Bennet George

A retrospective analysis of catheter-based thrombolytic therapy for acute submassive and massive pulmonary embolism

Catheter-based thrombolysis (CBT) is emerging as an option for acute pulmonary embolism (PE). Although prior studies have demonstrated improvement in right ventricular function, little data is available regarding clinical patient outcomes. Our institution adopted CBT as an option for patients with submassive and massive PE and we evaluated its effect on patient outcomes. Two hundred and twenty-one patients who presented to our institution with submassive and massive PE were analyzed over three years by time period; 102 prior to the use of CBT and 119 during the time CBT was performed. The primary outcome was in-hospital major adverse clinical events (a composite of death, recurrent embolism, major bleeding, or stroke). Secondary outcomes were overall and ICU length of stay and individual components of the composite outcome. Mean age was 56.3±16 years with high rates of central PE (57.9%), RV dysfunction (37%), and myocardial necrosis (26%). Mean RV/LV ratio was 1.2. Thirty-two patients were treated with CBT. The composite endpoint occurred more frequently in the CBT era vs the pre-CBT era (21.0% vs 14.7%, p=0.23). After multivariate adjustment, CBT treatment demonstrated no effect on major adverse clinical events (OR 0.84, CI 0.22–3.22, p=0.80). CBT era patients had an unadjusted 37% increase in ICU days and 54% increase in total length of stay (p<0.001). Within the CBT era, CBT treatment resulted in an adjusted 190% increase in overall length of stay (p<0.001). CBT did not demonstrate improvement in hospital outcomes, despite adjustments of PE severity, and was associated with a significant increase in overall and ICU length of stay.

A novel approach to percutaneous removal of large tricuspid valve vegetations using suction filtration and veno‐venous bypass: A single center experience

Tricuspid valve surgery has been the de facto standard treatment for tricuspid valve endocarditis (TVE) refractory to medical therapy. It is now possible to remove right‐sided vegetations percutaneously using a venous drainage cannula with an extracorporeal bypass circuit.

QT prolongation is associated with increased mortality in end stage liver disease

AIM To determine the prevalence of QT prolongation in a large series of end stage liver disease (ESLD) patients and its association to clinical variables and mortality. METHODS The QT interval was measured and corrected for heart rate for each patient, with a prolonged QT cutoff defined as QT > 450 ms for males and QT > 470 ms for females. Multiple clinical variables were evaluated including sex, age, serum sodium, international normalized ratio, creatinine, total bilirubin, beta-blocker use, Model for End-Stage Liver Disease (MELD), MELD-Na, and etiology of liver disease. RESULTS Among 406 ESLD patients analyzed, 207 (51.0%) had QT prolongation. The only clinical variable associated with QT prolongation was male gender (OR = 3.04, 95%CI: 2.01-4.60, P < 0.001). During the study period, 187 patients (46.1%) died. QT prolongation was a significant independent predictor of mortality (OR = 1.69, 95%CI: 1.03-2.77, P = 0.039). In addition, mortality was also associated with viral etiology of ESLD, elevated MELD score and its components (P < 0.05 for all). No significant reversibility in the QT interval was seen after liver transplantation. CONCLUSION QT prolongation was commonly encountered in an ESLD population, especially in males, and served as a strong independent marker for increased mortality in ESLD patients.

The Utility of Remote Hemodynamic Monitoring Devices in Patients with a Ventricular Assist Device

Remote intracardiac hemodynamic monitoring is a growing area of interest to help aid in the management of patients with chronic congestive heart failure. The utility of remote hemodynamic monitoring has not previously been investigated with a ventricular assist device population. We present two cases of patients with ventricular assist devices in which we employed remote hemodynamic monitoring data to aid in patient management.

Fulminant Necrotizing Eosinophilic Myocarditis: A Case Report and Comprehensive Literature Review

Acute eosinophilic myocarditis is a relatively rare disorder with serious morbidity and mortality. Due to its infrequency, standardized management guidelines are wanting. We present a case of acute, necrotizing eosinophilic myocarditis requiring several levels of critical care. We reviewed similar cases reported in the literature to highlight common clinical features, describe natural disease course and associated complications, and review varying approaches to medical therapy.

