Evaluation of Newly Integrated Bivalirudin Titration Protocol in Patients With Mechanical Circulatory Support.

BACKGROUND: Patients with cardiogenic shock or end-stage heart failure can be maintained on mechanical circulatory support (MCS) devices. Once a patient undergoes placement of a device, obtaining and maintaining therapeutic anticoagulation is vital. Guidelines recommend the use of institutional protocols to assist in dosing and titration of anticoagulants. OBJECTIVE: The purpose of this study was to characterize the use of bivalirudin before and after the implementation of a standardized titration protocol in patients with MCS. METHODS: A retrospective review of patients who received bivalirudin for MCS (VA ECMO [veno-arterial extracorporeal membrane oxygenation], Impella, or LVAD [left ventricular assist device]) before and after the implementation of the titration protocol into the electronic health record (EHR) was conducted. The primary outcome was to compare the proportion of therapeutic activated partial thromboplastin time (aPTT). Secondary outcomes included number of subtherapeutic and supratherapeutic aPTTs, incidence of bleeding and clotting events, bivalirudin titrations per day, and percentage of patients with therapeutic aPTT level. RESULTS: A total of 100 patients were included (precohort = 67; postcohort = 33). The proportion of therapeutic aPTTs was significantly higher in the postcohort than that in the precohort (62% vs 48%; P < 0.001). The postcohort had 0% of patients failing to achieve therapeutic aPTT levels. The number of titrations per day was significantly lower in the postcohort, with 1.20 titrations per day versus 1.93 in the precohort (P < 0.001). CONCLUSIONS: Implementation of the bivalirudin titration nomograms within the EHR significantly increased the number of therapeutic aPTTs, reduced the number of patients who never achieved a therapeutic aPTT, and reduced the required number of titrations per day.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.

BACKGROUND: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS: We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS: We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS: Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

Left Atrial Appendage Occlusion Device Placement Aborted Because of Coronary Artery Bypass Graft.

Left atrial appendage occlusion device (LAAO) implantation among patients who have had coronary artery bypass grafting can be challenging. We report a case of scheduled LAAO device implantation that was aborted due to the anomalous course of a bypass graft that appeared to be adherent to the left atrial appendage. (Level of Difficulty: Intermediate.).

Amiodarone induced movement disorder after cardiac arrest - A case report.

We describe a case of new onset movement disorder in a patient with ventricular tachycardia storm supported with peripheral VA ECMO. The differential diagnosis of abnormal movements in a post cardiac arrest patient requiring temporary mechanical circulatory support for cardiogenic shock is explored.

Impella 5.0 is associated with a reduction in vasoactive support and improves hemodynamics in cardiogenic shock: A single-center experience.

BACKGROUND: Treatment of cardiogenic shock (CS) often requires the use of vasopressors and inotropic agents, which are associated with an increase in mortality. Data on change in vasopressor and inotrope requirements post Impella 5.0 placement is scarce. Thus, we aimed to study the ability of Impella 5.0 to reduce these requirements. METHODS: Retrospective analysis of consecutive patients with CS receiving Impella 5.0 was performed. Vasopressor-Inotrope Score (VIS) and a Modified Catecholamine Equivalent score (MCES) was calculated prior to and up to 72 h post-Impella implantation. Primary outcome was change in MCES from baseline to 48-h post implantation and secondary outcomes included change in VIS, changes in MCES according to SCAI Stage and to underlying etiology, and freedom from mortality at 30-days. RESULTS: Twenty-eight patients with median age of 61 (48, 67) years were included. Impella 5.0 was associated with significant reduction in MCES from baseline [9.7 (5.3, 17)] to 48 h [5.7 (3.8, 7.5), p = 0.001]. VIS was also significantly reduced from baseline [8.3 (3.8, 19.9)] to 48 h [5.0 (2.5, 8), p = 0.003]. MCES at 48 h was significantly reduced in patients with SCAI Stage E versus Stage C (p = 0.026) and with acute myocardial infarction versus acute decompensated heart (p = 0.003). Thirty-day survival was 0% in patients that had a baseline MCES ⩾ 10 without a reduction in MCES of at least 5 at 24 h. CONCLUSION: Impella 5.0 is associated with a significant reduction in MCES and VIS scores in patients presenting with CS with 30-day survival being dependent on MCES.

Impact of Pre-Existing Mitral Regurgitation Following Left Ventricular Assist Device Implant.

OBJECTIVES: Optimal management of significant mitral regurgitation (SMR) during left ventricular assist device (LVAD) placement remains uncertain. This study evaluates the effect of untreated preop SMR on outcomes following LVAD implant. METHODS: Adults undergoing primary LVAD placement from April 2004 to May 2017 were included. Most recent preop transthoracic echocardiogram (TTE) was used to divide patients into an SMR group with moderate or greater regurgitation, and a group without SMR. Patients underwent LVAD implant without correction of SMR. Primary endpoint was 3-year postoperative survival, with secondary endpoints of length of stay (LOS), resolution of SMR following LVAD on postdischarge (30 day) TTE, and 1-year TTE. RESULTS: LVAD placement was performed in 270 patients, 172 (63.7%) without SMR and 98 (36.3%) with SMR. There were no differences in comorbidities including diabetes, hypertension, and renal disease. Preop ejection fraction was similar, but a higher pulmonary vascular resistance was recorded in the SMR group (3.6 vs 3.0 Wood Units, P = 0.048). There was no difference in 3-year mortality between the 2 cohorts (log-rank P = 0.0.803). The SMR group had decreased LOS (median 19.5 vs 22 days, P = 0.009). Of the 98 SMR patients, 91 (92.9%) had resolution of SMR to less than moderate at 30 days. At 1 year, 15% of those with preoperative SMR had recurrent SMR. CONCLUSIONS: Patients undergoing LVAD placement with preop SMR experience no differences in mortality, and a majority experience resolution of MR after implant. Longer-term SMR recurrence and need for mitral intervention with LVAD implant warrant further investigation.

