Intractable cardiac arrest due to lidocaine toxicity successfully resuscitated with lipid emulsion.

OBJECTIVE: Demonstrate a case report involving successful use of lipid emulsion therapy for intractable cardiac arrest due to lidocaine toxicity. DATA SOURCE: Lipid emulsion therapy has been shown to be effective in treating the cardiotoxic effects of such drugs as bupivacaine, verapamil, propranolol, and clomipramine as mentioned in a 2009 editorial in Critical Care Medicine by Jeffrey Bent. The mechanism of action of lipid emulsion therapy is not well defined and has been postulated to work by both a "lipid sink," decreasing circulating amounts of drugs to the periphery, or through a direct "energy source" to the myocardium. We present a case report of a patient successfully resuscitated with lipid emulsion therapy after prolonged and intractable lidocaine toxicity. Lidocaine is generally considered much less cardiotoxic than other local anesthetics and is used commonly as infusions for intractable ventricular arrhythmias. CONCLUSION: This case demonstrates the need to consider lipid emulsion therapy in the advanced cardiac life support algorithm for lidocaine toxicity as well as other lipid soluble drug intoxications.

Characteristics of patients who die with heart failure and a low ejection fraction in the new millennium.

BACKGROUND: Therapies for heart failure (HF) with a low ejection fraction (EF) have delayed disease progression and prolonged survival, but the implications of these therapies on the end stages of HF have not been examined. METHODS AND RESULTS: Patients seen by the Brigham and Women's cardiomyopathy service with an EF < or =35%, at least 1 outpatient visit or at least 30 days of follow-up who died between January 1, 2000, and October 20, 2003, were evaluated retrospectively. Of the 160 patients who died since 2000, 80 (50%) were outpatients. In the 6 months before death, 93% of patients had New York Heart Association (NYHA) class III or IV symptoms. The NYHA class, clinical characteristics, medications, and comorbidities differed little between inpatient and outpatient deaths. Renal insufficiency and hyponatremia were worse in the months preceding death than at the time of death (creatinine: 3.2 versus 2.3 mg/dL, P < .0001; sodium: 128 versus 135 mmol/L, P < .0001, respectively). Death was considered sudden in only 21% of patients. CONCLUSION: Deaths in the current era of HF management occur in patients with long-standing HF characterized by biventricular dysfunction and advanced symptoms. Most deaths are heralded by hyponatremia, acute on chronic renal insufficiency, and frequent hospitalizations.

The physiologic basis for the management of ventricular assist devices.

Mechanical ventricular assist devices are now approved as destination therapy for terminal heart failure. It is the purpose of this review to discuss the physiology of this technology that is considered in outpatient care. The currently available pulsatile devices are solely dependent of preload volume and, when placed in the automatic mode, can maintain physiologic cardiac outputs with exercise. However, because of their dependence on preload volume, there are unique physiologic consequences; device bradycardia represents volume depletion, device tachycardia reflects volume overload. The differential diagnosis of left ventricular assist device dysfunction includes native right ventricular failure, native left ventricular recovery, or other technical considerations. The management of biventricular mechanical support as well as arrhythmia management and the role of echocardiographic assessment in this unique patient population will be discussed. Expertise in outpatient management of such devices is now a requisite for subspecialists in heart failure, In the future, technical innovations may simplify management for professionals, patients, and their families.

Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure.

OBJECTIVES: This study was designed to determine the relevance of a proposed classification for advanced heart failure (HF). Profiles based on clinical assessment of congestion and perfusion at the time of hospitalization were compared with subsequent outcomes. BACKGROUND: Optimal design of therapy and trials for advanced HF remains limited by the lack of simple clinical profiles to characterize patients. METHODS: Prospective analysis was performed for 452 patients admitted to the cardiomyopathy service at the Brigham and Women's Hospital with a diagnosis of HF. Patients were classified by clinical assessment into four profiles: profile A, patients with no evidence of congestion or hypoperfusion (dry-warm, n = 123); profile B, congestion with adequate perfusion (wet-warm, n = 222); profile C, congestion and hypoperfusion (wet-cold, n = 91); and profile L, hypoperfusion without congestion (dry-cold, n = 16). Other standard predictors of outcome were included and patients were followed for the end points of death (n = 117) and death or urgent transplantation (n = 137) at one year. RESULTS: Survival analysis showed that clinical profiles predict outcomes in HF. Profiles B and C increase the risk of death plus urgent transplantation by univariate (hazard ratio [HR] 1.83, p = 0.02) and multivariate analyses (HR 2.48, p = 0.003). Moreover, clinical profiles add prognostic information even when limited to patients with New York Heart Association (NYHA) class III/IV symptoms (profile B: HR 2.23, p = 0.026; profile C: HR 2.73, p = 0.009). CONCLUSIONS: Simple clinical assessment can be used to define profiles in patients admitted with HF. These profiles predict outcomes and may be used to guide therapy and identify populations for future investigation.

