Cardiac Percutaneous Intervention Research Articles

Patent Ductus Arteriosus Device Closure in Interrupted Inferior Vena Cava

Interrupted inferior vena cava (IVC) with azygous continuation provides technical challenge in many percutaneous cardiac interventions. They are performed via the femoral venous access route. We describe four such cases in whom, patent ductus arteriosus (PDA) device closure was done in interrupted IVC. All the four cases were done using the femoral route. Two cases were done via retrograde approach through femoral artery access, in which one was closed with a muscular VSD device and the other with a Gianturco coil.The introduction of newer closure devices helps in the retrograde approach. Two cases were done via anterograde approach through the femoral venous route, with a loop through the azygous vein. One child had transient bradycardia due to cardiac stretch which normalized after the device deployment and introducer system removal.Thus, we describe different femoral approaches in interrupted IVC patients for PDA closure, with the difficulties faced and the complications managed.

Prevalence, management and outcomes of cardiac tamponade complicating 66,812 invasive cardiac procedures: single-center clinical registry.

IntroductionThere are numerous studies concerning iatrogenic cardiac tamponade. Those studies are predominantly focused on one cardiac procedure and the follow-up is not always presented.AimTo estimate the rate of cardiac tamponade following 66,812 percutaneous invasive cardiac interventions depending on the procedure. For each group the baseline characteristics and hospital management, as well as in-hospital, 30-day and 1-year mortality, were evaluated.Material and methodsThe study was a single-center retrospective analysis performed in a tertiary clinical hospital, which encompasses two cardiology departments, assessing a large sample of patients who underwent percutaneous invasive cardiac procedures complicated with cardiac tamponade between January 2006 and December 2018. For this purpose, medical records and hospital databases were analyzed. Long-term follow-up was obtained in cooperation with the Silesian Cardiovascular Base.ResultsThe rate of iatrogenic cardiac tamponade during the 13-year period was 0.176%. The incidence among selected invasive cardiac procedures ranged between 0.09% and 1.42%. The majority of cases (104/118) were treated by pericardiocentesis, 16 had pericardiotomy and 4 patients had both therapies. Inotropes were used in 25–45%, blood transfusion in 45% of patients. The highest in-hospital mortality was observed in patients with cardiac tamponade after transcatheter aortic valve implantation. The highest 30-day and 1-year mortality rates were seen in the group with temporary electrode pacing.ConclusionsThe low incidence of cardiac tamponade with the high number of patients requiring intensive care supply and high in-hospital mortality tend to confirm that cardiac tamponade is a rare but life-threatening complication.

In-Hospital and Mid-Term Outcomes of ECMO Support During Coronary, Structural, or Combined Percutaneous Cardiac Intervention in High-Risk Patients – A Single-Center Experience

IntroductionEvidence regarding the impact of prophylactic implantation of Extracorporeal Membrane Oxygenation (ECMO) during coronary or structural procedures is limited. The purpose of this paper is to evaluate the in-hospital and medium term outcomes of ECMO support in complex percutaneous coronary or structural intervention. MethodsThe present is an observational prospective study including consecutive patients who underwent to prophylactic ECMO implantation for percutaneous coronary intervention (PCI), structural or combined interventions between July 2018 and July 2020 in Maria Pia Hospital GVM Care & Research, Turin, Italy. Primary endpoints were in-hospital and medium term all-cause death. Secondary endpoints were vascular complication, bleeding and procedural success. Results27 patients were included with a mean age of 80 ± 6 years, 10 (37%) being diabetics and 19 (70%) with severe left ventricle dysfunction. Mean Logistic Euroscore was 28.7 ± 18.7. Seven patients (26%) underwent complex coronary revascularization, 7 (26%) combined PCI + TAVI, 5 (19%) combined PCI + Mitraclip, 5 (19%) TAVI alone and finally 3 (11%) combined TAVI + Mitraclip. The procedural success was 96%, with only one in-hospital death due to major vascular complication at the ECMO vascular access. At a mean follow-up of 11 ± 6.8 months 4 deaths were recorded (3 from not cardiovascular causes). ConclusionsProphylactic use of ECMO may be beneficial for high risk patients undergoing complex combined coronary/structural percutaneous interventions with good in-hospital and mid-term outcomes in term of safety and procedural success.

