Outcomes of Cardiac Arrest with Valve Surgery Among Infective Endocarditis Patients: A United States National Cohort Study.

OBJECTIVE: Cardiac arrest can complicate infective endocarditis (IE) and is associated with significant in-hospital complications and mortality rates. We report the characteristics, outcomes, and readmission rates for IE patients with cardiac arrest in the United States. METHODS: We surveyed the Nationwide Readmission Database (NRD), a database designed to support national level readmission analyses, for patients admitted with IE and who had cardiac arrest during index admission between 2016 and 2019. Baseline demographics, comorbidities, surgical procedures, and outcomes were identified using their respective International Classification of Diseases (ICD) codes. RESULTS: There were 663 index admissions (mean age 55.87 ± 17.21 years;34.2 % females) for IE with cardiac arrest in the study period, with an overall mortality rate of 55.3 %. Of these, 270 (40.7 %) had surgical procedures performed during the hospitalization encounter. In patients who had a surgical procedure, 72 (26.8 %) patients had in-hospital mortality while 293 (74.9 %) patients without surgical procedures had in-hospital mortality (p < 0.001). After coarsened matching for baseline characteristics, surgical valve procedures were less likely to be associated with mortality (OR = 0.09, 95%CI 0.04-0.24; p < 0.001). Among the 295 alive discharges associated with cardiac arrest, 76 (38.57 %) were readmitted within 30-days, with a mortality rate of 22 % noted for readmissions. CONCLUSION: Among IE patients who had cardiac arrest, surgical procedures subgroup had low mortality despite having higher complication rates. However, due to chances of bias more randomized trials are needed evaluate the hypothesis.

Clinical outcomes and 30-day readmissions associated with high-output heart failure.

BACKGROUND: High-output heart failure (HOHF) is an underdiagnosed type of heart failure (HF) characterized by low systemic vascular resistance and high cardiac output. OBJECTIVE: This study sought to characterize the causes, mortality, and readmissions related to HOHF within the United States. METHODS: Data were collected from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD) from January 1, 2017, to November 30, 2019. We used the International Classification of Diseases, 10th revision (ICD-10), diagnostic codes to identify encounters with HOHF and heart failure with reduced ejection fraction (HFrEF). RESULTS: Of the total 5,080,985 encounters with HF, 3,897 hospitalizations (mean age 62.5 ± 17.9 years, 56.5% females) with HOHF and 5,077,088 hospitalizations with HFrEF were recorded. The most commonly associated putative etiologies of HOHF included pulmonary disease (19.8%), morbid obesity (9.9%), sepsis (9.6%), cirrhosis (8.9%), myelodysplastic syndrome (MDS) (7.9%), hyperthyroidism (5.5%), and sickle cell disease (3.3%). There was no significant difference in mortality rates [4.3% vs. 5.2%; odds ratio (OR) 0.9, 95% confidence interval (CI) 0.7-1.2] between HOHF and HFrEF. However, the 30-day readmission rate for HOHF was significantly lower than that for HFrEF (5.7% vs. 21.2%; OR 0.39, 95% CI 0.30-0.51). Cardiovascular (39.9%) followed by hematological (20.6%) complications accounted for the majority of 30-day readmissions in the HOHF group. CONCLUSIONS: HOHF is an infrequently reported cardiovascular complication associated with noncardiovascular disorders and is encountered in 0.07% of all encounters with HF. Although comparable in-hospital mortality between studied cohorts was observed, raising awareness and timely recognition of this entity are warranted.

Clinical outcomes and 30-day readmissions for heart failure with reduced ejection fraction with cardiorenal syndrome: A National Cohort Study.

