scholarly journals A case report: percutaneous management of high-output heart failure from iatrogenic aortocoronary venous grafting to the coronary sinus

2021 ◽  
Vol 73 (1) ◽  
Author(s):  
Akarsh Parekh ◽  
Vivek Sengupta ◽  
Ryan Malek ◽  
Mark Zainea
Keyword(s):  
Heart Failure ◽  
Coronary Sinus ◽  
Saphenous Vein Graft ◽  
Left Ventricular ◽  
Heart Catheterization ◽  
Covered Stents ◽  
Bypass Grafting ◽  
Output State ◽  
State Management ◽  
High Output

Abstract Background Aortocoronary arteriovenous fistula (ACAVF) due to iatrogenic bypass grafting to a cardiac vein is an exceedingly rare complication resulting from coronary artery bypass grafting (CABG) surgery. If not identified in a timely fashion, ACAVF has known significant clinical consequences related to left to right shunting and possible residual myocardial ischemia. Case presentation An 82-year-old male with a history of CABG, presented with dyspnea. Over the span of 2 years following CABG, the patient experienced progressive exertional dyspnea and peripheral edema. The patient was found to have a new cardiomyopathy with a severely reduced ejection fraction at 30–35%. The patient underwent diagnostic left heart catheterization, and an ACAVF was discovered between a saphenous vein graft and the coronary sinus. The patient underwent successful percutaneous coiling of the ACAVF with no residual flow. Follow-up echocardiography at 3 months revealed restoration of left ventricular systolic function to 50% and significant improvement in heart failure symptoms. Conclusions ACAVF is an exceedingly rare iatrogenic complication of CABG that may result in residual ischemia from the non-grafted myocardial territory and other sequelae relating to left to right shunting and a high-output state. Management for this pathology includes but is not limited to the use of percutaneous coiling, implantation of covered stents, graft removal and regrafting, and ligation.

Abstract 14851: Under Pressure: Hemodynamics Bringing the Right "fix" to Heart Failure

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Estefania Oliveros ◽  
Ashish A Correa ◽  
Aditya Parikh ◽  
Robert Leber ◽  
Soheila Talebi ◽  
...  
Keyword(s):  
Heart Failure ◽  
Troponin I ◽  
Heart Sound ◽  
Venous Pressure ◽  
Heart Catheterization ◽  
Av Fistula ◽  
Flow Reserve ◽  
Hemodynamic Assessment ◽  
The Right ◽  
High Output

Introduction: High-output heart failure (HF) develops in the setting of excessive cardiac output. Case Presentation: 65-year-old male with HF (EF 40%), severe right ventricular dysfunction, and emphysema presented with dyspnea and anasarca. On admission, physical examination showed a BP 97/66mmHg, heart rate 109bpm, temperature 97.2F, respiratory rate of 19rpm, 93% on 2-Liters of oxygen. Jugular venous pressure was 20 cm H20 with large V waves. The rhythm was irregular, with a loud second heart sound, audible third heart sound, parasternal heave, and left lower sternal border murmur. Lung exam demonstrated basilar crackles and prolonged expiratory phase. The abdomen was distended with a pulsatile liver and the lower extremities were cool with 3+ pitting edema. There was an audible bruit with thrill at the right groin. Laboratory testing showed sodium=123mEq/L, creatinine=1.25mg/dL, bilirubin=2.2, ALT=135U/L, AST=146u/L, troponin-I=0.097ng/mL, BNP=1528pg/mL. CT and VQ scan were negative for acute/chronic pulmonary embolism. Lower extremity Doppler ultrasound revealed a right common femoral arteriovenous (AV) fistula (Fig.1). After diuretics and milrinone, a left heart catheterization demonstrated known three vessel disease, but without limitations in instant flow reserve. Right heart catheterization demonstrated RA=15mmHg, RV=50/16mmHg, PA=50/24(34)mmHg, PCWP=11mmHg, CO=5.4L/min, PVR=4.25WU, after which the fistula was ligated. On post-op day 2, repeat hemodynamics off inotropes showed an RA=4mmHg, PA=40/18mmHg, PCWP=18 mmHg, CO=4.4L/min and normalization of end-organ function. He was maximized on GDMT. Echocardiogram 5 months later showed improvement of RV function and he was able to go back to work with minimal symptoms. Conclusion: AV fistulas can lead to high-output HF if undiagnosed. A multidisciplinary approach and comprehensive hemodynamic assessment proved essential in allowing improvement of symptoms and resulting outcomes.

