Abdul Moiz Hafiz

Prevention of contrast-induced acute kidney injury in patients with stable chronic renal disease undergoing elective percutaneous coronary and peripheral interventions: Randomized comparison of two preventive strategies†

Objective: We compared use of intravenous (IV) normal saline (NS) to sodium bicarbonate (NaHCO3) with or without oral N‐acetylcysteine (NAC) for prevention of contrast‐induced acute kidney injury (CI‐AKI). Background: CI‐AKI is associated with significant adverse clinical events. Use of NAC has produced variable results. Recently, intravenous hydration with NaHCO3 for CI‐AKI prophylaxis has been adopted as standard treatment for patients with stable chronic renal disease undergoing catheterization procedures. Methods: We prospectively enrolled 320 patients with baseline renal insufficiency scheduled to undergo catheterization. Patients were randomly assigned to receive either IV NS ± NAC (n = 161) or IV dextrose 5% in water containing 154 mEq/l of NaHCO3 ± NAC (n = 159). IV NS was administered at 1 ml/kg body weight for 12 hr preprocedure and 12 more hr postprocedure. IV NaHCO3 was administered at 3 ml/kg body weight for 1 hr preprocedure followed by 1 ml/kg body weight postprocedure. A 1,200 mg oral dose of NAC was given 2–12 hr preprocedure and 6–12 hr postprocedure in 50% of patients in each study arm. CI‐AKI was defined as an increase of >0.5 mg/dl or >25% above baseline creatinine. Results: Overall incidence of CI‐AKI was 10.3%. There was no significant difference in incidence among the two groups (NS ± NAC 11.8% vs. NaHCO3 ± NAC 8.8%, p = ns). Incidence of CI‐AKI increased with increasing age (p = 0.001), contrast agent use >3 ml/kg body weight (p = 0.038) and diuretic use (p = 0.005). Conclusion: Incidence of CI‐AKI was no different in the NaHCO3 group compared to NS group, and NAC did not reduce CI‐AKI in the two study arms.

Contemporary clinical outcomes of primary percutaneous coronary intervention in elderly versus younger patients presenting with acute ST-segment elevation myocardial infarction.

BACKGROUND Primary percutaneous coronary intervention (PPCI) is the choice reperfusion strategy for acute ST-segment elevation myocardial infarction (STEMI). However, data on PPCI in elderly patients are sparse. This study determined clinical outcome post-PPCI in elderly versus younger patients with STEMI. METHODS AND RESULTS  A cohort of 790 consecutive STEMI patients was studied for survival and major adverse cardiovascular events (MACE) after PPCI using a precise cardiac catheterization protocol. Patients were divided into two groups: those ≥75 years (elderly) and those <75 years. Median door-to-balloon time (DBT) was 82 minutes in the elderly versus 66 minutes in the younger group (P = 0.002). In-hospital all-cause mortality was higher in the elderly group (15.5% vs. 2.7%, P < 0.001). In elderly patients, MACE were found to be higher (32.3% vs. 16.1%, P < 0.001). Using a multivariate logistic regression analysis, age (odds ratio [OR]= 1.04, 95% confidence interval [CI]= 1.02-1.05, P < 0.001), diabetes (OR = 2.17, 95% CI = 1.33-3.53, P = 0.002), renal failure (OR = 3.75, 95% CI = 1.30-10.79, P = 0.014) and coronary artery disease (OR = 1.61, 95% CI = 1.00-2.59, P = 0.050) were associated with higher in-hospital MACE, while age (OR = 1.05, 95% CI = 1.02-1.08, P = 0.001), diabetes (OR = 2.18, 95% CI = 1.06-4.47, P = 0.034) and renal failure (OR = 6.65, 95% CI = 2.01-22.09, P = 0.002) were associated with higher in-hospital mortality. Kaplan-Meier 1-year survival rate was lower in the elderly. CONCLUSIONS  In a contemporary population of STEMI patients treated with PPCI, overall in-hospital MACE and mortality remain higher in elderly compared to younger patients. Although partly due to higher burden of preexisting comorbidities, a higher DBT may also be responsible. (J Interven Cardiol 2011;24:357-365).

