Elevated high-sensitivity troponin does not indicate the presence of coronary artery disease in patients presenting with supraventricular tachycardia

Background: Patients with supraventricular tachycardia (SVT) and patients with coronary artery disease (CAD) often present with similar symptoms (chest pain, shortness of breath), similar electrocar¬diographic changes and elevated high-sensitivity troponin (Tn). It is not clear whether troponin reflects critical CAD or is elevated due to other causes in patients presenting with SVT. The aim of this study was to assess the role of elevated troponin in patients presenting with SVT. Methods: Patients undergoing radiofrequency ablation (RFA) for SVT and simultaneous coronary an¬giography at the Heart Centre Lucerne, Switzerland between January 2010 and October 2014 were in¬cluded in this analysis. Significant CAD was defined as diameter-stenosis ≥ 75% in vessels > 2.0 mm. The level of Tn was compared between patients with the presence or absence of CAD on coronary angi¬ography. A Tn value of ≥ 0.014 μg/L was considered as elevated. Results: During the study period a total of 473 patients underwent RFA for SVT. The study population consisted of 326 patients (69%, mean age 60 ± 12 years) who underwent invasive coronary angiogra¬phy during the same session. The prevalence of significant CAD was 14% (45/326 patients). The highest prevalence of CAD was found in patients with atrial flutter (35%, 18/45 patients). Tn was elevated in 83% (10/12 patients) with significant CAD and in 47% (26/55 patients) without CAD. Conclusions: The prevalence of CAD is low in patients with SVT, which questions the role of routine invasive coronary angiography during RFA. Tn measurement did not reliably exclude or confirm CAD in these patients

An Extremely Rare Congenital Muscle Bundle Crossing the Right Atrial Cavity

Muscle bundles in the right atrium are an extremely rare congenital anomaly. We report the case of a patient with 2 atrial septal defects and a large muscle bundle crossing the right atrium. Only 3 comparable cases have previously been published. (Level of Difficulty: Intermediate.)

T-cadherin is present on endothelial microparticles and is elevated in plasma in early atherosclerosis

Aims The presence of endothelial cell (EC)-derived surface molecules in the circulation is among hallmarks of endothelial activation and damage in vivo. Previous investigations suggest that upregulation of T-cadherin (T-cad) on the surface of ECs may be a characteristic marker of EC activation and stress. We investigated whether T-cad might also be shed from ECs and in amounts reflecting the extent of activation or damage. Methods and results Immunoblotting showed the presence of T-cad protein in the culture medium from normal proliferating ECs and higher levels in the medium from stressed/apoptotic ECs. Release of T-cad into the circulation occurs in vivo and in association with endothelial dysfunction. Sandwich ELISA revealed negligible T-cad protein in the plasma of healthy volunteers (0.90 ± 0.90 ng/mL, n = 30), and increased levels in the plasma from patients with non-significant atherosclerosis (9.23 ± 2.61 ng/mL, n = 63) and patients with chronic coronary artery disease (6.93 ± 1.31 ng/mL, n = 162). In both patient groups there was a significant (P = 0.043) dependency of T-cad and degree of endothelial dysfunction as measured by reactive hyperaemia peripheral tonometry. Flow cytometry analysis showed that the major fraction of T-cad was released into the EC culture medium and the plasma as a surface component of EC-derived annexin V- and CD144/CD31-positive microparticles (MPs). Gain-of-function and loss-of-function studies demonstrate that MP-bound T-cad induced Akt phosphorylation and activated angiogenic behaviour in target ECs via homophilic-based interactions. Conclusion Our findings reveal a novel mechanism of T-cad-dependent signalling in the vascular endothelium. We identify T-cad as an endothelial MP antigen in vivo and demonstrate that its level in plasma is increased in early atherosclerosis and correlates with endothelial dysfunctio

Optical coherence tomography findings in bioresorbable vascular scaffolds thrombosis

Background—Everolimus-eluting bioresorbable vascular scaffolds have been developed to improve late outcomes after coronary interventions. However, recent registries raised concerns regarding an increased incidence of scaffold thrombosis (ScT). The mechanism of ScT remains unknown.Methods and Results—The present study investigated angiographic and optical coherence tomography findings in patients experiencing ScT. Fifteen ScT (14 patients, 79% male, age 59±10 years) occurred at a median of 16 days (25%–75% interquartile range: 1–263 days) after implantation. Early ScT (1 month) and very late (>1 year) ScT (respectively, 5 and 2 cases), 5 scaffolds showed intimal neovessels or marked peristrut low-intensity areas. Scaffold fractures were additionally found in 2 patients, and scaffold collapse was found in 1 patient with very late ScT. Extensive strut malapposition was the presumed cause for ScT in 1 case. One scaffold did not show any morphological abnormality. Thrombectomy specimens were analyzed in 3 patients and did not demonstrate increased numbers of inflammatory cells.Conclusions—The mechanisms of early ScT seem to be similar to metallic stents (mechanical and inadequate antiplatelet therapy). The predominant finding in late and very late ScT is peristrut low-intensity area

Evaluation of comprehensive geriatric assessment in older patients undergoing pacemaker implantation.

