Midterm Clinical Outcomes of Robotic-Assisted Reverse Hybrid Coronary Revascularization: A Single-Center Experience

Outcomes of robotic-assisted reverse hybrid coronary revascularization (HCR) remain hindered. We aimed to analyze midterm clinical outcomes of robotic-assisted reverse HCR. All consecutive 285 patients who underwent reverse robotic-assisted HCR between September 2005 and July 2021 were included. Reverse HCR comprises percutaneous coronary intervention with stent implantation in non-left anterior descending (LAD) coronary arteries was performed within 30 days before robotic-assisted left internal thoracic artery (LITA) harvesting and LITA-to-LAD manual anastomosis through a 4-cm left minithoracotomy. Dual antiplatelet therapy was not interrupted in any patient. Preoperatively, mean age was 70.2 years (±11.2). Before surgery, 168 patients received 1 stent, 112 patients 2 stents, and 5 patients 3 stents. Intraoperatively, mean operating room time was 5.9 hours (±1); no case was converted to full sternotomy, whereas 9 patients (3.1%) received intraoperative blood product transfusions. Postoperatively, a small incidence of stroke, 1 (0.3%), reoperation for bleeding, 7 (2.4%), blood product transfusions, 48 (16.8%), and hospital stay (4.8 days) was observed. At 30-day follow-up, 1 patient (0.3%) underwent percutaneous coronary intervention with stent on a surgical LITA-LAD anastomosis owing to graft failure. Mean follow-up was 4.2 years. Reported midterm outcomes included all-cause death in 31 patients (10.9%), major adverse cardiovascular and cerebrovascular events in 102 of 285 (35.9%), nonfatal stroke in 2 of 285 (0.7%), myocardial infarction in 17 of 285 (5.9%), and repeat intervention in 50 of 285 patients (17.5%). This single-center study reports effective and safe clinical outcomes at midterm follow-up of reverse HCR procedures for treating multivessel coronary artery disease.

Clinical and Echocardiographic Outcomes of Patients Undergoing Transcatheter Edge-to-Edge Repair for Functional vs Degenerative Mitral Valve Regurgitation

To analyze clinical and echocardiographic outcomes after transcatheter edge-to-edge repair (TEER) with mitral valve clip device (MitraClip-TM) for functional vs degenerative mitral valve regurgitation (MR). All consecutive 185 patients undergoing TEER between January 2019 and March 2023 were included in the study. A propensity-adjusted analysis investigated differences among functional vs degenerative MR mechanism groups. Preoperatively, functional vs degenerative MR included 43 vs 142 patients, respectively. Mean ejection fraction (EF) values were 37% vs 57.8%, mean STS-PROM risk score was 7% vs 4% while patients with severe MR included 29 (67.4%) vs 129 (90.9%) patients, respectively. Postoperatively, functional MR patients experienced a higher incidence of prolonged postoperative length of stay (LOS), reduced creatinine clearance, and EF<50% compared to the degenerative MR group. Mean EF was 35.9% vs 56.2% (P < 0.0001) and 1 (2.3%) vs 16 (11.3%) patients had residual severe MR (P = 0.01) in functional vs degenerative MR groups, respectively. At 30-days follow-up, all-cause death incidence was 1 (2.3%) vs 3 (2.1%) patients in functional vs degenerative MR, respectively (P = 0.9). At a mean of 1.6-years follow-up, all-cause death (P = 0.01), major adverse cardiovascular and cerebrovascular events (MACCE) (P = 0.02), cardiac death (P = 0.01) and hazard ratio for all-cause death higher in functional vs degenerative MR group. Mean EF was 39.7% vs 56% (P < 0.001) while residual severe MR was 4 (9.3%) vs 34 (24.5%) (P = 0.1) in functional vs degenerative MR groups, respectively. TEER with MitraClip device showed a higher incidence of all-cause death, cardiac death, and MACCE at follow-up for functional compared to degenerative MR after TEER.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation

BACKGROUND

Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets.

AIMS

We aimed to analyse clinical outcomes of robotic-assisted CABG.

METHODS

A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients.

RESULTS

The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001).

CONCLUSIONS

Robotic-assisted CABG and HCR provide good long-term outcomes in patients who are not candidates for conventional CABG.

Paradoxical pulmonary artery systolic pressure response with catheter-directed therapies for pulmonary embolism

Background

Early data on use of catheter-directed therapies (CDT) for treatment of Intermediate or High-Risk pulmonary embolism (PE) show improvement in pulmonary artery systolic pressures (PAsP) and RV/LV ratios. Occasionally a paradoxical rise in PAsP was observed with CDT utilizing ultrasound-assisted thrombolysis (USAT). It is unclear whether this pattern is seen with CDT utilizing mechanical aspiration.

