Drug use associated tricuspid valve infective endocarditis in pregnancy.

BACKGROUND AND AIM: We report a case of intravenous drug use associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-week gestation. METHODS: Patient management required a multidisciplinary collaboration between cardiac surgery, obstetrics and gynecology, and neonatal critical care. RESULTS: Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement 1 week later. CONCLUSIONS: Both the patient and her infant were successfully managed through the perioperative period.

Crossroads of Care: Navigating Injection Drug Use-Associated Endocarditis.

Infective endocarditis (IE), with its high morbidity and mortality, is a frequent complication of injection drug use (IDU). We present a case highlighting the complexities in the management of IDU-associated IE (IDU-IE) in a 46-year-old male with active IDU who presented with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia and a large tricuspid valve vegetation. Urgent tricuspid valve surgery was indicated due to the size of the vegetation measuring up to 4 cm, along with recurrent pulmonary septic emboli. The patient underwent an uncomplicated and successful complete vegetectomy, tricuspid valve repair, and completed a 42-day antibiotic course. During the six-week follow-up, he showed complete recovery and maintained successful abstinence from illicit drug use, supported by an addiction medicine specialist. This case underscores the importance of early recognition, appropriate antibiotic therapy, and individualized surgical intervention in optimizing outcomes. Effective management of IE necessitates a multidisciplinary IE team, including addiction medicine specialists. Addressing the underlying substance use disorder (SUD) is crucial to reducing the risk of recurrent IE.

Diagnosis of left ventricular hypertrophy in the presence of left anterior fascicular block: a reexamination of the 2009 AHA/ACCF/HRS guidelines.

BACKGROUND: The 2009 "AHA/ACCF/HRS Recommendations for Standardization and Interpretation of the Electrocardiogram" state that left ventricular hypertrophy (LVH) criteria that include R-wave amplitude in leads I and aVL are not likely reliable in the presence of left anterior fascicular block (LAFB). This statement was referenced to three relatively small studies. The present study reexamines the utility of selected electrocardiographic (ECG) criteria for LVH in the presence of LAFB. METHODS: We identified 185 ECG tracings with LAFB from patients in whom echocardiogram had been performed within 30 days of the ECG. These ECGs were evaluated for the presence of selected LVH criteria: (1) Sokolow index (R-wave-aVL > 11 mm); (2) Cornell criteria (R-wave-aVL + S-wave-V3 > 28 mm in men (>20 mm in women); (3) Gertsch criterion (S-wave-III + (R + S) maximal precordial >30 mm); and (4) Bozzi criterion (SV1 or SV2 + (RV6 + SV6) > 25 mm). The "gold standard" for LVH was left ventricular mass index on echocardiogram. RESULTS: Although the aVL-based LVH criteria demonstrated lower sensitivity (45-68%) and a trend toward higher specificity (67-81%) compared to non-aVL-based criteria, the four studied criteria demonstrated similar diagnostic accuracy. CONCLUSIONS: In the presence of LAFB, the aVL-based Sokolow index and Cornell criteria, which were excluded from 2009 multisociety ECG guidelines, identify LVH with similar diagnostic accuracy as the non-aVL-based criteria that were included. Moreover, they are easier to calculate and are included in some of the computer-assisted ECG interpretation software presently in use. Their exclusion from the 2009 guidelines was unnecessary.

Colchicine and high-intensity rosuvastatin in the treatment of non-critically ill patients hospitalised with COVID-19: a randomised clinical trial.

OBJECTIVE: To evaluate the effect of colchicine and high-intensity rosuvastatin in addition to standard of care on the progression of COVID-19 disease in hospitalised patients. DESIGN: A pragmatic, open-label, multicentre, randomised controlled trial conducted from October 2020 to September 2021. Follow-up was conducted at 30 and 60 days. The electronic medical record was used at all stages of the trial including screening, enrolment, randomisation, event ascertainment and follow-up. SETTING: Four centres in the Yale New Haven Health System. PARTICIPANTS: Non-critically ill hospitalised patients with COVID-19. INTERVENTIONS: Patients were randomised 1:1 to either colchicine plus high-intensity rosuvastatin in addition to standard of care versus standard of care alone. Assigned treatment was continued for the duration of index hospitalisation or 30 days, whichever was shorter. PRIMARY AND SECONDARY OUTCOME MEASURES: The prespecified primary endpoint was progression to severe COVID-19 disease (new high-flow or non-invasive ventilation, mechanical ventilation, need for vasopressors, renal replacement therapy or extracorporeal membrane oxygenation, or death) or arterial/venous thromboembolic events (ischaemic stroke, myocardial infarction, deep venous thrombosis or pulmonary embolism) evaluated at 30 days. RESULTS: Among the 250 patients randomised in this trial (125 to each arm), the median age was 61 years, 44% were women, 15% were Black and 26% were Hispanic/Latino. As part of the standard of care, patients received remdesivir (87%), dexamethasone (92%), tocilizumab (18%), baricitinib (2%), prophylactic/therapeutic anticoagulation (98%) and aspirin (91%). The trial was terminated early by the data and safety monitoring board for futility. No patients were lost to follow-up due to electronic medical record follow-up. There was no significant difference in the primary endpoint at 30 days between the active arm and standard of care arm (15.2% vs 8.8%, respectively, p=0.17). CONCLUSIONS: In this small, open-label, randomised trial of non-critically ill hospitalised patients with COVID-19, the combination of colchicine and rosuvastatin in addition to standard of care did not appear to reduce the risk of progression of COVID-19 disease or thromboembolic events, although the trial was underpowered due to a lower-than-expected event rate. The trial leveraged the power of electronic medical records for efficiency and improved follow-up and demonstrates the utility of incorporating electronic medical records into future trials. TRIAL REGISTRATION: NCT04472611.

