Acute Hemodynamic Compromise Research Articles

Feasibility and safety of a cardiologist-only approach to sedation for DFT testing

Defibrillation threshold (DFT) testing has been performed to “prove” the ability of the implantable cardioverter–defibrillator (ICD) to effectively terminate ventricular fibrillation (VF). DFT testing has been considered as the gold standard for many years, but recently has become a matter of intense debate due to some limitations of the testing in predicting ICD efficacy and the reports of DFT testing-related near death, stroke, acute hemodynamic compromise [1–3]. Moreover, DFT is a painful procedure requiring sedation and analgesia, usually not required during the implant.

Transplantation in the highly sensitized pediatric patient.

Sensitization against HLA antigens is a growing problem in the field of pediatric cardiac transplantation. Although surgical outcomes for congenital heart disease have improved over the decades, these successes have added to the growing list of sensitized patients who eventually may require transplantation.Cardiac transplantation survival has improved, but morbidity and mortality secondary to HLA antibodies hinder outcome. Aside from acute hemodynamic compromise, there is compelling evidence linking sensitization and AMR with the development of CAV, a major limiting factor affecting long-term graft survival. Clinical advances have improved our understanding of the roles of antibody type, CFAs and non-CFAs, and DSAs and non-DSAs. Therapeutic strategies target both the T- and B-cell lines. Combinations that include plasmapheresis, IVIG, cyclophosphamide, and rituximab have been used in clinical studies with variable success.Two newer agents show promise, targeting both ends of the antibody-mediated spectrum: Bortezomib depletes plasma cell populations, and eculizumab blocks the terminal effects of antibody action, thus preventing myocardial cell dysfunction and death. Despite numerous diagnostic and therapeutic advances, many questions remain about the best approaches.The role of HLA antibodies remains the central target of investigation.

Effects of Aneurysm on the Mechanical Properties and Histologic Structure of Aortic Sinuses

Aortic root aneurysms are relatively uncommon but their rupture is a detrimental event with acute hemodynamic compromise and high mortality, and there are few available data on their mechanical properties, although aneurysm rupture occurs when hemodynamic stresses exceed wall strength. This study aimed to fill this gap by examining the effect of aneurysm on the mechanical and structural properties of aortic sinuses. Sinus tissue was procured from 16 aneurysmal patients during surgical repair and from 18 age-matched nonaneurysmal autopsy subjects, and grouped by age (young versus old), region (left versus right versus noncoronary), and direction (circumferential versus longitudinal). The tissue was submitted to histologic evaluation of elastin/collagen contents and to mechanical testing beyond rupture for the determination of failure properties and material characterization by the Fung-type model. Contrasting the direction-dependent (anisotropic) material constants and failure properties, and the primarily circumferential reinforcement of elastin/collagen fibers in healthy sinuses, near-similar (isotropic) properties and arbitrarily aligned fibers were found in the aneurysmal right and left coronary sinuses, together with less anisotropic properties in the aneurysmal noncoronary sinus. Variations between aneurysmal and healthy sinuses were comparable in young and old subjects. The former displayed significantly higher failure stress, failure stretch, and peak elastic modulus, justified by their increased elastin/collagen contents. We submit evidence of more isotropic histomechanical properties in the aneurysmal sinuses that seem consistent with the more axisymmetric stresses exerted on them owing to their more spherical shape, compared with the nondilated healthy sinuses that presented marked anisotropic properties.

Status 2 Patients Had Poor Prognosis Without Mechanical Circulatory Support

Indication for mechanical circulatory support (MCS) has been a matter of debate in less sick status 2 patients. Data were obtained from 183 consecutive patients assigned to stage D heart failure (HF) who were evaluated by the institutional review board of the University of Tokyo Hospital and then listed for heart transplantation as status 1 or 2 of the Japan Organ Transplant Network. Patients with status 2 (n=38) had a prognosis as poor as those dependent on inotropes (n=54) or MCS (n=91; P=0.615, log-rank test), and only 4 of them had eventual ventricular assist device (VAD) implantation (10.5%). Patients who eventually received VAD (n=92) had better 4-year survival than those without MCS among status 1 and 2 (P=0.030, log-rank test). On Cox regression analysis plasma B-type natriuretic peptide (BNP) >740pg/ml was the only significant predictor for 4-year survival among the status 2 group (P=0.014; hazard ratio, 8.267). Ten patients with status 2 died: 6 due to acute hemodynamic compromise and 4 due to ventricular fibrillation. Prognosis in status 2 patients was as poor as that of those dependent on inotrope infusion or VAD, mostly because of out-of-hospital sudden death without MCS. Status 2 patients with considerably high plasma BNP may be good candidates for continuous flow VAD therapy.

