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OBJECTIVE To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio [aOR] 2.03 [95% confidence interval {CI} 1.97-2.09]; p

Background Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR). Methods Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography. Results Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76–86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm2/m2 [IQR, 0.39–0.47 cm2/m2] vs 0.46 cm2/m2 [IQR, 0.41–0.51 cm2/m2], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P Conclusions AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

The survival benefits of pulmonary thromboendarterectomy (PTE) for the treatment of chronic thromboembolic pulmonary hypertension have been well described. However, the significance of right heart hemodynamic changes and their impact on survival remains poorly understood. We sought to characterize the effects of these changes. We conducted a single center, retrospective review of 159 patients who underwent PTE between 1993 and 2015. Echocardiographic and right heart catheterization data were compared longitudinally before and after PTE in order to establish the extent of hemodynamic response to surgery. Kaplan Meier estimates were used to characterize patient survival over time. Univariable and multivariable Cox proportional hazards regression models were used to assess factors associated with long-term mortality. Among the 159 patients studied, 74 (46.5%) were male with a median age of 55 (IQR: 42-66). One-, 5-, 10-, and 15-year survival was 91.0% (95% CI: 86.6-95.6), 79.6% (73.5-86.3), 66.5% (59.2-74.7), and 56.2% (48.1-65.8). Of the 9 candidate risk factors that were evaluated, only advanced age and increased cardiopulmonary bypass time were found to be significantly associated with increased risk of mortality. Pre- and postsurgical echocardiographic imaging data, when available, revealed a median reduction in right ventricular systolic pressure of 29.0 mm Hg (P0.0001) and improvement of tricuspid regurgitation (P0.0001), both of which appeared to be sustained across long-term follow-up. Improvements in right heart hemodynamics and tricuspid valvular regurgitation persist on long term surveillance following PTE. While patient selection is often driven by the distribution of disease, close postoperative follow up may improve outcomes.

OBJECTIVES Low forced expiratory volume in 1 s (FEV1) and elevated N-terminal pro-B-type natriuretic peptide (NT-Pro-BNP) have been individually associated with poor outcomes after transcatheter aortic valve replacement (TAVR). We hypothesized a combination of the 2 would provide prognostic indication after TAVR. METHODS We categorized 871 patients who received TAVR from 2008 to 2018 into 4 groups according to baseline FEV1 ( RESULTS Patients in group A had more severe aortic stenosis and achieved the best long-term survival at 1 [93% (95% CI: 90–96)] and 5 [45.3% (95% CI: 35.4–58)] years. Low FEV1 and high NT-Pro-BNP (group D) patients had more severe symptoms, higher Society of Thoracic Surgeons predicted risk of operative mortality, lower ejection fraction and aortic valve gradient at baseline. Patients in group D had the worst survival at 1 [76% (95% CI: 69–83)] and 5 years [13.1% (95% CI: 7–25)], hazard ratio compared to group A: 2.29 (95% CI: 1.6–3.2, P CONCLUSIONS The combination of FEV1 and NT-Pro-BNP stratifies patients into 4 groups with distinct risk profiles and clinical outcomes. Patients with low FEV1 and high NT-Pro-BNP have increased comorbidities, poor functional outcomes and decreased long-term survival after TAVR.

Aims There are limited contemporary data on the use of initial fibrinolysis in ST‐segment elevation myocardial infarction cardiogenic shock (STEMI‐CS). This study sought to compare the outcomes of STEMI‐CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI). Methods Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI‐CS admissions receiving pre‐hospital/in‐hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI‐CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in‐hospital mortality, development of non‐cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do‐not‐resuscitate status. Results During 2009–2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non‐White, with lower co‐morbidity, and admitted on weekends and to small rural hospitals (all P

