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Thrombotic complications associated with coronavirus disease 2019 (COVID-19) have been described; these have mainly included venous thromboembolic events. Limited literature is available regarding arterial thrombosis. Acute limb ischemia is associated with severe complications that can result in significant morbidity and mortality. Herein, we report 3 cases of COVID-19 infection complicated by arterial thrombosis in the form of acute limb ischemia. Our case series adds to the limited literature regarding arterial thrombosis.

Introduction Cardiovascular complications related to coronavirus disease 2019 (COVID‐19) have led to the need for echocardiographic services during the pandemic. The present study aimed to identify the echocardiographic findings in hospitalized COVID‐19 patients and their utility in disease management. Methods We included patients who were diagnosed with COVID‐19 using polymerase chain reaction and those who underwent echocardiographic examination during their hospitalization. Results Altogether, 45 patients were evaluated. The mean age was 61.4 ± 12.2 years. Hypertension (n = 29, 64%) and diabetes mellitus (n = 25, 55%) were the most common comorbidities followed by congestive heart failure (n = 11, 24%), coronary artery disease (n = 9, 20%), and valvular heart disease (n = 3, 7%). Eight patients (18%) showed evidence of myocardial injury, as suggested by elevated troponin levels. Brain natriuretic peptide was elevated in 14 patients (36%), and 14 patients had left ventricular dysfunction in the form of reduced ejection fraction (31%). Right ventricular (RV) dilatation was observed in six patients, and five patients had reduced RV ejection fraction. RV pressure and volume overload were observed in three patients. RV thrombus was observed in one patient. Pulmonary pressure was elevated in 10 patients (24%). Conclusion Two‐dimensional echocardiography can be an important bedside tool for the assessment of cardiovascular abnormalities and hemodynamic status of COVID‐19 patients.

Introduction Coronary Artery Disease (CAD) continues to be on the rise not only in the Western developed world but also affecting the South Asian race, particularly Bangladeshis. The objectives of this study were as follows: To determine whether or not risk factors of Bangladeshis differ from non-Bangladeshis, whether there is any difference in the extent of CAD for both groups, and if there are risk factors that can significantly affect the extent of CAD. Methods All patients with a diagnosis of CAD admitted to our 800-bed tertiary care hospital between January 2001 and December 2015 were retrospectively analyzed. We reviewed the age, sex, body-mass index (BMI), cardiac risk factors such as family history of CAD, dyslipidemia, hypertension, diabetes and smoking. We also reviewed coronary angiographic findings of these consecutive 150 Bangladeshis and a randomly selected group of 193 non-Bangladeshis. Results A total of 343 medical records were evaluated, this included two groups: 193 non-Bangladeshis and 150 Bangladeshi subjects. The Bangladeshi group was older than the non-Bangladeshi group (63.49 vs 59.22, p-value=0.001), and included a larger proportion of males than the non-Bangladeshi group (28.7% vs 15.68%, p-value=0.0116). Bangladeshi subjects are more likely to be smokers than non-Bangladeshi (11.75% vs 6.67%, χ2=12.7, p-value=0.0004). Non-obstructive, 1-vessel, 2-vessel and 3-vessel accounts for 13.33%, 36.67%, 22%, and 28% for Bangladeshis, and 16.39%, 20.77% 34.43% and 28.42% for non-Bangladeshis, respectively. The difference of extent of CAD is significant between two groups (χ2 =12.397, p-value=0.0061). The findings suggest that Bangladeshi ethnicity has almost 2 times the likelihood of having 1-vessel CAD at coronary angiography (OR=2.361, 95% CI 1.452-3.839, p=0.0005). Conclusion This study is a pivotal starting point for further evaluating the link between Bangladeshis and CAD. In our study we found that being Bangladeshi increases the risk of having CAD and may be an independent risk factor for multi-vessel CAD.

