Percutaneous Impella RP use for refractory right heart failure in adolescents and young adults-A multicenter U.S. experience.

OBJECTIVE: To assess the outcomes of the use of the percutaneous Impella RP device (Abiomed, Danvers, MA) in adolescents and young adults. BACKGROUND: Results of the Impella RP device have been reported in adults, but a multicenter experience in adolescents and young adults has yet to be reported. METHODS: Patients ≤21 years of age who underwent implantation of an Impella RP device for refractory right heart failure from June, 2016 to April, 2018 at nine U.S. Centers were included. RESULTS: A total of 12 adolescents, median age of 18 (14-21) years and median weight 74.4 (49-112.4) kg underwent Impella RP implantation (INTERMACS Profile 1 in nine and Profile 2 in three patients. The central venous pressure decreased from 20 (16-35) to 12 (7-17) mmHg, (p = .001). One patient was concomitantly supported with an intra-aortic balloon pump (IABP) and the rest with a percutaneous/surgically placed left ventricular assist device. There was one adverse event related to the Impella RP device (thrombosis requiring explant). The support duration was 6.5 days (4.8 hr-18.4 days) and survival to hospital discharge was 83%. At a median follow-up of 11 months (5 days-2.5 years), 8 of 12 (67%) patients are alive. CONCLUSIONS: In this multicenter experience, the Impella RP device was found to be efficacious and safe when used in adolescents and young adults. Further studies are warranted to identify suitable young/pediatric candidates for Impella RP therapy for right heart failure.

Low-dose heparin for elective percutaneous coronary intervention.

OBJECTIVES: We evaluated the safety and efficacy of low-dose heparin (40 IU/kg) for elective percutaneous coronary intervention (PCI). BACKGROUND: Current guidelines recommend a 70-100 IU/kg bolus of heparin for elective PCI, but this dose may be associated with increased bleeding risk. Low-dose heparin may have an advantage in this regard, but has not been well studied. METHODS: From January 2008 to October 2012, 300 patients underwent elective transfemoral PCI and were treated with an initial bolus of 40 IU/kg of heparin at the UCLA Medical Center. Dual antiplatelet therapy with clopidogrel and aspirin was administered prior to or just after diagnostic coronary angiography. The primary end-point was the composite of cardiac death, myocardial infarction, urgent target vessel revascularization for ischemia, or major bleeding within 30 days after PCI. RESULTS: The mean activating clotting time was 233 ± 28 seconds. The primary end-point occurred in 2.3%. The cardiac death rate was 0.3% but was not related to the PCI. The myocardial infarction rate was 1.3%. Urgent target vessel revascularization occurred in 1 patient (0.3%). The major bleeding rate was 0.3%. No stent thrombosis occurred. CONCLUSION: Using a lower dose of heparin with dual antiplatelet therapy is safe and is associated with a low bleeding risk after transfemoral PCI while providing suppression of ischemic events. This may also represent a cost savings compared with other antithrombotic strategies. A randomized clinical trial comparing low-dose heparin with bivalirudin in patients is required to determine the optimal anticoagulation strategy.

Sarcoidosis-associated pulmonary hypertension and lung transplantation for sarcoidosis.

Pulmonary hypertension (PH) is a significant complication of sarcoidosis, occurring in approximately 6 to > 20% of cases, and markedly increases mortality among these patients. The clinician should exercise a high index of suspicion for sarcoidosis-associated PH (SAPH) given the nonspecific symptomatology and the limitations of echocardiography in this patient population. The pathophysiology of PH in sarcoidosis is complex and multifactorial. Importantly, there are inherent differences in the pathogenesis of SAPH compared with idiopathic pulmonary arterial hypertension, making the optimal management of SAPH controversial. In this article, we review the epidemiology, diagnosis, prognosis, and treatment considerations for SAPH. Lung transplantation (LT) is a viable therapeutic option for sarcoid patients with severe pulmonary fibrocystic sarcoidosis or SAPH refractory to medical therapy. We discuss the role for LT in patients with sarcoidosis, review the global experience with LT in this population, and discuss indications and contraindications to LT.

Left main coronary artery compression from pulmonary artery enlargement due to pulmonary hypertension: a contemporary review and argument for percutaneous revascularization.

