Tamunoinemi Bob-Manuel

Trends, predictors and outcomes of ischemic stroke and intracranial hemorrhage in patients with a left ventricular assist device

Background Patients with a left ventricular assist device (LVAD) are at a higher risk of ischemic stroke (IS) and intracranial hemorrhage (ICH). There is limited data available on risk factors and outcomes associated with IS and ICH in LVAD patients. Methods All patients >18 years of age with an LVAD were identified based on the U.S. Nationwide Inpatient Sample (NIS) database from the year 2007 to 2011. Patients with a discharge diagnosis of IS were compared to those without IS. In a separate analysis, patients with a discharge diagnosis of ICH were compared to patients without ICH. Trends, predictors and outcomes of IS and ICH were analyzed using a multivariate regression model. Results Out of 17,323 discharges with a primary diagnosis of heart failure with LVAD, 624 (3.6%) patients had a co-diagnosis of IS and 387 (2.2%) had a co-diagnosis of ICH. From 2007 to 2011, the discharge diagnosis of heart failure with LVAD increased from 946 to 5,540, but the proportion of patients with IS remained about 3.4%, while the incidence of ICH decreased from 3.8% in 2007 to a plateau of around 2.2% in the following years. After adjusting for potential confounders, increasing Charlson Comorbidity Index (CCI) score was an independent predictor of IS and ICH. In-hospital mortality was four-fold higher in the IS group (odds ratio: 4.2; 95% CI: 2.3-7.6; P<0.0001) and 18-fold higher in the ICH group (OR: 18; 95% CI: 9-34, P<0.0001). Renal disease (OR: 5.3; CI: 1.3-22.1; P=0.02), liver disease (OR: 4.9; CI: 1.1-21.2; P=0.03) and abnormal coagulation profile (OR: 4.8; CI: 1.6-14.4; P=0.01) were independent predictors of mortality in LVAD patients with IS. Presence of diabetes mellitus (OR 4.3, P=0.1) and liver disease (or 2.8, P=0.2) showed trends towards predicting mortality in LVAD patients with ICH but did not reach statistical significance. Conclusions Increasing comorbidity burden significantly increases the risk of both IS and ICH with LVAD. In our cohort, the incidence of IS and ICH increases the mortality 4- and 18-fold, respectively. Renal disease, liver disease and abnormal coagulation profile were independent predictors of mortality in LVAD patients with IS.

Spontaneous rupture of sinus of valsalva aneurysm presenting as perivalvular hematoma

Acute rupture of sinus of Valsalva often presents as an acute emergency with significant hemodynamic compromise whereas contained rupture of sinus of Valsalva with a perivalvular hematoma formation is rarely seen. We describe the case of a 63-year-old male who presented with acute shortness of breath and was found to have rupture of sinus of Valsalva aneurysm (SVA) with a perivalvular hematoma and severe aortic regurgitation. We also review the presentation, diagnosis, and management of SVAs.

PREDICTORS OF TRUE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION IN COCAINE POSITIVE PATIENTS

Background: More than 500,000 emergency department visits in the United States each year are related to cocaine use. This patient population tends to have a low incidence of a true ST-segment elevation myocardial infarction (STEMI) (0.7% to 6.0%). Identification of the frequency and factors

Non-ST Elevation Acute Coronary Syndromes: A Comprehensive Review☆☆☆

Non-ST elevation-acute coronary syndrome (NSTE-ACS) includes NSTE myocardial infarction and unstable angina. This patient population forms approximately two-thirds of all hospital admissions for ACS in the United States each year and is associated with an in-hospital mortality of 5%. NSTE-ACS is primarily due to an acute change in the supply and demand balance of coronary perfusion and myocardial oxygen consumption, because of the significant coronary artery obstruction presenting as plaque rupture or erosion. Nevertheless, nonobstructive causes may lead to that same phenomenon by excessive myocardial oxygen demand or reduced coronary supply from hypotension, anemia, or sepsis, including transient coronary vasospasm and endocardial dysfunction. The recent clinical application of high-sensitivity troponin biomarker assays and computer tomography angiography shows promise for improving the diagnosis and the risk stratification of patients with angina symptoms. Implementation of recent updates to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on NSTE-ACS, especially regarding the selection and duration of antiplatelet therapy, have led to improvement in management and outcomes of this disease. Additionally, new adjunctive therapies and approaches to diagnosis and treatment are discussed. Despite the progress made in recent years in the diagnosis and management of NSTE-ACS, morbidity remains high and mortality is significant. Such a fact suggests that future research targeting prevention, early diagnosis, and intervention in these patients is warranted. This article provides a detailed overview of the most recent information on the pathophysiology, diagnosis, treatment, and prognosis of NSTE-ACS.

