Clinical impact of pulmonary artery catheter in patients with cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

The clinical utility of the pulmonary artery catheter (PAC) for the management of cardiogenic shock (CS) remains controversial. We performed a systematic review and meta-analysis exploring the association between PAC use and mortality among patients with CS.

METHODS

Published studies of patients with CS treated with or without PAC hemodynamic guidance were retrieved from MEDLINE and PubMed databases from January 1, 2000, to December 31, 2021. The primary outcome was mortality, which was defined as a combination of in-hospital mortality and 30-day mortality. Secondary outcomes assessed 30-day and in-hospital mortality separately. To assess the quality of nonrandomized studies, the Newcastle-Ottawa Scale (NOS), a well-established scoring system was used. We analyzed outcomes for each study using NOS with a threshold value of >6, indicating high quality. We also performed analyses based on the countries of the studies conducted.

RESULTS

Six studies with a total of 930,530 patients with CS were analyzed. Of these, 85,769 patients were in the PAC-treated group, and 844,761 patients did not receive a PAC. PAC use was associated with a significantly lower risk of mortality (PAC: 4.6 % to 41.5 % vs control: 18.8 % to 51.0 %) (OR 0.63, 95 % CI: 0.41-0.97, I2 = 0.96). Subgroup analyses demonstrated no difference in the risk of mortality between NOS ≥ 6 studies and NOS < 6 studies (p-interaction = 0.57), 30-day and in-hospital mortality (p-interaction = 0.83), or the country of origin of studies (p-interaction = 0.08).

CONCLUSIONS

The use of PAC in patients with CS may be associated with decreased mortality. These data support the need for a randomized controlled trial testing the utility of PAC use in CS.

Do Patients With Non-Viable Myocardium From Ischemic Cardiomyopathy Benefit From Revascularization? A Systematic Review And Meta-Analysis

BACKGROUND

Myocardial viability assessment is used to select patients who will derive the greatest benefit from revascularization. It remains controversial whether revascularization only benefits patients with ischemic cardiomyopathy who have viable myocardium. The objective of this meta-analysis was to compare mortality between patients with ischemic cardiomyopathy and non-viable myocardium who underwent revascularization and those who underwent medical therapy alone.

METHODS

The MEDLINE database was searched using PubMed to retrieve studies published up to December 2021. Inclusion criteria were 1. studies that evaluated the impact of revascularization (revascularization group) versus medical therapy alone (control group) following myocardial viability assessment; 2. patients who had coronary artery disease that was amenable to coronary artery bypass grafting or percutaneous coronary intervention; and 3. patients who had non-viable myocardium. The main outcome measure was all-cause mortality.

RESULTS

A total of 12 studies were included, evaluating 1363 patients with non-viable myocardium, of whom 501 patients underwent revascularization and 862 patients received medical therapy alone. There was a significant reduction in all-cause mortality (RR 0.76, 95 % CI: 0.62-0.93, I² = 0) in the revascularization group compared to the control group. There was no association between the type of viability imaging modality and the risk of all-cause mortality (P-interaction = 0.58).

CONCLUSIONS

The findings of this meta-analysis suggest a benefit from revascularization compared to medical therapy in patients with ischemic cardiomyopathy despite the lack of myocardial viability.

Survival Following Alcohol Septal Ablation or Septal Myectomy for Patients With Obstructive Hypertrophic Cardiomyopathy

BACKGROUND

There is little information regarding long-term mortality comparing the 2 most common procedures for septal reduction for obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA), and septal myectomy.

OBJECTIVES

This study sought to compare the long-term mortality of patients with obstructive HCM following septal myectomy or ASA.

METHODS

We evaluated outcomes of 3,859 patients who underwent ASA or septal myectomy in 3 specialized HCM centers. All-cause mortality was the primary endpoint of the study.

RESULTS

In the study cohort, 585 (15.2%) patients underwent ASA, and 3,274 (84.8%) underwent septal myectomy. Patients undergoing ASA were significantly older (median age: 63.0 years [IQR: 52.7-72.8 years] vs 53.7 years [IQR: 44.9-62.8 years]; P < 0.001) and had smaller septal thickness (19.0 mm [IQR: 17.0-22.0 mm] vs 20.0 mm [IQR: 17.0-23.0 mm]; P = 0.007). Patients undergoing ASA also had more comorbidities, including renal failure, diabetes, hypertension, and coronary artery disease. There were 4 (0.7%) early deaths in the ASA group and 9 (0.3%) in the myectomy group. Over a median follow-up of 6.4 years (IQR: 3.6-10.2 years), the 10-year all-cause mortality rate was 26.1% in the ASA group and 8.2% in the myectomy group. After adjustment for age, sex, and comorbidities, the mortality remained greater in patients having septal reduction by ASA (HR: 1.68; 95% CI: 1.29-2.19; P < 0.001).

