Anomalous origin of the right coronary artery from the left sinus of Valsalva is a rare congenital disease. It is mostly benign, with malignant variants reported in a few instances. One such ..."malignant course" is its course between the main pulmonary artery and the aortic root. It is relatively uncommon but may present with angina or sudden cardiac death (SCD) in the absence of significant atherosclerosis, especially in young patients. Therefore, diagnosis becomes pivotal.Here, we report a case of a female in her late 70s with a history of vertigo who presented to the hospital with exertional syncope without prodromal symptoms. Further workup demonstrated high-sensitivity troponin that peaked at 3300 ng/dl. She was evaluated by cardiology for NSTEMI (non-ST segment elevation myocardial infarction) and underwent a coronary angiogram that identified non-obstructive coronary artery disease but an anomalous origin of the right coronary artery arising from the left coronary cusp. She underwent a CT (computed tomography) chest angiogram, which demonstrated an interarterial course between the aorta and pulmonary artery with multiple areas of significant stenosis. After extensive discussion, she decided to be treated conservatively due to its benign condition and late presentation. Identification of this anomalous course becomes pivotal as surgical correction can improve patient outcomes.Definitive therapy is surgery with unroofing of intramural segments, stenting, or surgical intervention with bypass grafting, reimplantation of the anomalous artery, or osteoplasty. However, in older patients, conservative management with exercise limitations is an acceptable option.
Race has been identified as an independent risk factor for poor prognosis and an independent predictor of survival in coronary artery disease. Race-related dissimilarities have been identified in ...cardiovascular patients in terms of age of presentation, co-morbidities, socioeconomic status, and treatment approach as well as genetically driven race-related disparities in responsiveness to medications. Antiplatelet therapy represents a fundamental component of therapy in cardiovascular patients, especially in patients presenting with acute coronary syndromes. It has been argued that the different level of platelet reactivity and varying response to antiplatelet therapy among races may account in part for worse outcomes in certain populations. The purpose of this review is to describe genotypic and phenotypic race-related differences in platelet reactivity and responsiveness to cardiovascular treatment, focusing on antiplatelet therapy to highlight the need establish a more effective and targeted antithrombotic strategy.
Right ventricular (RV) mechanical circulatory support remains an important adjunctive therapy for RV failure refractory to medical therapy. Impella RP (Abiomed, Danvers, MA) is approved for providing ...temporary RV support for patients with acute right heart failure or decompensation following left ventricular assist device implantation, myocardial infarction, heart transplant, or open-heart surgery. Robust data on the most commonly reported complications and failure modes for the Impella RP are lacking. We analyzed the post-marketing surveillance data from the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to assess these endpoints.
The MAUDE database was queried for the time period January 1, 2009, through December 31, 2018, for Impella devices by Searching for the following event types: “injury”, “malfunction”, “death”, and “other”. The search yielded 436 device reports. Impella RP medical device reports were screened, and 35 reports were included for the final analysis.
In cases of reported complications, Impella RP was placed most commonly for right ventricular failure (RVF) developing in postcardiotomy patients (20%). The most commonly reported complications included bleeding (42.9%) and vascular complications (22.8%). The modes of failure included damage or fracture of the device elements (34.2%); thrombus, or clot in the system (17.1%); and device detachment (8.6%).
Findings from the MAUDE database highlight the failure modes of the Impella RP device that should be addressed in order to improve the device performance and obtain improved clinical outcomes when utilized for RVF.
•Impella RP is approved for temporary RV support for acute right heart failure.•35 reports from MAUDE database were included for the final analysis.•Most commonly reported complications included bleeding and vascular complications.•Most commonly reported failure mode was damage or fracture of the device elements.•Findings highlight failure modes that should be addressed to improve performance.
Probable transmission of an extended-spectrum-beta-lactamase-producing Escherichia coli strain (sequence type ST131) between a father and daughter was documented. The father developed severe, ...recurrent pyelonephritis with multiple small abscesses; the daughter later developed septic shock, bacteremia, and extensive emphysematous pyelonephritis. This multidrug-resistant E. coli clone appears to be highly pathogenic and transmissible.
The aim of this network meta-analysis is to assess the impact of strut thickness on clinical outcomes in patients who underwent percutaneous coronary intervention. We searched Medline/PubMed and ...performed a Bayesian network meta-analysis to compare outcomes of patients who underwent percutaneous coronary intervention with drug-eluting stents (DES) of different strut thicknesses (ultrathin 60 to 80 μm; thin 81 to 100 μm; intermediate 101 to 120 μm; thick ≥120 μm). Studies comparing DES with similar strut thickness, bare metal stents, and fully bioresorbable scaffolds were excluded. Odds ratios with credible intervals (OR CrIs) were generated with random-effects models to compare outcomes. Our primary end point was stent thrombosis (ST). We identified 69 RCTs including 80,885 patients (ultrathin group = 10,219; thin group = 36,575; intermediate group = 11,399; thick group = 22,692). Mean age was 64 ± 11 years and 75% were male gender. When compared with thick-strut DES, ultrathin struts had significant less ST and myocardial infarction (OR 0.43 CrI 0.27 to 0.68; and OR 0.73 CrI 0.62 to 0.92, respectively). Sensitivity analysis including only studies with permanent polymer DES gave similar results. Improvement in DES technology with thinner struts is associated with significant reduction in ST and myocardial infarction compared with thicker struts.
It is estimated that each year in the United States >780,000 persons will experience an acute coronary syndrome. Approximately 70% of these will have non-ST-elevation myocardial infarction (NSTEMI). ...Optimal timing of angiography in NSTEMI is a matter of debate. The aim of this retrospective analysis was to evaluate whether and how the timing of percutaneous coronary intervention (PCI) affects the 1-year rate of major adverse cardiac events (MACE) in patients presenting with NSTEMI. Within our PCI database, we identified 1550 patients who underwent PCI for NSTEMI. We then divided the population into 3 groups based on door-to-balloon time (D2BT) (group 1 = D2BT <90 minutes; group 2 = D2BT >90 minutes <24 hours; group 3 = D2BT >24 hours). Primary outcome was MACE, a composite of MI, death and target vessel revascularization (TVR), or TVR at 1 year. Baseline characteristics were heterogeneous among the 3 groups, with patients who underwent angiograms >24 hours from presentation being older with more cardiovascular co-morbidities. Patients with D2BT <90 minutes were more likely to present with cardiogenic shock and had higher troponin levels. In-hospital mortality was similar among the 3 groups, but 1-year MACE/TVR was significantly higher in groups 1 and 3, driven by worse mortality. In this large cohort of patients presenting with NSTEMI, patients who underwent PCI between 90 minutes to 24 hours from presentation had better 1-year outcomes but also had fewer co-morbidities and with significantly lower prevalence of cardiogenic shock and high troponin on presentation. Therefore, treatment selection bias makes causal inference concerning rapid revascularization and outcome unreliable. Randomized clinical trials are warranted to assess outcome of rapid revascularization in patients presenting with NSTEMI.
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