Ronan Margey

Contemporary management of and outcomes from cardiac device related infections

AIMS To describe the incidence and management of cardiac device infection. Infection is a serious, potentially fatal complication of device implantation. The numbers of device implants and infections are rising. Optimal care of device infection is not well defined. METHODS AND RESULTS We retrospectively identified cases of device infection at our institution between 2000 and 2007 by multiple source record review, and active surveillance. Device infection was related to demographics, clinical, and procedural characteristics. Descriptive analysis was performed. From 2000 to 2007, a total of 2029 permanent pacemakers and 1076 biventricular/implantable cardioverter-defibrillators (ICDs) or ICDs were implanted. Thirty-nine cases of confirmed device infections were identified--27 pacemaker and 12 bivent/ICD or ICD infections, giving an infection rate of 1.25%. Median time from implant or revision to presentation was 150 days (range 2915 days, IQR25% 35-IQR75% 731). Ninety percent of patients presented with generator-site infections. The most common organism was methicillin-sensitive Staphylococcus aureus (30.8%), followed by coagulase negative Staphylococcus (20.5%). Complete device extraction occurred in 82%. Of these, none had relapse, and mortality was 7.4% (n = 2/27). With partial removal or conservative therapy (n = 13), relapse occurred in 67% (n = 8/12), with mortality of 8.4% (n = 1/12). Median duration of antibiotics was 42 days (range 47 days, IQR25% 28-IQR75% 42 days). Re-implantation of a new device occurred in 54%, at a median of 28 days (range 73 days, IQR25% 8.5-IQR75% 35 days). Methicillin-Resistant Staphylococcus Aureus infection predicted mortality (P < 0.004, RR 37, 95% CI 5.3-250). Median follow-up was 36 months. CONCLUSION Cardiac device infection is a rare complication, with significant morbidity and mortality. Complete hardware removal with appropriate duration of antimicrobial therapy results in the best outcomes for patients.

Drug-eluting stent for left main coronary artery disease. The DELTA registry: a multicenter registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment.

OBJECTIVES The aim of this study was to compare, in a large all-comers registry, major adverse cardiac and cerebrovascular events (MACCE) after percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) in unprotected left main coronary artery (ULMCA) stenosis. BACKGROUND Percutaneous coronary intervention with DES implantation in ULMCA has been shown to be a feasible and safe approach at midterm clinical follow-up. METHODS All consecutive patients with ULMCA stenosis treated by PCI with DES versus CABG were analyzed in this multinational registry. A propensity score analysis was performed to adjust for baseline differences in the overall cohort. RESULTS In total 2,775 patients were included: 1,874 were treated with PCI versus 901 with CABG. At 1,295 (interquartile range: 928 to 1,713) days, there were no differences, at the adjusted analysis, in the primary composite endpoint of death, cerebrovascular accidents, and myocardial infarction (MI) (adjusted hazard ratio [HR]: 1.11; 95% confidence interval [CI]: 0.85 to 1.42; p = 0.47), mortality (adjusted HR: 1.16; 95% CI: 0.87 to 1.55; p = 0.32), or composite endpoint of death and MI (adjusted HR: 1.25; 95% CI: 0.95 to 1.64; p = 0.11). An advantage of CABG over PCI was observed in the composite secondary endpoint of MACCE (adjusted HR: 1.64; 95% CI: 1.33 to 2.03; p < 0.0001), driven exclusively by the higher incidence of target vessel revascularization with PCI. CONCLUSIONS In our multinational all-comers registry, no difference was observed in the occurrence of death, cerebrovascular accidents, and MI between PCI and CABG. An advantage of CABG over PCI was observed in the incidence of MACCE, driven by the higher incidence of target vessel revascularization with PCI.