Association of Fine Particulate Matter and Risk of Stroke in Patients With Atrial Fibrillation.

Importance: Air pollution is associated with cardiovascular outcomes. Specifically, fine particulate matter measuring 2.5 µm or less (PM2.5) is associated with thrombosis, stroke, and myocardial infarction. Few studies have examined particulate matter and stroke risk in individuals with atrial fibrillation (AF). Objective: To assess the association of residential-level pollution exposure in 1 year and ischemic stroke in individuals with AF. Design, Setting, and Participants: This cohort study included 31 414 individuals with AF from a large regional health care system in an area with historically high industrial pollution. All participants had valid residential addresses for geocoding and ascertainment of neighborhood-level income and educational level. Participants were studied from January 1, 2007, through September 30, 2015, with prospective follow-up through December 1, 2017. Data analysis was performed from March 14, 2018, to October 9, 2019. Exposures: Exposure to PM2.5 ascertained using geocoding of addresses and fine-scale air pollution exposure surfaces derived from a spatial saturation monitoring campaign and land-use regression modeling. Exposure to PM2.5 was estimated annually across the study period at the residence level. Main Outcomes and Measures: Multivariable-adjusted stroke risk by quartile of residence-level and annual PM2.5 exposure. Results: The cohort included 31 414 individuals (15 813 [50.3%] female; mean [SD] age, 74.4 [13.5] years), with a median follow-up of 3.5 years (interquartile range, 1.6-5.8 years). The mean (SD) annual PM2.5 exposure was 10.6 (0.7) µg/m3. A 1-SD increase in PM2.5 was associated with a greater risk of stroke after both adjustment for demographic and clinical variables (hazard ratio [HR], 1.08; 95% CI, 1.03-1.14) and multivariable adjustment that included neighborhood-level income and educational level (HR, 1.07; 95% CI, 1.00-1.14). The highest quartile of PM2.5 exposure had an increased risk of stroke relative to the first quartile (HR, 1.36; 95% CI, 1.18-1.58). After adjustment for clinical covariates, income, and educational level, risk of stroke remained greater for the highest quartile of exposure relative to the first quartile (HR, 1.21; 95% CI, 1.01-1.45). Conclusions and Relevance: This large cohort study of individuals with AF identified associations between PM2.5 and risk of ischemic stroke. The results suggest an association between fine particulate air pollution and cardiovascular disease and outcomes.

Sex and menopause differences in response to tadalafil: 6-minute walk distance and time to clinical worsening.

Pulmonary arterial hypertension (PAH) is a female-predominant disease, but there are little data on treatment response by sex and menopausal status. In this retrospective analysis of the Pulmonary Arterial Hypertension and Response to Tadalafil (PHIRST) randomized clinical trial, we assessed treatment response between the sexes by examining change in 6-minute walk distance (6MWD) and time to clinical worsening (TCW). We examined the effect of menopausal status on the same treatment measures. 6MWD was recorded before and after 16 weeks of treatment with tadalafil or placebo in the PHIRST study cohort of 340 subjects (264 females, 76 males). A univariate analysis was used to assess the effect of sex on change in 6MWD and TCW. Multivariate linear regression and Cox proportional hazards models were built for 6MWD and TCW, respectively. Women were subdivided by age as a surrogate for menopausal status. The linear trend test and the log-rank test were performed on change in 6MWD and TCW by age. For tadalafil-treated patients, a significant difference in change in 6MWD by sex (mean: 48.6 m for males vs. 34.7 m for females; P = 0.01) was found, but it was not significant in multivariate analysis (P = 0.08). There was a trend toward a female age-dependent effect in change in 6MWD; the premenopausal group showed the greatest improvement. A significant sex- or age-dependent effect on TCW was not present. In conclusion, this retrospective analysis of the PHIRST trial suggests that men and premenopausal women may experience greater functional improvement when treated with tadalafil than older women, but there was no consistent sex or menopausal effect on TCW.

The association between air ambulance distribution and trauma mortality.

OBJECTIVE: To determine whether increasing distance between helicopter ambulance airbase and either home residence or referring facility is associated with an increased risk of injury-related mortality. BACKGROUND: A dramatic increase in the absolute number and utilization of Helicopter Emergency Medical Services transports has occurred in the management of the critically injured patients. HEMS are resource intensive, and the most efficient geographic distribution of airbases necessary to improve patient outcomes is unknown. METHODS: We performed a retrospective analysis of 244,293 adult trauma patients who were treated at a designated trauma center (TC) in Pennsylvania during the period 1997 to 2007, using the Pennsylvania Trauma Outcomes Study data set. We performed a multivariate analysis, adjusting for differences in case mix, to determine whether airbase proximity to either residence or referring facility is associated with injury-related mortality. RESULTS: For patients residing distant (>20 miles) from a TC, increasing distance from an airbase is associated with an increased risk of death; for each mile, the risk of mortality increases by approximately 1% (adjusted odds ratio, 1.011; 95% confidence interval, 1.002-1.018; P = 0.02). There is no additional benefit to living close (<25 miles) to more than 1 airbase. However, most airbases are positioned near TC and other airbases. Despite the proliferation of helicopter ambulances, 18.1% of patients who did not live near a TC also did not live near airbase. CONCLUSIONS: For individuals residing distant from a TC, proximity to 1 airbase is associated with reduced risk of death. No additional benefit is observed when airbases are positioned close to a TC or other airbases.