Gregary D. Marhefka

Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation

Placement of the Avalon Elite bicaval dual lumen cannula for venovenous extracorporeal membrane oxygenation (VV-ECMO) via the internal jugular vein requires precise positioning of the cannula tip in the inferior vena cava with echocardiography or fluoroscopy guidance. Correct guidewire placement is clearly the key first step in assuring proper advancement of the cannula. We report a case of unexpected wire migration into the right ventricle at the time of final cannula advancement, resulting in right ventricular rupture and tamponade. Transesophageal echocardiography is an important monitoring modality for appropriate placement of the VV-ECMO guidewire and Avalon cannula, and in particular, for early identification of potential complications.

Saphenous vein graft disease: review of pathophysiology, prevention, and treatment.

Saphenous vein graft (SVG) disease after coronary artery bypass grafting (CABG) occurs in three phases: thrombosis, intimal hyperplasia, and atherosclerosis. Within the first month, thrombosis plays a major role. From month 1 to month 12, intimal hyperplasia occurs. Beyond 12 months, atherosclerosis becomes the primary cause for late graft failure. Endothelial damage has been shown to be the major underlying pathophysiology of SVG disease. Many factors contribute to endothelial damage from the moment the vein is harvested to when the vein is grafted into an arterial environment. To address this disease process, various therapeutic modalities, from surgical methods to medical treatment, have been evaluated. Surgically, the technical method of harvesting the vein has been shown to affect SVG patency. From a pharmacologic perspective, only two guideline class I recommended medications, aspirin and statins, have been shown to improve short- and long-term SVG patency after CABG. Despite these surgical and medical advances, SVG disease remains a significant problem with 1-year patency rates of 89% dropping to 61% after 10 years. This review discusses the pathogenesis of SVG disease, predictors of SVG failure, and current surgical and pharmacologic therapies to address SVG disease, including possible future treatment.

Intravenous Cocaine and QT Variability

Background: Dynamic instability in cardiac repolarization may contribute to drug‐induced arrhythmogenesis. We hypothesized that intravenous cocaine would significantly destabilize repolarization as measured by QT variability.

Rethinking Cocaine-Associated Chest Pain and Acute Coronary Syndromes

Every year more than 500,000 patients present to the emergency department with cocaine-associated complications, most commonly chest pain. Many of these patients undergo extensive work-up and treatment. Much of the evidence regarding cocaines cardiovascular effects, as well as the current management of cocaine-associated chest pain and acute coronary syndromes, is anecdotally derived and based on studies written more than 2 decades ago that involved only a few patients. Newer studies have brought into question many of the commonly held theories and practices regarding the etiology, diagnosis, and treatment of this common clinical scenario. However, there continues to be a paucity of prospective, randomized trials addressing this topic as it relates to clinical outcomes. We searched PubMed for English-language articles from 1960 to 2011 using the keywords cocaine, chest pain, coronary arteries, myocardial infarction, emergency department, cardiac biomarkers, electrocardiogram, coronary computed tomography, observation unit, β-blockers, benzodiazepines, nitroglycerin, calcium channel blockers, phentolamine, and cardiomyopathy; including various combinations of these terms. We reviewed the abstracts to confirm relevance, and then full articles were extracted. References from extracted articles were also reviewed for relevant articles. In this review, we critically evaluate the limited historical evidence underlying the current teachings on cocaines cardiovascular effects and management of cocaine-associated chest pain. We aim to update the reader on more recent, albeit small, studies on the emergency department evaluation and clinical and pharmacologic management of cocaine-associated chest pain. Finally, we summarize recent guidelines and review an algorithm based on the current best evidence.

The Effect of Aspirin on Bleeding and Transfusion in Contemporary Cardiac Surgery

Objective Despite evidence that preoperative aspirin improves outcomes in cardiac surgery, recommendations for aspirin use are inconsistent due to aspirin’s anti-platelet effect and concern for bleeding. The purpose of this study was to investigate preoperative aspirin use and its effect on bleeding and transfusion in cardiac surgery. Methods This retrospective study involved consecutive patients (n=1571) who underwent CABG, valve, or combined CABG and valve surgery at a single center between March 2007 and July 2012. Of all patients, 728 met the inclusion criteria and were divided into two groups: those using (n=603) or not using (n=125) aspirin within 5 days of surgery. Data were collected on chest tube drainage, re-operation for bleeding, and transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets. Results No significant difference was observed between the two groups in chest tube drainage or re-operation for bleeding. An increase in patients transfused with RBCs was observed in the aspirin group (61.9 vs 51.2%, adjusted OR 1.77, p=0.027); however, among those transfused RBCs, no significant difference in mean units transfused or massive transfusion was observed. No significant difference was seen in transfusion requirement of FFP or platelets. Conclusions In patients undergoing CABG, valve, or combined CABG/valve surgery, preoperative aspirin, within 5 days of surgery, was associated with an increased probability of receiving an RBC transfusion. Preoperative aspirin was not associated with an increase in chest tube drainage, re-operation for bleeding complications, or transfusion of FFP or platelets.

