Atman P. Shah

Drug-eluting stenting is superior to bare metal stenting in saphenous vein grafts

This study compared the outcomes of percutaneous coronary intervention (PCI) of saphenous vein grafts (SVGs) with drug‐eluting stents (DES) with bare metal stents (BMS). PCI of degenerated SVG is associated with worse outcomes and high incidence of in‐stent restenosis compared with PCI of native coronary arteries. There is a paucity of data on the outcomes of PCI of SVG with DES. Data from 223 consecutive patients who underwent PCI of SVG were imputed into a dedicated clinical database. We assessed the clinical outcomes at a mean follow‐up of 9.1 ± 2.1 months. A total of 139 patients underwent PCI of SVG with DES and 84 patients with BMS. The mean age of the SVG was 7.6 ± 3.8 years in the DES group and 7.7 ± 2.8 years in the BMS group (P = 0.38). Procedural success was achieved in all patients except for one patient in the BMS group who underwent emergent coronary artery bypass graft surgery for SVG dissection. There were no other in‐hospital cardiac events in both groups. There was one cardiac death in the DES group and three deaths in the BMS group (P = 0.03). When compared to the BMS, PCI of SVG with DES was associated with a lower incidence of myocardial infarction (4.3% vs. 20.2%; P = 0.04) and target vessel revascularization (10.1% vs. 36.9%; P = 0.035). When compared with BMS, PCI of SVG with DES was associated with a lower incidence of death, myocardial infarction, and target vessel revascularization.

A Comparison of Door-to-balloon Times and False-positive Activations between Emergency Department and Out-of-hospital Activation of the Coronary Catheterization Team

OBJECTIVES The objectives were to compare the proportion of false-positive activations and intervention times between emergency department (ED) and field-based activation of the coronary catheterization laboratory (cath) team for emergency medical services (EMS) patients identified by out-of-hospital (OOH) 12-lead electrocardiogram (ECG) with ST-segment elevation myocardial infarction (STEMI). METHODS This was a retrospective review of prospectively collected continuous quality improvement data at a single, urban, academic medical center. By protocol, weekday activation of the cath team occurred based on OOH notification of a computer-interpreted OOH ECG indicating potential STEMI. Night and weekend activation occurred at the discretion of the attending emergency physician (EP) after advanced ED notification and after patient arrival and assessment. Basic demographic information and cardiac risk factors were recorded, as well as door-to-balloon (DTB) and ultimate diagnosis. RESULTS From May 2007 through March 2008, there were 23 field activations and 33 ED activations. There was no difference in demographic or clinical characteristics between the two groups. In the field activation group, 9/23 (39%) were false-positives, while 3/33 (9%) were false-positives in the ED activation group (30% higher absolute difference in the field activation group, 95% confidence interval [CI] = 8% to 52%, p = 0.02). OOH times and time spent in the ED were similar between the two groups. DTB times were 77 minutes for field activation and 68 minutes for ED activation, respectively (difference 9 minutes, 95% CI = -9 to 27). CONCLUSIONS Emergency physician activation of the cath team results in a lower proportion of false-positive activations without clearly sacrificing DTB time when compared to field activation based solely on the results of the OOH ECG.

Cardiovascular and endothelial effects of fish oil supplementation in healthy volunteers.

Consumption of fish oil (FO) is associated with reduced adverse cardiovascular events. In a randomized, blinded, placebo-controlled trial, 26 subjects (17 men and 9 women; mean age [± SD] 31 ± 3.7 years) received 1 g FO capsule (n = 14) or placebo (1 g of corn oil, n = 12) for 14 days. At day 0 and day 14, heart rate (HR), blood pressure, endothelium-dependent brachial artery flow-mediated vasodilation (EDV), and endothelium-independent nitroglycerin-mediated vasodilation (EIDV) were assessed with ultrasound. FO supplementation resulted in a significant increase in EDV (20.4% ± 13.2% vs 9.9% ± 5.4%; P = .036) and EIDV (32.6% ± 16.8% vs 18.0% ± 14.9%; P = .043). Resting HR decreased by a mean of 5.9 ± 9.4 bpm (FO) compared with placebo (mean increase of 0.73 ± 4.8 bpm [P = .05]). FO supplementation in healthy subjects is associated with improved endothelial function and decreased resting HR.