Management of severe aortic regurgitation in a patient with cardiogenic shock using a percutaneous left ventricular assist device and transcatheter occlusion of the failed aortic valve homograft as a bridge to surgical valve replacement

Acute hemodynamic compromise due to severe aortic regurgitation remains a difficult problem. The optimal management strategy and timing of surgery continues to evolve as new technologies become available. Here, we report the case of a young woman presenting with severe regurgitation of an aortic homograft who developed precipitous cardiogenic shock and multi-organ dysfunction. Her mortality risk with emergent surgery was prohibitive, and no percutaneous valve-in-valve device was available. We stabilized her condition by placing an Amplatz-type Atrial Septal Defect (ASD) occluder across her aortic valve in conjunction with a percutaneous left ventricular assist device as a bridge to surgical valve replacement. She went on to a successful surgery and recovered well.

ECLS for children with late (post‐discharge) rejection after heart transplantation

Rejection with acute hemodynamic compromise after OHT is rare in children, and is associated with poor survival. We retrospectively reviewed the management, course and outcome of recipients with late (following initial hospital discharge) rejection with acute hemodynamic compromise who were supported on ECLS. Of 197 consecutive children undergoing OHT (84 male; mean [SD] age 8.3 [5.7] [range 0.1-18.8yr]) between 2/2002 and 10/2012, 187 children survived and were discharged from hospital. Mean (SD) follow-up was 5.0 (3.1) (range 0.1-10.6) yr. During follow-up, seven presented with severe hemodynamic compromise after transplantation (of whom one patient had been transplanted elsewhere). All seven children, who presented in hemodynamic collapse with poor cardiac function refractory to inotropic support, were placed on ECLS-two following in-hospital cardiac arrest. The median duration of ECLS was 6 (range 5-15) days. All survived to decannulation, with one death from overwhelming sepsis 20days after presentation. The median (range) duration (in days) of inotropic requirement post ECLS was 11 (5-27), the median ventilation time was 8 (7-30), median ICU length of stay was 14 (10-54), and median hospitalization was 24 (19-118). In all, ventricular function normalized (FS >28%) within 10 (7-22) days. There was significant short-term morbidity; however, over a median follow-up of 5.9 (range 0.7-9.2) yr, all survivors have good functional status with no significant apparent neurological sequelae. ECLS thus appears to be a good rescue therapy for children with severe acute rejection post OHT, refractory to conventional treatment, leading to good medium-term outcome.

Biventricular Mechanical Circulatory Support Does Not Prevent Delayed Myocardial Ventricular Rupture following Myocardial Infarction.

Cardiogenic shock and myocardial rupture can complicate an acute myocardial infarction (AMI). A case is reported in which a 58-year-old male with an acute inferior myocardial infarction required placement of biventricular assist device for hemodynamic support eight days after the onset of his AMI; eleven days after his AMI, the patient developed abrupt onset of hemodynamic instability with massive bleeding from his chest tube due to delayed free wall myocardial rupture that was discovered when he was taking emergently to the operating room. Myocardial rupture in patients with a ventricular assist device should be considered in the differential diagnosis in the event of acute hemodynamic compromise. A high level of suspicion for such a complication should prompt aggressive and emergent actions including surgery. We present a case of delayed free wall myocardial rupture following an acute inferior wall myocardial infarction in a patient with biventricular mechanical circulatory support.

Management of Peripartum Cardiomyopathy

Peripartum cardiomyopathy is diagnosed in women who develop systolic heart failure in the last month of pregnancy or within 5months of delivery. This diagnosis should not be made in women with pre-existing cardiac disease or another cause of cardiac dysfunction. To prevent delay in diagnosis and treatment, a high index of suspicion is required given the overlapping symptoms of late pregnancy and heart failure. Traditional heart failure medical therapies are indicated, although drugs must be carefully reviewed for safety during pregnancy and lactation. Long-term prognosis is largely determined by the degree of ventricular recovery. Patients with acute or persistent hemodynamic compromise despite medical therapy should be considered for mechanical circulatory support and evaluated promptly for cardiac transplantation. A multidisciplinary team is required to care for patients with peripartum cardiomyopathy through parturition and beyond. All peripartum cardiomyopathy patients should be counseled that repeat pregnancy can negatively impact cardiac function and lead to recurrent heart failure or even death. Patients with persistent ventricular dysfunction should be strongly advised against another pregnancy.

