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14th Annual Complex Cardiovascular Catheter Therapeutics (C3): Advanced Endovascular and Coronary Intervention Global Summit
Selected Abbreviations
BMP = basic metabolic panel; CABG = coronary artery bypass graft; CBC = complete blood count; CCS = Canadian Cardiovascular Society; CTO = chronic total occlusion; DAPT = dual-antiplatelet therapy; DES = drug-eluting stent; ECG = electrocardiogram; EEG = electroencephalogram; HAART = highly active antiretroviral therapy; LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; LVEF = left ventricular ejection fraction; MI = myocardial infarction; NSTEMI = non-ST segment elevation myocardial infarction; NYHA = New York Heart Association; OM1 = first obtuse marginal; PCI = percutaneous coronary intervention; RCA = right coronary artery; STEMI = ST-segment elevation myocardial infarction
C3 2018-1: Successful Management of Coronary Artery Aneurysm With a Covered Stent Implantation
Eyvaz Abbasov, MD; Afag Akhundova, MD; Elnur Isayev, MD, PhD; Fuad Samedov, MD, PhD
INTRODUCTION: A coronary artery aneurysm could present with or without atherosclerotic narrowing of the same vessel. They can be treated both percutaneously and surgically. Small aneurysm could be sealed with a simple stent, but big ones may need a covered stent. A disadvantage of covered stents is high thrombosis rate.
CASE PRESENTATION: A 54-year-old male presented to our hospital with a stable angina grade 3. He was hypertensive, had hypercholesterolemia, and smoked 1 pack per day. ECG showed left ventricular hypertrophy, echo showed inferior and lateral wall hypokinesia, LVEF=45%. Exercise tolerance test was positive. Coronary angiography was performed and revealed three-vessel disease. LAD had significant stenosis in the mid part, OM1 had a CTO with excellent distal filling, and RCA had 2 critical stenoses in the proximal and mid parts. At the site of the first stenosis, an aneurysm arose. A CABG was advised, but the patient absolutely refused an operation, so PCI was planned. After predilatation, a long DES (3.5 x 38 mm Resolute Integrity; Medtronik) was placed to cover the 2 critical stenoses and over the entrance of the aneurysm. As the aneurysm was not sealed yet, a 3.5 x 16 mm covered stent (JoStent Graftmaster; Abbott) was implanted inside the DES to seal it. Then, a short DES was implanted into the mid-LAD and the procedure was successfully completed. Patient was discharged on lifelong DAPT, atorvastatin 40 mg, and lisinopril 20 mg + hydrochlorothiazide 12.5 mg. He was asymptomatic for 2.5 years, but then suddenly stopped his aspirin and clopidogrel, and suffered inferior MI. He was admitted to our clinic 2 days later. Coronary angiography showed patent LAD stent and totally occluded RCA stent. It was successfully recanalized and a new DES was implanted inside a covered stent-graft. Thus, a covered stent was now sandwiched between 2 DESs. Now, 8 months later, he is still asymptomatic.
DISCUSSION: Coronary aneurysms may be saccular or fusiform in structure. Invasive treatment is indicated only for saccular structures. Many congenital and acquired pathologies may be the cause of the aneurysm, but the main cause is atherosclerosis. The main location of aneurysms is the right coronary artery, whereas a discrete aneurysm is more often seen in the LAD and almost always in the presence of a severe stenosis. Most discrete aneurysms can be sealed with a simple stent implantation; if not, a covered stent may be used. For huge aneurysms with a large neck, surgery is the best option.
C3-2018 2: Prognostic Value of SYNTAX Score II in Patients With Non-ST Elevation Myocardial Infarction and Multivessel Disease Undergoing Percutaneous Coronary Intervention
Abcha Farouk, MD; Bendag Nadra, MD; Najjar Hatem, MD; Boukhris Marouane, MD; Elghardallou Mariem, MD; Karmous Rahma, MD; Laabidi Oueies, MD; Abcha Oussama, MD; Kasbaoui Sami, MD; Benmrad Imtinene, MD; Kerkeni Mehdi, MD; Barakett Nadia, MD
INTRODUCTION: Previous risk scores like GRACE and TIMI include only clinical characteristics, while integrating angiographic features could be very useful to predict cardiac events. The prognosis value of SYNTAX score II (SSII) in non-randomized real-world patients with complex multivessel disease (MVD) or unprotected left main (ULM) involvement in the setting of non-ST elevation myocardial infraction (NSTEMI) remains uncertain.
AIMS: The aim of our study was to evaluate the usefulness of SSII in the setting of NSTEMI in patients with such complex coronary artery disease undergoing percutaneous coronary intervention (PCI).
METHODS: From March 2015 to August 2016, we prospectively enrolled all NSTEMI patients with MVD or ULM. The SSI and SSII were prospectively calculated in all patients. One-year clinical follow-up was performed for those who underwent PCI. Major cardiac and cerebrovascular events (MACCE) were defined as a composite of cardiovascular death, myocardial infarction (MI), repeat revascularization (RR), and stroke.
RESULTS: A total of 114 patients (mean age, 64.2 ± 10 years; 71.9% males) were enrolled. Eleven patients (11.6%) had ULM stenosis and 50 patients (43.5%) had three-vessel disease. The median SSI was 21 (range, 4-52). The median SSII was 29.6 (range, 12.6-64.7). Complete revascularization was achieved in 64.9% of cases. At 1 year, MACCE occurred in 37 patients (32.5%); 18 (15.8%) experienced RR, 12 (10.5%) experienced MI, and death was observed in 7 patients (6.1%). The 1-year MACCE-free survival rate was significantly lower in patients with a high SSII ≥29.6, compared with patients with a low SSII <29.6 (55.1% vs 86.7%; P<.001). In multivariate Cox regression analysis, the only predictors of MACCE at 1-year clinical follow-up were SSII ≥29.6 (hazard ratio [HR], 3.08; 95% confidence interval [CI], 1.06-8.9; P=.038), and complete revascularization (HR, 0.016; 95% CI, 0.004-0.071; P<.001). The c-index of SSII was 0.74 (95% CI, 0.64-0.84; P<.001).
CONCLUSIONS: By incorporating clinical and angiographic characteristics, the SSII may be a useful score to predict outcomes not only in stable patients, but also in unstable patients with NSTEMI and MVD undergoing PCI.
C3-2018 3: Orthostatic Hypertension is Underappreciated Phenomenon
Ma’en Al-Dabbas, MD; Jay Shah, MD; Mohammad Alahmad, MD; Bharat Marwaha, MD
INTRODUCTION: Orthostatic hypertension is defined as increase in systolic blood pressure at least 20 mm Hg upon standing. Orthostatic hypertension is an under-appreciated phenomenon. It is a form of prehypertension and should be addressed. Orthostatic hypertension has been associated with silent ischemic cerebrovascular events.
CASE PRESENTATION: Our patient is 66-year-old female with past medical history of diabetes mellitus type 2 and hypertension who presented with a chief complaint of dizziness and staring spells for 1 year. Her medications include amlodipine, Plavix, gabapentin, furosemide, metformin, and lisinopril. Physical exam was unremarkable. Routine laboratory studies (BMP, CBC, and liver function test) were unremarkable. Imaging studies were unremarkable. Her dizzy and staring spells continued without any seizure activity on EEG. During admission, it was noticed that the dizzy spells and starring were mostly related to postural changes. Her orthostatic vitals were obtained on more than two occasions and showed orthostatic hypertension. After that, home blood pressure medications were discontinued. We started the patient on clonidine with aim of treatment of orthostatic hypertension. The next day, she reported a decrease in her dizzy spells. Orthostatic vitals were measured and showed no orthostatic hypertension.
DISCUSSION: The pathophysiology of orthostatic hypertension was related to excess venous pooling with initial drop in cardiac output followed by over-compensation with excessive release of catecholamine. So the underlying pathophysiology is thought to involve activity of the sympathetic nervous system, but actual etiology remains poorly understood. It is also thought that alpha-adrenergic activity may be the prominent pathophysiologic mechanism of orthostatic hypertension. There are no officially recommended treatments currently for orthostatic hypertension, as the condition is still little known and can be due to different causes; hence, the treatment for this disorder is still trial and error experimental treatment. There are currently no data to indicate whether orthostatic hypertension should be specifically targeted therapeutically, which would be optimal, or what the therapeutic endpoints would be. In our case, we used central alpha-2 adrenergic receptor agonist (clonidine) as alpha adrenergic activity may be the prominent pathophysiologic mechanism of orthostatic hypertension.
C3-2018 4: Transcatheter or Surgical Aortic Valve Replacement in Patients With Advanced Kidney Disease: A Propensity-Score Matched Analysis
Ma’en Al-Dabbas, MD; Jay Shah, MD; Rajkumar Doshi, MD
BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an alternative for surgically inoperable patients with severe aortic stenosis. Advanced kidney disease may significantly affect outcomes in patients treated with TAVR and surgical aortic valve replacement (SAVR).
HYPOTHESIS: TAVR is associated with better in-hospital outcomes compared with SAVR in patients with advanced kidney disease.
METHODS: We identified our sample from the National Inpatient Sample between 2012 and 2014, using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We included patients with chronic kidney disease stages IV and V and end-stage renal disease advanced kidney disease patients. We excluded patients with acute kidney injury on admission and patients on dialysis.