AIMS There are limited data on the trends and outcomes of mechanical circulatory support (MCS)-assisted early percutaneous coronary intervention (PCI) in acute myocardial infarction with cardiogenic shock (AMI-CS). In this study, we sought to assess the use, temporal trends, and outcomes of percutaneous MCS-assisted early PCI in AMI-CS. METHODS AND RESULTS Using the National Inpatient Sample database from 2005-2014, a retrospective cohort of AMI-CS admissions receiving early PCI (hospital day zero) was identified. MCS use was defined as intra-aortic balloon pump (IABP), percutaneous left ventricular assist device (pLVAD) and extracorporeal membrane oxygenation (ECMO) support. Outcomes of interest included in-hospital mortality, resource utilisation, trends and predictors of MCS-assisted PCI. Of the 110,452 admissions, MCS assistance was used in 55%. IABP, pLVAD and ECMO were used in 94.8%, 4.2% and 1%, respectively. During 2009-2014, there was a decrease in MCS-assisted PCI due to a decrease in IABP, despite an increase in pLVAD and ECMO. Younger age, male sex, lower comorbidity, and cardiac arrest independently predicted MCS use. MCS-assisted PCI was predictive of higher in-hospital mortality (31% vs 26%, adjusted odds ratio 1.23 [1.19-1.27]; p

Background Chronic alcoholism causes brain damage. Published data from rural India is scant. Our aim is to determine computed tomography (CT) changes in the brain of rural chronic alcoholics. Methods This prospective cross-sectional study was done in our tertiary care hospital on chronic alcoholic patients referred from deaddiction center over a period of 2 years. Age- and sex-matched nonalcoholic controls were included and Student’s t-test and chi-square test comparison was done. Correlation coefficient was obtained by Pearson’s correlation coefficient. Patients and the controls were studied in two age groups: 30 to 45 and 46 to 60 years. Noncontrast CT scan of head was done in each case and CT indices of brain damage were measured. Results The study included 106 alcoholics out of which 55 were in the younger age group (30–45 years) and 51 in the older age group (46–60 years). Seven hundred age-matched, nonalcoholic controls were included. Mean values of ethanol were higher in the older age group than in the younger age group. As compared with controls, various CT scan indices of ventricular changes, cortical changes, and subcortical changes were significantly higher in both age groups. In both age groups, there was a significant decrease in the mean values of hemoglobin and a significant increase in the mean values of indices of brain damage with increase in the grade of alcoholism. Conclusion The results of this prospective epidemiological study showed marked alterations in all CT indices of brain atrophy and were correlated to the duration and amount of ethanol consumption. This study highlights that chronic alcoholism is a significant risk factor for brain atrophy.

SummaryThe airway epithelium is a key protective barrier, the integrity of which is preserved by the self-renewal and differentiation of basal stem cells. Epithelial cells are central to the pathogenesis of multiple lung diseases. In chronic lung diseases, increasing age is a principle risk factor. Few studies have explored the differences between airway epithelial cells in children and adults and how the function of basal stem cells changes during ageing is poorly understood. Here, we analyze airway epithelial cells from children and adults in homeostatic conditions (laser capture-microdissected whole epithelium and fluorescence-activated cell-sorted basal cells) and in proliferation-inducing cell culture conditions. We find that, while the cellular composition of the pediatric and adult tracheobronchial epithelium is broadly similar, in cell culture, pediatric airway epithelial cells displayed higher colony-forming ability, sustained in vitro growth and outcompeted adult cells in competitive proliferation assays. In RNA sequencing experiments, we observed potentially important differences between epithelium from children and adults, including higher baseline interferon-associated gene expression in pediatric epithelium. Our results demonstrate cell-intrinsic differences in transcriptional profile and regenerative capacity between proximal airway epithelial cells of children and adults.Graphical abstract

Objective: To analyze outcomes of patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (PCI) triaged to the cardiac intensive care unit (CICU) vs a general telemetry unit by a Zwolle risk score–based algorithm. Methods: We introduced a quality improvement protocol in 2014 encouraging admission of STEMI patients with Zwolle score of 3 or less to general telemetry units unless they were hemodynamically unstable. We subsequently conducted a retrospective single-center cohort study of consecutive STEMI patients who had undergone primary PCI from January 1, 2014, to December 31, 2018. Outcomes studied include immediate complications, need for urgent unplanned intervention, need for CICU care, length of hospitalization, and survival. Results: We identified 547 patients, 406 with a Zwolle score of 3 or less. Of these, 192 (47.3%) were admitted to general telemetry and 214 (52.7%) to the CICU. Reasons for CICU admission included persistent chest pain, late presentation, and procedural complications. The average hospital length of stay was 2.1±1.4 days for non-CICU patients and 3.3±2.8 days for low-risk CICU patients (P