Protocolo diagnóstico de la rectorragia

Rectal bleeding usually it is due to lesions of the colon, the most frequent diverticula and angiodysplasias; but it can also originate in the small intestine or in the upper gastrointestinal tract. The method of choice for the diagnosis is colonoscopy, which also provides for treatment in most cases. In patients with acute rectal bleeding and hemodynamic compromise should undergone first gastroscopy. When anal pathology is suspected it is useful to practice an anoscopy. Other methods may be needed to reach a diagnosis, capsule endoscopy, enteroscopy, angiography, isotope studies, computed tomography techniques and exploratory laparotomy. The study of mild rectal bleeding performed on an outpatient basis, while the rectal bleeding severe (hemodynamic instability) should be done with the patient hospitalized.

756 Can Right Ventricular Failure Associated with LVAD Insertion Be Avoided?

Background: Acute right ventricular failure (ARVF) can occur as a result of myocardial infarction, myocarditis, or postcardiotomy. Devices including implantable right ventricular assist devices (RVAD) and short-term microaxial devices offer improved hemodynamic support in this syndrome. Although the prognosis of ARVF has historically been grim, few studies have examined outcomes in the era of mechanical circulatory support. In this study, we describe our experience with mechanical right ventricular support in patients with ARVF. Methods: We performed a retrospective review of our institutional database. Sixteen consecutive patients underwent implantation of right-sided assist devices for ARVF between November 2005 and November 2010. Data were collected on the ARVF patients, including 30-day mortality, duration of support, and successful weaning rate. Results: Ten recipients were male and the mean age was 50.5 years (14 to 68 years). Etiology of ARVF included RV infarction (n56), myocarditis (n52), post-LVAD (n52), postheart transplant (n55), and post-cardiotomy (n51). Devices implanted included Thoratec IVAD and PVAD (n55), Impella RD 5.0 (n510), and Impella RP (n51). The mean duration of support ranged from 1 to 107 days (mean 24 days). Ten patients (62.5%) were successfully weaned, while six (37.5%) died during device therapy. No patients went on to transplantation. The 30-day mortality rate was 44% overall, with no difference between different etiologies of ARVF. Conclusions: ARVF continues to be associated with a high mortality rate, regardless of underlying etiology. Mechanical support with RVAD and microaxial devices can offer temporary support during acute hemodynamic compromise, allowing the RV to recover in many cases. Most patients who are successfully weaned will survive to hospital discharge. Our experience supports ongoing use of mechanical circulatory support in ARVF.

Aortic Dissection Mimics Acute Abdomen in an Older Patient

Aortic dissection is a relatively uncommon illness, but it often presents with acute hemodynamic compromise and severe chest pain. Early diagnosis and treatment are crucial for survival. Patients with an aortic dissection typically present with an acute, severe, sharp, or “tearing” posterior chest or anterior chest pain or back pain. We describe one example of ascending aortic dissection show atypical symptoms. And the symptoms are similar to acute abdomen initially. We should always keep in mind that the possibility of aortic dissection when a widened mediastinum is noted despite of atypical symptoms for aortic dissection.

Conduction Abnormalities in Pediatric Patients With Restrictive Cardiomyopathy

Pediatric restrictive cardiomyopathy carries a poor prognosis secondary to a high risk of sudden death previously attributed to ventricular tachyarrhythmias. The extent of conduction abnormalities in this population and their relationship to life-threatening events has not been previously reported. A retrospective study of pediatric patients with restrictive cardiomyopathy diagnosed between April 1994 and May 2011 was performed. Demographic, cardiac, and ECG characteristics and the mechanisms of serious arrhythmic events (death or episode of acute hemodynamic compromise thought to be secondary to arrhythmia) were evaluated. Sixteen patients (1-17 years of age) were reviewed, with 5 sudden cardiac events noted, including 4 deaths. Two deaths were caused by development of acute heart block; another patient with syncope had intermittent heart block and survived as the result of pacing features of an implanted defibrillator system. The median PR interval (222 versus 144 ms; P<0.01) and the QRS duration (111 versus 74; P=0.01) were significantly longer in those who had an acute cardiac event. Older age at presentation was associated with sudden cardiac events (P<0.01). No other functional or echocardiographic variables were associated with a sudden cardiac event. Pediatric patients with restrictive cardiomyopathy are at risk for acute high-grade heart block, and, in this cohort, bradycardic events represented a significant portion of all arrhythmic events. Aggressive ECG monitoring strategies looking for conduction system disease should be ongoing in all patients with restrictive cardiomyopathy. Implantation of a defibrillator/pacemaker should be considered as prophylactic management.

