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OBJECTIVES A paucity of point-of-care ultrasound (POCUS) databases limits machine learning (ML). Assess feasibility of training ML algorithms to visually estimate left ventricular ejection fraction (EF) from a subxiphoid (SX) window using only apical 4-chamber (A4C) images. METHODS Researchers used a long-short-term-memory algorithm for image analysis. Using the Stanford EchoNet-Dynamic database of 10,036 A4C videos with calculated exact EF, researchers tested 3 ML training permeations. First, training on unaltered Stanford A4C videos, then unaltered and 90° clockwise (CW) rotated videos and finally unaltered, 90° rotated and horizontally flipped videos. As a real-world test, we obtained 615 SX videos from Harbor-UCLA (HUCLA) with EF calculations in 5% ranges. Researchers performed 1000 randomizations of EF point estimation within HUCLA EF ranges to compensate for ML and HUCLA EF mismatch, obtaining a mean value for absolute error (MAE) comparison and performed Bland-Altman analyses. RESULTS The ML algorithm EF mean MAE was estimated at 23.0, with a range of 22.8-23.3 using unaltered A4C video, mean MAE was 16.7, with a range of 16.5-16.9 using unaltered and 90° CW rotated video, mean MAE was 16.6, with a range of 16.3-16.8 using unaltered, 90° CW rotated and horizontally flipped video training. Bland-Altman showed weakest agreement at 40-45% EF. CONCLUSIONS Researchers successfully adapted unrelated ultrasound window data to train a POCUS ML algorithm with fair MAE using data manipulation to simulate a different ultrasound examination. This may be important for future POCUS algorithm design to help overcome a paucity of POCUS databases.

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...

We examined skill-based differences in the detection and utilization of contextual information over a period of increasing exposure to an opponent’s action preferences in soccer. Moreover, we investigated the ability of athletes to adapt to changes in these action preferences over time. In an initial detection phase, the attacking opponent demonstrated a proclivity to either pass or dribble, with these preferences being reversed in a subsequent adaptation phase of the same length. Skilled soccer players showed superior anticipation accuracy across both phases compared with less-skilled counterparts. The skilled participants significantly enhanced their performance over both phases, despite a significant drop in performance immediately following the change in opponent action preferences. In contrast, the less-skilled group only improved over the detection phase. Gaze data revealed that the skilled participants fixated more on kinematically relevant areas, compared with the less-skilled group, and increased the time spent fixating the player “off the ball” following greater volumes of exposure. Our novel findings elaborate on how skilled performers use both action preferences and motion information to anticipate an opponent’s impending actions in sport.

Objective: Within Emergency Medical Systems (EMS) regional systems, there may be significant differences in the approach to patient care despite efforts to promote standardization. Identifying hospital-level factors that contribute to variations in care can provide opportunities to improve patient outcomes. The purpose of this analysis was to evaluate variation in post-cardiac arrest care within a large EMS system and explore the contribution of hospital-level factors.Methods: This was a retrospective analysis from a regional cardiac system serving over 10 million persons. Patients with out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) are transported to 36 cardiac arrest centers with 24/7 emergent coronary angiography (CAG) capabilities and targeted temperature management (TTM) policies based on regional guidelines. We included adult patients ≥18 years with non-traumatic OHCA from 2016-2018. Patients with a Do-Not-Resuscitate order and those who died in the emergency department (ED) were excluded. For the TTM analysis, we also excluded patients who were alert in the ED. The primary outcome was receiving CAG or TTM after cardiac arrest. The secondary outcome was neurologic recovery (dichotomized to define a "good" outcome as cerebral performance category (CPC) 1 or 2). We used generalized estimating equations including patient-level factors (age, sex, witnessed arrest, initial rhythm) and hospital-level factors (academic status, hospital size based on licensed beds, annual OHCA patient volume) to estimate the odds ratios associated with these variables.Results: There were 7831 patients with OHCA during the study period; 4694 were analyzed for CAG and 3903 for TTM. The median and range for treatment with CAG and TTM after OHCA was 23% (12-49%) and 58% (17-92%) respectively. Hospital size was associated with increased likelihood of CAG, adjusted odds ratio 1.71, 95% CI 1.05-2.86, p = 0.03. Academic status approached significance in its association with TTM, adjusted odds ratio 1.69, 95% CI 0.98-2.91, p = 0.06. Overall, 28% of patients survived with good neurologic outcome, ranging from 17 to 43% across hospitals.Conclusion: Within this regional cardiac system, there was significant variation in use of CAG and TTM after OHCA, which was not fully explained by patient-level factors. Hospital size was associated with increased CAG.

