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Accumulating evidence from clinical trials suggests that a lower (restrictive) hemoglobin threshold (8% g/dL) for red blood cell (RBC) transfusion, compared with a higher (liberal) threshold (≥10 g/dL) is safe. However, in anemic patients with acute myocardial infarction (MI), maintaining a higher hemoglobin level may increase oxygen delivery to vulnerable myocardium resulting in improved clinical outcomes. Conversely, RBC transfusion may result in increased blood viscosity, vascular inflammation, and reduction in available nitric oxide resulting in worse clinical outcomes. We hypothesize that a liberal transfusion strategy would improve clinical outcomes as compared to a more restrictive strategy.We will enroll 3500 patients with acute MI (type 1, 2, 4b or 4c) as defined by the Third Universal Definition of MI and a hemoglobin10 g/dL at 144 centers in the United States, Canada, France, Brazil, New Zealand, and Australia. We randomly assign trial participants to a liberal or restrictive transfusion strategy. Participants assigned to the liberal strategy receive transfusion of RBCs sufficient to raise their hemoglobin to at least 10 g/dL. Participants assigned to the restrictive strategy are permitted to receive transfusion of RBCs if the hemoglobin falls below 8 g/dL or for persistent angina despite medical therapy. We will contact each participant at 30 days to assess clinical outcomes and at 180 days to ascertain vital status. The primary endpoint is a composite of all-cause death or recurrent MI through 30 days following randomization. Secondary endpoints include all-cause mortality at 30 days, recurrent adjudicated MI, and the composite outcome of all-cause mortality, nonfatal recurrent MI, ischemia driven unscheduled coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), or readmission to the hospital for ischemic cardiac diagnosis within 30 days. The trial will assess multiple tertiary endpoints.The MINT trial will inform RBC transfusion practice in patients with acute MI.

Selective stent post-dilatation (PD) in a cohort of STEMI patients did not affect major adverse cardiac events but it did decrease device-oriented composite events, a secondary composite end point of less clear significance. This study suggests that selective stent PD in STEMI does not increase the incidence of acute no-reflow or long-term adverse clinical events. In primary PCI for STEMI, if the stent appears under-expanded, then PD, perhaps guided by intravascular imaging (which was not reported in this study), is reasonable.

Background Patients with angina and coronary microvascular dysfunction, without evidence of structural or epicardial coronary disease (Type I CMVD) remain without evidence based treatment options. Previous work has demonstrated that ranolazine can improve angina frequency and stability among patients with Type 1 CMVD; however, the mechanism remains unclear. Therefore, the objective of this pilot project was to assess the impact of ranolazine on Type I CMVD as measured using an invasive tool to measure global resistance (index of microcirculatory resistance (IMR)). Methods Patients with Type 1 CMVD diagnosed using IMR were enrolled and treated with ranolazine 1000mg BID. Coronary angiography and IMR were performed at baseline and on treatment after four weeks. The primary outcome measure was change in IMR pre- and post-treatment. Secondary outcome measures, improvement in angina and activity level, were assessed using the Seattle Angina Questionnaire (SAQ), Duke Activity Status Index (DASI) and Metabolic equivalent for Task (MET) scores. Results A total of 7 patient were enrolled and completed the study. Mean age was 57.6±7.5, 43% were female and 43% were Hispanic. Mean baseline IMR was 37.25±16.27 which decreased to 19.48±5.69 ( p =0.02; (−48% Δ) after treatment with ranolazine. Four of the five SAQ domains improved on treatment with significant improvement in physical limitation ( p =0.001), angina frequency ( p =0.04), angina stability ( p =0.05) and disease perception ( p =0.001). Non-significant improvements in activity were also seen in both the DASI and MET scores. Conclusion Among patients with Type 1 CMVD, our pilot data suggest favorable changes in IMR, anginal symptoms and activity status with ranolazine treatment. These findings support further evaluation of the effects of ranolazine on microcirculatory function and angina symptoms in a larger cohort of patients with Type 1 CMVD.

