Concomitant Redo Transcatheter Aortic Valve Replacement and Valve-in-Mitral Annular Calcification.

Contemporary challenges in structural heart intervention include redo transcatheter aortic valve replacement and transcatheter mitral valve replacement in severe mitral annular calcification. We report a case of concomitant redo transcatheter aortic valve replacement and transcatheter mitral valve replacement in mitral annular calcification in a patient with radiation heart disease. (Level of Difficulty: Advanced.).

Impact of hypothermia on cardiac performance during targeted temperature management after cardiac arrest.

INTRODUCTION: Targeted temperature management (TTM) is a well-accepted neuro-protective intervention in the management of comatose survivors of cardiac arrest (CA). However, the impact of TTM on cardiac performance has not been adequately evaluated. METHODS: We reviewed data on consecutive CA survivors undergoing TTM at a quaternary cardiac intensive care unit between January 2015 and June 2017. Enrollment was restricted to cases with invasive hemodynamics (iHDs) at TTM initiation, every 8 h at target temperature (32-34 °C) and at completion of rewarming (>36 °C), unless precluded by mortality. Cardiac index and cardiac index-derived variables were adjusted for a decreased oxygen consumption during hypothermia. We assessed the serial impact of cooling on iHDs and cardiac performance utilizing longitudinal data analysis accounting for the effects of time as surrogate for the expected change from the post arrest syndrome and instituted treatments. A Frank-Starling construct was used to evaluate changes in cardiac contractility. RESULTS: We evaluated the effects of cooling on iHDs and cardiac performance in 46 CA survivors. Heart rate decreased with cooling (p < 0.001), to return to baseline after rewarming (p = 0.6). Mean arterial pressure and pulmonary wedge pressure decreased by cooling (p < 0.001 for both), with sustained improvement after rewarming (p < 0.001 for both). Systemic vascular resistance was unaffected by hypothermia (p > 0.05). Left stroke work index increased with cooling (p < 0.001), with return to baseline after rewarming (p = 0.6). Cooling was associated with a left-upward shift in the Frank-Starling curve indicative of increased contractility. CONCLUSION: Mild hypothermia in CA survivors appears associated to positive changes in iHDs and cardiac performance, including a potential increase in cardiac contractility. Larger studies are needed to conclusively confirm these findings.

Invasive Hemodynamics and Outcomes in Cardiac Arrest Survivors Undergoing Targeted Temperature Management.

Most important prognostic factors in the postcardiac arrest patients who underwent targeted temperature management (TTM) derive from the periarrest period. Whether early invasive hemodynamics predict survival or neurologic outcomes remains unknown. We retrospectively reviewed all comatose survivors of cardiac arrest who underwent TTM at the Coronary Intensive Care Unit of a Quaternary Center between January 2015 and June 2017. Patients were required to have a set of invasive hemodynamics available at initiation of TTM to be included. Those with cooling initiated before admission and temperature of <36°C before obtaining hemodynamics were excluded. Univariate logistic and multivariate regression were conducted to test whether cardiac index (Fick-cardiac index ≥2.2 vs <2.2 L/min/m2), pulmonary capillary wedge pressure (PCWP ≥18 vs <18 mm Hg), systemic vascular resistance (SVR >1200 vs 800 to 1200 vs <800 dynes⋅s/cm5) or Forrester hemodynamic profiles were predictive of survival and favorable neurologic outcomes at hospital discharge. Total of 52 consecutive arrest survivors who underwent TTM were studied demonstrating a wide variability in invasive hemodynamic parameters. There was no association between cardiac index (p = 0.45 and p = 0.10), PCWP (p = 0.90 and p = 0.60), SVR (0.95 and p = 0.17) or Forrester hemodynamic profiles (p = 0.40 and p = 0.42) and survival or favorable neurologic outcome at discharge. In conclusion, comatose arrest survivors who underwent TTM presents with a wide spectrum of invasive hemodynamics highlighting the heterogeneity of the postcardiac arrest syndrome. Early invasive hemodynamics did not predict survival or favorable neurologic outcomes at hospital discharge.

Delirium After Transcatheter Aortic Valve Replacement.

