Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Cardiogenic shock (CS) is a clinical condition characterized by inadequate tissue perfusion in the setting of low cardiac output. CS is the leading cause of death following acute myocardial infarction (AMI). Several temporary mechanical support devices are available for hemodynamic support in CS until clinical recovery ensues or until more definitive surgical procedures have been performed. Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) has evolved as a powerful treatment option for short-term circulatory support in refractory CS. In the absence of randomized clinical trials, the utilization of ECMO has been guided by clinical experience and based on data from registries and observational studies. Survival to hospital discharge with the use of VA-ECMO ranges from 28-67%. The initiation of ECMO requires venous and arterial cannulation, which can be performed either percutaneously or by surgical cutdown. Components of an ECMO circuit include an inflow cannula that draws blood from the venous system, a pump, an oxygenator, and an outflow cannula that returns blood to the arterial system. Management considerations post ECMO initiation include systemic anticoagulation to prevent thrombosis, left ventricle unloading strategies to augment myocardial recovery, prevention of limb ischemia with a distal perfusion catheter in cases of femoral arterial cannulation, and prevention of other complications such as hemolysis, air embolism, and Harlequin syndrome. ECMO is contraindicated in patients with uncontrolled bleeding, unrepaired aortic dissection, severe aortic insufficiency, and in futile cases such as severe neurological injury or metastatic malignancies. A multi-disciplinary shock team approach is recommended while considering patients for ECMO. Ongoing studies will evaluate whether the addition of routine ECMO improves survival in AMI patients with CS who undergo revascularization.

Intracoronary Imaging Versus Coronary Angiography Guidance for Implantation of Second and Third Generation Drug Eluting Stents in a Systematic Review and Meta-Analysis of Randomized Controlled Trials

Intracoronary imaging (ICI) facilitates stent implant by characterizing the lesion calcification, providing accurate vessel dimensions, and optimizing the stent results. We sought to investigate the outcomes of routine ICI versus coronary angiography (CA) to guide percutaneous coronary intervention (PCI) with second- and third-generation drug-eluting stents. A systematic search of PubMed, Medline, and Cochrane databases was conducted from their inception to July 16, 2022 for randomized controlled trials comparing routine ICI with CA. The primary outcome was major adverse cardiovascular events. The secondary outcomes of interest were target lesion revascularization, target vessel revascularization, myocardial infarction, stent thrombosis, and cardiac and all-cause mortality. A random-effects model was used to calculate the pooled incidence and relative risk (RR) with 95% confidence intervals (CIs). A total of 9 randomized controlled trials with 5,879 patients (2,870 ICI-guided and 3,009 CA-guided PCI) met the inclusion criteria. The ICI and CA groups were similar in demographic characteristics and co-morbidity profiles. Compared with CA, patients in the routine ICI-guided PCI group had lower rates of major adverse cardiovascular events (RR 0.61, 95% CI 0.48 to 0.78, p <0.0001), target lesion revascularization (RR 0.60, 95% CI 0.43 to 0.83, p = 0.002), target vessel revascularization (RR 0.72, 95% CI 0.51 to 1.00, p = 0.05), and myocardial infarction (RR 0.48, 95% CI 0.25 to 0.95, p = 0.03). There were no significant differences in stent thrombosis or cardiac/all-cause mortality between the 2 strategies. In conclusion, routine ICI-guided PCI strategy, compared with CA guidance alone, is associated with improved clinical outcomes, largely driven by lower repeat revascularization.

A case report of non-dominant right coronary artery occlusion: not always benign!

Background

Non-dominant right coronary artery (RCA) occlusion is uncommon and usually affects a small area of the myocardium. Rarely, it can complicate fatal outcomes such as shock, cardiac arrest, bradyarrhythmia, or tachyarrhythmia.

Case summary

A 50-year-old man with no significant medical history presented with ventricular fibrillation (VF) cardiac arrest. He required prolonged cardiopulmonary resuscitation and multiple defibrillation shocks to achieve return of spontaneous circulation. ST elevation was noted on inferior leads. Due to refractory VF, extracorporeal membrane oxygenation (ECMO) was initiated followed by coronary angiography which demonstrated 100% acute occlusion of proximal RCA (small non-dominant), 90% stenosis of ramus intermedius (RI), and 80% stenosis of obtuse marginal (OM) arteries. Left ventricular ejection fraction was 35%. Percutaneous coronary intervention (PCI) of the RCA was performed with drug eluting stent. He had excellent clinical recovery without any neurological deficits. The ECMO was weaned off and decannulated within three days. Guideline directed medical therapy was administered. He remained hemodynamically stable and underwent staged PCI of RI and OM to achieve complete revascularization.

Discussion

Non-dominant RCA lesions are usually considered benign. However, when acute RCA occlusion results in cardiac arrest as seen in our patient, prompt revascularization is necessary. Treatment of cardiogenic shock with appropriate pharmacological and mechanical therapies is important, such as ECMO in our patient.

