Risks of paxlovid in a heart transplant recipient.

The burden of morbidity and mortality from SARS-CoV-2 infection is especially significant in heart transplant patients who are at higher risk for poor outcomes owing to immunosuppression, blunted response to vaccination, and multiple comorbid conditions. Over the last 3 years the therapeutic landscape for COVID-19 has evolved and our drug armamentaria continues to expand. With these advancements comes a time of great hope to mitigate significant illness from SARS - CoV - 2 infection. However, as with many emerging frontiers, the administration of novel therapeutics to a complex patient population remains challenging. We present a patient case encountered at our institution that highlights the need for increased awareness of nuances while managing COVID-19 infection in a heart transplant recipient.

Corrigendum to : One clot after another in COVID-19 patient: diagnostic utility of handheld echocardiogram.

[This corrects the article DOI: 10.1093/omcr/omaa141.].

Improved Physician Understanding of Patient End-of-Life Preferences: A Quality Improvement Project.

BACKGROUND: Code status (CS) orders lack a universal definition. We aimed to improve provider understanding of order options. MEASURES: Provider's knowledge of CS terminology, ease of understanding CS orders and ease of starting CS discussions. INTERVENTION: A multifaceted intervention including 1) altered CS order language in the electronic medical record (EMR) from "Full Interventions," "Limited Interventions," and "Comfort Measures Only" to "Full advanced cardiovascular life support (ACLS)," "Partial ACLS," and "No ACLS" 2) clinical tools for CS identification 3) provider education. OUTCOMES: Correct provider response rate for "Partial ACLS" and "No ACLS" terms increased from 43.5 to 60% and 20 to 71% (odds ratio 1.95; 95% confidence interval 0.99-3.83; P = 0.03, OR 9.8; CI 4.48-21.49; P < 0.001). The proportion of providers who felt understanding CS orders and starting conversations about CS was "very easy" (a score of 1-3 on a scale of 1 to 10) improved from 26.1 to 45.7% (P = 0.01) and 49.3 to 65.7% (P = 0.03). CONCLUSIONS/LESSONS LEARNED: Provider understanding of CS options can be improved with a combined QI intervention.

Pulmonary Vein Thrombosis in a Patient With Multiple Myeloma on Treatment With Lenalidomide.

Multiple myeloma (MM) poses inherent risk of thrombosis that can be amplified by the use of immunomodulator therapy. We present a patient with MM who was being treated with lenalidomide and dexamethasone when he developed progressive dyspnea on exertion consistent with a left lower pulmonary vein thrombosis (PVT) despite use of prophylactic aspirin. The PVT was not initially seen on standard computed tomography angiogram pulmonary embolism protocol but was seen on 192-slice multidetector computed tomography angiogram for assessment of coronary calcifications 8 months later. Subsequent treatment with full dose rivaroxaban resulted in full clot resolution and symptom improvement. PVT has not been previously reported with lenalidomide therapy and may not be a forefront differential diagnosis. In such cases, a multi-modality diagnostic approach may be beneficial. Consideration should be given to escalating venous thromboembolism prophylaxis to full dose anticoagulation during increased prothrombotic windows, such as the time of treatment initiation or dose adjustments, in low bleeding risk patients.

D-dimer driven deep vein thrombosis prophylaxis strategy for hospitalized patients with COVID-19.

COVID-19 induces a hypercoagulable state with early case reports of death from undetected venous thromboembolism. Various protocols and consensus statements have been proposed to address the optimal prophylaxis strategy for hospitalized patients. We offer our single institution experience with a d-dimer driven prophylaxis model with no deep vein thrombosis identified on discharge lower extremity ultrasounds.

One clot after another in COVID-19 patient: diagnostic utility of handheld echocardiogram.

A 63-year-old woman was admitted with severe respiratory distress requiring mechanical ventilation and shock requiring vasopressor support. She was found to have COVID-19 pneumonia. Focused cardiac ultrasound performed for evaluation of shock was significant for right ventricular dilation and dysfunction with signs of right ventricular pressure overload. Given worsening shock and hypoxemia systemic thrombolysis was administered for presumed massive pulmonary embolism with remarkable improvement of hemodynamics and respiratory failure. In next 24 h patient's neurologic status deteriorated to the point of unresponsiveness. Emergent computed tomography showed multiple ischemic infarcts concerning for embolic etiology. Focused cardiac ultrasound with agitated saline showed large right to left shunt due to a patent foramen ovale. This was confirmed by transesophageal echocardiogram, 5 months later. This case highlights strengths of focused cardiac ultrasound in critical care setting and in patients with COVID-19 when access to other imaging modalities can be limited.

