Abstract
Coronary ostial atresia is a developmental abnormality that typically causes asymptomatic anomalies in the coronary blood supply. This case report, which presents 2 symptomatic patients with right coronary artery abnormalities, explores difficulties in diagnosing coronary ostial atresia and distinguishing it from single coronary artery and coronary artery disease–related acquired occlusion. Factors underlying management decisions are also discussed.
Abstract
Trigeminal amyloidoma is a rare clinical phenomenon with scarce reports in the medical literature. This report presents a case of biopsy-proven trigeminal amyloidoma in a patient with cardiac amyloidosis. This case report sheds light on the differential diagnoses that may resemble trigeminal amyloidoma and strategies for workup and treatment.
Case Description
An 85-year-old man with stable angina underwent an elective percutaneous coronary intervention through the right radial artery under dual antiplatelet therapy. One hour after the procedure, he reported increasing pain in his right axilla. A noncontrast computed tomography scan revealed a massive axillary hematoma, suggestive of catheter-related arterial bleeding (Fig. 1). Urgent angiography via percutaneous right brachial artery access revealed the perforation of an axillary coronary artery branch (Fig. 2A). The extravasation was not observed in selective angiography of thoracoacromial artery branches (Fig. 2B). The small side branch distal to the thoracoacromial
Abstract
Background
Arrhythmogenic right ventricular (RV) cardiomyopathy is a progressive disease characterized by the replacement of the normal myocardium with fibrofatty tissue. This study aimed to determine the value of echocardiographic RV deformation parameters in predicting electrical progression as assessed by serial changes in RV lead sensing and threshold in patients with arrhythmogenic RV cardiomyopathy.
Methods
The present study recruited 40 patients with a definitive diagnosis of arrhythmogenic RV cardiomyopathy at a mean (SD) age of 38.6 (14.2) years between 2018 and 2020. All patients had received an implantable cardioverter-defibrillator for the primary or secondary prevention of sudden cardiac death. The patients underwent 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiographic examinations and RV 2D and 3D strain analyses, comprising free-wall longitudinal strain, global longitudinal strain, and strain rate. They were then followed up for electrical progression.
Results
During a mean (SD) follow-up period of 20 (6) months, the RV lead amplitude decreased from 7.95 (IQR, 4.53-10.25) mV to 5.25 (IQR, 2.88-8.55) mV (P < .001), and the lead threshold increased from 0.75 (IQR, 0.50-0.79) V to 0.75 (IQR, 0.75-1.00) V (P < .001). Right ventricular 2D free-wall (ρ = 0.56, P = .01), RV 2D global (ρ = 0.58, P = .007), and RV 3D free-wall (ρ = 0.65; P = .003) longitudinal strain correlated with electrical progression.
Conclusion
Right ventricular 2D and 3D deformation parameters were found to be significant predictors of electrical progression during follow-up of patients with arrhythmogenic RV cardiomyopathy. These findings suggest that echocardiography has a pivotal role in predicting patients at high risk for electrical progression.
Abstract
Background
COVID-19 may be a risk factor for developing cardiovascular autonomic dysfunction. Data are limited, however, on the association between heart rate variability, heart rate turbulence, and COVID-19. The aims of this study were to evaluate the effect of COVID-19 on the cardiovascular autonomic system in patients with persistent symptoms after recovering from COVID-19 and to determine whether these patients showed changes in ambulatory electrocardiography monitoring.
Methods
Fifty-one adults who had confirmed SARS-CoV-2 infection and presented with persistent symptoms to the cardiology outpatient clinic after clinical recovery between April and June 2021 were included. Patients were prospectively followed for 6 months. The patients were evaluated at the time of first application to the cardiology outpatient clinic and at 6 months after presentation. Ambulatory electrocardiography monitoring and echocardiographic findings were compared with a control group of 95 patients.
Results
Patients in the post–COVID-19 group had significantly higher mean (SD) turbulence onset (0.39% [1.82%] vs −1.37% [2.93%]; P < .001) and lower heart rate variability than those in the control group at both initial and 6-month evaluations. The post–COVID-19 group had no significant differences in echocardiographic findings compared with the control group at 6 months, except for right ventricle late diastolic mitral annular velocity (P = .034). Furthermore, turbulence onset was significantly correlated with turbulence slope (r = −0.232; P = .004), heart rate variability, and the parameters of left (r = −0.194; P=.049) and right (r = 0.225; P = .02) ventricular diastolic function.
Conclusions
COVID-19 may cause cardiovascular autonomic dysfunction. Heart rate variability and turbulence parameters can be used to recognize cardiovascular autonomic dysfunction in patients who have recovered from COVID-19 but have persistent symptoms.
