Nikhil Nalluri

Needle embolisms in the heart are quite rare, and their management is largely based on clinical experience. We describe a patient with chest pain and shortness of breath, whose electrocardiogram revealed subtle inferolateral ST segment elevations. The patient was found to have a bloody pericardial effusion causing tamponade from a long-ago injected needle. Removal of a needle is a complicated decision, that should be done in a multi-disciplinary fashion to minimize complications. Removal may not always be necessary if the needle is in a stable position and not in danger of migration.

A left main coronary artery (LMCA) iatrogenic dissection is a rare but potentially life-threatening complication of coronary angioplasty. It can range from a simple tear in the artery wall to a severe dissection, causing complete blood flow obstruction. We report the case of a 63-year-old male patient who was presented to our catheterization laboratory following a positive stress test. An angiogram showed a proximal left anterior descending (LAD) artery tight lesion. Balloon inflation was complicated by an ostial LAD dissection that rapidly extended into the left main and the left circumflex arteries treated with angioplasty and stenting. Cardiac catheterization four days later showed a residual LMCA intimal flap that remained asymptomatic and stable. This is an interesting case of a stable LMCA dissection with the intimal flap intermittently obstructing the ostium of the left anterior descending artery. In addition, we will discuss the factors that increase the risk of coronary dissection and focus on methods to help prevent the occurrence of such complications.

Background: The incidence of patients with previous history of coronary artery bypass grafting (CABG) presenting for aortic valvular replacement has been consistently on the rise. Repeat sternotomy for surgical aortic valve replacement (SAVR) carries an inherent risk of morbidity and mortality when compared to Transcatheter aortic valve replacement (TAVR).Methods: The Nationwide inpatient sample (NIS) from 2012 to 2014 was queried using the International Classification of Diseases‐Ninth edition, Clinical Modification (ICD‐9‐CM) codes to identify all patients ≥ 18 years with prior CABG who underwent TAVR (35.05 and 35.06) or SAVR (35.21 and 35.22). Propensity score matching (1:1) was performed and in‐hospital outcomes were compared between matched cohorts.Results: From 2012 to 2014, there was progressive increase in the annual number of TAVR procedures from 1485 to 4020, with a decrease in patients undergoing SAVR from 2330 to 1955 (P_trend < 0.0001) in the above population. There was no significant difference in in‐hospital mortality rates. Compared to SAVR, TAVR was associated with lower risk of stroke (1.2% vs. 3.3%, P = 0.009), AKI (12.9% vs. 21.3%, P < 0.0001), myocardial infarction (0.9% vs. 2.7%, P = 0.01) and major bleeding (9.1% vs. 25.1%, P < 0.0001). TAVR was associated with higher risk of pacemaker implants (9.6% vs. 4.9%, P = 0.001) and trend toward lower risk of vascular complications (2.3% vs. 4.1%, P = 0.05).Conclusion: In this large cohort of patients with previous CABG, there is no significant difference in in‐hospital mortality between TAVR and SAVR. TAVR was associated with lower risk of in‐hospital outcomes.

Since the inception of transcatheter aortic valve replacement (TAVR), there have been significant reductions in complications due to improvements of transcatheter heart valve (THV) designs and technologies. Given expanding TAVR applications, reducing complications further and better understanding THV durability has become a focus within the structural heart space. Recently, dedicated cardiac computed tomographic angiography (CTA) performed at 1 month post‐TAVR has identified subclinical leaflet thrombosis (SLT), with rates as high as 40%. From the SLT imaging hallmarks of hypoattenuated leaflet thickening (HALT) to hypoattenuation affecting motion (HAM), a postulated timeline of THV thrombosis advancing to clinical symptoms can be recognized. This review article focuses on leaflet thrombosis particularly following TAVR explaining the spectrum of this disease process, its diagnosis, current treatment options, and future directions in the field.

Background: Bioprosthetic (BP) valves have been increasingly used for aortic valve replacement over the last decade. Due to their limited durability, patients presenting with failed BP valves are rising. Valve in Valve − Transcatheter Aortic Valve Implantation (ViV‐TAVI) emerged as an alternative to the gold standard redo‐Surgical Aortic Valve Replacement (redo‐SAVR). However, the utility of ViV‐TAVI is poorly understood.Methods: A systematic electronic search of the scientific literature was done in PubMed, EMBASE, SCOPUS, Google Scholar, and ClinicalTrials.gov. Only studies which compared the safety and efficacy of ViV‐TAVI and redo‐SAVR head to head in failed BP valves were included.Results: Six observational studies were eligible and included 594 patients, of whom 255 underwent ViV‐ TAVI and 339 underwent redo‐SAVR. There was no significant difference between ViV‐TAVI and redo‐ SAVR for procedural, 30 day and 1 year mortality rates. ViV‐TAVI was associated with lower risk of permanent pacemaker implantation (PPI) (OR: 0.43, CI: 0.21‐0.89; P = 0.02) and a trend toward increased risk of paravalvular leak (PVL) (OR: 5.45, CI: 0.94‐31.58; P = 0.06). There was no significant difference for stroke, major bleeding, vascular complications and postprocedural aortic valvular gradients more than 20 mm‐hg.Conclusion: Our results reiterate the safety and feasibility of ViV‐TAVI for failed aortic BP valves in patients deemed to be at high risk for surgery. VIV‐TAVI was associated with lower risk of permanent pacemaker implantation with a trend toward increased risk of paravalvular leak.

Peptic ulcer disease (PUD) is a major public health burden significantly impacting the cost of hospitalization in the United States (US). We examined the trends, characteristics, complications, cost, and seasonality of PUD-related hospitalizations from 2000 to 2011. With the use of the Nationwide Inpatient Sample from 2000 through 2011, we identified PUD-related hospitalizations using the International Classification of Diseases (ICD-9), 9th Revision, and the Clinical Modification code 531.00 to 534.91 as the principal discharge diagnosis. The total number of hospitalizations for each calendar month of the year were added over a 12-year period, and this number was divided by the number of days in that particular month to obtain the mean hospitalizations per day for each month. The study found that 351,921 hospitalizations with the primary discharge diagnosis of peptic ulcer disease (PUD) occurred in the US between 2000 and 2011. This number dropped significantly from 49,524 to 17,499 between 2000 and 2011, and the rate of PUD-related mortality decreased from 4.3% to 3.1%. The mean age of the study population was 66.2 ± 17.4 years; 52.3% were males, and 56.8% were white. The number of hospitalizations in the US peaked in the spring season (916/day), and reached a nadir in the fall season (861/day). The mean cost of PUD hospitalization increased significantly from $11,755 in 2001 to $13,803 in 2011 (relative increase of 17%; p <0.001). The incidence of PUD and its mortality has decreased significantly in the last decade, but its economic burden on the healthcare system remains high. A seasonal pattern of PUD hospitalization showed a peak in PUD-related admissions in the spring season and a trough in the fall season.