BACKGROUND: Postoperative delirium is associated with increased mortality. Patients undergoing transcatheter aortic valve replacement are at risk for delirium because of comorbid conditions. OBJECTIVE: To compare the incidence, odds, and mortality implications of delirium between patients undergoing transcatheter replacement and patients undergoing surgical replacement. METHODS: The Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the Intensive Care Unit were used to assess arousal level and delirium prospectively in all patients with severe aortic stenosis who had transcatheter or surgical aortic valve replacement at an academic medical center. Multivariable logistic regression was used to determine the relationship between procedure type and occurrence of delirium. Cox regression was used to assess the association between postoperative delirium and 6-month mortality. RESULTS: A total of 105 patients had transcatheter replacement and 121 had surgical replacement. Patients in the transcatheter group were older (median age, 81 vs 68 years; P < .001) and had more comorbid conditions (median Charlson Comorbidity Index, 3 vs 2; P < .001). Patients in the transcatheter group also had lower incidence (19% vs 21%; P = .65) and odds of delirium developing (odds ratio, 0.4; 95% CI, 0.2-0.9; P = .03). Delirium was independently associated with a 3-fold higher mortality by 6 months (hazard ratio, 3.4; 95% CI, 1.3-8.8; P = .01). CONCLUSIONS: Delirium occurs in at least 1 in 5 patients after transcatheter or surgical aortic valve replacement. Delirium is less likely to develop in the transcatheter group but is associated with higher mortality in both groups.

Pre-existing medical comorbidity is not associated with neurological outcomes in patients undergoing targeted temperature management following cardiac arrest.

The prognostic significance of chronic medical illness in comatose survivors of cardiac arrest who undergo targeted temperature management (TTM) remains largely unknown. We sought to assess the association between overall burden of pre-existing medical comorbidity and neurological outcomes in survivors of cardiac arrest undergoing TTM. We analyzed a prospectively collected cohort of 314 patients treated with TTM following cardiac arrest at a tertiary care hospital between 2007 and 2014. Overall burden of medical comorbidity was approximated with the use of the Charlson Comorbidity Index (CCI). Poor neurological outcome at hospital discharge, defined as a cerebral performance category (CPC) score >2, was the primary outcome. Secondary outcomes included death prior to hospital discharge and at 1 year following cardiac arrest. Multivariable logistic regression was used to assess the association between CCI scores and outcomes. A poor neurological outcome at hospital discharge was observed in 193 (61%) patients. One hundred and seventy-nine (57%) patients died prior to hospital discharge and a total of 195 (62%) patients had died at 1-year post-arrest. In multivariable logistic regression, elevated CCI scores were not associated with increased odds of poor neurological outcomes (OR 1.04, 95% CI 0.90-1.19, p = 0.608) or death (OR 0.99, 95% CI 0.86-1.13, p = 0.816) at hospital discharge. No association was seen between CCI scores and death at 1-year post-arrest (OR 1.09, 95% CI 0.95-1.26, p = 0.220). Increasing burden of medical comorbidity, as defined by CCI scores, is not associated with neurological outcomes or survival in patients treated with TTM.

Teaching an Old Dog New Tricks: Colchicine in Cardiovascular Medicine.

Colchicine is one of the oldest known drugs that remains part of the current pharmacopeia. Recent studies have examined the efficacy of colchicine in cardiology with promising results. We conducted a search of electronic databases for studies on colchicine in cardiovascular medicine published through October 2016. As the utilization of colchicine in the management of cardiac conditions grows, it is paramount that internists and cardiologists are familiarized with its benefits and risks. We present a comprehensive review of the role of colchicine in the management of cardiovascular diseases with a strong emphasis on side effects and potential drug interactions.

Temperature variability during targeted temperature management is not associated with neurological outcomes following cardiac arrest.

INTRODUCTION: Recent studies on comatose survivors of cardiac arrest undergoing targeted temperature management (TTM) have shown similar outcomes at multiple target temperatures. However, details regarding core temperature variability during TTM and its prognostic implications remain largely unknown. We sought to assess the association between core temperature variability and neurological outcomes in patients undergoing TTM following cardiac arrest. METHODS: We analyzed a prospectively collected cohort of 242 patients treated with TTM following cardiac arrest at a tertiary care hospital between 2007 and 2014. Core temperature variability was defined as the statistical variance (i.e. standard deviation squared) amongst all core temperature recordings during the maintenance phase of TTM. Poor neurological outcome at hospital discharge, defined as a Cerebral Performance Category (CPC) score>2, was the primary outcome. Death prior to hospital discharge was assessed as the secondary outcome. Multivariable logistic regression was used to examine the association between temperature variability and neurological outcome or death at hospital discharge. RESULTS: A poor neurological outcome was observed in 147 (61%) patients and 136 (56%) patients died prior to hospital discharge. In multivariable logistic regression, increased core temperature variability was not associated with increased odds of poor neurological outcomes (OR 0.38, 95% CI 0.11-1.38, p=0.142) or death (OR 0.43, 95% CI 0.12-1.53, p=0.193) at hospital discharge. CONCLUSION: In this study, individual core temperature variability during TTM was not associated with poor neurological outcomes or death at hospital discharge.

