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Hopes for 2021

As 2020 concluded with all of the unprecedented events, with the tragedies people had to suffer and are still suffering from, with all the good and bad, we enter the New Year of 2021 with some hope; hoping for better health, better strategies to combat what we are dealing with in this pandemic, and being more responsible for each other.

COVID-19 Pandemic

COVID-19 pandemic has changed how we live our lives, and the impact of this pandemic will likely last at least a few years, if not more after the pandemic is over. There are a lot of “unknowns” about COVID-19 infection, including the long-term effects of this infection and the effectiveness of some medications, that we will get to encounter and manage in the next several years.

COVID-19 Vaccine

With multiple effective vaccines discovered recently, healthcare workers were given priority to get the vaccine, followed by more vulnerable patients, including the elderly and those with significant comorbidities. The Centers of Disease Control and Prevention (CDC) website provides helpful information on the currently available vaccines in the United States (US), Pfizer, and Moderna, including their storage, preparation, and expected side effects (Link is provided below) [1].  The hope is that by the Spring of 2021, 75% of the population in the United States will be vaccinated.  Moreover, efforts by international organizations, including the World Health Organization (WHO), to distribute the vaccine to all countries are ongoing [2].

COVID-19 New Strains

We have seen the discovery of new strains of COVID-19 infection in the United Kingdom and, most recently, the US. These new mutant strains of COVID-19 may not be covered by the available vaccines, as such, the vaccine is an additional layer of protection, with the other protection measures, including social distancing, masks, and hygiene, which may be the most important way to prevent the spread of these new strains at this point of time.

With all that being said, our hopes for a “normal 2021” depend on how we handle the COVID-19 pandemic, we may not see everything going back to normal in 2021, but we can work on making the initial right steps now so that we have less grief, less “loss,” fewer travel restrictions, with healthier and happier upcoming years!!

Special thank you to my sister, Rawan Ya’acoub, an assistant professor of Doctor of Pharmacy/Clinical Pharmacology at the University of Jordan in Amman, Jordan, who helped me write this blog, and for all of her support.

 

References

  • S. COVID-19 Vaccine Product Information: https://www.cdc.gov/vaccines/covid-19/info-by-product/index.html
  • COVID-19 vaccines: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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COVID-19 Vaccine: What We Need To Know

While we are living in the third peak of COVID-19 pandemic, we have been delighted to hear about the recent food and drug administration (FDA) approval of the COVID-19 vaccine, after trials involving hundreds or more of patients showed the vaccine safety and efficacy [1,2]. However, the COVID-19 vaccine is associated with some side effects, which in fact might be more common than the flu vaccine. Healthcare workers and first responders will have the priority to get the vaccine at many institutions given their high-risk work environment. So, I decided to share some knowledge about some of the side effects of the vaccine I recently read about and how institutions are planning to stagger the vaccines among their employees.

What are the side effects of the vaccine?

Side effects seem to be more common than the annual flu vaccine, with arm pain at the injection site, generalized fatigue and malaise, headaches, dizziness, fever, chills, nausea, vomiting, and diarrhea. Rare side effects include Bell’s palsy and temporary facial muscle paralysis. Most of these side effects are mild and resolve in a few days. These side effects occur more frequently after the second dose of the vaccine. These side effects actually suggest reactogenicity and that the immune system is responding to the vaccine [1,2].

Are there long-term adverse events of the COVID-19 vaccine?

This is still unknown and under close monitoring by FDA [1].

How will the vaccine change things from now on?

The COVID-19 vaccine is an additional protection layer, but it does not substitute the other protection measures we have been following; that means we should still conform to social distancing and follow hygienic instructions wherever we go till the pandemic is over. This pandemic has taught us all, as a healthcare professional and as members of the community, to be responsible for our actions toward each other and persist despite all the obstacles. The vaccine could be the first step that leads us back to “normal life” as long as we stay responsible for each other.

REFERENCES

[1] Walsh EE, Frenck RW Jr, Falsey AR, et al. Safety and Immunogenicity of Two RNA-Based Covid-19 Vaccine Candidates [published online ahead of print, 2020 Oct 14]. N Engl J Med. 2020;NEJMoa2027906. doi:10.1056/NEJMoa2027906

[2] Yuan P, Ai P, Liu Y, Ai Z, Wang Y, Cao W, Xia X, Zheng JC. Safety, Tolerability, and Immunogenicity of COVID-19 Vaccines: A Systematic Review and Meta-Analysis. medRxiv [Preprint]. 2020 Nov 4:2020.11.03.20224998. doi: 10.1101/2020.11.03.20224998. PMID: 33173896; PMCID: PMC7654888.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Highlights of “Not to Miss Sessions” at the #AHA20 Virtual Meeting!!