Percutaneous Transcatheter Aortic Valve Closure Successfully Treats Left Ventricular Assist Device–Associated Aortic Insufficiency and Improves Cardiac Hemodynamics

OBJECTIVES This study sought to assess the effectiveness of a novel percutaneous method to treat left ventricular assist device (LVAD)-associated severe aortic insufficiency (AI) in a series of patients determined to be poor reoperative candidates. BACKGROUND The increased use of continuous-flow LVAD in advanced heart failure has led to marked changes in the management of patients with this condition. However, secondary AI can become a significant complication. METHODS Five patients with continuous-flow LVAD and severe post-LVAD AI underwent percutaneous transcatheter aortic valve closure from September to October 2011 at a single quaternary care academic medical center. All patients had LVAD implanted as destination therapy. LVAD parameters, hemodynamics, and echocardiographic measurements were obtained before and after aortic valve closure. RESULTS All patients underwent successful closure with the Amplatzer cribriform device (AGA Medical, Plymouth, Minnesota) via a percutaneous transcatheter femoral approach with a significant reduction of AI from severe to trivial. Cardiac hemodynamics improved, and the pulmonary capillary wedge pressure was reduced in all patients. There was no change in mitral or tricuspid regurgitation, LVAD power, or pulsatility index. CONCLUSIONS Percutaneous transcatheter closure of the aortic valve effectively treats LVAD-associated AI and reduces pulmonary capillary wedge pressure. This procedure should be considered to treat LVAD-associated AI in patients who are poor candidates for repeat operation. Further data are needed to assess long-term results.

Antirestenotic Effects of a Locally Delivered Caspase Inhibitor in a Balloon Injury Model

Background—The precise role of arterial barotrauma-mediated apoptosis in causing restenosis is unclear. The purpose of this study was to determine if a link exists between angioplasty-mediated medial smooth muscle cell apoptosis and subsequent neointimal hyperplasia. Methods and Results—Bilateral iliac artery angioplasty was performed in 25 male New Zealand White rabbits. Simultaneous with balloon injury, each artery was treated locally with either the caspase inhibitor N-benzyloxycarbonyl-Val-Ala-Asp(Ome)-fluoromethylketone (ZVAD-fmk) or control. In the acute cohort that was survived to 4 hours (n=10, 7 high dose and 3 low dose), an apoptotic index was calculated using the terminal deoxynucleotidyl TUNEL method. In the intermediate cohort that was survived to 2 weeks (n=5), luminal reendothelialization was measured via CD-31 staining. In the chronic cohort that was survived to 4 weeks (n=10), neointimal area was measured. In the acute cohort, there was a 40% reduction in the apoptotic index with high-dose ZVAD-fmk (P =0.008) and a 33% reduction with low-dose ZVAD-fmk (P =0.08). At 2 weeks, there was no significant difference in the degree of luminal reendothelialization. However, at 4 weeks, there was a 33% (0.33±0.23 versus 0.22±0.20 mm2) (P <0.005) reduction in neointimal area in ZVAD-fmk–treated arteries. Conclusions—The local delivery of ZVAD-fmk during balloon injury inhibits smooth muscle cell apoptosis. This corresponds to a significant reduction in neointimal proliferation seen at 4 weeks without a significant change in the degree of reendothelialization at 2 weeks.

TCT-379 Percutaneous Transcatheter Aortic Valve Closure Successfully Treats Left Ventricular Assist Device-Associated Aortic Insufficiency and Improves Cardiac Hemodynamics

The increased use of continuous-flow LVADs in advanced heart failure has led to marked changes in the management of patients with this condition. However, secondary AI can become a significant complication. Our objective was to assess the effectiveness of a novel percutaneous method to treat left

Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO).

PURPOSE To characterize the current scope and practices of centers performing extracorporeal cardiopulmonary resuscitation (eCPR) on the undifferentiated patient with cardiac arrest in the emergency department. METHODS We contacted all US centers in January 2016 that had submitted adult eCPR cases to the Extracorporeal Life Support Organization (ELSO) registry and surveyed them, querying for programs that had performed eCPR in the Emergency Department (ED ECMO). Our objective was to characterize the following domains of ED ECMO practice: program characteristics, patient selection, devices and techniques, and personnel. RESULTS Among 99 centers queried, 70 responded. Among these, 36 centers performed ED ECMO. Nearly 93% of programs are based at academic/teaching hospitals. 65% of programs are less than 5 years old, and 60% of programs perform ≤3 cases per year. Most programs (90%) had inpatient eCPR or salvage ECMO programs prior to starting ED ECMO programs. The majority of programs do not have formal inclusion and exclusion criteria. Most programs preferentially obtain vascular access via the percutaneous route (70%) and many (40%) use mechanical CPR during cannulation. The most commonly used console is the Maquet Rotaflow(®). Cannulation is most often performed by cardiothoracic (CT) surgery, and nearly all programs (>85%) involve CT surgeons, perfusionists, and pharmacists. CONCLUSIONS Over a third of centers that submitted adult eCPR cases to ELSO have performed ED ECMO. These programs are largely based at academic hospitals, new, and have low volumes. They do not have many formal inclusion or exclusion criteria, and devices and techniques are variable.

