Three, dynamic variants of ST segment elevations in a patient with osteosarcoma and cardiac metastasis.

In the right clinical setting, ST segment elevation (STE) on electrocardiogram (ECG) is most concerning for acute injury due to transmural myocardial ischemia. This frequently points to significant epicardial coronary artery disease, mandating emergent cardiac intervention. In rare cases, cardiac metastases may cause transient STE. We present a case of a 28-year-old male patient with metastatic osteosarcoma with STE in three different ECG territories over ten months. Several transient, dynamic patterns of STE were noted: anteroseptal leads concerning for acute injury with reciprocal ST depressions in inferior leads, lateral leads, inferior leads with reciprocal ST depression in lateral leads, followed by STE again in lateral leads. Given the patient's young age, absence of cardiac history or symptoms, personal preference, bleeding risk, and cancer prognosis, cardiac catheterization was never pursued. We present this case to remind providers to include metastatic cancer in the differential diagnosis of STE on ECG, and that these changes can be dynamic.

Comprehensive Review of Cardiovascular Disease Risk in Nonalcoholic Fatty Liver Disease.

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising prevalence and deleterious effects on the cardiovascular system, a complete understanding of the disease must be undertaken, as well as effective strategies to prevent and treat its common comorbid conditions.

IVC measurement for the noninvasive evaluation of central venous pressure.

Central venous pressure (CVP) is one of only a handful of variables that can be used to assess a patient's volume status to attempt to optimize stroke volume. The gold standard method for assessing CVP is though pulmonary artery catheterization, which is invasive and risks severe complications such as pneumothorax and cardiac conduction abnormalities. Current noninvasive methods for estimating CVP such as jugular venous pressure assessment are imperfect with wide inter-examiner variability. The inferior vena cava (IVC) is a highly compliant vessel that uniquely does not constrict in response to hypovolemia, making it an ideal, noninvasive surrogate for the estimation of CVP. A range of IVC indices including minimum and maximum IVC diameter and fraction of IVC collapse with inspiration (known as collapsibility index) have been studied with highly variable results that range from excellent to poor correlation between these values and CVP. Despite this inconsistency in findings, multiple schemes have been proposed to attempt to estimate CVP from IVC measurements, but when prospectively tested, none has been shown to be accurate. Since the most recent 2015 American Society of Echocardiography guidelines, multiple studies have identified unique ways of improving the accuracy of IVC measurement, which could translate into better CVP estimation. The goal of this review is to summarize the many, often conflicting studies that exist in this area, and provide recommendations for future studies based on our findings.

Hypophosphatemia causing ST elevation in a critically ill noncardiac surgery postoperative patient.

The patient is a 73-year-old female with peripheral vascular disease, coronary artery disease, and systemic lupus erythematosus, who underwent mesenteric artery bypass surgery. She suffered from a pneumonia after surgery, causing acute hypoxic respiratory failure and septic shock. Due to shock, she developed acute renal failure. She was intubated, ventilated, and received continuous veno-venous hemodialysis for renal failure. ST elevation was first observed on telemetry and subsequently confirmed on electrocardiogram. Marked ST elevation is present in the anterior leads with reciprocal ST depression in the inferior leads. A prolonged QT interval is also present. What is the most likely diagnosis?

Coronary Revascularization Versus Optimal Medical Therapy in Renal Transplant Candidates With Coronary Artery Disease: A Systematic Review and Meta-Analysis.

