Recent Cardiac Catheterization Research Articles

Abstract 15756: To Close or Not to Close: A Case of Multisystem Immune Checkpoint Inhibitor Toxicity and PFO

Introduction: Recent emergence of immune checkpoint inhibitors (ICIs) in oncologic treatments has led to increasing research on their side effect profile. Myocarditis occurs in roughly 0.04-1.14% of patients treated with ICIs and is associated with up to 50% mortality. We present a case of multisystem ICI toxicity requiring comprehensive evaluation to ultimately reveal a PFO shunt as the cause of persistent hypoxemia. Case: A 67-year-old male with Stage IIIC cutaneous melanoma presented with non-radiating pleuritic chest pain, diplopia, dyspnea and syncope. ECG showed high grade AV block and right bundle branch block. Labs showed elevated troponin, creatinine kinase and inflammatory markers. An echocardiogram showed edematous myocardium, a small pericardial effusion, and akinetic apical/inferior septal segments. Despite diuresis, 5g of methylprednisolone, IV immunoglobulin plus mycophenolate and resolution of AV block, the patient had hypoxemia on 100% FiO2. He underwent a CTA (which ruled out PE and ICI-induced pneumonitis) and fluoroscopic sniff test (revealing bilateral moderate diaphragm paresis). A recent cardiac catheterization on prior admission showed no obstructive coronary disease. Arterial blood gas showed pO2 120 mmHg without hypercapnia on 100% FiO2. We suspected a shunt as the underlying cause and obtained a bubble study disclosing a large (> 25 bubble) PFO with right-to-left shunt. Results: Given the timing of symptoms, it was determined that pembrolizumab administration caused myocarditis and myositis with diaphragmatic paresis. In patients with pulmonary disease or diaphragmatic paresis, elevated intrathoracic and pulmonary artery pressures have been a proposed mechanism of acute worsening of right-to-left shunt resulting in hypoxemia. The patient underwent right heart catheterization and PFO closure using Gore Cardioform septal occluder with resolution of hypoxemia. A repeat echocardiogram obtained 1 month later was normal. Conclusion: All concerning clinical symptoms in the setting of ICI use require a thorough evaluation. In this case, persistent hypoxemia despite treatment for ICI toxicity unmasked a large PFO requiring closure. A multisystem approach should be used to assess suspected ICI myocarditis.

ANALYSIS OF TREATMENT STRATEGIES AND SHORT-TERM OUTCOMES FOR CORONARY ARTERY DISEASE IN END-STAGE RENAL DISEASE (ESRD) COMPARED TO NON-ESRD PATIENTS FOLLOWING CARDIAC CATHETERIZATION

We sought to assess the influence of ESRD status on revascularization strategies, readmission and in-hospital mortality rates in patients who underwent a recent cardiac catheterization. We performed a retrospective analysis of all consecutive patients who underwent cardiac catheterization between

Postoperative Acute Kidney Injury in Young Adults With Congenital Heart Disease

There is an increasing number of young adults living with congenital heart disease (CHD). The goal of this study was to ascertain the frequency of acute kidney injury (AKI) as well as the risk factors and outcomes associated with AKI in young adults with CHD after a surgical procedure. This was a single-center retrospective cohort study including all patients 18 to 40 years of age with a diagnosis of CHD admitted to a quaternary care children's hospital cardiac intensive care unit postoperatively from 2004 to 2015. We defined AKI using the Kidney Disease Improving Global Outcomes criteria for serum creatinine. We explored potential susceptibilities and exposures for AKI using multivariable logistic regression and determined the association of AKI with duration of mechanical ventilation and length of stay using Poisson regression. In 699 consecutively admitted patients AKI occurred in 13.2%. Suspected sepsis (odds ratio [OR], 2.87; 95% confidence interval [CI], 1.17 to 7.05), exposure to calcineurin inhibitors (OR, 5.80; 95% CI, 1.06 to 31.59), vancomycin (OR, 3.35; 95% CI, 1.11 to 10.14), and piperacillin-tazobactam (OR,4.12; 95% CI, 1.23 to 13.78) increased the odds of AKIeven after controlling for age, ejection fraction, recent cardiac catheterization, repeat cardiopulmonary bypass, bypass time, cross-clamp time, and other potential nephrotoxic medications. AKI was associated with a longer duration of mechanical ventilation (OR, 1.47; 95% CI, 1.15 to 1.89) and intensive care unit length of stay (OR, 1.50; 95% CI, 1.30 to 1.72). AKI is common in young adults with CHD postoperatively and is associated with negative outcomes. The results highlight the importance future research and clinical efforts aimed at prevention and improved management of AKI in this patient group.

