Search

Background: Transcatheter closure is the preferred treatment for atrial septal defects. The available devices are effective and safe though concerns persist over cardiac erosion risk. A review of t...

This study evaluates differences in out-of-hospital cardiac arrest (OHCA) characteristics, interventions, and outcomes by race/ethnicity.This is a retrospective analysis from a regionalized cardiac system. Outcomes for all adult patients treated for OHCA with return of spontaneous circulation (ROSC) were identified from 2011-2014. Stratifying by race/ethnicity with White as the reference group, patient characteristics, treatment, and outcomes were evaluated. The adjusted odds ratios (OR) for survival with good neurologic outcome (cerebral performance category 1 or 2) were calculated.There were 5178 patients with OHCA; 290 patients excluded for unknown race, leaving 4888 patients: 50% White, 14% Black, 12% Asian, 23% Hispanic. In univariate analysis, compared with Whites, Blacks had fewer witnessed arrests (83% vs 86%, p = 0.03) and less bystander CPR (37% vs 44%, p = 0.005), were less likely to undergo coronary angiography (14% vs 22%, p 0.0001), and less likely to receive PCI (32% vs 54%, p 0.0001). Asians presented less often with a shockable rhythm (27% vs 34%, p = 0.001) and were less likely to undergo angiography (15% vs 22%, p 0.0001). Hispanics presented less often with a shockable rhythm (31% vs 34%, p = 0.03), had fewer witnessed arrests (82% vs 86%, p = 0.001) and less bystander CPR (37% vs 44%, p = 0.0001). In multivariable analysis, Hispanic ethnicity was associated with decreased favorable neurologic outcome (OR 0.78 [95%CI 0.63-0.96]). Outcomes for Asians and Blacks did not differ from Whites. When accounting for clustering by hospital, race was no longer statistically significantly associated with survival with good neurologic outcome.We identified important differences in patients with OHCA according to race/ethnicity. Such differences may have implications for interventions; for example, emphasis on bystander CPR instruction in Black and Hispanic communities.

Background Despite the benefits of targeted temperature management (TTM) for out‐of‐hospital cardiac arrest), implementation within the United States remains low. The objective of this study was to evaluate the prevalence and factors associated with TTM use in a large, urban‐suburban regional system of care. Methods and Results This was a retrospective analysis from the Los Angeles County regional cardiac system of care serving a population of >10 million residents. All adult patients aged ≥18 years with non‐traumatic out‐of‐hospital cardiac arrest transported to a cardiac arrest center from April 2011 to August 2017 were included. Patients awake and alert in the emergency department and patients who died in the emergency department before consideration for TTM were excluded. The primary outcome measure was prevalence of TTM use. The secondary analysis were annual trends in TTM use over the study period and factors associated with TTM use. The study population included 8072 patients; 4154 patients (51.5%) received TTM and 3767 patients (46.7%) did not receive TTM. Median age was 67 years, 4780 patients (59.2%) were men, 4645 patients (57.5%) were non‐White, and the most common arrest location was personal residence in 4841 patients (60.0%). In the adjusted analysis, younger age, male sex, an initial shockable rhythm, witnessed arrest, and receiving coronary angiography were associated with receiving TTM. Conclusions Within this regional system of care, use of TTM was higher than previously reported in the literature at just over 50%. Use of integrated systems of care may be a novel method to increase TTM use within the United States.

OBJECTIVE To evaluate contrast media (CM) volume (CMV) saved using the DyeVert™ Plus Contrast Reduction System (DyeVert Plus System, Osprey Medical) in patients undergoing diagnostic coronary angiogram (CAG) and/or percutaneous coronary interventional (PCI) procedures performed with manual injections. BACKGROUND Current guidelines advocate for monitoring and minimization of the total volume of CM in chronic kidney disease (CKD) patients undergoing invasive cardiac procedures. The DyeVert Plus System is an FDA cleared device designed to reduce CMV delivered during angiography and permit real-time CMV monitoring. METHODS We performed a multicenter, single-arm, observational study. Eligible subjects were ≥ 18 years old with baseline estimated glomerular filtration rate (eGFR) 20-60 mL/min/1.73 m2 . The primary endpoint was % CMV saved over the total procedure. A secondary objective was to evaluate adverse events (AEs) related to DyeVert Plus System or to CM use. RESULTS A total of 114 subjects were enrolled at eight centers. Mean age was 72 ± 9 years, 72% were male, and mean body mass index was 29 ± 5. Baseline eGFR was 43 ± 11 mL/min/1.73 m2 . CAG-only was performed in 65% of cases. One hundred and five subjects were evaluable for the primary endpoint. Mean CMV attempted was 112 ± 85 mL (range 22-681) and mean CMV delivered was 67 ± 51 mL (range 12-403), resulting in an overall CMV savings of 40.1 ± 8.8% (95% CI 38.4, 41.8; P 0.3 mg/dL from baseline) was reported in 11 cases with seven occurring in subjects with baseline eGFR