Background Coronary artery disease (CAD) is highly prevalent in patients with chronic kidney disease and is a common cause of mortality in end-stage renal disease. Thus, patients with end-stage renal disease are routinely screened for CAD before renal transplantation. The usefulness of revascularization before transplantation remains unclear. We hypothesize that there is no difference in all-cause and cardiovascular mortality in waitlisted renal transplant candidates with CAD who underwent revascularization versus those treated with optimal medical therapy before transplantation. Methods and Results This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the modified Newcastle-Ottawa Scale and Cochrane risk of bias tool. The primary outcome of interest was all-cause mortality. Eight studies comprising 945 patients were included (36% women, mean age 56 years). There was no difference in all-cause mortality (risk ratio [RR], 1.16 [95% CI, 0.63-2.12), cardiovascular mortality (RR, 0.75 [95% CI, 0.29-1.89]), or major adverse cardiovascular events (RR, 0.78 [95% CI, 0.30-2.07]) when comparing renal transplant candidates with CAD who underwent revascularization versus those who were on optimal medical therapy before renal transplant. Conclusions This meta-analysis demonstrates that revascularization is not superior to optimal medical therapy in reducing all-cause mortality, cardiovascular mortality, or major adverse cardiovascular events in waitlisted kidney transplant candidates with CAD who eventually underwent kidney transplantation.

Development and Validation of a Prediction Model for Stroke, Cardiac, and Mortality Risk After Non-Cardiac Surgery.

Background Commonly used cardiovascular risk calculators do not provide risk estimation of stroke, a major postoperative complication with high morbidity and mortality. We developed and validated an accurate cardiovascular risk prediction tool for stroke, major cardiac complications (myocardial infarction or cardiac arrest), and mortality after non-cardiac surgery. Methods and Results This retrospective cohort study included 1 165 750 surgical patients over a 4-year period (2007-2010) from the American College of Surgeons National Surgical Quality Improvement Program Database. A predictive model was developed with the following preoperative conditions: age, history of coronary artery disease, history of stroke, emergency surgery, preoperative serum sodium (≤130 mEq/L, >146 mEq/L), creatinine >1.8 mg/dL, hematocrit ≤27%, American Society of Anesthesiologists physical status class, and type of surgery. The model was trained using American College of Surgeons National Surgical Quality Improvement Program data from 2007 to 2009 (n=809 880) and tested using data from 2010 (n=355 870). Risk models were developed using multivariate logistic regression. The outcomes were postoperative 30-day stroke, major cardiovascular events (myocardial infarction, cardiac arrest, or stroke), and 30-day mortality. Major cardiac complications occurred in 0.66% (n=5332) of patients (myocardial infarction, 0.28%; cardiac arrest, 0.41%), postoperative stroke in 0.25% (n=2005); 30-day mortality was 1.66% (n=13 484). The risk prediction model had high predictive accuracy with area under the receiver operating characteristic curve for stroke (training cohort=0.869, validation cohort=0.876), major cardiovascular events (training cohort=0.871, validation cohort=0.868), and 30-day mortality (training cohort=0.922, validation cohort=0.925). Surgery types, history of stroke, and coronary artery disease are significant risk factors for stroke and major cardiac complications. Conclusions Postoperative stroke, major cardiac complications, and 30-day mortality can be predicted with high accuracy using this web-based predictive model.

Clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade.

INTRODUCTION: The electrocardiogram (ECG) is one of the initial tests done in patients suspected of having a cardiac Tamponade. Historically the emphasis has been on low QRS voltage and electrical alternans, which lacks specificity and sensitivity respectively. Majority of these studies included patients with pericardial effusions without tamponade. Moreover, the influence of different therapeutic interventions such as pericardiocentesis on ECG variables has not been elucidated. OBJECTIVE: To determine the clinical significance of 12 lead ECG changes in patients undergoing pericardiocentesis for cardiac tamponade. METHODS: 144 patients underwent Echo guided pericardiocentesis for cardiac tamponade at a tertiary care hospital over a period of 7 years. We compared 19 EKG variables pre and post procedure. RESULTS: Low voltage was detected in only 31 patients (29%) with 19 (18%) patients having persistent low voltage (p value = 0.0047) after the pericardiocentesis. Electrical alternans was only observed in 25 patients (23%), and persisted in 10 patients (10%) following pericardiocentesis. None of the other EKG variables measured changed reliably post procedure. CONCLUSION: We found that although electrical alternans and low voltage were associated with cardiac tamponade, none of the ECG variables were highly sensitive or specific for the diagnosis, reproducibly changed after drainage or predicted recurrent effusion post-pericardiocentesis.