RESULTS: After propensity matching, 2485 patients were included in each group. The primary outcome of in-hospital mortality (12.9% vs 6.2%; P<.01) was higher with SAVR as compared with TAVR. Patients who underwent SAVR reported higher acute kidney injury (50.3% vs 33%; P<.01) and dialysis requirements (26.8% vs 20.1%; P<.01). Other secondary outcomes, including blood transfusion, atrial fibrillation, iatrogenic cardiac complications, pericardial complications, perioperative stroke, perioperative infections, and postoperative shock, were more common with SAVR. With SAVR, the length of hospitalization and hospitalization costs were significantly higher; however, permanent pacemaker placement was more common with TAVR compared with SAVR.
CONCLUSION: In patients with advanced kidney disease, SAVR was associated with higher mortality and higher periprocedural complications, as compared with TAVR. Thus, benefits of TAVR could be extended in patients with advanced kidney disease who cannot undergo surgery.
C3-2018 5: The Risk of Pulmonary Embolism and Deep Vein Thrombosis in Patients With Obstructive Sleep Apnea
Yazan Alkawaleet, MD; Majd Kanaa, MD; Laith Almomani, MD; Timir K. Paul, MD, PhD
INTRODUCTION: The adverse cardiopulmonary effects of sleep disorders are well documented in the literature. Obstructive sleep apnea has been linked to pulmonary hypertension, myocardial infarction, congestive heart failure, and cardiac arrhythmias including atrial fibrillation. The underlying mechanisms are proposed to be induction of oxidative stress, increasing the sympathetic tone and endothelial vascular alterations. This meta-analysis investigated the possible association between sleep apnea and deep vein thrombosis (DVT) and/or pulmonary embolism (PE).
METHODS: PubMed database was searched through November 2017. Fourteen studies assessing the relationship between sleep disorders and DVT and PE were included. Nine of these studies looked specifically at the relation between sleep apnea and PE. On the other hand, three studies investigated the association between sleep apnea and DVT. Endpoints were all-rate of DVT and/or PE. The odds ratio (OR) or hazard ratio (HR) with 95% confidence interval (CI) was computed and P<.05 was considered as a level of significance. This meta-analysis will use fixed-effects model as there is no heterogeneity.
RESULTS: The pooled effects of all the studies suggested that sleep apnea is an independent risk factor for DVT/PE. Sleep apnea was found to increase the risk for PE (RR, 2.27; 95% CI, 1.40-3.67). Sleep apnea was also associated with higher risk for developing DVT (RR, 2.63; 95% CI, 1.77-3.90).
CONCLUSION: The results of this meta-analysis showed the association between sleep apnea and DVT and/or PE. Further studies are needed to explore whether treating patients with sleep disorders would decrease the rate of DVT or PE.
C3-2018 6: Comparison of Outcomes of Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) vs Surgical Myomectomy (SM) for the Treatment of Hypertrophic Obstructive Cardiomyopathy, a Meta-Analysis
Yazan Alkawaleet, MD; Ghulam Murtaza, MD; Majd Kanaa, MD; Laith Almomani, MD; Kais Albalbissi, MD
INTRODUCTION: Left ventricular outflow tract (LVOT) obstruction is one of the most important factors that predisposes to heart failure in patients with hypertrophic cardiomyopathy. First-line treatment includes medical management aimed at increasing left ventricular volume and subsequently decreasing left ventricular outflow tract pressure gradient. However, if patients continue to have persistent symptoms, recurrent syncope, or significant LVOT gradient, more invasive approaches are undertaken to relief the obstruction. This meta-analysis was conducted to compare the outcomes of the two most commonly used interventional methods to treat hypertrophic obstructive cardiomyopathy, namely, surgical myomectomy and percutaneous transluminal septal myocardial ablation.
METHODS: PubMed database was searched through May 2018. Nine studies (n=954) comparing outcomes between patients with obstructive cardiomyopathy who underwent septal myomectomy (n=606) versus percutaneous transluminal septal myocardial ablation (n=348) met the inclusion criteria. Three other studies were excluded because the measurements were reported as medians. Another study was excluded because there was a statistically significant difference in the average NYHA functional class between the two treatment groups prior to intervention. The assessed endpoints were the degree of reduction in LVOT pressure gradient, reduction in septal wall thickness, and improvement in NYHA functional class. The mean difference (MD) with 95% confidence interval (CI) was computed and P<.05 was considered as a level of significance.
RESULTS: The reduction of LVOT pressure gradient was more pronounced with surgical myomectomy (mean difference, 18.51 mm Hg; CI, 17.85-19.17; P<.001). There was also more reduction in septal wall thickness with surgical myomectomy as compared to percutaneous transluminal septal myocardial ablation (mean difference, 0.23 cm; CI, 0.21-0.25; P<.001). Moreover, surgical myomectomy was associated with better improvement and reduction in heart failure NYHA functional class classification (mean difference, 0.05; CI, 0.02-0.08; P<.001).
CONCLUSION: Surgical myomectomy was associated with overall better outcomes when compared to percutaneous transluminal septal myocardial ablation for the treatment of hypertrophic obstructive cardiomyopathy. However, more research is needed to look at other aspects of these treatment modalities such as the rate of complications.
C3-2018 7: Coronary Artery Thrombus Leading to Acute Myocardial Infarction in an HIV Patient: A Case Report and Review of Literature
Yazan Alkawaleet, MD; Majd Kanaa, MD; Laith Almomani, MD; Paul K. Timir, MD, PhD
INTRODUCTION: Coronary artery disease (CAD) is the leading cause of mortality in the United States. In addition to patients with well-established risk factors for CAD, certain patient population like those with HIV can present with acute coronary syndrome (ACS) without having the conventional risk factors. Studies have shown an increased risk of myocardial infarction (MI) in patients who receive HAART treatment for example. These patients can also develop various cardiovascular conditions including, but not limited to, dilated cardiomyopathy, myocarditis, pericarditis, endocarditis, pericardial effusion and vasculitis. The prevalence of MI has also increased 4-fold in this population and HIV medications have been blamed as the main culprit. We present a case report of MI secondary to acute coronary thrombus in an otherwise healthy young patient with HIV.
CASE PRESENTATION: A 50-year-old white male, otherwise healthy except for a history of HIV infection controlled with HAART treatment, presented to ER after passing out. He was brought to the ER by the EMS and got intubated for altered mental status. After intubation, he went into cardiac arrest due to ventricular tachycardia for which cardiopulmonary resuscitation was started. During the code, he received intravenous lytic therapy. Patient’s rhythm stabilized and a 12-lead ECG showed 2 mm ST elevation in the anterior precordial leads. Emergent cardiac catheterization was performed and showed a mid left anterior descending (LAD) artery stenosis secondary to coronary thrombus. After mechanical thrombus aspiration, a stent was placed in the mid LAD. He subsequently got extubated and discharged 1 week later.
DISCUSSION: Recent advances in the treatment of HIV, mainly HAART, have transformed this previously terminal illness into a chronic disease. HIV medications have been blamed for increasing the risk of MI in patients with HIV. They have been associated with arteriopathy, increased inflammation, and coagulation disorder. For example, protease inhibitors (PI) have been shown to adversely alter blood lipids. Long-term use of HAART can also induce a metabolic syndrome, which subsequently leads to premature CAD. Moreover, adiponectin is reduced in HIV-infected patients with fat redistribution and may contribute to insulin resistance. Other explanations for the increased risk of MI secondary to HAART include coagulation disorder; a recent article reported that the PI drug class is associated with increased levels of fibrinogen. Increased inflammation has also been postulated to increase the risk of MI in this patient population. It is therefore an expert consensus that these patients should be aggressively treated for CAD risk factors.
C3-2018 8: The Pattern of Cardiovascular Risk Factors in Patients Under 40 Years Presenting With ST-Elevation Myocardial Infarction (STEMI)
Abdallah Almaghraby, MD; Mahmoud Abdelnaby, MD; Abdullah Abdullah, MD; Abdullah Arrash, MD; Ekinu Jin, MD; Baolo Sabbatini, MD; Francisco Jesus, MD; Muhammad Almuttair, MD; Ola Abdelkarim, MD; Yehia Saleh, MD; Ahmed Elamrawy, PhD; Haitham Badran, PhD
INTRODUCTION: Coronary heart disease (CHD) is the leading cause of death in the world and acute myocardial infarction (AMI) among young is very uncommon. Most of the cardiovascular risk factors studied are studied in older patients and there are a few data on the risk factors that may cause myocardial infarction in young patients less than 40 years of age.
AIM OF THE WORK: The purpose of this worldwide study was to determine the pattern of cardiovascular risk factors in patients who are under 40 years of age and presenting with acute STEMI.
METHODS: A descriptive study of patients under 40 years of age and over 18 years of age who were admitted with acute STEMI between the period of January 2013 to December 2016 to determine the cardiovascular risk factors as well as the initial laboratory data and the location of STEMI. The study was conducted in 27 tertiary-care hospitals in 7 countries.
