cardiac mass evident within 1 month and persisting to 6 months after initiation. Conclusions Doxorubicin causes a subacute decrease in cardiac mass in both mice and humans. In mice, doxorubicin-induced cardiac atrophy is dependent on MuRF1. These findings suggest that therapies directed at preventing or reversing cardiac atrophy might preserve the cardiac function of cancer patients receiving anthracyclines.

Correlation of infarct size with invasive hemodynamics in patients with ST-elevation myocardial infarction.

OBJECTIVES: To identify invasive hemodynamic parameters that correlate with infarction size in patients with ST-elevation myocardial infarction (STEMI). BACKGROUND: Invasive hemodynamics obtained during primary percutaneous coronary intervention (PPCI) are predictive of mortality in STEMI, but which parameters correlate best with the size of the infarction are unknown. METHODS: This is a single-center study of 405 adult patients with STEMI who had left ventricular end-diastolic pressure (LVEDP) measured during PPCI. Size of infarction was estimated by peak troponin I level and ejection fraction (LVEF) determined by echocardiography. RESULTS: The average (±SD) age was 61 ± 14 years, TIMI STEMI risk score was 3.5 ± 2.7 and Grace score was 157 ± 42. Hemodynamic parameters that correlated best with EF were LVEDP (r = -0.40), PP (r = 0.24), and SBP/LVEDP ratio (r = 0.22) and with peak troponin were SBP/LVEDP ratio (r = -0.41), LVEDP (r = 0.31), and PP (r = -0.29). SBP/LVEDP (AUC = 0.76) and SBP (AUC = 0.77) had a stronger association with in-hospital mortality than did LVEDP (AUC = 0.66) or PP (AUC = 0.64). Door-to-balloon time did not affect the correlations between hemodynamic parameters and infarct size. CONCLUSIONS: In this sample of 405 patients undergoing PPCI, SBP/LVEDP ratio had the strongest correlation with peak troponin levels and LVEDP with EF, whereas SBP/LVEDP and SBP had a strong association with in-hospital mortality. These results suggest that measurement of LVEDP as well as SBP may help risk stratify patients during PPCI.

Ratio of systolic blood pressure to left ventricular end-diastolic pressure at the time of primary percutaneous coronary intervention predicts in-hospital mortality in patients with ST-elevation myocardial infarction.

OBJECTIVE: To determine the ability of simple hemodynamic parameters obtained at the time of cardiac catheterization to predict in-hospital mortality following ST-elevation myocardial infarction (STEMI). BACKGROUND: Hemodynamic parameters measured at the time of primary percutaneous coronary intervention (PPCI) could potentially identify high-risk patients who would benefit from aggressive hemodynamic support in the Cardiac Catheterization laboratory. METHODS: This is a retrospective single-center study of 219 consecutive patients with STEMI. Left ventricular end-diastolic pressure (LVEDP), systolic blood pressure (SBP), and aortic diastolic blood pressure were obtained after successful revascularization. The prognostic ability of LVEDP, pulse pressure, and SBP/LVEDP ratio were compared to major mortality risk scores. RESULTS: Patients had a mean age of 60 ±14 years, were predominantly white (73%), male (64%), with anterior wall infarcts in 39%. Comorbidities included diabetes mellitus (27%), heart failure (9%), and chronic kidney disease (7%). In-hospital mortality was 9%. Patients with SBP/LVEDP ≤ 4 had increased risk of in-hospital death (32% vs. 5.3%, P < 0.0001), intra-aortic balloon pump (IABP) usage (51.6% vs. 9.6%, P < 0.0001) and combined endpoint of death or IABP usage (58.1% vs. 13.3%, P < 0.0001) compared to patients with SBP/LVEDP > 4. The area under curve (AUC) for SBP/LVEDP ratio for in-hospital mortality (0.69) was more predictive than LVEDP (0.61, P = 0.04) or pulse pressure (0.55, P = 0.02) but similar to Shock Index (ratio of heart rate to SBP) and Modified Shock Index (ratio of HR to mean arterial pressure). CONCLUSION: An SBP/LVEDP ratio ≤ 4 identified a group of STEMI patients at high risk of in-hospital death. © 2017 Wiley Periodicals, Inc.

Transcatheter Mitral Valve-in-Ring for Progressive Mitral Stenosis after Prior Repair with Annuloplasty: A Novel Balloon Sizing Technique.

An 83-year-old man with a previous mitral valve repair using a semi-rigid annuloplasty ring was found to have severe mitral stenosis. A transcatheter approach for mitral valve-in-ring replacement was selected due to the patient's high surgical risk. Pre-procedural computed tomography scans for transcatheter valve size selection were inconsistent with previously published recommendations. To determine the appropriate valve size, a 25 mm compliant balloon was inflated intraoperatively within the stenotic mitral ring, but yielded no resistance to movement and no 'waist'. Thus, a 29 mm balloon-expandable prosthetic valve was selected and deployed with no paravalvular leak. This novel balloon sizing technique helped lead to a successful outcome in this case. Video 1: Angiographic video displaying mitral valve-in-ring balloon sizing technique. The 25 mm compliant balloon was inflated within a stenotic mitral ring to determine which prosthetic transcatheter valve size was appropriate. As shown, this technique yielded no 'waist' and no resistance to movement, suggesting that a 29 mm valve was necessary.

Application of a Multidisciplinary Enhanced Recovery After Surgery Pathway to Improve Patient Outcomes After Transcatheter Aortic Valve Implantation.

Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.