Acute myocardial injury from carbon monoxide poisoning by cardiac magnetic resonance imaging

A 40-year-old patient presented to our emergency department with altered mental status and supraventricular tachycardia. His carboxyhaemoglobin level was detected at 14%. He was found to have developed myocardial injury with a typical troponin rise and fall peaking at 22.6 ng/mL. Coronary angiography demonstrated normal coronary arteries. A battery of inflammatory and viral serologies was also negative. Cardiac magnetic resonance (CMR) was performed to evaluate the patients left ventricular function and myocardial damage. Steady-state free-precision cine …

A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support

INTRODUCTION While the optimal care of patients with massive pulmonary embolism (PE) is unclear, the general goal of therapy is to rapidly correct the physiologic derangements propagated by obstructive clot. Extracorporeal membrane oxygenation (ECMO) in this setting is promising, however the paucity of data limits its routine use. Our institution expanded the role of ECMO as an advanced therapy option in the initial management of massive PE. The purpose of this project was to evaluate ECMO-treated patients with massive PE at an academic medical center and report shortterm mortality outcomes. METHODS Thirty-two patients placed on ECMO for confirmed, massive PE from January 2012 to December 2015 were retrospectively analyzed. All patients had PE confirmed by computerized tomography and/or invasive pulmonary angiography. RESULTS In our population of patients managed with ECMO, 21 (65.6%) patients survived to decannulation and 17 (53.1%) survived index hospitalization. Baseline characteristics and clinical variables showed no difference in age, gender, right ventricular-to-left ventricular ratios, or peak troponin-T between survivors and non-survivors. Non-survivors tended to have a previous history of malignancy. Cardiac arrest prior to ECMO cannulation was associated with worse outcomes. All 5 patients who received concomitant systemic thrombolysis died, while 11 of 15 patients who received catheter-directed thrombolysis survived. A lactic acid level ≤6mmol/L had an 82.4% sensitivity and 84.6% specificity for predicting survival to discharge. CONCLUSION The practical approach of utilizing ECMO for massive PE is to reserve it for those who would receive the greatest benefit. Patients with poor perfusion, for example from cardiac arrest, may gain less benefit from ECMO. Our findings indicate that a serum lactate >6mmol/L may be an indicator of worse prognosis. Finally, in our patient population, catheter-directed thrombolytics was effectively combined with ECMO.

A Rhythm Revealed: Transient Brugada Pattern

A Rhythm Revealed: Transient Brugada Pattern Julie Shelton, DO, Bennet George, MD, Christian Deutsch, MD, Alison Bailey, MD Department of Internal Medicine, University of Kentucky, Lexington; Division of Cardiovascular Medicine, Linda and Jack Gill Heart Institute, University of Kentucky, Lexington; Division of Cardiovascular Medicine, University of Tennessee COM Chattanooga Erlanger Health System.

RACIAL DIFFERENCES IN HEART FAILURE ADMISSIONS & OUTCOMES AMONG PATIENTS WITH HIV

Background: There is limited data on outcomes of heart failure (HF) hospitalizations in patient with Human Immunodeficiency Virus (HIV). Our study describes epidemiological characteristics regarding patients with HIV admitted with a primary diagnosis of heart failure over a 16 year period in the

Chronologic Changes and Correlates of Loop Diuretic Dose in Patients with Left Ventricular Assist Device

No study has systematically evaluated the prevalence and dosages of diuretic use for patients after left ventricular assist device (LVAD) implantation. The primary objective was to characterize chronologic change in prevalence and doses of loop diuretics after LVAD placement. The secondary objective was to identify correlates of actual doses of loop diuretics. We retrospectively reviewed medical records of adult patients with LVAD implantation at the University of Kentucky. Prevalence of diuretic use and furosemide equivalent dose were assessed before LVAD implantation and at seven time points thereafter: 1 week, 1 month, 3 months, 6 months, 1 year, 18 months, and 2 years. Correlation analyses and linear mixed modeling were used to identify correlates of diuretic dose before and after LVAD implantation. Eighty-two consecutive eligible patients were reviewed. The prevalence of loop diuretic use was 95% at baseline but significantly lower than that at all subsequent time points (p < 0.048 for all). Nevertheless, more than half of patients on whom we had such follow-up data were on loop diuretics 2 years after LVAD implantation. Average furosemide equivalent dose was significantly lower at every time point after implantation compared with baseline (p < 0.006 for all). Blood urine nitrogen (BUN) was the most robust predictor of dose after LVAD implant. The prevalence and average furosemide equivalent dose were significantly reduced after LVAD implantation, but the use of loop diuretic remained more than 50% for up to 2 years. Consistent association with BUN may indirectly indicate overuse of diuretics post-LVAD implant.