RESULTS: Of the 547 patients evaluated, 322 patients were males (58.9%) with a mean age of 32.86 years. Anterior STEMI was encountered in 250 patients (45.7%), inferior STEMI in 201 patients (36.7%), and other types of STEMI represented only 17.6%. Regarding risk factors, 276 patients were smokers (50.5%), 188 patients had a positive family history of coronary artery disease (CAD) (34.4%), 142 patients were hypertensive (26%), 111 patients were dyslipidemics (20.3%), 51 patients were diabetics (9.3%), 49 patients were alcoholics (9%), 21 patients had chronic renal impairment at presentation (3.8%), and 19 patients were already diagnosed with a thrombophilic disorder (3.5%). Regarding the laboratory data, the mean hemoglobin level was 13.5 g/dL, mean creatinine level was 0.95 mg/dL, mean total cholesterol level was 188.5 mg/dL, mean low-density lipoprotein (LDL) level was 101.1 mg/dL, mean triglyceride level was 155.4 mg/dL, and mean hemoglobin A1C (HbA1C) level was 6.51%. A total of 498 patients (91%) underwent primary percutaneous coronary intervention while 49 patients (9%) received thrombolytic therapy. The in-hospital mortality rate was only 2% (11 patients).
CONCLUSIONS: In young patients under 40 years of age presenting with STEMI, the most common cardiovascular risk factors were smoking, positive family history of CAD, hypertension, and dyslipidemia. Also, the in-hospital mortality rate was found to be only 2%.
C3-2018 9: Galectin-3 a New Proof of the Better Outcome of Deferred Stenting in STEMI Patients With High Thrombus Burden
Mohammad Gouda, MD; Mohamed Amin, MD; Hany Abdelwahab, MD
BACKGROUND: Inevitable microvascular blockade after PPCI, if high thrombus burden is present, raises the idea of deferred stenting (DS). DS refers to the concept of a minimalist immediate mechanical intervention (MIMI) using guidewire or small balloon in an emergency to reopen an infarct-related artery in acute STEMI and postpone stenting to the following days in stable conditions. Remodeling and myocardial fibrosis are inevitable with subsequent progression to heart failure (HF) if we fail to protect the microvasculature. Macrophages secrete galectin-3, which stimulates additional macrophages, pericytes, myofibroblasts, fibroblasts, cellular proliferation, and secretion of procollagen.
METHODS: This prospective study recruited 116 consecutive STEMI cases with high thrombus burden (grades 4-5). Galectin-3 was assessed on admission. Precise timing of onset of chest pain until wiring of the blocked artery (PWT). Echocardiography assessment occurred during preparation for PPCI, and measured LV systolic function (EF by modified Simpson’s method and left ventricular end-systolic volume index [LVESVI]). All cases were prepared with the same antiplatelet, anticoagulant, and statin therapies; PPCI was then performed as soon as possible. The decision for immediate stenting or wiring to achieve TIMI-3 flow or to maintain medical therapy and stent after 48 hours (DS) was at operator’s discretion. Patients were followed for 3 months, and the same echocardiographic parameters were measured by the same operators; measurement of the level of galectin-3 was repeated. We classified the patients into group I (immediate stenting, 78 cases) and group II (deferred stenting, 38 cases).
RESULTS: After 3 months of follow-up, there was a highly significant difference between both groups concerning EF, LVESVI, and galectin-3. EF decreased to 44.18 ± 11.32% in group I while it jumped to 52.89 ± 7.32% in group II (t=3.05; P<.001). LVESVI increased to 44.77 ± 11.84 mL3/m2 in group I while it decreased to 33.26 ± 6.27 mL3/m2 in group II (t=-3.96; P<.001). Galactin-3 level was 21.67 ± 6.48 ng/mL in group I and 15.71 ± 3.80 ng/mL in group II (t=-3.70; P<.001). The EF after 3 months has a highly significant negative correlation with the level of galectin-3 after 3 months of follow-up (r=-0.82; P<.001) while it has no significant correlation with the level of admission galactin-3. LVESVI after 3 months has a highly significant positive correlation with the level of galectin-3 after 3 months (r=0.89; P<.001) while it has no significant correlation with level of admission galectin-3. The regression analysis confirmed that level of galectin-3 after 3 months is a strong predictor of recovery of both LVESVI (t=8.13 and P<.001) and EF (t=-5.28; P<.001).
CONCLUSION: Admission galectin-3 level cannot predict the recovery of LV function after PPCI, while galectin-3 after 3 months can. DS is recommended in STEMI cases with high thrombus burden.
C3-2018 10: Kissing-Balloon Technique for Angioplasty of Tibio-Peroneal Artery Bifurcation Using Pedal Arterial Retrograde Revascularization in Patients With Peripheral Vascular Disease
Ahmed Amro, MD; Obadah Aqtash, MD; Adee Elhamdani; Alaa Gabi, MD; Mehiar El-Hamdani, MD
BACKGROUND: Tibio-peroneal occlusive disease is among one the most medically and surgically challenging problems in vascular surgery. A popular treatment modality is single-balloon angioplasty, which may disclose the plaque in adjacent untreated arteries causing thrombosis, dissection, or embolism. These complications can be avoided using the kissing-balloon technique. Patients with advanced peripheral disease may also require pedal access as anterograde recanalization attempts can fail. By using ultrasound and the tibio-pedal artery minimally invasive retrograde approach and common femoral approach, operators can access and perform revascularization of lower extremities.
METHODS: We reviewed 7 cases that underwent kissing-balloon technique with the combination of pedal and common femoral access in a single center. Utilizing Rutherford classification severity index, all cases were deemed stages 3-6. Mid-term follow-up after the kissing-balloon procedure ranged from 3 to 8 months. Patients’ demographics, vascular symptoms, disease characteristics, success, and complications were collected.
RESULTS: Arterial revascularization was successfully achieved by the kissing-balloon technique in all patients and no major complications were noted. Mid-term follow-up showed procedure success, which was defined as resolution of symptoms (no intermittent claudication and healing of the ulcer) as well as improvement in the preprocedure and postprocedure arterial brachial index. In some cases, angiogram showed patency of the artery with no residual lesions.
CONCLUSIONS: Kissing-balloon technique applied in tibio-peroneal bifurcation lesions appeared to be a safe and effective technique in all cases we reviewed. Also, the addition of retrograde pedal access to this method has expanded its applications in difficult to cross lesions.
C3-2018 11: Effect of Percutaneous Mitral Balloon Valvuloplasty on Mean Platelet Volume Among Patients With Mitral Stenosis
Amr Samy Hossien Mostafa, MSc; Walaa Farid Mousa, MD; Ahmed Emera, MD; Ahmed Magdy, MD
BACKGROUND: The mean platelet volume (MPV) is a marker and determinant of platelet function and is higher in patients with rheumatic mitral stenosis (RMS). That increase in MPV represents one possible mechanism by which subjects with RMS may be at increased thromboembolic risk.
OBJECTIVES: The purpose of this study was to assess the effects of successful percutaneous balloon mitral commissurotomy (PMC) “valvuloplasty” on mean platelet volume and platelet activity, before and after 1 month.
METHODS: A total of 22 consecutive patients with moderate and severe rheumatic mitral stenosis who underwent successful PMC and a control group of 22 apparently healthy subjects were included in this study.
RESULTS: Patients with RMS and sinus rhythm had higher mean platelet volume as compared to normal individuals.MPV decreased significantly following PMC procedure. There was significant negative correlation between value of MPV before PMC and mitral valve area, mitral valve area index, and left ventricular end-diastolic pressure, while there was significant positive correlation between value of MPV before PMC and mitral valve score, calcifications, mean diastolic pressure grade, mean left atrial pressure, and pressure gradient across mitral valve.
CONCLUSIONS: MPV was significantly elevated in patients with RMS who were in sinus rhythm compared to control subjects, which indicates that patients with RMS have a higher risk of systemic thromboembolism due to increased platelet activation. MPV decreased significantly following PMC procedure.
C3-2018 12: Aorto-ostial Right Coronary Artery Total Occlusion in Non-ST Segment Elevation, How to Treat? Solution in Galileo’s Illusion
Wassam El Din Hadad El Shafey, MD, FSCAI
INTRODUCTION: Ostial lesions have been defined as lesions located within 3 mm of the origin of a vessel, but some authors consider lesions up to 5 mm from the origin as ostial lesions. Percutaneous coronary intervention (PCI) of ostial lesions is a real challenge from multiple perspectives. Firstly, ostial lesions are most likely to be associated with suboptimal angiographic results due to lesion rigidity and recoil. Secondly, exact stent positioning is a main problem in performing PCI. Thirdly, difficulties in the placement of a guiding catheter and poor back-up support are other factors that may affect the final result.
CASE PRESENTATION: A 67-year-old hypertensive, dyslipidemic, and non-diabetic female presented with crescendo chest pain for the last 2 months. ECG showed ST depression in II, III, and aVF leads. Echocardiogram demonstrated normal wall motion, with an ejection fraction of 66%. Lab tests demonstrated elevated troponin I (TnI) levels. Coronary angiography revealed normal LAD, mid borderline lesion in LCX, and aorto-ostial total occlusion in flush of RCA with sluggish retrograde filling of the distal PDA from the left coronary system. It was challenging to start with regular angiographic mode where I could not clearly identify the stump for wire crossing, so I switched the mode to inverted gray-scale roadmap where I clearly noticed a small tapered stump for antegrade wire crossing, which helps me to use a parallel-wire technique to go through this stump. After successful wire crossing, I started using escalating sized balloons with a low-pressure inflation technique (EL Shafey) where the RCA was clearly visualized and 2 DESs were used to fix the lesions with flaring up the ostial part of the proximal sited stent with TIMI 3 flow and good myocardial blush grade.
