Hamang Patel

Successful Transition From Intravenous to Inhaled Prostacyclin in a Patient With Pulmonary Hypertension and Right Ventricular Failure

Pulmonary hypertension (PH) is a rare disease that was first described by Romberg in 1891. It wasn’t for an additional 100 years that the first targeted treatments for PH emerged. Epoprostenol was approved by the Food and Drug Administration (FDA) in 1994 for the long-term treatment of primary PH (PPH) and collagen vascular disease (CVD)‐associated PH in patients with New York Heart Association (NYHA) classes III and IV. Epoprostenol is a synthetic prostacyclin that is a direct vasodilator of the pulmonary vascular bed and a potent inhibitor of platelet aggregation. It is the only medication that has been shown in randomized controlled trials to improve mortality in idiopathic pulmonary arterial hypertension (PAH). 1 It has also been shown to improve symptoms, exercise capacity, and hemodynamic parameters in patients with idiopathic PAH and scleroderma-related PH. 2,3 Epopros

Diagnosis and Treatment of Heart Failure for Inpatient Providers

Heart failure (HF) affects more than 5.7 million adults in the United States and is the leading cause of hospitalization among the Medicare age group. As an emerging issue in hospital care, the hospitalist provider can anticipate a steady and large number of admissions with either primary or comorbid HF. The presence of HF may affect treatment decisions and may lead to prolonged hospital stays if not adequately managed. In this chapter we first review how to recognize and classify HF. After the diagnosis of HF is made, we further outline key treatment modalities and the role of subspecialty providers both in the inpatient and the outpatient environments. We conclude with strategies for optimal discharge planning as well as prevention of readmission.

CORONARY EMBOLISM AFTER LIPID RESCUE FOR BUPIVACAINE TOXICITY

Systemic toxicity from local anesthetics can cause bradycardia, hypotension, and cardiovascular collapse. Treatment with intravenous lipid emulsification (ILE) has been effective. No acute arterial embolus has been previously described in the literature as a result of ILE. A 59-year-old previously

Does Etiology of Heart Failure Predict Orthostatic Hypotension in Patents with Left Ventricular Assist Device

was the primary indication for device placement (n59), followed by chronic ischemic cardiomyopathy (n53) and cardiac transplant rejection (n51). The average duration of Impella support was 1167.5 days. Within 24 hours of device placement, patients had an increase in cardiac output to 5.5L/min61.4 vs 4.4L/min61.3 (p50.005), which was associated with an improvement in GFR from 45.0613.5 to 52.0614.5 (p50.01), pulmonary artery pressures 41 613.0 to 3167.0 (p50.01), right atrial pressures 11 64 to 1066 (p50.04) and pulmonary capillary wedge pressure 326 12.0 to 2065.0 (p50.03). In 84% of cases (n511), the Impella provided adequate left ventricular support, with patients either successfully weaned off support completely (n54), or receiving permanent LVADs (n55) or cardiac transplant (n52). Only 16% of patients (n52) died while actively on the Impella .The 30 day mortality was 23% (n53), while overall mortality at 90 days stood at 54% (n57). The causes of mortality included device malfunction, fatal arrhythmia 24 hours after Impella removal and withdrawal of care in 1 patient each and multi-organ failure in 4 patients who were transitioned to permanent LVAD’s. Conclusions: The Impella 5.0 has been shown to be a safe and efficacious device for use in patients with cardiogenic shock. In our high risk population, the device was easily and quickly inserted and demonstrated consistent hemodynamic augmentation. It also established itself as a good supportive modality in our acutely ill patients as well. Though our overall results in terms of mortality have not been very encouraging, the Impella was indeed successful in bridging patients to either, a permanent LVAD, transplant or in some cases ventricular recovery as well. Therefore in these high risk patients with profound cardiogenic shock, this is indeed a suitable treatment strategy.

Induced hypothermia prior to left ventricular assist device.

Induced hypothermia, a therapy that recently gained the attention of a broad spectrum of US and international medical authorities for its neuroprotective benefits in post-cardiac arrest patients, may represent an underexplored therapeutic option in patients with severe cardiac failure by optimizing hemodynamics and augmenting cardiac contractility. The authors present the first case report, to their knowledge, of a patient with severe congestive heart failure who underwent cooling prior to successful left ventricular assist device implantation.