End-organ Dysfunction Research Articles

Five-Year Analysis of the MBSAQIP Database: Are We Getting Better?

The MBSAQIP has been used to evaluate risk and create risk models. Previous studies have determined what complications matter most. This study was a registry-based analysis of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between January 1, 2015, and December 31, 2019, at centers participating in MBSAQIP. Cases were identified using Current Procedural Terminology. Patients less than 18 years old were excluded. A chi-square test was used to assess differences in the prevalence of complications and effects across years. Using a multivariable Poisson regression model with a link log and robust estimation, prevalence ratio estimates and 95% CI were obtained. A total of 690,770 observations met the inclusion criteria. Mean (SD) age was 44.5 (±12.0) years, and mean (SD) BMI was 45.2 kg/m2 (±7.9). SG cases accounted for 73.45% of all observations. There was a significant relative reduction in readmissions, end-organ dysfunction, and all-cause mortality from 2015 to 2019 in the SG subgroup. There were also noticeable reductions in 30-day readmission, ICU admission, and end-organ dysfunction in the RYGB subgroup. For complications, bleeding, postoperative pneumonia, and stroke were significantly decreased in the RYGB subgroup, but only bleeding was significantly decreased in the SG subgroup during the 5-year study period. There has been a continuous improvement in several (but not all) outcomes through the years that the MBSAQIP has been collecting data. Different outcomes were reduced between the SG and RYGB subgroups, and the decrease in all-cause mortality was only noted in the SG subgroup.

Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement.

Prevention of hospital-acquired conditions (HACs) is a focus of trauma center quality improvement. The relative contributions of various HACs to postinjury hospital outcomes are unclear. We sought to quantify and compare the impacts of six HACs on early clinical outcomes and resource utilization in hospitalized trauma patients. Adult patients from the 2013 to 2016 American College of Surgeons Trauma Quality Improvement Program Participant Use Data Files who required 5 days or longer of hospitalization and had an Injury Severity Score of 9 or greater were included. Multiple imputation with chained equations was used for observations with missing data. The frequencies of six HACs and five adverse outcomes were determined. Multivariable Poisson regression with log link and robust error variance was used to produce relative risk estimates, adjusting for patient-, hospital-, and injury-related factors. Risk-adjusted population attributable fractions estimates were derived for each HAC-outcome pair, with the adjusted population attributable fraction estimate for a given HAC-outcome pair representing the estimated percentage decrease in adverse outcome that would be expected if exposure to the HAC had been prevented. A total of 529,856 patients requiring 5 days or longer of hospitalization were included. The incidences of HACs were as follows: pneumonia, 5.2%; urinary tract infection, 3.4%; venous thromboembolism, 3.3%; surgical site infection, 1.3%; pressure ulcer, 1.3%; and central line-associated blood stream infection, 0.2%. Pneumonia demonstrated the strongest association with in-hospital outcomes and resource utilization. Prevention of pneumonia in our cohort would have resulted in estimated reductions of the following: 22.1% for end organ dysfunction, 7.8% for mortality, 8.7% for prolonged hospitalization, 7.1% for prolonged intensive care unit stay, and 6.8% for need for mechanical ventilation. The impact of other HACs was comparatively small. We describe a method for comparing the contributions of HACs to outcomes of hospitalized trauma patients. Our findings suggest that trauma program improvement efforts should prioritize pneumonia prevention. Therapeutic/Care Management; Level IV.

Status 2 Listing Strategies for Heart Transplantation: IABP or Impella?

