Virtual reality to reduce periprocedural anxiety during invasive coronary angiography: rationale and design of the VR InCard trial

INTRODUCTION

Patients undergoing invasive coronary angiography (ICA) experience anxiety due to various reasons. Procedural anxiety can lead to physiological and psychological complications, compromising patient comfort and overall procedural outcomes. Benzodiazepines are commonly used to reduce periprocedural anxiety, although the effect is modest. Virtual reality (VR) is a promising non-pharmacological intervention to reduce anxiety in patients undergoing ICA.

METHODS AND ANALYSIS

A single-centre open-label randomised controlled trial is conducted assessing the effectiveness of add-on VR therapy on anxiety in 100 patients undergoing ICA and experiencing anxiety in a periprocedural setting. The primary outcome is the Numeric Rating Scale (NRS) anxiety score measured just before obtaining arterial access. Secondary outcomes include postarterial puncture and postprocedural anxiety, patient-reported outcome measures (PROMs) of anxiety and physiological measurements associated with anxiety. The NRS anxiety level and physiological measurements are assessed five times during the procedure. The PROM State-Trait Anxiety Inventory and Perceived Stress Scale are completed preprocedure, and the PROM STAI and the Igroup Presence Questionnaire are performed postprocedure.

ETHICS AND DISSEMINATION

The protocol of this study has been approved by the Research Ethics Committee of the Radboud University Medical Centre, the Netherlands (CMO Arnhem-Nijmegen, 2023-16586). Informed consent is obtained from all patients. The trial is conducted according to the principles of the Helsinki Declaration and in accordance with Dutch guidelines, regulations, and acts (Medical Research involving Human Subjects Act, WMO).

REGISTRATION DETAILS

Trial registration number: NCT06215456.

Sinoatrial nodal artery fistula to bronchial arteries originating from the right coronary artery in the setting of chronic bronchiectasis and coronary artery disease

We present a 67-year-old male with past medical history of hyperlipidemia, hypertension, and emphysema, and who was a former smoker, with dyspnea on exertion and chest pain.

Coronary physiology thresholds associated with microvascular obstruction in myocardial infarction

OBJECTIVES

To ascertain whether invasive assessment of coronary physiology soon after recanalisation of the culprit artery by primary percutaneous coronary intervention is associated with the development of microvascular obstruction by cardiac magnetic resonance in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

Between November 2020 and December 2021, 102 consecutive patients were prospectively enrolled in five tertiary centres in Italy. Coronary flow reserve (CFR) and index of microvascular resistance (IMR) were measured in the culprit vessel soon after successful primary percutaneous coronary intervention. Optimal cut-off points of IMR and CFR to predict the presence of microvascular obstruction were estimated, stratifying the population accordingly in four groups. A comparison with previously proposed stratification models was carried out.

RESULTS

IMR>31 units and CFR≤1.25 yielded the best accuracy. Patients with IMR>31 and CFR≤1.25 exhibited higher microvascular obstruction prevalence (83% vs 38%, p<0.001) and lower left ventricular ejection fraction (45±9% vs 52±9%, p=0.043) compared with those with IMR≤31 and CFR>1.25, and lower left ventricular ejection fraction compared with patients with CFR≤1.25 and IMR≤31 (45±9% vs 54±7%, p=0.025). Infarct size and area at risk were larger in the former, compared with other groups.

CONCLUSIONS

IMR and CFR are associated with the presence of microvascular obstruction in STEMI. Patients with an IMR>31 units and a CFR≤1.25 have higher prevalence of microvascular obstruction, lower left ventricular ejection fraction, larger infarct size and area at risk.

TRIAL REGISTRATION NUMBER

NCT04677257.