This study aimed to evaluate the use and frequency of complementary and integrative medicine (CIM) therapies in an outpatient cohort with cardiovascular disease (CVD) and compare trends over time. This cross-sectional point-of-care prospective study assessed patients attending a cardiology outpatient clinic. As in our 2009 cohort, data were collected with a 17-question survey on demographic characteristics, CVD history, current use and future interest in CIM. In total, 964 patients completed the survey. CIM use continues to be high (2009 vs 2018, 83.4% vs 81.8%) (p = 0.34), with dietary supplements the most common therapy (75% in both studies). We observed increased use of mind-body therapies (28.5% vs 23.9%, p = 0.02), especially meditation, yoga, and tai chi. Of the patients receiving CIM therapies, 41.9% reported using CIM for heart-related symptoms. Relaxation, stress management, and meditation were the top three mind-body therapies for CVD-related symptoms in both cohorts. Reporting of CIM use to clinicians is low (15%) and interest on future use is high (47%). In conclusion, CIM is highly used in cardiology patients-4 of 10 patients use CIM for CVD-related symptoms. Most take dietary supplements, with an increased use of mind-body therapies. Our data highlight the importance of documenting CIM use in practice and the need for research to document efficacy.

Myocardial bridging is a common coronary abnormality often associated with left ventricular hypertrophy. It can be noted incidentally on coronary angiography by findings of systolic narrowing of the involved coronary artery. We present the case of a 59-year-old woman that presented with a non-ST elevation myocardial infarction. She had a history of angina and workup 9-months prior with CT coronary angiography that revealed an intra-myocardial course of the left anterior descending coronary artery (LAD) with minimal stenosis and no concomitant coronary artery disease. Invasive coronary angiography now demonstrated apparent myocardial bridging associated with a severe fixed stenosis of the LAD without change in diameter with nitroglycerin injection. Due to persistent symptoms, surgical myotomy was attempted and then aborted because of difficulty unroofing the LAD due to surrounding fibrosis. Coronary artery bypass grafting (CABG) was then successfully performed using a left internal mammary artery graft. The patient had complete resolution of her chest pain and was without functional limitation at 3-month follow-up. This case highlights possible sequelae of myocardial bridging and suggests that, in rare cases, fixed obstruction of the involved coronary artery may occur in the setting of fibrosis of the bridged segment. In such cases, surgical myotomy may not be feasible and CABG may be required.

Objective: To evaluate the safety and efficacy of balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) seen at a US medical center. Patients and Methods: Patients with inoperable or residual postendarterectomy CTEPH who underwent BPA at Mayo Clinic in Rochester, Minnesota, between August 11, 2014, and May 17, 2018, were included. Invasive hemodynamic, clinical, laboratory, and echocardiographic data were collected and analyzed retrospectively. Results: We identified 31 patients (26 with inoperable CTEPH and 5 with residual postendarterectomy CTEPH) who underwent 75 BPA procedures performed in a staged manner to reduce complications. The median number of sessions was 2 (interquartile range [IQR], 1-3) per patient, and the number of vessels treated per session was 3 (IQR, 2-3). Of the 31 patients, 24 (77.4%) were taking pulmonary vasodilators and 22 (71.0%) were taking riociguat. The mean pulmonary arterial pressure decreased from 40 mm Hg (IQR, 29-48 mm Hg) to 29 mm Hg (IQR, 25-37 mm Hg; P

