Amir Lotfi

Expert Consensus Statement on the Use of Fractional Flow Reserve, Intravascular Ultrasound, and Optical Coherence Tomography: A Consensus Statement of the Society of Cardiovascular Angiography and Interventions

The rationale for use of intracoronary physiology assessment and imaging arises from the limitations of coronary angiography, the traditional method for determining the severity of coronary stenoses. The visual assessment of percent diameter reduction has significant interobserver variability [1–3], even among experienced angiographers [4]. Computer-assisted quantitative coronary angiography only marginally improves diagnostic accuracy and its estimate of functional significance [5]. Fractional flow reserve (FFR) is used to determine the functional significance of a coronary stenosis [6]. Intravascular ultrasound (IVUS) offers excellent visualization of intraluminal and transmural coronary anatomy. Optical coherence tomography (OCT) further improves vascular visualization. There is now persuasive evidence regarding intracoronary diagnostic lesion assessments using physiology and anatomy. These adjunctive diagnostic procedures may influence the decision for coronary revascularization, guide the performance of percutaneous coronary interventions (PCI), and optimize procedural outcomes. There are substantial long-term outcome data showing benefit associated with FFR-guided decision-making. However, these techniques are underutilized in contemporary practice: the rates of use of IVUS and FFR during PCI for intermediate coronary stenoses (40–70% diameter stenosis) are 20.3% and 6.1% respectively [7]. In 2011, the ACCF/AHA/SCAI PCI guidelines [8] assigned levels of evidence for the use of these modalities in various clinical situations (Table T1 I). The purpose of this consensus statement is to review recent studies, to develop a consensus of how these

High-dose atorvastatin does not negatively influence clinical outcomes among clopidogrel treated acute coronary syndrome patients—A Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis in Myocardial Infarction 22 (PROVE IT–TIMI 22) analysis

BACKGROUND Clopidogrel is inactive in vitro and is metabolized by hepatic cytochrome P-450-3A4 to produce active metabolites. Unlike pravastatin, atorvastatin is a statin that is subject to metabolism by cytochrome P-450-3A4, and drug-drug interactions with other potent inhibitors of this cytochrome system have been demonstrated. However, the clinical impact of this interaction has created debate. METHODS In the PROVE IT-TIMI 22 study, 4162 patients with an acute coronary syndrome within the preceding 10 days were randomly assigned in a 1:1 fashion to pravastatin 40 mg or atorvastatin 80 mg daily. The primary efficacy outcome measure was the time from randomization until the first occurrence of a component of the primary end point: death from any cause, myocardial infarction, documented unstable angina requiring rehospitalization, revascularization with either percutaneous coronary intervention or coronary artery bypass grafting, or stroke. RESULTS At 30 days, there was a trend for less occurrence of the primary end point in patients randomized to atorvastatin compared with pravastatin, irrespective of whether they were taking clopidogrel. This becomes significant at 2-year follow-up in clopidogrel-treated patients (21.66 % vs 26.18% P = .0091). There was no evidence of interaction in the clopidogrel/no clopidogrel subgroup for the primary end point (interaction P = .65) or the components of the composite. CONCLUSION In conclusion, the beneficial affects of atorvastatin 80 mg in reducing the primary end point at 2 years is independent of coadministration with clopidogrel.

Long-term outcomes following fractional flow reserve-guided treatment of angiographically ambiguous left main coronary artery disease: A meta-analysis of prospective cohort studies

To define the long term outcomes of Fractional Flow Reserve (FFR) guided revascularization of ambiguous left main coronary artery (LMCA) lesions by performing a pooled meta‐analysis of all available studies.

Prevention of stent thrombosis: challenges and solutions

Stent thrombosis is an uncommon but serious complication which carries with it significant mortality and morbidity. This review analyzes the entity of stent thrombosis from a historical and clinical perspective, and chronicles the evolution of this condition through the various generations of stent development, from bare metal to first-generation, second-generation, and third-generation drug-eluting stents. It also delineates the specific risk factors associated with stent thrombosis and comprehensively examines the literature related to each of these risks. Finally, it highlights the preventative strategies that can be garnered from the existing data, and concludes that a multifactorial approach is necessary to combat the occurrence of stent thrombosis, with higher risk groups, such as patients with ST segment elevation myocardial infarction, meriting further research.

Eustachian valve endocarditis: Rare case reports and review of literature

Eustachian valve endocarditis (EVE) is a distinctly rare and underdiagnosed entity. We report 2 new cases caused by vancomycin resistant Staphylococcus aureus and Staphylococcus hominis diagnosed on transesophageal echocardiography (TEE). Although, 63% of Eustachian valve endocarditis is caused by Staphylococcus aureus, we report the first case of vancomycin resistant Staphylococcus aureus and first case related to implantable venous access systems. EVE is now seen more commonly in elderly population with diverse microbial cultures and antibiotic sensitivities. TTE is the first modality for investigation of EVE, however a negative TTE does not preclude the diagnosis, as only 88% of cases were diagnosed on TEE.