Background: The aim of the study was to compare the efficacy and safety of bivalirudin versus unfractionated heparin (UFH) in patients with acute myocardial infarction who undergo percutaneous coronary intervention (PCI). Earlier trials comparing bivalirudin and UFH during PCI demonstrated that bivalirudin caused less bleeding with more stent thrombosis. Since then, adjunct antiplatelet strategies have evolved. Improved upstream platelet inhibition with potent P2Y12 inhibitors decreased the need for routine glycoprotein IIb/IIIa inhibitor (GPI), resulting in similar outcomes among UFH and bivalirudin. Therefore, the role of bivalirudin in modern PCI practices is questionable. Methods: We utilized Cochrane Review Manager (RevMan) 5.3 to perform a meta-analysis of seven randomized controlled trials (RCTs) with 22,844 patients to compare bivalirudin to UFH in patients with acute myocardial infarction requiring revascularization. Results: There was no difference between bivalirudin and UFH regarding major adverse cardiac events (MACE), risk ratio (RR) 0.99, 95% confidence interval (CI) 0.87 - 1.12; P = 0.83) or cardiovascular mortality (RR 0.87, 95% CI 0.71 - 1.07; P = 0.18). Bivalirudin increased acute stent thrombosis (RR 2.77, 95% CI 1.49 - 5.13; P = 0.001), which was only significant among ST-elevation myocardial infarction (STEMI) only trials. Bivalirudin caused less major bleeding (RR 0.66, 95% CI 0.49 - 0.90; P = 0.007), which was negated when GPI was used provisionally (RR 0.93, 95% CI 0.64 - 1.33; P = 0.67). Conclusions: Among patients with acute myocardial infarction who underwent PCI, bivalirudin and UFH demonstrated similar MACE and cardiovascular mortality. Bivalirudin increased acute stent thrombosis, which was more remarkable among STEMI. Bivalirudin decreased major bleeding, but this benefit was negated when GPI was used provisionally. Cardiol Res. 2019;10(5):278-284 doi: https://doi.org/10.14740/cr921

BACKGROUND AND OBJECTIVES: To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetic ketoacidosis (DKA) -- a single center tertiary hospital experience MATERIALS AND METHODS: A retrospective study was conducted among patients admitted to our hospital in the United States between March 1st and June 15th, 2020 with DKA and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection known as COVID-19 We compared the baseline characteristics, laboratory data, and clinical course between survivors and nonsurvivors to identify the risk factors associated with mortality in the patients with DKA RESULTS: A total number of 43 patients were included in this study The median age was 52 years Thirty-three (76 7%) patients were male Median value of initial glucose on presentation was 553 mg/dL (300 0-1927 0 mg/dL) On admission, 33 (76 7%) patients had glycated hemoglobin (HbA1c)>=8% (64 mmol/mol) and HbA1cwas not obtained in 10 (23 3%) patients Acute kidney injury (AKI) was seen in 37 (86 0%) patients, 6 (14%) patients required renal replacement therapy and 22 (51 2%) required mechanical ventilation Among the 43 patients, 25 (58 1%) died Out of 25 patients who died 15 (60 0%) were Hispanics, 6 (24 0%) were White, 3 (12 0%) were African American, 1 (4%) was Arabic, and 1 (4%) was Asian The patients who died were older in age than who survived (mean age 58 +/- 6 13 vs 46 +/- 9 39;p = 0 023) Some 95% of the patients requiring mechanical ventilation died (odds ratio [OR]: 89 25;95% confidence interval [CI]: 9 10-874 96);p=0 001) Compared to survivors, nonsurvivors had significantly higher d-dimer (13 00 +/- 3 20 mcg/mL vs 6 15 +/- 3 66 mcg/mL;p< 0 006) and peak ferritin values (2763 66 +/- 1105 32 ng/mL vs 835 16 +/- 257 07 ng/mL;p= 0 016) Conclusion: Our retrospective study shows COVID-19 infection may present as DKA in patients with diabetes mellitus (DM) Older age, mechanical ventilation, elevated d-dimer, and ferritin are associated with poor prognosis in these patients Our study shows that COVID-19 is associated with substantial mortality in DKA patients and adds to the limited literature available regarding poor risk factors associated with mortality in these patients

Influenza and coronavirus disease 2019 (COVID-19) are both contagious respiratory illnesses, but they are caused by different viruses. COVID-19 pandemic is caused by a novel virus - severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Influenza is an infectious respiratory disease, caused by influenza A and influenza B viruses. We describe the three cases of influenza and COVID-19 co-infection.

