Protocolized screening effectively identifies myocardial recovery following destination therapy left ventricular assist device implantation.

BACKGROUND: Myocardial recovery following left ventricular assist device (LVAD) implantation has been of interest in transplant candidates with non-ischemic cardiomyopathy but is rare. Evidence suggests that a combination of left ventricular unloading and pharmacologic reverse remodeling is beneficial. Recovery in non-transplant candidates (i.e., destination therapy [DT]) patients is believed to be even rarer. METHODS: All DT LVADs between January 1, 2017 and November 23, 2020 were reviewed. All patients were subjected to an institutional protocol consisting of combined pharmacologic remodeling and mechanical unloading with proactive screening for recovery. The primary outcome of interest was the cumulative incidence of myocardial recovery. Baseline characteristics and operative outcomes were compared between recovered and non-recovered DT patients using non-parametric tests to identify predictive factors. RESULTS: A total of 49 patients received DT LVADs. Nine patients were identified as myocardial recovery candidates using the protocol screening criteria. Overall, 11 patients underwent formal confirmatory testing for recovery, of which 10 were deemed recovered and underwent LVAD explant, defunctionalization, or transplantation. 37.5% of patients that had a concomitant coronary artery bypass during LVAD implantation achieved recovery. An equal proportion of ischemic and non-ischemic cardiomyopathy patients achieved recovery. The cumulative incidence of myocardial recovery was 25.1% at 36 months. No factors were identified as being predictive of recovery. CONCLUSION: Myocardial recovery in DT LVAD patients can be achieved at a higher rate than previously reported. Revascularization at the time of LVAD is safe and may be beneficial. LVAD therapy may not be the final destination in these patients.

A 59-Year-Old Woman With Shortness of Breath and Chest Pain.

CASE PRESENTATION: A 59-year-old woman presented to the ED with syncope. She had progressive shortness of breath with minimal activity and precordial resting chest pain for 1 month prior to presentation. She had a medical history of heart failure with preserved ejection fraction, severe OSA well controlled with CPAP of 11 cm H2O, and a history of DVT and pulmonary embolism, diagnosed 10 years ago for which she was maintained on warfarin. The patient also had chronic myeloid leukemia in the chronic phase; she had initially been treated with imatinib but was later switched to dasatinib about 4.5 years prior to presentation. The patient had achieved major molecular remission with dasatinib 140 mg daily. Her family history was noncontributory and specifically negative for pulmonary hypertension and heart failure. She had a history of smoking (50 pack years) but had quit 23 years ago.

Acute Ostial Right Coronary Artery Occlusion During Valve Deployment of Transcatheter Aortic Valve Replacement Leading to Acute Right Ventricular Failure: A Perfect Storm and Successful Navigation.

Acute coronary obstruction is a relatively rare complication of transcatheter aortic valve replacement (TAVR). Left coronary ostial obstruction is much more common compared to right coronary occlusion due to its relatively lower ostial height from the aortic annulus. We present a case of acute ostial right coronary occlusion immediately upon deployment of a 29-mm Sapien 3 transcatheter aortic valve. The acute right coronary ostial occlusion manifested with ventricular fibrillation, acute right ventricular failure, and right-sided cardiogenic shock. The patient, after undergoing an initial unsuccessful attempt at percutaneous revascularization, was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). This was later transitioned to percutaneous right atrial to pulmonary artery right ventricular support, which led to subsequent recovery.

Early administration of the first antimicrobials should be considered a marker of optimal care of patients with community-acquired pneumonia rather than a predictor of outcomes.

BACKGROUND: The effect of time of the first antimicrobial dose (TFAD) on the outcomes of community-acquired pneumonia (CAP) remains a controversy. METHODS: This was an observational, retrospective study of consecutive adult patients hospitalized with CAP. TFAD was defined as the time in hours from arrival at the emergency department to the intravenous infusion of antimicrobial. All patients received appropriate antibiotic therapy according to available Infectious Diseases Society of America/American Thoracic Society guidelines during the time of our study. Multivariable analysis and a propensity score adjusted methodology were used to measure the association of TFAD with mortality, time to clinical stability (TCS), and length of stay in the hospital (LOS). RESULTS: Data of 372 patients with CAP were studied. A total 29 (8.4%) patients died within 30 days of hospitalization. Our propensity-adjusted logistic regression model did not show a significant association between TFAD and mortality (p=0.148). Patients who died received antimicrobials significantly earlier than survivors: 5.7h vs. 7.5h, respectively (p=0.04). The LOS and TCS were not significantly affected by the TFAD; the LOS hazard ratio was 0.996 (95% confidence interval 0.97-1.02; p=0.774) and the TCS hazard ratio was 1.01 (95% confidence interval 0.98-1.03; p=0.604). CONCLUSIONS: TFAD does not seem to be associated with the clinical outcome of patients with CAP. Early TFAD should be considered as an important marker of optimal care of patients with CAP rather than as a factor predicting outcomes.

