Texas Heart Institute Journal Volume 42: Issue 5

Patients with end-stage liver disease frequently have baseline coagulopathies. The international normalized ratio is in common use for the estimation of bleeding tendency in such patients, especially those undergoing an invasive procedure like cardiac catheterization. The practice of international normalized ratio measurement—followed by pharmacologic (for example, vitamin K or fresh frozen plasma) or nonpharmacologic intervention—is still debatable. The results of multiple randomized trials have shown the superiority of the radial approach over femoral access in reducing catheterization bleeding. This reduction in bleeding in turn decreases the risk and cost of blood-product transfusion. However, there is little evidence regarding the use of the radial approach in the end-stage liver disease patient population specifically. In this review, we summarize the studies that have dealt with cardiac catheterization in patients who have end-stage liver disease. We also discuss the role of the current measurements that are used to reduce the risk of bleeding in these same patients.

Left ventricular assist device (LVAD) therapy improves survival, hemodynamic status, and end-organ perfusion in patients with refractory advanced heart failure. Hospital readmission is an important measure of the intensity of LVAD support care.

We analyzed readmissions of 148 patients (mean age, 53.6 ± 12.7 yr; 83% male) who received a HeartMate II LVAD from April 2008 through June 2012. The patients had severe heart failure; 60.1% were in Interagency Registry for Mechanically Assisted Circulatory Support class 1 or 2. All patients were observed for at least 12 months, and readmissions were classified as planned or unplanned. Descriptive and multivariate regression analyses were used to identify predictors of unplanned readmission.

Twenty-seven patients (18.2%) had no readmissions or 69 planned readmissions, and 121 patients (81.8%) had 460 unplanned readmissions. The LVAD-related readmissions were for bleeding, thrombosis, and anticoagulation (n=103; 49.1%), pump-related infections (n=60; 28.6%), and neurologic events (n=28; 13.3%). The readmission rate was 2.1 per patient-year. Unplanned readmissions were for comorbidities and underlying cardiac disease (54.3%) or LVAD-related causes (45.7%). In the unplanned-readmission rate, there was no significant difference between bridge-to-transplantation and destination-therapy patients. Unplanned readmissions were associated with diabetes mellitus (odds ratio [OR]=3.3; P=0.04) and with shorter mileage from residence to hospital (OR=0.998; P=0.046).

Unplanned admissions for LVAD-related sequelae and ongoing comorbidities were common. Diabetes mellitus and shorter distance from residence to hospital were significant predictors of readmission. We project that improved management of comorbidities and of anticoagulation therapy will reduce unplanned readmissions of LVAD patients in the future.

The customary recommendation is that oral anticoagulation be withdrawn a few months after cryoablation for atrial fibrillation, independently of left atrial mechanical contraction in patients in sinus rhythm. Recently, a 5-fold increase in stroke has been described in sinus-rhythm patients who lack atrial mechanical contraction. One aim of this study was to evaluate the efficacy of oral anticoagulation in preventing postoperative stroke in such patients.

This prospective study divided 154 sinus-rhythm patients into 2 groups, depending on the presence (108 patients) or absence (46 patients) of left atrial mechanical contraction at 6 months after surgery, and monitored them annually for 5 years. Those without left atrial contraction were maintained on acenocumarol. The primary endpoint was the occurrence of ischemic stroke.

The median follow-up period was 29 ± 16 months; 4 patients (2.5%), all belonging to the group with preserved atrial contraction, had ischemic stroke; the group of patients without left atrial contraction had no episodes of stroke during follow-up. Logistic binary regression analyses showed no evidence of factors independently predictive of stroke.

Among anticoagulated patients in sinus rhythm without left atrial contraction, we found the incidence of stroke to be zero. In a small, nonrandomized group such as this, we cannot discount the element of chance, yet we suggest that maintaining anticoagulation might lower the incidence of stroke in this population.

Kenneth M. Ludmerer, MD. 431 pages. New York: Oxford University Press; 2015. Hardcover: US $34.95; ISBN 978-0-19-974454-1. Available from Oxford University Press, Amazon.com, and BarnesandNoble.com.

