The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), represents the pandemic of the century, with approximately 3.5 million cases and ...250,000 deaths worldwide as of May 2020. Although respiratory symptoms usually dominate the clinical presentation, COVID-19 is now known to also have potentially serious cardiovascular consequences, including myocardial injury, myocarditis, acute coronary syndromes, pulmonary embolism, stroke, arrhythmias, heart failure, and cardiogenic shock. The cardiac manifestations of COVID-19 might be related to the adrenergic drive, systemic inflammatory milieu and cytokine-release syndrome caused by SARS-CoV-2, direct viral infection of myocardial and endothelial cells, hypoxia due to respiratory failure, electrolytic imbalances, fluid overload, and side effects of certain COVID-19 medications. COVID-19 has profoundly reshaped usual care of both ambulatory and acute cardiac patients, by leading to the cancellation of elective procedures and by reducing the efficiency of existing pathways of urgent care, respectively. Decreased use of health care services for acute conditions by non-COVID-19 patients has also been reported and attributed to concerns about acquiring in-hospital infection. Innovative approaches that leverage modern technologies to tackle the COVID-19 pandemic have been introduced, which include telemedicine, dissemination of educational material over social media, smartphone apps for case tracking, and artificial intelligence for pandemic modelling, among others. This article provides a comprehensive overview of the pathophysiology and cardiovascular implications of COVID-19, its impact on existing pathways of care, the role of modern technologies to tackle the pandemic, and a proposal of novel management algorithms for the most common acute cardiac conditions.
La maladie à coronavirus 2019 (COVID-19), causée par le SARS-CoV-2 (severe acute respiratory syndrome coronarivus-2 pour coronavirus du syndrome respiratoire aigu sévère 2), est la pandémie du siècle; en mai 2020, on dénombrait quelque 3,5 millions de cas et 250 000 décès dans le monde. Bien que les symptômes respiratoires dominent généralement le tableau clinique, on sait maintenant que la COVID-19 peut aussi avoir de graves conséquences sur le plan cardiovasculaire, par exemple des lésions myocardiques, des myocardites, des syndromes coronariens aigus, des embolies pulmonaires, des accidents vasculaires cérébraux, des arythmies, des insuffisances cardiaques et des chocs cardiogéniques. Les manifestations cardiaques de la COVID-19 pourraient être liées à la stimulation adrénergique, à l’inflammation généralisée et au syndrome de libération des cytokines causés par le SARS-CoV-2, à l’infection directe des cellules myocardiques et endothéliales par le virus, à l’hypoxie provoquée par l’insuffisance respiratoire, à un déséquilibre électrolytique, à une surcharge liquidienne et aux effets indésirables de certains médicaments utilisés pour traiter les symptômes de la COVID-19. En forçant l’annulation des interventions non urgentes et en réduisant l’efficacité des voies d’accès aux soins d’urgence, la COVID-19 a profondément transformé les soins usuels prodigués à tous les patients en cardiologie, qu’ils aient besoin de soins ambulatoires ou aigus. On a aussi observé une diminution de l’utilisation de services de soins de santé pour des problèmes aigus par les patients non atteints de COVID-19, une situation attribuée à la crainte de contracter le virus à l’hôpital. Des approches novatrices faisant appel aux technologies modernes ont été mises en œuvre pour pallier les restrictions imposées par la pandémie de COVID-19, entre autres : télémédecine, diffusion de matériel éducatif dans les médias sociaux, suivi des cas au moyen d’applications pour téléphone intelligent et modélisation de la pandémie grâce à l’intelligence artificielle. Les auteurs de cet article passent en revue les conséquences de la COVID-19 sur les plans physiopathologique et cardiovasculaire, ses répercussions sur les voies d’accès aux soins actuelles et le rôle des technologies modernes dans la lutte contre la pandémie, et proposent de nouveaux algorithmes de prise en charge des problèmes de santé cardiaque aigus les plus courants.
