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There is a high prevalence of renal dysfunction in patients undergoing transcatheter mitral valve repair (TMVr) for mitral regurgitation (MR) and this has been shown to be an independent risk facto...

Objectives This study sought to describe clinical and procedural characteristics of veterans undergoing transcatheter aortic valve replacement (TAVR) within U.S. Department of Veterans Affairs (VA) centers and to examine their association with short- and long-term mortality, length of stay (LOS), and rehospitalization within 30 days. Background Veterans with severe aortic stenosis frequently undergo TAVR at VA medical centers. Methods Consecutive veterans undergoing TAVR between 2012 and 2017 were included. Patient and procedural characteristics were obtained from the VA Clinical Assessment, Reporting, and Tracking system. The primary outcomes were 30-day and 1-year survival, LOS >6 days, and rehospitalization within 30 days. Logistic regression and Cox proportional hazards analyses were performed to evaluate the associations between pre-procedural characteristics and LOS and rehospitalization. Results Nine hundred fifty-nine veterans underwent TAVR at 8 VA centers during the study period, 860 (90%) by transfemoral access, 50 (5%) transapical, 36 (3.8%) transaxillary, and 3 (0.3%) transaortic. Men predominated (939 of 959 [98%]), with an average age of 78.1 years. There were 28 deaths within 30 days (2.9%) and 134 at 1 year (14.0%). Median LOS was 5 days, and 141 veterans were rehospitalized within 30 days (14.7%). Nonfemoral access (odds ratio: 1.74; 95% confidence interval [CI]: 1.10 to 2.74), heart failure (odds ratio: 2.51; 95% CI: 1.83 to 3.44), and atrial fibrillation (odds ratio: 1.40; 95% CI: 1.01 to 1.95) were associated with increased LOS. Atrial fibrillation was associated with 30-day rehospitalization (hazard ratio: 1.79; 95% CI: 1.22 to 2.63). Conclusions Veterans undergoing TAVR at VA centers are predominantly elderly men with significant comorbidities. Clinical outcomes of mortality and rehospitalization at 30 days and 1-year mortality compare favorably with benchmark outcome data outside the VA.

Concomitant tricuspid regurgitation (TR) is common in patients with mitral regurgitation (MR). While current guidelines recommend repair of both valves at the time of surgery when feasible, high risk patients are often undertreated, leading to significant morbidity and mortality. With advances in transcatheter edge-to-edge repair (TEER) devices and technique, combined TEER for treating significant MR and TR has emerged as a new tool for heart failure management. Recent evidence has shed light on which patients with severe TR should be targeted for transcatheter intervention either in isolation or in combination with a MV TEER procedure and allows for expanded treatment options in patients who otherwise would be limited to medical management. Technological advancements remain ahead of robust clinical data, and thus randomized clinical studies in patients with severe MR and TR will be instrumental in determining the best approach in treating these patients with transcatheter therapies.

Purpose of review Coronary artery calcification (CAC) predisposes to suboptimal revascularization outcomes after percutaneous coronary intervention (PCI). Despite the availability of several plaque modification devices, their rates of use remain low despite the prevalence of CAC encountered in clinical practice. It is important to understand how each device can be utilized in clinical practice in order to improve outcomes after PCI. Recent findings This article summarizes the most recent clinical evidence for each plaque modification device. Although rotational atherectomy is the most frequently used device for plaque modification, the use of orbital atherectomy (OA) has been increasing. Balloon-based strategies including recent studies evaluating a novel intravascular lithotripsy balloon have shed light on the benefits of nonablative devices in modifying CAC during PCI. Summary CAC poses significant technical challenges in achieving optimal stent results. Several intracoronary plaque modification devices are currently available and understanding the technical aspects, indications and contraindications to the use of each device is essential. Although rotational and OA are most commonly used, laser atherectomy and balloon-based devices may offer an advantage in certain lesion subsets.

