First-in-man report of transsubclavian venous implantation of the Aveir leadless cardiac pacing system

INTRODUCTION

Transsubclavian venous implantation of the Aveir leadless cardiac pacemaker (LCP) has not been previously reported.

METHODS AND RESULTS

Three cases of transsubclavian implantation of the Aveir LCP are reported. Two cases were postbilateral orthotopic lung transplant, without appropriate femoral or jugular access due to recent ECMO cannulation and jugular central venous catheters. In one case, there was strong patient preference for same-day discharge. Stability testing confirmed adequate fixation and electrical testing confirmed stable parameters in all cases. All patients tolerated the procedure well without significant immediate complications.

CONCLUSIONS

We demonstrate the feasibility of transsubclavian implantation of the Aveir LCP.

Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of hemodynamic compromise, carries a significant risk for adverse clinical outcomes and represents a unique diagnostic challenge. While small clinical trials have evaluated advanced treatment strategies beyond standard anticoagulation, such as thrombolytic or endovascular therapy, there remains continued debate on the optimal care for this patient population. Here, we review the most recent risk stratification models, highlighting differences between prediction scores and their limitations, and discuss the utility of serologic biomarkers and imaging modalities to detect right ventricular dysfunction. Additionally, we examine current treatment recommendations including anticoagulation strategies, use of thrombolytics at full and reduced doses, and utilization of invasive treatment options. Current knowledge gaps and ongoing studies are highlighted.

A Case Report of Leukocytoclastic Vasculitis: Diagnostic Approach and Treatment

BACKGROUND Leukocytoclastic vasculitis is a small-vessel vasculitis associated with infections, autoimmune disorders, and certain drugs, but it may also be idiopathic. CASE REPORT We report the case of a 37-year-old woman with no significant past medical history who presented with a chief concern of a full-body rash. Before the rash appeared, she had been treated for group A Streptococcus with amoxicillin and prednisone. An outpatient skin biopsy revealed findings concerning for early leukocytoclastic vasculitis. On admission, she had a diffuse palpable rash on the trunk and upper and lower extremities. Laboratory test results were notable for neutrophilic leukocytosis with a left shift, reticulocytosis with normal hemoglobin, thrombocytosis, and elevated ESR and CRP. An infectious diseases workup was negative, serum levels of complement C3 and C4 were normal, and no evidence of hemolysis was found on blood smear. Results of schistocytes review, LDH, and haptoglobin were not consistent with hemolysis, and IgG, IgA, and IgM were all within normal limits. The patient was initially started on antibiotics due to concern for bullous impetigo, but the treatment regimen was changed to steroids because IgA vasculitis and leukocytoclastic vasculitis were suspected. Biopsy results were received 1 week later and did not reveal definitive findings of acute leukocytoclastic vasculitis. Staining with antibodies to human IgG, IgA, IgM, C3, fibrinogen, and albumin was negative. CONCLUSIONS Leukocytoclastic vasculitis can be triggered by penicillins, cephalosporins, sulfonamides, phenytoin, and allopurinol acting as haptens and stimulating an immune response, resulting in development of vasculitis.

The contemporary use of intracoronary brachytherapy for instent restenosis: A review

In-stent restenosis (ISR) has been a major limitation in interventional cardiology and constitutes nearly 10 % of all percutaneous coronary interventions in the United States. Drug-eluting stent (DES) restenosis proves particularly difficult to manage and poses a high risk of recurrence and repeat intervention. Intra-coronary brachytherapy (IBT) has been traditionally viewed as a potential treatment modality for ISR. However, its use was hindered by procedural complexity, cost, and the advent of newer-generation DES. Recent data suggests promising results regarding IBT for the treatment of resistant DES-ISR. This review addresses the mechanism of action of IBT, procedural details, and associated risks and complications of its use. It will also highlight the available clinical evidence supporting the use of IBT and the future directions of its utilization in the treatment of ISR.

Drug-Eluting Stent Restenosis: Modern Approach to a Classic Challenge

In-stent restenosis (ISR) is a recognized complication following percutaneous coronary intervention in which the luminal diameter is narrowed through neointimal hyperplasia and vessel remodeling. Although rates of ISR have decreased in most recent years owing to newer generation drug-eluting stents, thinner struts, and better intravascular imaging modalities, ISR remains a prevalent dilemma that proves to be challenging to manage. Several factors have been proposed to contribute to ISR formation, including mechanical stent characteristics, technical factors during the coronary intervention, and biological aspects of drug-eluting stents. Presentation of ISR can range from asymptomatic to late myocardial infarction and could be difficult to differentiate from acute thrombus formation. No definite guidelines are present on the management of ISR. In this review, we will discuss the mechanisms underlying ISR and provide insight into patient-related and procedural risk factors contributing to ISR, in addition to highlighting common treatment approaches utilized in the management of ISR.

