Sachin Shah

Right heart catheterization using antecubital venous access: feasibility, safety and adoption rate in a tertiary center.

To determine feasibility, safety, and adoption rates of right heart catheterization (RHC) using antecubital venous access (AVA) as compared to using the traditional approach of proximal venous access (PVA).

Impedance to retrograde and forward flow in chronic mitral regurgitation and the physiology of a double outlet ventricle.

Objective Mitral regurgitation (MR) is generally characterised as exhibiting a ‘low impedance leak into the left atrium’. This notion is widely accepted without measured impedance data. The aim of this study was to define the impedance to retrograde and forward blood flow and to examine hydraulic (pressure-volume) and mechanical (stress-shortening) function in chronic severe MR. Methods A mathematical model of a double outlet ventricle was developed and the ratio of retrograde to forward impedance was plotted over a wide range of regurgitant fraction (RF). The model predicts that an impedance ratio >1 indicates that the impedance to retrograde flow exceeds that of forward flow. Left ventricular (LV) systolic pressure/flow rate was used as an index of impedance (mm Hg/mL/s). Data from 10 patients with severe MR were used to assess the clinical applicability of the model. All patients had degenerative valve disease with partial flail leaflet, an RF >50% and an ejection fraction (EF) >0.60. There were seven males and three females, aged 59±10. LV volumes as well as retrograde and forward flow rates were determined with echocardiographic and Doppler techniques. Results The model indicates that the impedance ratio is >1 when the RF ranges from zero to 57%. Clinical data: end-diastolic volume=184±47 mL; EF=0.63±3%; RF=53±4%. Values for retrograde and forward impedance were 0.77±0.17 and 0.63±0.12 (p=0.003); the impedance ratio was 1.22±0.19. Total impedance to LV emptying was low (0.35±0.06). The ratio of systolic wall stress to EF (580±81 g/cm2) was normal. Data are mean±SD. Conclusions The model, supported by clinical data, indicates that the impedance to retrograde flow exceeds the impedance to forward flow in chronic severe MR. These findings refute the notion of a low impedance leak into the left atrium. The double outlet of an enlarged ventricle provides a mechanism for low total impedance to ejection in the presence of a normal stress-shortening relation.

Identifying patients for safe early hospital discharge following st elevation myocardial infarction.

To examine whether the CADILLAC risk score is an effective method of patient stratification for early discharge following ST elevation myocardial infarction (STEMI).

Durable left ventricular assist device therapy in advanced heart failure: Patient selection and clinical outcomes.

The increasing adoption of left ventricular assist devices (LVADs) into clinical practice is related to a combination of engineering advances in pump technology and improvements in understanding the appropriate clinical use of these devices in the management of patients with advanced heart failure. This review intends to assist the clinician in identifying candidates for LVAD implantation, to examine long-term outcomes and provide an overview of the common complications related to use of these devices.

Intracranial hemorrhage as a complication of dobutamine stress echocardiography: case report and review of the literature.

Dobutamine stress echocardiography is a generally well‐tolerated study to evaluate patients with suspected coronary artery disease. Rare but life‐threatening complications of this study have been well described. Severe hypertensive responses are a known but uncommon adverse reaction to dobutamine infusion. The authors report a case of intracranial hemorrhage in the setting of severe hypertension as a complication of dobutamine stress echocardiography. The patient was on systemic anticoagulation with warfarin for a prosthetic mitral valve and had an international normalized ratio (INR) of 3.8 that was slightly over the therapeutic goal INR of 2.5–3.5. He had no predisposing intracranial lesions such as tumor, vascular malformation, or aneurysm. He suffered an intraparenchymal hemorrhage in three distinct areas of his brain. Intracranial hemorrhage related to dobutamine infusion has not been reported previously, but given the known risk of hypertension, life‐threatening sequelae including intracranial hemorrhage are possible. (Echocardiography 2012;29:E119‐E121)

Visually guided TEE probe insertion, making a case based on anatomic variation: A cadaveric study

The variations in upper esophageal anatomy currently are unknown. This study was carried out to evaluate this variation and assess its impact on transesophageal echocardiography probe insertion.

Balloon-to-Door Time: Emerging Evidence for Shortening Hospital Stay After Primary PCI for STEMI

Nearly 250,000 patients have an ST-segment elevation myocardial infarction (STEMI) each year in the United States, and this condition results in an estimated 1 million hospital days and more than

Hypertension in Patients with Severe Aortic Stenosis: Emphasis on Antihypertensive Treatment and the Risk of Syncope

6 billion in hospital-related costs [(1,2)][1]. Reducing length of hospital stay (LOS) in this

Ibrutinib-Associated Atrial Fibrillation

Published guidelines for the management of hypertension (HTN) do not discuss HTN in patients with aortic stenosis (AS). Some clinicians have considered severe AS to be a relative contraindication to the use of antihypertensive agents. We sought to determine the incidence of syncope in AS patients who were treated with antihypertensive agents. We identified 89 patients with asymptomatic severe AS and normal ejection fraction. The prevalence of HTN, its treatment, and the occurrence of syncope was abstracted from medical records. HTN was documented in 63 of the 89 patients with severe AS; 62 were being treated (mean 2.2 drugs). The incidence of syncope (mean follow-up: 44 months) was similar in patients with treated HTN compared to those without HTN (8 vs 11%, p=NS). Of the 62 with treated HTN, those with syncope were older than those without syncope (88+/- 6 vs 78 +/- 9 years, p=0.02). When those with treated HTN and syncope were compared to an age and sex matched cohort without syncope there were no significant differences in severity of AS, ejection fraction, or arterial pressure. Patients with treated HTN and syncope had a lower stroke volume index than those without syncope (32 +/- 4 vs 40 +/- 6 mL/m2, p=0.01). In conclusion, the risk of syncope in patients with severe AS and treated HTN is low and similar to that seen in AS patients without HTN. Syncope is related to age, female sex, and a low stroke volume index.

DOES THE CONVERGENT ABLATION PROCEDURE AFFECT LEFT ATRIAL CONTRACTILE FUNCTION

Ibrutinib, a novel and potent Bruton tyrosine kinase inhibitor, is an effective and well-tolerated treatment for a variety of B-cell lymphomas. However, its use is associated with an increased incidence of atrial fibrillation (AF), ranging from 4% to 16%. We reviewed the original clinical trials that led to the approval of ibrutinib, as well as several other prospective and retrospective studies, to better appreciate the incidence of ibrutinib-associated AF. Based on 16 studies included in our analysis, the incidence of ibrutinib-associated AF was 5.77 per 100 person-years, which is much higher than rates previously reported with ibrutinib and compared with the general adult population. New onset AF in cancer patients is associated with a significantly higher risk of heart failure and thromboembolism, even after adjusting for known risk factors. In addition, ibrutinib poses unique challenges due to its interactions with many medications that are commonly used to manage AF. Ibrutinib also inhibits platelet activation and decisions regarding anticoagulation have to be carefully weighed against this increased risk of bleeding. Ibrutinibs interaction with calcium channel blockers, digoxin, amiodarone, and direct oral anticoagulants can result in either ibrutinib or other drug-related toxicity and careful selection and dose adjustment may be needed. Ibrutinib-associated AF can be a therapy-limiting side effect and physicians should be familiar with the special management considerations imposed by this agent. We review the potential mechanisms and incidence of ibrutinib-associated AF and propose an algorithm for its management.