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Background The healthcare burden posed by the coronavirus disease 2019 (COVID‐19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training. Methods We conducted a web‐based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows. Results Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID‐19 related duties. More than two‐thirds of PDs believed that the COVID‐19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one‐fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one‐third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship. Conclusions The COVID‐19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.

Purpura fulminans (PF) is a rare, potentially fatal complication of disseminated intravascular coagulation that is commonly associated with severe bacterial infections such as those caused by the bacterium Neisseria meningitidis. With the advent of vaccination, meningococcal disease has become infrequent, with a reported incidence of 1 case per 100,000 people per year. PF is an even rarer phenomenon that is only found in approximately 10 to 20% of patients with meningococcal septicemia. PF can cause irreversible tissue necrosis within 48 hours and, in severe cases, death. Early recognition is crucial as PF has a mortality rate as high as 60% in patients with meningococcal disease. Prompt recognition, treatment of the underlying cause, vigorous skin care, and multispecialty collaboration are required for optimal management of PF, though morbidity and mortality remain high as there is no cure for adult PF. We present a case of acute PF in a patient who presented with septic shock secondary to Neisseria bacteremia.

Objective Debate continues as to the optimal minimally invasive treatment modality for complex disease of the left anterior descending coronary artery, with advocates for both robotic-assisted minimally invasive direct coronary artery bypass and percutaneous coronary intervention with a drug-eluting stent. We analyzed the midterm outcomes of patients with isolated left anterior descending disease, revascularized by minimally invasive direct coronary artery bypass or drug-eluting stent percutaneous coronary intervention, focusing on those with complex lesion anatomy. Methods A retrospective review was undertaken of all patients who underwent coronary revascularization between January 2008 and December 2016. From this population, 158 propensity-matched pairs of patients were generated from 158 individuals who underwent minimally invasive direct coronary artery bypass for isolated complex left anterior descending disease and from 373 patients who underwent percutaneous coronary intervention using a second-generation drug-eluting stent. Midterm survival and incidence of repeat left anterior descending intervention were analyzed for both patient groups. Results Overall 9-year survival was not significantly different between patient groups both before and after propensity matching. Midterm mortality in the matched minimally invasive direct coronary artery bypass group was low, irrespective of patient risk profile. By contrast, advanced age (hazard ratio, 1.10; P = .012) and obesity (hazard ratio, 1.09; P = .044) predicted increased late death after drug-eluting stent percutaneous coronary intervention among matched patients. Patients who underwent minimally invasive direct coronary artery bypass were significantly less likely to require repeat left anterior descending revascularization than those who had percutaneous coronary intervention, both before and after propensity matching. Smaller stent diameter in drug-eluting stent percutaneous coronary intervention was associated with increased left anterior descending reintervention (hazard ratio, 3.53; P = .005). Conclusions In patients with complex disease of the left anterior descending artery, both minimally invasive direct coronary artery bypass and percutaneous coronary intervention are associated with similar excellent intermediate-term survival, although reintervention requirements are lower after surgery.

Background Hybrid coronary revascularization (HCR) constitutes a left internal mammary artery graft to the left anterior descending (LAD) coronary artery, coupled with percutaneous coronary intervention (PCI) for non-LAD lesions. This management strategy is not commonly offered to patients with complex multivessel disease. Our objective was to evaluate 8-year survival in patients with triple-vessel disease (TVD) treated by HCR, compared with that of concurrent matched patients managed by traditional coronary artery bypass grafting (CABG) or multivessel PCI. Methods A retrospective review was undertaken of 4805 patients with TVD who presented between January 2009 and December 2016. A cohort of 100 patients who underwent HCR were propensity-matched with patients treated by CABG or multivessel PCI. The primary endpoint was all-cause mortality at 8 years. Results Patients with TVD who underwent HCR had similar 8-year mortality (5.0%) as did those with CABG (4.0%) or multivessel PCI (9.0%). A composite endpoint of death, repeat revascularization, and new myocardial infarction, was not significantly different between patient groups (HCR 21.0% vs CABG 15.0%, P = .36; HCR 21.0% vs PCI 25.0%, P = .60). Despite a higher baseline synergy between percutaneous coronary intervention with taxus and cardiac surgery(SYNTAX) score, HCR was able to achieve a lower residual SYNTAX score than multivessel PCI (P = .001). Conclusions In select patients with TVD, long-term survival and FREEDOM from major adverse cardiovascular events after HCR are similar to that seen after traditional CABG or multivessel PCI. HCR should be considered for patients with multivessel disease, presuming a low residual SYNTAX score can be achieved.