Comprehensive imaging in patients with suspected pulmonary arterial hypertension

Currently, several imaging techniques are being used for a comprehensive evaluation of patients with suspected pulmonary hypertension (PH), in order to provide information that may clarify the presence and identify the aetiology of this complex pathology. The current paper is focused on recent updates regarding the importance of comprehensive imaging techniques for patients with suspected PH. Transthoracic echocardiography that can mainly detect right ventricle pressure overload and dysfunction is the cornerstone of imaging evaluation, while right heart catheterisation remains the gold standard assessment method. Chest radiography that may exclude pleuroparenchymal lung diseases, CT, the primary imaging modality for the assessment of lung parenchyma and CT pulmonary angiography, that allows for the non-invasive assessment of the pulmonary arteries, are equally important. Imaging techniques like dual-energy CT, single photon emission CT and ventilation perfusion scan may provide accurate diagnostic information for patients with chronic thromboembolic PH. Cardiac MRI provides the most accurate three-dimensional characterisation of the right ventricle. Accurate use of diagnostic imaging algorithms allows early detection of the disease, with the constant goal of improved PH patients prognosis.

Aortic valvuloplasty under echocardiographic guidance in a minor infant at a national referral center in Peru: case report

Aortic valve stenosis is a congenital heart defect that causes a fixed left ventricular outflow obstruction with a progressive course. Symptomatology in neonates and young infants resembles congestive heart failure. In addition, the diagnosis of this condition is made by imaging, through echocardiography. On the other hand, treatment can be surgical or interventional under fluoroscopic guidance, depending on the hospital in which it is performed. We describe the case of a minor infant patient who presented severe aortic valve stenosis; however, the fluoroscopy equipment was not available at the time of the emergency to perform the appropriate procedure, therefore, an aortic valvuloplasty was performed under echocardiographic guidance without complications.

Device Closure of Superior Sinus Venosus Atrial Septal Defects: A single centre experience

Sinus venosus atrial septal defects present a wide variety of anatomical features and are frequently associated with partial anomalous pulmonary venous drainage of one or more right pulmonary veins. Surgical correction used to be the standard treatment. In recent times, transcatheter correction of superior sinus venosus atrial septal defects has come into vogue. The transcatheter closure of these defects with covered stents at a tertiary care centre in Oman between 2018 and 2023 is reported.

[Relationship between the systolic-diastolic shock index and mortality in myocardial infarction]

Background

In the emergency room, the shock index was applied to determine the prognosis in various pathologies, such as acute infarction. The shock index is the re-sult of dividing heart rate by the systolic blood pressure.

Objective

To determine the relationship between the systolic shock index and the di-astolic shock index as prognostic factors for mortality in acute myocardial infarction with ST segment elevation prior to admission to the Hemodynamics Room.

Material and methods

A prolective analytical cross-sectional study was carried out in patients who were admitted to the Hemodynamics Room for cardiac catheterization within a period of 5 months in 2022. The systolic shock index and diastolic shock index were included as independent variables and mortality was the dependent variable. SPSS, version 25, was used and Pearson's chi-square test was used as statistical test, with a p value < 0.05 being significant.

Results

162 patients were analyzed and showed a diastolic shock index > 1.2143 with a sensitivity of 62.5% and a specificity of 77.4% with a p < 0.05. Their systolic shock in-dex was > 0.8908 with a sensitivity of 45.8% and specificity of 91.2%, with a p < 0.05.

Conclusion

It was determined that both shock indices are related as mortality prognos-tic factors in acute myocardial infarction with ST elevation prior to admission to the He-modynamic Room.

Preparation for cardiac procedures: a cross-sectional study identifying gaps between outpatients' views and experiences of patient-centred care

BACKGROUND

To examine and identify gaps in care perceived as essential by patients; this study examined outpatients': 1) views on what characterises essential care and 2) experiences of care received, in relation to cardiac catheterisation and subsequent cardiovascular procedures.

METHODS

Cross-sectional descriptive study. Surveys were posted to outpatients who had undergone elective cardiac catheterisation in the prior six months at an Australian hospital. Participants completed a 65-item survey to determine: a) aspects of care they perceive as essential to patients receiving care for a cardiac condition (Important Care Survey); or b) their actual care received (Actual Care Survey). Numbers and percentages were used to calculate the most frequently identified essential care items; and the experiences of care received. Items rated as either 'Essential'/'Very important' by at least 80% of participants were determined. A gap in patient-centred care was identified as being any item that was endorsed as essential/very important by 80% or more of participants but reported as received by less than 80% of participants.

RESULTS

Of 582 eligible patients, 264 (45%) returned a completed survey. 43/65 items were endorsed by > 80% of participants as essential. Of those, for 22 items, <80% reported the care as received. Gaps were identified in relation to GP consultation (1 item), preparation (1 item) subsequent decision making for treatment (1 item), prognosis (6 items) and post-treatment follow-up (1 item).

