Risk factors for percutaneous left ventricular assist device explant complications

INTRODUCTION

Percutaneous left ventricular assist device (pLVAD) explant remains nonstandardized with potential complications of bleeding and thrombosis. Explant settings include percutaneous techniques in the catheterization laboratory (CL), manually at bedside (MB), and surgically in the operating room (OR).

OBJECTIVE

Identify high-risk features for explant-related complications, including indication for support, setting, and technique.

METHODS

Postexplant bleeding and thrombosis/limb ischemia were identified following pLVAD removals over 2 years at a multicenter healthcare system.

RESULTS

Of 156 patients, bleeding (n = 26 [17%]) and thrombosis (n = 9 [6%]) occurred more often in patients with the peripheral arterial disease (PAD), female gender, anemia, and cardiogenic shock. OR explants had a higher combined endpoint (4/8 [50%]) versus CL (23/133 [17%], p < 0.05) driven by transfusion. There was no difference between OR versus MB (5/15 [33%], p = 0.66) or CL versus MB (p = 0.62). In shock patients, there was no difference between CL (7/30 [23%]) versus MB (5/15 [33%], p = 0.5) and OR (4/7 [57%], p = 0.16); or MB versus OR (p = 0.38). Average length of stay was significantly lower in the CL group versus MB and OR (3.6 ± 33.2 vs. 18.4 ± 10.9 vs. 28.1 ± 15.8 days, p < 0.0001). Preclosure in shock patients (5/25 [20%] vs. 11/27 [41%], p = 0.1383) and crossover balloon occlusion technique (9/44 [16%] vs. 25/112 [22%]; p = 1) were not associated with higher combined endpoints versus control.

CONCLUSION

Risk factors for pLVAD explant complications include PAD, female gender, and cardiogenic shock. There was no difference in complication rates between explant settings among cardiogenic shock patients, but shorter length of stay when performed in the CL. There was no difference in complication rates when using the crossover balloon occlusion technique.

Characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock during COVID-19

Objectives

To evaluate characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) during the coronavirus disease 2019 (COVID‐19) pandemic.

Background

The COVID‐19 pandemic has created challenges in delivering acute cardiovascular care. Quality measures and outcomes of patients presenting with AMICS during COVID‐19 in the United States have not been well described.

Methods

We identified 406 patients from the National Cardiogenic Shock Initiative (NCSI) with AMICS and divided them into those presenting before (N = 346, 5/9/2016−2/29/2020) and those presenting during the COVID‐19 pandemic (N = 60, 3/1/2020−11/10/2020). We compared baseline clinical data, admission characteristics, and outcomes.

Results

The median age of the cohort was 64 years, and 23.7% of the group was female. There were no significant differences in age, sex, and medical comorbidities between the two groups. Patients presenting during the pandemic were less likely to be Black compared to those presenting prior. Median door to balloon (90 vs. 88 min, p = 0.38), door to support (88 vs. 78 min, p = 0.13), and the onset of shock to support (74 vs. 62 min, p = 0.15) times were not significantly different between the two groups. Patients presented with ST‐elevation myocardial infarction more often during the COVID‐19 period (95.0% vs. 80.0%, p = 0.005). In adjusted logistic regression models, COVID‐19 period did not significantly associate with survival to discharge (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.54−2.19, p = 0.81) or with 1‐month survival (OR 0.82, 95% CI 0.42−1.61, p = 0.56).

Conclusions

Care of patients presenting with AMICS has remained robust among hospitals participating in the NCSI during the COVID‐19 pandemic.

Outcomes of mechanical circulatory support for acute myocardial infarction complicated by cardiogenic shock

BACKGROUND

Mechanical circulatory support (MCS) with the Impella device (Abiomed, Danvers, MA) has been associated with higher in-hospital mortality than intra-aortic balloon pump (IABP) in the Premier Healthcare Database and National Cardiovascular Data Registry.

