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Acute myocardial infarction during pregnancy is a very uncommon condition, atherosclerotic coronary artery disease is by far the most common cause of an acute coronary syndrome in the general population. The causes of an acute coronary syndrome in the pregnant patient are wide and varied. This has important implications with respect to the diagnosis of the etiology and the subsequent management of the cause. There are a number of diagnostic tools for the diagnosis of coronary artery disease but it is important to understand their role in pregnant patients. Spontaneous coronary artery dissection is one of the most common causes of acute coronary syndrome in pregnant patients. Understanding its pathophysiology and knowing the natural history of this condition is paramount in the management of this condition. The article also lists the various therapeutic modalities available to the clinician. Finally, we discuss the delivery of the baby and post partum care of these complex patients.

Acute myocardial infarction during pregnancy is a very uncommon condition; atherosclerotic coronary artery disease is by far the most common cause of an acute coronary syndrome in the general population. The causes of an acute coronary syndrome in the pregnant patient are wide and varied. This has important implications with respect to the diagnosis of the etiology and the subsequent management of the cause of the acute coronary syndrome. There are a number of diagnostic tools for the diagnosis of coronary artery disease but it is important to understand their role in pregnant patients. Spontaneous coronary artery dissection is one of the most common causes of acute coronary syndrome in pregnant patients. Understanding its pathophysiology and knowing the natural history of this condition is paramount in the management of this condition. The article also lists the various therapeutic modalities available to the clinician faced with an acute coronary syndrome in the pregnant patient. Finally, we discuss the delivery of the baby and post partum care of these complex patients. Keywords: Pregnancy, Acute myocardial infarction, Spontaneous coronary artery dissection

The MitraClip system can be used to control regurgitant blood flow in patients with mitral regurgitation who cannot tolerate open surgery to replace the mitral valve. Technical limitations make the right femoral vein the standard access point for placing the MitraClip. However, this route is not always suitable. We present the case of an 85-year-old woman in whom we successfully used a left-sided approach for inserting a MitraClip because her right femoral vein was occluded. This apparently novel left femoral approach merits consideration as an option for device insertion when right femoral vein access is precluded., NA

Fractional flow reserve (FFR) has been shown to improve clinical decision-making for revascularization in intermediate coronary stenosis in native coronary arteries of patients with stable coronary disease. However, its use for saphenous vein graft (SVG) lesions has not been well validated. We sought to determine the prognostic value of deferring intervention in lesions with FFR >0.8 in SVG lesions. Clinical, angiographic, and hemodynamic variables and long-term outcomes were recorded in consecutive patients in whom percutaneous coronary intervention was deferred based on an FFR >0.8 for intermediate native coronary artery or SVG stenosis. Thirty-three patients underwent FFR of SVG lesions and were compared with 532 patients who underwent native vessel FFR during the same period. There were no differences in age (66.6 [interquartile range, IQR 63 to 76] vs 65 years [IQR 61 to 70]; p = 0.12), diabetes (41% vs 50%; p = 0.35), or hypertension (94% vs 97%; p = 0.71). During a median follow-up of 3.2 years (IQR 1.7 to 4.6 years) major adverse cardiac event was significantly higher in SVG group (36% vs 21%; log rank p = 0.01). Similarly, the rate of target vessel failure was significantly higher in the SVG group (27% vs 14%; p = 0.01). Deferred SVG lesions had the worst survival free of target vessel failure compared with deferred native lesions in both patients with and without previous CABG. An SVG lesion was an independent predictor of major adverse cardiac events on Cox proportional hazards analysis (hazard ratio 2.26; confidence interval 1.19, 4.28; p = 0.01). In conclusion, nonischemic FFR carries a significantly worse prognosis in SVG compared with non-SVG lesions. Caution is warranted in utilizing FFR for clinical decision-making in SVG lesions.