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.

Although the learning benefits of interleaved practice schedules relative to blocked schedules are well-reported, the mechanisms underlying these effects are not fully understood. Researchers have generally suggested that random schedules of practice increase task-related information processing which arises due to switching between variations of the same task (or switching between different tasks). Thus, one potentially useful way to both probe and manipulate contextual interference is to pair it with error estimation during practice. Forced error estimation increases task-related information processing and recording these estimates provides insight into learners' self-awareness of their errors. In the present study, 84 participants were randomly allocated to four groups. Participants practiced a timing task under blocked or random schedules, with and without error estimations prior to feedback. During the acquisition phase, three target times were trained (1500, 1700, 1900 ms), with feedback delivered after every trial. We used delayed post-tests (24 hrs later) to evaluate the retention of these target times and their transfer to two new target times (1600, 1800 ms). Participants who practiced with a random schedule performed worse (i.e., greater absolute error) than those with a blocked schedule during acquisition (p = .006); however, randomly scheduled participants also showed reduced error (p = .004) on the retention and transfer tests. Although prompting error estimations led to greater self-reported mental effort being invested on the task (p = .001), error estimation was not reliably associated with superior learning (p = .133). The accuracy of error estimations did not differ as a function of practice structure (p = .070), although the accuracy of error estimations improved during acquisition (p = .006). Findings highlight the robustness of the contextual interference effect, but we did not find evidence that error estimations moderated the effect on this task. It is in some ways surprising that we found an effect of contextual interference, as past-work suggests that interference effects are attenuated (or eliminated) when participants switch between different parameters of the same task. We speculate that this might be due to the difficulty of the task; even though participants switched between parametric variations of the same task, the distinction between parameters was subtle (i.e., tenths of a second).

IntroductionCoronary artery disease is a common diagnosis among patients undergoing transcatheter aortic valve replacement (TAVR). The treatment and timing of percutaneous coronary intervention (PCI) remain controversial. We sought to compare in-hospital periprocedural outcomes of combined TAVR and PCI during the same index hospitalization versus the isolated TAVR procedure.Material and methodsThe study population was extracted from the 2016 Nationwide Readmissions Data (NRD) using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system codes for TAVR, coronary PCI, and post-procedural complications. Study endpoints included in-hospital all-cause mortality, length of index hospital stay, cardiogenic shock, need for mechanical circulatory support (MCS) devices, mechanical complications of prosthetic valve, paravalvular leak (PVL), acute kidney injury (AKI), bleeding and total hospital charges. Propensity matching was used to adjust for baseline characteristics.ResultsThere were 23,604 TAVRs in the 2016 NRD, of which 852 were combined with PCI during the same index hospitalization. Mean age was 80.5 years and 45.9% were female. In comparison to isolated TAVR, TAVR-PCI was associated with higher in-hospital all-cause mortality (4.5% vs. 1.7%, p < 0.01), longer length of stay (10.5 vs. 5.4 days, p < 0.01), and higher incidence of cardiogenic shock (9.4% vs. 2.1%, p < 0.01), use of MCS devices (6.8% vs. 0.7%, p < 0.01), mechanical complications of prosthetic valve (6.8% vs. 0.7%, p < 0.01), PVL (0.9% vs. 0.4%, p = 0.01), AKI (25.5% vs. 11.5%, p < 0.01), bleeding (25.2% vs. 18.1%, p < 0.01), and total hospital charges ($354,725 vs. $220474, p < 0.01).ConclusionsIn comparison to isolated TAVR, combined TAVR-PCI was associated with a higher incidence of in-hospital morbidity and mortality. The association and mechanism of increased mortality warrant further study.

