Rohit K. Singal

Targeting the Vicious Inflammation–Oxidative Stress Cycle for the Management of Heart Failure

Oxidative stress and inflammation are each implicated independently in the development and progression of heart failure. Their interaction, however, is also evident throughout the process from initial injury to cardiac remodeling and failure. In the failing heart, the linkage between excessive reactive oxygen species (ROS) and the cytokine elaboration is manifested in shared elements and cross-promotion within downstream signaling pathways. In spite of this, the failure of anticytokine immunotherapy and antioxidant therapy, which had previously shown promise, suggests that a more complete perspective of ROS-cytokine interaction is required. The present review focuses on two of the major cytokines that are demonstrably connected to oxidative stress--the pro-inflammatory tumor necrosis factor-alpha (TNF-alpha) and the anti-inflammatory interleukin-10 (IL-10)--and their interactions in cardiac remodeling and failure. It is proposed that an optimal balance between TNF-alpha and IL-10 may be of crucial importance in mitigating both inflammation and oxidative stress processes leading to heart failure.

Temporary Mechanical Circulatory Support in Cardiac Critical Care: A State of the Art Review and Algorithm for Device Selection

With more than 60 years of continuous development and improvement, a variety of temporary mechanical circulatory support (MCS) devices and implantation strategies exist, each with unique advantages and disadvantages. A thorough understanding of each available device is essential for optimizing patient outcomes in a fiscally responsible manner. In this state of the art review we examine the entire range of commonly available peripheral and centrally cannulated temporary MCS devices, including intra-aortic balloon pumps, the Impella (Abiomed, Danvers, MA) family of microaxial pumps, the TandemHeart (CardiacAssist Inc, Pittsburg, PA) pump and percutaneous cannulas, centrally cannulated centrifugal pumps such as the CentriMag (Thoratec Corp, Pleasanton, CA/St Jude Medical, St Paul, MN/Abbott Laboratories, Abbott Park, IL) and Rotaflow (Maquet Holding BV & Co KG, Rastatt Germany), and extracorporeal membrane oxygenation. Several factors need detailed consideration when contemplating MCS in any given patient, mandating a balanced, algorithmic approach for these sick patients. In this review we describe our approach to MCS, and emphasize the need for multidisciplinary input to consider patient-related, logistical, and institutional factors. Evidence is summarized and referenced where available, but because of the lack of high-quality evidence, current best practice is described. Future directions for investigation are discussed, which will better define patient and device selection, and optimize MCS-specific patient care protocols.

Surgical ablation of atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

Aims The aim of this review was to assess the effect of concomitant surgical atrial fibrillation (AF) ablation on postoperative freedom from AF and patient-important outcomes. Methods and results We searched Cochrane CENTRAL, MEDLINE, and EMBASE databases from inception to May 2016 for randomized controlled trials (RCTs) evaluating surgical AF ablation using any lesion set vs. no surgical AF ablation in adults with AF undergoing cardiac surgery. We performed screening, risk-of-bias evaluation, and data collection independently and in duplicate. We evaluated risk of bias with the modified Cochrane tool, quality of evidence using GRADE framework, and pooled data with a random-effects model. Of the 23 included studies, only one was considered at low risk of bias. Surgical AF ablation was associated with more freedom from AF at 12 months [relative risk (RR) = 2.32, 95% confidence interval (CI) 1.92-2.80; P < 0.001, low quality]. However, no significant difference was seen in mortality (RR = 1.07, 95% CI 0.72-1.52; P = 0.41, moderate quality), stroke (RR = 1.19, 95% CI 0.59-2.39; P = 0.63, moderate quality), or pacemaker implantation (RR = 1.28, 95% CI 0.85-1.95; P = 0.24, high quality). Comparing biatrial and left-sided lesion sets showed no difference in mortality (P-interaction = 0.60) or stroke (P-interaction = 0.12). At 12 months, biatrial procedures led to more freedom from AF (RR = 2.80, 95% CI 2.13-3.68; P < 0.0001) when compared with left-sided ablation (RR = 2.00, 95% CI 1.68-2.39; P < 0.0001) (P-interaction = 0.04) Biatrial procedures appear to increase the risk for pacemaker (RR = 2.68, 95% CI 1.41-5.11; P = 0.002) compared with no ablation while left-sided ablation does not (RR = 1.08, 95% CI 0.67-1.74; P = 0.76) (P-interaction = 0.03). Conclusion Surgical AF ablation during cardiac surgery improves freedom from AF. However, impact on patient-important outcomes including mortality and stroke has not shown statistical significance in current RCT evidence. Biatrial compared with left-sided lesion sets showed no difference in mortality or stroke but were associated with significantly increased freedom from AF and risk for pacemaker requirement.