Extrinsic compression of the left main coronary artery by an enlarged pulmonary artery is an increasingly recognized and potentially reversible cause of angina and left ventricular dysfunction in patients with pulmonary hypertension. The diagnosis of extrinsic left main coronary artery compression requires a high index of suspicion and should be considered in patients with severe pulmonary hypertension who experience angina. Coronary angiography with intravascular ultrasound is the gold standard for diagnosis of this condition, though cardiac computed tomography and magnetic resonance angiography allow for noninvasive means of screening. The optimal treatment is debatable, but percutaneous coronary intervention appears to be a feasible, safe, and effective treatment option for patients with extrinsic compression of the left main coronary artery from pulmonary artery enlargement. Given the high risk of postoperative right ventricular failure and mortality observed with surgical revascularization in these patients, we recommend that physicians recognize percutaneous coronary intervention as the preferred revascularization strategy for selected patients with extrinsic compression of the left main coronary artery due to pulmonary hypertension. © 2010 Wiley-Liss, Inc.

Combined preoperative use of celecoxib and gabapentin in the management of postoperative pain.

BACKGROUND: In 2005 we reported a study on the efficacy of the preoperative use of the selective COX-2 inhibitor celecoxib (Celebrex) for reducing both postoperative pain and opioid requirements in patients undergoing bilateral subpectoral breast augmentation. Our findings showed that patients who received 400 mg of celecoxib 30 min before surgery required significantly less postoperative opioid analgesics compared with those given a placebo. Gabapentin (Neurontin) is an agent commonly used to control neuropathic pain. Here we describe a prospective study assessing the efficacy of preoperative gabapentin in combination with celecoxib for reducing postoperative pain and opioid requirements in elective subpectoral breast augmentation. METHODS: One hundred eighteen patients were given 1200 mg of gabapentin and 400 mg of celecoxib 30-60 min before surgery. From the day of surgery until postoperative day 5, patients documented any use of analgesics and recorded their degree of pain. Results were then compared with those of our previous study in which only celecoxib was used. RESULTS: The combination of gabapentin and celecoxib was found to be significantly superior (p < 0.001) in reducing postoperative pain and opioid requirements than celecoxib alone in the management of postoperative pain and opioid requirements. CONCLUSION: To decrease postoperative opioid requirements, we recommend 400 mg of celecoxib and 1200 mg of gabapentin taken 30-60 min before surgery by patients undergoing subpectoral breast augmentation or a comparable plastic surgery procedure.

Lymphocytic Myocarditis and Cardiogenic Shock in Hawai'i: A Case Series.

Lymphocytic myocarditis is an inflammatory disease of the heart that may present in a myriad of fashions ranging from mild febrile illness to florid myocarditis and cardiogenic shock. Given its nonspecific clinical presentation, the diagnosis of lymphocytic myocarditis is often challenging. The authors describe four cases of lymphocytic myocarditis in young women who presented with cardiogenic shock. Two patients survived and two died. This presentation has not been seen previously in Hawai'i and the public awareness of this condition is critical. Early diagnosis and the prompt initiation of biventricular mechanical circulatory support appear to have been critical in improving patient survival.

Adoption of Routine Ultrasound Guidance for Femoral Arterial Access for Cardiac Catheterization.

BACKGROUND: A randomized controlled trial published in 2010 demonstrated that ultrasound-guided femoral artery access for coronary angiography was faster and associated with fewer vascular complications than conventional fluoroscopic-guided access. The landscape of ultrasound use among contemporary interventional cardiologists is unknown. METHODS: We sought to describe current knowledge, attitudes, and practices regarding ultrasound use among interventional cardiologists using an online survey. The questionnaire unfolded in phases, initially attempting to define current attitudes and then testing whether or not attitudes were adjustable after summarizing compelling research supporting the use of ultrasound-guided access. RESULTS: Sixty-eight responses were received (60.7%). Only 13.3% reported using ultrasound routinely despite widespread availability and technical expertise. The majority of respondents believed ultrasound use to be slower but safer than access by palpation alone. There was no significant association between age (P=.70) or annual case volume (P=.11) and baseline ultrasound use. After examining the results of a supporting clinical trial, 42.6% said ultrasound should be used routinely, but only 17.6% said they would adopt the technique. Younger operators tended to affirm routine ultrasound adoption after reading the trial summary more often than older respondents, although this did not reach statistical significance (relative risk = 1.8; P=.30). CONCLUSIONS: Routine ultrasound-guided femoral artery access and awareness of its validating evidence is uncommon among current interventional cardiologists; exposure to compelling data had minimal impact on respondents' willingness to change practice.

Clinical outcomes of endovascular treatment of TASC-II C and D femoropopliteal lesions with the Viabahn endoprosthesis.