BACKGROUND: Literature regarding outcomes of cardiorenal syndrome (CRS) among heart failure with reduced ejection fraction (HFrEF) is limited. OBJECTIVE: To study the clinical outcomes and 30-day readmission rates of CRS patients with HFrEF. METHODS: Data from the Nationwide Readmissions Database (NRD) that constitutes 49.1% of the stratified sample of all hospitals in the United States (US), representing >95% of the national population, was analyzed for the CRS with HFrEF visits from 2018 to 2019. CRS was defined by the ICD-10 codes. RESULTS: Out of the 1,530,749 index CRS-related hospitalizations (mean age:64.37 ± 13.30 years; 38.6%females) 73,126 (6.0%) CKD I-II, 883,119 (72.6%) CKD III-IV, and 258,835 (21.3%) CKD V-and-more related encounters were recorded. Mortality was higher among CKD stage V-and-more in comparison to other subgroups(7.6%vs5.73%;p < 0.001). AKI with underlying CKD was more common among stage III-IV compared to other subgroups (55.9%vs43.7%;p < 0.001). Respiratory failure, the second major complication, was more common among stage V-and-more compared to other subgroups (32.5%vs30%;p < 0.001). The overall CRS-related 30-day readmission rate was 22.7%, with CKD V-and-more accounting for highest rates(29.89%), followed by CKD stage III-IV(20.05%) and CKD I-II(12.99%). The primary etiology for 30-day readmission was cardiovascular among all subgroups (54.2%, 54.6%, and 41.80%, which corresponds to CKD I-II, CKD III-IV and CKD V-and-more, respectively). CONCLUSION: CRS among HFrEF accounts for substantial healthcare burden with high 30-day readmission rates. Higher all-cause mortality and 30-day readmissions were associated with worse renal disease. This would suggest that more vigilance is needed by physicians for discharge planning among this patient population.

Coronary Artery Aneurysms in ST-Elevation Myocardial Infarction (From a United States Based National Cohort).

This study aimed to study group differences in patients presenting with ST-elevation myocardial infarction (STEMI) based on the presence or absence of associated coronary artery aneurysms (CAA). The cause-and-effect relationship between CAAs and STEMI is largely unknown. The Nationwide Readmission database was used to identify and study group differences of patients with STEMI and with and without CAA from 2014 to 2018. The primary outcome in the 2 groups was mortality. Secondary outcomes in the 2 groups included differences in clinical outcomes, cardiovascular interventions performed, and prevalence of coronary artery dissection. The total number of patients with STEMI included was 1,038,299. In this sample, 1,543 (0.15%) had CAA. Compared with those without CAA, patients with CAAs and STEMI were younger (62.6 vs 65.4), more likely to be male (78 vs 66%), and had a higher prevalence of a history of Kawasaki disease (2.5 vs 0.01%). A difference exists in the prevalence of coronary dissection in patients with STEMI with and without CAA (73% vs 1%). Patients with CAA were more often treated with coronary artery bypass grafting (13.1 vs 5.6%), thrombectomy (16.5 vs 6%), and bare-metal stent implantation (8 vs 4.4). Patients in the CAA STEMI group had lower all-cause mortality (6.3 vs 11.7%). In conclusion, there are important differences in patients with STEMI with and without CAA, which include, but are not limited to, factors such as patient profile, the risk for coronary dissection, treatment, outcomes, and mortality.

ST-elevation myocardial infarction among cardiac amyloidosis patients; a national readmission database study.

Literature regarding recent trends, mortality outcomes of ST-elevation myocardial infarction (STEMI) in cardiac amyloidosis (CA) patients is limited.To study coronary interventions, and trends in prevalence and mortality outcomes among CA patients with STEMI.Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA, representing more than 95% of the national population, were analyzed for hospitalizations associated with CA with STEMI. A linear p-trend was used to assess the trends.Out of the total 4252 adult patients (mean age 73.3 ± 11.7 years, 40.2% females) with diagnosis of CA, 439 (10.3%) had STEMI while 3813 (89.7%) had no STEMI. STEMI-CA patients had higher rates of multi-organ manifestations including VT/VF (12% vs 8.5%; p-value < 0.001), cardiogenic shock (12.7% vs 7.3%; p < 0.001), AKI requiring dialysis (5.3% vs 4%; p < 0.001), and ICU admissions (25.2% vs 15.3%; p < 0.001) compared to CA without STEMI. CA-STEMI had increased mortality rates (23.7% vs 16.1%, p < 0.001) compared to CA without STEMI. On multivariate logistic regression analysis, coronary interventions including PCI (OR 0.6, CI 0.4-1.1; p = 0.3) and CABG (OR 0.7, CI 0.3-1.8; p = 0.2) had no association with mortality among CA patients. The absolute yearly trends for prevalence and mortality associated with STEMI in CA patients remained steady over the study years (linear p-trends 0.2 and 0.6, respectively).CA-STEMI is associated with significant complications and mortality. Coronary interventions may not have significant mortality benefits. Thus, more research will be needed to improve mortality rates among these patients.