Objectives

To investigate and compare the changes in PAsP between those who underwent CDT with USAT to those with mechanical aspiration.

Methods

A retrospective analysis of those diagnosed with Intermediate or High-Risk PE who underwent CDT using USAT or mechanical aspiration from 7/2013 to 3/2023. The primary outcome was comparison of PAsP changes between the two modalities. Secondary outcomes include length of stay, mortality, and bleeding complications.

Results

A total of 142 patients were analyzed, of which 93 underwent USAT and 49 underwent mechanical thrombectomy. The mechanical thrombectomy group had significantly lower post-intervention PAsP than the USAT group (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.5 ± 2.7 vs. -7.7 ± 3.2 mmHg. p < 0.0001). A higher frequency of a paradoxical rise in PAsP was observed in the USAT group (22 % vs 4.1 %, p < 0.001).

Conclusions

CDT utilizing mechanical thrombectomy was associated with lower post-interventional PAsP and greater mean negative change compared to USAT. Occasional paradoxical rises in PAsP were observed with both types of CDT, but they were more frequent with USAT. Hemodynamic monitoring should be considered after CDT.

Condensed unstructured abstract

We report a retrospective comparison of changes to pulmonary artery systolic pressures (PAsPs) between catheter-directed ultrasound-assisted thrombolysis (USAT) and catheter-directed mechanical thrombectomy in Intermediate and High-Risk pulmonary embolism. Those treated with mechanical thrombectomy compared to USAT had significantly lower post-interventional PAsP (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (-16.2 ± 2.7 vs. -7.5 ± 3.2 mmHg, p < 0.0001). A paradoxical rise in PAsP was observed more frequently in the USAT group than the mechanical thrombectomy group (22 % vs 4.1 %, p < 0.001).

Sheathless Apical-Femoral Rail Technique for Transcatheter Aortic Valve Replacement - Case Report of a Difficult to Cross Stenosis

A severely stenosed and calcified prosthetic aortic valve may be difficult to cross, on occasion even with only a wire. In the majority of cases eventually the valve will be crossed, but at a cost of prolonged fluoroscopy time, resulting in excessive exposure to radiation. It is therefore important to consider alternative techniques. The apical-femoral rail technique has been previously described. However, this technique involved establishing apical access, either surgically or percutaneously with a sheath. In the current case we describe a modified apical-femoral rail technique, performed sheathless with removal of the apical wire, allowing for spontaneous sealing.

Computed tomography-derived membranous septum length as predictor of conduction abnormalities and permanent pacemaker implantation after TAVI: A meta-analysis of observational studies

BACKGROUND

Permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is associated with higher risk of mortality and rehospitalization for heart failure. Efforts to prevent conduction abnormalities (CA) requiring PPI after TAVI should be made. The membranous septum (MS) length and its interaction with implantation depth (ID-ΔMSID) could provide useful information about the risk of CA/PPI following TAVI.

OBJECTIVES

To identify MS length and ΔMSID as predictors of CA/PPI following TAVI.

METHODS

Study-level meta-analysis of studies published by September 30, 2022.

RESULTS

Eighteen studies met our eligibility including 5740 patients. Shorter MS length was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: odds ratio [OR] 1.60, 95% confidence interval [CI] 1.28-1.99, p < 0.001). Similarly, lower ΔMSID was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: OR 1.75, 95% CI 1.32-2.31, p < 0.001). Meta-regression analyses revealed a statistically significant modulation of the effect of shorter MS length and lower ΔMSID on the outcome (CA/PPI) by balloon postdilatation (positive regression coefficients with p < 0.001); with increasing use of balloon postdilatation, the effect of shorter MS length and lower ΔMSID on the outcome increased. MS length and ΔMSID demonstrated excellent discriminative abilities, with diagnostic ORs equaling 9.49 (95% CI 4.73-19.06), and 7.19 (95% CI 3.31-15.60), respectively.

CONCLUSION

Considering that short MS length and low ΔMSID are associated with higher risk of CA and PPI, we should include measurement of MS length in the pre-TAVI planning with MDCT and try to establish optimal ID values before the procedure to avoid CA/PPI.

