TCT-175 Safety and Complications Associated With the Use of Protamine in Percutaneous Coronary Intervention

Background: There is a paucity of data on the use of protamine after percutaneous coronary intervention (PCI). Methods: We conducted a retrospective analysis of 168 patients who underwent PCI from 2015 to 2021. All patients received protamine intra- or immediately after index PCI. We evaluated baseline characteristics, intraprocedural characteristics including heparin dosing and protamine dosing, and complications such as acute stent thrombosis (ST), dissection, perforation, and access-site bleeding. The primary outcome was the incidence of acute ST, subacute ST, and other thrombotic complications. Secondary outcomes included mortality within 24 hours and within 28 days of the index procedure. Results: One hundred sixty-eight patients were included. The mean age of patients was 72 ± 12.1 years, and 36% were women. The majority of patients received antiplatelet therapy prior to the index procedure (90%), and the average ejection fraction (EF) was 50% ± 14.3%. Of the 33 insulin-dependent patients (20%), only 1 (0.5%) used neutral protamine Hagedorn insulin. One hundred fifteen of the procedures (68%) were elective, and the average procedure time was 3 hours 21 minutes (SD 1 hour 43 minutes). Fifty-nine patients underwent rotational, orbital, or laser atherectomy (27, 23, and 9 patients, respectively). An average of 2.59 ± 1.38 stents were deployed, and intravascular ultrasound was used in 96 patients (57%). An average protamine dose of 32 mg was administered. Seventy-three patients (43%) had coronary perforations, and 19 (11%) had pericardial effusions requiring pericardiocentesis. Twenty-one patients (13%) had coronary dissections following PCI, and 6 (4%) had access-site bleeding requiring transfusion. Three patients (2%) underwent urgent cardiac surgery. Eight (5%) died within 24 hours of PCI, and 6 (3.5%) died within 28 days of PCI. Four patients (2%) had acute ST, no patients experienced subacute ST, and 1 patient (0.5%) developed arterial thrombosis (common femoral artery). Conclusions: Use protamine in PCI typically occurred because of intraprocedural complications. In our series, protamine was tolerated well in the majority of patients, but 3% of patients experienced coronary or arterial thrombosis, warranting caution when using protamine in these challenging scenarios. Categories: CORONARY: Stents: Drug-Elutin

Nanopore sequencing of clonal IGH rearrangements in cell-free DNA as a biomarker for acute lymphoblastic leukemia

BackgroundAcute Lymphoblastic Leukemia (ALL) is the most common pediatric cancer, and patients with relapsed ALL have a poor prognosis. Detection of ALL blasts remaining at the end of treatment, or minimal residual disease (MRD), and spread of ALL into the central nervous system (CNS) have prognostic importance in ALL. Current methods to detect MRD and CNS disease in ALL rely on the presence of ALL blasts in patient samples. Cell-free DNA, or small fragments of DNA released by cancer cells into patient biofluids, has emerged as a robust and sensitive biomarker to assess cancer burden, although cfDNA analysis has not previously been applied to ALL.MethodsWe present a simple and rapid workflow based on NanoporeMinION sequencing of PCR amplified B cell-specific rearrangement of the (IGH) locus in cfDNA from B-ALL patient samples. A cohort of 5 pediatric B-ALL patient samples was chosen for the study based on the MRD and CNS disease status.ResultsQuantitation of IGH-variable sequences in cfDNA allowed us to detect clonal heterogeneity and track the response of individual B-ALL clones throughout treatment. cfDNA was detected in patient biofluids with clinical diagnoses of MRD and CNS disease, and leukemic clones could be detected even when diagnostic cell-count thresholds for MRD were not met. These data suggest that cfDNA assays may be useful in detecting the presence of ALL in the patient, even when blasts are not physically present in the biofluid sample.ConclusionsThe Nanopore IGH detection workflow to monitor cell-free DNA is a simple, rapid, and inexpensive assay that may ultimately serve as a valuable complement to traditional clinical diagnostic approaches for ALL

2019 Scholars at Work Conference Program

Program for the 2019 Scholars at Work Conference at Minnesota State University, Mankato on March 29, 2019

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Impact of Optimized Breastfeeding on the Costs of Necrotizing Enterocolitis in Extremely Low Birthweight Infants

To estimate risk of NEC for ELBW infants as a function of preterm formula and maternal milk (MM) intake and calculate the impact of suboptimal feeding on NEC incidence and costs