A substantial number of medical errors in radiology are attributed to failures of perception or decision making, although it is believed that experience (or expertise) might buffer diagnosticians from some types of perceptual-cognitive bias. We examined how the quality of contextual information influences decision making and how underlying perceptual-cognitive processes change as a function of experience and diagnostic accuracy. Twenty-one radiologists dictated their findings on 16 deidentified musculoskeletal radiographic cases while wearing a mobile-eye tracking system. Patient histories were mismatched on a subset of cases to be miscued relative to the correct diagnosis. Experienced radiologists outperformed less-experienced participants, but no systematic differences in gaze behaviors emerged between groups. Miscued case notes increased perceptual-cognitive bias in both groups, resulting in an approximate 40% decrease in diagnostic accuracy. Most errors were judgment errors, meaning participants visually fixated on the abnormality for longer than a second yet still failed to make the correct diagnosis. Findings suggest a physician's confidence in their diagnosis might be misplaced after spending insufficient time extracting relevant information from key areas of the visual display, or when decisions are based primarily on a priori expectations derived from patient histories. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Recent studies suggest that primary percutaneous coronary intervention (PCI) and targeted temperature management (TTM) improve outcome in ST-segment elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA). The objective of this study was to evaluate a contemporary series of patients with STEMI and OHCA to characterize treatment approaches and predictors of neurologic outcome.From January 2009 through November 2012, a total of 239 patients who underwent emergent coronary angiography at 10 medical centers across the United States were enrolled. All patients suffered OHCA with STEMI on either the prehospital or post-resuscitation electrocardiogram. Neurologic outcome was assessed using the cerebral performance category (CPC) score. Predictors of neurologic outcome were determined using multivariate logistic regression analysis. The primary endpoint was in-hospital survival with good neurologic function (CPC score 1 or 2).Mean age was 60 ± 13 years, 72% were male, and the majority of patients had a history of cardiovascular event. Initial rhythm was ventricular fibrillation in 72%. At hospital presentation, 76% of patients were intubated, 37% were in cardiogenic shock, and 33% were receiving vasopressors. Primary PCI was performed in 74%, with an average door-to-balloon time of 95 ± 77 minutes, and TTM was used in 51%. Forty-four percent of patients had full neurologic recovery (CPC score 1) and 55% had good neurologic function. Overall in-hospital survival rate was 66%. Independent predictors of in-hospital survival with good neurologic function were: receiving bystander cardiopulmonary resuscitation, location of arrest, receiving drug-eluting stents, and not experiencing a recurrent cardiac arrest.Short-term survival for patients with STEMI and OHCA undergoing emergent coronary angiography and revascularization with TTM in this contemporary, multicenter registry was high and neurologic outcome was good in more than half of patients.

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

Objectives The relative age effect (RAE), a phenomenon where relatively older athletes in a selection year are overrepresented, has been evidenced across different sports and age-levels. No published reports have assessed if the RAE influences practice time for relatively younger athletes, which could contribute to sport success. In this study, we compared patterns for performance and sport engagement between earlier-born and later-born adolescent alpine ski racers from Austria (AUT) and the United States (US). Design and methods We assessed birth quarter distribution and performance trends using a performance (FIS) database (US: N = 2172; AUT: N = 516), and sport engagement through administering a practice history questionnaire to athletes attending ski academies/boarding schools (US: N = 169; AUT: N = 209). Results Chi-square analyses revealed an underrepresentation of athletes born later in both samples. Mixed regressions only showed performance improvements for later-born US ski racers. Relatively younger athletes in Austria engaged in more individual and group practice over time, while no clear practice patterns emerged for US ski racers. Conclusions Results suggest that later-born ski racers in Austria need to practice more to bridge skill/performance gaps with their relatively older peers. Additionally, later-born ski racers who do not put in extra practice may be deselected. Practice time may be less pivotal for relatively younger ski racers in the US due to less strict talent filtration systems. Coaches can ameliorate the RAE by dedicating more attention during practice towards developing relatively younger athletes who are transiently overshadowed by older, higher-performing athletes.

