Donald S. Chang

MDCT of left anterior descending coronary artery to main pulmonary artery fistula.

4Imaging Service, VA Greater Los Angeles Healthcare System, Los Angeles, CA. ost coronary artery fistulas are congenital in origin, but they have been reported to be acquired as complications of chest trauma, coronary angioplasty, and bypass surgery. These fistulas are usually discovered incidentally on coronary angiography or are found at autopsy, because most patients are initially asymptomatic. Some, however, may present with congestive heart failure. Visualization of coronary fistulas has recently been reported using 3D CT in a cadaveric specimen [1]. We present a case of a fistulous communication between the left anterior descending artery and the main pulmonary artery as seen on MDCT in a patient with a medical history of myocardial infarction and percutaneous transluminal coronary angioplasty and a history of penetrating chest injury. Reconstructed images obtained on MDCT are illustrated with correlative angiographic images. To our knowledge, this is the first report of an evaluation of a coronary artery fistula using MDCT in the English-language literature.

Impact of a Multidisciplinary Heart Failure Post-hospitalization Program on Heart Failure Readmission Rates

Background: Specialized chronic heart failure (HF) clinics have demonstrated significant reductions in readmissions. Limited evidence is available regarding HF clinics in the immediate post-discharge period. Objective: To evaluate the effect of a multidisciplinary HF clinic on 90-day readmission rates and all-cause mortality in those recently discharged from a HF hospitalization. Methods: In this retrospective cohort study, patients discharged with a primary HF diagnosis who attended the HF postdischarge clinic in 2010-2012 were compared with controls from 2009. During 6 clinic visits, patients were seen by a physician assistant, clinical pharmacist specialist, and case manager, with care overseen by a cardiologist. The program focused on optimizing therapy, identifying HF etiology/precipitating factors, medication titration, education, and medication adherence. The primary outcome was 90-day HF readmission. A multivariate Cox proportional hazards model was used to compare outcomes. Results: Among the 277 patients (144 clinic, 133 control) in the study, 7.6% of patients in the clinic and 23.3% of patients in the control group were readmitted for HF within 90 days (aHR (adjusted hazard ratio) = 0.17; 95% CI = 0.07-0.41; P < 0.001; ARR (absolute risk reduction) = 15.7%; NNT (number needed to treat) = 7). Clinic patients had lower 90-day time-to-first HF readmission or all-cause mortality (9.0% vs 28.6%; aHR = 0.28; 95% CI = 0.06-0.31; P < 0.001; ARR = 19.6%; NNT = 6). Conclusions: The multidisciplinary HF posthospitalization outpatient program was associated with a significant reduction in 90-day HF readmissions in patients who were recently discharged from a HF hospitalization.

Suboptimal control of atherosclerotic disease risk factors after cardiac and cerebrovascular procedures.

Background and Purpose— Undergoing a carotid endarterectomy, a coronary artery bypass graft, or a percutaneous coronary intervention provides an opportunity to optimize control of blood pressure and low-density lipoprotein. Methods— Using Veterans Administration databases, we determined whether patients who underwent a carotid endarterectomy (n=252), coronary artery bypass graft (n=486), or percutaneous coronary intervention (n=720) in 2002 to 2003 at 5 Veterans Administration Healthcare Systems had guideline-recommended control of blood pressure and low-density lipoprotein in 12-month periods before and after a vascular procedure. Postprocedure control of risk factors across procedure groups was compared using &khgr;2 tests and multivariate logistic regression. Results— The proportion of patients undergoing carotid endarterectomy who had optimal control of both blood pressure and low-density lipoprotein increased from 23% before the procedure to 33% after the procedure (P=0.05) compared with increases from 32% to 43% for coronary artery bypass graft (P=0.001) and from 29% to 45% for percutaneous coronary intervention (P=0.002). Compared with the carotid endarterectomy group, the percutaneous coronary intervention group was more likely to achieve optimal control of blood pressure (OR: 1.92, 95% CI: 1.42 to 2.59) or low-density lipoprotein (OR: 1.51, 95% CI: 1.01 to 2.26) and the coronary artery bypass graft group was more likely to achieve optimal control of blood pressure (OR: 1.53, 95% CI: 1.42 to 2.59). Postprocedure cardiology visits, increase in medication intensity, and greater frequency of outpatient visits were also associated with optimal postprocedure risk factor control. Conclusions— Although modest improvements in risk factor control were detected, a majority of patients in each vascular procedure group did not achieve optimal risk factor control. More effective risk factor control programs are needed among most vascular procedure patients.