This study directly compared outcomes of transcatheter aortic valve-in-valve insertion (TAVI-in-valve) with repeat surgical aortic valve replacement (SAVR) for failing stented aortic biological prostheses.We retrospectively reviewed the records of 350 consecutive patients who underwent repeat aortic valve replacement of failing stented aortic biological valve prostheses at our institution between November 2008 and May 2018. Operations included TAVI-in-valve in 90 patients (26%) and repeat SAVR in 260 patients (74%).Patient age was 74 years (interquartile range [IQR], 65-79 years), 100 patients (29%) were women, aortic valve internal diameter was 21 mm (IQR, 19-22), Society of Thoracic Surgeons predicted operative mortality risk was 4.1% (IQR, 2.3%-6.8%), and the interval to repeat operation was 7 years (IQR, 5-11 years). A 23-mm or smaller valve was inserted in 57 patients (63%) in the TAVI-in-valve group and in 170 (65%) in the SAVR group (P = .725). Aortic root enlargement was done in 45 patients (17%) in the SAVR group. Procedure-related complications were less in the TAVI-in-valve group (23% vs SAVR 59%, P.001), whereas operative mortality was similar in both groups (2.2% vs SAVR 2.6%, P = 1.000). Severe patient-to-prosthesis mismatch was more common after TAVI-in-valve (44% vs SAVR 12%, P.001). Median duration of follow-up was 2.1 years (IQR, 1.2-4.2 years). Multivariable analysis demonstrated no association between TAVI-in-valve and intermediate-term mortality (hazard ratio, 1.18; 95% confidence interval, 0.62 to 2.22; P = .612).TAVI-in-valve and repeat SAVR can be done with similar operative and intermediate-term mortality. SAVR results in better hemodynamic function and thus appears the preferred option.

Objectives This study sought to evaluate the clinical characteristics and outcomes of Takotusbo cardiomyopathy cardiogenic shock (TC-CS) in comparison to those of acute myocardial infarction cardiogenic shock (AMI-CS) among patients hospitalized in the United States. We additionally sought to compare the incidence of multiorgan failure and use of supportive therapies as well as the trends over time, given the increasing awareness and diagnosis of TC. Background CS is a major complication of TC; however, there are limited data, especially as to how TC-CS compares to AMI-CS. Methods The National Inpatient Sample Database was used to identify adults hospitalized with CS in the setting of TC and AMI from 2007 to 2014. We required patients admitted with TC to have undergone coronary angiography without intervention. Clinical characteristics and in-hospital outcomes in TC-CS patients were compared with those in AMI-CS patients. Multivariate regression and propensity matching were used to adjust for potential confounding factors. Results Between 2007 and 2014, there were 374,152 admissions for CS due to either TC or AMI, of which 4,614 patients (1.2%) had TC-CS. TC-CS admission patients were more likely to be younger, white females with fewer comorbidities. Rates of respiratory failure and mechanical ventilation were higher in TC-CS, but cardiac arrest and acute kidney injury were lower. There were no differences between cohorts in use of intra-aortic balloon pumps. TC-CS admissions had lower in-hospital mortality (15% vs. 37%, respectively) and hospital costs (U.S. dollars: $135,397 ± $127,617 vs. $154,827 ± $186,035, respectively) and were discharged home more often (45% vs. 36%, respectively) compared to AMI-CS admissions (all: p Conclusions There are key differences between the clinical characteristics and multiorgan failure patterns in TC-CS compared to those in AMI-CS. In-hospital mortality (15%) is lower in TC-CS.

Chronic thromboembolic disease occurs when thromboemboli integrate into the wall of the pulmonary arteries, resulting in obstruction in the pulmonary vasculature. CTEPH can occur in the proximal, larger and/or distal, smaller pulmonary arteries. Surgical resection of the occlusive lesions has been the standard of care of proximal CTEPH, while resection of distal CTEPH is technically challenging. Pulmonary balloon angioplasty has emerged as an effective option to treat distal CTEPH. It involves percutaneous techniques, using wires and coronary artery balloon, to perform angioplasty of these distal lesions. Such procedures require careful planning, including lesion selection and pulmonary edema preventative strategies. This chapter reviews the steps in planning, execution and postoperative care in patients undergoing pulmonary balloon angioplasty.