Abstract 9589: Conduction Abnormalities in Pediatric Patients with Restrictive Cardiomyopathy

Introduction: Pediatric restrictive cardiomyopathy (RCM) carries a poor prognosis secondary to a high risk of sudden cardiac death. Sudden death in pediatric patients has previously been attributed to ventricular tachyarrhythmias. There are many reasons why patients with RCM might develop conduction system disease and it is conceivable that in the acute setting, this might be a triggering event for sudden death. Methods: A single center, retrospective chort of pediatric patients with RCM, diagnosed between April 1994 and April 2011 was analyzed for conduction system abnormalities and potential triggering events for sudden death. Patient demographic, cardiac and electrocardiographic characteristics were reviewed. Incidence of sudden cardiac events was determined (defined as death or an episode of acute hemodynamic compromise felt to be secondary to a cardiac arrhythmia). Non-parametric statistical methods were used to determine associations between clinical characteristics and sudden cardiac events. Results: Fifteen patients (1 - 17 years) were reviewed; there were 5 sudden cardiac events including 4 deaths. Two of the deaths were precipitated by the abrupt onset of complete heart block. Another patient with syncope had intermittent heart block and survived as a result of the defibrillator pacing features. Sudden cardiac events were statistically associated with an older age ( p &lt;0.01 ). On initial presentation, the median PR interval (222 vs. 140 msec; p &lt; 0.01 ) and the median QRS duration (111 vs. 73.5; p = 0.01 ) was significantly longer in those having an acute cardiac event. No other functional or echocardiographic variables were associated with a sudden cardiac event. Conclusion: Pediatric patients with RCM are at risk for acute high grade heart block and bradycardic events may represent a significant portion of all arrhythmic events. Since PR interval prolongation and wider QRS complex were associated with acute cardiac events, these findings suggest increased monitoring for bradyarrhythmic episodes with consideration for prophylactic pacemaker implantation in certain patients. Particular care should be taken in patients with RCM and evidence of conduction system disease.

Use of therapeutic plasma exchange as a rescue therapy in 2009 pH1N1 influenza A—An associated respiratory failure and hemodynamic shock

Acute pneumonitis with acute lung injury is a cause of significant mortality related to the 2009 pH1N1 influenza A virus. Widespread lung inflammation and increased pulmonary vascular permeability has been noted on autopsy. Also, many of these patients present with significant hemodynamic compromise suggesting systemic cytokine release. Therefore, attenuating circulating cytokines, and other mediators, by blood purification techniques is a theoretically attractive strategy. We report the use therapeutic plasma exchange in three children with 2009 H1N1 related acute lung injury with severe hemodynamic compromise that had failed conventional therapeutic interventions. Case series. Pediatric intensive care unit in a university children's hospital. Three children, aged 8, 11, and 17 yrs, with acute respiratory distress syndrome and hemodynamic compromise related to the 2009 pH1N1 influenza A virus documented by polymerase chair reaction. All patients were on mechanical ventilation and inhaled nitric oxide, and one patient was on extracorporeal membrane oxygenation. Therapeutic plasma exchange was used as a rescue strategy. Each patient received three exchanges of 35-40 mL/kg on consecutive days. All three patients had dramatic reduction in pediatric logistic organ dysfunction scores, oxygen requirements, and vasopressor requirements after two exchanges. All survived with good functional recovery. In this small series of patients with H1N1/acute respiratory distress syndrome and hemodynamic compromise, therapeutic plasma exchange appeared to benefit as a method of mitigating the associated cytokine storm. The procedure was well tolerated with no reported side effects. All three patients survived, defying the predicted mortality. Because these procedures used the filtration exchange method, it was performed in a timely fashion by intensive care unit personnel and on equipment already available in the intensive care unit for renal support. This very limited case series suggest there may be a role for therapeutic plasma exchange as a rescue therapy in severe shock and acute lung injury related to pH1N1 that has not responded to traditional therapy.

Review: The New Concept of ‘‘Interventional Heart Failure Therapy’’: Part 2—Inotropes, Valvular Disease, Pumps, and Transplantation

Recent advances in heart failure therapy include a variety of mechanical and device-based technologies that target structural aspects of heart failure that cannot be treated with drug therapy alone; these newer therapies can collectively be described as interventional heart failure therapy. This article is the second in a 2-part series reviewing interventional heart failure therapy. Interventions included in this discussion include those indicated for the treatment of end-stage refractory heart failure, including interventional medical therapy, interventional treatment of valvular disease, mechanical assist devices, and heart transplantation. Also included is a review of the currently available catheter-based pumps, which are intended to provide temporary support in patients with acute hemodynamic compromise. The use of cellular or stem cell therapy for the treatment of heart failure is an emerging interventional therapy and data supporting its use for the treatment heart failure will also be presented, as will a discussion of the role of palliative care and self-care in heart failure therapy.