Percutaneous Cardiac Chambers and Pulmonary Artery Aspiration

PURPOSE OF REVIEW

The clinical guidelines and current practice in the field of removable cardiovascular pathologies are not aligned and are in fluctuation. The purpose of this review manuscript is to propose adjustments and forecast changes in clinical practice in this field ahead of irrefutable evidence. Percutaneous aspiration devices may be used in case of pulmonary embolism, endocarditis, cardiac thrombi, and tumors. The rationale of treatment includes prevention of emboli, endocarditis debulking and modification, sampling of tissue, and salvage therapy. We are describing the contemporary treatments that are occurring in practice outside and above guidelines.

RECENT FINDINGS

The current standard therapy for the above-mentioned entities is not supported by robust data. Moreover, evidence suggesting priority for the use of percutaneous aspiration devices as first-line therapy-before turning to or in lieu of surgery or thrombolysis-continues to accumulate. However, guidelines still mention percutaneous aspiration only as an alternative to standard treatment. In the current review, we discuss the pathophysiology that supports percutaneous cardiac and pulmonary artery aspiration, the commonly used devices for that purpose, their clinical evidence, and accordingly propose a modified approach to patient management. In addition, this review highlights fluid dynamic principles important in matter extraction in order to better define the utility of catheter-based technologies in different cardiovascular territories. The target diseases encompassed in this review are pulmonary embolism, cardiac masses, and vegetations.

Use of Impella Devices for Acute Cardiogenic Shock in the Perioperative Period of Cardiac Surgery

INTRODUCTION

The Impella ventricular support system is a device that can be inserted percutaneously or directly across the aortic valve to unload the left ventricle. The purpose of this study is to determine the role of Impella devices in patients with acute cardiogenic shock in the perioperative period of cardiac surgery.

METHODS

A retrospective single-surgeon review of 11 consecutive patients who underwent placement of Impella devices in the perioperative period of cardiac surgery was performed. Patient records were evaluated for demographics, indications for placement, and postoperative outcomes.

RESULTS

Impella devices were placed for refractory cardiogenic shock preoperatively in 6 patients, intraoperatively in 4 patients, and postoperatively as a rescue in 1 patient. Seven patients received Impella CP, 1 Impella RP, 1 Impella CP and RP, and 2 Impella 5.0. Additionally, 3 patients required preoperative venovenous extracorporeal membrane oxygenation (VV-ECMO), and 1 patient required intraoperative venoarterial extracorporeal membrane oxygenation (VA-ECMO). All Impella devices were removed 1 to 28 days after implantation. Length of stay in the intensive care unit stay ranged from 2 to 53 days (average 23.9±14.6). The 30-day and 1-year mortality were 0%. Ten of 11 patients were alive at 2 years. Also, 1 patient died 18 months after surgery from complications of coronavirus disease (Covid-19). Device-related complications included varying degrees> of hemolysis in 8 patients (73%) and device malfunction in 1 patient (9%).

CONCLUSIONS

The Impella ventricular support system can be combined with other mechanical support devices for additional hemodynamic support. All patients demonstrated myocardial recovery with no deaths in the perioperative period and in 1-year of follow-up. Larger studies are necessary to validate these findings.

Neurological Manifestations of SARS-CoV-2 Infection: Protocol for a Sub-analysis of the COVID-19 Critical Care Consortium Observational Study

Introduction

Neurological manifestations and complications in coronavirus disease-2019 (COVID-19) patients are frequent. Prior studies suggested a possible association between neurological complications and fatal outcome, as well as the existence of potential modifiable risk factors associated to their occurrence. Therefore, more information is needed regarding the incidence and type of neurological complications, risk factors, and associated outcomes in COVID-19.

Methods

This is a pre-planned secondary analysis of the international multicenter observational study of the COVID-19 Critical Care Consortium (which collected data both retrospectively and prospectively from the beginning of COVID-19 pandemic) with the aim to describe neurological complications in critically ill COVID-19 patients and to assess the associated risk factors, and outcomes. Adult patients with confirmed COVID-19, admitted to Intensive Care Unit (ICU) will be considered for this analysis. Data collected in the COVID-19 Critical Care Consortium study includes patients' pre-admission characteristics, comorbidities, severity status, and type and severity of neurological complications. In-hospital mortality and neurological outcome were collected at discharge from ICU, and at 28-days.

Ethics and Dissemination

The COVID-19 Critical Care Consortium main study and its amendments have been approved by the Regional Ethics Committee of participating sites. No further approval is required for this secondary analysis.

Trial Registration Number

ACTRN12620000421932.