Thrombin Generation and Microparticles As Promising Biomarkers for Venous Thromboembolism in Children with Central Venous Lines

Background: Pediatric hospital-acquired venous thromboembolism (HA-VTE) has increased over the past ten years (Raffini et al. Pediatrics 2009; 124; 1001-1008), with an associated increase in both VTE-associated complications and treatment-related adverse events. Children with VTE have a four-fold increase in length of admission compared to children without VTE. There are many known clinical risk factors but the presence of central venous lines (CVLs) has been shown to be among the strongest risk factors in children (Mahajerin et al. Haematologica 2015 Aug; 100(8): 1045-50). Current tools, including clinical risk-prediction scoring systems as well as genetic risk factors, are not sufficient to predict VTE risk at this time. Identification of dependable, rapid and cost-effective biomarkers for the prediction of VTE in children with CVLs is essential in guiding anti-coagulation prophylaxis, thus reducing VTE occurrence among hospitalized children with CVLs.Objectives: Determine the ability of thrombin generation (TG) and microparticle-based phospholipid-dependent procoagulant potential (MP-PPL) to predict VTE occurrence in hospitalized children with CVLs.Methods: Plasma sample were collected from 34 hospitalized acutely ill children between the age of 1 month and 21 years, who are at risk for VTE due to multiple known clinical risk factors, including a newly placed non-tunneled CVL. Children that had undergone a recent cardiac catheterization or on dialysis, plasmapheresis or ECMO were excluded. Samples from 16 age matched healthy controls were also collected. Venous samples were collected prior to CVL placement. Platelet poor plasma (PPP) was obtained according to a strict protocol to minimize pre-analytical variable. All pertinent clinical and laboratory information was extracted, including CVL-related variables and details of VTE in affected subjects. TG was measured by means of the calibrated automated thrombogram (CAT). MP-PPL was measured using two methods: 1) Functional assay that detects the ability of circulating MPs to indirectly facilitate thrombin generation (Zymuphen MP-Activity kit, Hyphen BioMed, France), 2) Clot-based assay that measures phospholipid-dependent, factor Xa initiated clotting time in relation to normal controls (STA-Procoag-PPL, Diagnostica Stago).Results: The median age of our cohort was 10 yrs (IQR 12, range 0 - 19), with a slight male predominance (53%) and increased representation of adolescents (41%). CVLs were placed in an intensive care setting in 38% of subjects and 39% of subjects had an underlying condition associated with chronic inflammation. The median duration of CVL placement from admission was 2 days (IQR 5, range 1 - 19) and the median total duration of CVLs were 14 days (IQR 20, range 5 - 84). Line-associated VTE occurred in 9% (3/34) of children with CVL and one subject had a VTE unrelated to CVL. There was no observed significant difference between children with or without line-related VTE in terms of age, gender, lag of CVL placement from admission, duration of CVLs, caliber of initial vessel of insertion, number of lumens, size of CVL and internal length of the CVL. However, all subjects with line-associated VTE were admitted for acute infection to an intensive care setting, with the majority of VTE occurring within 48 hours from line placement (2/3). Correlation analysis of the two MP-PPL assays was significant (r = -0.659). Even though the MP-PPL functional assay did not show a significant difference between subjects with and without line-associated VTE (p-value 0.189), the MP-PPL clot-based assay showed measurable difference between the two groups, both as an absolute value and as a ratio (p-value: 0.04 and 0.038 respectively, Table 1). Peak thrombin generation (p-value 0.001), estimated thrombin potential (ETP) - (p-value 0.02) and velocity index (p-value 0.001) were significantly higher in subjects with line-associated VTE (see Figure 1). Subject recruitment and sample analyses, involving these assays and other potential biomarker candidates, are ongoing.Conclusion: Given the rising incidence of pediatric VTE, the ability to use biomarkers to stratify patients according to their VTE risk will provide a vital tool to guide preventative efforts, and minimizing unnecessary expense and toxicities. TGA and MP-PPL have shown great potential for differentiating children with CVLs that may develop a line-related VTE as a HA-VTE. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Perioperative morbidity in children with elastin arteriopathy.