AN INTERVENTIONAL CARDIOLOGY INVESTIGATION: PATIENT EXPOSURE TO RADIATION AND INTER-OPERATOR VARIABILITY IN AN IRISH SETTING.

To evaluate patient radiation exposure for Diagnostic Coronary Angiography (DCA) and Percutaneous Cardiac Intervention (PCI) performed by different operators. Retrospective (n=160) and prospective (n=62) data for DCA (n=179) and PCI (n=43) examinations performed by interventional cardiologists (n=3) using the same imaging equipment were reviewed. The operator with consistently low diagnostic reference levels (DRLs) was interviewed for their personal perceptions upon operator training. Retrospective Median [IQR] DAP was 18.8 [11.8-31.6] and 50.7 [35.3-85.6] Gy.cm2 for DCA and PCI, respectively. Prospective Median [IQR] DAP for DCA and PCI was 7.9 [5.2-10.6] and 15.9 [10.0-17.7] Gy.cm2, respectively. DRLs were within Irish and European DRLs; however, significant inter-operator variability (p<.001) was identified. Radiation exposure in Interventional cardiology is highly operator dependent; further research is warranted in standardization of operator training with evolving technologies.

Abstract 16420: Double Internal Thoracic Artery Grafts are Associated to Better 10-year Outcomes After Coronary Artery Bypass Grafting

Introduction: Few data on long-term follow-up of effectiveness and advantages related to the employ of double internal thoracic artery grafts (BITA) for coronary artery bypass grafting are available and the advantage of the employ of BITA have been recently questioned. Hypothesis: This observational cohort study was designed by the PRIORITY planning committee to evaluate 10-year follow-up of isolated CABG performed with and without BITA in order to evaluate the impact of BITA on long-term outcomes. Methods: The PRIORITY project was designed to evaluate the long-term outcomes of 2 large prospective multicenter cohort studies on CABG conducted between 2002-2004 and 2007-2008. Data on isolated CABG were linked to 2 administrative datasets. The primary endpoints were death and major adverse cardiac events (MACEs) at follow-up. Time-to-event data were analyzed using Kaplan-Meier estimates and Cox regression. Models generation was performed on the full dataset and the validation was performed with Montecarlo simulations. Results: The population consisted of 11021 patients who underwent isolated CABG; double thoracic internal artery grafts was employed in 23.5%. The median follow-up time was 7.9 years (interquartile range 7.4 - 10 years). After adjustment for potential confounding factors, BITA was significantly associated with better survival (HR 0.81, 95%CI 0.73-0.89, p &lt; 0.001). Moreover, the employment of BITA reduced the incidence of MACEs at follow-up (adjusted HR 0.83, 95%CI 0.77-0.89, p &lt; 0.001). In details, BITA was demonstrated to be a protective factor for acute myocardial infarction (adjusted HR 0.83, 95%CI 0.72-0.96, p = 0.001) and for rehospitalization for percutaneous cardiac intervention (PCI; adjusted HR 0.72, 95%CI 0.63-0.84, p &lt; 0.001). Conclusions: The employment of double internal thoracic artery grafts for coronary artery bypass grafting has been associated to significant survival advantage at long-term. Moreover, it is a protective factor for acute myocardial infarction and rehospitalization for percutaneous cardiac intervention, reducing the hazard by 28%.