METHODS

The objective of this retrospective cohort study was to describe trends and outcomes of Impella usage in acute myocardial infarction complicated by cardiogenic shock (AMICS) treated with MCS (Impella or IABP) using real-world observational data from the National Inpatient Sample (NIS) including hospitalizations for AMICS managed with MCS between January 2012 to December 2017. The primary outcomes included in-hospital mortality, transfusion, acute kidney injury, stroke, total costs, and length of stay. Propensity score matching was performed with hierarchical models using risk factor and Elixhauser comorbidity variables.

RESULTS AND CONCLUSION

We identified 54,480 hospitalizations for AMICS managed with MCS including 5750 (10.5%) utilizing Impella. Throughout the study period, Impella usage increased yearly to 19.9% of AMICS cases in 2017. After propensity score matching, Impella was associated with higher in-hospital mortality (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.41-2.13) and transfusions (OR 1.97, 95% CI 1.40-2.78) than IABP, without association with acute kidney injury or stroke. Impella use was associated with higher hospital costs (mean difference $22,416.80 [95% CI $17,029-27,804]). Impella usage for AMICS increased significantly from 2012 to 2017 and was associated with increased in-hospital mortality and costs. Randomized controlled trials are urgently needed to assess the safety and efficacy of Impella.

Case report: A novel application of the MicroVascular Plug (MVP) in treating distal coronary perforation

Coronary artery perforation during percutaneous coronary intervention (PCI) is a rare but severe complication which has been associated with a high rate of major adverse outcomes and is potentially fatal. We report a case of a 70-year-old male who presented with an anterior ST-elevation myocardial infarction. Coronary angiogram revealed a proximal left anterior descending (LAD) artery occlusion. Successful PCI was performed with stenting of the LAD. However, subsequent attempts to retrieve a jailed diagonal branch inadvertently led to distal coronary perforation of the LAD. After failed attempts to tamponade the perforation with prolonged balloon inflation, this was successfully sealed with the MicroVascular Plug (Medtronic) system. To our knowledge, this is the first reported case of such an application in the coronary system. This may prove to be a viable alternative in closure of distal coronary perforations.

Mechanical circulatory support in acute myocardial infarction and cardiogenic shock: Challenges and importance of randomized control trials

BACKGROUND

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with significant morbidity and mortality.

METHODS

We provide an overview of previously conducted studies on the use of mechanical circulatory support (MCS) devices in the treatment of AMI-CS and difficulties which may be encountered in conducting such trials in the United States.

RESULTS

Well powered randomized control trials are difficult to conduct in a critically ill patient population due to physician preferences, perceived lack of equipoise and challenges obtaining informed consent.

CONCLUSIONS

With growth in utilization of MCS devices in patients with AMI-CS, efforts to perform well-powered, randomized control trials must be undertaken.

A unique cause of coronary obstruction after transcatheter aortic valve replacement

Delayed coronary obstruction is a rare but often fatal complication of transcatheter aortic valve replacement that can present within 24 hr after the transcatheter aortic valve replacement procedure. We present a case of a 77-year-old woman whose distal left main coronary artery bifurcation became obstructed by an embolized piece of native valve leaflet material 16 hours after the uncomplicated transfemoral implantation of an Edwards Sapien Ultra 23 mm aortic valve, which was successfully treated with the simultaneous kissing stent technique.

Diabetes mellitus is independently associated with early stent thrombosis in patients undergoing drug eluting stent implantation: Analysis from the Victorian cardiac outcomes registry

BACKGROUND

Diabetes mellitus (DM) is a predictor of restenosis and late stent thrombosis (ST) in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting-stents (DES). Real-world data on rates of early ST is lacking. We compared clinical outcomes of patients with and without DM from the Victorian cardiac outcomes registry.

