Jon R. Resar

Left main coronary thrombosis after radiofrequency ablation: Successful treatment with percutaneous transluminal angioplasty

patible with Kawasaki disease or history consistent with vasculitis or trauma to the chest. As a result of the patients acute coronary syndrome and high-grade obstruction of the LMCA, surgical revascularization was undertaken with both internal mammary arteries. The left internal mammary artery was anastomosed to the LAD coronary artery. The right internal mammary artery was taken to the intermediate vessel. As to the best approach to the coronary artery aneurysm, the consensus was to avoid direct approach to or ligation of the aneurysm. There was concern about distal embolization of thrombus present in the aneurysm preoperatively. We were also of the opinion that risk of embolization would be low if retrograde flow from the distal anastomosis of the grafts exceeded forward flow through the critical stenosis in the distal portion of the aneurysm. A careful search for the cause of these coronary artery aneurysms has been made and, similar to other reported cases, we believe that this case may represent sequelae of an unrecognized case of Kawasaki disease and one of the 3 % of those cases which result in ischemic heart disease. Because there are no serologic markers for Kawasaki disease, this assertion is impossible to prove at this time; however, the angiographic appearance of these lesions is certainly compatible with known cases previously described#

Coronary air embolism: A case report and review of the literature

Coronary air embolism is a complication in the catheterization laboratory that can be associated with high morbidity and even mortality. A case report of air embolism and methods to prevent this complication from occurring are presented along with various management techniques.

Transcatheter aortic valve replacement: Historical perspectives, current evidence, and future directions

Severe aortic stenosis (AS) results in considerable morbidity and mortality without aortic valve replacement and is expected to increase in prevalence with the aging population. Because AS primarily affects the elderly, many patients with comorbidities are poor candidates for surgical aortic valve replacement (SAVR) and may not be referred. Transcatheter aortic valve replacement (TAVR) has emerged as transformative technology for the management of AS over the past decade. Randomized trials have established the safety and efficacy of TAVR with improved mortality and quality of life compared with medical therapy in inoperable patients, while demonstrating noninferiority and even superiority to SAVR among high-risk operative candidates. However, early studies demonstrated an early penalty of stroke and vascular complications with TAVR as well as increased paravalvular leak as compared with SAVR. Two device platforms have been evaluated and approved for use in the United States: the Edwards SAPIEN and the Medtronic CoreValve. Early studies also suggest cost-effectiveness for TAVR. Ongoing studies are evaluating new iterations of the aforementioned TAVR devices, novel device designs, and applications of TAVR in expanded populations of patients including those with lower risk profiles as well as those with comorbidities that were excluded from early clinical trials. Future improvements in TAVR technology will likely reduce periprocedural and long-term complications. Further studies are needed to confirm device durability over long-term follow-up and explore the applicability of TAVR to broader AS patient populations.

Quantitative Automated Assessment of Myocardial Perfusion at Cardiac Catheterization

Perfusion assessed in the cardiac catheterization laboratory predicts outcomes after myocardial infarction. The aim of this study was to investigate a novel method of assessing perfusion using digital subtraction angiography to generate a time-density curve (TDC) of myocardial blush, incorporating epicardial and myocardial perfusion. Seven pigs underwent temporary occlusion of the left anterior descending coronary artery for 60 minutes. Angiography was performed in the same projections before, during, and after occlusion. Perfusion parameters were obtained from the TDC and compared with Thrombolysis In Myocardial Infarction (TIMI) frame count and myocardial perfusion grade. In addition, safety and feasibility were tested in 8 patients after primary percutaneous coronary intervention. The contrast density differential between the proximal artery and the myocardium derived from the TDC correlated well with TIMI myocardial perfusion grade (R = 0.54, p <0.001). The arterial transit time derived from the TDC correlated with TIMI frame count (R = 0.435, p = 0.011). Using a cutoff of 2.4, the density/time ratio, a ratio of density differential to transit time, had sensitivity and specificity of 100% for coronary arterial occlusion. The positive and negative predictive values were 100%. The generation of a TDC was safe and feasible in 7 patients after acute myocardial infarctions, but the correlation between TDC-derived parameters and TIMI parameters did not reach statistical significance. In conclusion, this novel method of digital subtraction angiography with rapid, automated, quantitative assessment of myocardial perfusion in the cardiac catheterization laboratory correlates well with established angiographic measures of perfusion. Further studies to assess the prognostic value of this technique are warranted.