Clinical or Symptomatic Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Insights from the U.S. FDA MAUDE Database

ABSTRACT Background: Data on clinical or symptomatic leaflet thrombosis after transcatheter aortic valve replacement (TAVR) are limited. Whether clinical leaflet thrombosis has significance beyond peri-TAVR stroke or transient ischemic attacks (TIA) is yet to be elucidated. Methods: Between January 2012 and October 2015, we searched the MAUDE database for all entries with the identifier code, “NPT,” designated by the U.S. FDA to identify TAVR-related adverse events (AEs). Selected entries were searched further for the terms “leaflet,” “central aortic regurgitation,” and “aortic stenosis” to capture all events related to leaflet thrombosis causing structural valve dysfunction (SVD). Presentation of leaflet thrombosis (aortic stenosis or regurgitation or mixed valve lesion), mode of diagnosis (echocardiography, computed tomography, surgical explantation, or autopsy), and timing of presentation after TAVR were recorded. For all AEs of SVD due to leaflet thrombosis, the following outcomes were recorded: stroke or TIA, cardiogenic shock, and death from any cause. Results: A total of 5691 TAVR-related AEs were reported in the MAUDE database. SVD due to leaflet thrombosis was reported in 30 cases. Most cases (n = 18/30, 60.0%, 95% CI 0.41–0.77) occurred in the first year following TAVR. SVD manifested as either aortic stenosis (n = 16/30, 53.3%, 95% CI 0.34–0.72), or regurgitation (n = 7/30, 23.3%, 95% CI 0.10–0.42), or both (n = 4/30, 13.3%, 95% CI 0.04–0.31). Interventions to address leaflet thrombosis included either escalation of antiplatelet or anticoagulant therapy (n = 9/30, 30.0%, 95% CI 0.15–0.49), valve-in-valve TAVR (n = 5/30, 16.7%, 95% CI 0.06–0.35), or surgery (n = 14/30, 46.7%, 95% CI 0.28–0.66), or their combination. Outcome following leaflet thrombosis included stroke/TIA (n = 3/30, 10.0%, 95% CI 0.02–0.27), cardiogenic shock (n = 2/30, 6.7%, 95% CI 0.01–0.22), and death (n = 9/30, 30.0%, 95% CI 0.15–0.49). Conclusion: Clinically manifest leaflet thrombosis was associated with serious manifestations that included stroke, cardiogenic shock, and death.

Patient Awareness of Stent Type, Risk of Cardiac Events, and Symptoms of Myocardial Infarction Among PCI patients: A Missed Educational Opportunity?

BACKGROUND  Timely and successful treatment of myocardial infarction (MI) requires accurate recognition by the patient of the signs and symptoms. As patients who have undergone percutaneous coronary intervention (PCI) remain at risk for cardiac events, it is important that they have a basic understanding of their cardiac status. METHODS  We surveyed 80 consecutive patients following elective PCI using a simple multiple-choice questionnaire. Type of stent (bare metal or drug-eluting), how they perceive the procedure would affect their cardiovascular health, their perceived risk of a future MI, and whether they recalled specific education on how to recognize symptoms of an MI were queried. RESULTS  45% (n = 36) of patients were unaware of stent type. 10% stated PCI was performed to relieve symptoms of angina, 30% (n = 24) stated it would prevent MI, 56.3% (n = 45) stated that it would both prevent MI and reduce symptoms of angina, while 3.8% stated it would do neither. 86.3% (n = 69) stated they remained at risk for MI despite the procedure. However, 42.5% (n = 34) of patients did not perceive to have received specific education on the signs and symptoms of MI during their hospital stay. CONCLUSIONS  Patient understanding of stent type, expected cardiovascular outcomes, and recognition of MI post-PCI appears low in the real-world setting. A systematic approach to post-PCI education should be incorporated into routine care, in order to capitalize on the educational opportunity afforded by this high risk population.

Brain abscesses in a patient with a patent foramen ovale: a case report

IntroductionBrain abscesses arising from right-to-left cardiac shunting are very rare in adults.Case presentationWe describe the case of a 47-year-old non-hispanic white male with periodontal disease who developed several brain abscesses caused by Streptococcus intermedius. A comprehensive workup revealed a patent foramen ovale with oral flora as the only plausible explanation for the brain abscesses.ConclusionBased on this case and the relevant literature, we suggest an association between a silent patent foramen ovale, paradoxical microbial dissemination to the brain, and the development of brain abscesses.

