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Magnusson MMM, Gerk U, Schüpbach G, Rieger J, Plendl J, Marin I, Drews B, Kaessmeyer S. Microvascular changes following exposure to iodinated contrast media in vitro. A qualitative comparison to serum creatinine concentrations in post-cardiac catheterization patients. Microvasc Res 2024; 153:104659. [PMID: 38286222 DOI: 10.1016/j.mvr.2024.104659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 01/31/2024]
Abstract
INTRODUCTION Contrast-associated acute kidney injury (CA-AKI) is characterized as a loss of renal function following radiological contrast media administration. While all contrast media induce variable changes in microvascular endothelial cells in vitro, only few studies report clinical significance of their findings. A comprehensive assessment of the effect of iodinated contrast media on the renal function in vitro and in vivo is essential. The aim of our study was to morphometrically quantify the effect of two different contrast media (Iobitridol and Iodixanol) on vascular endothelial capillaries in vitro and to analyze their effect on the renal function of patients who underwent cardiac catheterization including the intra-arterial administration of contrast media, by measuring serum creatinine concentration (SCr), a byproduct of muscle metabolism, primarily excreted by the kidneys. Our hypothesis suggests that conducting a qualitative comparison of both outcomes will enable identification of differences and similarities between in vitro and in vivo exposure. MATERIAL AND METHODS In vitro, co-cultures of human dermal fibroblasts and human dermal microvascular endothelial cells forming capillary beds were exposed to a mixture of phosphate buffered saline and either Iobitridol, Iodixanol, or one of their supplements EDTA or Trometamol for 1.5 or 5 min. Negative control co-cultures were exposed exclusively to phosphate buffered saline. Co-cultures were either directly fixed or underwent a regeneration time of 1, 3 or 7 days. An artificial intelligence software was trained for detection of labeled endothelial capillaries (CD31) on light microscope images and measurements of morphometric parameters. In vivo, we retrospectively analyzed data from patients who underwent intra-arterial administration of contrast media and for whom SCr values were available pre- and post-contrast exposition (1, 3, and 7 days following procedure). Temporal development of SCr and incidence of CA-AKI were assessed. Both exposure types were qualitatively compared. RESULTS In vitro, Iobitridol, Iodixanol and EDTA induced a strong decrease of two morphometric parameters after 3 days of regeneration. In vivo, a significant increase of SCr and incidence of CA-AKI was observed 3 days following procedure in the post-contrast media patients. No difference was observed between groups. DISCUSSION Two of the morphometric parameters were inversely proportional to the SCr of the patients. If the endothelial damages observed in vitro occur in vivo, it may result in renal hypoxia, inducing a loss of kidney function clinically translated into an increase of SCr. Further development of our in vitro model could allow closer replication of the internal structure of a kidney and bridge the gap between in vitro studies and their clinical findings.
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Affiliation(s)
- Marine M M Magnusson
- Division of Veterinary Anatomy, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Ulrich Gerk
- Städtisches Klinikum Dresden, Dresden, Germany
| | - Gertraud Schüpbach
- Veterinary Public Health Institute, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Juliane Rieger
- Institute of Translational Medicine for Health Care Systems, Department of Human Medicine, Faculty of Medicine, MSB Medical School Berlin, Berlin, Germany
| | - Johanna Plendl
- Institute of Veterinary Anatomy, Department of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Ilka Marin
- Institute of Veterinary Anatomy, Department of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Barbara Drews
- Division of Veterinary Anatomy, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Sabine Kaessmeyer
- Division of Veterinary Anatomy, Vetsuisse Faculty, University of Bern, Bern, Switzerland.
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Tirziu D, Huang H, Parise H, Pietras C, Moses JW, Messé SR, Lansky AJ. Cerebral Embolic Risk in Coronary and Structural Heart Interventions: Clinical Evidence. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100631. [PMID: 39130705 PMCID: PMC11307836 DOI: 10.1016/j.jscai.2023.100631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 08/13/2024]
Abstract
Surgical and endovascular procedures for coronary and structural heart interventions carry a meaningful risk of acute stroke with greatly increased likelihood of disability and long-term neurocognitive sequelae. In the last decade, transcatheter aortic valve replacement procedures have focused our attention on a spectrum of procedure-related neurologic injuries that have led to various efforts to prevent ischemic injury with the use of embolic protection devices. As the number of patients undergoing surgical and transcatheter cardiac procedures in the United States continues to increase, the risk of iatrogenic brain injury is concerning, particularly in patient populations already at increased risk of thromboembolism and cognitive decline. In this study, we reviewed the current estimates of the incidence of iatrogenic cerebral embolization and ischemic infarction after surgical and percutaneous transcatheter interventions for coronary artery disease, stenotic aortic and mitral valves, atrial fibrillation, left atrial appendage and patent foramen ovale closure. Our findings show that every year in the United States, nearly 2 million patients undergo coronary and structural heart interventions, with approximately 8000 at risk of experiencing a symptomatic stroke and 330,225 (95% CI, 249,948-430,377) at the risk of ischemic brain injury after the procedure. Given the increased use of surgical and endovascular cardiac procedures in clinical practice, the risk of iatrogenic cerebral embolism is significant and demands careful consideration through neurologic and cognitive assessments and appropriate risk mitigation.
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Affiliation(s)
- Daniela Tirziu
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Haocheng Huang
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Helen Parise
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Cody Pietras
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey W. Moses
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York
- St. Francis Hospital & Heart Center, Roslyn, New York
| | - Steven R. Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexandra J. Lansky
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Agrawal A, Isogai T, Shekhar S, Kapadia S. Cerebral Embolic Protection Devices: Current State of the Art. US CARDIOLOGY REVIEW 2023. [DOI: 10.15420/usc.2022.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has become a first-line treatment for severe aortic stenosis with intermediate to high-risk population with its use increasingly expanding into younger and low-risk cohorts as well. Cerebrovascular events are one of the most serious consequential complications of TAVR, which increase morbidity and mortality. The most probable origin of such neurological events is embolic in nature and the majority occur in the acute phase after TAVR when embolic events are most frequent. Cerebral embolic protection devices have been designed to capture or deflect these emboli, reducing the risk of peri-procedural ischaemic events. They also carry the potential to diminish the burden of new silent ischemic lesions during TAVR. Our review explores different types of these device systems, their rationale, and the established clinical data.
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Affiliation(s)
- Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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Murakami T, Sakakura K, Jinnouchi H, Taniguchi Y, Tsukui T, Watanabe Y, Yamamoto K, Seguchi M, Wada H, Fujita H. Acute Ischemic Stroke and Transient Ischemic Attack in ST-Segment Elevation Myocardial Infarction Patients Who Underwent Primary Percutaneous Coronary Intervention. J Clin Med 2023; 12:jcm12030840. [PMID: 36769488 PMCID: PMC9917385 DOI: 10.3390/jcm12030840] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/11/2023] [Accepted: 01/18/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) is a rare but critical complication following ST-elevation myocardial infarction (STEMI). The risk of AIS or transient ischemic attack (TIA) may be amplified by invasive procedures, including primary percutaneous coronary intervention (PCI). This study aimed to investigate the factors associated with in-hospital AIS/TIA in patients with STEMI who required primary PCI. METHODS We included 941 STEMI patients who underwent primary PCI and divided them into an AIS/TIA group (n = 39) and a non-AIS/TIA group (n = 902), according to new-onset AIS/TIA. The primary interest was to find the factors associated with AIS/TIA by multivariate logistic regression analysis. We also compared clinical outcomes between the AIS/TIA and non-AIS/TIA groups. RESULTS The incidence of in-hospital deaths was significantly higher in the AIS/TIA group (46.2%) than in the non-AIS/TIA group (6.3%) (p < 0.001). Multivariate analysis revealed that cardiogenic shock (OR 3.228, 95% CI 1.492-6.986, p = 0.003), new-onset atrial fibrillation (AF) (OR 2.280, 95% CI 1.033-5.031, p = 0.041), trans-femoral approach (OR 2.336, 95% CI 1.093-4.992, p = 0.029), use of ≥4 catheters (OR 3.715, 95% CI 1.831-7.537, p < 0.001), and bleeding academic research consortium (BARC) type 3 or 5 bleeding (OR 2.932, 95% CI 1.256-6.846, p = 0.013) were significantly associated with AIS/TIA. CONCLUSION In STEMI patients with primary PCI, new-onset AIS/TIA was significantly associated with cardiogenic shock, new-onset AF, trans-femoral approach, the use of ≥4 catheters, and BARC type 3 or 5 bleeding. We should recognize these modifiable and unmodifiable risk factors for AIS/TIA in the treatment of STEMI.