Limited data are available on characteristics and long-term outcomes of patients with coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). Between January 2000 to December 2014, we identified STEMI patients with prior CABG undergoing primary percutaneous coronary intervention from 3 sites. Kaplan-Meier methods to estimate survival and major adverse cardiac events (MACE) were employed and compared to a propensity matched cohort of non-CABG STEMI patients. Independent predictors of outcomes were analyzed with Cox modeling. Of the 3,212 STEMI patients identified, there were 296 (9.2%) CABG STEMI patients, having nearly similar frequencies of culprit graft (47.6%) versus culprit native (52.4%) as the infarct-related artery (IRA). At 10 years, the adjusted survival was 44% in CABG STEMI versus 55% in non-CABG STEMI (HR 1.26; 95%CI 0.86 to 1.87; p = 0.72). Survival free of MACE was lower for CABG STEMI (graft IRA, 37%; native IRA, 46%) as compared to non-CABG STEMI controls (63%) (p = 0.02). Neither CABG history nor IRA (native vs graft) was independently associated with death or MACE in multivariable analysis. Temporal trends showed no significant change in death or MACE rates of CABG STEMI patients over time. In conclusion, long term survival of CABG STEMI patients is not significantly different than matched STEMI patients without prior CABG; however, CABG STEMI patients were at significantly higher risk for MACE events.

The Transcatheter Aortic Valve Replacement (TAVR) procedure requires an initial consultation and a subsequent procedure by an interventionalist (IC) and surgeon. The IC-surgeon pair coordination is extremely challenging, especially at Mayo Clinic due to provider time commitments distributed across practice, research, and education activities. Current practice aims to establish the coordination manually, resulting in a scheduling process that is cumbersome and time consuming for the schedulers. We develop an algorithm for pairing ICs and surgeons that minimizes the lead time (days elapsed between the clinic consult and procedure). As compared to current practice, this algorithm is able to reduce average lead time by 59% and increase possible IC-surgeon pairs by 7%. The proposed algorithm is shown to be flexible enough to incorporate practice variations such as lead time upper bound and two procedure days for a single consult day. Algorithm alternatives are also presented for practices who may find the proposed algorithm infeasible for their practice.

Transcatheter aortic valve replacement is a relatively recent revolutionary treatment that has now become a standard procedure for treating severe aortic stenosis. In this article, the authors review the clinical history of transcatheter aortic valve replacement, summarize the major clinical trials, and describe the evolution of the technique over time. In doing so, the authors hope to provide a clear and concise review of the history and clinical evidence behind transcatheter aortic valve replacement.

Background: Transcatheter mitral valve replacement using aortic transcatheter heart valves has recently become an alternative for patients with degenerated mitral bioprostheses, failed surgical repairs with annuloplasty rings or severe mitral annular calcification who are poor surgical candidates. Outcomes of these procedures are collected in the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry. A comprehensive analysis of mitral valve-in-valve (MViV), mitral valve-in-ring (MViR), and valve-in-mitral annular calcification (ViMAC) outcomes has not been performed. We sought to evaluate short-term outcomes of early experience with MViV, MViR, and ViMAC in the United States. Methods: Retrospective analysis of data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Results: Nine hundred three high-risk patients (median Society of Thoracic Surgeons score 10%) underwent MViV (n=680), MViR (n=123), or ViMAC (n=100) between March 2013 and June 2017 at 172 hospitals. Median age was 75 years, 59.2% female. Technical and procedural success were higher in MViV. Left ventricular outflow tract obstruction occurred more frequently with ViMAC (ViMAC=10%, MViR=4.9%, MViV=0.7%; P P =0.004) and 30-day mortality (MViV=8.1%, MViR=11.5%, ViMAC=21.8%; P =0.003) were higher in ViMAC. At 30-day follow-up, median mean mitral valve gradient was 7 mm Hg, most patients (96.7%) had mitral regurgitation grade ≤1 (+) and were in New York Heart Association class I to II (81.7%). Conclusions: MViV using aortic balloon-expandable transcatheter heart valves is associated with a low complication rate, a 30-day mortality lower than predicted by the Society of Thoracic Surgeons score, and superior short-term outcomes than MViR and ViMAC. At 30 days, patients in all groups experienced improvement of symptoms, and valve performance remained stable. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02245763.