Septic Coronary Artery Embolism Treated with Aspiration Thrombectomy: Case Report and Review of Literature

Coronary embolization is a potentially fatal sequela of endocarditis. We report a case of Candida endocarditis with septic embolism to the left anterior descending coronary artery. This embolism was successfully treated with aspiration thrombectomy followed by balloon angioplasty. The treatment of acute coronary syndrome in the presence of septic embolism is controversial. Aspiration thrombectomy has been performed in this situation before, and it appears to be safer and more feasible than is thrombolysis or percutaneous transluminal angioplasty.

Cardiac resynchronization therapy in patients with postero-lateral scar by cardiac magnetic resonance: A systematic review and meta-analysis

BACKGROUND Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with heart failure, but up to one third of patients may not respond to CRT. A transmural postero-lateral (TMPL) wall scar in the left ventricle (LV) or over the LV pacing site may attenuate clinical and echocardiographic response to CRT. METHODS AND RESULTS We systematically searched PubMed, EMBASE, and Cochrane databases for studies examining the association between Cardiac magnetic resonance (CMR)-determined postero-lateral or LV pacing site scar and clinical and echocardiographic response to CRT. Eleven prospective studies were included. The presence of TMPL scar on pre-implant CMR was associated with a 75% lower chance of echocardiographic response to CRT, and a similarly lower chance of clinical response. Significant scar over LV pacing site on pre-implant CMR was also associated with a 46% lower chance of echocardiographic response to CRT, and a 67% lower chance of clinical response. CONCLUSIONS The presence of transmural postero-lateral scar or significant scar within the LV pacing site detected by pre-implant CMR is associated with a lower rate of clinical or echocardiographic response to CRT.

Postoperative Atrial Fibrillation Is Not Associated With an Increase Risk of Stroke or the Type and Number of Grafts: A Single-Center Retrospective Analysis

Atrial fibrillation (AF) and atrial flutter are the 2 most common types of dysrhythmia in patients undergoing coronary artery bypass graft (CABG) surgery and are associated with increased morbidity and mortality. We sought to explore the association between the type and quantity of bypass grafts and cardiovascular outcomes in patients with postoperative AF (POAF).

Widowhood and severity of coronary artery disease: a multicenter study.

Objectives The aim of this study was to assess the association of widowhood with the severity and extent of coronary artery disease (CAD), and whether it is modified by sex or socioeconomic status. Patients and methods A total of 1068 patients undergoing coronary angiography at five centers in Saudi Arabia and the United Arab Emirates were included in the study. CAD was defined as more than 70% lumen stenosis in a major epicardial vessel or more than 50% in the left main coronary artery. Multivessel disease was defined as more than one diseased vessel. Results Of 1068 patients, 65 (6%) were widowed. Widowed patients were older (65±15 vs. 59±12), more likely to be female (75 vs. 25%), less likely to be smokers (18 vs. 47%), of lower economic and education status, and more likely to have undergone coronary angiography for urgent/emergent indications (75 vs. 61%) (P<0.05 for all). There was a significant association between widowhood and the number of coronary arteries with more than 70% lumen stenosis. Consequently, such a high degree of lumen stenosis in those who were widowed was more likely to require coronary artery bypass graft surgery (38 vs. 16%; P<0.01). After adjusting for baseline differences, widowhood was associated with a significantly higher odds of CAD [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI) 1.2–10.5] and multivessel disease (adjusted OR 4.6; 95% CI 2.2–9.6), but not left main disease (adjusted OR 1.3; 95% CI 0.5–3.1). All associations were consistent in men and women and not modified by age, community setting (urban vs. rural), employment, income, or educational levels (Pinteraction>0.1 for all). Conclusion Widowhood is associated with the severity and extent of CAD. The association is not modified by sex or socioeconomic status.

A Unique Case of Asystole Secondary to Facial Injury

Bradycardia has been reported during intraoperative settings of craniofacial, cerebropontine angle and trigeminal ganglion surgeries (Schaller et al. (2009, 1999); Parbhakar et al. (2009); Koerbel et al. (2005); Roberts et al. (1999)). It is also commonly seen in children undergoing orbital and maxillary fractures repair. This mechanism has been described as the trigeminocardiac reflex (TCR) (Schaller et al. (2009, 2004); Kim et al. (2000); Lang et al. (1991); Van Brocklin et al. (1982)). We report an unusual case of posttraumatic bradycardia and recurrent asystole in a previously healthy adult patient from possible TCR in the absence of any surgical intervention to the head and orbital area.