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Li Y, Zhao L, Xu T, Lv Q, He J, Wang Y, Fu G, Zhang W. Association Between Contrast Volume-to-Creatinine Clearance Ratio and the Risk of Perioperative Myocardial Infarction After Elective Percutaneous Coronary Intervention. Int Heart J 2022; 63:798-805. [PMID: 36104241 DOI: 10.1536/ihj.21-678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although the use of iodinated contrast for percutaneous coronary intervention (PCI) has known toxicity issues, the association between the contrast volume-to-creatinine clearance (V/CrCl) ratio and perioperative myocardial infarction (PMI) is unclear. The present study is aimed to investigate the predictive value of V/CrCl ratio on the incidence of PMI, and to determine a relatively safe contrast media V/CrCl ratio cut-off value to prevent PMI undergoing elective PCI. The V/CrCl ratio were obtained from 5970 patients undergoing elective PCI for single-vessel lesions. Cardiac troponin I (cTnI) were measured at baseline, 8, 16, and 24 hours after PCI. PMI was defined as postprocedural > 5 × upper limit of normal. Receiver operating characteristic (ROC) curves were performed to identify the optimal sensitivity for the V/CrCl range. Multivariate regression model were used to assess the association between V/CrCl ratios and PMI. Eight hundred and ninety-seven patients (15.0%) developed PMI. There was a significant association between higher V/CrCl ratio and the development of PMI (P < 0.001 for the trend). ROC curve analysis indicated that V/CrCl ratio of 2.05 was a discriminator for PMI (area under the curve = 0.674). After adjusting for other potential risk factors, V/CrCl ratio > 2.05 remained significant associated with PMI (odds ratio, 1.921; 95% confidence interval, 1.311-2.815; P = 0.001). The finding of this study suggests the importance of minimizing the contrast media dose to avoid PMI development. Use of a contrast media dose based on renal function with a V/CrCl value < 2.05 might be valuable in preventing PMI.
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Affiliation(s)
- Ya Li
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
| | - Liding Zhao
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
| | - Tian Xu
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
| | - Qingbo Lv
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
| | - Jialin He
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
| | - Yao Wang
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
| | - Guosheng Fu
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
| | - Wenbin Zhang
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Sir Run Run Shaw Hospital, Medical College of Zhejiang University
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Wexler NZ, Vogrin S, Brennan AL, Noaman S, Al-Mukhtar O, Haji K, Bloom JE, Dinh DT, Zheng WC, Shaw JA, Duffy SJ, Lefkovits J, Reid CM, Stub D, Kaye DM, Cox N, Chan W. Adverse Impact of Peri-Procedural Stroke in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2022; 181:18-24. [PMID: 35999069 DOI: 10.1016/j.amjcard.2022.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 11/01/2022]
Abstract
Peri-procedural stroke (PPS) is an important complication in patients who underwent percutaneous coronary intervention (PCI). The extent to which PPS impacts mortality and outcomes remains to be defined. Consecutive patients who underwent PCI enrolled in the Victorian Cardiac Outcomes Registry (2014 to 2018) were categorized into PPS and no PPS groups. The primary outcome was 30-day major adverse cardiovascular events (MACEs) (composite of mortality, myocardial infarction, stent thrombosis, and unplanned revascularization). Of 50,300 patients, PPS occurred in 0.26% patients (n = 133) (71% ischemic, and 29% hemorrhagic etiology). Patients who developed PPS were older (69 vs 66 years) compared with patients with no PPS, and more likely to have pre-existing heart failure (59% vs 29%), chronic kidney disease (33% vs 20%), and previous cerebrovascular disease (13% vs 3.6%), p <0.01. Among those with PPS, there was a higher frequency of presentation with ST-elevation myocardial infarction (49% vs 18%) and out-of-hospital cardiac arrest (14% vs 2.2%), PCI by way of femoral access (59% vs 46%), and adjunctive thrombus aspiration (12% vs 3.6%), all p = <0.001. PPS was associated with incident 30-day MACE (odds ratio [OR] 2.97, 95% confidence intervals [CIs] 1.86 to 4.74, p <0.001) after multivariable adjustment. Utilizing inverse probability of treatment weighting analysis, PPS remained predictive of 30-day MACE (OR 1.91, 95% CI 1.31 to 2.80, p = 0.001) driven by higher 30-day mortality (OR 2.0, 95% CI 1.35 to 2.96, p = 0.001). In conclusion, in this large, multi-center registry, the incidence of PPS was low; however, its clinical sequelae were significant, with a twofold increased risk of 30-day MACE and all-cause death.
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Affiliation(s)
- Noah Z Wexler
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Omar Al-Mukhtar
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - James A Shaw
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Curtain School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.
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Carraro do Nascimento V, de Villiers L, Hughes I, Ford A, Rapier C, Rice H. Transradial versus transfemoral arterial approach for cerebral angiography and the frequency of embolic events on diffusion weighted MRI. J Neurointerv Surg 2022:jnis-2022-019009. [DOI: 10.1136/jnis-2022-019009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/12/2022] [Indexed: 12/31/2022]
Abstract
BackgroundThe radial artery approach has become popular as a ‘radial first’ strategy for arterial access in neuroangiography and neurointerventions. Recent studies have shown that transradial arterial access (TRA) for cerebral angiography has been associated with reduced access site complication rates and improved patient satisfaction compared with transfemoral access (TFA). The goal of this study was to evaluate the presence of abnormal MRI diffusion weighted imaging (DWI) foci following DSA and correlate their frequency with TRA or TFA.MethodsWe prospective analyzed 200 consecutive adult DSAs performed from January 2021 to January 2022, at a single tertiary center.ResultsOf the 200 consecutive diagnostic cerebral angiograms, 52% were performed via TRA and 49% were performed via TFA. Of the TRA cerebral angiograms, 17.5% demonstrated at least one hyperintense focus on MRI DWI. Of the TFA procedures, 5.2% were considered positive. One patient (0.5%) in the TRA group experienced a minor neurologic deficit postoperatively that had not completely resolved at 90 days after the procedure and no neurologic deficits occurred in the TFA group.ConclusionsDespite the proven benefit of TRA over TFA in neurointervention, the number of MRI DWI restriction foci were significantly more frequent during cerebral angiography when TRA was selected. Although the number of clinically symptomatic events were minimal, the widespread use of the technique may become clinically relevant. Further studies contrasting the TRA and TFA techniques will be beneficial for cerebral angiography.
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Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures. Medicina (B Aires) 2021; 58:medicina58010045. [PMID: 35056353 PMCID: PMC8778528 DOI: 10.3390/medicina58010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for “frail patients”, in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.