Background: There are limited data on complications in acute myocardial infarction (AMI) admissions receiving extracorporeal membrane oxygenation (ECMO). Methods: Adult (>18 years) admissions with AMI receiving ECMO support were identified from the National Inpatient Sample database between 2000 and 2016. Complications were classified as vascular, lower limb amputation, hematologic, and neurologic. Outcomes of interest included temporal trends, in-hospital mortality, hospitalization costs, and length of stay. Results: In this 17-year period, in ~10 million AMI admissions, ECMO support was used in 4608 admissions (p = 0.10) but longer median hospital stay (12 [IQR 5−24] vs. 7 [IQR 3−21] days), higher median hospitalization costs ($458,954 [IQR 260,522−737,871] vs. 302,255 [IQR 173,033−623,660]), fewer discharges to home (14.7% vs. 17.9%), and higher discharges to skilled nursing facilities (44.1% vs. 33.9%) (all p < 0.001). Conclusions: Over half of all AMI admissions receiving ECMO support develop one or more severe complications. Complications were associated with higher resource utilization during and after the index hospitalization.

Objectives The purpose of this study was to explore the feasibility and safety of robotic PCI performed using an off-siteremote-control system in an animal model. Background Access to primary percutaneous coronary intervention (PCI) remains a challenge in acute myocardial infarction management. The combination of telemedicine and robotic PCI allow the potential delivery of primary PCI to remote locations without the delay of transfer. Methods This single-center prospective pilot preclinical feasibility study compared robotic PCI with remote PCI on swine across three stages (adjacent room, different floor of the same building, two different buildings). Latency up to 1,000 ms was introduced into the operating environment to simulate decreased network quality (blinded to operator). The primary outcome measures were technical success and acute safety. The secondary outcome measures included lesion wiring time, procedural time and qualitative scoring of the PCI experience by the operator. Results Across 52 experiments in 15 animals, technical success was 100%. No procedural complications occurred during the study. No significant difference in lesion treatment time was detected between stages (p = .11) and between time per target vessel when latency up to 1,000 ms was introduced (p = .58). Injected delay >250 ms had the greatest impact on procedure perceived lag. Longer procedure time was associated with lower procedure impact score, regardless of injected latency. Conclusions Remote robotic PCI was feasible and safe in an animal model. Procedural duration was acceptable and unaffected by network latency. Future studies are needed to determine the safety and feasibility of remote PCI in humans.

New technologies in medicine, even if they are promising medically, are often expensive and logistically difficult to implement at the hospital level. Transcatheter aortic valve replacement (TAVR) is a model technology that is revolutionary in treating aortic stenosis, but has been plagued with significant challenges with financial sustainability. In this article, a margin analysis at the hospital level was performed using literature data. A TAVR industry analysis was performed using Porter's Five Forces framework. The data indicate that TAVR is more expensive than surgical aortic valve replacement, although the cost of TAVR is declining with the use of an optimized minimalist protocol. The overall industry is growing as its clinical indications expand, and it will likely undergo significant reduction of costs when new valves enter the US market. As such, TAVR is a growing industry, with financial sustainability currently dependent on operational efficiency. A concluding list of specific program interventions is provided to help TAVR programs improve operational efficiency and clinical outcomes, as well as help decide whether to create, expand, or redirect funding for TAVR programs. Importantly, the frameworks used to analyze this rapidly evolving technology can be applied to other new technologies to determine financial sustainability.

BackgroundThere are limited data on the complications with a percutaneous left ventricular assist device (pLVAD) vs. intra-aortic balloon pump (IABP) in acute myocardial infarction-cardiogenic shock (AMI-CS).ObjectiveTo assess the trends, rates and predictors of complications.MethodsUsing a 17-year AMI-CS population from the National Inpatient Sample, AMI-CS admissions receiving pLVAD and IABP support were evaluated for vascular, lower limb amputation, hematologic, neurologic and acute kidney injury (AKI) complications. In-hospital mortality, hospitalization costs and length of stay in pLVAD and IABP cohorts with complications was studied.ResultsOf 168,645 admissions, 7,855 (4.7%) receiving pLVAD support. The pLVAD cohort had higher comorbidity, cardiac arrest (36.1% vs. 29.7%) and non-cardiac organ failure (74.7% vs. 56.9%) rates. Complications were higher in pLVAD compared to IABP cohort-overall 69.0% vs. 54.7%; vascular 3.8% vs. 2.1%; lower limb amputation 0.3% vs. 0.3%; hematologic 36.0% vs. 27.7%; neurologic 4.9% vs. 3.5% and AKI 55.4% vs. 39.1% (all pConclusionsAMI-CS admissions receiving pLVAD had higher rates of complications compared to the IABP, with worse in-hospital outcomes in the cohort with complications.