Frequency and impact of delayed decisions regarding heart transplantation on long-term outcomes in patients with advanced heart failure.

OBJECTIVES: We sought to characterize decisions regarding listing of heart transplant candidates and to determine the impact of delayed listing for a transplant on survival. BACKGROUND: Evaluation and listing for heart transplantation have evolved over the past decade, with the complex decision process often extending beyond the time of initial review. Little is known about the current impact of decisions and timing of listing on outcomes. METHODS: Decisions were prospectively recorded during the initial committee discussions regarding patients referred for heart transplant evaluation. Survival and transplantation rates were assessed. RESULTS: A total of 214 patients were evaluated for heart transplantation (age 49 +/- 11 years, ejection fraction 21 +/- 9%, New York Heart Association class III +/- I, peak oxygen consumption 13 +/- 4 ml/kg/min). At the initial evaluation, 44% of patients were deemed eligible, 25% were potentially eligible, 19% were ineligible, and 12% were deferred. For eligible patients, 37% of patients were listed within 10 days of evaluation, and a total of 71% of patients were ever listed. Regardless of transplantation, the three-year survival rate in eligible patients not listed early was similar to that in patients listed immediately (85% vs. 77%, p = 0.34). Ineligible and potentially eligible patients had a higher three-year mortality rate than did eligible patients if transplantation occurred (51% vs. 17%, p < 0.001) or not (57% vs. 19%, p = 0.04). CONCLUSIONS: Using current accepted guidelines, many patients referred for transplant evaluation were not considered eligible for transplantation, and those who were eligible were not often listed immediately. Eligible patients not listed initially did well in the long term, and patients with relative contraindications had worse outcomes with or without a transplant.

The management of mechanical hearts.

Mechanical ventricular assist devices are now approved as destination therapy for terminal heart failure. It is the purpose of this review to discuss the physiology of this technology that is considered in outpatient care. The currently available pulsatile devices are solely dependent of preload volume, and when placed in the automatic mode, can maintain physiologic cardiac outputs with exercise. However, because of their dependence on preload volume, there are unique physiologic consequences; device bradycardia represents volume depletion, device tachycardia reflects volume overload. The differential diagnosis of left ventricular assist device dysfunction includes native right ventricular failure, native left ventricular recovery, or other technical considerations. The management of biventricular mechanical support will be discussed, as well as arrhythmia management and the role of echocardiographic assessment in this unique patient population. Expertise in outpatient management of such devices is now a requisite for subspecialists in heart failure. In the future, technical innovations may simplify management for professionals, patients and their families.

Risk factors and outcomes for 'vasoplegia syndrome' following cardiac transplantation.

OBJECTIVE: Vasoplegia syndrome after orthotopic heart transplantation (OHT) is a rare but highly lethal syndrome of unknown etiology, characterized by severe refractory hypotension, metabolic acidosis, and decreased systemic vascular resistance (SVR). The objective of this retrospective study was to identify the risk factors contributing to the development of vasoplegia syndrome after OHT in order to provide potential algorithms for its management. METHODS: Between October 1992 and July 2001, 187 consecutive patients underwent OHT. Complete pre- and post-data were available in 147 patients (78%). Mean age was 49+/-11 years, 82% (120/147) were male, and donor ischemic time was 117+/-62 min. Twenty-eight of 147 (19%) developed vasoplegia syndrome, defined as SVR <800 dyns per cm(5) with serum bicarbonate <20 mEq/l. RESULTS: Patients who developed vasoplegia syndrome demonstrated greater hospital mortality (25 vs. 9%, P=0.031) compared to those who did not. Multivariate logistic regression identified pre-operative use of intravenous heparin (OR 2.8, CI 1-7.4, P=0.039) and body surface area >1.9 m(2) (OR 7, CI 0.98-50, P=0.052) as independent predictors for the development of post-operative vasoplegia syndrome. Pre-operative use of inotropic support conferred protection against the development of post-operative vasoplegia syndrome (OR 0.25, CI 0.08-0.79, P=0.018). Pre-operative use of ACE inhibitors was not associated with increased risk (55 vs. 59%, P=0.441). CONCLUSIONS: Vasoplegia syndrome following OHT is associated with high early mortality. The development of a risk stratification profile may help in patient selection as well as the post-operative management of vasoplegia syndrome following OHT.

