Joseph L. Fredi

Comparison of 30-day outcomes of coronary artery bypass grafting surgery verus hybrid coronary revascularization stratified by SYNTAX and euroSCORE.

OBJECTIVE The optimal treatment of multivessel coronary artery disease is not well established. Hybrid coronary revascularization by combining the left internal mammary artery-left anterior descending artery graft and drug-eluting stents in non-left anterior descending artery territories might offer superior results compared with sole coronary artery bypass grafting or sole percutaneous coronary intervention. METHODS We retrospectively analyzed the 30-day outcomes of 381 consecutive patients undergoing coronary artery bypass grafting (n = 301) vs hybrid coronary revascularization (n = 80). In a 2 × 2 matrix, the 2 groups were stratified by the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (≤32 vs ≥33) and the European System for Cardiac Operative Risk Evaluation (euroSCORE) (<5 vs ≥5). The composite endpoint (death from any cause, stroke, myocardial infarction, low cardiac output syndrome) and secondary endpoints (worsening postprocedural renal function and bleeding) were determined. RESULTS After stratification using the SYNTAX and the euroSCORE, the preoperative characteristics were similar within the 4 groups, except for the ≥33 SYNTAX/>5 euroSCORE. The hybrid coronary revascularization patients were older (77 vs 65 years, P = .001). The postoperative outcomes using combined SYNTAX and the euroSCORE stratification showed a similar rate of the composite endpoint for all groups except for patients with ≥33 SYNTAX/>5 euroSCORE (0% for the coronary artery bypass grafting group vs 33% for the hybrid coronary revascularization group, P = .001). An analysis of the secondary endpoint showed similar results across all groups, except for in the ≥33 SYNTAX/>5 euroSCORE group, in which bleeding (re-exploration for bleeding and transfusion >3 packed red blood cell units per patient) was 44% in the hybrid coronary revascularization group vs 11% in the coronary artery bypass grafting group (P = .05). CONCLUSIONS Hybrid coronary revascularization is a safe alternative to coronary artery bypass grafting in many patients with multivessel coronary artery disease. However, in high-risk patients with complex coronary artery disease (≥33 SYNTAX/>5 euroSCORE), coronary artery bypass grafting is superior to hybrid coronary revascularization.

Left Atrial Hypertension After Repeated Catheter Ablations for Atrial Fibrillation

To the Editor: Catheter ablation is an important treatment for recurrent, symptomatic atrial fibrillation (AF). The original procedure targeted focal triggers of AF arising from within the pulmonary veins (PVs). This technique generated minimal left atrial (LA) scar but was complicated by the

Clinical features of precocious acute coronary syndrome.

BACKGROUND Acute coronary syndrome due to acute plaque rupture has been well described and is associated with established risk factors, including hypertension, diabetes mellitus, hyperlipidemia, and smoking. The prevalence of these risk factors in very young patients (aged ≤35 years) is not well known, and they may have other nontraditional risk factors. We hypothesized that acute coronary syndrome in very young patients may represent a thrombotic event independent of underlying atherosclerotic disease. METHODS We performed a dual-institution, retrospective study of consecutive patients aged ≤35 years who presented with acute coronary syndrome and underwent coronary angiography from January 2000 to December 2011. Standard demographics, risk factors, and detailed angiographic information were obtained. RESULTS A total of 124 patients met inclusion criteria. The mean age was 31 ± 4 years for both sexes. Approximately half (49%) of the patients were obese (body mass index ≥30 kg/m(2)); 90% of patients had at least 1 traditional risk factor, most commonly hyperlipidemia (63%) and smoking (60%); 52% of patients underwent re-vascularization, of which 94% were by percutaneous coronary intervention, and 42.9% of patients had intracoronary thrombus, of whom approximately one third had no detectable underlying coronary disease. CONCLUSIONS Very young patients with acute coronary syndrome tend to be obese, with a high prevalence of smoking and hyperlipidemia. The presence of thrombus in the absence of underlying coronary disease suggests a thromboembolic event or de novo thrombotic occlusion, which may reflect primary hemostatic dysfunction in a considerable number of these patients.

Monitoring myocardial recovery during induced hypothermia with a disposable monoplane TEE probe.

A 73 year old female with a history coronary artery bypass grafting and coronary stents had a witnessed cardiac arrest at home. She was transferred to an outside hospital and emergency heart catheterization revealed patent LIMA to LAD, stented grafts open, and no new culprit lesions. A temporary transvenous pacing wire was placed for bradycardia. She was transferred to the ICU where she was sedated and paralyzed for induction of hypothermia approximately five hours after the arrest. A miniaturized disposable TEE probe (Photo 1) was placed to allow ongoing monitoring of cardiac function and intravascular volume.