Massive Pulmonary Embolism: Treatment with the Rotarex Thrombectomy System

This study was designed to evaluate the efficacy and safety of percutaneous mechanical thrombectomy (PMT) for acute massive pulmonary embolism (PE). Fourteen patients (8 men, 6 women) with a mean age of 55.4 (range, 38-71) years with acute massive PE were initially diagnosed by computed tomography (CT) and confirmed by pulmonary angiography. All patients presented with acute PE symptoms and hemodynamic compromise. Each patient was treated with Straub Rotarex thrombectomy device and five patients received additional thrombolysis. Technique success and clinical improvement were achieved in all patients without major complications. The mean pulmonary artery pressure (PAP) decreased from 37.6±6.6 to 29±6.4mmHg (P<0.01) after PMT. Partial arterial pressures of O(2) (PaO(2)) increased from 61.1±9.2 to 88±5.1mmHg (P<0.01). The Miller index was 0.67±0.11 and 0.37±0.13 (P<0.01), respectively, before and after PMT (P<0.01). Eleven patients had no recurrence of PE on a mean follow-up of 28.3months, whereas the other three patients were lost to follow-up. The preliminary experience in our series suggests that the Straub Rotarex thrombectomy device, which has been utilized in peripheral arteries, also is useful for the treatment of acute massive PE.

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism

To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE). The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate. We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index >or= 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all-cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT. Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in-hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long-term follow-up (35.5 +/- 21.7 months) except three who expired due to cancer and acute myocardial infarction. In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed.

A case report on asymptomatic ascending aortic dissection

Aortic dissection is a relatively rare but dreadful illness, often presenting with tearing chest pain and acute hemodynamic compromise. Early and accurate diagnosis and treatment are essential for survival. In the present review, a rare case of an asymptomatic ascending aortic dissection is reported. The general clinical manifestations, diagnosis and management of aortic dissection will also be reviewed.

NOTES Is Successful for Vertebral Spinal Interventions with Significant Advantages for Anterior Spinal Procedures

Introduction: Surgical vertebral spine procedures are currently performed via thoracoscopy and other percutaneous approaches. NOTES techniques allow easy access to the posterior mediastinum. Aims: To identify the technical challenges and to assess the feasibility of transesophageal thoracic spine bone biopsy in a porcine model. Methods: This study was approved by Animal Institutional Review Board. Four 50-kg pigs were intubated and underwent general anesthesia. A forward-viewing upper endoscope was advanced into the esophagus while in supine position. A needle knife was used to create a 15-mm long mucosal puncture in the esophageal wall followed by 3 cm long submucosal endoscopy with a mucosal flap, and scope passage into the posterior mediastinum. The pig was changed to prone position to facilitate visualization of the thoracic spine. After mediastinoscopy, 5-mm incisions were performed in the anterior longitudinal ligament using a needle knife at the level of proximal, middle, distal thoracic spine. A 19 g needle was advanced into the vertebral body and intervertebral space under fluoroscopic monitoring. Bone biopsy was performed using a 19 g needle or biopsy forceps. The endoscope was withdrawn and esophagotomy closed with T-bars. Pigs were euthanized immediately after translumenal closure for necropsy. Results: The posterior mediastinum was successfully accessed in all animals. There was spectacular visualization of anterior vertebral bodies throughout the thoracic spine. Using fluoroscopy specific spinal vertebra could be accurately identified. A needle knife was advanced about 1 cm into three vertebral bodies (T4, T8, T12) while avoiding adjacent structures. The intervertebral spaces were easily identified and dissected allowing access to the space. The hardness of bone tissue resulted in fragmented tissue samples. None of the pigs suffered any acute hemodynamic compromise during esophagotomy or bone biopsy. At necropsy, the sites of esophagotomy, biopsy and T-bars did not cause any visible adjacent organ or vascular damage. Conclusions: This is the first study to define the technical challenges and feasibility of NOTES vertebral spinal interventions. Trans-esophageal access and thoracic bone biopsy can be performed safely. The proximity of the esophagus to the vertebral column is favorable for NOTES procedures in the anterior thoracic spine, providing superior visibility and ease of access to the anterior spine compared to conventional surgical approaches allowing for intervertebral disc removal and replacement. Long-term survival studies are being performed with interventions in the thoracic and lumbosacral spine.

Neck Hematoma Causing Acute Airway and Hemodynamic Compromise After Anterior Cervical Spine Surgery

Department of Anesthesiology and Intensive Care, GB Pant Hospital, J. L. Nehru Marg, New Delhi, India