<h3>Purpose</h3> The use of temporary mechanical circulatory support, IABP and Impella, for UNOS Status 2 patients has increased since the new policy implementation. The aim of the study was to evaluate overall listing transplant trends and outcomes of status 2 patients <h3>Methods</h3> We evaluated the UNOS database from October 2018 to March 2021 for adult heart patients listed (n=10957) and transplanted (n=7025) based on their priority status. We analyzed the characteristics and outcomes of patients listed under Status 2 classifying them in two groups: with IABP or percutaneous mechanical circulatory support (pMCS) using descriptive, univariate and survival statistics <h3>Results</h3> During the study period 3687 patients were listed (3505 (95%) transplanted) as Status 2 of which 1823 (52%) were original Status 2 while the remainder (1682, 48%) were upgraded (21% status 4). Of Status 2 patients, 2033 (55%) had IABP and 423 (11%) had pMCS. The median age (57 v. 57) and BMI (26 v. 27) were comparable between the groups. The IABP patients had higher cardiac index (1.64 v. 1.6, p=0.08) and albumin (3.6 v. 3.2, p<.01), lower creatinine (1.2 v. 1.3, p<.01) and bilirubin (0.9 v. 1.1, p<.01) at time of device placement. Patients with pMCS were more likely male (87% v. 75%, p<.01) and on inotropes (82% v. 72%, p<.01) with dobutamine (28% v. 36%, p<.01) and epinephrine (2% v. 15%, p<.01). The 14 day transplant rate was better in IABP group (80% v. 73%) while post-transplant survival was comparable at 1 year (92% v. 88%, p=0.09). 72% of all IABPs were placed at IABP predominant centers (>80% Status 2 devices IABP) while 15% pMCS were implanted at pMCS predominant centers (p<.01) <h3>Conclusion</h3> Since the new policy, 50% of all transplants are performed with UNOS Status 2 of which 48% are after being upgraded and 66% have either an IABP or pMCS. Compared to IABP, patients requiring pMCS are more likely to be male, with end-organ dysfunction and higher requirement of inotropes which could be useful in choosing appropriate device. Center level variation exist in type of device used in favor of IABP

Does Hemodynamic Response to Inotropes Predict Early Right Heart Failure After LVAD Implantation?

<h3>Purpose</h3> Right ventricular (RV) failure is a highly morbid clinical condition following left ventricular assist device (LVAD) implantation. We aimed to compare baseline and post-inotrope(s) hemodynamics as predictors of early right heart failure (RHF) after LVAD implantation. <h3>Methods</h3> We performed a single-center, retrospective analysis of all patients implanted with an LVAD between January 2018 and September 2020. We included patients with pre-implant baseline hemodynamics without augmentation by inotropic or mechanical circulatory support (MCS). This cohort was then placed on inotrope(s) with documented hemodynamics at 24 hours. We then utilized the Academic Research Consortium early RHF criteria to define severe-acute RHF (requirement of assist device or high dose inotropes with end-organ dysfunction). Stroke volume index (SVI) was identified as a surrogate of RV inotropic reserve. Comparisons between patients with and without early RHF were made using Fisher's Exact and Chi-Square tests, with probabilities determined by a binary logistical regression model. <h3>Results</h3> A total of 48 patients met study inclusion criteria. Early post-implant RHF was noted in 45.8% (n=22) of this population. There were no statistical differences among these groups when evaluated for type of inotrope utilized (p=0.2126), change in cardiac index (p=0.8924), or change in SVI (p=0.5659). There was, however, a nonsignificant trend towards decreased probability of development of early RHF, as evidenced by percent improvement in post-inotrope(s) SVI. This was most apparent in patients who received milrinone monotherapy (Figure). <h3>Conclusion</h3> We observed a nonsignificant trend of improved RV inotropic reserve represented by improvement in post-inotrope SVI, which numerically correlated with less early RHF.

Horse, Donkey, Or Zebra: Delayed Diagnosis Of Giant Cell Myocarditis

<h3>Introduction</h3> Giant cell myocarditis (GCM) classically presents in a dramatic fashion. Initial manifestations may include fulminant heart failure, refractory ventricular arrhythmias, and high degree AV block. Treatment includes aggressive immunosuppression, but even with proper treatment, the risk of progression to end stage heart failure is high. Although the clinical scenario can strongly suggest GCM, endomyocardial biopsy (EMB) remains the gold diagnostic standard. <h3>Case Report</h3> A 70-year-old female with hypertension and hyperlipidemia presented to the hospital with syncope. She was found to have new systolic heart failure with a left ejection fraction of 32%. She had a new first degree AV block with intermittent 2:1 AV block. Cardiac MRI showed multiple areas of delayed enhancement thought to be consistent with RCA territory infarct pattern versus infiltrative cardiomyopathy, specifically, sarcoidosis. Subsequent coronary angiogram demonstrated mild, non-obstructive coronary artery disease. EMB at this time showed focal histiocytic infiltrate with scattered eosinophils. No granulomas or giant cells were identified. Given the clinical picture and EMB findings, presentation was felt to be most consistent with cardiac sarcoidosis, although other inflammatory etiologies remained in the differential. Prednisone and neurohormonal blockade were started. Given her intermittent AV block, a CRT-D device was implanted. The remainder of the patient's index admission was uneventful and she had NYHA Class II symptoms on discharge. However, the patient quickly returned to the emergency department after 17 appropriate ICD discharges in the setting of VT storm. She quickly deteriorated requiring emergent peripheral VA-ECMO cannulation. A second EMB was obtained at this time which showed profound inflammation as well as giant cells (Figure 1). She was treated for giant cell myocarditis with aggressive immunosuppression but had worsening end-organ dysfunction and continued to deteriorate clinically. Ultimately, the decision was made to transition to comfort measures and the patient expired. <h3>Discussion</h3> Both GCM and cardiac sarcoidosis can present with new onset heart failure, refractory ventricular arrhythmias, and life-threatening conduction abnormalities. Endomyocardial biopsy is critical to establish the diagnosis, yet the yield is not 100%. Given the exceedingly high mortality without proper treatment, repeat EMB may be necessary to establish the diagnosis of GCM.

