The use of protective mechanical ventilation during extracorporeal membrane oxygenation for the treatment of acute respiratory failure.

Acute respiratory failure (ARF) strikes an estimated two million people in the United States each year, with care exceeding US$50 billion. The hallmark of ARF is a heterogeneous injury, with normal tissue intermingled with a large volume of low compliance and collapsed tissue. Mechanical ventilation is necessary to oxygenate and ventilate patients with ARF, but if set inappropriately, it can cause an unintended ventilator-induced lung injury (VILI). The mechanism of VILI is believed to be overdistension of the remaining normal tissue known as the 'baby' lung, causing volutrauma, repetitive collapse and reopening of lung tissue with each breath, causing atelectrauma, and inflammation secondary to this mechanical damage, causing biotrauma. To avoid VILI, extracorporeal membrane oxygenation (ECMO) can temporally replace the pulmonary function of gas exchange without requiring high tidal volumes (VT) or airway pressures. In theory, the lower VT and airway pressure will minimize all three VILI mechanisms, allowing the lung to 'rest' and heal in the collapsed state. The optimal method of mechanical ventilation for the patient on ECMO is unknown. The ARDSNetwork Acute Respiratory Management Approach (ARMA) is a Rest Lung Approach (RLA) that attempts to reduce the excessive stress and strain on the remaining normal lung tissue and buys time for the lung to heal in the collapsed state. Theoretically, excessive tissue stress and strain can also be avoided if the lung is fully open, as long as the alveolar re-collapse is prevented during expiration, an approach known as the Open Lung Approach (OLA). A third lung-protective strategy is the Stabilize Lung Approach (SLA), in which the lung is initially stabilized and gradually reopened over time. This review will analyze the physiologic efficacy and pathophysiologic potential of the above lung-protective approaches.

The association of hyponatremia and clinical outcomes in patients with acute myocardial infarction: a cross-sectional study.

INTRODUCTION: Hyponatremia is a common electrolyte abnormality that has been associated with poor outcomes in several conditions including acute myocardial infarction (AMI). However, those studies were performed in the era before percutaneous coronary intervention (PCI), focused mostly on ST-elevation myocardial infarction (STEMI), and sodium levels up to 72 h of admission. The purpose of this study was to identify the association between hyponatremia and clinical outcomes in patients with acute myocardial infarction. METHODS: We performed a retrospective analysis of patients with a diagnosis of non-ST-elevation myocardial infarction (NSTEMI) and STEMI presenting at our institution from March 2021 to September 2021. Our independent variables were sodium levels on the day of admission and up to 7 days later. Dependent variables were in-hospital mortality, 30-day mortality, length of hospital stay, intensive care admission, new heart failure diagnosis, and ejection fraction. RESULTS: 50.2% of patients had hyponatremia up to 7 days of admission. Intensive care admission was higher in patients with hyponatremia up to7 days (69.7% vs 54.3%, P 0.019, OR 1.9), they had worse 30-day mortality (12.7% vs to 2.2%, P 0.004, OR 6.5), in hospital mortality (9.9% vs 1.1%, P 0.006, OR 9.9), and new heart failure diagnosis (31.5% vs 17.9%, P < 0.043, OR 2.1). Hyponatremia on admission was associated with in-hopital mortality (16.3% vs 3.8%, P 0.004, OR 4.9), 30-day mortality (18.4% vs 5.9%, P 0.017, OR 3.5). CONCLUSIONS: This study suggests that hyponatremia on admission and at any point during the first seven days of hospitalization are associated with in-hospital and 30-day mortality.

Impact of atrial fibrillation on the outcomes of transcatheter mitral valve repair using MitraClip: a systematic review and meta-analysis.