Background The extent of coronary disease affects clinical outcomes and may predict the effectiveness of coronary revascularization with either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). The SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score quantifies the extent of coronary disease. Objectives This study sought to determine whether SYNTAX scores predicted outcomes and the effectiveness of coronary revascularization compared with medical therapy in the BARI-2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial. Methods Baseline SYNTAX scores were retrospectively calculated for BARI-2D patients without prior revascularization (N = 1,550) by angiographic laboratory investigators masked to patient characteristics and outcomes. The primary outcome was major cardiovascular events (a composite of death, myocardial infarction, and stroke) over 5 years. Results A mid/high SYNTAX score (≥23) was associated with a higher risk of major cardiovascular events (hazard ratio: 1.36, confidence interval: 1.07 to 1.75, p = 0.01). Patients in the CABG stratum had significantly higher SYNTAX scores: 36% had mid/high SYNTAX scores compared with 13% in the PCI stratum (p Conclusions Among patients with diabetes and stable ischemic heart disease, higher SYNTAX scores predict higher rates of major cardiovascular events and were associated with more favorable outcomes of revascularization compared with medical therapy among patients suitable for CABG. (Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes; NCT00006305)

The American College of Cardiology/American Heart Association guidelines include a Class 1 recommendation to initiate therapeutic hypothermia (TH) in comatose patients with out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm who have achieved return of spontaneous circulation. There is also a Class 1 recommendation for immediate angiography in these patients whose initial electrocardiography shows ST-elevation myocardial infarction (STEMI). However, due to a lack of clinical trials evaluating these patients who have received both percutaneous coronary intervention (PCI) and TH, controversy remains regarding whether the two can be safely combined. Furthermore, in patients who receive TH and PCI, another question to address is which therapy to initiate first. This article focuses on how best to manage comatose OHCA survivors who have an initial shockable rhythm and STEMI.

We sought to evaluate midterm survival data and resource use for patients who received hybrid coronary revascularization for 2-vessel coronary disease (robotic-assisted left internal thoracic artery graft to left anterior descending coronary artery (minimally invasive direct coronary artery bypass), coupled with a stent to the circumflex or right coronary artery), compared with a concurrent cohort who had traditional coronary artery bypass grafting.A comprehensive retrospective review was undertaken of our prospectively collected database from January 2009 to December 2016. We propensity matched 207 patients who underwent hybrid coronary revascularization for double-vessel disease with patients who underwent coronary artery bypass grafting. Eight-year survival data were obtained from the National Death Index.Thirty-day mortality was 1 patient (0.5%) in each of the hybrid coronary revascularization and coronary artery bypass grafting groups. Eight-year survival for the hybrid coronary revascularization group was 187 of 207 patients (90.3%) compared with 182 of 207 patients (87.9%) for the coronary artery bypass grafting cohort. End-stage renal disease independently predicted late mortality in all patients (overall hazard ratio, 5.60, P .001; hybrid coronary revascularization hazard ratio, 5.58, P = .002; coronary artery bypass grafting hazard ratio, 4.59, P = .006). Female patients who underwent hybrid coronary revascularization had a higher incidence of late death (hazard ratio, 2.47, P = .05). Length of stay and perioperative transfusion requirements were lower in the hybrid coronary revascularization group (P .0001).Hybrid coronary revascularization for double-vessel coronary disease is associated with similar short-term outcomes and intermediate-term survival as traditional coronary artery bypass grafting. Hybrid coronary revascularization is associated with lower transfusion requirements and a shorter length of stay than coronary artery bypass grafting.

Objectives To compare the discriminatory value of differing risk scores for predicting clinical outcomes following PCI in routine practice. Background Various risk scores predict outcomes after PCI. However, these scores consider markedly different factors, from purely anatomical (SYNTAX risk score [SRS]) to purely clinical (ACEF, modified ACEF [ACEFmod], NCDR), while other scores combine both elements (Clinical SYNTAX score [CSS], NY State Risk Score [NYSRS]). Methods Patients with triple vessel and/or LM disease with 12 month follow-up were studied from a single center PCI registry. Exclusion criteria included STEMI presentation, prior revascularization and shock. Clinical events at 12 months were compared to baseline risk scores, according to score tertiles and area under receiver-operating-characteristic curves (AUC). Results We identified 584 eligible patients (69.8±12.3yrs, 405 males). All scores were predictive of mortality, with the SRS being least predictive (AUC=0.66). The most accurate scores for mortality were the CSS and ACEF (AUC=0.76 for both: P = 0.019 and 0.08 vs. SRS, respectively). For TLR, while the SRS trended toward being positively predictive (P = 0.075), several scores trended towards a negative association, which reached significance for the NCDR (P = 0.045). The SRS and CSS were the only scores predictive of MI (both P