Outcomes of Prediabetes Compared with Normoglycaemia and Diabetes Mellitus in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

Background: Patients with prediabetes are at increased risk of coronary artery disease (CAD). However, the association between prediabetes and adverse clinical outcomes following percutaneous coronary intervention (PCI) is inconsistent, in contrast to outcomes in patients with diabetes mellitus (DM). Thus, this meta-analysis evaluated the impact of dysglycaemia on PCI outcomes. Methods: The PubMed, Embase, Cochrane, and ClinicalTrials.gov databases were systematically reviewed from inception of databases until June 2022. In 17 studies, outcomes of PCI in patients with prediabetes were compared with patients who were normoglycaemic, and patients with DM. The primary outcome was all-cause mortality at the longest follow-up. Results: Included were 12 prospective and five retrospective studies, with 11,868, 14,894 and 13,536 patients undergoing PCI in the prediabetes, normoglycaemic and DM groups, respectively. Normoglycaemic patients had a statistically lower risk of all-cause mortality, (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.52-0.84), myocardial infarction (MI; RR 0.76, 95% CI 0.61-0.95) and cardiac mortality (RR 0.58, 95% CI 0.39-0.87) compared with prediabetic patients undergoing PCI at the longest follow-up. Patients with prediabetes had a lower risk of all-cause mortality (RR=0.72 [95% CI 0.53-0.97]) and cardiac mortality (RR =0.47 [95% CI 0.23-0.93]) compared with patients with DM who underwent PCI. Conclusion: Among patients who underwent PCI for CAD, the risk of all-cause and cardiac mortality, major adverse cardiovascular events and MI in prediabetic patients was higher compared with normoglycaemic patients but lower compared with patients with DM.

Cardiogenic shock and severe secondary mitral regurgitation successfully treated with transcatheter edge-to-edge repair: a case report

Background

Cardiogenic shock (CS) associated with severe mitral regurgitation (MR) forebodes a high risk of morbidity and mortality. Transcatheter edge-to-edge repair (TEER) is a rapidly evolving technique for severe MR in haemodynamically stable patients. However, the safety and efficacy of TEER for severe MR in CS are not well established.

Case summary

An 83-year-old male presented with dyspnoea and was hospitalized for heart failure. Chest X-ray revealed pulmonary oedema. Transthoracic echocardiography showed severely depressed ejection fraction (EF) with severe secondary MR. Right heart catheterization confirmed a low cardiac index. Diuretics and inotropes were administered. Due to persistent hypotension, we could not wean inotropes. The patient was deemed high risk for surgery by the heart team, and a decision was made to proceed with TEER with MitraClip. Under transoesophageal echocardiography and fluoroscopic guidance, two MitraClips were deployed sequentially. The MR grade was reduced to two mild jets subsequently. The patient was weaned off inotropes and eventually discharged. At the 30-day follow-up, he was participating in physical activities such as golf.

Discussion

Cardiogenic shock complicated by severe MR carries high mortality. With severe MR, the forward stroke volume is lower than the stated EF leading to poor organ perfusion. Inotropes and/or mechanical circulatory support devices are paramount for initial stabilization; however, they do not treat underlying MR. Transcatheter edge-to-edge repair with MitraClip has been shown to improve survival in CS patients with severe MR in observational studies. However, prospective trials are lacking. Our case demonstrates the utility of MitraClip to treat severe secondary MR refractory to medical therapy in a CS patient. The heart team must evaluate risks and benefits of this therapy in CS patients.

Sex Differences in Clinical Profile and Outcome After Percutaneous Coronary Intervention for Chronic Total Occlusion

BACKGROUND

There are limited data around sex differences in the risk profile, treatments and outcomes of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort.

METHODS & RESULTS

We created a longitudinal cohort (2006-2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75-2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78-1.29, P = 0.96). The crude and adjusted rates of procedural complications (adjusted OR: 1.37, 95 % CI: 1.23-1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26-2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62-2.61, P < 0.001) were higher in women compared with men.

CONCLUSION

Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients.

Advances in Intravascular Ultrasound

Since its inception, intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have played a significant role in evaluating the pathophysiology of coronary artery disease (CAD) guiding the interventional and medical management of CAD improving outcomes in patients. Although the benefits of each of these modalities have been proven, due to some limitations, no single intravascular imaging technique has been proven to provide a detailed and complete evaluation of all CAD lesions. The use of different intravascular imaging modalities sequentially may lead to complications, which are cumbersome, consume time, and add financial burden to the patient. Recently, hybrid imaging catheters that combine OCT and IVUS benefits have been developed to limit these problems. Intravascular imaging techniques we are using currently have some drawbacks that hinder accurate assessment of plaque morphology and pathobiology as demonstrated in many histological studies, causing difficulty in identifying high-risk plaques. To overcome these limitations, great efforts have been put into developing hybrid, dual-probe catheters by combining imaging modalities to get an accurate analysis of plaque characteristics, and high-risk lesions. At present, many dual-probe catheters are available including combined IVUS-OCT, near-infrared spectroscopy-IVUS that is available commercially, the OCT-near infrared fluorescence (NIRF) molecular imaging, IVUS-NIRF, and combined fluorescence lifetime-IVUS imaging. Application of this combined multimodal imaging in clinical practice overcomes the limitations of standalone imaging and helps in providing a comprehensive and accurate visualization of plaque characteristics, composition, and plaque biology. The present article summarizes the advances in hybrid intravascular imaging, analyses the technical hindrances that should be known to have a use in the different clinical circumstances, and the till date shreds of evidence available from their first clinical application aiming to bring these modalities into the limelight and their potential role in the study of CAD.