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Comparing Single- and Dual Antiplatelet Therapies Following Transcatheter Aortic Valve Implantation. Ann Thorac Surg 2021; 114:1951-1964. [PMID: 34715082 DOI: 10.1016/j.athoracsur.2021.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/24/2021] [Accepted: 09/20/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation has been an established treatment in patients with symptomatic severe aortic stenosis. However, the postoperative antiplatelet regimen after transcatheter aortic valve implantation was not established certainly. The aim of this meta-analysis is to compare the safety and efficacy of single- (SAPT) and dual-antiplatelet therapies (DAPT) in patients undergoing transcatheter aortic valve implantation. METHODS Eligible randomized controlled trials and cohort studies published before February 2021 were retrieved from PubMed, Embase, and the Cochrane Library. We calculated odds ratios with 95% confidence intervals. RESULTS Nine articles, involving 19,277 patients, met the selection criteria. In the short-term outcome, compared with SAPT, DAPT was associated with a significantly higher rate of bleeding (odds ratios, 95% confidence intervals: 3.00, 1.67-5.38) and showed no significant differences in thrombotic events (odds ratios, 95% confidence intervals: 1.25, 0.74-2.11) and all-cause mortality (odds ratios, 95% confidence intervals: 0.84; 0.42-1.69). In the long-term outcome, DAPT was associated with a significantly higher bleeding rate (odds ratios, 95% confidence intervals: 1.85, 1.24-2.78) and showed no differences in thrombotic events (odds ratios, 95% confidence intervals: 1.13, 0.86-1.48) and all-cause mortality (odds ratios, 95% confidence intervals: 1.12, 0.95-1.32). Our trial sequential analysis confirmed DAPT didn't confer any benefit for reducing all-cause mortality and thrombotic events, and carried a higher risk of bleeding than SAPT. CONCLUSIONS SAPT should be a sufficient antiplatelet strategy in post- transcatheter aortic valve implantation patients without indications for oral anticoagulation medication, especially in the long-term follow-up period.
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Kotani S, Inoue Y, Oki N, Yashiro H, Hachiya T. Actual incidence of cerebral infarction after thoracic endovascular aortic repair: a magnetic resonance imaging study. Interact Cardiovasc Thorac Surg 2021; 34:267-273. [PMID: 34632503 PMCID: PMC8766213 DOI: 10.1093/icvts/ivab240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The actual incidence of cerebral infarction (CI), including asymptomatic infarction, owing to thoracic endovascular aortic repair (TEVAR) has not been reported in detail. This study was performed to investigate the incidence of post-TEVAR CI by using diffusion-weighted magnetic resonance imaging (DW-MRI) and to determine the risk factors for both symptomatic and asymptomatic CI. METHODS We examined 64 patients undergoing TEVAR at our institute between April 2017 and November 2020. Aortic atheroma was graded from 1 to 5 by preoperative computed tomography. Cerebral DW-MRIs were conducted 2 days after the procedure to diagnose postoperative CI. RESULTS A total of 44 new foci were detected by post-interventional cerebral DW-MRI in 22 patients (34.4%). Only one patient developed a symptomatic stroke (1.6%), and TEVAR was successfully completed in all cases. Debranching of the aortic arch and left subclavian artery occlusion with a vascular plug was performed in 19 (29.7%) and 12 (18.8%) patients, respectively. The number of patients with proximal landing zones 0–2 was significantly higher in the CI group than in the non-CI group (68.2% vs 11.9%; P < 0.001). The following risk factors were identified for asymptomatic CI: aortic arch debranching (P < 0.001), left subclavian artery occlusion (P = 0.001) and grade 4/5 aortic arch atheroma (P = 0.048). CONCLUSIONS Over one-third of the patients examined by cerebral DW-MRI after TEVAR were diagnosed with CI. High-grade atheroma and TEVAR landing in zone 0–2 were found to be positively associated with asymptomatic CI. Clinical trial registration 02-014.
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Affiliation(s)
- Sohsyu Kotani
- Department of Cardiovascular Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Yoshito Inoue
- Department of Cardiovascular Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Naohiko Oki
- Department of Cardiovascular Surgery, Hiratsuka City Hospital, Kanagawa, Japan
| | - Hideki Yashiro
- Department of Radiology, Hiratsuka City Hospital, Kanagawa, Japan
| | - Takashi Hachiya
- Department of Cardiovascular Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
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Waqar A, Lopez JJ. Neurological complications of coronary heart disease and their management. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:57-63. [PMID: 33632457 DOI: 10.1016/b978-0-12-819814-8.00024-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
While risk factors for the development of neurovascular and coronary heart disease (CHD) are similar, it is important to consider neurologic complications of CHD separately, as many of these complications are a direct result of the underlying condition or procedures performed to treat atherosclerotic coronary disease. Stroke after myocardial infarction (MI) and acute coronary syndromes (ACSs) is not infrequent, occurring in 0.7%-2.5% of patients within 6 months of the coronary event. The etiology of these events can be frequently traced to the development of left ventricular thrombus (LVT) formation after large MI episodes. Often, however, these events are directly related to catheter-based procedures or anticoagulation strategies utilized to treat the ACS. Ischemic strokes outnumber hemorrhagic strokes in this population. While there is a modest evidence base for use of anticoagulation to treat LVT, catheterization-related ischemic stroke and anticoagulation-related hemorrhagic stroke are typically managed via standard approaches.
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Affiliation(s)
- Aneeq Waqar
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States; Department of Medicine, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States
| | - John J Lopez
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States; Department of Medicine, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States.
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Indja B, Woldendorp K, Vallely MP, Grieve SM. Silent Brain Infarcts Following Cardiac Procedures: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 8:e010920. [PMID: 31017035 PMCID: PMC6512106 DOI: 10.1161/jaha.118.010920] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Silent brain infarcts (SBI) are increasingly being recognized as an important complication of cardiac procedures as well as a potential surrogate marker for studies on brain injury. The extent of subclinical brain injury is poorly defined. Methods and Results We conducted a systematic review and meta‐analysis utilizing studies of SBIs and focal neurologic deficits following cardiac procedures. Our final analysis included 42 studies with 49 separate intervention groups for a total of 2632 patients. The prevalence of SBIs following transcatheter aortic valve implantation was 0.71 (95% CI 0.64‐0.77); following aortic valve replacement 0.44 (95% CI 0.31‐0.57); in a mixed cardiothoracic surgery group 0.39 (95% CI 0.28‐0.49); coronary artery bypass graft 0.25 (95% CI 0.15‐0.35); percutaneous coronary intervention 0.14 (95% CI 0.10‐0.19); and off‐pump coronary artery bypass 0.14 (0.00‐0.58). The risk ratio of focal neurologic deficits to SBI in aortic valve replacement was 0.22 (95% CI 0.15‐0.32); in off‐pump coronary artery bypass 0.21 (95% CI 0.02‐2.04); with mixed cardiothoracic surgery 0.15 (95% CI 0.07‐0.33); coronary artery bypass graft 0.10 (95% CI 0.05‐0.18); transcatheter aortic valve implantation 0.10 (95% CI 0.07‐0.14); and percutaneous coronary intervention 0.06 (95% CI 0.03‐0.14). The mean number of SBIs per patient was significantly higher in the transcatheter aortic valve implantation group (4.58 ± 2.09) compared with both the aortic valve replacement group (2.16 ± 1.62, P=0.03) and the percutaneous coronary intervention group (1.88 ± 1.02, P=0.03). Conclusions SBIs are a very common complication following cardiac procedures, particularly those involving the aortic valve. The high frequency of SBIs compared with strokes highlights the importance of recording this surrogate measure in cardiac interventional studies. We suggest that further work is required to standardize reporting in order to facilitate the use of SBIs as a routine outcome measure.
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Affiliation(s)
- Ben Indja
- 1 Sydney Translational Imaging Laboratory Heart Research Institute Charles Perkins Centre The University of Sydney Camperdown Sydney NSW Australia.,2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia
| | - Kei Woldendorp
- 2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia.,4 Department of Cardiothoracic Surgery Royal Prince Alfred Hospital Camperdown Sydney NSW Australia
| | - Michael P Vallely
- 2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia.,3 Sydney Heart and Lung Surgeons Camperdown Sydney NSW Australia
| | - Stuart M Grieve
- 1 Sydney Translational Imaging Laboratory Heart Research Institute Charles Perkins Centre The University of Sydney Camperdown Sydney NSW Australia.,2 Sydney Medical School The University of Sydney Camperdown Sydney NSW Australia.,5 Department of Radiology Royal Prince Alfred Hospital Camperdown Sydney NSW Australia
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13
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Nanjudappa A, Bhagat A, Bates MC. A rare cause of stroke after transcatheter aortic valve replacement: Retained foreign body. Catheter Cardiovasc Interv 2019; 94:870-873. [PMID: 31237082 DOI: 10.1002/ccd.28374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/10/2019] [Indexed: 11/07/2022]
Abstract
The field of transcatheter aortic valve replacement (TAVR) has matured significantly with the outcome and durability data now supporting use in lower-risk patients. We present a preventable complication from early in our experience (5 years ago) that illustrates the importance of heart team communication and cautious multidiscipline cross-pollination during the formative years of a program. An 87-year old female developed confusion, slurred speech and left upper extremity weakness 1 day following TAVR with inconclusive findings on carotid artery duplex and transthoracic echocardiography. Subsequent CT-scan disclosed a linear, ring-like, structure in the ascending aorta. The foreign body (FB) was radiolucent and successfully snared via tactile sensation and anatomic landmarks informed by the CT. The extricated FB was the valvuloplasty balloon guard (BG) that was inadvertently introduced into the patient via ascending aortic large sheath access. The failure mode was traced back to the first time use of a new balloon system and unrecognized BG by the surgical physician and technician components of the Heart Team who took the lead role in device insertion due to the open chest access. Subsequently, the heart team made changes to mitigate similar future complications by sharing multidiscipline responsibility for all procedural steps and ensuring the use of all new adjuvant devices are preceded by a procedural pause and team consensus regarding device preparation and use. Additionally, the manufacturer addition of a radiopaque marker or flair on the valvuloplasty BG may be warranted.