Coronary artery disease (CAD) accounts for approximately one-half of the sizable mortality in patients with end-stage renal disease who have undergone transplantation. The study was a retrospective review of 1460 patients who underwent renal transplantation at the Mount Sinai Medical Center from January 1, 2000 to October 31, 2009. Noninvasive stress testing was performed in 848 patients (88.1%) with 278 patients (32.8%) having abnormal results. Cardiac catheterization was performed in 357 patients (37.1%) and of these, 212 patients had obstructive disease (59.4%). At 5 years posttransplant, there was no statistically significant difference between those with nonobstructive CAD and those who required percutaneous or surgical interventions (adjusted hazard ratio [aHR], 1.243; CI 95%, 0.513-3.010; p = 0.630). Those with medically managed obstructive CAD had significantly higher rates of death at the 5-year period when compared to those who received percutaneous intervention (aHR, 3.792; CI 95%, 1.320-10.895; p = 0.013) or those who received coronary artery bypass grafting (aHR, 6.691; CI 95%, 1.200-37.323). Because noninvasive imaging is poorly predictive of coronary disease in this high-risk population, an anatomic diagnosis is recommended. Revascularization may result in improved long-term outcomes.

Objectives We evaluated the impact of the everolimus-eluting stent (EES) on the frequency of stent thrombosis (ST), target vessel revascularization (TVR), myocardial infarction (MI), and cardiac death in randomized controlled trials comparing the EES to non–everolimus-eluting drug-eluting stents (EE-DES). Background Whether or not the unique properties of the EES translate into reductions in ST remains unknown. Methods We searched MEDLINE, Scopus, the Cochrane Library, and Internet sources for articles comparing outcomes between EES and non–EE-DES without language or date restriction. Randomized controlled trials reporting the frequency of ST were included. Variables relating to patient and study characteristics and clinical endpoints were extracted. Results We identified 13 randomized trials (n = 17,101) with a weighted mean follow-up of 21.7 months. Compared with non–EE-DES, the EES significantly reduced ST (relative risk [RR]: 0.55; 95% confidence interval [CI]: 0.38 to 0.78; p = 0.001), TVR (RR: 0.77; 95% CI: 0.64 to 0.92; p = 0.004), and MI (RR: 0.78; 95% CI: 0.64 to 0.96; p = 0.02). There was no difference in cardiac mortality between the groups (RR: 0.92; 95% CI: 0.74 to 1.16; p = 0.38). The treatment effect was consistent by different follow-up times and duration of clopidogrel use. The treatment effects increased with higher baseline risks of the respective control groups with the strongest correlation observed for ST (R 2 = 0.89, p Conclusions Intracoronary implantation of the EES is associated with highly significant reductions in ST with concordant reductions in TVR and MI compared to non–EE-DES. Whether these effects apply to different patient subgroups and DES types merits further investigation.

Few data are available on factors associated with low adherence or early clopidogrel discontinuation after percutaneous coronary intervention (PCI). Patients (n = 284) were evaluated before hospital discharge after PCI to identify factors associated with low adherence to clopidogrel 30 days later. Adherence to daily medications before PCI was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (score6), medium (score 6 to8), or high (score 8). Low adherence to clopidogrel was defined as MMAS-8 score6 (n = 21) or having discontinued clopidogrel (n = 11), which was ascertained during a 30-day interview after PCI. At 30 days after PCI, 11% of patients had low adherence to clopidogrel. Odds ratios (95% confidence intervals [CIs]) for low adherence to clopidogrel were 3.78 (1.09 to 13.1), 3.06 (1.36 to 6.87), 2.46 (0.97 to 6.27), and 3.36 (0.99 to 11.4) for patients who before PCI reported taking smaller doses of medication because of cost, had difficulty filling prescriptions, had difficulty reaching their primary physician, and were not comfortable asking their doctor for instructions, respectively. Odds ratios (95% CIs) for low clopidogrel adherence after PCI in patients with medium and low versus high adherence to daily medications before PCI were 6.13 (1.34 to 28.2) and 10.9 (2.46 to 48.7), respectively. The c-statistic associated with MMAS-8 scores before PCI for discriminating low clopidogrel adherence at 30 days after PCI was 0.733 (95% CI 0.650 to 0.852). In conclusion, adherence to daily medications before PCI may be a useful indicator for identifying patients who will have low clopidogrel adherence after PCI.