Chronic total occlusion (CTO) of coronary artery remains the Achilles heel of the interventional cardiologist and is present in a significant proportion of referrals for coronary artery bypass graft surgery (CABG); however, with the development and standardization of modern CTO recanalization techniques, it has been able to achieve excellent success while coping with lesions of increasing complexity. Nevertheless, failure to recanalize despite the development of new techniques still remains one of the challenges in the field of interventional cardiology. Spontaneous recanalization has been described in nonocclusive coronary artery dissections in detail; none has addressed the possibility of spontaneous recanalization after failed percutaneous coronary intervention (PCI). We report a case of spontaneous but delayed recanalization of CTO of left anterior descending artery 3 years after attempted but failed revascularization during PCI.

Introduction Brugada Syndrome typically presents with sudden nocturnal arrhythmias. Diagnosis may be challenging due to variable and transient electrocardiogram patterns and nondiagnostic provocation studies. Genetic testing can establish the etiology, but results may be inconclusive with variants of uncertain significance. Case A 24-year-old male with family history of sudden cardiac death was found unresponsive due to seizure. He was hemodynamically stable. ECG showed saddle-back ST elevations in V1 and V2. Procainamide challenge was negative. We subsequently performed genetic testing, which demonstrated AKAP9 variant. Discussion AKAP9 is a scaffolding protein that facilitates phosphorylation of delayed-rectifier potassium channels. The AKAP9 variant alters potassium current causing disordered repolarization and ventricular reentry. It has been previously linked to other channelopathies, but its pathogenicity is fully undetermined. Conclusion Genetic testing is a useful tool to determine the origin of channelopathy, but inconclusive results with variants of uncertain significance should be clinically correlated.

Bleeding is a common complication of cardiac surgery, accounting for a significant proportion of the total transfusions performed in the United States and Europe. The relationship between platelet reactivity, bleeding, and other adverse events after coronary artery bypass graft surgery (CABGS) has been incompletely characterized. This study investigated the relationship between platelet reactivity and bleeding as a clinical outcome after successful CABGS. A total of 238 patients who underwent CABGS were retrospectively followed for postoperative bleeding. Platelet reactivity unit (PRU) values for all patients were obtained preoperatively to assess the platelet reactivity. The data showed that a range of 180-200 PRU suggests the likelihood of bleeding after CABGS (P = 0.004), with a statistically significant association only for dual antiplatelet therapy with aspirin and clopidogrel. In conclusion, by using PRU values as a method to assess platelet reactivity and antiplatelet responsiveness, our findings suggest that it may be possible to stratify patients undergoing CABGS for the risk of postoperative bleeding particularly patients on dual antiplatelet therapy.

Fractional flow reserve (FFR) is a standardized and well-established method frequently used in clinical practice to evaluate the hemodynamic significance of epicardial coronary stenosis identified by coronary angiography. It is based on the change in the pressure gradient across the stenosis after the achievement of maximal hyperemia of the coronary circulation which is commonly induced by intravenous (IV) or intracoronary (IC) administration of adenosine. Here, we have described three cases of IC adenosine-induced ventricular arrhythmias during FFR measurement from our institution, and after literature review we found that all the cases of ventricular arrhythmias induced by adenosine during FFR measurement were observed where it was administered via IC route. Although a causal relationship between the use of IC adenosine during FFR measurement and the induction of ventricular arrhythmias is not yet established, we suggest using IV adenosine as the preferred route of administration until we better understand the incidence and mechanism underlying this phenomenon.

Cardiac lesions resulting from blunt chest injuries can present as cardiac contusion; ventricular free wall rupture; ventricular septal rupture; and valvular lesion [1].