METHODS

Consecutive patients undergoing PCI with DES were analyzed with primary outcome being ST at 30-days. Secondary outcomes including major adverse cardiovascular events (MACE) and all-cause mortality.

RESULTS

Of 43,209 patients included, 9730 (22.5%) had DM. At 30 days, DM was independently associated with higher rates of early ST (0.7% vs. 0.5%) OR 1.41 (95% confidence interval; 1.05-1.87, p = 0.02), MACE (4.1% vs. 3.5%, p = 0.004) and mortality (1.9% vs. 1.5%, p = 0.01). Increased risk was not simply due to treatment. Patients with DM requiring insulin were equally affected in regard to MACE (4.7% vs. 3.9%, p = 0.069) and mortality (1.9%, vs. 1.8%, p = 0.746). On National Death Index linkage, patients with DM had increased all-cause mortality over five-year follow-up (OR 1.69 CI 1.55-1.83, p = < 0.001).

CONCLUSION

In this large real-world-registry, DM was an independent predictor of early ST, MACE and mortality at 30 days. These data suggest additional therapeutic strategies are required to reduce the risk of early complications in patients with DM undergoing PCI with DES.

Incidence, treatment, and outcomes of acute myocardial infarction following transcatheter or surgical aortic valve replacement

OBJECTIVES

This study aimed to evaluate the incidence, treatment, and outcomes of acute myocardial infarction (AMI) following transcatheter or surgical aortic valve replacement (TAVR or SAVR).

BACKGROUND

Coronary artery disease is common in patients who undergo aortic valve replacement. However, little is known about differences in clinical features of post-TAVR or post-SAVR AMI.

METHODS

We retrospectively identified post-TAVR or post-SAVR (including isolated and complex SAVR) patients admitted with AMI using the Nationwide Readmissions Database 2012-2017. Incidence, invasive strategy (coronary angiography or revascularization), and in-hospital outcomes were compared between post-TAVR and post-SAVR AMIs.

RESULTS

The incidence of 180-day AMI was higher post-TAVR than post-SAVR (1.59% vs. 0.72%; p < 0.001). Post-TAVR AMI patients (n = 1315), compared with post-SAVR AMI patients (n = 1344), were older, had more comorbidities and more frequent non-ST-elevation AMI (NSTEMI: 86.6% vs. 78.0%; p < 0.001). After propensity-score matching, there was no significant difference in in-hospital mortality between post-TAVR and post-SAVR AMIs (14.7% vs. 16.1%; p = 0.531), but the mortality was high in both groups, particularly in ST-elevation AMI (STEMI: 38.8% vs. 29.2%; p = 0.153). Invasive strategy was used less frequently for post-TAVR AMI than post-SAVR AMI (25.6% vs. 38.3%; p < 0.001). Invasive strategy was associated with lower mortality in both post-TAVR (adjusted odds ratio = 0.40; 95% confidence interval = [0.24-0.66]) and post-SAVR groups (0.60 [0.41-0.88]).

CONCLUSIONS

AMI, albeit uncommon, was more frequent post-TAVR than post-SAVR. Patients commonly presented with NSTEMI, but the mortality of STEMI was markedly high. Further studies are needed to understand why a substantial percentage of patients do not receive invasive coronary treatment, particularly after TAVR, despite seemingly better outcomes with invasive strategy.

Improvement of symptoms and coronary perfusion gradient with mechanical left ventricular unloading in flow-limiting complex spontaneous coronary artery dissection, without revascularization

Spontaneous coronary artery dissection (SCAD) can lead to acute coronary syndrome and sudden cardiac death, particularly in young women. Observational data show that, in SCAD patients, both percutaneous coronary intervention and coronary artery bypass grafting seem to be hampered by higher technical complexity, lower success rates, and worse outcomes. As spontaneous healing is a common occurrence, expert consensus advices medical management of the acute phase, when feasible. We present the case of a young woman with SCAD of left anterior descending artery causing myocardial infarction with ST-segment elevation. High-anatomical complexity and unstable conditions of the patient made both medical management and immediate revascularization unfeasible options. Therefore, we decided to implant a percutaneous off-loading mechanical support device to improve coronary perfusion pressure by unloading the left ventricle and preserve cardiac function, preventing worse complications of acute myocardial infarction. This strategy was successful in stabilizing the patient, until the definitive revascularization treatment became an option.