Atrial fibrillation (AF) is a common arrhythmia in patients with mitral regurgitation (MR) undergoing transcatheter mitral valve repair (TMVR). In this systematic review, we aimed to investigate the outcomes of TMVR using MitraClip in AF patients. We performed a systematic search using PubMed, SCOPUS, EMBASE, and Google Scholar, from inception to May 10, 2020, for studies that reported outcomes following MitraClip, in patients with AF versus without AF. Seven studies with a total of 7678 patients met the inclusion criteria. The risk of 1-year all-cause mortality following TMVR was higher in AF patients (RR 1.40, 95% CI 1.27-1.54, p ≤ 0.001). Similarly, the risk of heart failure hospitalization was higher in patients with AF (RR 1.17, 95% CI 1.06-1.30, p = 0.002) and the risk of bleeding was elevated in AF patients (RR 1.29, 95% CI 1.15-1.45, p ≤ 0.001). The risk of procedural failure, in-hospital mortality, cardiovascular mortality, and stroke was not significantly different between the two groups. The higher risk of all-cause mortality, HF hospitalization, and risk of bleeding in AF patients undergoing MitraClip warrants attention.

Traumatic aortic root rupture leading to acute aortic regurgitation and acute type A aortic dissection.

A 17-year-old male sustained a blunt thoracic trauma after he had a dirt bike accident. He was admitted for the management of multiple fractures, was hemodynamically stable, and presented without any cardiac symptoms. The patient underwent transthoracic echocardiography and CT angiogram of the thorax as the workup of possible cardiac injury as he had a new aortic regurgitation murmur, troponin rise, and a new RBBB. Imaging showed aortic root rupture, type A aortic dissection involving aortic root and proximal ascending aorta, and acute severe aortic regurgitation, not typically seen with blunt thoracic trauma. The patient was immediately taken to the operating room, underwent a surgical aortic valve and root replacement with the Bentall procedure, and had a good outcome.

Aortic dissection and multimodality imaging.

Aortic dissection is a life-threatening emergency warranting expeditious diagnosis. Computed tomographic angiography (CTA) is the established gold standard test but is not always fool proof. We report the case of an 18-year-old male patient with traumatic type A aortic dissection which was not evident on the CTA, suggestive on the transthoracic echocardiogram (TTE) and eventually confirmed with a transesophageal echocardiogram (TEE). When the clinical suspicion for dissection is high and in the presence of complications of type A dissection, such as aortic regurgitation, it would be prudent to obtain further imaging with a TTE/TEE to rule in or rule out the diagnosis.

The misleading electrocardiogram - Midventricular Takotsubo masquerading as anterior wall STEMI.

Midventricular Takotsubo cardiomyopathy (TC) is a relatively rare variant of stress induced cardiomyopathy, wherein there is akinesis of only the mid-ventricular segment with or without hyperkinesis of apical and basal ventricular segments. The ECG findings of TC typically do not include ST segment elevation in V1-V2 and are unlikely to be associated with reciprocal changes in inferior leads. The presence of these changes argues strongly in favor of anterior wall STEMI. In our patient, the ECG had changes strongly suggestive of STEMI, however had normal coronaries on cardiac catheterization. This case highlights the importance of carefully analyzing the ECG in emergency situations for differences between TC and STEMI and when in doubt, cardiac catheterization should be pursued.

Rare cardiac metastasis of lung cancer mimicking aneurysm and tamponade.

Metastasis of non-small cell lung carcinoma (NSCLC) is a rare cause of cardiac metastatic tumors (CMT). We present a case of NSCLC infiltrating the apical left ventricle mimicking cardiac aneurysm and tamponade. The patient, who had a history of NSCLC, presented with acute shortness of breath and an echocardiogram concerning for ruptured left ventricular aneurysm. A neoplastic mass found at the cardiac apex suggested CMT leading to ventricular wall rupture and cardiac tamponade. Transthoracic echocardiography is the most ubiquitous imaging modality for CMT diagnosis, with cardiac magnetic resonance imaging offering a more detailed assessment. CMT from NSCLC can cause dangerous cardiac tamponade, warranting consideration in patients with suspected metastases.

