Louai Razzouk

Infrarenal aortic pathology can complicate the approach to renal denervation using currently approved transfemoral systems. We describe a case of infrarenal aortic tortuosity precluding stable engagement of the right renal artery. Based on the patient's height and the treatment catheter's length, we successfully converted to a left transradial approach to complete the procedure without complication.

BACKGROUND: It remains unknown how often, and to which extent, patients with diabetes and non–ST-segment–elevation myocardial infarction are revascularized. This study aimed to identify practice patterns and clinical outcomes in patients with diabetes and non–ST-segment–elevation myocardial infarction according to completeness of revascularization. METHODS: All patients with diabetes and multivessel disease hospitalized for non–ST-segment–elevation myocardial infarction in Ontario, Canada, between April 2009 and March 2020 and undergoing coronary angiography were included. Patients with previous coronary artery bypass grafting (CABG) at any time, percutaneous coronary intervention (PCI) in the previous 90 days, or an ST-segment–elevation myocardial infarction in the previous 90 days were excluded, as were patients with hemodynamic instability at hospital admission. Patients were classified into 4 groups, from the most to the least complete revascularization strategy: CABG, complete revascularization with PCI, incomplete PCI, or no revascularization. The primary outcome was all-cause death at 5 years. Cox regression adjusted for multiple baseline characteristics was used to compare outcomes between groups. RESULTS: We included 14 511 patients (mean age: 68.7±11.5 years; 69.6% male patients); 4525 (31.2%) were treated with CABG, 3008 (20.7%) with complete PCI, 3624 (25.0%) with incomplete PCI, and 3354 (23.1%) did not receive any revascularization procedure. Adjusted 5-year risks of all-cause death after CABG, complete PCI, incomplete PCI, and no revascularization were progressively increased: 25.9%, 29.8%, 32.2%, and 39.4% respectively. Compared with no revascularization, a 46% reduction in all-cause death was observed after CABG (hazard ratio, 0.54 [95% CI, 0.50–0.58]), 35% after complete PCI (hazard ratio, 0.65 [95% CI, 0.60–0.71]), and 27% after incomplete PCI (hazard ratio, 0.73 [95% CI, 0.68–0.79]), over a median follow-up of 5.8 years (interquartile range, 3.3–8.6). CONCLUSIONS: Almost a quarter of the patients with diabetes and non–ST-segment–elevation myocardial infarction did not receive any revascularization procedure. There was an incremental mortality reduction associated with CABG or complete revascularization with PCI, compared with incomplete revascularization with PCI or no revascularization.

Background: Cognitive decline after coronary artery bypass graft (CABG) is common and affects morbidity, mortality, and quality of life. We systematically reviewed randomized CABG trial control arms to characterize cognitive assessments, testing frequency, attrition, and ability to detect perioperative change. Methods: We searched MEDLINE, Embase, Cochrane Library, and PsycINFO for randomized controlled trials of CABG surgery that included at least one arm of patients solely undergoing CABG and that reported at least one objective cognitive assessment, from January 2005 to February 2025. Trials with mixed cardiac surgery or only subjective measures were excluded. We summarized task frequency, cognitive domains, and attrition. For tasks assessed preoperatively and postoperatively in ≥3 trials, we reported control group means and SDs. Risk of bias was assessed using the Cochrane Risk of Bias tool among 6 bias domains. This study was supported by NIH–R01NS123639. Results: Of 3494 screened studies, 2284 were CABG trials, and only 71 (3.1%) reported cognitive evaluation. These involved 15 925 patients (79% men; mean age, 64.2 years; median follow‐up, 90 days) and used 145 unique cognitive tasks, with the Trail Making Test Part B (40 of 71; 56.3%) and Part A (38 of 71; 53.5%) being the most frequently administered. Among 7 tasks with sufficient data, none detected preoperative to postoperative changes. Attrition rates averaged 18.9%, with a broad range of 0 to 62%. Conclusions: Cognitive assessment is uncommon in CABG trials, and commonly used tests rarely detect change. Heterogeneity precluded meta‐analysis, and high attrition raises concerns about selection and survivorship bias. To evaluate cognitive impact after CABG, trials need standardized, sensitive assessment strategies resilient to attrition and feasible for broad deployment.

BACKGROUND: Myocardial injury detected after percutaneous coronary intervention (PCI) is associated with increased mortality. Predictors of post-PCI myocardial injury are not well established. The long-term prognostic relevance of post-PCI myocardial injury remains uncertain. METHODS: Consecutive adults aged ≥18 years with stable ischemic heart disease who underwent elective PCI at NYU Langone Health between 2011 and 2020 were included in a retrospective, observational study. Patients with acute myocardial infarction or creatinine kinase myocardial band (CKMB) or troponin concentrations >99% of the upper reference limit before PCI were excluded. All patients had routine measurement of CKMB concentrations at 1 and 3 hours post-PCI. Post-PCI myocardial injury was defined as a peak CKMB concentration >99% upper reference limit. Linear regression models were used to identify clinical factors associated with post-PCI myocardial injury. Cox proportional hazard models were generated to evaluate relationships between post-PCI myocardial injury and all-cause mortality at long-term follow-up. RESULTS: Among 10 807 patients undergoing elective PCI, the median age was 67 years (interquartile range, 15.6), and 24.9% were of female sex. Post-PCI myocardial injury occurred in 1813 (16.8%) patients. Myocardial injury was less common among female than male patients (14.1% versus 17.7%, P P <0.001). After adjustment for demographics and clinical covariates, post-PCI myocardial injury was associated with an excess hazard for long-term mortality (hazard ratio, 1.46 [95% CI, 1.20–1.78]). CONCLUSIONS: Myocardial injury defined by elevated CKMB early after PCI is common and associated with all-cause, long-term mortality. More complex coronary anatomy is predictive of post-PCI myocardial injury.

Hypertrophic cardiomyopathy is a common but underrecognized cardiac disorder characterized by a heterogenous phenotype that includes increased left ventricular thickness, outflow obstruction, diastolic dysfunction, and arrhythmia. Hypertrophic cardiomyopathy is often heritable and associated with pathogenic variants in sarcomeric genes. While not curable, an integrated approach involving medical, interventional, and surgical care can have a considerable impact on disease burden, quality of life, and mortality. This review provides a practical overview of important topics in hypertrophic cardiomyopathy, including evaluation of differential diagnosis, imaging, provocation of left ventricular outflow obstruction, treatment of obstructive and nonobstructive hypertrophic cardiomyopathy with negative inotropic therapy and myosin inhibition, as well as surgical and interventional approaches to septal reduction and mitral valve intervention.

Ventricular arrhythmias (VA) are a major cause of morbidity and mortality in patients with coronary artery disease (CAD). Current guidelines recommend revascularization of significant CAD to improve survival in patients with ventricular fibrillation (VF), polymorphic ventricular tachycardia (VT), or those who are post‐cardiac arrest. However, revascularization is not recommended for CAD patients with suspected scar‐mediated monomorphic VT. There is a paucity of data detailing the utility of revascularization in reducing VA in CAD patients who do not present with acute coronary syndrome (ACS) and are not immediately post‐cardiac arrest, which is the focus of this review. Medline, Scopus, and the Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies addressing this question. Studies that included patients presenting with ACS or those who were immediately post‐cardiac arrest at the time of revascularization were excluded. In total, five studies comprising 2663 patients were reviewed.