To compare patient-level risk assessment at Veterans Affairs (VA) hospitals in patients undergoing transcatheter aortic valve replacement (TAVR) with patients included in the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) registry.We retrospectively analyzed the outcomes of veterans with severe aortic stenosis (AS) receiving TAVR from 2012-2016 at eight VA hospitals and compared them with TVT registry outcomes from 2012-2015. Patients were identified via administrative data. Univariable and multivariable Cox proportional hazards models were used to examine 30-day and 1-year all-cause mortality, 30-day and 1-year transient ischemic attack/stroke rates, and permanent pacemaker (PPM) implantation rates.During the study period, a total of 726 veterans underwent TAVR including valve-in-valve procedures (n = 50). Patients were predominantly male (98.2%), with mean age of 78.5 ± 9.3 years; 49.1% were at prohibitive risk and 12.1% were at high risk for surgical aortic valve replacement; 30-day and 1-year all-cause mortality rates were 2.5% and 14.7%, respectively; 30-day and 1-year combined TIA/stroke rates were 6.5% and 13.5%, respectively. In the TVT registry, 15.8% and 37.8% of patients were at prohibitive and high risk, respectively; 30-day and 1-year mortality rates were 5.7% and 22.7%, respectively, and stroke rates were 2.1% and 4.0%, respectively.This report on TAVR risk assessment within the VA system demonstrates that despite a large proportion of patients classified as prohibitive risk, TAVR was associated with favorable 30-day and 1-year all-cause mortality rates when compared with published outcomes from the STS/ACC TVT registry.

We sought to compare outcomes with radial vs femoral approach in female patients undergoing coronary angiography.Women undergoing cardiac procedures have increased risk of bleeding and vascular complications, but are under-represented in randomized clinical trials (RCTs) involving coronary angiography.We performed a meta-analysis of RCTs comparing outcomes in women undergoing angiography with radial vs femoral approaches. The primary outcome was non-coronary artery bypass graft (CABG) related bleeding at 30 days. Secondary outcomes included major adverse cardiovascular or cerebrovascular events (MACCE; a composite of death, stroke or myocardial infarction), vascular complications, procedure duration, and access-site crossover.Four studies (n = 6041 female patients) met the inclusion criteria. In female patients undergoing coronary angiography, radial access decreased non-CABG related bleeding (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.44-0.72; P.001), MACCE (OR, 0.73; 95% CI, 0.58-0.93; P=.01), vascular complications (OR, 0.49; 95% CI, 0.32-0.75; P.001) with no significant difference in procedure time (mean difference, 0.04; 95% CI, -0.97 to 0.89; P=.93). There was an increase in access-site crossover using the radial approach (OR, 2.86; 95% CI, 2.24-3.63; P.001). Patients undergoing radial approach were more likely to prefer radial access for the next procedure (OR, 6.96; 95% CI, 5.70-8.50; P.001).In female patients undergoing coronary angiography or intervention, the radial approach is associated with decreased bleeding, MACCE, and vascular complications. These data suggest that radial access should be the preferred approach for women.

BACKGROUND Cardiac troponin elevation is associated with mortality. We compared the mortality risk related to elevated troponin from acute coronary syndrome (ACS) and non-ACS causes in a hospitalized elderly veteran population. METHODS AND RESULTS As part of a quality initiative at our Veterans Affairs hospital, all patients with elevated troponin were evaluated by a cardiologist to determine if ACS was present and to recommend management. We selected a sample (n = 761) of consecutive patients studied between February 2006 and February 2007 and examined all-cause mortality over extended follow-up. Nearly all were men (99.1%), and about half had coronary disease (n = 385, 50.5%) and diabetes (n = 339, 44.4%). ACS patients had lower mortality that non-ACS patients. Mortality began to diverge at 30 days; at 1 year it was 42.0% versus 29.0% (odds ratio [OR]: 0.56, 95% confidence interval [CI]: 0.41-0.78) and at 6 years 77.7% versus 58.7% (OR: 0.41, 95% CI: 0.30-0.56). Cox regression models for mortality at multiple time points yielded several independent factors associated with mortality; however, the distribution of the factors was not sufficient to explain the observed difference in mortality. CONCLUSIONS In this elderly, male veteran population, mortality related to an elevated troponin was higher at 1 and 6 years for non-ACS patients compared with ACS patients. Factors independently associated with a higher mortality risk were predominantly markers of general systemic illness, but did not elucidate the reasons why troponin elevation secondary to non-ACS causes carries this higher risk. A better understanding of these cardiac troponin elevations and implications for future mortality requires additional investigation. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine

CABG improves survival in CAD patients with severe LV dysfunction; trials comparing CABG with PCI have excluded these patients and the role of PCI has been unclear. The role of viability testing to guide revascularization is similarly unclear although Cardiac MRI (CMR) has not been well studied for