Management and outcomes of patients admitted with type 2 myocardial infarction with and without standard modifiable risk factors

BACKGROUND

Whilst it is known patients without standard modifiable cardiovascular risk factors (SMuRF; hypertension, diabetes, hypercholesterolaemia, smoking) have worse outcomes in Type 1 acute myocardial infarction (AMI), the relationship between type 2 AMI (T2AMI) and outcomes in patients with and without SMuRF is unknown. This study aimed to determine the prevalence, characteristics and clinical outcomes of patients hospitalised with T2AMI based on the presence of SMuRF.

METHODS

Using the National Inpatient Sample, all hospitalizations with a primary discharge diagnosis of T2AMI were stratified according to SMuRF status (SMuRF and SMURF-less). Primary outcome was all-cause mortality while secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and ischemic stroke. Multivariable logistic regression was used to determine adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

RESULTS

Among 17,595 included hospitalizations, 1345 (7.6%) were SMuRF-less and 16,250 (92.4%) were SMuRF. On adjusted analysis, SMuRF-less patients had increased odds of all-cause mortality (aOR 2.43, 95% CI 1.83 to 3.23), MACCE (aOR 2.32, 95% CI 1.79 to 2.90) and ischaemic stroke (aOR 2.57, 95% CI 1.56 to 4.24) compared to their SMuRF counterparts. Secondary diagnoses among both cohorts were similar, with respiratory disorders most prevalent followed by cardiovascular and renal disorders.

CONCLUSIONS

T2AMI in the absence of SMuRF was associated with worse in-hospital outcomes compared to SMuRF-less patients. There was no SMuRF-based difference in the secondary diagnoses with the most common being respiratory, cardiovascular, and renal disorders. Further studies are warranted to improve overall care and outcomes of SMuRF-less patients.

Same-Day Discharge after Percutaneous Left Atrial Appendage Closure: Insights from the Nationwide Readmission Database 2015-2019

Data on the feasibility of same-day discharge (SDD) following percutaneous left atrial appendage closure (LAAC) remain limited. We analyzed the US Nationwide Readmission Database from quarter four of 2015 to 2019 to study the safety and feasibility of SDD after LAAC. After excluding non-elective cases and in-hospital deaths, a total of 54,880 cases of LAAC were performed during the study period. Following LAAC, 2% (n=1077) of patients underwent SDD, 88% (n=48,428) underwent next-day discharge (NDD), 5.2% (n=2881) were discharged on the second day (ScD), and 4.5% of patients (n = 2494) were discharged 3 or more days after LAAC. There was no difference in 30-day readmission rates between SDD and NDD (7.3% [n=79] vs 7.4% [n=3585], P=0.94). The hospitalization costs were significantly lower for SDD compared with NDD ($22,963 vs $27,079, P≤0.01). SDD discharge following percutaneous LAAC appears to be safe and is associated with lower hospitalization costs. Further prospective studies are needed to determine the safety and feasibility of SDD with percutaneous LAAC.

Patterns and outcomes of cardiovascular emergency department encounters for men and women in the USA

Aims

We described sex-differential disease patterns and outcomes of over 20.6 million cardiovascular emergency department (ED) encounters in the USA.

Methods and results

We analysed primary cardiovascular encounters from the Nationwide Emergency Department Sample (between 2016–2018). We grouped the documented cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; average age was 67 [54,78] years. Men had greater overall baseline co-morbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common ED encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation (AF)/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (AMI, 10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, AF/flutter, supraventricular tachycardia, pulmonary embolism, or ischaemic stroke. Men were more likely to present with AMI or cardiac arrest. In logistic regression models adjusted for baseline covariates, women with intracranial haemorrhage had higher risk of hospitalisation and death. Women with ischaemic stroke had higher risk of hospitalisation and death in ED. Women presenting with pulmonary embolism were less likely to be hospitalised but were more likely to die. Women with aortic aneurysm/dissection had higher risk of hospitalisation and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, AF/flutter, AMI, or cardiac arrest.

Conclusion

In this large nationally representative sample of cardiovascular ED presentations, we demonstrate significant sex differences in disease distribution, hospitalisation, and death.

Funding Acknowledgement

Type of funding sources: None.

Sex-based differences of the impact of aortic valve calcium score on mortality and post-procedural outcomes after trans-catheter aortic valve replacement

Introduction

Sex based differences exist in the presentation, outcomes, and management of cardiovascular diseases. Although aortic valve calcium (AVC) score has been postulated to be associated with post-procedural outcomes after transcatheter aortic valve replacement (TAVR), data on the impact of AVC score on procedural outcomes after TAVR based on sex have been scarce.

