Acute Coronary Syndrome in a Young Patient with Dual Mechanical Valves and Therapeutic International Normalized Ratio - A Rare Occurrence

Patients of valvular heart disease treated with mechanical valve replacement are required to be on lifelong medication with anticoagulants. Complications may arise when adequate International Normalized Ratio (INR) control is not maintained, leading to thromboembolic events, but very few cases have been reported where these complications arise despite therapeutic INR control. We, here, highlight a case of rare fatal complication of Acute Coronary Syndrome in a one month postoperative patient of Dual Mechanical Valve Replacement with therapeutic INR, which evaded correct diagnosis due to unawareness on the part of the treating team of physicians

Primitive neuroectodermal tumor with inferior vena cava thrombus: A rare case report

Primitive neuroectodermal tumors (PNETs) are rare type of small cell, aggressive tumors, commonly seen in the central nervoussystem, and PNET of the kidney with inferior vena cava thrombus is an extremely uncommon presentation of this entity. There are noestablished distinctive signs or radiological characteristics for diagnosis, but a majority of cases report positivity for CD99 marker.The patients usually present in the advanced stages of the disease and require progressive techniques of immunohistochemicalanalysis and expertise of multidisciplinary team of physicians to arrive at a correct diagnosis and have a proper management.Although rare, these tumors should be considered in the differential diagnosis of all patients with large renal masses, especially inthe younger population. We present a case of a 23-years-old female, with PNET of the left kidney, treated with radical nephrectomyand adjuvant chemotherapy

A rare case of long-term graft complication in a patient of middle aortic syndrome

Middle aortic syndrome (MAS) is rare entity described as a progressive narrowing of the aorta between the aortic arch and terminal bifurcation of the aorta. Surgical treatment is with the use of grafts for bypassing the narrow aortic segment. Rarely, graft complications may occur over long periods of time due to the axial growth of the patient and loss of tensile strength of the graft material. This is a case of MAS, presenting 34 years after initial surgery due to aneurysmal dilation of the graft, treated with redo surgery and complete recovery of the patient

Interventions in Ischemic Heart Disease

The field of percutaneous coronary interventions (PCI) in ischemic heart disease is in continuous evolution. New insights on coronary stenting, dual antiplatelet therapy (DAPT), and mechanical support are generated daily. However, most data report on best therapies in the overall PCI population, which may not be directly applicable to women. Women are a minority in the PCI population, accounting for approximately one-third of the patient population treated with PCI. Women undergoing PCI have more comorbidities than their male counterparts. They have smaller coronary vessels and are more likely to experience radial artery spasm. As a result, trans radial access is less commonly used in women than in men. Women also have a higher chance of bleeding after PCI, which affects decision making regarding stent type and DAPT regimen. Many operators prefer stents that allow for shorter DAPT duration. Clinical outcomes after PCI in women remain less favorable compared to men, with higher rates of target lesion failure and higher all-cause death. These sex-related differences are driven by variation in comorbidities, clinical presentation, and lesion characteristics. While the field of mechanical assist devices is evolving rapidly, only very limited sex-specific data are available on this topic. Further research is needed to improve outcomes in women undergoing interventions for ischemic heart disease

Residual angina in female patients after coronary revascularization

Coronary revascularization, either percutaneous by stent implantation or surgical, has been established as the treatment of choice for patients with significant coronary stenosis. One of the main targets of coronary revascularization – especially in patients with stable disease – is to alleviate symptoms and thereby improve quality of life. Residual angina after successful coronary revascularization is not uncommon and indeed frustrating for the patient as much as for the treating physician. Several studies have shown worse outcomes in females with regard to post-revascularization morbidity and mortality in percutaneous as well as surgical coronary procedures. Although none of the studies has specifically looked at sex-related differences in residual angina after revascularization, some studies have found that female compared to male sex was a predictor of post-revascularization angina. This review article aims to summarize the results of these studies as well as to discuss the potential underlying mechanisms of these findings

Sex-related differences in patients at high bleeding risk undergoing percutaneous coronary intervention: a patient-level Pooled analysis from 4 postapproval studies