Incidence of in-stent restenosis in pre-transcatheter aortic valve replacement percutaneous coronary intervention

Background: In-stent restenosis (ISR) continues to be a vexing problem of contemporary percutaneouscoronary intervention (PCI). A large proportion ofpatients with severe aortic stenosis concomitantly have significant coronary artery disease requiring PCI prior to transcatheter aortic valve replacement(TAVR). No data exists on the incidence of ISR in the TAVR population. Methods: We retrospectively reviewed 355 patients who underwent TAVR at two tertiary referral centers (Henry Ford Hospital and the University of Miami) from April, 2010 to March, 2013. All patients who underwent coronary stenting within 1 year prior to TAVR were included in the analysis. Results: Sixty-one (17%) patients met inclusion criteria. Baseline patient and procedure characteristics are listed in Table 1. A total of 86 stents were placed: 59% bare metal, 18% first generation drug eluting stents (DES) and 44% second generation DES. All patients received Edward Sapien valves (Edwards Lifescience, Irvine, CA). On average stents were placed 104 days prior to TAVR (Range 0-350 days). Patients were followed for an average period of 1.1 years. Patients were evaluated either angiographically at time of TAVR or clinically thereafter with subsequent angiographic surveillance based on clinical symptoms. ISR occurred in 2 (2.3%) cases - one with a first-generation DES and the second with a bare metal stent. Conclusion: Our findings suggest that the incidence of ISR in patients who undergo TAVR is below previously published rates, despite a high use of bare metal stents. The mechanism underlying this finding is unknown. It is plausible the restenosismay have a different mechanism in this population

Exercise Testing and Exercise Rehabilitation for Patients With Atrial Fibrillation

INTRODUCTION AND PURPOSE: Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increasing prevalence with advancing age. It is associated with dyspnea, exercise intolerance, and increased risk for clinical events, especially stroke and heart failure. This article provides a concise review of exercise testing and rehabilitation in patients with persistent or permanent AF. CLINICAL CONSIDERATIONS: The first goal in the treatment of AF is to reduce symptoms (eg, palpitations) and a fast ventricular rate. The second goal is to reduce the risk of a stroke. Exercise testing and rehabilitation may be useful once these goals are achieved. However, there are no large, randomized exercise training trials involving patients with AF, and what data are available comes from single-site trials, secondary analyses, and observational studies. EXERCISE TESTING AND TRAINING: There are no specific indications for performing a graded exercise test in patients with AF; however, such testing may be used to screen for myocardial ischemia or evaluate chronotropic response during exertion. Among patients with AF, exercise capacity is 15% to 20% lower and peak heart rate is higher than in patients in sinus rhythm. Exercise rehabilitation improves exercise capacity, likely improves quality of life, and may improve symptoms associated with AF. Whole-body aerobic exercise is recommended. SUMMARY: Atrial fibrillation is a common cardiac condition and in these patients, exercise rehabilitation favorably improves exercise capacity. However, prospective randomized controlled trials are needed to better define the effects of exercise training on safety; quality of life; clinical outcomes; and central, autonomic, and peripheral adaptations

PERCUTANEOUS CLOSURE OF POST-TRAUMATIC PULMONARY ARTERIOVENOUS FISTULA

Background: Acquired pulmonary arteriovenous fistulas (PAVF) are very rare and have been reported as complications of thoracic surgery, infections, and lung trauma. PAVFs can cause significant dyspnea and hypoxia from right-to-left shunting. Therapeutic options include surgical resection or percutaneous closure. Case: A 43-year-old man with history of gunshot wound to the chest requiring emergent thoracotomy at age 19 presented with progressive dyspnea and fatigue. He was profoundly hypoxic. CT chest demonstrated a fistula between the distal left main PA and superior left pulmonary vein (PV). Pulmonary angiogram confirmed a large AVF measuring 13mm x 14mm in diameter between left PA and left superior PV. Shunt run confirmed R to L shunting with Qp/Qs ratio of 0.75. Decision-making: The Heart Team evaluated the patient and felt that he was at prohibitive surgical risk given his prior surgical history, and thus he was scheduled for percutaneous intervention. CT with 3-D reconstruction of the heart provided accurate fistula dimensions and allowed for 3-D printed model used for septal occluder sizing. The procedure was performed under transesophageal echocardiographic guidance. Femoral access was obtained and through a PA catheter, an Amplatz super stiff wire was advanced to left PA. The PA catheter was exchanged for JR 4 catheter through which a Glidewire Advantage wire was used to cross the fistula. Trans-septal puncture into the LA was performed using a BRK XS needle and a 12Fr SL1 sheath was advanced into the left upper PV. An Amplatz wire was advanced across the fistula into the right ventricle over which the SL1 sheath was advanced through the fistula to the left PA and into the RV. A 30mm GORE CARDIOFORM septal occluder was advanced through the trans-septal access to the pulmonary A-V fistula and deployed. Pulmonary artery angiogram confirming cessation of flow through the fistula. Conclusion: Percutaneous closure of pulmonary AV fistula is a feasible alternative therapeutic option to surgery. Use of 3-D printed modeling ad 3-D reconstruction provided accurate fistula dimensions and customization of accurately sized occluder device, such as the one used in this case