Antiplatelet Agents in the Perioperative Period

OBJECTIVE To determine the use of the 3 major classes of antiplatelet drugs (aspirin, thienopyridines, and glycoprotein IIb/IIIa inhibitors), their management in the perioperative period, and the risks associated with premature withdrawal. DATA SOURCES We reviewed the PubMed, EMBASE, and Cochrane databases using the terms antiplatelet agents in the perioperative period, antiplatelet agents and management of bleeding, drug-eluting stents and stent thrombosis, substitutes for antiplatelet agents, and premature withdrawal of antiplatelet agents. STUDY SELECTION Randomized, double-blind, placebo-controlled trials; prospective observational studies; review articles; clinical registry data; and guidelines of professional bodies pertaining to antiplatelet agents were included. DATA EXTRACTION AND SYNTHESIS Two researchers independently read the selected abstracts and selected the studies that matched the inclusion criteria. Any discordance between the 2 researchers was resolved by discussion so that 99 articles were finally included. CONCLUSIONS Aspirin use should not be stopped in the perioperative period unless the risk of bleeding exceeds the thrombotic risk from withholding the drug. With the exception of recent drug-eluting stent implantation, clopidogrel bisulfate use should be stopped at least 5 days prior to most elective surgery. Use of glycoprotein IIb/IIIa inhibitors must be discontinued preoperatively for more than 12 hours to allow normal hemostasis. Premature withdrawal of antiplatelet agents is associated with a 10% risk of all vascular events. Following drug-eluting stent implantation, withdrawal is associated with stent thrombosis and potentially fatal consequences. No definitive guidelines exist to manage patients who are actively bleeding while taking these drugs.

Sudden cardiac death in 14- to 35-year olds in Ireland from 2005 to 2007: a retrospective registry.

INTRODUCTION Sudden cardiac death (SCD) in young people is a rare but devastating event for families and communities. Ireland has previously had no measure of the incidence of SCD in young people. We report the incidence and causes of SCD in persons <35 years of age. METHODS AND RESULTS We undertook a retrospective study of SCD between 2005 and 2007 in persons aged 15-35 years in the Republic of Ireland. We identified potential cases of out of hospital SCD through the Central Statistics Office (CSO) death certificate records. Autopsy, toxicology, and inquest reports were then obtained and analysed by an expert panel who adjudicated on the cause of death. A total of 342 potential SCD cases were identified through the CSO. Fifty were younger than 15 years of age, and 86 had either incomplete or unavailable post-mortem reports. Of 206 full reports obtained, 116 were adjudicated as cases of SCD. Cases were predominantly male (75%), with a mean age of 25.8 years (standard deviation 6.3). The incidence of SCD in this age range was 2.85 per 100,000 person-years (4.36 for males and 1.30 for females) and the incidence of sudden arrhythmic death syndrome (SADS) was 0.76 per 100,000 person-years. The commonest causes were SADS, 26.7% (31 of 116), followed by coronary artery disease, 20.7% (24 of 116), hypertrophic cardiomyopathy (HCM), 14.7% (17 of 116), and idiopathic left ventricular hypertrophy not fulfilling criteria for HCM, 10.3% (12 of 116). CONCLUSIONS The incidence of SCD in the young in Ireland was 4.96 (95% CI 3.06, 6.4) for males and 1.3 (95% CI 0.62, 2.56) for females per 100 000 person-years. Sudden arrhythmic death syndrome was the commonest cause of SCD in the young, and the incidence of SADS was more than five times that in official reports of the Irish CSO.

Intravascular Detection of the Vulnerable Plaque

Coronary heart disease (CHD) remains the leading cause of death in the United States, and an estimated 1.4 million Americans have a heart attack each year. Over the past 2 decades, the concept of the “vulnerable plaque” (VP) being responsible for the majority of acute coronary syndromes (ACS) has become widely accepted. Coincidentally, there has been rapid expansion of coronary imaging modalities, both invasive and noninvasive, seeking the ability to detect high-risk plaques before their disruption and formation of occlusive thrombus. Histological characteristics of the plaques that are vulnerable to rupture are thin fibrous cap (<65 μm), large lipid pool, and activated macrophages near the fibrous cap, all of which can be detected with high-resolution coronary imaging.1 Cellular mechanisms associated with plaque instability include inflammation, reduced collagen synthesis, local overexpression of collagenase, and smooth muscle cell apoptosis. These pathological processes can alter the plaque surface and its mechanical properties, which also have been targets of recent research. Noninvasive tests, such as CT and MRI are limited by low resolution and are unable to visualize most of the features of VP. At present, only intravascular modalities can potentially distinguish VP from benign types of plaques. In this review, we focus on the recent data from the various types of intravascular modalities currently available or in development and compare their advantages and limitations. Coronary plaque develops eccentrically, and increasing plaque volume induces positive remodeling of the vessel, resulting in external elastic membrane expansion and preservation of luminal area. Coronary angiography only visualizes the coronary lumen and does not provide any information about the characteristics of the arterial wall and its contents. For this reason, coronary angiography has failed as a diagnostic modality for detection of VP, which often causes only modest luminal narrowing. Various histological plaque components have been targeted as …