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Affiliation(s)
- Aravinda Nanjudappa
- Cardiology and Structural Heart, Charleston Area Medical Center, Charleston, West Virginia
| | - Abhishek Bhagat
- Internal Medicine, Charleston Area Medical Center, Charleston, West Virginia
| | - Mark C Bates
- Cardiology and Vascular Medicine, Charleston Area Medical Center, Charleston, West Virginia.,Cardiology, West Virginia University, Morgantown, West Virginia.,Department of Surgery, West Virginia University, Charleston, West Virginia
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14
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Abdel-Latif A, Misumida N. Ischemic Stroke After Percutaneous Coronary Intervention: Rare, But Devastating. JACC Cardiovasc Interv 2019; 12:1507-1509. [PMID: 31395221 DOI: 10.1016/j.jcin.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 05/14/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmed Abdel-Latif
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
| | - Naoki Misumida
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
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15
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Voss S, Deutsch MA, Schechtl J, Erlebach M, Sideris K, Lange R, Bleiziffer S. Impact of a Two-Filter Cerebral Embolic Protection Device on the Complexity and Risk of Transcatheter Aortic Valve Replacement. Thorac Cardiovasc Surg 2019; 68:616-622. [PMID: 31091551 DOI: 10.1055/s-0039-1688483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is a growing use of cerebral protection devices in patients undergoing transcatheter aortic valve replacement (TAVR). We aimed to analyze if the use of these devices itself has an impact on the complexity and the risk of TAVR. METHODS Between February 2016 and July 2017, 391 patients underwent transfemoral TAVR with Medtronic CoreValve Evolut R (n = 196) or Edwards Sapien 3 (n = 195). In 39 patients, the Claret Sentinel™ embolic protection device (CS-EPD) was used. Prospectively collected data were retrospectively analyzed, comparing fluoroscopy/operation time, amount of contrast used, vascular events, and postprocedural renal function in TAVR patients with (n = 39) and without (n = 352) CS-EPD. RESULTS The CS-EPD was placed through the right radial (n = 35) or brachial (n = 4) artery. Procedural success rate defined as correct deployment and retraction of both filters was 94.9%. No device-related vascular complications occurred. TAVR patients with CS-EPD showed a significantly higher total operation time, total fluoroscopy time, and amount of used contrast (85.4 ± 39.3 vs. 64 ± 29.8 minutes, p = 0.002; 20.7 ± 9.3 vs. 13.7 ± 7 minutes, p ≤ 0.001; 133.7 ± 42.6 vs. 109.7 ± 44.5 mL, p = 0.001). Comparing the initial third of patients receiving a CS-EPD with the last third of CS-EPD cases, procedural time had decreased significantly (102.5 ± 34.9 vs. 67 ± 11.9; p = 0.002). There were no differences in postprocedural renal failure (p = 0.80). CONCLUSION Our data add evidence that the application of the CS-EPD is not associated with an additional risk for the patient. Although procedural time and amount of contrast are still higher when using the CS-EPD, there were no device-related complications or increased incidence of renal failure.
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Affiliation(s)
- Stephanie Voss
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Institute of Translational Cardiac Surgery (Insure), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Marcus-André Deutsch
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Institute of Translational Cardiac Surgery (Insure), German Heart Center Munich, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Johanna Schechtl
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Institute of Translational Cardiac Surgery (Insure), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Magdalena Erlebach
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Institute of Translational Cardiac Surgery (Insure), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Konstantinos Sideris
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Institute of Translational Cardiac Surgery (Insure), German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Institute of Translational Cardiac Surgery (Insure), German Heart Center Munich, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Sabine Bleiziffer
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Department of Cardiovascular Surgery, Institute of Translational Cardiac Surgery (Insure), German Heart Center Munich, Technische Universität München, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Munich, Germany
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16
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Ram P, Horn B, Lo KBU, Pressman G, Rangaswami J. Acute Kidney Injury Post Cardiac Catheterization: Does Vascular Access Route Matter? Curr Cardiol Rev 2019; 15:96-101. [PMID: 30421683 PMCID: PMC6520579 DOI: 10.2174/1573403x14666181113112210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute Kidney Injury as a complication of cardiac catheterization is associated with increased length of hospital stay and mortality. In recent years, the use of the radial artery for cardiac catheterization is increasing in frequency. OBJECTIVE The objective of this concise review was to evaluate the method of cardiac access site and its impact on Acute Kidney Injury following cardiac catheterization. METHODS After a thorough search on Medline, Google Scholar and PubMed, we included all the literature relevant to Acute kidney injury following transradial and transfemoral cardiac catheterization. RESULTS While acute kidney injury was caused due to a variety of reasons, it was important to consider each case on an individual basis. We found a trend towards increased use of transradial approach in patients at high risk of developing kidney injury. However, limitations such as operator experience, anatomical challenges and so on do exist with this approach. CONCLUSION Transradial access offers several advantages to a patient at high risk of acute kidney injury undergoing cardiac catheterization. Further large studies are needed to establish this trend in the years ahead.
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Affiliation(s)
- Pradhum Ram
- Address correspondence to this author at the Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA; Tel: 215-688-3183; E-mail:
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17
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Mahmoud AA, Mahmoud AN, Elgendy AY, Anderson RD. Current Status of Coronary Atherectomy. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2018. [DOI: 10.15212/cvia.2017.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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Louis DW, Kennedy K, Lima FV, Pancholy SB, Abbott JD, Gordon P, Aronow HD. Association Between Maximal Activated Clotting Time and Major Bleeding Complications During Transradial and Transfemoral Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2018; 11:1036-1045. [DOI: 10.1016/j.jcin.2018.01.257] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 12/26/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
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19
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Moraca RJ, Shah AA, Bailey SH, Benckart D, Lasorda D, Khalil R, Chess B, McGregor W, Halbreiner MS. Combined carotid endarterectomy and transcatheter aortic valve replacement: Technique and outcomes. J Card Surg 2018; 33:265-269. [PMID: 29663514 DOI: 10.1111/jocs.13601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Stroke and transient ischemic attack after transcatheter aortic valve replacement results in significantly higher morbidity and mortality. Severe carotid artery disease may be a contributing factor to this increased risk. We report our technique and outcomes of combined carotid endarterectomy (CEA) with transcatheter aortic valve replacement (TAVR). METHODS From March 2013 to November 2017 a total of 753 TAVRs were performed at our institution for symptomatic severe aortic stenosis. Of this group, 16 patients underwent concomitant TAVR and CEA. A retrospective review was performed to assess risk, outcomes, and short-term survival. RESULTS Sixteen patients underwent concomitant CEA/TAVR procedures for severe carotid and severe aortic stenosis. The mean Society of Thoracic Surgeons (STS) Risk Score was 7.0 ± 4.7. All patients had severe carotid artery stenosis and aortic stenosis. Nine patients had a transfemoral TAVR approach and eight patients had a transapical TAVR approach. The mean length of stay was 6.4 ± 3.7 days. At 30 days there were no cerebrovascular events and no mortalities. CONCLUSIONS The use of concomitant CEA and TAVR in patients with severe aortic stenosis and severe carotid stenosis can be done safely without increased risk of complications. This approach may reduce the risk of stroke associated with TAVR in appropriately selected patients.