CONCLUSIONS

In patients with obstructive hypertrophic cardiomyopathy, ASA is associated with increased long-term all-cause mortality compared with septal myectomy. This impact on survival is independent of other known factors but may be influenced by unmeasured confounding patient characteristics.

Pharmacokinetic and Pharmacodynamic Profile of a Novel Phospholipid Aspirin Formulation

Aspirin is one of the most widely used medicines. Although aspirin is commonly utilized for the treatment of several medical conditions, its broadest uptake is for the prevention of recurrent ischemic events in patients with atherosclerotic disease. Its mechanism of action of inhibiting platelet activation via blockade of thromboxane A2 production is unique and is not covered by any other antiplatelet agents. While plain, uncoated, immediate-release aspirin is used in acute settings to help assure rapid absorption, enteric-coated aspirin formulations dominate current chronic use, particularly in North America, including for secondary prevention of cardiovascular events. The unmet needs with current aspirin formulations include a high risk of gastrointestinal (GI) adverse events with plain aspirin, which enteric-coated formulations are not able to overcome, and subject to erratic absorption leading to reduced drug bioavailability. These observations underscore the need for aspirin formulations with a more favorable safety and efficacy profile. Phospholipid-aspirin complex (PL-ASA) is a novel formulation designed to address these needs. It is associated with reduced local acute GI injury compared with plain aspirin, and predictable absorption resulting in more reliable platelet inhibition compared with enteric-coated tablets. This review explores the rationale and pharmacologic profile of PL-ASA intended to address the unmet needs for aspirin therapy.

Percutaneous Decommissioning of a Left Ventricular Assist Device in a Patient With Myocardial Recovery

A 37-year-old man was referred for consideration of percutaneous decommissioning of a left ventricular assist device (LVAD). Following careful hemodynamic monitoring during pump turn-down and temporary outflow graft occlusion, the LVAD was permanently decommissioned by using a vascular plug to induce thrombosis of the outflow graft. (Level of Difficulty: Advanced.)

Comorbidity Burden and Adverse Outcomes After Transcatheter Aortic Valve Replacement

Background

Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for symptomatic patients with aortic stenosis and elevated procedural risk. Many deaths following TAVR are because of noncardiac causes and comorbid disease burden may be a major determinant of postprocedure outcomes. The prevalence of comorbid conditions and associations with outcomes after TAVR has not been studied.

Methods and Results

This was a retrospective single‐center study of patients treated with TAVR from January 2015 to October 2018. The association between 21 chronic conditions and short‐ and medium‐term outcomes was assessed. A total of 341 patients underwent TAVR and had 1‐year follow‐up. The mean age was 81.4 (SD 8.0) years with a mean Society of Thoracic Surgeons predicted risk of mortality score of 6.7% (SD 4.8). Two hundred twenty (65%) patients had ≥4 chronic conditions present at the time of TAVR. There was modest correlation between Society of Thoracic Surgeons predicted risk of mortality and comorbid disease burden (r=0.32, P<0.001). After adjusting for Society of Thoracic Surgeons predicted risk of mortality, age, and vascular access, each additional comorbid condition was associated with increased rates of 30‐day rehospitalizations (odds ratio, 1.21; 95% CI, 1.02–1.44), a composite of 30‐day rehospitalization and 30‐day mortality (odds ratio, 1.20; 95% CI, 1.02–1.42), and 1‐year mortality (odds ratio, 1.29; 95% CI, 1.05–1.59).

Conclusions

Comorbid disease burden is associated with worse clinical outcomes in high‐risk patients treated with TAVR. The risks associated with comorbid disease burden are not adequately captured by standard risk assessment. A systematic assessment of comorbid conditions may improve risk stratification efforts.

