Andrew N. Rassi

The Massachusetts General Hospital Pulmonary Embolism Response Team (MGH PERT): Creation of a Multidisciplinary Program to Improve Care of Patients With Massive and Submassive Pulmonary Embolism

Abstract New and innovative tools have emerged for the treatment of massive and submassive pulmonary embolism (PE). These novel treatments, when considered alongside existing therapy, such as anticoagulation, systemic intravenous thrombolysis, and open surgical pulmonary embolectomy, have the potential to improve patient outcomes. However, data comparing different treatment modalities are sparse, and guidelines provide only general advice for their use. Treatment decisions rest on clinician expertise and institutional resources. Because various medical and surgical specialties offer different perspectives and expertise, a multidisciplinary approach to patients with massive and submassive PE is required. To address this need, we created a novel multidisciplinary program – the Massachusetts General Hospital (MGH) Pulmonary Embolism Response Team (PERT) – which brings together multiple specialists to rapidly evaluate intermediate- and high-risk patients with PE, formulate a treatment plan, and mobilize the necessary resources to provide the highest level of care. Development of a clinical, educational, and research infrastructure, as well as the creation of a national PERT consortium, will make our experience available to other institutions and serve as a platform for future studies to improve the care of complex patients with massive and submassive PE.

Thrombectomy using suction filtration and veno-venous bypass: single center experience with a novel device.

To describe the first single center experience with a novel aspiration thrombectomy device.

Temporal trends and predictors in the use of aldosterone antagonists post-acute myocardial infarction.

OBJECTIVES This study explored temporal trends in the use of aldosterone antagonist therapy among eligible patients with post-acute myocardial infarction (AMI) and reduced ejection fraction and characteristics associated with use in clinical practice. BACKGROUND Current guidelines recommend initiation of aldosterone antagonist therapy post-AMI for patients with an ejection fraction ≤40% and heart failure or diabetes before hospital discharge, in the absence of contraindications. METHODS Data from the American Heart Associations Get with the Guidelines-Coronary Artery Disease national database were analyzed for 81,570 post-AMI patients from 219 hospitals between 2006 and 2009, of whom 11,255 (13.8%) were eligible for aldosterone antagonist therapy. RESULTS Among eligible patients, 1,023 (9.1%) were prescribed an aldosterone antagonist at discharge. Aldosterone antagonist use varied from 0% to 40% among hospitals. Patient and hospital characteristics independently associated with prescription of aldosterone antagonists were a history of diabetes, heart failure, coronary revascularization, and larger hospital size. Those with a history of kidney dysfunction, tobacco abuse, and higher ejection fraction were less likely to be prescribed an aldosterone antagonist. From 2006 to 2009, the use of aldosterone antagonists increased from 6.0% to 13.4% (p < 0.001). CONCLUSIONS Although rates of aldosterone antagonist use are increasing slightly over time, the vast majority of AMI patients eligible for treatment fail to receive it at hospital discharge. The reason for this discrepancy between guideline-based therapy and actual prescribing patterns is unclear and should be further studied.

Safety of “Bridging” With Eptifibatide for Patients With Coronary Stents Before Cardiac and Non-Cardiac Surgery

Patients with previously implanted coronary stents are at risk for stent thrombosis if dual-antiplatelet therapy is prematurely discontinued. Bridging with a glycoprotein IIb/IIIa inhibitor has been advocated as an alternative, with few supporting data. The aim of this study was to determine the safety of such a strategy by retrospectively analyzing bleeding in 100 consecutive patients with previously implanted coronary stents who were bridged to surgery with eptifibatide after discontinuing thienopyridine therapy. A propensity-matched control comparison was performed for a subgroup of 71 patients who underwent cardiovascular surgery. Blood transfusions were required in 65% in the bridged group versus 66% in the control group (p = 0.86). The mean numbers of units transfused were 4.84 ± 6.93 and 3.65 ± 7.46, respectively (p >0.25). Rates of return to the operating room for bleeding or tamponade were 10% and 2.9%, respectively (p = 0.085). Increased rates of transfusion were noted for patients who received concomitant aspirin and/or intravenous heparin infusion. In conclusion, there does not appear to be any increase in the need for blood transfusions or rate of return to the operating room for patients being bridged with eptifibatide when thienopyridines are discontinued in the perioperative period, but concomitant use of additional antiplatelet or anticoagulant agents may increase transfusions and delays to surgery. Clinicians who are considering this strategy must weigh the risks of stent thrombosis versus bleeding.

Left Ventricular Remodelling in Aortic Stenosis

Aortic stenosis (AS) is a progressive condition associated with high mortality if not treated. The hemodynamic effects of AS have serious implications for the left ventricle. In this review, we describe the responses of the left ventricle to AS by highlighting the process of adaptive remodelling, which begins as a beneficial compensatory mechanism but ultimately transitions to a maladaptive process with potentially irreversible consequences. We discuss the impact of left ventricular (LV) remodelling on diastolic and systolic function and on the development of symptoms. In addition, we review the adverse consequences of maladaptive LV remodelling on clinical outcomes before and after aortic valve replacement. The relative irreversibility of maladaptive remodelling and the clear relationship between its progression and clinical outcomes suggest a need to incorporate measures of LV performance beyond simply systolic function when deciding on the timing of valve replacement.