Cardiogenic shock (CS) is associated with high morbidity and mortality despite recent advances in the temporary mechanical circulatory support (MCS) devices. The current utilization and outcomes of these MCS devices with or without vasopressors compared with conventional medical therapy (no-MCS) in CS remain poorly described. The study population was extracted from the 2014 Nationwide Readmissions Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for CS, temporary MCS devices, and vasopressor infusion. Study end points included in-hospital all-cause mortality, length of index hospital stay (LOS), the likelihood of receiving invasive treatment, postprocedural bleeding, vascular complications, total hospitalization charges, and discharge disposition. A total of 59,148 discharges with a diagnosis of CS were identified (age 67 years; 38.5% female). Temporary MCS devices were utilized in 22.7%. The use of these devices was associated with lower in-hospital all-cause mortality (33.0% vs 39.7%, p

Advances in reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) provide optimal patient outcomes. Reperfusion therapies, including contemporary primary percutaneous coronary intervention, represent decades of clinical evidence development in large clinical trials and national databases. However, rapid identification of STEMI and guideline-directed management of patients across broad populations have been best achieved in advanced systems of care. Current outcomes in STEMI reflect the evolution of both clinical data and idealized health care delivery networks.

The noninvasive detection of turbulent coronary flow may enable diagnosis of significant coronary artery disease (CAD) using novel sensor and analytic technology. Eligible patients (n = 1013) with chest pain and CAD risk factors undergoing nuclear stress testing were studied using the CADence (AUM Cardiovascular Inc., Northfield MN) acoustic detection (AD) system. The trial was designed to demonstrate non-inferiority of AD for diagnostic accuracy in detecting significant CAD as compared to an objective performance criteria (sensitivity 83% and specificity 80%, with 15% non-inferiority margins) for nuclear stress testing. AD analysis was blinded to clinical, core lab-adjudicated angiographic, and nuclear data. The presence of significant CAD was determined by computed tomographic (CCTA) or invasive angiography. A total of 1013 subjects without prior coronary revascularization or Q-wave myocardial infarction were enrolled. Primary analysis was performed on subjects with complete angiographic and AD data (n = 763) including 111 subjects (15%) with severe CAD based on CCTA (n = 34) and invasive angiography (n = 77). The sensitivity and specificity of AD were 78% (p = 0.012 for non-inferiority) and 35% (p

Background We evaluated the first‐medical‐contact‐to‐balloon ( FMC 2B) time after implementation of a “Call 911” protocol for ST‐segment–elevation myocardial infarction (STEMI) interfacility transfers in a regional system. Methods and Results This is a retrospective cohort study of consecutive patients with STEMI requiring interfacility transfer from a STEMI referring hospital, to one of 35 percutaneous coronary intervention‐capable STEMI receiving centers ( SRCs ). The Call 911 protocol allows the referring physician to activate 911 to transport a patient with STEMI to the nearest SRC for primary percutaneous coronary intervention. Patients with interfacility transfers were identified over a 4‐year period (2011–2014) from a registry to which SRCs report treatment and outcomes for all patients with STEMI transported via 911. The primary outcomes were median FMC 2B time and the proportion of patients achieving the 120‐minute goal. FMC 2B for primary 911 transports were calculated to serve as a system reference. There were 2471 patients with STEMI transferred to SRC s by 911 transport during the study period, of whom 1942 (79%) had emergent coronary angiography and 1410 (73%) received percutaneous coronary intervention. The median age was 61 years (interquartile range [ IQR ] 52–71) and 73% were men. The median FMC 2B time was 111 minutes ( IQR 88–153) with 56% of patients meeting the 120‐minute goal. The median STEMI referring hospital door‐in‐door‐out time was 53 minutes ( IQR 37–89), emergency medical services transport time was 9 minutes ( IQR 7–12), and SRC door‐to‐balloon time was 44 minutes ( IQR 32–60). For primary 911 patients (N=4827), the median FMC 2B time was 81 minutes ( IQR 67–97). Conclusions Using a Call 911 protocol in this regional cardiac care system, patients with STEMI requiring interfacility transfers had a median FMC 2B time of 111 minutes, with 56% meeting the 120‐minute goal.