AHA20 virtual meeting has been packed by so many amazing sessions, covering all aspects of cardiovascular disease from basic science to clinical outcomes. I wanted to share some of the sessions “not to miss sessions” at AHA20 virtual meeting!!

Opening Session

Dr. Braunwald and Dr. Wenger, two of the legends in cardiology, took us back to history, structural racism, and correlated what we are living now during the pandemic and the social justice crisis to how it was when living in war!!!! Dr Harrington and Dr Yancy led a great discussion. Definitely, a very interesting talk that everyone should listen to!!

Structural Racism Session

This is a novel yet a wonderful session at AHA20!!! It is part of AHA leadership commitment to equity, diversity, social justice in healthcare across the nation and the globe. There were several amazing discussions with experts and leaders in the field, sharing data on how structural racism can in fact affect the health of both healthcare employees and patients, calling for action to increase diversity and inclusion in leadership positions for minorities and women. If you missed this session, you should check out the on-demand portal and listen to it. Kudos to everyone involved in this and who made this happen!!

Presidential Session

This was an inspiring session by Dr. Elkind, MD, AHA President about his journey in neurology and science. This was followed by an amazing talk by Nancy Brown, AHA CEO, emphasizing the AHA vision on social equity, diversity, and inclusion in research, science, and access to health care. Then, we watched many inspiring women receiving distinguished AHA awards for their excellence in leadership and academic achievement. They all share the AHA’s vision and commitment to lead science in order to have comprehensive policies and unite team efforts for better healthcare for all as well as bridge the AHA’s visions into actual practice not only across the nation and also across the globe.

Late-Breaking Science and Meet the Trialist Sessions

There are late-breaking science sessions on multiple days on various sub-specialties of cardiovascular diseases, including preventive cardiology, resuscitation, heart failure, interventional cardiology, structural heart disease, electrophysiology, among other specialties. Later each day, there are sessions where you can meet the trialist, ask questions through Q&A side chat and you’ll hear their input on the trials they presented earlier in the day.

Move More and Dance Break Session

This is a fun session to motivate us to move more!! It was the first session of each day on AHA20 but you can watch it on-demand anytime whenever you want!!

#AHA20 is packed with so many great sessions for all sub-specialties in cardiology!! I look forward to AHA21, and hopefully, it will be an in-person meeting next year!!

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Clinical trials in interventional cardiology to watch out for at the virtual AHA20!!

Our virtual AHA20 has started with all of the science, engagement and excitement!!! Since many of us are working and still want to squeeze in some time to check out what is going on at AHA20, I have decided to summarize clinical trials to look out for at AHA20 with their brief description.

Friday 11/13/2020

Trial Name Arrest Trial

 

Trial title Advanced Reperfusion Strategies For Refractory Ventricular Fibrillation Out-of-hospital Cardiac Arrest

 

Description In this trial,  patients (18-75 years old) with refractory ventricular fibrillation/pulseless ventricular tachycardia out-of hospital cardiac arrest, who are transferred by emergency medical services (EMS) with ongoing mechanical cardiopulmonary resuscitation (CPR) or who are resuscitated, were randomized to receive either early Extracorporeal Membrane Oxygenation (ECMO) or standard Advanced Cardiac Life Support (ACLS) Resuscitation [1]

 

Saturday 11/14/2020:

ALPHEUS, ATLANTIS, and RIVER Trials

Trial Name Alpheus Trial

 

Trial title Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting.

 

Description This is a multicenter study in stable patients undergoing elective PCI with a randomization between clopidogrel and ticagrelor. The primary ischemic endpoint is peri-procedural MI and myocardial injury and safety endpoint is bleeding by BARC definition [2].

 

Trial Name Atlantis Trial

 

Trial title Anti-Thrombotic Strategy After Trans-Aortic Valve Implantation (TAVI) for Aortic Stenosis

 

Description This trial looks at the strategy of anticoagulation with novel anticoagulant, apixaban, compared to the current standard of care in patients who had a successful TAVI. The randomization is performed according to the presence or absence of a mandatory indication for anticoagulation, including atrial fibrillation or venous thromboembolic disease [3].