Hybrid coronary revascularization (HCR) combines a left internal mammary artery (LIMA) to left anterior descending (LAD) surgical graft, usually performed via a robotic-assisted, minimally-invasive approach, with drug-eluting stents placed in the remaining diseased non-LAD vessels. We sought to

No significant difference in long-term survival has, as yet, been identified for patients with isolated proximal lesions of the left anterior descending (LAD) coronary artery undergoing either robotic-assisted minimally-invasive coronary artery bypass (MIDCAB) or percutaneous intervention (PCI) with

Background.Research has shown less aggressive treatment and poorer control of cardiovascular disease (CVD) risk factors in women than men.Methods.We analyzed sex differences in pharmacotherapy strategies and attainment of goals for hemoglobin A1c (HbA1c), blood pressure (BP), and low density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes and established coronary artery disease enrolled into the BARI 2D trial.Results.Similar numbers of drugs were prescribed in both women and men. Women were less frequent on metformin or sulfonylurea and more likely to take insulin and to be on higher doses of hydroxymethylglutaryl-CoA reductase inhibitors (statins) than men. After adjusting for baseline differences and treatment prescribed, women were less likely to achieve goals for HbA1c (OR = 0.71, 95% CI 0.57, 0.88) and LDL-C (OR = 0.64, 95% CI 0.53, 0.78). More antihypertensives were prescribed to women, and yet BP ≤ 130/80 mmHg did not differ by sex.Conclusions.Women entering the BARI 2D trial were as aggressively treated with drugs as men. Despite equivalent treatment, women less frequently met targets for HbA1c and LDL-C. Our findings suggest that there may be sex differences in response to drug therapies used to treat diabetes, hypertension, and hyperlipidemia.

As the survival of patients with primary coronary events continues to increase, the number of patients presenting with coronary artery disease unsuitable to further revascularization techniques and symptoms refractory to medical therapy also continues to rise. The aims of this review were to define the population of patients with refractory angina pectoris and to present the therapeutic options currently available for this condition. Refractory angina pectoris is defined, and traditional medical therapies are discussed. Then, current therapeutic options for patients with refractory angina are extensively reviewed. A multitude of therapeutic options exist for patients with refractory angina pectoris. Small, uncontrolled studies have shown a potential benefit for additional antiplatelet and antithrombotic therapy. In randomized trials, neurostimulation has been shown to be effective in reducing angina symptoms. Enhanced external counterpulsation is a viable treatment option for select patients with refractory angina. In many randomized trials, laser revascularization has been shown to diminish angina symptoms, although no placebo-controlled studies exist to date. Gene therapy is a promising area of research in this field. Percutaneous in situ coronary venous arterialization is in its infancy, but may be able to treat many patients if proved successful. No data support the role of chelation therapy in this population. Heart transplantation remains a final option for these patients. Further research of the techniques mentioned in this review is warranted. The importance of randomized, double-blinded, placebo-controlled trials cannot be overemphasized, as the placebo effect of these therapies is probably marked.

Sodium bicarbonate has been proposed for protection of the kidney from contrast-induced AKI (CIAKI). However, the effects of bicarbonate on long-term important clinical outcomes are uncertain.In a prospective, double-blind, multicenter randomized clinical trial, 391 patients with an eGFR45 ml/min per 1.73 m(2) undergoing elective coronary or peripheral angiography were randomized to an infusion with a high dose of isotonic sodium bicarbonate (target 2.0 mEq/kg) or a similar molar amount of isotonic sodium chloride. The primary outcome was a composite of mortality, dialysis, or a sustained 20% reduction in eGFR at 6 months.There were 391 patients enrolled between March 2010 and May 2012. The incidence of the primary outcome was 14.9% in the bicarbonate group and 16.3% in the control group in the intention-to-treat population (P=0.78). There was also no difference in the incidence of CIAKI between the treatment groups (14.5% versus 12.1%, respectively; P=0.20). CIAKI was associated with a higher incidence of sustained loss of kidney function at 6 months compared with those without CIAKI (21.2% versus 7.7%, respectively; P=0.06).High-dose sodium bicarbonate infusion in patients with eGFR45 ml/min per 1.73 m(2) undergoing angiography did not demonstrate a difference in incidence of the composite of death, dialysis, or sustained 6-month reduction in eGFR or CIAKI compared with sodium chloride.

