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Background: Cardiogenic shock (CS) carries high mortality. The roles of specific mechanical circulatory support (MCS) systems are unclear. We compared the clinical outcomes of Impella versus extracorporal membrane oxygenation (ECMO) in patients with CS. Methods: This is a systematic review and meta-analysis that was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Cochrane Central Register, Embase, Web of Science, Google Scholar, and ClinicalTrials.gov (inception through May 10, 2022) for studies comparing the outcomes of Impella versus ECMO in CS. We used random-effects models to calculate risk ratios (RRs) with 95% confidence interval (CIs). End points included in-hospital, 30-day, and 12-month all-cause mortality, successful weaning from MCS, bridge to transplant, all reported bleeding, stroke, and acute kidney injury. Results: A total of 10 studies consisting of 1,827 CS patients treated with MCS were included in the analysis. The risk of in-hospital all-cause mortality was significantly lower with Impella compared with ECMO (RR, 0.80; 95% CI, 0.65–1.00; P = 0.05), whereas there was no statistically significant difference in 30-day (RR, 0.97, 95% CI, 0.82–1.16; P = 0.77) and 12-month mortality (RR, 0.90; 95% CI, 0.74–1.11; P = 0.32). There were no significant differences between the two groups in terms of successful weaning (RR, 0.97; 95% CI, 0.81–1.15; P = 0.70) and bridging to transplant (RR, 0.88; 95% CI, 0.58–1.35; P = 0.56). There was less risk of bleeding and stroke in the Impella group compared with the ECMO group. Conclusions: In patients with CS, the use of Impella is associated with lower rates of in-hospital mortality, bleeding, and stroke than ECMO. Future randomized studies with adequate sample sizes are needed to confirm these findings.

Nonbacterial thrombotic endocarditis (NBTE) is illustrated by thrombi deposition on normal heart valves without the presence of bacteremia. It typically occurs in the setting of chronic debilitating diseases such as cancer or autoimmune disease. The pathogenesis involves an endothelial injury in the presence of a hypercoagulable state secondary to the effects of circulatory cytokines, which triggers platelet deposition. It usually forms on the upstream atrial surface of the mitral and tricuspid valves and the ventricular surface of the pulmonic and aortic valves and occurs most commonly in the fourth to eighth decades of life with no specific gender predisposition. These vegetations have a distinct morphology that varies from infective endocarditis (IE). Cerebrovascular lesions due to NBTE have a distinctive pattern of multiple, widely distributed small and large strokes on brain magnetic resonance imaging (MRI). We present a case of a 78-year-old man who was initially diagnosed as pneumonia and IE; he underwent a trans-esophageal echocardiogram (TEE), which revealed Libman-Sacks findings that have changed his diagnosis to lung cancer. We aim to highlight the characteristic TEE findings of NBTE to help clinicians search for underlying etiologies, including malignancies if NBTE is suspected.

In this first study evaluating long-term safety and feasibility of transulnar coronary angiography and complex coronary interventions, we conclude that transulnar approach appears to be safe and effective.

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Objectives To assess readmission rates in nonagenarians (age ≥ 90 years) with ST‐elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) versus no pPCI. Background There are limited data exploring readmissions following STEMI in nonagenarians undergoing pPCI versus no pPCI. Methods We retrospectively analyzed the Nationwide Readmissions Database to identify nonagenarians hospitalized with STEMI. We divided the cohort into two groups based on pPCI status. We compared mortality during index hospitalization and during 30‐day readmission, readmission rates, and causes of readmissions. Results We identified 58,231 nonagenarian STEMI hospitalizations between 2010 and 2018, of which 18,809 (32.3%) included pPCI, and 39,422 (67.7%) had no pPCI. Unadjusted unplanned 30‐day readmission was higher in pPCI cohort (21.0% vs. 15.4%, p < 0.001). However, mortality during index hospitalization and during 30‐day readmission were significantly lower in pPCI cohort (15.8% vs. 32.2%, p < 0.001; 7.4% vs. 14.2%, p < 0.001, respectively). After adjusting for baseline characteristics, hospitalizations that included pPCI had 25% greater odds of unplanned 30‐day readmission (adjusted odds ratio [aOR]: 1.25, 95% confidence interval [CI]: 1.12–1.39, p < 0.001) and 49% lower odds of in‐hospital mortality during index hospitalization (aOR: 0.51, 95% CI: 0.46–0.56, p < 0.001). Heart failure was the most common cause of readmission in both cohorts followed by myocardial infarction. Conclusions In nonagenarians with STEMI, pPCI is associated with slightly higher 30‐day readmission but significantly lower mortality during index hospitalization and during 30‐day readmission than no pPCI. Given the overwhelming mortality benefit with pPCI, further research is necessary to optimize the utilization of pPCI while reducing readmissions following STEMI in nonagenarians.