Trends in Incidence, and Mortality of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the United States Emergency Department (2010-2018).

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%; p < 0.001), VT/VF (0.14% vs 0.06%; p < 0.001), STEMI (0.22% vs 0.11%; p < 0.001) and NSTEMI (0.65% vs 0.2%; p < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%; p < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (p-trend 0.004 and 0.0003) and the trend of mortality had improved (p-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (p-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.

Large mural thrombus in the distal arch of the aorta without atherosclerotic disease.

Aortic mural thrombus (AMT) is an uncommon cause of arterial thromboembolism. It is very rare in patients without significant cardiovascular risk factors. Many aetiologies can cause AMT, but there are no clear guidelines for the evaluation and treatment. We present the case of a 43-year-old woman without arteriosclerotic disease who was admitted to the hospital with peripheral embolisation from the mural thrombus in the distal arch of the aorta. Therapy with systemic anticoagulation resulted in complete resolution without necessitating any surgical or endovascular interventions. There were no reported recurrence or complications of the intra-aortic thrombus within 1-year surveillance imaging study.

Takotsubo cardiomyopathy caused by infusion reaction to paclitaxel.

Takotsubo cardiomyopathy (TCM) secondary to an infusion reaction is extremely rare in the literature. Here, we present an unusual case of TCM in a patient with cervical squamous cell carcinoma who presented with acute hypoxic respiratory failure following the initiation of the first-cycle paclitaxel infusion therapy.

Spontaneous retroperitoneal haemorrhage secondary to anticoagulation polypharmacy.

Retroperitoneal haemorrhage (RH) is not uncommon in patients with provoking events like trauma. However, spontaneous RH (SRH) is a rare and life-threatening complication described as the development of bleeding into the retroperitoneal cavity, appearing spontaneously and without a preceding history of trauma or other predisposing illness. We are reporting a case of an elderly patient with recurrent deep vein thrombosis who had developed SRH secondary to concurrent use of multiple anticoagulation agents, resulting from poor healthcare follow-up and lack of sufficient medication reconciliation. This article highlights the significance of recognising risk factors for SRH, as well as management strategies through literature review.

Definity, echo contrast, induced cardiac arrest: brief review of the literature.

Definity is a contrast media used to enhance the endocardium during echocardiography. Cardiac arrest as an adverse reaction to Definity is still a debate. We are presenting a rare case of a 69-year-old male patient who developed cardiopulmonary arrest immediately after Definity injection during resting echocardiography.

Challenges of left atrial appendage closure device and anticoagulation in a patient with immune thrombocytopenia (ITP).

Among patients with atrial fibrillation (AF) who have high risk of bleeding secondary to haematologic disorders, left atrial appendage (LAA) occlusion therapy has been shown to be an excellent alternative to long-term use of oral anticoagulation for thromboembolic stroke prevention. However, there remains a major concern of device-associated thrombosis post-procedure, that can lead to life-threatening embolic events. To this date, there is no systematic guideline for the selection and management of patients with haematological disorders with LAA occlusion therapy, especially in those with platelet disorders such as immune thrombocytopenia (ITP). Patients with platelet disorders are at a higher risk for bleeding; however, that does not prevent such patients from thromboembolic events secondary to AF. We present a case of ITP with permanent AF, where an LAA device was complicated by thrombus formation due to challenges faced with anticoagulation therapy.

Dexmedetomidine Induced Polyuria in the Intensive Care Unit.

Dexmedetomidine is an α2-adrenergic used as an adjunct therapy for sedation in the intensive care unit. While it is known to cause polyuria exclusively in perioperative conditions, not many cases are known in the intensive care unit, thus making the diagnosis challenging. We present the case of a 61-year-old male who had developed polyuria secondary to central diabetes insipidus after receiving dexmedetomidine intravenous infusion in the medical ICU. Increased awareness of this uncommon side effect of dexmedetomidine will help clinicians recognize and address it early.

Synchrotron microangiography reveals configurational changes and to-and-fro flow in intramyocardial vessels.