Abstract
Background
Postoperative respiratory failure is a major complication that affects up to 10% of patients who undergo cardiac surgery and has a high in-hospital mortality rate. Few studies have investigated whether patients who require tracheostomy for postoperative respiratory failure after continuous-flow left ventricular assist device (CF-LVAD) implantation have worse survival outcomes than patients who do not.
Objective
To identify risk factors for respiratory failure necessitating tracheostomy in CF-LVAD recipients and to compare survival outcomes between those who did and did not require tracheostomy.
Methods
Consecutive patients who underwent primary CF-LVAD placement at a single institution between August 1, 2002, and December 31, 2019, were retrospectively reviewed. Propensity score matching accounted for baseline differences between the tracheostomy and nontracheostomy groups. Multivariate logistic regression was used to identify tracheostomy risk factors and 90-day survival; Kaplan-Meier analysis was used to assess midterm survival.
Results
During the study period, 664 patients received a CF-LVAD; 106 (16.0%) underwent tracheostomy for respiratory failure. Propensity score matching produced 103 matched tracheostomy-nontracheostomy pairs. Patients who underwent tracheostomy were older (mean [SD] age, 57.9 [12.3] vs 54.6 [13.9] years; P = .02) and more likely to need preoperative mechanical circulatory support (61.3% vs 47.8%; P = .01) and preoperative intubation (27.4% vs 8.8%; P < .001); serum creatinine was higher in the tracheostomy group (mean [SD], 1.7 [1.0] vs 1.4 [0.6] mg/dL; P < .001), correlating with tracheostomy need (odds ratio, 1.76; 95% CI, 1.21-2.56; P = .003). Both before and after propensity matching, 30-day, 60-day, 90-day, and 1-year survival were worse in patients who underwent tracheostomy. Median follow-up was 0.8 years (range, 0.0-11.2 years). Three-year Kaplan-Meier survival was significantly worse for the tracheostomy group before (22.0% vs 61.0%; P < .001) and after (22.4% vs 48.3%; P < .001) matching.
Conclusion
Given the substantially increased probability of death in patients who develop respiratory failure and need tracheostomy, those at high risk for respiratory failure should be carefully considered for CF-LVAD implantation. Comprehensive management to decrease respiratory failure before and after surgery is critical.
Abstract
Background
The study aimed to review differences in the presentation and outcomes of acute pulmonary embolism (PE) between men and women.
Methods
PubMed, CENTRAL, Web of Science, and Embase were searched for studies comparing clinical features or outcomes of PE between men and women. Baseline comorbidities, risk factors, clinical features, and mortality rates were also compared between men and women.
Results
Fourteen studies were included. It was noted that men presented with PE at a statistically significantly younger age than women (P < .001). Smoking history (P < .001), lung disease (P = .004), malignancy (P = .02), and unprovoked PE (P = .004) were significantly more frequent among men than among women. There was no difference between the sexes for hypertension, diabetes, and a history of recent immobilization. A significantly higher proportion of men presented with chest pain (P = .02) and hemoptysis (P < .001), whereas syncope (P = .005) was more frequent in women. Compared with men, women had a higher proportion of high-risk PE (P = .003). There was no difference in the use of thrombolytic therapy or inferior vena cava filter. Neither crude nor adjusted mortality rates were significantly different between men and women.
Conclusion
This review found that the age at presentation, comorbidities, and symptoms of PE differed between men and women. Limited data also suggest that women more frequently had high-risk PE compared with men, but the use of thrombolytic therapy did not differ between the 2 sexes. Importantly, both crude and adjusted data show that the mortality rate did not differ between men and women.
Abbreviations and Acronyms
- ASD
atrial septal defect
- hs-cTnT
high-sensitivity cardiac troponin T
- URL
upper reference limit
Troponin levels are used to rule in or rule out myocardial injury, with the T and I subunits being the biomarkers of choice. The use of high-sensitivity kits is recommended in clinical practice.1 There are no reference values after percutaneous occlusion of an ostium secundum–type atrial septal defect (ASD).
The objective of this study was to describe the values of high-sensitivity cardiac troponin T (hs-cTnT) in a population that received percutaneous treatment for ASD without complications.
This observational, prospective, and comparative study
Abbreviations and Acronyms
- D5W
dextrose 5% in water
- ECMO
extracorporeal membrane oxygenation
- IABP
intra-aortic balloon pump
- UFH
unfractionated heparin
Introduction
Anticoagulation is needed with most mechanical circulatory support devices to prevent device thrombosis and obstruction of flow at access sites, namely, the common femoral artery, especially in patients with small vessels and peripheral artery disease. However, these patients are also at high risk of bleeding, so close monitoring is required. Temporary mechanical support devices differ in profile, with the Impella (Abiomed) being smaller than the TandemHeart (CardiacAssist, Inc) or extracorporeal membrane oxygenation (ECMO) devices, providing different levels of hemodynamic support.
