Population health and sociodemographic variables as predictors of access to cardiac medicine and surgery in Haiti.

BACKGROUND: In Haiti, cardiovascular disease is a leading cause of morbidity and mortality, with congenital and rheumatic heart disease comprising a large portion of disease burden. However, domestic disparities in cardiac care access and their impact on clinical outcomes remain poorly understood. We analyzed population-level sociodemographic variables to predict cardiac care outcomes across the 10 Haitian administrative departments. METHODS: This cross-sectional study combined data from a 2016-17 Haitian national survey with aggregate outcomes from the Haiti Cardiac Alliance (HCA) database (n = 1817 patients). Using univariate and multivariable regression analyses, the proportion of HCA patients belonging to each of three clinical categories (active treatment, lost to follow-up, deceased preoperatively) was modeled in relation to six population-level variables selected from national survey data at the level of the administrative department. RESULTS: In univariate analysis, higher department rates of childhood growth retardation were associated with a lower proportion of patients in active care (OR = 0.979 [0.969, 0.989], p = 0.002) and a higher proportion of patients lost to follow-up (OR = 1.016 [1.006, 1.026], p = 0.009). In multivariable analysis, the proportion of department patients in active care was inversely associated with qualified prenatal care (OR = 0.980 [0.971, 0.989], p = 0.005), and child growth retardation (OR = 0.977 [0.972, 0.983]), p = 0.00019). Similar multivariable results were obtained for department rates of loss to follow-up (child growth retardation: OR = 1.018 [1.011, 1.025], p = 0.002; time to nearest healthcare facility in an emergency: OR = 1.004 [1.000, 1.008, p = 0.065) and for preoperative mortality (prenatal care: OR = 0.989 [0.981, 0.997], p = 0.037; economic index: OR = 0.996 [0.995, 0.998], p = 0.007; time to nearest healthcare facility in an emergency: OR = 0.992 [0.988, 0.996], p = 0.0046). CONCLUSIONS: Population-level survey data on multiple variables predicted domestic disparities in HCA clinical outcomes by region. These findings may help to identify underserved areas in Haiti, where increased cardiac care resources are required to improve health equity. This approach to analyzing clinical outcomes through the lens of population-level survey data may inform future health policies and interventions designed to increase cardiac care access in Haiti and other low-income countries.

Utility of coronary computed tomography guidance for intervention of an anomalous right coronary artery.

A case of a patient with an anomalous right coronary artery arising anteriorly and superiorly to the left main coronary artery from the left coronary cusp presented a dilemma in terms of treatment strategy for the ostial slit-like lesion and the atherosclerotic lesion in the mid vessel. Both lesions appeared severe on angiography, but the vessel could not be easily cannulated with diagnostic catheters for ideal visualization. Computed tomographic angiography (CTA) allowed high-resolution imaging of the artery, its location and course, and allowed characterization of the ostial lesion as a non-atherosclerotic, but significant, stenosis and showed the mid lesion to be a severe typical atherosclerotic plaque. In addition, CTA served as a map for the selection of optimal views of the coronary artery for cannulation and suggested the use of the guide catheter that was ultimately successful in addressing the unusual location of this ostium and in supporting the implantation of drug-eluting stents safely in the ostial and mid-vessel stenoses. Although previous reports are published on interventional treatment of slit-like ostia of anomalous coronary arteries, this is the first report to our knowledge of the concomitant use of CTA to support interventional treatment of a slit-like ostium.

Stenting the critical calyceal carotid bifurcation--a technical update.

There are several anatomical appearances of the carotid bifurcation. A calyceal type of bifurcation, superimposed with distal angulation of the internal carotid artery (ICA) and added ICA stenosis can be extremely challenging with regard to placement of embolic protection devices, prolonging manipulation of the lesion, procedure time, increasing contrast use and thus increasing the risk of complications. Certain technical maneuvers can facilitate the procedure and minimize risk. This case study describes the steps taken to safely treat these lesions.

Mid-term results and patient perceptions of robotically-assisted coronary artery bypass grafting.

We sought to study our mid-term outcomes and our patient's perceptions of robotically-assisted coronary artery bypass (RACAB). The daVinci robotic system was utilized to harvest and prepare the internal thoracic artery (ITA) as well as to open the pericardium and identify the target vessels. Anastomoses were performed by hand on the beating heart through limited incisions using an endoscopic stabilizing device. A follow-up telephone interview was conducted with patients at 3 to 6 months. Between 4/12/02 and 11/1/04, 37 patients underwent RACAB (1.2 distal anastomoses/patient). Median length of stay was 3 days (2-14 days) and 82% of patients reported full return to baseline activity within 10 days of surgery. There were two early LITA complications and one late anastomotic stenosis all of which occurred within the first two cases of each surgeon's experience. The majority of patients surveyed (95%) knew that robotics were involved in their surgery and most patients (95%) would recommend RACAB (95%). RACAB is an effective minimally invasive revascularization technique with excellent recovery times and high patient satisfaction. The early complication rate emphasizes the steep learning curve for this procedure as well as the need for intensive pre-procedure training.