Abstract 17072: Discordance Between Lactic Acid Elevation and Invasive Hemodynamics in Decompensated Heart Failure

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Nikhil Narang ◽  
Bow Chung ◽  
Ann Nguyen ◽  
Teruhiko Imamura ◽  
Sara Kalantari ◽  
...  
Keyword(s):  
Heart Failure ◽  
Lactic Acid ◽  
Inverse Correlation ◽  
Decompensated Heart Failure ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Heart Catheterization ◽  
Ventricular Ejection Fraction ◽  
Significant Difference ◽  
Invasive Hemodynamics

Introduction: Elevated lactic acid (LA) levels carry a poor prognosis in patients admitted with shock. Data is lacking on the association of LA level with the severity of decompensated heart failure (HF). This study assesses the relationship between LA levels, invasive hemodynamics and clinical outcomes. Methods: Patients presenting to the cardiac care unit with decompensated HF between 2015-18 were prospectively enrolled into an invasive hemodynamics study. LA (normal 0.7-2.1 mmol/L) levels were obtained within 12 hours prior to right heart catheterization (RHC). No significant changes in therapy were made in the time between LA level collection & RHC. Patients were divided into 4 groups: 1) normal pulmonary capillary wedge pressure (PCWP) (< 18 mmHg)/ normal Fick cardiac index (CI) (≥ 2.2 L/min/m 2 ), 2) normal PCWP/ low CI (< 2.2 L/min/m 2 ) 3) elevated PCWP (≥ 18 mmHg )/ normal CI, 4) elevated PCWP / low CI. Results: 80 patients were enrolled. Mean age 58±14 years; 78% male, left ventricular ejection fraction was 24±4%. Prior to RHC, 55% patients were on vasoactives and/or inotropes. Mean (SD) PCWP was 26 ± 8.8 mmHg and mean CI was 2.06 ± 0.61 L/min/m 2 . Overall 48 (60%) of the patients had high PCWP and low CI (group 4). 81% had normal LA (≤2.1 mmol/L) prior to RHC. There was no correlation between LA level and PCWP (R=0.12; p=0.30); there was a moderate inverse correlation between LA level and CI (R=-0.40; p<0.01). Only 25% of patients with the highest risk hemodynamic profile (elevated PCWP/low CI) had an elevated LA level (Figure A). 90- day all cause mortality was 33% When LA was stratified by tertile, there was no significant difference in mortality between the tertiles (Figure B). Conclusion: In patients with decompensated HF, normal LA levels do not exclude the presence of cardiogenic shock with profoundly impaired cardiac output. Invasive assessment of hemodynamics should not be delayed based on LA level alone.

P6452Circulating human epididymis protein 4 is a novel prognostic predictor in ambulatory patients with non-ischemic dilated cardiomyopathy

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T Okumura ◽  
H Oishi ◽  
T Kondo ◽  
Y Arao ◽  
H Kato ◽  
...  
Keyword(s):  
Heart Failure ◽  
Dilated Cardiomyopathy ◽  
Cardiac Catheterization ◽  
Coronary Sinus ◽  
Left Ventricular ◽  
Ascending Aorta ◽  
Left Ventricular Ejection ◽  
Composite Event ◽  
Ambulatory Patients ◽  
Non Ischemic Dilated Cardiomyopathy