Exercise stress echocardiography in patients with aortic stenosis: impact of baseline diastolic dysfunction and functional capacity on mortality and aortic valve replacement.

BACKGROUND Patients with aortic stenosis (AS) often undergo exercise echocardiography. Diastolic dysfunction (DD) is frequently associated with AS but little is known about its impact on functional capacity (FC). We sought to determine the relationship between DD and FC and their impact on mortality and need for aortic valve replacement (AVR) in patients with AS. METHODS AND RESULTS Data was analyzed for consecutive patients with any degree of AS undergoing exercise stress echocardiography between 2000 and 2010 at our institution. The primary endpoint was a composite of death or need for AVR. We identified 1,267 patients [mean age 67±11 years, ejection fraction (56±7)%, mean aortic valve gradient 19±12 mmHg, mean maximal metabolic equivalents (METs) achieved 8±2.6]. The proportion with normal, stage 1, and ≥ stage 2 diastology was 195 (15%), 928 (73%), 144 (12%). A total of 475 (37.5%) patients had a primary outcome with 164 deaths (mean follow up 5.6±4.1 years) and 341 AVR (mean follow up 2.4±2.6 years). Predictors of FC were age, gender, body mass index, Bruce protocol, heart rate recovery (HRR), ejection fraction, mean aortic valve gradient, and diabetes but not baseline DD. Baseline DD [HR 1.82, 95% CI (1.17, 2.82), P=0.008] and FC [HR 0.93, 95% CI (0.88, 0.98), P=0.003] were independent predictors of death or AVR. CONCLUSIONS For patients with AS undergoing exercise echocardiography, baseline DD was not predictive of FC. However, both baseline DD and FC were independent predictors of death or need for AVR.

TCT-136 Outcomes of Hemodynamic Support with Impella in very high-risk patients undergoing Balloon Aortic Aortic Valvuloplasty: Results From the Global cVAD Registry

TCT-135 Increased circulating plasma-free hemoglobin levels, not lactate dehydrogenase, levels identify hemolysis among patients with cardiogenic shock treated with an Impella micro-axial flow catheter Michele Esposito, Ryan O’Kelly, Nima Aghili, Shiva Annamalai, Anas Hamadeh, Michael Kiernan, Amanda Vest, David DeNofrio, Navin Kapur Hospital U. Central de la Defensa “Gómez Ulla”, Boston, Massachusetts, United States; Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany; Tufts Medical Center, Boston, Massachusetts, United States; Departmenf of Cardiac and Thoracic Surgery, BG University Hospital Bergmannsheil, Bochum, Germany; 2 Dept. of Cardiology-Fondazione IRCCS Policlinico San Matteo, Pavia/Italy; Hospital U. Central de la Defensa “Gómez Ulla”; University Clinic of Jena, 1st Medical Department; University Clinic of Jena, 1st Medical Department; Tufts Medical Center, Boston, Massachusetts, United States

Cardiovascular Event Risk After Noncardiac Surgery

Dr Hawn and colleagues1 evaluated the risk of undergoing noncardiac surgery following coronary stent placement. The analysis, which examines the outcomes of 28 029 veterans undergoing noncardiac surgery within 24 months of coronary stent implantation, found that emergency surgery and severity of cardiac disease were the principal factors associated with postoperative major adverse cardiovascular events (MACE).

Finding a lost coronary stent months later with use of multimethod imaging.

A 64-year-old man with refractory angina and a history of revascularization was referred after a failed attempt at revascularization. His medical regimen included maximal β-blocker, calcium channel blocker, and nitrate therapy. Cineangiograms before contrast injection suggested asymmetric calcification of the proximal left circumflex coronary artery (LCx) and showed previously implanted stents in the distal vessel (Fig. 1A). A cineangiogram after contrast injection revealed a severe lesion in the ostium of the first obtuse marginal branch (OM) and patent stents (Fig. 1B). Our initial attempts to advance a stent to the OM were impeded by an area of possible calcification in the proximal LCx. We used intravascular ultrasound (IVUS) to better understand the anatomy. We noted a circular density in the proximal LCx (Fig. 2). Optical coherence tomography (OCT) identified the circular structure as an undeployed stent, presumably lost during attempted revascularization months earlier (Fig. 3). We crushed the lost stent against the wall of the proximal LCx with use of a compliant balloon, then deployed a 2.5 × 15-mm everolimuseluting Xience® stent (Abbott Vascular, part of Abbott Laboratories; Redwood City, Calif) to the OM. Fig. 1. A) Cineangiogram before the injection of contrast material shows an area of possible calcification near the catheter tip, as well as stents deployed earlier in the distal anatomy. B) Cineangiogram after the injection of contrast material identifies the ... Fig. 2. Intravascular ultrasonographic image shows a circular structure. Fig. 3. Optical coherence tomogram identifies the circular structure as an undeployed stent.