Abbreviations and Acronyms
- INR
international normalized ratio
- LVAD
left ventricular assist device
Introduction
Patients with left ventricular assist devices (LVADs) are at a high risk of both bleeding and thrombotic complications. Patients must be on therapeutic anticoagulation to prevent pump thrombosis, but many develop acquired von Willebrand disease from the shear stress.1 Careful management of anticoagulation is essential for these patients.
Current Recommendations
The manufacturer of the HeartMate 3 LVAD (Abbott Vascular) recommends bridging with heparin, with gradual titration to therapeutic levels. In addition to warfarin, 81 to 100 mg aspirin is recommended, with a target international normalized
Abbreviations and Acronyms
- CMS
Centers for Medicare & Medicaid Services
- HF
heart failure
- LVAD
left ventricular assist device
- PC
palliative care
Left ventricular assist devices (LVAD) can be used as either short-term (ie, bridge) or long-term (ie, destination) therapies. In the latter instance, discussion with the patient about end of life with an LVAD is necessary. Important issues at end of life for these patients range from aggressive symptom management to quality-of-life and ethical dilemmas. Multiple members of the multidisciplinary team caring for a patient with an LVAD can manage these concerns, but the support of a palliative care (PC)
Abbreviations and Acronyms
- IVC
inferior vena cava
- VTi
velocity time integral
Introduction
Fluid management is a crucial component of acute care in the intensive care unit. Early goal-directed therapy has shown better outcomes in patients with septic shock.1 Increased end-diastolic volume and stroke volume depend on ventricular function. The accurate assessment of intravascular volume and adequate maintenance of cardiac preload can improve the outcomes of critically ill patients. Overresuscitation without fluid responsiveness may result in more harm by shifting fluid to the extravascular space and causing end-organ edema. To select patients who might benefit from volume expansion, many
Abbreviations and Acronyms
- ECMO
extracorporeal membrane oxygenation
Introduction
Over the past few decades, ultrasonography has become an increasingly popular method of imaging in various clinical settings, from rapid assessment of patients who are critically ill to real-time visualization of invasive procedures. This increasing utility of ultrasonography can be largely contributed to its ability to visualize blood vessels and organs with little to no risk for the patient, which reduces the need to rely on subjective experiences with procedures. For example, compared with central venous cannulation through anatomical landmark palpation, ultrasound-guided cannulation is associated with a significantly lower rate of overall
Abbreviations and Acronyms
- CVP
central venous pressure
- EUROMACS
European Registry for Patients With Mechanical Circulatory Support
- INTERMACS
Interagency Registry for Mechanically Assisted Circulatory Support
- IVS
interventricular septum
- LVAD
left ventricular assist device
- RV
right ventricular
- RVAD
right ventricular assist device
Introduction
Left ventricular assist devices (LVADs) have become an increasingly common therapeutic option for patients with advanced heart failure. Unfortunately, the right ventricle is not afforded the same benefit, and right ventricular failure (RVF) is a major cause of morbidity in patients with LVADs. Early intraoperative diagnosis and management of RVF after LVAD implantation is therefore crucial to improve patient
Abbreviations and Acronyms
- ECMO
extracorporeal membrane oxygenation
- FoCUS
focused cardiac ultrasonography
- LVEF
left ventricular ejection fraction
- LVOT
left ventricular outflow tract
- VA
venoarterial
- VTI
velocity time integral
Introduction
The timing of extracorporeal membrane oxygenation (ECMO) weaning and removal is crucial in the treatment of patients with cardiocirculatory failure, with direct impacts on outcomes and resource utilization. Although pulmonary recovery for patients receiving venovenous ECMO is dictated by intrinsic gas exchange, lung compliance, and mechanical ventilator settings, criteria for ventricular function recoverability in patients receiving venoarterial (VA) ECMO is more complex. For this reason, a methodical approach to weaning and removal
Abbreviations and Acronyms
- LVAD
left ventricular assist device
- VS
vasoplegic shock
Introduction
Vasoplegic shock (VS) after left ventricular assist device (LVAD) implantation is characterized by high cardiac output; low systemic vascular resistance; and refractory hypotension, with the need for higher-dose vasopressors. There is considerable heterogeneity in how VS is defined; as a result, its incidence can vary widely in published series and ranges from 10% to 45% after LVAD implantation.1–4
Current Limitations
Much of what the medical community understands about the pathophysiology of VS is derived from its understanding of distributive shock in sepsis and after cardiopulmonary