To evaluate the efficacy of advanced stent technology in the management of failing arteriovenous grafts (AVGs).End-stage renal disease rates and the need for hemodialysis are increasing worldwide. AVG remains a common dialysis access site. Several techniques have been previously suggested to restore and preserve AVG patency. A quantitative evaluation and synthesis of this information are essential in elucidating the role of newer stent platforms for the management of failing AVG.We performed a literature search using PubMed, Web of Science, and Embase from January 2006 to December 2017. Studies comparing the primary patency rates with stent placement vs balloon angioplasty alone in patients with failed AVGs were included.Seven studies with a total of 1109 patients met the inclusion criteria. The mean graft age was 2.89 years in the stent group and 3.29 years in the balloon angioplasty group. Stent placement was associated with improved primary patency rates compared with balloon angioplasty alone at short-term (3-month) follow-up (73.2% vs 42.6%, respectively; risk ratio [RR], 0.55; 95% confidence interval [CI], 0.35-0.88; P=.01) and mid-term (6-month) follow-up (50.8% vs 18.4%, respectively; RR, 0.65; 95% CI, 0.51-0.82; P.001). The primary patency rates remained favorable with stent placement at 12-month (40.3% vs 13.0%, respectively; RR, 0.69; 95% CI, 0.63-0.77; P.001) and 24-month follow-up (20.5% vs 6.8%; RR, 0.86; 95% CI, 0.80-0.92; P.001) compared with balloon angioplasty alone.Stent placement is associated with improved patency rates compared with balloon angioplasty alone.

To study the use of cardiac magnetic resonance (CMR) feature tracking technique in evaluation of myocardial amyloidosis.CMR scans of 28 patients with biopsy proven myocardial amyloidosis and 35 controls were reviewed. Conventional short axis, vertical long axis, and 4-chamber cine steady-state free precession images from CMR scans were used to generate radial, circumferential, and longitudinal myocardial strain maps using feature tracking software. Global and regional peak radial, circumferential, and longitudinal strain values were computed.There were significant decreases in radial, circumferential, and longitudinal strains in patients with myocardial amyloidosis globally and across layers (all P0.001). Strain was relatively preserved for the apex and most affected for the basal level. The area under the receiver operating characteristic curve for base peak radial, circumferential, and longitudinal strain 0.899, 0.884, and 0.866 and cut offs of 22.9, -13.3, and -10.9, respectively, were determined by receiver operating characteristic analysis. CMR feature tracking strain analysis of base-level strain parameters was able to differentiate patients with myocardial amyloidosis from those without myocardial amyloid with high sensitivity (82.5%) and specificity (82.9%) particularly for radial strain. The maximum sensitivity (89.3%) was achieved if any of the 3 parameters were abnormal, and the maximum specificity (88.6%) when all 3 parameters were abnormal.Myocardial amyloidosis produces significant changes in regional and global strain parameters, and the peak radial and circumferential strain are the most affected at the basal layer.

Revascularization or deferral of PCI based on coronary hemodynamics is paramount in left anterior descending artery (LAD) lesions. A recent post hoc analysis from a randomized study has suggested non-hyperemic pressure ratio (NHPR) based deferral may be associated with lower one year event rates

Deferring PCI based on a non-ischemic FFR has been well established and incorporated into guidelines. The deferred population, however, constitutes a heterogeneous group in terms of future events warranting further risk stratification. 575 consecutive patients with 664 non-ischemic lesions based on

Aims Intracoronary adenosine (ICA) yields similar fractional flow reserve (FFR) results to the "gold standard" of intravenous adenosine (IVA). Whether they have similar prognostic significance is unknown. We therefore sought to study the prognostic value of the route of adenosine administration for the measurement of FFR in deferred coronary lesions in a large, real-world cohort. Methods and results Five hundred and seventy-six patients with 787 lesions in whom PCI was deferred based on FFR >0.75 were studied. The primary outcome was the first major adverse cardiovascular event (MACE; defined as death, myocardial infarction [MI], or target vessel revascularisation [TVR]), and the secondary outcome was a composite of MI and target vessel failure (TVF). FFR was measured with ICA in 426 lesions and IVA in 361 lesions. Median follow-up duration was 3.2 years (interquartile range: 1.7- 4.6). Propensity-matched cohorts of ICA and IVA were well matched for baseline clinical, angiographic and haemodynamic characteristics. In the propensity-matched cohort, MACE occurred in 23.5% of the ICA group and in 22.3% of the IVA group (p=0.29). On multivariate analysis, acute coronary syndrome, FFR and prior MI/revascularisation were independent predictors of MACE and MI/TVF. The route of adenosine administration was not predictive of MACE or MI/TVF. Conclusions ICA and IVA yield similar FFR values and show comparable long-term prognostic utility in a deferred population. These findings provide confirmation that non-ischaemic FFR using a simpler ICA protocol provides prognostic data similar to the gold standard IVA.