Long-term outcomes following coronary artery bypass grafting: the role of off-pump strategy

Abstract Background The debate on the advantages and limitations of off-pump (OPCAB) on long-term outcomes has not still arrived to a conclusion. This study was designed to compare the impact of OPCAB vs on-pump coronary artery bypass grafting (CABG) on long-term mortality and major adverse cardiac events (MACEs). Methods The PRIORITY project was designed to evaluate the long-term outcomes of 2 large prospective multicenter cohort studies on CABG conducted between 2002–2004 and 2007–2008. Data on isolated CABG were linked to 2 administrative datasets. Time-to-event methods were employed to analyze outcomes. Results The population consisted of 11021 patients who underwent isolated CABG (27.2% OPCAB) that were divided into development and validation datasets. The median follow-up time was 8 years (interquartile range 7.6–10 years) and was 100% complete. Unadjusted long-term survival was significantly worst for OPCAB, nonetheless the adjustment did not confirm OPCAB as a risk factor for mortality (HR 0.94, 95% CI 0.85–1.03, p=0.19). OPCAB was associated to an increased risk of MACE at 10 years (adjusted HR 1.14, 95% CI 1.06–1.23, p=0.001). Inside the MACEs, OPCAB was significantly related to increased incidence of rehospitalization for percutaneous cardiac intervention (PCI), (adjusted HR 1.33, 95% CI 1.16–1.53, p&amp;lt;0.001), demonstrating to be an independent risk factor for PCI with an hazard that is 33% higher than on-pump CABG. Conclusions OPCAB did not affect long-term mortality but is associated with an increased long-term risk of repeat PCI. These findings may have important implications towards health resources allocation, particularly in a climate of cost containment of healthcare expenditures. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Minister of Health

Mixed reality interactive visualization of cardiovascular anatomy in interventional lab – clinical implementation in transvascular patent ductus arteriosus closure

Abstract Aim Three-dimensional (3D) noninvasively acquired datasets containing anatomical information about the heart are a modern option for procedural support during percutaneous cardiac interventions. We present initial experience of patent ductus arteriosus (PDA) closure with workflow integrated with innovative mixed reality display (MRD) to improve 3D perception and navigation in 3D computed tomography angiographic (CTA) datasets. Methods We report incorporation of intraprocedural mixed-reality display of segmented CTA (computed tomography angiography) data using a voice- and gesture controlled head-mounted display during routine percutaneous occlusions of PDA in adults. A dedicated software pathway was used for files conversion, real-time Wi-Fi streaming of 3D rendering from PC to device and manipulation of spatial data during the procedures. Results Pre-recorded CTA studies of aorta and ductus were manually segmented and uploaded into custom designed 3D DICOM for realtime export to MRD device. 3D holograms were successfully displayed during the procedure by commercially available head-mounted display allowing touchless control and image sharing within cath-lab. Wiring of PDA aortic orifice was assisted by 3D hologram controlled by the imaging specialist and shared by the operator. Thus, MRD using evolving versions of custom software was successfully executed with segmented data presented as a semitransparent cubic hologram positioned in a convenient part of visual field allowing real-world action and with touchless control by medical team. Operator appreciated the use of MRD hologram realistically visualizing spatial relationships as practical aid to establish anatomical relationships and facilitate entry into ductus orifice. Procedures were successfully completed using arteriovenous guidewire loop to implant vascular occluders. Conclusions We demonstrate the methodology and software evolution (segmentation, data fusion) allowing practical implementation of intraprocedural mixed reality display of 3D CTA data, with sterile, touchless control of holographic image shared by interventional and imaging team to support percutaneous PDA closure. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): MEDAPP

Can double internal thoracic artery grafts affect 10-year outcomes after coronary artery bypass grafting?