Effect of intravenous fentanyl on ticagrelor absorption and platelet inhibition among patients undergoing percutaneous coronary intervention: Design, rationale, and sample characteristics of the PACIFY randomized trial

INTRODUCTIONnMorphine reduces and delays the absorption of oral P2Y12 platelet inhibitors. Fentanyl is another opiate often administered during percutaneous coronary interventions (PCI). The PACIFY study will test whether intravenous fentanyl also impairs the absorption and action of oral P2Y12 inhibitors.nnnMETHODSnPACIFY is a single-center trial randomizing adults undergoing clinically-indicated coronary angiography to have the procedure with or without fentanyl. All patients will receive local anesthetic and intravenous midazolam. Doses of all drugs are at the discretion of treating providers. Patients that require PCI receive 180mg of oral ticagrelor during the angiography procedure. The primary outcome is area under the ticagrelor plasma concentration-time curve. Secondary outcomes include platelet inhibition 2-h after loading, measured both by VerifyNow® (Accriva Diagnostics, San Diego, California) and by light-transmission platelet aggregometry. We will also survey patient comfort and measure high-sensitivity troponin levels. Patients and outcomes assessors are blinded, treating providers are not.nnnRESULTSnA total of 212 patients are participating, 70 of whom required PCI. Baseline characteristics are numerically well balanced in both study arms. Mean age is 63years and 27% are female. There were no differences in total midazolam dose during the index PCI procedure, whereas mean total fentanyl dose was 9 mcg in the no-fentanyl arm (2 participants in this arm required fentanyl for bailout treatment of pain) versus 96 mcg in the fentanyl arm.nnnCONCLUSIONSnThis study will provide important information on the impact of fentanyl administered during PCI on the absorption of ticagrelor and its antiplatelet activity.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT02683707.

Patent Foramen Ovale in Patients with Sickle Cell Disease and Stroke: Case Presentations and Review of the Literature

Although individuals with sickle cell disease (SCD) are at increased risk for stroke, the underlying pathophysiology is incompletely understood. Intracardiac shunting via a patent foramen ovale (PFO) is associated with cryptogenic stroke in individuals without SCD. Recent evidence suggests that PFOs are associated with stroke in children with SCD, although the role of PFOs in adults with stroke and SCD is unknown. Here, we report 2 young adults with SCD, stroke, and PFOs. The first patient had hemoglobin SC and presented with a transient ischemic attack and a subsequent ischemic stroke. There was no evidence of cerebral vascular disease on imaging studies and the PFO was closed. The second patient had hemoglobin SS and two acute ischemic strokes. She had cerebral vascular disease with moyamoya in addition to a peripheral deep venous thrombosis (DVT). Chronic transfusion therapy was recommended, and the DVT was managed with warfarin. The PFO was not closed, and the patients neurologic symptoms were stabilized. We review the literature on PFOs and stroke in SCD. Our cases and the literature review illustrate the dire need for further research to evaluate PFO as a potential risk factor for stroke in adults with SCD.

Fentanyl Delays the Platelet Inhibition Effects of Oral Ticagrelor: Full Report of the PACIFY Randomized Clinical Trial