DISCUSSION: Ostial lesions are still challenging lesions during PCI. The inverted gray-scale mode of regular coronary angiography is underused in our daily practice in the catheterization laboratory, while that pattern is sometimes differently perceived by operators’ eyes. Scientists have studied a visual illusion first discovered by Galileo Galilei, and found that it occurs because of the surprising way our eyes see lightness and darkness in the world. Their results advance our understanding of how our brains are wired for seeing white versus black objects. Inverted gray-scale roadmap could help us in seeing small channels for starting the antegrade approach for wire crossing through totally occluded arteries – especially ostial lesions. The concept of optical diversities between black and white backgrounds in angiographic pictures should be investigated by ophthalmologists as it may be an important checkup for operators because it may affect their performance inside the cath lab.
C3-2018 13: Transradial Multivessel Intervention
Emad Effat Fakhry, PhD
CASE PRESENTATION: A 51-year-old, hypertensive male with family history of premature atherosclerotic coronary artery disease experienced nocturnal angina in 2011 for which PCI to RCA was done by DES. Three months ago, he started to develop effort angina CCS 3 despite optimal medical therapy, his stress ECG was highly positive with Duke treadmill score -14. Coronary angiography showed normal LM, a significant bifurcation lesion at the LAD-D1, Medina 1,1,1 with a narrow angle of 45°, and a significant bifurcation lesion at the distal LCX with its OM branch, Medina 1,1,1. The RCA showed mid-segment significant in-stent restenosis and a distal heavily calcified plaque causing 80% stenosis. SYNTAX I score was 31, EuroScore II was 0.5%. After heart team discussion and discussion with the patient, the patient refused CABG and was referred to PCI. Transradial approach was used. We started with the most critical stenosis, which was in the LCX. Two wires were negotiated – one in the LCX proper and the other in the OM branch. After predilatation, a DES was positioned in the LCX-OM and deployed. One stent technique was used with no need of a second stent owing to the small size of the distal LCX and the presence of TIMI 3 flow in the LCX. Regarding the LAD diagonal, owing to the narrow angle and the severe disease at the ostial diagonal, the DK-crush technique was used; we wired the LAD and the diagonal, then we placed a DES in the diagonal and at the same time a non-compliant balloon in the LAD. After deployment of the diagonal stent, we pulled back the wire and the stent’s balloon from the diagonal artery in order to crush the stent with the balloon in the LAD, followed by the first kiss, then a DES was deployed in the LAD followed by rewiring of the diagonal artery, then a step kiss in the diagonal at high pressure, then the second kiss in the LAD and diagonal. Shifting to the RCA, owing to the posterior origin and the inferior orientation of the RCA, an AR1 catheter was used. Due to the heavy calcification of the RCA, in order to pass the stent to the distal RCA we used a buddy wire and predilatation with an NC balloon, then another stent was deployed in the mid RCA in-stent restenosis followed by post deployment dilatation with an NC balloon.
DISCUSSION: Radial access is feasible for multivessel interventions including bifurcation techniques using 6 Fr guide.DK crush is suitable in bifurcations, especially with a critically stenosed side-branch ostium; the first kissing balloons facilitate the second rewiring of the side branch and the ability to finalize with the second kissing step.
C3-2018 14: Transfemoral Aortic Valve Implant in an Extremely Tortuous Aorta With Peripheral Vascular Disease
Carlos M. Giuliani, MD; Matias Sztejfman, MD; Carlos Sztejfman, MD; Marcelo Bettinotti, MD; Fabio Muñoz, MD; Marcela Albornoz, MD; Ana Mollon, MD
INTRODUCTION: With advances in technology, aortic valves can be treated percutaneously in patients with very tortuous aortas that were previously considered a contraindication for percutaneous aortic valve implantation (TAVR). Currently, the Core Valve Evolut R valve has a delivery system with a diameter of 14 Fr, which makes possible the transfemoral (TF) procedure.
CASE PRESENTATION: A 91-year-old man with a history of hypertension, dyslipidemia, and severe symptomatic aortic stenosis for dyspnea CF III, porcelain aorta, extreme tortuosity of the aorta, and peripheral vascular disease with severe calcification of the iliac-femoral axis with borderline diameters for treatment. Percutaneous and multiple hospitalizations for heart failure in the last year; fragile. An echocardiogram showed severe aortic stenosis with low flow-low gradient, peak gradient of 41.5 and a mean of 23.4 mm Hg, valvular area of 0.66 cm2. Fey 72%, moderate-severe aortic regurgitation, mild deterioration of RV systolic function, moderate tricuspid regurgitation, pulmonary hypertension, and moderate mitral regurgitation. In the coronary angiography, coronary arteries without significant lesions were observed and computed tomography of the aorta showed extreme aortic tortuosity with vascular disease of the aorto-iliac-femoral axis with left iliac diameter of 5 mm. EuroScore of 5.6% and STS of 5.8% mortality. For these reasons, it was decided to perform TAVR-TF.Left femoral access with a 14 Fr introducer. The marked tortuosity of the abdominal aorta made it difficult to elevate the prosthesis, which could be done by means of an exchange of the straight guide teflon 0.35˝ by the Lunderquist guide 0.35˝ performed inside the left ventricle. The Evolut R 26 mm valve was advanced without difficulty. Postdilatation was performed with a 26 mm balloon with minimal aortic insufficiency, pre-high echocardiogram confirmed adequate valve position with a mean gradient of 5 mm Hg, mild aortic insufficiency.The patient was discharged at 72 hours without complications. In the 30-day clinical follow-up, the patient was found to be in CF (NYHA class I).
DISCUSSION: The extreme tortuosity of the aorta may be a contraindication for TAVR; however, in this case we consider that the procedure was feasible given the characteristics of the CoreValve Evolut R valve and the delivery system, since the flexibility facilitates TF implantation. Extensive calcification at the site of femoral access and extreme tortuosity have been identified as additional factors for the appearance of major vascular complications. In our experience, the approach with direct vision of the femoral vessels decreases the number of vascular complications and allows resolution of these complications more quickly and easily, if they occur. TAVR-TF is a good alternative for patients with severe aortic stenosis with extremely tortuous aorta and peripheral vascular disease and can be carried out safely with therapeutic success.
C3-2018 15: Acute Severe Mitral Regurgitation with Cardiogenic Shock Due to Papillary Muscle Rupture in Acute Myocardial Infarction
Rahul Gupta, MD; Mohammad L. Alkotob, MD; Mohammed Osman, MD; Vijay Naraparaju, MD
INTRODUCTION: Severe mitral regurgitation (MR) due to a ruptured chordae or papillary muscle rupture can be a fatal complication following acute myocardial infarction. Mitral valve surgery remains a mainstay of treatment in emergent cases. Despite improvement in surgical and revascularization strategies, high mortality remains a major sticking point. We describe a case of cardiogenic shock from severe mitral regurgitation following acute myocardial infarction.
CASE PRESENTATION: A 59-year-old female patient arrived unresponsive to emergency department with symptoms concerning for acute coronary syndrome. There was no informant present along with the patient, so very limited information was available about patient’s past medical history or risk factors. Emergency medical services personnel who accompanied the patient reported that patient was complaining of some chest and back pain before she was brought unresponsive, cyanotic with agonal breathing. Pulse was lost shortly after arrival with pulseless electrical activity (PEA) noted on monitor. Patient was aggressively resuscitated with bag mask ventilation, high-quality chest compressions, multiple rounds of epinephrine, and atropine for bradycardic PEA and transient bradycardia. Cardiac catheterization lab was activated after initial electrocardiogram (ECG) review showed anterolateral ST-elevation MI (STEMI). Initial bedside echo showed poor contractility. Patient had several episodes of ventricular tachycardia responsive to defibrillation, treated with amiodarone. Once perfusion was restored, patient was placed on epinephrine drip. Repeat ECG showed wide irregular rhythm with ST-segment elevation in V3. Emergent cardiac catheterization revealed severe triple-vessel disease with over 90% stenosis in all 3 vessels, acute thrombotic occlusion of the proximal left anterior descending artery, anteroapical dyskinesis and severely reduced left ventricle ejection fraction, diffuse disease in the abdominal to pelvic aorta and in the left iliac artery precluding intra-aortic balloon pump implantation. Patient had significant hemodynamic and electrical instability requiring maximum pressor support but unfortunately passed away due to cardiogenic shock following severe mitral regurgitation most likely due to papillary muscle rupture.
DISCUSSION: Literature review suggests that less than 1% of patients with acute myocardial infarction present with papillary muscle rupture and represents about 5% of all cases of ischemic mitral regurgitation, with mortality ranging between 80%-90%. Transthoracic echocardiogram is a reliable diagnostic modality for severe mitral regurgitation; however, transesophageal echo can be equally helpful in critically ill patients as it is sometimes difficult to obtain optimal window due to mechanical ventilation or restrictions in optimal positioning. Time is of paramount importance, so diagnostic confirmation should be done rapidly and definitively. Emergent surgical intervention is imperative in acute MR with papillary muscle rupture; however, newer modalities like transcatheter edge-to-edge repair offer viable alternative options in severe chronic mitral regurgitation with elevated surgical risk.
C3-2018 16: Left Main Intervention – Did I Do the Right Thing?
Ayman Helal, MD
INTRODUCTION: Left main interventions is now challenging after implementation of newer devices and newer generations of DES. The debate was increased after the release of NOBEL and EXCEL trials in 2016 wither to perform PCI or CABG.