Abstract Background The advantages of the employment of double internal thoracic artery grafts (BITA) for coronary artery bypass grafting have been recently questioned and no data on long-term follow-up are available. This observational retrospective cohort study was designed by the PRIORITY planning committee to evaluate 10-year follow-up of isolated CABG performed with and without BITA in order to clarify and consolidate the contrasting literature. Methods The PRIORITY project was designed to evaluate the long-term outcomes of 2 large prospective multicenter cohort studies on CABG conducted between 2002–2004 and 2007–2008. Data on isolated CABG were linked to 2 administrative datasets. Time-to-event distributions were separately analyzed accordingly to primary event-type (death, MACEs), using Kaplan-Meier estimates and Cox regression. Results The population consisted of 11021 patients who underwent isolated CABG that were divided into development and validation datasets; double thoracic internal artery grafts was employed in 24.6%. The median follow-up time was 8 years (interquartile range 7.6–10 years) and was 100% complete. After adjustment for potential confounding factors, BITA was significantly associated with better survival (HR 0.85, 95% CI 0.76–0.95, p=0.003). Moreover, the employment of BITA reduced the incidence of MACEs at follow-up (adjusted HR 0.87, 95% CI 0.80–0.94, p=0.001). In details, BITA was demonstrated to be a protective factor for acute myocardial infarction (adjusted HR 0.84, 95% CI 0.71–0.99, p=0.05) and for rehospitalization for percutaneous cardiac intervention (PCI; adjusted HR 0.82, 95% CI 0.70–0.96, p=0.013). Conclusions The employment of double internal thoracic artery grafts for coronary artery bypass grafting has been associated to survival advantage at 10-year. Moreover, it significantly decreased the incidence of acute myocardial infarction and rehospitalization for percutaneous cardiac intervention. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Minister of Health

Virtual reality, the start of a new era for patient education in cardiology?

Abstract Background Anxiety, perceived in patients undergoing percutaneous cardiac intervention is a known problem, which is negatively correlated with quality of life, adherence to recommended clinical practice and medication, health promoting behavior, hospitalization, and patient experience and satisfaction. Hence, preprocedural interventions to alleviate anxiety are interesting. While preoperative education interventions were proven to be effective as anxiety reduction modality, especially those modalities that provide immersive experience appeared to be even more effective within this context. Given the non-invasive nature of these modalities and the introduction of innovative techniques such as Virtual Reality (VR), the question arises whether VR can be successfully introduced as an effective tool to alleviate anxiety in cardiology patients undergoing PFO or ASD closure. Purpose The purpose of the study was to alleviate pre-procedural anxiety in patients undergoing percutaneous PFO or ASD closure using a VR film as an innovative and immersive patient education modality. Methods Patients were randomized to either the VR-group or the control group. The control group received traditional patient information by their cardiologist. The intervention group additionally viewed a 4-minute VR-film, that was designed to create a representative patient-experience of the day of the procedure. The primary outcome was patient anxiety in the VR group compared to the control group, as measured with anxiety scores derived from the State Trait Anxiety Inventory (STAI) questionnaire. Measurements were performed directly after the informed consent visit and one week prior to the procedure. Secondary outcome measure was the duration of anesthesia during the procedure. Results In total 40 patients have been included (mean age = 45 yrs ± 11, male = 21), mean FU duration = 37 days ± 23). So far, 27 patients (VR-group n=14; Control group n=13) completed follow-up. At baseline the control and intervention group were equally anxious (37±9 vs 38±14). During follow-up we found a significant increase in anxiety in the control group (37±9 vs 46±12; p=0.034; figure 1), whereas anxiety in the VR-group remained unchanged (38±14 vs 36±9; figure 1). One week prior to the procedure, the control group was significantly more anxious compared to the VR group (+ 11±4; p=0.012; figure 2). The mean duration of the anesthesia was significantly shorter within the VR-group in comparison with the control group (57±10 min vs 71±18 min; p=0,029). This may be an indication that decreased anxiety could have beneficial effects on the complete duration of anesthesia. Conclusion Our results demonstrate that immersive VR patient education is both innovative and effective in alleviating anxiety prior to a cardiological procedure and may have beneficial effects on patient experience and anesthesia duration. Funding Acknowledgement Type of funding source: None

Infection des abords vasculaires et interventions cardiaques percutanées : un risque significatif ?

