Journal of the Society for Cardiovascular Angiography & Interventions最新文献

We document the elongation and shunting of a patent foramen ovale (PFO) after thoracic aortic dissection repair in a 63-year-old man. Initially, a presurgical echocardiogram showed insignificant PFO shunting; however, severe hypoxemia and inability to extubate after thoracic aortic dissection repair necessitated further investigation. A repeat transesophageal echocardiogram after cardiothoracic surgery revealed significant PFO elongation with bidirectional shunting. Subsequent urgent transcatheter PFO closure markedly improved oxygenation, allowing for successful weaning from mechanical ventilation. This case highlights the importance of recognizing dynamic PFO changes after thoracic surgery as a reversible cause of postoperative hypoxemia.

Background

Transcatheter aortic valve replacement (TAVR) is one of the primary treatment modalities for aortic stenosis (AS). Disparities affecting certain groups could result in lower utilization of this life-saving procedure. This study aims to investigate the effects of associated psychiatric conditions on the likelihood of TAVR in hospitalized AS patients.

Methods

Our retrospective observational study used the National Inpatient Sample to identify hospitalized patients with AS. Using the International Classification of Diseases, 10th Revision, Clinical Modification patients were stratified into those without psychiatric comorbidities, and those with psychiatric comorbidities. The primary outcome was comparing the odds of TAVR between AS patients with and without psychiatric comorbidities. The secondary outcome assessed the association between TAVR and specific psychiatric comorbidities, using multivariable logistic regression while adjusting for prespecified covariates.

Results

The study included 1,549,785 AS patients, of which 26% had psychiatric comorbidities. Patients with any psychiatric comorbidity had a significantly reduced likelihood of TAVR (adjusted odds ratio [aOR], 0.76; P < .001). For 2 psychiatric comorbidities, (aOR, 0.80; P < .001), and for more than 2 comorbid mental disorders (aOR, 0.46; P < .001). Lower TAVR odds were observed in patients with depression (aOR, 0.79), anxiety (aOR, 0.79), bipolar disorder (aOR, 0.74), substance use (aOR, 0.73), and psychotic disorders (aOR, 0.61), with P values < .001. There was no significant difference in the odds of surgical aortic valve replacement between those with and without psychiatric comorbidities.

Conclusions

AS patients with psychiatric conditions face reduced TAVR likelihood. Further research is needed to confirm, explore, and address factors contributing to this disparity.

Background

Reducing door-to-balloon (D2B) time for ST-segment elevation myocardial infarction (STEMI) has been shown to improve outcomes. Delays still occur due to various factors such as time to laboratory activation and diagnostic clarification in equivocal cases. We propose that early communication through a mobile application (app) between emergency medical services (EMS) and in-hospital providers can reduce EMS-to-balloon time and provide coordinated care to impact D2B time.

Methods

The General Devices e-Bridge mobile app, which allows real-time communication and data transmission between EMS providers and the cardiac catheterization laboratory and emergency department staff, was implemented on May 14, 2019. A single-center, retrospective observational study was conducted on 795 STEMI activations undergoing emergent coronary angiography between January 2017 and July 2020. After exclusions, EMS transmissions of 428 cases were analyzed, of which 132 used the app.

Results

Implementation of e-Bridge significantly reduced D2B time by 7.2 minutes (P = .005) and emergency department board time by 4.41 minutes (P = .01). First medical contact to balloon (FMC2B) time trended toward reduction but was not statistically significant. The app did not significantly reduce D2B or FMC2B time during the day shift but significantly improved these metrics during the night shift.

Conclusions

Implementation of app-based communication between EMS and in-hospital providers resulted in statistically significant reductions in D2B time at our institution. This approach holds promise in improving the timely management of STEMI patients, particularly during the night shift.

Background

Myocardial bridges (MB) are prevalent but not universally associated with angina. The mechanisms linking MB and angina are poorly defined. The objective of this study was to determine the prevalence of epicardial spasm, microvascular spasm, and/or endothelium-independent coronary microvascular dysfunction (CMD) in patients with MB which might explain symptoms.