Timeliness of interfacility transfer for ED patients with ST-elevation myocardial infarction ☆

OBJECTIVES Most US hospitals lack primary percutaneous coronary intervention (PCI) capabilities to treat patients with ST-elevation myocardial infarction (STEMI) necessitating transfer to PCI-capable centers. Transferred patients rarely meet the 120-minute benchmark for timely reperfusion, and referring emergency departments (EDs) are a major source of preventable delays. We sought to use more granular data at transferring EDs to describe the variability in length of stay at referring EDs. METHODS We retrospectively analyzed a secondary data set used for quality improvement for patients with STEMI transferred to a single PCI center between 2008 and 2012. We conducted a descriptive analysis of the total time spent at each referring ED (door-in-door-out [DIDO] interval), periods that comprised DIDO (door to electrocardiogram [EKG], EKG-to-PCI activation, and PCI activation to exit), and the relationship of each period with overall time to reperfusion (medical contact-to-balloon [MCTB] interval). RESULTS We identified 41 EDs that transferred 620 patients between 2008 and 2012. Median MCTB was 135 minutes (interquartile range [IQR] 114,172). Median overall ED DIDO was 74 minutes (IQR 56,103) and was composed of door to EKG, 5 minutes (IQR 2,11); EKG-to-PCI activation, 18 minutes (IQR 7,37); and PCI activation to exit, 44 minutes (IQR 34,56). Door-in door-out accounted for the largest proportion (60%) of overall MCTB and had the largest variability (coefficient of variability, 1.37) of these intervals. CONCLUSIONS In this cohort of transferring EDs, we found high variability and substantial delays after EKG performance for patients with STEMI. Factors influencing ED decision making and transportation coordination after PCI activation are a potential target for intervention to improve the timeliness of reperfusion in patients with STEMI.

Effect of Transcutaneous Aortic Valve Implantation on the Heyde's Syndrome

The association between aortic valve stenosis and gastrointestinal bleeding, traditionally known as Heydes syndrome, is the result of a quantitative loss of the highest molecular weight von Willebrand multimers (type 2A von Willebrand syndrome). This results in bleeding from areas of high shear stress such as gastrointestinal angiodysplasias. Correction of this bleeding diathesis after surgical aortic valve replacement has been well described. The effect of transcutaneous aortic valve implantation on Heydes syndrome has yet to be studied. Herein, we report a patient with severe aortic stenosis, type 2A von Willebrand syndrome, and hemorrhagic shock from gastrointestinal bleeding who underwent successful transcutaneous aortic valve implantation.

Peripheral Vascular Complications During Transcatheter Aortic Valve Replacement

PURPOSE To report a case of a major vascular complication during transcatheter aortic valve replacement (TAVR) and the endovascular management thereof. Additionally, we discuss a possible correlation with long-term steroid use. CASE REPORT A 79-year-old woman with a history of critical aortic stenosis underwent elective TAVR. Her procedure was complicated by rupture of her right iliac artery, life-threatening retroperitoneal hemorrhage, and thrombus extending into the distal right lower extremity. This case was emergently managed by stent placement, thrombectomy, and tissue plasminogen activator via a percutaneous approach. CONCLUSIONS Peripheral vascular complications are common during percutaneous TAVR, and chronic steroid use may predispose patients. Endovascular management is often possible and may potentially save valuable time in emergent situations.

Peripheral vascular complications during transcatheter aortic valve replacement: management and potential role of chronic steroid use.

PURPOSE To report a case of a major vascular complication during transcatheter aortic valve replacement (TAVR) and the endovascular management thereof. Additionally, we discuss a possible correlation with long-term steroid use. CASE REPORT A 79-year-old woman with a history of critical aortic stenosis underwent elective TAVR. Her procedure was complicated by rupture of her right iliac artery, life-threatening retroperitoneal hemorrhage, and thrombus extending into the distal right lower extremity. This case was emergently managed by stent placement, thrombectomy, and tissue plasminogen activator via a percutaneous approach. CONCLUSIONS Peripheral vascular complications are common during percutaneous TAVR, and chronic steroid use may predispose patients. Endovascular management is often possible and may potentially save valuable time in emergent situations.

Complete fusion of a percutaneous aortic valve placed after ventricular assist device

Severe aortic insufficiency following continuous flow left ventricular assist device (LVAD) placement requires intervention. Conventional corrective approaches are varied and morbid. Increasingly, percutaneous solutions, such as transcatheter aortic valve replacement (TAVR), have been used to rescue these patients. The unique flow characteristics in the aortic root following LVAD implantation may have unintended consequences to the TAVR leaflets. We describe the premature fusion of TAVR leaflets following 159 days of LVAD support. TAVR should be used with some caution in patients with continuous flow LVADs.

Delirium After Transcatheter Aortic Valve Replacement

Background Postoperative delirium is associated with increased mortality. Patients undergoing transcatheter aortic valve replacement are at risk for delirium because of comorbid conditions. Objective To compare the incidence, odds, and mortality implications of delirium between patients undergoing transcatheter replacement and patients undergoing surgical replacement. Methods The Richmond Agitation‐Sedation Scale and the Confusion Assessment Method for the Intensive Care Unit were used to assess arousal level and delirium prospectively in all patients with severe aortic stenosis who had transcatheter or surgical aortic valve replacement at an academic medical center. Multivariable logistic regression was used to determine the relationship between procedure type and occurrence of delirium. Cox regression was used to assess the association between postoperative delirium and 6‐month mortality. Results A total of 105 patients had transcatheter replacement and 121 had surgical replacement. Patients in the transcatheter group were older (median age, 81 vs 68 years; P < .001) and had more comorbid conditions (median Charlson Comorbidity Index, 3 vs 2; P < .001). Patients in the transcatheter group also had lower incidence (19% vs 21%; P = .65) and odds of delirium developing (odds ratio, 0.4; 95% CI, 0.2–0.9; P = .03). Delirium was independently associated with a 3‐fold higher mortality by 6 months (hazard ratio, 3.4; 95% CI, 1.3–8.8; P = .01). Conclusions Delirium occurs in at least 1 in 5 patients after transcatheter or surgical aortic valve replacement. Delirium is less likely to develop in the transcatheter group but is associated with higher mortality in both groups.