Impact of COVID-19 Infection on Clinical Outcomes Among Patients With Acute Decompensated Heart Failure: A Nationwide Analysis.

Heart Failure (HF) is a common comorbidity in the United state. COVID-19 infection has shown worse clinical outcomes among heart failure patients; however, there is limited evidence on the impact of COVID-19 infection on the subset of HF. Hence, we aimed to investigate the clinical outcomes in patients hospitalized with COVID-19 infection without HF vs concomitant COVID-19 infection with Acute Decompensated Heart Failure with Preserved Ejection Fraction (AD-HFpEF) vs concomitant COVID-19 Infection with Acute Decompensated Heart Failure with Reduced Ejection Fraction (AD-HFrEF) using a large dataset illustrating a real word analysis. A retrospective study design of hospitalizations using the National Inpatient Sample (NIS) database registry 2020 with a principal diagnosis of adult patients (≥18 years) hospitalized with COVID-19 infection as principal diagnosis using ICD-10 codes stratified to COVID-19 infection without HF vs COVID-19 infection with AD-HFpEF vs COVID-19 infection with AD-HFrEF. The primary outcome was in-hospital mortality. Multivariate logistic, linear, poisson, and Cox regression models were used for analysis. A P-value < 0.05 was considered statistically significant. A total of 1,050,045 COVID-19 infection cases were included in this study, out of which 1,007,860 (98.98%) had only COVID-19 infection without HF, while 20,550 (1.96%) had COVID-19 infection with Acute Decompensated HFpEF, and 21,675 (2.06%) had COVID-19 infection with Acute Decompensated HFrEF. Our study shows that patients with COVID-19 infection and AD-HFrEF had the highest in-hospital mortality rate (25.4%). Using COVID-19 infection without HF with a mortality of 10.6% as a reference, COVID-19 infection with AD-HFpEF with a 22.5% mortality rate (95% CI 2.3-2.6, aOR; 2.4) and COVID-19 infection with AD-HFrEF with 25.4% mortality rate (95% CI 2.7-3.1, aOR; 2.9). Acute Decompensated HF with concurrent COVID-19 infection is associated with higher in-hospital mortality, with higher in-hospital mortality outcome observed among COVID 19 infection with concurrent AD-HFrEF.

A Review of Heart Failure in Patients with COVID-19.

The interplay of COVID-19 and heart failure is complex and involves direct and indirect effects. Patients with existing heart failure develop more severe COVID-19 symptoms and have worse clinical outcomes. Pandemic-related policies and protocols have negatively affected care for cardiovascular conditions and established hospital protocols, which is particularly important for patients with heart failure.

Not all that Wheezes is Asthma.

We want to highlight the presentation of a 75-year-old female who was initially managed as asthma and subsequently diagnosed with concurrent excessive dynamic airway collapse (EDAC).

The Novel Data Collection and Analytics Tools for Remote Patient Monitoring in Heart Failure (Nov-RPM-HF) Trial: Protocol for a Single-Center Prospective Trial.

BACKGROUND: Heart failure remains a leading cause of mortality and a major driver of health care utilization. Despite numerous medical advances in heart failure, associated hospitalizations continue to increase, owing largely to suboptimal outpatient management. Remote patient monitoring (RPM) aims to further address this current need in heart failure care by providing data to clinical teams to act pre-emptively to address clinical decompensation. However, to date, RPM approaches using noninvasive home-based patient sensors have failed to demonstrate clinical efficacy. OBJECTIVE: The Novel Data Collection and Analytics Tools for Remote Patient Monitoring in Heart Failure (Nov-RPM-HF) Trial aims to address current noninvasive RPM limitations. Nov-RPM-HF will evaluate a clinician co-designed RPM platform using emerging data collection and presentation tools for heart failure management. These tools include a ballistocardiograph to monitor nocturnal patient biometrics, clinical alerts for abnormal biometrics, and longitudinal data presentation for clinician review. METHODS: Nov-RPM-HF is a 100-patient single-center prospective trial, evaluating patients over 6 months. The outcomes will include patient adherence to data collection, patient/clinician-perceived utility of the RPM platform, medication changes including the titration of guideline-directed medical therapy to target doses, heart failure symptoms/performance status, and unplanned heart failure hospitalizations or emergency department visits. RESULTS: This prospective trial began enrollment in March 2020 and anticipates enrollment completion by June 2022, with trial completion by December 2022. CONCLUSIONS: This trial protocol aims to provide a systematic framework for the evaluation of heart failure RPM strategies, which are currently heavily used but seldom robustly studied. The trial results will help to inform the role of noninvasive RPM as a viable clinical management strategy in heart failure care. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32873.

