Therapeutic inefficacy of protocol driven intravenous unfractionated heparin infusion in the current era.

Unfractionated heparin (UFH) is commonly used for several life-threatening conditions requiring anticoagulant therapy but failure to reach therapeutic levels in 24 h can be associated with adverse outcomes. Use of low molecular weight heparin (LMWH) may provide an alternative while providing superior outcomes as compared to UFH. We studied 100 patients who underwent UFH therapy for >24 h and found that theoretically 80 % were eligible for LMWH therapy. Only 29 % and 40 % of the total aPTT draws were in the therapeutic window within the first 24 h and at 25-48 h respectively. This study reports that a vast majority of patients remain outside of therapeutic aPTT within first 24-48 h when anticoagulated with UFH. With high eligibility for LMWH therapy, its substitution can potentially lead to better patient outcomes, higher levels of therapeutic efficacy, and decrease in hospital resources.

Declining Trend of Transapical Access for Transcatheter Aortic Valve Replacement in Patients with Aortic Stenosis.

Introduction: The last decade has witnessed major evolution and shifts in the use of transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Included among the shifts has been the advent of alternative access sites for TAVR. Consequently, transapical access (TA) has become significantly less common. This study analyzes in detail the trend of TA access for TAVR over the course of 7 years. Methods: The national inpatient sample database was reviewed from 2011-2017 and patients with AS were identified by using validated ICD 9-CM and ICD 10-CM codes. Patients who underwent TAVR through TA access were classified as TA-TAVR, and any procedure other than TA access was classified as non-TA-TAVR. We compared the yearly trends of TA-TAVR to those of non-TA-TAVR as the primary outcome. Results: A total of 3,693,231 patients were identified with a diagnosis of AS. 129,821 patients underwent TAVR, of which 10,158 (7.8%) underwent TA-TAVR and 119,663 (92.2%) underwent non-TA-TAVR. After peaking in 2013 at 27.7%, the volume of TA-TAVR declined to 1.92% in 2017 (p < 0.0001). Non-TA-TAVR started in 2013 at 72.2% and consistently increased to 98.1% in 2017. In-patient mortality decreased from a peak of 5.53% in 2014 to 3.18 in 2017 (p=0.6) in the TA-TAVR group and from a peak of 4.51% in 2013 to 1.24% in 2017 (p=0.0001) in the non-TA-TAVR group. Conclusion: This study highlights a steady decline in TA access for TAVR, higher inpatient mortality, increased length of stay, and higher costs compared to non-TA-TAVR.

Comparison of Suture-Based and Collagen-Based Vascular Closure Devices for Large Bore Arteriotomies-A Meta-Analysis of Bleeding and Vascular Outcomes.

BACKGROUND: Large bore access procedures rely on vascular closure devices to minimize access site complications. Suture-based vascular closure devices (S-VCD) such as ProGlide and ProStar XL have been readily used, but recently, newer generation collagen-based vascular closure devices (C-VCD) such as MANTA have been introduced. Data on comparisons of these devices are limited. METHODS: PubMed, Scopus and Cochrane were searched for articles on vascular closure devices using keywords, ("Vascular closure devices" OR "MANTA" OR "ProStar XL" OR "ProGlide") AND ("outcomes") that resulted in a total of 875 studies. Studies were included if bleeding or vascular complications as defined by Valve Academic Research Consortium-2 were compared between the two types of VCDs. The event level data were pooled across trials to calculate the Odds Ratio (OR) with 95% CI, and analysis was done with Review Manager 5.4 using random effects model. RESULTS: Pooled analyses from these nine studies resulted in a total of 3410 patients, out of which 2855 were available for analysis. A total of 1229 received C-VCD and 1626 received S- VCD. Among the patients who received C-VCD, the bleeding complications (major and minor) were similar to patients who received S-VCD ((OR: 0.70 (0.35-1.39), p = 0.31, I2 = 55%), OR: 0.92 (0.53-1.61), p = 0.77, I2 = 65%)). The vascular complications (major and minor) in patients who received C-VCD were also similar to patients who received S-VCD ((OR: 1.01 (0.48-2.12), p = 0.98, I2 = 52%), (OR: 0.90 (0.62-1.30), p = 0.56, I2 = 35%)). CONCLUSIONS: Bleeding and vascular complications after large bore arteriotomy closure with collagen-based vascular closure devices are similar to suture-based vascular closure devices.