Impella 5.5 Support Prior to Heart and Kidney Transplantation

<h3>Introduction</h3> End-stage renal disease (ESRD) is a challenge when evaluating patients for advanced heart failure therapies. We present a patient with end-stage heart failure (HF) and ESRD, who was successfully bridged to heart and kidney transplantation using Impella 5.5 (Abiomed, Danvers, MA, USA) following bilateral nephrectomy. <h3>Case Report</h3> A 37-year-old, obese man with nonischemic cardiomyopathy from remote methamphetamine use presented with symptoms of decompensated HF despite being on a Milrinone infusion. Concomitantly, he had ESRD secondary to xanthogranulomatous pyelonephritis in a setting of chronic staghorn calculi (Figure 1). Given his progression to refractory HF, he was considered for dual organ transplantation. As a prerequisite to kidney transplantation, bilateral nephrectomy was performed for source control of the chronic pyelonephritis. Post-operative course was complicated by hemodynamic deterioration with early end-organ dysfunction despite an intra-aortic balloon pump support. He was brought to the operating room to emergently escalate his support to an Impella 5.5. Upon induction, he went into cardiac arrest. After the return of spontaneous circulation, an Impella 5.5 was placed. The device reached blood flows up to 5.2 liters per minute, which preserved him during his surgical recovery while undergoing continuous renal replacement therapy. There were no complications of malpositioning, thrombosis, or hemolysis. 30 days later, he had a combined heart and kidney transplantation. He continues to have excellent graft function after 5 months. <h3>Summary</h3> To our knowledge, this is the first reported successful use of Impella 5.5 to preserve a patient prior to a heart and kidney transplantation following bilateral nephrectomy. This case highlights how Impella 5.5 can be an invaluable tool to provide left ventricular support and as a bridge to heart transplantation for patients with end-stage HF who have kidney disease and/or recovering from major abdominal operations.

Outcomes, Temporal Trends, And Resource Utilization In Ischemic Vs Non-ischemic Cardiogenic Shock

<h3>Background</h3> Cardiogenic shock (CS) is associated with significant morbidity and mortality. Differentiating the etiologic factors driving CS has epidemiological significance and aids in optimization of therapeutic strategies, prognostication and resource utilization. The aim herein is to investigate the epidemiology and clinical outcomes of cardiogenic shock in those with ischemic and non-ischemic CS etiologies. <h3>Methods</h3> : Using International Classification of Diseases (ICD) codes, we queried the National Inpatient Sample for cardiogenic shock hospitalization from 2007 to 2018 and divided the study sample into cohorts of ischemic (I-CS) and nonischemic cardiogenic shock. (NI-CS). We then compared the primary outcome of in-hospital mortality between these two cohorts. Two groups of secondary outcomes (clinical and procedural) were also assessed between the two cohorts. <h3>Results</h3> : CS was present in 557,860 hospitalizations; 84% of these were I-CS and 15.8% NI-CS. Patients with I-CS were older, more commonly males, with more risk factors for coronary artery disease (p<0.05). NI-CS had higher prevalence of pre-existing systolic heart failure and atrial fibrillation. The in-hospital mortality was significantly higher in patients with I-CS (32.2% vs 29.5%, adjOR 1.10, p<0.001). Frequencies of acute ischemic stroke, mechanical ventilation, ventricular arrhythmias, and vascular complications were higher in I-CS vs NI-CS, while AKI and acute liver failure were more common in NI-CS (p<0.05). The use of mechanical circulatory support devices was higher in the I-CS group. <h3>Conclusions</h3> : Patients with I-CS comprise the vast majority of CS, and are associated with higher mortality and higher resource utilization. Conversely, patients with NI-CS appear to have higher survival but with a higher prevalence of end-organ dysfunction.

