Improved Outcomes With NCSI Protocol
From July 2016 to December 2020, 73 sites participated in the National Cardiogenic Shock Initiative, or NSCI, a single-arm, prospective trial in which all centers agreed to treat patients with acute MI and cardiogenic shock using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of mechanical circulatory support (MCS). In accordance with the protocol, 71% of patients—average age was 64, 24% female, 67% admitted in shock, 85% on vasopressors or inotropes, 17% with a witnessed out-of-hospital cardiac arrest, 27% with in-hospital cardiac arrest, 9% under active cardiopulmonary resuscitation during MCS implantation, 73% presenting in SCAI stage C/D shock and 27% in stage E, and presenting with an average BP of 77/50, lactate of 4.8 mmol/dL, and cardiac power output of 0.67W—had MCS implanted prior to PCI. Procedural survival, survival to discharge, 30-day survival, and 1-year survival were 99%, 79%, 77%, and 62%, respectively, for patients presenting in stage C/D shock and 98%, 49%, 46%, and 32%, respectively, for patients in stage E shock.
Pattern of TAVR Program Growth & Inequities in Access
With the notion that inequitable diffusion of new technologies in areas with high socioeconomic status may generate disparities in care, researchers examined the growth of TAVR in the US to understand the characteristics of hospitals with cardiac surgery capabilities that developed TAVR programs and the socioeconomic status of the patients they served. Using Medicare claims data from January 2012 to December 2018, they compared the socioeconomic characteristics of patients treated at hospitals with and without TAVR programs. During the study period, 98.0% of hospitals that developed new TAVR programs were in metropolitan areas and 52.9% were in metropolitan areas with pre-existing TAVR programs. Hospitals that started TAVR programs treated patients with a higher median household income, and TAVR rates per 100,000 Medicare beneficiaries were higher in areas with higher median income, even after adjusting for age and clinical comorbidities.
Procedural Efficiencies Achieved for Congenital Heart Disease With Longer Covered Stent
Covered stent correction of sinus venous atrial septal defect (SVASD), an alternative to surgical repair, comes with the challenges of anchoring a stent of sufficient length in a distensible and non-stenotic superior vena cava (SVC) and expanding the stent to diameters up to 1.5-3.0 times the SVC at the SVC-right atrial junction. A covered CP (CCP) stent available in lengths of 5-11 cm and dilatable to 34 mm in diameter with moderate shortening has been FDA approved at lengths of 5-6 cm, with longer stents requiring more research. Investigators reviewed outcomes data from 75 patients aged 11-75 who received various lengths of the stent. In 32 participants, additional stents were used to anchor the stent in the SVC or to close residual shunts. All cases with SVC landing zone stents required a third stent for stability. In 80% of cases with 5.0-5.5 cm CCPs, an additional stent was placed, compared with 62% of those with 6.0 cm CCPs, 28% with 7.0 cm CCPs, 23% with 7.5-8.0 cm CCPs, and 0% of those with 11.0 cm CCPs.
Protocol & Technique Allow for Low Radiation for Pediatric Cardiac Catheterization
With prior research indicating that adding air gap technique (AGT) to an “as low as reasonably achievable (ALARA)” radiation protocol can reduce radiation exposure in patients weighing less than 20 kg, investigators assessed the radiation dosage using their AGT with ALARA protocol in patients younger than 21 weighing 20-40 kg. With the protocol, the flat panel detector was placed 100 cm from the patient. In patients with a median age of 9 and median weight of 27.5 kg, 49 catheterizations were interventional, the median fluoro time was 11.9 minutes, the median total air Kerma product was 38 mGy, the median does area product (DAP) was 175 µGym2 , and the DAP for weight was 7. The three minor complications observed were all self-limited.
Endocarditis Rare But Often Fatal in Low-Risk TAVR
Data indicate that prosthetic valve endocarditis (PVE) is a rare but devastating complication of TAVR. With the belief that understanding PVE in low-risk patients is imperative as indications expand, researchers sought to describe the mechanisms and incidence of PVE in patients in the Low Risk TAVR trials who underwent TAVR from 2016-2020. Among 396 low-risk patients with symptomatic severe aortic stenosis who underwent TAVR, PVE occurred in 11 at a mean of 349 days post-TAVR. In five patients, PVE occurred within 1 year, among whom three showed evidence of septic emboli of the brain and two underwent survival aortic valve reintervention. Among six patients with PVE after 1 year, three showed evidence of septic emboli to the brain and one underwent surgical aortic valve reintervention. Two patients with late PVE and septic emboli died.