There remains clinical equipoise in the appropriate selection of antiplatelet therapy for the patient on long-term anticoagulation requiring percutaneous coronary intervention. Since most of these patients represent an increasingly aging population, the significant risk of thromboembolism and stent thrombosis must be weighed against the risk of major bleeding. This article reviews the current state of evidence to provide a framework for the practicing clinician.

Background Endovascular approach to superficial femoral artery (SFA) disease, the most common cause of symptomatic peripheral arterial disease, remains fraught with high failure rates. Newer devices including second-generation nitinol stents, drug-coated stents, drug-coated balloons, covered stents, cryo-therapy, LASER, and directional atherectomy have shown promising results. Clinical equipoise still persists regarding the optimal selection of devices, largely attributable to the different inclusion criteria, study population, length of lesions treated, definition of “patency” and “restenosis,” and follow-up methods in the pivotal trials. Methods A prospective protocol was developed. We performed a literature search using PubMed from January 2006 to November 2013. Published articles including endovascular interventions in SFA or popliteal arteries with reported 12-month “primary patency” or “binary restenosis” rates as endpoints were included. Results We identified 6,024 patients in 61 trials reporting 12-month primary patency rates in patients with femoropoliteal disease. Primary patency rates were (weighted average) 77.2% for nitinol stents, 68.8% for covered stents, 84% for drug eluting stents, 78.2% for drug eluting/coated balloon, 60.7% for cryoballoon, 51.1% for LASER atherectomy, 63.5% for directional atherectomy and 70.2% with a combination of endovascular devices. Conclusion The most frequently used endovascular devices yielded various 12-month primary patency rates ranging from 51% to 85%. The increased variation in inclusion criteria, length, and complexity of lesions between studies does not allow direct comparison between them. Larger randomized trials in specific patient populations comparing those modalities is needed before we can make safe recommendation of the superiority of one device over the other. © 2014 Wiley Periodicals, Inc.

To evaluate the efficacy of advanced stent technology in the management of failing arteriovenous grafts (AVGs). End-stage renal disease rates and the need for hemodialysis are increasing worldwide. AVG remains a common dialysis access site. Several techniques have been suggested previously to

Deferring percutaneous coronary intervention in nonischemic lesions by fractional flow reserve (FFR) is associated with excellent long-term prognosis in patients with stable ischemic heart disease (SIHD). Although FFR is increasingly used for clinical decision making in acute coronary syndrome (ACS) patients with intermediate lesions, its effect on long-term prognosis has not been well established.This study investigated the clinical and prognostic utility of FFR in ACS patients with percutaneous coronary intervention deferred on the basis of nonischemic FFR.We studied 206 consecutive ACS patients with 262 intermediate lesions and 370 patients with SIHD (528 lesions) in whom revascularization was deferred on the basis of a nonischemic FFR (0.75). The primary outcome measure was a composite of myocardial infarction and target vessel failure (major adverse cardiovascular events [MACE]).In the entire cohort, the long-term (3.4 ± 1.6 years) MACE rate was higher in the ACS group than in the SIHD group (23% vs. 11%, p 0.0001). After propensity score matching (200 patients/group), MACE remained significantly higher (ACS 25% vs. SIHD 12%; p 0.0001). On Cox proportional hazards analysis for MACE, ACS had a hazard ratio of 2.8 (95% confidence interval: 1.9 to 4.0; p 0.0001). In both the matched and unmatched cohorts, across all FFR categories, ACS patients had a significantly higher annualized myocardial infarction/target vessel revascularization rate compared with SIHD (p 0.05). Receiver-operating characteristic analysis identified FFR cutoffs (best predictive accuracy for MACE) of 0.84 for ACS (MACE 21% vs. 36%; p = 0.007) and 0.81 for SIHD (MACE 17% vs. 9%; p = 0.01).Deferring percutaneous coronary intervention on the basis of nonischemic FFR in patients with an initial presentation of ACS is associated with significantly worse outcomes than SIHD. Caution is warranted in using FFR values derived from patients with SIHD for clinical decision making in ACS patients.