Objective

The aim of the present study was to elucidate sex related differences in the prognostic impact of AVC score as a predictor of post-procedural outcomes and mortality in patients with severe aortic stenosis (AS) who underwent TAVR.

Methods

We retrospectively abstracted the records of 497 patients with severe AS who underwent TAVR between January 2016 and July 2019 at our institution. All patients underwent a non-contrast cardiac CT scan on a Siemens Somatom Definition Flash 128 slice scanner. AVC score using the Agatston method was calculated retrospectively. Primary outcome was 1-year mortality. Patients were divided into two groups: 1) Non-severe AVC score group [women &lt;1200 Agatston unit (AU) and men &lt;2000 AU]; 2) Severe AVC Score group [women &gt;1200 AU and men &gt;2000 AU]. Cox-regression model was used to predict effect of variables on 1-year mortality in male and female patients.

Results

Among 466 patients included, 268 patients were male and 198 were female (57.5% vs 42.5%). When compared with males, female patients had significantly lower AVC score (p&lt;0.001), aortic valve area (AVA) (p&lt;0.001), obstructive CAD (p&lt;0.001), and history of previous PCI (p&lt;0.004), and CABG (&lt;0.001) but had a significantly higher STS score (6.7±3.2 vs 5.8±3.3 P=0.01). There was no difference between need for permanent pacemaker (PPM) implantation (11% vs 9.6%, p=0.4), major complications (16% vs 15%, p=0.9), stroke (0.8% vs 1.6%, p=0.7), 30-day (3.7% vs 4%, p=0.9), and 1-year mortality (14% vs 12%, p=0.6) between males and females, respectively. Female patients required smaller bio-prosthetic valves compared with males (26±3.2 vs 30±3, p&lt;0.001). Cox regression analysis for female patients showed BMI, hemoglobin level, and AVA independently predicted 1-year mortality, while there was no impact of severe AVC score (&gt;1200 AU) on 1-year mortality in females. Similarly, Cox regression analysis for male patients showed there was no impact of severe AVC score (&gt;2000 AU) on 1-year mortality in males. When males in the severe AVC group were compared with female patients in the severe AVC group, there was no difference in 30 day (4.3% vs 3.3%, p=0.82) and 1-year mortality (14.2% vs 13.3%, p=0.77). Similarly, in the severe AVC group there was no difference between need for PPM implantation (12.8% vs 12.1%, p=0.9), major complications (19.7% vs 15.8%, p=0.4), and stroke (2.2% vs 1%, p=0.6) between males and females, respectively.

Conclusion

There were no sex differences in the impact of AVC score on mortality and post-procedural outcomes after TAVR.

Funding Acknowledgement

Type of funding sources: None.

Comparing direct oral anticoagulants versus vitamin K antagonist in patients with atrial fibrillation after transcatheter aortic valve replacement: an updated meta-analysis

Background

Oral anticoagulation therapy is indicated for patients undergoing transcatheter aortic valve replacement (TAVR) with concomitant or new onset atrial fibrillation (AF). However the data on optimal anticoagulation regimen in this population remains unclear.

Purpose

To compare efficacy and safety outcomes of direct oral anticoagulants (DOACs) versus Vitamin K antagonists (VKA) in patients with AF post TAVR.

Methods

We searched electronic databases (PubMed, Embase, Scopus, Cochrane) from inception to February28th, 2022 using MeSH terms and keywords for DOACs, AF or TAVR. Primary outcome of interest was all-cause stroke or systemic embolic event. Secondary safety outcomes were major bleeding and all-cause mortality. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effects model. Interstudy heterogeneity was assessed using the Higgins I 2 value. All statistical analysis were performed using RevMan 5.4.1 software.

Results

We identified five eligible studies (1RCT, 4 observational) including 3694 patients (DOAC n=1581, VKA n=2113). The mean age was 81.4±0.9 years. The mean follow-up was 12.4±14.3 months. Type of DOACs included apixaban (n=394, 24.9%), rivaroxaban (n=354, 22.4%), dabigatran (n=119, 7.5%) and edoxaban (n=714, 45.2%).There was no significant difference in primary outcome of stroke or systemic embolic event (RR: 0.93; CI: 0.65–1.33; p&gt;0.05; I2=5%), or in secondary outcomes of major bleeding (RR: 1.02; CI: 0.78–1.34; p&gt;0.05; I2=44%) and all-cause mortality (RR: 0.87; CI: 0.59–1.27; p&gt;0.05; I2=56%) between DOACs and VKA groups.

Conclusion

This meta-analysis shows anticoagulation therapy with DOACs has similar safety and efficacy outcomes compared to VKA in patients with AF undergoing TAVR.

Funding Acknowledgement

Type of funding sources: None.

To compare efficacy and safety of direct oral anticoagulants in patients with concurrent atrial fibrillation and bioprosthetic heart valve repair or replacement: a systematic review and meta-analysis

Background

Use of direct oral anticoagulants (DOACs) is contraindicated in patients with mechanical valves. However data on their use in patients with atrial fibrillation (AF) and bioprosthetic valves (BV) is still limited.

