Anticoagulation management of post-cardiac surgery new-onset atrial fibrillation

New-onset post-cardiac surgery atrial fibrillation (PCSAF) is a frequent complication with estimated incidence of 17% to 64%, depending on type of surgery. It is associated with higher mortality, morbidity, and predisposition to stroke and systemic embolism postoperatively. Standard care involves rate or rhythm control, in addition to antithrombotic therapy in those with history of stroke, transient ischemic attack, or high risk of systemic thromboembolism. However, risk of bleeding is not negligible, and treating physicians should weigh the risks and benefits before committing to postoperative anticoagulation therapy. More investigations are warranted to explore antithrombotic therapy benefit, particularly postoperative anticoagulation, considering the potentially self-limited nature of the arrhythmia and high risk of postoperative bleeding.

Glycemic control in the critically ill: Less is more

Hyperglycemia is associated with poor clinical outcomes in critically ill patients. Initial clinical trials of intensive insulin therapy targeting blood glucose levels of 80 to 110 mg/dL showed improved outcomes, but subsequent trials found no benefits and even increased harm with this approach. Emerging literature has evaluated other glycemic indices including time-in-target blood glucose range, glycemic variability, and stress hyperglycemia ratio. These indices, while well described in observational studies, have not been addressed in the initial trials. Additionally, the patient's pre existing diabetes status and preadmission diabetic control may modulate the outcomes of stringent glycemic control, with worse outcomes of hyperglycemia being observed in patients without diabetes and in those with well-controlled diabetes. Most medical societies recommend less stringent glucose control in the range of 140 to 180 mg/dL for critically ill patients.

Microvascular Angina: Diagnosis and Management

Recognition of suspected ischaemia with no obstructive coronary artery disease – termed INOCA – has increased over the past decades, with a key contributor being microvascular angina. Patients with microvascular angina are at higher risk for major adverse cardiac events including MI, stroke, heart failure with preserved ejection fraction and death but to date there are no clear evidence-based guidelines for diagnosis and treatment. Recently, the Coronary Vasomotion Disorders International Study Group proposed standardised criteria for diagnosis of microvascular angina using invasive and non-invasive approaches. The management strategy for remains empirical, largely due to the lack of high-levelevidence- based guidelines and clinical trials. In this review, the authors will illustrate the updated approach to diagnosis of microvascular angina and address evidence-based pharmacological and non-pharmacological treatments for patients with the condition.

Description and Clinical Implications of Myocardial Clefts Using Echocardiography

Background Myocardial clefts (MCs) are rare anomalies with debatable clinical significance. Increased use of cardiac magnetic resonance (CMR) has led to the appreciation of subtle left ventricular (LV) wall structural defects, and studies showed varying clinical significance, ranging from asymptomatic incidental findings to being considered a novel imaging marker of hypertrophic cardiomyopathy. Sparse data are available about the utility of two-dimensional echocardiography (2DE) to visualize these anomalies. We describe our institutional experience categorizing MCs using 2DE. Methods The echocardiography database was retrospectively queried for diagnosing MCs using Synapse® Cardiovascular Picture Archiving and Communication System (PACS) (Fujifilm, Tokyo, Japan). Identified patients were admitted to Detroit Medical Center (DMC) between January 2012 and May 2019. MCs were defined as recesses filled with luminal blood, obliterate during systole, and have U, wedge, and tunnel shapes. Images were interpreted by a cardiologist blinded to the data. Baseline demographics and clinical characteristics were documented. The study was descriptive; no intervention was done. Results Sixteen patients with a mean age of 62.43 were included; 68.75% were women, and 81.25% were African American. The prevalence of cardiac comorbidities was primary hypertension 12 (75%), coronary artery disease 5 (31.25%), heart failure with reduced ejection fraction (HFrEF) 4 (25.0%), valvular heart disease 4 (25.0%), arrhythmia/heart block 4 (25.0%), and heart failure with preserved ejection fraction (HFpEF) 2 (12.5%). The indications for 2DE evaluation were heart failure/cardiogenic shock 2 (12.5%), acute coronary syndrome 2 (12.5%), syncope/presyncope 2 (12.5%), atypical chest pain 2 (12.5%), and others 8 (50.0%). Twenty-one MCs were visualized in eight segments of LV walls and septum as follows: basal inferior 7, mid inferoseptal 6, mid inferior 3, mid anteroseptal 2, mid inferolateral 1, mid anterolateral 1, basal inferoseptal 1, apical inferoseptal 1, and apical septal 1. Morphology was classified as tunnel in 66.66%, wedge in 23.8%, and U in 9.5%. Conclusion In various LV and septal walls, MCs detected on 2DE were benign and incidental findings without significant implications for preclinical hypertrophic cardiomyopathy (HCM).

