Transcatheter aortic valve replacement (TAVR) has transformed the treatment of aortic stenosis and should ideally be performed as a totally percutaneous procedure via the transfemoral (TF) approach. ...Peripheral vascular disease may impede valve delivery, and vascular access site complications are associated with adverse clinical outcome and increased mortality. We review strategies aimed to facilitate TF valve delivery in patients with hostile vascular anatomy and achieve percutaneous management of vascular complications.
Background
The availability of advanced technologies for mechanical support in hospitals with on-site cardiac surgery (CS), along with the ability to perform urgent coronary artery bypass graft ...(CABG) surgery, may result in improved clinical outcomes in patients with acute coronary syndrome (ACS).
Methods
We conducted a retrospective analysis of the bi-annually Acute Coronary Syndrome Israeli Survey (ACSIS) registry from the year 2000 to 2020, performed in hospitals with and without CS. Mortality rates and major adverse cardiac and cerebrovascular events (MACCE) rates are reported. We evaluated two periods of the study—early (2000–2010) vs. late (2011–2020). Propensity score matching was performed to reduce bias between the two groups.
Results
The study included 16,979 patients (52.3% in the on-site CS group). Patients in the on-site CS group were more likely to undergo percutaneous coronary intervention (PCI), (odds ratio OR, 1.26 95% CI, 1.18–1.35;
p
< 0.001) and CABG OR, 1.91 (95%CI, 1.63–2.24);
P
< 0.001, and patients in hospitals without on-site CS had higher 30-day MACCE OR, 1.17 (95% CI, 1.07–1.27);
p
< 0.0005. Overall, there was no difference in 1-year mortality (hazard ratio HR, 0.98 95% CI, 0.89–1.08;
p
= 0.71) between the groups. During the late period of the study, patients in the group without on-site CS had lower 30-day mortality OR, 0.69 (95% CI, 0.49–0.97);
P
= 0.04, yet with no difference in 1-year mortality HR, 0.81 (95% CI, 0.65–1.01);
p
= 0.07.
Conclusions
The availability of on-site CS resulted in variations in treatment modality, yet it did not affect the clinical outcomes of ACS. A trend to a better short-term outcomes was noted in hospitals without CS during the late period of the study, which warrants further investigation.
Background A risk score for secondary prevention after myocardial infarction (Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention TRS2P), based on 9 established clinical ...factors, was recently developed from the TRA 2°P- TIMI 50 (Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events) trial. We aimed to evaluate the performance of TRS 2P for predicting long-term outcomes in real-world patients presenting for coronary angiography. Methods and Results A retrospective analysis of 13 593 patients referred to angiography for the assessment or treatment of coronary disease was performed. Risk stratification for 10-year major adverse cardiovascular events was performed using the TRS 2P, divided into 6 categories (0 to ≥5 points), and in relation to the presenting coronary syndrome. All clinical variables, except prior coronary artery bypass grafting, were independent risk predictors. The annualized incidence rate of major adverse cardiovascular events increased in a graded manner with increasing TRS 2P, ranging from 1.65 to 16.6 per 100 person-years ( P
<0.001). Compared with the lowest-risk group (risk indicators=0), the hazard ratios (95% CIs) for 10-year major adverse cardiovascular events were 1.60 (95% CI, 1.36-1.89), 2.58 (95% CI, 2.21-3.02), 4.31 (95% CI, 3.69-5.05), 6.43 (95% CI, 5.47-7.56), and 10.03 (95% CI, 8.52-11.81), in those with 1, 2, 3, 4 and ≥5 risk indicators, respectively. Risk gradation was consistent among individual clinical end points. TRS 2P showed reasonable discrimination with C-statistics of 0.693 for major adverse cardiovascular events and 0.758 for mortality. The graded relationship between the risk score and event rates was observed in both patients presenting with acute and nonacute coronary syndromes. Conclusions The use of TRS 2P, a simple risk score based on routinely collected variables, enables risk stratification in patients undergoing coronary angiography. Its predictive value was demonstrated in a real-world setting with long-term follow-up and regardless of the acuity of coronary presentation.