Cardiac Function and the Proinflammatory Cytokine Response After Recovery From Cardiac Arrest in Swine

Increased levels of cytokines have been reported after resuscitation from cardiac arrest. We hypothesized that proinflammatory cytokines, released in response to ischemia/reperfusion, increase following resuscitation and play a role in post-cardiac arrest myocardial dysfunction. Ventricular fibrillation (VF) was induced by coronary occlusion in 20 swine. After 7 min of VF, resuscitation was performed as per guidelines. Plasma levels of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, and IL-6 were measured 15 min after the start of resuscitation in all animals and at intervals of 6 h in resuscitated animals. Intravascular pressures and cardiac output (CO) were also recorded. TNF-alpha abruptly increased after resuscitation, peaking at 15 min following return of spontaneous circulation, and declined to baseline levels after 3 h. IL-1beta increased more slowly, reaching a maximum 2 h after reperfusion. IL-6 concentrations were not significantly different from control values at any time point. Males demonstrated greater elevations of TNF-alpha and IL-1beta than females. Stroke work was significantly depressed at all time points with a nadir at 15-30 min after reperfusion, corresponding to the peak TNF-alpha values. The anti-TNF-alpha antibody infliximab attenuated the decrease in myocardial function observed 30 min after reperfusion. TNF-alpha increases during recovery from cardiac arrest are associated with depression of left ventricle (LV) function. The effect of TNF-alpha can be attenuated by anti-TNF-alpha antibodies.

Coronary sinus is dilated and outwardly displaced in patients with mitral regurgitation: quantitative angiographic analysis.

Our aim was to define the anatomy of the coronary sinus (CS) by venography. These measurements are essential in the selection of physical characteristics of percutaneous annuloplasty devices for mitral regurgitation (MR).

Infliximab attenuates early myocardial dysfunction after resuscitation in a swine cardiac arrest model.

Objective:Left ventricular dysfunction after successful cardiopulmonary resuscitation contributes to early death after resuscitation. Proinflammatory cytokines are known to decrease myocardial function, and tumor necrosis factor-&agr; has been shown to increase after successful resuscitation. We hypothesized that blocking the effects of tumor necrosis factor-&agr; with infliximab would prevent or minimize postresuscitation cardiac dysfunction. Design:Randomized, placebo-controlled comparative study. Setting:Large animal research laboratory. Subjects:Twenty-eight anesthetized and instrumented domestic male swine (Yorkshire and Yorkshire/Hampshire mix; weight, 35-45 kg). Interventions:Infusion of infliximab (5 mg/kg) or normal saline after resuscitation from ventricular fibrillation cardiac arrest. Measurements and Main Results:Hemodynamic variables, indices of left ventricular function, and tumor necrosis factor-&agr; were measured before and after 8 mins of cardiac arrest during the early postresuscitation period (3 hrs). Within 5 mins of restoration of spontaneous circulation, 14 animals received infliximab, 5 mg/kg, infused over 30 mins. Fourteen animals received an infusion of normal saline. Inotropes and vasopressors were not administered to either group after resuscitation. Tumor necrosis factor-&agr; increased after restoration of circulation and remained elevated throughout the observation period. Differences between groups were not significant. Interleukin-1&bgr; concentration did not change significantly during the observation period in either study group. Mean arterial pressure and stroke work were significantly greater in the infliximab group within 30 mins of resuscitation, and these differences were sustained throughout the 3-hr postresuscitation period. The effect of tumor necrosis factor-&agr; blockade was evident only in animals with a significant increase (doubling) in plasma tumor necrosis factor-&agr; at 30 mins after arrest. Conclusion:Tumor necrosis factor-&agr; plays a role in cardiac dysfunction after arrest and infliximab may attenuate or prevent postresuscitation myocardial dysfunction when administered immediately after resuscitation.