Dobutamine stress echo-induced apical ballooning (Takotsubo) syndrome

AIMS We report a case of dobutamine stress echocardiography (DSE) resulting in transient apical ballooning syndrome to highlight this rare condition as a potential complication of DSE. BACKGROUND Takotsubo cardiomyopathy, or transient apical ballooning syndrome, is a recently described form of left ventricular (LV) dysfunction induced by stress. Clinically it can mimic acute coronary syndrome in its presentation. It is characterized by an atypical distribution of LV dysynergy with apical ballooning and compensatory basal hyperkinesis. Coronary angiography is normal. It has preponderance in females. Although the aetiology of Takotsubo syndrome remains obscure catecholamine release appears to be the principal trigger. RESULTS We report a case of dobutamine-induced transient LV apical ballooning in a woman without coronary disease, during a dobutamine stress echocardiogram. There was evidence of ventricular recovery by 72 h. To our knowledge, only three other case reports describe dobutamine-induced Takotsubo cardiomyopathy. CONCLUSION Dobutamine stress echocardiography is a widely performed diagnostic test, however, it can rarely result in presumed catecholamine-induced transient apical ballooning syndrome.

Long-term clinical outcomes after percutaneous coronary intervention versus coronary artery bypass grafting for ostial/midshaft lesions in unprotected left main coronary artery from the DELTA registry: A multicenter registry evaluating percutaneous coronary intervention versus coronary artery bypass grafting for left main treatment

OBJECTIVES The aim of this study was to report the long-term clinical outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for ostial/midshaft lesions in an unprotected left main coronary artery (ULMCA). BACKGROUND Data regarding outcomes in these patients are limited. METHODS Of a total of 2,775 patients enrolled in the DELTA multinational registry, 856 patients with isolated ostial/midshaft lesions in an ULMCA treated by PCI with DES (n = 482) or CABG (n = 374) were analyzed. RESULTS At a median follow-up period of 1,293 days, there were no significant differences in the propensity score-adjusted analyses for the composite endpoint of all-cause death, myocardial infarction (MI), and cerebrovascular accident (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.79 to 1.86; p = 0.372), all-cause death (HR: 1.35, 95% CI: 0.80 to 2.27; p = 0.255), the composite endpoint of all-cause death and MI (HR: 1.33, 95% CI: 0.83 to 2.12; p = 0.235) and major adverse cardiac and cerebrovascular events (HR: 1.34, 95% CI: 0.93 to 1.93; p = 0.113). These results were sustained after propensity-score matching. However, a higher incidence of target vessel revascularization (HR: 1.94, 95% CI: 1.03 to 3.64; p = 0.039) was observed in the PCI compared with the CABG group, with a trend toward higher target lesion revascularization (HR: 2.00, 95% CI: 0.90 to 4.45; p = 0.090). CONCLUSIONS This study demonstrates that PCI for ostial/midshaft lesions in an ULMCA is associated with clinical outcomes comparable to those observed with CABG at long-term follow-up, despite the use of older first-generation DES.

