Gabriel A. Hernandez

Argatroban as novel therapy for suspected thrombosis in patients with continuous-flow left ventricle assist device and hemolysis

The growing use of left ventricular assist devices as a bridge to transplant and their increased duration as destination therapy in patients successfully treated for advance heart failure unwrap a new spectrum of complications seen in long-term use of the devices. Device thrombosis remains a therapeutic dilemma, and limited data are available for the use of direct thrombin inhibitors as a treatment option. We performed a review of literature and present a series of four patients with suspected left ventricular assist device-associated thrombosis, manifesting as hemolysis, who were treated empirically with argotraban, a direct thrombin inhibitor with the ability to interact with both free and clot-bound thrombin. In this case series, we treated four patients with argatroban for suspected device thrombosis. All showed significant improvement of hemolysis according to lactate dehydrogenase measurements, and device removal was prevented in three. Bleeding complications occurred when therapy was used closer to the operative period. Argatroban can be a viable option to treat patients with hemolysis from suspected device thrombosis in patients with HeartMate II continuous-flow left ventricular assist device. Prompt attention is needed to monitor any bleeding complications.

Incidence of Hemolysis in Patients with Cardiogenic Shock Treated with Impella Percutaneous Left Ventricular Assist Device.

Impella assist devices have been increasingly used in cardiogenic shock (CS). This study aims to assess the incidence of hemolysis when Impella support is used longer than 6 hours in CS. We retrospectively studied all patients who required Impella between April 2009 and September 2013. Demographic data and hemolysis indicators were sampled and analyzed using paired t-test. A total of 118 devices were placed and 40 used longer than 6 hours. The average time of support was 86.63 hours, and the 30 and 90 days of survival were 65% and 60%, respectively. After 24 hours of support, the hemoglobin (Hb) decreased significantly despite 17% of patients receiving blood transfusion (p = 0.0001). By the time of removal, 65% of patients were transfused to maintain a Hb of 10 mg/dl (p = 0.0014). The lactate dehydrogenase (LDH) increased to 5,201 U/L (n = 22; p = 0.0096), the bilirubin to 5.6 mg/dl (p = 0.008), and the haptoglobin level was 15.4 mg/dl (n = 25). The cumulative incidence of hemolysis was 62.5%. Hemolysis is a common occurrence in patients with long-term Impella support for CS, evaluated by the persistent decline in Hb and haptoglobin as well as increase in LDH and bilirubin. Strict monitoring of hemolysis parameters at baseline and at frequent intervals is crucial.

In-stent thrombosis when switching ticagrelor to clopidogrel after percutaneous coronary intervention.

Abstract Dual antiplatelet therapy with aspirin and a P2Y12 receptor blocker has been proven to reduce subsequent cardiovascular events and in-stent thrombosis in patients undergoing percutaneous coronary intervention. Newer P2Y12 antagonists with faster onset and greater inhibition of platelet activity have improved cardiovascular outcomes but have created uncertainty with the appropriate dosing when switching between agents. Currently, there are no evidence-based guidelines to aid clinicians when switching between P2Y12 receptor blockers. Here we describe two patients that developed in-stent thrombosis when switching from ticagrelor to clopidogrel using a 300 mg clopidogrel loading dose. Both patients presented with ST elevation myocardial infarction and underwent stent placement but then developed in-stent thrombosis 48 hours after switching from ticagrelor to clopidogrel. These cases illustrate the severe consequences of suboptimal platelet inhibition and the need for prospective trials thoroughly powered to assess clinical outcomes in order to determine the most appropriate strategy when switching from ticagrelor to clopidogrel.

Leiomyosarcoma of the Splenic Vein

Leiomyosarcomas arising from the wall of blood vessels are rare and aggressive neoplasm. We report a case of a previously healthy 66-year-old woman who presented with intermittent abdominal pain, progressive constipation, and weight loss. Abdominal computed tomography showed a 12 cm solid heterogeneous tumor in the tail of the pancreas. The patient subsequently underwent surgical resection of the pancreatic mass. Surprisingly, histological and immunohistochemical analyses revealed leiomyosarcoma arising from the smooth muscle of the splenic vein. After surgery, she received adjuvant chemotherapy. One year later, there was no evidence of local recurrence. In this paper, we discuss the available information about leiomyosarcomas of splenic vein and its management.

Mycobacterium abscessus Left Ventricle Assist Device Driveline Infections: An Emerging Pathogen?

The use of left ventricular assist device is associated with improvement in survival in patients with refractory heart failure. However, driveline infection limits the success of its use as it is associated with significant mortality. We describe the first 2 cases of Mycobacterium abscessus driveline infection. Both patients had persistent infection despite of aggressive antibiotic treatment and local debridement, and only improved after removal of their left ventricular assist devices.

