Akanksha Agrawal

Real World Utility of Dobutamine Stress Echocardiography in Predicting Perioperative Cardiovascular Morbidity and Mortality after Orthotopic Liver Transplantation

Background and Objectives Stress echocardiography is the current standard for cardiac risk stratification of patients undergoing orthotopic liver transplantation (OLT). We aim to evaluate the role of dobutamine stress echocardiography (DSE) in predicting perioperative major adverse cardiac event (MACE) in patients undergoing OLT. Methods This was a single-center retrospective study including 144 OLT patients. Of 144 patients, 118 had DSE. MACE included myocardial infarction (MI), heart failure (HF), cardiovascular and all-cause death 1 year after OLT. Results Our study cohort included 118 patients. The mean age was 57.3±8.2 years (range, 25–72 years). There were 85 men and 33 women, male to female ratio being 2.6:1. Of 118, 15 (13%) had positive DSE and 103 (87%) had negative DSE. Perioperative MACE incidence was 5.9% (95% confidence interval [CI], 2.6–12.3%). In predicting MACE, DSE had sensitivity of 5.6% (95% CI, 0.2–29.4%), specificity 86% (95% CI, 77.3–91.9%), positive predictive value 6.7% (95% CI, 0.3–33.4%), and negative predictive value (NPV) 83.5% (95% CI, 74.6–89.8%). Eighteen patients had MACE in first year post OLT (15%, 95% CI, 9.5–23.3%). Adverse events included cardiogenic shock (2/18), systolic HF (2/18), non-ST-elevated MI (7/18), cardiac mortality (3/18), and all-cause mortality (7/18). The overall complication rate of DSE was 17% (20/118). Conclusions In our cohort, DSE had a low sensitivity but high NPV in predicting perioperative MACE post OLT. A similar trend was noted for DSE in predicting 1-year MACE post OLT. We reiterate the need of a better screening and risk stratification tool for OLT.

Trends, etiologies, and predictors of 90-day readmission after percutaneous ventricular assist device implantation: A national population-based cohort study

Percutaneous ventricular assist devices (pVADs) are indicated to provide hemodynamic support in high‐risk percutaneous interventions and cardiogenic shock. However, there is a paucity of published data regarding the etiologies and predictors of 90‐day readmissions following pVAD use. We studied the data from the US Nationwide Readmissions Database (NRD) for the years 2013 and 2014. Patients with a primary discharge diagnosis of pVAD use were collected by searching the database for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM) procedural code 37.68 (Impella and TandemHeart devices). Amongst this group, we examined 90‐day readmission rates. Comorbidities as identified by “CM_” variables provided by the NRD were also extracted. The Charlson Comorbidity Index was calculated using appropriate ICD‐9‐CM codes, as a secondary diagnosis. A 2‐level hierarchical logistic regression model was then used to identify predictors of 90‐day readmission following pVAD use. Records from 7074 patients requiring pVAD support during hospitalization showed that 1562 (22%) patients were readmitted within 90u2009days. Acute decompensated heart failure (22.6%) and acute coronary syndromes (11.2%) were the most common etiologies and heart failure (odds ratio [OR]: 1.39, 95% confidence interval [CI]: 1.17–1.67), chronic obstructive pulmonary disease (OR: 1.26, 95% CI: 1.07–1.49), peripheral vascular disease (OR: 1.305, 95% CI: 1.09–1.56), and discharge into short‐ or long‐term facility (OR: 1.28, 95% CI: 1.08–1.51) were independently associated with an increased risk of 90‐day readmission following pVAD use. This study identifies important etiologies and predictors of short‐term readmission in this high‐risk patient group that can be used for risk stratification, optimizing discharge, and healthcare transition decisions.

High Right Ventricular Stroke Work Index Is Associated with Worse Kidney Function in Patients with Heart Failure with Preserved Ejection Fraction

Background: In patients with heart failure with preserved ejection fraction (HFpEF), worse kidney function is associated with worse overall cardiac mechanics. Right ventricular stroke work index (RVSWI) is a parameter of right ventricular function. The aim of our study was to determine the relationship between RVSWI and glomerular filtration rate (GFR) in patients with HFpEF. Method: This was a single-center cross-sectional study. HFpEF is defined as patients with documented heart failure with ejection fraction > 50% and pulmonary wedge pressure > 15 mm Hg from right heart catheterization. RVSWI (normal value 8–12 g/m/beat/m2) was calculated using the formula: RVSWI = 0.0136 × stroke volume index × (mean pulmonary artery pressure – mean right atrial pressure). Univariate and multivariate linear regression analysis was performed to study the correlation between RVSWI and GFR. Result: Ninety-one patients were included in the study. The patients were predominantly female (n = 64, 70%) and African American (n = 61, 67%). Mean age was 66 ± 12 years. Mean GFR was 59 ± 35 mL/min/1.73 m2. Mean RVSWI was 11 ± 6 g/m/beat/m2. Linear regression analysis showed that there was a significant independent inverse relationship between RVSWI and GFR (unstandardized coefficient = –1.3, p = 0.029). In the subgroup with combined post and precapillary pulmonary hypertension (Cpc-PH) the association remained significant (unstandardized coefficient = –1.74, 95% CI –3.37 to –0.11, p = 0.04). Conclusion: High right ventricular workload indicated by high RVSWI is associated with worse renal function in patients with Cpc-PH. Further prospective studies are needed to better understand this association.

A Review of Neurogenic Stunned Myocardium.

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physicians awareness of NSM and its features to help tailor management according to the patients clinical profile.

