Vishal Dhulipala

Background: Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG. Methods and Results: Consecutive patients with stable ischemic heart disease and unprotected left main or 3‐vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI‐recommended; (2) CABG‐eligible but refused CABG (CABG‐refusal); and (3) CABG‐ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI‐recommended, n=1718 [46.6%]), CABG‐refusal (n=1595 [43.3%]), and CABG‐ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG‐ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI‐recommended, CABG‐refusal, and CABG‐ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG‐refusal (hazard ratio [HR], 1.67 [95% CI, 1.08–3.56]; P =0.02) and CABG‐ineligible patients (HR, 3.26 [95% CI, 1.28–3.65]; P =0.004) groups compared with the reference PCI‐recommended group, driven by increased death and stroke. Conclusions: Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real‐world data to inform shared decision‐making discussions.

In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications.

Background: In patients with chronic coronary disease (CCD), it is unclear whether the use of potent P2Y ₁₂ inhibitors (ticagrelor or prasugrel) offers advantages to clopidogrel when prescribed in conjunction with aspirin in patients undergoing percutaneous coronary intervention (PCI) with atherectomy. Methods: Consecutive patients undergoing PCI with atherectomy for CCD at a tertiary care center between January 2011 to December 2020 were included. Patients discharged on ticagrelor or prasugrel were compared to patients on clopidogrel. The primary outcome was a composite of death or myocardial infarction (MI), secondary outcomes included individual components of the primary outcome, stroke, major bleeding, and target vessel revascularization at 1 year. Adjusted analyses were performed using propensity score stratification. Results: Overall, 3,612 patients undergoing atherectomy were included in the analysis (clopidogrel [70.4%, n= 2,543], ticagrelor/prasugrel [29.5%, n=1,069]). Clopidogrel was prescribed more often in older patients with multimorbid risk factors, whereas ticagrelor/prasugrel was used more in patients with greater anatomical and procedural complexity. There was an increase in the use of potent antiplatelet agents over time (p<0.001). At 1-year follow-up, the primary outcome was observed in 5.2% and 4.0% of those taking clopidogrel and ticagrelor/prasugrel, respectively (adjusted hazard ratio (AHR) 0.87, 95% CI 0.58 – 1.3, p = 0.50). There were no significant differences in the rate of bleeding (5.5% vs 3.7%, AHR 0.98, 95% CI 0.66 - 1.46, p = 0.92) or other secondary outcomes between the two groups. Conclusion: The use of clopidogrel was associated with comparable ischemic and bleeding outcomes compared to ticagrelor/prasugrel in patients with CCD undergoing PCI with atherectomy.

Infective endocarditis (IE) is an infection of the heart valves or endocardium, usually due to the spread of infection through the blood. It can cause a varied range of symptoms, from being asymptomatic to reduced heart function, valvular abnormalities, embolization, or death. Enterococci are usually present as normal gut flora but can also cause bacteremia, urinary tract infections, or IE, especially in the elderly population. The source of enterococcal spread in most of the cases is unidentifiable and sometimes associated with the genitourinary tract or damage to the gut mucosa due to trauma, malignancy, and infection, among others. Very few cases have been reported so far on Enterococcus faecalis (E. faecalis) endocarditis and even rarer for such cases complicated by osteomyelitis. Here, we describe the case of a 63-year-old male patient with a recent history of cardiac arrest, a percutaneous endoscopic gastrostomy tube placement, and endotracheal tube placement. He presented with back pain and was found to have osteomyelitis on magnetic resonance imaging and aortic valve vegetations on transthoracic echocardiography (TTE). His blood cultures were positive for E. faecalis. Repeat TTE showed growth in the vegetation, and the patient underwent bioprosthetic aortic valve replacement.

Polyarteritis nodosa (PAN) is a type of vasculitis that mainly affects small and medium-sized blood vessels. The clinical presentation can be nonspecific as weight loss, abdominal pain, and hypertension, or fatal as myocardial infarction (MI) and bowel perforation depending upon the organ involved. Cardiac involvement of PAN usually manifests as congestive heart failure, aneurysms, or MIs and is mostly identified during postmortem studies of autopsied patients. Here, we report a case of anterior MI as a sequela of PAN in a 40-year-old female who was diagnosed with PAN two weeks before her MI. She presented with intermittent chest pain for one day. At the time of admission, an electrocardiogram revealed anterior MI, and she was subsequently found to have 95-99% stenosis of the proximal left anterior descending artery during cardiac catheterization. The patient was successfully treated with percutaneous coronary intervention and was started on dual antiplatelet therapy. Her treatment was continued with steroids and cyclophosphamide. The case illustrates the importance of recognizing MI as a sequela of PAN as timely treatment could be lifesaving.