Background The ratio of the transmitral early inflow wave velocity (E wave velocity) and the velocity of the septal (or lateral) mitral annulus as measured by tissue Doppler (the e’ wave velocity) can be used to estimate left atrial pressure on echocardiographic examination. An elevated E/e’ (more than 15 when using the septal mitral annular velocity) is an established measure of elevated LAP. Furthermore when the left atrial pressure rises, simultaneous changes take place in the pulmonary venous flow. The normal flow pattern in the pulmonary veins consist of a prominent systolic and a smaller diastolic component with the ratio of the peak systolic to diastolic velocities more than 1. With elevated left atrial pressure the ratio drops to below 1.

Aortic dehiscence is an uncommon but serious complication of aortic valve surgery. The most common presentation is that of congestive heart failure and or cardiogenic shock. A number of other local complications can ensue due to involvement of the fibrous skeleton of the heart. We present a case where the dehiscence of the aortic valve resulted in elevated pulmonary arterial pressures and right sided heart failure due to the involvement of the right ventricular outflow tract. We review the literature focusing on the causes, summarize the diagnostic findings and the local complications that can result from aortic dehiscence. This complication of aortic valve dehiscence has not been reported so far.

Background: Deferring PCI based on a non-ischemic FFR has been well established. Growing evidence suggests an increasingly important role of post-PCI FFR in outcome prediction. Whether the FFR value post-PCI contains the same prognostic weight as FFR in deferred lesions is not known. Methods: Major

Endovascular approach to superficial femoral artery (SFA) disease, the most common cause of symptomatic peripheral arterial disease, remains fraught with high failure rates. Newer devices including second-generation nitinol stents, drug-coated stents, drug-coated balloons, covered stents, cryo-therapy, LASER, and directional atherectomy have shown promising results. Clinical equipoise still persists regarding the optimal selection of devices, largely attributable to the different inclusion criteria, study population, length of lesions treated, definition of "patency" and "restenosis," and follow-up methods in the pivotal trials.A prospective protocol was developed. We performed a literature search using PubMed from January 2006 to November 2013. Published articles including endovascular interventions in SFA or popliteal arteries with reported 12-month "primary patency" or "binary restenosis" rates as endpoints were included.We identified 6,024 patients in 61 trials reporting 12-month primary patency rates in patients with femoropoliteal disease. Primary patency rates were (weighted average) 77.2% for nitinol stents, 68.8% for covered stents, 84% for drug eluting stents, 78.2% for drug eluting/coated balloon, 60.7% for cryoballoon, 51.1% for LASER atherectomy, 63.5% for directional atherectomy and 70.2% with a combination of endovascular devices.The most frequently used endovascular devices yielded various 12-month primary patency rates ranging from 51% to 85%. The increased variation in inclusion criteria, length, and complexity of lesions between studies does not allow direct comparison between them. Larger randomized trials in specific patient populations comparing those modalities is needed before we can make safe recommendation of the superiority of one device over the other.

Most biological outcomes in a cell arise from a complex interplay between different cellular entities such as proteins, DNA, RNA and metabolites. Therefore, a key challenge for biology in the twenty-first century is to understand the structure and dynamics of the complex web of interactions in a cell that contribute to its proper functioning. Recent years have seen a surge in the amount of “omics” data and an integration of several disciplines which has influenced all areas of life sciences, from molecular biology to medicine. With the emergence of a number of sophisticated tools and technologies as a result of genomics revolution, we are now in a position to view the molecular aspects of diseases at a systems level by incorporating various cellular entities into a network framework. Such systems/network-based approaches are not only enabling us to develop models of disease and wellness in a population but also contributing to our efforts to reverse engineer the molecular networks corresponding to disease states by perturbing using drug cocktails. These multi-scale personalized medicine approaches are likely to significantly re-shape the health care industry in the coming decades and decrease the division that we currently see between medicine and other biotechnology disciplines.

Adenosine is used to induce maximal hyperemia during fractional flow reserve (FFR) measurement. Adenosine administration can be time consuming, with added cost and sometimes may have undesirable side effects. We evaluated the predictive accuracy of resting trans-lesional gradient (distal coronary

A fractional flow reserve (FFR) value between 0.75 and 0.80 is considered the “gray zone” and outcomes data are limited in this group. We sought to evaluate the impact of revascularization vs. medical therapy alone (deferral) on long term outcomes for patients in the gray zone. Consecutive

A sizeable proportion of PCI-deferred patients based on non-ischemic FFR, continue to experience symptoms. Consecutive patients undergoing FFR evaluation in whom PCI was deferred were followed. Patients who had FFR re-measured across the same lesion during follow-up for recurrent symptoms were