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Oral anticoagulation therapy (OAC) is a mainstay for mitigating stroke and other embolic events in patients with atrial fibrillation (AF). Despite the demonstrated efficacy of OAC in reducing events, many patients are unable to tolerate OAC due to bleeding risks. Left atrial appendage occlusion (LAAO) devices were developed as implantable technologies to moderate stroke risk in patients with intolerance to OAC. Despite clinical data supporting near-comparable protection against thromboembolic events with OAC, device-related thrombus formation has emerged as a critical complication following LAAO that remains a potential limitation to the safety and efficacy of LAAO. Improved biocompatibility of LAAO devices with fluoropolymers, a well-established stent-coating technology used to reduce thrombus formation and promote endothelialization, may optimize outcomes after LAAO. Article highlights Original concept & evidence of left atrial appendage occlusion To prevent thromboembolism in nonvalvular atrial fibrillation (NVAF) patients, left atrial appendage occlusion (LAAO) technology has evolved as an alternative to oral anticoagulation therapy (OAC) in those with high bleeding risk. Randomized trials demonstrated noninferiority of LAAO in safety and efficacy compared with conventional oral OAC, with similar stroke rates and potentially lower bleeding rates. As LAAO therapy evolves, it could be a viable first-line alternative to direct oral anticoagulants in NVAF patients. Device-related thrombus after the implantation of LAAO Device-related thrombus (DRT) is a critical complication after LAAO that can lead to thromboembolic events, with incidences ranging from 1.6 to 16%. DRT is defined as a density confirmed in multiple planes on imaging transesophageal echocardiography or coronary CT angiography, which appears to be related to device, patients, and anatomical factors. DRT is associated with a higher incidence of thromboembolic events, underscoring its clinical importance. Second-generation WATCHMAN FLX device The second-generation WATCHMAN FLX is one LAAO device that has improved LAA sealing and is designed to facilitate implantation in complex LAA anatomies. The WATCHMAN FLX has demonstrated promising short-term safety and efficacy in accommodating diverse LAA structures, with a reduction in procedural complications and the incidence of DRT as compared with earlier generations. Strategies to prevent DRT Antithrombotic treatment and endothelialization after the device implantation are key to preventing DRT after LAAO. Improving thromboresistance and augmenting endothelialization after device implantation may favorably impact DRT incidence and thromboembolic events. Fluoropolymer coating technology has good biocompatibility and thromboresistance as shown in drug-eluting stents and vascular grafts. New-generation FP coated LAAO device The WATCHMAN FLX Pro device (FP-WATCHMAN) with fluoropolymer coating technology is designed to further improve hemocompatibility and reduce the incidence of DRT compared with the conventional WATCHMAN FLX. An animal study demonstrated that FP-WATCHMAN showed significantly less thrombus formation and inflammation, attributed to greater albumin adsorption which inhibits platelet adhesion and subsequent thrombus formation. FP-WATCHMAN is expected to enhance early endothelial coverage, leading to further improvements in the prevention of DRT. [ABSTRACT FROM AUTHOR]

In response to the COVID-19 pandemic, hospitals have adopted protocols geared to optimize the care of patients with COVID-19, while mitigating risk of exposure to other patients and to health care workers. These modifications can have un-intended consequences and impact the care of non-COVID patients. In the campaign against COVID-19, we must remain vigilant that patients with traditional disease processes also receive thoughtful and coordinated care. [ABSTRACT FROM AUTHOR]

Coronary artery disease continues to remain the leading cause of mortality worldwide. Coronary blood supply is provided through the right and left main coronary arteries. The left main coronary artery (LMCA) in turn gives rise to the left anterior descending (LAD) and left circumflex (LCX) arteries. In some cases, LMCA may trifurcate into the ramus intermedius (RI) in addition to the LAD and LCX arteries. Atherosclerotic plaque formation and rupture with subsequent clot formation and occlusion of coronary arteries are the underlying mechanisms of myocardial infarction. Though the clinical implications of the presence of ramus intermedius (RI) are controversial some data suggest that the RI is associated with an increased risk of atherosclerotic plaque formation in the LMCA and the proximal LAD. Conversely, it has been proposed that the RI provides an additional collateral source of blood supply to the myocardium and may potentially contribute to improved survival. Case reports tout the benefits of RI, specifically in the setting of multivessel coronary artery occlusions. Whether it increases the risk of atherosclerotic plaque formation or whether it is protective has yet to be determined. We present a case of a 58-year-old male who presented with acute coronary syndrome and cardiogenic shock due to total ostial occlusion of LAD. The patient had also chronic total occlusions of the right coronary artery and LCX but a patent RI, which was the only source of blood supply to the myocardium and practically determined the patient's survival. Additionally, we performed a literature review to identify similar cases, to support RI's potentially protective role in enhancing survival., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Khachatryan et al.)