Oesophageal intramural pseudodiverticulosis presenting as non-resolving pneumonia: A sinister cause diagnosed by EUS-B-FNA.

We report a case of an oesophageal intramural pseudodiverticulosis leading to a mediastinal collection caused by Candida glabrata presenting as a non-resolving pneumonia and mimicking an oesophageal mass. The patient was a 60-year-old diabetic male who was referred from another hospital and presented with a history of low-grade fever and breathlessness. His computed tomography (CT) of the chest disclosed a mediastinal mass alongside the oesophagus with pleural collection. Endobronchial ultrasound scope was inserted through the oesophagus (EUS-B) and fine-needle aspirate was taken from the mass. The cultures of specimen from the mediastinum grew drug-resistant C. glabrata. The patient was managed with oral voriconazole along with oesophageal stenting after which he showed remarkable recovery. Repeat CT revealed a near-complete reduction of the mediastinal infection. The case highlights the need of a high degree of suspicion, right approach to diagnostic work-up and appropriate histopathological and microbiological examination of clinical specimens.

Alveolar Air Leak Syndrome a Potential Complication of COVID- 19-ARDS - Single Center Retrospective Analysis.

BACKGROUND: Alveolar air leak comprising of pneumothorax, pneumomediastinum, and subcutaneous emphysema in the ongoing COVID 19 pneumonia have been increasingly reported in literature. These air leaks were also recognized in the severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and H1N1 viral pandemics. Here we review the incidence and outcomes of alveolar air leaks over 400 patients admitted to our tertiary care institution for moderate-severe COVID-19 pneumonia. METHODS: We performed a retrospective audit of moderate to severe COVID-19 cases admitted to our hospital. Patients who were recognized as either a spontaneous pneumothorax, pneumomediastinum, pneumopericardium and subcutaneous emphysema were identified. Their clinical features and characteristics were thoroughly documented and clinical outcomes were gathered. Each case has been presented as a brief synopsis. RESULTS: During the audit period, we reviewed over 670 patients, out of these 419 patients required intensive care for moderate to severe disease. 10 patients developed Pneumothorax, pneumomediastinum, pneumopericardium and/ or subcutaneous emphysema - referred to as Alveolar Air leak syndrome; The incidence of alveolar air leak was found to be 2.39%. 6 patients did not survive the resultant complication. CONCLUSION: Spontaneous alveolar air leaks are a rare but definite complication of COVID-19 viral pneumonia and may occur in the absence of mechanical ventilation. ICU Clinicians must be alert about the diagnosis and treatment of this complication.

Concurrent massive hemoptysis and acute pulmonary embolism: A therapeutic dilemma.

Pulmonary Embolism and Massive hemoptysis are two very potentially fatal emergencies in Respiratory medicine practice. These two conditions are kind of antagonizing conditions requiring completely different and pharmacologically opposite nature of treatment. We hereby present the case of a 37-year old young male presented to our Hospital with massive hemoptysis, who on evaluation also had a concurrent large pulmonary embolism. The bleed was managed with bronchial artery embolization followed by anticoagulation therapy from a day later for embolism. This case report gives an insight on to how to manage a practical therapeutic challenge which is the concurrence of a massive hemoptysis and life threatening pulmonary embolism.

Remote Patient Monitoring in Heart Failure: Factors for Clinical Efficacy.

Despite clinical advances in its treatment, heart failure (HF) is associated with significant adverse clinical outcomes and is among the greatest drivers of healthcare utilization. Outpatient management of HF remains suboptimal, with gaps in the provision of evidence-based therapies, and difficulties in predicting and managing clinical decompensation. Remote patient monitoring (RPM) has the potential to address these issues, and thus has been of increasing interest to HF clinicians and health systems. Economic incentives, including increasing RPM reimbursement and HF readmission penalties, are also spurring increased interest in RPM. This review establishes a framework for evaluating RPM based on its various components: 1) patient data collection, 2) data transmission, analysis, and presentation, and 3) care team review and clinical action. The existing evidence regarding RPM in HF management is also reviewed. Based on the data, we identify RPM features associated with clinical efficacy and describe emerging digital tools that have the promise of addressing current needs.

Regulation of aged skeletal muscle regeneration by circulating extracellular vesicles.