Predictors and risk factors of short-term readmission of acute pericarditis

Background: The 30-day readmission risk factors for acute pericarditis are not well known. We investigated the risk factors and predictors of pericarditis from a national cohort.Methods: Readmission data from the National Readmission Database (NRD) from the year 2016 were used to analyze the prevalence of risk factors and predictors of pericarditis 30-day readmission.Results: From the year 2016, 16,475 acute pericarditis hospitalizations were recorded. The rate of readmission from the year 2016 is similar to 2012 reported data (18%). A total of 13,844 patients (mean age 55.2 years, 40% of women) were found for acute pericarditis readmissions. The incidence rate of 30-day readmission of acute pericarditis patients in our study was 17.8% with the major cause of readmission was related to cardiovascular (pericarditis, endocarditis, and myocarditis) during 30-day follow-up. The median cost of the index and 30 days pericarditis admission $10,048 and $9,932, respectively.Conclusion: Chronic comorbidities, prolonged hospitalization, and admission to a short-term hospital/left against medical advice admission to metropolitan teaching hospital were associated with a higher risk of 30-day readmission.

The efficacy and safety of transradial and transfemoral approach in treatment of coronary chronic total occlusion: a systematic review and meta-analysis

BACKGROUND

The clinical efficacy and safety of transradial (TR) percutaneous coronary intervention (PCI) in comparison to transfemoral (TF) for chronic total occlusion (CTO) is not well studied in literature. Objectives: We sought to study the outcome and complications associated with TR compared with TF for CTO interventions.

METHODS

After a systematic literature search was done in PubMed and EMBASE, we performed a meta-analysis of studies comparing TF and TR for CTO PCI. Results: Twelve studies with 19,309 patients were included. Compared to those who has TF access, individuals who were treated via TR approach had statistically significant lower access complication rates [odds ratio (OR): 0.33; 95% confidence interval (CI): 0.22 to 0.49; p < 0.0001]. The procedural success was in the favor of TR method (OR: 1.4; 95% CI: 1.31-1. 51; p < 0.0001). The incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and contrast-induced nephropathy were similar in both groups.

CONCLUSION

When compared with TF access interventions in CTO PCI; the TR approach appears to be associated with far less access-site complications, higher procedural success, and comparable MACCE.

Hypercalcemia Is of Uncertain Significance in Patients With Advanced Adenocarcinoma of the Prostate

Hypercalcemia in the setting of prostate cancer is rare with an uncertain pathophysiology and more research is needed into the role of parathyroid hormone-related peptide as a growth factor and possibly target-directed monoclonal antibody therapies.

P4727Comparing in-hospital outcomes of transcatheter mitral valve repair vs surgical mitral valve repair in patients with pulmonary hypertension

Background

The comparative outcomes of transcatheter mitral valve repair with Mitraclip (TMVR) versus surgical mitral valve repair (SMVR) in pulmonary hypertension (PH) patients are underexplored.

Methods

The Nationwide Inpatient Sample (NIS) database was queried from 2009 to 2015 and those who underwent TMVR or SMVR with PH were identified. International Classification of Diseases (ICD) codes were used to identify the target population, primary and secondary outcomes. Propensity scores (PS) were calculated for each patient. A standardized morbidity ratio (SMR) weight was then calculated for each patient in both groups. Absolute standardized differences (ASD) were used to compare the baseline characteristics.

Results

We identified a total of 341 and 4,665 cases from NIS who underwent TMVR and SMVR, respectively, over the study period. The mean age of patients was 67 yrs. Patients who underwent TMVR were older (75 vs. 66, ASD =0.32). Women comprised 47.8% of TMVR admission while 42.16% of SMVR admissions were females. Patients who underwent TMVR had a significantly higher Elixhauser comorbidity score >4 (43.4% vs 34.2%, ASD =0.3). TMVR group had higher rates of previous myocardial infarctions (16.7% vs. 7.1%, ASD = 0.30), congestive heart failure (80% vs. 6.2%, ASD = 0.44), percutaneous intervention (PCI) (15.6% vs. 5.9%, ASD = 0.32), coronary artery bypass grafting (CABG) (22.8% vs. 2.7%, ASD = 0.63), cerebrovascular disease (13.5% vs. 5.5%, ASD = 0.27), chronic obstructive pulmonary disease (30.8% vs. 21.1%, ASD = 0.22)and chronic renal failure (43.1% vs. 18.9%, ASD = 0.54). Inpatient mortality was similar between the 2 groups (3.6% vs 6.2%, p=0.573). TMVR patients had less hemorrhage requiring transfusion (8.1% vs 21.1, p<0.001), acute kidney injury (22.2% vs 33.6%, p<0.001), pacemaker placement (1.20% vs 6.89%, p<0.001), cardiogenic shock (4.5% vs 11.5%, p=0.0012) and mechanical circulatory device need (3.9% vs 9.7%, p=0.003). The TMVR group had lower median hospital cost ($53,824 vs $68,311, p<0.001) and LOS (7.5 days vs 13.1 days, p<0.001).

Conclusions

While in-hospital mortality in PH patients after TMVR compared to SMVR, TMVR was associated with significantly lower periprocedural complications.