Mechanical Circulatory Support in Acute Myocardial Infarction and Cardiogenic Shock

Mechanical circulatory support devices are increasingly used for the treatment of acute myocardial infarction complicated by cardiogenic shock. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Institutions require expert teams to safely implant and manage these devices. This article reviews the mechanism of action, physiologic effects, and data as they relate to the utilization of these devices

Utility of the CHA2DS2-VASc score for predicting ischaemic stroke in patients with or without atrial fibrillation: a systematic review and meta-analysis

AIMS: Anticoagulants are the mainstay treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), and the CHA2DS2-VASc score is widely used to guide anticoagulation therapy in this cohort. However, utility of CHA2DS2-VASc in NVAF patients is debated, primarily because it is a vascular scoring system, which does not incorporate atrial fibrillation related parameters. Therefore, we conducted a meta-analysis to estimate the discrimination ability of CHA2DS2-VASc in predicting ischaemic stroke overall, and in subgroups of patients with or without NVAF. METHODS AND RESULTS: PubMed and Embase databases were searched till June 2020 for published articles that assessed the discrimination ability of CHA2DS2-VASc, as measured by C-statistics, during mid-term (2-5 years) and long-term (\u3e5 years) follow-up. Summary estimates were reported as random effects C-statistics with 95% confidence intervals (CIs). Seventeen articles were included in the analysis. Nine studies (n = 453 747 patients) reported the discrimination ability of CHA2DS2-VASc in NVAF patients, and 10 studies (n = 138 262 patients) in patients without NVAF. During mid-term follow-up, CHA2DS2-VASc predicted stroke with modest discrimination in the overall cohort [0.67 (0.65-0.69)], with similar discrimination ability in patients with NVAF [0.65 (0.63-0.68)] and in those without NVAF [0.69 (0.68-0.71)] (P-interaction = 0.08). Similarly, at long-term follow-up, CHA2DS2-VASc had modest discrimination [0.66 (0.63-0.69)], which was consistent among patients with NVAF [0.63 (0.54-0.71)] and those without NVAF [0.67 (0.64-0.70)] (P-interaction = 0.39). CONCLUSION: This meta-analysis suggests that the discrimination power of the CHA2DS2-VASc score in predicting ischaemic stroke is modest, and is similar in the presence or absence of NVAF. More accurate stroke prediction models are thus needed for the NVAF population

Racial, Ethnic, and Sex Disparities in Patients With STEMI and Cardiogenic Shock

OBJECTIVES: The aim of this study was to evaluate the combined impact of race, ethnicity, and sex on in-hospital outcomes using data from the National Inpatient Sample. BACKGROUND: Cardiogenic shock (CS) is a major cause of mortality following ST-segment elevation myocardial infarction (STEMI). Early revascularization reduces mortality in such patients. Mechanical circulatory support (MCS) devices are increasingly used to hemodynamically support patients during revascularization. Little is known about racial, ethnic, and sex disparities in patients with STEMI and CS. METHODS: The National Inpatient Sample was queried from January 2006 to September 2015 for hospitalizations with STEMI and CS. The associations between sex, race, ethnicity, and outcomes were examined using complex-samples multivariate logistic or generalized linear model regressions. RESULTS: Of 159,339 patients with STEMI and CS, 57,839 (36.3%) were women. In-hospital mortality was higher for all women (range 40% to 45.4%) compared with men (range 30.4% to 34.7%). Women (adjusted odds ratio [aOR]: 1.11; 95% confidence interval [CI]: 1.06 to 1.16; p \u3c 0.001) as well as Black (aOR: 1.18; 95% CI: 1.04 to 1.34; p = 0.011) and Hispanic (aOR: 1.19; 95% CI: 1.06 to 1.33; p = 0.003) men had higher odds of in-hospital mortality compared with White men, with Hispanic women having the highest odds of in-hospital mortality (aOR: 1.46; 95% CI: 1.26 to 1.70; p \u3c 0.001). Women were older (age: 69.8 years vs. 63.2 years), had more comorbidities, and underwent fewer invasive cardiac procedures, including revascularization, right heart catheterization, and MCS. CONCLUSIONS: There are significant racial, ethnic, and sex differences in procedural utilization and clinical outcomes in patients with STEMI and CS. Women are less likely to undergo invasive cardiac procedures, including revascularization and MCS. Women as well as Black and Hispanic patients have a higher likelihood of death compared with White men

Non-obstructive Plaque and Treatment of INOCA: More to Be Learned

PURPOSE OF REVIEW: A significant proportion of patients evaluated for chest pain have ischemia with non-obstructive coronary artery disease (INOCA). Studies have shown INOCA is associated with increased risk of major adverse cardiac events and significant burden on the health care system. RECENT FINDINGS: While there is scarce scientific evidence on management of INOCA, the CorMicA trial showed that stratified medical therapy based on the type of INOCA improved patients\u27 symptoms and quality of life. There are multiple ongoing trials, including Women\u27s IschemiA Trial to Reduce Events in Non-ObstRuctIve CORonary Artery Disease (WARRIOR trial), assessing the benefit of intensive medical therapy versus usual care for this increasingly recognized clinical entity. In this review, we discuss the definition of INOCA, epidemiology and risk factors, pathophysiology, and management as well as the current knowledge gaps and ongoing clinical trials in this arena

Valve-in-valve transcatheter aortic valve replacement for a failed bioprosthetic valve in a patient with repaired truncus arteriosus and right-sided aortic arch

We are seeing more patients with repaired congenital cardiac diseases. These patients are often complex requiring careful clinical evaluation. In this case report, we present a very interesting case in a patient with repaired truncus arteriosus and right-sided aortic arch, who was hospitalized at our institution for recurrent heart failure exacerbation. He was found to have severe eccentric aortic valve regurgitation due to failed bioprosthetic valve. Given his multiple cardiac surgeries, he was deemed high risk for surgery and underwent successful valve-in-valve transcatheter aortic valve replacement with immediate improvement in his hemodynamics and symptoms

Impact of COVID-19 on Management Strategies for Coronary and Structural Heart Disease Interventions

PURPOSE OF REVIEW: The COVID-19 pandemic has created unprecedented challenges globally, with significant strain on the healthcare system in the United States and worldwide. In this article, we review the impact of COVID-19 on percutaneous coronary interventions and structural heart disease practices, as well as the impact of the pandemic on related clinical research and trials. We also discuss the consensus recommendations from the scientific societies and suggest potential solutions and strategies to overcome some of these challenges. FINDINGS: With the limited resources and significant burden on the healthcare system during the pandemic, changes have evolved in practice to provide care to the highest risk patients while minimizing unnecessary exposure during elective surgical or transcatheter procedures. The COVID-19 crisis has significantly impacted the management of patients with acute coronary syndromes, chronic coronary syndromes, and structural heart disease

A Visual Depiction of Left Ventricular Unloading in Veno-Arterial ExtraCorporeal Membrane Oxygenation With Impella

Left ventricular (LV) unloading has been associated with improved survival in patients treated with venoarterial extracorporeal membrane oxygenation. This case describes a patient with a COVID-19 infection who subsequently developed non-ischemic cardiomyopathy with an LV ejection fraction of 10% to 15% (baseline echocardiography). He did poorly in the outpatient setting and was admitted to an outside hospital with heart failure symptoms and was subsequently transferred to our hospital for escalation of care and consideration of advanced heart failure therapies. This clinical image and related video series help to visually demonstrate the effect of LV unloading in a 30-year-old male with a history of COVID-19 myocarditis