CASE PRESENTATION: A 75-year-old, diabetic, hypertensive patient presented with accelerated unstable angina. ECG showed ST-segment depression in V1-6, I, avL. Echocardiography revealed global hypokinesia with EF of 33%. Stress TC (1 week before presentation) demonstrated viable with large reversible ischemia in the LAD territory, viable with small area of scar in the LCX and RCA territory. Coronary angiography was performed that showed distal LM 90% calcific stenosis that involved the ostial and proximal segments of the LAD and LCX that was followed by mid LAD total occlusion with faint antegrade filling. The RCA was totally occluded with faint antegrade flow. Syntax II and EuroScore II were calculated and both were very high. The patient was advised to perform CABG but he refused. PCI was planned. An XB 3.5 (7 Fr) guiding catheter was used to engage the LM. A Fielder XT wire was used to cross the LAD and a PT2 MS wire was used to cross the LCX. PTCA to the LM-LAD was performed with a 2 x 20 mm balloon, at which time the patient immediately arrested and CPR was started. Immediate PCI to the LM-LAD was performed using Promus DES (4 x 38 mm). The patient regained sinus rhythm again after stenting. Using a short balloon (4.5 x 10 mm), Proximal optimization technique (POT) was performed to the LM. Then, wire recrossing and PTCA to LCX ostium was performed to open the stent struts. A Promus DES (3 x 28 mm) was deployed at ostial LCX with minimal protrusion in the LM. Balloon kissing was then performed followed by final POT to LM with good final result and TIMI 3 flow. The patient was admitted to CCU and was discharged 2 days later.
DISCUSSION: LM intervention in high SYNTAX score patients who are at high risk or refusing surgery is still a good option with favorable outcome.
C3-2018 17: New VSD as a Consequence of Ventricular Tachycardia Catheter Ablation
Jerald Insel, MD and Basha Behrman, BS
INTRODUCTION: Coronary ablation has proven to be a very useful addition to the cardiac electrophysiology armamentarium for treatment of arrhythmias. It can be life-saving and can provide tremendous improvement in quality of life. It does, however, have the potential for both local and systemic complications, including local vascular complications, cardiac perforation, thromboembolism, iatrogenic cardiac arrhythmias, phrenic nerve injuries, and valvular damage, as well as injury to the coronaries arteries. We will present a case of a very unusual complication detected by physical exam and echocardiogram, with the goal of increasing awareness of this possibility and preventing future such complications.
CASE PRESENTATION: A 63-year-old man with a history of CAD was seen status post CABG. Patient had an ICD for ventricular tachycardia and had normal EF. No cardiac murmur was noted. Patient developed electical storm and underwent VT catheter ablation of the left ventricle (LV) sans complications. The ablation location was the LV septum and LV apex using radiofrequency ablation technique. Patient presented 2 weeks later for follow-up and was asymptomatic, with BP at 130/70. S1 and S2 were noted, with a new loud 4/6 holosystolic murmur, plus a 2/6 holodiastolic murmur. No signs of heart failure. Echo revealed new restrictive VSD in the distal septum extending to the RV. Presently, the patient is carefully clinically monitored without intervention.
DISCUSSION: This is a rare complication of catheter ablation, with potential for very major consequences. This complication, diagnosed on physical exam, could have been predicted prior to performing the ablation by examination of echocardiogram, which clearly showed the high risk that this patient was at due to scarring and extensive thinning. One can see that the endocardium is significantly thinned in the distal septum in the area where the VSD formed, which presents a high risk for the possibility of tearing and perforation during ablation. We propose that prior to doing a ventricular ablation, one should conduct a thorough review of the echocardiogram, including color flow, to make certain there is adequate scar tissue with no thinning, which would increase the risk of potential perforations during the ablation. It is important to do this as well in the ventricular free wall to reduce the potential risk of a ventricular wall perforation and cardiac tamponade. If there is both scarring and thinning of the endocardium, this is not a good site for ablation due to risk of complications, and one must consider this before proceeding. While this patient only developed a restrictive VSD from the ablation, a patient who had an ablation done in the free wall of the ventricle could be at risk for free wall rupture, cardiac tamponade, and death.
C3-2018 18: Efficacy of High-Dose Atorvastatin in Preventing Contrast-Induced Nephropathy in Patients Undergoing Elective Coronary Angiography
Osama Ramadan Kandeel, MBBCH, MD
OBJECTIVE: The aim of this study was to examine the efficacy of high-dose atorvastatin in preventing contrast-induced nephropathy in statin-naïve patients with moderate or high risk of contrast-induced nephropathy (CIN) undergoing coronary angiography.
BACKGROUND: CIN is defined as an increase of >25% or >0.5 mg/dL (44 µmol/L) serum creatinine (S.Cr) from baseline within 48-72 hours following intravenous injection of contrast material (CM) if other etiologies of renal impairment can be excluded, usually peaking on the third to fifth day, and returning to baseline within 10-14 days. CIN occurred in 20%~30% of patients who received the standard preventive measures; this means that current treatments are not adequate. Statins exert a number of pleiotropic effects including the enhancement of endothelial function, stabilization of atherosclerotic plaque, decrease of oxidative stress and inflammation, and inhibition of thrombogenic response.
PATIENTS AND METHODS: The study population comprised 300 patients presenting because of suspected or having coronary artery disease for elective coronary angiography, with moderate or high risk for CIN based on Mehran score. They were randomized into two groups: atorvastatin group who received 80 mg atorvastatin, 12 hours before the procedure, with a further 40 mg preprocedural dose, and placebo group who didn’t receive loading dose of atorvastatin. Primary endpoint of the study was the evaluation of renal function before and 48 hours after CM administration.
RESULTS: Of the whole study population, 44 patients developed CIN (14.7%). Thirty patients were included in the placebo group (20%) while 14 patients were included in the atorvastatin group (9.3%) with statistically significant difference (P<.01).
DISCUSSION: The protective effect of atorvastatin is contributed mainly to the pleiotropic effects acting at different stages of CIN mechanisms including down-regulation of angiotensin receptors reducing endothelin production, increasing nitric oxide bioavailability attenuating inflammation limiting reactive oxygen species synthesis, and preventing complement-mediated injury. In our study, there was a statistically significant difference between pre- and post-procedural renal functions in the placebo group with P<.01 for mean S.Cr and P<.01 for mean creatinine clearance (Cr.Cl); the difference was not significant in the atorvastatin group, with P=.15 for mean S.Cr and P=.87 for mean Cr.Cl, which means that high loading dose of atorvastatin prevents the significant increase in S.Cr and significant decrease in Cr.Cl that occurs with CM administration. Our study concluded that high-dose atorvastatin has a significant protective role against CIN in patients with moderate and high risk for CIN undergoing coronary angiography.
C3-2018 19: Prognostic Value of the CHA2DS2-VASc Score in Patients With Chronic Total Occlusion
Oueies Labidi, MD; Elyes Neffati, MD; Rim Gribaa, MD; Karim Ben Brahim, MD; Mehdi Slim, MD; Houda Ghardallou, MD; Sami Ouanes, MD; Essia Boughzela, MD
BACKGROUND: The CHA2DS2-VASc score has initially been recommended for the assessment of the risk of thromboembolic event among patients with atrial fibrillation. However, little is known about its predictive value of the outcomes among patients with chronic total occlusion (CTO). The aim of the present study is to further investigate whether the CHA2DS2-VASc score could predict higher major adverse cardiovascular events (MACE) and all-cause mortality of patients with CTO.
METHODS: This is a single-center study analyzing data of 144 consecutive patients with CTO from 2006 to 2017. We studied the occurrence of MACE and all-cause mortality during follow-up among these patients. The CHA2DS2-VASc score considered was the one calculated before the patient’s admission.
RESULTS: The average age was 61.7 ± 9 years. Half of the patients (n = 72) were revascularized. The median CHA2DS2-VASc score was 2 (Q1: 1; Q3: 3). During median follow-up of 44 months (Q1: 19; Q3: 74), 20% of patients presented a MACE and 12% had died. According to ROC analysis, a CHA2DS2-VASc score of at least 3 was predictive of MACE with 65% sensitivity and 75% specificity (area under curve, 0.71; P=.003; 95% CI, 0.57-0.85) and predictive of all-cause mortality with 67% sensitivity and 72% specificity (area under curve, 0.73; P=.01; 95% CI, 0.55-0.90). The long-term survival was shorter in the group with CHA2DS2-VASc ≥3 (P=.006). Subgroup analysis showed that among revascularized patients (n = 72), a CHA2DS2-VASc score ≥3 was associated with an increased risk of MACE (37.5% vs 5.3%; P=.009) and increased mortality (12.5% vs 0%; P=.04). In non-revascularized patients (n = 72), a CHA2DS2-VASc score ≥3 was associated with an increased occurrence of MACE (43.8% vs 19.2%; P=.048), but the mortality was not statistically significant (37.5% vs 15.4%; P=.207).
CONCLUSION: The study has shown that CHA2DS2-VASc score was a useful predictor for follow-up MACE among patients with CTO. It loses its predictive value for mortality of patients with non-recanalized CTO.
C3-2018 20: CA-MRSA Pericardial Effusion: An Unusual Complication Post Pericarditis
Rupesh Manam, MD; Elias Couto Barbosa, MD; Alberto Sabates, MD; Carlos Miniet Cespedes, MD; Seth J. Baum, MD;
Eli S. Levine, MD
INTRODUCTION: Purulent pericarditis is a rare disease process associated with infection of the pericardial sac. Mechanisms of infection include hematogenous spread or direct spread (trauma, infection, or intrathoracic surgery). Predisposing factors include immunocompromised status, renal disease, malignancy, and alcohol abuse. Widespread use of antibiotics has resulted in decreased prevalence of infective pericarditis but infections with multidrug-resistant organisms arose. Methicillin-resistant staphylococcus aureus infection (MRSA), which was previously hospital acquired (HA), has now become more common as a community acquired (CA) source of infection. We present an interesting case of CA-MRSA purulent pericarditis without systemic infectious process.