Abbreviations and Acronyms
- ICU
intensive care unit
- MCS
mechanical circulatory support
- PT
physical therapy
Introduction
Patients on mechanical circulatory support (MCS) are at particularly high risk for deconditioning during a stay in the intensive care unit (ICU). Although mobilization of the general ICU population has been proven safe, effective, and feasible,1 the mobilization of the critically ill MCS population requires specific knowledge of support devices and may present specific barriers to mobilization. Patient factors such as anxiety, motivation, difficult ventilator weaning, diaphragmatic weakness, femoral cannulation concerns, and sedation practices often limit mobility progression with traditional rehabilitative methods. Although
Abbreviations and Acronyms
- INR
international normalized ratio
- LVAD
left ventricular assist device
- PCC
prothrombin complex concentrate
- VWF
Von Willebrand factor
Introduction
Implantation of a left ventricular assist device (LVAD) is 1 of the most complex interventions in cardiovascular surgery. Nevertheless, use of this procedure has increased, with the number of procedures doubling between 2010 and 2019. Left ventricular assist device implantation is performed by select teams at a limited number of facilities. Clinical practice for LVAD support continues to evolve as teams gain experience and devices are improved. This article discusses the interplay of LVAD implantation and the coagulation process—specifically,
Abbreviations and Acronyms
- CPB
cardiopulmonary bypass
- LVAD
left ventricular assist device
- PA
pulmonary artery
- RV
right ventricle
Introduction
This article summarizes the perspective from Baylor College of Medicine and The Texas Heart Institute on the key surgical considerations for ensuring a successful outcome after left ventricular assist device (LVAD) implantation.
Currently, the HeartMate 3 (Abbott Cardiovascular) is the only US Food and Drug Administration–approved durable LVAD on the market (Fig. 1).1 The HeartMate 3 is an excellent device associated with good long-term survival, with 5-year survival at 58.4% compared with 43.7% for the HeartMate II in
Abbreviations and Acronyms
- LVAD
left ventricular assist device
- MCS
mechanical circulatory support
- RV
right ventricle
- VA-ECMO
venoarterial extracorporeal membrane oxygenation
Introduction
The goals of temporary mechanical circulatory support (MCS) are to treat cardiogenic shock, restore sufficient end-organ perfusion, reduce left ventricle end-diastolic pressure, and alleviate pulmonary congestion. In anticipation of durable left ventricular assist device (LVAD) implantation, volume status and right ventricle (RV) function must be optimized. Additional objectives of MCS before LVAD implant include preservation of sternal integrity, minimizing infectious complications, and improving the physical conditioning of the patient.
Candidate Evaluation
Patient considerations include hemodynamic status and the need
Abbreviations and Acronyms
- LVAD
left ventricular assist device
- RVF
right ventricular failure
Introduction
The past 10 years have seen an increase in left ventricular assist device (LVAD) implantation, sicker patients at implant, and improved long-term LVAD survival.1 This article provides an updated review of the fundamentals and limitations of LVAD optimization, particularly in the perioperative phase.
Current Limitations
Notable areas for improvement in postoperative LVAD care are lack of a consensus definition for right ventricular failure (RVF), limited long-term options for persistent RVF, and the absence of randomized trials to guide perioperative therapies.
Recent Developments
Right ventricular failure
Abbreviations and Acronyms
- POCUS
Point-of-care ultrasonography
Introduction
Point-of-care ultrasonography (POCUS) refers to the use of portable ultrasonography devices that can be used at the bedside by health care professionals in a variety of settings to augment diagnosis, manage disease, and expedite patient care as well as guide invasive procedures. The rate of adoption of POCUS is outpacing current safeguards, and a new framework will be necessary to mitigate diagnostic errors as multiple clinicians acquire and implement POCUS skills.1 Given the prevalence of medical diagnostic errors, it will be crucial to incorporate approaches that address the risk of those
In the article titled “Anticoagulation Management in Temporary Mechanical Circulatory Support Devices,”1 published July 21, 2023, minor corrections to the final text should have been incorporated.
Introduction, sentence 5
The TandemHeart manufacturer was identified as LivaNova, and this has now been corrected to CardiacAssist, Inc.
Current Recommendations, Extracorporeal Membrane Oxygenation, column 2
Original
However, viscoelastic assays need to be studied further before they can be recommended for widespread use in the cardiac critical care unit with UFH in patients receiving ECMO. Existing studies have shown lower rates of mortality, transfusions,