The Dublin cardiac arrest registry: temporal improvement in survival from out-of-hospital cardiac arrest reflects improved pre-hospital emergency care

AIMS Out-of-hospital cardiac arrest (OOHCA) survival remains poor, estimated at 3-7%. We aim to describe the incidence of OOHCA, survival from OOHCA, and the impact of improved pre-hospital care on survival from OOHCA. METHODS AND RESULTS A retrospective registry was established using multi-source information to assess survival from cardiac arrest following the introduction of several improvements in pre-hospital emergency medical care from 2003. Survival from OOHCA, from asystole/pulseless electrical activity, and from ventricular tachycardia/ventricular fibrillation was estimated. Adjusted per 100 000 population annual incidence rates from national population census data were calculated. Mean and median emergency medical services (EMS) response times to OOHCA calls were assessed. A total of 962 OOHCAs occurred from 1 January 2003 until 31 December 2008. Sixty-nine per cent (69%, n = 664) were male. Seventy-two per cent (72%, n = 693) occurred at home with 28% occurring in a public venue. Of these public venues, 33.9% (91 of 268) had an automated external defibrillator available. Bystander cardiopulmonary resuscitation (CPR) was in progress when emergency services arrived in 11% (n = 106) of the cases. Nineteen per cent (19.4%, n = 187) had a known prior cardiac history or chest pain prior to circulatory collapse. Overall survival to hospital discharge improved significantly from 2.6 to 11.3%, P = 0.001. Survival from ventricular fibrillation (VF) to hospital admission, rose from 28.6 to 86.3%, P = 0.001. Survival to hospital discharge from VF improved from 21.4 to 33%, P = 0.007. Mean EMS response times to the scene of arrest decreased from 9.18 to 8.34 min. Emergency medical services scene time, reflecting acute pre-hospital medical care, rose from 14.46 to 18.12 min. The adjusted incidence of OOHCA for our catchment population declined from 109.4 to 88.2 per 100,000 population between 2003 and 2008. CONCLUSIONS The incidence of OOHCA has declined but importantly, survival to hospital discharge has improved dramatically. Reduction in ambulance response time, resulting in earlier initiation of basic and advanced life support and earlier defibrillation, was associated with an increase in the proportion of victims found in VF rather than asystole and likely accounted for most of the improvement. Further improvements in response times and public education to improve bystander CPR rates should remain a priority.

The Echo Score Revisited: Impact of Incorporating Commissural Morphology and Leaflet Displacement to the Prediction of Outcome for Patients Undergoing Percutaneous Mitral Valvuloplasty

Background— Current echocardiographic scoring systems for percutaneous mitral valvuloplasty (PMV) have limitations. This study examined new, more quantitative methods for assessing valvular involvement and the combination of parameters that best predicts immediate and long-term outcome after PMV. Methods and Results— Two cohorts (derivation n=204 and validation n=121) of patients with symptomatic mitral stenosis undergoing PMV were studied. Mitral valve morphology was assessed by using both the conventional Wilkins qualitative parameters and novel quantitative parameters, including the ratio between the commissural areas and the maximal excursion of the leaflets from the annulus in diastole. Independent predictors of outcome were assigned a points value proportional to their regression coefficients: mitral valve area ⩽1 cm2 (2), maximum leaflets displacement ⩽12 mm (3), commissural area ratio ≥1.25 (3), and subvalvular involvement (3). Three risk groups were defined: low (score of 0–3), intermediate (score of 5), and high (score of 6–11) with observed suboptimal PMV results of 16.9%, 56.3%, and 73.8%, respectively. The use of the same scoring system in the validation cohort yielded suboptimal PMV results of 11.8%, 72.7%, and 87.5% in the low-, intermediate-, and high-risk groups, respectively. The model improved risk classification in comparison with the Wilkins score (net reclassification improvement 45.2%; P<0.0001). Long-term outcome was predicted by age and postprocedural variables, including mitral regurgitation, mean gradient, and pulmonary pressure. Conclusions— A scoring system incorporating new quantitative echocardiographic parameters more accurately predicts outcome following PMV than existing models. Long-term post-PMV event-free survival was predicted by age, degree of mitral regurgitation, and postprocedural hemodynamic data.

Comprehensive Medical Management of Peripheral Arterial Disease

Peripheral arterial disease (PAD) is highly prevalent and is associated with high morbidity and mortality. The medical management of PAD involves a comprehensive approach to the patient with emphasis on cardiovascular risk factor modification in addition to therapies directed at treatment of limb symptoms. This manuscript will review the current status of medical therapy in management of patients with PAD.