Colossal left main to right atrium fistula ligation complicated by left circumflex STEMI

Congenital left main (LM) coronary artery to right atrium fistulas with progression to aneurysm development are rare. Most patients remain asymptomatic, but for those with progressive symptoms, intervention is required. However, there are potential life-threatening complications associated with surgical intervention. We present a case of an extremely rare markedly aneurysmal LM to right atrial fistula treated with surgical ligation complicated by inferolateral ST-elevation myocardial infarction several days post-operatively treated successfully using mechanical aspiration thrombectomy, a stent-retriever, balloon angioplasty, and subsequent intravascular ultrasound-guided percutaneous coronary intervention with drug-eluting stent.

Remote robotic percutaneous coronary intervention: An animal feasibility study

OBJECTIVES

The purpose of this study was to explore the feasibility and safety of robotic PCI performed using an off-siteremote-control system in an animal model.

BACKGROUND

Access to primary percutaneous coronary intervention (PCI) remains a challenge in acute myocardial infarction management. The combination of telemedicine and robotic PCI allow the potential delivery of primary PCI to remote locations without the delay of transfer.

METHODS

This single-center prospective pilot preclinical feasibility study compared robotic PCI with remote PCI on swine across three stages (adjacent room, different floor of the same building, two different buildings). Latency up to 1,000 ms was introduced into the operating environment to simulate decreased network quality (blinded to operator). The primary outcome measures were technical success and acute safety. The secondary outcome measures included lesion wiring time, procedural time and qualitative scoring of the PCI experience by the operator.

RESULTS

Across 52 experiments in 15 animals, technical success was 100%. No procedural complications occurred during the study. No significant difference in lesion treatment time was detected between stages (p = .11) and between time per target vessel when latency up to 1,000 ms was introduced (p = .58). Injected delay >250 ms had the greatest impact on procedure perceived lag. Longer procedure time was associated with lower procedure impact score, regardless of injected latency.

CONCLUSIONS

Remote robotic PCI was feasible and safe in an animal model. Procedural duration was acceptable and unaffected by network latency. Future studies are needed to determine the safety and feasibility of remote PCI in humans.

SARS-COV-2 infection presenting as ST-elevationmyocardial infarction

We describe a patient presenting with chest discomfort, anterolateral ST elevation, and developing acute cardiogenic shock secondary to SARS-COV-2infection-patient zero presenting to our institution's cardiac catheterization laboratory. The emergent presentation with limited clinical information led to exposure of personnel. The diagnosis was complicated by two negative tests for SARS-COV-2, and high-clinical suspicion from the patient's occupational history led to additional testing in order to confirm the diagnosis.

Outcome of left main stem percutaneous coronary intervention in a UK nonsurgical center: A 5-year clinical experience

OBJECTIVES

To evaluate the outcome of unprotected left main stem (LMS) percutaneous coronary intervention (PCI) in a large UK nonsurgical center.

BACKGROUND

PCI on unprotected LMS is increasingly regarded as a viable alternative to coronary artery bypass grafting (CABG) with comparable outcome and safety profile in select groups. The safety and efficacy of unprotected LMS PCI without on-site surgical back up has not been reported.

METHODS

Data on all unprotected LMS PCI performed between January 2011 and December 2015, was collected from the local PCI database and electronic patient records. In hospital and 1-year major adverse cardiovascular events (MACE) (all-cause mortality, myocardial infarction [MI], stroke, and target vessel revascularization [TVR]) was recorded.