Multimodality Imaging of Constrictive Pericarditis: Pathophysiology and New Concepts.

PURPOSE OF REVIEW: The unique pathophysiological changes of constrictive pericarditis (CP) can now be identified with better imaging modalities, thereby helping in its early diagnosis. Through this review, we outline the pathophysiology of CP and its translation into symptomology and various imaging findings which then are used for both diagnosis and guiding treatment options for CP. RECENT FINDINGS: Multimodality imaging has provided us with the capability to recognize early stages of the disease and identify patients with a potential for reversibility and can be treated with medical management. Additionally, peri-procedural planning and prediction of post-operative complications has been made possible with the use of advanced imaging techniques. Advanced imaging has the potential to play a greater role in identification of patients with reversible disease process and provide peri-procedural risk stratification, thereby improving outcomes for patients with CP.

Intravascular ultrasound guided transcatheter electrosurgical revascularization of an interrupted aortic arch.

Interrupted aortic arch is a rare (prevalence 1:100000) but malignant cause of secondary hypertension, with late sequela of early myocardial infarction, stroke, and heart failure. We present the case of a 49-year-old male patient with aortic interruption successfully treated by intravascular ultrasound guided transcatheter electrosurgical wire crossing and revascularization using a covered stent. Learning objective: Transcatheter electrosurgical wire techniques utilizing intravascular ultrasound facilitate safe and effective percutaneous revascularization of complex aortic coarctation patients.

Recurrent Silicone Embolism Syndrome requiring VA ECMO.

The illegal use of liquid silicone in injectable procedures has been on the rise for the last few years. While originally thought to be an inert material, today, silicone is associated with several inflammatory complications-including Silicone Embolism Syndrome (SES). SES is the most dreaded complication of unlicensed liquid silicone injections. It is characterized by pneumonitis, diffuse alveolar and silicone pulmonary emboli leading to acute respiratory distress syndrome and cardiopulmonary failure. We present a case of a patient who was diagnosed with SES after she received unlicensed liquid silicone injections for gluteal augmentation. Her disease necessitated treatment with veno-arterial extracorporeal membrane oxygenation. Her neurological status remained poor. Our patient was also treated for SES status-post illicit silicone injections several years prior to the current episode. To our knowledge, this is the only reported instance of the same patient experiencing SES status-post illicit silicone injections on two separate occasions. Our patient's case suggests that robust education is needed for patients and the general public regarding the dangers of illicit body modifications. Given the widespread availability of counterfeit "medical grade" silicone, it is likely that the number of SES cases will continue to increase. Physicians must to be able to recognize the symptoms of SES, and not discount the possibility that patients will continue to receive illicit injections-even if they experienced devastating consequences the first time.

Right Atrial Thrombi, the Management Conundrum: 2 Case Reports.

BACKGROUND There are no guidelines providing an algorithmic approach for the management of right atrial thrombi, to date, owing to a lack of strong supporting studies. In this case series, we describe 2 cases of high-risk patients with massive right atrial thrombi who had different outcomes. CASE REPORT Case 1: A 62-year-old man with ischemic cardiomyopathy and atrial fibrillation, who was on a permanent pacemaker for sick sinus syndrome and was noncompliant with medication for 2 years, presented to the Emergency Department for evaluation of a 2-month history of progressive shortness of breath and swollen neck veins. A cardiac ultrasound confirmed a large right atrial thrombus, and a computed tomography (CT) pulmonary angiogram was negative for pulmonary emboli. He was managed with a heparin infusion and thrombolytic therapy with favorable evolution. Case 2: A 66-year-old man, with a past medical history of nonischemic cardiomyopathy, atrial fibrillation, deep venous thrombosis, and pulmonary emboli a year earlier, presented to an urgent care unit with sudden onset of shortness of breath. A cardiac ultrasound confirmed a large right atrial thrombus, and a CT pulmonary angiogram confirmed bilateral pulmonary emboli. He was managed with a heparin infusion and EkoSonic endovascular system therapy. He subsequently needed venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation and underwent mechanical aspiration thrombectomy. The patient's evolution was unfavorable. CONCLUSIONS In the absence of an evidence-based guideline to approach right atrial thrombi, management should be individualized for each patient, based on the type of thrombi, hemodynamic status, and presence or absence of associated pulmonary emboli.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Thrombosis: Phlegmasia Cerulea Dolens Presenting with Venous Gangrene in a Child.