Rapid, Fatal Acute Right Ventricular Failure After Locoregional Cytokine Therapy for Uveal Melanoma Liver Metastases.

Locoregional cytokine treatment, or immunoembolization, is an experimental targeted therapy for uveal melanoma metastatic to the liver. Unlike systemic cytokine treatments that have been associated with substantial toxicity, this method of drug delivery appears to be better tolerated. Because this newer therapy is being prescribed more widely, oncologists, interventional radiologists, cardiologists, pulmonologists, critical care specialists, and other providers should become familiar with potential adverse reactions. We describe the case of a 67-year-old man who had metastatic uveal melanoma. Before he underwent liver-directed immunoembolization, he had elevated markers of endothelial dysfunction. He died after the rapid onset of acute right ventricular failure from severe pulmonary hypertension with possible superimposed isolated right ventricular takotsubo cardiomyopathy. In discussing this rare case, we focus on the differential diagnosis.

Very High-Dose Furosemide Continuous Infusions: A Case Series.

BACKGROUND: There is paucity of data evaluating the efficacy and safety of very high-dose furosemide continuous infusions (≥40 mg/h) for volume removal. This infusion is a novel strategy of loop diuretic administration that may add valuable data to current literature. METHODS AND RESULTS: This was a retrospective chart review. Patients were eligible for inclusion if prescribed a very high-dose furosemide infusion (defined as ≥40 mg/h, up to 240 mg/h) from April 1, 2017, to January 1, 2019, at Thomas Jefferson University Hospital. Data collected included the change in cumulative urine output, net urine output, incidence of acute kidney injury, occurrences of hypotension, electrolyte abnormalities, body weight, and ototoxicity. Twenty-two patients were included in this analysis. The median change in 24-hour urine output from before to after very high-dose continuous furosemide infusion increased from 1193 mL at 24 hours before infusion initiation to 3518 mL at 24 hours after infusion initiation (P < .01). Serum creatinine increased 24 hours after infusion initiation but decreased within 48 hours. There were no electrolyte abnormalities. Out of 22 patients, only 2 had an occurrence of hypotension. No patients were reported to have ototoxicity. CONCLUSIONS: Very high-dose furosemide continuous infusions provide a significant increase in diuresis without worsening renal function, disturbing electrolytes, or increasing the risk of ototoxicity. Further studies are necessary to examine the efficacy and safety of this novel strategy.

Surgical Pulmonary Embolectomy Outcomes for Acute Pulmonary Embolism.

BACKGROUND: Acute pulmonary embolism (PE) is associated with significant mortality. Surgical embolectomy is a viable treatment option; however, it remains controversial as a result of variable outcomes. This review investigates patient outcomes after surgical embolectomy for acute PE. METHODS: An electronic search was performed to identify articles reporting surgical embolectomy for treatment of PE. 32 studies were included comprising 936 patients. Demographic, perioperative, and outcome data were extracted and pooled for systematic review. RESULTS: Mean patient age was 56.3 years (95% confidence interval [CI], 52.5, 60.1), and 50% were male (95% CI, 46, 55); 82% had right ventricular dysfunction (95% CI, 62, 93), 80% (95% CI, 67, 89) had unstable hemodynamics, and 9% (95% CI, 5, 16) experienced cardiac arrest. Massive PE and submassive PE were present in 83% (95% CI, 43, 97)] and 13% (95% CI, 2, 56) of patients, respectively. Before embolectomy, 33% of patients (95% CI, 14, 60) underwent systemic thrombolysis, and 14% (95% CI, 8, 24) underwent catheter embolectomy. Preoperatively, 47% of patients were ventilated (95% CI, 26; 70), and 36% had percutaneous cardiopulmonary support (95% CI, 11, 71). Mean operative time and mean cardiopulmonary bypass time were 170 minutes (95% CI, 101, 239) and 56 minutes (95% CI, 42, 70), respectively. Intraoperative mortality was 4% (95% CI, 2, 8). Mean hospital and intensive care unit stay were 10 days (95% CI, 6, 14) and 2 days (95% CI, 1, 3), respectively. Mean postoperative systolic pulmonary artery pressure (sPAP) was significantly decreased from the preoperative period (sPAP 57.8, mm Hg; 95% CI, 53, 62.7) to the postoperative period (sPAP, 31.3 mm Hg; 24.9, 37.8); P < .01). In-hospital mortality was 16% (95% CI, 12, 21). Overall survival at 5 years was 73% (95% CI, 64, 81). CONCLUSIONS: Surgical embolectomy is an acceptable treatment option with favorable outcomes.

