Safe use of hemodialysis for dabigatran removal before cardiac surgery.

OBJECTIVE: To describe a case in which hemodialysis was performed before cardiac transplantation in an attempt to reverse the effects of dabigatran and reduce the risk of bleeding associated with surgery. CASE SUMMARY: A 59-year-old female with heart failure and atrial fibrillation was admitted for orthotropic heart transplant. She had been stable at home with continuous milrinone therapy 0.25 µg/kg/min, amiodarone 200 mg twice daily, and dabigatran 150 mg twice daily for stroke prevention secondary to atrial fibrillation. Upon notification of organ availability, the patient was admitted to the hospital for transplant surgery, with her last dose of dabigatran taken approximately 36 hours before admission. Coagulation studies indicated normal activated partial thromboplastin time, slightly elevated international normalized ratio of 1.2, and elevated thrombin time (TT) of 90.6 seconds (upper limit of normal 19.9 seconds). A hemodialysis catheter was emergently placed and dialysis was initiated. One hour after initiation, TT decreased to 65.5 seconds. After 2.5 hours of dialysis, TT further decreased to 60.2 seconds; at that time, the patient underwent transplantation with no abnormal bleeding during or following surgery. DISCUSSION: Minimal data exist on techniques to reverse the effects of dabigatran in cases of bleeding or emergent surgery. This case examines the efficacy of hemodialysis to decrease dabigatran's effect on clotting assays prior to surgery to reduce the risk of bleeding. In this case, a TT of 60.2 seconds with recent dabigatran administration did not result in abnormal bleeding associated with cardiac surgery. CONCLUSIONS: To our knowledge, this case report represents the first published data on the effects of hemodialysis on dabigatran removal and reversal of anticoagulation associated with dabigatran before surgery. The routine use of preoperative hemodialysis in patients on dabigatran is not recommended; however, the potential efficacy in such circumstances is supported by the successful results in this case.

Ceftaroline-related acute eosinophilic pneumonia.

Ceftaroline fosamil is a novel 5th generation broad-spectrum oxyimino-cephalosporin with activity against Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA), Streptococcus pneumoniae, Haemophilus influenzae, and Gram-negative bacteria. It has been approved by the United States Food and Drug Administration for the treatment of acute bacterial skin and skin structure infections and community-acquired bacterial pneumonia. There have been reported cases of successful treatment of MRSA bacteremia with this agent. Common adverse drug reactions from ceftaroline include skin rash, hives, neutropenia, thrombocytopenia, and anemia. Acute eosinophilic pneumonia is a rare untoward drug reaction associated with it. We report a case of fever and acute hypoxic respiratory failure with bilateral interstitial pulmonary infiltrates while on ceftaroline therapy for sternal osteomyelitis and ascending aortic graft infection secondary to MRSA. Laboratory studies revealed peripheral blood eosinophilia (>3000 cells/mm3). After exclusion of infectious, autoimmune, and other extrinsic allergic causes of pneumonia, ceftaroline-related acute eosinophilic pneumonia was suspected. Ceftaroline was discontinued and a therapeutic trial of high-dose steroid was initiated. Significant improvement of clinical symptoms and hypoxia was achieved after 24 h of steroid therapy. There was no recurrence of clinical symptoms after completing steroid course, which supported our suspicion of acute eosinophilic pneumonia from ceftaroline. Radiographic improvement of pulmonary infiltrates occurred 4 weeks later with complete resolution at 3 months from the initial event. The current case adds to this rarely reported adverse effect from this relatively newer antimicrobial agent. Increased awareness, early recognition, discontinuation of medication, and steroid therapy are key in favorable clinical outcome and recovery.

Significance of Residual Mitral Regurgitation After Continuous Flow Left Ventricular Assist Device Implantation.

OBJECTIVES: This study hypothesized that the presence of residual mitral regurgitation (MR) post-continuous flow (CF) left ventricular assist device (LVAD) implantation based on quantitative assessment would be negatively associated with right ventricular (RV) size and function and clinical outcomes. BACKGROUND: MR is associated with elevated left atrial pressure, secondary pulmonary hypertension and RV dysfunction. Implantation of a LVAD leads to mechanical unloading of the left ventricle and generally improves MR. The clinical significance of residual MR in patients supported with CF LVADs is uncertain. Most studies evaluating the presence of MR in LVAD patients have utilized predominantly qualitative assessments of MR. METHODS: We retrospectively identified patients implanted with CF LVADs at our institution from 2007 to 2013 who had a pre-operative transthoracic echocardiogram (TTE) within 3 months of LVAD implant and who had a post-operative TTE at least 1 month post-LVAD. MR was assessed quantitatively using the ratio of MR color jet area (CJA)/left atrial area (LAA) in apical views. We also compared quantitative RV metrics, hospitalizations, and mortality in patients with and without significant residual MR (defined as MR CJA/LAA >0.2) on post-implantation TTE. RESULTS: Sixty-nine patients were included in this study. Post-LVAD implantation, 55 patients (80%) had mild or less MR (mean MR CJA/LAA 0.08) but 14 (20%) had significant residual MR (mean MR CJA/LAA 0.34). Patients with residual MR had significantly larger RV size (right ventricular end diastolic dimension 49 mm vs. 45 mm; p = 0.04) and worse RV function (tricuspid annular plane systolic excursion 10 mm vs. 12 mm; p = 0.02; and right ventricular fractional area change 29% vs. 34%; p = 0.02). Post-implantation pulmonary artery pressures were higher in patients with residual MR (pulmonary artery systolic 43 mm Hg vs. 35 mm Hg; p = 0.05). In patients with residual MR there was slightly greater posterior displacement of the mitral coaptation point on pre-operative TTE (28 mm vs. 26 mm; p = 0.16) but this difference was not significant. Time from LVAD implantation to first hospitalization was shorter in patients with residual MR (62 days vs. 103 days; p = 0.05) as was time from LVAD implantation to death (80 days vs. 421 days; p = 0.03). CONCLUSIONS: Significant residual MR post-LVAD implantation assessed by a quantitative measure is associated with persistent pulmonary hypertension, worse RV function, and significantly shorter time to hospitalization and death. MR post-LVAD implantation may serve as a surrogate for adverse outcomes post-LVAD implantation.

Severe Acute Traumatic Mitral Regurgitation, Cardiogenic Shock Secondary to Embolized Polymethylmethracrylate Cement Foreign Body After a Percutaneous Vertebroplasty.

We report the case of a 61-year-old woman with acute decompensated heart failure secondary to acute traumatic mitral regurgitation, resulting from polymethylmethacrylate cement found in the left ventricle less than 24 hours after fluoroscopic percutaneous vertebroplasty. The patient had a history of ovarian cancer and had undergone treatment for symptomatic osteoporotic compression fractures of the vertebrae (T11, L1, and L3). The patient underwent a successful emergency open-heart operation, mitral valve replacement, closure of an atrial septal defect, and video-assisted removal of the cement foreign body from the left ventricle. The patient was later discharged with a good outcome.