Through contemporary literature, the optimal strategy to manage coronary chronic total occlusions (CTOs) remains under debate.
The aim of the Italian Registry of Chronic Total Occlusions (IRCTO) was ...to provide data on prevalence, characteristics, and outcome of CTO patients according to the management strategy.
The IRCTO is a prospective real world multicentre registry enrolling patients showing at least one CTO. Clinical and angiographic data were collected independently from the therapeutic strategy optimal medical therapy (MT), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG); a comparative 1-year clinical follow-up was performed.
A total of 1777 patients were enrolled for an overall CTO prevalence of 13.3%. The adopted therapeutic strategies were as follows: MT in 826 patients (46.5%), PCI in 776 patients (43.7%), and CABG in the remaining 175 patients (9.8%). At 1-year follow-up, patients undergoing PCI showed lower rate of major adverse cardiac and cerebrovascular events (MACCE) (2.6% vs. 8.2% and vs. 6.9%; P < 0.001 and P < 0.01) and cardiac death (1.4% vs. 4.7% and vs. 6.3%; P < 0.001 and P < 0.001) in comparison with those treated with MT and CABG, respectively. After propensity score-matching analysis, patients treated with PCI showed lower incidence of cardiac death (1.5 vs. 4.4%; P < 0.001), acute myocardial infarction (1.1 vs. 2.9%; P = 0.03), and re-hospitalization (2.3 vs. 4.4% P = 0.04) in comparison with those managed by MT.
Our data showed how CTO PCI might significantly improve the survival and decrease MACCE occurrence at 1 year follow-up in comparison with MT and/or CABG.
Abstract Background We aimed to determine the prevalence of iatrogenic aortic dissection in chronic total occlusion (CTO) recanalization procedures, and to assess the management strategy and outcome ...of such a complication. Methods This study was a retrospective analysis of CTO percutaneous coronary intervention (PCI) cases performed by a single CTO experienced operator. Iatrogenic aortic dissection was defined as persistent contrast staining in the aortic cusp or root. Results Among 956 CTO PCI cases, iatrogenic aortic dissection occurred in 8 patients for an overall frequency of 0.83%. The right coronary artery was the CTO involved vessel in all cases with ostial location and severe calcifications in 37.5% and 62.5% of cases, respectively. Four patients underwent the antegrade approach and a retrograde strategy was adopted in the remaining 4 patients. The iatrogenic aortic dissection started from the right sinus of Valsalva in 87.5% of cases and catheter trauma was the presumed mechanism of dissection in most cases. Stenting of the entry point was performed in all cases, and dissection was limited (< 40 mm) in all patients. No patients required emergency surgery. One cardiac death was observed 12 days after the index procedure (12.5%), and a mean follow-up of 31.5 months was uneventful in the remaining 7 patients. Conclusions CTO recanalization procedures might be associated with a greater incidence of iatrogenic aortic dissection than non-CTO PCI. The therapeutic strategy and outcome depend on the rapidity of the entry point sealing and the degree of extension of the dissection into the aorta in serial imaging assessment.
Data is controversial regarding the existence of an “obesity paradox” in patients undergoing Transcatheter Aortic Valve Replacement (TAVR). We sought to investigate the prognostic value of the body ...mass index (BMI) on outcomes following TAVR.
This is an observational, single-center study involving all patients who underwent TAVR from 2009 to 2019. BMI was calculated in all patients before TAVR. The cohort was subdivided into four groups: underweight (<20 kg/m2), normal weight (≥20 to <25 kg/m2), overweight (≥25 to <30 kg/m2) and obese (≥30 kg/m2). The main endpoint was all-cause 30-day and one-year mortality.
