Richard H. Cooke

Implantable Mechanical Circulatory Support: Demystifying Patients With Ventricular Assist Devices and Artificial Hearts

Engineering advancements have expanded the role for mechanical circulatory support devices in the patient with heart failure. More patients with mechanical circulatory support are being discharged from the implanting institution and will be seen by clinicians outside the immediate surgical or heart‐failure team. This review provides a practical understanding of device design and physiology, general troubleshooting, and limitations and complications for implantable left ventricular assist devices (pulsatile‐flow and continuous‐flow pumps) and the total artificial heart.

Left Circumflex Occlusion in Acute Myocardial Infarction (from the National Cardiovascular Data Registry)

Compared to occlusions of other major coronary arteries, patients presenting with acute left circumflex (LCx) occlusion usually have ST-segment elevation on the electrocardiogram <50% of the time, potentially delaying treatment and resulting in worse outcomes. In contemporary practice, little is known about the clinical outcomes of patients with LCx territory occlusion without ST-segment elevation myocardial infarction (STEMI). We identified patients with myocardial infarction from April 2004 to June 2009 in the CathPCI Registry treated with percutaneous coronary intervention for culprit LCx territory occlusion, excluding those with previous coronary artery bypass grafting. Logistic generalized estimating equation modeling was used to compare the outcomes, including in-hospital mortality between patients with STEMI and non-STEMI (NSTEMI) adjusting for differences in the baseline characteristics. Of the 27,711 patients with myocardial infarction and acute LCx territory occlusion, 18,548 (67%) presented with STEMI and 9,163 (33%) with NSTEMI. With the exception of a greater proportion of cardiac risk factors and cardiac history in the NSTEMI group, the demographic and baseline characteristics were clinically similar between the 2 groups, despite the statistical significance resulting from the large population. The patients with STEMI were more likely to have a proximal LCx culprit lesion (63% vs 27%, p <0.0001) and had greater risk-adjusted in-hospital mortality (odds ratio 1.36, 95% confidence interval 1.12 to 1.65, p = 0.002) compared to patients with NSTEMI. In conclusion, acute LCx territory occlusion often presents as NSTEMI, but patients with NSTEMI and occlusion have a lower mortality risk than those with STEMI, possibly because of factors such as the amount of myocardium involved, the lesion location along the vessel, and/or a dual blood supply.

Induction immunosuppression for orthotopic heart transplantation: a review

Objectives To describe the appropriateness and safety of induction immunosuppression for patients at risk for fatal rejection, and to describe the safety and effectiveness profiles of the induction regimens available in the United States. Data Sources MEDLINE/PubMed database, EMBASE database, Google Scholar; references from pertinent articles were also reviewed to identify additional data. Study Selection A systematic literature review from January 1, 1980, through June 30, 2008, was performed. Included articles ranged from case series to prospective randomized controlled double-blind placebo-controlled trials that detailed the following topics with respect to induction immunosuppression: risk of fatal rejection, renal sparing, malignancy, OKT3, rabbit or equine antithymocyte globulin, daclizumab, basiliximab, and alemtuzumab. Results Patients at highest risk for fatal rejection experienced a survival benefit from induction immunosuppression, whereas all other patients experienced no benefit or harm. Most of the early data detail positive experiences with polyclonal antibody regimens. Several newer trials compare the use of polyclonal strategies with the use of anti-CD25 targeted monoclonal antibodies. Few researchers have assessed the usefulness of an anti-CD52 approach. Overall, induction therapy remains a poorly studied and widely variable practice among the major US heart transplant centers. Conclusion At present, the unrestricted use of induction for all patients does not seem prudent. Induction should be individualized for each patient on the basis of a well-designed protocol, careful analysis of the transplant centers demographics, and the effectiveness and safety profiles of the regimens used.

Clinical Outcomes in Patients with Acute Left Circumflex/Obtuse Marginal Occlusion Presenting with Myocardial Infarction

