Intracardiac Shunt Reversal and Early Right Ventricular Failure after Left Ventricular Assist Device Implantation.

Right ventricular failure (RVF) is a common complication that occurs after a left ventricular assist device (LVAD) is implanted. We report an interesting case of severe and refractory hypoxia during the early postoperative period after HeartMate3 (HM3) (Abbott Laboratories, Lake Forest, IL) implantation resulting in the unmasking of a right-to-left intracardiac shunt through a patent foramen ovale (PFO), triggered by early RVF. Importantly, the patient had a small left-to-right shunt after receiving a left-sided Impella 5.5 micro-axial pump (Abiomed, Danvers, MA, USA) pre-LVAD implantation. We observed improved hypoxia but worsening RVF after percutaneous PFO closure, necessitating right-sided mechanical circulatory support. We outline potential reasons for the significant PFO-related shunting seen after HM3 implantation, but not after Impella 5.5 placement. Uncertainty exists regarding the approach to a PFO in patients undergoing LVAD implantation. We propose an approach based on existing literature.

An Updated Safety Review of the Relationship Between Atypical Antipsychotic Drugs, the QTc Interval and Torsades de Pointe As: Implications for Clinical Use.

INTRODUCTION: The rising prevalence of psychiatric disorders has resulted in a significant increase in the use of antipsychotic medications. These agents may prolong the corrected QT interval (QTc), running the risk of precipitating ventricular arrhythmias, notably Torsades de Pointes (TdP). Current recommendations vary regarding the optimal approach to safe prescribing practices and QTc surveillance for antipsychotics. This review summarizes the current literature addressing these clinical concerns. AREAS COVERED: The physiologic basis of the QTc interval, mechanisms underlying its susceptibility to pharmacological influence, specific risks associated with atypical antipsychotic agents, and recommendations for safe prescription practices. We performed a literature review using Pubmed and Embase databases, searching for 'antipsychotics' and 'torsades de pointes.' EXPERT OPINION: Finding a safe and universally accepted protocol for prescribing antipsychotics remains a persistent challenge in medicine. Predictive models that integrate clinical history with demographic and ECG characteristics can help estimate an individual's susceptibility to therapy-associated risks, including QTc prolongation. Agents such as ziprasidone and iloperidone are significantly more likely to prolong the QTc interval compared to others such as brexpiprazole, cariprazine, olanzapine, and clozapine. A personalized approach using low-risk medications when clinically feasible, and at the lowest efficacious dose, offers a promising path toward safer antipsychotic prescribing.

Antipsychotic medications are used to treat conditions such as schizophrenia and bipolar disorder; however, they can also affect cardiac electrical conduction. This effect on cardiac function increases the risk of a dangerous heart rhythm, which can potentially be fatal. Patients and doctors need to be aware of and monitor for these potential heart-related side effects, although antipsychotics can be very helpful for mental health conditions.

Pancreatitis as a Pulmonary Pathology: A Rare Case of a Pancreaticopleural Fistula Presenting as Recurrent Pleural Effusions Causing Mediastinal Shift.

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis and pancreatic pseudocyst. It can present as recurrent pleural effusions and can be difficult to diagnose and treat. We present the case of a 37-year-old male with a history of chronic idiopathic pancreatitis complicated by a pseudocyst who came in with progressive dyspnea, cough, and pleuritic chest pain. The chest X-ray on presentation showed near-complete opacification of the left hemithorax, suggesting a large pleural effusion. Upon thoracentesis, black-bloody fluid was drained, and the pleural fluid analysis was consistent with an exudate with significantly elevated levels of amylase, lipase, and bilirubin. Cytology revealed abundant lipofuscin-laden macrophages, suggesting an intra-abdominal source of the accumulated fluid. A post-drainage CT of the chest showed the resolution of the pleural effusion and an interval decrease in the pancreatic pseudocyst size, indicating a fistulous connection to the pleural space. An endoscopic ultrasound (EUS) was performed with efforts to perform cystogastrostomy aspiration that was hindered by the interference of splenic vasculature obstructing the needle's path. The patient was transferred to another facility for definitive treatment with surgical pancreatectomy and auto islet cell transplant. This case underscores the importance of considering PPF as a possible diagnosis, especially in cases of recurrent pleural effusions and a history of pancreatitis and pancreatic pseudocyst. It also emphasizes the significance of EUS as the preferred modality for pseudocyst evaluation and its potential for minimally invasive treatment.

One Pump for Two Hearts: Using an Impella 5.5 Micro-Axial Pump in Peripartum Cardiogenic Shock.

Cardiogenic shock (CS) occurs infrequently in pregnancy and has a high mortality rate. Medical treatment options are few, with limited evidence of efficacy. Temporary mechanical circulatory supports (tMCS) may play a key role in addressing this therapeutic lacuna. We report successfully managing second-trimester CS using an Impella 5.5 micro-axial pump. Our patient presented in the second-trimester with CS. Hemodynamic parameters indicated biventricular dysfunction (low cardiac index, low pulmonary artery pulsatility index). She received diuresis and inotropic support to optimize her fluid status and cardiac function. However, failure to improve to the point where she would be able to tolerate the hemodynamic stresses of labor despite optimizing medical therapy prompted consideration of tMCS. The Impella 5.5 was chosen for its higher output (to maximize fetal perfusion), relative longevity, and lower hemolysis rates compared to other devices. It was used to support her from gestational weeks 28-30 and through the delivery. Support was continued for 4 weeks postpartum to allow for any potential cardiac recovery. Hope unrealized, a workup for destination therapy was initiated. Patient preference and high panel reactive antibodies informed the decision to pursue destination left ventricular assist device (LVAD) therapy. After a 3 month neonatal intensive care unit (NICU) stay, mother and baby were successfully discharged home.

