Outcomes of viral myocarditis in patients with and without COVID-19: a nationwide analysis from the United States

UNLABELLED: Cardiovascular complications contribute to 40% of coronavirus disease 2019 (COVID-19) related deaths. The viral myocarditis associated with COVID-19 accounts for significant morbidity and mortality. How COVID-19 myocarditis compares to other viral myocardites is unknown. METHODS: The authors conducted a retrospective cohort study using the National Inpatient Sample database to identify adult patients hospitalized for viral myocarditis in 2020 and to compare outcomes between those with and without COVID-19. The primary study outcome was in-hospital mortality. Secondary outcomes included in-hospital complications, length of stay, and total costs. RESULTS: The study population included 15 390 patients with viral myocarditis, of whom 5540 (36%) had COVID-19. After adjustment for baseline characteristics, patients with COVID-19 had higher odds of in-hospital mortality [adjusted odds ratio (aOR) 3.46, 95% CI 2.57-4.67], cardiovascular complications (aOR 1.46, 95% CI 1.14-1.87) including cardiac arrest (aOR 2.07, 95% CI 1.36-3.14), myocardial infarction (aOR 2.97, 95% CI 2.10-4.20), venous thromboembolism (aOR 2.01, 95% CI 1.25-3.22), neurologic complications (aOR 1.82, 95% CI 1.10-2.84), renal complications (aOR 1.72, 95% CI 1.38-2.13), and hematologic complications (aOR 1.32, 95% CI 1.10-1.74), but lower odds of acute heart failure (aOR 0.60, 95% CI 0.44-0.80). The odds of pericarditis, pericardial effusion/tamponade, cardiogenic shock, and the need for vasopressors or mechanical circulatory support were similar. Patients with COVID-19 had longer length of stay (7 days vs. 4 days, P\u3c0.01) and higher total costs ($21,308 vs.$14,089, P\u3c0.01). CONCLUSIONS: Among patients with viral myocarditis, COVID-19 is associated with higher in-hospital mortality and cardiovascular, neurologic, renal, and hematologic complications compared to non-COVID-19 viruses

Rotational atherectomy for calcified lesions during ST-segment elevation myocardial infarction: a case series and literature review

BACKGROUND: ST elevation myocardial infarction (STEMI) has traditionally been a relative contraindication for the utilization of rotational atherectomy (RA). However, in severely calcified lesions, RA may be necessary to facilitate stent delivery. CASE SUMMARY: Three patients who present with STEMI are found to have severely calcified lesions on intravascular ultrasound. Equipment was unable to pass the lesions in all three cases. Rotational atherectomy was therefore performed to allow for stent passage. All three cases had achieved successful revascularization with no intraoperative or post-operative complications. The patients remained angina-free the rest of their hospitalization and at the 4 month follow-up. DISCUSSION: Rotational atherectomy for calcific plaque modification during STEMI when equipment will not pass is a feasible and safe therapeutic option

Meta-Analysis Comparing Valve-in-Valve Transcatheter Mitral Valve Replacement Versus Redo Surgical Mitral Valve Replacement in Degenerated Bioprosthetic Mitral Valve

Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) and redo surgical mitral valve replacement (redo-SMVR) are 2 treatment strategies for patients with bioprosthetic mitral valve dysfunction. We conducted a systematic review and meta-analysis to compare the outcomes of ViV-TMVR versus redo-SMVR. We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of ViV-TMVR versus redo-SMVR in degenerated bioprosthetic mitral valves. We used a random-effects model to calculate odd ratios (ORs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, stroke, bleeding, acute kidney injury, arrhythmias, permanent pacemaker insertion, and hospital length of stay (LOS). A total of 6 observational studies with 707 subjects were included. The median follow-up was 2.7 years. Despite their older age and greater co-morbidity burden, patients who underwent ViV-TMVR had a similar in-hospital mortality (OR 0.52, 95% CI 0.22 to 1.23, p = 0.14), 30-day mortality (OR 0.65, 95% CI 0.36 to 1.17, p = 0.15), 1-year mortality (OR 0.97, 95% CI 0.63 to 1.49, p = 0.89), and 2-year mortality (OR 1.17, 95% CI 0.65 to 2.13, p = 0.60) compared with redo-SMVR. ViV-TMVR was associated with significantly lower periprocedural complications, including stroke, bleeding, acute kidney injury, arrhythmias, and permanent pacemaker insertion, and shorter hospital LOS than redo-SMVR. In conclusion, ViV-TMVR was associated with better outcomes than redo-SMVR in patients with degenerated bioprosthetic mitral valves, including lower complication rates and shorter hospital LOS, with no significant difference in mortality rates. Large-scale randomized trials are needed to mitigate biases and confirm our findings

