Gastrointestinal haemorrhage in extracorporeal membrane oxygenation: insights from the national inpatient sample.

Introduction: Extracorporeal membrane oxygenation (ECMO) is associated with gastrointestinal haemorrhage (GIH), which may result from coagulopathy, systemic inflammation, reduced gastric perfusion, and arteriovenous malformation from non-pulsatile blood flow. Data are limited regarding the burden of this complication in the United States. Material and methods: We analysed the National Inpatient Sample (NIS) database for the years 2007 to 2011 to identify hospitalisations in which an ECMO procedure was performed. Hospitalizations complicated by GIH in this cohort were then identified by relevant codes. Results: Between 2007 and 2011, ECMO hospitalisations increased from 1869 to 3799 (p < 0.01). The proportion of hospitalisations complicated by GIH increased from 2.12% in 2007 to 7.46% in 2011 (p < 0.01). Gastrointestinal haemorrhage was more common in men (56.7%) and in Caucasians (57.4%). Common comorbidities in this population were renal failure (71%), anaemia (55%), and hypertension (26%). All-cause inpatient mortality showed a numerical but nonsignificant increase from 56.7% to 61.9% (p = 0.49). The average cost of care per hospitalisation with GIH associated with ECMO use increased from $132,420 in 2007 to $215,673 in 2011 (p < 0.01). Conclusions: Gastrointestinal haemorrhage during ECMO hospitalisations occurred in small but significantly increasing proportions. The inpatient mortality rate and costs associated with GIH were substantial and increased significantly during the study period.

Management of Atrial Fibrillation Post Transcatheter Aortic Valve Implantation.

Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.

Transcatheter Systemic AV Valve-in-Valve Implantation in a Patient With LTGA and Ebstein Anomaly.

We present the first in-human transcatheter systemic atrioventricular valve-in-valve implantation in a 37-year-old patient with Ebstein anomaly, levo-transposition of the great arteries, and prior systemic valve replacement. She had severe bioprosthetic valve regurgitation and reduced systolic function. She had high surgical risk and was planned for transcatheter intervention. (Level of Difficulty: Advanced.).

Utility of Handheld Ultrasound Performed by Cardiology Fellows in Patients Presenting with Suspected ST-Elevation Myocardial Infarction.

Background: In academic hospitals, cardiology fellows may be the first point of contact for patients presenting with suspected ST-elevation myocardial infarction (STEMI) or acute coronary syndrome (ACS). In this study, we sought to determine the role of handheld ultrasound (HHU) in patients with suspected acute myocardial injury (AMI) when used by fellows in training, its association with the year of training in cardiology fellowship, and its influence on clinical care. Methods: This prospective study's sample population comprised patients who presented to the Loma Linda University Medical Center Emergency Department with suspected acute STEMI. On-call cardiology fellows performed bedside cardiac HHU at the time of AMI activation. All patients subsequently underwent standard transthoracic echocardiography (TTE). The impact of the detection of wall motion abnormalities (WMAs) on HHU in regard to clinical decision-making, including whether the patient would undergo urgent invasive angiography, was also evaluated. Results: Eighty-two patients (mean age: 65 years, 70% male) were included. The use of HHU by cardiology fellows resulted in a concordance correlation coefficient of 0.71 (95% confidence interval: 0.58-0.81) between HHU and TTE for left ventricular ejection fraction (LVEF), and a concordance correlation coefficient of 0.76 (0.65-0.84) for wall motion score index. Patients with WMA on HHU were more likely to undergo invasive angiogram during hospitalization (96% vs. 75%, P < 0.01). The time interval between the performance of HHU to initiation of cardiac catheterization (time-to-cath) was shorter in patients with abnormal versus normal HHU examinations (58 ± 32 min vs. 218 ± 388 min, P = 0.06). Finally, among patients who underwent angiography, those with WMA were more likely to undergo angiography within 90 min of presentation (96% vs. 66%, P < 0.001). Conclusion: HHU can be reliably used by cardiology fellows in training for measurement of LVEF and assessment of wall motion abnormalities, with good correlation to findings obtained via standard TTE. HHU-identified WMA at first contact was associated with higher rates of angiography as well as sooner angiography compared to patients without WMA.

Cardiac involvement in hydrocarbon inhalant toxicity - role of cardiac magnetic resonance imaging: A case report.