The purpose of this analysis was to evaluate the cardioprotective benefit of β blockers in preventing anthracycline-induced cardiotoxicity (AIC) in breast cancer patients. Anthracyclines are the cornerstone treatment for breast cancer. Yet, their use has declined in the last decade due to associated AIC. Although β blockers may protect left ventricular (LV) function, previous trials were underpowered with equivocal results. The authors systematically searched online databases through August 2018 for studies evaluating effectiveness of β blockers in preventing AIC in breast cancer patients. We analyzed 9 studies including 771 patients. Data on converting-enzyme inhibitors, trastuzumab, or other malignancies were excluded. The primary outcome was comparison of postchemotherapy LV ejection fraction (LVEF) between β blocker and placebo. Secondary outcomes were changes in global longitudinal strain, LV end-diastolic diameter (LVEDD), and diastolic function parameters, as assessed by 2D echocardiogram and MRI. The mean pre-chemotherapy LVEF was >60% in all studies. Our pooled analysis demonstrated significantly higher LVEF postchemotherapy in the β blocker group in comparison to placebo: mean difference −3.84 with 95% confidence interval [−(6.19 to 1.48) p = 0.001]. The absolute change in EF also favored β blockers: mean difference −3.66 with 95% confidence interval [−(6.20 to 1.12) p = 0.005]. Diastolic function, global longitudinal strain, and LVEDD were also preserved by β blockers, but only LVEDD reached statistical significance. In conclusion, this study suggests that β blockers during anthracycline chemotherapy may prevent cardiotoxicity by preserving LV function.

Background Obesity is associated with right ventricular (RV) dysfunction, but its effect on RV remodeling in patients with pulmonary hypertension (PHTN) has not been studied. We evaluated the effect of obesity, and its interplay with diabetes, in patients with PHTN using RV echocardiographic strain imaging. Methods One hundred eighty-five patients underwent echocardiographic imaging and pulmonary artery pressure was calculated using tricuspid regurgitation jet velocity. From focused RV apical-four-chamber view, global and mid peak systolic RV free wall longitudinal strain (FWLS) was calculated using speckle-tracking software. Results Global and mid RV FWLS in patients with PHTN (N.=84) was lower (-16.8±7 vs. 18.9±6.3, P=0.035 and -11.2±12.8 vs. -18.9±9.2, P=0.002 respectively) compared with patients without PHTN (N.=101). Among patients without PHTN, obese patients (BMI>30) had lower global and mid RV FWLS (-17.2±6.2 vs. -20.3±5.7, P=0.012 and -17.6±7.2 vs. -21.9±7.3, P=0.004), even after excluding diabetic patients (Mid RV FWLS -18.2±6.8 vs. -22.1±8, P=0.032). Among patients with PHTN, obese patients had similar RV FWLS compared with non-obese patients (P=0.46). However, on excluding diabetic patients from PHTN group, obese patients with PHTN had higher global and mid RV FWLS (-21.7±5.7 vs. -16.1±8, P=0.017 and 23.8±4.8 vs. -17±9.4, P=0.009 respectively) compared to non-obese patients which suggests a protective effect of obesity on RV function in patients with PHTN. Conclusions Obesity is associated with subclinical RV dysfunction as assessed by RV strain imaging, but paradoxically it may confer a protective effect on RV function once the patient develops PHTN. Future studies should evaluate the clinical impact of this paradox.

Atherosclerosis is chronic disease, the prevalence of which has increased steadily as the population ages. Vascular injury is believed to be critical initiating event in pathogenesis of spontaneous atherosclerosis. Syndrome of accelerated atherosclerosis has been classically described in patients undergoing heart transplantation, coronary artery bypass graft, and percutaneous transluminal coronary angioplasty. In contrast to spontaneous atherosclerosis, denuding endothelial injury followed by thrombus formation and initial predominant smooth muscle cell proliferation is believed to be playing a significant role in accelerated atherosclerosis. There is no universal definition of rapid progression of atherosclerosis. However most studies describing the phenomenon have used the following definition: (i) > or = 10% diameter reduction of at least one preexisting stenosis > or = 50%, (ii) > or = 30% diameter reduction of a preexisting stenosis

We report a case emphasizing the importance of including type A acute aortic dissection in the differential diagnosis of patients presenting with compete heart block, where emergent surgery is the treatment of choice and any delay in diagnosis and treatment can be catastrophic.

