Methamphetamine‐associated cardiomyopathy ( MACM ) is an increasingly recognized disease entity in the context of a rapidly spreading methamphetamine epidemic. MACM may afflict individuals with a wide range of ages and socioeconomic backgrounds. Presentations can vary greatly and may involve several complications unique to the disease. Given the public health significance of this disease, there is a relative dearth of consensus material to guide clinicians in understanding, diagnosing, and managing MACM . This review therefore aims to: (1) describe pathologic mechanisms of methamphetamine as they pertain to the development, progression, and prognosis of MACM , and the potential to recover cardiac function; (2) summarize existing data from epidemiologic studies and case series in an effort to improve recognition and diagnosis of the disease; (3) guide short‐ and long‐term management of MACM with special attention to expected or potential sequelae of the disease; and (4) highlight pivotal unanswered questions in need of urgent investigation from a public health perspective.

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Background: Intravascular ultrasound (IVUS) has several benefits during percutaneous coronary interventions (PCIs), including more accurate vessel sizing, improved stent expansion, and better strut apposition. Prior clinical trials have demonstrated a reduction in cardiac events when IVUS is used. However, there is limited information about the utilization of IVUS and the outcomes of IVUS-guided versus angiography-guided PCI in patients with complex lesions in a contemporary population-based setting. Methods: New York’s PCI registry was used to identify 44 305 patients with complex lesions (lesions that complicate stenting or that require multiple stents) undergoing PCI with and without IVUS guidance and discharged between December 1, 2013 and November 30, 2018. Trends and inter-hospital variation in IVUS use were examined. Risk-adjusted mortality and target vessel revascularization were compared. Results: A total of 6174 (13.9%) PCI patients underwent IVUS-guided PCI. The median follow-up period was 2.5 years. The percent of patients with complex lesions who underwent IVUS-guided PCI rose from 13.4% in 2014 to 16.5% in 2018 ( P <0.0001 for trend), with the main increases occurring in the last 2 years of the period. Only 31 of 66 hospitals in the study used IVUS for >5% of their study patients. IVUS-guided PCI patients experienced significantly lower mortality (adjusted hazard ratio=0.89 [0.79–0.98] after adjustment using a Cox proportional hazards model, and HR=0.88 [0.78–0.99] for propensity-matched patients). We also found that IVUS-guided PCI patients had a lower rate of target vessel revascularization (adjusted hazard ratio=0.88 [0.80–0.97]) after adjusting using Cox proportional hazards with competing risk of mortality and after propensity matching (0.88 [0.79–0.99]). Conclusions: Utilization of IVUS for complex lesions has increased but contemporary rates remain low, and there are large inter-hospital variations. The use of IVUS for complex lesions was associated with lower risk of medium-term mortality and target vessel revascularization.

BackgroundAorto-ostial interventions are challenging due to the limitations of contemporary equipment, imprecise ostial demarcation, and problematic ostial lesion characteristics. Suboptimal stent placement is common and portends worse clinical outcomes. Procedural and long-term outcomes of the bumper wire technique with intravascular ultrasound (IVUS) assessment have not been investigated.MethodsA single-center retrospective study was conducted. Patients who underwent ostial lesion percutaneous coronary intervention (PCI) with the bumper wire technique between January 2019 and September 2020 were identified. The primary endpoint was to determine the geographic miss rate defined by inadequate ostial coverage or excess stent protrusion of &gt; 2 mm by IVUS or angiography. The secondary endpoint was target lesion failure (TLF) at 6 months after PCI, defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularization.ResultsIn total, 45 patients were identified. The average age was 71.7 years old, and 85.4% were men. Indication for PCI was acute coronary syndrome in about a third of patients. Twenty-six patients had left main ostial lesions and 19 patients had right coronary artery ostial lesions. Geographic miss was detected in two patients (4.4%): one patient (2.2%) had excess proximal stent protrusion and one patient (2.2%) had an ostial miss. Six patients were lost to follow-up. TLF, stroke, or major bleeding were not observed in any of the patients.ConclusionThe bumper wire technique is safe and efficient with low rates of geographic miss or adverse clinical outcomes. This is the first study to confirm precise aorto-ostial stent implantation with the bumper wire technique using IVUS confirmation.

Background Right atrial thrombus (RAT) may be managed according to morphology and aetiology, i.e. Type A thrombi (‘clot-in-transit’, hypermobile) are managed with thrombolytics and surgical embolectomy due to high risk of embolization; Type B thrombi (broad-based, globular) may be managed medically as they will very likely maintain a benign course. Experience with management of a Type C thrombus (hypermobile but also broad-based) has not been explicitly described in the literature. Case summary A 25-year-old man with history of leukaemia with prior right subclavian vein chemoport is found to have massive RAT. Multimodal imaging shows a hypermobile mass attached to the right atrial lateral wall inferior to superior vena cava and prolapsing into right ventricle in diastole. Given the thrombus morphology and likely propagation from subclavian port, risk of catastrophic embolization was deemed high and as such, intervention was indicated. Systemic anticoagulation was considered but deferred due to theoretical risk of dissolving the thrombus stalk leading to embolization. Surgical thrombectomy was offered but the patient declined. Due to evidence for success in RAT, the AngioVac System: Generation 3 (Angiodynamics, Inc., Latham, NY, USA) was chosen for intervention. The RAT was successfully removed without any complication. Discussion AngioVac suction thrombectomy is a safe alternative option for removal of a Type C, massive, hypermobile RAT.

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