OBJECTIVES: The objective of this study was to evaluate clinical outcomes and patency rates using the Viabahn endoprosthesis in complex (TASC-II C and D) femoropopliteal lesions. BACKGROUND: Traditional treatment of symptomatic TASC-II C and D femoropopliteal lesions has mainly centered on open surgical options in patients deemed appropriate candidates. Endovascular treatment of these lesions with balloon angioplasty has been historically hampered by aggressive restenosis and relatively early clinical failure. The Viabahn endoprosthesis was developed with the intent of reducing restenosis while improving overall flexibility in the femoropopliteal segment. METHODS: Between March 2009 and July 2011 a total of 51 limbs in 41 patients underwent implantation of one or more Viabahn endovascular stent grafts for the treatment of symptomatic TASC-II C or D lesions. Patients were followed clinically at regular intervals and also underwent routine surveillance duplex ultrasound at 1, 3, 6, and 12 months post-procedure. The average follow-up from the index procedure was 14.6 months (range 13-35.2 months). RESULTS: A total of 22 TASC-II C and 29 TASC-II D lesions were treated (51 limbs in 41 patients). The mean lesion length was 22.4 cm. The overall 1-year primary patency rate was 74.8% (95% CI: 61.2%-88.4%), assisted primary patency rate was 87.4% (95% CI: 70.9%-95.9%), and the secondary patency rate was 94.9% (95% CI: 88.0%-100.0%). CONCLUSIONS: The Viabahn endoprosthesis is a safe and effective option for the treatment of TASC-II C and D femoropopliteal lesions. Patency rates are favorable despite the complexity of these lesions, although multiple endovascular re-interventions may be necessary to achieve an acceptable long-term result.

Unprotected left main PCI: status report 2013.

Unprotected left main coronary artery (ULMCA) disease is seen in 4% of patients who undergo angiography. Though coronary artery bypass graft surgery has traditionally been the preferred approach to revascularization, recent major society guidelines support the use of percutaneous coronary intervention (PCI) in properly selected patients. This article provides an overview of recent studies evaluating the efficacy of ULMCA PCI and looking at contemporary approaches to the evaluation and percutaneous treatment of ULMCA disease. The ongoing EXCEL trial will help elucidate the role of ULMCA PCI in the treatment of left main disease compared with coronary artery bypass graft surgery.

Aspergillus fumigatus vegetation of a prosthetic aortic root graft with mycotic aneurysm and subarachnoid hemorrhage.

A 58-year-old woman with a history of Bentall aortic graft and bioprosthetic aortic valve replacement 3 months prior to admission, presented with headache and fever. Imaging yielded a large obstructive filling defect in the ascending aorta, a subarachnoid hemorrhage, and a mycotic aneurysm. Intraoperative specimens grew Aspergillus fumigatus, and despite aggressive measures the patient died. Aspergillus infections of prosthetic vascular grafts are rare surgical complications and are difficult to diagnose given the low incidence of positive microbiology cultures and the long median time between surgery and diagnosis. Treatment has consisted of antifungal and surgical treatment, although mortality remains high.

Comparison of sirolimus-eluting stents with paclitaxel-eluting stents in saphenous vein graft intervention (from a multicenter Southern California Registry).

This study was designed to compare the safety and efficacy of sirolimus-eluting stents (SESs) to paclitaxel-eluting stents (PESs) in percutaneous intervention of saphenous vein graft (SVG) lesions. SVGs develop atherosclerosis at high rates and often require repeat revascularization. Percutaneous intervention with drug-eluting stents has become the preferred method of revascularization due to higher restenosis with bare metal stents and increased morbidity and mortality with repeat coronary artery bypass grafting. We sought to compare the rate of major adverse cardiac events and stent thrombosis between SESs and PESs in patients undergoing SVG intervention. A multicenter analysis of 172 patients with SVG lesions treated with SESs or PESs was performed. The 30-day and 1-year clinical outcomes of 102 patients receiving SESs were compared to those of 70 patients receiving PESs. There was no significant difference in baseline demographic, angiographic, and procedural characteristics between the SES and PES treatment groups. There was no statistical difference in major adverse cardiac events at 30 days and at 1 year (hazard ratio [HR] 1.58, 95% confidence interval [CI] 0.77 to 3.23, log-rank p = 0.21). There was also no difference in survival (HR 1.28, 95% CI 0.39 to 4.25, log-rank p = 0.69) or target vessel revascularization (HR 2.54, 95% CI 0.84 to 7.72, log-rank p = 0.09). In conclusion, this multicenter analysis of real-world patients demonstrated that SESs and PESs have similar clinical outcomes when used in SVG intervention.

Impaired glucose tolerance is associated with postganglionic sudomotor impairment.

We compared quantitative sudomotor axon-reflex test responses in persons with normal and impaired glucose tolerance (IGT). Responses were significantly impaired in those with IGT, which may be indicative of early distal small fiber neuropathy.