Background Women have been associated with higher rates of recurrent events after percutaneous coronary intervention than men, possibly attributable to advanced age at presentation and greater comorbidities. These factors also put women at higher risk of bleeding, which may influence therapeutic strategies and clinical outcomes. Methods and Results We performed a patient-level pooled analysis of 4 postapproval registries to evaluate sex-related differences in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. HBR required fulfillment of at least 1 major or 2 minor criteria of the Academic Research Consortium definition. Outcomes of interest were major bleeding and major adverse cardiac events (composite of cardiac death, myocardial infarction, or definite/probable stent thrombosis). Of the total 10 502 patients, 2832 (27.0%) were women. The prevalence of HBR was higher in women compared with men (29.0% versus 20.5%, P<0.0001). Women at HBR were older and had more comorbidities, while men at HBR were more often smokers, with prior myocardial infarction and more complex coronary lesions. At 4 years, women at HBR had significantly higher major bleeding compared with men at HBR (10.8% versus 6.2%, P<0.0001); however, this difference was attenuated after multivariable adjustment (hazard ratio, 0.92; 95% CI, 0.41-2.08). Major adverse cardiac event rates between groups were similar (12.2% versus 12.6%, P=0.82) and remained consistent after adjustment (hazard ratio, 0.64; 95% CI, 0.32-1.28). Conclusions The prevalence of HBR was higher in women compared with men, with considerable differences in the distribution of criteria. Women at HBR experienced higher rates of major bleeding but similar major adverse cardiac event rates compared with men at HBR at 4 years

Impact of Race/Ethnicity on Long Term Outcomes After Percutaneous Coronary Intervention with Drug-Eluting Stents

Cardiovascular disease constitutes the leading cause of mortality worldwide, irrespective of race/ethnicity. Previous studies have shown that minority patients with acute coronary syndrome have distinct clinical, anatomic, and socioeconomic characteristics which may affect clinical outcomes. We included patients who underwent percutaneous coronary intervention with drug-eluting stents for ST-segment elevation myocardial infarction (STEMI), non-STEMI, or unstable angina in a single center. Patients were stratified into Caucasian, African-American, Hispanic, and Asian. Caucasians were the reference group. The primary end point was major adverse cardiac and cerebrovascular events, composite of death, spontaneous myocardial infarction, or stroke at 1 year. Of 6,800 patients included, 49.7% were Caucasian, 20.7% Hispanic, 17.0% Asian and 12.6% African-American. Caucasians were the oldest, Hispanics and Asians had the highest prevalence of diabetes mellitus whereas African-Americans had more chronic kidney disease. Hispanics and African-Americans had the highest STEMI rates, whereas Asians were more likely to present with unstable angina. Compared with Caucasians, Asians had a lower rate of major adverse cardiac and cerebrovascular events at 1 year (3.9% vs 7.1%; p <0.01) whereas Hispanics (6.2% vs 7.1%; p = 0.17) and African-Americans (8.0% vs 7.1%; p = 0.38) had comparable outcomes. Differences were driven by mortality. Findings remained unchanged after adjustment. In conclusion, in acute coronary syndrome patients who underwent percutaneous coronary intervention, Asian race/ethnicity was associated with favorable cardiovascular outcomes compared with Caucasians. No significant differences were observed for Hispanics and African-Americans

Impact of diabetes mellitus on short term vascular complications after TAVR : Results from the BRAVO-3 randomized trial

AIMS: The impact of diabetes mellitus (DM) on clinical outcomes after transcatheter aortic valve replacement (TAVR) remains unclear. The aim of this study was to investigate the impact of DM on short-term clinical outcomes after TAVR in a large randomized trial population. METHODS AND RESULTS: BRAVO-3 trial randomized 802 patients undergoing trans-femoral TAVR to procedural anticoagulation with bivalirudin or unfractionated heparin. The study population was divided according to the presence of DM, and further stratified according to the use of insulin. Net adverse cardiovascular outcomes (NACE - death, myocardial infarction (MI), stroke or major bleeding by Bleeding Academic Research Consortium (BARC) type 3b or above) was the primary outcome in-hospital and at 30-days. Of the total 802 randomized patients, 239 (30%) had DM at baseline, with 87 (36%) being treated with insulin. At 30-days, DM patients experienced numerically higher rates of net adverse cardiovascular events (16.3% vs. 14.4%, p = 0.48) and acute kidney injury (19.7% vs. 15.1%, p = 0.11), while non-DM (NDM) patients had numerically higher rates of cerebrovascular accidents (3.6% vs. 1.7%, p = 0.22). After multivariable adjustment, DM patients had higher odds of vascular complications at 30-days (OR 1.57, p = 0.03) and life-threatening bleeding both in-hospital (OR 1.50, p = 0.046) and at 30-days (OR 1.50, p = 0.03) with the excess overall risk primarily attributed to the higher rates observed among non-insulin dependent DM patients. CONCLUSIONS: Patients with DM had higher adjusted odds of vascular and bleeding complications up to 30-days post-TAVR. Overall, there was no significant association between DM and early mortality following TAVR