Trigger related outcomes of takotsubo syndrome in a cancer population

Background

Takotsubo syndrome (TTS) occurs more frequently in cancer patients than in the general population, but the effect of specific TTS triggers on outcomes in cancer patients is not well studied.

Objectives

The study sought to determine whether triggering event (chemotherapy, immune-modulators vs. procedural or emotional stress) modifies outcomes in a cancer patient population with TTS.

Methods

All cancer patients presenting with acute coronary syndrome (ACS) between December 2008 and December 2020 at our institution were enrolled in the catheterization laboratory registry. Demographic and clinical data of the identified patients with TTS were retrospective collected and further classified according to the TTS trigger. The groups were compared with regards to major adverse cardiac events, overall survival and recovery of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) after TTS presentation.

Results

Eighty one of the 373 cancer patients who presented with ACS met the Mayo criteria for TTS. The triggering event was determined to be "cancer specific triggers" (use of chemotherapy in 23, immunomodulators use in 7, and radiation in 4), and "traditional triggers" (medical triggers 22, and procedural 18 and emotional stress in 7). Of the 81 patients, 47 died, all from cancer-related causes (no cardiovascular mortality). Median survival was 11.9 months. Immunomodulator (IM) related TTS and radiation related TTS were associated with higher mortality during the follow-up. Patients with medical triggers showed the least recovery in LVEF and GLS while patients with emotional and chemotherapy triggers, showed the most improvement in LVEF and GLS, respectively.

Conclusion

Cancer patients presenting with ACS picture have a high prevalence of TTS due to presence of traditional and cancer specific triggers. Survival and improvement in left ventricular systolic function seem to be related to the initial trigger for TTS.

Reclassification of Treatment Strategy with Fractional Flow Reserve in Cancer Patients with Coronary Artery Disease

Background and Objectives: Cancer and coronary artery disease (CAD) often coexist. Compared to quantitative coronary angiography (QCA), fractional flow reserve (FFR) has emerged as a more reliable method of identifying significant coronary stenoses. We aimed to assess the specific management, safety and outcomes of FFR-guided percutaneous coronary intervention (PCI) in cancer patients with stable CAD. Materials and Methods: FFR was used to assess cancer patients that underwent coronary angiography for stable CAD between September 2008 and May 2016, and were found to have ≥50% stenosis by QCA. Patients with lesions with an FFR > 0.75 received medical therapy alone, while those with FFR ≤ 0.75 were revascularized. Procedure-related complications, all-cause mortality, nonfatal myocardial infarction, or urgent revascularizations were analyzed. Results: Fifty-seven patients with stable CAD underwent FFR on 57 lesions. Out of 31 patients with ≥70% stenosis as measured by QCA, 14 (45.1%) had an FFR ≥ 0.75 and lesions were reclassified as moderate and did not receive PCI nor DAPT. Out of 26 patients with <70% stenosis as measured by QCA, 6 (23%) had an FFR < 0.75 and were reclassified as severe and were treated with PCI and associated DAPT. No periprocedural complications, urgent revascularization, acute coronary syndromes, or cardiovascular deaths were noted. There was a 22.8% mortality at 1 year, all cancer related. Patients who received a stent by FFR assessment showed a significant association with decreased risk of all-cause death (HR: 0.37, 95% CI 0.15−0.90, p = 0.03). Conclusions: Further studies are needed to define the optimal therapeutic approach for cancer patients with CAD. Using an FFR cut-off point of 0.75 to guide PCI translates into fewer interventions and can facilitate cancer care. There was an overall reduction in mortality in patients that received a stent, suggesting increased resilience to cancer therapy and progression.