Endovascular treatment of the subclavian artery: stent implantation with or without predilatation.

The endovascular treatment of subclavian artery (SA) lesions is less invasive than open surgical repair, with a low rate of complications. We report our experience in 89 subclavian obstructive lesions (n = 86) treated with stenting: 76 (85.3%) stenoses and 13 (14.6%) total occlusions. The left side was most frequently involved (83.1%), localized at the prevertebral segment in 91%. Technical success was obtained in 83 (93.3%) cases, 100% in stenotic lesions and 53.8% in total occlusions. There were nine global complications (10.1%): five (5.6%) at site of puncture, two distal embolization (2.2%), and two (2.3%) major events. The long-term follow-up was 3.51 +/- 1.98 years, during which time 13 (16.8%) restenoses and 2 (2.6%) reocclusions were noted. Subgroup analysis of patients with stenting after predilatation versus direct stenting technique showed in-hospital complications only in the first group, with a restenosis rate of 28.5% vs. 4.7%, respectively (P = 0.003). We consider stenting for SA obstructive lesions the first therapeutic option.

AngioJet thrombectomy.

The AngioJet rheolytic thrombectomy system is designed to remove thrombus with the Venturi-Bernoulli effect, with multiple high-velocity, high-pressure saline jets which are introduced through orifices in the distal tip of the catheter to create a localized low-pressure zone, resulting in a vacuum effect with the entrainment and dissociation of bulky thrombus. Rheolytic thrombectomy with the AngioJet catheter can reduce the thrombus burden in the setting of AMI and degenerated SVGs. The long-term follow-up appears to be favorable in patients treated with rheolytic thrombectomy in the setting of acute myocardial infarction over conventional primary angioplasty.

Establishing a new target range for unfractionated heparin for acute coronary syndromes.

INTRODUCTION: The target activated partial thromboplastin time (aPTT) range of 1.5 to 2.5 times the control value or 45 to 75 seconds recommended by the ACC/AHA for patients receiving unfractionated heparin (UFH) for acute coronary syndromes (ACS) is vulnerable to variation in test reagents. Rather than use the standard target aPTT range, it has been recommended that each institution establish its own target aPTT range based upon anti-factor Xa heparin levels. As a quality assurance project, we evaluated our institution's therapeutic aPTT range by examining the correlation between aPTTs and anti-factor Xa heparin levels and established a new target aPTT range with a new thromboplastin reagent based upon the therapeutic anti-factor Xa heparin levels. METHODS: Sixty-two plasma samples from 26 consecutive patients receiving UFH for ACS were analyzed. Plasma aPTTs measured with a thromboplastin reagent and a new thromboplastin reagent and anti-factor Xa heparin levels were obtained on each plasma sample. Linear regression analysis was performed to establish a new target aPTT range from corresponding therapeutic anti-factor Xa heparin levels. RESULTS: Thirty-two percent of patients with our institution's target range aPTTs of 61 to 100 seconds had anti-factor Xa heparin levels below 0.35 to 0.7 U/mL while 68% of patients had therapeutic anti-factor Xa heparin levels (positive predictive value = 68%). When the same blood was tested with a new thromboplastin reagent lot, only 9% of patients with target range aPTTs had anti-factor Xa heparin levels below 0.35 U/mL while 91% of patients had therapeutic anti-factor Xa heparin levels (positive predictive value = 91%). The Pearson correlation coefficient ( r ) for the new thromboplastin reagent lot was 0.93. The target aPTT range established with the new thromboplastin reagent lot was 61 to 100 seconds. CONCLUSION: Monitoring aPTTs without standardizing the thromboplastin reagent may not adequately reflect therapeutic heparin levels. Despite apparently target aPTTs, patients treated with UFH may be under-anticoagulated. Our new anti-Xa-adjusted target aPTT range shows an increase in the positive predictive value of aPTTs. Large-scale clinical studies are needed to determine the optimal anti-factor Xa range for ACS patients treated with UFH, with further refinements if glycoprotein IIb/IIIa inhibitors are concomitantly used and to show a benefit in clinical outcomes for monitoring plasma heparin levels with anti-factor Xa heparin levels. Institutional standardization of the aPTT is necessary to ensure optimal patient care when changing thromboplastin reagents.