 

Trial Name RIVER Trial

 

Trial title RIvaroxaban for Valvular Heart diseasE and atRial Fibrillation Trial

 

Description This trial compares Rivaroxaban Versus Warfarin In Patients With Bioprosthetic Mitral Valves And Atrial Fibrillation [4].

 

Sunday 11/15/2020:

One-Month DAPT

Trial Name One-Month DAPT

 

Description One month dual antiplatelet Therapy Followed By Aspirin Monotherapy After Drug Eluting Stent Implantation.

 

 

 

References:

  • ARREST trial: https://www.clinicaltrials.gov/ct2/show/NCT03880565
  • ALPHEUS trial: https://clinicaltrials.gov/ct2/show/NCT02617290
  • ATLANTIS trial: https://clinicaltrials.gov/ct2/show/NCT02664649
  • RIVER trial: https://clinicaltrials.gov/ct2/show/NCT02303795

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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How is the AHA leading the way in Cardiopulmonary resuscitation (CPR)?

In writing this last post as a junior blogger, I decided to highlight the tremendous efforts by the American Heart Association (AHA) to improve cardiovascular care in the field of cardiac arrest and cardiopulmonary resuscitation (CPR). As we know, the AHA is a worldwide leader in first aid, CPR, and Automated External Defibrillator (AED) training – educating millions of people globally in CPR every year. Here, I will share some fun facts about CPR, and you can refer to the AHA website for further details about this important topic.

Important CPR statistics

  • Majority of cardiac arrests occur outside of the hospital, with estimated 475,000 Americans dying from cardiac arrests every year [1]
  • Bystander CPR is a key component in the out-of-hospital “chain of survival” [Figure 1] and studies have shown it improves survival in cardiac arrest [1-3].

Figure 1: The adult out-of-hospital “chain of survival”. Each link of the chain from left to right is numbered 1 through 5: 1- Recognize cardiac arrest and activate the emergency response system, 2- early CPR with high-quality chest compressions, 3- Use AED for rapid defibrillation, 4- basic and advanced emergency services and 5- post-cardiac arrest care and advanced life support [2].

  • Bystander CPR has been increasing over the recent years in both men and women. Despite that, survival improved in men only, but not women [2]. This is important as it highlights that more work is needed to identify additional predictors of survival in women with cardiac arrest.
  • Efforts mandating CPR training in high schools in multiple states [5] and availability of AED in public places, including airports [Figure 2], have helped in increasing the awareness and familiarity of bystander CPR in cardiac arrest [4].

  • Figure 2: A photo of Automated External Defibrillator (AED) in one of the airports.

Personal Experience

From a personal experience, I have visited multiple high schools in my home country as well as in the United States, and have participated as an organizer in the sessions teaching high school students how to perform effective CPR. It is inspiring to see junior students interested in learning and saving lives. The takeaway from my experience is that engagement plays a major role in spreading the word and encouraging the general public to take the extra step and learn how to perform basic and advanced life support techniques.

In conclusion, it is important to remember that the general public are oftentimes our first “link” in the chain of survival; making them an important part of our efforts to improve survival and cardiovascular care in patients with cardiac arrest. A strong chain of survival improves survival and recovery after cardiac arrest. Although there have been improvements in CPR and advanced life support, there remains room for further improvement, and perhaps we can do our part by encouraging our patients, friends and relatives to take the first step and learn how to perform effective CPR and possibly how to use AEDs!!

I have added a few online references for those interested in sharing this with their patients and encouraging them to sign up for both the online and class programs [3,6]!!

References:

  • Meaney PA, Bobrow BJ, Mancini ME, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association [published correction appears in Circulation. 2013 Aug 20;128(8):e120] [published correction appears in Circulation. 2013 Nov 12;128(20):e408]. Circulation. 2013;128(4):417-435. doi:10.1161/CIR.0b013e31829d8654
  • Malta Hansen C, Kragholm K, Dupre ME, et al. Association of Bystander and First-Responder Efforts and Outcomes According to Sex: Results From the North Carolina HeartRescue Statewide Quality Improvement Initiative. J Am Heart Assoc. 2018;7(18):e009873. doi:10.1161/JAHA.118.009873
  • CPR facts and stats:

https://cpr.heart.org/en/resources/cpr-facts-and-stats

  • Chain of Survival:

https://cpr.heart.org/en/resources/cpr-facts-and-stats/out-of-hospital-chain-of-survival

