New Impella Cardiac Power Device Used in Patient with Cardiogenic Shock due to Nonischemic Cardiomyopathy.

The new percutaneous Impella CP (Cardiac Power; Abiomed, Inc., Danvers, MA) was designed to provide a higher level of support than Impella 2.5 (Abiomed, Inc.). We present the first documented case of a patient that was transitioned from the Impella 2.5 to Impella CP. A 48-year-old male patient with no medical history was transferred to our institution with a one day history of worsening shortness of breath. The patient was unstable and found to have monomorphic ventricular tachycardia at 220 beats/min that was cardioverted to normal sinus rhythm. An emergent right and left heart catheterization was performed showing nonobstructive coronary artery disease, biventricular failure with a left ventricular ejection fraction (LVEF) of 5 to 10%, high pulmonary capillary wedge pressure (PCWP) 22 mm Hg, right atrial (RA) pressure 22 mm Hg, and a very low cardiac index of 1.0 L/min/m2. Because of severe cardiogenic shock, Impella 2.5 was inserted providing flow up to 2.1 L/min; however, the patient remained unstable and critically ill with severe multiorgan failure. To provide better mechanical support, the device was upgraded to the new Impella CP that can provide up to 3.5 L/min of cardiac output. Over the course of the next 72 hours, the patient showed significant improvement in hemodynamics and cardiac function (LVEF 45%), with recovery of liver function. The Impella CP was removed with no complications. The new Impella CP was shown to be safe and effective for prolonged use in critically ill patients and may significantly improve their prognosis.

The value of diastolic function parameters in the prediction of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation.

BACKGROUND: Left ventricular diastolic impairment and consequently elevated filling pressure may contribute to stasis leading to left atrial appendage thrombus (LAAT) in nonvalvular atrial fibrillation (AF). We investigated whether transthoracic echocardiographic parameters can predict LAAT independent of traditional clinical predictors. METHODS: We conducted a retrospective cohort study of 297 consecutive nonvalvular AF patients who underwent transthoracic echocardiogram followed by a transesophageal echocardiogram within one year. Multivariate logistic regression analysis models were used to determine factors independently associated with LAAT. RESULTS: Nineteen subjects (6.4%) were demonstrated to have LAAT by transesophageal echocardiography. These patients had higher mean CHADS2 scores [2.6 ± 1.2 vs. 1.9 ± 1.3, P = 0.009], higher E:e' ratios [16.6 ± 6.1 vs. 12.0 ± 5.4, P = 0.001], and lower mean e' velocities [6.5 ± 2.1 cm/sec vs. 9.1 ± 3.2 cm/sec, P = 0.001]. Both E:e' and e' velocity were associated with LAAT formation independent of the CHADS2 score, warfarin therapy, left ventricular ejection fraction (LVEF), and left atrial volume index (LAVI) [E:e' odds-ratio = 1.14 (95% confidence interval = 1.03 - 1.3), P = 0.009; e' velocity odds-ratio = 0.68 (95% confidence interval = 0.5 - 0.9), P = 0.007]. Similarly, diastolic function parameters were independently associated with spontaneous echo contrast. CONCLUSION: The diastolic function indices E:e' and e' velocity are independently associated with LAAT in nonvalvular AF patients and may help identify patients at risk for LAAT.

B-type natriuretic peptide predicts left atrial appendage thrombus in patients with nonvalvular atrial fibrillation.

PURPOSE: To investigate whether plasma B-type Natriuretic peptide (BNP), a surrogate of left ventricular filling pressure (LVFP), is predictive of left atrial appendage thrombus (LAAT) in patients with nonvalvular atrial fibrillation (AF) independent of known clinical risk predictors. METHODS: We conducted a retrospective cohort study of 297 consecutive subjects with AF who underwent a clinically indicated transesophageal echocardiogram (TEE) to evaluate for LAAT and spontaneous echo contrast (SEC). Among those, 136 had a clinically indicated BNP level. Using multivariate logistic regression analysis models, we determined factors independently predictive of the primary endpoint of LAAT and the secondary endpoint of either LAAT or SEC. RESULTS: Nineteen subjects (6.4%) had LAAT and they were found to have a higher mean CHADS2 score (2.53 vs 1.76, P = 0.01) and mean BNP level [1949 vs. 819 pg/mL, P = 0.001] than those without LAAT. None of the patients with a BNP level ≤500 pg/mL had LAAT. Multivariate logistic regression analysis demonstrated that BNP was predictive of LAAT and the composite of LAAT/SEC independent of the CHADS2 score and warfarin therapy [OR = 1.23 and 1.6 per 500 pg/mL increment in BNP, P-values = 0.03 and 0.001; respectively]. Moreover, adding BNP to the predictive model negated the influence of the CHADS2 score. CONCLUSION: These data indicate that BNP is an independent predictor of LAAT in AF and may complement the role of the CHADS2 score in predicting stroke risk.

Safety of endoscopic procedures after acute myocardial infarction: a systematic review.

BACKGROUND: The management of patients who develop gastrointestinal (GI) bleeding after acute myocardial infarction (MI) is difficult due to concerns about possible cardiovascular complications. Gastroenterologists are often reluctant to perform endoscopic procedures despite urgent indications. We performed a systematic review of the literature to determine the safety of endoscopic procedures after MI. METHODS: We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled trials for controlled clinical trials or case series examining the diagnostic efficacy and complications of esophagogastroduodenoscopy (EGD), colonoscopy and flexible sigmoidoscopy after MI. Title and abstract screening was followed by full-text review with subsequent data extraction of included studies. RESULTS: A total of seven studies met inclusion criteria. Four studies evaluated safety and efficacy of EGD after MI. The reported complication rate ranged between 1-8%, with a large predominance of minor complications. We found one study addressing safety of flexible sigmoidoscopy that reported minor complications in two patients. We also identified one study addressing the safety of colonoscopy after MI, which showed a complication rate of 9%. Most of these complications were minor. A decision analysis was also included in this review. CONCLUSIONS: Our review demonstrated that endoscopic procedures are safe and beneficial in stable patients with GI bleeding after recent MI and should be performed without a requisite delay. Unstable patients should undergo endoscopic procedures only in the intensive care setting, after stabilization and with close monitoring.