BACKGROUND: We report a patient who was diagnosed with toxic myopericarditis secondary to hydrocarbon abuse using cardiac magnetic resonance imaging (CMR). CASE SUMMARY: A 25-year-old male presented to emergency department with chest pain for 3 d. Patient also reported sniffing hydrocarbon containing inhalant for the last 1 year. Labs showed elevated troponin and electrocardiography was suggestive of acute pericarditis. Echocardiogram showed left ventricular (LV) ejection fraction (EF) of 40%. Given patient's troponin elevation and reduced EF, cardiac catheterization was performed which showed normal coronaries. CMR was performed for myocardial infarction with non-obstructive coronary arteries evaluation. CMR showed borderline LV function with edema in mid and apical LV suggestive of myocarditis. CONCLUSION: CMR can be used to diagnose toxic myopericarditis secondary to hydrocarbon abuse.

Echocardiography-Based Hemodynamic Monitoring Use on Inpatients Listed for Heart Transplantation Under 2018 Allocation Policy in United States.

BACKGROUND: One notable change to the 2018 United Network for Organ Sharing listing criteria was to allow for the use of noninvasive hemodynamic monitoring for inpatients listed as status 3 for heart transplantation. We wanted to explore the feasibility of performing daily focused echocardiograms in place of invasive monitoring in this population. METHODS: On retrospective chart review of inpatients listed for transplantation at our institution, 8 patients in the invasive monitoring group listed as status 1A (October 2016 to October 2018) and 9 patients in the echocardiographic group listed as status 3 (October 2018 to February 2020) were identified. RESULTS: There were no significant differences between the 2 cohorts in the average measured/estimated right atrial, pulmonary artery systolic, and wedge pressures, although the echo cohort had lower cardiac index (P = .001). There were 2 patients with positive blood cultures treated with Swan exchange in Swan cohort and a total of 14 Swan exchanges. There were no infections in the noninvasive group. CONCLUSION: We present our experience with the use of noninvasive daily hemodynamic assessment using focused echocardiograms to manage patients undergoing heart transplantation listing as status 3 under the new United Network for Organ Sharing allocation system. This approach appears safe and feasible; however, it requires validation in larger cohorts.

Cardiovascular Safety and Benefits of Noninsulin Antihyperglycemic Drugs for the Treatment of Type 2 Diabetes Mellitus-Part 1.

Cardiovascular disease (CVD) is a major contributor to the morbidity and mortality associated with type 2 diabetes mellitus (T2DM). With T2DM growing in pandemic proportions, there will be profound healthcare implications of CVD in person with diabetes. The ideal drugs to improve outcomes in T2DM are those having antiglycemic efficacy in addition to cardiovascular (CV) safety, which has to be determined in appropriately designed CV outcome trials as mandated by regulatory agencies. Available evidence is largely supportive of metformin's CV safety and potential CVD risk reduction effects, whereas sulfonylureas are either CV risk neutral or are associated with variable CVD risk. Pioglitazone was also associated with improved CVD risk in patients with diabetes. The more recent antihyperglycemic medications have shown promise with regards to CVD risk reduction in T2DM patients at a high CV risk. Glucagon-like peptide-1 receptor agonists, a type of incretin-based therapy, were associated with better CV outcomes and mortality in T2DM patients, leading to the Food and Drug Administration approval of liraglutide to reduce CVD risk in high-risk T2DM patients. Ongoing and planned randomized controlled trials of the newer drugs should clarify the possibility of class effects, and of CVD risk reduction benefits in low-moderate CV risk patients. While metformin remains the first-line antiglycemic therapy in T2DM, glucagon-like peptide-1 receptor agonists should be appropriately prescribed in T2DM patients with baseline CVD or in those at a high CVD risk to improve CV outcomes. Dipeptidyl peptidase-4 inhibitors and sodium-glucose cotransporter-2 inhibitors are discussed in the second part of this review.

Esophagopericardial Fistula and Pneumopericardium From Caustic Ingestion and Esophageal Stent.

Esophagopericardial fistulas are rare. Most reported cases are related to malignancy or prior surgical intervention. We report a case of an esophagopericardial fistula presenting as pneumopericardium and purulent pericarditis in a patient with a history of caustic ingestion and an esophageal stent.

Newer hormonal pharmacotherapies for heart failure.

INTRODUCTION: Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways. AREAS COVERED: A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed. EXPERT COMMENTARY: A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.

Noncanonical regulation of insulin-mediated ERK activation by phosphoinositide 3-kinase γ.