Patient characteristics and predictors of mortality associated with pericardial decompression syndrome: a comprehensive analysis of published cases

Background: Pericardial decompression syndrome (PDS) is a rare and potentially fatal complication of pericardial drainage, either by needle pericardiocentesis or surgical pericardiostomy. It manifests with paradoxical hemodynamic deterioration and/or pulmonary edema, commonly associated with ventricular dysfunction. We sought to elucidate factors associated with mortality in PDS. Methods: MEDLINE was systematically searched for PDS case reports and case series published between 1983 and 2013. For this analysis, clinical variables, echocardiographic and hemodynamic variables, details of drainage procedure and clinical outcomes were collected for each case. Results: A total of 35 cases (12 male, 23 female) were identified. PDS developed after pericardiocentesis, pericardiostomy, or both, in 18, 16, and one patients, respectively. Cardiac tamponade was the indication in 33 cases (94%). The mean age was 47 ± 17 years. The mean amount of effusion drained was 888 mL. The minimum amount of effusion drained was 450 mL. The onset of PDS after the procedure varied widely, ranging from ‘immediate’ to 48 hours. Presentations included 10 (29%) with cardiogenic pulmonary edema without shock, 14 (40%) with left ventricular failure, three (9%) with right ventricular failure, seven (20%) with biventricular failure, and one (3%) with non-cardiogenic pulmonary edema. Ten patients (29%) died of PDS. Mortality was associated only with surgical drainage (p<0.001). Severe LV dysfunction normalized in PDS survivors. Conclusions: PDS is a rare complication of pericardial drainage with a high mortality rate. Surgical pericardiostomy was associated with mortality in PDS.

Poor positive predictive value of McConnell's sign on transthoracic echocardiography for the diagnosis of acute pulmonary embolism.

Abstract Background: Acute pulmonary embolism (PE) is a life-threatening condition. Making a definitive diagnosis with radiologic studies may delay therapy or be unsafe for the patient. Echocardiography is readily available and can suggest PE by demonstrating right ventricular (RV) dysfunction. McConnells sign on echocardiogram (ECHO-CG) (RV dysfunction with characteristic sparing of the apex) has been reported to have high sensitivity and specificity for the diagnosis of acute PE. It is hypothesized that McConnells sign on ECHO-CG in patients hospitalized with suspected acute PE would have a high positive predictive value (PPV). Methods: Data, from 2005 to 2010, were retrospectively collected on all patients with an ECHO-CG interpreted as revealing McConnells sign, who had undergone another diagnostic study (computed tomography pulmonary angiography, ventilation-perfusion scan, upper or lower extremity Doppler ultrasound, or autopsy) for venous thromboembolic disease (VTE). The PPV on transthoracic ECHO-CG was calculated for the diagnostic accuracy of McConnells sign in all patients. To minimize the potential for ECHO-CG reader bias of patients already confirmed to have had a PE by another modality, the PPV was then recalculated only on the patients in whom the ECHO-GM was the first diagnostic study. Results: Seventy-three patients had findings of McConnells sign on ECHO-CG. The PPV of McConnells sign on ECHO-CG was 57% (CI, 45%-67%). Of the 37 patients who underwent an ECHO-CG in the first study for suspected acute PE, 15 patients had VTE confirmed; the PPV in this subset was only 40% (CI, 24%-56%). There were 20 patient deaths overall; of these, only 9 of the patients were confirmed to have VTE. Conclusion: We concluded that the presence of McConnells sign has a relatively poor PPV for the diagnosis of acute PE and should not be used in isolation when making a diagnosis of PE in patients.

