Coronary air embolism: incidence, severity, and suggested approaches to treatment

Because no well-controlled study of inadvertent coronary air embolism has been done to truly quantify the incidence of this cardiac catheterization complication, we wanted to determine its incidence and severity in an active teaching medical center and assess approaches to treatment. We retrospectively reviewed 3,715 coronary angiogram and PTCA reports performed over 32 months. Further, we classified severity based on angiographic findings and symptoms as minimal, mild, moderate, and massive. Two independent angiographers reviewed 764 consecutive cines performed in the first 2 months of training of each new fellow and 740 cines performed in the last 2 months of training. We found that during the first 2 months of training the overall incidence for significant intracoronary air embolism was 0.19% (7 documented cases) compared with 0.2% (3 cases) for non-reported, minimal asymptomatic air embolism. The estimated incidence for total air emboli events was 0.27% (10/3,715). We did not find coronary air emboli in the 740 cines performed at the end of fellowship training. Additionally, the incidence of coronary air emboli during PTCA training was much higher compared with coronary angiography training (0.84 vs. 0.24%). Although there is no best technique to restore blood flow after blockage by air emboli, we suggest as options aspirating the air or forcefully injecting saline, with auxiliary supportive measures like 100% oxygen, IABP, CPR, and DC cardioversion.

Carotid stenting in patients older than 65 years with inoperable carotid artery disease: a single-center experience

Carotid angioplasty and stenting to treat extracranial carotid stenosis is an alternative (as yet not widely accepted) to high-risk surgery, but its safety and efficacy are little known, especially in elderly patients. We reviewed our 3-year experience of treating 100 elderly patients (> 65 years old) considered to be inoperable (76 men, 24 women, mean age 76+/-10 years, mean follow-up 18+/-9.2 months) and present two case histories. Most (85%) were symptomatic (transient ischemic attacks in 60, stroke in 25); 80 had concomitant coronary artery disease (severe in 30 [defined by > 70% stenosis in two or more epicardial coronary arteries or the left main coronary artery]) and 25 had severe left ventricular dysfunction (ejection fraction < or =20%). The procedure was technically successful in all patients; there was one major stroke and no patient died. Postprocedure, 15% had minor complications: reversible neurological deficit (5%), pulmonary edema (3%), prolonged hypotension (3%), vascular access complications (3%), and neck hematoma (1%). Over 90% of patients were discharged home within 24 hr.

Amniotic fluid embolism causing severe left ventricular dysfunction and death: case report and review of the literature

Hemodynamic instability in amniotic fluid embolism has previously been demonstrated only by right heart catheterization. We present detailed documentation obtained by echocardiography and cardiac catheterization of a 35-year-old woman who developed amniotic fluid embolism and died from severe left ventricular dysfunction and wide QRS complex tachycardia despite intensive medical therapy (inotropes) and mechanical (intraaortic balloon pump) support.

A prospective, controlled study of Helicobacter pylori seroprevalence in coronary artery disease

OBJECTIVE

Recent studies have suggested that chronic infections may be a risk factor for coronary artery disease. The aim of this study was to determine whether Helicobacter pylori (H. pylori) infection was an independent risk factor for coronary artery disease.

METHODS

A total of 179 patients undergoing coronary angiography for suspected coronary artery disease were prospectively studied. Angiograms were read by experienced invasive cardiologists blinded to the results of H. pylori serology, which was determined by a validated multiwell ELISA assay.

RESULTS

A total of 121 patients (68%) had evidence of coronary artery disease, whereas 58 patients (32%) had normal coronary angiograms. Of the 121 patients with coronary artery disease, 29 had single vessel disease, 39 had double vessel disease, and 53 had triple vessel disease, respectively. There was no significant difference in seroprevalence of H. pylori infection in patients with and without coronary artery disease (p = 0.63). The odds ratio (after adjustment for other known risk factors) for coronary artery disease in H. pylori-infected subjects was 0.45 (95% CI = 0.15, 1.37; p = 0.107). In patients with coronary artery disease, H. pylori infection did not increase the likelihood of severe disease (odds ratio for triple vessel disease = 0.53; 95% CI 0.18, 1.60; p = 0.201).