Remote ischemic preconditioning for renal protection in patients undergoing transcatheter aortic valve interventions

Background: Severe aortic stenosis remains a major source of morbidity and mortality of the elderly with an estimated nearly 27,000 patients becoming candidates for transcatheter aortic valve interventions (TAVI) annually. Pre-procedural CT scans are routinely performed for planning. Despite use of pre-hydration strategies, contrast induced nephropathy (CIN) remains a major source of concern particularly in this aging population with baseline renal dysfunction. We sought to evaluate the effects of remote ischemic preconditioning (RIPc) on prevention of CIN post TAVI. Methods: Single center, randomized controlled trial enrolling 46 patients from February 2018 to October 2018. Selected patients had an estimated glomerular filtration rate (eGFR) less than 60ml/min indicating advanced chronic kidney disease stage 3 based on the modified diet in renal disease (MDRD) equation. Following procedural sedation RIPc was initiated and completed prior to valve implantation. The control group received the sham with manual blood pressure cuff inflations to 40 mmHg for 5 minutes, followed by 5 minutes of reperfusion for a total of 4 cycles. The intervention group received manual blood pressure cuff inflations to 200 mmHg for 5 minutes, followed by 5 minutes of reperfusion for a total of 4 cycles. Labs were ordered for 48-72 hours post procedure. CIN was defined as a serum rise in creatinine (Cr) of 0.5 mg/dl or a 25% relative rise in Cr 48-72 hours after contrast exposure. Results: Of the 46 patients enrolled, 26 were randomized to the intervention group and 20 to the control group. The average age of study participants was 80. In the intervention group, the average eGFR was 43 ml/min, average Cr was 1.39 mg/dl, and average contrast load was 120 mL. In the control group, the average eGFR was 41 ml/min, average Cr was 1.49 mg/dl, and average contrast was load 99 ml. One patient developed CIN in the intervention group however, they did not require renal replacement therapy. Otherwise, there was no change or a decrease in measured Cr post intervention. Conclusions: This study was designed as a pilot study to evaluate the effects of RIPc on renal function post TAVI. In this study, there was no trend towards benefit and no signals towards harm however, a larger sample size is needed

Aggressive acute coronary thrombosis in ulcerative colitis flare.

Background Thromboembolic disease is a well-recognized complication of Ulcerative Colitis (UC), but coronary involvement is rare. Chest pain in UC flare should raise suspicion for acute coronary thrombosis. Case A 46 year old male with UC was admitted after 3 weeks of bloody diarrhea despite treatment with prednisone. He also reported severe refractory chest pain. ECG showed ST-segment elevation myocardial infarction in inferior/lateral leads. Emergent left heart catheterization (LHC) revealed a large thrombus in mid left anterior descending (LAD) artery with distal embolization. Aspiration thrombectomy was unsuccessful. A drug eluting stent (DES) was placed in mid-LAD. Intracoronary vasodilators improved distal coronary flow. The patient was continued on DAPT. Five days later, his chest pain recurred. Decision-making LHC showed acute in-stent thrombosis. Two DES were placed in overlapping fashion to proximal-mid LAD with PTCA on the diagonal. Persistent thrombus was treated with balloon inflations. The patient continued to be symptomatic, so an intra-aortic balloon bump (IABP) was placed. He was continued on DAPT. Hemodynamics and chest pain improved in next 2 days, and IABP was removed. Conclusion Acute coronary thrombosis in pro-inflammatory states are challenging to treat, since both the underlying condition and treatment of UC are pro-thrombotic. Close monitoring and consideration of mechanical support devices may improve coronary perfusion while controlling the underlying flare