Outcomes of extracorporeal life support for the treatment of acute massive pulmonary embolism: A systematic review.

BACKGROUND: Massive pulmonary embolism (PE) can cause hemodynamic instability leading to high mortality. Extracorporeal life support (ECLS) has been increasingly used as a bridge to definitive therapy. This systematic review investigates the outcomes of ECLS for the treatment of massive PE. METHODS: Electronic search was performed to identify all relevant studies published on ECLS use in patients with PE. 50 case series or reports were selected comprising 128 patients with acute massive PE who required ECLS. Patient-level data were extracted for statistical analysis. RESULTS: Median patient age was 50 [36, 63] years and 41.3% (50/121) were male. 67.2% (86/128) of patients presented with cardiac arrest. Median heart rate was 126 [118, 135] and median systolic pulmonary artery pressure (sPAP) was 55 [48, 69] mmHg. The majority of ECLS included veno-arterial ECLS [97.1% (99/102)]. Median ECLS time was 3 [2, 6] days. 43.0% (55/128) patients received systemic thrombolysis, 22.7% (29/128), received catheter-guided thrombolysis, and 37.5% (48/128) underwent surgical embolectomy. 85.1% (97/114) were weaned off ECLS. Post-ECLS complications included bleeding in 23.4% (30/128), acute renal failure in 8.6% (11/128), dialysis in 6.3% (8/128), heparin-induced thrombocytopenia in 3.1 (4/128), and extremity hypoperfusion in 2.3% (3/128). The most common cause of death was shock at 30.3% (10/33). The median length of hospital stay was 22 [11, 39] days including 8 [5, 13] intensive care unit (ICU) days. The 30-day mortality rate was 22% (20/91). CONCLUSIONS: ECLS is safe and effective therapy in unstable patients with acute massive pulmonary embolism and offers acceptable outcomes.

Use of Cangrelor as a Bridge to Left Ventricular Assist Device Implantation in a Patient with a Recent Drug-Eluting Stent Who Developed Acute Tirofiban-Related Thrombocytopenia.

Current guidelines emphasize the need for at least 6-12 months of oral dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor following drug-eluting coronary artery stent implantation. In patients with recently implanted coronary artery stents who require urgent cardiac or noncardiac surgery, the benefits of maintaining oral dual antiplatelet therapy must be carefully weighed against the risks of excessive bleeding, and current practice is largely guided by individual surgeon preferences. When the effects of a second oral antiplatelet agent are undesirable during the perioperative period, the use of a short-acting intravenous antiplatelet agent as "bridge" therapy that can be discontinued shortly before surgery is associated with a reduced occurrence of adverse clinical events in patients with recently implanted coronary stents requiring urgent coronary artery bypass graft surgery. Cangrelor is an intravenous adenosine triphosphate analog P2Y12 receptor antagonist with a short plasma half-life that has been used off label in patients with recent coronary stents as a bridge to invasive procedures with excessive bleeding risk. To our knowledge, this is the first case report to demonstrate the safe and effective use of cangrelor as a bridge to left ventricular assist device implantation in a patient with a recently implanted drug-eluting coronary artery stent who developed acute thrombocytopenia following reexposure to tirofiban, a glycoprotein IIb/IIIa inhibitor.

