Cardiology Critical Care Crisis: Can Working Across The Aisle Be The Salvation?

There are many changes in the demographics of patients admitted to Cardiac Care Unit (CCU) due to the aging of US population and coexistence of chronic illnesses, such as diabetes mellitus, hypertension, renal dysfunction, and obstructive lung disease. There is increasing evidence that intensivist staffing in the critical care settings is associated with not only improvements in both Intensive Care Unit (ICU) and in-hospital mortality, but also with better medical resource use. Evidence for decreased mortality has led to increased involvement of critical care trained physicians in multidisciplinary care teams in both medical and surgical ICUs, a trend that has not been adopted to any significant extent in CCUs. A partnership between cardiologists and critical care specialists may offer a better roadmap to deal with cardiac critical care crisis, provide better care for our patients, and prepare the next generation of cardiologists to deal with emerging challenges in the field.

Subvalvular Aortic Stenosis.

Obstruction of the left ventricular outflow tract (LVOT) occurs in six out of 10,000 live births. The obstruction occurs in the aortic valve level in 71 percent, in subvalvular level in 14 percent, and supravalvular level in 8 percent of cases. Subvalvular aortic stenosis (AS) can be either a fixed stenosis resulting from subaortic membrane or a dynamic stenosis because of hypertrophic cardiomyopathy. Here, we report a patient with subaortic membrane who became symptomatic in her sixth decade of life. Echocardiography is the preferred diagnostic modality. Indications for surgery include symptoms, LVOT gradient of 50 mmHg or more, and development of significant aortic regurgitation.

Aortocoronary Saphenous Vein Graft Aneurysm with Fistula to the Right Atrium: Percutaneous Management of Surgical Complication.

Aneurysmal dilatation of aortocoronary saphenous vein grafts (SVG) is a rare but known complication after coronary artery bypass grafting (CABG). They are most commonly found incidentally, although some may present with unstable angina or myocardial infarction (MI). Rarely, these aneurysms can develop into fistulas to the neighboring cardiac chambers. We report the case of a 66-year old woman with a history of CABG in 1996 with a left internal mammary artery (LIMA) graft to the left anterior descending and a SVG to distal right coronary artery presenting with non-ST segment elevation myocardial infarction (NSTEMI) complicated with congestive heart failure. Selective Coronary and Graft angiography showed an aneurysm in the mid SVG with a fistula into the right atrium (RA) resulting in a significant left to right shunt. The significant left to right shunt diverted blood flow from right coronary artery territory resulting in recurrent ischemia and angina and introduced a significant volume overload on the right ventricle resulting in over heart failure. Secondary to the course of LIMA graft along the sternum, surgery was not an option. Secondary to continued symptoms percutaneous intervention was performed with placement of two 6.0 x 50 mm Viabahn self-expanding covered stent with aggressive post-dilation resulting in successful closure with no residual flow. Percutaneous intervention is shown to be an effective approach to manage both aortocoronary fistula and grafts ruptures and is associated with better outcomes than surgical and conservative options. To the best of our knowledge, this is the first reported case of a successful closure of fistulous communication of a SVG aneurysm to the RA utilizing multiple peripheral covered stents.

Alopecia areata: pathogenesis and potential for therapy.

Although the complete picture for alopecia areata (AA) pathogenesis has yet to be determined, recent research has made much progress in our understanding of the disease mechanism. Numerous circumstantial evidence supports the notion that AA is fundamentally a disease mediated by inflammatory cells and may be autoimmune in nature. Recent research has shown the hair-loss phenotype is precipitated predominantly by CD8+ lymphocytes, but the disease mechanism is driven by CD4+ lymphocytes. Although genetic susceptibility is a key contributor to disease development, disease onset and phenotypic presentation are probably modified by complex environmental interplay. On the basis of our current understanding of AA disease pathogenesis, several experimental and theoretical therapeutic approaches might be possible. However, the pathogenetic disease mechanism is particularly robust and the development of a cure for AA will be a significant challenge.