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Affiliation(s)
- Robert J Moraca
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Anil A Shah
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Stephen H Bailey
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Daniel Benckart
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - David Lasorda
- Department of Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Ramzi Khalil
- Department of Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Bart Chess
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Walter McGregor
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Michael S Halbreiner
- Department of Thoracic and Cardiovascular Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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20
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Fernando RJ, Johnson SD, Augoustides JG, Patel PA, Gutsche JT, Ha B, Feinman JW, Weiss SJ, Cheruku S, McCartney SL, Dave N, Fabbro M, Morris BN. The Hostile Thoracic Aorta: Management Considerations for Severe Aortic Atheroma in a Challenging Case of Coronary Artery Bypass Grafting and Mitral Valve Replacement. J Cardiothorac Vasc Anesth 2018; 33:223-231. [PMID: 29685800 DOI: 10.1053/j.jvca.2018.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Sean D Johnson
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bao Ha
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sreekanth Cheruku
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sharon L McCartney
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Duke University, Durham, NC
| | - Nisha Dave
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Benjamin N Morris
- Cardiothoracic and Critical Care Sections, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
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21
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Hirota S, Yoshimura M, Fujii S, Kiyokawa J, Yamamoto S. Induction of a Guiding Sheath to Carotid Artery without Intra-aortic Manipulation by Using a Pigtail-type Inner Catheter: Technical Note and Report of Two Cases. JOURNAL OF NEUROENDOVASCULAR THERAPY 2018; 12:206-212. [DOI: 10.5797/jnet.tn.2017-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Affiliation(s)
- Shin Hirota
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Masataka Yoshimura
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Shoko Fujii
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Juri Kiyokawa
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Shinji Yamamoto
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
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22
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Kataoka Y, Puri R, Pisaniello AD, Hammadah M, Qintar M, Uno K, Montarello JK, Nicholls SJ, Worthley SG. Aortic atheroma burden predicts acute cerebrovascular events after transcatheter aortic valve implantation: insights from volumetric multislice computed tomography analysis. EUROINTERVENTION 2017; 12:783-9. [PMID: 27542792 DOI: 10.4244/eijv12i6a127] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Embolisation of atheromatous debris during catheter manipulation is considered to underlie acute cerebrovascular events (CVE) after transcatheter aortic valve implantation (TAVI). However, the relationship between aorta atheroma burden and acute CVE after TAVI has not been established. We investigated the impact of aorta atheroma burden on acute CVE. METHODS AND RESULTS Preoperative multislice computed tomographic (MSCT) images in 278 patients receiving TAVI were analysed. Total atheroma volume (TAV) was calculated by measuring aorta vessel and lumen areas in every 1 mm cross-sectional image. Acute CVE was observed in 16 patients. Patients having acute CVE were more likely to have a prior CVE (p=0.002), and to exhibit greater TAV in the ascending aorta (12.8±3.5 vs. 7.0±2.1 cm3, p<0.001) and the aortic arch (3.1±1.6 vs. 1.2±0.2 cm3, p<0.001). TAV in the ascending aorta >10.3 cm3 and in the aortic arch >2.9 cm3 predicted acute CVE. The incidence of acute CVE was highest (36.4%) if patients had a prior CVE and TAV in the ascending aorta and the aortic arch above cut-offs. CONCLUSIONS Patients with acute CVE after TAVI had greater aorta atheroma burden. Our findings might underscore preoperative MSCT analysis of aorta atherosclerosis to identify high-risk patients for acute CVE, who might require an embolic protection device during TAVI.
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Affiliation(s)
- Yu Kataoka
- South Australian Health & Medical Research Institute, University of Adelaide, Adelaide, Australia
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23
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Percutaneous Coronary Intervention as a Trigger for Stroke. Am J Cardiol 2017; 119:35-39. [PMID: 27776798 DOI: 10.1016/j.amjcard.2016.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 11/21/2022]
Abstract
Percutaneous coronary intervention (PCI) is a plausible triggering factor for stroke, yet the magnitude of this excess risk remains unclear. This study aimed to quantify the transient change in risk of stroke for up to 12 weeks after PCI. We applied the case-crossover method, using data from the Norwegian Patient Register on all hospitalizations in Norway in the period of 2008 to 2014. The relative risk (RR) of ischemic stroke was highest during the first 2 days after PCI (RR 17.5, 95% confidence interval [CI] 4.2 to 72.8) and decreased gradually during the following weeks. The corresponding RR was 2.0 (95% CI 1.2 to 3.3) 4 to 8 weeks after PCI. The RR for women was more than twice as high as for men during the first 4 postprocedural weeks, RR 10.5 (95% CI 3.8 to 29.3) and 4.4 (95% CI 2.7 to 7.2), respectively. Our results were compatible with an increased RR of hemorrhagic stroke 4 to 8 weeks after PCI, but the events were few and the estimates were very imprecise, RR 3.0 (95% CI 0.8 to 11.1). The present study offers new knowledge about PCI as a trigger for stroke. Our estimates indicated a substantially increased risk of ischemic stroke during the first 2 days after PCI. The RR then decreased gradually but stayed elevated for 8 weeks. Increased awareness of this vulnerable period after PCI in clinicians and patients could contribute to earlier detection and treatment for patients suffering a postprocedural stroke.
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24
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Eftychiou C, Barmby DS, Wilson SJ, Ubaid S, Markwick AJ, Makri L, Blaxill JM, Spratt JC, Gunning M, Greenwood JP. Cardiovascular Outcomes Following Rotational Atherectomy: A UK Multicentre Experience. Catheter Cardiovasc Interv 2016; 88:546-553. [DOI: 10.1002/ccd.26587] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 03/25/2016] [Accepted: 04/22/2016] [Indexed: 11/10/2022]
Affiliation(s)
| | - David S. Barmby
- Department of Cardiology; Leeds General Infirmary; Leeds United Kingdom
| | - Simon J. Wilson
- Department of Cardiology; Royal Infirmary of Edinburgh; Edinburgh United Kingdom
| | - Salahaddin Ubaid
- Department of Cardiology; University Hospital of North Staffordshire; Stoke-on-Trent United Kingdom
| | - Andrew J. Markwick
- Department of Cardiology; University Hospital of North Staffordshire; Stoke-on-Trent United Kingdom
| | - Loukia Makri
- Department of Cardiology; Leeds General Infirmary; Leeds United Kingdom
| | | | - James C. Spratt
- Department of Cardiology; Forth Valley Royal; Edinburgh United Kingdom
| | - Mark Gunning
- Department of Cardiology; University Hospital of North Staffordshire; Stoke-on-Trent United Kingdom
| | - John P. Greenwood
- Department of Cardiology; Leeds General Infirmary; Leeds United Kingdom
- Division of Cardiovascular and Diabetes Research; Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds; Leeds United Kingdom
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25
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Grabert S, Lange R, Bleiziffer S. Incidence and causes of silent and symptomatic stroke following surgical and transcatheter aortic valve replacement: a comprehensive review. Interact Cardiovasc Thorac Surg 2016; 23:469-76. [PMID: 27241049 DOI: 10.1093/icvts/ivw142] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/11/2016] [Indexed: 12/24/2022] Open
Abstract
Stroke associated with aortic valve replacement in calcific aortic stenosis, either via transcatheter implantation (TAVR) or via surgical replacement (SAVR), is one of the most devastating complications. However, data concerning the clinical impact and incidence of clinical and silent stroke complicating SAVR and TAVR are varying. This comprehensive review of the literature explores the genuine incidence of neurological events after these procedures. Additionally, potential factors responsible for the discrepancies in stroke rates in the current literature are analysed and a lack of uniform neurological definitions and standardized neurological assessments revealed. Current stroke rates after TAVR show a decline from 7 to 1.7-4.8% in recent studies. Randomized studies comparing TAVR with SAVR yielded initially a significantly higher stroke rate after TAVR procedures as opposed to SAVR. Recently published data showed opposite results with strokes being higher following SAVR. Current data concerning stroke after surgical valve replacement report significantly higher rates of clinical strokes (17%) than previously mentioned in the literature (≤4.9%). Silent cerebral lesions were detected in 68-93% after TAVR and 38-54% after SAVR. A broader application of cerebral protection devices may help to reduce embolic cerebral events.