Sarcoidosis: Hiding in Plain Sight

<h3>Introduction</h3> Sarcoidosis is a systemic disease that can masquerade as many conditions. Due to its often patchy distribution, myocardial biopsy is only ∼30% sensitive. Herein we present a case of sarcoidosis diagnosed from an extra-cardiac biopsy years after the onset of cardiomyopathy. <h3>Case Report</h3> A 54 year old man initially presented with dyspnea and fatigue due to new onset HFrEF of 20%. He had a significant family history of SCD. His workup revealed non-obstructive CAD, a myxomatous mitral valve with bileaflet prolapse and moderate regurgitation, and a cystic structure attached to the tricuspid valve. Given his frequent ventricular ectopy, he was discharged on guideline therapy for HFrEF and a wearable cardioverter defibrillator. Genetic testing for dilated cardiomyopathies revealed EYA4 and TTN variants of unknown significance. A cardiac MRI a few months later demonstrated no abnormal late gadolinium enhancement and persistent systolic dysfunction, so he underwent AICD implant. His course was further complicated by recurrent admissions for supraventricular and ventricular tachyarrhythmias. A cardiopulmonary exercise stress test demonstrated low-risk results. Further evaluation noted prolonged AV conduction. A RHC revealed mild post-capillary pulmonary hypertension and a mildly decreased cardiac index at 2.01 L/min/m². Months later, he underwent CRT-D upgrade. He started improving functionally until he developed left eyelid swelling, initially thought to be lymphoma. An orbital biopsy revealed non-caseating granulomas. A PET/CT demonstrated FDG uptake within subcarinal lymph nodes but no cardiac uptake. Initially he declined immunomodulatory therapy, but as his symptoms worsened, he started corticosteroids and transitioned to mycophenolate mofetil due to intolerance of methotrexate. Due to disease progression on repeat FDG-PET, he was switched to infliximab. <h3>Summary</h3> The diagnosis of sarcoidosis can be difficult due to its variable presentation, including heart block, heart failure, ventricular arrhythmias and sudden cardiac death. Cardiac involvement occurs in 25% of cases. Our case was complicated by a cMRI that was negative for cardiac involvement, which emphasizes the importance of complimentary inflammatory imaging with FDG-PET. A multidisciplinary approach is needed that engages sarcoid specialists for earlier diagnosis to ensure rapid initiation of therapy to reduce end-organ dysfunction.

COVID-19 and Long-Term Outcomes: Lessons from Other Critical Care Illnesses and Potential Mechanisms.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that is currently causing a pandemic and has been termed coronavirus disease (COVID-19). The elderly or those with preexisting conditions like diabetes, hypertension, coronary heart disease, chronic obstructive pulmonary disease, cerebrovascular disease, or kidney dysfunction are more likely to develop severe cases when infected. Patients with COVID-19 admitted to the ICU have higher mortality than non-ICU patients. Critical illness has consistently posed a challenge not only in terms of mortality but also in regard to long-term outcomes of survivors. Patients who survive acute critical illness including, but not limited to, pulmonary and systemic insults associated with acute respiratory distress syndrome, pneumonia, systemic inflammation, and mechanical ventilation, will likely suffer from post-ICU syndrome, a phenomenon of cognitive, psychiatric, and/or physical disability after treatment in the ICU. Post-ICU morbidity and mortality continue to be a cause for concern when considering large-scale studies showing 12-month mortality risks of 11.8-21%. Previous studies have demonstrated that multiple mechanisms, including cytokine release, mitochondrial dysfunction, and even amyloids, may lead to end-organ dysfunction in patients. We hypothesize that COVID-19 infection will lead to post-ICU syndrome via potentially similar mechanisms as other chronic critical illnesses and cause long-term morbidity and mortality in patients. We consider a variety of mechanisms and questions that not only consider the short-term impact of the COVID-19 pandemic but its long-term effects that may not yet be imagined.

