Colin M. Barker

Outcome After Surgery and Percutaneous Intervention for Cardiogenic Shock and Left Main Disease

BACKGROUND The ideal revascularization strategy (bypass surgery versus percutaneous coronary intervention [PCI]) for patients with cardiogenic shock in the setting of left main coronary artery disease is unknown. METHODS The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock Trial and Registry included 164 patients with left main disease who underwent revascularization. Although the standard of care at the time and the trial protocol recommended coronary artery bypass graft surgery for patients with left main disease, the revascularization strategy (79 coronary artery bypass graft surgery and 85 PCI) was individualized for each patient by site investigators. RESULTS The median time from myocardial infarction to revascularization was 24.3 hours (interquartile range, 8.7 to 82.5 hours) in the surgical group and 7.4 hours (interquartile range, 3.7 to 19.5 hours) in the PCI group (p < 0.05). Overall 30-day survival with surgery in this setting was 54% (95% confidence interval, 0.43 to 0.69) and was significantly superior to the 14% (95% confidence interval, 0.09 to 0.35) in the PCI group (p <or= 0.001). When the left main was the infarct-related artery, the 30-day survival rate was 40% in the surgical group (n = 6) and 16% in the PCI group (n = 15; p = 0.03). Coronary artery bypass graft surgery (hazard ratio, 0.41; 95% confidence interval, 0.22 to 0.77; p = 0.006) and age (per 10 years, hazard ratio, 1.04; 95% confidence interval, 1.01 to 1.08; p = 0.02) were independently associated with 30-day survival. CONCLUSIONS Coronary artery bypass graft surgery appeared to provide a survival advantage over PCI at 30-day follow-up in patients with left main coronary artery disease. The impact of current PCI strategies on this subgroup is undetermined.

Replicating Patient-Specific Severe Aortic Valve Stenosis with Functional 3D Modeling

Background—3D stereolithographic printing can be used to convert high-resolution computed tomography images into life-size physical models. We sought to apply 3D printing technologies to develop patient-specific models of the anatomic and functional characteristics of severe aortic valve stenosis. Methods and Results— Eight patient-specific models of severe aortic stenosis (6 tricuspid and 2 bicuspid) were created using dual-material fused 3D printing. Tissue types were identified and segmented from clinical computed tomography image data. A rigid material was used for printing calcific regions, and a rubber-like material was used for soft tissue structures of the outflow tract, aortic root, and noncalcified valve cusps. Each model was evaluated for its geometric valve orifice area, echocardiographic image quality, and aortic stenosis severity by Doppler and Gorlin methods under 7 different in vitro stroke volume conditions. Fused multimaterial 3D printed models replicated the focal calcific structures of aortic stenosis. Doppler-derived measures of peak and mean transvalvular gradient correlated well with reference standard pressure catheters across a range of flow conditions (r=0.988 and r=0.978 respectively, P<0.001). Aortic valve orifice area by Gorlin and Doppler methods correlated well (r=0.985, P<0.001). Calculated aortic valve area increased a small amount for both methods with increasing flow (P=0.002). Conclusions—By combing the technologies of high-spatial resolution computed tomography, computer-aided design software, and fused dual-material 3D printing, we demonstrate that patient-specific models can replicate both the anatomic and functional properties of severe degenerative aortic valve stenosis.

Functional testing methods for the antiplatelet effect of P2Y12 receptor antagonists

Dual antiplatelet therapy with aspirin and a P2Y(12) receptor antagonist is the cornerstone of management in patients with acute coronary syndrome and those with coronary artery disease who have undergone coronary stent implantation. Clopidogrel is the most commonly used P2Y(12) antagonist. Despite clopidogrels clinical effectiveness in reducing recurrent cardiovascular events in patients with coronary artery disease, the pharmacodynamic effect of clopidogrel is heterogeneous. Various platelet function tests that provide a quantitative measure of the downstream effects of clopidogrel on the P2Y(12) receptor are available. The consistent observation that a lack of clopidogrel effect based on these tests is associated with poor clinical outcome has led to the promise of an individualized, patient-centered approach to antiplatelet therapy. Over the past few years, a wealth of data have helped bring this promise closer to reality, and upcoming clinical trials of platelet function testing could at last bring personalized medicine into routine clinical practice.