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Affiliation(s)
- Stephanie Grabert
- Department of Cardiovascular Surgery, German Heart Center Munich, Clinic at the Technical University, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Clinic at the Technical University, Munich, Germany
| | - Sabine Bleiziffer
- Department of Cardiovascular Surgery, German Heart Center Munich, Clinic at the Technical University, Munich, Germany
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26
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López-Mínguez JR, Millán-Núñez V, González-Fernández R, Nogales-Asensio JM, Fuentes-Cañamero ME, Merchán-Herrera A. Unusual cause of central aortic prosthetic regurgitation during transcatheter replacement. Rev Port Cardiol 2016; 35:239.e1-5. [DOI: 10.1016/j.repc.2015.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/13/2015] [Indexed: 11/25/2022] Open
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27
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Unusual cause of central aortic prosthetic regurgitation during transcatheter replacement. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2015.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Didier R, Gaglia MA, Koifman E, Kiramijyan S, Negi SI, Omar AF, Gai J, Torguson R, Pichard AD, Waksman R. Cerebrovascular accidents after percutaneous coronary interventions from 2002 to 2014: Incidence, outcomes, and associated variables. Am Heart J 2016; 172:80-7. [PMID: 26856219 DOI: 10.1016/j.ahj.2015.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cerebrovascular accident (CVA) and transient ischemic attack (TIA) related to percutaneous coronary intervention (PCI) are relatively rare complications, but they are associated with high morbidity and mortality. Given the evolution of both CVA risk and PCI techniques over time, this study was conducted to evaluate trends in CVA and TIA associated with PCI and to identify variables associated with neurologic events. METHODS Consecutive patients undergoing PCI at the Washington Hospital Center between January 2002 and June 2015 were included. Prespecified data were prospectively collected, including baseline and procedural characteristics, in-hospital outcomes, and 1-year mortality. The subjects who had a CVA or TIA during or immediately after PCI were compared with those without procedure-associated CVA or TIA. RESULTS Overall, 25,626 patients were included in the study. The mean age was 65.0 ± 12.4 years, 16,949 (65.2%) were male, and 7,436 (28.6%) were African American. From 2002 to 2015, 110 neurologic events post-PCI were diagnosed (0.43%); this included 86 CVAs (0.34%) and 24 TIAs (0.09%). The annual rate of postprocedural neurologic events was 0.42% ± 0.12%. There were significant changes in baseline risk factors over time, with increasing age, incidence of insulin-dependent diabetes, and chronic kidney disease. Patients with neurologic events were more often African American (43.6% vs 28.6%, P < .001) with prior history of CVA (24.5% vs 7.8%, P < .001), chronic renal insufficiency (26.6% vs 15.2%, P < .001), and insulin-dependent diabetes (19.1% vs 12.4%, P = .03). Acute myocardial infarction (56% vs 30.4%, P < .001) and cardiogenic shock (20.2% vs 3%, P < .001) were also more common among patients with neurologic events post-PCI. After multivariable adjustment, use of an intraaortic balloon pump was strongly associated with neurologic events (odds ratio [OR] 4.9, 95% CI 2.7-8.8, P < .001), as was prior CVA (OR 2.4, 95% CI 1.4-4.4, P = .002) and African American race (OR 2.4, 95% CI 1.5-3.9, P < .001); there was a borderline association with the use of a thrombus extraction device (OR 1.7, 95% CI 0.9-3.2, P = .09). In-hospital mortality (20.0% vs 1.5%, P < .001) and 1-year mortality (45.0% vs 7.3%, P < .001) were also much higher in patients with neurologic events. CONCLUSION Neurologic events post-PCI are associated with markedly worse in-hospital outcomes. The incidence of CVA and TIA post-PCI, however, remained stable over the last 12 years despite an increase in risk factors for CVA.
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Kwok CS, Kontopantelis E, Myint PK, Zaman A, Berry C, Keavney B, Nolan J, Ludman PF, de Belder MA, Buchan I, Mamas MA. Stroke following percutaneous coronary intervention: type-specific incidence, outcomes and determinants seen by the British Cardiovascular Intervention Society 2007–12. Eur Heart J 2015; 36:1618-1628. [DOI: 10.1093/eurheartj/ehv113] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Wilson RF. Coronary Angiography. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hoffman SJ, Yee AH, Slusser JP, Rihal CS, Holmes DR, Rabinstein AA, Gulati R. Neuroimaging patterns of ischemic stroke after percutaneous coronary intervention. Catheter Cardiovasc Interv 2014; 85:1033-40. [DOI: 10.1002/ccd.25678] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 09/10/2014] [Accepted: 09/22/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Scott J. Hoffman
- Division of Cardiovascular Disease; Mayo Clinic; Rochester Minnesota
| | - Alan H. Yee
- Division of Neurology; Mayo Clinic; Rochester Minnesota
| | - Joshua P. Slusser
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester Minnesota
| | | | - David R. Holmes
- Division of Cardiovascular Disease; Mayo Clinic; Rochester Minnesota
| | | | - Rajiv Gulati
- Division of Cardiovascular Disease; Mayo Clinic; Rochester Minnesota
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Shivaraju A, Yu C, Kattan MW, Xie H, Shroff AR, Vidovich MI. Temporal trends in percutaneous coronary intervention--associated acute cerebrovascular accident (from the 1998 to 2008 Nationwide Inpatient Sample Database). Am J Cardiol 2014; 114:206-13. [PMID: 24952927 DOI: 10.1016/j.amjcard.2014.04.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 11/24/2022]
Abstract
Acute cerebrovascular accident (CVA) after percutaneous coronary intervention (PCI) for acute coronary syndrome and coronary artery disease is associated with high rates of morbidity and mortality. Nationwide Inpatient Sample from 1998 to 2008 was used to identify 1,552,602 PCIs performed for acute coronary syndrome and coronary artery disease. We assessed temporal trends in the incidence, predictors, and prognostic impact of CVA in a broad range of patients undergoing PCI. The overall incidence of CVA was 0.56% (95% confidence interval [CI] 0.55 to 0.57). The incidence of CVA remained unchanged over the study period (adjusted p for trend=0.2271). The overall mortality rate in the CVA group was 10.76% (95% CI 10.1 to 11.4). The adjusted odds ratio (OR) of CVA for in-hospital mortality was 7.74 (95% CI 7.00 to 8.57, p<0.0001); this remained high but decreased over the study period (adjusted p for trend<0.0001). Independent predictors of CVA included older age (OR 1.03, 95% CI 1.02 to 1.03, p<0.0001), disorder of lipid metabolism (OR 1.31, 95% CI 1.24 to 1.38, p<0.001), history of tobacco use (OR 1.21, 95% CI 1.10 to 1.34, p=0.0002), coronary atherosclerosis (OR 1.56, 95% CI 1.43 to 1.71, p<0.0001), and intra-aortic balloon pump use (OR 1.39, 95% CI 1.09 to 1.77, p=0.0073). A nomogram for predicting the probability of CVA achieved a concordance index of 0.73 and was well calibrated. In conclusion, the incidence of CVA associated with PCI has remained unchanged from 1998 to 2008 in face of improved equipment, techniques, and adjunctive pharmacology. The risk of CVA-associated in-hospital mortality is high; however, this risk has decreased over the study period.