Mechanical Thrombectomy in Pulmonary Embolism Associated with COVID-19: A "Clotography" Gallery

Venous thromboembolism from a "thrombotic storm"-like syndrome is a major cause of morbidity and mortality in patients with active or "recovered" COVID-19. Patients should be risk-stratified, optimally by a pulmonary embolism (PE) response team (PERT), and considered for escalation of care if found with intermediate or high-risk PE. We present a series of patients with COVID-19-associated PE and thrombotic storm with D-dimer >10 000 ng/mL who underwent successful mechanical thrombectomy for intermediate to high-risk PE. All patients had immediate improvement in hemodynamics and large amounts of thrombi were retrieved.

Prognostic Factors and Overall Survival After Pericardiocentesis in Patients With Cancer and Thrombocytopenia

Background: Pericardiocentesis is an important diagnostic and therapeutic tool for cancer-associated pericardial effusion. Limited safety and outcomes data exists regarding the management of malignancy-related pericardial effusion in patients with thrombocytopenia.

Objectives: Our study aimed to analyze prognostic factors and overall survival (OS) after pericardiocentesis in thrombocytopenic cancer patients.

Methods and Results: A retrospective review of 136 thrombocytopenic cancer patients who underwent primary percutaneous pericardiocentesis was performed. Degree of thrombocytopenia was classified by platelet count recorded on day of pericardiocentesis: 75–149 × 10³ cells/μL (41%); 50–74 × 10³ cells/μL (10%); 25–49 × 10³ cells/μL (24%); <25 × 10³ cells/μL (25%). Median OS was 2.6 months and median follow-up was 37.4 months. Kaplan-Meier survival analysis showed significant OS differences among thrombocytopenia severity groups (p = 0.023), and worse OS with platelets <100 vs. ≥100 × 10³ cells/μL (p = 0.031). By univariate analysis, thrombocytopenia severity was associated with increased risk of death (HR 0.993; 95% CI 0.989–0.997; p = 0.002). Poor prognostic factors for OS were advanced cancer, malignant effusion, elevated international normalized ratio (INR), quantity of platelet transfusions, and platelet transfusion resistance. However, thrombocytopenia severity became insignificant for OS (p = 0.802), after adjusting for advanced cancer and INR.

Conclusions: For patients with malignancy-related large pericardial effusion and thrombocytopenia, pericardiocentesis is a feasible intervention and should be considered due to low complication rates. There is no absolute contraindication to pericardiocentesis in case of hemodynamic instability, even with severe thrombocytopenia.

Radiation-Induced Vascular Disease-A State-of-the-Art Review

Since the 1990s, there has been a steady increase in the number of cancer survivors to an estimated 17 million in 2019 in the US alone. Radiation therapy today is applied to a variety of malignancies and over 50% of cancer patients. The effects of ionizing radiation on cardiac structure and function, so-called radiation-induced heart disease (RIHD), have been extensively studied. We review the available published data on the mechanisms and manifestations of RIHD, with a focus on vascular disease, as well as proposed strategies for its prevention, screening, diagnosis, and management.

Usefulness of Coronary Computed Tomographic Angiography to Evaluate Coronary Artery Disease in Radiotherapy-Treated Breast Cancer Survivors

Breast cancer is the most commonly diagnosed cancer in women and radiotherapy is a widely used treatment approach. However, there is an increased risk of coronary artery disease and cardiac death in women treated with radiotherapy. The present study was undertaken to clarify the relation between radiotherapy and coronary disease in women with previous breast irradiation using coronary computed tomographic angiography (CCTA). We conducted a retrospective analysis of women with a history of right or left-sided breast cancer (RBC; LBC) treated with radiotherapy who subsequently underwent CCTA. RBC patients who had reduced radiation doses to the myocardium served as controls. Patients (n = 6,593) with a history of nonmetastatic breast cancer treated with radiotherapy were screened for completion of CCTA; 49 LBC and 45 RBC women were identified. Age and risk factor matched patients with LBC had higher rates of coronary disease compared with RBC patients; left anterior descending (LAD) coronary artery (76% vs 31% [p < 0.001]), left circumflex (33% vs. 6.7% [p = 0.004]), and right coronary artery (37% vs 13% [p = 0.018]). Mean LAD radiation dose and mean heart dose strongly correlated with coronary disease, with a 21% higher incidence of disease in the LAD per Gy for mean LAD dose and a 95% higher incidence of disease in the LAD per Gy for mean heart dose. In conclusion, LBC patients treated with radiotherapy have a significantly higher incidence of coronary disease when compared with a matched group of patients treated for RBC. Radiation doses correlated with the incidence of coronary disease.

