The role of endovascular treatment of pelvic fracture bleeding in emergency settings.

PURPOSE: To evaluate the role of endovascular treatment for controlling haemorrhage in haemodynamically unstable patients with pelvic bone fractures and to relate clinical efficacy to pre-procedural variables. MATERIALS AND METHODS: From March 2009 through April 2013, 168 patients with major pelvic trauma associated with high-flow haemorrhage were referred to our emergency department and were retrospectively reviewed. Pelvic arteries involved were one or more per patient. Embolisation was performed using various materials (micro-coils, Spongostan, plug, glue, covered stent), and technical success, complications, treatment success, clinical efficacy, rebleeding, and mortality rates were assessed. Factors influencing clinical efficacy were also evaluated. RESULTS: The technical success rate was 100%; no complications occurred during the procedures. Treatment was successful in 94.6% cases, and clinical efficacy was 85.7%. Three patients had to undergo a second arteriography due to recurrent haemorrhage. Fifteen patients died. Pre-embolisation transfusion demand was significantly associated with clinical efficacy. CONCLUSIONS: Percutaneous embolisation of pelvic bleeding may be considered a safe, effective, and minimally invasive therapeutic option. As haemodynamic stability is the first objective with traumatic haemorrhagic patient, arterial embolisation can assume a primary role. On the basis of our results, pre-procedural transfusion status may be considered a prognostic factor. KEY POINTS: • The series presented is one of the largest in a single centre. • Arterial embolisation is a life-saving procedure in patients with pelvic haemorrhage. • In pelvic traumas associated with haemorrhage, prognosis is dependent upon prompt treatment. • Transfusion status is significantly related to clinical efficacy.

Device-related thrombus overlying a left-atrial occlusion device implanted for persistent spontaneous echo contrast despite prolonged oral anticoagulation therapy.

A 75-year-old woman with a history of atrial fibrillation, severe biatrial enlargement, persistent dense spontaneous echo contrast in the left atrium and left-atrial appendage on appropriate oral anticoagulant therapy underwent implantation of the left-atrial occlusion device to decrease her risk of thromboembolic stroke. Six weeks later, a scheduled transesophageal echocardiography showed a partially mobile mass (4.1 × 2.1 cm) overlying the atrial surface of the device: a suspected thrombus. This report highlights the importance of follow-up examination and the limitation of this treatment modality among patients with persistent atrial fibrillation, large left atria and dense spontaneous echo contrast.

Long-term outcome of first 300 implanted Absorb bioresorbable vascular scaffolds in an all-comers Middle East population.

OBJECTIVES: To evaluate long-term clinical outcomes of the Absorb bioresorbable vascular scaffold (BVS) system (Abbott Vascular) in an all-comers Middle East population. METHODS: This prospective registry study included an initial set of patients with coronary lesions treated using Absorb BVS. Patients were followed for target vessel failure (TVF) including cardiac death, target vessel myocardial infarction (MI), and target lesion revascularization. RESULTS: A total of 217 patients (age, 55 ± 11 years; male, 169) with 300 treated lesions were included (median follow-up, 36 months [range, 26-41 months]; complete follow-up, 201 patients). Diabetes mellitus and acute coronary syndrome were present in 50% and 57% of patients, respectively. TVF rate was 32/201 (15.9%), including cardiac death in 10 (5%), target vessel MI in 13 (6.5%), and target lesion revascularization in 22 patients (10.9%). Definite or probable device thrombosis occurred in 11/201 patients (5.5%). TVF was associated with heart failure, worse ejection fraction, multi-vessel BVS, multi BVS in lesion, and total BVS length >50 mm. CONCLUSIONS: Long-term outcome following Absorb BVS implantation in a population with high prevalence of high-risk and complex patients is acceptable, but heart failure, worse ejection fraction, and multi-vessel or long BVS implantation were associated with worse outcomes.

Skirt followed by trouser stenting technique: True anatomical preservation of coronary Y-shaped bifurcation lesions while using "vanishing" bioresorbable scaffolds: A report of two cases.