Surgical Repair of a Giant Sinus of Valsalva Aneurysm with an Anomalous Left Circumflex Artery in a Patient with Bicuspid Aortic Valve.

Congenital cardiac abnormalities are not always found in isolation. We describe a case of a giant right coronary sinus of Valsalva aneurysm with anomalous left circumflex artery in a 46-year-old male with bicuspid aortic valve and prior ventricular septal defect repair.

Left Ventricular Mechanical Circulatory Support-Assessing Outcomes With New Data.

Ventricular assist devices continue to play a significant role in the surgical management of advanced heart failure. Left ventricular assist devices in particular have seen a rapid evolution in design, technology, implantation, and outcomes. This concise review focuses on the key data that have been published in the past 5 years that have demonstrated this rapid evolution in left-sided mechanical circulatory support from principally bridge to transplantation to destination therapy, with an increasing emphasis on quality-of-life measures and durability.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2020.

THIS SPECIAL article is the 13th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series; namely, the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology.1 The major themes selected for 2020 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in the specialty for 2020 begin with an update on valvular disease, with a focus on updates in management of aortic and mitral valve disorders. The second major theme is an update on coronary artery disease, with discussion of both medical and surgical management. The third major theme is focused on the perioperative management of patients with coronavirus disease 2019 (COVID-19), with the authors highlighting literature discussing medical, surgical, and anesthetic considerations for their cardiac care. The fourth major theme is an update in heart failure, with discussion of medical, psychosocial, and procedural aspects of this complicated disease process. The fifth and final theme focuses on the latest analyses regarding survival in heart transplantation. The themes selected for this 13th special article are only a few of the diverse advances in the specialty during 2020. These highlights will inform the reader of key updates on a variety of topics, leading to improvement of perioperative outcomes for patients with cardiothoracic and vascular disease.

Impact of Preoperative Lymphopenia on Survival Following Left Ventricular Assist Device Placement.

Lymphopenia has been implicated in poor outcomes in the heart failure population. However, the prognostic implication of lymphopenia in left ventricular assist device (LVAD) patients is unknown. We examine the impact of lymphopenia on all-cause mortality in this population over a 24-month period post-implantation. A total of 170 patients between June 2011 and July 2018 receiving permanent durable LVAD at a single center formed the study population. Criteria for lymphopenia on admission, defined as an absolute lymphocyte count (ALC) <1500 cells/µl, was met in 99 patients. A total of 11 patients were excluded: two with ALC >4800/µl and nine with incomplete data. Survival across groups was compared with a Kaplan-Meier plot and log-rank statistics. The Cox proportional hazard model was used to examine the association between lymphopenia and 24-month all-cause mortality. In the lymphopenia group, mean ALC was 909.6 ± 331.9 versus 2073.6 ± 501.1 in the non-lymphopenic group. Twenty-four-month all-cause mortality was significantly higher in the lymphopenia group (p = 0.009). The lymphopenic patients had worse unadjusted (hazard ratio [HR] = 2.14, confidence interval [CI] = 1.19-3.82; p = 0.01) and adjusted survival (HR = 2.07, CI = 1.13-3.79; p = 0.02). Further clinical investigations are required to assess the utility of continued clinical monitoring of ALC levels beyond LVAD placement.

Parachute Mitral Valve: A Case of Isolated Accessory Mitral Valve Tissue.

A 69-year-old male presented to the emergency room with dyspnea on exertion lasting more than 2 weeks. Echocardiography showed an ill-defined subaortic structure. Subsequent transesophageal echocardiography revealed a parachute-like structure prolapsing into the left ventricular outflow tract causing subvalvular aortic obstruction. Surgical excision confirmed this structure as an accessory anterior mitral leaflet. (Level of Difficulty: Intermediate.).

Mulibrey Nanism Syndrome: A Case for Heart Transplantation.

Mulibrey nanism syndrome is a rare genetic disorder affecting multiple organ systems. The cardiovascular system is one of the most significantly affected, with simultaneous myocardial and pericardial disease. These patients are usually managed by pericardiectomy to resolve the milieu of hemodynamic problems ensuing due to concurrent constrictive and restrictive pathologies. We highlight the use of cardiac transplantation as a definitive management for a hemodynamically decompensated patient with Mulibrey nanism syndrome.