A Hybrid Model for Advanced Structural Heart Disease Training Programs: The Attending-Fellow-in-Training Model

Structural heart disease (SHD) fellowship programs in the United States are growing, but they are still not accredited by the Accreditation Council for Graduate Medical Education. This results in a lack of standardized curriculum and complicates funding for a dedicated fellowship, as Medicare and

A Novel Approach to Managing Trans-Subclavian Transcatheter Aortic Valve Replacement with Regional Anesthesia

Abstract Transfemoral transcatheter aortic valve replacement (TAVR) has evolved, through increased operator experience and technical advancements, from a procedure done routinely under general anesthesia (GA) to one that can be safely performed under conscious sedation. Although local anesthesia and conscious sedation is widely applied to transfemoral procedures, TAVR using alternative vascular access routes requiring surgical cutdown is still performed under GA. We describe the use of regional anesthesia and moderate sedation in an 82-year-old woman undergoing trans-subclavian TAVR. A pectoral (PECS-1) nerve block provided adequate anesthesia throughout the procedure and excellent post-operative analgesia with no complications.

Pearls for a Successful Early Career in Structural Heart Disease Interventions

Early career (EC) cardiologists are defined as practicing physicians within 10 years of graduation fromcardiology fellowship training. The recent growth of structural heart disease (SHD) interventions has led some interventional cardiologists to dedicate a significant part of their practice to this subspecialty. Some have received formal fellowship training, while others have learned their skills “on the job” throughmentorship and/or dedicated institutional or industry-sponsored courses. In either case, building a successful career in this field can be challenging. This is a very exciting phase when, after years of training, interventionalists finally begin to practice in their field of choice. Nonetheless, the emerging SHD field is very competitive, rapidly evolving, and becoming increasingly regulated. These factors canmake it especially difficult for EC SHD interventionalists to be successful. In this article we discuss tips on how to overcome some of the EC pitfalls in this field.

Procedure Logging in Interventional Cardiology Training Curriculum: The Interventional Fellows' T-Score.

Procedure logging is an integral part of the fellowship curriculum in cardiovascular medicine and its subspecialties, particularly for the cardiovascular disease fellows who are acquiring advanced training in interventional cardiology, structural heart diseases, or clinical cardiac electrophysiology

Longitudinal Case Based Presentations in HCM

A significant volume of data has been published over the past few decades regarding HCM. In 2011 the ACCF/AHA issued guidelines for management and diagnosis, and in 2014 the ESC guidelines were formalized. Nonetheless, the acute and chronic management of HCM is highly nuanced, based on collective experience of many patients. To elucidate the subtleties of management, eight carefully selected cases attempt to depict the medical decision-making process at various stages of illness. Case 1 is a middle-aged male with refractory NYHA Class III symptoms who eventually improved after surgical septal reduction. Case 2 is a young female with history of sudden death and refractory symptoms who required invasive therapy, and a successful alcohol septal ablation was performed due to strong patient preference. Case 3 is a young female without significant outflow tract obstruction but with advanced diastolic heart failure who eventually required a heart transplant. Case 4 depicts severe obstructive HCM in a female with advanced age who after an extended course of medical therapy eventually improved post-alcohol septal ablation. Case 5 is a relatively young female post ICD for SCD with ICD lead complications and atrial fibrillation but well managed medically. Case 6 is a middle-aged male with severe obstructive HCM who required invasive therapy eventually and preferred alcohol septal ablation to surgery. Case 7 is a patient with obstructive HCM referred for alcohol septal ablation who was subsequently determined to have a subaortic membrane and ultimately required surgical treatment. Case 8 is a 40-year-old patient who underwent surgical myectomy but became symptomatic again 3 years after her surgery and eventually underwent alcohol septal ablation. As will become clear, appropriate care of HCM patients requires an individualized and comprehensive approach keeping in view their specific and oftentimes changing presentation, currently available data, and guidelines, all within the confines of a dedicated HCM center.