A 12-year-old girl with severe acute respiratory syndrome coronavirus 2 infection presented as phlegmasia cerulea dolens with venous gangrene. Emergent mechanical thrombectomy was complicated by a massive pulmonary embolism and cardiac arrest, for which extracorporeal cardiopulmonary resuscitation and therapeutic hypothermia were used. Staged ultrasound-assisted catheter-directed thrombolysis was used for treatment of bilateral pulmonary emboli and the extensive lower extremity deep vein thrombosis while the patient received extracorporeal membrane oxygenation support. We highlight the need for heightened suspicion for occult severe acute respiratory syndrome coronavirus 2 infection among children presenting with unusual thrombotic complications.

Emergent TandemHeart-ECMO for acute severe mitral regurgitation with cardiogenic shock and hypoxaemia: a case series.

BACKGROUND: Acute severe mitral regurgitation (MR) associated with cardiogenic shock is a life-threatening emergency. Traditional teaching has focused on the need for emergent coronary angiography and/or intra-aortic balloon counterpulsation in preparation for emergent open-heart surgery for repair/replacement. Unfortunately, emergent open-heart surgery in patients with acute MR complicated by cardiogenic shock is associated with 25-46% perioperative mortality. New devices have provided additional options for stabilization prior to emergent surgery which facilitate improved outcomes. CASE SUMMARY: We present two cases of acute severe MR resulting in cardiogenic shock and profound hypoxaemia. TandemHeart® mechanical circulatory support with an oxygenator spliced into the circuit, akin to veno-arterial extracorporeal membrane oxygenation (ECMO), facilitated haemodynamic stabilization and decongestion of the lungs facilitating successful bridge to mitral valve surgery. Successful discharge to home was achieved in both patients with good neurological outcomes and sustained long-term functional recovery at 18 and 14 months, respectively. DISCUSSION: Selective use of the TandemHeart®, with or without ECMO, facilitates management of the critically ill cardiogenic shock patient with acute severe MR.

Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types.

Advances in cardiovascular (CV) imaging, redefined electrocardiogram criteria, and high-sensitivity CV biomarker assays have enabled more differentiated etiological classification of myocardial infarction (MI). Type 1 MI has a different underlying pathophysiology than type 2 through type 5 MI; type 1 MI is characterized primarily by intracoronary atherothrombosis and the other types by a variety of mechanisms, which can occur with or without an atherosclerotic component. In type 2 MI, there is evidence of myocardial oxygen supply-demand imbalance unrelated to acute coronary atherothrombosis. Types 1 and 2 MI are spontaneous events, while type 4 and type 5 are procedure-related; type 3 MI is identified only after death. Most type 1 and type 2 MI present as non-ST-elevation MI (NSTEMI), although both types can also present as ST-elevation MI. Because of their different underlying etiologies, type 1 and type 2 NSTEMI have different presentation and prognosis and should be managed differently. In this article, we discuss the epidemiology, prognosis, and management of NSTEMI occurring in the setting of underlying type 1 or type 2 pathophysiology. Most NSTEMI (65%-90%) are type 1 MI. Patients with type 2 MI have multiple comorbidities and causes of in-hospital mortality among these patients are not always CV-related. It is important to distinguish between type 1 and type 2 NSTEMI early in the clinical course to allow for the use of the most appropriate treatments that will provide the greatest benefit for these patients.

Implications of Misclassification of Type 2 Myocardial Infarction on Clinical Outcomes.