Field of Medicine: Residency training in America

Format: Hardcover book. Trim size: 6½ × 9½ inches

Recommended Readership: Anyone interested in or involved with medical education and patient care in America

Purpose: To provide the first-ever account of the residency system for training doctors in the United States

Content: There are 334 pages of text and 13 chapters that trace residency training in America from its

The Houston HeartReach Registry: Recruitment Methods and Current Registry Demographics

Jaqueline FerrufinoBA,

Symone A. TaylorBSA,

Karla CamposMD,

Keri SprungMBA,

Matthew W. SegarMD, MS, and

Stephanie A. CoulterMD

In Memoriam: Jerome H. Kay, Floyd D. Loop, and Jack M. Matloff

Jerome H. Kay, MD (1921–2015)

Let Me Heal: An Instant Classic

A Heartfelt Letter to My Father's Doctor

Risk of Bleeding in End-Stage Liver Disease Patients Undergoing Cardiac Catheterization

Present-Day Hospital Readmissions after Left Ventricular Assist Device Implantation: A Large Single-Center Study

Efficacy of Oral Anticoagulation in Stroke Prevention among Sinus-Rhythm Patients Who Lack Left Atrial Mechanical Contraction after Cryoablation

Coronary Interventions before Liver Transplantation Might Not Avert Postoperative Cardiovascular Events

Combined Retrograde/Antegrade Approach to Transcatheter Closure of an Aortic Paravalvular Leak

Evaluation of Previously Cannulated Radial Arteries as Patent Coronary Artery Bypass Conduits

Conservative Management of Cardiac Hemangioma for 11 Years

Cobrahead Deformity in the Right Atrial Disc of a New-Generation Occlutech Figulla Flex II Atrial Septal Defect Occluder Device

Down Syndrome with Complete Atrioventricular Septal Defect, Hypertrophic Cardiomyopathy, and Pulmonary Vein Stenosis

Unruptured Sinus of Valsalva Aneurysm with Right Ventricular Outflow Tract Obstruction and Supracristal Ventricular Septal Defect: A Rare Case

Massive Pulmonary Artery Aneurysm Causing Left Main Coronary Artery Compression in the Absence of Pulmonary Hypertension

Aspergillus Mediastinitis after Orthotopic Heart Transplantation: A Case Report

Extracorporeal Membrane Oxygenation as a Bridge to Surgery for Infective Endocarditis Complicated by Aorto-Atrial Fistula and Cardiopulmonary Collapse

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

Spontaneous Coronary Artery Dissection with Cardiac Tamponade

Successful Prasugrel Therapy for Recurrent Left Main Stent Thrombosis in a Clopidogrel Hyporesponder

Very Late Stent Thrombosis 11 Years after Implantation of a Drug-Eluting Stent

A Reminder of Methylene Blue's Effectiveness in Treating Vasoplegic Syndrome after On-Pump Cardiac Surgery

Acute Respiratory Failure Induced by Magnesium Replacement in a 62-Year-Old Woman with Myasthenia Gravis

Platypnea-Orthodeoxia Syndrome: Diagnostic Challenge and the Importance of Heightened Clinical Suspicion

Atrial Fibrillation in a 35-Year-Old Man with Wolff-Parkinson-White Syndrome

Pulmonary Artery Sling Causing Tracheal Stenosis in a Neonate

Let Me Heal: The Opportunity to Preserve Excellence in American Medicine

Repair of Bland-White-Garland Syndrome via a Modified Technique

The Houston HeartReach Registry: Recruitment Methods and Current Registry Demographics

In Memoriam: Mark Wholey, MD

Nine-Year Follow-Up of Conservatively Managed Acute Type A Aortic Dissection in an Older Patient

The Texas Heart Institute and Ray C. Fish Award for Scientific Achievement in Cardiovascular Diseases

Extravascular Images of a Penetrating Aortic Ulcer Discovered During Robotic Segmentectomy