CONCLUSION

H. pylori infection rates are similar in patients with normal and abnormal coronary arteries, and infection with H. pylori is not an independent risk factor for coronary artery disease. In patients who have coronary artery disease, H. pylori infection is not a risk factor for more severe disease. These data argue against a causal role for H. pylori in the pathogenesis of coronary artery disease.

Congenital clavicular pseudoarthrosis associated with vascular thoracic outlet syndrome: case presentation and review of the literature

Thoracic outlet syndrome (TOS) associated with congenital clavicular pseudoarthrosis is rare in adults and often misdiagnosed. In this case report, we describe an adult female who was found to have thrombosis of the subclavian and axillary arteries with embolization documented by invasive angiography. This unusual vascular manifestation of TOS should remind physicians that anatomic derangements may predispose to upper extremity ischemia.

Validation of Doppler FloWire for measurement of coronary flow reserve in humans

Previous studies have validated the 133Xenon (133Xe) method to assess regional myocardial blood flow and coronary flow reserve (CFR). Doppler FloWire (DFW) has been used recently for measuring CFR to assess the physiological significance of coronary stenosis. Data obtained by DFW has never been correlated to 133Xe. Our study compared data from DFW measurement of CFR to that obtained by 133Xe in 31 consecutive patients with variable coronary stenosis. Regional myocardial blood flow was measured by assessing the rate constants of 133Xe washout using multicrystal gamma camera after injection (20 millicuries) in the right or left coronary artery. CFR was assessed by measuring resting and hyperemic coronary blood flow by 133Xe and DFW using i.v. adenosine (140 mcg/k/min x 3 min). CFR was also measured by DFW giving intracoronary (i.c.) adenosine (12 microg in the right coronary, 18 microg in the left). In both methods--133Xe and DFW--coronary flow reserve was defined as the ratio of maximal hyperemic-to-baseline flow. DFW and 133Xe assessment of CFR correlated highly, whether adenosine was used i.c.(r=0.87; P=0.0001) or i.v.(r=0.78; P=0.0001). CFR obtained by DFW following i.c. and i.v. adenosine correlated well (r=0.79; P=0.0001). i.c. adenosine has fewer side effects. Both DFW and 133Xe are comparable in measuring CFR in humans.

P1854Clinical implications of physical function and resilience in patients undergoing transcatheter aortic valve implantation

Background

Gait speed, as a measure of physical function and marker of frailty, is now routinely screened when evaluating patients with aortic stenosis (AS) for transcatheter aortic valve implantation (TAVI). Assessment of physical function is important to identify patients for whom TAVI may be futile and to assign patients to a procedural risk category. After TAVI, patients may exhibit physical resilience (improvement in physical function) or vulnerability (worsening). Characterizing the trajectory and clinical consequences of physical function after TAVI represent knowledge gaps in the field.

Purpose

Evaluate associations between physical resilience (improved gait speed) vs vulnerability (decline) after TAVI and subsequent death/hospitalization.

Methods

The REPRISE III trial compared a mechanically-expanded vs a self-expanding valve in 912 high/extreme risk patients with symptomatic AS. Patients (n=587) who underwent valve implantation and who had a gait speed recorded both pre- and 1-year post-TAVI were analyzed. Gait speed is based on the 5m walk test (slow: 5m in >6s, <0.83m/s; normal: ≥0.83m/s). Trajectory of physical function after TAVI was characterized in 2 ways. Model 1 examined 4 groups based on slow or normal gait speeds at baseline and 1-year post-TAVI. Model 2 examined gait speed change pre-TAVI to 1 year (adjusted for baseline gait speed). Using a landmark approach, the relationships between baseline and 1-year gait speed were evaluated in multivariable Cox PH models of outcomes between 1 and 2 years post-TAVI.

Results

A clinically-meaningful improvement (≥0.1m/s), no change (±0.1m/s), or decline (≥0.1/ms) in gait speed 1 year after TAVI was observed in 39%, 36%, and 26% of patients, respectively. Among the 4 groups defined by pre- and 1-year post-TAVI gait speeds, 1 to 2 year mortality or hospitalization rates were: 6.6% (normal/normal), 20.9% (normal/slow), 8.0% (slow/normal), and 21.5% (slow/slow). Adjusted hazard ratios of the 2 models are shown (Table).