Heterochronic blood exchange (HBE) has demonstrated that circulating factors restore youthful features to aged tissues. However, the systemic mediators of those rejuvenating effects remain poorly defined. We show here that the beneficial effect of young blood on aged muscle regeneration was diminished when serum was depleted of extracellular vesicles (EVs). Whereas EVs from young animals rejuvenate aged cell bioenergetics and skeletal muscle regeneration, aging shifts EV subpopulation heterogeneity and compromises downstream benefits on recipient cells. Machine learning classifiers revealed that aging shifts the nucleic acid, but not protein, fingerprint of circulating EVs. Alterations in sub-population heterogeneity were accompanied by declines in transcript levels of the pro-longevity protein, α-Klotho, and injection of EVs improved muscle regeneration in a Klotho mRNA-dependent manner. These studies demonstrate that EVs play a key role in the rejuvenating effects of HBE and that Klotho transcripts within EVs phenocopy the effects of young serum on aged skeletal muscle.

Right Heart Failure While on Left Ventricular Assist Device Support Is Associated with Primary Graft Dysfunction.

Primary graft dysfunction (PGD) is a potentially devastating complication of heart transplantation. Understanding the risk factors for PGD in the modern era of heart transplantation is of vital importance. This study investigated the relationship between post-left ventricular assist device (LVAD) right heart failure (RHF) and transplant outcomes. Patients with durable, continuous-flow LVADs who were transplanted between 2010 and 2016 at Barnes-Jewish Hospital were included in the study. Data collection was performed through retrospective chart review. The primary outcome was the incidence of PGD stratified by pretransplant incidence of RHF while on LVAD support. Among the 141 patients included in the study, 41 developed RHF. In the RHF cohort, 18 patients developed PGD as compared to 14 patients in the group without RHF (44% vs. 14%; p < 0.001). Mortality was significantly higher in the RHF group at 30 days (20% vs. 1%; p < 0.001) and 1 year (22% vs. 6%; p = 0.013). In a multivariable logistic regression model adjusted for confounding variables, RHF was associated with a nearly fourfold increased risk of PGD (odds ratio, 3.91; p = 0.003). The results of this study show that patients supported with LVADs who develop early severe RHF or late RHF are at increased risk of PGD and death following cardiac transplantation.

Necrotizing lymphadenitis: Not always tuberculosis, its Kikuchi-Fujimoto's disease.

Kikuchi-Fujimoto's disease is an uncommon self limiting, benign cause of generalised lymphadenopathy with fever. It can present as a triad of fever, night sweats and lymphadenopathy which resembles more common causes like tuberculosis and lymphoma. Being an endemic country a patient may be treated on the lines of tuberculosis often. We present case of a young female who was diagnosed as Kikuchi-Fujimoto's disease after not responding to antitubercular treatment. Pathologists and Clinicians must be aware of this condition to prevent unnecessary treatment.

Home Inotropes in Patients Supported with Left Ventricular Assist Devices.

There is little data outlining the use of outpatient inotropic medications in patients with existing left ventricular assist devices (LVADs). This case series explores this patient population and seeks to define the indications, complications, and safety of dual support. A retrospective chart review was conducted for all patients on LVAD and then subsequently started on home inotropes post device implant. Eight patients met inclusion criteria. The indications for inotropes were right ventricular failure, aortic insufficiency with biventricular failure, LVAD thrombosis with contraindication to device exchange, and cannula malposition with elevated pulmonary vascular resistance. Mean duration of combined support was 273 ± 170 days. Cardiac index improved from 1.96 ± 0.24 to 2.31 ± 0.35 L/min/m(2) after inotropes (p = 0.02). There was no change in hospital admissions. The most common reason for readmission was heart failure symptoms, followed by bleeding. Five patients died during the study period, one underwent heart transplant, and two remain on inotropic support. Home inotropes may be indicated in selected continuous flow left ventricular assist device (CF-LVAD) patients with refractory right ventricular failure or impaired LVAD function. Inotropes can improve hemodynamics and provide palliation of symptoms. However, long-term inotrope use does not reduce hospital readmissions and is associated with multiple complications related to the need for an indwelling intravenous line.

Left Atrial Appendage Occlusion With Left Ventricular Assist Device Decreases Thromboembolic Events.

