Mark Wiley

INTRODUCTION: Patients with end-stage liver disease (ESLD) awaiting transplant are at increased risk of bleeding. Nevertheless, these patients routinely undergo cardiac catheterization for various indications. Safety and outcomes of cardiac catheterization in these patients are not well reported. METHODS: In a case-control study 43 patients with ESLD who underwent angiography for liver transplant work-up were compared to 43 age and gender-matched controls with no liver dysfunction. In-hospital outcomes and procedural variables were compared. RESULTS: Patients with ESLD had a lower baseline hemoglobin (12.1 ± 2.1 vs. 13.7 ± 1.8, P < 0.0005), lower platelet counts (86.8 ± 66 vs. 247 ± 80, P < 0.0001) and higher international normalized ratio (INR) (1.4 ± 0.2 vs. 1.1 ± 0.2, P < 0.0001) than controls. Among ESLD group, five (11.6%) patients received platelet transfusions, one received blood transfusion, and three patients (7%) with INR > 1.6 received fresh frozen plasma (FFP) compared with none in the control group. Smaller size (four French) vascular sheaths were used more frequently in the group with ESLD (16% vs. 4%, P = 0.04). There were no significant vascular or bleeding complications in either group. CONCLUSIONS: Elective cardiac catheterization can be safely performed in patients with ESLD with outcomes (vascular and bleeding complications, length of hospital stay and in-hospital mortality) similar to patients without liver disease despite significant thrombocytopenia and elevated INR in patients with ESLD. Practices such as platelet transfusion for platelets <60,000 μL, prophylactic FFP transfusion for INR ≥ 1.6, less frequent use of antiplatelet therapy and more frequent use of smaller vascular sheaths may have contributed to the safety of cardiac catheterization in ESLD patients.

Abstract Background Over the last decade, there has been a significant increase in the use of percutaneous left ventricular assist devices(p‐LVADs). p‐LVADs are being increasingly used during complex coronary interventions and for acute cardiogenic shock. These large bore percutaneous devices have a higher risk of vascular complications. We examined the vascular complication rates from the use of p‐LVAD in a national database. Methods We conducted a secondary analysis of the National In‐patient Sample (NIS) dataset from 2005 till 2015. We used the ICD‐9‐CM procedure codes 37.68 and 37.62 for p‐LVAD placement regardless of indications. We investigated common vascular complications, defining them by the validated ICD 9 CM codes. χ 2 test and t test were used for categorical and continuous variables, respectively for comparison. Results A total of 31,263 p‐LVAD placements were identified during the period studied. A majority of patients were male (72.68%) and 64.44% were white. The overall incidence of vascular complications was 13.53%, out of which 56% required surgical treatment. Acute limb thromboembolism and bleeding requiring transfusion accounted for 27.6% and 21.8% of all vascular complications. Occurrence of a vascular complication was associated with significantly higher in‐hospital mortality (37.77% vs. 29.95%, p &lt; .001), length of stay (22.7 vs. 12.2 days, p &lt; .001) and cost of hospitalization ($ 161,923 vs. $ 95,547, p &lt; .001). Conclusions There is a high incidence of vascular complications with p‐LVAD placement including need for vascular surgery. These complications are associated with a higher in‐hospital, LOS and hospitalization costs. These findings should be factored into the decision‐making for p‐LVAD placement.

OBJECTIVES: To assess the prognostic significance of high vs. low grade coronary artery ectasia (CAE) and the impact of antithrombotic or anticoagulant therapy on adverse cardiac outcomes. BACKGROUND: There is paucity of knowledge on the impact of angiographic characteristics in CAE or that of antithrombotic or anticoagulant therapy on outcomes. METHODS AND RESULTS: In this retrospective study, we reviewed angiograms and medical records of all cases of confirmed CAE (2001-2011). Extent of CAE was categorized using the Markis classification. Types 1 and 2 were categorized as high-grade and types 3 and 4 as low-grade CAE. Angiographic flow was recorded as normal or sluggish (<TIMI 3). Outcomes assessed were acute coronary syndromes and all-cause mortality on follow-up. The study included 317 patients with CAE (mean follow-up of 9.7 ± 2.3 years). High-grade CAE (n = 151) had a significantly higher incidence of ACS on follow-up (41% vs. 30%, P = 0.01; OR 2.0, CI 1.3-3.3, P = 0.01) despite similar underlying CAD. Sluggish coronary flow (irrespective of CAE grade) was also associated with a higher incidence of ACS (45% vs. 28%, P < 0.01; OR 2.25, CI 1.4-3.6, P = 0.01). Presence of both sluggish flow and high-grade CAE had an additive effect on occurrence of ACS (OR 4, CI 2.0-7.8, P < 0.01). Neither sluggish flow nor high-grade CAE were associated with mortality. Dual-antiplatelet therapy (DAPT) or use of oral anticoagulation was associated with a reduced incidence of ACS (17% vs. 34%, P = 0.03 and 29% vs. 42%, P = 0.02, respectively). CONCLUSION: The angiographic extent of CAE and sluggish coronary flow are independent predictors of future ACS despite good medical management. DAPT or oral anticoagulation reduces the risk of future ACS.

BACKGROUND: This study assessed the safety of intravenous adenosine infusion during fractional flow reserve (FFR) evaluation of intermediate coronary lesions in severe aortic stenosis (AS). In severe AS, the extent of underlying coronary artery disease (CAD) can be an important determinant for deciding between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). Hemodynamic assessment of coronary lesion severity using FFR may reduce the extent of revascularization needed and make TAVR more feasible in higher-risk patients (compared with coronary artery bypass surgery with SAVR). METHODS AND RESULTS: We retrospectively analyzed the demographic, clinical, and hemodynamic parameters of 72 patients with severe AS who underwent FFR procedure with intravenous adenosine infusion for hemodynamic assessment of intermediate coronary artery lesions. Severe AS patients were elderly, predominantly male, and had a high prevalence of peripheral arterial disease, prior myocardial infarction, left ventricular hypertrophy, and chronic kidney disease. Mean aortic valve area in these patients was 0.71 ± 0.24 cm². No patient with severe AS required discontinuation of the adenosine and all patients tolerated the infusion well. We observed a statistically significant reduction in systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) during adenosine infusion compared with the baseline values. However, no clinically significant adverse events occurred. CONCLUSION: In elderly patients with severe AS, adenosine infusion is safe and well tolerated during FFR evaluation of intermediate coronary lesions. There was a significantly greater drop in SBP, DBP, MAP, and HR with adenosine infusion as compared with baseline values. This, however, was not associated with clinically significant adverse events.