Vascular access site infections are infrequent and rarely reported as a potential complication of percutaneous cardiac intervention. A case of access site infection is reported with a literature review. Femoral access is mainly concerned in some circumstances: delayed sheath withdrawal, vascular complications (hematoma, false-aneurysm, arteriovenous fistula), or use of hemostatic closure device. These infectious complications are always serious requiring medical and surgical treatment and potentially associated with life-threatening complications. Preventive measures should be applied in order to reduce the risks: optimisation of femoral punctures with the support of echography guidance, avoid a new puncture in a area with hematoma, femoral angiographic evaluation and strict aseptic precautions with vascular closure devices, and obviously preferential choice of radial access.

Long-term outcome after off-pump coronary artery bypass grafting: implication for public health

Abstract Background The debate on the benefits and limitations of off-pump (OPCAB) coronary artery bypass grafting (CABG) on long-term outcomes is not yet settled. This study aimed to compare the impact of OPCAB vs on-pump CABG on long-term outcomes and to evaluate possible public health implications linked to their use. Methods The PRIORITY project was planned to evaluate the long-term outcomes of two prospective multicenter studies on CABG conducted between 2002-2004 and 2007-2008. Data on isolated CABG were linked to administrative data in order to retrieve patients' late outcome. Time-to-event distributions were analyzed accordingly to primary event-type (death, major adverse cardiac events (MACEs)) using the Kaplan-Meier and the Cox proportional hazards methods. Results The study population consisted of 11 021 patients who underwent isolated CABG (27.2% OPCAB). The median follow-up time was 8.0 years (interquartile range 7.6-10.0 years). OPCAB had comparable late all-cause mortality to on-pump CABG (HR 0.94, 95%CI 0.85-1.03, p = 0.19), but it was associated to an increased risk of MACE (adjusted HR 1.14, 95%CI 1.06-1.23, p = 0.001). In particular, OPCAB had an increased risk of repeated revascularization with percutaneous cardiac intervention (PCI) (adjusted HR 1.33, 95%CI 1.16-1.53, p &amp;lt; 0.001) compared to on-pump CABG. Conclusions OPCAB does not affect long-term mortality, but it significantly increases the risk of MACEs. In particular, OPCAB had an increased risk of repeated revascularization with PCI. These findings may have important implications towards health resources allocation. Key messages Off-pump coronary artery bypass grafting strategy is associated with an increased long-term risk of MACE and repeated PCI. Off-pump strategy is mainly based on operator preferences and can have important implications in terms of healthcare costs.

Bilateral internal thoracic artery grafting in coronary surgery: 10-year outcomes

Abstract Background The advantages to use the bilateral internal thoracic artery grafting (BITA) technique for coronary artery bypass grafting (CABG) have been recently questioned, but data on long-term follow-up is limited. Using data from the PRIORITY project, this study aims to assess the outcome with the use of BITA grafting and its implications for public health. Methods The PRIORITY project was planned to evaluate the long-term outcomes of two prospective multicenter studies on CABG conducted between 2002-2004 and 2007-2008. Data on isolated CABG were linked to administrative data in order to retrieve patients' late outcome. Time-to-event distributions were analyzed accordingly to primary event-type (death, major adverse cardiac events (MACEs)) using the Kaplan-Meier and the Cox proportional hazards methods. Results The study population consisted of 11021 patients who underwent isolated CABG. BITA grafting was employed in 24.6% of patients. The median follow-up time was 8.0 years (interquartile range 7.6-10.0 years). After adjustment for potential confounding factors, BITA grafting was significantly associated with better survival (HR 0.85, 95%CI 0.76-0.95, p = 0.003). Moreover, using BITA grafting reduced the incidence of MACE (HR 0.87, 95%CI 0.80-0.94, p = 0.001), showing to be a protective factor for recurrent acute myocardial infarction (HR 0.84, 95%CI 0.71-0.99, p = 0.05) and for rehospitalization for percutaneous cardiac intervention (HR 0.82, 95%CI 0.70-0.96, p = 0.013). Conclusions BITA grafting during isolated CABG is associated with survival advantage at 10-year with a significantly reduced incidence of MACE. Being the choice to perform isolated CABG with or without BITA based mainly on operator personal preferences, these findings may have important implications from a public health perspective. Key messages The choice to perform CABG with or without BITA grafting is associated to different outcomes. The choice to perform CABG with or without BITA grafting is mainly based on operator preferences and may have important implications in terms of healthcare expenditures.