To compare outcomes of elective percutaneous coronary interventions (PCI) in same-day discharge and overnight hospital stays.Advances in PCI techniques and equipment have allowed same-day discharge after elective PCI. In this study, we investigated the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores.The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. Patients were stratified into tertiles based on ACEF score: low (1.08), mid (≥1.08 and1.31), and high (≥1.31). The primary endpoint was 30-day major adverse cardiac events, defined as readmission, all-cause mortality, non-fatal myocardial infarction, and target lesion revascularization. Propensity score matching was done to evaluate outcomes based on similar baseline characteristics.There were 16,407 elective PCIs, of which 21.2% were in the ambulatory group. Patients who stayed overnight had similar 30-day composite outcomes as their same-day discharge counterparts in the high ACEF score (odds ratio [OR], 1.213; 95% confidence interval [CI], 0.625-2.355; P=.57) and mid ACEF score (OR, 0.636; 95% CI, 0.356-1.134; P=.13) comparisons, but had worse outcomes in the low ACEF score comparison (OR, 1.867; 95% CI, 1.134-3.074; P=.01).In this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories.

To compare the discriminatory value of differing risk scores for predicting clinical outcomes following PCI in routine practice.Various risk scores predict outcomes after PCI. However, these scores consider markedly different factors, from purely anatomical (SYNTAX risk score [SRS]) to purely clinical (ACEF, modified ACEF [ACEFmod], NCDR), while other scores combine both elements (Clinical SYNTAX score [CSS], NY State Risk Score [NYSRS]).Patients with triple vessel and/or LM disease with 12 month follow-up were studied from a single center PCI registry. Exclusion criteria included STEMI presentation, prior revascularization and shock. Clinical events at 12 months were compared to baseline risk scores, according to score tertiles and area under receiver-operating-characteristic curves (AUC).We identified 584 eligible patients (69.8±12.3yrs, 405 males). All scores were predictive of mortality, with the SRS being least predictive (AUC=0.66). The most accurate scores for mortality were the CSS and ACEF (AUC=0.76 for both: P = 0.019 and 0.08 vs. SRS, respectively). For TLR, while the SRS trended toward being positively predictive (P = 0.075), several scores trended towards a negative association, which reached significance for the NCDR (P = 0.045). The SRS and CSS were the only scores predictive of MI (both P0.05). No score was particularly accurate for predicting MACE (death+MI+TLR), with AUCs ranging from 0.53 (NCDR) to 0.63 (SRS).Competing factors influence mortality, MI and TLR after PCI. An increasing burden of comorbidities is associated with mortality, whereas anatomical complexity predicts MI. By combining these outcomes to predict MACE, all scores show reduced utility.

Background— Same-day discharge after percutaneous coronary intervention (PCI) may be safe for some patients. Few data are available on patient-reported outcomes and preferences for same-day discharge after PCI. Methods and Results Between March 2008 and March 2010, a total of 298 patients undergoing elective PCI via femoral access at 2 medical centers (Mount Sinai Hospital, New York, NY, and Baylor Medical Center, Dallas, TX) were randomized to same-day (n=150) or next-day (n=148) discharge. The primary outcome was high patient coping during the 7 days after discharge defined as scores P Conclusions— Same-day discharge after PCI was associated with patient-reported and clinical outcomes similar to those of next-day discharge and was preferred by most patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov/show/NCT01230606 . Unique identifier: NCT01230606.

A case of symptomatic myocardial bridge requiring intracoronary stent complicated by in-stent restenosis is reported. A stratified approach for the treatment of a symptomatic myocardial bridge is proposed.

This work describes the longest reported interval between drug-eluting stent (DES) placement and very late stent thrombosis (VLST). A 69-year-old male presented with substernal chest pain associated with ST-segment myocardial infarction (STEMI) after having a DES deployed 6.9 years (2506 days) prior. The patient's medical history revealed several risk factors for VLST. The patient suspended clopidogrel therapy in preparation for elective cystoscopy approximately 10 days before presenting.