Morphine delays oral P2Y 12 platelet inhibitor absorption and is associated with adverse outcomes after myocardial infarction. Consequently, many physicians and first responders are now considering fentanyl as an alternative. We conducted a single-centre trial randomizing cardiac patients undergoing coronary angiography to intravenous fentanyl or not. All participants received local anaesthetic and intravenous midazolam. Those requiring percutaneous coronary intervention (PCI) with stenting received 180u2009mg oral ticagrelor intra-procedurally. The primary outcome was area under the ticagrelor plasma concentration–time curve (AUC 0–24 hours ). The secondary outcomes were platelet function assessed at 2 hours after loading, measured by P2Y 12 reaction units (PRUs) and light transmission platelet aggregometry. Troponin-I was measured post-PCI using a high-sensitivity troponin-I assay (hs-TnI). All participants completed a survey of pain and anxiety. Of the 212 randomized, 70 patients required coronary stenting and were loaded with ticagrelor. Two participants in the no-fentanyl arm crossed over to receive fentanyl for pain. In as-treated analyses, ticagrelor concentrations were higher in the no-fentanyl arm (AUC 0–24 hours 70% larger, p u2009=u20090.03). Platelets were more inhibited by 2 hours in the no-fentanyl arm (71 vs. 113 by PRU, p u2009=u20090.03, and 25% vs. 41% for adenosine diphosphate response by platelet aggregation, p u2009<u20090.01). Mean hs-TnI was higher with fentanyl at 2 hours post-PCI (11.9 vs. 7.0 ng/L, p u2009=u20090.04) with a rate of enzymatic myocardial infarction of 11% for fentanyl and 0% for no-fentanyl ( p u2009=u20090.08). No statistical differences in self-reported pain or anxiety were found. In conclusion, fentanyl administration can impair ticagrelor absorption and delay platelet inhibition, resulting in mild excess of myocardial damage. This newly described drug interaction should be recognized by physicians and suggests that the interaction between opioids and oral P2Y 12 platelet inhibitors is a drug class effect associated with all opioids. Clinical Trial Registration: u2003 https://clinicaltrials.gov/ct2/show/NCT02683707 ( NCT02683707).

A Hybrid Model for Advanced Structural Heart Disease Training Programs: The Attending-Fellow-in-Training Model

Structural heart disease (SHD) fellowship programs in the United States are growing, but they are still not accredited by the Accreditation Council for Graduate Medical Education. This results in a lack of standardized curriculum and complicates funding for a dedicated fellowship, as Medicare and

Mediastinal Fibrosis of the Pulmonary Artery Secondary to Tuberculosis.

Mediastinal fibrosis is an uncommon disease involving the esophagus, respiratory tract, and great vessels. We report a man who presented with dyspnea on exertion. Computed tomography of the chest demonstrated granulomatous disease with dense calcifications leading to severe stenosis of the main pulmonary artery (PA) and narrowing of the superior vena cava. The results of tuberculosis (TB) interferon-γ release assay and TB-polymerase chain reaction were positive for Mycobacterium tuberculosis. The patient received 2 weeks of treatment for latent TB before undergoing resection of fibrotic tissue and replacement of the main and branch PAs using a homograft.

Phase of Care Mortality Analysis: A Unique Method for Comparing Mortality Differences Among Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Patients

The objective of this study is based on the phase of care mortality analysis (POCMA), an effective tool to evaluate the root cause of in-hospital mortality in cardiac surgery patients. POCMA has not been used to compare operative mortalities among transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) populations, and may provide insight that could affect patient safety initiatives and improve outcomes in aortic valve surgery. We included patients who underwent TAVR or isolated SAVR between 2011 and March 31, 2015 and did not survive the index hospitalization. A multidisciplinary heart team made POCMA assignments as part of the weekly morbidity and mortality conference, pinpointing the phase of care and subcategory that directly caused or had the greatest effect on each mortality. During the study period, 240 patients underwent TAVR and 530 underwent SAVR. Unadjusted mortality rates were significantly higher in the TAVR group, 5.0% (n = 12) compared with SAVR, 1.9% (n = 10) (P = 0.016). TAVR deaths by phase of care are as follows: 0 for preoperative, 9 (72.8%) for intraoperative, 2 (18.2%) for postoperative intensive care unit, and 1 (9.1%) for postoperative floor. By comparison, 4 (40%) SAVR deaths had a root cause in the preoperative phase, 1 (10%) in the intraoperative phase, and 5 (50%) in the postoperative intensive care unit phase. POCMA is a novel method of categorizing in-hospital mortalities. Our single institution review revealed that patients who underwent TAVR more often expired because of intraoperative technical issues, whereas SAVR deaths were typically the result of patient selection or postoperative complications.