Understanding the roles of cytokines and neutrophil activity and neutrophil apoptosis in the protective versus deleterious inflammatory response in pneumonia.

Inflammation is a double-edged sword in the outcome of pneumonia. On the one hand, an effective and timely inflammatory response is required to eliminate the invading respiratory pathogen. On the other, a toxic and prolonged inflammatory response may result in lung injury and poor outcomes, even in those receiving advanced medical care. This review focuses on recent understanding of the dynamics of the cytokine response, neutrophil activity, and responsiveness to cytokines and neutrophil lifespan as major elements of lung inflammation resulting in favorable or poor outcomes in lung infection primarily due to pneumococcus and influenza virus. Although some progress has been made in our understanding of the molecular mechanisms of the pneumonia inflammation axis composed of cytokines modulating neutrophil activation and neutrophil apoptosis, important questions remain to be answered. The degree of neutrophil activation, generation of reactive oxygen species, and the release of granule antimicrobial peptides play a key role in microbial pathogen clearance; however, prolonged neutrophil activation may contribute to lung injury and poor outcomes in pneumonia. Molecular markers of the mechanisms regulating neutrophil survival and apoptosis may help in the identification of novel therapeutic targets to modulate inflammation by inducing timely neutrophil apoptosis. A major task is to identify the mechanisms of dysregulation in inflammation leading to toxic responses, thereby targeting a biomarker and enabling timely therapies to modulate inflammation.

Klebsiella pneumoniae antimicrobial drug resistance, United States, 1998-2010.

We studied antimicrobial-resistant Klebsiella pneumoniae for 1998-2010 by using data from The Surveillance Network. Susceptibility results (n = 3,132,354) demonstrated significant increases in resistance to all antimicrobial drugs studied, except tetracycline. Cross-resistance among carbapenem-resistant K. pneumoniae was lower for tetracycline and amikacin.

CD4+ cell counts and HIV-RNA levels do not predict outcomes of community-acquired pneumonia in hospitalized HIV-infected patients.

BACKGROUND: Outcomes of community-acquired pneumonia (CAP) in relation to CD4+ cell counts have not been established. We examined the correlation of CD4+ cell count and HIV-RNA level with the clinical outcomes of CAP in hospitalized HIV-infected patients. METHODS: This was a retrospective study of 127 adult hospitalized patients with HIV infection enrolled with the CAP Organization (CAPO), examining the time to clinical stability (TCS), length of hospital stay (LOS), and all-cause mortality. RESULTS: Mortality data were available for 117 HIV-infected patients with CAP. Death within 28 days was reported in 28 patients. The risk of mortality at 28 days was not significant when adjusted for CD4+ cell count (p=0.123), HIV-RNA <400-1000 copies/ml (p=0.093), HIV-RNA ≥ 1000-10,000 copies/ml (p=0.543), and HIV-RNA ≥ 10,000-100,000 copies/ml (p=0.383). The propensity-adjusted Cox proportional hazards regression models did not show any statistically significant differences in LOS or TCS for CD4+ cell counts (p=0.590 and p=0.420, respectively) or HIV-RNA levels (p=0.470 and p=0.080, respectively). Multivariable Cox proportional hazards models did not reveal any statistically significant relationships between CD4+ cell counts or HIV-RNA levels with LOS or TCS. CONCLUSIONS: Our study shows that clinical outcomes of HIV-infected patients with CAP are not predicted by CD4+ cell counts or HIV-RNA levels after adjusting for confounders. The management of CAP in patients with HIV infection should not be based on CD4+ cell counts or HIV-RNA levels of the HIV infection.

Methicillin-resistant Staphylococcus aureus resistance to non-beta-lactam antimicrobials in the United States from 1996 to 2008.

We report the resistance rates of Staphylococcus aureus to non-beta-lactam antimicrobials from The Surveillance Network Database-USA (Eurofins-Medinet, Chantilly, VA). Specimens studied were from lower respiratory tract, wounds, and blood. Patients were stratified by age group and patient setting. There were 2,053,219 isolates of S. aureus and 973,116 of methicillin-resistant S. aureus (MRSA). The MRSA rate increased until 2004 and then leveled off. MRSA showed decreasing resistance to tetracycline and trimethoprim-sulfamethoxazole (TMP-SMX). By age group, the greatest MRSA rate increase was for individuals 17 years and younger. Non-beta-lactam antimicrobials and particularly TMP-SMX should be considered therapeutic options for staphylococcal infections.