Francisco Cordova

Reduced hospitalizations in severe, refractory congestive heart failure with peritoneal dialysis: a consecutive case series.

BACKGROUND Peritoneal dialysis (PD) for long-term management of diuretic resistant volume overload in heart failure (HF) may provide potential benefit with few adverse consequences. We examined the impact of PD on clinical status hospitalizations, and complications of therapy in severe end-stage HF. METHODS A consecutive case series of 10 transplant ineligible patients receiving PD solely for HF volume management between 2007 and 2011 was evaluated with clinical data reviewed pre- and post-PD initiation. RESULTS The mean ejection fraction (EF) pre-PD was 24.5 ± 6.0% with the majority of patients having NYHA class IIIB symptoms and moderate-severe right ventricular dysfunction. 9/10 patients were Stage 3 chronic kidney disease (CKD) or worse. After PD initiation, average weight loss was almost 7 kg (p = 0.016) with improvement in diuretic response, peripheral edema, and functional class. There was a significant decrease in re-hospitalization from an average of 3.2 ± 2.5 to 0.1 ± 0.3 admissions per patient (p = 0.007) and reduced average length of stay from 37 ± 36.7 to 0.78 ± 2.3 days (p = 0.019). SUMMARY Objective criteriabased institution of PD for the treatment of diuretic refractory severe-end-stage HF was well tolerated and demonstrated favorable outcomes; these included improved clinical status, reduced hospitalizations and length of stay, with very few and easily treatable PDrelated complications. PD appears to be a viable option in refractory, end-stage congestive heart failure (CHF).

Diagnosis of Left Ventricular Assist Device Outflow Graft Obstruction Using Intravascular Ultrasound

Originally conceived of as a means for bridging patients to heart transplantation, the encouraging long-term outcomes of left ventricular assist devices (LVADs) have led to their increased use in the treatment of heart failure, even in cases where transplant candidacy or availability is unlikely. Despite the life-saving aspects of LVAD therapy to support the patient with end-stage heart failure, issues of pump obstruction and thrombosis persist, resulting in an increasing need for emergent device exchanges or deaths from thrombosis.1 This forms a diagnostic dilemma for care providers because there are a variety of clinical syndromes that may mimic this feared complication, yet the treatment options for bona fide pump thrombosis are limited. Although algorithms have been proposed to address this problem in a standardized fashion,2 there remains considerable heterogeneity in the diagnosis and management of pump thrombosis between centers. Where outflow graft obstruction is suspected, vascular ultrasound has previously been used intraoperatively to confirm the presence of outflow graft obstruction.3 However, intravascular ultrasound (IVUS) offers the benefit of confirming obstruction before taking the patient to the operating suite for device exchange. We present a case of HeartMate II LVAD (Thoratec Corporation, CA) thrombosis in which IVUS was used in this very manner; the first reported case of its kind. A 65-year-old female (62 kg) with …

Serum sickness after antithymocyte globulin administration in a cardiac transplant patient.

CLINICAL HISTORY A 57-year-old gentleman with allo-geneic heart transplantation for nonischemic cardiomyopathy developed nonspecific graft dysfunction 3 years posttransplant. He had no documented cellular or antibody-mediated rejection, graft vasculopathy, and donor-specific antibodies on panel reactive antibody testing. Plasmapheresis and IV immunoglobulin infusions were initiated in addition to increases in maintenance immuno-suppression therapy with no significant impact on his reduced ejection fraction. Because of recurrent presentations of decompensated heart failure despite escalation of care, ATG therapy was initiated with 75 mg of IV rabbit ATG daily for 3 days followed by 50 mg IV for 1 day. Nine days after IV thymoglobulin therapy, he presents with fever, chills, lip swelling, and myalgias. Physical examination revealed mild congestive heart failure and an erythematous and pruritic maculopapular rash. He had tender polyarthritis in his extremities with significant restriction to active and passive range of motion (Fig. 1). Laboratory investigations revealed mild leukocytosis, elevated C-reactive protein, and acute renal insufficiency with no evidence of active sediments on urinalysis. Cytomegalovirus testing was unremarkable. Based on this inflammatory presentation and clinical context, he was diagnosed with SS secondary to IV ATG and started on IV methylprednisolone 1 g daily for 6 days. Failing to show significant improvement at 48 hours, plasmapheresis was initiated for 5 days with marked symptomatic relief after the first exchange. He was discharged home on his 10th day of admission with complete resolution of his presenting symptoms.

Amiodarone‐induced thyrotoxicosis in heart failure with a reduced ejection fraction: A retrospective cohort study

Amiodarone‐induced thyrotoxicosis (AIT) is associated with significant morbidity and mortality. We aimed to describe AIT and its clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF).

CHARACTERISTICS OF ACUTE CORONARY SYNDROME PRESENTATION IN YOUNG PATIENTS

Background: Acute coronary syndrome (ACS) is a major cause of death worldwide. ACS is primarily thought to occur in the elderly and less frequently in adults younger than ≤35 years of age. In this study, we proposed to analyze the presentation of ACS, risk factors, and description of coronary