Rihal, Charanjit S.

Background: Risks and mechanisms of extension of conservatively managed spontaneous coronary artery dissection (SCAD) remain incompletely understood. Study objectives were to (1) evaluate mechanisms of early SCAD evolution through serial angiographic analysis, and (2) determine predictors of early SCAD progression. Methods and Results: Retrospective registry study of patients with SCAD managed with an initial conservative strategy (n=240). Patients who experienced significant SCAD progression within 14 days, defined as clinical worsening plus new critical coronary obstruction on repeat angiography, were compared with remaining controls. A total of 42 of 240 (17.5%) experienced significant SCAD progression after index conservative approach; 91% by day 6. Isolated intramural hematoma (IMH) at baseline (no intimal dissection) was observed more frequently in those experiencing progression compared with controls (69.1% versus 44.4%; P =0.004). Multivariable predictors of SCAD progression included lesion severity, multivessel involvement, and isolated IMH. To investigate mechanisms of SCAD evolution, all repeat angiograms ≤14 days were compared with corresponding baselines (n=82 patient angiogram pairs). Of those with isolated IMH at baseline, 20% developed intimal dissection at repeat study. IMH was associated with greater longitudinal lesion extension (11.5 versus 2.8 mm; P =0.01), worsening Thrombolysis in Myocardial Infarction flow (−0.8 versus 0.1; P =0.003), and a nonsignificant lower rate of angiographic improvement (20.0% versus 31.3%; P =0.16) compared with the group with baseline intimal dissection. Optical coherence tomography subgroup analysis (n=17) indicated intimo-medial thickness to be lowest at the midpoint of IMH. Conclusions: Conservatively managed SCAD carries a 1:6 hazard for serious deterioration within 6 days. The risk was higher in those with isolated IMH at baseline. IMH often precedes development of intimal dissection, which has implications for mechanisms of SCAD.

BACKGROUND: Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Second-generation drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS: The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS: A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0–90, 91–180, 181–365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0–90 days and 3.4 (0.8 to 15.3) at 91–180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS: The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT.

AbstractObjectivesTo measure the intraprocedural change in left atrial pressure (LAP) with saline administration during transcatheter mitral valve repair (TMVR).BackgroundTMVR with MitraClip offers an alternative to surgery in select patients. During this procedure, large volumes of fluid are routinely administered with anesthesia and to facilitate transcatheter valve repair. LAP, a measure used to guide repair, may thereby change as a result of volume expansion, suggesting a need for continuous intracardiac pressure monitoring.MethodsConsecutive patients with severe mitral regurgitation underwent TMVR with MitraClip and continuous LAP monitoring through a dedicated sampling catheter. Specific LAP values were acquired immediately after transseptal access; before first clip deployment; and after deployment of the last clip.Results151 patients (age 80 ± 8 years, 64% male) underwent TMVR with MitraClip and continuous LAP monitoring. Mean LAP and v‐wave pressure increased significantly from baseline to pre‐MitraClip deployment (P < 0.0001) and decreased significantly from deployment to procedure end (P < 0.0001). Linear regression of v‐wave pressure change (from procedure start to clip deployment) relative to volume administration yielded a significantly nonzero slope (0.28 mmHg/min, P < 0.0001, r = 0.30).ConclusionFluid administration during TMVR leads to time‐dependent increases in LAP. Such intraprocedural change underscores the need for targeted, if not continuous, LAP measurement during TMVR to optimize MitraClip placement and mitral regurgitation reduction.

Abstract Background Transcatheter Aortic Valve Implantation (TAVI) is commonly used to deploy new bioprosthetic valves inside degenerated surgically implanted aortic valves in high risk patients. The three scoring systems used to assess risk of postprocedural mortality are: Logistic EuroSCORE (LES), EuroSCORE II (ES II), and Society of Thoracic Surgeons (STS). Objective The purpose of this study is to analyze the accuracy of LES, ES II, and STS in estimating all‐cause mortality after transcatheter aortic valve‐in‐valve (ViV) implantations, which was not assessed before. Methods Using the Valve‐in‐Valve International Data (VIVID) registry, a total of 1,550 patients from 110 centers were included. The study compared the observed 30‐day overall mortality vs. the respective predicted mortalities calculated by risk scores. The accuracy of prediction models was assessed based on calibration and discrimination. Results Observed mortality at 30 days was 5.3%, while average expected mortalities by LES, ES II and STS were 29.49 (± 17.2), 14.59 (± 8.6), and 9.61 (± 8.51), respectively. All three risk scores overestimated 30‐day mortality with ratios of 0.176 (95% CI 0.138–0.214), 0.342 (95% CI 0.264–0.419), and 0.536 (95% CI 0.421–0.651), respectively. 30‐day mortality ROC curves demonstrated that ES II had the largest AUC at 0.722, followed by STS at 0.704, and LES at 0.698. Conclusions All three scores overestimated mortality at 30 days with ES II showing the highest predictability compared to LES and STS; and therefore, should be recommended for ViV procedures. There is a need for a dedicated scoring system for patients undergoing ViV interventions.

Background— A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited. Methods and Results— We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 ( P trend <0.001). There were 3880 records in each group in the matched cohort. Compared with SAVR, TAVR was associated with similar in-hospital mortality (2.3% versus 2.4%; P =0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P <0.001), stroke (1.4% versus 2.7%; P <0.001), bleeding complications (10.6% versus 24.6%; P <0.001), and acute kidney injury (16.2% versus 19.3%; P <0.001). Requirement for prior permanent pacemaker was higher in the TAVR cohort, whereas the incidence of vascular complications and acute kidney injury requiring dialysis was similar in the 2 groups. Average length of stay was shorter in patients undergoing TAVR. Conclusions— TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.

Background— Women have higher rates of all-cause mortality after percutaneous coronary intervention. Whether this is because of greater age and comorbidity burden or a sex-specific factor remains unclear. Methods and Results— We retrospectively assessed cause-specific long-term mortality after index percutaneous coronary intervention over 3 time periods (1991–1997, 1998–2005, and 2006–2012). Cause of death was determined using telephone interviews, medical records, and death certificates. We performed competing risks analyses of cause-specific mortality. A total of 6847 women and 16 280 men survived index percutaneous coronary intervention hospitalization 1991 to 2012. Women were older (mean±SD: 69.4±12 versus 64.8±11.7 years; P <0.001) with more comorbidities (mean±SD: Charlson index 2.1±2.1 versus 1.9±2.1; P <0.001). Across the 3 time periods, both sexes exhibited a decline in cardiac deaths at 5 years (26% relative decrease in women, 17% in men, trend P <0.001 for each). Although women had higher all-cause mortality compared with men in all eras, the excess mortality was because of noncardiac deaths. In the contemporary era, only a minority of deaths were cardiac (33.8% in women, 38.0% in men). After adjustment, there was no evidence for a sex-specific excess of risk for cardiac or noncardiac mortality. The commonest causes of death were chronic diseases and heart failure in women (5-year cumulative mortality, 5.4% and 3.9%) but cancer and myocardial infarction/sudden death in men (5.4% and 4.3%). Conclusions— The higher mortality after percutaneous coronary intervention in women is because of death from noncardiac causes. This is accounted for by baseline age and comorbidities rather than an additional sex-specific factor. These findings have implications for sex-specific clinical care and trial design.