James P. Herlihy

Implantable cardioverter defibrillator patch erosion in a heart transplant patient

A 57-year-old man who had received an automatic implantable cardioverter defibrillator and subsequent orthotopic heart transplant presented to medical attention for hemoptysis. The hemoptysis was caused by the migration of the left ventricular patch of the automatic implantable cardioverter defibrillator, which had been left in place at the time of orthotopic heart transplant. The patch had eroded into the left lung. We recommend that implantable cardioverter defibrillators be removed completely at the time of heart transplantation to prevent subsequent complications.

Perioperative Management of LVAD Patients

A recent INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) annual report on the outcomes of patients who underwent continuous-flow left ventricular assist device (CF-LVAD) or biventricular assist device implantation showed that these patients had a 1-year survival rate of 80% [1]. Most of the mortalities occurred within the first 30 days after device implantation or during the postoperative period of the index hospitalization [1, 2]. The major causes of death during this period were as follows: 60–65% were due to multisystem organ failure (MSOF), which was driven primarily by poor oxygen delivery (DO2) and, often, specifically by right heart failure (RHF) [1, 2]; 15–20% were due to embolic and hemorrhagic stroke [1, 2]; 10–15% were due to bleeding events [1, 2]; 5–10% were sepsis related [3, 4]; and approximately 5% were due to respiratory failure [3]. The remaining deaths were mainly due to device malfunction, arrhythmias, or other less common complications [3, 4]. These data suggest that poor LVAD implantation outcomes can often be prevented or effectively managed. Therefore, diligent perioperative care is paramount to ensure positive outcomes for these patients. This chapter reviews the critical components of effective post operative care, and troubleshooting for the newly implanted CF-LVAD patient.

REDUCTION IN IN-HOSPITAL CARDIAC ARREST WITH EARLY INTERVENTIONS IN THE EMERGENCY DEPARTMENT AND NON-ICU UNITS BY A NOVEL APPROACH OF RAPID RESPONSE TEAMS (RRT) AND MOBILE ICU MANAGEMENT

METHODS: The study was conducted at Baylor St Luke’s Medical center, an 850-bed quaternary and academic medical center in Houston, Texas. Patients in the emergency department and non-ICU units that met the criteria of decompensation were evaluated by RRT. RRT consisted of a team of experienced nurses specifically trained in medical emergency response. If needed, RRT requested immediate management by the Mobile ICU team which had extended scope of ICU interventions and was made up of a critical care attending physician, critical care fellow and a mid-level provider. The advanced ICU capabilities included obtaining point of care labs including lactic acid levels, portable ultrasound, airway management, and resuscitation capabilities such as placing central lines, rapid infusers and initiation of pressors. A mobile procedure cart was specifically built for this purpose and was stationed in the emergency department and in the hospital wards. Patients were transferred to the ICU as soon as beds became available. Retrospective analysis of a cohort of patients from January 2013 to September 2014 (Cohort A) when only RRT services had been rolled out, was compared with a cohort of patients from October 2014 to December 2017 (Cohort B) when Mobile ICU service was implemented as well.