Abstract Background Myofibroblasts, which are activated fibroblasts, play an important role in interstitial fibrosis in non-ischemic dilated cardiomyopathy (NIDCM). Recently, human epididymal body protein 4 (HE4) has attracted attention as a marker specific to myofibroblasts. However, the prognostic impact of HE-4 on cardiovascular events in NIDCM patients has not been reported. Purposes The purpose of this study was to investigate the impact of circulating serum HE4 on the prognosis in patients with NIDCM. Methods Forty-four NIDCM patients underwent echocardiography, laboratory measurements, cardiac catheterization, and endomyocardial biopsy within one week under stable heart failure condition. Patients with cancer were excluded from this study. We collected blood samples from peripheral vain, ascending aorta, and coronary sinus during cardiac catheterization and measured serum HE4 level. They were divided into two groups at the median of HE4 level: High-HE4 group (HE4 >69 pmol/L); n=22, Low-HE4 group (HE4 <69 pmol/L); n=22. Cardiac composite event was defined as cardiac related deaths and hospitalization due to worsening heart failure. Results The mean age, left ventricular ejection fraction (LVEF), and plasma brain natriuretic peptide level were 56 years, 32%, and 205 pg/mL. Between two groups, there were no significant differences in age, gender, LVEF, left ventricular end-diastolic diameter, cardiac index, and pulmonary capillary wedge pressure. However, estimated glomerular filtration rate was significantly lower in the High-HE4 group (p=0.025). Kaplan-Meier survival analysis revealed that the High-HE group had a higher rate of cardiac composite event (p=0.011, see Figure). However, as for the pathological analysis, not only the peripheral HE4 level but also HE4 value subtracting coronary sinus from ascending aorta did not significantly correlate with collagen volume fraction in biopsy samples. Circulating HE4 level and prognosis Conclusion Elevated circulating HE4 is associcated with poor prognosis in ambulatory patients with NIDCM.

scholarly journals The heart regulates the endocrine response to heart failure: cardiac contribution to circulating neprilysin

2017 ◽  
Vol 39 (20) ◽  
pp. 1794-1798 ◽  
Author(s):  
Mattia Arrigo ◽  
Nicolas Vodovar ◽  
Hélène Nougué ◽  
Malha Sadoune ◽  
Chris J Pemberton ◽  
...  
Keyword(s):  
Heart Failure ◽  
Coronary Sinus ◽  
Artificial Heart ◽  
Systolic Function ◽  
Systolic Dysfunction ◽  
Venous Blood ◽  
Left Ventricular Systolic Function ◽  
Left Ventricular ◽  
Total Artificial Heart ◽  
Endocrine Response

Abstract Aims Heart failure (HF) is accompanied by major neuroendocrine changes including the activation of the natriuretic peptide (NP) pathway. Using the unique model of patients undergoing implantation of the CARMAT total artificial heart and investigating regional differences in soluble neprilysin (sNEP) in patients with reduced or preserved systolic function, we studied the regulation of the NP pathway in HF. Methods and results Venous blood samples from two patients undergoing replacement of the failing ventricles with a total artificial heart were collected before implantation and weekly thereafter until post-operative week 6. The ventricular removal was associated with an immediate drop in circulating NPs, a nearly total disappearance of circulating glycosylated proBNP and furin activity and a marked decrease in sNEP. From post-operative week 1 onwards, NP concentrations remained overall unchanged. In contrast, partial recoveries in glycosylated proBNP, furin activity, and sNEP were observed. Furthermore, while in patients with preserved systolic function (n = 6), sNEP concentrations in the coronary sinus and systemic vessels were similar (all P > 0.05), in patients with reduced left-ventricular systolic function, sNEP concentration, and activity were ∼three-fold higher in coronary sinus compared to systemic vessels (n = 21, all P < 0.0001), while the trans-pulmonary gradient was neutral (n = 5, P = 1.0). Conclusion The heart plays a pivotal role as a regulator of the endocrine response in systolic dysfunction, not only by directly releasing NPs but also by contributing to circulating sNEP, which in turn determines the bioavailability of other numerous vasoactive peptides.

scholarly journals Cardiac resynchronization therapy system implantation complications

2021 ◽  
Vol 27 (3) ◽  
pp. 7-15
Author(s):  
Svetoslav Iovev ◽  
Peyo Zhivkov ◽  
Mariana Konteva
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Coronary Sinus ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Successful Therapy ◽  
Resynchronization Therapy ◽  
Established Method