BACKGROUND: Patients with type 2 myocardial infarction (MI) are often classified under the diagnosis of non-ST-segment-elevation MI (NSTEMI) despite the significant differences in clinical characteristics, management, and outcomes between type 2 MI and type 1 NSTEMI. This may have significant implications that can lead to inaccurate assessment of quality measures by MI quality review programs. METHODS: A single-center retrospective study of 1224 patients discharged with the diagnosis of type 1 NSTEMI between January 2015 and September 2017. Based on the third universal definition of MI, we stratified patients into type 2 MI or type 1 NSTEMI. Patient's characteristics, comorbidities, medications prescribed during hospitalization and at discharge, readmissions within 30 days after discharge, and diagnostic and therapeutic interventions data was collected. The primary goal of this study was to identify how often type 2 MI patients were misclassified as type 1 NSTEMI, we also assessed the differences in treatment and outcomes between type 2 MI and type 1 NSTEMI. RESULTS: 1224 patients assigned the ICD-9 and ICD-10 codes of type 1 NSTEMI at discharge were evaluated for study inclusion. After application of the inclusion criteria, 945 patients were included in the final analysis. Of these 945 patients, 281 (29.7%) patients were classified as type 2 MI and 664 (70.3%) patients were classified as type 1 NSTEMI. Patients with type 2 MI were older, more likely to have systolic heart failure, had lower peak troponin levels, were less likely to receive aspirin, P2Y12 inhibitors and statin at discharge, and had longer length of stay. Compared with type 1 NSTEMI patients, those with type 2 MI had higher all cause 30-day mortality (13.5% versus 2.9%, P < 0.0001) (RR: 4.65; 95% CI, 2.85-9.65). After adjusting for patient demographics, comorbidities, and medications, patients with type 2 MI were still more likely to die within 30 days after discharge (RR: 2.89; 95% CI, 1.58-7.46). In addition, patients with type 2 MI were more likely to be readmitted within 30 days after discharge than patients with type 1 NSTEMI (17.7% versus 13.9%, P < 0.01) (RR: 1.27; 95% CI, 1.08-2.5). CONCLUSIONS: Close to one third of patients given the diagnosis of type 1 NSTEMI at discharge at our institution were type 2 MI patients. Patients with type 2 MI are managed differently from type 1 NSTEMI patients and have higher 30-day mortality and readmission rate. Misclassification of type 2 MI as type 1 NSTEMI can have a significant impact on hospitals MI clinical performance and quality measures.

Jetstream atherectomy and balloon angioplasty with distal embolic protection for Angio-Seal related vascular access complications.

Arteriotomy closure devices (ACDs) are routinely used for vascular closure during invasive cardiovascular procedures. They decrease time to hemostasis as well as length of stay. Major complications such as arterial ischemia and occlusion can be encountered in a minority of patients. We are describing a series of 3 patients with access site closure using Angio-Seal after coronary angiography who developed intermittent claudication within 2-3 weeks of follow-up. Access site thrombosis/stenosis in the CFA was found in all the three cases. They were successfully revascularized using Jetstream atherectomy with embolic protection filter followed by balloon angioplasty. This technique can treat extensive thrombus burden as well as extract the collagen and foot plate of Angio-Seal through atherectomy with cutting blades and thrombectomy via rheolytic macerating aspiration port. All cases had excellent angiographic and clinical results.

Differential responses to larger volume intra-aortic balloon counterpulsation: Hemodynamic and clinical outcomes.

OBJECTIVES: Examine hemodynamic and clinical correlates of use of an intra-aortic balloon pump catheter in a single center. BACKGROUND: The intra-aortic balloon pump catheter (IABC) has been used for 50 years but the clinical benefit is still debated. We reviewed 76 patients with right heart catheter measurements prior to IABC to assess response and outcomes. METHODS: All patients who received IABC with a 50cc balloon for at least 1 hour were included in this retrospective chart review study. Demographics, comorbidities, lab values, and hemodynamic parameters were recorded at baseline and 15 h postinsertion. RESULTS: Seventy-six patients had paired measurements of cardiac output. 60 patients had a higher cardiac output with IABC treatment (responder group) and 16 did not (nonresponders). In the 60 patients in the responder group, cardiac output and index significantly increased from baseline 3.6 ± 1.3 L/min to 5.2 ± 1.8 L/min, and 1.8 ± 0.5 L/min/m2 to 2.6 ± 0.8 L/min/m2 respectively following IABC placement (P < 0.0001 for both comparisons). Various hemodynamic variables were examined and the best predictor of response to IABC was a cardiac power index of 0.3 or less. Regardless of response, in hospital survival was similar between groups. CONCLUSIONS: The majority of patients improve their cardiac output with IABC but survival was unchanged. Further work into the pathophysiology of cardiogenic shock is needed.