We report on two cases in which Y-shaped coronary bifurcations were treated with the use of Bioresorbable scaffolds. The first case was of a 50-year-old man with NSTEMI. Coronary angiography showed stenosis involving a Y-shaped bifurcation of proximal to mid LAD and diagonal. The lesion was wired using two 0.14 BMW guide wires, followed by serial pre-dilatation of LAD and Diagonal branch. The stent into proximal LAD was deployed first as a skirt (3.5 × 12 BVS). Stent was post-dilated. A second 2.5 × 28 BVS was deployed into diagonal branch, protruding backwards; along with a 2.0 × 15 SC balloon continuing into the mid LAD. Both balloons where pulled back proximally and re-inflated. The technique was repeated in reversed order for stenting the mid LAD using the third BVS (3.0 × 18 BVS). Finally two NC balloons where used to post-dilate both legs of the newly-formed trouser. The result was checked by OCT. The second case was that of a 62-year-old man with chest pain and NSTEMI. He had a history of previous PCI to LCx using bare metal stent. Coronary angiogram showed severe in-stent restenosis in mid LCX, extending into two large obtuse marginal branches. After wiring both OMs, serial pre-dilatation was done with two NC 2.5 × 20 balloons, followed by initial stenting of mid LCx inside old stent, as the proximal segment of bifurcation, using a 3.5 × 12 BVS, followed by implanting a 2.5 × 28 BVS into OM2 and 2.5 × 18 into OM1. At 6 months a clinical follow up via telephone contact revealed no recurrence of chest pain in both cases and no further intervention required.

The impact of severity of initial illness, determined by SOFA score, and presence of anemia on outcomes among patients requiring Extra Corporal Membrane Oxygenation (ECMO) support: A single center experience.

INTRODUCTION: ECMO provides respiratory and circulatory support in critically ill patients. In our study, we report on a single center experience with ECMO and aim to identify the prognostic markers for survival to discharge from hospital. METHODS: A registry was maintained on all patients who underwent ECMO implantation from September 2012 till January 2016 at a single institution. The collected data was analyzed to identify baseline characteristics, outcomes including clinical variables predictive of poor outcome. RESULTS: A total of 29 patients underwent ECMO implantation. The average age of patients was 42±18years. 59% were males (N=17). 19 cases had a cardiac indication for ECMO (66%) while 10 cases had a pulmonary indication (34%). On univariate analysis; presence of Multi-organ failure, SOFA score more than 18 and hemoglobin less than 10g/dl at baseline and after ECMO removal were associated with increased 30day mortality. Pearson correlation with 30day mortality showed a positive correlation with MOF (+0.562, p=0.002) and SOFA score >18 (+0.448, p=0.015) and a negative correlation with anemia (-0.507, p=0.005). 15 out of the total 29 patients (52%) died within 30days of admission. Patients with MOF (log rank: 10.926, p=0.001), SOFA score >18 (log rank: 7.758, p=0.005) and hemoglobin <10g/dl (log rank: 5.595, p=0.018) had decreased survival on 30day follow up. CONCLUSIONS: Although the use of ECMO as a last line in the treatment of critical patients refractory to conventional treatment measures constitutes an important improvement in their care; with 48% overall survival; patient selection and timing of ECMO initiation remains challenging. Patients who already had signs of MOF and a high SOFA score portended a poor response. Similarly for anemic patients. Hence the importance of consideration for ECMO use earlier in course of illness rather than later. Screening and aggressive treatment of anemia in those patients may help improve the outcomes.

Prevalence and clinical implications of anemia in congestive heart failure patients followed at a specialized heart function clinic.

The objective of this study was to assess the prevalence of anemia and to investigate its association with comorbidities and its impact on clinical outcomes in patients with heart failure. The association of predefined anemia, as well as the correlation of serum hemoglobin level as a continuous variable, with outcomes of emergency department visits, hospitalization, and mortality was investigated. There were fewer anemic patients in New York Heart Association classes I and II than in classes III and IV. Anemia was associated with higher rates of emergency department visits, hospital admissions, and all-cause mortality. Multivariable analysis showed that anemia is independently associated with mortality. When hemoglobin level was considered as a continuous variable, the authors noted that the mortality risk correlated with hemoglobin level disappears when hemoglobin level exceeds 140 g/L. The authors conclude that anemia has strong impacts on functional class and other clinical outcomes in patients with heart failure.

Acute coronary syndrome. An acute inflammatory syndrome.

Atherosclerosis begins with the accumulation of small lipoprotein particles within arterial intima. These particles coalesce together and are modified and then they induce localized endothelial inflammation, thereby attracting leukocytes. Scavenger receptors over the surface of monocytes bind to the modified low density lipoprotein particles, which transform into foam cells that become a source for further inflammatory cytokines. The level of inflammation is heightened in ruptured coronary plaques. In patients dying of an acute myocardial infarction, the level of inflammation is heightened in all lesions in the coronary tree. The inflammatory reaction in acute coronary syndrome is not confined to cellular immunity, but also encompasses humoral immunity. High sensitivity CRP hs-CRP measures systemic inflammation, and at low levels it has emerged as a strong predictor of adverse cardiovascular events. It is mainly used to further stratify the intermediate-risk patients. Many other molecules have shown promise as markers for increased inflammation and increased risk of adverse cardiac events. That risk may be additive in nature, and some studies suggest that inflammatory markers can also predict response to various treatment strategies during acute coronary syndromes.

