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The role and timing of percutaneous mechanical circulatory support (MCS) devices in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS) are not well understood. We sought to evaluate patient characteristics and predictors of outcomes in patients presenting with AMICS supported with an axial flow percutaneous MCS device; 287 consecutive unselected patients enrolled in the catheter-based ventricular assist device registry presenting with AMICS who underwent percutaneous coronary intervention (PCI) were included in this analysis. All patients were supported with either the Impella 2.5 or Impella CP. Mean patient age was 66 ± 12.5 years, 76% were men, and mean left ventricular ejection fraction was 25 ± 12%. Before receiving MCS, 80% of patients required inotropes or vasopressors and 40% were supported with intra-aortic balloon pump; 9% of patients were under active cardiopulmonary resuscitation at the time of MCS implantation. Survival to discharge was 44%. In a multivariate analysis, early implantation of a MCS device before PCI (p = 0.04) and before requiring inotropes and vasopressors (p = 0.05) was associated with increased survival. Survival was 66% when MCS was initiated <1.25 hours from shock onset, 37% when initiated within 1.25 to 4.25 hours, and 26% when initiated after 4.25 hours (p = 0.017). Survival was 68%, 46%, 35%, 35%, and 26% for patients requiring 0, 1, 2, 3, and ≥4 inotropes before MCS support, respectively (p <0.001). In conclusion, MCS implantation early after shock onset, before initiation of inotropes or vasopressors and before PCI, is independently associated with improved survival in patients presenting with AMICS.

Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is a rare but life-threatening complication. Paravalvular regurgitation, compression of native leaflets, and space between transcatheter valve prosthesis and native valves could dispose TAVI recipients at increased risk of IE compared with SAVR. To assess the comparative risk of IE between TAVI and SAVR, we performed a systematic review and meta-analysis. A literature search of PUBMED and EMBASE was performed to identify randomized controlled trials that reported the event rate of IE in both TAVI and SAVR. A Mantel-Haenszel method and a random-effects model was used to calculate the odds ratio (OR) and 95% confidence interval (CI). The studied outcomes were early (at 1-year), late (>1-year), and overall IE (postprocedure to longest follow-up) in TAVI versus SAVR. We performed subgroup analysis based on valve-type (self or balloon-expandable) and surgical risk (high or intermediate). A total of 4 studies with 3,761 (1,895 TAVI and 1,866 SAVR) patients were included. The incidence of early IE, (3 studies, 0.86% vs 0.73%, OR 1.17, 95% CI 0.51 to 2.65, p = 0.71, I2 = 0%), late IE (mean follow-up 2.0 years) (3 studies, 1.3% vs 0.6%, OR 1.85, 95% CI 0.81 to 4.20, p = 0.42, I2 = 0%), and overall IE (mean follow-up 3.4 years) (4 studies, 2.0% vs 1.3%, OR 1.44, 95% CI 0.85 to 2.43, p = 0.18, I2 = 0%) was similar between TAVI and SAVR. Subgroup analysis suggested that in intermediate surgical risk cohort, there was a trend toward increased risk of overall IE in TAVI (2.3% in TAVI and 1.2% in SAVR, OR 1.92, 95% CI 0.99 to 3.72, p = 0.05 I2 = 0%). In this meta-analysis, we did not find an increased risk of IE in TAVI compared with SAVR. Appropriate preventative measure and early recognition of IE in these cohorts are important.

Gender disparities in ST-segment elevation myocardial infarction (STEMI) outcomes continue to be reported worldwide; however, the magnitude of this gap remains unknown. To evaluate gender-based discrepancies in clinical outcomes and identify the primary driving factors a global meta-analysis was performed. Studies were selected if they included all comers with STEMI, reported gender specific patient characteristics, treatments, and outcomes, according to the registered PROSPERO protocol: CRD42020161469. A total of 56 studies (705,098 patients, 31% females) were included. Females were older, had more comorbidities and received less antiplatelet therapy and primary percutaneous coronary intervention (PCI). Females experienced significantly longer delays to first medical contact (mean difference 42.5 min) and door-to-balloon time (mean difference 4.9 min). In-hospital, females had increased rates of mortality (odds ratio [OR] 1.91, 95% confidence interval [CI] 1.84 to 1.99, p <0.00001), repeat myocardial infarction (MI) (OR 1.25, 95% CI 1.00 to 1.56, p=0.05), stroke (OR 1.67, 95% CI 1.27 to 2.20, p <0.001), and major bleeding (OR 1.82, 95% CI 1.56 to 2.12, p <0.00001) compared with males. Older age at presentation was the primary driver of excess mortality in females, although other factors including lower rates of primary PCI and aspirin usage, and longer door-to-balloon times contributed. In contrast, excess rates of repeat MI and stroke in females appeared to be driven, at least in part, by lower use of primary PCI and P2Y12 inhibitors, respectively. In conclusion, despite improvements in STEMI care, women continue to have in-hospital rates of mortality, repeat MI, stroke, and major bleeding up to 2-fold higher than men. Gender disparities in in-hospital outcomes can largely be explained by age differences at presentation but comorbidities, delays to care and suboptimal treatment experienced by women may contribute to the gender gap.