  • Mandatory CPR training in high school:

https://www.sca-aware.org/schools/school-news/mandatory-cpr-training-in-us-high-schools

  • CPR AED and first aid classes:

https://cpr.heart.org/en/course-catalog-search

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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CardioPulmonary Resuscitation (CPR) in the Time of COVID-19

As we continue to see the increasing number of coronavirus disease 2019 (COVID-19) cases and amid the second peak of this pandemic in the United States (US), everyone from physicians to the general public should know how to approach and perform basic life support (BLS) with certain precautions and modifications of routine BLS protocols for patients with suspected or confirmed COVID-19 status. Importantly, rescuers should always balance the immediate needs of patients with their own safety. Several recently published articles have demonstrated that many patients with COVID-19 can present with cardiac arrest or experience cardiac arrest while hospitalized. In this post, I am going to share a few points on recommended modifications in order to ensure a safe yet effective CPR protocol for our patients.

  • Reduce Provider Exposure to COVID-19

Resuscitations carry added risks to rescuers and healthcare workers for many reasons. CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway [1]. It is important to keep in mind that these viral particles can remain suspended in the air with a half-life of around 1 hour per some reports and can be inhaled by those nearby [1]. In addition, resuscitation efforts require numerous providers to work in close proximity to each other and to the patient; thus, the advised social distancing protocols may not be applicable.

Strategies

  • Before entering the scene, all rescuers should don personal protective equipment (PPE) to guard against both airborne and droplet particles.
  • Limit personnel on the scene to only those essential for patient care.
  • In settings with protocols in place and expertise in their use, consider replacing manual chest compressions with mechanical CPR devices to reduce the number of rescuers whenever it is available and in patients who meet the manufacturer’s height and weight criteria.
  • It is important to clearly communicate the COVID-19 status to anyone arriving to the scene and when transferring patients to another setting.

 

  • Prioritize Oxygenation and Ventilation Strategies with Lower Aerosolization Risk
Strategies
  • Attach a high-efficiency particulate air (HEPA) filter securely [Figure 1], if available, to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths.
  • After healthcare providers assess the rhythm and defibrillate any ventricular arrhythmias, patients in cardiac arrest should be intubated with a cuffed tube at the earliest feasible opportunity. Connect the endotracheal tube to a ventilator with a HEPA filter when available.
  • Minimize the likelihood of failed intubation attempts by doing the following:
    • Assign the provider/approach with the best chance of first-pass success, and
    • Pause chest compressions while intubating with minimal disruption.
  • Video laryngoscopy may reduce exposure to aerosolized particles and should be considered.
  • Once on a closed circuit, minimize disconnections in order to reduce aerosolization.
  • Barriers can be used to minimize spread of the particles during aerosol-generating procedures (Figure 2).

Figure 1: A high-efficiency particulate air (HEPA) filter (arrow) is securely attached to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths [2].

Figure 2: Example of barriers potentially used to minimize the spread of the particles during aerosol-generating procedures [2].

  •  Consider the Appropriateness of Starting and Continuing Resuscitation

Like any cardiac arrest, it is important to know when resuscitation efforts are likely to be futile. Although the outcomes for cardiac arrest in COVID-19 are still unknown, the mortality for critically ill patients with COVID-19 is high, especially with increasing age and comorbidities, particularly cardiovascular disease. As such, it is critical to consider all these factors in determining the appropriateness of initial and continued resuscitation efforts, to weigh the likelihood of success against the risk to rescuers.

Strategies
  • Address goals of care with patients, or their proxies, in anticipation of the potential need for increased levels of care.
  • Healthcare systems and Emergency Medical Services (EMS) agencies should institute policies to guide frontline providers in determining the appropriateness of starting and terminating CPR for patients with COVID-19 on the scene, early in the process. The risk stratification and potential policies should be communicated to patients (or proxy) during discussions of goals of care.

In conclusion, there have been modifications to the routine CPR protocols in patients with suspected or confirmed COVID-19. With the increasing number of COVID-19 cases, it is very important, for us as physicians and for the general public as well, to review recommended modifications to BLS protocols and apply them where possible, in a step to win the battle against this virus during these unprecedented times!!