Low rate of intracerebral hemorrhage after cardiac catheterization in patients with acute ischemic stroke in a large case series

Background and aimsMyocardial infarction complicating acute ischemic stroke (IS) is associated with high mortality, but evidence guiding the acute management is scarce. In particular, data on the risk of intracerebral hemorrhage (ICH) due to early cardiac catheterization including the peri-procedural application of antithrombotic drugs in patients with acute ischemic stroke are limited. Here, we aimed to evaluate the incidence and patient characteristics of ICH after cardiac catheterization in acute stroke patients to help to govern the risk of intracranial bleeding versus the benefits of myocardial reperfusion via cardiac catheterization. MethodsWe screened a consecutive cohort of n = 126 patients with acute ischemic stroke (IS) who underwent cardiac catheterization during the same hospital stay at a large German neurovascular center (LMU Munich). Eventually, we identified n = 42 patients with cardiac catheterization after acute stroke. N = 22/42 patients did not receive neuroimaging post cardiac catheterization and were discharged without any new neurological deficits, n = 20/42 had neuroimaging after cardiac catheterization and were included for final analysis. ResultsCardiac catheterization was performed within a median of 3,6 days after ischemic stroke (No-ICH 7,3 days (IQR, 3,8–16,2) vs. ICH 1,1 days (IQR, 0,8–74,6), p = 0,40), One patient showed new neurological deficits after cardiac procedures (n = 1/42, 2,4 %). New or progressive ICH was ultimately found in 15 % (3/20) of cases. They were classified as HT1, PH1 and PH2 according to ECASS II criteria, respectively. With regards to the coronary catheterization, 85 % of all patients undergoing catheterization ultimately received percutaneous cardiac intervention. ICH was not significantly associated with any of the independent variables. Intrahospital death due to either ischemic stroke, ICH or cardiovascular events did not occur. ConclusionThe incidence of ICH in ischemic stroke followed by early cardiac catheterization and application of antithrombotic drugs was comparable to studies reporting on the incidence of ICH in ischemic stroke patients without catheterization. This study’s results strengthen the hypothesis that in presence of both, acute myocardial infarction and acute ischemic stroke, the general risk for ICH is not prohibitive of cardiac catheterization.

The Prevalence of Familial Hypercholesterolemia (FH) in Chinese Patients With Acute Myocardial Infarction (AMI): Data From Chinese Acute Myocardial Infarction (CAMI) Registry

Background: The prevalence of familial hypercholesterolemia (FH) in the patients with acute myocardial infarction (AMI) in China is unclear.Materials and Methods: In China Acute Myocardial Infarction (CAMI) Registry, 13,002 patients with age 18–80 were consecutively enrolled with first-onset AMI who were naïve to statin before admission from January 1st, 2013 to October 31st, 2014. According to Dutch Lipid Clinical Network Criteria (DLCNC), the patients were divided to heterozygous familial hypercholesterolemia (HeFH) (definite/probable HeFH, possible HeFH) or non-HeFH group.Results: The number of the patients in the three groups was as following, 62 in definite/probable HeFH group, 484 in possible HeFH group, 12,456 in non-HeFH group. The prevalence of HeFH is 4.2% (including 0.47% of definite/probable HeFH, 3.73% of possible FH). The average age of onset of first-time AMI was 54 ± 12, 56 ± 12, 63 ± 12 years old (p < 0.0001) in definite/probable HeFH group, possible HeFH group and non-HeFH group, respectively. The percentage of Killip III or above (8.1 vs. 4.3 vs. 6.3%, p = 0.1629), cardiac arrest (1.6 vs. 0.6 vs. 0.9%, p = 0.6990), and TIMI 0–2 grade after primary percutaneous cardiac intervention (PCI) (0 vs. 6.8 vs. 4.3%, p = 0.5866) was not significantly different in definite/probable HeFH group, possible HeFH group and non-HeFH group, respectively.Conclusions: The prevalence of HeFH in Chinese patients with AMI is 4.2%. The patients were significantly younger in HeFH group, when compared with those with non-HeFH. However, no significant differences were found in the severity of clinical manifestations in both HeFH and non-HeFH group.