Echocardiographic Assessment of Left Ventricular Assist Device Outflow Velocity During Percutaneous Decommissioning

Left ventricular assist devices (LVADs) have been used as an effective therapeutic option in patients with advanced heart failure, either as a bridge to transplantation or, in some patients, as a bridge to recovery. LVAD withdrawal with ventricular recovery represents the optimal outcome for patients previously implanted with an LVAD. In this E-Challenge, the authors present a case of percutaneous decommissioning of an LVAD, in which TEE provided critical, real-time perioperative evaluation. The authors also review the current perspectives on LVAD decommissioning in terms of patient selection and surgical techniques.

2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases.

STRUCTURE

Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.

2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Aim This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use. Methods A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Structure Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.

Morphine in primary percutaneous coronary intervention-No pain, questionable gain

The clinical impact of concurrently administered morphine and P2Y12 inhibitors in primary percutaneous coronary intervention (PCI) is not well understood. Large, randomized clinical trials are required to assess clinical outcomes with concurrent morphine and P2Y12 inhibitor use in ST-segment elevation myocardial infarction patients undergoing PCI. Based on the currently available pharmacologic data, cautious use of morphine in primary PCI would seem prudent.

Combined alcohol septal ablation and transcatheter aortic valve replacement: Drunk and playing with fire

Evaluation of the severity of aortic stenosis in the presence of dynamic left ventricular outflow (LVOT) obstruction is challenging. Invasive hemodynamic assessment with provocative maneuvers can be useful to differentiate of the relative components of obstruction. In patients with both dynamic LVOT obstruction and aortic stenosis, surgical myectomy and concurrent surgical aortic valve replacement is the optimal treatment strategy; combined alcohol septal ablation and transcatheter aortic valve replacement should only be considered for very high surgical risk patients.

Guideline-Based Referral for Septal Reduction Therapy in Obstructive Hypertrophic Cardiomyopathy Is Associated With Excellent Clinical Outcomes

BACKGROUND

The outcome of medically refractory patients with obstructive hypertrophic cardiomyopathy treated according to the American College of Cardiology/American Heart Association consensus guideline recommendations is not known. The objectives of this study were to define the short- and long-term outcomes of medically refractory obstructive hypertrophic cardiomyopathy patients undergoing alcohol septal ablation (ASA) and surgical septal myectomy (SM) with patient management in accordance with these consensus guidelines, as well as to quantify procedural risk and burden of comorbid conditions at the time of treatment.

METHODS AND RESULTS

Patients with obstructive hypertrophic cardiomyopathy referred for either ASA or SM from 2004 to 2015 were followed for the primary end point of short- and long-term mortality and compared with respective age- and sex-matched US populations. Of 477 consecutive severely symptomatic patients, 99 underwent ASA and 378 SM. Compared with SM, ASA patients were older ( P<0.001), had a higher burden of comorbid conditions ( P<0.01), and significantly higher predicted surgical mortality ( P<0.005). Procedure-related mortality was 0.3% and similarly low in both groups (0% in ASA and 0.8% in SM). Over 4.0±2.9 years of follow-up, 95% of patients had substantial improvement in heart failure symptoms to New York Heart Association class I/II (96% in SM and 90% in ASA). Long-term mortality was similar between the 2 groups with no difference compared with age- and sex-matched US populations.

CONCLUSIONS

Guideline-based referral for ASA and SM leads to excellent outcomes with low procedural mortality, excellent long-term survival, and improvement in symptoms. These outcomes occur in ASA patients despite being an older cohort with significantly more comorbidities.

Enhanced potency of prasugrel on protease-activated receptors following bivalirudin treatment for PCI as compared to clopidogrel