In 8 dogs, in situ microangiography using synchrotron radiation visualized penetrating transmural arteries (PTAs) with a diameter of >60 micrometers and allowed quantitation of vessel diameters of >140 micrometers. Myocardial contraction reduced the vascular short-axial diameters to 87 +/- 17% (n = 62, P < 0.001, paired t-test) of the end-diastolic values and increased the longitudinal dimension to 129 +/- 5% (n = 45, P < 0.001). The diameter reduction in the subendocardial PTA segments was significantly more marked than that in the subepicardial PTA segments (60 +/- 12 vs. 88 +/- 12%, n=13, P < 0.001, paired t-test). Intracoronary administration of dobutamine (0.1 micrograms. kg-1. min-1) increased, and in contrast, partial clamping of the coronary artery (ischemia) decreased, the configurational changes. To-and-fro blood flow was clearly observed in PTAs with visual identification of capacitive backflow, resistive forward flow during ischemia on coronary arteriography, and even under baseline conditions in coronary venography. Thus this method advances our understanding of mechanical influences on the coronary circulation.

High-spatial-resolution and real-time medical imaging using a high-sensitivity HARPICON camera.

A HARPICON(TM) camera has been applied to a digital angiography system with fluorescent-screen optical-lens coupling. It uses avalanche multiplication in the photoconductive layer for high-sensitivity imaging. The limiting spatial resolutions in the 1050 scanning-line mode of the camera are about 30 and 50 micro m at input field sizes of 20 x 20 and 50 x 50 mm on the screen, respectively. For high-speed imaging, the 525 scanning-line mode at a rate of 60 images s(-1) can be selected. High-quality images of coronary arteries in dogs were obtained by intra-aortic coronary angiography and superselective coronary angiography using a single-energy X-ray above the iodine K-edge energy.

Small-vessel radiography in situ with monochromatic synchrotron radiation.

PURPOSE: To evaluate the usefulness of a radiographic system with monochromatic synchrotron radiation to depict small vessels and peripheral secretory ducts. MATERIALS AND METHODS: Radiography of various organs was tested in 14 anesthetized dogs and pancreatography was performed in an excised human pancreas by using the following system: monochromatic synchrotron radiation with an energy level just above the k absorption edge of iodine as an x-ray source and a high-definition TV system with a high-light-sensitivity image pick-up tube camera coupled with a fluorescent screen as a detector. RESULTS: This system allowed depiction of small vessels (diameter < 50-100 microns) of the heart (penetrating transmural artery), brain (perforating arteries that arise directly in the circle of Willis), and intestinal organs (vasa recta and their submucosal communications) and of small branches (down to the fifth order) of the pancreatic duct. CONCLUSION: The synchrotron radiation system may be useful for evaluating microcirculatory disorders and early-stage malignant tumors in various human organs.

Local continuity of myocardial blood flow studied by monochromatic synchrotron radiation-excited x-ray fluorescence spectrometry.

We have developed a monochromatic synchrotron radiation-excited system for two-dimensional mapping of x-ray fluorescence evoked from heavy element-loaded microspheres, which can evaluate myocardial blood flow in small contiguous regions with a small methodological error: 10.8 +/- 2.4% of the average of difference of the dual flow for 7- to 10-mg myocardial tissue (4 dogs). The fractal D value obtained from the slope of the log relative dispersion-log mass plot was 1.21 +/- 0.08 for a voxel size of 7 to 1260 mg (5 dogs) and that for a voxel size of 2.5 to 40 mg (1.12 +/- 0.06) was smaller than that for a voxel size of 40 to 1280 mg (1.25 +/- 0.14, P < .05, ANOVA, 4 dogs). The distance-correlation coefficient relation for paired myocardial regions was attenuated (correlation analysis), and the correlation coefficients between the original grouping and the two aggregates of the adjacent regions were dissociated (extended correlation analysis) under reduction of coronary perfusion pressure (6 dogs). Suppression of myocardial contraction with lidocaine (3 dogs) and vasodilation with adenosine partly improved the distance-correlation coefficient relation under reduced coronary perfusion pressure. Thus, an x-ray fluorescence system designed for precise flow measurement shows that the fractal nature of local flow distribution can be extended into regions smaller than previously reported, that in these regions the flow becomes more homogeneous, and that the self similarity and continuity of local flow are attenuated by the reduction of coronary perfusion pressure and improved by contractile suppression and coronary vasodilation.