BACKGROUND: Thromboembolic events (TEs) are common adverse events with continuous-flow left ventricular assist devices (LVADs). Left atrial appendage occlusion (LAAO) is commonly performed at the time of a cardiac operation. The effect of LAAO on TEs in LVAD patients remains unknown. METHODS: All patients receiving a first LVAD implantation between January 2013 and January 2014 were reviewed. TEs included device thrombosis and ischemic cerebrovascular accidents. The incidence of TEs with respect to LAAO was evaluated using Kaplan-Meier and Cox proportional hazards analyses. RESULTS: The analysis included 102 patients, 36 of whom received LAAO and 66 did not. LAAO patients were an average age of 60 years, and 69.4% were men. Non-LAAO patients were an average age of 59.3 years, and 71.2% were men. There were no significant differences in characteristics other than history of coronary artery bypass grafting (8.3% of LAAO vs 44% of non-LAAO, p = 0.0005). Preoperative atrial fibrillation was present in 19 LAAO patients (52.7%) and in 36 non-LAAO patients (54.5%; p = 1.0). Patients were monitored for a median of 306 days. TEs occurred in 3 LAAO patients (1 device thrombosis and 2 cerebrovascular accidents) compared with 15 non-LAAO patients (5 device thromboses and 11 cerebrovascular accidents, p = 0.049). In a Cox hazards analysis including age, sex, hypertension, and atrial fibrillation, LAAO demonstrated a decreased risk of TE (hazard ratio, 0.27; 95% confidence interval, 0.08 to 0.95; p = 0.04). CONCLUSIONS: In patients undergoing LVAD implantation, LAAO is associated with reduced TEs, and this effect may be independent of atrial fibrillation. A prospective randomized study to examine the efficacy LAAO in prevention of TE is needed to confirm these findings.

Incidence and Outcomes of Postoperative Atrial Fibrillation After Left Ventricular Assist Device.

This study sought to determine the incidence, predictors, and outcomes of postoperative atrial fibrillation (POAF) in patients undergoing implantation of left ventricular assist devices (LVADs). A retrospective analysis of all patients who underwent LVAD implantation from 2013 to 2014 was conducted. Postoperative AF, survival, and thrombotic complications were evaluated after surgery. A total of 47 patients (mean age, 56.4 ± 12.5 years; 33 male) were included and followed for a median of 331 days. Within 30 days of surgery, 13 (28%) patients developed POAF at mean 7.9 ± 8.5 days. Obstructive lung disease was a predictor of POAF (p = 0.01). Postoperative AF was not associated with increased mortality, length of stay, or thrombotic complication within 30 days. Postoperative AF was predictive of recurrent new AF (24 vs. 5.5%) after 30 days of LVAD implantation. Also, POAF was associated with increased risk of ischemic stroke and device thrombosis during follow-up (p = 0.01). These results show that unlike in other cardiac surgery, POAF does not have a negative impact on early postoperative morbidity or mortality. However, POAF is a predictor for future AF, ischemic stroke, and device thrombosis.

Increased Risk of Bleeding in Left Ventricular Assist Device Patients Treated with Enoxaparin as Bridge to Therapeutic International Normalized Ratio.

Anticoagulation therapy is used to prevent thromboembolic events in patients with left ventricular assist devices (LVADs). This study aims to determine the safety of low molecular weight heparin (enoxaparin) for bridging subtherapeutic international normalized ratio (INR) in LVAD patients. In this retrospective single-center study, all patients who underwent LVAD implantation were examined between January 1, 2013, and December 31, 2014. Patients were divided into two groups: enoxaparin bridge and no bridge, with identification of major bleeding episodes (MBEs) and thrombotic events (TEs). Major bleeding episode and TE incidence was compared between the two groups, with subanalysis of incidence in the enoxaparin group between the periods on and off treatment. One hundred eighteen patients were included in this analysis. Fifty-five patients received enoxaparin, whereas 63 patients did not receive enoxaparin, with no significant difference between groups in all baseline characteristics. For the study period, enoxaparin patients had no increased incidence of MBEs (0.53 vs. 0.35 MBE per year; p = 0.12). However, there was a fourfold increase in MBEs during the bridged period in the enoxaparin group (2.02 vs. 0.45 MBE per year; p = 0.03). Major bleeding episodes on versus off enoxaparin had no major difference in transfusion requirements (2.7 ± 2.9 vs. 2.5 ± 3.4 units; p = 0.57) or mortality (p = 0.11). The enoxaparin group trended to a higher incidence of TEs (0.20 vs. 0.11 events per year; p = 0.08). Enoxaparin bridging in patients with subtherapeutic INR is associated with a significantly increased risk of MBEs. Prospective studies are needed to confirm these findings; however, until then, caution should be used with enoxaparin for bridging in LVAD patients.