ACS patients undergoing percutaneous coronary intervention (PCI) when treated with bivalirudin and clopidogrel had increased frequency of early stent thrombosis. 24 patients referred for intervention with planned bivalirudin therapy, not previously treated with a P2Y₁₂ inhibitor and not receiving heparins or αIIbβ3 inhibitors were randomized to treatment with either clopidogrel (600 mg) or prasugrel (60 mg). Platelet aggregation (PA) was measured by light transmission aggregometry (LTA) of platelet-rich plasma in response to ADP, PAR1/PAR4 thrombin receptor agonists and collagen at baseline and at 1, 2, 4 and 16 h following the cessation of bivalirudin infusion. Prasugrel-mediated inhibition of PA was significantly greater than that of clopidogrel at all time points for ADP as well as PAR1. There was an unanticipated, significantly greater protection of PAR4-mediated platelet aggregation only detected with prasugrel and not observed with clopidogrel. We further examined the effect of the hyperreactive PAR4 Thr120 variant in the protease-activated receptor 4 (PAR4), single nucleotide polymorphism (SNP) rs773902 on aggregation protection. The PAR4 protective effect with prasugrel was lost in individuals carrying the PAR4 Thr120 variant, and not in Ala120 homozygote. PAR1, ADP and collagen inhibition was not significantly affected in the hyperreactive PAR4 Thr120 variant. We documented that the P2Y₁₂ ADP receptor-mediated regulation of the strength of the high-affinity conformation of αIIbβ3 as detected by PAC-1 ab, and in control of platelet adhesiveness through Rap1 GTPase protein activation. Importantly, the PAR4 Thr120 variant resulted in the increased rate and magnitude of Rap1 activation. Human platelet PAR4 mediated-activation of αIIbβ3 was phospholipase C beta (PLCβ)-dependent and unlike mouse platelet PI3K-independent. These data identify a PAR4-dependent inhibitory mechanism for the prasugrel-mediated platelet inhibition, not seen with clopidogrel that could explain the reduction in stent thrombosis documented in clinical trials with prasugrel.

Real life experience with bioresorbable-polymer everolimus-eluting stents. Is this an answer in search of a question?

Stent thrombosis and clinically driven restenosis are rare in the era of newer generation DES. The Synergy bioresorbable polymer DES appears to be comparable to other durable polymer and other bioabsorbable polymer DES in terms of safety and efficacy at 1-year post implantation. Further long-term study is needed to determine the specific role of the Synergy stent and other DES with bioabsorbable polymers.

Heparin or bivalirudin for non-primary PCI: Beware of neat and simple answers…

The debate regarding the choice of heparin or bivalirudin as the preferred anticoagulant in PCI is still ongoing Nonrandomized registry data are severely limited for comparative analyses and should therefore always be interpreted with caution Clinicians should resist simplistic data interpretations or populist cries relating to cost, but rather focus on valid benefit:risk analyses for their clinical decision making.

Striking a balance between quality and cost in PCI

Procedural cost control will continue to be increasingly important to the bottom line of health care institutions. Reducing cost in PCI need not compromise clinical outcomes. Cost awareness can alter physician behavior, enabling monetary savings.

Ablation or surgery for medically refractory HCM. Updating an imperfect dataset

Retrospective comparison of alcohol septal ablation with surgical myectomy suggests that although there is a greater reduction in LVOT gradient with surgical myectomy, symptom relief and survival are similar between the two treatment strategies. In patients who don't have an anatomic indication for surgical myectomy, alcohol septal ablation appears to be a safe and effective alternative. Patients with medication-refractory HOCM require a multi-disciplinary assessment, which is best performed at specialized treatment centers, to assess which therapy is best suited to treat them.

Thrombin inhibition during PCI in heart failure patients

In this retrospective analysis, CHF patients undergoing PCI had a decrease in mortality, bleeding, and transfusion as well as decreased length of stay and hospital cost when bivalirudin was used when compared to heparin. This study suggests bivalirudin may be the preferred anticoagulant for patients with CHF undergoing PCI. Confirmation of these data might entail analysis of patient-level, pooled data from randomized controlled trials comparing bivalirudin to heparin in PCI patients with pre-existing CHF.

Bivalirudin Is Associated With Improved In-Hospital Outcomes Compared With Heparin in Percutaneous Vascular Interventions

Background—

Peripheral vascular interventions are increasingly preferred for the treatment of patients with symptomatic peripheral arterial disease because they are associated with similar clinical outcomes and lower morbidity than open surgical procedures. The objective of this study was to assess the comparative effectiveness of procedural anticoagulation with bivalirudin compared with unfractionated heparin in patients undergoing peripheral vascular interventions.

Methods and Results—

This was a retrospective, observational study using the Premier Hospital administrative database. We examined 23 934 consecutive patients undergoing lower extremity peripheral vascular interventions between January 2008 and December 2012 who were treated with either bivalirudin or unfractionated heparin. In-hospital end points included death, myocardial infarction, transfusion, stroke, amputation, and the composite end points of major adverse cardiovascular events, and net adverse clinical events. Propensity score matching was performed to control for baseline imbalances and yielded 3649 matched pairs. After propensity score matching, patients treated with bivalirudin had lower in-hospital event rates with significantly lower mortality (odds ratio, 0.40; P =0.017), need for blood product transfusion (odds ratio, 0.74; P =0.009), major adverse cardiovascular events (odds ratio, 0.64; P =0.003), and net adverse clinical events (odds ratio, 0.72; P <0.001). These associations were observed consistently across clinically relevant subgroups.