Study Objectives: To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on health care utilization among a nationally representative and sample of older adults with multiple morbidities and pre-existing cardiovascular disease and subsequently diagnosed with obstructive sleep apnea in the United States., Methods: Our data source was a random 5% sample of Medicare administrative claims data. All participants (n = 1,921) were of age ≥ 65 years, diagnosed with cardiovascular disease and obstructive sleep apnea, and subsequently began treatment with CPAP between 2009-2013. Based on the number of CPAP machine charges, individuals were categorized as low, partial, or high adherers (ie, < 4, 4-12, and > 12 CPAP charges, respectively). The impact of CPAP adherence status on health care utilization was assessed across multiple points of service, including outpatient encounters, inpatient stays, emergency department visits, and prescription fills over 24 months following CPAP initiation., Results: Significant differences in demographic and comorbid disease characteristics were observed between low adherers (n = 377), partial adherers (n = 236), and high adherers (n = 1,308). After adjusting for covariates and relative to low adherers, high adherers demonstrated reduced inpatient visits (hazard ratio 0.75; 95% confidence interval 0.57, 0.97)., Conclusions: In this nationally representative sample of older Medicare beneficiaries with multiple morbidities and relative to low adherers, high adherers demonstrated reduced inpatient utilization., Citation: Wickwire EM, Bailey MD, Somers VK, et al. CPAP adherence is associated with reduced inpatient utilization among older adult Medicare beneficiaries with pre-existing cardiovascular disease. J Clin Sleep Med . 2022;18(1):39-45., (© 2022 American Academy of Sleep Medicine.)

Study Objectives: To examine the impact of adherence to continuous positive airway pressure (CPAP) therapy on risk of stroke among a nationally representative sample of older adults with obstructive sleep apnea., Methods: We performed a retrospective cohort study among Medicare beneficiaries aged ≥ 65 years who were newly diagnosed with obstructive sleep apnea and had initiated CPAP (2009-2013). Monthly indicators of CPAP adherence included charges for machines, masks, or supplies and were summed over a 25-month follow-up to create a CPAP adherence variable. Stroke was modeled as a function of CPAP adherence using generalized estimating equations., Results: We found that 5,757 beneficiaries met the inclusion criteria and were included in the final sample. Of these, 407 (7%) experienced stroke. After adjusting for demographic and clinical characteristics, CPAP adherence was associated with a reduced risk of stroke (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99) over 25 months, indicating a 2% reduction in risk of stroke for each month of CPAP adherence. When sensitivity analyses were performed to stratify results by time since the first CPAP charge, the protective effect remained significant for the 12- and 6-month but not the 3-month outcome models., Conclusions: In this national analysis of older adult Medicare beneficiaries with obstructive sleep apnea, CPAP adherence was associated with significantly reduced risk of stroke., (© 2021 American Academy of Sleep Medicine.)

Patients with spontaneous coronary artery dissection (SCAD) often present as clinically unstable, requiring management with percutaneous coronary intervention. Complications from persistent dissection and initial percutaneous management can present with later challenges. Intravascular and non-invasive imaging modalities are adjunct modalities to coronary angiography to delineate coronary anatomy and guide therapeutic strategies. Herein, we describe the case of a 23-year-old female patient who presented with heart failure and severe mitral regurgitation eight months after an index SCAD event during which she underwent extensive stenting of the left anterior descending artery. The multimodal imaging used in this case and how it helped in formulating the management rationale is also reviewed., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Ahmed et al.)

