Abhishek Mishra

Acute ST-elevation myocardial infarction due to septic embolism: A case report and review of management options

Acute ST‐elevation myocardial (STEMI) infarction due to septic embolism is rare and management strategies differ from those applied to atherothrombotic STEMI. A 70‐year‐old male with aortic valve endocarditis and persistent bacteremia developed acute inferior wall STEMI due to septic embolism. Due to inferior STEMI accompanied by hemodynamic instability, coronary angiography and primary PCI (stenting) to a totally occluded right coronary artery (RCA) was performed. Despite excellent immediate angiographic results and hemodynamic stabilization, repeat angiogram two weeks later showed mycotic aneurysms at the site of stent placement. Patient later suffered from intracranial hemorrhage and splenic infarct and had worsening aortic regurgitation, prompting surgical aortic valve replacement with bypass of the RCA. Despite aggressive medical, interventional and surgical management, he expired four weeks after the surgery. Selection of an optimal revascularization strategy in this scenario is unclear with a potential harm from standard therapies. We have reviewed prior reports and summarized results in a tabular form.

National Trends and Outcomes in Dialysis-Requiring Acute Kidney Injury in Heart Failure: 2002–2013

BACKGROUND Dialysis-requiring acute kidney injury (D-AKI) is a serious complication in hospitalized heart failure (HF) patients. However, data on national trends are lacking after 2002. METHODS We used the Nationwide Inpatient Sample (2002-2013) to identify HF hospitalizations with and without D-AKI. We analyzed trends in incidence, in-hospital mortality, length of stay (LoS), and cost. We calculated adjusted odds ratios (aORs) for predictors of D-AKI and for outcomes including in-hospital mortality and adverse discharge (discharge to skilled nursing facilities, nursing homes, etc). RESULTS We identified 11,205,743 HF hospitalizations. Across 2002-2013, the incidence of D-AKI doubled from 0.51% to 1.09%. We found male sex, younger age, African-American and Hispanic race, and various comorbidities and procedures, such as sepsis and mechanical ventilation, to be independent predictors of D-AKI in HF hospitalizations. D-AKI was associated with higher odds of in-hospital mortality (aOR 2.49, 95% confidence interval [CI] 2.36-2.63; P < .01) and adverse discharge (aOR 2.04, 95% CI 1.95-2.13; P < .01). In-hospital mortality and attributable risk of mortality due to D-AKI decreased across 2002-2013. LoS and cost also decreased across this period. CONCLUSIONS The incidence of D-AKI in HF hospitalizations doubled across 2002-2013. Despite declining in-hospital mortality, LoS, and cost, D-AKI was associated with worse outcomes.

Percutaneous Coronary Intervention Versus Surgery in Left Main Stenosis–A Meta-Analysis and Systematic Review of Randomised Controlled Trials

OBJECTIVE To investigate the safety and efficacy of percutaneous coronary interventions (PCI) versus coronary artery bypass graft (CABG) surgery for left main coronary artery (LMCA) disease. METHODS Six randomised controlled trials (RCTs) were reviewed by searching PubMed/Medline, Embase and the Cochrane Library. Estimates were pooled according to random effects model. Binary outcomes were reported as risk ratio (RR) and continuous outcomes were reported as mean difference (MD) with 95% confidence interval (CI). RESULTS 3794 patients were randomised into PCI and CABG arms. Mean age of the total population was 64.7 years, 74.4% were male and mean Logistic EURO score (LES) was 2.9. When compared with CABG, patients treated with PCI had reduced risk of major adverse cardiovascular events (MACE) at 30 days: (RR: 0.55; 95% CI, 0.41-0.75; p<0.001; I2=0) but similar risk at 1year (RR: 1.15; 95% CI, 0.92-1.45; p=0.22; I2=0). Five years MACE rates favoured CABG (RR: 1.32; 95% CI, 1.13-1.53; p<0.001; I2=0) driven by a higher rate of target vessel revascularisation (TVR) (RR: 1.71; 95%CI, 1.38-2.12; p<0.001; I2=0) and myocardial infarction (MI) (RR: 1.97; 95%CI, 1.28-3.04; p<0.001; I2=22). Percutaneous coronary intervention was comparatively a safer procedure with lower rates of periprocedural adverse events including MI, stroke, bleeding events and need for blood transfusions. CONCLUSION Percutaneous coronary intervention reduced MACE at 30days with comparable MACE at 1year. However, CABG was a more effective modality when considering mid- to long-term outcomes. PCI is a safer procedure with regards to periprocedural adverse events.

Short-term outcomes of atrial flutter ablation

Understanding the factors associated with early readmissions following atrial flutter (AFL) ablation is critical to reduce the cost and improving the quality of life in AFL patients.

MYCOTIC ANEURYSM AFTER CORONARY STENTING FOLLOWING SEPTIC EMBOLISM: A RARE COMPLICATION OF BACTERIAL ENDOCARDITIS

A 72-year-old male with end stage renal disease presented with febrile illness and was found to have Methicillin-resistant Staphylococcus Aureus bacteremia that persisted despite antibiotic therapy. On the 5th hospitalization day, patient developed acute inferior wall ST-elevation myocardial