CONCLUSIONS

Areas were identified where actual care fell short of patients' perceptions of essential care.

Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes

We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.

Severity of obstructive coronary artery stenosis after pre-eclampsia

INTRODUCTION

Women with a history of pre-eclampsia are at higher risk of premature coronary artery disease. Assessment of obstructive coronary artery stenosis by invasive coronary angiography has not been evaluated after pre-eclampsia.

METHODS

A population-based cohort study was completed in Ontario, Canada, where there is universal healthcare and collection of angiographic data. Included were women with a live birth or stillbirth from 2002 to 2020, and without known heart disease. One birth was randomly selected per woman. The main exposure compared women with versus without pre-eclampsia. The primary outcome was angiographically established obstructive coronary artery stenosis, assessed starting 42 days after the index birth. Cause-specific hazard models accounting for competing risks generated HRs, adjusted for age, parity, income, rurality, diabetes, chronic hypertension, renal disease, substance use and dyslipidaemia.

RESULTS

Among 42 252 women ever with pre-eclampsia and 1359 122 never with pre-eclampsia, mean age was 31.1 years and 30.6 years, respectively. After 9 years of follow-up, obstructive coronary artery stenosis occurred in 186 women with pre-eclampsia (4.53 per 10 000 person-years) versus 1237 women without pre-eclampsia (0.97 per 10 000 person-years)-an unadjusted HR 4.41 (95% CI 3.78 to 5.14) and adjusted HR 2.07 (95% CI 1.77 to 2.43). Relative to those with neither, the adjusted HR for coronary stenosis was highest in women with pre-eclampsia and preterm birth (3.11, 95% CI 2.51 to 3.87), or pre-eclampsia and stillbirth (2.80, 95% CI 1.05 to 7.47).

CONCLUSIONS

Pre-eclampsia is associated with a greater risk of premature-onset obstructive coronary artery stenosis, especially when it is complicated by a preterm birth or a stillbirth.

Imaging and haemodynamic parameters associated with clinical outcomes following isolated tricuspid valve surgery

INTRODUCTION

Isolated tricuspid valve surgery (TVS) may be associated with high morbidity and mortality. The aim of this study was to investigate the association of preoperative imaging and haemodynamic data derived from echocardiography (ECHO), cardiac magnetic resonance (CMR) and right heart catheterisation (RHC) with postoperative outcomes following TVS.

METHODS

In a retrospective cohort study, patients who underwent isolated TVS at our institution between 2012 and 2020 were screened and followed up to 1 year. We only included those who had all three tests before surgery: ECHO, CMR and RHC. Patients with congenital heart disease, infective endocarditis and those who underwent concomitant valve or pericardial surgery were excluded. The primary outcome was a composite of mortality and congestive heart failure at 1 year. Time-to-event analyses at 1 year and Cox proportional hazards regression analyses were performed.

RESULTS

A total of 60 patients were included (mean age of 60±14 years, 63% women), of whom 67% underwent TV repair. The primary outcome occurred in 16 patients (27%) with a 1-year mortality of 7%. It was associated with ECHO-derived right ventricular (RV) free wall strain and RHC-derived RV systolic and diastolic as well as mean pulmonary pressures. On multivariable Cox regression analysis, only RV systolic and diastolic pressures were significantly associated with the primary outcome at 1 year (HRs=5.9 and 3.4, respectively, p<0.05).

CONCLUSION

Baseline invasive haemodynamic assessment could have a strong association with clinical outcomes and help risk-stratify patients undergoing isolated TVS.

Comparative Assessment of Propofol and Ketamine on Hemodynamic Indices and Cerebral Oximetry of Pediatric Patients Undergoing Cardiac Catheterization

Background

Propofol and ketamine are widely used in the induction and maintenance of anesthesia and sedation with different cardiovascular and respiratory effects. In cardiac anesthesia (including pediatric cardiac catheterization), due to the high risk of neurologic complications, cerebral oximetry can effectively monitor cerebral blood oxygen saturation to prevent neurological and respiratory complications.