The AmBulatory Closure Device Percutaneous Intervention (ABCD-PCI) study is a multicenter randomized prospective controlled trial evaluating the safety of and patient satisfaction with same-day discharge following ambulatory percutaneous intervention with a closure device. This article reviews the findings from a single center, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, from October 2008 through April 2010, with 23 patients in the same-day discharge group and 21 patients in the next-day discharge group. There were no differences between the groups in demographic or procedure characteristics. Outcomes were measured by a questionnaire and 7-day and 30-day follow-up phone calls. Results showed that same-day discharge after percutaneous intervention with a closure device is as safe as next-day discharge. However, there was a trend for a higher comfort level among patients in the next-day discharge group.

We evaluated the impact of the everolimus-eluting stent (EES) on the frequency of stent thrombosis (ST), target vessel revascularization (TVR), myocardial infarction (MI), and cardiac death in randomized controlled trials comparing the EES to non-everolimus-eluting drug-eluting stents (EE-DES).Whether or not the unique properties of the EES translate into reductions in ST remains unknown.We searched MEDLINE, Scopus, the Cochrane Library, and Internet sources for articles comparing outcomes between EES and non-EE-DES without language or date restriction. Randomized controlled trials reporting the frequency of ST were included. Variables relating to patient and study characteristics and clinical endpoints were extracted.We identified 13 randomized trials (n = 17,101) with a weighted mean follow-up of 21.7 months. Compared with non-EE-DES, the EES significantly reduced ST (relative risk [RR]: 0.55; 95% confidence interval [CI]: 0.38 to 0.78; p = 0.001), TVR (RR: 0.77; 95% CI: 0.64 to 0.92; p = 0.004), and MI (RR: 0.78; 95% CI: 0.64 to 0.96; p = 0.02). There was no difference in cardiac mortality between the groups (RR: 0.92; 95% CI: 0.74 to 1.16; p = 0.38). The treatment effect was consistent by different follow-up times and duration of clopidogrel use. The treatment effects increased with higher baseline risks of the respective control groups with the strongest correlation observed for ST (R(2) = 0.89, p0.001).Intracoronary implantation of the EES is associated with highly significant reductions in ST with concordant reductions in TVR and MI compared to non-EE-DES. Whether these effects apply to different patient subgroups and DES types merits further investigation.

Background In adult inpatients with acute kidney injury (AKI), clinicians routinely order a renal ultrasonography (RUS) study. It is unclear how often this test provides clinically useful information. Methods Cross-sectional study, including derivation and validation samples, of 997 US adults admitted to Yale–New Haven Hospital from January 2005 to May 2009, who were diagnosed as having AKI and who underwent RUS to evaluate elevated creatinine level. Pregnant women, renal transplant recipients, and patients with recently diagnosed hydronephrosis (HN) were excluded. Demographic and clinical characteristics were abstracted from the medical records. A multivariable logistic regression model was developed to create risk strata for HN and HN requiring an intervention (HNRI); a separate sample was used for validation. The frequency of incidental findings on RUS was assessed for each stratum. Results In a derivation sample of 200 patients, 7 factors were found to be associated with HN: history of HN; recurrent urinary tract infections; diagnosis consistent with obstruction; nonblack race; and absence of the following: exposure to nephrotoxic medications, congestive heart failure, or prerenal AKI. Among 797 patients in the validation sample (mean age, 65.6 years), 10.6% had HN and 3.3% had HNRI. Of 223 patients in the low-risk group, 7 (3.1%) had HN and 1 (0.4%) had HNRI (223 patients needed to be screened to find 1 case of HNRI). In this group, there were 0 incidental findings on RUS unknown to the clinical team. In the higher-risk group, 15.7% had HN and 4.7% had HNRI. Conclusion In adult inpatients with AKI, specific factors can identify patients unlikely to have HN or HNRI on RUS.

Left main coronary artery (LMCA) disease remains an important risk factor for increased mortality and morbidity at all stages of diagnosis and treatment of coronary artery disease. Left main stem pathology is often silent, with unpredictable presentation: as such it poses diagnostic and management challenges. This article reviews the anatomy, epidemiology and diagnosis of left main stem disease, as well as advances in multidisciplinary concepts of diagnosis and management, and summarises the outcomes of recent prospective studies comparing percutaneous and surgical revascularisation in LMCA disease.

