Atrial Septal Defect Closure Device-Related Infective Endocarditis in a 20-Week Pregnant Woman.

With increasing atrial septal defect (ASD) repairs, more women of childbearing age will have ASD closure devices. Current ASD closure trials have excluded women planning pregnancy, making their management challenging. We present a pregnant woman, with a repaired ASD, who presented with device-related infective endocarditis. (Level of Difficulty: Beginner.).

Infection with New York Orthohantavirus and Associated Respiratory Failure and Multiple Cerebral Complications.

We report a case of infection with New York orthohantavirus in a woman who showed renal impairment and hemorrhage, complicated by hydrocephalus, in Long Island, New York, USA. Phylogenetic analysis showed that this virus was genetically similar to a New York orthohantavirus isolated in the same region during 1993.

Impact of Pulmonary Capillary Wedge Pressure on Long-Term Mortality in Patients With Pulmonary Arterial Hypertension Treated With Parenteral Trepostinil.

BACKGROUND: The clinical impact of pulmonary capillary wedge pressure (PCWP) on long-term mortality among patients with pulmonary arterial hypertension (PAH) has been incompletely reported, particularly in relation to concomitant treprostinil administration. The goal of this study was to assess the impact of PCWP on long-term mortality in PAH patients treated with parenteral treprostinil. METHODS: We studied a cohort of 743 patients with PAH treated with parenteral treprostinil therapy. The long-term all-cause mortality was compared in patients with baseline mean PCWP≤8mmHg, 811mmHg over 4-year follow-up. RESULTS: Of the 743 patients studied, 280 patients (37.7%) had a baseline mean PCWP ≤ 8mmHg, 233 patients (31.4%) had a mean PCWP of >8mmHg and ≤11mmHg, and 230 patients (31.0%) had a mean PCWP >11mmHg. While patients with higher PCWP had higher mean right atrial and PA pressures, no difference was noted in cardiac output and pulmonary vascular resistance (PVR). All-cause mortality was similar between patients with PCWP≤8mmHg, 811mmHg at 1 year (10.4% vs 9.9% vs 10.0%, p=0.980) and 4 years (16.8% vs 21.9% vs 19.2%, p=0.353) respectively. In multivariate analysis, PCWP was not independently predictive of 4-year all-cause mortality [HR 1.00, 95%CI 0.95-1.05, p=0.98 (permmHg)]. Predictors of 4-year mortality included older age [HR 1.02, 95%CI 1.00-1.03, p=0.0091 (per year)], non-​Caucasian race, and higher PVR [HR 1.06, 95% CI 1.04-1.08, p<0.0001 (per Woods Unit)]. CONCLUSIONS: In this study of patients with PAH receiving parenteral treprostinil, PCWP was not associated with long-term all-cause mortality. Further studies examining prognostic indicators in patients with PAH optimised on guideline-based therapies are warranted.

In vitro delivery of aerosolized treprostinil via modern mechanical ventilation.

BACKGROUND: The Tyvaso Inhalation System is a hand-held nebulizer system used to administer treprostinil, an approved therapy for pulmonary arterial hypertension. Our goal was to establish an in vitro method for delivering a standard dose of treprostinil through a ventilator circuit and artificial airway. METHODS: An AeroTech II jet nebulizer (continuous air flow at 10 L/min; Biodex Medical Systems) was placed in the ventilator circuit with a test lung. Two ventilators were tested, the Dräger Evita 2 Dura (Dräger Medical GmbH) and Avea (CareFusion), without humidity. Delivered dose was defined by capturing radiolabeled particles exiting the endotracheal tube with a filter (Pari) and measuring radioactivity. Particle distributions were measured distal to the endotracheal tube by cascade impaction. We hypothesized that drug delivery would be determined by the number of breaths needed, such that the complete time of inspiration totaled 29 sec (e.g., number of breaths needed=29 sec/TI, where TI is the inspiratory time of an average breath read from the ventilator display). RESULTS: Nebulizer output was linear for 6 min, and the standard prescribed target dose of 54 µg (3.1% of full ampule) was delivered in 29 sec. Using our TI algorithm to control delivery, the mean inhaled dose±SD was 72.2±16.5 µg (range 47.2-98.6; n=23). Dräger delivered higher doses than Avea. Effects of mode, breathing pattern, and positive-end expiratory pressures were not significant. The mass median aerodynamic diameter and fine particle fraction were 0.71±0.015 and 0.997±0.0006, respectively. CONCLUSIONS: Using the algorithm, it was possible to deliver aerosolized treprostinil, at controlled doses, via mechanical ventilation over a wide range of controlled breathing patterns. The conditions of nebulization must be precisely followed (one full ampule per treatment, use of the AeroTech II nebulizer, continuous nebulization using an external flow of 10 L/min, bypass of the humidifier or removal of in-line heat and moisture exchanger, and treatment completed in 6 min or less).

Right ventricular strain rate predicts clinical outcomes in patients with acute pulmonary embolism.

BACKGROUND: Echocardiographic quantification of global and regional right ventricular (RV) function is critical in patients with acute pulmonary embolism (PE), but remains a challenge particularly in acute RV dilatation. METHODS: Apical two-dimensional images of patients with acute PE were analyzed using both conventional and speckle tracking imaging compared with controls; patients with PE were divided into those who received thrombolysis and those who did not. The basal, mid and apical segments of the RV free wall and septum were analyzed. Correlations between speckle tracking measurements and in-hospital mortality were made. RESULTS: 53 patients with PE were compared with 15 controls. Of the PE patients, 98.1% were treated with systemic anticoagulation, 15.1% with thrombolysis; 38% required ICU admission and 5.6% died. Strain rate of the mid interventricular septum and strain of the basal and mid interventricular septal segments were significantly lower in patients with PE than control. However, strain rate of the basal RV free wall was higher than controls. In thrombolysed patients, basal RV free wall strain rate was lower than in non-thrombolysed patients. RV strain rate significantly correlated with in-hospital mortality. CONCLUSIONS: Speckle tracking may be a sensitive tool for assessing RV dysfunction and predicting mortality in patients with PE in this pilot study.

Recurrent rhabdomyolysis associated with polydipsia-induced hyponatremia - a case report and review of the literature.

Rhabdomyolysis involves the breakdown of muscle due to an inciting insult. It has been reported to have many etiologies. Some of the more common causes are trauma and medications. Therapy involves vigorous hydration with a crystalloid or bicarbonate infusion and aims to prevent renal failure caused by the release of myoglobin. This case report describes a patient with a recurrent episode of rhabdomyolysis associated with self-induced water intoxication. He was initially treated with a 3.0% saline infusion, followed by a sodium bicarbonate infusion, with correction of his electrolytes and resolution of the rhabdomyolysis.

Mental status change, myoclonus, electrocardiographic changes, and acute respiratory distress syndrome induced by quetiapine overdose.

A 41-year-old man with bipolar disorder came to the emergency department with mental status changes, prolonged rate-corrected QT interval, and myoclonus after ingesting 4500 mg of quetiapine, an atypical antipsychotic drug. Within 24 hours, respiratory failure ensued, requiring intubation and mechanical ventilation. Chest radiograph demonstrated bilateral infiltrates consistent with acute respiratory distress syndrome (ARDS). To our knowledge, this is the first report of ARDS resulting from quetiapine overdose. Clinicians should be aware that in cases of large overdoses of quetiapine, patients should be closely monitored if mental status changes, electro-cardiographic changes, or hypoxia occur, preferably in an intensive care unit.