Ventricular assist devices the challenges of outpatient management.

The need for mechanical assistance of the failing heart, whether acute after a myocardial infarction or permanent in patients with end-stage heart failure, has increased with improvements in medical therapy and a growing aged population. Over the past few decades, much progress has been made in the development and refinement of ventricular assist devices (VADs), medical devices capable of maintaining circulatory output of the diseased ventricle. Initially designed as a temporary support to allow ventricular recovery or as a bridge for patients to cardiac transplantation, these devices are now being used as a permanent form of "destination" therapy. Improvements in technological design, durability, and medical management have allowed individuals with VADs to be managed in their communities. Although these devices provide excellent hemodynamic support and enhance patient functional status, discharged individuals face many unique challenges. In this article, we discuss 1) the spectrum of VADs for outpatient therapy, including their basic physiology and hemodynamics; 2) the multidisciplinary approach required to care for a patient with such a device in the community; 3) routine general cardiac issues that are encountered; 4) associated long-term device and nondevice-related complications; and 5) the reported overall improvements in quality of life.

Management of end-stage heart failure: a perspective on the Arab Gulf states.

The ever expanding epidemic of end-stage heart failure represents one of the greatest challenges of modern cardiovascular medicine. With medical treatments hampered by significant limitations, physicians caring for patients with advanced heart disease have turned to cardiac transplantation and durable mechanical circulatory assist devices as definitive therapies. These advanced therapeutic modalities are not widely available outside the United States and Europe, but nevertheless offer enormous potential for patients in the Arab Gulf suffering from end-stage heart failure. This review will discuss the management of end-stage heart failure in the Gulf States, with an emphasis on therapies best utilized within a framework of regional cooperation and coordination.

Thresholds of physical activity and life expectancy for patients considering destination ventricular assist devices.

BACKGROUND: Current implantable left ventricular assist devices (LVAD) improve survival and function for patients with very late stage heart failure (HF) but may also offer benefit before inotrope dependence. Debate continues about selection of HF patients for LVAD therapy. We sought to determine what level of personal risk and disability HF patients thought would warrant LVAD therapy. METHODS: The study included 105 patients with symptomatic HF and an LV ejection fraction (EF) < 35% who were given a written paragraph about LVADs and asked about circumstances under which they would consider such a device. New York Heart Association (NYHA) functional class, time trade-off utility, and patient-assessed functional score were determined. RESULTS: Participants (mean age, 58 years) had an LVEF of 21%. The median duration of HF was 5 years, and 65% had a primary prevention implantable cardioverter defibrillator. Presented with a scenario of bed-ridden HF, 81% stated they would definitely or probably want an LVAD; 50% would consider LVAD to prolong survival if HF survival were predicted to be < 1 year and 75% if < 6 months. Meanwhile, 44% would consider LVAD if they could only walk < 1 block and 64% if they could not dress without stopping. Anticipated thresholds did not differ by NYHA class, time trade-off, or functional score. CONCLUSIONS: Patient thresholds for LVAD insertion parallel objective survival and functional data. HF patients would be receptive to referral for discussion of LVAD by the time expected mortality is within 6 to 12 months and activity remains limited to less than 1 block.

BK viral reactivation in cardiac transplant patients: evidence for a double-hit hypothesis.