Introduction: Drug-eluting Stent(DESs) have demonstrated improved patency and freedom from target lesion revascularization compared with Bare-Metal stents or Percutaneous Transluminal Angioplasty(PTA); however, the effect on clinical outcome parameters, such as limb salvage and wound healing, remains unidentified. We present a direct comparison of clinical outcomes in patients who underwent DES vs PTA. Methods: We collected data of patients who underwent infra-popliteal arterial interventions at our institution. Clinical end points analyzed were all cause mortality, target vessel revascularization, primary vessel patency, and target limb major and minor amputations. Differences between two groups were analyzed by chi square for categorical variables and t test for continuous variables. Statistical significance was considered for P values less than .05 in a 2-sided test. Results: Total of 83 cases, n=42 in DES group and n=41 in PTA group were analyzed. Mean age was 71.6 years (range 49-95). Out of the total 83 patients in the study 45 had a history of diabetes (54%) and 51 (61%) were current /past smokers. Average follow up period of 14 months for both the groups. Primary vessel patency was defined as absence of ≥50% restenosis on follow up. During the follow up period vessel patency in DES group [69% (n=29/42)] was significantly higher as compared to 36% (15/41) in PTA group (P=0.04, odds ratio 3.867, 95% Confidence interval: 1.5 - 9.6). Target vessel revascularization in DES group was 24% (10/42) as compared to 32% (13/28) in PTA group (P=0.47, odds ratio 0.67, 95% confidence interval: 0.26 - 1.77). Target limb amputation was 10% (4/42) in DES group as compared to 24% (10/41) in PTA group (P = 0.085), odds ratio 0.33, 95% confidence interval: 0.09 - 1.14). All cause mortality in both the groups were at 10%, 4/42 in DES group and 4/41 in PTA group (P=1, odds ratio 0.97, 95% confidence interval: 0.23 - 4.19). Conclusion: To conclude primary vessel patency was superior in DES group as compared to PTA group. Target limb amputation rates were higher in PTA group but not statistically significant. Target vessel revascularization and all cause mortality were similar in both the groups. Thus primary treatment with DES should be considered in patients with infra-popliteal PAD.

Rheumatoid arthritis (RA) is a systemic disorder that is chronic in nature and difficult to treat. RA presents in many variants. Here we present an interesting case only seldom described before. Our patient presented to emergency room with acute shortness of breath and was seen to have acute pulmonary edema. Patient later had urgent echocardiography which revealed severe mitral regurgitation from ruptured anterior leaflet. Patient was taken for heart valve replacement and was found to have RA nodule on ruptured leaflet. There are cases involving aortic valve but to our knowledge there are no reports of RA nodule on mitral leaflet.

Infective endocarditis (IE) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). The study aim was to evaluate the demographic, clinical, microbiological and inpatient mortality data of IE in hemodialysis patients.Data were analyzed for all IE patients admitted to the authors' 800-bed tertiary care hospital between January 2001 and December 2014. These data included demographics, comorbidities, clinical and microbiological characteristics, echocardiographic findings, complications, outcomes, and in-patient mortality.A total of 296 patients, including 52 on hemodialysis, was admitted with a diagnosis of IE. The median age of patients with ESRD (28 females, 24 males) was 55.9 ± 15.47 years. The prevalences of comorbidities such as hypertension (80%) and diabetes mellitus (46%) were significantly higher in ESRD patients, whereas other comorbidities were similarly distributed in both groups. The mitral valve was the most commonly involved (55.8%), followed by aortic (21.7%), tricuspid (21.2%) and pulmonary (1.9%) valves. Staphylococcus aureus was the most common organism (40%), followed by Enterococcus sp. (13.7%), Gram-negative staphylococci (13.7%), coagulase-negative staphylococci (11.5%), and Streptococcus sp. (5.7%). Polymicrobes were found in 11.5% of patients and cultures were negative in 19%. The mean ejection fraction in these patients was 42 ± 4.19% and the mean area of vegetation was 63.5 ± 40 mm2. The in-hospital course of 11 patients was complicated by embolic events, while three patients had acute heart failure and one patient had heart block secondary to IE. A total of four patients (7.7%) died during the index hospitalization.IE in patients receiving chronic hemodialysis is a very frequent occurrence. Its diagnosis is complex and its presence should be considered in all hemodialysis patients with bacteremia. In the present study the etiology was shown to be multifactorial, with the mitral valve being the most commonly involved and S. aureus the most common organism.