Trends in utilization of mechanical circulatory support in patients hospitalized after out-of-hospital cardiac arrest

OBJECTIVE This study sought to examine the trends and predictors of mechanical circulatory support (MCS) use in patients hospitalized after out-of-hospital cardiac arrest (OHCA). BACKGROUND There is a paucity of data regarding MCS use in patients hospitalized after OHCA. METHODS We conducted an observational analysis of MCS use in 960,428 patients hospitalized after OHCA between January 2008 and December 2014 in the Nationwide Inpatient Sample database. On multivariable analysis, we also assessed factors associated with MCS use and survival to discharge. RESULTS Among the 960,428 patients, 51,863 (5.4%) had MCS utilized. Intra-aortic balloon pump (IABP) was the most commonly used MCS after OHCA with frequency of 47,061 (4.9%), followed by extracorporeal membrane oxygenation (ECMO) 3650 (0.4%), and percutaneous ventricular assist devices (PVAD) 3265 (0.3%). From 2008 to 2014, there was an increase in the utilization of MCS from 5% in 2008 to 5.7% in 2014 (P trend < 0.001). There was a non-significant decline in the use of IABP from 4.9% to 4.7% (P trend = 0.95), whereas PVAD use increased from 0.04% to 0.7% (P trend < 0.001), and ECMO use increased from 0.1% to 0.7% (P trend < 0.001) during the study period. Younger, male patients with myocardial infarction, higher co-morbid conditions, VT/VF as initial rhythm, and presentation to a large urban hospital were more likely to receive percutaneous MCS implantation. Survival to discharge was significantly higher in patients who were selected to receive MCS (56.9% vs. 43.1%, OR: 1.16, 95% CI: (1.11-1.21), p < 0.001). CONCLUSIONS There is a steady increase in the use of MCS in OHCA, especially PVAD and ECMO, despite lack of randomized clinical trial data supporting an improvement in outcomes. More definitive randomized studies are needed to assess accurately the optimal role of MCS in this patient population.

TCT-23 Contemporary Trends in Utilization of Mechanical Circulatory Support in Patients Hospitalized After Out-of-Hospital Cardiac Arrest

TCT-23 Contemporary Trends in Utilization of Mechanical Circulatory Support in Patients Hospitalized After Out-of-Hospital Cardiac Arrest Nileshkumar Patel, Nish Patel, Gabriel Hernandez, Shilpkumar Arora, Apurva Badheka, Abhishek Deshmukh, Eduardo DeMarchena, Mauricio Cohen, Carlos Alfonso, Deepak Bhatt, Navin Kapur University of Miami, MIAMI, Florida, United States; University of Miami Miller School of Medicine, Miami, Florida, United States; Novosibirsk State Research Institute of Circulation Pathology; Mount Sinai st luke’s roosevelt, New York, New York, United States; Yale university, New haven, Connecticut, United States; UAMS erwqeqweqw, little rock, Arkansas, United States; University of Miami, Miami, Florida, United States; University of Miami Hospital, Miami, Florida, United States; University of Miami Miller School of Medicine, Miami, Florida, United States; Brigham and Women’s Hospital, Boston, Massachusetts, United States; Tufts Medical Center, Boston, Massachusetts, United States

Aortic pseudocoarctation: a late presentation of an uncommon anomaly

A 64-year-old woman with a history of diabetes mellitus, hypertension and previous unsuccessful coronary angiography via femoral approach presented to the emergency room with intermittent non-exertional chest discomfort. Physical examination revealed symmetrical blood pressure of 150/90 mm Hg with equally weak pulses in all extremities and a soft systolic murmur over the sternum, appreciated on auscultation. Chest radiograph (figure 1) revealed a double density in the aortic arch mimicking the number 3. Echocardiogram showed normal left ventricle ejection fraction and aortic valve structure without gradient. …

Successful Transradial Retrieval of an Embolized Guidewire During Transradial Vascular Access

Transradial catheterization is associated with lower complication rates; however limited information is available regarding techniques to overcome unusual complications. We present a case of a 58‐year‐old male with suspected non‐ST‐elevated myocardial infarction who underwent transradial coronary angiography complicated by guidewire embolization into the radial artery and subsequent access loss. Successful retrieval of the embolized guidewire was achieved by re‐accessing the same radial artery and the use of a 2 mm gooseneck microsnare. This technique was safe and prevented the need for surgical intervention or femoral access for retrieval, which are commonly described in the literature and can result in additional complications.