Stretchable electrochemical impedance sensors for intravascular detection of lipid-rich lesions in New Zealand White rabbits

Flexible electronics have enabled catheter-based intravascular sensing. However, real-time interrogation of unstable plaque remains an unmet clinical challenge. Here, we demonstrate the feasibility of stretchable electrochemical impedance spectroscopy (EIS) sensors for endoluminal investigations in New Zealand White (NZW) rabbits on diet-induced hyperlipidemia. A parylene C (PAC)-based EIS sensor mounted on the surface of an inflatable silicone balloon affixed to the tip of an interrogating catheter was deployed (1) on the explants of NZW rabbit aorta for detection of lipid-rich atherosclerotic lesions, and (2) on live animals for demonstration of balloon inflation and EIS measurements. An input peak-to-peak AC voltage of 10 mV and sweeping-frequency from 300 kHz to 100 Hz were delivered to the endoluminal sites. Balloon inflation allowed EIS sensors to be in contact with endoluminal surface. In the oxidized low-density-lipoprotein (oxLDL)-rich lesions from explants of fat-fed rabbits, impedance magnitude increased significantly by 1.5-fold across the entire frequency band, and phase shifted ~5° at frequencies below 10 kHz. In the lesion-free sites of the normal diet-fed rabbits, impedance magnitude increased by 1.2-fold and phase shifted ~5° at frequencies above 30 kHz. Thus, we demonstrate the feasibility of stretchable intravascular EIS sensors for identification of lipid rich lesions, with a translational implication for detecting unstable lesions.

Use of coronary computed tomography angiography to detect coronary ostial stenosis after Bentall procedure

Coronary ostial stenosis is a rare complication of the Bentall procedure for aortic root and aortic valve replacement. We report a case of coronary ostial stenosis after a Bentall procedure that was detected by coronary computed tomography angiography and subsequent percutaneous coronary interventions.

Impact of a Multidisciplinary Heart Failure Postdischarge Management Clinic on Medication Adherence

PURPOSE Disease management programs have been associated with improved adherence to heart failure (HF) medications. However, there remain limited data on the benefit of a comprehensive multidisciplinary HF postdischarge management (PDM) clinic that promptly follows HF-related hospitalization on evidence-based HF medication adherence. OBJECTIVE The aim of this study was to evaluate the effects of an HF-PDM clinic on adherence to evidence-based HF medication therapy. METHODS In this retrospective cohort study, we identified patients discharged from the Veterans Affairs Greater Los Angeles Healthcare System between 2009 and 2012 with a primary diagnosis of HF. Data from patients who attended the HF-PDM clinic immediately following HF-related hospitalization between 2010 and 2012 were compared with those from historical controls, who did not attend the HF-PDM clinic, from 2009. The main outcome was adherence to evidence-based HF medications during the 90 days after discharge. Adherence was defined as the proportion of days covered at 90 days after discharge (PDC-90) of ≥0.80. The percentages of patients adherent to each medication were compared between the 2 groups using the χ2 test. A logistic regression model adjusted for potential confounding variables was constructed to evaluate the percentages of patients adherent to evidence-based HF medications. FINDINGS A total of 277 patients (144 clinic, 133 control) were included in the study. Both univariate and multivariate analyses showed that the clinic was associated with improved medication adherence to angiotensin-converting enzyme inhibitors, a twice-daily β-blocker, and aldosterone antagonists compared with controls. The most significant increases were in adherence to angiotensin-converting enzyme inhibitors, with mean PDC-90 values of 0.84 (control) versus 0.93 (clinic) (P = 0.008) and 90-day adherence rates of 69% (control) versus 87% (clinic) (P = 0.005). IMPLICATIONS Care in the multidisciplinary HF-PDM clinic was associated with significant increases in 90-day adherence to evidence-based HF medications in patients who were recently discharged after an HF-related hospitalization.

IMPACT OF A MULTI-DISCIPLINARY HEART FAILURE POST-DISCHARGE MANAGEMENT CLINIC ON MEDICATION ADHERENCE

Specialized clinics have been associated with improved medication adherence to evidence-based heart failure (HF) therapies. We evaluated a structured multi-disciplinary HF clinic focused specifically on those recently discharged after a HF hospitalization. In addition to reducing readmissions, one