The aim of this study was to evaluate the treatment and outcomes of patients with ST-segment elevation myocardial infarctions complicated by out-of-hospital cardiac arrest in a regional system of care. In this retrospective study, the effect of the absence of an initial shockable arrest rhythm was analyzed. The primary end point of survival with good neurologic outcome in patients with and without an initial shockable arrest rhythm was adjusted for age, witnessed arrest, bystander cardiopulmonary resuscitation, and treatment with therapeutic hypothermia and percutaneous coronary intervention. One-hundred sixty-eight of 348 patients (49%) survived to hospital discharge. Patients with a shockable initial rhythm were more likely to receive therapeutic hypothermia (48% vs 37%, risk ratio 1.2, 95% confidence interval [CI] 1.0 to 1.5) and to be treated in the cardiac catheterization laboratory (80% vs 43%, risk ratio 2.8, 95% CI 2.0 to 3.8). The likelihood of survival with good neurologic outcome in patients with a shockable initial rhythm compared with those presenting without a shockable rhythm was 4.8 (95% CI 2.7 to 8.7). In patients who underwent percutaneous coronary intervention, the likelihood of survival with good neurologic outcome was higher (risk ratio 2.7, 95% CI 1.1 to 6.8) in those with a shockable rhythm. In conclusion, the absence of an initial shockable rhythm in patients with ST-segment elevation myocardial infarctions plus out-of-hospital cardiac arrest is associated with significantly worse survival and neurologic outcome. These differences persist despite application of therapies including therapeutic hypothermia and percutaneous coronary intervention within a regionalized system of care.

Aims To compare the effects of two TNF-α antagonists, etanercept and infliximab, on post-cardiac arrest hemodynamics and global left ventricular function (LV) in a swine model following ventricular fibrillation (VF). Methods Domestic swine ( n = 30) were placed under general anesthesia and instrumented before VF was induced electrically. After 7 min of VF, standard ACLS resuscitation was performed. Animals achieving return of spontaneous circulation (ROSC) were randomized to immediately receive infliximab (5 mg/kg, n = 10) or etanercept (0.3 mg/kg [4 mg/m 2 ], n = 10) or vehicle (250 mL normal saline [NS], n = 10) and LV function and hemodynamics were monitored for 3 h. Results Following ROSC, mean arterial pressure (MAP), stroke work (SW), and LV dP / dt fell from pre-arrest values in all groups. However, at the 30 min nadir, infliximab-treated animals had higher MAP than either the NS group (difference 14.4 mm Hg, 95% confidence interval [CI] 4.2–24.7) or the etanercept group (19.2 mm Hg, 95% CI 9.0–29.5), higher SW than the NS group (10.3 gm-m, 95% CI 5.1–15.5) or the etanercept group (8.9 gm-m, 95% CI 4.0–14.4) and greater LV dP / dt than the NS group (282.9 mm Hg/s, 95% CI 169.6–386.1 higher with infliximab) or the etanercep group (228.9 mm Hg/s, 95% CI 115.6–342.2 higher with infliximab). Conclusions Only infliximab demonstrated a beneficial effect on post cardiac arrest hemodynamics and LV function in this swine model. Etanercept was no better in this regard than saline.