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Silent Cerebral Ischemia After Thoracic Endovascular Aortic Repair: A Neuroimaging Study. Ann Thorac Surg 2014; 98:53-8. [DOI: 10.1016/j.athoracsur.2014.03.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 03/10/2014] [Accepted: 03/20/2014] [Indexed: 11/20/2022]
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Tomey MI, Kini AS, Sharma SK. Current Status of Rotational Atherectomy. JACC Cardiovasc Interv 2014; 7:345-53. [DOI: 10.1016/j.jcin.2013.12.196] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 12/05/2013] [Accepted: 12/19/2013] [Indexed: 01/06/2023]
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Pregowski J, Kepka C, Kruk M, Mintz GS, Kalinczuk L, Ciszewski M, Kochanowski L, Wolny R, Chmielak Z, Jastrzębski J, Klopotowski M, Zalewska J, Demkow M, Karcz M, Witkowski A. The clinical significance and management of patients with incomplete coronary angiography and the value of additional computed tomography coronary angiography. Int J Cardiovasc Imaging 2014; 30:825-32. [DOI: 10.1007/s10554-014-0397-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 03/04/2014] [Indexed: 01/08/2023]
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Werner N, Zahn R, Zeymer U. Stroke in patients undergoing coronary angiography and percutaneous coronary intervention: incidence, predictors, outcome and therapeutic options. Expert Rev Cardiovasc Ther 2014. [DOI: 10.1586/erc.12.78] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Patel VG, Brayton KM, Kumbhani DJ, Banerjee S, Brilakis ES. Meta-analysis of stroke after transradial versus transfemoral artery catheterization. Int J Cardiol 2013; 168:5234-8. [DOI: 10.1016/j.ijcard.2013.08.026] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 08/03/2013] [Indexed: 11/16/2022]
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Popovic B, Carillo S, Agrinier N, Christophe C, Selton-Suty C, Juillière Y, Aliot E. Ischemic stroke associated with left cardiac catheterization: the importance of modifiable and non-modifiable risk factors. Am Heart J 2013; 165:421-6. [PMID: 23453113 DOI: 10.1016/j.ahj.2012.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Stroke associated with left cardiac catheterization is a devastating complication, and its incidence has not changed over the decades. We investigated the incidence, in-hospital outcomes and the modifiable and non-modifiable risk factors for periprocedural ischemic stroke. METHODS Our retrospective cohort study included all patients experiencing periprocedural ischemic stroke among the 24,500 patients who underwent left cardiac catheterization between January 2003 and October 2010. The case group was compared with a group of control patients randomly selected among those who underwent the procedure during this period. RESULTS Ischemic cerebrovascular events attested by brain imaging occurred in 37 patients (0.15% of procedures), transient ischemic attack occurred in 9 cases, and persistent neurological deficit occurred in 28 cases. Patients who developed strokes were more likely to be older and were more often female with a greater prevalence of comorbidities. Emergency and longer procedures were more frequent in patients in the case group who had more coronary complications. A multivariate analysis identified diabetes mellitus (adjusted odds ratio (OR) 4.2; 95% CI 1.8-9.9; P < .001), chronic renal dysfunction (OR 2.4; 95% CI 1.1-5.4; P < .001), known cerebrovascular disease (OR 5.1; 95% CI 2.3-11.5; P < .001), emergency procedure (OR 3.1; 95% CI 1.4-9.2; P < .01) and recent congestive heart failure (OR 6.1; 95% CI 2.9-13; P < .001) as independent predictors for stroke. The independent modifiable predictive factors were represented by left ventricular angiography (OR 7.5; 95% CI 2.7-21; P < .001), and low operator volume (OR 3.1; 95% CI 1.3-7.4; P < .01). CONCLUSION Limiting the performance of left cardiac catheterization to high volume operators and avoiding unnecessary left ventricular angiography may reduce periprocedural ischemic stroke.
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Hoffman SJ, Routledge HC, Lennon RJ, Mustafa MZ, Rihal CS, Gersh BJ, Holmes DR, Gulati R. Procedural Factors Associated With Percutaneous Coronary Intervention-Related Ischemic Stroke. JACC Cardiovasc Interv 2012; 5:200-6. [DOI: 10.1016/j.jcin.2011.10.014] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 10/07/2011] [Accepted: 10/18/2011] [Indexed: 11/24/2022]
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Carpenter JP, Carpenter JT, Tellez A, Webb JG, Yi GH, Granada JF. A percutaneous aortic device for cerebral embolic protection during cardiovascular intervention. J Vasc Surg 2011; 54:174-181.e1. [PMID: 21236621 DOI: 10.1016/j.jvs.2010.11.109] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 09/29/2010] [Accepted: 11/14/2010] [Indexed: 10/18/2022]
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Hoffman SJ, Holmes DR, Rabinstein AA, Rihal CS, Gersh BJ, Lennon RJ, Bashir R, Gulati R. Trends, Predictors, and Outcomes of Cerebrovascular Events Related to Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2011; 4:415-22. [DOI: 10.1016/j.jcin.2010.11.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 11/26/2010] [Indexed: 11/28/2022]
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Rodés-Cabau J, Dumont E, Boone RH, Larose E, Bagur R, Gurvitch R, Bédard F, Doyle D, De Larochellière R, Jayasuria C, Villeneuve J, Marrero A, Côté M, Pibarot P, Webb JG. Cerebral Embolism Following Transcatheter Aortic Valve Implantation. J Am Coll Cardiol 2011; 57:18-28. [DOI: 10.1016/j.jacc.2010.07.036] [Citation(s) in RCA: 182] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 07/06/2010] [Accepted: 07/27/2010] [Indexed: 10/18/2022]
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Umeda H, Ota T, Iwase M, Izawa H, Miyata S, Sugino S, Hayashi K, Misumida N, Takeichi Y, Ishiki R, Inagaki H, Murohara T. Subtle myocardial damage associated with diagnostic coronary angiography alone. EUROINTERVENTION 2010; 6:388-93. [PMID: 20884419 DOI: 10.4244/eijv6i3a64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the frequency, predictors and prognostic significance of elevation in cardiac troponin I (cTnI) after coronary angiography (CAG). METHODS AND RESULTS A series of 296 consecutive patients with normal pre-procedural cTnI levels and undergoing elective CAG at our centre were prospectively analysed. Positive cTnI elevation was defined as >0.06 ng/ml. Positive cTnI elevation was observed in 44 patients (14.8%), but CK-MB was elevated in only four patients (1.3%) after the procedure. The risk of cTnI elevation was independently associated with left ventricular hypertrophy (odds ratio [OR] 5.52; 95% confidence interval [CI], 2.54 to 12.02; P<0.001), inexperienced operator (OR 10.83; 95% CI, 2.47 to 47.43; P=0.002) and the amount of contrast agent (OR 1.12; 95% CI, 1.03 to 1.23; P=0.009 for each 10 ml increase), whereas it was not associated with the severity of coronary artery disease. At one year, however, postprocedural elevation of cTnI was not associated with an increased risk of death (2.3% vs. 0.8%, P=0.384) or myocardial infarction (2.3% vs. 2.0%, P=0.623). CONCLUSIONS A minor elevation of cTnI is observed commonly after CAG, which might be associated with left ventricular hypertrophy, operator's experience and the amount of contrast used; however, it does not influence 1-year events rates.
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Affiliation(s)
- Hisashi Umeda
- Toyota Memorial Hospital, Bantane Hospital, Fujita Health University, Nagoya University Graduate School of Medicine, Japan.
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Kahlert P, Knipp SC, Schlamann M, Thielmann M, Al-Rashid F, Weber M, Johansson U, Wendt D, Jakob HG, Forsting M, Sack S, Erbel R, Eggebrecht H. Silent and Apparent Cerebral Ischemia After Percutaneous Transfemoral Aortic Valve Implantation. Circulation 2010; 121:870-8. [PMID: 20177005 DOI: 10.1161/circulationaha.109.855866] [Citation(s) in RCA: 388] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The risk of stroke after transfemoral aortic valve implantation (TAVI) due to dislodgement and subsequent embolization of debris from aortic arch atheroma or from the calcified valve itself ranges between 2% and 10%. The rate of clinically silent cerebral ischemia is unknown but may be even higher.
