The emerging role of cardiac contractility modulation in heart failure treatment.

PURPOSE OF REVIEW: Heart failure often progresses despite optimal medical and device therapies, and advanced mechanical circulatory support has limited availability and substantial associated morbidity. Cardiac contractility modulation (CCM) provides nonexcitatory stimulation to ventricular myocardium which increases cardiac contractility without increasing oxygen demand. This review describes the emerging role of CCM in heart failure treatment. RECENT FINDINGS: The FIX-HF-5C2 study demonstrated similar safety and efficacy profile of the two-lead Optimizer device in comparison with the prior three-lead system, thereby decreasing procedural complexity and minimizing endocardial hardware. The FIX-HF-5C trial underscored the benefit of CCM in patients with mild-moderate left ventricular dysfunction (ejection fraction, 25-45%) with New York Heart Association (NYHA) Class III symptoms. The summarized randomized trial data show consistent improvements in peak VO2, 6-min walk distance, and NYHA functional class with CCM. Future trials are planned to determine the role of CCM in heart failure patients with preserved ejection fraction, obligate ventricular pacing, and atrial arrhythmias. SUMMARY: Nonexcitatory extracellular electric potentials can facilitate inotropic improvements in the failing heart. The mechanism of CCM does not increase myocardial oxygen consumption and has been shown to mitigate heart failure symptoms, decrease hospitalizations, and work in synergy with guideline-directed therapy for heart failure.

Prevention and Early Recognition of Complications During Catheter Ablation by Intracardiac Echocardiography.

The effective diagnosis and management of procedural complications remains an important challenge for electrophysiology operators. Intracardiac echocardiography provides a real-time imaging modality with spectral and color Doppler capabilities that integrates directly with electroanatomic mapping systems. It provides detailed characterization of anatomic variants, which allows the operator to optimize the ablation strategy to the individual thereby avoiding the inherent risk of excessive or ineffective lesions. Complications, such as intracardiac thrombus or pericardial effusion, can be detected and managed before the onset of clinical symptoms. Intracardiac echocardiography facilitates the diagnosis and management of intraoperative hypotension.

Left ventricular filling pressure and survival following aortic valve replacement for severe aortic stenosis.

OBJECTIVE: To determine whether echocardiography-derived left ventricular filling pressure influences survival in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). METHODS: We retrospectively reviewed 1383 consecutive patients with severe AS, normal ejection fraction and interpretable filling pressure undergoing AVR. Left ventricular filling pressure was determined according to current guidelines using mitral inflow, mitral annular tissue Doppler, estimated right ventricular systolic pressure and left atrial volume index. Cox proportional hazards regression was used to assess the influence of various parameters on mortality. RESULTS: Age was 75±10 years and 552 (40%) were female. Left ventricular filling pressure was normal in 325 (23%), indeterminate in 463 (33%) and increased in 595 (43%). Mean follow-up was 7.3±3.7 years, and mortality was 1.2%, 4.2% and 18.9% at 30 days and 1 and 5 years, respectively. Compared with patients with normal filling pressure, patients with increased filling pressure were older (78±9 vs 70±12, p<0.001), more often female (45% vs 35%, p=0.002) and were more likely to have New York Heart Association class III-IV symptoms (35% vs 24%, p=0.004), coronary artery disease (55% vs 42%, p<0.001) and concentric left ventricular hypertrophy (63% vs 37%, p<0.001). After correction for other factors, increased left ventricular filling pressure remained an independent predictor of mortality after successful AVR (adjusted HR 1.45 (95% CI 1.16 to 1.81), p=0.005). CONCLUSIONS: Preoperative increased left ventricular filling pressure is common in patients with AS undergoing AVR and has important prognostic implications, regardless of symptom status. Future prospective studies should consider whether patients with increased filling pressure would benefit from earlier operation.

aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion.

BACKGROUND: Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression. METHODS: STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression. RESULTS: Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001). CONCLUSIONS: STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

Hydrocortisone, Vitamin C and thiamine for the treatment of sepsis and septic shock following cardiac surgery.