The objective of this study was to evaluate the time to primary percutaneous coronary intervention (PCI) and the outcome for patients with ST elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA). In this regional system, all patients with STEMI and/or OHCA with return of spontaneous circulation were transported to STEMI Receiving Centers. The outcomes registry was queried for patients with STEMI with underwent primary PCI from April 2011 to December 2014. Patients with STEMI complicated by OHCA were compared with a reference group of STEMI without OHCA. The primary end point was the first medical contact-to-device time. Of 4,729 patients with STEMI who underwent primary PCI, 422 patients (9%) suffered OHCA. Patients with OHCA were on average 2 years (95% confidence interval 0.7 to 3.0) older and had a slightly higher male predominance. The first medical contact-to-device time was longer in STEMI with OHCA compared with STEMI alone (94 ± 37 vs. 86 ± 34 minutes, p 0.0001). In-hospital mortality was higher after OHCA, 38% versus 6% in STEMI alone, odds ratio 6.3 (95% confidence interval 5.3 to 7.4). Among OHCA survivors, 193 (73%) were discharged with a cerebral performance category score of 1 or 2. In conclusion, despite longer treatment intervals, neurologic outcome was good in nearly half of the surviving patients with STEMI complicated by OHCA, suggesting that these patients can be effectively treated with primary PCI in a regionalized system of care.

Author(s): Budoff, Matthew J; Kalia, Nove; Cole, Jason; Nakanishi, Rine; Nezarat, Negin; Thomas, Joseph L | Abstract: BackgroundAlthough several studies have shown promise for noninvasive angiography by coronary computed tomographic angiography (CCTA), few prospective multicenter trials have been conducted. This study evaluated the diagnostic accuracy of Visipaque enhanced CCTA to detect obstructive coronary stenosis compared with quantitative coronary angiography (QCA).Patients and methodsThree sites prospectively enrolled 77 patients (58.1% men, 54 years) with chest pain referred for invasive coronary angiography (ICA). Patients underwent CCTA (Lightspeed VCT/Visipaque 320) before ICA. CCTAs were graded on a 15-segment American Heart Association model by a CCTA core lab with blinded readers for the presence of obstructive stenosis (g50% or g70%); ICAs were independently graded for %stenosis by QCA, considered the reference standard. The efficacy of CCTA was assessed including all vessel segments for per-patient and per-vessel analyses.ResultsA total of 46 more than 50% stenoses in 27 (35%) patients, and 31 more than 70% stenoses in 20 (26%) patients, were identified by QCA. Per-patient and per-vessel efficacy of CCTA compared with QCA yielded sensitivities of 85% and specificities of 90 and 95%, respectively.ConclusionThis study shows the high accuracy of CCTA to reliably detect more than 50% and more than 70% stenoses in low-probability to intermediate-probability chest pain patients being referred for ICA. The high negative predictive values observed (92-100%) indicate that CCTA is also an effective noninvasive alternative to exclude obstructive coronary stenosis.

Inflammatory cytokines have been implicated in the pathophysiology of post cardiac arrest syndrome, including myocardial dysfunction and hypotension, often leading to multi-organ system dysfunction and death. We hypothesized that administration of infliximab after return of spontaneous circulation (ROSC) would ameliorate hypotension and myocardial dysfunction and prolong survival.Domestic swine were anesthetized and instrumented. Balloon occlusion of the LAD coronary artery just distal to the first septal perforator was performed and VF followed spontaneously in all animals. After 7 min, chest compressions, defibrillation, and standard ACLS resuscitation was performed. Animals achieving ROSC (N=32) were randomized to receive infliximab (5 mg/kg, n=16) or vehicle (250 mL normal saline, n=16) immediately post-ROSC and survival and hemodynamics were monitored for 3 h.There were no differences in prearrest hemodynamic variables, TNF-α levels, or resuscitation variables between groups. Both groups demonstrated a time dependent decline in mean arterial pressure (MAP) and stroke work (SW) post-ROSC with a nadir at 1 h followed by recovery over hours 2 and 3. This decline was blunted in infliximab-treated swine (1-h between group difference in MAP 21 mm Hg, 95% CI 3-38 mm Hg and SW 6.7 gm-m, 95% CI 0.4-13 at 1 h). Left ventricular systolic dp/dt fell in the vehicle group (-437 mm Hg/s, 95% CI -183 to -690) but did not in the infliximab group. Tau rose only in the vehicle group (44 ms, 95% CI 1-87). Short-term survival was higher in the infliximab group (Kaplan-Meier p=0.022).Blockade of TNF-α in the immediate post-ROSC period improved survival and hemodynamic parameters in this swine model of ischemic VF.