Impact of a Multidisciplinary Team Approach Including an Intensivist on the Outcomes of Critically Ill Patients in the Cardiac Care Unit.

OBJECTIVE: To investigate the impact of integrating a medical intensivist into a cardiac care unit (CCU) multidisciplinary team on the outcomes of CCU patients. PATIENTS AND METHODS: We conducted a retrospective cohort study of 2239 CCU admissions between July 1, 2011, and July 1, 2013, which constituted patients admitted in the 12 months before and 12 months after the introduction of intensivists into the CCU multidisciplinary team. This team included a cardiologist, a medical intensivist, medical house staff, nurses, a pharmacist, a dietitian, and physical and respiratory therapists. The primary outcome was CCU mortality. Secondary outcomes included hospital mortality, CCU length of stay, hospital length of stay, and duration of mechanical ventilation. RESULTS: After the implementation of a multidisciplinary team approach, there was a significant decrease in both adjusted CCU mortality (3.5% vs 5.9%; P=.01) and hospital mortality (4.4% vs 11.1%; P<.01). A similar impact was observed on adjusted mean CCU length of stay (2.5±2.0 vs 2.9±2.0 days; P<.01), adjusted mean hospital length of stay (7.0±4.5 vs 7.5±4.5 days; P<.01), and adjusted mean ventilation duration (2.0±1.0 vs 4.3±2.5 days; P<.01). CONCLUSION: The implementation of a multidisciplinary team approach in which an intensivist and a cardiologist comanage the critical care of CCU patients is feasible and may result in better patient outcomes.

Percutaneous closure of acquired Gerbode defect: management of a rare complication of cardiac surgery.

Although rare, acquired Gerbode defect (abnormal communication between left ventricle and right atrium) may result as a complication of myocardial infarction, endocarditis as well as aortic or mitral valve replacement resulting in resistant heart failure secondary to significant left to right shunting. We are reporting the case of a 50-year old lady with repeated aortic valve replacement presenting with resistant heart failure secondary to an acquired Gerbode defect. Management of this defect in these high-risk patients may be challenging and percutaneous closure, if feasible, may represent the best management option.

Comparison of in-hospital outcomes with low-dose fibrinolytic therapy followed by urgent percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction.

In patients with acute ST-elevation myocardial infarction (STEMI), a strategy of prehospital reduced dose fibrinolytic administration coupled with urgent percutaneous coronary intervention (PCI), termed FAST-PCI strategy, has been found to be superior to primary PCI (PPCI) alone. A coordinated STEMI system of care that includes FAST-PCI should offer better outcomes than a system in which prehospital diagnosis of STEMI is followed by PPCI alone. The aim of this study was to compare the in-hospital outcomes for patients treated with the FAST-PCI approach with outcomes for patients treated with the PPCI approach in a common system. The in-hospital data for 253 STEMI patients (March 2003-December 2009) treated with a FAST-PCI protocol were compared with 124 patients (January 2010-August 2011) treated with PPCI strategy alone. In-hospital mortality was the primary comparator. Stroke, major bleeding, and reinfarction during index hospitalization were also compared. The in-hospital mortality was significantly lower with FAST-PCI than with PPCI (2.77% vs 10.48%, p = 0.0017). Rates of stroke, reinfarction, and major bleeding were similar in the 2 groups. There was a lower frequency of pre-PCI Thrombolysis In Myocardial Infarction 0 flow (no patency) seen in patients treated with FAST-PCI compared with the PPCI patients (26.7% vs 62.7%, p <0.0001). Earlier infarct artery patency in the FAST-PCI group had a favorable impact on the incidence of cardiogenic shock on hospital arrival (3.1% vs 20.9%, p <0.0001). In conclusion, compared with a PPCI strategy in a common STEMI system of care, the FAST-PCI strategy was associated with earlier infarct artery patency and lower incidence of cardiogenic shock, as well as with reduced in-hospital mortality.