Table. Outcome by Change in Gait Speed Death/Hospitalization P-value Death P-value Hospitalization P-value Adjusted HR [95% CI] Adjusted HR [95% CI] Adjusted HR [95% CI] Model 1: Baseline/1 year Gait Speed   (Normal/Normal (n=150) [referent])   Normal/Slow (n=59) 3.82 [1.61, 9.08] <0.01 2.75 [0.96, 7.86] 0.06 7.31 [1.94, 27.58] <0.01   Slow/Normal (n=114) 1.39 [0.53, 3.59] 0.50 1.44 [0.50, 4.12] 0.50 1.69 [0.38, 7.60] 0.49   Slow/Slow (n=253) 3.88 [1.91, 7.91] <0.01 2.36 [1.02, 5.46] 0.045 3.89 [1.14, 13.27] 0.03 Model 2: Gait speed change   Baseline to 1 year per 0.1m/s increase 0.83 [0.74, 0.92] <0.01 0.92 [0.80, 1.04] 0.19 0.75 [0.64, 0.88] <0.01

Conclusion

These data reveal there is marked heterogeneity in the trajectory of physical function after TAVI and that this trajectory–more so than baseline physical function–is clinically consequential. Identifying and optimizing factors associated with physical resilience after TAVI may improve outcomes.

Acknowledgement/Funding

Boston Scientific

Hemophagocytic Lymphohistiocytosis (HLH) Flare Following the COVID-19 Vaccine: A Case Report

Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory state that leads to overactivation of the immune system due to underlying disease. It can lead to multiorgan failure and death if not treated properly. HLH after vaccination is rare but has been reported in a few cases. Here, we present a case of a patient who developed HLH after she received the COVID-19 vaccine. Workup was done to find the underlying cause of her symptoms. However, as all investigations yielded negative results, the close temporal association with the COVID-19 vaccine suggested that the vaccine might have been the causative factor. She was treated appropriately with steroids and discharged with follow-up appointments. The exact pathogenesis of HLH caused by COVID vaccine is unknown, but it is likely related to the inflammatory response caused by the vaccine in the body. The treatment of HLH depends on the treatment of underlying conditions causing the HLH. Very few cases have been reported in the literature regarding HLH caused by COVID vaccine. Immediate recognition and treatment are imperative for improved prognosis and improved chances of survival.

Impact of COVID-19 lockdowns on STEMI percutaneous interventions

Background

Measures taken to mitigate the spread of coronavirus disease 2019 (COVID-19) have been correlated to a decline in the number of patients seeking medical care for emergency cardiovascular illness. Here we evaluate the impact of a state-wide lockdown on ST-elevation myocardial infarction (STEMI) care.

Purpose

The purpose of this study is to help understand the impact of COVID-related lockdowns on STEMI interventions.

Methods

All consecutive adult patients admitted with an acute STEMI diagnosis and percutaneous intervention (PCI) performed between January 17, 2020, and July 14, 2020, at five sites across our health care network, were included in this study. Patient demographics, medical history and procedure details were collected retrospectively from electronic medical records. Data were segregated according to date into pre-lockdown, lockdown (March 17 to May 13, 2020) and post-lockdown groups.

Results

A total of 225 patients formed the study cohort. Median age was 62 (IQR: 53–71) years. Patients were predominantly male (n=154, 68%), white (n=208, 92%), hypertensive (n=139, 61%) and dyslipidemic (n=135, 60%). The average weekly rate of STEMI PCIs performed pre-lockdown decreased by 40% during the lockdown from 10.9 to 6.5 PCIs per week (p&lt;0.05). Door-to-balloon (D2B) times increased from 42 (IQR: 28–68) min pre-lockdown to 53 (IQR: 40–72) min during the lockdown (p=0.01). No significant differences were observed in in-hospital mortality or cardiac troponin measurements within 24 h of procedure between the three groups.

Conclusion

Adverse effects of COVID-19-related lockdowns on acute STEMI care include a decrease in PCI volumes and prolonged D2B times. Our results provide valuable data-driven criteria to help inform patient decisions to seek care and to find ways to protect healthcare workers without compromising timely critical intervention.

Funding Acknowledgement

Type of funding sources: None.