Atherosclerotic disease within coronary arteries causes disruption of normal, laminar flow and generates flow turbulence. The characteristic acoustic waves generated by coronary turbulence serve as a novel diagnostic target. The frequency range and timing of microbruits associated with obstructive coronary artery disease (CAD) have been characterized. Technological advancements in sensor, data filtering and analytic capabilities may allow use of intracoronary turbulence for diagnostic and risk stratification purposes. Acoustic detection (AD) systems are based on the premise that the faint auditory signature of obstructive CAD can be isolated and analyzed to provide a new approach to noninvasive testing. The cardiac sonospectrographic analyzer, CADence, and CADScore systems are early-stage, investigational and commercialized examples of AD systems, with the latter two currently undergoing clinical testing with validation of accuracy using computed tomography and invasive angiography. Noninvasive imaging accounts for a large percentage of healthcare expenditures for cardiovascular disease in the developed world, and the growing burden of CAD will disproportionately affect areas in the developing world. AD is a portable, radiation-free, cost-effective method with the potential to provide accurate diagnosis or exclusion of significant CAD. AD represents a model for digital, miniaturized, and internet-connected diagnostic technologies.

Introduction: Gender differences have been noted in outcomes from out-of-hospital cardiac arrest (OHCA) but remain poorly defined. The purpose of this study was to evaluate gender differences in OHCA characteristics, interventions, and outcomes. Methods: This is a retrospective analysis of registry data from a regionalized cardiac arrest system. Patients treated for OHCA with return of spontaneous circulation (ROSC) are transported to the nearest cardiac arrest receiving center with percutaneous coronary intervention (PCI) capability and therapeutic hypothermia protocols. Outcomes are reported to a single registry, from which all adult patients were identified from 2011 through 2014. The characteristics, treatment interventions, and outcomes were evaluated by gender and then further stratified by ECG presence of STEMI and initial rhythm. The adjusted odds ratio (OR) for survival with good neurologic outcome (defined as cerebral perfusion category (CPC) 1 or 2) was calculated for women compared to men. Results: There were 5174 OHCA in the registry, 3080 males and 2094 females. Women were older, median 71 years (inter-quartile range (IQR) 59-82) vs 66 (IQR 55-78) and, despite similar frequency of witnessed arrest, were less likely to present with a shockable rhythm (22% vs 35%, Risk Difference (RD) 13% 95%CI 11-15%) compared to men. Women were also less likely to have STEMI on the ECG (23% vs 32%, RD 13% 95%CI 7-11%) receive catheterization (11% vs 25%, RD 14% 95%CI 12-16%), PCI (5% vs 14%, RD 9% 95%CI 7-11%) or TH (33% vs 40%, RD 7% 95%CI 4-10%). Women had decreased survival to hospital discharge (33% vs 40%, RD 7% 95%CI 4-10%) and a lower proportion with good neurologic outcome (16% vs 24%, RD 8% 95%CI 6-10%). The differences persisted with stratification by STEMI or initial rhythm. However, after adjustment for age, arrest characteristics (initial rhythm, witness, bystander CPR), interventions (catheterization, PCI, and TH) and interaction between gender and treatment, female gender was not associated with decreased survival with good neurologic outcome, OR 0.9, 95%CI 0.7-1.1. Conclusion: Gender-related differences in OHCA characteristics and treatment (including PCI, catheterization, and TH) are independent predictors of outcome disparities.

Primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI) is beneficial if performed in a timely manner. Self-transport patients with STEMI have prolonged treatment times compared with Emergency Medical Services–transported patients. This study evaluated self-transport patients with STEMI undergoing primary percutaneous coronary intervention to identify factors associated with prolonged door-to-balloon (D2B) times. From January 2007 to March 2011, data for 13,379 self-transport patients with STEMI treated at 432 hospitals in the Acute Coronary Treatment Intervention Outcomes Network Registry–Get With The Guidelines Registry were evaluated. Patients with a D2B time >90 minutes were compared with those with D2B time ≤90 minutes. Factors associated with prolonged D2B (>90 minutes) were explored using logistic generalized estimating equations. The median (twenty-fifth, seventy-fifth percentiles) D2B time for the entire cohort was 72 minutes (58, 86), and 19% had a D2B time of >90 minutes. Over the study period, there was a significant increase in the percentage of patients achieving D2B time ≤90 minutes. There were significant baseline differences between patients with D2B time ≤ versus >90 minutes. The main factors associated with prolonged treatment time were off-hour presentation (weekends and 7 p.m. to 7 a.m. weekdays), not obtaining an electrocardiogram within 10 minutes of hospital arrival, previous coronary artery bypass surgery, black race, older age, and female gender. In conclusion, although prolonged delay from arrival to electrocardiographic acquisition is a modifiable factor contributing to prolonged D2B times among self-transport patients with STEMI, additional factors (age, race, and gender) indicate that historic disparities for cardiovascular care still persist in terms of contemporary metrics for STEMI reperfusion.