Contemporary practices for hemodynamically supported high-risk percutaneous coronary intervention have evolved over the last decade. This study sought to compare outcomes of the prospective, multicenter, PROTECT III study to historic patients treated with Impella in the PROTECT II randomized controlled trial. Of 1,134 patients enrolled in PROTECT III from March 2017 to March 2020, 504 were “PROTECT II-like” (met eligibility for PROTECT II randomized controlled trial) and are referred to as PROTECT III for comparative analysis. Major adverse cardiac and cerebrovascular events (MACCE), comprising all-cause mortality, stroke/transient ischemic attack, myocardial infarction, and repeat revascularization, were compared at hospital discharge and 90 days. Compared with PROTECT II (N = 216), PROTECT III patients were less often Caucasian (77.1% vs 83.8%, P = .045), with less prior CABG (13.7% vs 39.4%; P < .001) and prior myocardial infarction (40.7% vs 69.3%; P < .001). More PROTECT III patients underwent rotational atherectomy (37.1% vs 14.8%, P < .001) and duration of support was longer (median 1.6 vs 1.3 hours; p<0.001), with greater improvement achieved in myocardial ischemia jeopardy scores (7.0±2.4 vs 4.4±2.9; P < .001) and SYNTAX scores (21.4±10.8 vs 15.7±9.5; P < .001). In-hospital bleeding requiring transfusion was significantly lower in PROTECT III (1.8% vs 9.3%; P < .001), as was procedural hypotension (2.2% vs 10.1%; P < .001) and cardiopulmonary resuscitation or ventricular arrhythmia (1.6% vs 6.9%; P < .001). At 90 days, MACCE was 15.1% and 21.9% in PROTECT III and PROTECT II, respectively (p=0.037). Following propensity score matching, Kaplan-Meier analysis showed improved 90-day MACCE rates in PROTECT III (10.4% vs 16.9%, P = .048). The PROTECT III study demonstrates improved completeness of revascularization, less bleeding, and improved 90-day clinical outcomes compared to PROTECT II for Impella-supported high-risk percutaneous coronary intervention among patients with severely depressed LVEF.

Impella was approved by the Food and Drug Administration in 2015 for use during high-risk percutaneous coronary interventions (PCIs); however, its safety and efficacy compared with intra-aortic balloon pump (IABP) has not been evaluated in contemporary practice and remains debated. We aimed to compare postapproval outcomes and costs of Impella versus IABP support for high-risk PCI in real-world practice across hospitals in the United States. We identified patients from the Premier Healthcare Database undergoing nonemergent Impella- or IABP-supported high-risk PCI. We used propensity adjustment to control baseline, procedure, and post-PCI medical treatment differences between treatment groups. We included patients undergoing nonemergent single-PCI procedures with either Impella or IABP support and excluded patients presenting with acute ST-elevation myocardial infarction or cardiogenic shock or requiring >1 mechanical support devices during index hospitalization. Outcomes included in-hospital survival, myocardial infarction (MI), cardiogenic shock, stroke, bleeding requiring transfusion, acute kidney injury, index hospitalization length of stay, and costs. From April 2016 to June 2019, a total of 48,179 patients were treated with Impella or IABP mechanical circulatory support at 304 hospitals in the United States. Among these, we identified 2,156 patients undergoing nonemergent high-risk PCI treated with Impella (n = 1,447) or IABP (n = 709). After propensity adjustment, Impella use was associated with improved survival (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.02 to 2.36) and less MI (OR 0.29, 95% CI 0.18 to 0.46) and cardiogenic shock (OR 0.54, 95% CI 0.39 to 0.74). Stroke, bleeding requiring transfusion, and acute kidney injury were similar between groups. In conclusion, this Premier Healthcare Database propensity-adjusted analysis, Impella use during nonemergent high-risk PCI was associated with improved survival and reduced in-hospital MI and cardiogenic shock compared with IABP.

