Mohamad Kabach

The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: Systematic review

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in diagnosis and staging of mediastinal lymph node (LN) lesions in lung cancer. Adequate sedation is an important part of the procedure since it provides patient′s comfort and potentially increases diagnostic yield. We aimed to compare deep sedation (DS) versus moderate sedation (MS) in patients undergoing EBUS-TBNA procedure. Methods: PubMed, EMBASE, MEDLINE, and Cochrane Library were searched for English studies of clinical trials comparing the two different methods of sedations in EBUS-TBNA until December 2015. The overall diagnostic yield, LN size sampling, procedural time, complication, and safety were evaluated. Results: Six studies with 3000 patients which compared two different modalities of sedation in patients performing EBUS-TBNA were included in the study. The overall diagnostic yield of DS method was 52.3%-100% and MS method was 46.1%-85.7%. The overall sensitivity of EBUS-TBNA of DS method was 98.15%-100% as compared with 80%-98.08% in MS method. The overall procedural times were 27.2-50.9 min and 20.6-44.1 min in DS and MS groups, respectively. The numbers of LN sampled were between 1.33-3.20 nodes and 1.36-2.80 nodes in DS and MS groups, respectively. The numbers of passes per LN were 3.21-3.70 passes in DS group as compared to 2.73-3.00 passes in MS group. The mean of LN size was indifferent between two groups. None of the studies included reported serious adverse events. Conclusions: Using MS in EBUS-TBNA has comparable diagnostic yield and safety profile to DS. The decision on the method of sedation for EBUS-TBNA should be individually selected based on operator experience, patient preference, as well as duration of the anticipated procedure.

Risk factors for coronary artery disease and acute coronary syndrome in patients ≤40 years old

OBJECTIVE In this study, we assessed the risk factor profile in premature coronary artery disease (CAD) and acute coronary syndrome for adults ≤40 years old. METHODS A retrospective chart analysis of 397 patients ≤40 years old admitted from 2005 to 2014 for chest pain and who underwent coronary arteriography. RESULTS Of 397 patients that had undergone coronary arteriography, 54% had CAD while 46% had normal coronary arteries. When compared with patients with normal coronary arteries, patients with CAD were more likely to smoke tobacco, have dyslipidemia, be diabetic, have BMI >30 kg/m(2), have a family history of premature CAD and be male in gender. CONCLUSION Healthcare intervention in the general population through screening, counseling and education regarding the risk factors is warranted to reduce premature CAD.

A case of electromagnetic interference between HeartMate 3 LVAD and implantable cardioverter defibrillator

Implantable cardioverter defibrillators (ICDs) have been shown to have a significant benefit in reducing sudden cardiac death (SCD) in patients with systolic heart failure. Additionally, cardiac devices as a bridge to transplant or destination therapy are often used in patients with end‐stage systolic heart failure. As a result, most patients with left ventricular assist devices (LVADs) also have an ICD. Here, we present an electromagnetic interference (EMI) between HeartMate 3 LVAD and ICD. This issue might be critical for both electrophysiologists and advanced heart failure cardiologists to understand prior to implantation of ICD/LVADs in these patients.

FOLFOX Induced Takotsubo Cardiomyopathy Treated with Impella Assist Device

Chemotherapy induced cardiotoxicity is becoming increasingly prevalent with several new agents being used recently. The incidence of Takotsubo cardiomyopathy due to 5-fluorouracil based chemotherapeutic regimens like FOLFOX is not uncommon. It is also seen with platinum based chemotherapy. Most of these patients have reversible cardiotoxicity and the cardiac function recovers within a short period with supportive treatment. Here we have a patient who presented with cardiogenic shock after 5 days of receiving FOLFOX regimen for colorectal adenocarcinoma. She was treated with a percutaneous left ventricular assist device, Impella CP, for hemodynamic support with excellent outcome.

Ultrafiltration versus intravenous loop diuretics in patients with acute decompensated heart failure: a meta-analysis of clinical trials

Background Intravenous loop diuretics are the first-line therapy for acute decompensated heart failure (ADHF) but many patients are discharged with unresolved congestion resulting in higher re-hospitalization and mortality rates. Ultrafiltration (UF) is a promising intervention for ADHF. However, studies comparing UF to diuretics have been inconsistent in their clinical outcomes. Methods A comprehensive literature search was performed. Trials were included if they met the following criteria: (1) randomization with a control group, (2) comparison of UF with a loop diuretic, and (3) a diagnosis of ADHF. Results When compared to diuretics, UF was associated with a reduced risk of clinical worsening (odds ratio (OR) 0.57, 95% CI: 0.38-0.86, P-value 0.007), increased likelihood for clinical decongestion (OR 2.32, 95% CI: 1.09-4.91, P-value 0.03) with greater weight (0.97 Kg, 95% CI: 0.52-1.42, P-value <0.0001) and volume reduction (1.11 L, 95% CI: 0.68-1.54, P-value <0.0001). The overall risk of re-hospitalization (OR 0.92, 95% CI: 0.62-1.38, P-value 0.70), return to emergency department (OR 0.69, 95% CI: 0.44-1.08, P-value 0.10) and mortality (OR 0.99, 95% CI: 0.60-1.62, P-value 0.97) were not significantly improved by UF treatment. Conclusions UF is associated with significant improvements in clinical decongestion but not in rates of re-hospitalization or mortality.