BACKGROUND This study evaluated the use of comprehensive geriatric assessment (CGA) in older patients undergoing pacemaker implantation. METHODS In this prospective cohort, CGA was performed in 197 patients ≥75 years at pacemaker implantation and yearly thereafter. CGA embraced the following domains: cognition, mobility, nutrition, activities of daily living (ADLs), and falls (with or without loss of consciousness). Based on comorbidities, the Charlson comorbidity index (CCI) was calculated. For predictive analysis, logistic regression was used. RESULTS During a mean follow-up duration of 2.4 years, the incidence rates of syncope decreased from 0.46 to 0.04 events per year (p < 0.001), and that of falls without loss of consciousness from 0.27 to 0.15 (p < 0.001) before vs. after implantation. Sixty-three patients (32.0%) died. Impaired mobility (OR 2.60, 95%CI 1.22-5.54, p = 0.013), malnutrition (OR 3.26, 95%CI 1.52-7.01, p = 0.002), and a higher CCI (OR per point increase 1.25, 95%CI 1.04-1.50, p = 0.019) at baseline were significant predictors of mortality. Among 169 patients who survived for more than 1 year and thus underwent follow-up CGA, CGA domains did not deteriorate during follow-up, except for ADLs. This decline in ADLs during follow-up was the strongest predictor of later nursing home admission (OR 9.29, 95%CI 1.82-47.49, p = 0.007). Higher baseline age (OR per year increase 1.10, 95%CI 1.02-1.20, p = 0.018) and a higher baseline CCI (OR per point increase 1.32, 95%CI 1.05-1.65, p = 0.017) were associated with a decline in ADLs during follow-up. CONCLUSIONS CGA is useful to detect functional deficits, which are associated with mortality or nursing home admission after pacemaker implantation. The present study seems to support the use of CGA in older patients undergoing pacemaker implantation as functional deficits and falls are amenable to geriatric interventions

Local versus general anesthesia for transcatheter aortic valve implantation (TAVR) – systematic review and meta-analysis

BACKGROUND: The hypothesis of this study was that local anesthesia with monitored anesthesia care (MAC) is not harmful in comparison to general anesthesia (GA) for patients undergoing Transcatheter Aortic Valve Implantation (TAVR). TAVR is a rapidly spreading treatment option for severe aortic valve stenosis. Traditionally, in most centers, this procedure is done under GA, but more recently procedures with MAC have been reported. METHODS: This is a systematic review and meta-analysis comparing MAC versus GA in patients undergoing transfemoral TAVR. Trials were identified through a literature search covering publications from 1 January 2005 through 31 January 2013. The main outcomes of interest of this literature meta-analysis were 30-day overall mortality, cardiac-/procedure-related mortality, stroke, myocardial infarction, sepsis, acute kidney injury, procedure time and duration of hospital stay. A random effects model was used to calculate the pooled relative risks (RR) with 95% confidence intervals. RESULTS: Seven observational studies and a total of 1,542 patients were included in this analysis. None of the studies were randomized. Compared to GA, MAC was associated with a shorter hospital stay (-3.0 days (-5.0 to -1.0); P = 0.004) and a shorter procedure time (MD -36.3 minutes (-58.0 to -15.0 minutes); P <0.001). Overall 30-day mortality was not significantly different between MAC and GA (RR 0.77 (0.38 to 1.56); P = 0.460), also cardiac- and procedure-related mortality was similar between both groups (RR 0.90 (0.34 to 2.39); P = 0.830). CONCLUSION: These data did not show a significant difference in short-term outcomes for MAC or GA in TAVR. MAC may be associated with reduced procedural time and shorter hospital stay. Now randomized trials are needed for further evaluation of MAC in the setting of TAVR

“Burying” covered coronary stents under drug-eluting stents: A novel approach to ensure long-term stent patency

Background: Covered coronary stent (CS) implantation is associated with a high risk for in-stent restenosis (ISR) and stent thrombosis (ST). We describe the outcomes after overstenting (“burying”) CS using contemporary drug-eluting stents (DES). Methods: We analyzed short- and long-term outcomes of consecutive patients who had had a CS implanted, which was consecutively covered (“buried”) with a third-generation DES. CSs were primarily post-dilated and then covered with a longer DES overlapping the proximal and distal edges of the CS. To ensure optimal stent expansion and appositions, all lesions were post-dilated using adequately sized non-compliant balloons. Results: Between 2015 and 2020, 23 patients (mean age 67 ± 14 years, 74% males) were treated using this novel approach. Reasons for implanting CS included treatment of coronary aneurysms (n = 7; 30%), coronary perforations (n = 13; 57%), and aorto-ostial dissections (n = 3; 13%). All CSs were successfully deployed, and no peri-procedural complications occurred. The median time of follow-up was 24.5 (interquartile range [IQR] 11.7–37.9) months. All patients had a 1-month follow-up (FU) and 19/23 (83%) patients had 12-month FU (FU range 1–60 months). No probable or definite STs occurred, and no cardiovascular deaths were observed. Among patients undergoing angiographic FU (11/23 [48%]), 1/23 showed angiographically significant ISR 6 months post CS implantation. Conclusions: Burying a coronary CS under a DES appears to be a safe and promising strategy to overcome the limitations of the currently available CS devices, including a relatively high risk for target lesion failure due to ISR and ST