Background Cardiac allograft vasculopathy (CAV) is a leading cause of graft failure in cardiac transplant recipients. Progression of intimal thickening noted during routine surveillance intracoronary imaging is associated with the development of CAV. However, mechanisms of CAV development are poorly understood and targets for therapy modification remain elusive. We investigated the association of neovessels (INs) within the intima, noted by optical coherence tomography (OCT) during routine CAV surveillance imaging, with intimal thickening and co-incident CAV. Methods Coronary angiography and OCT images of 45 consecutive cardiac transplant recipients undergoing surveillance coronary imaging were reviewed. The presence of INs, defined as dark, tubular or rotund intimal structures, measuring 50-200 µm in diameter, noted in at least three OCT frames, was quantified. CAV diagnosis was determined by utilizing the International Society of Heart and Lung Transplant classification system. Demographic and clinical data was obtained by chart review. Significant associations between the presence of INs and CAV, intimal thickening, and demographic features were evaluated. Results INs were observed in 22/45 evaluated patients (49%), while angiographic CAV was observed in 24/45 patients, with a significant association noted between the presence of INs and CAV ( p < 0.001). INs were also associated with increasing intimal thickness ( p < 0.001), co-morbid hypertension ( p = 0.010), and increasing transplant age ( p = 0.002) on multivariate analysis. Conclusion INs are prevalent in cardiac transplant recipients and are significantly associated with CAV, increased intimal thickness, increasing transplant age, and co-morbid hypertension. Further investigation is warranted regarding the temporal relationship of IN development and the onset of CAV, as well as the mechanisms of IN development in this population., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Chahal et al.)

Heart disease in pregnancy may manifest as acute coronary syndromes, decompensated valvular disease, and acute heart failure. These disease processes may represent progression of preexisting disease versus newly developed disease resulting from the physiologic changes of pregnancy. Early recognition of clinical presentations, judicious use of diagnostic studies, and multidisciplinary management of patient and fetal considerations can lead to optimal outcomes in this unique patient subset., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Valvular heart disease (VHD) is a common clinical entity. Recognition of decompensated VHD is crucial to instituting appropriate workup and management. Initial evaluation focuses on hemodynamics, peripheral perfusion, volume overload, and active myocardial ischemia. Initial therapy is targeted at improving hemodynamics, fluid status, and decreasing myocardial ischemia before intervention. Echocardiography can rapidly identify VHD etiology and severity along with physical examination findings. Owing to improved survival with cardiac surgery over the past several decades, prosthetic valve dysfunction should be recognized and initial treatment understood. Mechanical circulatory support is increasingly part of clinical practice in stabilizing patients with decompensated VHD., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence., Methods: A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group., Results: Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021)., Conclusions: In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

Approximately 330,000 ST-elevation myocardial infarctions (STEMI) occur yearly in the United States. Emergent reperfusion is the cornerstone of STEMI therapy and the key to restoration of coronary blood flow in an infarct-related vessel. Reperfusion methods include thrombolysis, primary percutaneous coronary intervention, or both methods combined. Selection of the appropriate reperfusion strategy is essential, along with having an efficient system of care capable of delivering these therapies. Timely reperfusion is highly dependent on a well-structured care system designed to meet the needs of each individual community. This article reviews the data behind different reperfusion strategies and introduces successful systems-of-care models., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Robotic totally endoscopic coronary artery bypass (TECAB) is a minimally invasive endoscopic surgical approach using the daVinci robotic telemanipulation system to perform coronary artery bypass grafting on the arrested or beating heart. It is a procedure that can be a useful alternative to the classic open procedure performed through sternotomy. After extensive modeling in cadavers, the first clinical case was performed in June 1998 placing a left internal thoracic artery graft (LITA) to the left anterior descending artery completely robotically on the arrested heart. During the early and late 2000s, international groups have adopted this evolving technology, which has included iterations such as beating-heart TECAB, use of bilateral ITA grafting and radial artery grafting, as well as 3- and 4-vessel TECAB. TECAB is combined with percutaneous coronary intervention in hybrid procedures. Despite increasing complexity of endoscopic coronary bypass surgery, conversion rates to open bypass surgery have dropped significantly and operative times have decreased. Published major morbidities and mortality rates in arrested-and beating-heart TECAB have been cumulatively in the 0-2% range and are considered well within the expected range for these highly complex surgical procedures. Long-term survival and freedom from major adverse events also meet the standards of open bypass surgery.