Utilization of palliative care services for cardiac arrest patients undergoing therapeutic hypothermia: A retrospective analysis.

BACKGROUND: Palliative care (PC) services are integral to the care of patients with advanced medical illnesses. Given the significant morbidity and mortality associated with cardiac arrest, we sought to measure the use and impact of PC in the care of patients treated with therapeutic hypothermia (TH). METHODS: We conducted a retrospective study of 317 consecutive patients undergoing TH after cardiac arrest. We compared intensive care unit (ICU) characteristics and clinical outcomes of subjects who received PC consultation (n=125) to those who did not (n=192). RESULTS: The proportion of TH patients with PC consultations increased to greater than 60% by 2013, corresponding to our institution's expansion of PC services, development of a dedicated PC unit, and integration of this service into our published TH protocol. In the TH population, time to return of spontaneous circulation (ROSC) was associated with higher inpatient mortality (p<0.001) and placement of a PC consult (p=0.011). TH patients who received PC consultation had longer ICU stays (p=0.034), more ventilator days (p<0.001), and higher inpatient mortality (p<0.001). When these measures were analyzed cohort-wide comparing all TH patients pre- and post-2013, at which time the frequency of PC consultation had dramatically increased, there were no statistically significant differences in ICU care or outcomes. CONCLUSION: In our population of cardiac arrest patients undergoing TH, the utilization of PC services has increased over time, particularly for those patients with high morbidity and mortality. Future randomized studies may further delineate optimal patient selection for PC consultation to better facilitate goals of care discussions and timely medical decision-making.

Unprotected Left Main Coronary Artery Disease: Management in the Post NOBLE and EXCEL Era.

The optimal management of unprotected left main coronary artery (ULMCA) disease is currently a debated topic. Percutaneous coronary intervention (PCI) has seen an increased adoption for the management of ULMCA disease after numerous small-scale randomised trials and cohort studies showed equipoise with coronary artery bypass grafting (CABG) for low complexity lesions. The recently published NOBLE and EXCEL trials are two of the largest international randomised clinical trials comparing PCI and CABG in patients with ULMCA disease. In lieu of all the available evidence, PCI appears to be equivalent to CABG in regard to mortality in patients with ULMCA disease. In non-diabetic patients with low complexity coronary disease (SYNTAX score ≤32), PCI appears to be a reasonable alternative to CABG, especially for ostial and midshaft left main coronary lesions. CABG is preferable in the presence of diabetes, multivessel coronary disease in addition to ULMCA or complex coronary lesions (SYNTAX score >33) including distal left main lesions.

Characterizing the Clamor: An In-Depth Analysis of Inpatient Paging Communication.

PURPOSE: Communication failures contribute to adverse clinical events and health care inefficiencies. Paged messaging remains a predominant communication mechanism at many academic medical centers. An interprofessional, institutionally sponsored initiative to improve inpatient care team communication sought to understand the content and quantity of paged messages. METHOD: A retrospective analysis at Vanderbilt University Medical Center was performed for messages delivered to the 15 highest-volume pagers carried by inpatient medical, surgical, and pediatric residents over two monthlong periods of data collection between November 2013 and February 2014. An interprofessional team defined message content categories a priori. Descriptive statistics were used to demonstrate message volume and distribution by content category. Team members and stakeholder groups discussed common message themes during and after categorization to identify targets for improving care efficiency. RESULTS: During the data collection period, 10,928 messages were paged (median 38 messages per pager per shift). The most common primary content categories were bedside nursing (2,570; 30%) and medication (2,285; 26%). Common bedside nursing communications included notification of vital signs (915; 36%), patient activity (481; 19%), and diet (444; 18%). Most medication messages were requests to start (1,253; 55%) or change (694; 30%) a common medication. The team recommended implementing anticipatory orders for common medications and routine nursing staff needs using computerized order algorithms to reduce the volume of noncritical messages. CONCLUSIONS: An interprofessional assessment of the content and volume of paged communication identified high volumes of noncritical messages that could be eliminated through better anticipation of patient care needs.

Thoracoplasty for Postpneumonectomy Empyema Associated with Bronchopleural Fistula: A Case Series.

Thoracoplasty is a historical procedure, initially devised for the treatment of refractory tuberculous empyema. Advances in medical treatments have nearly eliminated the need for this surgical procedure in pulmonary tuberculosis and it is rarely performed or taught in modern day surgical practice. However, few indications still exist, most prominently, in the treatment of postpneumonectomy refractory empyema often but not always associated with a bronchopleural fistula. In this case report, we present two cases of postpneumonectomy refractory empyema treated by thoracoplasty with long-term follow-up.