Cardiac tamponade: an educational review.

Cardiac tamponade is a pericardial syndrome characterised by an impairment of the diastolic filling of the ventricles causing reduction of cardiac output, usually producing signs and symptoms of cardiac arrest, if untreated. The main causes of cardiac tamponade include percutaneous cardiac interventions, malignacies, infectious/inflammatory causes, mechanical complications of myocardial infarction and aortic dissection. The diagnosis of cardiac tamponade is a clinical diagnosis based on a suggestive history and clinical presentation with worsening dyspnoea, distended jugular veins, muffled heart sounds and pulsus paradoxus, and should be confirmed by echocardiography. Cardiac tamponade is a life-threatening syndrome that requires urgent treatment by pericardiocentesis. Pericardiocentesis is an interventional technique to drain pericardial fluid by a percutaneous route. The standard technique for pericardiocentesis is guided by echocardiography or fluoroscopy under local anaesthesia. Pericardiocentesis should be performed by experienced operators and carries a variable risk of complications, mainly cardiac chamber puncture, arrhythmias (ventricular arrhythmias suggest puncture of the ventricle), coronary artery puncture or haemothorax, pneumothorax, pneumopericardium and hepatic injury. The prognosis of cardiac tamponade is essentially related to aetiology. Cardiac tamponade in patients with cancer and metastatic involvement of the pericardium has a bad short-term prognosis because it is a sign of advanced cancer, on the contrary, patients with cardiac tamponade and a final diagnosis of idiopathic pericarditis generally have a good long-term prognosis.

Recent advances in nonoperating room anesthesia for cardiac procedures.

The number of complex procedures performed in the cardiac catheterization laboratory (CCL) is rapidly increasing. Because of their complexity, they frequently require the assistance of an anesthesiologist. The CCL is primarily designed to facilitate a percutaneous cardiac intervention; therefore, it might be a challenging workplace for an anesthesiologist. The aim of this review is to briefly present tasks and challenges of providing anesthesia in the CCL and to provide a concise description of common cardiac procedures performed there. Recent literature indicates that many complicated cardiac procedures can be performed in CCL under monitored anesthesia care. At the same time several of them (e.g. transcatheter aortic valve replacement) are quickly becoming a viable alternative for surgical valve replacement. The most recent expansion of CCL procedures is related to rapidly growing population of grown-ups with congenital heart disease. All aforementioned developments present new challenges to an anesthesiologist. New and fast development of percutaneous cardiac interventions has created a new working place for the anesthesiologist - the CCL. Our expertise in complex cardiac pathophysiology allows conduct of complicated procedures outside of the operating theater. For the same reasons, there is ongoing discussion whether anesthesia support in CCL should be provided by a general or cardiac anesthesiologist.

Vessel Preservation in Chronic Kidney Disease.

Chronic kidney disease (CKD) is a major noncommunicable disorder and has become the 9th leading cause of death in the United States. Most patients with CKD in the United States choose hemodialysis as their treatment of choice. A functioning arteriovenous access is essential to reduce dependence on central venous catheters. An arteriovenous fistula (AVF), though the preferred access, has a major limitation with a high primary maturation failure rate. A functioning AVF requires well-preserved vessels, both arteries and veins, along with an acceptable cardiac pump function. Vessel preservation is crucial from a surgeon's perspective to create an AVF but is also relevant for maturation. More recently, concerns regarding the sequelae of transradial approach for percutaneous cardiac interventions have been raised. Educating and empowering the patient is the first step, but equally important is to educate all caregivers involved in providing care to a patient with advanced CKD. The current review evaluates the strategies used to preserve peripheral veins, central veins, and peripheral arteries.

Cardiac Surgery During Pregnancy.

