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Background Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG. Methods and Results Consecutive patients with stable ischemic heart disease and unprotected left main or 3‐vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI‐recommended; (2) CABG‐eligible but refused CABG (CABG‐refusal); and (3) CABG‐ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI‐recommended, n=1718 [46.6%]), CABG‐refusal (n=1595 [43.3%]), and CABG‐ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG‐ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI‐recommended, CABG‐refusal, and CABG‐ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG‐refusal (hazard ratio [HR], 1.67 [95% CI, 1.08–3.56]; P=0.02) and CABG‐ineligible patients (HR, 3.26 [95% CI, 1.28–3.65]; P=0.004) groups compared with the reference PCI‐recommended group, driven by increased death and stroke. Conclusions Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real‐world data to inform shared decision‐making discussions.

Transcatheter aortic valve replacement (TAVR) has become the treatment option for symptomatic severe aortic stenosis patients across all risk profiles. Despite remarkable advancements in technology and operator experience, the occurrence of periprocedural stroke remains a significant concern, predominantly attributed to thromboembolic events in the immediate postprocedural period. To optimize patient outcomes, various strategies have been developed to minimize the risk of stroke, encompassing comprehensive preprocedural planning, effective management of comorbidities, utilization of cerebral embolic protection devices, and tailored medical therapy. This comprehensive review summarizes the currently available strategies for mitigating periprocedural stroke post-TAVR and provides insights into future directions.

Ellis Type III cavity spilling coronary perforation is a rare complication. We report to our knowledge, the first case of rotational atherectomy induced Type III cavity spilling coronary perforation of right posterior descending artery draining into middle cardiac vein, successfully managed by covered stent deployment. (Level of Difficulty: Advanced.)

Abstract Introduction Numerous case series have reported on the baseline characteristics and in-hospital mortality of patients with COVID-19, however, these studies included patients localized in a specific geographic region. The purpose of our study was to identify differences in the clinical characteristics and the in-hospital mortality of patients with a laboratory-confirmed diagnosis of COVID-19 internationally. Methods A comprehensive search of all published literature on adult patients with laboratory-confirmed diagnosis of COVID-19 that reported on the clinical characteristics and in-hospital mortality was performed. Groups were compared using a Chi-square test with Yates correction of continuity. A two-tailed p value of less than 0.05 was considered as statistically significant. Results After screening 516 studies across the globe, 43 studies from 12 countries were included in our final analysis. Patients with COVID-19 in America and Europe were older compared to their Asian counterparts. Europe had the highest percentage of male patients. American and European patients had a higher incidence of co-morbid conditions (p

Acute pulmonary thromboembolism is associated with high mortality, similar to that of myocardial infarction and stroke. We studied the clinical presentation and management of pulmonary thromboembolism in the Indian population. An analysis of 140 patients who presented with acute pulmonary thromboembolism at a large volume center in India from June 2015 through December 2018 was performed. The mean age of our study population was 50 years with 59% being male. Comorbidities including deep vein thrombosis, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease were present in 52.9%, 40%, 35.7% and 7.14% of patients, respectively. Out of 140 patients, 40 (28.6%) patients had massive pulmonary thromboembolism, 36 (25.7%) sub-massive pulmonary thromboembolism, and 64 (45.7%) had low-risk pulmonary thromboembolism. Overall, in-hospital mortality was 25.7%. Multivariate regression analysis found chronic kidney disease and pulmonary thromboembolism severity to be the only independent risk factors. Thrombolysis was performed in 62.5% of patients with a massive pulmonary thromboembolism and 63.9% of patients with a sub-massive pulmonary thromboembolism. In the massive pulmonary thromboembolism group, patients receiving thrombolytic therapy had lower mortality compared with patients who did not receive therapy ( p =0.022), whereas this difference was not observed in patients in the sub-massive pulmonary thromboembolism group. We conclude that patients with acute pulmonary thromboembolism in India presented more than a decade earlier than our western counterparts, and it was associated with poor clinical outcomes. Thrombolysis was associated with significantly reduced in-hospital mortality in patients with massive pulmonary thromboembolism.

A 69-year-old man, who had earlier undergone reconstruction of the aortic bifurcation with kissing nitinol stents, presented with occlusion of the left external iliac artery. The occlusion was successfully and safely recanalized using contralateral femoral approach with passage of interventional hardware through the struts of the stents in the aortic bifurcation. Presence of contemporary flexible nitinol stents with open-cell design in the aortic bifurcation is not a contraindication to the use of the contralateral femoral approach.

Aims: In India, larger proportions of patients with ACS present with STEMI. We sought to study the recent trends of reperfusion in patients of acute STEMI. Methods and Results: 1905 patients presenting with acute STEMI enrolled. 1636 (86%) received some form of reperfusion therapy. Streptokinase, 1235 (65%) patients, was the most common mode of reperfusion therapy used followed by primary PCI (205, 10.7%) and tenecteplase (196, 10%). 269 (14%) did not receive any form of reperfusion therapy, the most common reason being late presentation in 230 (85.7%). Patients presenting with STEMI increased from 297 to 446 comparing first and last half-year of study period. The PCI and tenecteplase numbers increased from 19 to 68 and 27 to 97 respectively. Conclusion: There was 20% increase in STEMI every year. Younger patients are least likely to receive primary PCI or tenecteplase. 1 in 8 patients of STEMI did not receive any form of reperfusion therapy.

Aims: Coronary artery disease is the leading cause of mortality and morbidity in our country, of which ST elevation myocardial infarction (STEMI) accounts for the major part of health spending. We sought to study the effect of induction of government health insurance scheme on the trends of reperfusion in patients of acute STEMI. Methods and results: 1133 patients presenting with acute STEMI enrolled. 1079 (95.1%) received some form of reperfusion therapy. Primary PCI was used in 60.6% of patients as the primary reperfusion modality, a six fold increase as compared to previous years. Government health insurance accounted for the one third of all. 34.5% patients underwent pharmacological reperfusion, most commonly with streptokinase. 4.9% patients of STEMI did not receive any form of reperfusion therapy in contrast to 14% during previous years. Conclusion: Introduction of government health insurance along with increased awareness has resulted in dramatic changes in the management of STEMI patients.