Background: Acute Coronary Syndrome (ACS) is a leading cause of morbidity and mortality. Perturbed gut-microbiota (dysbiosis) and increased intestinal permeability (leaky-gut) with translocation of bacterial antigens, play critical role in obesity and metabolic syndrome, which are also major ACS risk factors. Additionally, Trimethylamine-N-Oxide (TMAO), a metabolite produced by phylum Proteobacteria in gut is implicated in developing ACS. As Proteobacteria is a major source of translocated antigen lipopolysaccharides (LPS), we hypothesized that ACS patients have leaky-gut condition characterized by dysbiosis with increased Proteobacteria, leading to elevated blood levels of TMAO and LPS. Methods: In a pilot case-control study, we enrolled 19 ACS patients (within 72-h of cardiac events) and 19 healthy-controls. Gut barrier function was determined using lactulose-to-mannitol urinary excretion ratio (L/M ratio). Stool microbiome composition was examined using16S sequencing and predictive functional analysis for LPS biosynthesis pathway by PICRUSt tool. Serum TMAO and LPS levels were measured. Results: ACS patients had increased Gammaproteobacteria compared to controls:1.8 ± 3.0 vs. 0.2 ± 0.4% (P = 0.04). Though Proteobacteria level was increased but not statistically significant: 4.1 ± 3.8 vs. 2.1 ± 1.7% (P = 0.056). L/M-ratio was three times higher in ACS patients; 0.06 ± 0.07 vs 0.023 ± 0.02, (P = 0.014). Surprisingly, there was no difference in the mean serum LPS or TMAO levels. However, PICRUSt analysis indicated increased Proteobacteria population increasingly contributed to LPS biosynthesis in ACS patients only. Conclusions: ACS patients likely to have leaky-gut and perturbed gut microbiota. Further studies are required to precisely define the role of dysbiosis in ACS. Keywords: Dysbiosis, Intestinal permeability, Proteobacteria, TMAO, Endotoxins, Acute coronary syndrome

Background: World Health Organization (WHO) Surgical Safety Checklist had a significant impact on surgical outcomes(1). In 2009, The United Kingdom National Patient Safety Agency required the use of this checklist(2). A pre procedure checklist for central venous line placements was one of the first commonly used checklists, and since then, the concept has been expanded to include venous thromboembolism prophylaxis, patient discharge, and many more(3). In 2016, Society of Cardiovascular Angiography and Interventions (SCAI) published a best practices consensus statement Update, which included a pre-procedure checklist for cardiac catheterizations(4). Objectives: The goals of the project were two-fold. First, to formalize the pre-procedure evaluation of patients referred to the cardiac catheterization laboratory, and second, to introduce a ‘Morning Huddle’ for all team members. The huddle is directed by a physician and includes a brief patient history and procedural plan to ensure everyone has a clear understanding of the procedure indication, patient specific risks, and procedural equipment needed. It would also provide an opportunity for group questions or to raise concerns. Methods: Safety Attitudes Questionnaire (SAQ) was used with permission from University of Texas Health Science Center at Houston, to assess the attitudes towards safety of the staff working at the cardiac catheterization laboratory, as well as the general cardiology fellows. Cardiology fellows were provided with pre-catheterization checklist, adapted from the SCAI best practices consensus statement Update, as well as an outline for the format of the ‘Morning Huddle’. Results: The total number of responses obtained were 23. The survey revealed that the majority of the staff felt that the physicians and nurses worked in a well-coordinated team (95.7%, 22 of 23). Almost 26% (6 of 23) of the staff interviewed reported difficulty in speaking up when a problem was perceived. Communication breakdown was not noted to be a problem by the majority interviewed, although a small percentage did disagree (26%, 6 of 23). Conclusions: Although the survey was overwhelmingly positive at baseline, room for improvement was noted. It is anticipated that the intervention will allow the staff an opportunity to speak up when a problem is perceived, and improve communication, by empowering the team during the ‘Morning Huddle’. Our overarching goal is to improve the safety climate in the catheterization laboratory.