The need for cardiac surgery during pregnancy is rare. Only 1% to 4% of pregnancies are complicated by maternal cardiac disease and most of these can be managed with medical therapy and lifestyle changes. On occasion, whether due to natural progression of the underlying cardiac disease or precipitated by the cardiovascular changes of pregnancy, cardiac surgical therapy must be considered. Cardiac surgery is inherently dangerous for both, the mother and fetus with mortality rates near 10% and 30%, respectively. For some conditions, percutaneous cardiac intervention offers effective therapy with far less risk to the mother and her fetus. For others, cardiac surgery, including procedures that mandate the use of cardiopulmonary bypass, must be entertained to save the life of the mother. Given the extreme risks to the fetus, if the patient is in the third trimester, strong consideration should be given to delivery before surgery involving cardiopulmonary bypass. At earlier gestational ages when this is not feasible, modifications to the perfusion protocol including higher flow rates, normothermic perfusion, pulsatile flow, and the use of intraoperative external fetal heart rate monitoring should be considered.

HOSPITAL ADMISSIONS FOR AORTIC STENOSIS IN PREGNANCY IN THE UNITED STATES: A TWELVE-YEAR ANALYSIS

Cardiac disease is still the leading cause of non-pregnancy related maternal morbidity and mortality. Valvular disease is one of the most concerning cardiac conditions in pregnancy. Aortic stenosis (AS) is rare in young populations but deadly complications have been reported in pregnant women. This study is a retrospective review of data from the HCUP-NIS Database from 2002-2014. There were 1108 weighted discharges for both pregnancy and AS. The data contained ten or fewer unweighted discharges with AS in pregnancy that underwent a cardiac intervention: open heart surgery or percutaneous cardiac intervention. Patients who had at least one diagnosis for AS had a greater mean cost per discharge than the comparison groups. No deaths were identified in this group. We found a statistically significant increase in the billing codes for pulmonary hypertension and heart failure. Conditions commonly associated with AS such as atrial arrhythmias, ventricular arrhythmias, diastolic dysfunction, ischemic heart disease and stroke were poorly reported. Our study identified a low incidence of AS and its complications in pregnancy in the USA over our 13-year study period. Even though, the morbidity and mortality are low, it is important that clinicians be aware of this diagnosis due higher costs and risk of complications.

Long-Term Clinical Outcome according to Changes of Glomerular Filtration Rate in AMI Patients with Multivessel Disease after Percutaneous Coronary Intervention.

Glomerular filtration rate (GFR) is an important indicator of renal failure. However, regarding delta GFR in acute myocardial infarction (AMI) is rare. In this study, it was examined whether the delta GFR had an adverse effect on outcomes in patients with AMI and multivessel disease (MVD). Among 13,105 consecutive patients enrolled in the Korea Acute Myocardial Infarction–National Institute of Health registry, 2619 with AMI and MVD who underwent percutaneous cardiac intervention (PCI) were assigned to the better delta GFR (group I, n=1432 [54.7%]) or worse delta GFR (group II, n=1187 [45.3%]) groups and followed for 3 or more years. The mean age of group I was lower than that of group II (62.64±11.52 years vs. 64.29±11.64 years; p<0.001). On multivariate analysis, delta GFR (hazard ratio, 1.50; 95% confidence interval, 1.05-2.13; p=0.024) was a negative risk factor for adverse cardiac events. Age over 65 years (p<0.001), history of MI (p=0.008), low hemoglobin (p<0.001), high triglyceride (p=0.008), low high-density lipoprotein cholesterol (p=0.002), and low left ventricular ejection fraction (LVEF) (p<0.001) were prognostic factors for major adverse cardiac events (MACE). In patients with a GFR <60 mL/min/1.73 m2, mortality was increased by 0.9% in the multivessel PCI group and 0.7% in the IRA-only PCI group at the 1-year follow-up. According to the 3-year clinical follow-up analysis, prognosis was better in better delta GFR patients with AMI and MVD who underwent PCI than in worse delta GFR patients.