Objectives

This study aimed to compare the effect of propofol and ketamine on hemodynamic indices and cerebral oxygenation results in children undergoing cardiac catheterization.

Methods

This clinical trial study was performed on 48 patients who were candidates for cardiac catheterization by easy and continuous sampling. Patients were randomly divided into 2 groups: ketamine and propofol. In the ketamine group, ketamine was injected at a dose of 1 - 2 mg/kg, and in the propofol group, propofol was injected at a dose of 0.5 - 1.5 mg/kg. In both groups, incremental doses were repeated as needed. The hemodynamic indices, including blood pressure, heart rate, and peripheral SpO₂, were recorded. Cerebral regional oxygen saturation (RSO₂) was recorded using infrared spectroscopic sensors. Data were analyzed using chi-square, independent t-test, paired t-test, and 1-way analysis of variance (ANOVA).

Results

The results showed that all demographic characteristics of patients and also the mean duration of catheterization were homogeneous between the 2 groups. Hemodynamic indices (such as systolic, diastolic, and mean arterial blood pressure) did not show a significant difference between the 2 groups; however, in the ketamine group compared to the propofol group, the heart rate was significantly higher, and mean RSO₂ was lower (P = 0.023).

Conclusions

Propofol has fewer complications than ketamine and is a good drug for sedating children undergoing cardiac catheterization.

Is the folk medicine known as "The Secret" efficient in reducing bleeding after percutaneous coronary procedures?: a double-blinded, randomised trial

AIM

Percutaneous coronary interventions require an arterial approach and administration of antithrombotic drugs. This may lead to bleeding complications. The aim of this study was to test whether "The Secret" - a pagan prayer - is effective in reducing post-interventional bleeding.

DESIGN

Randomised controlled trial.

SETTING

Monocentric, tertiary care centre.

PARTICIPANTS

From January to July 2022, 200 patients (aged >18 years) undergoing elective coronary angiography were included in the study.

INTERVENTION

The intervention group received "The Secret" in addition to the normal procedure. The control group was treated according to standard practice.

MAIN OUTCOME MEASURES

The primary outcome was the rate of in-hospital bleeding according to the Bleeding Academic Research Consortium (BARC) consensus definition.

RESULTS

The rate of bleeding was similar in both groups ("The Secret" group vs control group) with 16% versus 14% (p=0.69) of BARC 1, 12% versus 13% (p=0.81) of BARC 2, and 0% versus 0% of BARC 3 and 5 (p=1.00). Most (76%) of the participants believed that "The Secret" would be efficient in preventing bleeding.

CONCLUSIONS

This study demonstrates no effect on bleeding after percutaneous coronary procedures. A large majority of our study population believe that "The Secret" can have a positive effect on their hospital care.

Activated clotting time in inpatient diagnostic and interventional settings

Monitoring for the anticoagulant effect of unfractionated (UFH) at the point of care using activated clotting time in real time is vital where risk of thrombosis is high. Although monitoring UFH effect is a routine and important task, changing from one ACT instrument type or technology to another must be preceded by a clinical and statistical evaluation to determine the suitability and repeatability and establish normal and treatable ranges of this newer instrument. In this multi-center prospective evaluation we tested 1236 paired ACT+ samples, and 463 paired ACT-LR samples (1699 total) from enrolled study subjects. Clinical settings included CVOR cardiopulmonary bypass, at the beside in extracorporeal life support (ELS), the Cardiac Catheterization Lab (CCL) during diagnostic studies and percutaneous coronary interventions (PCI), interventional radiology procedures and EP interventions. This study found more consistent clinical performance from the GEM Hemochron 100 as compared to the current clinical model, the Hemochron Signature Elite. The bias of GEM Hemochron 100 for ACT+ and ACT-LR was greatest in the setting of the CVOR where ACT levels were high. ACT-LR measurements by the GEM Hemochron 100 were comparable to the SE when performed in settings of CCL, ECM, EP and ICU. Results obtained for both ACT-LR and ACT+ in all clinical settings in this study using the GEM Hemochron 100 are as accurate and more repeatable as those with the current clinically available Signature Elite.