Spatio-temporal hybrid neural networks reduce erroneous human "judgement calls" in the diagnosis of Takotsubo syndrome

BACKGROUND

We investigate whether deep learning (DL) neural networks can reduce erroneous human "judgment calls" on bedside echocardiograms and help distinguish Takotsubo syndrome (TTS) from anterior wall ST segment elevation myocardial infarction (STEMI).

METHODS

We developed a single-channel (DCNN[2D SCI]), a multi-channel (DCNN[2D MCI]), and a 3-dimensional (DCNN[2D+t]) deep convolution neural network, and a recurrent neural network (RNN) based on 17,280 still-frame images and 540 videos from 2-dimensional echocardiograms in 10 years (1 January 2008 to 1 January 2018) retrospective cohort in University of Iowa (UI) and eight other medical centers. Echocardiograms from 450 UI patients were randomly divided into training and testing sets for internal training, testing, and model construction. Echocardiograms of 90 patients from the other medical centers were used for external validation to evaluate the model generalizability. A total of 49 board-certified human readers performed human-side classification on the same echocardiography dataset to compare the diagnostic performance and help data visualization.

FINDINGS

The DCNN (2D SCI), DCNN (2D MCI), DCNN(2D+t), and RNN models established based on UI dataset for TTS versus STEMI prediction showed mean diagnostic accuracy 73%, 75%, 80%, and 75% respectively, and mean diagnostic accuracy of 74%, 74%, 77%, and 73%, respectively, on the external validation. DCNN(2D+t) (area under the curve [AUC] 0·787 vs. 0·699, P = 0·015) and RNN models (AUC 0·774 vs. 0·699, P = 0·033) outperformed human readers in differentiating TTS and STEMI by reducing human erroneous judgement calls on TTS.

INTERPRETATION

Spatio-temporal hybrid DL neural networks reduce erroneous human "judgement calls" in distinguishing TTS from anterior wall STEMI based on bedside echocardiographic videos.

FUNDING

University of Iowa Obermann Center for Advanced Studies Interdisciplinary Research Grant, and Institute for Clinical and Translational Science Grant. National Institutes of Health Award (1R01EB025018-01).

"Water running in my chest": Delayed spontaneous rupture of an aortocoronary saphenous vein graft aneurysm

Saphenous vein graft aneurysm is an uncommon condition and knowledge about its natural history, and a multi-specialty heart team approach is of utmost importance for better clinical outcomes. This case highlights importance of percutaneous intervention as a viable therapeutic option in the case of saphenous vein graft aneurysms.

The role of extracorporeal life support for patients with COVID-19: Preliminary results from a statewide experience

Objective

There is a paucity of clinical data on critically ill patients with COVID‐19 requiring extracorporeal life support.

Methods

A statewide multi‐institutional collaborative for COVID‐19 patients was utilized to obtain clinical data on the first 10 critically ill COVID‐19 patients who required extracorporeal membrane oxygenation (ECMO).

Results

Of the first 10 patients that required ECMO for COVID‐19, the age ranged from 31 to 62 years with the majority (70%) being men. Seven (70%) had comorbidities. The majority (80%) of patients had known sick contact and exposure to COVID‐19 positive patients or traveled to pandemic areas inside the United States within the 2 weeks before symptom onset. None of the patients were healthcare workers. The most common symptoms leading to the presentation were high fever ≥103°F (90%), cough (80%) and dyspnea (70%), followed by fatigue and gastrointestinal symptoms (both 30%), myalgia, loss of taste, pleuritic chest pain, and confusion (all 10%). All patients had bilateral infiltrates on chest X‐rays suggestive of interstitial viral pneumonia. All patients were cannulated in the venovenous configuration. Two (20%) patients were successfully liberated from ECMO support after 7 and 10 days, respectively, and one (10%) patient is currently on a weaning course. One patient (10%) died after 9 days on ECMO from multiorgan dysfunction.

Conclusions

These preliminary multi‐institutional data from a statewide collaborative offer insight into the clinical characteristics of the first 10 patients requiring ECMO for COVID‐19 and their initial clinical course. Greater morbidity and mortality is likely to be seen in these critically ill patients with longer follow‐up.

A Review of percutaneous mechanical support devices and strategies

The technology available to offer acute hemodynamic support to critically ill patients has evolved exponentially in recent years. As our experience grows, and our armamentarium of mechanical therapies expands, devices are becoming increasingly important to providing acute hemodynamic support. This review article will describe approaches to providing acute support and a concise review of the percutaneous mechanical support devices currently available. In an effort to define how and when to use them in acute situations, we will also describe some advantages and disadvantages of each platform, and highlight the primary limitations in defining safety and efficacy.