CASE PRESENTATION: A 32-year-old Caucasian male with history of illicit drug use presented with left-sided chest pain. Electrocardiogram was consistent with acute pericarditis. Echocardiogram did not show apparent pericardial effusion. Patient was discharged 3 days later with colchicine and methylprednisolone due to NSAID allergy. Six hours after discharge, patient was readmitted with worsening chest pain and dyspnea. CT angiography revealed moderate pericardial effusion without tamponade. Follow-up echocardiogram showed pericardial thickening, 3.5 cm mass overlying the right ventricle, and large pericardial effusion. After initiation of antibiotic, patient required pericardial window with chest tube placement. Pericardial fluid cultures grew CA-MRSA. Transesophageal echocardiogram was negative for vegetations. Repeat CT chest scan displayed 6.8 cm pericardial abscess adjacent to right atrium and 3.9 cm pericardial phlegmon adjacent to right ventricle prompting sternotomy. Unfortunately, a surgical complication only allowed right atrial pericardial abscess evacuation with cultures confirming CA-MRSA. Repeat imaging showed the pericardial right ventricular phlegmon size increased to 7.5 cm and pericardial right atrial abscess resolution. After consultation with multiple cardiothoracic surgeons, the phlegmon overlying the right ventricle was thought to be less suspicious for infection. Patient continued with medical management along with serial CT scan monitoring. Final chest CT scan prior to discharge showed 3.1 x 1.4 cm pericardial phlegmonous collection overlying right ventricle. Blood cultures remained negative throughout hospitalization and patient was discharged with 3-month course of Bactrim.
DISCUSSION: Purulent pericarditis is an uncommon disease process in the post-antibiotic era. Immediate life-threatening complications include cardiac tamponade, sepsis, and constrictive pericarditis, and it carries an alarmingly high mortality. Our literature review has found only 22 cases of MRSA purulent pericarditis. Of these, only 7 cases (21%) were CA-MRSA related. To our knowledge, this is the 4th reported case of isolated CA-MRSA purulent pericarditis in the English literature. It is our understanding that in patients colonized with CA-MRSA with history of drug use, pericarditis provides an encapsulated space for infection to shield from the antibiotics, allowing progression to purulent pericarditis and abscess formation. Early involvement of antibiotics, cardiothoracic surgery, and timely pericardiectomy can be life-saving.
C3-2018 21: Enigma of Complete Heart Block in Pauci-Immune Vasculitis
Bharat Marwaha, MD; Ma’en Al-Dabbas, MD; Owais Idris, MD; Jay Shah, MD; Hossameldin Mustafa, MD; Raza Hashmi, MD
INTRODUCTION: Vasculitis is a heterogeneous disorder of unknown etiology with low prevalence. They usually present with wide spectrum of clinical manifestations which makes it challenging to diagnose in initial stages. Cardiac involvement is frequent but absence of lab markers in earlier phases make it harder to diagnose clinically silent disease. Grave consequences of a cardiac manifestation are described in our case report.
CASE PRESENTATION: A 58-year-old female with history of mild asthma came to hospital with chief complaint of productive sputum and shortness of breath, with no relief after a 1-week course of antibiotic. She was found to be afebrile, tachypneic along with basal rales on physical examination. Chest x-ray showed bilateral opacities. Labs showed hemoglobin 6.2, serum creatinine 3.67, BNP 9856, troponin <0.03, and CRP 206. Patient was started on azithromycin and received 1 unit of PRBC transfusion along with normal saline. ANA and fecal occult blood test results were negative. ANCA myeloperoxidase was 778. Myeloperoxidase antibodies were 252. Antibodies to glomerular basement membrane were negative. Patient was started on pulsed dose of solumedrol, plasmapheresis, and hemodialysis for the acute renal failure. Renal biopsy showed pauci-immune necrotizing glomerulonephritis. First ECG showed sinus tachycardia while telemonitor showed spells of high-degree AV block intermittently. Echo showed ejection fraction of 55% without valvulopathy. Patient had an episode of dizziness during hospital stay and was found to be in complete heart block on telemonitor. Dual-chamber pacemaker was placed and cyclophosphamide was started for microscopic polyangitis.
DISCUSSION: Recent study has shown cardiac manifestations in microscopic polyangitis ranges from 46% detected with echo to 61% found with cardiac MRI. Pericarditis (50%) and coronary arteritis (50%), with conduction tissue involvement in 15% of cases presenting in form of bundle branch and supraventricular arrhythmia, are found among patients with microscopic polyangitis. Myocarditis is present in 25%-75% of cases and more commonly found in necrotizing vasculitis. Coronary artery aneurysm, dissection, and stenosis are found commonly in Kawasaki and polyarteritis nodosa disease. Pericardial involvement is found commonly in Churag-Strauss disease and manifests in the form of constrictive pericarditis in 20% of patients. Vascular inflammation as predictor of progressive atherosclerosis is established in multiple studies and associated with increased risk of myocardial infarction. Our case has highlighted the importance of keeping high suspicion and close monitoring in vasculitis patients. There is uncertainty about the disease course of complete heart block in such patients, with ambiguity about reversibility after treatment for vasculitis. Prospective future studies with implantable loop recorder in such patients will help guide the treatment strategies.
C3-2018 22: Incidence and Prognosis of New-Onset Left Bundle-Branch Block (LBBB) After Surgical Aortic Valve Replacement
Bharat Marwaha, MD; Hemindermeet Singh, MD; Ma’en Al-Dabbas, MD; Waqar Zainulabedin, MD; Ameer Kabour, MD; Fayyaz Hashmi, MD
INTRODUCTION: Aortic stenosis (AS) is the most common valvular disorder and is found in almost 2.7 million patients >75 years of age in North America. Surgical aortic valve replacement (SAVR) had been the standard of treatment for severe AS, but since the approval of transcatheter aortic valve replacement (TAVR) by the FDA in November 2011, it has emerged as a non-surgical alternative for intermediate (class 2A) to high-risk patients (class 1A). Post-SAVR incidence of left bundle-branch block (LBBB) has been reported to be 4% compared to 16% among TAVR patients. LBBB has been associated with increased incidence of heart failure and permanent pacemaker (PPM) placement among such patients.
OBJECTIVES: (1) Estimate the incidence of new-onset LBBB and its impact on mortality and length of hospitalization in patients after SAVR. (2) Determine incidence of post-op conduction tissue changes manifesting in the form of atrial fibrillation (AFib), supraventricular tachycardia, and complete heart block. (3) Secondary objectives of this study include the readmission rates at 30 days and 1 year for post-op congestive heart failure (CHF) along with mortality rates at 30 days and 1 year post SAVR.
METHODS: Study design was descriptive and retrospective; a chart review of 160 patients through our electronic medical record system (EPIC) was done for those who underwent SAVR for severe AS at Mercy St. Vincent Medical Center between June 30th, 2013 and December 31st, 2016.
RESULTS: Five of the 160 patients had new-onset LBBB with incidence rate of 3.1% (95% confidence interval, 0.4%-5.8%). One of the 5 patients with new-onset LBBB (20%) died during hospital stay. Out of the 4 new-onset LBBB patients who were discharged alive, 2 patients had sustained LBBB post op 1 month and another 2 required PPM.The median length of stay for new-onset LBBB patients was 14 days compared to 7 days for no new LBBB onset. Post-op AFib was found to be in 31.5% of the patients. Thirty-day readmission rate post SAVR was found to be 18.5% and 1-year readmission rate was 32.5%. Post-op mortality rate during the hospital stay was 3.2%, with 30-day mortality rate of 4.5% and 1-year mortality rate of 13.9% in patients post SAVR.
DISCUSSION: Incidence of LBBB post SAVR is low in our study but has been independently associated with worse outcomes. AFib is the most common post-op arrhythmia. Current studies are seeking approval of TAVR in low-risk patients. Higher incidence of LBBB post TAVR puts these patients at higher risk for PPM and worse outcomes.
C3-2018 23: Elevated Baseline B-type Natriuretic Peptide in Transcatheter Aortic Valve Replacement Results in Longer Length of Stay
Giorgio A. Medranda, MD; Jake Rosenblum, BS; Khaled Salhab, MD; Richard Schwartz, DO; Stephen Green MD
PURPOSE: Short-term outcomes have been well studied in patients who undergo transcatheter aortic valve replacement (TAVR). Despite this, little is known regarding predictors of these short-term outcomes. B-type natriuretic peptide (BNP) levels have been shown to predict short-term outcomes in patients who undergo surgical aortic valve replacement (SAVR). BNP levels have not been studied in the intermediate and high-risk group of patients undergoing TAVR. The purpose of this study was to define the utility of baseline BNP levels in predicting short-term mortality and post-TAVR length of stay (LOS).
METHODS: In this retrospective, observational study from 2012-2016, we reviewed data on 825 patients who underwent TAVR at our institution. Patients were dichotomized into those with pre-TAVR BNP levels above or below 500 pg/mL. The outcomes of interest were ICU stay, post-TAVR length of stay (LOS), and inpatient mortality. Statistical analyses were performed using binary logistic regression.