A total of 412 patients (mean age 79.6 ± 7.8 years, mean STS score 5.3 ± 3.6) were included. Patients were grouped as follows: underweight (n = 35, 8.5%), normal weight (n = 121, 29.4%), overweight (n = 140, 34%) and obese (n = 116, 28.1%). Obese patients were younger, included more females and had lower STS score than the rest of the cohort whereas underweight patients were older, had higher STS score, more chronic kidney disease, more left ventricular dysfunction and more often underwent non-transfemoral TAVR. BMI predicted 30-day survival (AUC:0.692 95%CI 0.522–0.862; p = 0.030) with an optimal cut-off of 24.4 (sensitivity = 66.6%, specificity = 63.6%). On multivariate analysis, higher BMI trended toward lower 30-day mortality (HR = 0.87 95%CI 0.75–1.01; p = 0.071).
Thirty-day mortality was higher in the underweight group (8.3%) in comparison with other BMI subgroups (normal weight 2.5%, overweight 1.4%, obese 0.9%; p = 0.045). However, no significant difference was found after adjustment of confounders (all p = NS). BMI did not predict one-year mortality. No significant difference in one-year survival was observed between the four BMI subgroups (log rank p = 0.925).
BMI could represent an interesting prognostic tool for short-term mortality in patients undergoing TAVR. BMI < 20 kg/m2 was associated with higher 30-day mortality. Symptoms improved similarly in obese patients compared to lower BMI patients. For 30-day survivors, no evidence of the existence of an obesity paradox was observed in this cohort.
Abstract Background A promising variant of the subintimal tracking and re-entry (STAR) technique, called “mini-STAR,” has been recently described as a successful rescue technique after ...revascularization failure by conventional techniques for coronary chronic total occlusion (CTO). Methods The current study enrolled patients with CTO who underwent successful revascularization by the mini-STAR technique as a bailout strategy. Two-year clinical follow-up and angiographic control procedures were performed. Results From March 2009-September 2011, 100 of 117 patients (mean age, 61.4 ± 10.9 years) underwent successful recanalization of CTO by the mini-STAR technique as a bailout strategy. Drug-eluting stents (DESs) were implanted in all cases. At 2-year follow-up, the major adverse cardiac events (MACE)-free survival was 89.2%, with a target lesion revascularization (TLR) rate of 6.5%. Angiographic follow-up was performed in 72% of patients. CTO target lesion restenosis was observed in 25% of patients, whereas the reocclusion rate was 12.5%. At multivariate Cox analysis, final thrombolysis in myocardial infarction (TIMI) flow < grade 3 was related to occurrence of MACE (hazard ratio, 5.9; 95% confidence interval CI, 1.4-24.4; P = 0.013). Final TIMI flow < grade 3 (odds ratio OR, 5.41; 95% CI, 1.05-27.73; P = 0.043) and CTO stent length (OR, 0.96; 95% CI, 0.93-0.99; P = 0.017) were independent predictors of reocclusion. The independent variables related to restenosis were first-generation DESs (OR, 4.10; 95% CI, 1.23-13.64; P = 0.022) and CTO stent length (OR, 0.97; 95% CI, 0.95-0.99; P = 0.027). Conclusions As bailout strategy for CTO revascularization, the mini-STAR technique shows low MACE and TLR rates at long-term follow-up.
Abstract Objective We report our initial experience with extracorporeal membrane oxygenation (ECMO) use in elective high-risk complex percutaneous coronary intervention (PCI). Background ECMO has ...been employed as hemodynamic support in patients with cardiac arrest and hemodynamic shock. Methods We performed a single-center prospectical study, enrolling all patients at very high-risk for coronary artery bypass grafting (CABG). Major adverse cardiac and cerebrovascular events (MACCE) were defined as a composite of death, acute myocardial infarction (MI), stroke and further need for revascularization. Results Twelve patients underwent elective high-risk PCI with ECMO support (mean age = 63.5 ± 8.7 years). The mean SYNTAX score was 30.1 ± 10.1. All PCI procedures were successful and no in-hospital MACCE was observed. At 6-months, neither death nor MI was noticed. Two patients (17%) required further revascularization, and one patient required chronic hemodialysis. Conclusions Elective high-risk PCI supported by ECMO is a viable alternative for patients who are at very high risk for CABG.
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