Dual Antiplatelet Therapy With Aspirin and Clopidogrel: What Is the Risk in Noncardiac Surgery? A Narrative Review

Abstract Clopidogrel is one of the most commonly prescribed medications and is currently recommended along with aspirin as treatment to be used for 1 year in all patients without contraindications following an acute coronary syndrome. Patients who are committed to clopidogrel therapy due to recent coronary artery stent implantation may require noncardiac surgery during this recommended period of dual antiplatelet therapy (DAPT). Due to differing rates of endothelialization, patients who undergo bare-metal stent implantation generally require ≥ 1 month of uninterrupted DAPT, and those who undergo drug-eluting stent implantation require ≥ 12 months. Many surgeons ask their patients to stop taking clopidogrel in advance of their procedure to decrease perioperative bleeding. This practice is based largely on anecdotal experience and extrapolated from limited data in cardiac surgery. Premature cessation of aspirin and/or clopidogrel following coronary artery stenting, however, has been associated with acute stent thrombosis, myocardial infarction, and death. We searched PubMed for English language articles published from 1960 to 2012, using the keywords aspirin, clopidogrel, surgery, general, vascular, genitourinary, thoracic, orthopedic, ophthalmologic, dermatologic, endoscopy, colonoscopy, cardiac device implantation, pacemaker, defibrillator, bronchoscopy, bridging, bleeding complications, and transfusion, including various combinations. Abstracts were reviewed to confirm relevance, and then the full articles were extracted. References from extracted articles were also reviewed for relevant articles. Literature regarding perioperative clopidogrel continuation is predominantly composed of small, nonrandomized data, but suggests that most noncardiac surgeries or procedures can be performed safely while patients are taking clopidogrel. In this article, we review the current best evidence on the risk for bleeding with clopidogrel therapy in noncardiac surgery, summarize recent guidelines on appropriate duration of DAPT, and make recommendations on the management of perioperative DAPT.

Right Ventricular Enlargement within Months of Arteriovenous Fistula Creation in 2 Hemodialysis Patients.

Surgically created arteriovenous fistulae (AVF) for hemodialysis can contribute to hemodynamic changes. We describe the cases of 2 male patients in whom new right ventricular enlargement developed after an AVF was created for hemodialysis. Patient 1 sustained high-output heart failure solely attributable to the AVF. After AVF banding and subsequent ligation, his heart failure and right ventricular enlargement resolved. In Patient 2, the AVF contributed to new-onset right ventricular enlargement, heart failure, and ascites. His severe pulmonary hypertension was caused by diastolic heart failure, diabetes mellitus, and obstructive sleep apnea. His right ventricular enlargement and heart failure symptoms did not improve after AVF ligation. We think that our report is the first to specifically correlate the echocardiographic finding of right ventricular enlargement with AVF sequelae. Clinicians who treat end-stage renal disease patients should be aware of this potential sequela of AVF creation, particularly in the upper arm. We recommend obtaining preoperative echocardiograms in all patients who will undergo upper-arm AVF creation, so that comparisons can be made postoperatively. Alternative consideration should be given to creating the AVF in the radial artery, because of less shunting and therefore less potential for right-sided heart failure and pulmonary hypertension. A multidisciplinary approach is optimal when selecting patients for AVF banding or ligation.

Coronary artery vasospasm induced acute myocardial infarction in pregnancy: a new case and systematic review of the literature

Abstract Background Acute myocardial infarction (AMI) in pregnancy is a rare event and of the causes, coronary artery vasospasm (CAV) is considered even more uncommon. Purpose We present a new case report of a woman at 32 weeks of pregnancy with an AMI from CAV with a normal coronary angiogram. We performed a systematic review of similar cases of spontaneous AMI related to CAV to better understand its characteristics and management. AMI was defined as elevated cardiac enzymes (troponin or CKMB) with chest pain and/or electrocardiogram (EKG) changes consistent with ischemia. Methods We use the terms “acute myocardial infarction”, “myocardial infarction”, “coronary artery vasospasm” and “pregnancy” for our PubMed review. We also evaluated all references in identified manuscripts. Six cases of AMI in pregnancy due to CAV have been reported as of November 2016, including ours. Results and conclusion Six cases of AMI due to CAV during pregnancy or postpartum are reported in the literature, including ours. Patients experiencing this condition tend to be of advanced maternal age, multigravida and in their third trimester or postpartum. Successful management with a combination of long acting nitrates and/or calcium channel blockers achieved symptomatic control in all published cases. Obstetric outcomes were mostly normal, with the majority experiencing uncomplicated deliveries at term.