Metastasis of non­small cell lung carcinoma (NSCLC) to the heart is uncommon but can lead to serious complications including life-threatening cardiac tamponade.Diagnosis of cardiac metastatic tumors from NSCLC often involves echocardiography, but cardiac magnetic resonance imaging provides additional insights in cases where echocardiography results are inconclusive.

A meta-analysis of outcomes of aspiration thrombectomy for high and intermediate-risk pulmonary embolism.

BACKGROUND: Aspiration thrombectomy has gained popularity in patients with massive and sub-massive pulmonary embolism (PE) and having contraindications to thrombolysis. METHODS: A meta-analysis was conducted including studies on aspiration thrombectomy in patients with high-risk and intermediate-risk PE. The pooled odds ratio for efficacy parameters, including change in heart rate, blood pressure and right ventricle/left ventricle (RV/LV) ratio, and safety parameters including major bleeding and stroke, was calculated using a random effects model. RESULTS: The meta-analysis of 24 selected studies revealed that intermediate and high-risk pulmonary embolism (PE) patients demonstrated significant improvements: modified Miller score odds ratio of 10.60, mean pulmonary artery pressure reduction by 0.04 mm Hg, and an overall all-cause mortality odds ratio of 0.10. Considerable heterogeneity was observed in various outcomes. CONCLUSION: Aspiration thrombectomy has success rates in both high-risk and intermediate-risk PE, however, procedural risks, including bleeding, must be anticipated.

Adherence to antihypertensives in the United States: A comparative meta-analysis of 23 million patients.

Adherence to antihypertensives is crucial for control of blood pressure. This study analyzed factors and interventions that could affect adherence to antihypertensives in the US. PubMed, Scopus, Web of Science, and Embase were searched on January 21, 2022 and December 25, 2023 for studies on the adherence to antihypertensives in the US. Nineteen studies and 23 545 747 patients were included in the analysis, which showed that adherence to antihypertensives was the highest among Whites (OR: 1.47, 95% CI 1.34-1.61 compared to African Americans). Employment status and sex were associated with insignificant differences in adherence rates. In contrast, marital status yielded a significant difference where unmarried patients demonstrated low adherence rates compared to married ones (OR: 0.8, 95% CI 0.67-0.95). On analysis of comorbidities, diabetic patients reported lower adherence to antihypertensives (OR: 0.95, 95% CI 0.92-0.97); furthermore, patients who did not have Alzheimer showed higher adherence rates. Different BMIs did not significantly affect the adherence rates. Patients without insurance reported significantly lower adherence rates than insured patients (OR: 3.93, 95% CI 3.43-4.51). Polypill users had higher adherence rates compared with the free-dose combination (OR: 1.21, 95% CI 1.2-1.21), while telepharmacy did not prove to be as effective. Lower adherence rates were seen among African Americans, uninsured, or younger patients. Accordingly, interventions such as fixed-dose combinations should be targeted at susceptible groups. Obesity and overweight did not affect the adherence to antihypertensives.

Left Frontal Lobe Cardioembolic Stroke as a Co-presentation of Bicuspid Aortic Valve With Severe Stenosis and a Basal Interventricular Septal Aneurysm in a Young Female Patient.

Bicuspid aortic valve (BAV) and interventricular septum (IVS) aneurysms are common congenital heart defects affecting 1.3% and 0.3% of the population, respectively. The coexistence of membranous types of IVS aneurysm and BAV is even rarer. We report a case of a 48-year-old woman with a history of BAV and severe aortic stenosis who had a seizure in a grocery store and was brought to the emergency department (ED). An MRI of the brain without contrast revealed a left frontal lobe acute lacunar infarct, suggestive of embolic origin. A transesophageal echocardiogram confirmed a basal IVS aneurysm measuring 12.2 mm × 16 mm without intracardiac shunting or thrombi. We diagnosed her with cardioembolic stroke as a complication of BAV and IVS aneurysm and initiated anticoagulation as she did not qualify for surgical intervention. This report emphasizes that IVS aneurysms associated with BAV, although often asymptomatic, may cause adverse outcomes such as cardioembolic stroke. Therefore, timely detection by non-invasive imaging, including echocardiography, CT scans, and MRI, and appropriate intervention are essential to improving health outcomes and survival.