The objectives of the present study were to evaluate the feasibility and safety of implanting a prophylactic left ventricular (LV) assist device prior to high-risk percutaneous coronary intervention (PCI) and to assess the impact of suturemediated preclosure of the arteriotomy site on minimizing vascular complications.Patients with multivessel disease, left main coronary artery disease (LMCA) or left main equivalent and/or moderate-to-severe LV dysfunction with elevated LV end-diastolic pressure are at increased risk of complications during PCI. The TandemHeart (TH) is a nonpulsatile percutaneous transseptal ventricular assist device (PTVA) that offers vital temporary hemodynamic support during high-risk PCI.Between April 2004 and November 2005, the TH was implanted in 20 patients undergoing high-risk PCI. Eight patients underwent unprotected LMCA stenting, and rotational atherectomy was used in 17 patients. Suture-mediated femoral artery preclosure was performed prior to inserting a large-bore arterial cannula.The TH was successfully implanted in all 20 patients. Mean LV ejection fraction of the study patients was 38 +/- 18%. Time-to-implantation of the TH, duration of hemodynamic support and mean flow of the TH device were 31 +/- 9 minutes, 74 +/- 40 minutes and 2.5 +/- 1.3 L/minute, respectively. At the end of PCI, the TH was removed in all cases and Perclose sutures were deployed in 18/20 (90%) patients. There was only 1 minor vascular complication, and the average length of stay was 2 +/- 1 days. Periprocedural and inhospital mortality was 0%.Implantation of the TH PTVA is safe and feasible in patients undergoing high-risk PCI with excellent hemodynamic support. Application of suture-mediated devices prior to large arteriotomies can significantly reduce the incidence of vascular complications.

Percutaneous coronary interventions (PCI) of bifurcation lesions using simultaneous kissing stents (SKS) technique have shown to have good short-term and mid-term results. Limited data are available regarding long-term outcome with this strategy. Methods: We analyzed the long-term outcome of 300 consecutive patients treated with drug-eluting stenting using SKS technique for 305 de novo bifurcation lesions. Cypher stents were used in 265 lesions and Taxus stents were used in 40 lesions, from May 2003 to September 2006 at Mount Sinai Hospital. Clinical follow-up was obtained in 98.6%. All pts were given Aspirin and Plavix 75 mg daily for one year and GP IIb/IIIa inhibitors were used in 72% of cases. Results: Overall procedural success was 99% for main vessel (MV) and 98% for side-branch (SB), with one case of intra-procedural stent thrombosis of left main bifurcation. 30-day MACE (MI, death, repeat target vascularization or stent thrombosis) occurred in 5% of cases. Long-term follow-up results at a mean of 14 ± 5 months are shown in the Table . Overall incidence of stent thrombosis was 1.7% (1.5% for Cypher vs. 2.5% for Taxus). Multivariate predictors of TVR were left main (LM) intervention (odds ratio [OR] 4.97; 95% confidence interval [CI] 2.00 to 12.37, p = 0.01) and diabetes mellitus (OR 4.21; 95% CI 1.15 to 18.56, p = 0.04) and of follow-up MACE were LM intervention (OR 3.79; 95% CI 1.76 to 8.14, p = 0.01) and acute MI (OR 3.24; 95% CI 0.95 to 15.32, p = 0.02). Conclusions: The SKS technique for bifurcation lesions using Cypher or Taxus DES is associated with long-term favorable outcomes in this complex, high-risk PCI group. Delayed stent thrombosis with dual antiplatelet therapy remains within acceptable limits. Further work is needed to lower the event rates in some specific subgroups such as LM lesions and AMI settings (perhaps by IVUS guidance and Plavix 75 mg twice a day).

The seven-component Thrombolysis In Myocardial Infarction (TIMI) score has been used to risk stratify, and to guide the medical management of, patients with unstable angina or non-ST-elevation myocardial infarction. We assessed the usefulness of the risk score in predicting in-hospital and 30-day outcomes in such patients who were undergoing percutaneous coronary intervention.Using the TIMI score, 2501 patients with unstable angina or non-ST-elevation myocardial infarction were divided into low-risk (zero to two risk factors; n = 974), intermediate-risk (three to four risk factors; n = 1339), and high-risk (five to seven risk factors; n = 188) groups, and outcomes were compared.Angiographic/clinical success and the rate of minor procedural events were similar among the three groups. A higher TIMI risk score was associated with more cardiac comorbid conditions and more complicated angiographic lesions: longer lesions (P = 0.0009), more thrombotic lesions (P = 0.03), more multivessel disease (P0.0001), and more American College of Cardiology/American Heart Association type B2/C lesions (P = 0.05). Although the risk score did not predict interventional technical success or intraprocedural complications, a high score was associated with prolonged hospital stay, higher postprocedural peak troponin levels, and 30-day major adverse cardiac events. Stepwise logistic regression showed that in conjunction with lesion length and patient sex, a high score was an independent predictor of 30-day major adverse cardiac events (odds ratio = 2.3; 95% confidence interval: 1.1 to 4.1; C statistic = 0.62).Although a higher TIMI risk score in patients with unstable angina or non-ST-elevation myocardial infarction who were undergoing percutaneous coronary intervention correlated with adverse clinical outcome, the score alone cannot be used to guide diagnostic or therapeutic strategies.