Cholesterol embolization syndrome: An under-recognized entity in cardiovascular interventions

Cholesterol embolization syndrome (CES) is a multi-systemic disease caused by embolization of atherosclerotic plaque contents from proximal large-caliber artery to distal small to medium arteries, occurring spontaneously or more commonly after vascular intervention. This report is a comprehensive review of the reported cases of CES found in our literature search. We discuss the risk factors, clinical manifestations, management, and prognosis of CES. The major predisposing factors for CES include older age, male sex, atherosclerotic cardiovascular risk factors, anticoagulation, and femoral access route. The composite incidence of atheroembolic renal disease was 92% and mortality 63%. Our review highlights the importance to recognize this disease entity for the cardiologist and nephrologist.

Pericardium: The Forgotten Space During Acute Myocardial Infarction

BACKGROUNDnAcute pericardial pathologies, such as pericardial effusion, pericarditis, and cardiac tamponade, have been reported rarely in patients presenting as ST-elevation myocardial infarction (STEMI). We present a series of 3 patients with STEMI, where an undiagnosed pericardial effusion led to pericardial tamponade and subsequent cardiocirculatory collapse.nnnCASE REPORTSnThis is a case series of 3 patients, all women, aged 72, 64, and 54xa0years who presented to the emergency department with chest pain or syncope and were found to have STEMI with hemodynamic instability. They were taken to the catheterization laboratory for urgent coronary revascularization requiring mechanical circulatory support (intra-aortic balloon pump or impella). During catheterization, all 3 patients were diagnosed with large pericardial effusion using hemodynamic parameters and bedside transesophageal echocardiogram. Commonly ignored, pericardial tamponade and acute large pericardial effusion can be the cause of cardiocirculatory collapse. Two of the 3 patients survived with aggressive interventions requiring pericardial drains, long-term mechanical circulatory support, and effective postoperative rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important for treating clinicians, including emergency physicians, intensivist, and cardiologist, to consider the differential of a cardiac tamponade due to a pericardial effusion as a potential cause for hypotension in patients with an acute STEMI.

Acute Pancreatitis Mimicking ST-Segment Elevation Myocardial Infarction

Introduction Electrocardiographic changes imitating myocardial ischemia have been occasionally reported in patients with intra-abdominal pathology including acute pancreatitis. Case Report A 60-year-old man with no past medical history presented to the emergency department (ED) after a syncopal episode. In ED, his vitals were stable. His ECG showed sinus bradycardia at 53 beats per minute, peaked T waves, 1u2009mm ST-segment elevation in leads II, III, and aVF, and 2u2009mm ST elevation in V3 as shown in the figures. With the concern for STEMI, he was taken for left heart catheterization (LHC) emergently, showing nonobstructive coronary artery disease (CAD). His laboratory workup was remarkable for lipase of 25,304u2009IU/l (normal level 8–78u2009IU/l). His liver function test and triglyceride level were normal. Troponin was <0.01u2009ng/ml. A computed tomographic exam of the abdomen revealed acute interstitial pancreatitis with a small discrete fluid collection in the uncinate process. He was treated with aggressive intravenous fluid resuscitation and was discharged on day 3. Discussion Intra-abdominal pathologies like acute pancreatitis can lead to transient ECG changes mimicking STEMI. It is important to use ECG clues, echocardiographic findings, and clinical judgement to avoid cardiac catheterization, contrast exposure, and associated health care costs.

Common, yet elusive: a case of severe anion gap acidosis

Abstract Acid–base disturbances are common occurrence in hospitalized patients with life threatening complications. 5-oxoproline has been increasingly recognized as cause of high anion gap metabolic acidosis (AGMA) in association with chronic acetaminophen use. However, laboratory workup for it are not widely available. We report case of 56-year-old female with severe AGMA not attributable to ketoacidosis, lactic acidosis or toxic ingestion. History was significant for chronic acetaminophen use, and laboratory workup negative for all frequent causes of AGMA. Given history and clinical presentation, our suspicion for 5-oxoproline toxicity was high. Our patient required emergent hemodialysis and subsequently improved clinically. With an increasing awareness of the uncommon causes of high AGMA, tests should be more readily available to detect their presence. Physicians should be more vigilant of underdiagnosed causes of AGMA if the presentation and laboratory values do not reflect a common cause, as definitive treatment may vary based on the offending agent.

Hyperplastic Polyps and Gastroduodenal Pseudomelanosis

Pseudomelanosis is a rare endoscopic finding of the upper gastrointestinal tract characterized by hemosiderin deposits in histiocytes of lamina propria. We report a case of 72-year-old lady on chronic oral iron supplementation diagnosed with gastric hyperplastic polyps with background pseudomelanosis of stomach and duodenum. Concomitant occurrence of gastric pseudomelanosis, duodenal pseudomelanosis, and gastric hyperplastic polyps has never been reported. Its presence in the absence of gastritis raises question if pseudomelanosis could be associated with hyperplastic polyp. With limited literature on its etiology and prognosis, these patients should be prospectively followed and reported to study the natural history of the disease.

Overt Lower Gastrointestinal Bleeding and Pseudotumor: A Rare Presentation of Cytomegalovirus Infection

Cytomegalovirus (CMV) is a ubiquitous organism which can infect multiple organs of the body. In an immunocompromised patient, it can have a myriad of gastrointestinal manifestations. We report a case of recurrent hematochezia and concomitant pseudotumor in an AIDS (acquired immunodeficiency syndrome) patient attributable to CMV infection. A 62-year-old man with a history of AIDS, noncompliant with highly active antiretroviral therapy (HAART), presented with bright red blood per rectum. Index colonoscopy showed presence of multiple ulcers, colonic stenosis, and mass-like appearing lesion. Biopsy confirmed CMV infection and ruled out malignancy. Cessation of dual antiplatelet therapy and compliance with HAART lead to clinical cessation of bleeding and endoscopic healing of ulcers with complete resolution of colon mass on follow-up colonoscopy.