622 Oral Ketamine Administration During Bromelain Based Enzymatic Debridement of Burn Injury

IntroductionExisting literature supports bromelain enzymatic debridement as an early tool for selective escharectomy, resulting in fewer skin grafts after burn injury. Enzyme application is painful, so many centers use continuous infusions of narcotics, ketamine, and sedatives in the intensive care unit. The authors utilize oral ketamine in burn practice- as it is safe, can decrease the need for higher level of care, and be used without fasting. The purpose of this study is to evaluate whether oral ketamine can safely be utilized as an alternative to continuous infusions of medications for bromelain treatment.MethodsThis was a retrospective study of patients who received oral ketamine (for analgesia) and oral lorazepam (for anxiolysis and prevention of dysphoria) for bromelain-based selective enzymatic debridement application over a 6-month period. Data collected included patient demographics, burn characteristics, sedatives and analgesics administered, pain scores, adjunct medications, and vital signs. Presence of respiratory insufficiency (desaturations < 93%, need for bag-valve mask, or intubation), hypertensive urgency (SBP >180, DBP >110 w/out end organ dysfunction), dysphoric reactions, and uncontrolled pain were recorded. Oral ketamine (2-4 mg/kg) was given 30 minutes prior to the procedure. Patients were monitored per sedation guidelines and had capnography plus supplemental oxygen. Small PRN IV boluses of narcotics were given during the procedure, along with their baseline oral multimodals and narcotics. Pain was measured with the 1-10 verbal rating scale with minimal pain defined as < 4 or the patient clinically observed as sleeping. Patients were not made NPO for the procedure.ResultsTen patients were included. Four patients (40%) had minimal pain during enzyme application, 3 (30%) patients slept through their procedure, and 3 (30%) patients reported 10/10 pain during treatment (2 had 10/10 pain before treatment). Five patients were treated on the floor, 7 were treated in the ICU. The median ketamine dose was 225 mg (IQR:177,250), or 3mg/kg (IQR:2.75,3). Additional oral and IV opioids received during the 8–14-hour interval was 21 morphine milligram equivalents (MEs). The median benzodiazepine dosing before and during enzymatic debridement was 1.4 lorazepam MEs. Three patients (30%) had hypertensive urgency, 2 (20%) of whom reported 10/10 pain, and all 3 received 10mg IV labetalol. No one had dysphoric reactions or respiratory insufficiency.ConclusionsThis preliminary study reveals oral ketamine administration is safe and effective for pain control during bromelain-based enzymatic debridement. Most patients required small to moderate amounts of PRN IV opioids, had acceptable pain control, and there were no significant adverse effects. Future large, prospective studies should evaluate dosing and timing for optimal patient outcomes.

Thrombotic Microangiopathy Syndromes-Common Ground and Distinct Frontiers.

Thrombotic microangiopathies (TMAs) have in common a terminal phenotype of microangiopathic hemolytic anemia with end-organ dysfunction. Thrombotic thrombocytopenic purpura results from von Willebrand factor multimerization, Shiga toxin-mediated hemolytic uremic syndrome causes toxin-induced endothelial dysfunction, while atypical hemolytic uremic syndrome results from complement system dysregulation. Drug-induced TMA, rheumatological disease-induced TMA, and renal-limited TMA exist in an intermediate space that represents secondary complement activation and may overlap with atypical hemolytic uremic syndrome clinically. The existence of TMA without microangiopathic hemolytic features, renal-limited TMA, represents an undiscovered syndrome that responds incompletely and inconsistently to complement blockade. Hematopoietic stem cell transplant-TMA represents another more resistant form of TMA with different therapeutic needs and clinical course. It has become apparent that TMA syndromes are an emerging field in nephrology, rheumatology, and hematology. Much work remains in genetics, molecular biology, and therapeutics to unravel the puzzle of the relationships and distinctions apparent between the different subclasses of TMA syndromes.