Background Cardiac troponin assays have improved the ability to detect myocardial damage. However, ascertaining whether troponin elevation is due to myocardial infarction (MI) or secondary to another process can be challenging. Our aim is to evaluate provider-level variation in the diagnosis of MI and the use of invasive coronary angiography (ICA) among patients with undifferentiated elevations in cardiac troponin. Methods We analyzed data from all patients with elevated troponin levels in a single Veterans Affairs (VA) Medical Center between 2006 and 2007. One of several cardiologists prospectively evaluated each patient’s presentation and course of care. We compared the frequency of MI diagnosis and ICA use between physicians using univariate odds ratios (OR). Results Among 761 patients, 34.0 % were diagnosed with MI and 25.9 % underwent ICA. The unadjusted rates of MI (23.9 to 56.7 %, P = 0.02) and ICA (17.3 to 73.3 %, P

Fibrinogen is a plasma glycoprotein that is a major factor in the blood clotting process. In the presence of thrombin, fibrinogen polymerizes into a network of fibers called fibrin. Previous microscopy measurements show that the rate of polymerization affects the microscopic structure of the fibrin network. Although there is a good understanding of the blood clotting process, triggers and pathways, there are remaining questions regarding its kinetics and how the internal structure of fibrin develops. This study was designed to investigate how protein concentration and osmotic stress affect the rate of fibrinogen polymerization and the internal structure of the fibers. Dynamic light scattering measurements were done to quantify the relationship between the concentration ratio of fibrinogen to thrombin and the rate of polymerization. Time-resolved small-angle neutron scattering (SANS) experiments were performed to study the kinetics of fibrinogen polymerization, and contrast variation was used to study this process under osmotic stress. A suitable concentration ratio of fibrinogen (4 mg/ml) to thrombin (0.01 units/ml) was found to produce a polymerization reaction that lasts approximately 90 minutes; a reaction slow enough to yield a significant signal-to-noise ratio for SANS experiments. Various concentration series were measured using SANS. Guinier fits were used as a first approximation to obtain the radius of gyration (Rg) of the distinct domains of fibrinogen and fibrin. Pair distribution functions were used to monitor the shifts in structural parameters. SANS measurements show that osmotic stress affects fibrin structure and fibrinogen polymerization rate.

Highlights • One dreaded complication of EGD that has attributed to substantial morbidity and mortality is duodenal perforation. • Due to its relative infrequency, significant ambiguity exists surrounding the optimal management of duodenal perforations following EGD. • We describe a case of nonoperative treatment for duodenal perforation following EGD that ended in mortality. • The case we present here is novel and unique in that it describes the medical management of an uncommon and devastating complication of a procedure that is frequently performed. • Outcomes for duodenal perforation following EGD appear to be improved when select patients with duodenal free wall perforation leading to peritonitis and hemodynamic instability are taken for laparotomy and surgical repair., Introduction The utilization of esophagogastroduodenoscopy (EGD) and related procedures continues to rise. Due to this increase in utilization is an inevitable rise in serious complications such as hemorrhage and perforation. One understudied and dreaded complication of EGD causing significant morbidity and mortality is duodenal perforation. Presentation of case We present the case of a 63-year-old male who presented to our institution’s emergency room with dyspepsia, melanic stools, tachycardia, and hypotension. Initial laboratory evaluation was significant for severe anemia, lactic acidosis, and acute kidney injury, while CT scan of the abdomen pelvis did not suggest retroperitoneal hematoma or bowel perforation. An emergent EGD was performed which showed multiple bleeding duodenal ulcers that were cauterized and injected with epinephrine. Post-procedure the patient developed worsening abdominal pain, distension, diaphoresis, and tachypnea, requiring emergent intubation. A CT scan of the abdomen and pelvis with oral contrast confirmed pneumoperitoneum and duodenal perforation. Discussion Due to the patient’s hemodynamic instability and multiple comorbidities, he was treated non-operatively with strict bowel rest and intravenous antibiotics. The patient ultimately had a 19-day hospital course complicated by renal failure requiring hemodialysis and an ischemic limb necessitating above knee amputation. Conclusion This case describes an unsuccessful attempt at nonoperative management of duodenal perforation following EGD.