Tatiana Busu

Incidence and Outcomes of Myocardial Infarction in Patients Admitted With Acute Ischemic Stroke

Background and Purpose— Data on the incidence and outcomes of acute myocardial infarction (AMI) complicating acute ischemic stroke (AIS) are limited. We aim to evaluate the incidence, treatment patterns, and outcomes of AMI in patients with AIS using a nationwide database. Methods— The National Inpatient Sample was used to identify patient with AIS between 2003 and 2014. Trends of incidence of AMI and its associated in-hospital mortality were evaluated. Univariate and multivariate logistic regressions were used to evaluate predictors of AMI. The impact of AMI on in-hospital outcomes was assessed in a comparative analysis of propensity-matched groups of patients with and without AMI. Results— Patients with AIS (n=864u2009043) were identified in the national inpatient sample, of whom 13u2009573 patients (1.6%) had an AMI (79.5% non–ST-segment–elevation myocardial infarction and 20.5% ST-segment–elevation myocardial infarction). In-hospital mortality was 21.4% and 7.1% in propensity-matched cohorts of patients with and without AMI, P<0.001. In-hospital length of stay and cost of care were 50% higher in the AMI group. In a multivariate logistical regression analysis, the strongest predictors of having AMI after AIS were older age, history of coronary artery disease, chronic renal insufficiency, undergoing mechanical thrombectomy, and rhythm and conduction abnormalities. In the AMI group, undergoing coronary angiography and undergoing percutaneous coronary intervention both strongly correlated with lower in-hospital mortality (odds ratio, 0.34 [confidence interval, 0.23–0.51] and 0.26 [confidence interval, 0.20–0.34], respectively, P<0.001). However, these were only performed in 7.5% and 2% of patients, respectively. Conclusions— AMI complicating stroke carries a substantial in-hospital mortality and cost of care. Patients who underwent coronary angiography with or without intervention may have improved survival although it was only utilized in a minority of patients. Further studies needed to discern the ideal approach in AMI in patients with AIS.

Percutaneous closure of left ventricular pseudoaneurysm caused by a central venting cannula

Minimally invasive transcatheter closure using Amplatzer occluders have been used to treat myocardial and aortic fistulas following surgical procedures. We present images demonstrating the use of an Amplatzer plug to treat a left ventricular (LV) pseudoaneurysm following a surgical procedure in which an LV vent was inserted. A 72-year old female with severe tricuspid regurgitation, history of patent foramen ovale closure, and pacemaker implantation was evaluated for recurrent heart failure and constrictive pericarditis and underwent a pericardiectomy, tricuspid valve ring repair, and bypass grafting of the right coronary artery. During cardiopulmonary bypass, a 15-French DLP vent cannula (Medtronic, Minneapolis, MN) was advanced into the LV via the right superior pulmonary vein. After a

Antegrade Transcatheter Closure of a Large Aortic Paravalvular Leak

A 72-year-old female was evaluated for recurrent admissions with decompensated heart failure. She has a history of ischemic cardiomyopathy (ejection fraction 25%), porcelain aorta, chronic abdominal aortic dissection, atrial septal defect (ASD), and a recent transapical aortic valve replacement with a 23-mm Sapien-XT valve (Edwards, Irvine, CA, USA). She was found to have severe aortic paravalvular leak (PVL) (Supplemental Video 1). Baseline hemodynamic measurements revealed the following pressures: aorta 105/38mmHg, right atrium 10mmHg, andmean pulmonary artery pressure 28 mmHg. Left ventricular (LV) end diastolic pressure was 25 mmHg. Initially, we performed postdilation of the Sapien-XT valve with a 22-mm True Flow balloon (C. R. Bard Inc.,MurrayHill, NJ, USA), but observed no change in the PVL severity (Supplemental Video 2). Hence, percutaneous closure guided by intracardiac echocardiography (ICE) was planned. The leak was crossed readily via a retrograde approach with a 0.035” straight stiff glide wire (Terumo, Tokyo, Japan). However, due to the serpiginous and calcified PVL track, we were only able to partially advance a 5-French Raabe sheath (Cook Medical, Bloomington, IN, USA) and deploy one 12-mm Amplatzer-Vascular-Plug (AVP)-II device (St. JudeMedical, Saint Paul, MN, USA) (Supplemental Video 3). Unfortunately, the PVL remained severe and therefore the device was removed and antegrade access with veno-arterial rail was planned.We contemplated arterial-arterial rail but were concerned about dislodgment of a newly placed transcatheter heart valve. A balloon wedge catheter was advanced via the ASD into the LV and exchanged with an EnSnare delivery catheter (Merit Medical Systems Inc., South Jordan, UT, USA). The leak was re-crossed with the stiff glide wire, which was then snared with a 12–20mm EnSnare establishing a veno-arterial rail (Figure 1A,B).A 6-FrenchRaabe sheathwas advanced antegrade over the rail through the leak (Figure 1C). The ICE probe was advanced into the right ventricular outflow tract allowing excellent imaging of the aortic annulus, and avoidance of general anesthesia (Figure 2). Three 10-mm and one 8-mmAVPII devices were then sequentially deployed reducing the PVL to

Impact of acute diabetes decompensation on outcomes of diabetic patients admitted with ST-elevation myocardial infarction