Transcatheter Aortic Valve Replacement Versus Surgical Valve Replacement in Low-Intermediate Surgical Risk Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a viable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (SAS) who are at high risk for surgery. We sought to evaluate the outcomes of TAVR vs SAVR in low-intermediate risk patients with SAS. METHODS AND RESULTS: We performed random-effects meta-analysis of randomized controlled trials (RCTs) and propensity-matched observational studies comparing TAVR vs SAVR for low-intermediate risk patients. Five RCTs and 5 observational studies with a total of 6891 patients (3489 TAVR patients; 3402 SAVR patients) were included. Pooled data from RCTs showed no significant differences in all-cause mortality between TAVR and SAVR at 30 days (risk ratio [RR], 1.04; 95% confidence interval [CI], 0.73-1.47) and intermediate-term follow-up (RR, 0.86; 95% CI, 0.67-1.10). A trend toward decreased mortality was found with TAVR using the self-expandable vs balloon-expandable valves (RR, 0.77; 95% CI, 0.52-1.15 and RR, 1.91; 95% CI, 0.25-14.53, respectively) and transfemoral vs transthoracic approach (RR, 0.74; 95% CI, 0.55-1.01 and RR, 2.09; 95% CI, 0.40-11.03, respectively). Compared to SAVR, TAVR was associated with similar risks of stroke (RR, 0.91; 95% CI, 0.74-1.11) and myocardial infarction (RR, 1.00; 95% CI, 0.71-1.41). Furthermore, risks of major vascular complications, moderate-severe paravalvular regurgitation, and new permanent pacemaker implantation were higher with TAVR, whereas SAVR was associated with higher rates of acute kidney injury, atrial fibrillation, and major or life-threatening bleed. Finally, the above results from RCTs were consistent with pooled analyses of observational studies. CONCLUSION: TAVR appears to be a suitable alternative for patients with SAS who are at low-intermediate risk for SAVR.

A single center tertiary care experience utilizing the large volume mega 50cc intra-aortic balloon counterpulsation in contemporary clinical practice.

OBJECTIVE: Clinical outcomes and adverse events utilizing the large volume 50cc intra-aortic balloon (IAB) in contemporary clinical practice. BACKGROUND: The newer large volume 50cc IAB, recently introduced into clinical practice offers improved diastolic augmentation and better left ventricular (LV) unloading compared to the older 40cc IAB. METHODS: In 150 consecutive patients who received intra-aortic balloon counterpulsation (IABC) with a 50cc balloon from 2011 to 2015, we retrospectively analyzed demographic, clinical, laboratory, and hemodynamic variables, adverse events and survival to discharge from index hospitalization. RESULTS: Median LVEF was 20%. The most common indication was cardiogenic shock (CS) in 100 patients. Median duration of IABC was 92.5 hr. 95% of patients were free of any IAB device related complications. Five patients received a transfusion for bleeding causally related to IABC. 70 of the 150 patients who received MCS with IABC with no escalation of therapy, recovered and were discharged alive. Fifteen patients were stabilized on IABC and bridged to orthotopic heart transplant. All 15 were discharged alive. Thirty-four patients were initiated on IABC and escalated to VAD and/or Impella/Tandem Heart, with 24 patients surviving to hospital discharge. Overall survival to hospital discharge for the 150 patients was 72.7%. CONCLUSION: IABC using a larger volume 50cc balloon appears effective as a first line percutaneous MCS strategy in a large fraction of critically ill cardiac patients with few adverse events. A large scale registry or randomized clinical trial utilizing the larger volume IAB is needed to validate our results. © 2017 Wiley Periodicals, Inc.

Acute left ventricular dysfunction complicating pregnancy on ECMO: Tri-iodothyronine to the rescue with real time transesophageal echocardiography.

Cardiac dysfunction is a common accompaniment to severe sepsis. Clinical management of the same complicating pregnancy presents unique challenges balancing maternal and fetal well-being. Can short-term intravenous (IV) tri-iodothyronine (T3) be used in the management of these patients? T3 has been reported in varied clinical settings to favorably affect cardiac lusitropy, inotropy, and chronotropy without significant side effects. We report a case of acute severe left ventricular dysfunction in a pregnant woman with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation managed with short-term IV T3. Hemodynamic stability was rapidly achieved and the improvement in contractility imaged in real time by transesophageal echocardiography. .