Shorter Door-To-Balloon ST-Elevation Myocardial Infarction Time: Should There Be a Minimum Limit?

In ST-elevation myocardial infarction (STEMI) ischemic time is directly related to permanent myocardial damage and mortality. Therefore, it is crucial to restore myocardial perfusion rapidly. Door-to-balloon (DTB) time is defined as the duration between the arrival time of the patient to the medical facility until the time he or she is treated with percutaneous coronary intervention. Currently, DTB is the criterion that measures the quality of care provided to patients with STEMI at any given institution. It is well documented in the literature that longer DTB is associated with higher mortality; however, lowering DTB beyond current recommendations has not shown to decrease mortality rates. The current recommendations call for a DTB less than 90 minutes from the patients first contact within the healthcare system, typically the arrival to the emergency department, to the time of the balloon inflation of the culprit coronary artery. Conversely, efforts to keep reducing DTB time may lead to unnecessary percutaneous coronary intervention (in false-positive STEMI) and delay appropriate therapy when needed, possibly missing an alternate potentially life-threatening diagnosis. In conclusion, we herein review the literature on DTB and mortality rate. We also make suggestions about ideal DTB time and hazards of shortening it beyond the recommended guidelines.

Impact of Pre-existing Kidney Dysfunction on Outcomes Following Transcatheter Aortic Valve Replacement

Background: Pre-existing chronic kidney disease (CKD) portends adverse outcomes following heart valve surgery. However, only limited and conflicting evidence is available on the impact of CKD on outcomes following transcatheter aortic valve replacement (TAVR). The objective of this review was to evaluate the effect of pre-existing CKD on TAVR outcomes. Methods: We performed a systematic electronic search using the PRISMA statement to identify all randomized controlled trials and observational studies investigating the effect of pre-existing CKD on outcomes following TAVR. 30-day and long-term outcomes were measured comparing patients with Glomerular filtration rate (GFR) ≥60 to those with GFR <60. Results: Ten studies were analyzed comprising of 8688 patients. Compared to patients with GFR ≥60, those with GFR < 60 had worse 30-day all cause mortality (OR 1.40, 95% CI: 1.13-1.73), cardiovascular mortality (OR 1.66, 95% CI: 1.04-2.67), strokes (OR 1.39, 95% CI: 1.05-1.85), acute kidney injury (OR 1.42, 95% CI: 1.21-1.66) and the risk for dialysis (OR 2.13, 95% CI: 1.07-4.22). There was no difference in device success (p=0.873), major or life threatening bleeds (p = 0.302), major vascular complications (p=0.525), need for pacemaker implantation (p = 0.393) or paravalvular leaks (p = 0.630). All-cause mortality at 1 year was also significantly higher in patients with GFR <60 (OR 1.80, 95% CI: 1.26-2.56). Conclusion: Pre-existing CKD defined as GFR <60 is a strong predictor of worse short and long-term outcomes following TAVR. Active measures should be taken to mitigate the postprocedure risk in these group of patients.

Complete revascularization of simultaneous multiple culprit lesions in a septuagenarian with ST-elevation myocardial infarction

Patient: Female, 74 Final Diagnosis: Multiple culprit lesions in ST-elevation myocardial infarction Symptoms: Chest pain • shortness of breath Medication: — Clinical Procedure: Cardiac catheterization Specialty: Cardiology Objective: Unusual clinical course Background: ST-elevation myocardial infarction (STEMI) is usually caused by rupture of unstable plaque with thrombus formation and abrupt cessation of blood flow through a single coronary artery that is deemed the culprit. The simultaneous thrombotic occlusions of multiple coronary arteries in the setting of STEMI is a rare occurrence with implications for patient management and outcome not fully addressed in the current STEMI guidelines, although more recent studies suggest a benefit of complete revascularization compared to culprit vessel-only treatment in the setting of STEMI. Case Report: A 74-year-old female presented with STEMI. Coronary angiography revealed simultaneous multiple coronary thrombotic occlusions involving the right coronary, left circumflex, and ramus intermedius arteries successfully treated with primary percutaneous revascularization at the same setting with good outcome and short hospital length of stay. Conclusions: Although the most appropriate timing to treat simultaneous multiple culprit lesions has yet to be definitively defined, multi-vessel percutaneous coronary intervention in the setting of a STEMI with multiple culprit lesions is feasible with good outcome as shown by our index case.