BACKGROUND AND AIMS: The effect of vitamin C on vasopressor requirement in critically ill patients have been evaluated previously. We aimed to evaluate the effect of vitamin C, hydrocortisone and thiamine on vasopressor requirement and mortality in post-operative adult cardiac surgical patients with septic shock. METHODS: About 24 patients with septic shock were randomised into Group 1 (receiving matching placebo per day for 4 days) and Group 2 (receiving 6 g vitamin C, 400 mg thiamine and 200 mg hydrocortisone per day for 4 days). Vasopressor dose over 4 days of therapy was the primary endpoint, whereas in-hospital mortality was the secondary endpoint. RESULTS: APACHE IV and EUROSCORE II scores were similar between both the groups. Significant reductions in the requirement of vasopressin (difference from day 1 - 0.0008 ± 0.00289 vs 0.0033 ± 0.00492 units/kg/min; P = 0.019) and noradrenaline (difference from day 1 - 0.0283 ± 0.040 vs 0.023 ± 0.035 µg/kg/min; P = 0.006) were observed with vitamin C treatment as compared to control group. PCT levels on Day 3 (68.11 ± 33.64 vs 33.2 ± 27.55 ng/mL; P = 0.0161) and Day 4 (70.03 ± 29.74 vs 26.3 ± 23.08 ng/mL; P = 0.0009) were significantly lower in treatment group as compared to control. However, there was no difference in the Sepsis-Related Organ Failure Assessment (SOFA) score and mortality between the studied groups. CONCLUSION: Combination of vitamin C, thiamine and hydrocortisone reduces vasopressor requirement in adult cardiac surgical patients with septic shock.

Minimal incision scar-less open umbilical hernia repair in adults - technical aspects and short-term results.

BACKGROUND: There is no gold standard technique for umbilical hernia (UH) repair. Conventional open UH repair often produces an undesirable scar. Laparoscopic UH repair requires multiple incisions beyond the umbilicus, specialized equipments, and expensive tissue separating mesh. We describe our technique of open UH repair utilizing a small incision. The technique was derived from our experience with single incision laparoscopy. We report the technical details and short-term results. METHODS: This is a retrospective analysis of the first 20 patients, who underwent minimal incision scar-less open UH repair, from June 2011 to February 2014. A single intra-umbilical curved incision was used to gain access to the hernia sac. Primary suture repair was performed for defects up to 2 cm. Larger defects were repaired using an onlay mesh. In patients with a BMI of 30 kg/m(2) or greater, onlay mesh hernioplasty was performed irrespective of the defect size. RESULTS: A total of 20 patients, 12 males and 8 females underwent the procedure. Mean age was 50 (range 29-82) years. Mean BMI was 26.27 (range 20.0-33.1) kg/m(2). Average size of the incision was 1.96 range (1.5-2.5) cm. Mesh hernioplasty was done in nine patients. Eleven patients underwent primary suture repair alone. There were no postoperative complications associated with this technique. Average postoperative length of hospital stay was 3.9 (range 2-10) days. Mean follow-up was 29.94 months (2 weeks to 2.78 years). On follow-up there was no externally visible scar in any of the patients. There were no recurrences on final follow-up. CONCLUSION: This technique provides a similar cosmetic effect as obtained from single port laparoscopy. It is easy to perform, safe, offers good cosmesis, does not require incisions beyond the umbilicus, and cost effective, with encouraging results on short-term follow-up. Further research is needed to assess the true potential of the technique and the long-term results.

Large patent ductus arteriosus in an adult complicated by pulmonary endarteritis and embolic lung abscess.

Patent ductus arteriosus in the adult is an extremely rare clinical phenomenon. We report the case of a 34-year old man who developed pulmonary endarteritis and subsequent embolic lung abscess secondary to a large patent ductus arteriosus. This brief report also provides an overview of the natural history, potential complications, optimal therapy, and diagnostic dilemmas associated with this persistent congenital cardiac defect in adults.