BACKGROUND  Acute occlusion of left circumflex (LCx) or obtuse marginal (OM) arteries can present as ST elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI). NSTEMI patients (pts) with occlusions have worse outcomes than those without occlusions, but no studies specifically examine outcomes in acute myocardial infarction (AMI) pts with LCx/OM occlusion. This study aims to define the incidence of NSTEMI in pts presenting with LCx/OM occlusion and analyzes clinical characteristics and outcomes in those presenting with NSTEMI compared to STEMI. METHODS AND MATERIALS A review of our catheterization and STEMI database was performed to identify AMI pts presenting with LCx or OM occlusion from 1/1/2007 to 7/31/2009 at the Medical College of Virginia. Patients were divided into STEMI and NSTEMI groups, and a chart review was performed. Primary end-points were in-hospital mortality (HM), cardiogenic shock (CS), and in-hospital CHF. Secondary end-points included peak CK-MB and time to catheterization, as well as combined end-points of 1-month mortality, and recurrent AMI and CHF. RESULTS Fifty-six pts met inclusion criteria, 54% of whom presented with NSTEMI. STEMI pts were significantly more likely to meet the primary end-points, as well as the combined secondary end-points. They had shorter times to catheterization but larger infarct sizes. Patients with left or mixed coronary dominance were more likely to have STEMI. CONCLUSIONS AMI pts with LCx/OM occlusion present with NSTEMI as often as STEMI. Those with NSTEMI have better outcomes, which may be related to right coronary dominance. SUMMARY  Patients with acute LCx or OM occlusion present with NSTEMI as often as STEMI, but those with STEMI have worse outcomes. The difference in presentation may be related to coronary dominance.

Surveillance Endomyocardial Biopsy in the Modern Era Produces Low Diagnostic Yield for Cardiac Allograft Rejection.

Background The changing epidemiology of cardiac allograft rejection has prompted many to question the yield of surveillance endomyocardial biopsy (EMB) in heart transplantation (HT) patients. We sought to determine the yield of EMB in the modern era. Methods We evaluated 2597 EMBs in 182 consecutive HT patients who survived to their first EMB. The EMBs were categorized as asymptomatic or clinically driven and were compared based on era of antiproliferative therapy use at our center (early azathioprine era: 1990–2000 vs modern mycophenolate era: 2000–2011). Results In the modern era, patients had a higher prevalence of risk factors for developing rejection (≥ International Society of Heart and Lung Transplantation grade 2R); however, the frequency of rejection was decreased at all times (0–6 months: 60.2% vs 21.5%, P < 0.001, 6–12 months: 26.8% vs 1.8%, P < 0.001, 12–36 months: 32.3% vs 10.5%, P = 0.006). The yield of asymptomatic EMB decreased in the modern era between 0 and 6 months (10.9% vs 3.12%), 6 to 12 months (17% vs 0%), and years 2 to 3 (6.1% vs 1.5%). In the early era, the odds ratio of rejection during asymptomatic EMB compared to a clinically driven EMB was 0.47 (95% confidence interval, 0.31–0.71) and was decreased in the modern era (0.17 [0.07–0.42], P = 0.04). The probability of detecting rejection on asymptomatic EMB was significantly reduced in the modern era, even after adjustment for tacrolimus and induction therapy (1% vs 8%, P < 0.001). Conclusions The clinical yield of surveillance EMB has decreased in the modern era. The EMB in asymptomatic patients longer than 6 months after HT warrants further scrutiny.

Impact of INTERMACS Profile on Clinical Outcomes for Patients Supported With the Total Artificial Heart

BACKGROUND Insufficient data delineate outcomes for Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 patients with the total artificial heart (TAH). METHODS We studied 66 consecutive patients implanted with the TAH at our institution from 2006 through 2012 and compared outcome by INTERMACS profile. INTERMACS profiles were adjudicated retrospectively by a reviewer blinded to clinical outcomes. RESULTS Survival after TAH implantation at 6 and 12 months was 76% and 71%, respectively. INTERMACS profile 1 patients had decreased 6-month survival on the device compared with those in profiles 2-4 (74% vs 95%, log rank: P = .015). For the 50 patients surviving to heart transplantation, the 1-year posttransplant survival was 82%. There was no difference in 1-year survival when comparing patients in the INTERMACS 1 profile with less severe profiles (79% vs 84%; log rank test P = .7; hazard ratio [confidence interval] 1.3 [0.3-4.8]). CONCLUSIONS Patients implanted with the TAH as INTERMACS profile 1 had reduced survival to transplantation compared with less sick profiles. INTERMACS profile at the time of TAH implantation did not affect 1-year survival after heart transplantation.

Anticoagulation in transradial percutaneous coronary intervention

Transradial percutaneous coronary intervention (PCI) is associated with significant reductions in access site complications and major bleeding as compared with the transfemoral approach. Bivalirudin is now the most commonly used anticoagulant for transradial PCI in the United States, while weight adjusted unfractionated heparin remains the most common choice outside the United States. A growing number of reports suggest that transradial intervention may offer improved outcomes across a variety of clinical situations, including those at the highest risk of bleeding complications, such as those with acute myocardial infarction. The following review provides an overview of the studies evaluating anticoagulation in transradial PCI and a rationale for the combination of the transradial approach to coronary interventions with an optimal anticoagulant strategy to reduce both access site and nonaccess site‐related bleeding.