A concise and convenient pocket guide to interventional cardiology's latest procedures and technologies Interventional cardiology is growing more and more integral to the modern-day management of cardiovascular problems. Indeed, trainees are taught interventional methods as a matter of course. With a widening range of options open to them, however, the practicing cardiologist must be diligent and discerning when selecting the appropriate course of action for each patient, adapting their strategy as circumstance demands. Developing the skills and experience necessary to make these key judgments can be a challenging and lengthy process. Bringing together the knowledge of an international group of over 50 experts, this fifth edition of the Practical Handbook of Advanced Interventional Cardiology helps cardiologists of all levels to find interventional solutions to a wide range of problems. Its revised contents cover topics including new devices, valve procedures, and venous and atrial occlusion, and also feature new chapters on bioresorbable vascular scaffolds, protected percutaneous coronary intervention, coronary atherectomy, pulmonary embolism, and more. This essential companion: * Offers clear, easy-to-follow guidance for cardiology practitioners of all levels of skill and experience * Grades each strategic or tactical action by level of complexity * Includes full-color clinical images and illustrations * Covers all key interventional procedures and techniques * Provides practical tips and tricks for handling difficult clinical scenarios and complications The Practical Handbook of Advanced Interventional Cardiology is an invaluable resource for both practitioners and trainees in interventional cardiology and all related areas of cardiovascular medicine.

Percutaneous ventricular assist devices (pVAD) are frequently utilized in high-risk percutaneous coronary intervention (HR-PCI) to provide hemodynamic support in patients with complex cardiovascular disease and/or multiple comorbidities who are poor candidates for surgical revascularization. Using the National Inpatient Sample we identified pVAD-assisted PCI (excluding intra-aortic balloon pump) in patients without cardiogenic shock from January 2008 to December 2018. We evaluated the trends in patient and procedural characteristics, and complication rates across the 11-year study period. A total of 26,661 pVAD-PCI was performed. From 2008 to 2018 there has was a 27-fold increase in the number of pVAD-PCIs performed annually. There has also been an increase in the proportion of procedures performed in small to medium sized hospitals. The use of atherectomy, image-guided PCI, FFR/iFR, drug-eluting stents, and multi-vessel intervention has significantly increased. Patients undergoing pVAD-PCI had a higher burden of comorbidities, without a significant difference in mortality over time. There were decreased rates of acute stroke and blood transfusions over time, while vascular complications and acute kidney injury (AKI) requiring dialysis remained mostly unchanged. In conclusion, the use of pVAD for HR-PCI has increased significantly, along with adjunctive PCI techniques such as atherectomy, intravascular imaging, and physiologic lesion assessment. With increasing use of this device, there appeared to be lower rates of peri-procedural stroke, and blood transfusions. Despite a higher burden of comorbidities, adjusted mortality remained stable over time.

Clinical outcomes of transcatheter aortic valve implantation (TAVI) have significantly improved with the accumulation of operator and institution experience as well as the wide use of newer generation devices. There is limited data on TAVI outcomes compared with surgical aortic valve replacement (SAVR) in contemporary practice in the United States. We queried the 2018 Nationwide Readmission Database of the United States. International Classification Diagnosis code 10 was used to extract TAVI and SAVR admissions. A propensity-matched cohort was created to compare TAVI and SAVR outcomes. A weighted 48,349 TAVI and 24,896 SAVR for aortic stenosis were included and 4.9% of TAVI were performed with an embolic protection device. In propensity-matched cohort (12,708 TAVI and 12,708 SAVR), TAVI conferred lower in-hospital mortality (1.7% vs 3.8%), acute kidney injury (11.3% vs 22.9%), and transfusion rate (5.9% vs. 20.6%) whereas new pacemaker rate was higher in TAVI compared with SAVR (10.5% vs. 7.0%) (all p values < 0.001). Stroke rate was similar between TAVI and SAVR (1.5% vs. 1.5%) (p value = 0.79). The routine discharge was more frequent (66.9% vs 25.8%) and length of stay was shorter (4.8 vs. 9.8 days) in TAVI than SAVR. Hospitalization cost was higher in SAVR than TAVI (51,962 vs 57,754 U.S. dollars) (all p values < 0.001). In-hospital mortality was also lower in TAVI compared with isolated SAVR. TAVI was performed more frequently than SAVR in 2018 in the United States with lower in-hospital mortality of TAVI compared with both SAVR and isolated SAVR.