First in-human modified atrial septostomy combining radiofrequency ablation and balloon dilation

OBJECTIVE

Preclinical research suggests that the combined use of radiofrequency ablation and balloon dilation (CURB) could create stable interatrial communications without device implantation. This study examined the first in-human use of CURB for modified atrial septostomy in patients with severe pulmonary arterial hypertension (PAH).

METHODS

Between July 2018 and October 2021, CURB was performed in 19 patients with severe PAH (age: 31.5±9.1 years; mean pulmonary artery pressure: 73 mm Hg (IQR: 66-92); pulmonary vascular resistance: 18.7 Wood units (IQR: 17.8-23.3)). Under guidance of intracardiac echocardiography and three-dimensional location system, (1) fossae ovalis was reconstructed and ablated point-by-point with radiofrequency; (2) then graded balloon dilation was performed after transseptal puncture and the optimal size was determined according to the level of arterial oxygen saturation (SatO₂); (3) radiofrequency ablation was repeated around the rims of the created fenestration. The interatrial fenestrations were followed-up serially.

RESULTS

After CURB, the immediate fenestration size was 4.4 mm (IQR: 4.1-5.1) with intracardiac echocardiography, systolic aortic pressure increased by 10.2±6.9 mm Hg, cardiac index increased by 0.7±0.3 L/min/m² and room-air resting SatO2 decreased by 6.2±1.9% (p<0.001). One patient experienced increased pericardiac effusion postoperatively; the others had no complications. On follow-up (median: 15.5 months), all interatrial communications were patent with stable size (intraclass correlation coefficient=0.96, 95%CI:0.89 to 0.99). The WHO functional class increased by 1 (IQR: 1-2) (p<0.001) with improvement of exercise capacity (+159.5 m, P<0.001).

CONCLUSION

The interatrial communications created with CURB in patients with severe PAH were stable and the mid-term outcomes were satisfactory.

TRIAL REGISTRATION NUMBER

NCT03554330.

Early versus delayed complete revascularisation in patients presenting with ST-segment elevation myocardial infarction and multivessel disease: a systematic review and meta-analysis of randomised controlled trials

Background

Several studies have demonstrated that complete revascularisation improves clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary disease. However, the optimal timing of non-culprit lesion revascularisation remains controversial.

Objective

The aim of this systematic review and meta-analysis was to assess the effect of timing of complete revascularisation on cardiovascular outcomes in patients with STEMI and multivessel coronary artery disease.

Methods

Searches of PubMed, the Cochrane Library, ClinicalTrials.gov and the reference lists of relevant papers were conducted covering the period from 2004 to 2019. A pairwise analysis was performed to compare the difference in clinical outcome between early complete revascularisation (index procedure or index hospitalisation) and delayed complete revascularisation (after discharge) in patients with STEMI.

The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as the composite of all-cause mortality, recurrent myocardial infarction, unplanned repeated revascularisation and cardiovascular death.

Results

Twelve studies including a total of 7596 patients were identified. The MACE rate was 10.37% in early complete revascularisation compared with 18.17% in culprit only (p=0.01). When complete revascularisation was delayed, the MACE rate was 11.81% after complete revascularisation compared with 17.21% in culprit-only percutaneous coronary intervention (PCI) (p=0.01). A meta-regression analysis demonstrated no relationship between timing of complete revascularisation and reduction in MACE relative to culprit-only PCI (p=0.862).

Conclusion

In patients with STEMI treated by primary PCI and multivessel disease, there is a benefit of complete revascularisation over culprit-only PCI whether non-culprit revascularisation is performed early in hospital or delayed as an elective procedure. We have not demonstrated a relationship between timing of complete revascularisation and MACE.

PROSPERO registration number

CRD42021226789.

Cannot Extubate a Newborn Patient after an Arterial Switch Operation? Check Major Aortopulmonary Collaterals!

The standard treatment of transposition of the great arteries is the arterial switch operation (ASO). Despite successful surgical correction, patients cannot tolerate extubation after the operation. Major aortopulmonary collaterals (MAPCAs) are one of the rare causes of prolonged mechanical ventilation due to significant hemodynamic effects. We report a 28-day-old newborn with transposition of the great arteries and a ventricular septal defect (VSD) who underwent ASO and VSD closure. After postoperative extubation failed twice, four large MAPCAs were revealed during heart catheterization. After transcatheter closure of these four MAPCAs, the patient was extubated and discharged 27 days after the procedure.