Purpose

To assess the safety and efficacy of DOACs versus Vitamin K antagonist (VKA) in patients with AF after BV repair or replacement.

Methods

We performed a comprehensive review of electronic databases (PubMed, Embase, Scopus, Cochrane) using MeSH terms and keywords for DOACs, AF and BVs from inception through December 2021. Randomized clinical trials (RCT) or observational studies that reported clinical outcomes comparing DOACs versus VKA in patients with AF and BVs were eligible for inclusion. Ten articles were reviewed for full text. Primary outcome was a composite of all cause stroke or systemic embolic event.

Secondary outcomes included major bleeding and all-cause mortality. Subgroup analysis stratified by study design was performed. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using Mantel-Haenszel method with DerSimonian-Laird estimator for tau2 for random effects model.

Interstudy heterogeneity was assessed using the Higgins I 2 value. All statistical analysis was performed using RevMan 5.4.1 software.

Results

Ten studies (5 RCTs, 5 observational studies) with a total of 5,333 patients (DOACs n=2434; VKA n=2899) were included. Aortic, mitral and mixed BV repair or replacement were 74.2%, 25.6% and 0.02% respectively. The mean age was 72.6±11.9 years. The mean follow-up was 15.7±12.9 months. Type of DOACs included apixaban (n=553, 22.7%), rivaroxaban (n=893, 36.7%), dabigatran (n=151, 6.2%) and edoxaban (n=837, 34.4%). There was no significant difference in primary outcome of stroke or systemic embolic event (RR: 0.79; CI: 0.56–1.11; p&gt;0.05; I2=12%) or secondary outcomes of major bleeding (RR: 0.84; CI: 0.64–1.11; p&gt;0.05; I2=45%), and all-cause mortality (RR: 0.84; CI: 0.64–1.11; p&gt;0.05; I2=29%) between DOACs compared with VKA.

Conclusion

In patients with AF and BV, DOACs are non-inferior to VKA for risk of stroke or systemic embolism, major bleeding, and all-cause mortality. Thus, DOACs can serve as a viable alternative to VKAs which have a narrow therapeutic index, multiple drug interactions, and require frequent monitoring.

Funding Acknowledgement

Type of funding sources: None.

Differential Patterns and Outcomes of 20.6 Million Cardiovascular Emergency Department Encounters for Men and Women in the United States

Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest. In logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage had higher risk of hospitalization and death. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest. Conclusions In this large nationally representative sample of cardiovascular emergency department presentations, we demonstrate significant sex differences in disease distribution, hospitalization, and death.

Age Considerations in the Invasive Management of Acute Coronary Syndromes

The elderly constitute a major proportion of patients admitted with acute coronary syndrome (ACS) in the US. Due to pre-existing comorbidities, frailty, and increased risk of complications from medical and invasive therapies, management of ACS in the elderly population poses challenges. In patients with ST-elevation MI, urgent revascularization with primary percutaneous coronary intervention remains the standard of care irrespective of age. However, an early invasive approach in elderly patients with non-ST-elevation MI is based on individual evaluation of risks versus benefits. In this review, the authors discuss the unique characteristics of elderly patients presenting with ACS, specific geriatric conditions that need to be considered while making treatment decisions in these situations, and available evidence, current guidelines, and future directions for invasive management of elderly patients with ACS.

Outcomes of Percutaneous Coronary Intervention in Patients With Acquired Immunosuppression

There are limited data on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with acquired immunosuppression who are frequently underrepresented in clinical trials. All PCI procedures between October 2015 and December 2018 in the Nationwide Inpatient Sample were retrospectively analyzed, stratified by immunosuppression status. Multivariable logistic regression models were performed to examine (1) the association between immunosuppression status and in-hospital outcomes, expressed as adjusted odds ratio (aOR) with 95% confidence intervals (CIs) and (2) predictors of mortality among patients with severe acquired immunosuppression. In this contemporary analysis of nearly 1.5 million PCI procedures, approximately 4% of patients who underwent PCI had acquired immunosuppression. Of these, chronic steroid use accounted for approximately half of the cohort who underwent PCI who had acquired immunosuppression, with the remainder divided between hematologic cancer, solid organ active malignancy, and metastatic cancer, with the latter group having the highest rates of composite of in-hospital mortality or stroke (9.3%) (mortality 7.5% and acute ischemic stroke 2.4%). In conclusion, immunosuppression was independently associated with increased adjusted odds of adverse clinical outcomes, specifically mortality or stroke (aOR 1.11, 95% CI 1.06 to 1.15, p <0.001) and in-hospital mortality (aOR 1.21, 95% CI 1.13 to 1.29, p <0.001), with outcomes dependent on the cause of immunosuppression.

A Comprehensive Review of Mechanical Circulatory Support Devices

Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.