Alcohol septal ablation (ASA) is indicated for symptomatic hypertrophic cardiomyopathy (HC) patients. We sought to analyze the incidence of the 30-day readmission rate, predictors, causes of readmission, and incremental healthcare resource (cost and length of stay) utilization after ASA. Nationwide Readmission Database from 2010 January to 2015 September was queried to identify 30-day unplanned readmission after ASA for HC by using the International Classification of Disease, 9th Revision, Clinical Modification. Those readmitted were similar in terms of age and sex but had higher burden of co-morbidities compared with those not readmitted within 30-days. The 30-day unplanned readmission rate was 10.4% (511/4,932) after ASA. Readmissions lead to an additional mean hospitalization cost of 8,433 US dollars and mean of 4.9 days of length of stay. Predictors of 30-day unplanned readmission were liver disease (adjusted odds ratio [aOR] 2.62, 95% confidence interval [CI] 1.22 to 5.59), renal failure (aOR 2.30, 95%CI 1.52 to 3.50), previous myocardial infarction (aOR 1.97, 95%CI 1.16 to 3.33), previous pacemaker (aOR 1.50, 95%CI 1.09 to 2.08), atrial fibrillation (aOR 1.43, 95%CI 1.08 to 1.89), Medicaid (aOR 1.74, 95%CI 1.12 to 2.68), and weekend admission (aOR 1.75, 95%CI 1.12 to 2.75). Common reasons for readmissions were atrial fibrillation (12.6%), acute on chronic systolic heart failure (12.6%), paroxysmal ventricular tachycardia (6.4%), atrioventricular block (4.9%), and HC (3.0%). Unplanned readmissions after ASA occur in patients with higher burden of co-morbidities and are mainly caused by cardiac etiologies.

Facilitated percutaneous coronary intervention for ST-segment-elevation myocardial infarction (STEMI) is defined as the use of pharmacological substances before a planned immediate intervention, to improve coronary patency. We undertook a meta-analysis of randomised controlled trials (published and unpublished) to compare facilitated and primary percutaneous coronary intervention. We identified 17 trials of patients with STEMI assigned to facilitated (n=2237) or primary (n=2267) percutaneous coronary intervention. We identified short-term outcomes (up to 42 days) of death, stroke, non-fatal reinfarction, urgent target vessel revascularisation, and major bleeding. Grade 3 flow rates for prethrombolysis and post-thrombolysis in myocardial infarction (TIMI) were also analysed. The facilitated approach resulted in a greater than two-fold increase in the number of patients with initial TIMI grade 3 flow, compared with the primary approach (832 patients [37%] vs 342 [15%], odds ratio 3·18, 95% CI 2·22–4·55); however, final rates did not differ (1706 [89%] vs 1803 [88%]; 1·19, 0·86–1·64). Significantly more patients assigned to the facilitated approach than those assigned to the primary approach died (106 [5%] vs 78 [3%]; 1·38, 1·01–1·87), had higher non-fatal reinfarction rates (74 [3%] vs 41 [2%]; 1·71, 1·16–2·51), and had higher urgent target vessel revascularisation rates (66 [4%] vs 21 [1%]; 2·39, 1·23–4·66); the increased rates of adverse events seen with the facilitated approach were mainly seen in thrombolytic-therapy-based regimens. Facilitated intervention was associated with higher rates of major bleeding than primary intervention (159 [7%] vs 108 [5%]; 1·51, 1·10–2·08). Haemorrhagic stroke and total stroke rates were higher in thrombolytic-therapy-containing facilitated regimens than in primary intervention (haemorrhagic stroke 15 [0·7%] vs two [0·1%], p=0·0014; total stroke 24 [1·1%] vs six [0·3%], p=0·0008). Facilitated percutaneous coronary intervention offers no benefit over primary percutaneous coronary intervention in STEMI treatment and should not be used outside the context of randomised controlled trials. Furthermore, facilitated interventions with thrombolytic-based regimens should be avoided.