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Background: Because of the COVID-19 pandemic, cath labs have had to modify their workflow for elective and urgent patients., Methods: We surveyed 16 physicians across 3 hospitals in our healthcare system to address COVID-19 related concerns in the management of interventional and structural heart disease patients, and to formulate system wide criteria for deferring cases till after the pandemic., Results: Our survey yielded common concerns centered on the need to protect patients, cath lab staff and physicians from unnecessary exposure to COVID-19; for COVID-19 testing prior to arrival to the cath lab; for clear communication between the referring physician and the interventionalist; but there was initial uncertainty among physicians regarding the optimal management of ST elevation myocardial infarction (STEMI; percutaneous coronary intervention versus thrombolytics). Patients with stable angina and hemodynamically stable acute coronary syndromes were deemed suitable for initial medical management, except when they had large ischemic burden. Most transcatheter aortic valve implantations (TAVI) were felt appropriate for postponement except in symptomatic patients with aortic valve area <0.5 cm 2 or recent hospitalization for heart failure (HF). Most percutaneous mitral valve repair (pMVR) procedures were felt appropriate for postponement except in patients with HF. All left atrial appendage closure (LAAC) and patent foramen ovale (PFO)/atrial septal defect (ASD) closure procedures were felt appropriate for postponement., Conclusion: Our survey of an experienced team of clinicians yielded concise guidelines to direct the management of CAD and structural heart disease patients during the initial phases of the COVID-19 pandemic., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We evaluated the influence of glycemic control on cardiovascular outcomes in diabetic patients with acute myocardial infarction (AMI) who underwent successful percutaneous coronary intervention (PCI) with stent placement. Background: In patients presenting with AMI, diabetic status confers adverse cardiovascular outcomes after PCI. However, the influence of glycemic control on outcomes after successful PCI is less well studied. Methods: We examined 231 consecutive diabetes mellitus ( DM) patients with AMI who underwent successful primary PCI and had evaluation of glycosylated hemoglobin (HbA1c) from 30 days before to 90 days after AMI. Patients were categorized in 2 groups, controlled DM with HbA1c ≤ 7.0 (N = 83, 36%) and uncontrolled DM with HbA1c > 7.0 (N = 148, 64%). We assessed 12-month cardiovascular outcomes in study groups. Results: Uncontrolled diabetics were younger, tended to be less hypertensive, and had higher baseline glomerular filtration rate and final vessel diameter compared to controlled diabetics. Uncontrolled DM patients had similar major adverse cardiovascular events (MACE; composite of all-cause death, MI, target vessel revascularization [TVR], and stent thrombosis [ST]; 20% vs. 30%, log-rank P = 0.54), death (8.8% vs. 12%, P = 0.40), MI (8.8% vs. 9.6%, P = 0.76), TVR (9.5% vs. 8.4%, P = 0.95), and ST (3.4% vs. 4.8%, P = 0.54) as the controlled diabetics. In Cox regression analysis, after adjustment for baseline differences, glycemic control had no independent influence on study outcomes. Conclusion: Glycemic control, determined by HbA1c, does not seem to influence cardiovascular outcomes in diabetic patients with AMI after successful stent placement. (J Interven Cardiol 2012;25:262-269) [ABSTRACT FROM AUTHOR]

A recent observational study of coronary artery graft (CABG) versus drug-eluting stents (DES) performed in the state of New York reported that CABG was superior to DES for multivessel disease. Our comment provides rational criticism of this study, reviews the data that support a role for DES in the management of multivessel coronary disease, and emphasizes the need for ongoing prospective clinical trials in this area. Till randomized trial data become available, physicians should continue to use their clinical judgment based on existing evidence in managing their patients with multivessel coronary artery disease (CAD). [ABSTRACT FROM AUTHOR]

Contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) has multiple definitions. We attempted to identify the optimal definition of CIN. In 985 patients undergoing PCI (derivation group), we assessed the prognostic significance of 4 commonly used contemporary definitions of CIN (increases in serum creatinine after PCI [δCr] >1.0 mg/dl, >0.5 mg/dl, and >25% after PCI; and the American College of Cardiology National Cardiovascular Data Registry definition) with respect to 6-month major adverse cardiovascular events (MACEs) and all-cause mortality (at 863 ± 324 days). Incidence of CIN ranged widely (2.0% to 15%) depending on the definition used. Only 2 definitions (δCr >0.5 mg/dl, >25%) consistently correlated with study outcomes. Using these 2 definitions, we devised a new grading system (grade 0 δCr ≤25% and ≤0.5 mg/dl; grade 1 δCr >25% but ≤0.5 mg/dl; and grade 2 δCr >0.5 mg/dl). Nephropathy grades (0 vs 1 vs 2) showed significant correlation with 6-month MACEs (12.4 vs 19.4 vs 28.6%, p = 0.003) and all-cause mortality (10.2 vs 10.4 vs 40.9%, p <0.0001). In multivariate analyses, the grading system showed an independent association with MACEs and mortality. The prognostic value of nephropathy grades was prospectively confirmed in an independent validation group of 539 patients. In conclusion, of the 4 contemporary definitions of CIN, only δCr >25% and >0.5 mg/dl consistently predicted adverse events after PCI. By unifying these 2 definitions, we devised a novel nephropathy grading system that is predictive of 6-month MACEs and all-cause mortality after PCI. [Copyright &y& Elsevier]

Background: Left ventricular systolic deterioration (LVSD) develops in some patients despite successful percutaneous intervention and medical therapy for myocardial infarction (MI). We sought to determine predictors of LVSD by comparing demographic, procedural, angiographic variables, and 6-month major adverse cardiac events (MACE) in patients with and without LVSD after MI. Methods: We performed a posthoc analysis of patients prospectively enrolled in the Stent-PAMI trial if they had successful percutaneous intervention for MI (<50% residual stenosis and TIMI-3 grade flow), normal left ventricular systolic function on index ventriculogram, and protocol driven coronary angiography with ventriculography at 6 months. We defined LVSD as an absolute decrease in ejection fraction ≥15% compared to baseline value. Results: Of the 900 patients enrolled in Stent-PAMI, 187 patients met the inclusion criteria. LVSD developed in 30 patients (16%) and occurred independent of demographic, procedural, angiographic variables, and 6-month MACE. Multivariate predictors of LVSD were higher baseline ejection fraction (P = 0.0065, OR 1.09; 95% CI = 1.02–1.16) and peak creatine phosphokinase (CPK) level (P = 0.0022, OR 1.04; 95% CI = 1.02–1.07). Conclusions: LVSD occurs in a minority of patients despite successful mechanical reperfusion and occurred independent of procedural, angiographic variables, target vessel revascularization, reinfarction, and combined MACE. Infarct size (determined by peak CPK) and high baseline ejection fraction predicted development of LVSD at 6 months. LVSD in this population likely occurred by negative left ventricular remodeling. (J Interven Cardiol 2005;18:255–260) [ABSTRACT FROM AUTHOR]

The presence of bundle branch block (BBB) has been associated with poor outcomes in patients who have acute myocardial infarction. Whether this is true in the angioplasty era is not known. We sought to evaluate the outcome of patients with acute myocardial infarction and BBB who were treated with primary angioplasty. We evaluated 3,053 patients who underwent emergency catheterization in the PAMI trials. Patients who had left BBB (n = 48, 1.6%) on presenting electrocardiogram were compared with patients who had right BBB (n = 95, 3.1%) or no BBB (n = 2,910, 95.3%). Patients who had BBB were older and more frequently had diabetes mellitus, peripheral vascular disease, and previous coronary artery bypass grafting. They had lower ejection fraction and more multivessel disease. There were no significant differences in door-to-balloon time, final Thrombolysis In Myocardial Infarction flow grade or stent use. In-hospital major adverse cardiac events (death, ischemic target vessel revascularization, and reinfarction) were higher in patients who had BBB due primarily to increased in-hospital death (left BBB 14.6%, right BBB 7.4%, no BBB 2.8%, p &#60; 0.0001). In multivariate logistic regression analysis, left BBB was an independent predictor of in-hospital death (odds ratio 5.53, 95% confidence interval 1.89 to 16.1, p = 0.002). In conclusion, patients who have acute myocardial infarction and BBB have increased co-morbidities and higher mortality rates despite treatment with primary angioplasty. Despite early identification of multivessel disease with triage to angioplasty or coronary artery bypass grafting, if necessary, similar treatment times, and final Thrombolysis In Myocardial Infarction grade 3 flow, the presence of left BBB on admission electrocardiogram in patients who have acute myocardial infarction is an independent predictor of in-hospital mortality. Because 85% of deaths in patients who have left BBB occur within the first week, these patients should be recognized early and receive prompt and aggressive treatment. [Copyright &y& Elsevier]