RESULTS

249 patients had unprotected LMS intervention during the study period. 77% of patients (n = 192) were male and mean age was 70 ± 12 years. 31% (n = 78) of cases were elective, 44% (n = 109) NSTEMI, and 25% (n = 62) STEMI. Anatomical distribution: 19% (n = 47) ostial left main, 31% (n = 77) shaft, and 50% (n = 125) bifurcation. The mean SYNTAX score was 24.4 ± 10.6. 22% (n = 55) of patients had severe LV impairment preprocedure and 13% (n = 33) were in cardiogenic shock at presentation. 35% (14%) required IABP support. The vast majority (98.4%) of procedures were successful. No patients required emergency transfer for CABG surgery. There were 25 (10%) in-hospital deaths. 68% of in-hospital deaths occurred in patients undergoing primary PCI for STEMI. 72% of patients who died were in cardiogenic shock at presentation. The 12-month MACE rate was 17.2%. Death occurred in 11.6%, MI in 2.4%, TVR in 2.4%, and stroke in 0.8% of patients.

CONCLUSION

These results highlight the safety and efficacy of unprotected LMS PCI in a high volume non-surgical center.

Post hoc closure of large bore vascular access using the MANTA closure device

Successful closure of large bore vascular access (≥12 Fr) is facilitated by the MANTA vascular closure device; however, it requires a critical first step of measuring "skin to arterial wall" depth of the access site using the depth locator before dilating the vessel above 8 Fr. It may be challenging at times to acquire the deployment depth at the onset of the procedure due to case urgency, delayed closure, or when large bore access is obtained at a different institution. We discuss a novel technique of measuring the deployment depth and successful delayed closure of large bore arterial access using the MANTA closure device.

Five-year follow-up of patients who underwent everolimus-eluting bioresorbable scaffold implantation

OBJECTIVES

The aim of this study was to evaluate very long-term results after unrestricted everolimus-eluting bioresorbable scaffolds (BRS) implantation.

BACKGROUND

Previous randomized studies mainly included selected patients differing from those seen during daily routine and long-term data from all-comers registries are sparse.

METHODS

Consecutive patients undergoing BRS implantation were included in this observational, single center study. Clinical follow-up was conducted up to 5 years. Endpoint of interest was the composite of target lesion failure (TLF), including target-vessel myocardial infarction and target lesion revascularization and cardiac death. Furthermore, ARC-defined scaffold thrombosis (ScT) were assessed.

RESULTS

A total of 176 patients with a median age of 64 (55 - 72) years were analyzed, of which 59.6% presented an acute coronary syndrome. A total of 183 mainly complex lesions (55.8%) were treated. At 5 years, the rate for TLF was 21.6%. Definite or probable ScT rate was 4.1%. The rate of ScT within the first year was 2.8% and afterwards 1.2%. Notably, no ScT was seen later than 2 years.

CONCLUSIONS

Although this real-world registry displays high rates of clinical events during long-term follow-up, no ScT was seen after 2 years.

Adverse impact of chronic kidney disease on clinical outcomes following percutaneous coronary intervention

AIMS

We aimed to assess the impact of the severity of chronic kidney disease (CKD) with long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI).

METHODS

We analyzed data on consecutive patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR) from January 2014 to December 2018. Patients were stratified into tertiles of renal function; estimated glomerular filtration (eGFR) ≥60, 30-59 and < 30 ml/min/1.73 m² (including dialysis). The primary outcome was long-term all-cause mortality obtained from linkage with the Australian National Death Index (NDI). The secondary endpoint was a composite of 30 day major adverse cardiac and cerebrovascular events.