Children with elastin arteriopathy (EA), the majority of whom have Williams-Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia. The aim of this study was to present one institution's rate of morbidity and mortality in all children with EA undergoing anesthesia and to examine patient characteristics that pose the greatest risk. We reviewed medical records of children with EA who underwent anesthesia or sedation for any procedure at our institution from 1990 to 2013. Cardiovascular hemodynamic indices from recent cardiac catheterization or echocardiography were tabulated for each child. The incidence, type, and associated factors of complications occurring intraoperatively through 48 h postoperatively were examined. Forty-eight patients with confirmed EA underwent a total of 141 anesthetics. There were seven cardiac arrests (15% of patients, 5% of anesthetics) and nine additional intraoperative cardiovascular complications (15% of patients, 6% of anesthetics). Extracorporeal life support was initiated in five cases. There were no perioperative deaths. All children having a cardiac arrest or complication were <3 years old and had biventricular outflow tract obstruction (BVOTO). Subgroup analysis demonstrated high rates of cardiac arrest in two groups: children with BVOTO (44%) and age <3 years old (21%). We have confirmed that the rate of cardiac arrest and complications is significantly elevated in children with EA undergoing anesthesia. Children <3 years old and with BVOTO were at the greatest risk in our population.

Efficacy of the 'intrapulmonary-artery septation' surgical approach for Fontan candidates with unilateral pulmonary arterial hypoplasia†.

The bilaterally unbalanced development of pulmonary arteries (PAs), as a result of unilateral pulmonary arterial hypoplasia (PAhypo) makes patients either ineligible for the Fontan operation or candidates for the one-lung Fontan operation. In the present study, we examined the efficacy of intrapulmonary-artery septation (IPAS), a technique we reported in 2007 in which a septation is constructed within the central PA, in patients with unilateral PAhypo. Sixteen patients with unilateral PAhypo and an affected PA index of ≤60 mm(2)/m(2), including non-confluent PA (NCPA), underwent IPAS between January 2000 and March 2012; patients with pulmonary venous obstruction were excluded from this study. We compared the affected PA index values before and after IPAS and after the Fontan operation as well as the bilateral pulmonary blood flow ratio using pulmonary scintigraphy. The post-Fontan operation values of central venous pressure (CVP), pulmonary vascular resistance (PVR), ventricular end-diastolic pressure (VEDP), cardiac index (CI) and arterial oxygen saturation (SaO2) at the most recent cardiac catheterization, as well as the pre-IPAS and post-Fontan New York Heart Association (NYHA) classification levels were examined. One patient died after IPAS (survival rate, 93.8%). Thirteen (86.7%) of the surviving 15 patients underwent the Fontan operation. The mean PA indexes were 25.5 ± 18.9 mm(2)/m(2) before IPAS and 67.9 ± 34.2 mm(2)/m(2) after IPAS (P = 0.003); the mean PA index was 71.1 ± 50.0 mm(2)/m(2) after the Fontan operation. Restenosis did not occur after the Fontan operation, and the PA diameters were maintained. The mean affected/unaffected lung blood flow ratio was 0.89 ± 0.67. The most recent cardiac catheterization after the Fontan operation indicated the following values: CVP, 11.7 ± 1.8 mmHg; PVR, 1.3 ± 0.4 U m(2); EDP, 5.7 ± 2.0 mmHg; CI, 3.1 ± 0.5 l/min/m(2) and SaO2, 94.9 ± 2.0%. The mean pre-IPAS and post-Fontan NYHA levels were 2.3 ± 0.6 and 1.2 ± 0.4, respectively (P = 0.0002). With IPAS, the affected PA diameters increased significantly, and were maintained after the Fontan operation, and continuity of the native PAs was achieved. IPAS is very effective for patients suffering from otherwise intractable diseases.

Transmyocardial laser therapy: a strategic approach.