Classically Class IB phosphoinositide 3-kinase (PI3Kγ) plays a role in extracellular signal-regulated kinase (ERK) activation following G-protein coupled receptor (GPCR) activation. Knock-down of PI3Kγ unexpectedly resulted in loss of ERK activation to receptor tyrosine kinase agonists such as epidermal growth factor or insulin. Mouse embryonic fibroblasts (MEFs) or primary adult cardiac fibroblasts isolated from PI3Kγ knock-out mice (PI3KγKO) showed decreased insulin-stimulated ERK activation. However, expression of kinase-dead PI3Kγ resulted in rescue of insulin-stimulated ERK activation. Mechanistically, PI3Kγ sequesters protein phosphatase 2A (PP2A), disrupting ERK-PP2A interaction, as evidenced by increased ERK-PP2A interaction and associated PP2A activity in PI3KγKO MEFs, resulting in decreased ERK activation. Furthermore, ß-blocker carvedilol-mediated ß-arrestin-dependent ERK activation is significantly reduced in PI3KγKO MEF, suggesting accelerated dephosphorylation. Thus, instead of classically mediating the kinase arm, PI3Kγ inhibits PP2A by scaffolding and sequestering, playing a key parallel synergistic step in sustaining the function of ERK, a nodal enzyme in multiple cellular processes.

Correlation between electrocardiographic changes and coronary findings in patients with acute myocardial infarction and single-vessel disease.

BACKGROUND: Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI. METHODS: In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria. RESULTS: Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD. CONCLUSIONS: Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.

Cardiovascular benefits and safety of non-insulin medications used in the treatment of type 2 diabetes mellitus.

Diabetes mellitus is a growing in exponential proportions. If the current growth trend continues, it may result in every third adult in the United States having diabetes mellitus by 2050, and every 10th adult worldwide. Type 2 diabetes mellitus (T2DM) confers a 2- to 3-fold increased risk of cardiovascular (CV) events compared with non-diabetic patients, and CV mortality is responsible for around 80% mortality in this population. Patients with T2DM can have other features of insulin resistance-metabolic syndrome like hypertension, lipid abnormalities, and obesity which are all associated with increased CV disease and stroke risk even in the absence of T2DM. The management of a T2DM calls for employing a holistic risk factor control approach. Metformin is the first line therapy for T2DM and has been shown to have cardiovascular beneficial effects. Intense debate regarding the risk of myocardial infarction with rosiglitazone led to regulatory agencies necessitating cardiovascular outcome trials with upcoming anti-diabetic medications. Glucagon like peptide-1 agonists and sodium glucose co-transporter-2 inhibitors have shown promising CV safety and additional CV benefit in recent clinical trials. These drugs have favorable effects on traditional CV risk factors. The findings from these studies further support that fact that CV risk factor control plays an important role in reducing morbidity and mortality in T2DM patients. This review article will discuss briefly the cardiovascular safety and benefits of the oral medications which are currently being used for T2DM and will then discuss in detail about the newer medications being investigated for the treatment of T2DM.

Health Related Quality of Life in Indian Children with Cystic Fibrosis.

OBJECTIVE: This study was devised to translate Cystic Fibrosis Questionnaire-Revised to Hindi and administer it to Indian children and adolescents diagnosed with cystic fibrosis. DESIGN: Cross-sectional study. SETTING: This study was carried out in cystic fibrosis patients attending Pediatric Chest Clinic of a tertiary-care hospital in Northern India from July 2012 to December 2012. PARTICIPANTS: 45 children (6-13 years) and their parents, and 14 adolescents. Patients with unstable health in the past two weeks were excluded. INTERVENTION: Cystic Fibrosis Questionnaire- Revised translated in Hindi was administered. Clinical evaluation and scoring, throat swab cultures and spirometry were also done during the same visit. MAIN OUTCOME MEASURES: Health Related Quality of Life scores were the primary measures, and clinical scores, swab cultures and spirometry were secondary measures. RESULTS: Cronbachs alpha ranged from 0.020-0.863.The Factor analysis indicated that most test-items correlated more with competing scales than the intended scales. Convergence between self and proxy-rating was found to be dependent on the domain. The Cystic Fibrosis Questionnaire- Revised scores correlated well with clinical scores (r=0.65,P=0.011), Pseudomonas spp culture data and pulmonary function tests. There was an inverse relation between Health Related Quality of Life scores and age at diagnosis (r=-0.339, P=0.02). CONCLUSIONS: Hindi versions of Cystic Fibrosis Questionnaire- Revised: Child, Adolescent and Parents instruments will act as an important step towards data on Health Related Quality of Life of Indian patients with cystic fibrosis.