Clinical characteristics of patients with acute myocardial infarction treated with thrombolysis

BACKGROUND

In patients with ST elevation myocardial infarction (STEMI) thrombolytic therapy is the optimal reperfusion strategy when primary percutaneous intervention is not available.

OBJECTIVE

To determine the clinical characteristics and hospital evolution of patients with STEMI who were treated with thrombolytic therapy in the Emergency department.

METHOD

Retrospective and transversal study; we included all patients who were diagnosed with STEMI in the Emergency department of the Hospital General Regional No. 46 and received thrombolytic therapy, within a 12 month period.

RESULTS

We analyzed 59 cases, with a mean age of 62.2 years old, 70% were male sex; the average age for men was 60 years (range 38-84) and for women was 71 years (range 43-87); according to the initial electrocardiogram the most common myocardial affected regions were inferior (43.8%) and extense anterior (43.8%); tenecteplase was the most used thrombolytic therapy (93%), with an average door in-needle time of 82 minutes (range 10-360 min), 52.6% met clinical criteria for reperfusion; in 49 cases a cardiac catheterism was performed in subsequent days, 49% of them was for rescue percutaneous coronary intervention; in-hospital mortality was 28%.

CONCLUSIONS

Thrombolytic therapy in STEMI is effective and increases the opportunity for preserving myocardial tissue; in our institute, its mandatory that such therapy is easily available and used, taking into account the patient referral times to a hospital with catheterism laboratory.

Increased Cancer Incidence Following up to 15 Years after Cardiac Catheterization in Infants under One Year between 1980 and 1998-A Single Center Observational Study

OBJECTIVE

To evaluate the incidence of cancer within the first 15 years of life in children who underwent cardiac catheterization under the age of one year.

METHODS

In this retrospective, single center study, 2770 infants (7.8% with trisomy 21) were studied. All infants underwent cardiac catheterization under one year of age between January 1980 and December 1998. Newly diagnosed cancer in the first 15 years of life was assessed through record linkage to the German Childhood Cancer Registry (GCCR). Cancer risk in study patients was compared to the GCCR population of children less than 15 years. Patients with trisomy 21 were compared to the Danish Cytogenic Register for trisomy 21. Effective radiation doses were calculated for each tumor patient and 60 randomly selected patients who did not develop cancer.

RESULTS

In total, 24,472.5 person-years were analyzed. Sixteen children developed cancer, while 3.64 were expected (standardized incidence ratio (SIR) = 4.4, 95% confidence interval (CI): 2.5-7.2, p < 0.001). There was no preferred cancer type. The observed incidence of leukemia and solid tumors in trisomy 21 was only slightly higher (1 in 476 py) than expected (1 in 609 py, p = 0.64). There was no direct relationship between the radiation dose and the incidence of cancer.

CONCLUSION

Cardiac catherization in the first year of life was associated with a significantly increased cancer risk in a population with congenital heart disease.

Management of Coarctation of The Aorta in Adult Patients: State of The Art

Coarctation of the aorta (CoA) is a common form of congenital heart disease. Adult patients with CoA may be asymptomatic or may present with hypertension. Over the last few years, endovascular management of adult patients with CoA emerged as the preferred strategy. Stent implantation, though technically challenging, offers the best and most lasting therapy. In this paper, we will review technical considerations and outcome of patients undergoing stent implantation for CoA.

An Exploratory Study Monitoring Respiratory Status Using Arterial Blood Gases during Cardiac Catheterization with Conscious Sedation

BACKGROUND

Benzodiazepines and opioids are commonly used for conscious sedation (CS) in cardiac catheterization laboratory (CCL) patients. Both drugs are known to predispose to hypoxemia, apnea and decreased responsiveness to PCO₂, resulting in decreased arterial pH and PO₂, as well as increased PCO₂. We want to determine the effects of CS on arterial blood gas (ABG) in CCL patient, and identify if pulse oximetry monitoring is adequate.

METHODS

We enrolled 18 subjects undergoing elective catheterization. Measurement of ABGs at one-minute intervals was done from the moment of arterial access until case end. The results of ABGs were not available to the clinician who administered sedation. Relationships of pH, PCO₂, PaO₂ and SaO₂ were studied by plotting time series graphs. Significant changes were defined as pH <7.30, SaO₂ < 90, and PCO₂ > 50 mmHg.