Coronary artery ectasia (CAE) is defined as a segment of the coronary artery that has a diameter of more than 1.5 times the normal adjacent segments. It was described many years ago, but many aspects ...of this phenomenon are still unknown. It can be found in 1.2–2% of patients referred for coronary angiography. Risk factors are similar to atherosclerosis, but not in all patients. Histology shows extensive destruction of the musculoelastic elements, with marked degradation of the medial collagen and elastin fibers with disruption of the internal and external elastic lamina. These patients have abnormal levels of matrix metalloproteinases and other related proteins. Yet, the actual etiology of CAE is still unknown. Advances in new and improved imaging modalities such as CT and magnetic resonance angiography enable easier and more accessible diagnosis and evaluation. Treatment is aimed mostly at common cardiovascular risk factors. In small series, CAE was associated with worse prognosis. Anticoagulation was never examined in large trials. Nitrates worsen the flow and should not be administered. Interventional treatments are also an option, but a challenging one. This review presents an update on the current knowledge on CAE.
Giant coronary aneurysms are late sequelae of Kawasaki disease (KD). We describe a 53-year-old patient who presented with acute myocardial infarction and proximal aneurysms of all three coronary ...arteries. Coronary angiography demonstrated the aneurysms, but CT angiography allowed accurate assessment of the real dimensions of the aneurysms and making the decision on the preferred method of revascularization. The patient underwent coronary bypass surgery and is asymptomatic at follow-up.
This case describes management of recurrent valve migration during a TAVR procedure in a patient with a hypertrophic and hyperdynamic left ventricle. Since anchoring a valve in an optimal position ...within the aortic annulus was not possible, a valve was intentionally deployed deep within the left ventricular outflow tract. This valve was used as an anchoring site for an additional valve, which achieved an optimal hemodynamic result and clinical outcome outcome.
Involvement of atherosclerosis in extracardiac vascular territories may identify coronary artery disease (CAD) patients at higher risk for adverse events. We investigated the long-term prognostic ...implications of polyvascular disease in patients with CAD, and further analyzed lipid goal attainment and its relation to patient outcomes. The study was a retrospective analysis of 10,297 patients who underwent coronary revascularization, categorized as having CAD alone (83.1%) or with multisite artery disease (MSAD) (16.9%) including cerebrovascular disease (CBVD) and/or peripheral artery disease (PAD). Incidence rates and hazard ratios (HR) for major adverse cardiovascular events (MACE) (myocardial infarction, ischemic stroke, or all-cause death) according to vascular territories involved, and in relation to most-recent lipid levels attained, were analyzed. Patients with MSAD were older with higher burden of co-morbidities. The rate of MACE (myocardial infarction, ischemic stroke, or all-cause death) and its individual components increased with the number of affected vascular beds. Adjusted HR (95% confidence interval) for MACE was 1.41 (1.24 to 1.59) in patients with CAD and CBVD, 1.46 (1.33 to 1.62) in CAD and PAD, and 1.69 (1.49 to 1.92) in those with CAD and CBVD and PAD, compared with CAD alone. Most-recent low-density lipoprotein cholesterol (LDL-C) levels <55 mg/dl and <70 mg/dl were attained by 21.8% and 44.6% of patients with CAD alone, in comparison to 22.7% and 43.3% in MSAD. Compared with patients with most-recent LDL-C > 100 mg/dl, attaining LDL-C < 70 mg/dl had an adjusted HR for MACE of 0.52 (0.47 to 0.57) in CAD only patients and 0.66 (0.57 to 0.78) in MSAD patients. In conclusion, the presence of CBVD and/or PAD in patients with CAD is associated with higher burden of co-morbidities and progressive increase in long-term MACE. More than half of CAD patients with or without MSAD do not achieve lipid goals, which are associated with a significantly lower risk for adverse events.
