End-of-life care in patients with advanced heart failure.

PURPOSE OF REVIEW: With an aging population with heart failure, there is a growing need for end-of-life care in this population, including a focus on symptom management and quality-of-life considerations. RECENT FINDINGS: Targeted therapies focusing on symptom control and improving quality of life is the cornerstone of providing care in patients with heart failure near the end of life. Such therapies, including the use of inotropes for palliative purposes, have been shown to improve symptoms without an increase in mortality. In addition, recent evidence shows that implementing certain strategies in planning for end of life, including advance care planning and palliative care involvement, can significantly improve symptoms and quality of life, reduce hospitalizations, and ensure care respects patient values and preferences. SUMMARY: Shifting focus from prolonging life to enhancing quality of life in heart failure patients approaching the end of life can be achieved by recognizing and managing end-stage heart failure-related symptoms, advanced care planning, and a multidisciplinary care approach.

Fluoroless Catheter Ablation of Cardiac Arrhythmias: A 5-Year Experience.

BACKGROUND: Catheter ablations have been traditionally performed with the use of fluoroscopic guidance, which exposes the patient and staff to the inherent risks of radiation. We have developed techniques to eliminate the use of fluoroscopy during cardiac ablations and have been performing completely fluoroless catheter ablations on our patients for over 5 years. METHODS: We present a retrospective analysis of the safety, efficacy, and feasibility data from 500 consecutive patients who underwent nonfluoroscopic catheter ablation, targeting a total of 639 arrhythmias, including atrioventricular reciprocating tachycardia (AVRT), atrioventricular nodal reentrant tachycardia (AVNRT), atrial tachycardia (AT), atrial fibrillation (AF), premature ventricular contractions (PVCs), and ventricular tachycardia (VT). We perform fluoroless ablations using intracardiac electrograms, electroanatomic mapping, and for most cases intracardiac echocardiography. Our experience includes exclusively endocardial cardiac ablations. RESULTS: The mean follow-up was 20.5 months. Recurrence rate for AVRT was 6.5%, for AVNRT 2.5%, for macro-reentrant AT 6.4%, for focal AT 5.4%, for AF 22.6%, for PVC 6.7%, and for VT 21.4%. Major complications occurred in five patients (1.0%); minor complications occurred in three patients (0.6%). No deaths occurred. Fluoroscopy was used in one instance, for 0.3 minutes, to confirm venous access. CONCLUSIONS: Completely fluoroless catheter ablations may be routinely performed for all endocardial ablations without compromising safety, efficacy, or procedural duration.

Establishing a gradient between partial pressure of arterial carbon dioxide and end-tidal carbon dioxide in patients with acute respiratory distress syndrome.

End-tidal carbon dioxide (ETCO2) monitoring is useful in many situations. However, ETCO2 monitoring is unreliable in patients with acute respiratory distress syndrome (ARDS) due to widespread lung inflammation. In our study, we attempt to establish the gradient between the arterial pressure of carbon dioxide (PaCO2) and ETCO2 in patients with ARDS, which we defined as the PaETCO2 gradient. The main objective of the study was to establish a PaETCO2 gradient in each severity of ARDS. We analyzed 35 patients with ARDS and a total of 88 arterial blood gases were included. PaCO2, PaO2/FiO2 and ETCO2 were measured. Patients were stratified into mild, moderate and severe ARDS as classified by the Berlin ARDS criteria. PaCO2 and ETCO2 were compared at each severity stratification. The mean PaCO2 was 50.0, the mean ETCO2 was 26.6 and the gradient among all samples was 23.24 (±12.02). The mean gradient for each severity is as follows: mild: 19.3 (±9.9), moderate: 27.9 (±13.2) and severe: 23.9 (±7.8). The difference between the PaETCO2 gradient of the mild to moderate (p=0.001) and mild to severe groups (p=0.01) reached statistical significance. However, the difference between the moderate to severe groups did not reach statistical significance (p=0.48). We found the gradient between PaCO2 and ETCO2 in patients with ARDS is vast and tends to worsen with increasing severity of ARDS. This indicates that the gradient between the 2 may be used as an indicator of increasing severity of ARDS.

Pulmonary Hypertension in a Patient With Congenital Heart Defects and Heterotaxy Syndrome.

BACKGROUND: Heterotaxy syndrome, also called isomerism, is a condition in which abdominal and thoracic organs are located in abnormal body positions. Pulmonary hypertension (PHTN) is an uncommon clinical feature of heterotaxy syndrome. CASE REPORT: We describe the case of a 26-year-old male who developed PHTN as a rare manifestation of heterotaxy syndrome. To our knowledge, PHTN has never been reported as a prominent clinical feature in a patient with heterotaxy syndome and congenital cardiac abnormalities. CONCLUSION: It is important for the clinician to be aware of potentially serious consequences of PHTN in the setting of heterotaxy syndrome.

Clopidogrel-Induced Severe Hepatitis: A Case Report and Literature Review.

Clopidogrel is a commonly prescribed antiplatelet agent that carries a rare risk of hepatotoxicity. We describe a case of severe clopidogrel-induced hepatitis with liver biopsy assessment. Prompt recognition and withdrawal of the offending agent are imperative to prevent progression and potentially fatal liver injury.

Safety of percutaneous endoscopic gastrostomy tube placement in patients with continuous-flow ventricular assist devices.