Catheter-Directed Thrombectomy: An Alternative in Massive Pulmonary Embolism.

Massive pulmonary embolism (PE) is a life-threatening condition. The mainstay treatment is thrombolysis. Catheter-directed thrombectomy involves a group of new techniques that appear to have relatively low complications and mortality. These techniques have so far been studied mostly in submassive PE. We present a patient with massive PE that was successfully treated with catheter-directed thrombectomy.

Acute ST-Segment Elevation Myocardial Infarction as a Rare Postoperative Complication of Biventricular Implantable Cardioverter-Defibrillator Placement.

We present a rare case of an 84-year-old woman who suffered an acute ST-segment elevation myocardial infarction as a postoperative complication of biventricular implantable cardioverter-defibrillator placement, caused by the left ventricular lead impinging onto the second obtuse marginal artery. (Level of Difficulty: Intermediate.).

Displaced AICD Lead Presenting as Hiccups: A Rare Complication.

Ventricular fibrillation can lead to sudden cardiac death. Automatic implantable cardioverter defibrillator (AICD) devices have shown to be highly successful in the termination of these arrhythmias and are a first-line modality of treatment for the prevention of sudden cardiac death. We present the case of a 69-year-old female with a history of paroxysmal atrial fibrillation on anticoagulation with apixaban and rate controlled with metoprolol who presented from home with a chief complaint of hiccups. She had a prior admission to the hospital after she was found to have monomorphic ventricular tachycardia during a nuclear stress test. A cardiac work-up including cardiac catheterization and cardiac magnetic resonance imaging did not show any evidence of significant coronary artery disease or reversible cardiomyopathy. The patient underwent successful placement of a single chamber ICD and was discharged home. Twelve weeks after placement of the AICD, the patient was lifting furniture and experienced sudden onset of hiccups. A chest X-ray showed displacement of the AICD lead from the right ventricular apex to the superior vena cava. The patient underwent lead repositioning with complete resolution of her hiccups. The etiology hiccups was suspected to be secondary to irritation of the right phrenic nerve which travels along the anterolateral border of the superior vena cava. We present the case of hiccups following ICD lead displacement. This serves to highlight a rare complication of ICD displacement that healthcare providers should consider when patients with recently placed ICD devices complain of hiccups.

Aerococcus urinae tricuspid valve infective endocarditis.

Aerococcus urinae is an alpha-hemolytic, gram-positive coccus that is responsible for 54/1,000,000 cases of all urinary tract infections. Risk factors include male gender, advanced age, and genitourinary tract abnormalities. It has often been misidentified as Staphylococcus or Streptococcus due to its morphological similarities. Fewer than 50 cases of A. urinae infective endocarditis have been reported, most affecting the mitral or aortic valve. We present the case of a 61-year-old woman who presented with recurrent fevers and worsening dyspnea on exertion and was found to have A. urinae bacteremia. A transesophageal echocardiogram showed evidence of moderate tricuspid valve regurgitation and vegetations involving its posterior and septal leaflets. The patient was successfully treated with intravenous penicillin G for 6 weeks. She was not deemed a candidate for cardiac surgery.

Invasive Lipoma of the Interventricular Septum, a Rare Benign Cardiac Mass With Atypical Presentation and Management.

Lipoma of the interventricular septum involving the tricuspid valve is a rare entity. A 50-year-old woman presented with exertional dyspnea. She was found to have a large right interventricular septal mass in the initial transthoracic echocardiography. This mass was further investigated by transesophageal echocardiography, cardiac gated CT, and cardiac magnetic resonance imaging. It was found to be lipomatous and embedded into the septal leaflet of the tricuspid valve. The diagnosis was confirmed by biopsy. Surgical exploration revealed that the mass was deeply embedded in the interventricular septum and septal leaflet of the tricuspid valve. The mass was resected along with sections of the interventricular septum and tricuspid valve. She underwent bioprosthetic tricuspid valve placement and patch reconstruction of the interventricular septum. We also searched case reports from MEDLINE and studied pathological and epidemiological characteristics of the published cases of cardiac masses in the past year. Cardiac lipoma although a benign tumor can cause serious hemodynamic complications. Initial transthoracic echocardiography followed by multimodality imaging is the cornerstone of the diagnosis.