Abstract 302: Prevalence of Acquired Long QT Syndrome in Patients with Aortic Valve Stenosis

Introduction: QT prolongation is associated with an increased risk of sudden cardiac death (SCD). Patients (pts) with aortic valve stenosis (AVS), in particular, have a higher incidence of SCD. We hypothesized that cardiac remodeling in the structural heart abnormalities may result in secondary QT prolongation in AVS.

Methods: Electronic medical records in AVS pts prior to valve repairs/replacement in a single center from 2005-2015 were retrieved. ECGs showing QRS duration (QRSD) > 120 ms or non-sinus rhythm were excluded for QT evaluations. Information regarding concomitant hypertension (HTN), dyslipidemia, diabetes, coronary artery disease, heart failure and presence of QT-prolonging factors (electrolytes imbalance and using QT prolonging drugs) was also evaluated.

Results: Among 419 AVS pts [median age 75 (13) yrs, male 56%] with normal QRSD [94 (16) ms], the prevalence of acquired long QT syndrome with and without known QT-prolonging factors is shown in Table 1. More pts with heart failure had QTc ≥ 450 ms than those without HF (64% vs. 48%, p <0.01).

Conclusions: Regardless of the known QT prolonging factors, the prevalence of QT prolongation is high in AVS and may serve as a pathogenetic factor for sudden death in patients with aortic valve stenosis.

Abstract 308: Aortic Valve Stenosis Causes Both Delayed Ventricular Depolarization and Repolarization

Background: Increased QRS duration (QRSD), a common ECG finding in patients (pts) with aortic valve stenosis (AVS), can result in false QT prolongation. This study aimed to test a hypothesis that in AVS delayed ventricular repolarization is independent from the delayed depolarization.

Methods: In a retrospective AVS study, ECGs prior to valve repair/replacements were evaluated. QRSD and QTc (Bazett's) were compared between pts with severe and non severe AVS. ECGs showing QRSD > 120 ms or non-sinus rhythm were excluded for analysis. In pts with both wider QRS and longer QT interval (QTc > 440 ms), JT (QT-QRSD) was used to determine the repolarization time.

Results: Pts with severe AVS (n=219) had longer QRSD [100 (16) ms vs. 88 (12) ms, p<0.001], with QTc ≥ 450 ms seen in 53%. JT is much longer in the ALQTS group (Table 1). More pts had QTc ≥ 470 ms (33% vs 23%, p<0.05) in the severe AVS than the non-severe AVS.

Conclusion: A wider QRS and higher prevalence of moderate to markedly prolonged QT interval in pts with severe AVS indicates AVS itself can result in a delay of both ventricular depolarization and repolarization.

Primary pericardial mesothelioma unique case and literature review

A 72-year-old woman, on warfarin therapy and with a remote history of breast cancer and radiation treatment, presented with a 10-day history of nausea, dyspnea, dry cough, and dizziness. An electrocardiogram showed new-onset atrial fibrillation. Computed tomography of the chest revealed multiple pulmonary emboli and a pericardial effusion. Echocardiography showed a pericardial effusion with tamponade characteristics. The patient's condition deteriorated, and a pericardiectomy was performed. Histologic evaluation confirmed primary pericardial mesothelioma. She underwent palliative treatment and died 3 months after discharge from the hospital. We discuss the patient's case and the nature of primary pericardial mesothelioma, a rare oncologic entity.

Critical analysis of a computer-assisted tutorial on ECG interpretation and its ability to determine competency

BACKGROUND

We developed a computer-based tutorial and a posttest on ECG interpretation for training residents and determining competency.

METHODS

Forty residents, 6 cardiology fellows, and 4 experienced physicians participated. The tutorial emphasized recognition and understanding of abnormal ECG features. Active learning was promoted by asking questions prior to the discussion of ECGs. Interactivity was facilitated by providing rapid and in-depth rationale for correct answers. Responses to questions were recorded and extensively analyzed to determine the quality of questions, baseline knowledge at different levels of training and improvement of grades in posttest. Posttest grades were used to assess improvement and to determine competency.

RESULTS

The questions were found to be challenging, fair, appropriate and discriminative. This was important since the quality of Socratic questions is critical for the success of interactive programs. The information on strengths and weakness in baseline knowledge at different levels of training were used to adapt our training program to the needs of residents. The posttest revealed that the tutorial contributed to marked improvement in feature recognition. Competency testing distinguished between residents with outstanding grades and those who needed remediation.

CONCLUSIONS

The strategy for critical evaluation of our computer program could be applied to any computer-based educational program, regardless of topic.