Amlodipine-Induced Subacute Cutaneous Lupus

Dear Editor, A 62-year-old man was seen in Cardiology clinic, where he complained of a worsening asymptomatic skin eruption on both arms and shoulders for 3 months duration. He had no history of cutaneous disease and was concerned about a possible drug reaction. The patient had a 4-year history of coronary artery disease; he had status post vein graft percutaneous coronary interventions and multiple stent implantations. Four weeks prior to the onset of the skin eruption he was started on amlodipine. His medications also included, isosorbide dinitrate, lisinopril, metoprolol, aspirin, clopidrogel, finofibrate, simvastatin and ranitidine. He was referred to Dermatology with non-pruritic, erythematous, scaling plaques on his arms and chest. The total body surface area involved was 7% [Figure 1]. Skin biopsy revealed perivascular inflammation with disruption of the epidermal-dermal junction consistent with subacute cutaneous lupus erythematosus (SCLE) [Figure 2]. Laboratory studies were positive for anti-RO (SS-A), negative for antinuclear antibodies (ANA) and anti-LA (SS-B), with a normal blood count and metabolic panel. He was instructed to apply topical triamcinolone 0.1% and to stop amlodipine, while increasing his dose of isosorbide. He had a 4 week follow-up and the skin eruption was much improved. When seen in Cardiology clinic 6 months later his eruption had disappeared. Figure 1 Drug-induced subacute lupus erythematosus: Erythematous and scaly plaque on a left posterior arm Figure 2 Drug-induced subacute lupus erythematosus (×20): Slight parakeratosis with mild epidermal atrophy, liquefaction of the basal layer and perivascular and periadnexal lymphocytic infiltrate SCLE is a subset of cutaneous lupus erythematosus described in 1979.[1] It presents as a non-scarring, annular, papulosquamous eruption on sun exposed skin, primarily on the upper torso, arms, and lateral neck, in conjunction with anti-Ro/SS-A antibodies.[2] Antinuclear antibodies were positive in about 60-80% of the patients,[3,4] more often found in the annular presentation rather than the papulosquamous form.[4] About one-third of all SCLE cases could be attributed to a previous drug exposure.[5] Drug-induced subacute cutaneous lupus erythematosus (DI-SCLE) occurs as an adverse reaction to certain medications, especially anti-hypertensives and anti-fungals.[3] Within the anti-hypertensive group diuretics, beta-blockers, angiotensin conversion enzyme inhibitors and calcium channel blockers have been reported as possible causes of DI-SCLE. Within the calcium channel blocker group diltiazem, verapamil, nifedipine, and nitrendipine have been implicated.[2,3,5] There is no previous report of amlodipine and DI-SCLE in the literature; however, there is a single report of a patient in one study, where the combination of benazepril/amlodipine was associated with DI-SCLE,[6] but this does not rule out the possibility that benazepril was the culprit. In addition to this, our patients lesions resolved upon withdrawal of amlodipine, which makes lisinopril and simvastatin less likely culprits. Amlodipine is one the most common medications used to treat hypertension and angina, making this adverse event potentially significant. Although, there are reports of DI-SCLE persisting after withdrawal of the suspected drug, DI-SCLE is usually reversible once the offending drug is discontinued. Thus, it is important to include drug-induced SCLE in the differential diagnosis of eruptions in patients taking anti-hypertensive medications and obtain a complete medication history.

Hospital readmissions after discharge to home with the Total Artificial Heart Freedom driver: Readmission reasons, clinical outcomes, and health care costs.

Hospital readmissions after discharge to home with the Total Artificial Heart Freedom driver: Readmission reasons, clinical outcomes, and health care costs Mohammed A. Quader, MD, Andrew J. Green, BS, Keyur B. Shah, MD, Richard Cooke, MD, and Vigneshwar Kasirajan, MD From the Department of Surgery, Division of Cardio-thoracic Surgery; and the Department of Medicine, Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia

Mechanical Circulatory Support Devices in the ICU

The medical community has used implantable mechanical circulatory support devices at increasing rates for patients dying from heart failure and cardiogenic shock. Newer-generation devices offer a more durable and compact option when compared with bulky early-generation devices. This article is a succinct introduction and overview of the hemodynamic principles and complications after device implantation for ICU clinicians. We review the concepts of device physiology, clinical pearls for perioperative management, and common medical complications after device implantation.