P3629Invasive versus medical management of non-ST elevation myocardial infarction in cancer patients: knowledge is bliss

Background

Cancer patients with non-ST elevation myocardial infarction (NSTEMI) frequently present with comorbidities (e.g., anaemia, thrombocytopenia) that discourage invasive treatment.

Purpose

To compare outcomes of cancer patients with NSTEMI treated with optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) versus OMT alone and to identify variables associated with overall survival (OS).

Methods

All cancer patients diagnosed with NSTEMI between March 2016 and December 2018 at our institution were included. Patients were classified based on treatment of NSTEMI into 2 groups: invasive strategy or OMT alone. The invasive group was further classified into early (PCI≤72 hours since presentation) or delayed strategy (PCI>72 hours). Clinical and laboratory data, oncologic history, major adverse cardiovascular events, and survival were collected. Univariate Cox proportional hazards regression analyses were conducted to identify variables associated with OS.

Results

We included 201 patients with a mean age of 68±11 years, 136 (68%) of which were women. Median OS was 13 months. Factors influencing OS are presented in Table I. Patients receiving PCI had better OS compared to patients treated with OMT only (Figure 1, p<0.0001). Procedure-related complications were non-fatal and present in 2 (1.85%) cases.

Table I Covariate Hazard Ratio (95% confidence interval) p-value Early invasive treatment (≤72 hours) 0.327 (0.207–0.516) <0.0001 Delayed invasive treatment (>72 hours) 0.496 (0.252–0.977) 0.0426 Presenting symptom: chest pain 0.406 (0.254–0.649) 0.0002 Presenting symptom: others 1.869 (1.223–2.855) 0.0039 Single agent antiplatelet therapy 0.434 (0.263–0.716) 0.0011 Dual agent antiplatelet therapy 0.294 (0.174–0.496) <0.0001 Statins 0.440 (0.276–0.703) 0.0006 Active cancer 4.487 (1.646–12.234) 0.0033 Prior chemotherapy 2.312 (1.328–4.023) 0.0030 Prior chest radiation 1.752 (1.065–2.884) 0.0272 Active chemotherapy 1.931 (1.271–2.934) 0.0021

Figure 1

Conclusions

An invasive management of NSTEMI in cancer patients, especially within 72 hours, appears to be associated with improved OS. Patients presenting with symptoms other than chest pain were less likely to undergo PCI and had worse outcomes. Active cancer, a history of chest radiation, and active or prior chemotherapy were also associated with decreased OS.

Acknowledgement/Funding

None

Percutaneous valve-in-valve procedure and simultaneous paravalvular leak closure

Concern for early degeneration limits the use of bioprosthetic heart valves. A 77-year-old man who underwent surgical aortic valve replacement at age 70 for severe aortic stenosis (AoS) presented with premature bioprosthesis degeneration and AoS recurrence. Transthoracic echocardiography demonstrated severe AoS and aortic regurgitation, a 30% ejection fraction, and pulmonary hypertension. Transesophageal echocardiography revealed that the aortic regurgitation was due to a 5-mm paravalvular leak (PVL). A high EuroScoreII excluded surgical treatment. Simultaneous transcatheter aortic valve replacement and PVL closure with an Occlutech PLD Square 5 Twist PVL closure device were performed with good results and improved clinical status.

Limitations of Coronary Computed Tomography Angiography in Predicting Acute Coronary Syndrome in a Low to Intermediate-risk Patient with Chest Pain

The optimal management of patients with chest pain relies on the prognostic information provided by noninvasive cardiovascular testing. Coronary computed tomography angiography (CCTA) is an increasingly utilized, highly accurate noninvasive test for diagnosing coronary artery disease. We illustrate an exceptional limitation of the prognostic information provided by CCTA. A 46-year-old female presented with chest pain suggestive of angina. Noninvasive testing for ischemia was negative, with CCTA showing mild stenosis of the proximal left anterior descending (LAD) artery. An electrocardiogram after two weeks demonstrated ST elevation in leads V1-V2 and aVR, with ST depression in the lateral leads. Cardiac catheterization revealed a significant proximal LAD lesion requiring percutaneous coronary intervention. An anatomic assessment of coronary arteries should be considered in cases of strong clinical suspicion for cardiac ischemia and initial nondiagnostic findings. Further studies are needed to improve the accuracy and the negative predictive value of CCTA in intermediate-risk individuals.