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The aim of this study was to determine the prevalence and prognostic impact of high bleeding risk (HBR), as determined by the Academic Research Consortium HBR criteria, in real-world patients undergoing left main (LM) percutaneous coronary intervention (PCI). LM PCI is often reserved for patients at increased risk for periprocedural adverse events. Patients at HBR represent a relevant percentage of this cohort, but their outcomes after LM PCI are still poorly investigated. All patients undergoing LM PCI between 2014 and 2017 at a tertiary care center were prospectively enrolled. Patients were defined as having HBR if they met at least 1 major or 2 minor Academic Research Consortium HBR criteria. The primary endpoint was the composite of all-cause death, myocardial infarction (MI), or stroke at 12 months. Among 619 enrolled patients, 55.3% were at HBR. The rate of the primary endpoint was 4-fold higher in patients at HBR compared with those without HBR (20.5% vs 4.9%; HR: 4.43; 95% CI: 2.31-8.48), driven by an increased risk for all-cause death (HR: 3.88; 95% CI: 1.88-8.02) and MI (HR: 6.18; 95% CI: 1.83-20.9). Rates of target vessel or lesion revascularization and stent thrombosis were comparable in the 2 groups. Bleeding occurred more frequently in patients at HBR (HR: 3.77; 95% CI: 1.83-7.76). Consistent findings were observed after Cox multivariable regression adjustment. Among patients undergoing LM PCI, those with HBR are at increased risk for all-cause death, MI, and bleeding. Conversely, rates of repeat revascularization and stent thrombosis were comparable, suggesting frailty and comorbidities as primary causes of worse outcomes in patients at HBR. [Display omitted] [ABSTRACT FROM AUTHOR]

Dens fractures are an increasingly common injury, yet their epidemiology and its implications remain underexamined. We retrospectively analyzed all traumatic dens fracture patients managed at our institution over a 10-year period, examining demographic, clinical, and outcomes data. Patient subsets were compared across these parameters. Among 303 traumatic dens fracture patients, we observed a bimodal age distribution with a strong goodness of fit centered at age 22.3 ± 5.7 (R = 0.8781) and at 77.7 ± 13.9 (R = 0.9686). A population pyramid demonstrated a bimodal distribution among male patients, but not female patients, which was confirmed with a strong goodness of fit for male patient subpopulations age <35 (R = 0.9791) and age ≥35 (R = 0.8843), but a weaker fit for a second female subpopulation age <35. Both age groups were equally likely to undergo surgery. Patients younger than age 35 were more likely to be male (82.4% vs. 46.9%, odds ratio [OR] = 5.29 [1.54, 17.57], P = 0.0052), have motor vehicle collision as their mechanism of injury (64.7% vs. 14.1%, OR = 11.18 [3.77, 31.77], P < 0.0001), and to have a severe trauma injury severity score (17.6% vs. 2.9%, OR = 7.23 [1.88, 28.88], P = 0.0198). Nevertheless, patients age <35 were less likely to have fracture nonunion at follow (18.2% vs. 53.7%, OR = 0.19 [0.041, 0.76], P = 0.0288). The dens fracture patient population comprises 2 subpopulations, distinguished by differences in age, sex, injury mechanism and severity, and outcome, with male dens fracture patients demonstrating a bimodal age distribution. Young, male patients were more likely to have high-energy injury mechanisms leading to severe trauma, yet were less likely to have fracture nonunion at follow-up. [ABSTRACT FROM AUTHOR]

Abstract Background Kounis syndrome is a systemic complication following an allergic reaction, presenting with coronary artery spasm or thrombosis and occasionally with stent thrombosis that can have fatal outcome. Objectives Heparins can induce allergic reactions via tissue antigenicity, heparin induced thrombocytopenia and contact system-activating effects of contaminants but allergy bivalirudin has not been reported so far. Methods Herein, we describe a patient with fatal acute coronary in-stent thrombosis following an allergic reaction soon after an intra-arterial heparin dose and intravenous administration of bivalirudin during angioplasty. Results The patient received intense myocardial infarction protocol treatment including angioplasty and defibillation together with antiallergic therapy but despite all of these efforts and measures, he succumbed 2 h later. Conclusions Significant suspicion should be raised that life saving drugs such as heparin and bivalirudin could join forces with concurrent medication acting as antigens and induce fulminant and fatal stent thrombosis as a manifestation of Kounis syndrome [ABSTRACT FROM AUTHOR]