Infective Endocarditis in the Intensive Care Unit

Infective endocarditis has many facets and various expressions depending on the site of infection, microorganism, underlying heart lesion, immune status of the host, and remote effects such as emboli, organ dysfunction, and the condition of the host. Diagnosis depends on meticulous clinical examination, blood cultures results, and echocardiographic findings. The management of the patient with endocarditis in the intensive care unit is complex and needs a multidisciplinary team, including an intensivist, cardiologist, experienced echocardiologist, infectious diseases specialist, and cardiac surgeon. The medical and surgical management of such patients is complex, and timely decisions are important.

Images in cardiovascular medicine. Sinus of valsalva rupture with dissection into the interventricular septum: diagnosis by echocardiography and magnetic resonance imaging.

27-year-old previously healthy woman presented with a 3-month-long history of dyspnea after a nonspecific flu-like illness. Congestive heart failure was diagnosed clinically and confirmed radiographically. A transthoracic echocardiogram demonstrated rupture of the sinus of Valsalva with dissection into the interventricular septum (Figures 1 and 2). Severe early diastolic regurgitation into the false, noncommunicating cavity was observed within the septum, as well as moderate left ventricular chamber dilatation, distortion of the anteromedial papillary muscle, and consequent severe mitral regurgitation. A transesophageal echocardiogram showed the site of the rupture with flow into the false cavity (Figure 3, A and B). These findings were confirmed on magnetic resonance imaging (MRI; Figure 4). The patient was stabilized medically and underwent surgical repair. The postoperative transesophageal echocardiogram demonstrated elimination of the regurgitation into the false cavity and decreased mitral regurgitation (although still moderate) and a much smaller aneurysmal sac. Dissections into the interventricular septum from rupture of the sinus of Valsalva are rare; only 4 similar cases have been reported with an intact false lumen in the left ventricle. 1 No previous MRI images of this finding have been reported. Although the MRI images did not provide any extra information with regard to the diagnosis, it did give our surgeons a better 3D appreciation when approaching the surgical repair.A 27-year-old previously healthy woman presented with a 3-month-long history of dyspnea after a nonspecific flu-like illness. Congestive heart failure was diagnosed clinically and confirmed radiographically. A transthoracic echocardiogram demonstrated rupture of the sinus of Valsalva with dissection into the interventricular septum (Figures 1 and 2⇓). Severe early diastolic regurgitation into the false, noncommunicating cavity was observed within the septum, as well as moderate left ventricular chamber dilatation, distortion …

Early Rehospitalization After Prolonged Intensive Care Unit Stay Post Cardiac Surgery: Outcomes and Modifiable Risk Factors

Background Prolonged intensive care unit length of stay (prICULOS) following cardiac surgery (CS) in older adults is increasingly common but rehospitalization characteristics and outcomes are understudied. We sought to describe the rehospitalization characteristics and subsequent non‐institutionalized survival of prICULOS (ICULOS ≥5 days) patients and identify modifiable risk factors to decrease 30‐day rehospitalization. Methods and Results Consecutive patients from January 1, 2000 to December 31, 2011 were analyzed utilizing linked clinical and administrative databases. Logistic regression was used to identify risk factors associated with 30‐day rehospitalization. Out of 9210 consecutive patients discharged from the hospital alive, 596 (6.5%) experienced prICULOS. Cumulative incidence of rehospitalization for the prICULOS cohort at 30 and 365 days was 17.5% and 45.6% versus 11.4% and 28.1% for non‐prICULOS (P<0.01). Over 40% of rehospitalizations for the entire cohort occurred within 30 days of discharge costing over

Current and Future Status of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest

12 million. The most common reasons for rehospitalization were heart failure (in prICULOS) and infection (in non‐prICULOS). Rehospitalization within 30 days was associated with a 2.29‐fold risk of poor 1‐year noninstitutionalized survival for the entire cohort. Potentially modifiable factors affecting 30‐day rehospitalization included lack of physician visits within 30 days of discharge (odds ratio 2.11; P=0.01), and preoperative anxiety diagnosis (odds ratio 2.20; P=0.01). Conclusions PrICULOS patients have high rates of rehospitalization that is associated with an increased rate of poor noninstitutionalized survival. Addressing modifiable risk factors including early postdischarge access to physician services, as well as access to mental health services may improve patient outcomes.