The Single-Access Technique for Impella Protected Percutaneous Coronary Intervention: A Single-Center Experience

BACKGROUND

In this era of complex high-risk percutaneous coronary intervention (HR-PCI), mechanical support is being increasingly used. Traditionally, mechanical circulatory support with the Impella CP device requires a large-bore arterial access and an additional arterial access for the subsequent coronary intervention. We present a case series of the novel single-access for HR-PCI (SHIP) technique, in which a single arterial access is used for both mechanical support and coronary intervention. We reviewed 35 patients from June 2019 to February 2021 in whom the procedure was successfully employed in all but 1 case. In our case series, this technique appeared to be safe and feasible, and none of our patients suffered any major bleeding or vascular complications. As our experience with the procedure grew, we started employing this technique in patients presenting with ST-segment elevation myocardial infarction and cardiogenic shock. We discuss in detail the nuances of the technique, including troubleshooting, procedural characteristics, and complications, and review the currently available literature.

Frailty Among Patients With Acute ST-Elevation Myocardial Infarction in the United States: The Impact of the Primary Percutaneous Coronary Intervention on In-Hospital Outcomes

OBJECTIVES

To determine the average treatment effect (ATE) of primary percutaneous coronary intervention (pPCI) versus medical treatment (MT) on in-hospital outcomes across the spectrum of frailty in patients with ST-elevation myocardial infarction (STEMI).

METHODS

Adult patients hospitalized for STEMI between October 2015 until December 2017 from the National Inpatient Sample (NIS) database were retrospectively analyzed and stratified by the Hospital Frailty Risk Score into low, intermediate, and high frailty risk subgroups. Propensity score matching analysis was performed to estimate the ATE of pPCI in each frailty subgroup. The primary outcome was all-cause in-hospital death.

RESULTS

A total of 429,070 patients were included in the final analysis, with 28.4% at an increased frailty risk. Frail patients were significantly less likely to receive pPCI (85.6%, 47.2%, and 22.6% for low, intermediate, and high frailty risk groups). Rates of adverse in-hospital events including death, cerebrovascular event, and major bleeding were significantly higher in patients with increased frailty risk. pPCI was associated with a significant reduction of in-hospital death in low (-8.0%), intermediate (-14.6%), and high (-14.7%) frailty subgroups, compared to MT (P<.001).

CONCLUSIONS

pPCI was associated with reduced rates of in-hospital death in patients with frailty presenting with STEMI. These findings suggest a benefit of pPCI in this complex patient population, although based on observational data. Long-term effects and safety need to be investigated in future studies.

Subclinical Leaflet Thrombosis After Transcatheter Aortic Valve Replacement: A Meta-Analysis

This meta-analysis and systematic review was performed to evaluate the clinical relevance of subclinical leaflet thrombosis (SLT) following transcatheter aortic valve replacement. PubMed, Web of Science, and CENTRAL were searched for eligible randomized and nonrandomized studies until November 2020. Risk ratios (RRs) or odds ratios and 95% CIs were calculated, using a random-effects model. Overall, 25 studies were eligible for the analysis and comprised a total of 11,098 patients. The median incidence of SLT was 6% at a median follow-up of 30 days. Use of intra-annular valves was associated with 2-fold greater risk for the development of SLT compared with use of supra-annular valves. There was no difference in the risk for SLT (RR: 0.97; 95% CI: 0.72-1.29; P = 0.83) between single-antiplatelet therapy (SAPT) and dual-antiplatelet therapy (DAPT), whereas oral anticoagulation (OAC) was associated with a 58% relative risk reduction for SLT (RR: 0.42; 95% CI: 0.29-0.61; P < 0.00001) compared with SAPT and DAPT. In patients with diagnosed leaflet thrombosis at follow-up, the risk for stroke or transient ischemic attack was increased by 2.6-fold (RR: 2.56; 95% CI: 1.60-4.09; P < 0.00001) compared with patients without leaflet thrombosis. In patients diagnosed with SLT, the odds of SLT resolution increased by 99% after switch from antiplatelet agents to OAC (odds ratio: 0.01; 95% CI: 0.00-0.06; P < 0.00001). To summarize, indication-based use of OAC after transcatheter aortic valve replacement is associated with a lower risk for SLT compared with SAPT and DAPT. Switching to OAC seems to be effective for SLT resolution. As SLT increased the odds of stroke or transient ischemic attack in the included population, further studies are needed to investigate whether screening tests for SLT and appropriate antithrombotic therapy improve long-term valve functionality and clinical prognosis.

Addressing disparities of care in non-ST-segment elevation myocardial infarction patients without standard modifiable risk factors: insights from a nationwide cohort study

AIMS

The importance of standard modifiable cardiovascular risk factors (SMuRFs) in preventing non-ST-segment elevation myocardial infarction (NSTEMI) is established. However, NSTEMI may present in the absence of SMuRFs, and little is known about their outcomes.