References

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Transcatheter Interventions of the “Forgotten Valve”

We have witnessed tremendous advances in the transcatheter therapies for various cardiac conditions in the past couple of decades! The “forgotten valve” usually refers to the tricuspid valve, due to the fact that most of the research in the literature is on the left-sided heart valves. In the past two decades, although there has been progressive interest in implementing transcatheter techniques to treat tricuspid valve pathologies, we are still in the early stages of this development.  So, I decided to write briefly about some of these transcatheter techniques, which will continue to improve in the future; as we get more experience with these tools and continue to implement the advances in related technologies.

Tricuspid Valve Interventions

There are two main types of transcatheter interventions of the tricuspid valve: repair and replacement.

  • Tricuspid Valve Repair

Tricuspid valve repair can involve the tricuspid annulus and/or leaflet coaptation. Leaflet coaptation is performed using the off-label use of MitraClip (Abbott) in the tricuspid valve (also known as TriClip), mainly because of the device availability and operator familiarity [1]. There are other repair systems to repair the tricuspid leaflet coaptation, including Forma (Figure 1) and Pascal systems from Edwards Lifesciences.  The Forma repair system consists of a spacer that occupies the regurgitant orifice and thus decrease regurgitation. The Pascal repair system consists of two paddles, clasps and a spacer, thus overcoming some of the limitations of Forma repair system regarding anchoring and dislodgement [1]. Other repair interventions involving the annulus are usually performed using sutures or an annuloplasty ring (Figure 2) [1].

Figure 1: Forma repair system (Edwards Lifesciences), which is a transcatheter approach to improve the leaflet coaptation of native tricuspid valve by occupying the regurgitant orifice area [2].

Figure 2: Cardioband (Edwards Lifesciences) is a transcatheter annuloplasty ring for the tricuspid valve [3].

  • Tricuspid Valve Replacement

The first transcatheter tricuspid valve replacement was performed by Kefer et al in 2014 using the balloon-expandable SAPIEN valve (Edwards Lifesciences). There are 6-7 types of dedicated transcatheter tricuspid valves that have been developed in the recent years; these include NaviGate (NaviGate Cardiac Structures, Lake Forest, California), Edwards Evoque, Medtronic Intrepid, Lux (Chinese designed and manufactured self-expanding prosthesis made from bovine pericardial tissue mounted on a nitinol stent frame), and Tricares (TRiCares GmbH, München, Germany) valve is a self-expanding prosthesis made from bovine pericardial tissue mounted on a nitinol stent frame. Figure 3 illustrates a NaviGate valve, which is the first tricuspid prosthetic valve implanted in humans in the United States, which was performed by Navia et al in November 2016 [1].  It is an example of a self-expanding dedicated tricuspid valve with 3 pericardial leaflets.

Figure 3: NaviGate valve, which is currently available for transcatheter tricuspid valve replacement [4].

  • Caval Stenting

In addition, stenting of the inferior and/or superior vena cava has also been performed to mitigate the effects of tricuspid regurgitation on the central venous system. It is another option for those patients with tricuspid regurgitation, but there are concerns that this procedure might ultimately promote significant hemodynamic deterioration, with ventricularization of the right atrium and increased load on the right ventricle. Ongoing studies are being conducted to assess these effects and the outcomes of this procedure [1].

Do transcatheter interventions of the tricuspid valve affect mortality?

So far, the current evidence we have is from observational studies suggesting improved mortality in patients treated with tricuspid repair/replacement compared to medical therapy [1]. Overall, these transcatheter interventions have shown significant improvement in patient’s symptoms and New York Heart Association (NYHA) functional class, despite only moderate reduction in tricuspid regurgitation severity [1]. There are multiple ongoing trials assessing the impact of these therapies on outcomes.  The TRILUMINATE trial is one example, which is comparing outcomes of tricuspid clipping to medical treatment in patients with functional tricuspid regurgitation.

In conclusion, there are several transcatheter therapies that have been developed for treatment of tricuspid valvular pathologies, most commonly for functional tricuspid regurgitation, in the past few years. Although most of these techniques are still in their early stages, the initial results of the observational data are promising. I look forward to seeing the advances in these therapies in the near future, as we continue to build our experience as operators and familiarize ourselves with these new advanced tools.