RESULTS: We found that 23.4% (136/582) of patients with a baseline BNP <500 pg/mL and 35.4% (86/243) of those with a baseline BNP >500 pg/mL had an ICU stay of >48 hours. Those with a baseline BNP level of >500 pg/mL were 1.83 times more likely (CI, 0.395-0.758) to have an ICU stay of >48 hours (P<.001). We found that 13.6% (79/582) of patients with a baseline BNP <500 pg/mL and 28.8% (70/243) of patients with a baseline BNP >500 pg/mL had a post-TAVR LOS >7 days. Those with a baseline BNP level of >500 pg/mL were 2.58 times more likely (CI, 0.269-0.559) to have a post-TAVR LOS of >7 days (P<.001). We found that 1.7% (10/582) of patients with a baseline BNP <500 pg/mL and 5.3% (13/243) of patients with a baseline BNP >500 pg/mL had inpatient death. Those with a baseline BNP level of >500 pg/mL were 3.24 times more likely (CI, 0.134-0.715) to have inpatient death (P<.001).
CONCLUSIONS: Identification of predictors of short-term outcomes following TAVR carries significant clinical implications in this growing group of patients. In intermediate-risk and high-risk TAVR patients, we found elevated baseline BNP levels to be predictive of longer ICU stay, longer post-TAVR LOS, and increased inpatient mortality. Patients whose baseline BNP is >500 pg/mL may ultimately require aggressive medical optimization prior to TAVR to improve short-term outcomes.
C3-2018 24: The Impact of Pre-Existing Aortic Regurgitation on Mitral Regurgitation Following Transcatheter Aortic Valve Replacement
Giorgio A. Medranda, MD; Richard Schwartz, DO; Khaled Salhab, MD; Srihari Naidu, MD; Stephen Green, MD; Ramesh Daggubati, MD
PURPOSE: Severe aortic stenosis (AS) is seldom isolated and often co-exists with some degree of aortic regurgitation (AR). Patients with significant aortic valve disease often have mitral regurgitation (MR), which has been shown to be an independent predictor of MACE. Initial studies suggest that there are at least short-term improvements in MR following TAVR. Predictors of worsening MR remain unclear. The purpose of this study was to examine pre-existing characteristics as predictors of worsening MR following TAVR.
METHODS: In a retrospective, observational study from 2012-2018, we reviewed data from 1048 intermediate-risk and high-risk patients who underwent TAVR at our institution. We reviewed MR grades, AR grades, ejection fraction (EF), and left ventricular internal diastolic dimension (LVIDd) on pre-TAVR and MR grade on pre-discharge transthoracic echocardiograms (TTEs). Statistical analysis of outcomes was performed using binary logistic regression.
RESULTS: Of the 1048 patients, MR grade worsened in 11.5% of patients following TAVR. The 121 patients whose MR worsened were 1.65 times less likely to have had co-existing AR (mild/2+, moderate/3+, or severe/4+) at time of TAVR (CI, 1.030-2.646; P=.0374) and 2.928 times less likely to have a co-existing LVIDd >5.6 cm at time of TAVR (CI, 1.112-7.710; P=.0296). Pre-TAVR EF <50% was not found to correlate with worsening MR following TAVR (P=.8870). There was no statistically significant interaction between AR and LVIDd (P=.7068).
CONCLUSIONS: In intermediate-risk and high-risk patients undergoing TAVR, we found that MR grade worsened in 11.5% of patients. Patients whose MR progressed following TAVR were less likely to have co-existing AR or dilated cardiomyopathies. It is plausible that chronic AR and eccentrically adapted left ventricles prevent worsening in MR grade following TAVR.
C3-2018 25: Survival of Achromobacter Xylosoxidans Native Tricuspid Valve Endocarditis as a Complication of Intravenous Drug Abuse
Mohamad Alhoda Mohamad Alahmad, MD and Faraz Khan Luni, MD
INTRODUCTION: Infective endocarditis due to Achromobacter xylosoxidans (AX), a gram-negative rod, is rare and most frequently reported with prosthetic devices and immunocompromised status. The outcome is often fatal unless treated promptly with antibiotic and surgical intervention. This case of successfully treated AX endocarditis occurred on a native tricuspid valve as a complication of intravenous drug abuse (IVDA).
CASE PRESENTATION: A 34-year-old man with a history of intravenous drug abuse presented with fever, gradual onset of dyspnea, orthopnea, and lower-extremity edema for several weeks. Physical examination was remarkable for bilateral basal crackles, new cardiac murmur, lower-extremity edema, and splenomegaly. Blood and urine cultures were positive for AX. Echocardiogram showed vegetation and suggested infective endocarditis. Patient was treated with meropenem based on sensitivity. Two weeks later, patient was admitted with similar symptoms. Repeated blood cultures showed AX again that is resistant to meropenem, so piperacillin-tazobactam was initiated based on the new sensitivity report. After a week of documented negative blood cultures, the patient had a bioprosthetic tricuspid valve implantation with uneventful recovery.
DISCUSSION: Infective endocarditis is usually diagnosed by modified Duke criteria, which can be challenging in the setting of low virulent organisms such as AX. AX is a rare cause of endocarditis. Including ours, 14 cases has been reported due to AX. Nosocomial outbreaks related to this organism has been reported and were found to be due to contaminated solutions used during dialysis or cardiac surgery. In our case, we believe that the opioid-containing intravenous solution was the source of infection. This explains the unique location on the native tricuspid valve in our case. A literature review showed that the case fatality rate in cases of AX endocarditis that were treated exclusively with antibiotics was 100% in comparison to 25% in cases that were treated by combined surgical and medical therapies. In conclusion, AX is a rare but lethal cause of bacterial endocarditis, which requires prompt consideration of surgical as well as medical therapies.
C3-2018 26: Sickle Cell Disease Associated Pulmonary Arterial Hypertension
Cornelius C. Nwora, MD
PURPOSE: The purpose of the present study is to understand the prevalence of pulmonary arterial hypertension (PAH) amongst patients with sickle cell disease (SCD), the pathophysiology of this disease process, accepted diagnostic modalities, and the peculiar treatment protocols.
METHODS: Review of published articles on the subject matter. Pulmonary arterial hypertension can be screened non-invasively by applying echocardiography to measure tricuspid regurgitation jet velocity (TRV – normal value <2.5 m/sec) in combination with estimated right arterial pressure, considered to be a valid estimate of systolic pulmonary arterial pressure (PAP). The definitive diagnosis of PAH is by right heart catheterization. The diagnosis is possible if the TRV is 2.9-3.4 m/sec and likely if it is >3.4 m/sec.
RESULTS: Pulmonary hypertension (PH) is relatively common in SCD and should be considered both in the broader picture of PAH in patients without SCD, with the view that SCD pathophysiology affects the pathogenesis, classification, and prognosis of this disorder. It is estimated that PAH affects approximately 10% of adult patients with SCD, particularly those with the homozygous genotype.
About half of SCD-related PH patients have precapillary PH with potential etiologies of (1) a nitric oxide deficiency state and vasculopathy consequent to intravascular hemolysis, (2) chronic pulmonary thromboembolism, or (3) unregulated hypoxic responses secondary to anemia, low oxygen saturation, and microvascular obstruction. The other half have postcapillary PH secondary to left ventricular dysfunction (group 2).
Pulmonary hypertension is defined as mean pulmonary pressure ≥25 mm Hg at rest as determined by right heart catheterization, according to the World Symposium on PH. Some authorities consider that PAH within the range between 21 and 24 mm Hg may identify subjects with reduced exercise capacity and poor outcomes. Clinically, PAH is divided into five broad categories, and in 2013, the decision was made at the Fifth World Symposium on PH to move PAH associated with chronic hemolytic anemia including SCD from group 1 to group 5 – ie, pulmonary hypertension with unclear or multiple etiologies. Pathologically, all three layers of the pulmonary arterial wall – intima, media, and adventitia – are differentially affected in the various groups of PAH, and according to the site of primary initiation of elevated pulmonary arterial pressure (PAP) – as precapillary PH, postcapillary PH, and chronic thromboembolic PH (CTEPH).
Management of adults with SCD-related PH is based on anticoagulation for those with thromboembolism; oxygen therapy for those with low oxygen saturation; treatment of left ventricular failure in those with postcapillary PH; and use of hydroxyurea, which increases the concentration of fetal hemoglobin (HbF), and red blood cell transfusions to raise the hemoglobin concentration, reduce hemolysis, and prevent vaso-occlusive events that cause additional increase in pulmonary pressure.
CONCLUSION: SCD patients with PH have a markedly higher risk of death and shorter life expectancy than those without. Patients with hemodynamically significant pulmonary hypertension should be referred to specialized centers for proper evaluation, diagnosis, and management using protocols specifically directly toward ameliorating the classified etiologies.
C3-2018 27: Utilization of the EuroScore for the Prediction of Intrahospital Death in Left Main Coronary Angioplasty
M. Payaslian, MD; A. Girassolli, MD; H. Chuliber, MD; P. Rattagan, MD; V. Gonzalez, MD; F. Albornoz, MD; B. Mangariello, MD; P. Gitelman, MD; G. Leiva, MD
INTRODUCTION: The prognostic value of EuroScore II (E) as a predictor of death in cardiac surgery is reported in several studies. However, the evidence of its importance in left main coronary angioplasty is scarce. Some studies combined with clinical and anatomic characteristics (SYNTAX [S]) have improved the predictive ability.