Recurrent angina from chronic coronary obstruction following transcatheter aortic valve implantation

Severe aortic stenosis and coronary artery disease often coexist. Coronary angiography (CA) and percutaneous coronary intervention (PCI) can be challenging in patients with prior transcatheter aortic valve implantation (TAVI). Depending on the type and position of the implanted valve, the procedure can be challenging or even unfeasible due to interference of diagnostic catheters and valve parts. The correct positioning of the TAVI prosthesis during TAVI was identified as an important factor with regard to the feasibility of subsequent CA or PCI. TAVI has been also associated with vascular, cerebrovascular and conduction complication. One is rare but life-threatening complication, coronary ostial obstruction. Coronary ostial obstruction can develop, especially if a safety check of more than 10 mm of coronary ostial height is not taken into consideration during TAVI. This complication can cause recurrent episodes of angina and can severely worsen the patient′s cardiac systolic function.

Left Ventricular Aneurysm Presenting as Bidirectional Ventricular Tachycardia

Background: Bidirectional ventricular tachycardia is a rare form of ventricular arrhythmia, characterized by a changing of the mean QRS axis of 180 degrees. Digitalis toxicity is the most common cause of bidirectional ventricular tachycardia; other causes include myocarditis, aconite toxicity, metastatic cardiac tumor, myocardial infarction, and cardiac channelopathies. Case Report: A 73-year-old male with hypertension and a pacemaker implanted for sick sinus syndrome presented with a complaint of substernal chest pressure for several days. He also stated he had had an episode of near syncope. The patients physical examination was unremarkable; however, electrocardiogram demonstrated sustained bidirectional ventricular tachycardia. Echocardiogram showed severe anterior wall hypokinesis and an estimated ejection fraction of 35%, as well as an apical ventricular aneurysm. Electrophysiology study showed that the apical ventricular aneurysm was the site of the bidirectional arrhythmia. The patient was successfully treated with ventricular tachycardia ablation. Conclusion: This case is a unique example of a patient with bidirectional ventricular tachycardia originating from an apical left ventricular aneurysm that was treated successfully by ablation.

REDUCTION IN RADIATION AND CONTRAST DOSE IN TRANSCATHETER AORTIC VALVE REPLACEMENT OVER TIME: A SINGLE-CENTER EXPERIENCE

Transcatheter aortic valve replacement (TAVR) is recommended for severe aortic valve stenosis (AS). This study aims to evaluate the association between radiation dose, time and contrast dose in TAVR with improved experience over time. A Retrospective analysis of 570 patients with severe AS who

CRT-700.26 The Impact of Gradient and Flow on the Outcomes of TAVR in Severe Aortic Stenosis with Preserved Left Ventricular Ejection Fraction

While transaortic flow and gradient are important determinant of prognosis in patients with severe aortic stenosis treated medically or with surgical aortic valve replacement, it is unclear whether these echocardiographic values are still predictive of outcomes in patients with severe aortic

Non-ST Elevation Myocardial Infarction and Severe Peripheral Artery Disease in a 20-Year-Old with Perinatally Acquired Human Immunodeficiency Virus Infection

Human immunodeficiency virus (HIV) infection confers an increased risk of cardiovascular disease, including acute coronary syndrome (ACS). Patients with perinatally acquired HIV may be at increased risk due to the viral infection itself and exposure to HAART in utero or as part of treatment. A 20-year-old female with transplacentally acquired HIV infection presented with symptoms of transient aphasia, headache, palpitations, and blurry vision. She was admitted for hypertensive emergency with blood pressure 203/100 mmHg. Within a few hours, she complained of typical chest pain, and ECG showed marked ST depression. Troponin I levels escalated from 0.115 to 10.8. She underwent coronary angiogram showing 95% stenosis of the right coronary artery (RCA) and severe peripheral arterial disease including total occlusion of both common iliacs and 95% infrarenal aortic stenosis with collateral circulation. She underwent successful percutaneous intervention with a drug-eluting stent to the mid-RCA. Patients with HIV are at increased risk for cardiovascular disease. Of these, coronary artery disease is one of the most critical complications of HIV. Perinatally acquired HIV infection can be a high-risk factor for cardiovascular disease. A high degree of suspicion is warranted in such patients, especially if they are noncompliant to their ART.