Heart Failure as the Initial Presentation of Anomalous Left Coronary Artery From the Pulmonary Artery.

Coronary arteries arising from the pulmonary artery have an incidence of 0.002% in the general population. We present a 29-year-old woman who presented to our hospital with acute decompensated heart failure and atrial fibrillation with a rapid ventricular rate. She underwent a cardiac catheterization to rule out ischemic disease, which revealed retrograde contrast flow through the left coronary artery from the right coronary artery. A coronary computed tomography (CT) angiogram was pursued which showed the presence of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA). For the management of her atrial fibrillation, she was electrically cardioverted. She was discharged on guideline-directed medical therapy for her heart failure, with a cardiac surgery referral for the surgical fixation of her ALCAPA.

Association of Marijuana Use and Cardiovascular Disease: A Behavioral Risk Factor Surveillance System Data Analysis of 133,706 US Adults.

BACKGROUND: Marijuana is the most commonly used psychoactive drug, while its effects on cardiovascular health are not well known and remain a subject of interest. METHODS: We used the pooled 2016-2018 data from the Behavioral Risk Factor Surveillance System to perform a cross-sectional analysis evaluating the association of marijuana and cardiovascular disease among US adults who never smoked cigarettes. RESULTS: Among US adults ages 18-74 years, when compared with nonusers, frequent marijuana use was associated with 88% higher odds of myocardial infarction or coronary artery disease (adjusted odds ratio [aOR] 1.88; 95% confidence interval [CI], 1.15-3.08), and 81% higher odds of stroke (aOR 1.81; 95% CI, 1.14-2.89). Among the premature cardiovascular disease group, frequent marijuana users had 2.3 times higher odds of myocardial infarction or coronary artery disease (aOR 2.27; 95% CI, 1.20-4.30), and 1.9 times higher odds of stroke (aOR 1.92; 95% CI, 1.07-3.43). In terms of the modality of marijuana use, frequent marijuana smoking had 2.1 times higher odds of myocardial infarction or coronary artery disease (aOR 2.07; 95% CI, 1.21-3.56), and 1.8 times higher odds of stroke (aOR 1.84; 95% CI, 1.09-3.10). A similar association was observed in the premature cardiovascular disease group who smoked marijuana (aOR [for myocardial infarction or coronary artery disease] 2.64; 95% CI, 1.37-5.09; aOR [for stroke] 2.00; 95% CI, 1.05-3.79). No association was observed between marijuana use in any form other than smoking and cardiovascular disease, across all age groups. CONCLUSION: Frequent marijuana smoking is associated with significantly higher odds of stroke and myocardial infarction or coronary artery disease, with a possible role in premature cardiovascular disease.

Management of Life-Threatening Bleeding in Patients With Mechanical Heart Valves.

Valvular heart disease is common in the United States, with a number of patients undergoing valve replacement procedures every year. The two types of valve prostheses include mechanical and bioprosthetic valves. Mechanical heart valves require lifelong anticoagulation with vitamin K antagonists like warfarin. The clinicians are often faced with the dilemma of major bleeding episodes such as intracranial hemorrhage or gastrointestinal bleeding in these patients. The management includes reversing warfarin-induced coagulopathy with vitamin K supplementation, fresh frozen plasma, or prothrombin complex concentrate (PCC), with PCC being the treatment of choice. With regard to the safe resumption of anticoagulation, guidelines are silent, and data is limited to case reports/series. This article reviews the present literature for the management of bleeding in patients with mechanical heart valves and the safe duration for holding off anticoagulation with minimal risk of valve thrombosis/thromboembolism.