Improved Physician Understanding of Patient End-of-Life Preferences: A Quality Improvement Project.

BACKGROUND: Code status (CS) orders lack a universal definition. We aimed to improve provider understanding of order options. MEASURES: Provider's knowledge of CS terminology, ease of understanding CS orders and ease of starting CS discussions. INTERVENTION: A multifaceted intervention including 1) altered CS order language in the electronic medical record (EMR) from "Full Interventions," "Limited Interventions," and "Comfort Measures Only" to "Full advanced cardiovascular life support (ACLS)," "Partial ACLS," and "No ACLS" 2) clinical tools for CS identification 3) provider education. OUTCOMES: Correct provider response rate for "Partial ACLS" and "No ACLS" terms increased from 43.5 to 60% and 20 to 71% (odds ratio 1.95; 95% confidence interval 0.99-3.83; P = 0.03, OR 9.8; CI 4.48-21.49; P < 0.001). The proportion of providers who felt understanding CS orders and starting conversations about CS was "very easy" (a score of 1-3 on a scale of 1 to 10) improved from 26.1 to 45.7% (P = 0.01) and 49.3 to 65.7% (P = 0.03). CONCLUSIONS/LESSONS LEARNED: Provider understanding of CS options can be improved with a combined QI intervention.

Catheter-Related Right Atrial Thrombus Requiring Surgical Embolectomy.

Temporary central venous hemodialysis (HD) catheters are commonly used in end-stage renal disease (ESRD) patients while awaiting peritoneal dialysis catheter, arterio-venous fistula or graft placement and maturation. Catheter-related right atrial thrombus (CRAT) is a common finding in patients with central venous catheters (CVCs) and can cause CVC to malfunction. The incidence of CRAT is about 29% with a mortality of 18.3% or greater if not identified and managed appropriately. Two major types of right atrial (RA) thrombi have been identified. Type A thrombus usually originates in the peripheral veins embolizing to the RA. Type B originates within a structurally abnormal RA and is usually attached to the chamber walls or foreign bodies like CVC or intra-cardiac wires. There is a high risk of thrombi embolization leading to pulmonary embolism as in our patient, systemic embolization if a right to left shunt is present and potential hemodynamic compromise. The optimal therapeutic approach is still a subject of discussion, but timely catheter removal with prompt initiation of systemic anticoagulation is key. Surgical management is pursued when medical therapy fails or if the thrombus is greater than 6 cm. Our case is that of a 30-year-old male with CRAT successfully treated with surgical embolectomy after the failure of systemic anticoagulation. This case highlights the importance of early detection of CRAT, initiation of optimal medical therapy and the need for surgical intervention when medical therapy fails.

Design and rationale of the colchicine/statin for the prevention of COVID-19 complications (COLSTAT) trial.

BACKGROUND: Despite improvement in the standard of care (SOC) for hospitalized COVID-19 patients, rates of morbidity and mortality remain high. There continues to be a need for easily available and cost-effective treatments. Colchicine and rosuvastatin are both safe and well-studied medications with anti-inflammatory and other pleiotropic effects that may provide additional benefits to hospitalized COVID-19 patients. METHODS AND RESULTS: The Colchicine/Statin for the Prevention of COVID-19 Complications (COLSTAT) trial is a pragmatic, open-label, multicenter, randomized trial comparing the combination of colchicine and rosuvastatin in addition to SOC to SOC alone in hospitalized COVID-19 patients. Four centers in the Yale New Haven Health network will enroll a total of 466 patients with 1:1 randomization. The trial will utilize the electronic health record (Epic® Systems, Verona, Wisconsin, USA) at all stages including screening, randomization, intervention, event ascertainment, and follow-up. The primary endpoint is the 30-day composite of progression to severe COVID-19 disease as defined by the World Health Organization ordinal scale of clinical improvement and arterial/venous thromboembolic events. The secondary powered endpoint is the 30-day composite of death, respiratory failure requiring intubation, and myocardial injury. CONCLUSIONS: The COLSTAT trial will provide evidence on the efficacy of repurposing colchicine and rosuvastatin for the treatment of hospitalized COVID-19 patients. Moreover, it is designed to be a pragmatic trial that will demonstrate the power of using electronic health records to improve efficiency and enrollment in clinical trials in an adapting landscape. CLINICAL TRIAL REGISTRATION: NCT04472611 (https://clinicaltrials.gov/ct2/show/NCT04472611).