Real-time, 3-dimensional transesophageal echocardiography (RT 3D TEE) is now used routinely in conjunction with x-ray fluoroscopy to guide percutaneous structural heart disease (SHD) interventions. Unlike fluoroscopy, RT 3D TEE provides excellent detail of 3D anatomy and soft tissue structures, and

Excisional atherectomy alone or followed by stenting is considered an appropriate treatment strategy for patients with lifestyle-limiting claudication due to obstructive infra-inguinal peripheral arterial disease (Ramaiah et al., J Endovasc Ther 2006;13:592–6021). We present a case of a 69-year-old man with eccentric severely calcified disease of the superficial femoral artery (SFA) treated with excisional atherectomy followed by stenting with an interwoven nitinol stent. The procedure was complicated by extravascular stent migration associated with a contained rupture presenting 30 days after the intervention. The complication was successfully treated with a stent graft. Although rare, pseudoaneurysms have been reported at the site of prior atherectomy; however, this case is the first description of a contained rupture post atherectomy associated with erosion of a nitinol stent into an extra-luminal position. The mechanism and management of this complication are discussed. © 2014 Wiley Periodicals, Inc.

A previously asymptomatic young female with no previous medical or cardiac history collapsed during indoor exercise. A portable automatic external defibrillator showed a shockable rhythm. She received multiple electrical shocks with return to normal sinus rhythm without ischaemic ECG changes. Her troponin level was mildly elevated. A transthoracic echocardiogram revealed moderately reduced left ventricular ejection fraction with global hypokinesis. During emergent coronary angiography, the left main coronary artery could not be found. The right coronary artery was normal with robust collaterals to the entire left coronary circulation extending to the left main coronary artery, but did not fill the ostium. Coronary CT angiogram confirmed nearly complete absence of the left main coronary artery ostium. A diagnosis of left main coronary artery atresia was made. Patient underwent successful two vessel coronary artery bypass grafting. She continues to do well 1 year postoperatively.

Cardiogenic shock (CS) in the setting of acute myocardial infarction is associated with high in-hospital mortality rates. Society guidelines provide a Class Ib recommendation for the use of hemodynamic support devices in patients with CS following ST-elevation myocardial infarction. Exchanging of hemodynamic support devices is often complicated by inability to maintain percutaneous vascular access upon device removal in the setting of anticoagulation. This report highlights one potential solution to the dilemma of maintaining vascular access following removal of an Impella® 2.5 mechanical support device to allow safe transition to a TandemHeart system in a patient with refractory CS. © 2013 Wiley Periodicals, Inc.

Cardiogenic shock (CS) in the setting of acute myocardial infarction is associated with high in-hospital mortality rates. Society guidelines provide a Class Ib recommendation for the use of hemodynamic support devices in patients with CS following ST-elevation myocardial infarction. Exchanging of hemodynamic support devices is often complicated by inability to maintain percutaneous vascular access upon device removal in the setting of anticoagulation. This report highlights one potential solution to the dilemma of maintaining vascular access following removal of an Impella® 2.5 mechanical support device to allow safe transition to a TandemHeart system in a patient with refractory CS.

Excisional atherectomy alone or followed by stenting is considered an appropriate treatment strategy for patients with lifestyle-limiting claudication due to obstructive infra-inguinal peripheral arterial disease (Ramaiah et al., J Endovasc Ther 2006;13:592-6021). We present a case of a 69-year-old man with eccentric severely calcified disease of the superficial femoral artery (SFA) treated with excisional atherectomy followed by stenting with an interwoven nitinol stent. The procedure was complicated by extravascular stent migration associated with a contained rupture presenting 30 days after the intervention. The complication was successfully treated with a stent graft. Although rare, pseudoaneurysms have been reported at the site of prior atherectomy; however, this case is the first description of a contained rupture post atherectomy associated with erosion of a nitinol stent into an extra-luminal position. The mechanism and management of this complication are discussed.

Peritoneopericardial fistula (PPF) is rare and usually acquired as a complication of trauma or surgery. In patients with ascites, PPF can allow the development of pericardial effusion(PE) potentially leading to cardiac tamponade. 41-year-old man with hepatitis C, alcohol abuse and remote history of

In the 2012 expert consensus document on transcatheter aortic valve replacement (TAVR), the inexact name TAVR appears in nearly every paragraph ([1][1]). But, what's in a name? According to William Shakespeare, “That which we call a rose; by any other name would still smell as sweet” ( Romeo and