Background: Mechanical injury in the conduction system requiring permanent pacemaker (PPM) associated with transcatheter aortic valve replacement (TAVR) procedure is a common complication. The objective of this study was to use ambulatory monitor BodyGuardian to assess late occurrence of atrioventricular block (AVB) after TAVR. Methods: This prospective study evaluated 365 patients who underwent TAVR at Mayo Clinic, Rochester, Minnesota between June 2016 and August 2017. Patients who received PPM for bradycardia after TAVR before discharge were considered as the PPM group. Those not requiring PPM received a BodyGuardian system (BodyGuardian group) for 30 days of continuous monitoring. Primary end point was Mobitz II or third-degree atrioventricular block (II/III AVB) at 30-day follow-up. Results: Of 365 patients, 74 who had a PPM or an implantable cardioverter-defibrillator before TAVR and 94 who were enrolled in other studies were excluded. Of 197 patients enrolled in the study, 70 (35.5%) received PPM and 127 had BodyGuardian before the hospital dismissal. Eleven of 127 (8.6%) BodyGuardian group required PPM within 30 days after TAVR for late occurrence of symptomatic bradycardia. In total, 33 of 197 (16.7%) patients developed II/III AVB (24 before and 9 after discharge). Thirty-four patients had preexisting right bundle branch block. Of them, 16 (47%) developed II/III AVB. Of 53 patients who developed new left bundle branch block after TAVR, 14% progressed to II/III AVB within 30 days. Conclusions: In patients without a standard post-TAVR pacing indication, yet a potential risk to develop AVB, a strategy of 30-day monitoring identifies additional patients who require permanent pacing.

There are limited data on the outcomes of acute myocardial infarction with cardiogenic shock (AMI-CS) in patients with prior coronary artery bypass grafting (CABG).A retrospective cohort of AMI-CS admissions during 2000-2016 from the National Inpatient Sample was created and prior CABG status was identified. Outcomes of interest included in-hospital mortality and resource utilization in the two cohorts. Temporal trends of prevalence, in-hospital mortality, and cardiac procedures were evaluated.In 513,288 AMI-CS admissions, prior CABG was performed in 22,832 (4.4%). Adjusted temporal trends showed a 2-fold increase in CS in both cohorts. There was a temporal increase in coronary angiography and percutaneous coronary intervention (PCI) across both cohorts. The cohort with prior CABG was on average older, of male sex, of white race, and with higher comorbidity. The cohort with prior CABG received coronary angiography (50% vs. 75%), PCI (32% vs. 49%), right heart catheterization/pulmonary artery catheterization (15% vs. 20%), mechanical circulatory support (26% vs. 46%) less frequently compared to those without (all p 0.001). The cohort with CABG had higher in-hospital mortality (53% vs. 37%; adjusted odds ratio 1.41 [95% confidence interval 1.36-1.46]), greater use of do not resuscitate status (13% vs. 6%), shorter lengths of hospital stay (7 ± 8 vs. 10 ± 12 days), lower hospitalization costs ($92,346 ± 139,565 vs. 138,508 ± 172,895) and fewer discharges to home (39% vs. 43%) (all p 0.001).In AMI-CS, admission with prior CABG was older and had lower use of cardiac procedures and higher in-hospital mortality compared to those without prior CABG.

Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute myocardial infarction (AMI); however, there are limited large-scale national data. Methods: Using the National Inpatient Sample database from 2000 to 2014, a retrospective cohort of AMI utilizing ECMO was identified. Use of percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous left ventricular assist device (LVAD) was also identified in this population. Outcomes of interest included temporal trends in utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD), in-hospital mortality, and resource utilization. Results: In ≈9 million AMI admissions, ECMO was used in 2962 ( Conclusions: In AMI admissions, a steady increase was noted in the utilization of ECMO alone and with concomitant procedures (percutaneous coronary intervention, intra-aortic balloon pump, and percutaneous LVAD). In-hospital mortality remained high in AMI admissions treated with ECMO.