A 24-year-old male with past medical history of hypoplastic left heart syndrome and staged reconstructive surgery in infancy culminating in the Fontan circulation presented to the hospital with a chief complaint of chest pain described as an “elephant sitting” on his chest. Initial 12-lead electrocardiogram revealed 2-mm ST segment elevation in inferior leads, 3-mm ST-segment elevation in anterolateral precordial leads V3 and V4, and 2-mm ST-segment elevation in V5 and V6, with right axis deviation. He was transported emergently to the cardiac catheterization laboratory where coronary angiography revealed complete occlusion of multiple anomalous branches of the right coronary system with hazy appearance suggesting the presence of thrombotic material. An aspiration catheter was used successfully to reestablish TIMI grade III flow. The patient was treated with aspirin, brilinta (ticagrelor), and anticoagulation with vitamin K antagonism to prevent recurrent thromboembolic complications.

Aims Type 2 diabetes has grown to epidemic proportions in the U.S. and physical activity levels in the population continues to remain low, although it is one of the primary preventive strategies for diabetes. The objectives of this study were to estimate the direct medical costs of type 2 diabetes attributable to not meeting physical activity Guidelines and to physical inactivity in the U.S. in 2012. Methods This was a cross sectional study that used physical activity prevalence data from the Behavioral Risk Factor Surveillance System to estimate the population attributable risk percentage for type 2 diabetes. These data were combined with the prevalence and cost data of type 2 diabetes to estimate the cost of type 2 diabetes attributable to not meeting physical activity Guidelines and to inactivity in 2012. Results The cost of type 2 diabetes in the U.S. in 2012, attributable to not meeting physical activity guidelines was estimated to be $18.3 billion, and that attributable to physical inactivity was estimated to be $4.65 billion. Based on sensitivity analyses, these estimates ranged from $10.19 billion to $27.43 billion for not meeting physical activity guidelines and $2.59 billion–$6.98 billion for physical inactivity in the year 2012. Conclusions This study shows that billions of dollars could be saved annually just in terms of type 2 diabetes cost in the U.S., if the entire adult population met physical activity guidelines. Physical activity promotion, particularly at the environmental and policy level should be a priority in the population.

Objective Less than 10% of patients presenting with acute myocardial infarction (AMI) are young adults. The primary objective of this study was to provide an overview of similarities and dissimilarities among younger and older patients presenting with AMI with the expectation of using the information as an aid in primary and secondary preventions in the future. Methods From the database of 3527 patients with AMI admitted from January 2001 to December 2008, young adults aged 21-40 years (n = 43) who were diagnosed with ST-segment elevation myocardial infarction were identified. They were then compared with their older counterparts who were admitted from January 2007 to December 2008 subdivided into age groups of 41-60 (n = 86) and 61-80 years (n = 51). Data on clinical cardiovascular risk factors, demographic features, and angiographic findings were gathered and analyzed. Results Only 2.58% of ST-segment elevation myocardial infarction patients who were admitted to our hospital over an 8-year period were less than 40 years. Young adults were found to be predominantly male patients (P = 0.04) and had positive family history for coronary artery disease (P = 0.0005). Diabetes and hypertension were less prevalent in the younger group (P = 0.048 and 0.078). Analysis of lipid profile showed comparatively higher total cholesterol, low-density lipoprotein and high-density lipoprotein values in the younger group (≤ P = 0.004). Angiographically, youngsters had propensity toward single-vessel involvement (P = 0.0001). Conclusion The risk factor profile and the angiographic involvement differ considerably in the high-risk younger adults and substantiate the need for an aggressive approach directed toward primary and secondary preventions of premature cardiovascular disease.