Objectives: We sought to evaluate the incidence, predictors, and outcomes of ventricular tachycardia and/or ventricular fibrillation (VT/VF) in the cardiac catheterization laboratory among patients undergoing primary percutaneous coronary intervention (PCI).Background: Although VT/VF has been known to occur during primary PCI, the current data do not identify patients at risk for these arrhythmias or the outcomes of such patients.Methods: We evaluated 3,065 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI) trials, who underwent primary PCI to evaluate the associations of VT/VF and the influence of these arrhythmias on in-hospital and one-year outcomes.Results: In patients undergoing primary PCI, VT/VF occurred in 133 (4.3%). Multivariate analysis identified the following as independent correlates of VT/VF: smoking (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.26 to 3.02), lack of preprocedural beta-blockers (OR 2.34, 95% CI 1.35 to 4.07), time from symptom onset to emergency room of ≤180 min (OR 2.63, 95% CI 1.42 to 4.89), initial Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 (OR 2.06, 95% CI 1.23 to 3.47), and right coronary artery-related infarct (OR 1.93, 95% CI 1.25 to 2.99). Although patients with VT/VF had a higher incidence of bradyarrhythmias, hypotension, cardiopulmonary resuscitation, and endotracheal intubation in the catheterization laboratory, their in-hospital and one-year adverse outcomes were similar to those of the cohort without these arrhythmias.Conclusions: Our findings suggest that the incidence of VT/VF during primary PCI is low, indicating that these arrhythmias do not influence PCI success or in-hospital or one-year outcomes. Our data further help identify patients at risk of VT/VF during primary PCI and suggest that pretreatment with beta-blockers should be strongly considered to reduce these arrhythmias. [Copyright &y& Elsevier]

(J Interven Cardiol 2012;25:317-318) [ABSTRACT FROM AUTHOR]

: ObjectivesThis study was designed to evaluate the safety profile of glycoprotein IIb/IIIa receptor inhibitors (GPI) in octogenarians undergoing percutaneous coronary intervention (PCI).: BackgroundPatients ≥80 years old constitute the fastest growing segment of the U.S. population and have a high prevalence of coronary artery disease. Few data exist regarding the use of GPI during PCI in octogenarians, as these patients have been excluded from randomized clinical trials of GPI.: MethodsConsecutive patients ≥80 years old undergoing PCI between January 1998 and June 2001 were evaluated for clinical outcomes and bleeding complications.: ResultsOne thousand three hundred and ninety two of 14,308 patients (9.7%) undergoing PCI were ≥80 years old. Of these, 459 of 1,392 (33%) of the patients were treated with GPI. Octogenarians treated with GPI were more likely to present with acute coronary syndrome or infarction, receive stents, require an intra-aortic balloon pump, or undergo multi-vessel PCI. Glycoprotein receptor inhibitor use was associated with a higher rate of bleeding, but the transfusion rate was similar to that in patients who did not receive GPI (9.8% vs. 8.6%, p = NS). No cases of intracranial hemorrhage were observed. By multivariate analysis, GPI treatment was associated with longer hospitalization but did not independently predict the need for transfusion or affect mortality.: ConclusionsOctogenarians have a high incidence of bleeding and need for transfusion after PCI. Although the use of GPI was associated with more access and non-access site bleeding and longer hospital stay, GPI treatment does not significantly increase the risk of transfusion or intracranial hemorrhage in this non-randomized cohort. [Copyright &y& Elsevier]

Ventricular fibrillation (VF) developing out of hospital or even in hospital has a reported prognosis for survival that is &#60;50%. We examined the prognosis for VF in 19,497 patients undergoing percutaneous coronary intervention and identified 164 who had VF (0.84%). The time to defibrillation was &#60;1 minute and was successful in all without sequelae. Thus, VF developing in the catheterization laboratory is unique in terms of prognosis. [Copyright &y& Elsevier]