Methods

Patients with known MB and chest pain at the University of Chicago Medical Center between 2020-2023 were included. All patients underwent dobutamine testing with measurement of resting full-cycle ratio to determine hemodynamic significance (resting full-cycle ratio ≤0.76). Endothelium-independent CMD was defined as coronary flow reserve <2.0 or index of microvascular resistance ≥25 on adenosine testing. Microvascular spasm was defined as chest pain and electrocardiogram changes with nonischemic fractional flow reserve with acetylcholine. Epicardial spasm was defined as dynamic stenosis of >90% of the epicardial vessel or ischemic fractional flow reserve (≤0.8) with acetylcholine.

Results

A total of 30 patients (mean age, 47 ± 10 years; 60% female) with MB were studied. Endothelium-independent CMD, microvascular spasm, and epicardial spasm occurred commonly in 60%, 29%, and 37% of patients respectively, with 77% having at least one abnormality. The MB was hemodynamically significant in 47% of patients, and the prevalence of these coexisting conditions was not affected by hemodynamic significance.

Conclusions

Epicardial spasm, microvascular spasm, and endothelium-independent CMD are prevalent in patients presenting with known MB and chest pain irrespective of the hemodynamic significance of the bridge. Invasive coronary function testing may play an important role in uncovering alternative explanations for angina in patients with known MB.

Background

Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension (CTEPH) is limited by a lack of safe and effective tools for crossing these lesions. We aim to identify a safety window for an intraluminal crossing device in this vascular bed by studying the piercing properties of pulmonary arterial vessel walls and intraluminal CTEPH lesion specimens. As a secondary objective, we also describe the histopathologic features of CTEPH lesions.

Methods

Specimens were procured from 9 patients undergoing pulmonary endarterectomy. The specimens were subsampled and identified grossly as arterial wall or intraluminal CTEPH lesions. The force needed for tissue penetration was measured using a 0.38-mm (0.015-in) diameter probe in an ex vivo experimental model developed in our lab. Concurrent histology was also performed.

Results

The mean force needed to penetrate the arterial wall and intraluminal CTEPH lesions was 1.75 ± 0.10 N (n = 121) and 0.30 ± 0.04 N (n = 56), respectively (P < .001). Histology confirmed the presence of intimal hyperplasia with calcium and hemosiderin deposition in the arterial wall as well as an old, organized thrombus in the lumen.

Conclusions

The pulmonary arterial wall is friable and prone to perforation during instrumentation with workhorse coronary guide wires. However, the results of this study demonstrate that a much lower force is needed for the 0.38-mm (0.015-in) probe to penetrate an intraluminal CTEPH lesion compared to pulmonary arterial intima. This finding suggests the existence of a safety window for lesion-crossing devices, enabling effective balloon pulmonary angioplasty.

Background

Mechanical thrombectomy (MT) is playing an increasingly important role in treating deep vein thrombosis (DVT). Although degrees of safety and efficacy have been shown in independent studies, there remains a lack of comparative evidence between MT devices. To address this, we aimed to compare demographics, clinical outcomes, and resource metrics of patients receiving MT for DVT with 3 common devices using a real-world database.

Methods

Patients receiving MT for DVT between January 2018 and March 2022 were identified from the PINC AI Healthcare Database and divided into analysis populations for the AngioJet ZelanteDVT (AJ), the ClotTriever system (CT), and the Indigo system (IN). Rates of in-hospital mortality, resource utilization, and 30-day readmission were compared. Regression modeling was performed to adjust for potential covariates and compare outcomes.

Results

A total of 4455 MT encounters were identified and met inclusion criteria (AJ, 1753; CT, 1344; IN, 1358). In-hospital mortality ranged from 1.0% (CT) to 2.9% (IN), with modeling predicting significantly higher odds for the AJ (odds ratio [OR], 3.42) and IN (OR, 3.38) groups. Similarly, higher rates of resource utilization were predicted in the AJ and IN groups when compared with the reference group (CT). Average costs ranged from $29,549 (CT: SD, $30,705) to $42,705 (IN: SD, $41,114). Thirty-day readmissions ranged from 10.0% (AJ) to 14.6% (IN), while modeling predicted significantly greater odds for the IN group (OR, 1.47).

Conclusions

These results suggest that all MT interventions may be unequal in terms of outcomes and resources, with the CT device associated with lower in-hospital mortality and resource burden.