Methods and Results—
Thirty-two patients who underwent TAVI with the use of a balloon-expandable (n=22) or self-expandable (n=10) stent valve prosthesis were included in this descriptive study and compared with a historical control group of 21 patients undergoing open surgical aortic valve replacement. Periprocedural apparent and silent cerebral ischemia was assessed by neurological testing and serial cerebral diffusion-weighted magnetic resonance imaging at baseline, at 3.4 (2.5 to 4.4) days after the procedure, and at 3 months. TAVI was successful in all patients. After the procedure, new foci of restricted diffusion on cerebral diffusion-weighted magnetic resonance imaging were found in 27 of 32 TAVI patients (84%) and were more frequent than after open surgery (10 of 21 patients [48%];
P
=0.011). These lesions were usually multiple (1 to 19 per patient) and dispersed in both hemispheres in a pattern suggesting cerebral embolization. Volumes of these lesions were significantly smaller after TAVI than after surgery (77 [59 to 94] versus 224 [111 to 338] mm
3
;
P
<0.001). There were neither measurable impairments of neurocognitive function nor apparent neurological events during the in-hospital period among TAVI patients, but there was 1 stroke (5%) in the surgical patient group. On 3-month follow-up diffusion-weighted magnetic resonance imaging, there were no new foci of restricted diffusion, and there was no residual signal change associated with the majority (80%) of the foci detected in the periprocedural period.
Conclusions—
Clinically silent new foci of restricted diffusion on cerebral magnetic resonance imaging were detected in almost all patients (84%) undergoing TAVI. Although typically multiple, these foci were not associated with apparent neurological events or measurable deterioration of neurocognitive function during 3-month follow-up. Further work needs to be directed to determine the clinical significance of these findings in a larger patient population.
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Affiliation(s)
- Philipp Kahlert
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Stephan C. Knipp
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marc Schlamann
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Matthias Thielmann
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fadi Al-Rashid
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marcel Weber
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Uwe Johansson
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Daniel Wendt
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Heinz G. Jakob
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Michael Forsting
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Stefan Sack
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Raimund Erbel
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Holger Eggebrecht
- From the Departments of Cardiology (P.K., F.A.-R., M.W., S.S., R.E., H.E.) and Thoracic and Cardiovascular Surgery (S.C.K., M.T., D.W., H.G.J.), West German Heart Center Essen; and Institute of Diagnostic and Interventional Radiology and Neuroradiology (M.S., M.F.) and Department of Neurology (U.J.), University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Röther J, Laufs U, Böhm M, Willems S, Scheller B, Borggrefe M, Darius H, Endres M, Zeymer U, Diener HC, Grond M, Hacke W, Forsting M, Schumacher M, Hennerici M. Konsensuspapier „Peri- und postinterventioneller Schlaganfall bei Herzkatheterprozeduren“. DER KARDIOLOGE 2009. [DOI: 10.1007/s12181-009-0214-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mansi IA. In vitro effects of coronary angiography: Unknown clinical implications. Med Hypotheses 2009; 73:389-92. [DOI: 10.1016/j.mehy.2009.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 02/25/2009] [Accepted: 02/28/2009] [Indexed: 10/20/2022]
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Aggarwal A, Dai D, Rumsfeld JS, Klein LW, Roe MT. Incidence and predictors of stroke associated with percutaneous coronary intervention. Am J Cardiol 2009; 104:349-53. [PMID: 19616666 DOI: 10.1016/j.amjcard.2009.03.046] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 03/23/2009] [Accepted: 03/23/2009] [Indexed: 11/19/2022]
Abstract
Stroke is a serious complication of percutaneous coronary intervention (PCI). Clinical characteristics associated with this complication have not been well defined. Data were analyzed from the National Cardiovascular Data Registry. All patients undergoing PCI from January 1, 2004, to March 30, 2007, were included in the analysis (n = 706,782). Stroke is defined in the National Cardiovascular Data Registry as a central neurologic deficit persisting >72 hours with onset starting anytime in the cardiac catheterization laboratory until the time of hospital discharge. Periprocedural stroke developed in 0.22% of patients (n = 1,540). Patients who developed a stroke had a greater prevalence of concomitant medical illnesses and were more likely to present with an acute coronary syndrome. Patients with a stroke had a greater percentage of high-risk coronary lesions and worse PCI angiographic results. In multivariable analysis, known cerebrovascular disease, older age, acute coronary syndromes (unstable angina, ST- and non-ST-elevation myocardial infarction), and use of an intra-aortic balloon pump were factors most strongly associated with stroke. In-hospital mortality was 30% for patients who developed a stroke compared with 1% for those without stroke. In conclusion, stroke developing in association with PCI is rare but a devastating complication. Older patients and those with known cerebrovascular disease and acute coronary syndromes appear to be at the highest risk of stroke. The strong association of in-hospital stroke after PCI with acute coronary syndromes is noteworthy.
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Affiliation(s)
- Atul Aggarwal
- Comprehensive Cardiovascular Medical Group, Bakersfield, California, USA.
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Soheilian M, Haghi AR, Rofagha S, Peyman GA. Simultaneous multiple branch retinal artery occlusions after diagnostic cardiac catheterization. Retin Cases Brief Rep 2009; 3:15-17. [PMID: 25390828 DOI: 10.1097/icb.0b013e31815e93ad] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE We describe a 53-year-old man with a decrease in visual acuity in the left eye 2 weeks after diagnostic cardiac catheterization. DESIGN Interventional case report. METHODS A 53-year-old man with a decrease in visual acuity in the left eye 2 weeks after diagnostic cardiac catheterization underwent ophthalmoscopic, angiographic, and laboratory evaluations. Both funduscopy and fluorescein angiography confirmed the diagnosis of simultaneous multiple branch retinal artery occlusions in the left eye. RESULTS The left eye had a mildly positive (1+) relative afferent pupillary defect. Slit-lamp biomicroscopy was unremarkable except for 2+ nuclear cataract bilaterally. Intraocular pressure was 12 mmHg in the right eye and 11 mmHg in the left eye by applanation tonometry. Funduscopy revealed a normal right eye. CONCLUSION This case report of multiple branch retinal artery occlusions due to cholesterol embolus after diagnostic cardiac catheterization is extremely rare. Visual symptoms after cardiac catheterization should alert both ophthalmologists and cardiologists to this potential post-cardiac catheterization complication.
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Affiliation(s)
- Masoud Soheilian
- From the *Department of Ophthalmology and Ophthalmic Research Center, Labbafinejad Medical Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran; †Negah Eye Hospital, Tehran, Iran; and the ‡Department Of Ophthalmology, University of Arizona Health Science Center, Tucson, Arizona
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Wilson RF, White CW. Coronary Angiography. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Katritsis D, Korovesis S, Karvouni E, Giazitzoglou E, Paxinos G, Haliassos A. Does diagnostic coronary angiography induce significant coronary microembolization in stable, ischemic patients? A prospective study. J Interv Cardiol 2006; 19:346-9. [PMID: 16881984 DOI: 10.1111/j.1540-8183.2006.00159.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Although microembolization during percutaneous coronary interventions is a frequent event, the extent of possible microembolization during diagnostic coronary angiography is unknown. The aim of the study was to investigate whether diagnostic coronary angiography results in coronary microembolization and consequent subtle, subclinical myocardial necrosis with enzyme elevations. METHODS Fifty-three consecutive patients underwent diagnostic coronary angiography due to inducible ischemia. Creatine kinase MB isoenzyme (CK MB) and cardiac troponin I (cTnI) were used as sensitive surrogate markers of myocardial necrosis. Serial measurements, before, and 6 and 24 hours following a diagnostic procedure, were performed. RESULTS Baseline cTnI was below the limits of detection in all patients (<0.20 ng/mL), except for one patient with 1.31 ng/mL. Baseline median CK-MB was 1.05 ng/mL (interquartile range, 0.80-1.56 ng/mL) (Fig. 1). Both at 6 and 24 hours, no patients had any increase in cTnI, with the exception of a minor increase to 0.22 ng/mL at 24 hours in one patient. At 6 hours, 25 patients had decreases in CK MB, while 22 had increases (exact P = 0.77). At 24 hours, 26 patients had decreases in CK MB and 19 patients had increases. CONCLUSIONS Detectable embolization with subsequent subclinical myonecrosis is an unlikely event.
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