Cardiology

Eidt, J.F. (2020). “Is a “petticoat” just cosmetic or like a “belt and suspenders”?” J Vasc Surg 72(3): 1121.

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Although it is clear that proximal thoracic endografting has improved the management of dissections involving the descending thoracic aorta, there remain significant challenges with the management of this condition. In the acute setting, excluding patients with impending or frank rupture, it is the treatment of malperfusion that takes first priority. In the chronic phase, aneurysmal degeneration in the uncovered visceral and infrarenal aorta occurs in 30% to 50% of patients and represents the Achilles heel of current endovascular management strategies. With the dual goals of reducing visceral malperfusion acutely and improving long-term aortic remodeling, a number of authors have proposed the placement of a bare-metal stent extension distal to the proximal thoracic endograft. The current article was designed to compare the outcomes of combined proximal covered stent grafting either with or without distal bare stenting. [No abstract; excerpt from article.].

Sudhakaran, S. and Choi, J.W. (2020). “Coronary Chronic Total Occlusion Antegrade Wire Technique to Successfully Cross a Common Iliac Chronic Total Occlusion from Retrograde Access.” Am J Cardiol 129: 118-119

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Percutaneous endovascular intervention is the preferred modality of revascularization for iliac arterial obstructive disease. Chronic total occlusions (CTO) of the iliac arteries can be uniquely challenging, as typically utilized polymer jacketed 0.035 in wires have a tendency to enter subintimal planes within the iliac artery or aorta, which consequently require complicated re-entry wire techniques. We present a case of a common iliac chronic total occlusion, initially unable to be crossed with a traditional 0.035 in polymer jacketed guidewire due to subintimal entry. Instead, using an antegrade coronary CTO wire escalation technique with a 0.014 in coronary CTO guidewire, the iliac occlusion was successfully crossed via the true lumen.

Brinkman, W.T. (2020). “DARTS Trial.” Ann Thorac Surg Aug 21;S0003-4975(20)31339-4. [Epub ahead of print.].

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The DARTS trial presented in this issue of The Annals was a prospective, nonrandomized, international trial of patients with acute DeBakey I dissections. During the period of deep hypothermic arrest, the Ascyrus Medical Dissection Stent (AMDS) was deployed antegrade across the aortic arch and into the descending aorta in the true lumen. It is important to note that the centers enrolled “all comers” in a consecutive manner with Debakey type 1 dissections with certain exclusion criteria (such as known connective tissue disorder, iatrogenic dissections, preoperative ongoing CPR, age 80, or an arch or ascending aneurysm greater than 45mm). The primary entry tear was present in the ascending aorta and was resected in all cases. Secondary entry tears in the aortic arch were not required to be resected and were treated per individual surgeon preference. Surprisingly, it’s important to also realize that this is perhaps the first prospective multicenter trial ever done for ATAAD in the medical literature.

Daoulah, A., Al-Faifi, S.M., Alhamid, S., Youssef, A.A., Alshehri, M., Al-Murayeh, M., Farghali, T., Maghrabi, M., Balghith, M., ElSayed, O., Alasmari, A., Arafat, A.A., Elmahrouk, A.F., Eldesoky, A., Refaat, W.A., Alshahrani, S.S., Ghazi, A.M., Al-Azizi, K.M., Dahdouh, Z. and Lotfi, A. (2020). “Spontaneous Coronary Artery Dissection in the Gulf: G-SCAD Registry.” Angiology Aug 13;3319720946974. [Epub ahead of print.].

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Data on spontaneous coronary artery dissection (SCAD) is based on European and North American registries. We assessed the prevalence, epidemiology, and outcomes of patients presenting with SCAD in Arab Gulf countries. Patients (n = 83) were diagnosed with SCAD based on angiographic and intravascular imaging whenever available. Thirty centers in 4 Arab Gulf countries (Kingdom of Saudi Arabia, United Arab Emirates, Kuwait, and Bahrain) were involved from January 2011 to December 2017. In-hospital (myocardial infarction [MI], percutaneous coronary intervention, ventricular tachycardia/fibrillation, cardiogenic shock, death, implantable cardioverter-defibrillator placement, dissection extension) and follow-up (MI, de novo SCAD, death, spontaneous superior mesenteric artery dissection) cardiac events were recorded. Median age was 44 (37-55) years, 42 (51%) were females and 28.5% were pregnancy-associated (21.4% were multiparous). Of the patients, 47% presented with non-ST-elevation acute coronary syndrome, 49% with acute ST-elevation myocardial infarction, 12% had left main involvement, 43% left anterior descending, 21.7% right coronary, 9.6% left circumflex, and 9.6% multivessel; 52% of the SCAD were type 1, 42% type 2, 3.6% type 3, and 2.4% multitype; 40% managed medically, 53% underwent percutaneous coronary intervention, 7% underwent coronary artery bypass grafting. Females were more likely than males to experience overall (in-hospital and follow-up) adverse cardiovascular events (P = .029).

Packer, M., Anker, S.D., Butler, J., Filippatos, G., Pocock, S.J., Carson, P., Januzzi, J., Verma, S., Tsutsui, H., Brueckmann, M., Jamal, W., Kimura, K., Schnee, J., Zeller, C., Cotton, D., Bocchi, E., Böhm, M., Choi, D.J., Chopra, V., Chuquiure, E., Giannetti, N., Janssens, S., Zhang, J., Gonzalez Juanatey, J.R., Kaul, S., Brunner-La Rocca, H.P., Merkely, B., Nicholls, S.J., Perrone, S., Pina, I., Ponikowski, P., Sattar, N., Senni, M., Seronde, M.F., Spinar, J., Squire, I., Taddei, S., Wanner, C. and Zannad, F. (2020). “Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure.” N Engl J Med Aug 29. [Epub ahead of print.].

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BACKGROUND: Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of hospitalization for heart failure in patients regardless of the presence or absence of diabetes. More evidence is needed regarding the effects of these drugs in patients across the broad spectrum of heart failure, including those with a markedly reduced ejection fraction. METHODS: In this double-blind trial, we randomly assigned 3730 patients with class II, III, or IV heart failure and an ejection fraction of 40% or less to receive empagliflozin (10 mg once daily) or placebo, in addition to recommended therapy. The primary outcome was a composite of cardiovascular death or hospitalization for worsening heart failure. RESULTS: During a median of 16 months, a primary outcome event occurred in 361 of 1863 patients (19.4%) in the empagliflozin group and in 462 of 1867 patients (24.7%) in the placebo group (hazard ratio for cardiovascular death or hospitalization for heart failure, 0.75; 95% confidence interval [CI], 0.65 to 0.86; P<0.001). The effect of empagliflozin on the primary outcome was consistent in patients regardless of the presence or absence of diabetes. The total number of hospitalizations for heart failure was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.70; 95% CI, 0.58 to 0.85; P<0.001). The annual rate of decline in the estimated glomerular filtration rate was slower in the empagliflozin group than in the placebo group (-0.55 vs. -2.28 ml per minute per 1.73 m(2) of body-surface area per year, P<0.001), and empagliflozin-treated patients had a lower risk of serious renal outcomes. Uncomplicated genital tract infection was reported more frequently with empagliflozin. CONCLUSIONS: Among patients receiving recommended therapy for heart failure, those in the empagliflozin group had a lower risk of cardiovascular death or hospitalization for heart failure than those in the placebo group, regardless of the presence or absence of diabetes.