A 76-year-old female with severe symptomatic aortic stenosis underwent cardiac CT angiography imaging. Severe calcification of the ascending aorta (porcelain aorta) (Figures 1A and 1B) precluded ...surgical aortic valve replacement. The aortic annular area, perimeter, and diameter were 372 mm2, 68.5 mm, and 20 mm, respectively. Transcatheter aortic valve replacement (TAVR) was performed with direct implantation of a 23 mm Sapien S3 valve (Edwards Lifesciences). The valve was delivered via the right femoral artery and a pigtail catheter was delivered to the aortic root via the left femoral artery. The balloon ruptured during valve implantation (Video).A 76-year-old female with severe symptomatic aortic stenosis underwent cardiac CT angiography imaging. Severe calcification of the ascending aorta (porcelain aorta) (Figures 1A and 1B) precluded surgical aortic valve replacement. The aortic annular area, perimeter, and diameter were 372 mm2, 68.5 mm, and 20 mm, respectively. Transcatheter aortic valve replacement (TAVR) was performed with direct implantation of a 23 mm Sapien S3 valve (Edwards Lifesciences). The valve was delivered via the right femoral artery and a pigtail catheter was delivered to the aortic root via the left femoral artery. The balloon ruptured during valve implantation (Video).
Smoking is associated with increased risk for acute ST-elevation myocardial infarction (STEMI) at a young age. Although smoking is a modifiable risk factor, smoking cessation rates after STEMI are ...suboptimal. We investigated the association between smoking status 1 year after STEMI and adverse events in patients (n = 765) aged ≤60 years. Patients were categorized as: (1) nonsmokers, (2) quit smoking, and (3) continued/resumed smoking. The association between smoking status and risk for major adverse cardiovascular events (MACEs) was analyzed during a median follow-up of 8 years. At presentation with STEMI, the mean age was 51 ± 7 years (88% men) and 427 (56%) were smokers. A year after STEMI, 272 continued smoking, 35 quit but later resumed smoking (summed to a single group; n = 307), and 120 quit smoking. Continued smoking was associated with younger age, male gender, lower weight, and low socioeconomic status. Compared with nonsmokers, the adjusted hazard ratio (95% confidence interval) for myocardial infarction, stroke, unstable angina, death, and MACE was 2.51 (1.67 to 3.73), 2.07 (0.94 to 4.56), 3.73 (1.84 to 7.58), 2.52 (1.53 to 4.13), and 2.40 (1.80 to 3.22), accordingly, in those who continued to smoke. However, the adjusted hazard ratio was not significantly associated with these outcomes in patients who quit smoking (MACE: 1.20 0.77 to 1.87, p=0.414; nonsignificant for individual end points). In conclusion, the prevalence of smoking in young and middle-aged patients presenting with STEMI is high and smoking cessation rates are low. A year after STEMI, those who continued to smoke had worse cardiovascular outcomes and death compared with nonsmokers; however, the long-term outcomes among those who quit smoking appear to be comparable with nonsmokers. The results highlight the contrast between health benefits of quitting smoking after STEMI and low abstinence rates in clinical practice.
Estimation of kidney function by glomerular filtration rate (eGFR) is affected by age and is important for decision making regarding treatment and prognosis of patients with cardiovascular disease. ...We investigated the impact of eGFR on long-term cardiovascular outcomes in an elderly population undergoing coronary angiography for evaluation or treatment of coronary artery disease.
GFR was estimated according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in 3690 elderly patients (aged 70-100 years) undergoing coronary angiography. Patients receiving maintenance dialysis were excluded. The association between eGFR and major adverse cardiovascular events (MACE) including myocardial infarction, ischemic stroke or death, was investigated. GFR was further calculated according to modification of diet in renal disease (MDRD) and the Cockcroft-Gault equations, and compatibility between estimations was analyzed.
Cardiovascular comorbidities were more prevalent with the reduction in kidney function as was the proportion of patients presenting with acute coronary syndromes. The adjusted hazard ratio (95% confidence interval) for MACE during a mean follow-up of 5 years was 0.95 (0.77-1.16), 1.04 (0.84-1.29), 1.56 (1.16-1.84), 2.22 (1.65-2.97) and 3.74 (2.20-6.38) in patients with eGFR 60-89, 45-59, 30-44, 15-29 and <15 ml/min/1.73m2, respectively, compared to >90 ml/min/1.73m2. Reclassification of eGFR stages by MDRD (upward 23.8%, downward 0.4%) and Cockcroft-Gault (upward 4.3%, downward 28.1%) compared to CKD-EPI estimation, was noted. However, the association between eGFR stages and MACE was similar between equations.
Kidney function, as manifested by eGFR, has a graded inverse association with the burden of cardiovascular comorbidities and long-term adverse events in elderly patients undergoing coronary angiography.
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