Antithrombotic strategy variability in atrial fibrillation and obstructive coronary disease revascularised with percutaneous coronary intervention: Primary results from the AVIATOR 2 international registry

Background: Managing percutaneous coronary intervention (PCI) patients with atrial fibrillation (AF) presents challenges given that there are several potential antithrombotic therapy (ATT) strategies. Aims: We examined ATT patterns, agreement between subjective physician ratings and validated risk scores, physician-patient perceptions influencing ATT and 1-year outcomes. Methods: The AVIATOR 2 prospective registry enrolled 514 non-valvular AF-PCI patients from 11 sites. Treating physicians selected ATT and completed smartphone surveys rating stroke and bleeding risks, compared against CHA2DS2-VASc and HAS-BLED scores. Patients completed surveys regarding treatment understanding. Primary outcomes were 1-year major adverse cardiac or cerebrovascular events (MACCE: composite of death, myocardial infarction, definite/probable stent thrombosis, stroke, target lesion revascularisation) and actionable bleeding (Bleeding Academic Research Consortium 2, 3 or 5). Results: The mean patient age was 73.2±9.0 years, including 25.8% females. Triple therapy (TT: 1 anticoagulant and 2 antiplatelet agents) was prescribed in 66.5%, dual antiplatelet therapy (DAPT) in 20.7% and dual therapy (1 anticoagulant+1 antiplatelet agent) in 12.8% of patients. Physician ratings and validated risk scores showed poor agreement (stroke: kappa=0.03; bleeding: kappa=0.07). Physicians rated bleeding-related safety (93.8%) as the main factor affecting ATT choice. Patients worried about stroke over bleeding (50.6% vs 14.8%). No group differences by ATT strategy were observed in 1-year MACCE (TT 14.1% vs dual therapy 12.7% vs DAPT 18.5%; p=0.25), or actionable bleeding (14.7% vs 7.9% vs 15.1%, respectively; p=0.89). Conclusions: The AVIATOR 2 study is the first digital health study examining physician-patient perspectives on ATT choices after AF-PCI. TT was the most common strategy without differences in 1-year outcomes in ATT strategy. Physicians rated safety first when prescribing ATT; patients feared stroke over bleeding

Comparative influence of bleeding and ischemic risk factors on diabetic patients undergoing percutaneous coronary intervention with everolimus-eluting stents

OBJECTIVE To investigate the impact of ischemic and bleeding risk factors on long-term clinical outcomes of patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) with everolimus-eluting stents. BACKGROUND Second-generation drug-eluting stents have substantially improved outcomes after PCI in the general population; however, DM patients continue to experience high rates of ischemic and bleeding complications. METHODS DM patients from the pooled XIENCE V registry were divided into high or low bleeding and ischemic risk groups (HBR, LBR, HIR, and LIR) based on established bleeding (age ≥ 75 years; chronic kidney disease; anemia; prior stroke; oral anticoagulation; thrombocytopenia; prior major bleeding) and ischemic (acute coronary syndrome; prior myocardial infarction [MI]; ≥3 stents implanted; ≥3 vessels treated; ≥3 lesions treated; stent length > 60 mm; bifurcation treated with ≥2 stents; chronic total occlusion) risk factors. The primary outcomes were major adverse cardiac events (MACE; cardiac death, MI, or stent thrombosis) and major bleeding at 4-year follow-up. RESULTS A total of 3,704 DM patients were divided into four groups (21.5% LBR/LIR; 39.0% LBR/HIR; 15.6% HBR/LIR; 23.9% HBR/HIR). Compared with LBR/LIR patients, those at HBR/HIR and HBR/LIR had a significantly higher risk of MACE (HR (95% CI) 2.7 (1.9-3.9) and 2.2 (1.5-3.2), respectively) and major bleeding (2.7 (1.6-4.8) and 2.6 (1.4-4.7), respectively), while LBR/HIR patients did not. CONCLUSIONS Among DM patients undergoing PCI, presence of bleeding risk factors was associated with a higher risk of both ischemic and bleeding events, whereas commonly used features of ischemic risk did not impact long-term clinical outcomes