In this retrospective study, the safety of percutaneous endoscopic gastrostomy (PEG) tube placement was evaluated as maintaining adequate nutritional support for patients with left ventricular assist devices is crucial. Nineteen patients who underwent PEG tube placement were followed for an average of 40 days. Overall, minor complications such as infections, bleeding, and PEG tube malposition occurred in just 19% of patients while the rate of major complications such as perforation was 5%. Further randomized control trials are necessary to validate this assertion that the safety of PEG placement in patients with left ventricular assist devices is similar to that of the general population.

Impact of Chest Pain Protocol Targeting Intermediate Cardiac Risk Patients in an Observation Unit of an Academic Tertiary Care Center.

BACKGROUND: Chest pain (CP) is a frequent cause of emergency room visits in United States and adds a huge financial burden to our healthcare cost. With the addition of observation units, standard CP protocols have shown to decrease length of stay (LOS) and cost per discharge (CPD). We report our experience with the development and implementation of "CP protocol for intermediate cardiac risk patients" and its impact on healthcare resource utilization at our medical center. METHODS AND RESULTS: We retrospectively analyzed 30 patients who presented to Advocate Christ Medical Center (ACMC) with CP and were considered to be at intermediate risk for acute coronary syndrome after obtaining IRB approval. Patients were treated with our standardized CP protocol and labeled as "protocol patients". Our control group consisted of patients with similar demographics and diagnosis but not treated with our CP protocol admitted in the same time period and under our own faculty. This helped remove the bias of different treating attending. Our protocol algorithm consisted of medications, an electrocardiogram (EKG), cardiac troponin I level, and a stress test if indicated. Primary clinical endpoints for this study were LOS in hours and CPD for patients in our protocol group compared to control group. LOS in the protocol group was lower compared to the control but the difference was not statistically significant (P = 0.74). The average CPD in the control group (mean = $13,446) was almost $830 more than the protocol group (mean = $14,276, P = 0.827). CONCLUSION: Implementation of standardized protocols for patients with CP has proven to be a cost effective strategy at several institutions across the country. Our study showed a reduction in CPD although not statistically significant. LOS was also reduced but did not meet statistical significance mainly due to our small sample size. Previous studies had demonstrated much larger savings between a protocol-driven group and a non-protocol-driven group. On further analysis of our data, our protocol group contained five patients who underwent invasive diagnostic tests including computed tomography for pulmonary embolism scans which were not present in the control group. This accounted for the small reduction in costs for the protocol group.

In Search for Equilibrium: Immunosuppression Versus Opportunistic Infection.

Post-transplant immunosuppression is necessary to prevent organ rejection. Immunosuppression itself can introduce complications arising from opportunistic infections. We present a case of disseminated blastomycosis manifested only as a skin lesion in an asymptomatic patient post-orthotopic heart transplantation. A 64-year-old female who had recently undergone orthotopic heart transplant for end-stage ischemic cardiomyopathy presented for a scheduled routine cardiac biopsy. The patient had no current complaints other than a crusted plaque noticed at her nasal tip. It initially manifested 6 months after surgery as a pimple that she repeatedly tried to manipulate resulting in redness and crust formation. Her immunosuppressive and prophylactic medications included: mycophenolate, tacrolimus, prednisone, bactrim, acyclovir, valganciclovir, pyrimethamine/sulfadiazine, and fluconazole. On physical examination, she was flushed, with a large and exquisitely tender crusted necrotic lesion involving almost the entire half of the nose anteriorly, the left forehead and right side of the neck. She had decreased air entry over the right lung field as well. A computed tomography (CT) image of the chest was ordered to investigate this concerning physical exam finding in the post-transplant state of this patient on immunosuppressive therapy. Chest CT revealed bilateral nodular pulmonary infiltrates with confluence in the posterior right upper lobe. Blood cultures for aerobic and anerobic organisms were negative. Both excisional biopsy of the nasal cutaneous ulcer and bronchial biopsy demonstrated numerous fungal yeast forms morphologically consistent with Blastomyces. Cultures of both specimens grew Blastomyces dermatitidis, with methicillin-resistant Staphylococcus aureus (MRSA) superinfection of the nose. She received 14 days of intravenous (IV) amphotericin B for disseminated blastomycosis and 7 days of IV vancomycin for MRSA. Her symptoms and cutaneous lesions improved and she received maintenance itraconazole treatment for 1 year. This case illustrates a delicate balance that must be struck between suppressing the immune response to prevent graft rejection and avoiding over-immunosuppression that can lead to susceptibility to infection. Thus, in any post-transplant patient, a vigorous history and physical must be performed given that infections may present without symptoms and cause grave consequences.

Management of Atrio-Esophageal Fistula Following Left Atrial Ablation.

Currently, no guidelines have been established for the treatment of atrio-esophageal fistula (AEF) secondary to left atrial ablation therapy. After comprehensive literature review, we aim to make suggestions on the management of this complex complication and also present a case series. We performed a review of the existing literature on AEF in the setting of atrial ablation. Using keywords atrial fibrillation, atrial ablation, fistula formation, atrio-esophageal fistula, complications, interventions, and prognosis, a search was made using the medical databases PUBMED and MEDLINE for reports in English from 2000 to April 2015. A statistical analysis was performed to compare the three different intervention arms: medical management, stent placement and surgical intervention. The results of our systematic review confirm the high mortality rate associated with AEF following left atrial ablation and the necessity to diagnose atrio-esophageal injury in a timely manner. The mortality rates of this complication are 96% with medical management alone, 100% with stent placement, and 33 % with surgical intervention. Atrio-esophageal injury and subsequent AEF is an infrequent but potentially fatal complication of atrial ablation. Early, prompt, and definitive surgical intervention is the treatment of choice.