BackgroundAcute hyperglycemia is associated with worse outcomes in diabetic patients admitted with ST-elevation myocardial infarction (STEMI). However, the impact of full-scale decompensated diabetes on STEMI outcomes has not been investigated.MethodsWe utilized the national inpatient sample (2003–2014) to identify adult diabetic patients admitted with STEMI. We defined decompensated diabetes as the presence of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). We compared in-hospital morbidity and mortality and cost between patients with and without diabetes decompensation before and after propensity-score matching.ResultsA total of 73,722 diabetic patients admitted with STEMI were included in the study. Of those, 1131 (1.5%) suffered DKA or HSS during the hospitalization. After propensity-score matching, DKA/HHS remained associated with a significant 32% increase in in-hospital mortality (25.6% vs. 19.4%, pu2009=u20090.001). The DKA/HHS group also had higher incidences of acute kidney injury (39.4% vs. 18.9%, pu2009<u20090.001), sepsis (7.3% vs. 4.9%, pu2009=u20090.022), blood transfusion (11.3% vs. 8.2%) and a non-significant trend towards higher incidence of stroke (3.8% vs. 2.4%, pu2009=u20090.087). Also, DKA/HHS diagnosis was associated with lower rates of referral to coronary angiography (51.5% vs. 55.5%, pu2009=u20090.023), coronary stenting (26.1% vs. 34.8%, pu2009<u20090.001), or bypass grafting (6.2% vs. 8.7%, pu2009=u20090.033). Referral for invasive angiography was associated with lower odds of death during the hospitalization (adjusted OR 0.66, 95%CI 0.44-0.98, pu2009=u20090.039).ConclusionsDecompensated diabetes complicatesu2009~u20091.5% of STEMI admissions in diabetic patients. It is associated with lower rates of referral for angiography and revascularization, and a negative differential impact on in-hospital morbidity and mortality and cost.

Meta-Analysis Comparing the Frequency of Stroke After Transcatheter Versus Surgical Aortic Valve Replacement

Stroke is one of the most feared complications of aortic valve replacement. Although the outcomes of transcatheter aortic valve implantation (TAVI) improved substantially over time, concerns remained about a potentially higher incidence of stroke with TAVI compared with surgical replacement (SAVR). However, comparative data are sparse. We performed a meta-analysis comparing the incidence of stroke among patients undergoing TAVI versus SAVR. Of the 5067 studies screened, 28 eligible studies (22 propensity-score matched studies and 6 randomized trials) were analyzed. Primary endpoints were 30-day stroke and disabling stroke. Secondary endpoints were 1-year stroke and disabling stroke. A total of 23,587 patients were included, of whom 47.27% underwent TAVI and 52.72% underwent SAVR. For each endpoint, pooled estimates of odds ratio (OR) with 95% confidence interval (CI) were calculated. The pooled estimates for stroke (2.7% vs 3.1%, OR 0.86; 95% CI 0.72 to 1.02; p=0.08) and disabling stroke (2.5% vs 2.9%, OR 0.96; 95% CI 0.57 to 1.62; p=0.89) were comparable following TAVI versus SAVR at 30 days. Similarly, the pooled estimates for stroke (5.0% vs 4.6%, OR 1.01; 95% CI 0.79 to 1.28; p=0.96) and disabling stroke (4.1% vs 4.5%, OR 0.92; 95% CI 0.92 to 1.39; p=0.71) were similar at 1 year. A sensitivity analysis including only RCTs yielded similar results. Our meta-analysis documents comparable rates of strokes and disabling strokes following TAVI or SAVR both at 30 days and 1 year.

Meta-analysis Comparing Transcatheter and Surgical Treatments of Paravalvular Leaks

Percutaneous paravalvular leak (PVL) closure has emerged as a feasible alternative to redo valve surgery. However, comparative data on percutaneous and surgical treatment of PVL are scarce. We performed a systematic review and a meta-analysis of studies on percutaneous and surgical treatments of PVL. Of the 2,267 studies screened, 22 eligible studies were analyzed. Primary end points were technical success, 30-day mortality, stroke, and length of stay. Secondary end points were 1-year mortality, readmission for heart failure, reoperation, and symptomatic improvement at follow-up. A total of 2,373 patients were included, of whom 1,511 (63.7%) underwent percutaneous closure. Technical success was higher with surgery (96.7% vs 72.1%, odds ratio [OR] 9.7, pu2009<0.001) but at the cost of higher 30-day mortality (8.6% vs 6.8%, OR 1.90, pu2009<0.001), a trend toward higher stroke (3.3% vs 1.4%, OR 1.94, pu2009=u20090.069), and longer hospitalizations. However, surgery was associated with similar 1-year mortality (17.3% vs 17.2%, OR 1.07, pu2009=u20090.67), reoperation (9.1% vs 9.9%, OR 0.72, pu2009=u20090.1), readmission for heart failure (13.3% vs 26.4%, OR 0.51, pu2009=u20090.29), and improvement in New York Heart Association classification (67.4% vs 56%, OR 1.37, pu2009=u20090.74), compared with percutaneous closure. A sensitivity analysis including comparative studies only yielded similar results. Surgical treatment of PVL achieves higher technical success rates but is associated with higher early morbidity and mortality compared with percutaneous closure. Nevertheless, mortality rates and clinical efficacy parameters were similar at midterm with both procedures. Further studies are warranted to identify the ideal management approach to patients with symptomatic PVL.

Iatrogenic Circumflex Artery Stenosis Following Mitral Valve Repair

Injury of the left circumflex coronary artery is a potentially serious complication of mitral valve surgery due to the proximity of the vessel to the posterior segment of the mitral annulus. Suture-related distortion of the artery with partial or subtotal occlusion is the most commonly implicated mechanism. Herein, we present a case of symptomatic iatrogenic circumflex coronary artery stenosis following mitral valve annuloplasty for degenerative mitral valve regurgitation.