Non-Invasive Cardiac Output Monitoring in Cardiogenic Shock: The NICOM Study.

BACKGROUND: The bioreactance technique is a relatively new, totally noninvasive technique that is used to measure cardiac output (CO) and is easy to use. The Non-Invasive Cardiac Output Monitor (NICOM) is 1 such system. Although approved by the Food and Drug Administration for measurement of stroke volume, there is a paucity of literature validating this technology in decompensated heart failure and cardiogenic shock. METHODS AND RESULTS: Fifty patients admitted to our cardiac intensive care unit for cardiogenic shock and Swan-Ganz catheter-guided therapy were prospectively enrolled in the study after informed consent. Simultaneous measurements of CO were obtained using NICOM, indirect Fick and bolus thermodilution. The intraclass correlation coefficient (ICC) was used to assess the precision of NICOM for CO using the 3 repeated measurements of CO over the pooled data. The agreement of the NICOM device in the defined clinical population, compared to indirect Fick and thermodilution, was evaluated by comparing the Pearson correlation coefficient, the Bland-Altman plot and the Lin concordance correlation coefficient. The ICC for cardiac output measured by NICOM showed excellent repeatability (ICC = 0.93, 95% CI = 0.92-0.94, n = 262) in the pooled data. The Pearson correlation coefficient for cardiac output measured by NICOM was poor when compared to indirect Fick (n = 263, r = 0.132, P = 0.033) and TD (n = 258, r = 0.275, P < 0.001). CONCLUSIONS: NICOM technology is not a reliable method of measuring CO in patients with decompensated heart failure and cardiogenic shock.

Impact of short term oral steroid use for intravenous contrast media hypersensitivity prophylaxis in diabetic patients undergoing nonemergent coronary angiography or interventions.

OBJECTIVES: Oral steroids are routinely administered in the United States for prophylaxis of iodinated contrast media hypersensitivity (ICMH). We studied the impact of short-term steroid use in diabetic patients with ICMH undergoing nonemergent coronary angiography. METHODS: We retrospectively analyzed records of diabetic patients with and without ICMH who underwent nonemergent coronary angiography at our center. Primary study endpoint was 30-day major adverse cardiac events (MACE) and secondary endpoints were pre- and postprocedure fasting blood glucose (FBG), highest in hospital blood glucose, pre- and postprocedure systolic blood pressure (SBP), and use of intravenous insulin and antihypertensive medications. RESULTS: A total of 88 diabetics with ICMH (study group) and 76 diabetics without ICMH (control group) undergoing angiography were enrolled. Demographics and hemoglobin A1c values were similar in both groups. Preprocedural FBG was significantly higher in the study group. The study group had significantly higher post angiography FBG (239.93 + 96.88 mg/dl vs. 156.6 + 59.88 mg/dl) and greater use of intravenous (IV) insulin (67.27% vs. 32.43%). Further, those who received steroids had significantly higher systolic SBP postprocedure (146.16 + 25.35 mmHg vs. 130.8 + 21.59 mmHg), a higher incidence of severe hypertension and use of IV antihypertensive medications (80.95% vs. 19.05%) periprocedurally. There were no differences in 30-day MACE between groups. CONCLUSION: Short-term steroid use for ICMH results in a significant increase in surrogate markers for adverse clinical events after coronary procedures. Study findings highlight the need for better periprocedural management of these patients and to limit steroid prophylaxis to those with only true ICMH.

Subclinical involvement of common carotid arteries in patients with fibromuscular dysplasia - a case-control study.

Background: Fibromuscular dysplasia (FMD) primarily involves medium-sized arteries, though the entire spectrum of vascular involvement is not fully understood. We hypothesized that larger arteries may also be affected, albeit sub-clinically. Patients and methods: We measured the cross-sectional diameter of the thoracic aorta, abdominal aorta, common iliac arteries (CIA) and common carotid arteries (CCA) in FMD subjects and compared them to matched controls. We retrospectively analyzed records of FMD subjects (n = 74) and of age- and sex- matched controls (n = 74) that underwent computed tomography of the neck, chest or abdomen. Cross-sectional diameters of the thoracic and abdominal aorta, CIA and CCA were measured in a standardized manner by two trained physicians. Results: The FMD group had a significantly greater diameter of the CIA and CCA bilaterally. The measurements (mm) in FMD and control groups were as follows: Right CIA: 10.85 + 1.75 vs. 10.23 + 1.36, p = 0.04, left CIA: 11.01 + 1.93 vs. 10.15 + 1.38, p = 0.007, right CCA: 7.70 + 0.81 vs. 6.80 + 1.10, p < 0.001 and left CCA: 7.70 + 1.10 vs. 6.80 + 1.0, p < 0.001). There was no difference in the diameter between the two groups in the ascending aorta, descending and the abdominal aorta. After adjusting for baseline differences, common carotid arteries (but not common iliac) were significantly larger in FMD group compared with controls. Conclusions: There is sub-clinical involvement of the common carotid arteries in patients with FMD and this manifests as a greater diameter of these arteries compared to age and sex matched controls.