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.

IntroductionField identification of ST-elevation myocardial infarction (STEMI) and advanced hospital notification decreases first-medical-contact-to-balloon (FMC2B) time. A recent study in this system found that electrocardiogram (ECG) transmission following a STEMI alert was frequently unsuccessful.HypothesisInstituting weekly test ECG transmissions from paramedic units to the hospital would increase successful transmission of ECGs and decrease FMC2B and door-to-balloon (D2B) times.MethodsThis was a natural experiment of consecutive patients with field-identified STEMI transported to a single percutaneous coronary intervention (PCI)-capable hospital in a regional STEMI system before and after implementation of scheduled test ECG transmissions. In November 2014, paramedic units began weekly test transmissions. The mobile intensive care nurse (MICN) confirmed the transmission, or if not received, contacted the paramedic unit and the department’s nurse educator to identify and resolve the problem. Per system-wide protocol, paramedics transmit all ECGs with interpretation of STEMI. Receiving hospitals submit patient data to a single registry as part of ongoing system quality improvement. The frequency of successful ECG transmission and time to intervention (FMC2B and D2B times) in the 18 months following implementation was compared to the 10 months prior. Post-implementation, the time the ECG transmission was received was also collected to determine the transmission gap time (time from ECG acquisition to ECG transmission received) and the advanced notification time (time from ECG transmission received to patient arrival).ResultsThere were 388 patients with field ECG interpretations of STEMI, 131 pre-intervention and 257 post-intervention. The frequency of successful transmission post-intervention was 73% compared to 64% prior; risk difference (RD)=9%; 95% CI, 1-18%. In the post-intervention period, the median FMC2B time was 79 minutes (inter-quartile range [IQR]=68-102) versus 86 minutes (IQR=71-108) pre-intervention (P=.3) and the median D2B time was 59 minutes (IQR=44-74) versus 60 minutes (IQR=53-88) pre-intervention (P=.2). The median transmission gap was three minutes (IQR=1-8) and median advanced notification time was 16 minutes (IQR=10-25).ConclusionImplementation of weekly test ECG transmissions was associated with improvement in successful real-time transmissions from field to hospital, which provided a median advanced notification time of 16 minutes, but no decrease in FMC2B or D2B times.D’ArcyNT, BossonN, KajiAH, BuiQT, FrenchWJ, ThomasJL, ElizarrarazY, GonzalezN, GarciaJ, NiemannJT. Weekly checks improve real-time prehospital ECG transmission in suspected STEMI. Prehosp Disaster Med. 2018;33(3):245–249.

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 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.

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.

Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients.Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2.The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%.We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

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.

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.

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.

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.

Therapeutic hypothermia (TH) improves neurologic outcome in patients resuscitated from ventricular fibrillation. The purpose of this study was to evaluate TH effects on neurologic outcome in patients resuscitated from a non-shockable out-of-hospital cardiac arrest rhythm. This is a retrospective cohort study of data reported to a registry in an emergency medical system in a large metropolitan region. Patients achieving field return of spontaneous circulation are transported to designated hospitals with TH protocols. Patients with an initial non-shockable rhythm were identified. Patients were excluded if awake in the Emergency Department or if TH was withheld due to preexisting coma or death prior to initiation. The decision to initiate TH was determined by the treating physician. The primary outcome was survival with good neurologic outcome defined by a cerebral performance category of 1 or 2. Of the 2772 patients treated for cardiac arrest during the study period, there were 1713 patients resuscitated from cardiac arrest with an initial non-shockable rhythm and 1432 patients met inclusion criteria. The median age was 69 years [IQR 59–82]; 802 (56 %) male. TH was induced in 596 (42 %) patients. Survival with good neurologic outcome was 14 % in the group receiving TH, compared with 5 % in those not treated with TH (risk difference = 8 %, 95 % CI 5–12 %). The adjusted OR for a CPC 1 or 2 with TH was 2.9 (95 % CI 1.9–4.4). Analyzing the data collected from the registry of the standard practice in a large metropolitan region, TH is associated with improved neurologic outcome in patients resuscitated from initial non-shockable rhythms in a regionalized system for post-resuscitation care.