Clinical Significance of Spontaneous Echo Contrast on Extracorporeal Membrane Oxygenation.

BACKGROUND: Spontaneous echo contrast (SEC) is known to be a predisposition to thromboembolism and cerebrovascular accident. The aim of this study was to investigate the risk factors and the consequences of SEC in patients who were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) because of cardiogenic shock. METHODS: Between January 2011 and December 2014, 98 patients underwent the insertion of VA-ECMO because of cardiogenic shock in our institution. Transthoracic and transesophageal echocardiography was performed and interpreted by National Board of Echocardiography certified cardiologists. Patients were divided into 2 groups based on the presence or absence of SEC. Clinical data, echocardiographic measurements, and outcomes were compared between the 2 groups. RESULTS: Of the 98 patients, 22 patients (22%) had SEC on echocardiography. Patients in the SEC group had a lower ejection fraction (8.0% versus 29%; p < 0.001), a lower pulsatility index (defined by [systolic blood pressure - diastolic blood pressure]/mean blood pressure) while receiving ECMO (0.13 ± 0.14 versus 0.26 ± 0.22; p = 0.009). The SEC group had a higher rate of intracardiac thrombus (46% versus 13%; p = 0.002) and stroke (36% versus 7.9%; p = 0.002). On univariate analysis, intracardiac thrombus, SEC, and low pulsatility were significant risk factors for the development of stroke. On multivariate analysis, SEC was the only independent risk factor for stroke. CONCLUSIONS: SEC on VA-ECMO resulted in an increased risk of intracardiac thrombus and stroke. Maintaining pulsatility while the patient is on ECMO may result in a decreased chance of developing SEC and stroke.

Right Ventricular Enlargement within Months of Arteriovenous Fistula Creation in 2 Hemodialysis Patients.

Surgically created arteriovenous fistulae (AVF) for hemodialysis can contribute to hemodynamic changes. We describe the cases of 2 male patients in whom new right ventricular enlargement developed after an AVF was created for hemodialysis. Patient 1 sustained high-output heart failure solely attributable to the AVF. After AVF banding and subsequent ligation, his heart failure and right ventricular enlargement resolved. In Patient 2, the AVF contributed to new-onset right ventricular enlargement, heart failure, and ascites. His severe pulmonary hypertension was caused by diastolic heart failure, diabetes mellitus, and obstructive sleep apnea. His right ventricular enlargement and heart failure symptoms did not improve after AVF ligation. We think that our report is the first to specifically correlate the echocardiographic finding of right ventricular enlargement with AVF sequelae. Clinicians who treat end-stage renal disease patients should be aware of this potential sequela of AVF creation, particularly in the upper arm. We recommend obtaining preoperative echocardiograms in all patients who will undergo upper-arm AVF creation, so that comparisons can be made postoperatively. Alternative consideration should be given to creating the AVF in the radial artery, because of less shunting and therefore less potential for right-sided heart failure and pulmonary hypertension. A multidisciplinary approach is optimal when selecting patients for AVF banding or ligation.