Stereotactic body radiotherapy (SBRT) has been established as a safe and effective treatment modality for control of long-term pain and tumor growth. However, few studies have investigated the efficacy of postoperative SBRT versus conventional external beam radiation therapy (EBRT) in extending survival within the context of systemic therapy. A retrospective chart review of patients who underwent surgery for spinal metastasis at our institution was conducted. Demographic, treatment, and outcome data were collected. SBRT was compared with EBRT and non-SBRT, and analyses were stratified by whether patients received systemic therapy. Survival analysis was conducted using propensity score matching. Bivariate analysis in the nonsystemic therapy group revealed longer survival with SBRT compared with EBRT and non-SBRT. Further analysis also showed that primary cancer type and preoperative mRS significantly affected survival. Within patients who received systemic therapy, overall median survival for patients receiving SBRT was 22.7 months (95% confidence interval [CI] 12.1–52.3) versus 16.1 months (95% CI 12.7–44.0; P = 0.28) for patients who received EBRT and 16.1 months (95% CI: 12.2–21.9; P = 0.07) for patients without SBRT. Within patients who did not receive systemic therapy, overall median survival for patients with SBRT was 62.1 months (95% CI 18.1–unknown) versus 5.3 months (95% CI 2.8–unknown; P = 0.08) for patients with EBRT and 6.9 months (95% CI 5.0–45.6; P = 0.02) for patients without SBRT. In patients who do not receive systemic therapy, treatment with postoperative SBRT may increase survival time compared with patients not receiving SBRT. [ABSTRACT FROM AUTHOR]

Although the number of complex percutaneous coronary intervention (CPCI) procedures is increasing, data regarding sex-related outcomes following CPCI are scarce. We retrospectively analyzed data of patients enrolled in a single-center registry between 2009 and 2017. Patients were divided into two groups (CPCI and non-CPCI) stratified by sex. CPCI was defined as any PCI procedure with ≥1 of the following characteristics: ≥3 target vessels/lesions, ≥3 stents implanted, bifurcation with ≥2 stents, stent length > 60 mm, or chronic total occlusion. The primary outcome was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and target vessel revascularization, at oneon-year follow-up. Among 20,419 patients, 5004 (24.5%) underwent CPCI of whom 25.6% (n = 1281) women and 74.4% (n = 3723) men. Women presented with more comorbidities yet less complex coronary anatomy than men (syntax score: 19.5 ± 10.3 vs. 20.6 ± 10.7, p = 0.009). Moreover, women were more likely to fulfill a single rather than multiple CPCI criteria. At one year, a higher rate of MACE occurred in women (14.0% vs. 11.6%, p = 0.02). After multivariable adjustment for confounders, the risk of MACE at one year was similar among both sexes (HR:1.04, 95% CI [0.85–1.26], p = 0.71), without significant interaction between the complexity of the procedure and sex (p-interaction = 0.96). Nonetheless, the risk of MI was significantly higher in women than men undergoing CPCI (HR:1.63, 95% CI [1.12–2.38], p = 0.01). Despite presenting with less challenging lesions than men, women had a higher rate of MI at one year following CPCI, even after adjusting for potential confounders. Unlabelled Image • Women represent one fourth of patients undergoing complex PCI. • Women have more comorbidities yet less complex coronary anatomy than men. • Compared with men, women have a worse prognosis following complex PCI. [ABSTRACT FROM AUTHOR]

Female subjects constitute half of all transcatheter aortic valve implantation (TAVI) candidates, but the association between important comorbidities such as diabetes mellitus (DM) and clinical outcomes after TAVI remains unclear in this group. WIN-TAVI is a real-world international registry of exclusively female subjects undergoing TAVI. The study population was stratified into those with (DM) and those without DM (NDM). Valve Academic Research Consortium (VARC)-2 efficacy (composite of all-cause death, stroke, myocardial infarction, hospitalization for valve-related symptoms or worsening congestive heart failure, or valve-related dysfunction) was the primary endpoint for this analysis. Of the 1012 subjects included in this study, 264 (26.1%) had DM at baseline. DM patients were younger but had a higher burden of comorbidities. There were no differences in VARC-2 efficacy events between DM and NDM patients at 30 days or 1 year. Conversely, patients with DM had a lower risk of VARC-2 life threatening bleeding at 30 days and 1 year after TAVI compared to NDM patients, which remained significant even after multivariable adjustment (HR, 0.34, 95% CI, 0.12–0.99; p =.047). In the subgroup analysis, insulin-dependent DM was not associated with an increased risk of adverse outcomes. Among female patients undergoing TAVI, more than one-fourth of the subjects presented with DM. At 1-year follow-up, DM was associated with lower bleeding complications and no increase in the risk of other adverse events, including mortality, after TAVI. Unlabelled Image • One fourth of female subjects undergoing transcatheter aortic valve implantation have diabetes mellitus at baseline. • DM female patients undergoing TAVI have higher comorbidities and lower transvalvular gradients. • DM in female subjects is associated with lower risk of VARC-2 life threatening bleeding up to 1 year after TAVI. [ABSTRACT FROM AUTHOR]