Contemporary use of dual antiplatelet therapy for preventing cardiovascular events.

ObjectivesCHARISMA was a landmark randomized clinical trial that failed to demonstrate a benefit of dual antiplatelet therapy (DAPT) over aspirin alone for preventing cardiovascular events. However, subgroup analyses of the trial found fewer major adverse cardiovascular events (MACEs) for patients with established cardiovascular disease but more MACEs for patients with multiple risk factors without established cardiovascular disease. Our objective was to examine DAPT use in contemporary clinical practice after publication of CHARISMA results.Study designRetrospective analysis of a large clinical registry of outpatient cardiovascular visits to over 1000 physicians that collected data on patient clinical history, symptoms, vital signs, and medications.MethodsClinical characteristics and prescription rates of aspirin and clopidogrel were compared for patients with established cardiovascular disease and for patients with only multiple cardiovascular risk factors. Prescription of DAPT by calendar quarter was evaluated from 2008 to 2011 using multivariable Poisson regression models.ResultsOf 167,839 patients with established cardiovascular disease, 20.5% were prescribed both aspirin and clopidogrel. Of 20,478 patients with multiple risk factors but no known cardiovascular disease, 3.5% were prescribed both aspirin and clopidogrel. Across 14 calendar quarters, prescription rates of DAPT did not change significantly for patients with established CVD but decreased for patients with multiple risk factors with an incidence rate ratio of 0.77.ConclusionsUse of DAPT is modest in patients with established cardiovascular disease, for whom the CHARISMA trial suggested decreased MACEs, and prescription rates have remained stable over time. Use of DAPT in patients with multiple risk factors only, for whom CHARISMA suggested that DAPT may lead to increased MACE, was low and decreased over time

Mechanical circulatory support following out-of-hospital cardiac arrest: Insights from the National Cardiogenic Shock Initiative

BACKGROUND: Evidence is limited regarding the role of mechanical circulatory support (MCS) in patients with acute coronary syndromes (ACS) complicated by cardiogenic shock (CGS). In particular, the role of MCS in patients with out-of-hospital cardiac arrest (OHCA) is unknown. METHODS: The National Cardiogenic Shock Initiative (NCSI) is a multicenter United States registry of patients with ACS complicated by CGS treated with MCS. We compared the rate of survival to hospital discharge among patients with OHCA, in-hospital cardiac arrest (IHCA), or no cardiac arrest. We subsequently used multivariable analyses to determine independent predictors of OHCA survival. RESULTS: Survival to hospital discharge occurred in 85.7% (42/49) of OHCA, 72.4% (50/69) of IHCA, and 74.5% (111/149) of non-cardiac arrest patients. By multivariable analysis, pre-procedural predictors of survival included younger age, female sex, fewer diseased vessels, left anterior descending coronary artery culprit, lower troponin, higher lactate, and delayed initiation of MCS. Procedural and post-procedural predictors of survival included fewer vessels treated, complete revascularization, higher post-MCS cardiac power output, and fewer inotropic medications required. CONCLUSIONS: This study demonstrates that excellent outcomes may be achieved following OHCA when MCS is employed for patients appropriately selected by prognostic demographic, anatomic, and health status characteristics. A larger study population, currently being enrolled, is needed to validate the observation further