References

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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Innovations in 3-D and 4-D Technology in the Cath Lab

There have been tremendous advances in 3-dimensional (3-D) technologies in the past few years, not only in various medical and surgical fields but also in our daily lives outside of work; with more and more new features in cell phones, computer design programs, and movies!!  4-dimensional (4-D) imaging captures 3-D images over time. These technologies are particularly important in cardiology, especially in interventional cardiology. The heart is a very dynamic organ, and understanding the variation in the anatomy of vessels and geometry of cardiac structures is key to ensuring successful procedures, patient’s safety and good outcomes. More recently, newer innovations in both 3-D and 4-D technologies have been developed, so I decided to shed light on some of these innovations and how they can be potential game-changers in the cath lab.

  • 3-D Holograms

This technology was actually displayed at the Transcatheter Cardiovascular Therapeutics (TCT) 2019 meeting. It converts live transesophageal echo (TEE) imaging into real-time 3-D holographic video in the cath lab to aid structural heart procedures.  The 3-D hologram is projected on a special display screen, and the interventional cardiologist uses hand movements and a foot pedal/switch to change the image orientation without breaking the sterile field. It also allows the operator to see the tools they use in the cath lab, including catheters or devices, in real-time in a 3-D format. This technology does not even require the user to wear 3-D glasses! It was submitted for FDA regulatory review in September 2019.

  • HeartFlow Planner

This is a noninvasive, real-time virtual tool for coronary artery disease intervention. It allows interventional cardiologists to virtually map vessels on a 3-D coronary tree, with color codes indicating the fractional flow reserve-computed tomography (FFR-CT) values for each vessel as measured by a computational fluid dynamics algorithm. This seems to be a good tool for percutaneous coronary intervention (PCI) planning in vessels with significant disease; as it aims to provide us with a non-invasive way to determine whether a stenotic lesion if potentially flow limiting. However, it is important to note the CT-FFR has its own limitations, and some patients might still need invasive FFR for accurate assessment. This tool was approved by the FDA in September 2019.

Figure 1: 3-D CT-FFR coronary tree showing both flow limiting and non-flow limiting lesions [from reference 1].

  • 3-D Printing

3-D printing has been used in the surgical fields for more than a decade. It refers to making complex 3-D objects from computer-aided designs. This technology has been increasingly utilized in structural heart procedures in the past few years, where these 3-D models can be printed from a patient’s CT, magnetic resonance imaging (MRI), or 3-D ultrasound images (Figure 1). These 3-D printed structures not only help with procedural planning and device sizing but also allow operators to practice dry runs and perform pre-procedural navigation.

Figure 2: Image of a 3-D printed model which shows cardiac valves and major vessels with their geometric locations relative to each other (reference 3).

  • 4-D Imaging

4-D imaging adds an important component to 3-D imaging, which is the change of these 3-D images over time. 4-D flow images include the direction of blood flow, blood velocities and shear wall stress [2] (Figure 3). This is particularly important in coronary interventions, structural heart procedures and different congenital abnormalities where identification of blood flow in the 4-D view is useful, especially when the anatomy is complex. These changes in position over time help guide our procedures, not only to ensure successful outcomes but also to avoid potential complications. These 4-D images require large amounts of data, but they can be obtained from either cardiac MRI or computational fluid dynamics, which is a specialized area of mathematics and fluid mechanics in engineering [2]. 4-D imaging is still in its early phases, but it is another exciting advancement in our field.

Figure 3: Representation of an MRI-generated 4-D flow image showing blood flow through the aorta and major vessels (reference 4).

In conclusion, we have seen and continue to see tremendous advances in the innovations of 3-D and 4-D imaging with important implications in our work in the cath lab. With our continued collaboration with informational technology experts, engineers, and scientists, these innovations are potentially game-changers in different fields, including coronary interventions and structural heart procedures. I look forward to seeing how this technology continues to evolve in the coming decades!!

References:

  • Fornell, Dave “Overview of the top news and new technologies at the 2019 Transcatheter Cardiovascular Therapeutics meeting”, November 2019,

https://www.dicardiology.com/article/6-hot-topics-interventional-cardiology-tct-2019

https://www.itnonline.com/content/arterys-showcases-fda-cleared-4d-flow-mri-software-rsna-2016

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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How is the COVID-19 pandemic affecting cardiac patients and the cath lab?