The expanding medical and behavioral resources with access to care for everyone health plan.

Healthcare Professionals for Healthcare Reform is a group of physicians and others interested in health care reform who, recognizing the urgent need for change, convened to propose a universal health care plan that builds on the strengths of the U.S. health care system and improves on its coverage, efficiency, and capacity for patient choice. The group proposes a tiered plan, the core of which (Tier 1) would be lifetime, basic, publicly funded coverage for the entire population on the basis of the best evidence about which therapies are considered life saving, life-sustaining, or preventive. Optional coverage (Tier 2) would be funded by private insurance and cover all therapies considered to help with quality of life and functional impairment. Items considered to be luxury or cosmetic (Tier 3) would generally not be covered, as is the case under the current system. The entire system would be overseen by a quasi-governmental, largely independent organization known as "The Board," which would resemble the Federal Reserve and interact with U.S. Department of Health and Human Services agencies to oversee implementation and coverage. By building on the current health care system while introducing other features and efficiencies, the Expanding Medical and Behavioral Resources with Access to Care for Everyone (EMBRACE) plan for universal health insurance coverage offers several advantages over alternative plans that have been proposed.

Aspirin resistance: an update.

Aspirin resistance (AR) still lacks a universally accepted definition, but it may be discussed as either a laboratory phenomenon or a clinical presentation. Laboratory resistance is mainly defined as abnormal platelet response to aspirin, whereas the clinical manifestation is the failure of aspirin to prevent cardiovascular events. Although there is evidence of an association, it appears that a laboratory abnormality in platelet function is not the only risk factor for the clinical manifestation of AR. Therapies for primary and secondary prevention of AR still need to be elucidated, but there are some data to suggest that in an acute episode of aspirin failure because of AR, different therapeutic interventions need to be considered.

Invasive Evaluation of the Microvasculature in Acute Myocardial Infarction: Coronary Flow Reserve versus the Index of Microcirculatory Resistance.

Acute myocardial infarction (AMI) is one of the most common causes of death in both the developed and developing world. It has high associated morbidity despite prompt institution of recommended therapy. The focus over the last few decades in ST-segment elevation AMI has been on timely reperfusion of the epicardial vessel. However, microvascular consequences after reperfusion, such as microvascular obstruction (MVO), are equally reliable predictors of outcome. The attention on the microcirculation has meant that traditional angiographic/anatomic methods are insufficient. We searched PubMed and the Cochrane database for English-language studies published between January 2000 and November 2019 that investigated the use of invasive physiologic tools in AMI. Based on these results, we provide a comprehensive review regarding the role for the invasive evaluation of the microcirculation in AMI, with specific emphasis on coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR).

The role of aspirin resistance in the treatment of acute coronary syndromes.

The TIMI Risk Score recognizes prior aspirin use as an independent risk factor for adverse outcomes in subjects presenting with an acute coronary syndrome. The etiology of this increased risk awaits clarification, but prior aspirin use may be associated with altered thrombus composition which is more resistant to current treatment modalities as compared to thrombus formation in subjects without prior aspirin use. Post hoc analysis of acute coronary syndrome trials has shown that prior aspirin users treated with unfractionated heparin are at particularly high risk. The addition of glycoprotein IIb/IIIa receptor inhibitor to unfractionated heparin or substitution of low-molecular-weight heparin significantly improves outcomes in prior aspirin users. The prognostic significance of prior aspirin use in acute coronary syndromes has important implications not only in clinical practice, but also in the design and interpretation of clinical trials.

Aortic arch replacement for recurrent cerebral embolization.

Replacement of the aortic arch for atheroma with cerebral embolization is in its infancy. The appropriateness of such intervention is controversial. Over a 10-month period, a 58-year-old woman suffered multiple debilitating cerebral vascular accidents manifested by motor, sensory, and memory deficits and documented by computed tomographic scanning and magnetic resonance imaging. Carotid and vertebral arteries were free of arteriosclerotic disease. Transesophageal echocardiography demonstrated two large atheromas with friable, pedunculated forms, one in the aortic arch and one in the very proximal descending thoracic aorta. Transcranial ultrasound revealed recurrent cerebral microembolic events. Cerebrovascular events continued, and the atheromas increased in size, despite treatment with Coumadin and aspirin. Under deep hypothermic arrest, the segment of the aortic arch harboring the atheroma was excised and replaced with a Dacron graft. Repeat transcranial ultrasound revealed cessation of embolic signals. All cerebrovascular events ceased. No further anticoagulation therapy was required. The patient has made substantial recovery from the preoperative deficits and continues to do well 1 year after aortic arch replacement. Resection of mobile aortic arch atheromas is likely to become increasingly important in the future as transesophageal echocardiography leads to their more common identification as a cause of cerebral ischemic events.