A case of dilated cardiomyopathy and severe mitral regurgitation treated using a combined percutaneous approach of MitraClip followed by CARILLON® mitral contour system.

Functional mitral regurgitation (FMR) is common in severe heart failure. Medical therapy is the standard of care since the role of surgery is less established. Various trans-catheter percutaneous techniques may avoid the risks of surgery; such as edge-to-edge repair using MitraClip system (Abbott Vascular, Illinois, USA) and CARILLON® Mitral Contour System® (Model XE2; Cardiac Dimensions., Kirkland, WA, USA). We present the case of a 41-year-old man with severe dilated cardiomyopathy, NYHA IIIb, and grade 3 MR. Due to high surgical risk (logistic EuroScore 35.1) he initially underwent single MitraClip insertion with significant echocardiographic and clinical improvement (MR reduced from 3+ to 1+, NYHA classes III to II). Fifteen months later, he developed heart failure symptoms due to recurrence of severe MR and was retreated with percutaneous CARILLON® Mitral Contour System® with resolution of MR and doing well at nine-month follow-up. A combined approach of MitraClip followed by percutaneous mitral annuloplasty demonstrated clinically meaningful reduction of MR and resulted in significant symptomatic improvement for up to 6months. Follow-up for longer period is warranted to ensure sustained favorable outcome.

Left ventricular assist devices as bridge to heart transplantation in congestive heart failure with pulmonary hypertension.

Severe pulmonary hypertension (PH) has been considered a significant contraindication to cardiac transplantation. Ongoing clinical experience, however, has shown that temporary support using left ventricular assist devices (LVADs) in these patients can result in significant reductions in PH. A comprehensive review of the available literature regarding the use of LVADs in heart failure patients with PH was conducted. The existing literature to date supports the use of LVADs in heart failure patients with PH and demonstrates that significant reductions in PH in these patients can be achieved. This subsequently allows for safe and effective cardiac transplantation in patients who were previously excluded from this modality. For heart failure patients with severe PH, the use of LVADs can provide significant benefits by significantly reducing PH and allowing subsequent staged transplantation.

The epidemic of the metabolic syndrome.

The incidence of metabolic syndrome (MS) is rising worldwide. This is partly due to a significant increase in the prevalence of obesity. Observational cross-sectional studies as well as demographic health surveys from the Middle East, point out that the prevalence of obesity increases from an average of 6% in healthy children to 20% in adolescent males and to a further 32% in elderly patients. The impact of obesity on our population is expected to be considerable; especially, as it feeds into further rising in the prevalence of hypertension, diabetes, MS and cardiovascular disease. The prevalence of MS in nondiabetic adults in Europe was recently reported to be 15%. In the Middle East, as pointed out by pilot observational projects, is estimated to be anywhere between 15-25%. The medical system is unprepared to deal with this epidemic partly due to scanty knowledge on the clinical significance of the MS and importantly as there is a limited number of specific treatments that we can offer these patients.

Severe reversible myocardial injury associated with aluminium phosphide toxicity: A case report and review of literature.

Aluminium phosphide is commonly used as an insecticide and can be toxic to humans at the cellular level by interfering with mitochondrial energy metabolism. We report on three cases of severe aluminium phosphide cardio-toxicity, resulting in severe decrease in both ventricular heart functions. The first case succumbed to intractable ventricular arrhythmias complicated by multi-organ failure before she died; while the other two cases required invasive hemodynamic support and eventually improved over the course of 10-14 days. We describe our experience and the challenges faced while managing one of them.

Left atrial appendage occlusion device-related thrombus: a case report and review of the literature.

A 75-year-old male with persistent atrial fibrillation underwent implantation of a left atrial occlusion device. After 6 weeks, a scheduled trans-esophageal echocardiogram showed a 1.1-cm × 1.1-cm mass within the occluded left atrial appendage, suspected to be thrombus. He was continued on warfarin for an additional 6 weeks and a repeat trans-esophageal echocardiogram showed obliteration of the left atrial appendage. This report describes an uncommon observation detected at scheduled follow up by trans-esophageal echocardiogram, which sheds some light on the mechanism by which this device "matures" after it is implanted inside the left atrial appendage.