PURPOSE: Analyze the value of EuroScore as a predictor of intrahospital death in left main coronary angioplasty. Analyze whether the EuroScore combined with SYNTAX score improves the intrahospital death predictive value.
METHODS: We analyzed the computed epicrisis of the patients who were treated consecutively with left main coronary angioplasty between July 2008 and March 2018. Finally, the intrahospital mortality (M) was analyzed. We used E and S as continuous variables. Logistic regression models were designed to evaluate prediction of M with: E and S, and the combination of both. AUC (area under the curve) was constructed to evaluate differences of each model and the comparison with each other.
RESULTS: The medium age of 47 patients was 70 years old (SD ± 11), and 22% were women. Risk factors: 18% diabetes; 78% arterial hypertension; 16% smoking exposure; 43% previous current smoking status; and 36% dyslipemia. Coronary history: 33% acute myocardial infarction; 42% chronic stable angina; 25% coronary angioplasty; and 11% myocardial revascularization surgery. Left main coronary angioplasty was performed with protected main in 9% of patients. The E was 5 (IQ25-75: 2-13) and the S was 28 (IQ25-75: 20-32). In the evolution, M was observed in 30% of patients (n = 13), with 0% in programmed, 21% in urgency, and 69% in emergency.
CONCLUSIONS: The E was a better predictor of M than S and independent of it in patients with left main coronary angioplasty. The combination of both scores showed a tendency toward greater discrimination than S. It is probable that statistically significant differences would be evidenced with an increased sample of patients.
C3-2018 28: Primary PCI the Setting of Acute and Inferior STEMI With Cardiogenic Shock
Mohamed Zahran, MD, MSc, PhD and Amr Salah Mohamed, MD, MSc
INTRODUCTION: ST-elevation myocardial infarction (STEMI) is the most serious presentation of atherosclerotic coronary artery disease, carrying the most hazardous consequences, and patients with ST elevation are candidates for immediate reperfusion therapy. Reperfusion therapy is the cornerstone of the treatment of patients with STEMI; it aims to reduce mortality and morbidity by achieving patency of the epicardial infarct-related artery and by restoring myocardial tissue perfusion either pharmacologically or mechanically.
CASE PRESENTATION: A 55-year-old male driver, smoker, hypertensive who presented to us with typical chest pain of 2-hour duration. On examination, the patient was shocked with blood pressure 70/40, apical HR was 55, no audible murmurs, ECG showed ST elevation in the anterior and inferior leads. The patient was immediately taken to the catheterization laboratory after receiving 300 mg of aspirin and 180 mg ticagrelor. Intravenous inotropes and vasopressors were initiated, but failed to elevate the blood pressure despite high doses.We suspected that we would find total LAD and RCA, or total LAD that was supplying the RCA retrograde due to chronic total occlusion, but we found something different and unexpected – we found total left main occlusion. Two PTCA wires were used in LAD and LCX, PTCA to LAD and LCX, leading to establishment of flow. Blood pressure immediately normalized and the patient was much better, the left main lesion became clear to us as a Medina class 1,1,1; we decided to go for the T and small protrusion (TAP) technique, as this allowed us to stent the LAD first and is the least time-consuming, and the bifurcation anatomy was favorable (narrow angle for the LCX).The procedure was done and resulted in final TIMI 3 flow. The patient was then transferred to our Cardiac Care Unit, were he spent about 3 days. Echocardiography showed ejection fraction of 45%, segmental wall-motion abnormality in the LAD territory, and no mechanical complications. The patient followed up in our outpatient clinic 2 weeks later and was chest pain free on optimal medical therapy.
DISCUSSION: Primary PCI is the cornerstone for the management of STEMI, and the key for the survival of this patient was that there was no delay and we chose the simplest bifurcational technique, the least time-consuming technique, and the one that we have mastered. More procedure time in cardiogenic shock patients is equal to more mortality.
C3-2018 29: Predictors of In-Hospital Mortality With Octogenarians and Nonagenarians Undergoing Transcatheter Aortic Valve Replacement
Jay Shah, MD; Ma’en Al Dabbas, MD; Bharat Marwaha, MD; Rajumar Doshi, MD
OBJECTIVE: We sought to analyze predictors of in-hospital mortality in patients who underwent TAVR.
BACKGROUND: Patients >80 years older – particularly nonagenarians – are considered high risk because of the presence of various comorbidities. Because of the surgical risk, transcatheter aortic valve replacement (TAVR) is more often performed in this age group. In this study, we evaluated the predictors of in-hospital mortality in octogenarians and nonagenarians.
METHODS: This is a retrospective, observational study that analyzes various factors to estimate in-hospital mortality in patients >80 years old using a multivariate predictor model. The sample for this study was obtained from the National Inpatient Sample (NIS) for the years 2012-2014 using ICD-9 CM procedure codes 35.05 and 35.06 for TAVR.
RESULTS: Higher age (OR: 1.080; P=.0029) and female gender (OR: 1.570; P=.0036) are associated with higher risk mortality. Among comorbidities, the following were associated with greater risk of mortality: fluid and electrolyte disorders (OR: 2.014; P=<.0001), chronic pulmonary disease (OR: 1.388; P=.0394), and patients on dialysis (OR; 4.943; P<.0001).Greater risk of mortality was also associated in patients who required mechanical circulatory support (MCS) such as intra-aortic balloon pump (OR: 11.626; P<.0001), percutaneous left ventricular assist device (Impella, Tandem Heart, etc.) (OR: 10.269; P=.0005), and extracorporeal membrane oxygenation (OR: 53.470; P<.0001). In contrast, uncomplicated diabetes mellitus (OR: 0.664; P=.0475) and hypertension (OR: 0.454; P<.0001) were associated with lower in-hospital mortality.
CONCLUSION: Better patient care is vital with those patients undergoing TAVR with higher age, female gender, electrolyte imbalance, chronic pulmonary disease, patients on dialysis or those who required MCS.
C3-2018 30: Comparison of ECMO and pLVAD for Patients With Cardiogenic Shock Undergoing High-Risk Percutaneous Coronary Intervention
Ma’en Al Dabbas, MD; Jay Shah, MD; Bharat Marwaha, MD; Rajkumar Doshi, MD
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) support is often utilized to stabilize patients presenting with severe cardiogenic shock (CS). Despite improved oxygenation and peripheral circulation, left ventriclar unloading may be completely impeded due to increased afterload by ECMO. Therefore, we describe here, for the first time, a large series of patients treated with either ECMO or a percutaneous left ventricular assist device (pLVAD) for the treatment of CS undergoing percutaneous coronary intervention (PCI).
METHODS: We included all patients undergoing PCI with CS supported by either ECMO or pLVAD between 2012 and 2014 from the NIS database using appropriate ICD 9 CM procedure and diagnostic codes.
RESULTS: A total of 983 patients (weighted 4915) were included in our study. Average age was higher in the pLVAD group. Most procedures were non-elective in both groups. Baseline differences existed between the groups with higher comorbidity in the pMCS group (Charlson’s comorbidity index ≥2 in 52.6%). Primary outcome of in-hospital mortality was higher with the ECMO group. All secondary outcomes were higher with the ECMO group. Length of stay and median cost were higher with the ECMO group as well.
CONCLUSION: Higher cost with ECMO is attributed to longer length of stay and higher in-hospital outcomes.
C3-2018 31: Value of Right Ventricular 2D-Speckle Tracking Parameters in Predicting the TIMI Flow Grade of the RCA in Patients With Acute RV Infarction
Hesham Tayel, MD; Walaa Farid, MD; Ghada A. Soltan, MD; Neveen Samy, MD
BACKGROUND: Two-dimensional (2D) strain and strain rate (SR) analyses are novel Doppler-independent techniques to assess myocardial deformation. While this method has been frequently used to assess LV function, it has rarely been used to examine RV function despite the fact that RV function is an important prognostic factor in patients with acute first inferior and right MI.
METHODS: This is a prospective study that was carried out from March 2015 to April 2016. Forty patients with acute inferior and right MI were included in this study (average age, 46 ± 9 years; 25 males and 15 females) based on the ECG criteria. All patients received thrombolytic therapy within 6 hours from chest pain onset, coronary angiography was done within the first 24 hours from admission, and TIMI flow grade in the RCA was determined and recorded for each patient. Echocardiography was performed before coronary angiography using a Vivid 9 (GE Vingmed; Norway) equipped with a harmonic M5S transducer. For speckle tracking analysis of the RV, 2D apical four-chamber views were acquired over three cardiac cycles during a breath-hold with the frame rate set between 60-80 frames/sec. Measurements of the RV TAPSE, RV FAC, EPASP, and RV TDI-St were done in accordance with current American Society of Echocardiography recommendations. Measurements of RV free-wall strain and SR were performed offline on a PC workstation using custom analysis software (Echopac PC, v. 1.8.1.X; GE). The data were collected and statistically analyzed with SPSS v. 17.
RESULTS: Positive significant correlation between TIMI flow grade in the RCA and the cumulative systolic strain rate SRs s-1 (P<.001 and r=0.48). There was no statistically significant (P<.05) correlation between the other echocardiographic RV parameters and the TIMI flow grade of the RCA.
CONCLUSIONS: The RV free-wall cumulative strain rate (SRs s-1) can predict the TIMI flow grade in the RCA in patients with acute RV infarction. Thus, it can help determine successfulness of the thrombolytic therapy in this group of patients.