Comparative effectiveness research (CER) is taking a more prominent role in formalizing hospital treatment protocols and health-care coverage policies by having health-care providers consider the impact of new devices on costs and outcomes. CER balances the need for innovation with fiscal responsibility and evidence-based care. This study compared the clinical and economic impact of percutaneous ventricular assist devices (pVAD) with intraaortic balloon pumps for high-risk patients undergoing percutaneous coronary intervention (PCI).This study conducted a review of all comparative randomized control trials of the pVADS (Impella and TandemHeart) vs IABP for patients undergoing high-risk percutaneous coronary intervention (PCI). A retrospective analysis of the 2010 and 2011 Medicare MEDPAR data files was also performed to compare procedural costs and hospital length of stay (LOS). Readmission rates between the devices were also studied.Based on available trials, there is no significant clinical benefit with pVAD compared to IABP. Use of pVADs is associated with increased length of Intensive Care Unit stay and a total longer LOS. The incremental budget impact for pVADs was $33,957,839 for the United States hospital system (2010-2011).pVADs are not associated with improved clinical outcomes, reduced hospital length of stay, or reduced readmission rates. Management of high-risk PCI and cardiogenic shock patients with IABP is more cost effective than a routine use of pVADS. Use of IABP as initial therapy in high-risk PCI and cardiogenic shock patients may result in savings of up to $2.5 billion annually of incremental costs to the hospital system.

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

We report the case of a 59-year-old woman who presented with symptoms of angina that was refractory to medical management. Although her cardiac catheterization revealed microvascular coronary artery disease, her symptoms were refractory to optimal medical management that included ranolazine. After undergoing transmyocardial revascularization, her myocardial ischemia completely resolved and her symptoms dramatically improved. This case suggests that combination of ranolazine and transmyocardial revascularization can be applied to patients with microvascular coronary artery disease.

Patients with contraindications to iodinated radiographic contrast agents present a significant challenge during endovascular intervention. A 46-year-old man with end-stage renal disease and a normally functioning left upper extremity arteriovenous fistula presented with severe left arm edema. The patient's history included repeated severe anaphylactoid reactions with severe respiratory distress upon exposure to iodinated contrast. In an attempt to avoid the use of iodinated contrast, angioplasty and stent placement of a severe central venous stenosis were performed using only fluoroscopy and intravascular sonography. In patients unable to receive iodinated contrast secondary to anaphylactoid reactions, intravascular sonography can be used to guide angioplasty and stenting of central venous stenosis.

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.

To compare the early postarrest inflammatory cytokine response between animals administered amiodarone (AMIO) and lidocaine (LIDO) intra-arrest during resuscitation from ventricular fibrillation (VF). Domestic swine (n=32) were placed under general anesthesia and instrumented before spontaneous VF was induced by balloon occlusion of the left anterior descending coronary artery. After 7 min of VF, standard ACLS resuscitation was performed and animals were randomized to either bolus AMIO (5 mg/kg, n=13) or LIDO (1 mg/kg, n=14) for recurrent or refractory VF. A non-antiarrhythmic (n=5) was also used for comparison. Following return of spontaneous circulation (ROSC), tumor necrosis factor (TNF)-α levels were drawn at 30 and 60 min. Groups were comparable with respect to prearrest hemodynamics and resuscitation variables. In the postarrest period, the LIDO and non-antiarrhythmic group demonstrated virtually identical TNF-α response trajectories. However, TNF-α levels were significantly higher in AMIO- than LIDO-treated animals at 30 min (geometric mean 539 versus 240 pg/mL, 2.2-fold higher, 95% confidence interval [CI] 1.3–3.8-fold higher, P=0.003) and at 60 min (geometric mean 570 versus 204 pg/mL, 2.8-fold higher, 95% CI 1.1–7.0-fold higher, P=0.03). Significant differences in the postarrest TNF-α levels were observed between animals treated with AMIO as compared to those treated with LIDO. Improved rates of ROSC seen with AMIO may come at the expense of a heightened proinflammatory state in the postcardiac arrest period.