Case report: It wasn't cupid: multimodality imaging of inferior vena cava filter fracture with strut migration to the interventricular septum.

198 houstonmethodist.org/debakey-journal M. Kassi, M.D. IT WASN’T CUPID: MULTIMODALITY IMAGING OF INFERIOR VENA CAVA FILTER FRACTURE WITH STRUT MIGRATION TO THE INTERVENTRICULAR SEPTUM Mahwash Kassi, M.D.a; Jose Lopezb; Colin Barker, M.D.b; Scott Trerotola, M.D.c; Neal Kleiman, M.D.b; Karla Kurrelmeyer, M.D.b aHouston Methodist Hospital, Houston, Texas; bHouston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas; cUniversity of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Case report: Severe hypercalcemia mimicking ST-segment elevation myocardial infarction.

The identification of ST-segment elevation on the electrocardiogram is an integral part of decision making in patients who present with suspected ischemia. Unfortunately, ST-segment elevation is nonspecific and may be caused by noncardiac causes such as electrolyte abnormalities. We present a case of ST-segment elevation secondary to hypercalcemia in a patient with metastatic cancer.

Percutaneous Repair of Severe Eccentric Mitral Regurgitation Due to Medial Commissural Flail: Challenges for Imaging and Intervention

Graphical abstract

Minimally Invasive Repair of Left Ventricular Pseudoaneurysm after Transapical Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement is becoming a routine procedure to treat severe symptomatic aortic stenosis. At most transcatheter aortic valve replacement centers, transapical access is a frequent alternative for use in patients whose ileofemoral access is inadequate. Transapical access is increasingly applied to a variety of other structural heart and aortic procedures as well. There is a caveat, however. When performed in elderly patients with friable myocardium, transapical access is associated with such serious sequelae as bleeding and left ventricular apical pseudoaneurysmal formation. Here, we describe the case of a 70-year-old woman who developed a left ventricular apical pseudoaneurysm 3 weeks after transapical transcatheter aortic valve replacement. Our successful repair took a minimally invasive left lateral approach that involved peripheral cardiopulmonary bypass cannulation, Foley catheter occlusion and primary defect closure, and BioGlue reinforcement.

PREDICTION OF OPTIMAL DEPLOYMENT ANGLE FOR TAVR: FEASIBILITY OF CT ANGIOGRAPHY AND NON–CONTRAST DYNACT IMAGE REGISTRATION BASED APPROACH AND ITS POTENTIAL IMPLICATION ON LIMITING CONTRAST VOLUME

Prediction of an optimal C–arm angle that aligns the coronary sinuses for valve deployment is critical during TAVR. Current solutions derive the deployment angle from multiple angiograms, reconstruction of multi–slice CT (MSCT) or C–arm CT rotational angiography (CTRA). We evaluated a method

Transcatheter Mitral Valve Replacement for Native and Failed Bioprosthetic Mitral Valves

Transcatheter mitral valve replacement (TMVR) is a novel approach for treatment of severe mitral regurgitation. A number of TMVR devices are currently undergoing feasibility trials using both transseptal and transapical routes for device delivery. Overall experience worldwide is limited to fewer than 200 cases. At present, the 30-day mortality exceeds 30% and is attributable to both patient- and device-related factors. TMVR has been successfully used to treat patients with degenerative mitral stenosis (DMS) as well as failed mitral bioprosthesis and mitral repair using transcatheter mitral valve-in-valve (TMViV)/valve-in-ring (ViR) repair. These patients are currently treated with devices designed for transcatheter aortic valve replacement. Multicenter registries have been initiated to collect outcomes data on patients currently undergoing TMViV/ViR and TMVR for DMS and have confirmed the feasibility of TMVR in these patients. However, the high periprocedural and 30-day event rates underscore the need for further improvements in device design and multicenter randomized studies to delineate the role of these technologies in patients with mitral valve disease.

Left Main Coronary Trunk Compression by a Severely Enlarged Pulmonary Artery: Noninvasive and Invasive Assessment

The incidence of left main coronary trunk (LMT) compression by an enlarged pulmonary artery (PA) is unknown. Furthermore, there are no guidelines recommending optimal management of this disease entity. A 54-year-old woman with a history of severe PA hypertension (PAH) presented to our hospital with