Fulminant Myocarditis with Combination Immune Checkpoint Blockade.

Immune checkpoint inhibitors have improved clinical outcomes associated with numerous cancers, but high-grade, immune-related adverse events can occur, particularly with combination immunotherapy. We report the cases of two patients with melanoma in whom fatal myocarditis developed after treatment with ipilimumab and nivolumab. In both patients, there was development of myositis with rhabdomyolysis, early progressive and refractory cardiac electrical instability, and myocarditis with a robust presence of T-cell and macrophage infiltrates. Selective clonal T-cell populations infiltrating the myocardium were identical to those present in tumors and skeletal muscle. Pharmacovigilance studies show that myocarditis occurred in 0.27% of patients treated with a combination of ipilimumab and nivolumab, which suggests that our patients were having a rare, potentially fatal, T-cell-driven drug reaction. (Funded by Vanderbilt-Ingram Cancer Center Ambassadors and others.).

Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis.

OBJECTIVES: To evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) in the treatment of acute pulmonary embolism (PE). BACKGROUND: The use of CDT for the treatment of acute submassive and massive PE is increasing in frequency. However, its safety and efficacy have not been well elucidated. METHODS: This study is made of two parts: one is a two-center registry of acute PE patients treated with CDT. The safety outcome evaluated was any major complication including fatal, intracranial (ICH), intraocular, or retroperitoneal hemorrhage or any overt bleeding requiring transfusion or surgical repair. The efficacy outcome was acute change in invasive pulmonary artery systolic pressure (PASP). The second part is a meta-analysis of all contemporary studies that used CDT for PE. Reported outcomes are the same as in the registry, with the addition of right ventricular to left ventricular (RV/LV) ratio change. RESULTS: In the registry, 137 patients were included (age 59 ± 15, 50% male, 88% submassive PE). ICH occurred in two patients and major complications in 13 (9.4%). PASP decreased post procedure by 19 ± 15 mm Hg (95% CI 16-23). In the meta-analysis, 16 studies were included with 860 patients. Rate of ICH was 0.35% and the major complication rate was 4.65%, most requiring transfusion only. In-hospital mortality was 12.9% in the massive and 0.74% in the submassive group. All studies showed improvement in PASP and/or RV/LV ratio post CDT. CONCLUSIONS: CDT is associated with a low major complication rate. Randomized studies are needed to evaluate its efficacy relative to anticoagulation alone. © 2017 Wiley Periodicals, Inc.

Acute Pulmonary Embolism Network and Multidisciplinary Response Team Approach to Treatment.

BACKGROUND: The ideal treatment strategy for acute pulmonary embolism (PE) remains a subject of debate. Treatment strategies vary based on numerous factors including the clinical scenario, hemodynamic variables, PE location, and personnel who are trained in advanced PE management therapies. METHODS: Similar to an acute myocardial infarction network, we created a regional referral system called the Acute PE Network to facilitate the transport of patients with PE from referring facilities and improve access to advanced therapies. Simultaneously, we created a multidisciplinary PE response team (PERT), developed diagnostic protocols, and created a therapeutic pathway that includes the use of ultrasound-assisted catheter-directed thrombolysis (USAT) for submassive PE. Data were collected on patient characteristics, echocardiographic findings, and clinical outcomes for patients treated with USAT utilizing this pathway. RESULTS: From January 2012 to May 2014, 31 patients who were treated with USAT for acute PE were identified. Fourteen of these patients were transferred through our Acute PE Network, whereas 17 patients presented directly to the emergency department. All patients were consulted upon by our PERT. Among those patients who had both pre-USAT and post-USAT echocardiograms performed for comparison (n = 19), right ventricular function improved or was preserved in 94% of patients, and right ventricular size improved or was preserved in 88% of patients. CONCLUSIONS: Through the development of an Acute PE Network, with incorporation of a PERT and implementation of a critical care pathway, we report an innovative treatment approach to acute PE that includes utilization of USAT for submassive PE.

Hybrid endovascular pseudoaneurysm and pulmonary stenosis repair in bovine arch.

This case report details the endovascular management of a large aortic pseudoaneurysm in a high-risk patient with a complicated history using a multi-disciplinary, hybrid approach. The pseudoaneurysm compressed the main pulmonary artery to 5 mm with near complete obstruction of the left main pulmonary artery, while also compromising the lumens of the left superior pulmonary vein and left main bronchus. Furthermore, the patient's left upper extremity arteriovenous dialysis fistula and bovine arch anatomy required a hybrid approach of repair that preserved the fistula while treating the aortic, pulmonary, and bronchial pathology.