Hybrid revascularization using percutaneous coronary intervention and robotically assisted minimally invasive direct coronary artery bypass surgery.

Hybrid revascularization (HR) combines staged percutaneous coronary intervention (PCI) on stenoses in the non-left anterior descending (LAD) territories with minimally invasive direct coronary artery bypass (MIDCAB) using the left internal thoracic artery (LITA) to the LAD. The LITA-to-LAD graft, which has a 5-year patency rate of 95%, is the major determinant of the long-term survival for patients. Thus, HR aims to perform full revascularization without compromising the survival advantage of the LITA-to-LAD graft, while preserving the minimally invasive advantages associated with the percutaneous treatment of symptomatic coronary stenoses. We investigated whether HR was a valid alternative to conventional coronary artery bypass graft surgery in patients with multivessel coronary artery disease. We also present our early experiences with HR using a combined approach of advanced PCI and robotically-assisted MIDCAB.

Molecular and cellular basis of restenosis after percutaneous coronary intervention: the intertwining roles of platelets, leukocytes, and the coagulation-fibrinolysis system.

The major limitation of percutaneous coronary intervention (PCI) is restenosis. Restenosis is considered to be an overreaction of the natural healing process after traumatic balloon dilatation. An elaborate web of cellular and molecular responses, including the interaction of platelets, leukocytes, and the coagulation-fibrinolysis system, as well as the secretion of various growth factors and pro-inflammatory cytokines, contributes to neointimal hyperplasia and the development of restenosis. Moreover, platelet and neutrophil activation after stenting appears to be different from that after balloon angioplasty alone. Pharmacotherapy targeting the cell-to-cell interaction between platelets and neutrophils may potentially offer an effective treatment strategy against restenosis after PCI.

Treatment of coronary aneurysm in acute myocardial infarction with AngioJet thrombectomy and JoStent coronary stent graft.

A 54-year-old male with a history of coronary artery disease with a percutaneous transluminal coronary angioplasty and stenting presented to the emergency with an acute myocardial infarction. The patient underwent angiography which showed in-stent thrombosis of the right coronary artery along with 2 aneurysms proximal to the lesion. The right coronary artery was treated with AngioJet rheolytic thrombectomy and the JoStent coronary stent graft. To our knowledge, this is the first report of the use of the AngioJet rheolytic thrombectomy and the JoStent coronary stent graft in acute myocardial infarction.

Cutting balloon angioplasty.

The Cutting Balloon is a unique angioplasty device used in percutaneous coronary interventions. The advantage of the Cutting Balloon is its ability to reduce vessel stretch and vessel injury by scoring the vessel longitudinally rather than causing an uncontrolled disruption of the atherosclerotic plaque. The atherotomes deliver a controlled fault line during dilatation to ensure that the crack propagation ensues in an orderly fashion. Lower balloon inflation pressures (4 8 atmospheres) are recommended with the Cutting Balloon. The Cutting Balloon also dilates the target vessel with less force to decrease the risk of a neoproliferative response and in-stent restenosis.

Retinal embolization during carotid angioplasty and stenting: mechanisms and role of cerebral protection systems.

Carotid stenting has become an accepted alternative to endarterectomy, but fear of embolic stroke has impeded its generalized application. The retina provides a unique observatory for the study of emboli, which may occur either directly or indirectly via collaterals to the ophthalmic artery. Systems under development for cerebral protection differ in their capacity to trap small emboli and in their protection of the collateral circulation. We evaluated 118 sequential patients undergoing carotid stenting using fundoscopy, fluorescein retinal angiography, and visual field examination. The site and size of emboli was assessed, and degree of edema estimated. All patients were treated using distal protection during carotid stent implantation: 38 patients with the Théron system (using routine flushing toward the external carotid) and 80 patients with the Percusurge system (aspiration only). Retinal embolization occurred in 6 of the 118 patients (4%), of whom 2 were symptomatic (1.7%). Using the Théron system, 5 of 38 patients (13.2%) had emboli while 1 of 80 (1.25%) had emboli using the Percusurge system (P = 0.019). Symptoms occurred only with emboli >20 microm. Symptomatic retinal embolization is uncommon during carotid stenting, but is more likely when external to internal carotid collaterals are not protected. Cerebral protection system designs should take into consideration the existence of collaterals and the need to protect against smaller sized emboli, which may cause blindness in the retinal circulation.