Exercise during pregnancy in normal-weight women and risk of preterm birth: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Preterm birth is the major cause of perinatal mortality in the United States. In the past, pregnant women have been recommended to not exercise because of presumed risks of preterm birth. Physical activity has been theoretically related to preterm birth because it increases the release of catecholamines, especially norepinephrine, which might stimulate myometrial activity. Conversely, exercise may reduce the risk of preterm birth by other mechanisms such as decreased oxidative stress or improved placenta vascularization. Therefore, the safety of exercise regarding preterm birth and its effects on gestational age at delivery remain controversial. OBJECTIVE: The objective of the study was to evaluate the effects of exercise during pregnancy on the risk of preterm birth. DATA SOURCES: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and Cochrane Library were searched from the inception of each database to April 2016. STUDY DESIGN: Selection criteria included only randomized clinical trials of pregnant women randomized before 23 weeks to an aerobic exercise regimen or not. Types of participants included women of normal weight with uncomplicated, singleton pregnancies without any obstetric contraindication to physical activity. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals. The primary outcome was the incidence of preterm birth <37 weeks. TABULATION, INTEGRATION, AND RESULTS: Of the 2059 women included in the meta-analysis, 1022 (49.6%) were randomized to the exercise group and 1037 (50.4%) to the control group. Aerobic exercise lasted about 35-90 minutes 3-4 times per week. Women who were randomized to aerobic exercise had a similar incidence of preterm birth of <37 weeks (4.5% vs 4.4%; relative risk, 1.01, 95% confidence interval, 0.68-1.50) and a similar mean gestational age at delivery (mean difference, 0.05 week, 95% confidence interval, -0.07 to 0.17) compared with controls. Women in the exercise group had a significantly higher incidence of vaginal delivery (73.6% vs 67.5%; relative risk, 1.09, 95% confidence interval, 1.04-1.15) and a significantly lower incidence of cesarean delivery (17.9% vs 22%; relative risk, 0.82, 95% confidence interval, 0.69-0.97) compared with controls. The incidence of operative vaginal delivery (12.9% vs 16.5%; relative risk, 0.78, 95% confidence interval, 0.61-1.01) was similar in both groups. Women in the exercise group had a significantly lower incidence of gestational diabetes mellitus (2.9% vs 5.6%; relative risk, 0.51, 95% confidence interval, 0.31-0.82) and a significantly lower incidence of hypertensive disorders (1.0% vs 5.6%; relative risk, 0.21, 95% confidence interval, 0.09-0.45) compared with controls. No differences in low birthweight (5.2% vs 4.7%; relative risk, 1.11, 95% confidence interval, 0.72-1.73) and mean birthweight (mean difference, -10.46 g, 95% confidence interval, -47.10 to 26.21) between the exercise group and controls were found. CONCLUSION: Aerobic exercise for 35-90 minutes 3-4 times per week during pregnancy can be safely performed by normal-weight women with singleton, uncomplicated gestations because this is not associated with an increased risk of preterm birth or with a reduction in mean gestational age at delivery. Exercise was associated with a significantly higher incidence of vaginal delivery and a significantly lower incidence of cesarean delivery, with a significantly lower incidence of gestational diabetes mellitus and hypertensive disorders and therefore should be encouraged.

Prompt Recognition of Left Ventricular Free-Wall Rupture Aided by the Use of Contrast Echocardiography.

In the modern period of reperfusion, left ventricular free-wall rupture occurs in less than 1% of myocardial infarctions. Typically, acute left ventricular free-wall rupture leads to sudden death from immediate cardiac tamponade. We present the case of a 59-year-old woman who sustained a posterior-wall myocardial infarction and subsequent cardiac arrest with pulseless electrical activity. A bedside transthoracic echocardiogram showed pericardial effusion with cardiac tamponade. Emergency pericardiocentesis yielded 500 mL of blood, and spontaneous circulation returned. Contrast-enhanced echocardiograms revealed inferolateral akinesis and a new, small myocardial slit with systolic extrusion of contrast medium, consistent with left ventricular free-wall rupture. During immediate open-heart surgery, a small hole in an area of necrotic tissue was discovered and repaired. This case highlights the usefulness of bedside contrast-enhanced echocardiography in confirming acute left ventricular free-wall rupture and enabling rapid surgical treatment.

The Effect of Aspirin on Bleeding and Transfusion in Contemporary Cardiac Surgery.