Coronary artery bypass and percutaneous intervention have become the established methods of coronary revascularization in treating angina pectoris. Subsets of angina patients, however, are not amenable to either of these procedures. Transmyocardial laser revascularization (TMR) has been developed as a potential treatment to address such patients, and clinical research to date illustrates the success of TMR for this patient group. Although the symptoms of ischemic heart disease manifest themselves in a variety of ways, the best results with TMR are seen in patients with severe angina rather than in patients with silent ischemia or congestive heart failure. Potential TMR patients receive diagnostic tests to determine if and where the therapy should be applied. A recent cardiac catheterization is required to document the status of and the coronary-system suitability for the planned intervention. It is not appropriate to assume that a patient with nonbypassable, noninterventional coronary artery disease has to be relegated to medical therapy only. Additionally, echocardiography demonstrates the status of cardiac valves and segmental wall motion activity. This knowledge allows the surgeon to determine the sequence of surgery and if abnormalities are present. Once the decision to use TMR use has been made, there are 2 approaches--sole therapy or adjunctive therapy. TMR is not to be substituted for a feasible bypass graft, but the best time to make this decision may well be during the surgery itself, because grafts that appear surgically feasible on an angiogram may be less feasible after the chest has been opened. The decision to perform sole-therapy TMR in the absence of bypassable vessels clearly must be made before opening the chest. Whether to use cardiopulmonary bypass (CPB) and the sequence in which to perform TMR and bypass grafts are based on surgeon preference. The advantage of performing TMR on CPB is that channels can quickly be lased without pause. A potential advantage of performing TMR before bypass grafts is that "channel leak" (bleeding) can be minimized by the conclusion of the surgery. Complete revascularization has become technically more difficult because of the increasing use of percutaneous approaches and because patients are being referred for coronary artery bypass grafting much later in the course of their coronary disease progression than before. TMR may well be a viable alternative to bypassing a heavily diseased, previously intervened, small-diameter coronary artery. Thus, a model in which myocardial perfusion is considered within the context of the natural circulation can be conceived as an alternative to a model in which circulation is altered by interventional, surgical, and/or transmyocardial methods. TMR has been shown to be effective in accomplishing a complete revascularization when the restoration of circulation to ischemic territories with interventional therapy, bypass surgery, or a combination of both has been ineffective. We recommend that interested users follow this "complete revascularization strategy" algorithm for all ischemic vessels being considered for interventional or surgical treatment. Running each diseased vessel through this thought process will ensure that available treatment options are considered in the optimization of a patient's outcome. The use of TMR for angina relief has evolved into a clinically proven technology that has enabled physicians to address difficult revascularization cases with a therapy that is safe and effective.

Asymmetric cerebral near-infrared oximetric measurements during cardiac surgery

A 67-YEAR-OLD man with unstable angina was scheduled for coronary artery bypass graft surgery (CABG). His past medical history was significant for essential hypertension, diet-controlled diabetes mellitus, previous carcinoma of the bladder, and degenerative arthritis. He had had a prior myocardial infarction followed by percutaneous transluminal coronary angioplasty (PTCA) and stenting of the right coronary artery. A recent cardiac catheterization revealed normal left ventricular function and 60% to 70% stenosis of the first obtuse marginal and diagonal coronary arteries. Carotid artery ultrasound showed 40% to 59% stenosis of the right and 40% stenosis of the left carotid arteries, with retrograde flow demonstrable in the left vertebral artery.

Nonsurgical closure of femoral pseudoaneurysms complicating cardiac catheterization and percutaneous transluminal coronary angioplasty

Objectives. This study was performed to describe the initial experience and follow-up of ultrasound-guided compression of pseudoaneurysms in patients receiving systemic anticoagulant or antiplatelet therapy, or both, after recent cardiac catheterization or percutaneous transluminal coronary angioplasty.Background. Femoral artery pseudoaneurysm formation after an interventional procedure is becoming more common as larger caliber catheters and prolonged anticoagulant and antiplatelet therapy are being used. Traditional treatment of this complication has been surgical repair. This study describes a new method of closing femoral pseudoaneurysms by using external compression guided by Doppler color flow imaging.Methods. Fifteen patients, 3 undergoing cardiac catheterization and 12 undergoing coronary angioplasty, developed an expansile groin mass at the vascular access site diagnosed as a femoral artery pseudoaneurysm by Doppler ultrasound. Seven of the patients had undergone coronary stenting and were receiving postprocedural anticoagulant therapy. These patients underwent progressive graded mechanical (C-clamp) external compression guided by ultrasound. The mechanical compression was titrated to obliterate the vascular tracts to these aneurysms and maintain adequate flow in the femoral artery.Results. After an average compression time of 30 min (range 10 to 120), these tracts remained closed. Follow-up ultrasound examination at 24 h or later confirmed continued closure in all. Conclusions. This study suggests that nonsurgical closure of femoral pseudoaneurysms is feasible. This technique may be valuable in managing vascular access-related complications after diagnostic and interventional procedures, even in patients requiring prolonged anticoagulant therapy.

How to Give Thrombolytic Therapy Safely

To maximize the safety of thrombolytic therapy, optimal patient selection is crucial. Absolute and relative contraindications must be sought before initiating treatment. All patients receiving thrombolysis should have serial examinations that include evaluating neurologic status as well as vital signs. To detect expanding groin hematomas, sites of recent cardiac catheterization should be monitored closely. More patients are eligible for thrombolytic therapy than is commonly realized. After a period of initial familiarization and education, the hospital staff will become confident and enthusiastic about using this important therapeutic modality.