METHODS AND RESULTS

We analysed 176 083 adult (≥18 years) hospitalizations with NSTEMI using data from the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP). Clinical characteristics and all-cause in-hospital mortality were analysed according to SMuRF status, with 135 223 patients presenting with at least one of diabetes, hypertension, hypercholesterolaemia, or current smoking status and 40 860 patients without any SMuRFs. Those with a history of coronary artery disease were excluded. Patients without SMuRFs were more frequently older (median age 72 year vs. 71 years, P < 0.001), male (62% vs. 61%, P < 0.001), and Caucasian (95% vs. 92%, P < 0.001). Those without SMuRFs less frequently received statins (71% vs. 81%, P < 0.001), had their left ventricular (LV) function recorded (62% vs. 65%, P < 0.001) or for those with moderate or severe LV systolic dysfunction were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (80% vs. 85%, P < 0.001). Following propensity score matching the odds of all-cause mortality [odds ratio (OR): 0.85, 95% confidence interval (CI): 0.77-0.93], cardiac mortality (OR: 0.85, 95% CI: 0.76-0.94), and major adverse cardiovascular events (MACE) (OR: 0.85, 95% CI: 0.77-0.93) were lower in patients without SMuRFs.

CONCLUSION

More than one in five patients presenting with NSTEMI had no SMuRFs, who were less frequently received guideline-recommended management and had lower in-hospital (all-cause and cardiac) mortality and MACE than patients with SMuRFs.

Social Media as a Tool to Advance Women in Cardiology: Paving the Way for Gender Equality and Diversity

Although the number of women in the field of medicine continues to rise, the discrimination against women and the gender inequity in both leadership roles and salary remains persistent. The gender divide is particularly prominent in male-dominated specialties, such as cardiology. Social media help foster global connections and disseminate information quickly and worldwide. The rise of social media has influenced how female physicians communicate and has shown its benefits particularly within the field of cardiology. Virtual platforms are important avenues where female physicians have united for greater representation of gender issues and advocacy efforts. Social media further amplify gender-equality activism by facilitating the conversations surrounding gender equity and proposing solutions to self-identified issues by the virtual community of female physicians and their allies. In this review, we discuss the role of social media as tools for advancing women in the field of cardiology and fostering gender equality and diversity.

Radial versus femoral access in patients with coronary artery bypass surgery: Frequentist and Bayesian meta-analysis

BACKGROUND

The optimal access site for cardiac catheterization in patients with prior coronary artery bypass surgery (CABG) continues to be debated.

METHODS

We performed a random effects frequentist and Bayesian meta-analysis of 4 randomized trials and 18 observational studies, including 60,192 patients with prior CABG (27,236 in the radial group; 32,956 in the femoral group) that underwent cardiac catheterization. Outcomes included (1) access-site complications, (2) crossover to a different vascular access, (3) procedure time, and (4) contrast volume. Mean differences (MD) and 95% confidence interval (CI) were calculated for continuous outcomes and odds ratios (OR) and 95% CI for binary outcomes.

RESULTS

Among randomized trials, crossover (OR: 7.63; 95% CI: 2.04, 28.51; p = 0.003) was higher in the radial group, while access site complications (OR: 0.96; 95% CI: 0.34, 2.87; p = 0.94) and contrast volume (MD: 15.08; 95% CI: -10.19, 40.35; p = 0.24) were similar. Among observational studies, crossover rates were higher (OR: 5.09; 95% CI: 2.43, 10.65; p < 0.001), while access site complication rates (OR: 0.52; 95% CI: 0.30, 0.89; p = 0.02) and contrast volume (MD: -7.52; 95% CI: -13.14, -1.90 ml; p = 0.009) were lower in the radial group. Bayesian analysis suggested that the odds of a difference existing between radial and femoral are small for all endpoints except crossover to another access site.

CONCLUSION

In a frequentist and Bayesian meta-analysis of patients with prior CABG undergoing coronary catheterization, radial access was associated with lower incidence of vascular access complications and lower contrast volume but also higher crossover rate.

Impact of sex on outcomes of percutaneous coronary intervention for chronic total occlusion: A meta-analysis

BACKGROUND

Women are underrepresented in chronic total occlusion (CTO) trials and little is known about sex differences in the outcomes of CTO percutaneous coronary intervention (PCI). This meta-analysis aims to compare the outcomes of CTO PCI in males and females.

METHODS

A comprehensive search of PubMed, EMBASE, Cochrane, Web of Science, and Google Scholar was performed for studies comparing outcomes of CTO PCI in females versus males from inception to January 26, 2021. The current statistical analysis was performed using STATA version 15.1 software (Stata Corporation, TX); P < 0.05 indicated statistical significance.

RESULTS

Fourteen observational studies were included in the analysis with 75% males and 25% females. The mean age was 64.47 ± 10.5 years and 68.98 ± 9.5 years for males and females, respectively. The median follow-up duration was 2.4 years. Males had a higher Japanese-CTO (J-CTO) score compared with females (MD = -0.17; 95% CI: -0.25 to -0.10). Females had statistically higher success rates of CTO PCI (RR = 1.03; 95% CI: 1.01 to1.05), required less contrast volume (MD = -18.64: 95% CI: -30.89 to -6.39) and fluoroscopy time (MD = -9.12; 95% CI: -16.90 to -1.34) compared with males. There was no statistical difference in in-hospital (RR = 1.50; 95% CI: 0.73 to 3.09) or longer term (≥6 months) all-cause mortality (RR = 1.10; 95% CI: 0.86 to 1.42) between the two groups.