Background: Small vessel diameter is associated with higher risk of target lesion revascularization (TLR) after percutaneous coronary intervention (PCI). The COMBO sirolimus-eluting biodegradable-polymer stent has a proprietary anti-CD34 antibody layer to enhance homogeneous endothelialization, which may be advantageous in treating small vessels.Objective: We examined for differences in 1-year clinical outcomes after PCI by maximum implanted stent diameter from the COMBO collaboration.Methods: The COMBO collaboration (n = 3614) is a patient-level pooled dataset of patients undergoing PCI with COMBO stents in the MASCOT and REMEDEE multicenter registries. Stent diameter was available in 3590 (99.3%) patients. We compared patients receiving COMBO stents <3 mm versus ≥3 mm. The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel-myocardial infarction (TV-MI) or clinically driven TLR. Secondary outcomes included stent thrombosis (ST). Adjusted outcomes were assessed using Cox regression methods.Results: The study included 792 (22%) patients with small stents <3 mm and 2798 (78%) patients with large stents ≥3 mm. Small stent patients included more women with lower body mass index and higher prevalence of diabetes but similar prevalence of acute coronary syndrome. Risk of 1-year TLF was similar in small and large stent groups (4.4% vs. 3.8%, HR 1.12, 95% CI 0.74-1.72, p = 0.58). There were no differences in the rates of cardiac death (1.7% vs. 1.5%, p = 0.74), TV-MI (1.4% vs. 1.2%, p = 0.58) or TLR (2.7% vs. 2.1%, p = 0.31). Definite or probable ST occurred in 1.3% of the small stent and 0.7% of the large stent PCI patients, p = 0.14, HR 2.13, 95% CI 0.93-5.00, p = 0.07.Conclusions: One-year ischemic outcomes after COMBO PCI were similar irrespective of stent diameter in this all-comers international cohort. [ABSTRACT FROM AUTHOR]

Background: Bleeding following percutaneous coronary intervention has important prognostic implications. The Academic Research Consortium (ARC) recently proposed a list of clinical criteria to define patients at high bleeding risk (HBR).Objectives: This study sought to validate the ARC definition for HBR patients in a contemporary real-world cohort.Methods: Patients undergoing coronary stenting between 2014 and 2017 at a tertiary-care center were defined as HBR if they met at least 1 major or 2 minor ARC-HBR criteria. To account for the presence of multiple criteria, patients were further stratified by the number of times they fulfilled the ARC-HBR definition. The primary endpoint was a composite of peri-procedural in-hospital or post-discharge bleeding at 1 year. Secondary endpoints included individual components of the primary bleeding endpoint, myocardial infarction, and all-cause mortality.Results: Among 9,623 patients, 4,278 (44.4%) qualified as HBR. Moderate or severe anemia was the most common major criterion (33.2%); age ≥75 years was the most frequent minor criterion and the most common overall (46.8%). The rate of the primary bleeding endpoint at 1 year was 9.1% in HBR patients compared with 3.2% in non-HBR patients (p < 0.001), with a stepwise increase in bleeding risk corresponding to the number of times the ARC-HBR definition was fulfilled. HBR patients also experienced significantly higher rates of all secondary endpoints.Conclusions: This study validates the ARC-HBR definition in a contemporary group of patients who underwent percutaneous coronary intervention. The ARC-HBR definition identified patients at increased risk not only for bleeding but also for thrombotic events, including all-cause mortality. Coexistence of multiple ARC-HBR criteria showed additive prognostic value. [ABSTRACT FROM AUTHOR]