Conclusions—

In patients undergoing peripheral vascular interventions, procedural anticoagulation with bivalirudin may result in more favorable in-hospital outcomes compared with unfractionated heparin, the current standard of care. These observations will require prospective confirmation in a randomized, controlled trial.

Rotational atherectomy: A persistently relevant niche device

Rotational atherectomy is effective and safe in selected complex calcified lesions. Despite an older population with more comorbidities, rotational atherectomy is not associated with worse clinical outcomes. Coronary interventionalists need to be well-trained in both the use of atherectomy techniques as well as how to manage potential complications.

Hemodynamic effects of standard versus larger-capacity intraaortic balloon counterpulsation pumps

OBJECTIVE

Several recent trials have examined the clinical utility of intraaortic balloon counterpulsation pumps (IABPs) in cardiogenic shock and acute coronary syndromes. More recently, a larger-capacity 50 cc IABP was introduced into practice. No data comparing the hemodynamic effects of the 40 cc vs 50 cc IABP exist. Our aim was to explore the hemodynamic effects of the 50 cc IABP in real-world clinical practice.

METHODS

Demographic, hemodynamic, and laboratory data were retrospectively examined in 26 consecutive subjects treated with a 50 cc IABP and compared with 26 patients receiving a 40 cc IABP between 2012 and 2013. IABP tracings were analyzed within 24 hours of implantation in all patients. Pulmonary artery catheter data were available before and after IABP implantation in 20 subjects.

RESULTS

Baseline demographics, including body surface area, were similar between groups. Compared with the 40 cc IABP group, 50 cc IABP recipients showed higher augmented diastolic blood pressure, greater systolic unloading, and a larger reduction in pulmonary capillary occlusion pressure (PCOP). Percent diastolic augmentation was higher among 50 cc IABP recipients. Only 58% of subjects achieved <10 mm Hg of systolic unloading in the 40 cc group compared with 27% in the 50 cc group. For both the 40 cc and 50 cc IABPs, the magnitude of systolic unloading correlated inversely with PCOP and directly with the magnitude of diastolic augmentation.

CONCLUSION

In real-world practice, greater systolic unloading and diastolic augmentation were observed among 50 cc vs 40 cc IABP recipients. Future trials evaluating the clinical utility of the 50 cc IABP are required.

Suppression of arterial thrombosis without affecting hemostatic parameters with a cell-penetrating PAR1 pepducin

BACKGROUND

Thrombin-dependent platelet activation is heightened in the setting of percutaneous coronary intervention and may cause arterial thrombosis with consequent myocardial necrosis. Given the high incidence of adverse effects in patients with acute coronary syndromes, there remains an unmet need for the development of new therapeutics that target platelet activation without unduly affecting hemostasis. The thrombin receptor, PAR1, has recently emerged as a promising new target for therapeutic intervention in patients with acute coronary syndromes.

METHODS AND RESULTS

We report the development of a first-in-class intracellular PAR1 inhibitor with optimized pharmacokinetic properties for use during percutaneous coronary intervention in patients with acute coronary syndromes. PZ-128 is a cell-penetrating pepducin inhibitor of PAR1 that targets the receptor-G-protein interface on the inside surface of platelets. The structure of PZ-128 closely resembles the predicted off-state of the corresponding juxtamembrane region of the third intracellular loop of PAR1. The onset of action of PZ-128 was rapid and suppressed PAR1 aggregation and arterial thrombosis in guinea pigs and baboons and strongly synergized with oral clopidogrel. There was full recovery of platelet function by 24 hours. Importantly, PZ-128 had no effect on bleeding or coagulation parameters in primates or in blood from patients undergoing percutaneous coronary intervention.

CONCLUSIONS

Based on the efficacy data in nonhuman primates with no noted adverse effects on hemostasis, we anticipate that the rapid onset of platelet inhibition and reversible properties of PZ-128 are well suited to the acute interventional setting of percutaneous coronary intervention and may provide an alternative to long-acting small-molecule inhibitors of PAR1.