Incomplete endothelialization of intracoronary stents has been associated with stent thrombosis and recurrent symptoms, whereas prolonged use of dual antiplatelet therapy increases bleeding-related adverse events. Facilitated endothelialization has the potential to improve clinical outcomes in patients who are unable to tolerate dual antiplatelet therapy. The objective of this study was to demonstrate the feasibility of magnetic cell capture to rapidly endothelialize intracoronary stents in a large animal model. A novel stent was developed from a magnetizable duplex stainless steel (2205 SS). Polylactic-co-glycolic acid and magnetite (Fe(3)O(4)) were used to synthesize biodegradable superparamagnetic iron oxide nanoparticles, and these were used to label autologous blood outgrowth endothelial cells. Magnetic 2205 SS and nonmagnetic 316L SS control stents were implanted in the coronary arteries of pigs (n = 11), followed by intracoronary delivery of magnetically labeled cells to 2205 SS stents. In this study, we show extensive endothelialization of magnetic 2205 SS stents (median 98.4% cell coverage) within 3 days, whereas the control 316L SS stents exhibited significantly less coverage (median 48.9% cell coverage, p

Patients with acute coronary syndrome (ACS) due to unprotected culprit left main coronary artery disease (LMCAD) treated with percutaneous coronary intervention (PCI) are rare, high-risk, and not represented in trials. Data regarding long term outcome after PCI are limited.Between January 2000 and December 2014, there were 8,794 patients hospitalized with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI) treated with PCI at our institution; of these, 83 (0.94%) patients were identified as having culprit LMCAD ACS.Of the 83 patients with unprotected LMCAD ACS, 40 patients presented with STEMI and 43 patients presented with UA/NSTEMI. As compared to LM UA/NSTEMI, LM STEMI patients were younger and had less hypertension, with a trend towards greater frequency of cardiogenic shock. Distal LM involvement was common in both groups and did not differ by ACS type. In-hospital mortality was 33% in LM STEMI and 9% in LM UA/NSTEMI (P = .009). Over median follow up of 6.3 years, long term survival rates in both groups were similar (46% for STEMI vs 51% for UA/NSTEMI; P = .50 by log-rank).Unprotected culprit LMCAD ACS necessitating PCI is uncommon, occurring in1% of cases, but is associated with reduced survival, with long term follow-up noting continued and similar risk of death regardless of index ACS type.

Objective There are limited data on transcatheter aortic valve insertion after previous mitral valve operation. To better understand the associated procedural risks, we reviewed our single-center experience. Methods We retrospectively reviewed the records of 772 consecutive patients who received transcatheter aortic valve insertion from November 2008 through August 2016. There were 18 (2%) patients who had previous mitral valve operation that included valve repair in 4 patients (22%) and replacement in 14 (78%). Results Baseline characteristics included age of 77 years (interquartile range 68, 84), female sex in 11 patients (61%), New York Heart Association functional class III/IV in 14 (78%), and Society of Thoracic Surgeons predicted risk of mortality of 7.0% (5.3, 12.0). Access was transfemoral in 14 patients (78%). Valve insertion was successful in all patients and involved a balloon expandable device in 10 (56%). No patient experienced acute mitral valve dysfunction or procedure-related mortality. Follow-up echocardiography demonstrated mean systolic aortic valve gradient of 9 mm Hg (8, 12), no grade moderate or greater aortic paravalvular regurgitation, and stable mitral valve function. Kaplan-Meier estimated survival was 90.9% ± 9.1% at 1 year. Conclusions Transcatheter aortic valve insertion appears to be a safe and effective operation after previous mitral valve operation. Procedure success was achieved with both balloon expandable and self-expanding devices and was independent of arterial access method. Transcatheter valve insertion should not be denied strictly on the basis of a previous mitral valve operation.