Cardiac resynchronization therapy (CRT) using coronary sinus (CS) leads is an established method for the therapy of congestive heart failure (CHF) in the case of asynchronous ventricular contractions. Successful therapy depends on the placement of left ventricular leads usually via the coronary sinus (CS), a technically more challenging procedure than regular pacemaker implantations. Without specifi c precautions CRT implantation can be the gateway to a time-consuming nightmare. Therefore, CS lead implantation methods, with a focus on complications, were reviewed according to the literature and our own experience with approximately 4500 procedures from 2002-2021.

scholarly journals Preoperative Factors Influencing the Results of Coronary Artery Bypass Grafting with Reduced Left Ventricular Myocardial Contractility

2020 ◽  
pp. 38-42
Author(s):  
S. A. Rudenko ◽  
Y. V. Kaschenko ◽  
L. A. Klimenko ◽  
N. S. Osipenko ◽  
A. V. Rudenko ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Coronary Artery ◽  
Coronary Artery Bypass Grafting ◽  
Coronary Artery Bypass ◽  
Myocardial Contractility ◽  
Artery Bypass ◽  
Left Ventricular ◽  
Bypass Grafting ◽  
Artery Bypass Grafting

Myocardial infarction remains one of the most common causes of disability in patients. Prior myocardial infarction in 15–30% of cases leads to decrease in left ventricle (LV) contractility. Isolated drug therapy is ineffective in most cases – impressions of the coronary arteries require revascularization, including coronary artery bypass grafting. Data on the choice of optimal tactics in such patients is also limited. In addition, there is no consensus on the prognosis of mortality and management of this group of patients. Materials and methods. The study included 190 patients with the left ventricular ejection fraction (EF LV) of 35% or less, who underwent CABG at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine in the period from 01.01.2015 to 31.12.2018. The age of patients ranged from 29 to 83 years (61.13 ± 8.87). There were 170 men (89.47%) and 20 women (10.53%). Our data suggests that patients with low EF LV have complications typical of coronary artery bypass grafting, but the incidence of these complications is higher and increases with the EF LV decrease (except for the central nervous system (CNS) complications where there is no correlation). At the same time, such indicators as the duration of mechanical ventilation, the number of days of stay in the intensive care unit and the total number of days of stay in the hospital are increasing. The following complications most often arose in the postoperative period: acute heart failure, respiratory failure, renal failure. Based on our data, we came to the following conclusions: in patients with reduced LV myocardial contractility, the main complications after coronary artery bypass grafting were congestive heart failure, respiratory failure, renal failure and CNS complications. Among them, regardless of the level of EF LV, the most common were acute heart failure and complications of the respiratory system. The most significant factors of preoperative condition of patients with reduced LV myocardial contractility, which increase the risk of postoperative complications and increased mortality are: EF LV 30% and below, patient age over 60 years, creatinine rise to >200 mmol/L, pulmonary hypertension over 50 mmHg. Concomitant mitral regurgitation (moderate or severe) requires obligatory intraoperative correction.

scholarly journals Underlying Causes of High Output Heart Failure

2020 ◽  
pp. 1-4
Author(s):  
Qiuhua Shen ◽  
Qiuhua Shen ◽  
John B. Hiebert ◽  
Janet D. Pierce
Keyword(s):  
Heart Failure ◽  
Neurohormonal Activation ◽  
Chronic Anemia ◽  
Output State ◽  
Arterial Blood ◽  
High Output Heart Failure ◽  
Underlying Causes ◽  
Venous Fistula ◽  
High Output ◽  
Pathophysiologic Mechanisms

In the U.S., each year, there are more than 500,000 new cases of all types of heart failure. With high output cardiac failure, there is an elevated cardiac output associated with several conditions and diseases, including obesity, chronic anemia, systemic arterio-venous fistula, hypercapnia, mitochondrial dysfunction, and hyperthyroidism. The underlying pathophysiologic mechanisms relate to a reduction in systemic vascular resistance from arterio-venous shunting or peripheral vasodilation. Often there is a decrease in systemic arterial blood pressure and neurohormonal activation leading to heart failure symptoms of dyspnea and fatigue. In a persistent high output state, patients may experience tachycardia, valvular abnormalities, and ventricular dilatation and/or hypertrophy. In this article, there is a review of high output heart failure, including the prevalence, pathophysiology, and common clinical causes of this disease.

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