RESULTS

No significant change in pH, PCO₂, PaO₂ and SaO₂ was noted in 4/18 (22%) subjects. A significant drop in SaO₂ was noted in 4/18 (22%). A significant change in PCO₂ and/or pH was noted in 10/18 (55%) cases. Among the 16 (16/18) subjects receiving supplemental oxygen, 7 (7/18, 39%) had no drop in SaO₂, but developed respiratory acidosis. At the end of the case, 5/18 (28%) subjects had respiratory acidosis with normal PaO₂.

CONCLUSION

Significant hypercarbia and acidosis occurred frequently in this small study during CS in patients undergoing cardiac catheterization. Relying on pulse oximetry alone especially with patients on supplemental oxygen may lead to failure in detecting respiratory acidosis in a significant number of patients.

The implications of cocaine use and associated behaviors on adverse cardiovascular outcomes among veterans: Insights from the VA Clinical Assessment, Reporting, and Tracking (CART) Program

BACKGROUND

Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors.

HYPOTHESIS

Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization METHODS: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1-year all-cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine.

RESULTS

3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08-1.39), MI (HR: 1.40, 95% CI: 1.07-1.83), and CVA (HR: 1.88, 95% CI: 1.38-2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine.

CONCLUSIONS

Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.

Transcatheter Closure of Ruptured Sinus of Valsalva Aneurysm: Report of two cases

A ruptured sinus of Valsalva aneurysm (RSVA) is a rare cardiac anomaly. Traditionally, RSVAs were repaired surgically; however, percutaneous transcatheter closure is the current treatment of choice. We report two cases of RSVA which were closed using this approach. The first case was a 45-year-old female who presented to the Royal Hospital, Muscat, Oman, in 2014 with a RSVA in the right ventricle. The second case was a 39-year-old male who was admitted to the Sultan Qaboos University Hospital, Muscat, in 2015 with a large multifenestrated RSVA extending into the right ventricle outflow tract. Each patient underwent transcutaneous cardiac catheterisation using three-dimensional echocardiography. Both interventions were technically successful; however, the second patient required a subsequent surgery due to the continuing presence of a significant shunt. Transcatheter closure of RSVAs is an effective alternative to surgical repair, although large multifenestrated RSVAs should be repaired surgically to ensure complete closure.

Thyroid Hormone Profile in Patients With Acute Coronary Syndrome

Background:

Thyroid hormone has the a major role in the cardiovascular system function and cardiac a As well as to maintain the cardiovascular homeostasis A slightly change ind thyroid status actually affects cardiovascular mortality hemodynamic. The background of this study was to define the prevalence of thyroid dysfunction in acute coronary syndrome (ACS).

Objectives:

The primary objective was to define the prevalence of thyroid dysfunction in acute coronary syndrome, including Non-ST Segment Elevation Myocardial Infarction (NSTEMI), ST-segment Elevation Myocardial Infarction (STEMI), and unstable angina groups. The secondary objective was to determine any associations of thyroids function tests with cardiac catheterization and mortality.

Patients and Methods:

In a prospective, observational, and cross section study, we enrolled 400 patients admitted at the coronary care unit of King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Venous blood samples were collected from patients for the evaluation of thyroid function (thyroids stimulating hormones, free triiodothyronine, and free thyroxin).

Results:

Excluding those taking thyroid hormone preparations, 76.7% of patients admitted with acute coronary heart disease (ST-segment elevation myocardial infarction and Non-ST segment elevation myocardial infarction), and unstable angina had euthyroidism. Thyroid dysfunction was reported in 23.3% of patients with coronary heart disease. Overall hypothyroidism prevalence was 7.8%, while subclinical hyperthyroidism in our study was 2.7%. Overt hyperthyroidism and subclinical hyperthyroidism was reported 2.0% and 0.5%, respectively. Euthyroid sick syndrome was noticed in 41 (10.2%) of critically ill patients. The mortality rate was 9.8%; all death patients had low triiodothyronine (T3) syndrome and were associated with statistically significant low free triiodothyronine (FT3) (P > 0.001).

