Mukta Srivastava

Veno-venous extracorporeal membrane oxygenation bridging to pharmacotherapy in pulmonary arterial hypertensive crisis

We report the case of a treatment-naive patient with pulmonary arterial hypertension who presented with decompensated right ventricular failure and cardiogenic shock. Unstable hemodynamics, hypoxia and end-organ hypoperfusion limited up-titration of pharmacotherapy. Mechanical circulatory support with veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated to permit dose titration of pulmonary vasodilator therapy. VV-ECMO was weaned after 10 days of support, with successful transition to intravenous epoprostenol and oral sildenafil.

Factors Influencing Hospital Length of Stay After Robotic Totally Endoscopic Coronary Artery Bypass Grafting

BACKGROUND Robotic totally endoscopic coronary artery bypass grafting (TECAB) is an evolving minimally invasive technology with the potential to reduce hospital length of stay (LOS). Little is known about the factors that influence LOS after this procedure. The aim of this study is to define the preoperative, intraoperative, and postoperative variables that predict LOS after TECAB. METHODS From 2001 to 2011, 541 patients, aged 60 years (range, 26 to 90 years), 394 (72.8%) male, 147 (27.1%) female, underwent TECAB using the daVinci telemanipulation system at one European and one American institution. Three hundred forty-six (63.9%) single-, 171 (31.6%) double-, 23 (4.2%) triple-, and 1 (0.2%) quadruple-vessel TECABs were carried out with an overall LOS of 6 days (range, 2 to 54 days) and 30-day mortality of 0.9% (5 of 541); 44.5% of patients (241 of 541) were hybrid intent-to-treat candidates. RESULTS The following variables showed significant positive correlation with LOS: age, r = 0.188 (p < 0.001); Society of Thoracic Surgeons risk score, r = 0.263 (p < 0.001); EuroSCORE, r = 0.191 (p < 0.001); creatinine, r = 0.135 (p = 0.002); and operative time, r = 0.216 (p < 0.001). Other factors that had significant influence on LOS were hemodialysis (p = 0.037), cerebrovascular disease (p = 0.002), learning curve case (p < 0.001), intraoperative surgical problem (p < 0.001), conversion or on-table revision (p < 0.001), revision for bleeding (p < 0.001), postoperative stroke (p < 0.001), intraaortic balloon pump (p < 0.001), hemodialysis (p < 0.001), and atrial fibrillation (p < 0.001). By multivariate analysis, learning curve case, conversion or on-table revision, and revision for bleeding were independent predictors for prolonged LOS (defined as LOS > 6 days). CONCLUSIONS Multiple variables affect LOS after TECAB. Older patients, patients on hemodialysis, patients with cerebrovascular disease, and those with higher general risk scores should expect prolonged LOS. Intraoperative surgical difficulties and conversion to open coronary artery bypass grafting also lead to extended LOS. Postoperative events that are known to prolong LOS in open coronary artery bypass grafting also prolong LOS after TECAB.

Management of coronary artery disease and acute coronary syndrome in the chronic kidney disease population-A review of the current literature.

Coronary Artery Disease (CAD) is a large contributor to morbidity and mortality in the chronic kidney disease (CKD) and end‐stage renal disease (ESRD) population. Due to the fact that many large‐scale trials evaluating management for acute coronary syndromes (ACS) and CAD have excluded patients with CKD, there is a paucity of data investigating medical management of CAD and revascularization strategies of these patients. Further, while there have been many advances in the treatment for ACS and CAD, both medically and technologically, few studies have focused on the CKD population and many predate these advancements in management. Newer studies that include CKD patients have shown heterogeneity in various outcomes, making management decisions challenging. In this review, we summarize the epidemiologic significance of ACS and CAD in patients with CKD, discuss the diagnosis of ACS in this patient population, and review the therapeutic interventions in patients with CKD.

Acute Valvular Heart Disease

Valvular heart disease (VHD) is a common clinical entity. Recognition of decompensated VHD is crucial to instituting appropriate workup and management. Initial evaluation focuses on hemodynamics, peripheral perfusion, volume overload, and active myocardial ischemia. Initial therapy is targeted at improving hemodynamics, fluid status, and decreasing myocardial ischemia before intervention. Echocardiography can rapidly identify VHD etiology and severity along with physical examination findings. Owing to improved survival with cardiac surgery over the past several decades, prosthetic valve dysfunction should be recognized and initial treatment understood. Mechanical circulatory support is increasingly part of clinical practice in stabilizing patients with decompensated VHD.

Cardiovascular Emergencies in Pregnancy

Heart disease in pregnancy may manifest as acute coronary syndromes, decompensated valvular disease, and acute heart failure. These disease processes may represent progression of preexisting disease versus newly developed disease resulting from the physiologic changes of pregnancy. Early recognition of clinical presentations, judicious use of diagnostic studies, and multidisciplinary management of patient and fetal considerations can lead to optimal outcomes in this unique patient subset.

Augmenting Function for Infarction from Infection: Impella 2.5 for Ischemic Cardiogenic Shock Complicating Sepsis.

Cardiac dysfunction is a common complication of sepsis in individuals with preexisting coronary disease and portends a poor prognosis when progressing to ischemic cardiogenic shock. In this setting, maximal medical therapy in isolation is often inadequate to maintain cardiac output for patients who are poor candidates for immediate revascularization. Furthermore, the use of vasopressors and inotropes increases myocardial demand and may lead to further injury. Percutaneous ventricular assist devices provide a viable option for management of severe shock with multiorgan failure. The Impella is one of several novel mechanical support systems that can effectively augment cardiac output while reducing myocardial demand and serve as a bridge to recovery from severe hemodynamic compromise. This case report describes the successful utilization of the Impella 2.5 in a patient with baseline profound anemia and coronary artery disease (CAD) presenting in combined distributive and cardiogenic shock associated with a type 2 myocardial infarction complicating sepsis.

Hybrid Coronary Revascularization

Hybrid coronary revascularization (HCR) is a treatment strategy for revascularization of multi-vessel coronary artery disease that utilizes minimally invasive coronary artery bypass grafting (CABG) techniques in conjunction with percutaneous coronary intervention (PCI), integrating the advantages of both. The long-term symptom relief and survival benefit of an internal mammary artery (IMA) graft to the left anterior descending (LAD) artery are attained in this approach, as well as the durability of PCI with drug-eluting stents (DES) to non-LAD targets. This chapter will review the range of minimally invasive surgical techniques that form the basis of the surgical leg of HCR, address pharmacologic issues unique to HCR, and finally to review logistical considerations in the sequencing of each leg of HCR, surgical and percutaneous.

PREDICTORS OF LONG–TERM OUTCOMES IN HYBRID CORONARY REVASCULARIZATION

Hybrid Coronary Revascularization (HCR) couples surgical bypass and percutaneous coronary intervention (PCI) techniques, allowing complete coronary revascularization with a minimally invasive approach. Short and long term outcomes appear similar to multi–vessel open coronary bypass surgery while