Usage of older donors is associated with higher mortality after heart transplantation: A UNOS observational study.

BACKGROUND: Utilization of heart from older donors is variable across centers with uncertain outcomes of recipients. We sought to utilize a national registry to examine the usage and outcomes of heart transplant (HT) recipients from older donors. We also explored the impact of current donor heart allocation scheme on the outcomes of hearts from older donors. METHODS: This observational study utilized the United Network for Organ Sharing database between 2015 and 2023 with donors categorized into age <45 years or ≥45 years and evaluated organ disposition and geographical variation. Thirty-day, 1-, and 3-year mortality, and graft failure rates were compared among recipients as per donor age group. We also evaluated annual trends in HT for each group over the follow-up period. RESULTS: A total of 24,966 adult donors were recovered: 3,742 (15.0%) were ≥45 years; 3,349 (15.6%) adults received heart from such donors with significant geographical variation, and a declining utilization in the transplantation rate in current donor allocation system. Donors with age ≥45 years had higher comorbidities and were allotted with a significantly shorter ischemic time to recipients who were significantly less likely to receive temporary mechanical circulatory support and more likely female. Unadjusted and adjusted, 30-day mortality were similar but 1- and 3-year mortality and graft failure rates were significantly higher in recipients of such donors. Spline analysis suggested a higher 1-year mortality risk at older donor age with risk increasing after age 40 years. CONCLUSIONS: Older donor age was associated with worsened 1- and 3-year mortality and graft failure for heart transplant recipients.

Using first-contact serum ferritin to predict severe thrombocytopenia in dengue patients: determination and validation in independent cohorts.

BACKGROUND: Severe thrombocytopenia and associated haemorrhage are dreaded complications of dengue fever. The identification of a biomarker that can predict, or rule out, its subsequent development can help identify at-risk individuals. METHODS: 200 dengue patients were included - the first 100 in the deterministic cohort and the latter, the validation cohort. Serum ferritin levels were measured at first presentation. Platelets were monitored serially. Data from the first cohort was used to determine the optimal ferritin level to predict significant thrombocytopenia (<20,000/µL). This threshold was validated in the second cohort. RESULTS: In the deterministic cohort, a ferritin threshold of 593 ng/mL predicted severe thrombocytopenia with a sensitivity of 93.33%, negative predictive value of 98.18% and negative likelihood ratio (LR-) of 0.10. In the validation cohort, the sensitivity and negative predictive value of this threshold were both 100%. The power of the study (determined post-hoc) for each cohort was 98.4% and 86.4% respectively. CONCLUSION: First-contact ferritin consistently identified at-risk individuals. Individuals with ferritin levels below 593 ng/mL were unlikely to develop severe thrombocytopenia independent of clinical presentation.

A retrospective cohort study exploring diltiazem as a pharmaco-enhancer for tacrolimus, in a post-heart transplant setting.

BACKGROUND: A significant proportion of heart transplant-associated expenditure are attributable to immunosuppressants. Post-transplant hypertension adds to the pill burden and subsequent costs. In this study, we describe the effect of diltiazem-the antihypertensive and pharmaco-enhancer-on reducing the required oral dose of tacrolimus. METHODS: We included 17 recipients who had successfully undergone heart transplants but later developed post-transplant hypertension and were treated with diltiazem. Serum trough levels of the immunosuppressant tacrolimus were measured every 2 weeks. Required doses before and after the introduction of diltiazem were compared. Patients were assessed at each follow-up visit for any evidence of toxicity. Medication-related expenditure was estimated based on government-mandated standardized retail price. RESULTS: The power of the study was 98.92% at α = 0.05. The mean tacrolimus dose required prior to initiation of diltiazem was 5.85 ± 1.55 mg. After initiating diltiazem, the mean required doses reduced to 2.88 ± 1.24 mg (p < .0001). Relatively, the required doses reduced by 52.4 ± 10.9%-independently of age, sex, and dose of diltiazem. Medication-related monthly expenditure reduced by 50.3 ± 10.4%. No patient demonstrated evidence of toxicity. CONCLUSIONS: Concomitant use of diltiazem and tacrolimus can safely, effectively, and predictably reduce the required dose of tacrolimus and significantly reduce corresponding costs.

DREEM Study: Students Perceptions of Learning Environment in a Medical College in Mumbai, India.

PURPOSE: This study was carried out to assess medical education environment (MEE) at our institution and to determine if there is an association between the assessment scores and factors such as gender, residence, family educational background and medium of instruction during school years. METHODS: Students appearing for the final qualifying examination were enrolled in the cross-sectional survey after obtaining written informed consent. Demographic data and personal information such as place of residence, parental education and medium of instruction was collected. The Dundee Ready Education Environment Measure (DREEM) Questionnaire was used for assessment of MEE. The numerical variables were described in terms of mean and standard deviation, median and inter-quartile range and percentages. Independent t-test, one-way Anova, Mann-Whitney test and Kruskall- Wallis test were the analytical tests used depending upon the number of groups and characteristics of the data. RESULTS: Fifty-five students were enrolled in the study. The overall DREEM score was 119+/-22 (Median 116), 46(83.64%) reported overall positive perception). Students' perception of atmosphere (SPA) scored highest as compared to other domains. Teacher-centered teaching with emphasis on factual learning, authoritarian teachers, boredom in the course and lacking support systems were some of the problem areas identified on the basis of students' perceptions. There was a significant difference in Students' academic self-perception (SASP) and students' social self-perception scores between students coming from urban and rural backgrounds. CONCLUSIONS: Students reported an overall positive perception of MEE. Problem areas and research priorities were identified leading to a preparation of an action plan.