Conclusions:

No significant variance was observed among patients underwent for cardiac catheterization, STEMI, NSTEMI, unstable angina, and atrial fibrillation with respect to FT4, FT3, and TSH levels during coronary care unit hospitalization based on their profile data.

Impact of Percutaneous Interventions for Pulmonary Artery Stenosis in Alagille Syndrome

OBJECTIVE

The study aims to examine acute and midterm outcomes after percutaneous interventions for treatment of pulmonary artery stenosis (PAS) in patients with Alagille Syndrome (ALGS).

BACKGROUND

PAS affects up to two thirds of ALGS patients. Responsiveness to transcatheter therapies may differ from other causes of PAS. To date, there has been no study to evaluate outcomes of transcatheter interventions on PAS exclusively in ALGS.

METHODS

In this single-center series, we reviewed procedural, hemodynamic, and angiographic data from patients with ALGS and PAS from 2007 to 2011 who underwent an interventional catheterization. Minimal luminal diameter (MLD) was assessed pre- and postintervention, and at follow-up catheterization(s) when available. Acute and midterm response to high-pressure balloon angioplasty (HBA), bare metal stent (BMS) placement, and cutting balloon angioplasty (CBA) were assessed.

RESULTS

Nine patients (median age 9.1 years) underwent 16 cardiac catheterizations with 34 interventions performed (20 HBA, 11 BMS, 3 CBA). There was a significant acute increase in MLD for all three modalities (42% HBA, P < .01; 91% BMS, P < .01; 58% CBA, P = .04). Follow-up data were available for 19 treated lesions at a median of 11 months. There was no significant difference in the improvement of MLD from baseline between the HBA and BMS groups, although in contrast to the BMS group, the HBA group showed continued interval vessel growth.

CONCLUSIONS

Transcatheter intervention for PAS in ALGS is generally safe and acutely effective. Although BMS implantation was associated with the greatest immediate improvement in MLD, HBA-treated vessels demonstrate interval growth, whereas BMS-treated lesions do not.

Severe tricuspid regurgitation mimicking constrictive pericarditis

Patient: Female, 62

Final Diagnosis: Tricuspid regurgitation

Symptoms: Dyspnea exertional • fatigue • leg edema

Medication: —

Clinical Procedure: —

Specialty: Cardiology

Treatment of femoral artery thrombosis with streptokinase and heparin after cardiac catheterization

Background:

Thrombosis is the most common complication during cardiac catheterization via femoral artery access. Alongside heparinization, fibrinolytic therapy is recommended if there are signs of ischemia in the lower extremity.

Objectives:

Given the paucity of data in the existing literature on streptokinase (SK) therapy in pediatrics, we designed this study to assess the efficacy of SK in pediatric patients with diagnosed femoral artery thrombosis following cardiac catheterization.

Patients and Methods:

The study population initially consisted of 1788 pediatric patients who underwent cardiac catheterization via the femoral artery access. Diminished or absent pulses in the lower extremity were detected in 123 patients, 45 of whom (2.5% of 1788) required treatment and were therefore considered for the next stage of study. Treatment was comprised of post-procedural intravenous heparin, either 50 U/kg/Q4h or 10 - 20 U/kg/h continuously. After heparinization for 24 hours, if the pulse of the affected extremity was not palpable, heparin therapy was continued (heparin-treated group, n = 28), and if the symptoms of femoral artery ischemia were persistent, heparin was discontinued and intravenous SK with a loading dose of 2000 U/kg over 20 - 30 minutes was commenced (SK-treated group, n =17).

Results:

In the presence of pulselessness in the lower extremity, a maintenance dose of SK (1000 U/kg/h, during 1 - 24 hours) was intravenously administered. Regarding the return of the pulses post-therapeutically, normal and weak/absent pulses were detected in seven (25.2%) and 21 (74.8%) of the 28 patients, respectively, in the heparin-treated group (P value < 0.001), whereas normal and weak/absent pulses were detected in 15 (88.2%) and two (11.8%) of the 17 patients, respectively, in the SK-treated group (P value < 0.001).

Conclusions:

Our findings demonstrated a high success rate and a low complication rate for systemic SK therapy in femoral artery thrombosis after catheterization.