Amongst the uncertainty of the future and how this pandemic will end, there comes a huge responsibility on all healthcare workers to care for the sickest patients while staying safe, to lead their healthcare systems and to come together as one unit against this crisis. Seeing how this pandemic has affected our healthcare system, from the evolving utility of telehealth to canceling elective procedures in multiple specialties, I decided to share a few thoughts on COVID-19 and the cardiovascular manifestations associated with this infection and how COVID-19 has affected our approach to commonly performed procedures in the cardiac catheterization lab.

Cardiovascular manifestations of COVID-19

Although coronavirus predominantly affects the respiratory system, causing a variety of symptoms from flu-like symptoms to acute respiratory failure requiring intubation, it can affect other organs, and patients may present with non-respiratory complaints [1]. The cardiovascular manifestations of COVID-19 have a wide range of clinical presentations (Figure 1), from pericarditis, myocarditis, pericardial effusion, and decompensated heart failure to tamponade, cardiogenic shock and ST-elevation myocardial infarction (STEMI) [1-2]. In addition, right ventricular strain should raise suspicion for pulmonary embolism as these infected patients tend to be hyper-coagulable with a high incidence of venous thromboembolism for currently unclear reasons. It is important to recognize these cardiovascular manifestations of COVID-19, as it is thought that cardiovascular involvement is associated with a worse prognosis [1].

Figure 1: Potential risk factors and cardiovascular manifestations of COVID-19 patients.

Approach to Acute Coronary Syndrome (ACS) and Structural Procedures in the Cath Lab in COVID-19 Pandemic

Like any procedural field, interventional cardiology has been affected by this pandemic. All elective procedures are being postponed until the crisis settles down per recommendations from the Centers for Disease Control and Prevention (CDC), with emergent, urgent, time-sensitive procedures still being performed, in an attempt to preserve hospital beds and personal protective equipment (PPE) for COVID-19 patients [2]. This pandemic has led to several changes in the ACS approach across the world, with the main goal of reducing un-necessary exposure to health care workers and limiting the spread of this highly contagious disease [1,2].

To summarize, some of the key changes many hospitals have applied in their approach to some of the most commonly performed percutaneous cardiac procedures in COVID-19 patients:

  • ACS patients
  • Thrombolytics are considered standard therapy in many hospitals for many STEMI patients with symptoms <12 hours and no contraindications: signs of success are resolution of symptoms and/or >50% decrease in ST elevation. If thrombolytics fail, coronary angiogram and percutaneous coronary intervention (PCI) should be considered in an isolated cath lab (Figure 2) and the benefit versus the exposure risk should be carefully evaluated.
  • For patients with low risk Non-ST elevation myocardial infarction (NSTEMI): medical therapy is reasonable. For those with high risk NSTEMI or failure of medical treatment, coronary angiogram and/or PCI should be performed. These coronary procedures are usually performed in isolated cath labs with only limited staff in the cath lab room, to avoid unnecessary exposure (Figure 2).
  • Structural heart disease patients
  • For patients who are unstable and have severe aortic stenosis (AS), balloon aortic valvuloplasty (BAV) should be performed emergently to stabilize the patient if this is thought to be the cause of the hemodynamic instability. For those who develop significant aortic regurgitation after BAV, transcatheter aortic valve replacement (TAVR) should be performed.
  • Patients with severe symptomatic AS, TAVR is considered a time-sensitive procedure. The benefit of TAVR and risk of infection exposure should be discussed.It is important to note that this change in policy, in part, could explain the decrease in cath lab activation rates for STEMI during this pandemic [2]; as many STEMI patients are receiving thrombolytics. In addition to that, many patients are not seeking medical care, or if they do, they are presenting late, possibly due to fear from contracting the virus in the hospital, potentially leading to late STEMI complications [2]. Thus, it is important to counsel our patients in our virtual clinic visits that if significant symptoms develop, they should seek medical care.

Lastly, I want to thank all of my colleagues and healthcare workers across the nation and across the globe for risking their lives for patients and for their continued dedication. This is a critical time for everyone in the health care system. In light of this pandemic, I hope we continue to learn and share our experiences in this global crisis in order to improve our patient’s care, safety for our healthcare workers and the dynamics of our healthcare system.

Figure 2: Simplified Set-up of an Isolated Cath Lab during the COVID-19 pandemic.

References

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

 

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The Robotic Technology in Interventional Cardiology

The past few years have witnessed amazing advances in the robotic technology leading to its widespread utilization in both research and clinical aspects across multiple fields, including the cardiovascular field! I have recently attended a few conferences and the footprint of the robotic technology has been remarkable in each of them, emphasizing the great interest in the progress and utility of technology in our field. I decided to talk about robotic technology in interventional cardiology, the advantages and limitations of its use, and how I see it impacting the future of interventional cardiology.

