M. Chadi Alraies

Risk of Left Atrial Enlargement in Obese Patients With Obesity-Induced Hypoventilation Syndrome vs Obstructive Sleep Apnea

Background: Obstructive sleep apnea (OSA) is a known risk factor for atrial fibrillation (AF) that is principally driven by left atrial enlargement. The impact of hypoventilation caused by obesity-induced hypoventilation syndrome (OHS) on left atrial diameter has not been examined. We investigated the association between OHS and left atrial diameter in obese patients. Methods: We performed a retrospective review of 210 consecutive medical records of patients diagnosed as obese (body mass index [BMI] >30 kg/m2) and as having OHS and OSA for the period January 2010 through December 2016 at St. Vincent Charity Medical Center in Cleveland, OH. Logistic regression analysis was performed for left atrial diameter ≥4 cm in 2 groups of patients: those with OHS+OSA and those with OSA alone. Results: A total of 104 obese patients with OHS+OSA and 106 obese patients with OSA alone were identified. Statistically significant differences were found in 6 demographic and baseline characteristics: median BMI, median left atrial diameter, history of type 2 diabetes mellitus, history of stroke, history of coronary artery disease, and history of congestive heart failure. The median left atrial diameter for the OHS+OSA and OSA alone groups was 4.45 cm and 4.20 cm, respectively (P = 0.014). Left ventricular ejection fraction <50% was found in 22% of the patients with OHS+OSA and in 21% of the patients with OSA alone (P = 0.777). Multivariate logistic regression analysis showed that patients in the OHS+OSA group had 2 times higher odds (odds ratio 2.151, 95% confidence interval 1.016-4.550, P = 0.045) of exhibiting a larger left atrial diameter vs patients in the OSA alone group. Conclusion: The results of this study indicate that OHS may be an independent risk factor for left atrial enlargement and may possibly contribute to AF development irrespective of left ventricular function.

Should Ultrasound Guidance Be Routinely Used for Femoral Artery Access

ABSTRACT Ultrasound-guided femoral artery access should always be utilized as it has been shown to significantly reduce vascular complications, number of arterial access attempts, accidental venipunctures, and time to access. Despite the increased adoption of transradial access, the conventional femoral artery cannulation remains the primary route for performing peripheral angiography and cardiac catheterization in the setting of high-risk interventional procedures requiring mechanical hemodynamic support. Similarly, with the expansion of structural heart interventions such as transcatheter aortic valve replacement and mitral valve interventions, femoral access has been increased especially for large-bore sheaths.

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement

BACKGROUNDnThe concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR).nnnMETHODnUsing weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in-hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility.nnnRESULTSnA total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (Pu2009<u20090.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (Pu2009<u20090.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in-hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392-0.964, Pu2009=u20090.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group.nnnCONCLUSIONnIn patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism

BACKGROUNDnRight ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown.nnnMETHODSnWe included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP.nnnRESULTSnTotal of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m2, (0.88-2.15u2009L/min/m2 ), to 2.5u2009L/min/m2 (range 1.88-3.4), after 24u2009h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79-105), and mean systolic blood pressure increased to 140u2009mmHg (115-179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3u2009g/dL but did not require blood transfusion. All patients survived to discharge.nnnCONCLUSIONnIn patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge.

Mechanical support for high risk PCI: One pump still doesn't fit all

Mechanical circulatory support using Impella for high risk PCI is associated with better procedural and hemodynamic outcome compared with IABP although mortality benefit has been elusive. Limited evidence is available to study the effectiveness and safety of mechanical circulatory support in high risk PCI patients and much of it is confounded by underpowered and heterogeneous sample sizes. Lack of randomized trials studying contemporary percutaneous left ventricular assist devices is attributed to difficulty in randomizing high risk patients into trials of hemodynamic support.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

Background The radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)‐guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US‐guided RA access compared with palpation alone on first‐pass success to access RA. Methods and Results Meta‐analysis of 12 randomized controlled trials comparing US‐guided with palpation‐guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound‐guided radial access was associated with increased first‐attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16‐1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32‐0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27‐1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI −1.06 to 51.34) or to any successful attempt (mean difference −4.74 seconds; 95% CI −22.67 to 13.18) between both groups. Conclusions Ultrasound‐guided technique for RA access has higher first‐attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access.