Hemodynamic-based Assessment and Management of Cardiogenic Shock

Cardiogenic shock (CS) remains a deadly disease entity challenging patients, caregivers, and communities across the globe. CS can rapidly lead to the development of hypoperfusion and end-organ dysfunction, transforming a predictable hemodynamic event into a potential high-resource, intense, hemometabolic clinical catastrophe. Based on the scalable heterogeneity from a cellular level to healthcare systems in the hemodynamic-based management of patients experiencing CS, we present considerations towards systematic hemodynamic-based transitions in which distinct clinical entities share the common path of early identification and rapid transitions through an adaptive longitudinal situational awareness model of care that influences specific management considerations. Future studies are needed to best understand optimal management of drugs and devices along with engagement of health systems of care for patients with CS.

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

Anaesthetic management of a parturient with Takayasu’s arteritis coming for emergency caesarean section

Takayasu’s arteritis (TA) also known as pulseless disease is a rare disease that involves aorta and its main branches. It can cause inflammatory reaction of tunica media and adventitia of the arteries involved causing stenosis, occlusion or aneurysm., Anaesthesia for caesarean section in a parturient with Takayasu’s arteritis is complicated by associated hypertension, end organ dysfunction, stenosis of major blood vessels and overall vasculopathy.The optimal anaesthetic management in a parturient with Takayasu’s arteritis is controversial, but avoidance of regional anaesthesia has been recommended by some authors because of the risk of hypotension and the subsequent need for vasopressors., We herein report the use of general anaesthesia in a term parturient with Takayasu’s arteritis coming for emergency Lower segment caesarean section (LSCS).

Approach to Shock

Shock is a life-threatening pathophysiologic state referring to inadequate organ perfusion, which can progress to end-organ dysfunction and eventually, multiple organ failure and death. The diagnosis of shock is clinical, necessitating good understanding of the underlying etiology, pathophysiology, as well as the clinical, biochemical, and hemodynamic manifestations of the various presentations of shock. This article describes an approach to shock, highlighting the important initial actions, pertinent clinical findings, and the four main types of shock, and offers an overview of the inotropes and vasopressors used in the intensive care setting. A case study and additional figures are included to supplement the presented concepts.

Evaluation of post-discharge deterioration following major gastrointestinal cancer surgery.

667 Background: Clinical deterioration, defined as end-organ dysfunction following surgery, is a devastating, yet potentially preventable set of complications, usually occurring after an inciting event. The extent to which deterioration occurs post-discharge after major gastrointestinal cancer surgeries is unknown. Our objectives were to (1) evaluate the incidence of post-discharge deterioration (PDD), (2) characterize the events surrounding PDD, and (3) identify factors associated with PDD. Methods: Patients who underwent gastrointestinal resection for cancer were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data File (2016-2019). Clinical deterioration was measured as a composite event consisting of respiratory failure, acute renal failure, cardiac arrest, or septic shock. Factors associated with PDD were evaluated using multivariable logistic regression. Results: Of 121,458 patients, 3,947 (3.3%) experienced clinical deterioration, with 19.1% occurring post-discharge. The median time to PDD from discharge was 8 days (IQR 4-13 days). Among patients who developed PDD, 58.9% had a previously diagnosed post-discharge complication, most commonly surgical site infection (38.2%), pneumonia (9.9%), and venous thromboembolism (5.4%). PDD was associated with older age, male sex, medical comorbidities, dependent functional status, longer operative time, transfusion, and discharge to a facility (all p &lt; 0.05). Patients who underwent esophagectomy (OR 2.08 [95%CI, 1.39-3.10]) or pancreatectomy (OR 1.36 [95%CI, 1.07-1.74]) had significantly higher odds of developing PDD compared to patients who underwent colectomy. Conclusions: Post-discharge deterioration after major cancer surgeries commonly occurred after other potentially treatable post-discharge complications. Efforts should focus on improving post-discharge monitoring and timely and effective management of post-discharge complications to arrest their progression to post-discharge deterioration and mortality.