Diagnosis of Left Ventricular Assist Device Outflow Graft Obstruction Using Intravascular Ultrasound

Numerous series, propensity-matched trials, and meta-analyses suggest that appropriate use of extracorporeal cardiopulmonary resuscitation (E-CPR) for in-hospital cardiac arrest (IHCA) can be lifesaving. Even with an antecedent cardiopulmonary resuscitation (CPR) duration in excess of 45 minutes, 30-day survival with favourable neurologic outcome using E-CPR is approximately 35%-45%. Survival may be related to age, duration of CPR, or etiology. Associated complications include sepsis, renal failure, limb and neurologic complications, hemorrhage, and thrombosis. However, methodological biases-including small sample size, selection bias, publication bias, and inability to control for confounders-in these series prevent definitive conclusions. As such, the 2015 American Heart Association Advanced Cardiac Life Support guidelines update recommended E-CPR as a Level of Evidence IIb recommendation in appropriate cases. The absence of high-quality evidence presents an opportunity for clinician/scientists to generate practice-defining data through collaborative investigation and prospective trials. A multidisciplinary dialogue is required to standardize the field and promote multicentre investigation of E-CPR with data sharing and the development of a foundation for high-quality trials. The objectives of this review are to (1) provide an overview of the strengths and limitations of currently available studies investigating the use of E-CPR in patients with IHCA and highlight knowledge gaps; (2) create a framework for the standardization of terminology, clinical practice, data collection, and investigation of E-CPR for patients with IHCA that will help ensure congruence in future work in this area; and (3) propose suggestions to guide future research by the cardiovascular community to advance this important field.

Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest: The State of the Evidence and Framework for Application

Originally conceived of as a means for bridging patients to heart transplantation, the encouraging long-term outcomes of left ventricular assist devices (LVADs) have led to their increased use in the treatment of heart failure, even in cases where transplant candidacy or availability is unlikely. Despite the life-saving aspects of LVAD therapy to support the patient with end-stage heart failure, issues of pump obstruction and thrombosis persist, resulting in an increasing need for emergent device exchanges or deaths from thrombosis.1 This forms a diagnostic dilemma for care providers because there are a variety of clinical syndromes that may mimic this feared complication, yet the treatment options for bona fide pump thrombosis are limited. Although algorithms have been proposed to address this problem in a standardized fashion,2 there remains considerable heterogeneity in the diagnosis and management of pump thrombosis between centers. Where outflow graft obstruction is suspected, vascular ultrasound has previously been used intraoperatively to confirm the presence of outflow graft obstruction.3 However, intravascular ultrasound (IVUS) offers the benefit of confirming obstruction before taking the patient to the operating suite for device exchange. We present a case of HeartMate II LVAD (Thoratec Corporation, CA) thrombosis in which IVUS was used in this very manner; the first reported case of its kind. A 65-year-old female (62 kg) with …

The impact of the Rasouli decision: a Survey of Canadian intensivists

Out-of-hospital cardiac arrest (OHCA) affects 134 per 100,000 citizens annually. Extracorporeal cardiopulmonary resuscitation (ECPR), providing mechanical circulatory support, may improve the likelihood of survival among those with refractory OHCA. Compared with in-hospital ECPR candidates, those in the out-of-hospital setting tend to be sudden unexpected arrests in younger and healthier patients. The aims of this review were to summarize, and identify the limitations of, the evidence evaluating ECPR for OHCA, and to provide an approach for ECPR program application. Although there are many descriptions of ECPR-treated cohorts, we identified a paucity of robust data showing ECPR effectiveness compared with conventional resuscitation. However, it is highly likely that ECPR, provided after a prolonged attempt with conventional resuscitation, does benefit select patient populations compared with conventional resuscitation alone. Although reliable data showing the optimal patient selection criteria for ECPR are lacking, most implementations sought young previously healthy patients with rapid high-quality cardiopulmonary resuscitation. Carefully planned development of ECPR programs, in high-performing emergency medical systems at experienced extracorporeal membrane oxygenation centres, may be reasonable as part of systematic efforts to determine ECPR effectiveness and globally improve care. Protocol evaluation requires regional-level assessment, examining the incremental benefit of survival compared with standard care, while accounting for resource utilization.