RESULTS

We identified a total of 51,480 patients (eGFR ≥60, n = 40,534; eGFR 30-59, n = 9,521; eGFR <30, n = 1,425). Compared with patients whose eGFR was ≥60, those with eGFR 30-59 and eGFR<30 were on average older (77 and 78 vs. 63 years) and had a greater burden of cardiovascular risk factors. Worsening CKD severity was independently associated with greater adjusted risk of long-term NDI mortality: eGFR<30 hazard ratio 4.21 (CI 3.7-4.8) and eGFR 30-59; 1.8 (CI 1.7-2.0), when compared to eGFR ≥60, all p < .001.

CONCLUSION

In this large, multicentre PCI registry, severity of CKD was associated with increased risk of all-cause mortality underscoring the high-risk nature of this patient cohort.

The benefit of complete revascularization after primary PCI for STEMI is attenuated by increasing age: Results from the DANAMI-3-PRIMULTI randomized study

OBJECTIVES

To ascertain the effect of age on outcomes after culprit-only and complete revascularization after Primary PCI (PPCI) for ST-elevation myocardial infarction (STEMI).

BACKGROUND

The numbers of older patients being treated with PPCI are increasing. The optimal management of nonculprit stenoses in such patients is unclear.

METHODS

We conducted an analysis of patients aged ≥75 years randomized in the DANAMI-3-PRIMULTI study to either culprit-only or complete FFR-guided revascularization. The primary endpoint was a composite of all-cause mortality, nonfatal reinfarction, and ischaemia-driven revascularization of lesions in noninfarct-related arteries after a median of 27 months of follow-up.

RESULTS

One hundred and ten of six hundred and twenty seven patients in the DANAMI-3-PRIMULTI trial were aged ≥75 years. These patients were more likely female (p < .001), hypertensive (p < .001), had lower hemoglobin levels (p < .001), and higher serum creatinine levels (p < .001) than the younger patients in the trial. Other than less use of drug-eluting stents (96.6 versus 88.0%: p = .02), there were no significant differences in procedural technique and success between patients aged <75 years and those ≥75 years of age. There was no significant difference in the incidence of the primary endpoint in patients ≥75 years randomized to culprit-only or FFR-guided complete revascularization (HR 1.49 [95% CI 0.57-4.65]; log-rank p = .19; p for interaction versus patients <75 years <.001). There was a significant interaction between age as a continuous variable, treatment assignment, and the primary outcome (p < .001); beyond the age of about 75 years, there may be no prognostic advantage to complete revascularization.

CONCLUSIONS

In patients ≥75 years, after treatment of the culprit lesion in STEMI, there is no significant prognostic benefit to prophylactic complete revascularization of nonculprit stenoses. Pending further study, data would support a symptom-guided approach to further invasive treatment.

Impact of coronavirus disease 2019 (COVID-19) outbreak on outcome of myocardial infarction in Hong Kong, China

Objective

To determine whether COVID‐19 may adversely affect outcome of myocardial infarction (MI) patients in Hong Kong, China.

Background

The COVID‐19 pandemic has infected thousands of people and placed enormous stress on healthcare system. Apart from being an infectious disease, it may affect human behavior and healthcare resource allocation which potentially cause treatment delay in MI.

Methods

This was a single center cross‐sectional observational study. From November 1, 2019 to March 31, 2020, we compared outcome of patients admitted for acute ST‐elevation MI (STEMI) and non‐ST elevation MI (NSTEMI) before (group 1) and after (group 2) January 25, 2020 which was the date when Hong Kong hospitals launched emergency response measures to combat COVID‐19.

Results

There was a reduction in daily emergency room attendance since January 25, 2020 (group 1,327/day vs. group 2,231/day) and 149 patients with diagnosis of MI were included into analysis (group 1 N = 85 vs. group 2 N = 64). For STEMI, patients in group 2 tended to have longer symptom‐to‐first medical contact time and more presented out of revascularization window (group 1 27.8 vs. group 2 33%). The primary composite outcome of in‐hospital death, cardiogenic shock, sustained ventricular tachycardia or fibrillation (VT/VF) and use of mechanical circulatory support (MCS) was significantly worse in group 2 (14.1 vs. 29.7%, p = .02).