  • How long have we used robotic technology in the cath lab?

Robotic technology has been used in surgical specialties and radiation therapy since the mid-1990s. Then, robotics systems for endovascular interventions were developed and have been utilized for different percutaneous interventions, including simple and complex coronary and peripheral interventions, as well as other structural heart disease procedures, including atrial septal defect closure.

  • Do we have scientific evidence-based trials assessing the robotic technology in interventional cardiology?

There are many prospective trials looking at robotic technology in both coronary and peripheral interventions. The two major studies are:

  1. PRECISE (Percutaneous Robotically Enhanced Coronary Interventions) trial: 164 patients with relatively simple lesions (>87% ACC/AHA type A/B; lesion length 12.2 6 4.8 mm), the investigators reported clinical success of 97.6%, technical success of 98.8% and > 95% median operator radiation reduction. Based on the results of this study, in 2012, the FDA approved the CorPath 200 System as the first robotic system for PCI.
  2. The RAPID (Robotic-Assisted Peripheral Interventions for Peripheral Artery Disease) trial, a prospective single-center, safety and feasibility study demonstrated the utility of the CorPath 200 system for robotic peripheral interventions. The study demonstrated 100% device technical and clinical success. No significant adverse events related to the device were reported, and based on this study, the CorPath 200 system received FDA approval for peripheral interventions.
  • Advantages
  • One of the main advantages of the robotic system in the cath lab is the reduction of radiation exposure for both the operators. The hazards of radiation are well-known and studies have demonstrated that the use of robots led to a reduction in radiation exposure [1]. Operators using the robotic system can either be in the cath lab several feet away from the radiation source or even in a separate room, where they can control the joystick and use the control pad to adjust the robot movements to control wires, the guide catheters and other devices (balloon, stents, etc..).
  • Robots also help avoid wearing heavy lead aprons and thus decrease the orthopedic problems that many operators suffer from in the long run, including back pain and arthritis.
  • Moreover, studies have also shown that robotic system use is associated with good precision and outcomes [1].
  • Robots have been increasingly utilized with around 100 hospitals in the US currently using robots in the cath lab. This quick and widespread utilization of this new technology demonstrates not only how safe and successful the robotic system is, but also how easy and user-friendly it is.

 

  • Limitations

In my opinion, this tool was developed to help operators, but not to replace them. Like any tool, the machine can potentially stop working, for a technical reason or other reasons, and at the end of the day, it is the physician’s responsibility to deal with the situation and solve the problem. In addition, the use of robotic system is limited in the following:

  • The use of robotics in STEMI or bifurcation lesions has not been well-established yet, although reports and smaller studies have shown it can be performed safely.
  • There are technical limitations of the robotic system, and if a lesion could not be treated, manual conversion is recommended.
  • Limited devices used by the current generation of robotic technology: use of over-the-wire balloons, intra-vascular imaging catheter, or mechanical circulatory support is not available with the current generation of robotics.
  • How will robots change the future of interventional cardiology?

The robotic technology has been increasingly utilized in multiple hospitals across the world. With more experience with robotic technology utilization, more knowledge and future upgrade of robotic systems, I think this tool will be increasingly utilized and updated to conform to the needs of patients, operators and different kinds of procedures and interventions; in fact, the robotic system is being studied in the utility of transcatheter aortic valve replacement (TAVR) procedures! Moreover, the utility of the robotic technology could potentially enable experienced operators to remotely perform complex interventional procedures in patients in different hospitals in rural or urban areas, different states, different countries or even different continents!

With the rapid progress in technology in all fields of our life, I think it is very important to establish and encourage more collaborations between technology and medical sciences, especially in procedural specialties, where precision and safety can be provided by these advanced robotics systems for optimal outcomes. I look forward to seeing how these technologies will evolve and transform our practice in the future!!

 

I would like to thank my colleague and friend, Dr. Jeff Hsu, for his help on this blog and for being an awesome senior buddy!!

References

  • Mahmud et al: Robotic technology in interventional cardiology: Current status and future perspectives. Catheter Cardiovasc Interv.2017 Nov 15;90(6):956-962.

https://onlinelibrary.wiley.com/doi/abs/10.1002/ccd.27209

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”