The risk of cardiac erosion with commercially available atrial septal defect occluders has led to changes in device labeling and implantation technique. Previous reports have described publicly-available data on erosion events but have not included recent experience. The FDA Manufacturer and User

This report focuses on cardioprotection and describes the advantages and disadvantages of various methods of inducing therapeutic hypothermia (TH) with regard to neuroprotection and cardioprotection for patients with cardiac arrest and ST-segment elevation myocardial infarction (STEMI). TH is recommended in cardiac arrest guidelines. For patients resuscitated after out-of-hospital cardiac arrest, improvements in survival and neurologic outcomes were observed with relatively slow induction of TH. More rapid induction of TH in patients with cardiac arrest might have a mild to modest incremental impact on neurologic outcomes. TH drastically reduces infarct size in animal models, but achievement of target temperature before reperfusion is essential. Rapid initiation of TH in patients with STEMI is challenging but attainable, and marked infarct size reductions are possible. To induce TH, a variety of devices have recently been developed that require additional study. Of particular interest is transcoronary induction of TH using a catheter or wire lumen, which enables hypothermic reperfusion in the absence of total-body hypothermia. At present, the main methods of inducing and maintaining TH are surface cooling, endovascular heat-exchange catheters, and intravenous infusion of cold fluids. Surface cooling or endovascular catheters may be sufficient for induction of TH in patients resuscitated after out-of-hospital cardiac arrest. For patients with STEMI, intravenous infusion of cold fluids achieves target temperature very rapidly but might worsen left ventricular function. More widespread use of TH would improve survival and quality of life for patients with out-of-hospital cardiac arrest; larger studies with more rapid induction of TH are needed in the STEMI population.

The purpose of this study was to determine the prevalence of in-hospital hypotension in patients surviving to admission after resuscitation from out-of-hospital cardiac arrest and compare it to that of traditional Utstein factors in predicting in-hospital mortality.Single-center retrospective cohort of adult patients surviving to hospital admission after resuscitation from out-of-hospital sudden death between January 1, 2006 and October 31, 2009. Study variables included Utstein template data: age, sex, initial rhythm, witnessed or nonwitnessed arrest, presence or absence of bystander CPR, location of arrest, response time (time of 9-1-1 dispatch to first vehicle arrival), and hypotension (systolic pressure90 or mean arterial pressure60) within 24h of ROSC. Univariate comparisons of categorical variables were performed and the Wilcoxon rank-sum test was used to compare continuous variables. Multivariable logistic regression was then performed after inclusion of Utstein variables.73 patients met the inclusion criteria, and in-hospital mortality occurred in 54 (74%). On univariate analysis, in-hospital hypotension (OR=3.5, 95%CI 1.1-10.0, p=0.02), pre-hospital rhythm other than VF/VT (OR 4.3, 95%CI 1.4-13.3, p=0.008), and an unwitnessed arrest (OR=6.9, 95%CI 0.8-56.5, p=0.04), were significant predictors of in-hospital mortality. On multivariable analysis, in-hospital hypotension (OR=9.8, 95%CI 1.5, 63.0, p=0.02), pre-hospital rhythm other than VT/VF (OR=8.5, 95%CI 1.3-58.8, p=0.03), and lack of bystander CPR (OR=13.2, 95%CI 1.6-111, p=0.02) remained statistically significant predictors of in-hospital mortality.In-hospital hypotension was predictive of mortality, as was a pre-hospital nonshockable rhythm and lack of bystander CPR. In contrast, traditional pre-hospital risk factors: age, gender, public location of arrest, response time, and witnessed arrest, were not predictive.