BACKGROUND: BK nephropathy is a significant cause of renal dysfunction in renal allograft recipients. The question of whether BK viral infection plays a role in renal dysfunction in cardiac transplantation patients remains to be answered. METHODS: We prospectively examined the prevalence of BK viral reactivation in the setting of cardiac transplantation and performed a cross-sectional analysis of 111 cardiac transplantation patients. We also assessed the prevalence of viremia in a cohort of 29 renal transplant recipients. RESULTS: We found urinary decoy cells in 28 cardiac transplantation patients. Of these, 14 patients had evidence of BK viral DNA in the urine. None, however, had evidence of BK viremia. Mean age, gender, levels of pre- and post-transplant serum creatinine, cardiopulmonary bypass time, and ischemic time were not significantly different between the groups. We found that 7 of 29 renal transplant recipients studied had BK viral DNA in their urine. CONCLUSION: These findings are evidence of BK virus reactivation in the setting of cardiac transplantation at a percentage similar to that seen in renal allograft recipients. In contrast to renal allograft recipients, none had evidence of viremia. Thus, even in the setting of established BK virus reactivation, immunosuppression in combination with renal allograft dysfunction and renal ischemic injury is usually insufficient to cause BK viremia and nephropathy, and it appears that a second, organ-specific hit is necessary, such as kidney inflammation, kidney ischemia, or donor-recipient human leukocyte antigen mismatch.

Effect of vitamins C and E on progression of transplant-associated arteriosclerosis: a randomised trial.

BACKGROUND: Cardiac transplantation is associated with oxidant stress, which may contribute to the development of accelerated coronary arteriosclerosis. We postulated that treatment with antioxidant vitamins C and E would retard the progression of transplant-associated arteriosclerosis. METHODS: In a double-blind prospective study, 40 patients (0-2 years after cardiac transplantation) were randomly assigned vitamin C 500 mg plus vitamin E 400 IU, each twice daily (n=19), or placebo (n=21) for 1 year. The primary endpoint was the change in average intimal index (plaque area divided by vessel area) measured by intravascular ultrasonography (IVUS). Coronary endothelium-dependent vasoreactivity was assessed with intracoronary acetylcholine infusions. IVUS, coronary vasoreactivity, and vitamin C and E plasma concentrations were assessed at baseline and at 1 year follow-up. All patients received pravastatin. Analyses were by intention to treat. FINDINGS: Vitamin C and E concentrations increased in the vitamin group (vitamin C 43 [SD 21] to 103 [43] mmol/L; vitamin E 24 [14] to 65 [27] mmol/L) but did not change in the placebo group (vitamin C 45 [15] vs 43 [16] mmol/L; vitamin E 27 [14] vs 27 [9] mmol/L; p<0.0001 for difference between groups). During 1 year of treatment, the intimal index increased in the placebo group by 8% (SE 2) but did not change significantly in the treatment group (0.8% [1]; p=0.008). Coronary endothelial function remained stable in both groups. INTERPRETATION: Supplementation with antioxidant vitamins C and E retards the early progression of transplant-associated coronary arteriosclerosis.

Severity of intraoperative tricuspid regurgitation predicts poor late survival following cardiac transplantation.

BACKGROUND: This study evaluates the significance of tricuspid regurgitation (TR) on long-term survival as detected by intraoperative transesophageal echocardiography at the time of orthotopic heart transplantation. Although significant (2+ to 4+) TR after orthotopic heart transplantation is rare, its influence on long-term survival is unknown, warranting further investigation. METHODS: Between January 1992 and July 2001, 181 consecutive patients underwent orthotopic heart transplantation. Tricuspid regurgitation was graded by intraoperative transesophageal echocardiography after final separation from cardiopulmonary bypass in 130 of 181 patients (72%). RESULTS: Although 80% (104/130) of patients had either no (0, n = 77) or trace (1+, n = 27) TR, 9% (12/130 patients) had mild (2+), 10% (13/130 patients) had moderate (3+), and 0.8% (1/130 patients) had severe (4+) TR. The severity correlated strongly with the presence of right ventricular dysfunction (p < 0.001). In a multivariate regression model, gender mismatch (p = 0.002) and right ventricular dysfunction (p < 0.001) were independent predictors for equal to or greater than mild (2+ to 4+) TR (p = 0.015). Although the degree of recipient pulmonary vascular resistance did not influence the grade (p = 0.600), higher pulmonary vascular resistance tended to increase the severity of TR in the setting of prolonged donor ischemic times (p = 0.054). Proportional hazards regression analysis demonstrated significantly decreased survival for patients with mild or greater (2+ to 4+) TR detected by transesophageal echocardiography at the time of transplantation (p < 0.001) and RV dysfunction (p = 0.023). CONCLUSIONS: Even mild (> or = 2+) TR identified by transesophageal echocardiography at the time of orthotopic heart transplant predicts poor late survival, suggesting a possible role for concomitant tricuspid valve repair at the time of transplant. Whether or not tricuspid valve repair will improve long-term survival is unknown.