In this study, we investigated the safety of ambulatory percutaneous coronary intervention (PCI) in high-risk patients according to age, creatinine, ejection fraction (ACEF) scores. The ambulatory PCI group consisted of all consecutive PCI with same-day discharges at Mount Sinai Hospital from

Hypertrophic obstructive cardiomyopathy (HOCM) affecting both the right and left ventricular (RV and LV) outflow tracts is rare, and the mechanism of obstruction is different in each ventricle. A 21-year-old man with a family history of HOCM and sudden death was referred with breathlessness (New York Heart Association grade II) and occasional presyncope. There had been no discharges of an implantable defibrillator inserted 2 years earlier, and the sole medication …

As the survival of patients with primary coronary events continues to increase, the number of patients presenting with coronary artery disease unsuitable to further revascularization techniques and symptoms refractory to medical therapy also continues to rise. The aims of this review were to define the population of patients with refractory angina pectoris and to present the therapeutic options currently available for this condition. Refractory angina pectoris is defined, and traditional medical therapies are discussed. Then, current therapeutic options for patients with refractory angina are extensively reviewed. A multitude of therapeutic options exist for patients with refractory angina pectoris. Small, uncontrolled studies have shown a potential benefit for additional antiplatelet and antithrombotic therapy. In randomized trials, neurostimulation has been shown to be effective in reducing angina symptoms. Enhanced external counterpulsation is a viable treatment option for select patients with refractory angina. In many randomized trials, laser revascularization has been shown to diminish angina symptoms, although no placebo-controlled studies exist to date. Gene therapy is a promising area of research in this field. Percutaneous in situ coronary venous arterialization is in its infancy, but may be able to treat many patients if proved successful. No data support the role of chelation therapy in this population. Heart transplantation remains a final option for these patients. Further research of the techniques mentioned in this review is warranted. The importance of randomized, double-blinded, placebo-controlled trials cannot be overemphasized, as the placebo effect of these therapies is probably marked.

Patients with low and high BMI are noted to have higher bleeding/vascular complications following PCI. It is not clear if reduction in bleeding outcomes following PCI performed via radial compared to femoral access exhibits a U-shaped relationship with BMI. CathPCI registry data on 5,628 PCI

Although effective, directional atherectomy of lower extremity peripheral arterial disease (PAD) is limited by frequent restenosis. Histopathologic correlates of restenosis and the impact of deep cuts into the adventitial layer of the vessel wall on risk for restenosis is not known. We conducted a

Objectives This study evaluated the outcomes of patients discharged the day of percutaneous coronary intervention (PCI) by analyzing the data from a single-center, large, multioperator registry of interventions. Background Although same-day discharge is likely safe after interventions on low-risk stable patients, there is limited data to guide selection of a broader population of patients. Due to numerous patient variables and physician preferences, standardization of the length of stay after PCI has been a challenge. Most of the reported studies on same-day discharge have strict inclusion criteria and hence do not truly reflect a real-world population. Methods We analyzed the outcomes of consecutive same-day discharge in 2,400 of 16,585 patients who underwent elective PCI without any procedural or hospital complication. Composite end point included 30-day major adverse cardiac cerebral events and bleeding/vascular complications. Results The mean age of the study population was 57.0 ± 23.7 years with 12% aged over 65 years. Twenty-eight percent received glycoprotein IIb/IIIa inhibitor with closure devices in 90.5%. Clinical and angiographic success was noted in 97% of all PCIs. The average length-of-stay following PCI was 8.2 ± 2.5 h. The composite end point was reached in 23 patients (0.96%). Major adverse cardiac cerebral events occurred in 8 patients (0.33%) and vascular/bleeding complications in the form of Thrombolysis In Myocardial Infarction minor bleeding in 14 patients (0.58%) and pseudoaneurysm in 1 patient (0.04%). Conclusions When appropriately selected, with strict adherence to the set protocol, same-day discharge after uncomplicated elective PCI is safe despite using femoral access in a wide spectrum of patients.