Conclusions

More MI patients during COVID‐19 outbreak had complicated in‐hospital course and worse outcomes. Besides direct infectious complications, cardiology community has to acknowledge the indirect effect of communicable disease on our patients and system of care.

Management of ST-segment-elevation myocardial infarction during the coronavirus disease 2019 (COVID-19) outbreak: Iranian"247" National Committee's position paper on primary percutaneous coronary intervention

World Health Organization has designated coronavirus disease 2019 (COVID‐19) as a pandemic. During the past several weeks, a considerable burden has been imposed on the Iranian's healthcare system. The present document reviewed the latest evidence and expert opinion regarding the management of ST‐segment‐elevation myocardial infarction during the outbreak of COVID‐19 and outlines a practical algorithm for it.

Outcomes of cardiogenic shock complicating acute coronary syndromes

OBJECTIVES

We aimed to assess the outcomes of cardiogenic shock (CS) complicating acute coronary syndromes (ACS).

BACKGROUND

CS remains the leading cause of mortality in patients presenting with ACS despite advances in care.

METHODS

We studied 13,184 patients undergoing percutaneous coronary intervention (PCI) for all subtypes of ACS enrolled prospectively in a large multicentre Australian registry (Melbourne Interventional Group registry) from 2005 to 2013. All-cause mortality was obtained via linkage to the National Death Index. Patients were divided into those with and those without CS.

RESULTS

Compared to the non-CS group (n = 12,548, 95.2%), the CS group (n = 636, 4.8%) had a higher proportion of out-of-hospital cardiac arrest (OHCA) (31.1 vs. 2.2%) and ST-elevation myocardial infarction (STEMI) presentation (89 vs. 34%), both p < .01. Patients in the CS group had higher rates of in-hospital (40.4 vs. 1.2%) and 30-day (41 vs. 1.7%) mortality compared to the non-CS group. Long-term mortality over a median follow-up of 4.2 years was higher in the CS group (50.6 vs. 13.8%), p < .001. Trends of in-hospital and 30-day mortality rates of CS complicating ACS were relatively stable from 2005 to 2013. Predictors of long-term NDI-linked mortality within the CS group include severe left ventricular systolic dysfunction (HR 3.0), glomerular filtration rate (GFR) <30 (HR 2.56), GFR 30-59 (HR 1.94), OHCA (HR 1.46), diabetes (HR 1.44), and age (HR 1.02), all p < .05.

CONCLUSIONS

Rates of CS-related mortality complicating ACS have remained very high and steady over nearly a decade despite progress in STEMI systems of care, PCI techniques, and medical therapy.

Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative

BACKGROUND

The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI).

METHODS

Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the "SHOCK" trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS.

RESULTS

A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12-24 hr reliably predicted overall mortality postindex procedure.

CONCLUSION

In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.

Comparison of short-term clinical outcomes of proximal versus nonproximal lesion location in patients treated with primary percutaneous coronary intervention for ST-elevation myocardial infarction: The PROXIMITI study

OBJECTIVES

The objective of this study was to investigate the association of proximal and nonproximal location of culprit coronary lesions with clinical outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI).

BACKGROUND

Proximal culprit lesion location in patients presenting with STEMI is associated with increased mortality when compared to distal culprit lesions in the thrombolytic era. The impact of lesion location on clinical outcomes in the era of PCI remains unclear.

METHODS

We analyzed 3,283 patients with STEMI who enrolled in the Victorian Cardiac Outcomes Registry. We compared outcomes in those with proximal lesion location versus patients with nonproximal location.