How to Give Thrombolytic Therapy Safely

To maximize the safety of thrombolytic therapy, optimal patient selection is crucial. Absolute and relative contraindications must be sought before initiating treatment. All patients receiving thrombolysis should have serial examinations that include evaluating neurologic status as well as vital signs. To detect expanding groin hematomas, sites of recent cardiac catheterization should be monitored closely. More patients are eligible for thrombolytic therapy than is commonly realized. After a period of initial familiarization and education, the hospital staff will become confident and enthusiastic about using this important therapeutic modality.

Nichtinvasive Beurteilung aortokoronarer Venenbrücken mit Kernspintomographie

Fortyfour patients with recent cardiac catheterization because of recurrent chest pain after coronary artery bypass surgery were studied by magnetic resonance imaging to evaluate graft patency. To assess the efficacy of this non-invasive method 92 coronary artery bypass grafts were examined by the spin-echo technique. ECG-gated transversal sections were acquired between the diaphragm and the aortic arch. The specificity of magnetic resonance imaging was 83% (48/58) for patent grafts. However, the sensitivity in the detection of occluded bypasses was only 56% (19/34). Despite the good specificity, clinical applications of this method are limited because of its low sensitivity.

Magnetic resonance imaging to evaluate patency of aortocoronary bypass grafts.

To assess the efficacy of magnetic resonance (MR) imaging in evaluating graft patency after coronary bypass surgery, 20 patients who had prior surgery (average 5.5 years, range 1.5 to 14) and recent cardiac catheterization because of chest pain were studied. No patient had surgical intervention or change in symptoms in the time interval between catheterization and MR imaging. These 20 patients had a total of 47 grafts, defined as proximal anastomoses: 20 to the left anterior descending or diagonal artery (LAD), 13 to the left circumflex artery marginal branches (LCX), and 14 to the right coronary artery or posterior descending artery (RCA). The patients underwent cardiac and respiratory gated MR scans in a 0.5 tesla magnet with an echo time of 22 msec and two repetitions in a 128 X 256 matrix. In-plane resolution was 2.7 mm. Every patient had a scan in the transaxial plane and some underwent scanning in the sagittal and coronal planes as well. A graft was considered patent by MR when a signal-free lumen was visualized in an anatomic position consistent with that of a bypass graft, had a lumen larger than the native vessels, was seen on more than one slice, and was seen at a level higher than that of the native vessels. If a known graft was not seen it was considered occluded. The scans were interpreted by consensus of two physicians aware of the operative but not the cardiac catheterization data.(ABSTRACT TRUNCATED AT 250 WORDS)

Regression in thromboembolic type of primary pulmonary hypertension during 2½ years of antithrombotic therapy

Primary pulmonary hypertension carries a poor prognosis, with a 5 year survival rate of less than 25%. However, a previous study of more than 100 patients with tissue-proved primary pulmonary hypertension suggested that antithrombotic therapy may have a beneficial effect on survival, especially in patients with the thromboembolic type of primary pulmonary hypertension. This report describes a 54 year old white man with primary pulmonary hypertension of the thromboembolic type (proved by right upper lobe lung biopsy) who, after long-term antithrombotic therapy, showed resolution of symptoms of dyspnea and fatigue, regression of electrocardiographic signs of right ventricular hypertrophy and regression of elevated pulmonary artery pressure. Base-line cardiac catheterization in January 1982 revealed elevated pulmonary artery pressure (104/37 mm Hg) and pulmonary vascular resistance (14.6 units/m2) that did not decrease with 100% oxygen or intravenous hydralazine (12 mg). The patient was treated with warfarin and dipyridamole, 100 mg four times daily. The most recent cardiac catheterization in January 1984 revealed a pulmonary artery pressure of 50/15 mm Hg and a pulmonary vascular resistance of 8.7 units/m2. It is believed that this is the first report of regression of the symptoms and signs of biopsy-proved primary pulmonary hypertension. In view of the lack of a response to vasodilators in 1982, it is suggested that antithrombotic therapy is partially responsible for the improvement of this patient.

Irreversible Pulmonary Hypertension after Correction of Tetralogy of Fallot

A case of tetralogy of Fallot in which irreversible pulmonary hypertension developed in the postoperative period is presented. A recent cardiac catheterization has shown this to be caused by reopening of the ventricular septum and complete relief of infundibular pulmonic stenosis. The patient's hemodynamics are now those of a ventricular septal defect with reversal of shunting. The need for careful postoperative follow-up and early evaluation by catheterization when the hemodynamic status is in doubt is illustrated and stressed.