Comparison of Trends, Mortality, and Readmissions After Insertion of Left Ventricular Assist Devices in Patients <65 Years Vs ≥65 Years.

Left ventricular assist devices (LVADs) use in treatment of stage D heart failure (HF) has evolved and expanded in the past decade. There is paucity of data on LVAD utilization in patients with age ≥65 years with multiple co-morbidities. We aimed to investigate utilization trends, outcomes, and rates and predictors of readmissions in patients receiving LVADs with age ≥65 years (AO) and comparing them with patient age <65 years (AY). We analyzed hospitalization data from the Nationwide Inpatient Sample from 2007 to 2015 to evaluate LVAD utilization trends and outcomes between the 2 patient cohorts. We also queried the Nationwide Readmission Database from 2014 to third quarter of 2015 to identify trends and compare etiologies of readmissions. Implants in AO patients increased from 20% (154) of the total LVADs implanted in 2007 to 33.2% (1,215) in 2014 and 31.8% (910) through September 2015 (p < 0.01). Over the study period there was a steady and significant increase in the mean Elixhauser scores in elderly patients who underwent LVAD implantation from 15.4 in 2007 to 24.54 in 2015 (p < 0.01). Despite this finding, the mean LOS in the AO cohort decreased from 56.0 days in 2007 to 33.8 days in 2015 (p < 0.001). Furthermore, the in-hospital mortality associated with LVAD implantation among the AO group gradually decreased over the study time period (39% in 2007 to 12.2% in 2015, p < 0.001). The overall readmission rate was not significantly different between AO versus AY group (28% vs 33%, p = 0.2). The most common cause in both groups was gastrointestinal bleed but it was significantly higher in AO group (24.3% vs 11.3%, p = 0.01). In conclusion, patients age ≥65 years with multiple co-morbidities are receiving increasing number of LVADs with improved survival outcomes. Their 30-day readmissions are comparable to the younger patients.

In-Hospital Outcomes and Trends of Tricuspid Valve Surgery in Heart Transplant Patients.

INTRODUCTION: Tricuspid valve (TV) regurgitation is the most common valvular pathology after orthotopic heart transplant (OHT). The number of transplants being performed is increasing with patients living longer after heart transplant. Data on TV surgery in OHT recipients is limited. METHODS: We sought to analyze the outcomes of patients undergoing TV surgery from a large diverse, multicentric, nationwide cohort using the Nationwide Inpatient Sample (NIS) database. RESULTS: A total of 42,766 TV repair or replacement (bioprosthetic and mechanical) involving adult patients (age ≥18 years) between 2007 and September 2015 were identified. Of these, 366 were performed in patients with OHT. TV repair was the most common surgery performed in both groups (OHT group and native heart group). Compared to the native group, patients with OHT had a significantly higher incidence of cardiogenic shock (20 vs. 11%, p = 0.024), acute kidney injury (AKI) (59 vs. 30%, p < 0.001), and AKI requiring hemodialysis (13 vs. 4%, p < 0.001). Also, the mean length of stay for the index admission was significantly longer in the OHT group (27 vs. 17 days, p = 0.008). The mortality rate was similar between the two groups (7 vs. 8%, p = 0.753). The number of TV surgeries performed in OHT patients from 2007 to 2014 have remained stable (p = 0.803) compared to those in native heart patients which showed a significantly increasing trend (p = 0.019) during the same time period. CONCLUSIONS: TV surgery remains an important treatment modality among the OHT population and carries a similar mortality during index hospitalization as that in native heart patients undergoing TV surgery.