The management of cardiac arrest during coronary angiography and intervention presents substantial challenges. Patients presenting with ST-segment elevation myocardial infarction or following resuscitation from cardiac arrest are at greatest risk and may represent a significant portion of patients in some centers. Timely and effective cardiopulmonary resuscitation (CPR), with manual chest compressions is the primary mode of support though novel circulatory assist devices may have some role. To this end, the use of mechanical compression devices provides multiple patient- and provider-level benefits. This series provides a description of the use of the LUCAS mechanical CPR device and examples of coronary imaging and intervention during mechanical CPR.

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.

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Endothelin-1 (ET-1) increases in the ischemically induced ventricular fibrillation (VF) swine model of cardiac arrest and affects outcome by potentially attenuating the hemodynamic response to epinephrine. Fifty-one swine underwent percutaneous left anterior descending occlusion. Seven minutes postonset of ischemic VF, cardiopulmonary resuscitation (CPR) was initiated. If VF persisted after 3 shocks, 1 mg of epinephrine was given. ET-1 (collected at baseline and every 5 min until VF onset) was assayed with ELISA. Bayesian multivariate logistic regression analysis compared peak ET-1 levels with the binary outcome of a positive coronary perfusion pressure response of >20 mmHg following epinephrine. Sixteen animals (31%) failed to achieve a positive response. Restoration of spontaneous circulation (ROSC) was observed in 1/16 (6.3%) of epinephrine nonresponders and 20/35 (57.1%) of epinephrine responders (P=0.0006). The median peak ET-1 level was 2.71 pg/mL [interquartile range (IQR) 1.06–4.40] in nonresponders and 1.69 pg/mL (IQR 0.99–2.35) in responders. ET-1 levels were inversely associated with epinephrine response with a median posterior odds ratio (OR) of a coronary perfusion pressure response of 0.72 (95% confidence interval [CI] 0.48–1.06) for each one-unit increase in ET-1 and a probability that the associated OR is

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 …

We sought to describe the use of the TandemHeart percutaneous left ventricular assist device (PVAD) in a group of high-risk patients undergoing complex cardiovascular procedures.There is a substantial risk of acute decompensation and death in patients with cardiogenic shock or a reduced cardiac reserve undergoing high-risk cardiovascular interventions. The TandemHeart PVAD provides near-total hemodynamic support in this setting.Thirty-seven high-risk patients underwent placement of the TandemHeart PVAD during 38 separate procedures between April 2007 and April 2009. PVAD insertion was considered emergent if a patient was not expected to survive more than 6 hours without PVAD support. Technical success was defined as successful initiation of the PVAD and completion of the intended interventional procedure.All 37 patients were in cardiogenic shock or undergoing complex coronary and valvular interventions with a high probability of hemodynamic collapse. The mean (+/- standard deviation) patient age was 73 +/- 14 years; 97% were in either NYHA class III-IV heart failure or cardiogenic shock; and the mean EuroSCORE was 11 +/- 3.4. Indications for ventricular assist device placement included critical aortic stenosis (n = 8), severe left main coronary stenosis (n = 18), severe multivessel coronary stenosis (n = 19) and severe cardiomyopathy (n = 23). Four patients were being managed for fulminant myocarditis, ventricular free-wall rupture, flail mitral valve or severe paravalvular leak. Despite their critical status and frequent (82%) need for post-procedure blood transfusion, this complex and high-risk patient population tolerated PVAD-supported intervention well and technical success was achieved in all patients. Seventy-one percent of patients survived to hospital discharge with improved functional status. Most deaths occurred in patients not expected to survive due to their moribund status and multiorgan failure.This experience demonstrates the utility and effectiveness of TandemHeart PVAD support in patients with advanced disease, critical clinical status and limited therapeutic options.

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