A 61-year-old Latino woman with no past medical history presented to the emergency department with 2 weeks of gradual onset of dyspnea on exertion, cough, and palpitations. She denied any recent illnesses, fevers, or unintentional weight loss. She was not taking any medications or using tobacco, alcohol, or illicit drugs. On physical examination, she had a temperature of 100.6°F, a heart rate of 122 bpm, respiratory rate of 25 breaths per minute, blood pressure of 155/92 mm Hg, and oxygen saturation of 92% on bilevel positive airway pressure. Her physical examination was notable for jugular venous distension, a loud S1 and normal S2, a grade 2/6 middiastolic murmur heard loudest at the apex, crackles throughout her posterior lung fields, and trace bilateral lower-extremity edema. Her ECG showed sinus rhythm with no significant ST-T abnormalities (Figure 1). A portable chest radiograph showed mild enlargement of the cardiac silhouette, bilateral air space opacities, and small bilateral pleural effusions (Figure 2). Computed tomography of the chest with intravenous contrast was done to evaluate for pulmonary embolism; it revealed a mass with lobulated margins within the left atrium (Figure 3) protruding into the left ventricular cavity and infiltrating the left atrial wall. Figure 1. Twelve-lead ECG demonstrating normal sinus rhythm with no significant ST-T segment abnormalities. Figure 2. Portable chest radiograph showing mild enlargement of the cardiac silhouette, bilateral air space opacities, and small bilateral pleural effusions. Figure 3. A …

Objectives Coronary perfusion pressure (CPP) during resuscitation from cardiac arrest has been shown to correlate with return of spontaneous circulation. Adrenergic blockade of beta-1 and alpha-1 receptors is common in the long-term management of ischemic heart disease and congestive heart failure. We sought to compare the CPP response to vasopressin vs. epinephrine in a swine model of cardiac arrest following pre-arrest adrenergic blockade. Methods Eight anesthetized and instrumented swine were administered 0.1 mg epinephrine and arterial pressure and heart rate response were measured. An infusion of labetalol was then initiated and animals periodically challenged with epinephrine until adrenergic blockade was confirmed. The left anterior descending coronary artery was occluded to produce ventricular fibrillation (VF). After 7 min of untreated VF, mechanical chest compressions were initiated. After 1 min of compressions, 1 mg epinephrine was given while CPP was recorded. When CPP values had returned to pre-epinephrine levels, 40 U of bolus vasopressin was given. Differences in CPP (post-vasopressor–pre-vasopressor) were compared within animals for the epinephrine and vasopressin response and with eight, non-adrenergically blocked, historical controls using Bayesian statistics with a non-informative prior. Results The CPP response following epinephrine was 15.1 mmHg lower in adrenergically blocked animals compared to non-adrenergically blocked animals (95% Highest Posterior Density [HPD] 2.9–27.2 mmHg lower). CPP went up 18.4 mmHg more following vasopressin when compared to epinephrine (95% HPD 8.2–29.1 mmHg). The posterior probability of a higher CPP response from vasopressin (vs. epinephrine) in these animals was 0.999. Conclusions Pre-arrest adrenergic blockade blunts the CPP response to epinephrine. Superior augmentation of CPP is attained with vasopressin under these conditions.

The frequency and significance of adverse events (AE) reported with transcatheter aortic valve replacement (TAVR) using Edwards SAPIEN THV in the voluntary, publicly available MAUDE database has not been characterized. The FDA MAUDE Database was queried for all reported events relating to Edwards

Inter-facility transfer (IFT) for primary PCI for STEMI presents multiple logistic challenges. Recent data from ACC/AHA ACTION Registry of approximately 300 hospitals within the United States found that fewer than 20% of IFT patients achieved a door to balloon time < 90 minutes. The objective of

The use of vascular closure devices (VCDs) following transfemoral procedures reduces recovery time and may reduce bleeding. Transradial (TR) access is associated with fewer adverse events (AEs). The frequency of real-world AEs with VCDs and the effect of increasing TR access are unknown. The FDA

Pre-hospital (PH) ECG enables field diagnosis and triage of STEMI patients to specialized STEMI receiving centers. Despite the proven benefits of early identification, false-positive ECG interpretations and unnecessary cardiac catheterization laboratory activations remain a common, challenging