CONCLUSIONS

CTO PCI is feasible and safe in female patients with comparable outcomes in female versus male patients.

Meta-Analysis of Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease

Data comparing outcomes of transradial (TR) versus transfemoral (TF) access for percutaneous coronary intervention (PCI) in chronic kidney disease (CKD) including patients with eGFR< 30 ml/min/1.73m² and patients with end-stage renal disease on dialysis (ESRD) are lacking. This meta-analysis compares the outcomes of TR versus TF approach for PCI in patients with CKD. PubMed, Embase, Cochrane, ClinicalTrials.gov, and Google Scholar were searched for studies including adults with CKD undergoing PCI via a TR versus TF approach from January 1, 2000, until January 15, 2021. The primary outcome was in-hospital all-cause mortality and secondary outcomes included major bleeding, stroke, myocardial infarction (MI), blood transfusion, contrast volume, and fluoroscopy time. The analysis was performed using a random-effects-model using the Mantel-Haenszel method. Five observational studies met inclusion criteria, including 1,156 and 6,156 patients in the TR and TF arms, respectively. The mean age of included patients was 70.5 years, 66% were male and 90% had ESRD. In patients with CKD, TR access for PCI was associated with lower all-cause mortality (RR = 0.48; 95% CI: 0.32 to 0.73), major bleeding (RR = 0.51; 95% CI: 0.36 to 0.73), blood transfusion (RR = 0.53, 95% CI: 0.42 to 0.68) and contrast volume (SMD -0.34 [-0.60 to -0.08]) with no difference in stroke, MI, or fluoroscopy time compared with TF access. In conclusion, in patients with CKD undergoing PCI, the TR approach was associated with a lower risk of in-hospital mortality, post-procedural bleeding, and blood transfusion compared with TF access.

Comparison of Outcomes of Patients With Versus Without Chronic Liver Disease Undergoing Percutaneous Coronary Intervention

There are limited data on the outcomes of chronic liver disease (CLD) patients admitted for percutaneous coronary intervention (PCI). All PCI hospitalizations from the Nationwide Inpatient Sample (2004 to 2015) were analyzed and stratified by the presence, cause and severity of CLD, as well as the indication for PCI. Multivariable logistic regression analysis was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in patients with CLD compared with those without CLD. Among 7,296,679 PCI admissions, 54,368 (0.7%) had a CLD diagnosis. Among patients with CLD, 36,853 (67.8%) had severe CLD. Patients with CLD had higher likelihood of adverse outcomes including major adverse cardiovascular and cerebrovascular events (MACCE) (aOR 1.25, 95%CI 1.20 to 1.30), mortality (aOR 1.43, 95%CI 1.35 to 1.51), major bleeding (aOR 2.22, 95%CI 2.12 to 2.32). When accounting for severity, only severe CLD subgroup was more likely to have MACCE and all-cause mortality compared to no-CLD patients (p <0.001). Among CLD etiologic subgroups, those with 'alcohol-related liver disease' and 'other CLD' were consistently more likely to develop MACCE, all-cause mortality and major bleeding in comparison to no-CLD patients, while 'chronic viral hepatitis' subgroup had only increased odds of major bleeding (p <0.001). In conclusion, CLD patients admitted for PCI are more likely to have worse in-hospital outcomes, particularly in the severe CLD subgroup and 'alcohol-related liver disease' and 'other CLD' etiologic subgroups.

Gender Differences in the Pursuit of Cardiac Electrophysiology Training in North America

BACKGROUND

Despite the increase in the number of female physicians across most specialties within cardiology, <10% of clinical cardiac electrophysiology (EP) fellows are women.

OBJECTIVES

This study sought to determine the factors that influence fellows-in-training (FITs) to pursue EP as a career choice and whether this differs by gender.

METHODS

The authors conducted an online multiple-choice survey through the American College of Cardiology to assess the decision factors that influence FITs in the United States and Canada to pursue cardiovascular subspecialties.

RESULTS

A total of 933 (30.5%) FITs completed the survey; 129 anticipated specializing in EP, 259 in interventional cardiology (IC), and 545 in a different field or were unsure. A total of 1 in 7 (14%) FITs indicated an interest in EP. Of this group, more men chose EP than women (84% vs 16%; P < 0.001). The most important factor that influenced FITs to pursue EP was a strong interest in the field. Women were more likely to be influenced by having a female role model (P = 0.001) compared with men. After excluding FITs interested in IC, women who deselected EP were more likely than men to be influenced by greater interest in another field (P = 0.004), radiation concerns (P = 0.001), lack of female role models (P = 0.001), a perceived "old boys' club" culture (P = 0.001) and discrimination/harassment concerns (P = 0.001).

CONCLUSIONS

Women are more likely than men to be negatively influenced by many factors when it comes to pursuing EP as a career choice. Addressing those factors will help decrease the gender disparity in the field.