Abstract TP185: Cardiac Gadolinium Enhancement And Cerebral Small Vessel Disease

Background: Accumulation of cerebral small vessel disease (CSVD) leads to various well described detrimental clinical consequences. Similar to CSVD, the development of coronary microvascular disease (CMD) yields end-organ dysfunction, namely myocardial ischemia and chamber dilation. We aimed to investigate the relationship between cardiac gadolinium enhancements (CGE), a marker for CMD, on CSVD burden on brain MRI. Methods: We performed a retrospective cross-sectional analysis of adults between January 2014 and December 2019 who completed a cardiac and brain MRI within one year of each other. The ordinal total small vessel disease score (tSVD) was used to quantify CSVD with two cohorts being created: tSVD 0 to 1 (low CSVD) and tSVD 2 to 4 (high CSVD). Cardiac MRI data was obtained under the guidance of an experienced cardiologist with advanced cardiac imaging training. Chi-squared or Fisher’s, Wilcoxon rank-sum analyses were performed for binary and ordinal variables, respectively. Adjusted multivariate logistic regression models were used to calculate odds ratios. Statistical significance was defined as &lt; 0.05. Results: A total of 259 individuals were included with 140 and 119 in the low and high CSVD groups, respectively. Those with low CSVD were significantly lower in age, predominately female and had lower rates of hypertension, hyperlipidemia, diabetes mellitus and congestive heart failure. CGE was more common in those with higher burdens of CSVD (23.2% vs 47.2%, p&lt;0.001). CGE increased the odds of being within the high CSVD group despite adjustment for significant clinical and demographic factors (OR 2.1, 95% CI 1.1 - 4.0). Discussion: In those with CMD as identified by CGE, there was a 2 fold increase in being within the high burden of CSVD cohort likely as a result of similar intrinsic pathological processes. Further studies are needed to determine whether CGE predates development of CSVD, its association with development of acute cerebrovascular diseases and its influence on specific subtypes of CSVD.

Heart Xenotransplant: A Door That Is Finally Opening.

Heart Xenotransplant: A Door That Is Finally Opening.

Management of P Management of Patients with Refr atients with Refractory Cardiogenic Shock and diogenic Shock and Cardiointestinal Syndrome with Impella 5.5 as Bridge to Decision: Case Series

Patients with advanced heart failure require multi-system management as a majority succumb to end-organ dysfunction, including gastrointestinal sequelae. Temporizing measures, such as early mechanical circulatory support, can assist in the recovery of patients with acute cardiogenic shock. The temporary support can improve patient characteristics to enable future definitive heart failure therapies such as durable left ventricular assist devices and orthotopic heart transplantation. We present two cases of cardiogenic shock that were successfully bridged with an Impella 5.5 (Abiomed). The management enabled the patients to recover from reversible cardiointestinal syndrome and undergo successful definitive therapies.

Intraabdominal pressure as a marker for physiologic and pathologic processes in pregnancy

Increased intraabdominal pressure (IAP) can result in compression of the abdominal-pelvic venous system leading to end organ dysfunction, presenting as glomerulopathy with proteinuria, elevated creatinine and hypertension, hepatic ischemia with elevated liver enzymes, uteroplacental ischemia with fetal growth restriction or placental abruption, and thrombocytopenia. It has been hypothesized to be a pathophysiologic process of preeclampsia (PreE). We sought to evaluate factors affecting IAP in pregnancy, including PreE and twin gestations. We hypothesized that IAP would be higher in pregnancies complicated by PreE and in twin gestations. We prospectively enrolled women >28 weeks gestational age (GA) undergoing scheduled Cesarean delivery (CD) with regional anesthesia. Exclusion criteria included ruptured membranes, uterine contractions, known abdominal-pelvic mass, and preexisting renal or liver disease. IAP was measured using standard technique preoperatively. We compared IAP in: 1) PreE to Norm in both singletons and twins, and 2) Norm singletons to twins. Data were analyzed using linear regression models and adjusted for potential confounders. Thirty-nine patients were enrolled: Singletons: 10 Norm, 8 PreE; Twins: 12 Norm, 9 PreE. Demographic and delivery data are presented in the Table. In singletons, IAP was significantly higher in PreE compared to Norm pregnancies (mean±SD, 11.8±3.5 vs 7.1±1.2, p=0.0007, Figure). Among Norm women, IAP was significantly higher in twin compared to singleton pregnancies (9.6±2.6 vs 7.1±1.2, p=0.036). For both, significance remained after adjusting for maternal BMI, total birthweight (BW), and maximum vertical pocket (MVP), but was attenuated after adjusting for GA at delivery (p=0.17 and p=0.11, respectively). IAP was similar in Norm and PreE twins. Elevated IAP was seen in singleton pregnancies complicated by PreE, representing a pathologic process. Increased IAP was also recorded in twin pregnancies, suggesting a physiologic process.View Large Image Figure ViewerDownload Hi-res image Download (PPT)