Atypical forms of Takosubo cardiomyopathy include mid-ventricular, basal and focal. Focal type is the rarest type, accounting for 1.5% of all cases. A 48 year old female was admitted for seizure and near drowning incident. EKG revealed ST depressions in the inferior-lateral leads with elevated

Background: The purpose of this study was to determine the value of transesophageal echocardiography (TEE) in determining the presence of cardiac manifestations that required anticoagulation in patients presenting with acute stroke. Methods: Of 626 consecutive stroke patients who underwent TEE, 188 patients with no obvious etiology for stroke were subcategorized according to age. TEE results were analyzed for cardiac findings suggestive of a cause for embolic stroke, including complex atheromas in the arch/ascending aorta, patent foramen ovale (PFO), atrial septal aneurysm (ASA), and intracavitary thrombi. Data were analyzed using Fisher's exact test. Results: Of 188 patients, 66% (125/188) were older than 50 years and 34% (63/188) were younger than 50 years. The incidence of complex atheroma was 12.8% (16/125) in patients older than 50 years as compared to 0% (0/63) in patients who were younger than 50 years (P = 0.002). In patients older than 50 years, findings that indicated a need for anticoagulation based on TEE results were found in 22.4% (28/125) (atheroma = 16, PFO = 12, ASA = 5, thrombus = 3, PFO + ASA = 1) compared to 14.3% (9/63) (atheroma = 0, PFO = 5, ASA = 2, thrombus = 2, PFO + ASA = 1) in patients younger than 50 years. Conclusions: TEE plays an important role in suspected embolic stroke patients of all age groups. Due to the higher incidence of complex atheromas in patients older than 50 years of age, TEE might be of added importance in identifying the candidates who may benefit from anticoagulation. (Echocardiography 2010;27:1086-1092)

Background Limited information is available regarding outcome of very elderly patients referred for percutaneous coronary intervention (PCI). Purpose This study aimed to assess acute and intermediate term clinical outcomes among nonagenarians. Methods The study included 32 consecutive nonagenarian patients undergoing PCI between January 2001 to August 2006. There were 6 (19%) patients admitted with acute ST-segment elevation myocardial infarction (STEMI), 10 (31%) patients with non-STEMI, and 16 (50%) patients with unstable angina pectoris. Receiver-operator characteristic curve (ROC) analysis was done to define the relationship between heart rate, blood pressure, left ventricle ejection fraction, serum creatinine level, and mortality. Results Results: Immediate procedure success was achieved in 28 (88%) patients. Cumulative mortality at hospital discharge was 3(9%), at 6 months it was 6 (19%) and remained 6(19%) at 1 year follow-up. Conclusion Hypotension and low ejection fraction correlated with in-hospital mortality and worst clinical outcome. Procedural success does not appear to decline in nonagenarians. Copyright © 2009 Wiley Periodicals, Inc.

Objectives: Our goal is to report the first large multicenter data for percutaneous coronary intervention (PCI) of bifurcation disease with drug-eluting stents (DES) in the United States. Background: Bifurcation PCI remains a challenge to this date. There are limited data on outcomes of patients treated with bifurcation DES implantation, particularly in the United States. Methods: There were 161 patients with bifurcation disease [side branch (SB) ≥2-mm] treated with ≥1 sirolimus-eluting stents at 41 centers participating in the Stent deployment Techniques on cLinicaL outcomes of patients treated with the cypheR™stent (STLLR) trial. There was no protocol mandated strategy for bifurcation PCI. One-year outcome data were collected. Angiographic and clinical data were adjudicated independently. Results: There were 147 patients (91.3%) treated with single stent strategy. Only 14 (8.7%) patients received sirolimus-eluting stents implantation in both branches. Among patients with single stent strategy, double wire strategy (DW) was selected in 27 (18.4%) patients whereas single wire strategy (SW) was selected in 120 (81.6%) patients. There were 48 (32.7%) Medina 1,1,1 bifurcations treated with SW (n = 34; 70.8%) and DW (n = 14; 29.2%). There were 26 procedures started with SW which had SB dilatation during the procedure, one as a bailout (TIMI-1 grade flow in the SB). Overall 1-year death, myocardial infarction, and target lesion revascularization occurred in 2.4, 4.0, and 5.6%, respectively. There was no significant difference in clinical outcomes between SW and DW. SB dilatation was associated with a high rate of stent thrombosis (8.6%). Conclusions: Main branch stenting without SB protection is the most common approach utilized in the STLLR study, which may reflect contemporary DES bifurcation strategies in the Unite States. This strategy was associated with an acceptable low incidence of adverse outcomes at 1-year. © 2009 Wiley-Liss, Inc.

Summary Introduction: National consensus guidelines recommend that ST-segment elevation myocardial infarction (STEMI) patients achieve a door-to-balloon time of