OBJECTIVE: Despite evidence that preoperative aspirin improves outcomes in cardiac surgery, recommendations for aspirin use are inconsistent due to aspirin's anti-platelet effect and concern for bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on bleeding and transfusion in cardiac surgery. METHODS: This retrospective study involved consecutive patients (n=1571) who underwent CABG, valve, or combined CABG and valve surgery at a single center between March 2007 and July 2012. Of all patients, 728 met the inclusion criteria and were divided into two groups: those using (n=603) or not using (n=125) aspirin within 5 days of surgery. Data were collected on chest tube drainage, re-operation for bleeding, and transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets. RESULTS: No significant difference was observed between the two groups in chest tube drainage or re-operation for bleeding. An increase in patients transfused with RBCs was observed in the aspirin group (61.9 vs 51.2%, adjusted OR 1.77, p=0.027); however, among those transfused RBCs, no significant difference in mean units transfused or massive transfusion was observed. No significant difference was seen in transfusion requirement of FFP or platelets. CONCLUSIONS: In patients undergoing CABG, valve, or combined CABG/valve surgery, preoperative aspirin, within 5 days of surgery, was associated with an increased probability of receiving an RBC transfusion. Preoperative aspirin was not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of FFP or platelets.

Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases.

BACKGROUND: Pericardial decompression syndrome (PDS) is a rare and potentially fatal complication of pericardial drainage, either by needle pericardiocentesis or surgical pericardiostomy. It manifests with paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. We sought to elucidate factors associated with mortality in PDS. METHODS: MEDLINE was systematically searched for PDS case reports and case series published between 1983 and 2013. For this analysis, clinical variables, echocardiographic and hemodynamic variables, details of drainage procedure and clinical outcomes were collected for each case. RESULTS: A total of 35 cases (12 male, 23 female) were identified. PDS developed after pericardiocentesis, pericardiostomy, or both, in 18, 16, and one patients, respectively. Cardiac tamponade was the indication in 33 cases (94%). The mean age was 47 ± 17 years. The mean amount of effusion drained was 888 mL. The minimum amount of effusion drained was 450 mL. The onset of PDS after the procedure varied widely, ranging from 'immediate' to 48 hours. Presentations included 10 (29%) with cardiogenic pulmonary edema without shock, 14 (40%) with left ventricular failure, three (9%) with right ventricular failure, seven (20%) with biventricular failure, and one (3%) with non-cardiogenic pulmonary edema. Ten patients (29%) died of PDS. Mortality was associated only with surgical drainage (p<0.001). Severe LV dysfunction normalized in PDS survivors. CONCLUSIONS: PDS is a rare complication of pericardial drainage with a high mortality rate. Surgical pericardiostomy was associated with mortality in PDS.

Feasibility of SPECT myocardial perfusion imaging in the super-obese using a multi-head semiconductor camera with attenuation correction.

BACKGROUND: Obesity is not only associated with an increased risk of coronary artery disease, but also decreases the accuracy of many diagnostic modalities pertinent to this disease. Advances in myocardial perfusion imaging (MPI) have mitigated somewhat the effects of obesity, although the feasibility of MPI in the super-obese (defined as a BMI > 50) is currently untested. We undertook this study to assess the practicality of MPI in the super-obese using a multi-headed solid-state gamma camera with attenuation correction. METHODS: We retrospectively identified consecutive super-obese patients referred for MPI at our institution. The images were interpreted by 3 blinded, experienced readers and graded for quality and diagnosis, and subjectively evaluated the contribution of attenuation correction. Clinical follow-up was obtained from review of medical records. RESULTS: 72 consecutive super-obese patients were included. Their BMI ranged from 50 to 67 (55.7 ± 5.1). Stress image quality was considered good or excellent in 45 (63%), satisfactory in 24 (33%), poor in 3 (4%), and uninterpretable in 0 patients. Rest images were considered good or excellent in 34 (49%), satisfactory in 23 (33%), poor in 13 (19%), and uninterpretable in 0 patients. Attenuation correction changed the interpretation in 34 (47%) of studies. CONCLUSIONS: MPI is feasible and provides acceptable image quality for super-obese patients, although it may be camera and protocol dependent.