RESULTS

Of 3,283 participants, 1,376 (41.9%) had a proximal lesion location. Patients with proximal lesion location presented with greater rates of cardiogenic shock and out-of-hospital cardiac arrest, and left ventricular systolic dysfunction, all P < .01. Procedural success rates were similar (96% vs. 95%, P = .08). Patients with proximal lesion location had higher rates of in-hospital and 30-day mortality, major adverse cardiac events (MACE; mortality, myocardial infarction, stent thrombosis, and unplanned revascularization) and major adverse cardiac and cerebrovascular events (MACCE; MACE, and stroke) compared to the nonproximal group, all P < .001. However, on multivariable regression analysis, proximal lesion location was not independently associated with MACE during in-hospital stay or at 30-days (OR 1.32, 95% CI 0.95-1.83, P = .09 and OR 1.23, 95% CI 0.92-1.65, P = .15) respectively.

CONCLUSIONS

Patients with proximal lesion location had greater hemodynamic instability and higher-risk features; however, proximal lesions per se were not independently associated with worse clinical outcomes compared to nonproximal lesions.

Acute, total occlusion of the left main stem: coronary intervention options, outcomes, and recommendations

Introduction

Acute, total occlusion of the unprotected left main stem (uLMo) in acute coronary syndrome (ACS) patients is a catastrophic event often accompanied by sudden cardiac death (SCD) and/or cardiogenic shock (CS) with high mortality rates and limited methods of successful treatment. Emergent, surgical and percutaneous revascularization has been reported before, yet comprehensive data remains scarce.

Aim

To examine emergency percutaneous coronary intervention (PCI) outcomes in ACS cases presenting with uLMo.

Material and methods

Data on 23 subjects undergoing primary PCI in uLMo cases were analyzed. The primary end-point was in-hospital death; secondary end-points were successful salvage of coronary anatomy and 90-day major cardiac adverse events (MACE).

Results

About 40% of LM occlusion cases presented following successful on-site cardio-pulmonary resuscitation (CPR). Of all patients arriving for treatment the occluded LM was successfully opened and stented in ~90% of cases. CS was present in > 85% of cases, and circulatory support in the form of intra-aortic balloon pump and/or extracorporeal membrane oxygenation systems was applied in every eligible case (~80%). The in-hospital death rate was 56%, mostly including individuals requiring prior CPR. At 6 months, additional MACE rates were low at 8.7%.

Conclusions

We found that uLMo ACS cases often present with preceding CPR and mostly in manifest CS. Coronary salvage is generally successful, yet uLMo even with optimal present day complex treatment yields quite high mortality rates. This is especially true for patients receiving prior CPR. In surviving patients, however, 6-month MACE rates are acceptable.

A method for maintaining vascular access when Impella exchange is required

A 45-year old male with no prior cardiac history, presented with cardiogenic shock in the setting of an anterolateral ST elevation myocardial infarction. We first placed a 2.5 Impella for hemodynamic support, and proceeded with emergent percutaneous coronary intervention to the proximal LAD. Several hours following percutaneous coronary intervention (PCI), the patient became acutely hypotensive and an echocardiogram revealed the Impella catheter was kinked within the left ventricle. The patient was taken back to the cath lab for Impella adjustment; however, damage to the distal catheter required the Impella be exchanged. As the patient was therapeutically anticoagulated and on dual antiplatelet therapy, we modified the Impella catheter in order to maintain existing vascular access during Impella exchange. This case demonstrates our method for maintaining vascular access during Impella exchange, thereby eliminating the need for a second arterial puncture. © 2017 Wiley Periodicals, Inc.

Late subannular aortic root rupture following transcatheter aortic valve implantation presenting as ST elevation myocardial infarction

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis. Here, we present a case of late aortic root rupture presenting as ST-elevation myocardial infarction five weeks following successful TAVI. Aortic root rupture is a rare complication of TAVI, which occurs in ∼1% of procedures and usually arises during or soon after the procedure and is associated with high mortality (∼50%). Early recognition of late-presenting complications related to TAVI, including aortic root rupture, is essential for specialists and nonspecialists. © 2016 Wiley Periodicals, Inc.